Late lower extremity fractures in patients with paraplegia

We report the result of the treatment of 26 lower limb fractures in patients with established paraplegia. We treated one fracture of the femoral neck, one intertrochanteric, two subtrochanteric, two of the femoral shaft, seven of the supracondylar region, six of the proximal tibia, one of the tibial shaft, and six pilon fractures. Nine fractures were treated non-operatively, and the remaining fractures were treated operatively. Union was achieved in all the patients, but we think that open reduction and internal fixation may improve the level of independence and mobility of these patients during fracture healing.     

The weight of obesity in patients with lower extremity vascular injuries

ObjectiveClinical obesity is an epidemic problem in the United States. The impact of this disease upon traumatic lower extremity vascular injuries (LEVI) is as yet undefined. We hypothesized that clinical obesity adversely affects outcome in patients with traumatic LEVI.MethodsAll adult patients admitted over a 5-year period with a traumatic LEVI were identified. Clinical obesity was defined as body mass index (BMI) > 30. Obese and non-obese patient groups were compared for surgical management and outcome.ResultsA total of 145 patients were identified. BMI data were available for 115 (79.3%) of these patients (obese n = 47; non-obese n = 68). Obese and non-obese groups were similar. Obese patients underwent more vascular repairs but the amputation rate and mortality were not significantly different.ConclusionsWhile obese body habitus can increase the complexity of evaluation and management of patients with LEVI, we have demonstrated that equivalent outcomes to the non-obese population can be achieved for the clinically obese patient with a BMI > 30. However, patients with a BMI > 40 did reveal a significantly higher chance of amputation and death after LEVI. Due to the small number of patients in this subset, one should use caution when interpreting this data.     

Operative management of ankle fractures in patients with diabetes mellitus

BACKGROUND: Multiple studies have documented increased risks associated with treatment of ankle fractures in patients with diabetes mellitus. We reviewed our results in the largest series to date of this complex patient group to determine the frequency of complications. METHODS: Eighty-four patients with diabetes had open reduction and internal fixation using standard fixation techniques for acute, closed ankle fractures. The 51 men and 33 women had an average age was 49.3 (22 to 77) years. The average followup was 4.1 years (11 to 97 months). Seventy-five fractures were closed and nine were open. Thirty-nine patients used insulin and 45 used oral hypoglycemics or diet for control of their diabetes. Diabetic complications, including nephropathy, hypertension, peripheral vascular disease, and neuropathy were evaluated. The management of diabetes, fracture classification, and presence of diabetic complications were assessed with chi-square, ANOVA, and univariate logistic regression to determine the presence of statistical significance for these factors. RESULTS: Twelve of the 84 patients developed postoperative complications. Ten patients developed infections (eight deep and two superficial). Four of 12 patients with preoperative evidence of peripheral neuropathy developed Charcot arthropathy. Ten of 12 patients who had absent pedal pulses preoperatively developed complications (p<0.0001) and 11 of 12 patients with peripheral neuropathy had complications (p<0.0001). A trend towards complications was noted with nephropathy (two of five patients) and hypertension (nine of 12 patients). Open fractures, insulin dependence, patient age, and fracture classification had no significant effect on outcome. CONCLUSIONS: Most patients with diabetes can undergo open reduction and internal fixation of acute ankle fractures without complications. Patients with absent pedal pulses or peripheral neuropathy are at increased risk for complications.     

Updates in the management of orthopedic soft-tissue injuries associated with lower extremity trauma

Management of traumatic soft-tissue injuries remains a challenging and ever evolving field within orthopedic surgery. The basic principle of addressing life before limb in the initial assessment of critically injured patients has not changed. Although arteriography remains the gold standard for vascular injury screening, computed tomography angiography is being used more often to determine limb viability, and its sensitivity and specificity for detecting vascular lesions are reported to be excellent. Thorough debridement and irrigation with early institution of antibiotics are crucial in preventing infection; debridement should be performed urgently once life-threatening conditions have been addressed. Increasing use of vacuum-assisted closure therapy has created a trend down the reconstructive ladder, with improvements in resulting wound closure. Although the orthoplastics approach and new microsurgical techniques have made limb salvage possible in even the most severely injured extremities, it is important to clearly identify the zone of injury and to inform patients and their families of the outcomes of limb salvage versus amputation. Results from the LEAP (Lower Extremity Assessment Project) trials and similar studies should guide orthopedic surgeons in the management of these complex injuries. Nevertheless, it is important to individualize management plans according to patient factors.     

Some problems of the lower extremity in patients with spinal cord injuries

Spinal cord injury (SCI) is devastating, leaving patients wholly or partly paralyzed. Health care providers who care for SCI patients during the acute or chronic phases are faced with different phenomena in the lower extremities of these subjects. In this article, the authors review the relevant changes associated with SCI. Preventive measures of these medical complications are directed according to the specific cause. Early comprehensive rehabilitation carried out by a specialized team prevents complications while enhancing functional gains.     

Prehospital management of patients with severe head injuries

Advanced prehospital emergency medical care of patients with a severe head injury must essentially focus on the impact of secondary cerebral insults of systemic origin on the outcome. The first objective of prehospital care is to prevent hypoxaemia and hypercapnia. Therefore, all patients with a Glasgow Coma Scale score equal to or lower than 8 must be treated with endotracheal intubation and controlled ventilation under continuous monitoring of SpO2 and PETCO2. Treatment is similar in head-injured patients with significant deterioration of consciousness level, seizures, respiratory distress, or severe facial and thoracoabdominal injuries. The endotracheal tube is inserted by the orotracheal route under direct laryngoscopy, after a rapid induction sequence of anaesthesia and immobilization of the cervical spine in neutral position. For the induction of anaesthesia in these high-risk patients (full stomach, unknown medical history, deteriorated haemodynamic status), etomidate and suxamethonium are the preferred agents. Sedation is maintained with an hypnoticopioid association (fentanyl). Simultaneously, the main goal is the maintenance of an optimal cerebral perfusion pressure, as arterial hypotension severely worsens cerebral ischaemia. Volume loading is accomplished with 0.9% saline and hydroxyethyl starch.     

Pediatric lower extremity mower injuries

Lawn mower injuries in children represent an unfortunate common problem to the plastic reconstructive surgeon. There are approximately 68,000 per year reported in the United States. Compounding this problem is the fact that a standard treatment algorithm does not exist. This study follows a series of 7 pediatric patients treated for lower extremity mower injuries by a single plastic surgeon. The extent of soft tissue injury varied. All patients were treated with negative pressure wound therapy as a bridge to definitive closure. Of the 7 patients, 4 required skin grafts, 1 required primary closure, 1 underwent a lower extremity amputation secondary to wounds, and 1 was repaired using a cross-leg flap. Function limitations were minimal for all of our patients after reconstruction. Our basic treatment algorithm is presented with initial debridement followed by the simplest method possible for wound closure using negative pressure wound therapy, if necessary.     

Microsurgery for lower extremity injuries

SUMMARY: An entire generation of orthopaedic and plastic surgeons has been indelibly and perhaps overwhelmingly influenced by the introduction of microvascular technology to the fields of limb salvage and musculoskeletal reconstruction. Free-tissue transfer using microsurgical techniques has become a valuable method for the salvage of lower extremities after trauma. The goals of free flaps are both soft-tissue coverage and improvement of the functional outcome. The flap selection criteria for lower extremity reconstruction are based on the wound surface area, the type of tissue deficiency, length of the pedicle, volume of deficient tissue components and donor site morbidity. Composite flaps represent the state-of-the-art for reconstructive microsurgery, providing more than one function. Although many different treatment protocols have been proposed, they all highlight the importance of early tissue coverage with bone management performed in a later stage.     

Stump fractures in lower extremity amputees

A series of 23 above-knee and below-knee amputees who sustained an ipsilateral lower extremity fracture was qualitatively evaluated with respect to the nature of the injuries sustained, associated problems, and results of fracture treatment. The overall incidence of these fractures was 3% in a population of lower-extremity amputees. The stump fractures encountered were distal femur fractures and fractures about the hip. More than one fourth of these fractures had an initially missed or 'delayed' diagnosis. Most femur fractures were successfully treated by nonoperative means, and most of the hip fractures were treated operatively. The final rehabilitated status of the dysvascular amputees was the poorest: one half of those who were previous household ambulators remained wheelchair confined postinjury.     

胸腰段骨折伴脊髓损伤的手术治疗

胸腰段为脊柱骨折、脊髓损伤最１９９８０６１５收稿,１９８０９０１修回作者单位：内蒙古医学院第二附属医院骨科,内蒙古呼和浩特０１００３０作者简介：李恩超,男,３５岁,主治医师。研究方向：创伤骨科常见的部位。早期正确的手术治疗,既可重建其稳定性,...     

Physical and occupational therapist rehabilitation of lower extremity fractures in veterans with spinal cord injuries and disorders

Context/ObjectiveThe risk of lower extremity (LE) fractures in persons with spinal cord injury or disorders (SCI/D) is double that of the able-bodied population. LE fractures are the most common fracture location in SCI/D. Physical therapists (PTs) and occupational therapists (OTs) play an important role in rehabilitating LE fractures in Veterans with SCI/D. This paper describes their role in assisting persons with SCI/D and LE fractures to return to previous function and levels of participation.DesignCross-sectional semi-structured interviews were conducted by telephone. Setting: VA SCI centersParticipantsPurposive sample of therapists (PTs and OTs) experienced in LE fracture rehabilitation in SCI/D Interventions: NA.Outcome MeasuresCoding of responses used a data-driven thematic and deductive approach, dictated by a semi-structured interview guide addressing the entire treatment process.ResultsParticipants strongly advocated for early PT/OT involvement in post-fracture rehabilitation in order to recommend braces and devices to minimize skin breakdown, and needs for patient equipment, skills training and/or caregiver assistance resulting from post-fracture mobility changes. Seating specialists should be involved in post-fracture seating assessments in wheelchair users to address changes in alignment, deformities, limb length discrepancies and/or seating posture during and following fracture management.ConclusionPTs and OTs are critical in rehabilitating LE fractures in persons with SCI/D and LE fractures, bringing expertise in patient function, ambulatory status, transfer strategies, mobility equipment, spasticity, lifestyle, and home and caregiver support. Involving them early in the rehabilitation process, along with orthopedic surgeons, physiatrists and other SCI clinicians can address the multiple and often unique issues that occur in managing fractures in this population.     

四肢骨折患者的路径化疼痛管理

目的探讨路径化管理对骨科四肢骨折患者疼痛控制的效果。方法将136例四肢骨折患者按入院时间分为对照组和观察组各68例,对照组采用常规疼痛教育及护理;观察组根据四肢骨折患者疼痛管理团队制定的疼痛护理路径,对患者实施路径化疼痛管理。观察两组患者手术前后不同时间段的疼痛程度、患者术后2周时的康复效果及疼痛护理满意度。结果观察组疼痛评分及功能独立性评分显著优于对照组,患者对疼痛护理满意度显著高于对照组(P0.05,P0.01)。结论对四肢骨折患者采用路径化疼痛管理能够及时控制患者疼痛,有利于促进患者术后恢复,提高患者护理满意度。     

Cycling injuries of the lower extremity

Cycling is an increasingly popular recreational and competitive activity, and cycling-related injuries are becoming more common. Many common cycling injuries of the lower extremity are preventable. These include knee pain, patellar quadriceps tendinitis, iliotibial band syndrome, hip pain, medial tibial stress syndrome, stress fracture, compartment syndrome, numbness of the foot, and metatarsalgia. Injury is caused by a combination of inadequate preparation, inappropriate equipment, poor technique, and overuse. Nonsurgical management may include rest, nonsteroidal anti-inflammatory drugs, corticosteroid injection, ice, a reduction in training intensity, orthotics, night splints, and physical therapy. Injury prevention should be the focus, with particular attention to bicycle fit and alignment, appropriate equipment, proper rider position and pedaling mechanics, and appropriate training.     

Management of lower extremity arterial injuries

Past and current military experience has contributed considerably to the advances made in the treatment of extremity vascular injuries. However, the management of arterial injuries of the lower extremity is still associated with significant rates of limb loss and functional deficits. The incidence of civilian arterial limb injuries, including those related to iatrogenic vessel catheterization, has increased over time, but remains fortunately uncommon. Several related issues, such as the initial order of intervention for associated bony injuries, use of temporary intravascular shunt, repair of concomitant venous injuries, and prophylactic fasciotomy, have been debated extensively and remain controversial. The current treatment of extremity arterial injuries continues to evolve with the availability of superior imaging modalities and emerging endovascular technology. Additionally, the multi-disciplinary approach to the injured patients has produced improved limb-salvage and patient survival. In this review, we discuss the diagnostic evaluation, surgical and endovascular treatment of arterial injuries in the lower extremity.