Limb salvage of lower-extremity wounds using free gracilis muscle reconstruction

An extensive series reviewing the benefits and drawbacks of use of the gracilis muscle in lower-extremity trauma has not previously been collected. In this series of 50 patients, the use of microvascular free transfer of the gracilis muscle for lower-extremity salvage in acute traumatic wounds and posttraumatic chronic wounds is reviewed. In addition, the wound size, injury patterns, problems, and results unique to the use of the gracilis as a donor muscle for lower-extremity reconstruction are identified. In a 7-year period from 1991 to 1998, 50 patients underwent lower-extremity reconstruction using microvascular free gracilis transfer at the University of Maryland Shock Trauma Center, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center. There were 22 patients who underwent reconstruction for coverage of acute lower-extremity traumatic soft-tissue defects associated with open fractures. The majority of patients were victims of high-energy injuries with 91 percent involving motor vehicle or motorcycle accidents, gunshot wounds, or pedestrians struck by vehicles. Ninety-one percent of the injuries were Gustilo type IIIb tibial fractures and 9 percent were Gustilo type IIIc. The mean soft-tissue defect size was 92.2 cm2. Successful limb salvage was achieved in 95 percent of patients. Twenty-eight patients with previous Gustilo type IIIb tibia-fibula fractures presented with posttraumatic chronic wounds characterized by osteomyelitis or deep soft-tissue infection. Successful free-tissue transfer was accomplished in 26 of 28 patients (93 percent). All but one of the patients in this group who underwent successful limb salvage (26 of 27, or 96 percent) are now free of infection. Use of the gracilis muscle as a free-tissue transfer has been shown to be a reliable and predictable tool in lower-extremity reconstruction, with a flap success and limb salvage rate comparable to those in other large studies.     

High-energy orbital dislocations: the possibility of traumatic hypertelorbitism

In a 4-year period from 1983 to 1987, 7160 patients with blunt injuries were admitted to the Maryland Institute of Emergency Medical Services Systems Shock Trauma Center. Facial injuries occurred in 10 percent of this population. High-energy fractures (characterized by computed tomography) were seen in approximately 10 percent of these patients. In this high-energy group, five cases of high-energy orbital dislocations, some representing examples of traumatic hypertelorbitism, were observed. They represent 1.5 percent of the 342 midface fractures observed and 4.8 percent of the naso-orbital ethmoid fractures observed (105 patients). One additional patient is described who was seen at the UCLA Medical Center for late repair of the condition. High-energy impacts of the upper midface created fractures of both orbits, zygomas, and nasoethmoidal regions permitting lateral transposition, enlargement, and divergence of the orbits. Interorbital, intercanthal, and interpupillary distances were increased, criteria that confirm the diagnosis of hypertelorbitism. Fifty percent of the patients were bilaterally blind, and one patient sustained unilateral blindness.     

Accurate,firm stabilization using external pins: a proposal for closed reduction of unfavorable nasal bone fractures and their simple classification

Nasal bone fractures are the most common among facial fractures and are the third most common fractures in the human frame. Although many forms of treatment have been introduced, controversy regarding the optimal treatment still remains. Nasal bone fractures are complex, with significantly varying types that are often undermanaged in closed reduction procedures. The authors' experiences with nasal bone fractures have shown that the baseline for surgical intervention depends on the type of fracture and the method of maintenance after reduction, both of which have considerable impact on the final result. Therefore, it is very important and challenging to determine the proper method of reduction and maintenance. The periosteal covering plays an important role in the splinting action after closed reduction, but sagging, depression, and instability remain major complications in some cases. The authors devised a new method of accurate, firm stabilization of the fractured nasal bone by using external pins in those unfavorable fractures determined radiologically to gain optimal reduction and fixation. In the present study, fractures were grouped into favorable and unfavorable fractures, the latter being those that remained unstable or impacted even after reduction and thus needed open reduction. Unfavorable fractures were divided into four subclasses according to radiologic findings: (1) type I (frontal), including chip or tip fractures, which often depress the upper lateral cartilage and tend to sag after reduction; (2) type II (lateral), or laterally depressed segmental fractures with a lateral shift of the arch in fragments or as a unit; (3) type III (mixed), or type II with septal involvement; and (4) type IV (complex), including open or multiple comminuted fractures. After an initial evaluation to determine the fracture type, closed reduction and external fixation were performed for types I, II, and III fractures and open reduction was performed for type IV fractures 5 to 7 days after the fracture. Closed reduction with the use of external pins was done in eight cases: type I (two), type II (four), and type III (two). The mean age of the patients was 27.8 years, and the average follow-up period was 11.7 months. Functional and aesthetic results were satisfactory. This new method for support and fixation is an alternative to the conventional closed reduction and a promising way to prevent secondary deformity.     

Blow-in fractures of the orbit

A blow-in fracture is an inwardly displaced fracture of the orbital rim or wall resulting in decreased orbital volume. The purpose of this study is to classify orbital blow-in fractures, describe the distinguishing clinical and radiologic features, and review the result of treatment. The series consists of 41 patients with blow-in fractures (34 males and 7 females). The mean age of the patients was 36 years. All were treated between 1979 and December of 1986 at Sunnybrook Medical Centre in Toronto. Clinical features of blow-in fractures were primarily related to the decrease in volume of the orbital cavity. Proptosis was a consistent finding, and in 27 percent of patients, the globe was further displaced in a coronal plane. Restricted ocular motility and diplopia were documented in 24 and 32 percent of patients, respectively. Fracture fragments displaced into the orbit resulted in globe rupture in 12 percent of patients, superior orbital fissure syndrome in 10 percent, and optic nerve injury in 1 patient. Blow-in orbital injuries were classified as pure fractures, consisting of an isolated blow-in of a segment of the roof, floor, or walls, or impure fractures, where the orbital rim itself was disrupted. In all cases, early decompression of the orbit and open reduction of fractures was necessary. Late sequelae of blow-in fractures were primarily related to injuries of intraorbital contents. Twelve percent of patients underwent enucleation and 8 percent reported persistent diplopia. Despite the presence of superior orbital fissure syndrome and complete ophthalmoplegia in 10 percent of patients, early orbital decompression resulted in resolution of nerve palsies in all but one patient.     

Management of open tibial fractures

A prospective study was undertaken to accurately classify open tibial fractures and to evaluate the benefit of muscle flaps in the management of these injuries. From 191 open tibial fractures, 59 type III and 14 type IV open fractures were identified and managed prospectively. Fractures managed with open-wound techniques have a much higher complication rate than those closed with flaps. Results with flap coverage are affected by the biologic phase of the wound. The best results are seen in the acute flap coverage group and are thought to be secondary to removal of devitalized tissue with provision of a vascularized soft-tissue envelope prior to wound colonization. Flap coverage of the colonized subacute wound is subject to invasive infection with additional tissue loss. The subacute wound should be managed with open-wound technique until the parameters of a chronic localized wound are established, at which time flap coverage is again indicated. Microvascular free flaps are the preferred cover for type IV wounds because the local tissues are too ischemic and devitalized for transfer. With meticulous wound care and adherence to the enumerated surgical procedures, limb salvage may be achieved in most injuries.     

Bicycle spoke injuries in the lower extremity

This study reports the authors' 5-year experience with treating lower extremity injuries in bicycle passengers caused by the spokes. This patient group was selected from 716 lower extremity injuries that received treatment at our outpatient plastic surgery clinic. A total of 26 patients were treated during the study. Patients ranged from 2 to 19 years old, with a mean age of 5.6 years. The authors treated more female passengers (62 percent) than male passengers. The right foot (52 percent) was involved more often than was the left. Most patients were injured in the afternoon, from 2 to 7 PM (62 percent), and between May and October (77 percent). The rear wheel (89 percent) injured the majority of patients. The Achilles tendon was the most common site of injury (63 percent). The typical types of wounds observed included the following: type I, laceration with partial avulsion of skin and subcutaneous tissue (41 percent) and laceration forming a distally based flap (33 percent); type II, abrasions with ecchymoses and friction burn from the shearing effect of the spokes creating a partial- to full-thickness skin defect (26 percent). Of the type I injuries, full-thickness skin lacerations (33 percent) were closed primarily. Partial-thickness skin lacerations, abrasions, ecchymoses, and skin defects (67 percent) were treated conservatively with wound irrigation and dressing. The wound healing time for type I injuries was 29 days; for type II injuries, it was 27 days. These healing times were prolonged compared with healing by first intention. No significant difference was found in healing time when comparing both types of injury. Four patients required hospitalization. No patient required skin grafting. No fractures were noted because these patients were selected from the outpatient plastic surgery clinic and did not include patients from the emergency room. Since the first report of bicycle spoke injuries a half-century ago, prevention has not improved.     

Early and late results of treating peripheral arterial injuries]

Forty six patients with injuries to the great peripheral arteries were treated at the III Department of Surgery, Medical Academy in Cracow in 1968-1987. An injury to the blood vessels was accompanied by bone fractures or joint dislocation in 9 (19.5%) patients whereas 35 (76%) patients suffered also from vein injuries and nervous trunks trauma. In 13 (28%) cases an accident took place when the victims were drunk. Favourable result of the treatment, i.e. return of peripheral pulse, was achieved in 33 (75%) patients, acceptable result, i.e. an increase in limb temperature, in 11 (23%) patients. Two patients underwent an amputation of the limb because of its necrosis. One patient died. Anti-thrombolytic agents were given intra- and postoperatively, and in 9 patients with extensive contusions fasciotomy proved successful. Late results were similar to early ones.     

Management of hand and upper-extremity infections in heart transplant recipients

Hand and upper-extremity infections are routinely managed by antibiotics, immobilization, and limited incision and drainage. However, in immunocompromised patients, these infections may be more aggressive and they may require more emergent treatment. The authors performed a retrospective review of the Stanford University Medical Center experience with hand and upper-extremity infections in 911 cardiac transplant recipients over the past 30 years. Thirteen heart transplant recipients were treated for infections of the hand and upper extremity on an inpatient basis. Ten patients (77 percent) required operative debridement, and three (23 percent) required more than one operative procedure. Nine patients (69 percent) had bacterial infections, six (46 percent) had fungal infections [four of these patients (31 percent) had both bacterial and fungal infections], one (7.7 percent) had a mycobacterial infection, and one (7.7 percent) was not cultured. Hand and upper-extremity infections in transplant recipients frequently resulted in deep-space infections, tenosynovitis, and osteomyelitis. The authors believe such infections represent a surgical emergency, requiring immediate evaluation by hand surgeons and early, aggressive treatment.     

The causes and consequences of maxillofacial injuries in elderly people

Objective: The occurrence of trauma in older people is well‐documented; however the incidence of maxillofacial trauma is scarcely reported. Therefore, the objective of this study is to determine the causes and consequences of maxillofacial trauma in older people. Design: A five‐year (March 95 ‐ March 2000) retrospective study was earned out of all patients over the age of 65 years with facial trauma presenting to Accident and Emergency Department (A&E). The information was collected using the medical notes and discharge summaries. Setting: The Departments of A&E and Maxillofacial Surgery. Subjects: A total of 42 patients' records were examined for study related data. Results: A total of 42 patients were seen during the study period. Thirty‐six gave a history of a fall, of which 15 had tripped, 5 had slipped, 3 resulted from a Transient Ischaemic Attack (TIA), 1 as a result of alcohol abuse, in 1 a prosthetic knee gave way and 11 gave no cause for the fall. Of the remaining 6 patients. 5 were assaulted and 1 had a wardrobe fall on top of him. The majority of the falls occurred during the winter months. Maxillofacial injuries were noted in 27 of the 42 patients. Sixteen patients had cheekbone fractures, 8 mandibular fractures, 2 midface and 1 orbital complex fracture. Twenty‐five percent of cheekbone fractures and 50% of mandibular fractures were treated surgically. Medical history was noted in 27 patients. Conclusions: This study clearly demonstrates the majority of the facial trauma in the older people can be treated conservatively unless the patients complain of functional problems.     

Long-term results of frontal lobe suspension in children with congenital dystrophic ptosis

Long-term results achieved by our own operative technique in children with congenital dystrophic ptosis, with frontal muscle lobe shaping with or without shaping of corrugator muscle lobe attached to the tarsal plate, are presented. Data on 146 patients with congenital dystrophic ptosis operated on during the 1984-1998 period at Zagreb University Hospital Center were retrospectively analyzed. Postoperative success was defined as a situation with eyes open in which 1) upper eyelid covers the cornea at 12 o'clock position by 1-2 mm; 2) there is a good contour of the eyelid margin; 3) there is no lagophthalmos; and 4) there is symmetry with the other eye. Immediate re-operation due to undercorrection was required in 26 of 146 (18%) patients. Upon re-operation, 133 (91%) patients met the criteria for successful outcome at 6 months, 124 (85%) at one year, and 121 (83%) at 5 years. Correction of congenital dystrophic ptosis using a shaped frontal/corrugator lobe is an efficient and safe procedure ensuring long-lasting success.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

可吸收螺钉结合克氏针治疗跟骨骨折

目的评价可吸收螺钉结合克氏针治疗跟骨骨折的疗效。方法采用可吸收螺钉结合克氏针对17例跟骨骨折行切开复位内固定。按Sanders分型[1]:其中Ⅱ型6例,Ⅲ型10例,IV型1例。结果 17例均获得随访,随访时间6～42个月,平均11.6个月,骨折全部愈合。疗效优6例,良8例,可2例,差1例,优良率82.4%。结论可吸收螺钉结合克氏针用于治疗跟骨骨折,值得推广。     

Management of soft-tissue problems in leg trauma in conjunction with application of the Ilizarov fixator assembly

Forty-five patients presenting with high-energy open grade III tibial diaphyseal fractures were treated with the Ilizarov technique. Of these patients, 28 required plastic surgical intervention for achieving wound closure. Most of the injuries were complicated by initial neglect and inadequate primary soft-tissue coverage resulting in osteitis, sequestration, and segmental diaphyseal tibial defects, often in combination with skin-envelope deficits of various types in and around the fracture perimeter. The unique soft-tissue problems encountered while using the Ilizarov fixator have not been focused on in previous reports on the management of segmental bone defects. Four basic local flap procedures: the transposition flap, rotation flap, adipofascial turnover flap, and Z-plasty are useful and versatile for managing most types and grades of soft-tissue defects associated with a segmental bone loss with the Ilizarov technique.     

Robust human body model injury prediction in simulated side impact crashes

This study developed a parametric methodology to robustly predict occupant injuries sustained in real-world crashes using a finite element (FE) human body model (HBM). One hundred and twenty near-side impact motor vehicle crashes were simulated over a range of parameters using a Toyota RAV4 (bullet vehicle), Ford Taurus (struck vehicle) FE models and a validated human body model (HBM) Total HUman Model for Safety (THUMS). Three bullet vehicle crash parameters (speed, location and angle) and two occupant parameters (seat position and age) were varied using a Latin hypercube design of Experiments. Four injury metrics (head injury criterion, half deflection, thoracic trauma index and pelvic force) were used to calculate injury risk. Rib fracture prediction and lung strain metrics were also analysed. As hypothesized, bullet speed had the greatest effect on each injury measure. Injury risk was reduced when bullet location was further from the B-pillar or when the bullet angle was more oblique. Age had strong correlation to rib fractures frequency and lung strain severity. The injuries from a real-world crash were predicted using two different methods by (1) subsampling the injury predictors from the 12 best crush profile matching simulations and (2) using regression models. Both injury prediction methods successfully predicted the case occupant's low risk for pelvic injury, high risk for thoracic injury, rib fractures and high lung strains with tight confidence intervals. This parametric methodology was successfully used to explore crash parameter interactions and to robustly predict real-world injuries.     

Injuries associated with mandible fractures sustained in motor vehicle collisions

Motor vehicle collisions are second only to altercations as the most common cause of mandible fractures. This article details in a retrospectively studied group the incidence of isolated mandible fractures and associated injuries in patients who were involved in motor vehicle collisions. This group consisted of 148 patients with mandible fractures listed in the University of Mississippi's trauma registry during the past 5 years. In almost all patients, associated injuries occurred with mandible fractures that were caused by motor vehicle collisions, with an incidence of 99.3 percent. Facial and head lacerations and facial fractures were the leading associated injuries, occurring in more than half of the patients who had a mandible fracture. Closed head injury is the major life-threatening associated injury and cause of mortality. The life-threatening injuries occurred in 64.8 percent of patients in this study. The mortality rate in this group of patients was 8.1 percent. These data suggest that mandible fractures from motor vehicle collisions should never be viewed as an isolated injury but rather as part of a spectrum of significant and sometimes life-threatening injuries that require thorough trauma evaluation at the time of presentation.     

Long-term physical impairment and functional outcomes after complex facial fractures

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified.Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records.Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent).When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms.The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance.Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.     

Immediate closure of traumatic upper arm and forearm injuries with the latissimus dorsi island myocutaneous pedicle flap

This paper reports the authors' experience with latissimus dorsi island pedicle flaps in the acute treatment of massive arm injuries. Seven patients with upper arm injuries and four patients with forearm injuries were treated with latissimus dorsi pedicle flaps. All cases involved massive soft-tissue loss and open fractures. Primary healing of wounds occurred without complications in 10 of 11 patients; the eleventh developed a wound infection. There were no instances of flap loss or vascular complications. This report compares and discusses surgical management options and details the importance of robust, immediate soft-tissue coverage for optimal functional recovery. Contrary to traditional thought, delay in definitive wound closure may be unnecessary when aggressive debridement is followed by acute flap closure.     

Effect of ruthenium complexes on the activities of succinate dehydrogenase and cytochrome oxidase

In this article, we report the effects of acute administration of ruthenium complexes, trans-[RuCl(2)(nic)(4)] (nic=3-pyridinecarboxylic acid) 180.7 micromol/kg (complex I), trans-[RuCl(2)(i-nic)(4)] (i-nic=4-pyridinecarboxylic acid) 13.6 micromol/kg (complex II), trans-[RuCl(2)(dinic)(4)] (dinic=3,5-pyridinedicarboxylic acid) 180.7 micromol/kg (complex III) and trans-[RuCl(2)(i-dinic)(4)]Cl (i-dinic=3,4-pyridinedicarboxylic acid) 180.7 micromol/kg (complex IV) on succinate dehydrogenase (SDH) and cytochrome oxidase (COX) activities in brain (hippocampus, striatum and cerebral cortex), heart, skeletal muscle, liver and kidney of rats. Our results showed that complex I inhibited SDH activity in hippocampus, cerebral cortex, heart and liver; and inhibited COX in heart and kidney. Complex II inhibited SDH in heart and hippocampus; COX was inhibited in hippocampus, heart, liver and kidney. SDH activity was inhibited by complex III in heart, muscle, liver and kidney. However, COX activity was increased in hippocampus, striatum, cerebral cortex and kidney. Complex IV inhibited SDH activity in muscle and liver; COX activity was inhibited in kidney and increased in hippocampus, striatum and cerebral cortex. In a general manner, the complexes tested in this work decrease the activities of SDH and COX in heart, skeletal muscle, liver and kidney. In brain, complexes I and II were shown to be inhibitors and complexes III and IV activators of these enzymes. In vitro studies showed that the ruthenium complexes III and IV did not alter COX activity in kidney, but activated the enzyme in hippocampus, striatum and cerebral cortex, suggesting that these complexes present a direct action on COX in brain.