TIBIAL SHAFT FRACTURES

ABSTRACTThe long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures

A new low-cost negative-pressure wound therapy versus a commercially available therapy device widely used to treat complex traumatic injuries: a prospective, randomized, non-inferiority trial

OBJECTIVES: Negative-pressure wound therapy has been widely adopted to reduce the complexity of treating a broad range of acute and chronic wounds. However, its cost is high. The objective of this study was to evaluate the following two different methods of negative-pressure wound therapy in terms of healing time: a low-cost method of negative-pressure wound therapy (a pressure stabilizer device connected to a hospital wall-vacuum system with a gauze-sealed dressing, USP) and the standard of care (vacuum-assisted closure, VAC). METHODS: This is a randomized, controlled, non-inferiority, unblinded trial. Patients admitted with complex injuries to a trauma center in a public referral hospital who were indicated for orthopedic surgery were randomized to a USP or VAC group. The primary outcome was the time required to achieve a “ready for surgery condition”, which was defined as a wound bed with healthy granulation tissue and without necrosis or purulent secretion. Wound bed area contraction, granulation tissue growth and the direct costs of the dressings were secondary outcomes. RESULTS: Variation in area and granulation tissue growth were essentially the same between the systems, and healing time was equal between the groups (p=0.379). In both systems, serial debridement increased wound area (p=0.934), and granulation tissue was also increased (p=0.408). The mean treatment cost was US$15.15 in the USP group and US$ 872.59 in the VAC group. CONCLUSIONS: For treating complex traumatic injuries, USP was non-inferior to and less expensive than VAC

Localization of the tibial entry point

OBJETIVE: To assess, through a questionnaire, the intramedullary nail entry point in the proximal aspect of the tibia. Me-thods: 230 attendees who treat tibial fractures were interviewed. The questionnaire was created with three sections that could be answered with Yes or No answers and a fourth section that had two figures representing anteroposterior (AP) and lateral view x-rays that could be answered with a format A, B or C. RESULTS: The most frequent reason was ease of access (67.8%), followed by the better nail insertion access (60.9%) and the third one was to prevent knee pain (27.4%). Reasons for choosing access so as to prevent knee pain and prevent tendinitis had a significant relationship with points A and C of the schematic figure in the AP x-ray, especially C (medial tibial crest). No significant difference was observed between types of access to the patellar ligament in the schematic figure of the AP and lateral x-ray among age groups. CONCLUSION: The greater the age, the larger the proportion choosing the question avoid valgus deformity. Reasons from a medical (practical) perspective were related to the type of access in the transpatellar ligament, while reasons from a patient (functional) perspective were related to medial parapatellar access. Transpatellar access was chosen by most participants (66.5%).OBJETIVO: Verificar, através de um questionário, o ponto de entrada da haste intramedular na região proximal da tíbia. Métodos: 230 participantes que tratam fraturas da tíbia foram entrevistados. O questionário foi formulado com três segmentos que poderiam ser respondidos com um formato sim ou não e um quarto, com duas figuras que representavam uma radiografia em anteroposterior (AP) e lateral que poderiam ser respondidas com um formato A, B ou C. RESULTADOS: A razão mais frequente foi a facilidade de acesso (67,8%), seguida do melhor acesso para inserção da haste (60,9%) e em terceiro prevenir a dor no joelho (27,4%). Existiu relação significativa entre as razões de escolha do acesso como prevenir dor no joelho e evitar tendinites com os pontos A e C da figura esquemática de radiografia em AP, principalmente o ponto C (crista tibial medial). Observou-se que não existiu diferença significativa nos tipos de acesso em relação ao ligamento patelar, nas figuras esquemáticas de radiografia em AP e perfil entre as faixas etárias. CONCLUSÃO: Observou-se que quanto maior a faixa etária maior a proporção de escolher a pergunta evitar deformidade em valgo. As razões de aspecto médico (prático) foram relacionadas com o tipo de acesso no ligamento transpatelar, enquanto que as razões de aspecto paciente (funcional) foram relacionadas com o acesso parapatelar medial. O acesso transpatelar foi escolhido pela maioria dos participantes (66,5%).Universidade Federal de São Paulo (UNIFESP)Hospital Santa TeresaUniversidade Federal do Rio de Janeiro Faculdade de Medicina Departamento de Ortopedia e TraumatologiaHospital de IpanemaSanta Casa de São Paulo Faculdade de Ciências MedicasSanta Casa de São Paulo da Faculdade de CiênciasUNIFESPSciEL

Fraturas da diáfise da tíbia

A fratura de osso longo mais frequente é a da diáfise da tíbia, e seu tratamento adequado evita o aparecimento de falhas da consolidação, consolidação viciosa e reoperações. Para classificar a fratura ainda se utiliza a classificação AO/OTA, mas vale a pena conhecer a classificação de Ellis, que também inclui a avaliação da lesão das partes moles. A síndrome compartimental é uma associação frequente, e o diagnóstico precoce pode ser feito precocemente com avaliação dos parâmetros clínicos e uma monitorização clínica constante. Feito o diagnóstico, deve-se realizar a fasciotomia. A avaliação da consolidação sempre é difícil, mas o método de RUST pode ajudar nessa avaliação. Avalia-se a radiografia em duas projeções, dando-se pontos para a presença da linha de fratura e a presença de calo ósseo visível. Hoje em dia se discute o dogma das seis horas para a limpeza da fratura exposta. Considera-se de mais importância o início precoce da antibioticoterapia endovenosa e a gravidade da lesão. A questão do fechamento precoce ou tardio da lesão em uma fratura exposta passou por várias fases, com épocas se indicando o fechamento precoce e épocas o tardio. Atualmente se preconiza, sempre que possível, o fechamento precoce da lesão, pois isso diminui o risco de infecção. A fresagem do canal quando da introdução da haste intramedular ainda é um assunto controverso. Apesar de fortes posições pessoais a favor da fresagem, os estudos mostram haver alguma vantagem nas fraturas fechadas, mas não nas expostas

Comparação entre o uso de placas e o de hastes flexíveis para a osteossíntese de fraturas do terço médio da clavícula: resultados preliminares

OBJETIVO: Comparar os resultados clínicos e radiográficos de dois diferentes métodos de fixação para fraturas do terço médio da clavícula, a saber, placas e hastes intramedulares. MÉTODOS: De maio de 2010 a fevereiro de 2011, 22 pacientes com fraturas desviadas do terço médio da clavícula foram randomizados para a fixação com placa (dez pacientes) e fixação com haste (doze pacientes). Entre os principais desfechos analisados estão: o escore funcional de Constant, o escore DASH, a presença de complicações relacionadas aos métodos e as características radiográficas. RESULTADOS: Treze pacientes completaram pelo menos 4 meses de seguimento (seis do grupo placa e sete do grupo haste). O tempo de consolidação radiográfica foi semelhante entre os dois grupos, com média de 12,3 semanas no grupo haste e 12,4 semanas no grupo placa. Também não houve diferença quanto à amplitude de movi- mento do ombro, dor pós-operatória ou presença de pseudartrose. Um paciente do grupo haste apresentou re-fratura após a retirada da síntese aos 3 meses de PO e um pacientes do grupo placa apre- sentou angulação da placa e soltura, sendo necessária re-operação. As avaliações funcionais foram semelhantes entre os dois grupos. CONCLUSÃO: Há uma tendência para que os resultados nos dois grupos clínicos avaliados sejam muito semelhantes quanto ao tempo médio de consolidação, numero de complicações e função do ombro. A ampliação desta casuística deve, no futuro, oferecer resultados mais conclusivos

International needs analysis in orthopaedic trauma for practising surgeons with a 3-year review of resulting actions

Introduction: To ensure best-quality education in orthopaedic trauma, the AOTrauma Education Commission conducted a Global Needs Analysis with practising surgeons worldwide. Material and methods: During July to November 2012, an email invitation to complete an online set of 30 questions in eight languages was sent to our members and associates in all countries through AOTrauma’s regional networks. Non-members were invited to participate through collaboration with orthopaedic societies. Results: A total of 3,790 surgeons practising orthopaedic trauma (49%), orthopaedic (15%), general trauma (15%) and specialty orthopaedic (13%) surgeons responded worldwide. Seventy per cent completed all questions, and the top 10 countries accounted for half the responses. The top 3 areas of educational need were orthopaedic trauma, joint replacement and preservation, and pelvis and acetabulum. Aspects influencing likelihood to attend face-to-face courses were: expert faculty, focus on a specific topic, clear objectives, and discussion and feedback from experts. Barriers to attending courses were time away from practice, cost and lack of availability or access. Conclusion: The Global Needs Analysis helped our educational committees to identify short- and mid-term priorities over recent years. Adjustments in our planning have helped meet the needs of our audience on a global, regional and national level

A comparison study of radiographic and computerized tomographic angles in slipped capital femoral epiphysis

ABSTRACT Objective: To compare proximal femur radiologic angles in patients with slipped capital femoral epiphysis and to analyze whether computerized tomography may modify the treatment. Methods: Cross-sectional study comparing and analyzing the similarity between angles and radiologic classification of interest in slipped capital femoral epiphysis (SCFE) . Results: It was observed that the therapeutic management in slipped capital femoral epiphysis might be modified depending on the classification and radiologic acquisition method adopted. Conclusion: Multiplanar assessment of proximal femoral deformity in patients with slipped capital femoral epiphysis is a viable option, with the potential to modify the disease classification and, consequently, the therapeutic management

Epidemiological study on calcaneus fractures in a tertiary hospital

ABSTRACT Objective: To analyze the epidemiology and characteristics of patients with calcaneus fractures. Methods: This is a retrospective revision of patients with calcaneus fractures hospitalized in the Institute of Orthopedics and Traumatology of this institution between 2006 and 2010. Data such as age, gender, laterality, trauma mechanism, type of fracture, associated injuries, compound fractures, and time from injury to surgery were analyzed. Results: The analysis of 52 patients showed that men were more commonly affected than women, at a ratio of 5.5:1. Bilateral fractures were observed in ten cases, resulting in a total of 62 calcaneus fractures. A fall from a height was the most frequent trauma mechanism (75%), followed by motorcycle accidents (11.5%) and automobile accidents (9.6%). The most frequent fractures were intra-articular, with 47 cases. Compound fractures were observed in 15 patients (28.9%). Non-surgical management was adopted for 11 patients while 41 patients underwent surgery. The mean time between trauma and the definitive treatment was 7.8 days (range: 0-21 days), and 58.5% of cases were treated within seven days. Conclusion: Patients with calcaneus fractures, most commonly young men, were admitted to a high complexity care hospital, victims of a fall from a height with associated injuries. The great severity of these fractures is characterized by the high prevalence of bilateral (19.2%) and compound fractures (28.9%) in this population group

Como o especialista em ortopedia e traumatologia avalia o atendimento ao trauma ortopédico no Brasil How do orthopedic surgeons rate the orthopedic trauma care in Brazil

OBJETIVO: Apresentar os resultados de pesquisa Datafolha, realizada no período de 23 de setembro a 18 de outubro de 2010, sobre as condições existentes para o exercício profissional na área do trauma ortopédico no Brasil. MÉTODOS: pesquisa quantitativa, com abordagem telefônica dos entrevistados, por meio de sorteio aleatório de membros da Sociedade Brasileira de Ortopedia e Traumatologia, em cadastro contendo mais de 7.000 nomes. As entrevistas foram realizadas mediante aplicação de questionário estruturado, com aproximadamente 25 minutos de duração. RESULTADOS: 97% dos entrevistados dedica parte do seu tempo ao trauma ortopédico. 87% dos entrevistados exercem outra sub-especialidade, que não o trauma ortopédico. Na média dos atendimentos no país, 43% dos pacientes pertencem à rede pública de saúde e 41% pertencem à rede de convênios. O uso de implantes importados ocorre na minoria das situações (36%) e 83% dos médicos que utilizam ambos os tipos de implantes julga que os nacionais apresentam qualidade inferior. 61% dos entrevistados julga a qualidade do atendimento em serviços públicos regular, ruim ou péssima. Metade dos entrevistados declara ter problemas para a liberação de suas solicitações de procedimentos junto aos planos de saúde em pelo menos 25% das vezes em que encaminham tais pedidos. CONCLUSÃO: O trauma ortopédico é uma especialidade exercida pela grande maioria dos ortopedistas brasileiros. A estrutura dos serviços públicos é considerada insatisfatória pela maioria dos ortopedistas entrevistados. A maioria dos ortopedista deseja uma reformulação nos honorários médicos e na infra-estrutura de serviços.<br>OBJECTIVES: The aim of this article is to present the data collected by Datafolha institute, from September 23rd. through October 18th. 2010 about orthopedic trauma care in Brazil. METHOD: A quantitative analysis based on telephonic interviews has been performed. From Brazilian Orthopedic Society database containing more than 7000 records. A structured query has been applied and the interview lasted around 25 minutes. RESULTS: 97% of interviewees dedicate part of his/her time to orthopedic trauma. 87% of all interviewees dedicate his/her time to more than one sub-specialty. The majority of orthopedic trauma patients comes from government insurance system (43%), while 41% of patients come from private insurance. 61% of all interviewees think that the quality of public health system could be rated as unsatisfactory. Northeast of Brazil is the place where the majority of patients are from public health system and where we have highest rates of dissatisfaction (85%) related to available infrastructure for orthopedic trauma care. Half of all interviewed individuals have problems for getting private insurance authorization previously to a surgery. CONCLUSIONS: Orthopedic trauma is a specialty practiced by the vast majority of orthopedic surgeons in our country. Neither the infrastructure nor the salaries satisfy the majority or orthopedic surgeons dedicated to trauma care