Cases reported "Fractures, Open"

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1/80. Immediate autografting of bone in open fractures with bone loss of the hand: a preliminary report. case reports.

    Three patients with open fractures of the hand associated with bone loss were treated within four to six hours of injury by corticocancellous bone grafting and soft tissue coverage after meticulous debridement, copious irrigation of the wounds, and broad-spectrum antibiotics given intravenously. Long term follow-up was uneventful and showed that the graft had taken and healed well with early and full restoration of function and a good cosmetic result. Immediate corticocancellous bone grafting of an injured hand could be used in selected cases with well-debrided, surgically clean wounds as long as there is a rich blood supply. Adequate bone fixation, soft tissue coverage, and broad-spectrum antibiotics given intravenously will remove the risk of infection. hand architecture is corrected while wound contracture and secondary deformity are avoided. Both patients' discomfort and hospital costs are considerably reduced.
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2/80. Using the Ilizarov external fixation device for skin expansion.

    Addressing war injuries requires tailoring treatment that provides the best functional and aesthetic results within a reasonable period of time. The authors report a young soldier who sustained a gunshot injury that caused an open fracture of the proximal tibia and patella (Gustilo type B-III). A local muscle flap could not be used, and thus the authors decided to use the already applied Ilizarov device for gradual expansion of the wound edge. The expanded skin covered the exposed fracture successfully, and later enabled solid union of the fracture. This reconstructive method seems to be an original solution for the management of open fractures, and additional proof that well-vascularized skin may be equivalent to a muscle flap, and may be considered for selected patients.
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3/80. Management of lawnmower injuries to the lower extremity in children and adolescents.

    Lawnmower-associated trauma remains a substantial source of extremity injury in the pediatric and adolescent patient populations, producing complex wounds that require a combined orthopedic and plastic surgical approach. The authors review their experience with 16 patients, 2 to 17 years of age (mean age, 6.2 years), who were admitted to Duke University Medical Center for lower extremity lawnmower trauma between January 1988 and December 1999. The average hospitalization time was 13.5 days, and an average of 2.9 surgical procedures per patient were performed. Early debridement and bony fixation were carried out in all patients; 8 patients sustained traumatic amputations. Fifteen of 20 nonamputation fractures involved the foot and were managed with either closed reduction or K-wire fixation. Three of five long-bone fractures underwent external fixation. Wound closure was achieved with direct closure or skin grafting in the majority of patients. However, five microsurgical free flap transfers were required for extensive defect reconstruction of the foot (N = 4) and knee (N = 1). Adequate immediate debridement, fracture reduction, and early primary or if necessary secondary wound coverage including microsurgical free tissue transfer to prevent further damage and long-term disability in these type of devastating injuries is recommended.
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4/80. 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.
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5/80. One-stage emergency treatment of open grade IIIB tibial shaft fractures with bone loss.

    The purpose of this study was to report the authors' experience with emergency reconstruction of severe tibial shaft fractures. Five male patients were admitted to the emergency room with a grade IIIB open tibial shaft fracture with bone loss (average age, 33 years; age range, 18-65 years). Injuries were the result of motorcycle accidents (N = 2), pedestrian accidents (N = 1), gunshot wound (N = 1), and paragliding fall (N = 1). Primary emergent one-stage management for all patients consisted of administration of antibiotics, debridement, stabilization by locked intramedullary nailing, bone grafting from the iliac crest, and coverage using free muscle flaps (four latissimus dorsi and one gracilis). The average follow-up was 21 months (range, 8 months-3.5 years). Partial weight bearing with no immobilization was started at 3 months, and full weight bearing began 5 months after trauma. No angular complications and no nonunions were observed. There was one case of superficial infection without osteitis. All fractures healed within 6 months in 4 patients and within 10 months in 1 patient. At the last follow-up examination, ankle and knee motion was normal and no pain was noted, except for 1 patient who had associated lesions (ankle motion reduced by 50%). Aggressive emergency management of severe open tibial fractures provides good results. It improves end results markedly, not only by reducing tissue loss from infection, but also reducing healing and rehabilitation times.
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6/80. Surgical emphysema over the pelvis: an unusual physical sign found on primary survey.

    Open fractures of the pelvis are associated with high energy trauma and present a challenge to successful management and sometimes, early and correct diagnosis. These patients require more aggressive blood resuscitation particularly in the first 24 hours, repeated wound care operations, and often require a diverting colostomy. Usually these pelvic fractures can be distinguished from closed pelvic fractures by an open wound or lacerations of the vagina and rectum. Occasionally, however, the wounds associated with these fractures may remain undetected and the severity of the injury underestimated until complications develop. The authors believe this to be the first report of subcutaneous surgical emphysema associated with an open pelvic fracture.
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keywords = wound
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7/80. Sagittal split tibialis anterior muscle flap.

    The potential use of the tibialis anterior muscle as a vascularized flap requires consideration of some function preservation technique because this is not an expendable muscle. A direct longitudinal vertical or partial sagittal split of this muscle will allow coverage of mid-tibial defects without impairing function. This is a valuable alternative for small defects, especially if the muscle is already exposed in the wound. The muscle must be malleable enough to allow stretching over the tibia, because otherwise posteromedial undermining (as used in the medial- hinged anterior turnover version) would be necessary to obtain the desired reach. This as a variation of the latter, if possible, not only is more expedient to implement but also better preserves the microcirculation of the muscle to ensure viability.
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keywords = wound
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8/80. Open anterior-inferior hip dislocation.

    Traumatic hip dislocations result from high-energy trauma. These dislocations are usually posterior in direction and have severe associated injuries. The less common anterior dislocation is usually of the inferior type. We report a case of an open anterior-inferior hip dislocation secondary to a high-speed motor vehicle collision. The wound was in the medial upper ipsilateral thigh. To our knowledge, this is the first reported case of an adult with an open inferior-type anterior hip dislocation.
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9/80. The simple and effective choice for treatment of chronic calcaneal osteomyelitis: neurocutaneous flaps.

    The authors describe their experience with the use of distally based saphenous and sural neurofasciocutaneous flaps for the treatment of calcaneal osteomyelitis in nine cases. Aggressive debridement of all nonviable and poorly vascularized tissue and coverage with a distally based neurofasciocutaneous flap were coupled with a thorough antibiotic course in all cases. The deepithelized peripheral parts of all flaps were buried in the bone cavities after bone debridement. Follow-up periods ranged from 15 to 27 months. All flaps survived completely. All of the wounds except one healed completely. These flaps have adequate blood flow for the management of chronic bone infections. They also have many advantages, such as easy quick elevation, short operative time, and acceptable donor-site morbidity. Moreover, patients treated with neurocutaneous flaps do not require debulking procedures or special shoes. Reconstruction with neurocutaneous flaps after radical debridement is a versatile alternative to the use of local or distant muscle flaps and calcanectomy procedures for patients with osteomyelitis of the os calcis.
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10/80. Successful reimplantation of a large segment of femoral shaft in a type IIIA open femur fracture: a case report.

    Segmental bone loss associated with high-energy open fractures is a difficult problem. The more perplexing and controversial problem is that faced when the extruded segment of bone is retrieved from the field and available for potential reimplantation. Here we present successful reimplantation of a 13-cm segment of meta-diaphyseal femur in a 15-year-old boy. Successful reimplantation of the fragment was attributed to the anatomic location of the injury, meticulous wound care, multiple debridements, sterilization of the extruded fragment in chlorhexidine, and the patient's age.
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