RESUMEN

Between 1991 and 1995 five hundred and twenty tibial diaphyseal fractures were treated with intramedullary nailing in Northern Ireland. We retrospectively reviewed three hundred and thirty eight patients in three out of the four fracture units in Northern Ireland. Within this group there were three hundred and forty fractures and we identified twenty five episodes of implant failure. This group of patients had a higher percentage of open injuries with a higher degree of comminution and had been treated with smaller diameter nails when compared with the group of patients, who had no implant failure. Failure occurred most frequently at the transverse proximal locking screw when a single screw was used. Fractures in the distal third of the tibia had a higher incidence of nail breakage. We would recommend early elective dynamisation and the use of statically locked larger diameter nails, especially in comminuted or distal third fractures.

Asunto(s)

Asunto(s)

RESUMEN

With increasing violence in our society, the number of gunshot fractures is likely to increase. Fourteen femoral fractures caused by gunshot injuries were treated with statically locked intramedullary nailing within 8 h of injury. Three patients had concomitant femoral arterial injuries. At follow-up (average 22 months) the results were assessed using a standardized grading system. Thirteen fractures had progressed to stable bony union and there were no deep infections. Nine fractures had an excellent outcome and four a good outcome. One fracture was graded as a poor outcome because of a non-union which was treated with an exchange nailing procedure and progressed to bony union. Our experience of immediate intramedullary nailing of gunshot femoral fractures has yielded results which approximate to those observed in treating closed femoral fractures. We would therefore recommend this as the treatment of choice in fractures of the femoral shaft caused by gunshots.

Asunto(s)

RESUMEN

Crush-type injuries are potentially serious, and the foot is particularly vulnerable. Despite this, they are often inappropriately dismissed as trivial when first seen. This tendency to underestimate the severity of the injury is reinforced by unimpressive radiographic findings. Poor initial management may have significant physical and medicolegal implications. Four recently treated cases illustrate the covert severity of crush injuries to the foot.

Asunto(s)

RESUMEN

We report three cases of tibial compartment syndrome after closed intramedullary nailing of the tibia. In no case was there any obvious other predisposing factor for the development of the syndrome apart from the surgery and the fracture potential itself. It is recommended that tibial compartment syndrome be regarded as a rare, but significant complication of tibial nailing.

Asunto(s)

RESUMEN

We describe a patient who developed serious vascular complications following gunshot wounds to both popliteal fossae. There was minimal evidence of vascular injury on presentation to hospital, in particular ankle systolic pressures were normal. Five days following the initial injuries he was found to have a false aneurysm of the popliteal artery in his right leg and an arteriovenous fistula affecting the popliteal vessels of his left leg. The roles of arteriography and Doppler pressure studies in assessment of possible peripheral vascular injury following penetrating trauma are discussed. It is emphasised that a high index of suspicion and careful clinical review is essential if vascular injuries and their complications are not to be missed.

Asunto(s)

RESUMEN

Native Americans appear to be at higher risk than other U.S. ethnic groups for mental health problems, including depression, substance abuse, domestic violence, and suicide. Despite recent increases in the federal budget for mental health services for Native Americans, less than 50 percent of the estimated need for ambulatory services is being met. Initiatives to improve the quantity and quality of mental health services for Native Americans in the 1990s include development of a national mental health plan, increased technical assistance to Native American communities, additional training and research, and continued attention to standards that promote high-quality, culturally relevant care. Tribes themselves are seen as the most appropriate locus for initiation of programs for preventing emotional problems in their communities.

Asunto(s)

RESUMEN

One hundred consecutive Richard's Maximum Contact (RMC) knee replacements were performed in Belfast between 1978 and 1982. Most of the 100 knees (86 patients) involved had been in severe pain, had marked stiffness or gross knee deformity, or were chairbound because of the knee. They were reviewed between five and eight and a half years (mean five years and eleven months) after operation. Thirteen patients (13 knees) died before review leaving eighty seven knees in 73 patients available for study. Using a modification of the British Orthopaedic Association knee function assessment chart, 26 knees (30%) were graded as excellent, 22 (25%) as good, 19 (22%) as fair and nine (10%) as poor. There were five implant failures, four the result of deep infection, one due to loosening. Six patients were chairbound at review and were also graded as failures. These results support the view that total knee replacement approaches the predictability and success of arthroplasty of the hip.

Asunto(s)

RESUMEN

A knee joint that has sustained a painful injury will typically require skillful examination, by an orthopaedic surgeon, for signs of internal damage. These signs include characteristic sounds and vibrations, which are produced by the knee when it is stressed. The technique of vibration arthrometry is being developed to assist the clinical examiner in identifying these vibrations and to improve diagnostic accuracy. To detect and record the knee vibrations, small lightweight accelerometers are positioned on various bony prominences around the knee. These produce electronic signals which permit objective analysis of the vibration characteristics. It has been found that varying the investigative procedure can affect the magnitude of some parameters of the vibration signal. If these parameters are to be used in evidence of knee pathology, the effect of the investigative procedure must be normalized. The effect of speed of joint movement has been quantified in a pilot study involving 24 patients with internal knee damage. Custom-designed hardware was used to measure joint speed as the rate of change of joint angle, which was measured by an electrogoniometer. It was found that the energy content of the vibration, reflected by the peak amplitude and root mean square value was strongly affected by joint speed. However, the characteristic shape of the vibration, reflected by the peak frequency in the harmonic spectrum of the signal, remained similar for the range of joint speed in the investigation.

Asunto(s)

RESUMEN

Throughout the ages, physicians have listened to sounds and felt vibrations from human joints in their attempts to diagnose pathology. They have used a wide vocabulary to describe these phenomena, but technology has been slow to provide recording and analytic equipment. Lately, accelerometers have been used with considerable success in a new noninvasive method now known as vibration arthrometry (formerly "arthrography"). The technique has been used in early detection of congenital dislocation of the hip and also in diagnosis of meniscal pathology. More recently, patellar vibration has been used to assess the mechanical properties of articular cartilage. Vibration arthrometry has also yielded new information on a possible damage mechanism associated with shock vibration that arises during cavitation of synovial fluid. Joint vibrations are therefore useful aids to diagnosis and may even be etiologic in orthopedic disease.

Asunto(s)

RESUMEN

It is widely accepted that the elderly are more vulnerable to trauma than other groups. We examined our records of more than 6,000 accident cases, 312 over 65 years of age, and found that not only were older people more likely to sustain more serious injury in any given accident, but that the risk of life was significantly greater for a given injury severity. The mortality rate for all grades of injury rose from approximately 1% in the age group less than 20 years old to almost 11% in the age group more than 70. As none of the existing injury scales take age into account when predicting the outcome, it is suggested that such scales should be weighted to reflect more accurately the likely outcome or injury in the elderly.

Asunto(s)

RESUMEN

The records of 131 road accident fatalities which occurred in Oxfordshire over a 2-year period were reviewed. Aspects of the accident circumstances, the injuries incurred and the cause of death were examined. The majority of fatal accidents occurred during daylight hours and in dry weather. Deaths were mainly due to cerebral injury (34.4 per cent) or uncontrollable (mainly thoracic) haemorrhage (25.2 per cent), or a combination of both (8.4 per cent). A number of deaths occurred in hospital from complications rather than from the injury itself. In addition to this, there were four deaths from natural causes. Where death occurred at the scene of the accident, blood alcohol levels were determined. Almost 50 per cent of the drivers for whom a level was obtained had measurable alcohol in their bloodstream, and 28 per cent of such drivers were over the legal limit. Three cases who reached hospital alive were, on review, assessed to have potentially survivable injuries, and a further two patients died in the post-accident period of potentially survivable complications.

Asunto(s)

RESUMEN

ANATOMICAL STUDY: The common pathway to failure in total hip replacements is loosening of the acetabular and femoral components. The reliable diagnosis of this loosening is difficult. A non-invasive technique has been developed which analyses a vibration signal transmitted through the femur. This can distinguish between a femoral component which is loose and one which is firmly fixed. Charnley femoral components were cemented securely into ten cadaver femurs and the transmitted vibration signal recorded. The prostheses were then loosened first at the cement-prosthesis and then at the cement-bone interface. The tests were then repeated. Consistent and distinct differences between output vibration signals were observed between the firmly implanted and the loss prostheses. PILOT CLINICAL STUDY: Seven patients admitted for revision surgery because of clinical and radiological evidence of femoral implant loosening were tested using this technique. A further four patients with secure femoral components were tested approximately two weeks after total hip replacement. The differences in output signal, which had been observed between firmly implanted and loose prostheses during the anatomical study, were again demonstrated.

Asunto(s)

RESUMEN

The mechanism of pelvic fractures has been well documented from radiographs but little is known of the forces required to produce these injuries. We examined 40 cases of pelvic injury sustained in road traffic accidents where the direction of impact and the velocity differential was known. In frontal impacts, indirect shear injuries of the pelvis were prominent, while in side impacts, lateral compressive injuries occurred. With increasing velocity differentials and vehicle deformation and intrusion, more severe pelvic injury occurred, often in association with significant head, chest, and lower limb injuries. Side impacts were noted to produce more severe injuries at lower velocity differentials when compared with frontal crashes.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

Supracondylar osteotomy for traumatic cubitus varus is usually considered to be difficult, and to have a significant incidence of complications. Most difficulty is in maintaining correction after operation. We report 20 osteotomies performed by a modification of French's technique and managed postoperatively with the elbow extended. When a plaster splint was used only three of seven cases had good or satisfactory results, two requiring revision. Postoperative management by straight arm traction maintained correction and achieved a good or satisfactory result in all 13 cases. This new technique is recommended.

Asunto(s)

Asunto(s)

RESUMEN

Important advances have been made within the last two decades in the field of fracture management. The development of the AO internal fixation system and the advances in cast bracing techniques are but two of the improvements worthy of mention. It is, however, in the field of external fixation of fractures that the greatest advances have been made. This paper traces the history of external fixation up to the present day and discusses, with examples, the application of external fixation in the management of complex limb fractures.

Asunto(s)

RESUMEN

The technique of vibration arthrography (VAG) permits the non-invasive evaluation of internal derangements of the knee. Using the computer-assisted recording and analysis equipment which has previously been described, a major survey was conducted into the signal patterns present in subjects with symptomatic knee joints. Two hundred and forty-seven patients were examined, and all of these subsequently underwent arthroscopy. One hundred and seventy-two patients were demonstrated arthroscopically to have a meniscal lesion and 150 of these gave characteristic meniscal signals. This paper discusses the vibration signal patterns associated with the various types of meniscal tear and the effect of surgery on the meniscal signal. The overall accuracy of vibration arthrography in the diagnosis of meniscal pathology was 86%. In many cases, not only could the site of a meniscal tear be determined, but the type of tear could be diagnosed with reasonable accuracy.

Asunto(s)