Acute management of clavicle fractures. A long term functional outcome study

The purpose of this study was to evaluate the long-term results after acute treatment of clavicle fractures. We reviewed 139 patients with an average age of 39.3 years (range: 18 to 74) who sustained a clavicle fracture either isolated or as part of a polytrauma. Besides demographic data, both clinical result and residual symptoms were also recorded. The average follow-up was 7.2 years (range: 4 to 13). The fracture showed a higher prevalence in young men and older women. The most frequent mechanism of injury was a fall (39.6%) and coexisting injuries were found in 12.9% of patients. Conservatively treated fractures united in 96.9% of cases and the time to union was no different with a sling or figure-of-eight bandage. Fracture location did not influence the functional outcome. One third of patients were still complaining of mild pain and discomfort during overhead activities and polytrauma patients had a lower Constant score.     

Management of acute traumatic atlas fractures

OBJECTIVE: A prospective review of a clinical series was performed. The treatment features of atlas fractures with and without associated axis injuries were investigated. METHODS: Twenty-nine patients were investigated. RESULTS: No displaced fractures were treated with a cervical orthosis. Patients with displaced fractures were managed with a halo vest immobilization; 96.4% patients had a solid fusion at their last follow-up evaluations. CONCLUSIONS: Isolated not displaced or combined with not displaced axis fractures atlas fractures can be treated effectively with a rigid cervical collar alone. Isolated displaced fractures or not displaced but with concurrent displaced axis fractures require immobilization by the halo vest.     

Short and long term outcome after laparoscopic cholecystectomy

BACKGROUND: As an audit of patients undergoing laparoscopic cholecystectomy this study not only reports the short term results, but attempted to assess the long term effect of the operation on the symptom profiles of the patients. METHODS: Three hundred unselected consecutive patients underwent elective laparoscopic cholecystectomy from January 1991 to July 1994. Short term outcome was analysed by reviewing patient files for operation details, postoperative morbidity, complications, and gallbladder histology. Long term (median 2 years) outcome was evaluated by a detailed postal questionnaire. Symptomatic benefit ratios (BR) accruing from the laparoscopic removal of the gallbladder were calculated. RESULTS: Twelve operations (4.0%) were converted to open surgery and were excluded from long term outcome analyses. Median operation time was 93 (range 40-245) minutes. There were no deaths. Overall morbidity was 13 %. Median postoperative hospital stay was 2 days (range 1-18 days) and median time-off work 15 days (range 2-49 days). The overall response rate to the questionnaire was 87%. Only one of the 261 patients (0.4%) suffered from recurrent common bile duct stones so far. As shown by the benefit ratios the symptoms most effectively relieved by laparoscopic cholecystectomy were biliary pain (0.97), nausea (0.95), vomiting (0.96) and jaundice (0.94). Most patients with diarrhoea (0.70) and heartburn (0.66) felt relief. Constipation (0.39) and food intolerance (0.57) were unaffected. Most patients (90%) felt that the operation-initiating symptom had disappeared and 98 percent of the patients considered that they had obtained overall symptomatic improvement by the operation. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a safe and effective way of treating the most common symptoms related to gallstone disease.     

Organ dysfunction and long term outcome in secondary peritonitis

Background and aims Secondary peritonitis is still associated with high mortality, especially when multiorgan dysfunction complicates the disease. Good prognostic tools to predict long term outcome in individual patients are lacking and therefore require further study. Patients and methods 163 consecutive patients with secondary peritonitis were included, except those with postoperative or traumatic peritonitis. In 58 patients treated in the intensive care unit (ICU), organ dysfunction was quantified using Sequential Organ Failure Assessment (SOFA) score in the first 4 days. Predictive factors for poor outcome were evaluated in all patients. Hospital and 1-year mortality was assessed. Results Hospital mortality was 19% and 1-year mortality 23%. Acute physiology and chronic health evaluation II (APACHE II), previous functional status, and sepsis category were predictive of fatal outcome in the total cohort (p = 0.034, p < 0.001, and p < 0.001). In patients treated in the ICU, advanced age and admission SOFA score were independent predictors of death (p = 0.014, p < 0.0001). The SOFA score showed the best discriminative ability for poor outcome (AuROC 0.78). Conclusion Degree of organ dysfunction measured using SOFA score was the best predictor of hospital mortality in patients suffering from secondary peritonitis. This study was supported by the Helsinki University Hospital HUS-EVO funding.     

Acute traumatic fibular bowing associated with tibial fractures

Acute traumatic fibular bowing associated with angular fracture of the tibia was observed in three young adults. The fibular bowing may have had a negative effect on the healing of the tibial fracture by transmitting tension through the interosseous membrane, thereby preventing proper reduction of the tibial fracture fragments and delaying the union.     

Short and long term outcome of severe acute pancreatitis.

OBJECTIVE: Between 1985 and 1994, 883 cases of acute pancreatitis were treated in Malm?, Sweden (population 233,000). The purpose of this study was to report the short- and long-term outcome of the 79 cases that were severe, according to the Atlanta classification. DESIGN: Retrospective and follow-up study a median time of 7 years since the attack. SETTING: University hospital, Sweden. SUBJECTS: 79 patients with severe acute pancreatitis. MAIN OUTCOME MEASURES: Mortality, cause of death, organ failure, local complications, surgical procedures, mortality since the attack, and endocrine and exocrine dysfunction. RESULTS: Twenty-one patients died from their attack. Organ failure was the predominant cause of death in the 13 patients who died during the first 10 days after admission, whereas infection was the most common cause of death in patients who died later. Mortality was low under the age of 60 and increased with age. Organ failure developed in 72 patients. Twenty-four patients developed pancreatic necrosis or abscesses and 18 patients were treated by necrosectomy and open or closed drainage. At follow-up, 13 patients had died, 2 from pancreatic carcinoma. 35 patients were included in the follow-up survey. 15 of these had diabetes and an additional 4 had impaired glucose tolerance. 9 patients had signs of severe exocrine dysfunction. CONCLUSIONS: There was a high incidence of endocrine and exocrine dysfunction together with, in many patients, ongoing social problems related to chronic alcoholism several years after an attack of severe acute pancreatitis.     

Acute management of traumatic forequarter amputations: case reports

Traumatic forequarter amputation is a rare and very devastating injury. The arm, including the scapula, clavicle, and pectoral muscle, is torn from the body by a tremendous traction force, usually combined with a counteracting force from the body. The cases of three patients are presented. One patient was caught by the axle of a harvesting machine, resulting in a forequarter amputation of his right extremity and amputation of his left arm at the level of the upper arm. The other two patients had their arms caught in conveyer belts. All patients survived. Closure of the defect was performed acutely using a local pedicled musculocutaneous flap in one case and free vascularized musculocutaneous flaps from the amputated limbs in the two other cases.     

Complicated vs uncomplicated mild traumatic brain injury: Acute neuropsychological outcome

Primary objective: The purpose of this study was to carefully examine the effects of a complicated vs uncomplicated mild traumatic brain injury (MTBI) on acute neuropsychological outcome.

Research design: Participants were derived from an archival trauma database. This is a retrospective matched groups design.

Methods and procedures: All patients were seen through a Head Injury Trauma Service clinical pathway. To be included, all patients must have undergone a day-of-injury CT scan and completed a small battery of neuropsychological tests within 2 weeks of injury. Patients were sorted into two groups on the basis of having a normal or abnormal CT scan. Patients were then carefully matched on age, education, gender and mode of injury (e.g. car accident, fall or assault). The final sample consisted of 100 patients, with 50 in each group.

Main outcomes and results: The patients with complicated MTBIs performed significantly more poorly on some of the neuropsychological tests. However, the effect sizes were small or medium and the two groups could not be differentiated using logistic regression analysis.

Conclusions: The reasons why people recover slowly or fail to recover fully from MTBIs remain poorly understood. Visible structural brain damage carries increased risk for slow and incomplete recovery, but certainly does not provide an explanation for good or poor outcome in the majority of patients.     

Acute surgical management of Jones' fractures

The purpose of this study was to evaluate the effectiveness of surgical management for acute Jones' fractures and Torg types I and II proximal diaphyseal stress fractures presenting acutely in both athletes and nonathletes. Twenty-two patients underwent intramedullary screw fixation between 1994 and 1999. Immediate intramedullary screw fixation of acute Jones' fractures and type I stress fractures resulted in a 100% union rate with an average time to union of 6.2 weeks. Fixation of type II stress fractures had a union rate of 100% with a mean time to union of 8.3 weeks. The overall complication rate was 9%. Surgical intervention allowed an earlier return to weight-bearing with a more rapid and predictable union rate. The authors recommend intramedullary fixation as a treatment of choice for the management of fifth metatarsal fractures distal to the tuberosity in nonathletes as well as athletes.