ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

The appearance of porous bone under fixation plates during fracture healing, attributed to disturbance of blood supply by the plate, has led to new plate designs with reduced plate to bone contact. The fixation stability afforded by these devices, in comparison to implants commonly used for fixation, is not well known. Therefore, the construct stiffnesses of osteotomized synthetic tibiae fixed with dynamic compression plates, external fixators, or two configurations of noncontact plates were compared in axial compression, bending, and torsion with and without cortical contact at the osteotomy site. The results of this study show that (1) the noncontact plated constructs achieve comparable fixation rigidity to constructs using dynamic compression plates or external fixators, if applied at a distance no greater than 5 mm from the surface of the tibia, and (2) the fixation rigidity of the noncontact plate decreases as the distance between plate and bone surface increases.

ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Twenty-seven patients with complex femoral fractures (combined shaft and proximal femoral fractures) were treated with a modified Grosse-Kempf slotted locking nail (cephalomedullary nail), wherein two screws were inserted in the hip. Four types of complex, multifocal femoral fractures were represented in the series. Eleven of the femoral shaft fractures were secondary to a previous, internally fixed, not yet united hip fracture (type I). Ten comminuted peritrochanteric fractures occurred in normal bone (type II). Three similar fractures were pathologic because of metastasis. Two patients had an ipsilateral fracture of the femoral shaft and the trochanteric area (type III), and one of the shaft and the femoral neck (type IV). Locking was made static in 24 cases. Additional cerclage wiring was used in three type II fractures. Five complications were as follows: one cutting out of a screw in the femoral head, two fractures of the nail, one deep venous thrombosis, and one wound hematoma. Reoperations were two salvage operations using a new nail and one evacuation of hematoma. One patient with multiple injuries and four elderly patients died within 2 months. Eighteen patients with fractures in normal bone were followed for a median of 20 (6 to 37) months. All fractures united. Two nails were removed. The end result was excellent in ten patients, good in seven, and fair in one (2-cm shortening and 20-degree external rotation). We conclude that a locked intramedullary construct with locking screws in femoral neck and distal femur controls a complex fracture situation well.

ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveThe aim of this study was to determine (1) if internal fixation was associated with a high amputation rate in patients with femur fracture and vascular injury; and (2) if patients who underwent internal fixation before vascular repair had a higher amputation rate.DesignThis is a retrospective analysis.Materials and MethodsTwenty-six patients requiring femoral stabilization with injury to the superficial femoral artery, popliteal artery, or common femoral vein were studied. The Injury Severity Score and the Mangled Extremity Severity Score were calculated for each. Nineteen patients underwent internal fixation. Ten patients had internal fixation before vascular repair.ResultsSixteen of 19 patients treated with internal fixation had limb salvage. Nine of 10 patients who had internal fixation before vascular repair had limb salvage. Poor outcomes (gangrene, amputation, or death) were associated with a Mangled Extremity Severity Score greater than or equal to6 (p = 0.005).ConclusionsIn these patients, poor outcome is associated with severe leg injury, (with a Mangled Extremity Severity Score of greater than or equal to6). Internal fixation can be safely used, and skeletal stabilization can be safely performed before vascular repair. If ischemic time is prolonged, vascular shunts should be used until skeletal stabilization is completed.

ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Avulsion injuries of the hand caused by moving rollers usually create a distally or, less commonly, a laterally based skin flap. Progressive necrosis in the distant part of the flap usually occurs because of arterial insufficiency and venous stasis over the next 2 to 3 weeks. From 1991 to 1994, we applied the concept of the "arterialized venous flap" to salvage the palmar tissue by revascularizing the superficial palmar venous network with an arterial anastomosis in eight patients. Six of the flaps survived completely and two had a small strip of marginal necrosis which healed secondarily. When compared with conventional methods, this method can remarkably improve the circulation of the flap and provide a better cosmetic and functional result for the highly specialized palmar tissue.

ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

The remains of 53 men that had been beaten to death were examined. Six (11.3%) died of either blood aspiration or intracranial hemorrhage; 15 of the cases (28.3%) succumbed to hypovolemic shock, and 32 of the cases (60.4%) died of fat embolism syndrome (FES). Fractures of long bones were found only in four victims. Fatal FES produced by the mechanical disintegration of adipose tissue that migrates into the bloodstream seems to be a common phenomenon in the fatalities examined in this study. No correlation, however, was found between the presence of long bone fractures and the severity of FES, and no bone marrow emboli were detected on histologic examination of target organs. Scattered subcutaneous hematomata were present in all of the victims, although the volume of extravasated blood could not be calculated from the total surface area of the bruises. Contusions limited to the limbs have the potential of masking fatal volumes of extravasated blood that suffuse the musculature mass. Hypovolemic and neurogenic shock, as well as systemic effects of crush injury, should be considered contributing factors to death from FES. These findings contradict the previously published postulate that victims of blunt force trauma succumb primarily to massive hemorrhages.

ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

IntroductionNonoperative management is presently considered the treatment modality of choice in over 50% of adult patients sustaining blunt hepatic trauma who meet inclusion criteria. A multicenter study was retrospectively undertaken to assess whether the combined experiences at level I trauma centers could validate the currently reported high success rate, low morbidity, and virtually nonexistent mortality associated with this approach. Thirteen level I trauma centers accrued 404 adult patients sustaining blunt hepatic injuries managed nonoperatively over the last 5 years. Seventy-two percent of the injuries resulted from motor vehicle crashes. The mean injury severity score for the entire group was 20.2 (range, 4-75), and the American Association for the Surgery of Trauma-computerized axial tomography scan grading was as follows: grade I, 19% (n = 76); grade II, 31% (n = 124); grade III, 36% (n = 146); grade IV, 10% (n = 42); and grade V, 4% (n = 16). There were 27 deaths (7%) in the series, with 59% directly related to head trauma. Only two deaths (0.4%) could be attributed to hepatic injury. Twenty-one (5%) complications were documented, with the most common being hemorrhage, occurring in 14 (3.5%). Only 3 (0.7%) of these 14 patients required surgical intervention, 6 were treated by transfusions alone (0.5 to 5 U), 4 underwent angio-embolization, and 1 was further observed. Other complications included 2 bilomas and 3 perihepatic abscesses (all drained percutaneously). Two small bowel injuries were initially missed (0.5%), and diagnosed 2 and 3 days after admission. Overall, 6 patients required operative intervention: 3 for hemorrhage, 2 for missed enteric injuries, and 1 for persistent sepsis after unsuccessful percutaneous drainage. Average length of stay was 13 days. Nonoperative management of blunt hepatic injuries is clearly the treatment modality of choice in hemodynamically stable patients, irrespective of grade of injury or degree of hemoperitoneum. Current data would suggest that 50 to 80% (47% in this series) of all adult patients with blunt hepatic injuries are candidates for this form of therapy. Exactly 98.5% of patients analyzed in this study successfully avoided operative intervention. Bleeding complications are infrequently encountered (3.5%) and can often be managed nonoperatively. Although grades IV and V injuries composed 14% of the series, they represented 66.6% of the patients requiring operative intervention and thus merit constant re-evaluation and close observation in critical care units. The optimal time for follow-up computerized axial tomography scanning seems to be within 7 to 10 days after injury.

ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

IntroductionThe effect of resuscitation status on the use of laboratory and radiologic studies was analyzed in patients at the Walter Reed Army Medical Center's Surgical Intensive Care Unit.MethodsA retrospective assessment of laboratory and radiologic charges incurred during the last 48 hours of life by 81 patients who died in the Surgical Intensive Care Unit between 1990 and 1992 was performed. Data were analyzed after separation by patient's resuscitation status. Each patient was assigned a resuscitation category: no limitation, do not resuscitate (no CPR in event of arrest), or limited therapy (specific order limiting care or monitoring).ResultsThere were 4,095 laboratory tests performed for a total charge of $191,247. Arterial blood gas testing accounted for over $75,000 of these charges. Resuscitation status significantly affected test frequency.ConclusionsDuring the last 48 hours of life in intensive care unit, the use of laboratory tests and radiologic exams has a substantial effect on the cost of care and is modified by the patient's resuscitation status.

ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveIn 1986, data from 25,000 major trauma outcome study patients were used to relate Trauma and Injury Severity Score (TRISS) values to survival probability. The resulting norms have been widely used. Motivated by TRISS limitations, A Severity Characterization of Trauma (ASCOT) was introduced in 1990. The objective of this study was to evaluate and compare TRISS and ASCOT probability predictions using carefully collected and independently reviewed data not used in the development of those norms.DesignThis was a prospective data collection for consecutive admissions to four level I trauma centers participating in a major trauma outcome study.Materials and MethodsData from 14,296 patients admitted to the four study sites between October 1987 through 1989 were used. The indices were evaluated using measures of discrimination (disparity, sensitivity, specificity, misclassification rate, and area under the receiver-operating characteristic curve) and calibration [Hosmer-Lemeshow goodness-of-fit statistic (H-L)].Measurements and Main ResultsFor blunt-injured adults, ASCOT has higher sensitivity than TRISS (69.3 vs. 64.3) and meets the criterion for model calibration (H-L statistic < 15.5) needed for accurate z and W scores. The TRISS does not meet the calibration criterion (H-L = 30.7). For adults with penetrating injury, ASCOT has a substantially lower H-L value than TRISS (20.3 vs. 138.4), but neither meets the criterion. Areas under TRISS and ASCOT ROC curves are not significantly different and exceed 0.91 for blunt-injured adults and 0.95 for adults with penetrating injury. For pediatric patients, TRISS and ASCOT sensitivities (near 77%) and areas under receiver-operating characteristic curves (both exceed 0.96) are comparable, and both models satisfy the H-L criterion.ConclusionsIn this age of health care decisions influenced by outcome evaluations, ASCOT's more precise description of anatomic injury and its improved calibration with actual outcomes argue for its adoption as the standard method for outcome prediction.

ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Cerebral blood flow and metabolism were investigated in five patients with severe diffuse brain injury in the chronic stage, using positron emission tomography (PET). Regional cerebral blood flow, regional oxygen extraction fraction, regional cerebral blood volume, regional cerebral metabolic rate for oxygen, and regional cerebral metabolic rate for glucose were measured bilaterally in the frontal, temporal, occipital, and parietal gray matter, as well as the white matter of the centrum semiovale. In 4 of 5 patients, a follow-up PET study was also performed. In three cases, below-normal regional cerebral blood flow and regional cerebral metabolic rate for oxygen values accompanied by above-normal regional oxygen extraction fraction values, as well as low metabolism, were demonstrated in the initial PET studies. In two of three cases, clinical improvements were observed, and follow-up PET data also improved. These findings suggest that chronological PET studies may be able to assess quantitatively clinical improvements in patients with diffuse brain injury.

ISSN:0022-5282    

出版商:OVID    

年代:1996

数据来源: OVID