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Venous blood flow rate in the lower extremity after applying different pneumatic compression devices was evaluated. Five healthy individuals, aged 21-35, were recruited for this study. The ability of six different pneumatic compression devices to increase femoral venous blood flow velocity was analyzed and compared to that of active and passive foot dorsiflexion. Baseline venous blood flow velocity was measured using an ATL Duplex Doppler before leg compression. Venous blood flow velocity was then monitored before, during, and after each compression cycle. Average peak venous velocity increased >200% on dorsiflexion of the ankle. Among the investigated devices, the increase in venous velocity varied significantly. Design of compression chambers enabling compression on the lateral and medial aspects of the calf produced an increase in venous velocity closest to active foot dorsiflexion. Foot compression devices produced the smallest increase in venous velocity. The relative effectiveness of pneumatic compression devices, particularly with respect to increasing venous blood flow in the lower extremity, may correlate well with how closely the device simulates the physiologic contraction of the calf muscles. Clinical trials are needed to further compare the effectiveness of these devices, as other less readily measured factors play a role in thromboprophylaxis.

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To determine whether the accepted principles of management of open tibia fractures apply to children, 40 consecutive open fractures of the tibial shaft in skeletally immature patients were retrospectively reviewed. Attempts were made to evaluate the functional and social impact of open tibia fractures in children. All open fractures were initially treated by rapid irrigation and debridement which was repeated every 48 hours until soft tissues stabilized. The average age was 10.1 years and average follow up was 26 months (range: 18 to 84). There were 16 grade I, 10 grade II, and 14 grade III open fractures. The grade III fractures were further subdivided into 6 grade IIIA, 7 grade IIIB, and 1 grade IIIC. The average time to union was 7.5 and 11.0 weeks in the grade I and II fractures respectively, with no infections and no delayed unions. In grade III fractures, the average time to union was 15 weeks, with 1 infection and 3 delayed unions. Bone grafting using autogenous iliac crest was performed on 2 patients. The children surveyed missed an average of 4.1 months of school and 33% had to repeat a year. Twenty-five percent of the children complained of nightmares involving the events of the accident. Chronic pain despite solid union was found in 30% of patients. Forty percent of those surveyed (7 grade III fractures) complained of a limp. The low incidence of soft tissue complications and infections in the study population supports applying in children the same basic soft tissue management principles of open fracture treatment as used in adults. While bone stabilization options are limited in children, the rate of successful union without adjunctive bone grafting is much higher than that of adults treated under similar protocols. Routine early iliac crest bone grafting is unnecessary. The prevalence of gait abnormality despite fracture union should be taken into account during the patient's rehabilitation. The extensive time missed from school and resulting scholastic setback should not be underestimated.

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Between 1990 to 1993, 21 patients with tibial plateau or proximal tibial fractures resulting from high-energy trauma were treated with the Monticelli-Spinelli external fixator. There were 13 men and 8 women (mean age, 45.2 years; range, 26 to 78). There were a total of 5 type A, 2 type B, and 14 type C fractures, using the Arbeitsgemeinschaft Fur Osteosynthesefragen (AO) classification system. Immediate postoperative reductions were good or excellent, according to strict radiographic criteria, in 16 of 21 patients. All patients obtained at least 90 degrees of knee flexion, and only one patient lost more than 5 degrees of full extension. Complications included seven superficial pin-tract infections and one deep vein thrombosis with resultant pulmonary embolism. Nineteen patients were available for follow-up (mean, 14 months). Clinically, 13 patients had satisfactory results where good or excellent radiographic reductions were maintained, knee extension was within 5 degrees of full, flexion was > or = 90 degrees, with < or = 5 degrees valgus/varus angulation. Six patients had unsatisfactory results, not meeting the above criteria. The Monticelli-Spinelli external fixator is a much-needed tool in the treatment of high-energy tibial plateau fractures that are not amenable to more extensive surgical procedures because of the associated soft-tissue injuries.

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The treatment of the displaced intraarticular fracture of the os calcis continues to be controversial. One of the reasons for this is the lack of a workable classification system which would allow comparison among different treatment modalities. Plain radiographs are unable to depict the complex three-dimensional pathology of this fracture. Computed tomography (CT) scanning, however, has the potential to quite accurately depict all components of this injury. At our hospital, a five-part, CT-based classification system has been utilized. This system suggests which fractures will do well with conservative care, and which fractures are amenable to operative stabilization.

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Pain and swelling, which may lead to inhibition of the extensor mechanism and ultimately a delay in rehabilitation, are common complications of knee arthroscopy. Cryotherapy is the most often used means of decreasing both knee edema and discomfort. A number of methods have been used to provide cold pressure dressings, including ice and elastic bandages. Commercial devices, such as the Cryo/Cuff, also have been developed to provide similar beneficial effects. This article describes a multicenter randomized study undertaken to determine whether the Cryo/Cuff or the ice and elastic bandage offers the greatest convenience and relief of pain. One hundred two patients between the ages of 18 and 65 scheduled to undergo knee arthroscopy were enrolled. Postoperatively, the Cryo/Cuff patients required significantly less pain medication than those patients using the ice and elastic wrap. The Cryo/Cuff patients also expressed a high level of satisfaction with the effectiveness and convenience of the therapy. There were no differences between either group in the amount of pain reported, or preoperative and postoperative examinations in regard to knee range of motion and thigh circumference. These results indicate that the Cryo/Cuff is a useful adjunct in the rehabilitation of knee arthroscopy patients.

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The management of intraarticular fractures such as tibial plateau fractures in weightbearing joints is inherently complex. Bicondylar tibial plateau fractures resulting from high energy trauma are particularly difficult to treat successfully. The objectives in managing these fractures are to obtain adequate reduction and appropriate stabilization while allowing early range of motion and limiting potential morbidity. The incidence of complications and long-term sequelae is relatively high in cases treated with traditional open reduction and internal fixation. From 1986 through 1993, 32 bicondylar tibial plateau fractures were treated at our institution. Of these, 26 were treated operatively using various methods of open reduction and internal fixation, and, more recently, indirect reduction techniques with percutaneous screw and/or external fixation. These newer techniques include arthroscopically-assisted reduction with percutaneous screw fixation or applications of a hybrid circular external fixator with or without limited internal fixation. These techniques provide adequate reduction and fixation while limiting the complications associated with traditional open methods. This retrospective study was conducted to compare these newer techniques with more traditional methods of open reduction and internal fixation (ORIF).

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Using an in-shoe plantar pressure sensor, the pressure under the first metatarsophalangeal (MTP) joint was measured in 20 asymptomatic control subjects during their normal gait. A 7-micron in-shoe pressure sensor recorded the pressure under the first MTP joint in the 20 volunteers while they were wearing their normal footwear (athletic footwear), a wooden postoperative shoe, a fiberglass short leg walking cast, and a postoperative shoe with a first MTP joint cutout orthotic device. The results showed both casting, and the postoperative shoe with the first MTP joint cutout orthotic device significantly reduced pressure under the first MTP joint compared with normal footwear, with an average decrease of 31% and 43%, respectively. However, the standard postoperative shoe did not significantly reduce first MTP pressure compared with normal footwear. Certain surgeries performed on the distal first metatarsal may benefit from a diminution of loading forces encountered during normal gait. The results of this study indicate that a reduction of first MTP pressures can best be accomplished with either a postoperative shoe with a cutout orthotic device or a short leg walking cast. A standard postoperative shoe showed inconsistent results and had no statistically significant effect on decreasing the pressure under the first MTP joint.

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The calcaneus is the most commonly fractured of all the tarsal bones. Soft-tissue interposition, usually involving the peroneal tendons, has been reported to block reduction of calcaneal fractures and subtalar dislocations. To our knowledge, no case of entrapment of the neurovascular bundle has been reported. This is the subject of our report.

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From 1975 to 1984, 134 consecutive lateral tibial plateau fractures were treated as part of this prospective study. Eighty-six fractures (64%) were followed until union, with an average follow-up period of 22.7 months. The two aims of this study were: First, to analyze the results of operative and nonoperative therapy in each fracture type, and second, to evaluate the effect of early weight bearing in a cast brace in both types of treatment. All lateral tibial plateau fractures with greater than 5 mm depression or displacement were treated operatively. Forty-four patients were treated operatively and 42 patients nonoperatively. All patients were treated with early range of motion and weight bearing in a cast brace. Fractures were initially classified using Hohl's classification system. Overall, 95% of the patients with Type I, II, or V fractures had satisfactory results, as opposed to only 70% of patients with Type III fractures. Of the Type III fractures, 83% treated operatively had satisfactory results compared with 53% treated nonoperatively. Moreover, early weight bearing did not produce further depression greater than 2 mm.

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In a retrospective, nonrandomized study from 1980 until 1988, 43 patients with 46 open tibial fractures were treated with Ender rods. The configuration of each fracture was classified using the Orthopaedic Trauma Association's (OTA) tibial fracture guidelines, and the extent of soft-tissue damage was graded using the Gustilo classification of open fractures. The OTA classification was further divided into stable, unstable, and highly unstable fracture configurations. Ender rods were placed immediately into 90% of fractures; and within one week of initial injury in the remainder. Follow-up evaluation of four patients (six fractures) could not be completed. The average time to union was 22.1 weeks, and there was a low incidence of complications. Otherwise there was a 40% incidence associated with early rod removal. Most complications occurred in those fractures that had extensive soft-tissue damage, and minimal or no inherent axial stability (unstable and highly unstable OTA classes). Except for the above-noted complications, Ender rods provide effective fixation for open tibial fractures with some degree of axial and rotational stability. In fractures with minimal or no inherent axial stability (OTA Classes IIIC, D; IVA, B), and in Grade IIIB or IIIC open tibial fractures, Ender rods have a higher incidence of complications and should be used with caution.

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Reamed intramedullary nailing was used within 36 hours of patient admission to treat 32 consecutive femoral shaft fractures caused by low-velocity gunshot wounds. The femoral shaft fracture was classified according to the AO system, and comminution was graded according to the classification of Winquest and Hansen. Patients were followed for an average of 14.7 months (range, 6 to 36 months), and the average time to union was 18.6 weeks. The average hospital stay was 7 days, which is approximately one half the average stay reported in the literature for treating this kind of injury with delayed nailing. The shorter hospital stay represents potential savings of up to $9,000 per patient. Immediate intramedullary rodding is a safe, effective, and economic option for the treatment of a femoral shaft fracture caused by a low-velocity gunshot wound. However, a lack of compliance with instructions concerning weight-bearing in this patient population needs to be taken into account when planning postoperative care.

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A prospective study was initiated using functional bracing to treat isolated ulnar shaft fractures. Forty-seven consecutive patients with 48 fractures were treated from July 1987 to January 1989. Twenty-eight patients with 29 fractures were available for follow up. Three of these fractures were subsequently excluded, as they had open reduction and internal fixation, leaving a group of 26 fractures. The mean time to union was 45 days (6.4 weeks). Fractures of the middle third of the ulnar diaphysis had the highest mean time to union, as did those with an oblique fracture pattern of 26% to 50% initial displacement. For union time, there was no significant difference for fracture location (P > .05 via t-test) or for fracture pattern (P > .05 via analysis of variance).

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Comminuted bicondylar tibial plateau fractures remain a difficult problem for the orthopaedic surgeon. Treatment has ranged from traction to cast immobilization to open reduction and internal fixation; none of these has emerged as ideal. Recently, one of the senior authors (DJC) used a technique of indirect reduction followed by application of a hybrid circular external fixator, noting a stability similar to that of an open reduction and internal fixation but with fewer complications. This paper reviews both the authors' experience and citations from the literature with regard to this problematic fracture.

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A 23-year-old man injured his foot in a motorcycle accident. Roentgenograms and computed tomography scans demonstrated a Hawkins Type III fracture-dislocation of the talus with a suspected disruption of the anterior tibiofibular ligament. Prompt anatomic reduction of the talus with rigid internal fixation was performed. Intraoperative stress roentgenograms confirmed the presence of a syndesmotic disruption. No cases of this injury have been reported in the literature. When no obvious fracture of the ankle mortise is present in a Hawkins Type III or IV talar fracture-dislocation, care must be taken to fully evaluate the osseous and ligamentous structures of the ankle to rule out an occult injury. Computed tomography scans, stress roentgenograms, intraoperative clinical examination, and direct visual inspection can all be used to aid in this evaluation.

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Destruction of the calcaneal fat pad has been implicated as a source of chronic pain following fractures of the os calcis. Several investigators postulate that the initial trauma that produces a calcaneal fracture also results in destruction of the U-shaped fibrous septa that maintain the piston-like organization of the fat columns. Fibrosis and loss of the protective cushioning provided by the fat pad may eventually occur. The authors report on the largest series of magnetic resonance images of the calcaneal fat pad in the heels of patients with calcaneal fractures. A prospective consecutive study utilizing magnetic resonance imaging was performed on 22 heels with calcaneal fractures. Ten contralateral heels without calcaneal fracture and the heels of five normal subjects were scanned as controls. No signal changes suggestive of increased fat pad edema, fibrosis, or fatty release were detected. In addition, the vertical septa were well visualized and found to be intact in all cases. The height of the fat pad was measured, with no changes noted as compared with the contralateral heel. In those patients with acute fractures, signal changes suggestive of hematoma were well visualized in the soft tissue surrounding the calcaneus. In two of these cases, there was extension beneath the plantar fascia, but no penetration into the fat columns. Magnetic resonance imaging allows excellent detailed visualization of the calcaneal fat pad and surrounding structures. No evidence is found to support the hypothesis that marked damage to the gross structure of the fat pad occurs at the time of injury.(ABSTRACT TRUNCATED AT 250 WORDS)

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A consecutive series is reported of 17 patients who underwent early surgical treatment for acetabular or unstable pelvic fractures associated with ipsilateral fractures of the femur. Treatment included external and internal fixation, and required careful consideration of the surgical approach and the positioning of the patient. The multiple injuries sustained by these patients required simultaneous procedures by several surgical teams. All the femoral fractures were internally fixed at the initial operation and eight patients had primary definitive treatment of all their other fractures as well. In nine patients the definitive treatment of their other fractures was delayed for an average of 11 days. There were no deaths, and no serious infections. The long-term morbidity resulted from the associated injuries and not from the pelvic or femoral fractures.

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Forty-two competitive athletes with posterior medial pain in the lower one-half of the tibia were evaluated by plain roentgenograms and bone scans. Twenty stress fractures were diagnosed in 17 patients by plain roentgenograms or bone scans or both. The remaining 25 patients were diagnosed as having shin splints. All 42 patients subsequently had a pneumatic leg brace applied to the affected limb or limbs. The 17 patients with stress fractures were able to ambulate without pain and were allowed to resume light training in an average of one week. Their injuries were nontender to palpation. The patients were allowed to resume intensive training at an average of 3.7 weeks postinjury. Patients returned to competition at the preinjury level in an average of 5.3 weeks after application of the brace. The pneumatic leg brace allowed the athletes with tibial stress fractures to begin pain-free ambulation and rehabilitation, thus facilitating the maintenance of their cardiovascular fitness and permitting an early return to competition.

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Of 36 patients who presented over a 3-year period with nailgun injuries, nine of these injuries were found to have penetrated into the knee joint. Six of these injuries were treated by operative nail removal, curettage of the nail tract, and examination of the joint. The remaining three patients had nail removal, followed by irrigation of the joint in the emergency room. All nine injuries had antibiotic prophylaxis before and after nail removal. In three of six patients treated by operative irrigation and debridement, a piece of clothing or nailgun resin was discovered in the nail tract or floating within the knee joint. None of the patients in the group treated by operative nail removal, joint visualization, irrigation, and nail tract curettage experienced any complications, whereas one patient treated nonoperatively developed a septic knee. Due to the unique nature of these nailgun puncture wounds, we strongly advocate operative nail removal, curettage of the nail tract, visualization of the joint, and use of prophylactic antibiotics in the treatment of nailgun arthrotomies.

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