Clinical orthopaedics and related research
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Clin. Orthop. Relat. Res. · Jun 1995
Nonreamed interlocked intramedullary tibial nailing. One community's experience.
Forty-nine acute displaced tibial fractures (31 closed, 18 open: 5 Grade I, 7 Grade II, 4 Grade IIIA, and 2 Grade IIIB) were treated in 1 community with a standard operative protocol using a distractor without a fracture table, and an unreamed interlocked tibial nail. Forty-six fractures healed (94%). Complications included 3 nonunions (6%), 2 deep infections (4%), 9 delayed unions (18%), 4 angular malunions (8%), 2 rotatory malunions (4%), and 12 interlocking screws bent or broke (24%). ⋯ However, static locking is required in axially unstable fractures. Early dynamization or exchange nailing and bone grafting should be considered to hasten union and avoid screw failure. The distractor is an excellent adjunctive technique for reduction and alignment of tibial shaft fractures during intramedullary nailing.
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Clin. Orthop. Relat. Res. · Jun 1995
A sequential protocol for management of severe open tibial fractures.
Fifty consecutive open fractures of the tibia, including 22 Grade IIIB and 4 Grade IIIC, were treated using a protocol of debridement, immediate wound coverage, and intramedullary nailing. Fasciocutaneous flaps were used extensively to cover areas of exposed bone. The severity of the soft tissue injury dictated the timing of definitive fixation. ⋯ Locking screws broke in 1 patient (2%); the fracture united with < 5 mm of shortening. Immediate postdebridement wound coverage, and intramedullary nailing after reconstruction of the soft tissue envelope facilitate fracture healing in these complex open injuries. Intramedullary nailing can be performed safely to include all grades of open tibial fractures from the proximal to distal metaphysis.
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Clin. Orthop. Relat. Res. · Jun 1995
ReviewFractures of the fifth metatarsal. Analysis of a fracture registry.
To understand better the natural history of fractures of the fifth metatarsal, a fracture registry was established consisting of patients who had acute fractures of the fifth metatarsal. The first 100 patients were studied to develop data on the natural history of injuries to this bone, and on the results of standard treatment for those injuries. In this study, 3 fracture subtypes were identified: avulsion, true Jones' fracture, and shaft/neck fracture. ⋯ This method was, however, successful in 72% of patients (average time until union, 21.2 weeks). For the 7 patients in whom conservative treatment failed, surgical fixation at an average of 25 weeks after injury reliably achieved bony union in half the time required with cast treatment. This low-risk procedure met with higher patient satisfaction than prolonged casting.
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Thirty-two extraarticular fractures of the proximal third of the tibia were treated with locked intramedullary nails. There were 10 closed and 22 open injuries. Treatment consisted of a reamed nail in each of the 5 closed fractures, and an unreamed nail in the remaining 27 fractures. ⋯ Valgus, apex anterior angulation, and residual displacement at the fracture site are common after nailing. Surgical errors of a medialized nail entry point and a posteriorly and laterally directed nail insertion angle contributed to malalignment. Based on their findings, the authors have limited the use of intramedullary nailing for proximal third tibial shaft fracture and consider alternate forms of fixation (plate or external fixation).
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Clin. Orthop. Relat. Res. · Jun 1995
Unstable fractures of the tibia treated with a reamed intramedullary interlocking nail.
One hundred thirty-four acute unstable fractures of the tibia were treated with a reamed intramedullary nail with locking capabilities. There were 101 closed and 33 open fractures (20 Grade 1 fractures, 12 Grade 2 fractures, and 1 fracture from a gunshot wound). Patients were seen in followup for an average of 16 months after nailing. ⋯ In closed fractures, there were 2 superficial (2%) and 3 deep (3%) infections; in open fractures there was 1 superficial (3%) and 7 deep (21%) infections. The authors conclude that reamed intramedullary nails should be restricted to unstable, closed tibial shaft fractures. Its use in open fractures even on a delayed basis cannot be recommended because of unacceptably high infection rates.