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Established non-unions treated with intramedullary nails
S-B 20
Injury: International Journal of the Care of the Injured (1994) Vol. 251Suppl.
Fifty-two tibiae united uneventfully in a mean time to radiological union of 5.5 months (range from 3 to 8 months); 9 fractures were slow to unite (mean time to union 15.5 months). These fractures united after the locking screws had broken either proximally or distally. Nine fractures failed to unite and required a further operation (dynamization, bone grafting or exchange nailing). There were two complications. One infection was treated by exchange nailing and a free myocutaneous flap. In another case, a drill bit was broken in one of the distal locking holes. There were no instances of compartment syndrome, heterotopic ossification or neurovascular injury. The factors common to delayed and non-union were a lower third fracture distracted more than 3 mm by a statically locked nail. If, during Russell-Taylor nailing of the tibia, the fracture site is distracted by more than 3 mm and the nail is statically locked, delayed union or non-union is inevitable. In these cases, early dynamization of the fractures is recommended. R. D. Chakravarty, C. E. A. Esler, D. J. O’Dwyer (Truro and Exeter, UK) The effect of reaming on union rates of tibia1 shaft fractures Seventy tibia1 shaft fractures treated by intramedullary nailing were examined retrospectively. There were two groups. The first group comprised 35 cases using a Herzog intramedullary nail. The canal was reamed with hand reamers to the nail diameter only. The second group was treated with a Grosse and Kempf or A0 nail after power reaming to I mm above the diameter of the nail. There was no statistical difference between the types of fracture treated in both groups. In the hand-reamed group, the mean time to union was 15.1 weeks. There were two delayed unions, one malunion, one Sudeck’s atrophy and no non-unions. In the power reamed group, the mean time to union was 19.9 weeks. There were 10 delayed unions, z non-unions, I pulmonary embolus, z compartment syndromes and transient foot drops. These differences were statistically significant. Our findings suggest that power reaming has a higher post-operative complication rate and a higher rate of both delayed and non-union. Where tibia1 fractures are to be treated by intramedullary nailing, unreamed nails should be inserted. A. C. Howard, M. Saleh (Sheffield, UK) Eshblisked non-unions treated with intramedullay nails The exact role of intramedullary nails in the management of established non-unions is unclear. We reviewed 39 consecutive patients, 17 females and 22 males, with non-unions treated with intramedullary nails. The bones involved were the tibia (17), femur (13), humerus (5), radius and ulna (4), and one ununited knee arthrodesis. All fractures had failed to unite before nailing despite prolonged periods of treatment including internal fixation, external fixation, conservative treatment and bracing. Intramedullary nailing was considered when the stability offered was felt desirable (e.g. osteoporosis), following failed external fixation, if soft tissue problems excluded other approaches, and in cases of poor patient compliance with other techniques. There are technical difficulties during surgery - especially in passing the guidewire across the non-union. Patients were reviewed at an average of 29 months (range 6-65 months). Twenty-five had united by bone, 9 were functionally united, and 4 remained ununited. Complications included three cases of deep infection all of which had a pre-existing focus of infection and followed exchange nailing. Intramedullary nailing has a role in the management of established non-union. The surgery is demanding with a signifi-
2
cant morbidity and should only be attemped by surgeons with experience in this field. Of particular concern is the high incidence of deep infection following exchange nailing. M. F. Gargan (Oxford, UK) G. C. Hannister (Bristol UK) The rate of recovery following whiplash injury Fifty consecutive patients presenting with soft tissue neck injuries following rear-end collisions were studied prospectively to assess the rate of their recovery. Patients were seen within 5 days of the accident, after 3 months, 1 year and 2 years, and their symptoms were classified into 1 of 4 groups: A, asymptomatic; B, nuisance; C, intrusive; and D, disabling) Fourteen out of 15 patients (93 per cent) who were asymptomatic after 3 months remained symptom-free after 2 years. Of 35 patients with symptoms after 3 months, 30 (86 per cent) remained asymptomatic after 2 years. After 1 year, 26 (52 per cent) stated that they had recovered completely but after 2 years this had fallen to 19 (38 per cent). Nine out of the 15 patients who had improved between 3 months and 1 year deteriorated to their previous status or worse, between 1 and 2 years. In asymptomatic cases a prognosis that is 93 per cent accurate after 2 years can be given after 3 months; and 86 per cent of patients who are symptomatic after 3 months will remain so after 2 years. However the severity of their symptoms will change during this period and will be at the same level of severity in less than 50 per cent. M. S. Walsh (Windhoek, Namibia) The management of penefrufing injuries to the anterior triangle of the neck The management of penetrating injuries of the neck is controversial. The main debate is whether to explore all such wounds or use a selective policy based on clinical and investigative findings. Exploration was carried out if the wound was thought to have (or had) penetrated the platysma. Twenty-seven patients presented to one firm between 1 October 1991 and 31 December 1992. The mechanism of injury was: stabbing 24, panga slash 1, gunshot 2. Patients were resuscitated according to ATLS guidelines. One required cricothyroidotomy in the Accident department. All patients underwent early neck exploration under general anaesthesia. There were no abnormal physical signs in 15 patients. In 17 (63 per cent) patients 22 significant injuries were found (12 vascular, 6 neurological, 3 oesophageal and 1 thyroid). Five patients had a significant injury without prior physical signs. In 8 (30 per cent) patients neck exploration was negative and none of these patients presented with physical signs. Two patients died, I stabbing and the panga slash both with major vascular injuries. Two further patients who presented late had complications which could have been avoided by early exploration at the time of injury. In conclusion, the policy of mandatory neck exploration was justified since no major injuries were missed and 38 per cent of patients with no physical signs had a significant injury on exploration. N. H. Jenkins, M. S. Lavis (Abergavenny, UK) An aid to the interpretation of the cervical radiograph Advanced Trauma Life Support emphasizes the care of the cervical spine in the management of the injured patient, the lateral radiograph being performed early during resuscitation to screen for injury. Unfortunately, the junior doctors initially reading these radiographs are often unable to interpret subtle abnormalities, especially those relating to the soft tissues, and are frequently presented with Mms that do not show the full extent of the cervical spine.
Injury: International Journal of the Care of the Injured (1994) Vol. 251Suppl.
Fifty-two tibiae united uneventfully in a mean time to radiological union of 5.5 months (range from 3 to 8 months); 9 fractures were slow to unite (mean time to union 15.5 months). These fractures united after the locking screws had broken either proximally or distally. Nine fractures failed to unite and required a further operation (dynamization, bone grafting or exchange nailing). There were two complications. One infection was treated by exchange nailing and a free myocutaneous flap. In another case, a drill bit was broken in one of the distal locking holes. There were no instances of compartment syndrome, heterotopic ossification or neurovascular injury. The factors common to delayed and non-union were a lower third fracture distracted more than 3 mm by a statically locked nail. If, during Russell-Taylor nailing of the tibia, the fracture site is distracted by more than 3 mm and the nail is statically locked, delayed union or non-union is inevitable. In these cases, early dynamization of the fractures is recommended. R. D. Chakravarty, C. E. A. Esler, D. J. O’Dwyer (Truro and Exeter, UK) The effect of reaming on union rates of tibia1 shaft fractures Seventy tibia1 shaft fractures treated by intramedullary nailing were examined retrospectively. There were two groups. The first group comprised 35 cases using a Herzog intramedullary nail. The canal was reamed with hand reamers to the nail diameter only. The second group was treated with a Grosse and Kempf or A0 nail after power reaming to I mm above the diameter of the nail. There was no statistical difference between the types of fracture treated in both groups. In the hand-reamed group, the mean time to union was 15.1 weeks. There were two delayed unions, one malunion, one Sudeck’s atrophy and no non-unions. In the power reamed group, the mean time to union was 19.9 weeks. There were 10 delayed unions, z non-unions, I pulmonary embolus, z compartment syndromes and transient foot drops. These differences were statistically significant. Our findings suggest that power reaming has a higher post-operative complication rate and a higher rate of both delayed and non-union. Where tibia1 fractures are to be treated by intramedullary nailing, unreamed nails should be inserted. A. C. Howard, M. Saleh (Sheffield, UK) Eshblisked non-unions treated with intramedullay nails The exact role of intramedullary nails in the management of established non-unions is unclear. We reviewed 39 consecutive patients, 17 females and 22 males, with non-unions treated with intramedullary nails. The bones involved were the tibia (17), femur (13), humerus (5), radius and ulna (4), and one ununited knee arthrodesis. All fractures had failed to unite before nailing despite prolonged periods of treatment including internal fixation, external fixation, conservative treatment and bracing. Intramedullary nailing was considered when the stability offered was felt desirable (e.g. osteoporosis), following failed external fixation, if soft tissue problems excluded other approaches, and in cases of poor patient compliance with other techniques. There are technical difficulties during surgery - especially in passing the guidewire across the non-union. Patients were reviewed at an average of 29 months (range 6-65 months). Twenty-five had united by bone, 9 were functionally united, and 4 remained ununited. Complications included three cases of deep infection all of which had a pre-existing focus of infection and followed exchange nailing. Intramedullary nailing has a role in the management of established non-union. The surgery is demanding with a signifi-
2
cant morbidity and should only be attemped by surgeons with experience in this field. Of particular concern is the high incidence of deep infection following exchange nailing. M. F. Gargan (Oxford, UK) G. C. Hannister (Bristol UK) The rate of recovery following whiplash injury Fifty consecutive patients presenting with soft tissue neck injuries following rear-end collisions were studied prospectively to assess the rate of their recovery. Patients were seen within 5 days of the accident, after 3 months, 1 year and 2 years, and their symptoms were classified into 1 of 4 groups: A, asymptomatic; B, nuisance; C, intrusive; and D, disabling) Fourteen out of 15 patients (93 per cent) who were asymptomatic after 3 months remained symptom-free after 2 years. Of 35 patients with symptoms after 3 months, 30 (86 per cent) remained asymptomatic after 2 years. After 1 year, 26 (52 per cent) stated that they had recovered completely but after 2 years this had fallen to 19 (38 per cent). Nine out of the 15 patients who had improved between 3 months and 1 year deteriorated to their previous status or worse, between 1 and 2 years. In asymptomatic cases a prognosis that is 93 per cent accurate after 2 years can be given after 3 months; and 86 per cent of patients who are symptomatic after 3 months will remain so after 2 years. However the severity of their symptoms will change during this period and will be at the same level of severity in less than 50 per cent. M. S. Walsh (Windhoek, Namibia) The management of penefrufing injuries to the anterior triangle of the neck The management of penetrating injuries of the neck is controversial. The main debate is whether to explore all such wounds or use a selective policy based on clinical and investigative findings. Exploration was carried out if the wound was thought to have (or had) penetrated the platysma. Twenty-seven patients presented to one firm between 1 October 1991 and 31 December 1992. The mechanism of injury was: stabbing 24, panga slash 1, gunshot 2. Patients were resuscitated according to ATLS guidelines. One required cricothyroidotomy in the Accident department. All patients underwent early neck exploration under general anaesthesia. There were no abnormal physical signs in 15 patients. In 17 (63 per cent) patients 22 significant injuries were found (12 vascular, 6 neurological, 3 oesophageal and 1 thyroid). Five patients had a significant injury without prior physical signs. In 8 (30 per cent) patients neck exploration was negative and none of these patients presented with physical signs. Two patients died, I stabbing and the panga slash both with major vascular injuries. Two further patients who presented late had complications which could have been avoided by early exploration at the time of injury. In conclusion, the policy of mandatory neck exploration was justified since no major injuries were missed and 38 per cent of patients with no physical signs had a significant injury on exploration. N. H. Jenkins, M. S. Lavis (Abergavenny, UK) An aid to the interpretation of the cervical radiograph Advanced Trauma Life Support emphasizes the care of the cervical spine in the management of the injured patient, the lateral radiograph being performed early during resuscitation to screen for injury. Unfortunately, the junior doctors initially reading these radiographs are often unable to interpret subtle abnormalities, especially those relating to the soft tissues, and are frequently presented with Mms that do not show the full extent of the cervical spine.