Thromboprophylaxis following cast immobilisation for lower limb injuries--survey of current practice in United Kingdom

The risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) is well documented in patients following cast immobilisation for injuries of lower extremities. There are no generally accepted approaches to preventing this complication and hence there remains substantial practice variation amongst surgeons regarding the use of anticoagulation measures. The present survey was conducted to investigate the current chemothromboprophylaxis practice among UK orthopaedic departments for patients immobilised with plasters for lower extremity injuries and establish any variations in practice. A telephone questionnaire survey was conducted on junior doctors (Senior House Officers and Registrars) in orthopaedic departments of 70 randomly selected hospitals in United Kingdom. This survey assessed the thromboprophylaxis practice for lower limb injuries in plaster casts. Our results show substantial variation amongst British orthopaedic surgeons in the use of chemothromboprophylaxis measures. Sixty-two percent of the departments do not use any DVT prophylaxis in this group of trauma. Furthermore, only 11.4% of the departments performed risk stratification on their patients. Ninety-nine percent of the respondents were unaware of any existing guidelines in this regard. Although the incidence of DVT in patients in plaster for lower extremity injuries is low compared to the Hip/Knee arthroplasty group, this is not insignificant. Both over and under treatment with thromboprophylaxis can have implications in terms of side effects and costs. One possible solution is to use risk stratification to identify individuals who are likely to benefit from prophylaxis. There is a substantial variation and inconsistency in practice among orthopaedic departments in United Kingdom due to a lack of clinical guidelines in this group of trauma and it remains underused even in high-risk group.     

Common lower limb injuries in children

The clinical evaluation and management of lower limb injuries in children are of importance because of the high incidence of trauma in this population. Although many of the fracture patterns and principles of treatment are similar to those in adults, notable differences exist and these will be highlighted. The features of common lower limb trauma and their treatment in children will also be described.     

罗哌卡因和布比卡因用于老龄患者下肢手术麻醉中的对比研究

【摘要】 目的 探讨在老龄患者下肢手术的麻醉中等效剂量罗哌卡因和布比卡因麻醉效果以及对手术的影响。方法 选择拟行股骨颈骨折手术老龄患者50例,随机分为罗哌卡因组(R组)和布比卡因组(B组)。两组均采用腰硬联合麻醉(CSEA),分别给予0.5%罗哌卡因2.5 mL和0.5%布比卡因2.5 mL注入蛛网膜下腔。术中麻醉效应不足时硬膜外给予2%利多卡因。术中监测呼吸循环状况,评估麻醉效果,并观察不良反应。结果 两组麻醉效果,最高阻滞平面及不良反应的差异无统计学意义(P>0.05),B组的血压下降更加明显(P<0.05),R组下肢感觉阻滞起效更慢,持续时间更短(P<0.05),下肢运动阻滞程度显著低于B组(P<0.05)。结论 罗哌卡因和布比卡因在老龄患者下肢手术的腰硬联合麻醉都有效,罗哌卡因对循环系统影响更小,运动神经阻滞更轻且恢复迅速,更适合老龄患者下肢手术麻醉中的应用。     

U型钉方法矫治儿童下肢不等长和成角畸形

目的回顾总结北京儿童医院自1989年至2007年应用U型钉方法矫治儿童下肢不等长和成角畸形的体会。方法对于下肢成角畸形,以及由于肢体过度生长造成的肢体不等长,采用U型钉皮下置入方法（亦即Blount临时骺阻滞钉技术）。如果达到治疗效果,即时取出,如果暂时未达到治疗目的 ,需要在置入U型钉后1年左右暂时取出,3个月后重新置入,以避免损伤骨骺。结果共有16例患儿接受了临时骺阻滞技术的治疗。1例先天性单侧肢体过度生长,1例神经纤维瘤病合并单侧肢体过度生长,2例K-T综合征,2例Proteus综合征,4例重度双侧膝外翻,1例内生骨软骨瘤合并膝外翻畸形,2例外伤骺早闭造成的膝外翻,1例骨骺发育不良合并膝外翻,1例Blount＇s病,1例佝偻病合并膝内翻。2例U型钉脱出,无断裂现象,1例出现骨骺变形,1例在置钉位置出现软骨样组织增生,本组病例并发症的发生率为25%。结论骨骺未闭合之前的儿童存在生长发育的潜力,在这个时期的儿童如果患有肢体过度生长导致的肢体不等长,以及不同原因造成的下肢成角畸形,可以采用临时骺阻滞技术,依靠自身的生长发育能力,自动调节后予以矫治。该方法具有创伤小,近似微创,手术较为简单,效果良好的优点。但是,置入钉的数量、位置、体内维持的时间等问题还需要进一步观察和研究。     

Postoperative lower limb paralysis due to retractors

We report a case of femoral neuropathy caused by retractors used during operation. The patient (a 74-year-old woman) was scheduled for right hemicolectomy for cecum cancer, and anesthesia was maintained with nitrous oxide and sevoflurane in oxygen plus extradural anesthesia. After operation, the patient complained of hypesthesia in the anterolateral and medial area governed by the femoral nerve. Magnetic resonance imaging findings, were normal and the straight leg raising test was negative. After 2 months, the patient had completely recovered from the neurological symptoms. These manifestations were indicative of femoral neuropathy resulting from the pressure of large-bladed self-retraining retractors. It is important to include femoral neuropathy in the differential diagnosis of postoperative paralysis of the lower limb.     

高龄患者下肢手术行外周神经阻滞效果分析

目的：在老年患者下肢手术过程中分别采用硬膜外麻醉与外周神经阻滞两种方法,并观察这两种麻醉方法的麻醉效果和安全性。方法选取2013年1月~2014年1月因下肢外伤就诊于我院的老年患者24例。按随机分组的方法分为外周神经阻滞组和硬膜外麻醉组,每组12例。外周神经阻滞组：在神经刺激器引导下行后路腰丛及坐骨神经阻滞。硬膜外麻醉组常规硬膜外麻醉。结果两组手术麻醉效果无显著差异（P＞0.05）。血流动力学改变：外周神经阻滞组患者阻滞前后及术毕均无明显波动,麻醉后15,30min两组心率、收缩压、舒张压及平均动脉压均有显著差异（P＜0.05）。镇痛时间：外周神经阻滞组明显长于硬膜外阻滞组。外周神经阻滞组起效时间明显短于硬膜外阻滞组,差异有统计学意义（P＜0.05）。外周神经阻滞组维持时间长于硬膜外阻滞组,差异有统计学意义（P＜0.05）。运动神经阻滞：外周神经阻滞组起效时间、维持时间均短于硬膜外阻滞,差异有统计学意义（P＜0.05）。结论外周神经阻滞可安全有效地应用于80岁以上高龄老人下肢手术。     

高龄患者单侧下肢创伤后手术的麻醉方法比较

目的 探讨高龄患者单侧下肢创伤后手术麻醉的安全性. 方法 使用电脑随机编码、随机抽签将60例年龄为80岁～99岁的老年骨科手术患者随机分为神经阻滞组(N组)和轻比重腰麻组(S组),每组30例.N组行腰丛加坐骨神经阻滞麻醉,S组行轻比重腰麻,记录麻醉前及麻醉后1、3、5、10、15、30 min、1、2h、手术结束时患者的平均动脉压(mean arterial pressure,MAP)、心率(heart rate,HR)、血氧饱和度(blood oxygen saturation,SpO2);记录两组局麻药用量、麻醉起效时间、阻滞完善时间、辅助用药、感觉阻滞平面;观察两组麻醉效果、副作用和术后并发症等. 结果 N组麻醉后10 min MAP、HR、SpO2分别为(156±15) mm Hg(1 mm Hg=0.133 kPa)、(85±7)次/min、(98.5±1.5)％(P＞0.05);S组麻醉后10min MAP、HR、SpO2分别为(99±11)mmHg、(99±5)次/min、(98.5±1.5)％(P＜0.05);S组与N组MAP比较,P＜0.05; HR两组间比较,P＞0.05;N组SpO2麻醉后与术前比较,P＜0.01;S组SpO2麻醉后与术前比较,P＜0.05;两组间比较,P＞0.05;S组术中低血压的发生率及术后寒战、恶心、呕吐的发生率均升高(P＜0.05,P＜0.01). 结论 腰丛加坐骨神经阻滞麻醉比轻比重腰麻更安全,在高龄患者单侧下肢手术中患者血流动力学更平稳,并发症少,腰丛加坐骨神经阻滞麻醉可以作为高龄患者的下肢手术不适宜腰麻而又不愿全麻时的麻醉方法之一.     

Titanium elastic nailing versus hip spica cast in treatment of femoral-shaft fractures in children

Background  

There is no consensus on treatment of closed femoral-shaft fractures in children. We compared hip spica cast with titanium elastic nailing (TEN) in the treatment of femoral-shaft fractures in children.     

Coordination strategies of lower limb muscles during curve-turning tasks in preschool children

BackgroundPreschoolers are within their critical time in motion development; while muscles are the fundamental units in motion control and by monitoring activated intensity and duration of muscles, preschooler’s motor ability which would disclose their potential pathogenesis quality can be objectively and quantitatively assessed. Although a large number of studies were available on this issue, questions still being there: what are the patterns and characteristics of lower limb muscles when they are facing with the curve walking(CW) tasks; and then how individual muscle or muscle groups coordinated while turning curves. Our purpose of this study is first to portray the patterns and characteristics of lower limb muscles of healthy preschoolers while CW and then to insight their muscles’ coordination mechanism and "neuro-musculo-skeletal" feedback during motion.Method35 healthy preschoolers and 35 healthy adults’ lower limbs surface electromyography (sEMG) were collected while left and right CW and four muscle groups (Tibialis Anterior, Lateral Gastrocnemius, Rectus Femoris, and Biceps Femoris) were recorded. sEMG variables such as Muscle Activation Time, Total Duration of Activity Time, Average Muscle Activation Rate and Average Rate of Change were calculated. Paired sample t-test was used to explore the differences of sEMG variables between preschoolers and adults when turning curves.ResultsPreschoolers would adjust the gait by changing the activation time and activation rate to fulfill the curve turning tasks; but they also showed variations in coordination mechanism when contrasting with the adults group. Those findings in preschoolers would support to build muscles’ coordination mechanism and further insight to neuro-muscular skeletal feedback regulation.ConclusionAlthough preschoolers performed good enough to switching gait from normal walking to CW, but gaps in their abilities were still apparent when compared to adults. Hence, with the help of highly recognizable muscle coordination mechanism in CW, motor dysfunction in lower limbs of preschool children can be effectively identified.     

下肢严重开放性损伤的显微外科修复

目的探讨下肢严重开放性损伤的显微外科修复及临床疗效。方法对下肢损伤根据Gustil和Andserson分类ⅢB16例、ⅢC29例，采用显微外科技术修复结合稳定的固定方法和损伤肢体部位筋膜间室广泛切开减压进行治疗结果38例43肢存活，7例二期截肢。全部病例随访5～60个月，骨折愈合，无骨关节感染发生．组织瓣全部成活，质地与色泽较好；存活肢体外形与功能满意16例，基本满意20例．不满意2例。结论下肢严重开放性损伤危及肢体的存活与功能，对伤肢主干血管重建、神经损伤及软组织缺损的修复是关键。应用显微外科技术修复与重建，可提高临床疗效。     

微波腔内治疗下肢静脉曲张的研究

目的:探讨微波腔内闭合大隐静脉治疗静脉曲张的临床疗效。方法:将陕西省咸阳市第一人民医院普外科收治的36例病人(40条肢体)行微波腔内闭合曲张静脉;50例(60条肢体)行传统剥脱术的病人为对照组。比较两组病人手术时间、术中出血量、住院时间及术后恢复情况。结果:两种治疗均可有效治疗下肢静脉曲张,但微波治疗组比对照组具有更短的手术时间、更少的术中出血量及更少的手术切口,且病人术后住院时间亦明显缩短,微波治疗具有更低的术后下肢瘀血发生率;且其下肢麻木发生率亦低于对照组组,但无统计学差异(P=0.13)。结论:微波腔内闭合术治疗下肢静脉曲张具有安全、操作简捷、创伤小、恢复快等优点。     

Management of open lower limb injuries in South West England and Wales

IntroductionThe joint British Association of Plastic, Reconstructive and Aesthetic Surgeons/British Orthopaedic Association standards define best practice management in open diaphyseal fractures of the lower limb. The aim of our study was to review the regional approach and experience in South West England and Wales. A further objective was to evaluate service provision with regard to the standards’ key recommendations.MethodsA prospective audit was undertaken of open diaphyseal fracture patients. Compliance with published standards within all orthoplastic services in South West England and Wales was assessed, and facilities were evaluated.ResultsA total of 86 patients were managed between October 2012 and March 2013. This was a 56% increase from 2008. Over half (56%) presented directly to the orthoplastic services with all patients undergoing debridement within 24 hours. Two-thirds (66%) of procedures were in daylight hours excluding those requiring immediate surgical intervention. Adherence to correct antibiotic therapy was 88% at admission, 50% at primary surgery and 62% at definitive surgery. Almost two-thirds (60%) of primary procedures were performed with combined senior orthoplastic teams, with 81% achieving definitive soft tissue coverage and fixation within seven days. Compliance improved in units with larger patient caseloads and where there was an early combined approach during daylight hours.ConclusionsIncreased open lower limb fracture workload was demonstrated across South West England and Wales, probably owing to centralisation of trauma services. An improvement in early transfer of this patient group to orthoplastic facilities has allowed all patients to be assessed and debrided within the recommended timeframe. Standards were most likely to be met in those centres seeing higher numbers of injuries and when there was a daylight hours procedure by combined orthoplastic teams.     

Lower limb injuries in children

This article provides an overview of lower limb injuries in children from pelvic fractures to phalangeal injuries. We will focus more on the common injuries such as tibial and femoral shaft fractures and review the aetiology of injuries in the different age groups. We discuss the appropriate considerations for management of different age groups to give a general overview of available treatment options.     

Single-stage revascularization and free flap coverage in the treatment of ischemic lower limb lesions

Old age, diabetes and atherosclerotic disease all have been considered to be relative contraindications for microsurgery. As such, gangrenous lesions of the lower limb traditionally resulted in staged amputations. A more aggressive approach, combining revascularization and free tissue transfer, allowed us to limit the level of amputation and to start early ambulation and rehabilitation, without the need for major orthotic help. Performing the vascular procedure, debridement, and free tissue transfer in one single intervention greatly reduces the number of operative procedures without substantial increase in operative time. Twenty consecutive patients underwent a combined free flap and revascularization procedure, two patients died perioperatively. One free flap was lost and needed replacement. All surviving patients were ambulating postoperatively.This paper was presented at the Eleventh Congress of the IPRAS, April 17–21, 1995, Yokohama, Japan     

对地震灾害中下肢严重损伤进行保肢治疗的若干思考

作出保肢还是截肢的决定仍然是一个高度个体化的方案,需权衡肢体和生命的关系,综合考虑肢体损伤程度、全身情况、伤员心理、年龄、潜在的疾病和职业要求以及医疗技术、社会经济等多方面的因素.在抗震救灾的特殊环境下,伤员转运至后方将失去宝贵的治疗"时间窗",因而进行保肢尝试的危险性极大,不得不早期施行截肢术以保全生命.而在具备医疗技术与设备的前方医疗机构,应尽量保全伤员肢体.     

A comparison between the Major Trauma Centre management of complex open lower limb fractures in children and the elderly

Introduction: Open lower limb fractures can be devastating with outcomes determined by tissue damage and adherence to strictly defined care pathways. Managing such injuries in paediatric and elderly populations presents logistical and technical challenges to achieve best outcomes. Orthoplastic principles were developed mainly in the young adult population whereas requirements for paediatric and elderly patients need further understanding.Methods: A retrospective analysis was performed on two groups of patients at the extremes of age, with type IIIb (severe) open lower limb fractures, presenting to a Major Trauma Centre (MTC) with orthoplastic services over a six-year period - the first group being under 16 years; the second group being over 65. The timelines of combined surgery to both fix the fracture and flap the soft-tissue defect were strictly observed. Each group were followed-up for a minimum of nine months. Data were analysed according to patient demographics, mechanism of trauma, time to wound excision, time to definitive surgery, fixation technique, soft-tissue reconstruction type, deep infection rate, flap survival, bony union, secondary amputation and functional outcome (Enneking score).Results: 33 paediatric patients and 99 elderly patients were identified.Paediatric: The median age was 12 years. All the children were ASA Grade I. Open tibial fractures were most common (76%) followed by ankle fracture dislocation (12%). The majority were high-energy injuries and were commonly managed with external fixators (or frames) and free flap coverage. Median hospital stay was 12 days, and time to union 114 days, with median Enneking scores of 85%. There was one flap failure and no deep infections.Elderly: The median age was 76 years. ASA grades varied and reflected multiple comorbidities. High-energy injuries required free flaps, while more common, low-energy fragility fractures were covered with loco-regional flaps. Internal fixation with intramedullary nails was most commonly used. Median hospital stay was 13 days, and time to union was 150 days, with median Enneking scores of 70%. There was one flap failure, one deep infection, and one delayed amputation.Discussion: These results reflect both similarities and important differences in managing open fractures in the extremes of age. The specific challenges of each group of patients are discussed, including surgical aspects, but also the importance of orthoplastics infrastructure within the MTC and input from allied professionals to facilitate patient pathways.     

Upper limb fractures in children

This article provides an overview of upper limb fractures in children from clavicle fractures to fractures of the wrist. We will focus more on common injuries including fractures around the elbow and those of the forearm. We will review the aetiology and classifications of common fractures and discuss appropriate considerations for management to provide a general overview of treatment options. This article will cover injuries that are managed differently from those seen in adults.     

外周血干细胞移植治疗慢性下肢动脉缺血性疾病

目的 观察自体外周血干细胞移植治疗慢性下肢缺血性疾病的疗效.方法 应用自体外周血干细胞移植治疗46例慢性下肢缺血性疾病的患者.结果 42例小腿疼痛缓解,小腿冷、凉感觉消失;35例足部疼痛改善;29例足部冷、凉感消失;4例术后4周因为小腿中段以下出现坏死导致截肢.42例保肢病例,干细胞移植术后3个月,间歇性跛行距离由(87.45±41.22)m增加到(348.52±147.24)m,下肢皮温由(28.52±0.51)℃增加到(33.56±0.62)℃,踝肱指数(ABI)由(0.48±0.06)增加到(0.75±0.07),移植前后3项指标的差异均具有统计学意义(P＜0.05),移植后优于移植前.术后6个月和12个月下肢动脉影像学检查显示,37例均有不同程度的新生侧支血管形成.结论 自体外周血干细胞移植治疗下肢缺血性疾病是一种有效的方法,尤其对远端动脉流出道差的患者是一种较好的治疗手段.