Trauma: menos "sensibilidad" quirúrgica en las fracturas de húmero

Nonoperative treatment of humeral shaft fractures revisited.

Ali E, Griffiths D, Obi N, Tytherleigh-Strong G, Van Rensburg L

J Shoulder Elbow Surg 2014 Jul 31.

PURPOSE

The purpose of this study was to examine the union rate of humeral shaft fractures treated nonoperatively and to establish whether a particular fracture type is more likely to go on to nonunion.

METHODS

Radiographs and patient records of 207 humeral shaft fractures occurring during 5 years were retrospectively reviewed. All patients were initially managed nonoperatively and placed in a U-slab on diagnosis in the emergency department; this was converted to a functional humeral brace at 7 to 10 days after injury. Fracture location, morphology and comminution were assessed radiologically. Union was defined as the absence of pain and movement at the fracture site in the presence of radiographic callus formation. Nonunion was defined as no evidence of bone union by 1 year after injury or fractures requiring delayed fixation, defined as operative fixation undertaken more than 6 weeks after injury.

RESULTS

The study included 138 humeral shaft fracture patients; 18 patients (11%) were lost to follow-up, and 24 went on to nonunion, giving an overall union rate of 83%. Of the 24 nonunions, 15 underwent delayed operative fixation at an average of 8.3 months after injury. The union rate for proximal-third fractures was 76% compared with 88% for middle-third fractures and 85% for distal-third fractures. Comminuted fractures (defined as 3+ parts) had a 89% union rate regardless of position.

CONCLUSION

A lower threshold for surgical intervention may be considered in proximal-third, two-part spiral-oblique humeral shaft fractures. Brace therapy can be the optimal treatment regimen, but it is not the only option.

Trauma: Va bien la fijación con placas de ángulo fijo en la fractura declavicula lateral

Angular stable fixation of displaced distal-third clavicle fractures with superior precontoured locking plates
Mark A. Fleming, Robert Dachs, Sithombo Maqungo, Jean-Pierre du Plessis, Basil C. Vrettos, Stephen J.L. Roche
Journal of Shoulder and Elbow Surgery
Published Online: October 29, 2014

Hypothesis

We reviewed the outcome of angular stable plates in addressing displaced lateral-third clavicle fractures. We investigated union, shoulder function, request for implant removal, and return to sport. Our hypothesis was that these implants provide predictable union and return to sports without the negative consequence of leaving plates in situ, reducing the requirement for a second surgery.

Methods
We undertook a retrospective review of a consecutive series of patients who underwent this surgery between 2007 and 2010. Nineteen patients with a mean follow-up of 25 months were included. Postoperative follow-up was performed at 2 weeks and monthly thereafter until union was assessed as achieved clinically and radiographically. Two telephone interviews at a mean of 7 months and 25 months postoperatively assessed shoulder function by Oxford Shoulder Score, presence of any plate or scar discomfort, need for implant removal, and return to sport.

Results
Nineteen patients achieved union by 4 months (median, 12 weeks; range, 6-16 weeks). The mean Oxford Shoulder Score was 46 (range, 41-48) at a mean of 7 months (range, 3-18 months) and 47 (range, 44-48) at 25 months (range, 18-48 months). Initially, 2 patients requested implant removal; later, however, both declined surgery. No plates have been removed. Four patients complained of mild plate discomfort but did not wish removal. All patients had returned to sporting activities.

Conclusion
Angular stable plate fixation of Neer group II, type II clavicle fractures resulted in a 100% union rate with excellent return of function with no mandatory need for removal.

Level of evidence:
Level IV, Case Series, Treatment Study

General: Otra razón para no fumar

Cigarette Smoking Increases Complications Following Fracture: A Systematic Review

John A. Scolaro, Mara L. Schenker, Sarah Yannascoli, Keith Baldwin, Samir Mehta, Jaimo Ahn

J Bone Joint Surg Am, 2014 Apr 16;96(8):674-681

Abstract

Background: 

Smoking has been suggested to increase the rate of perioperative complications including soft-tissue complications, to decrease the rate of fracture union, and to prolong healing time. The purpose of our study was to systematically evaluate and analyze the literature regarding the relationship between smoking and healing following operative treatment of long-bone fractures.

Methods: 

We searched the MEDLINE, Embase, and Cochrane databases by pairing the search terms “smoking,” “tobacco,” and “nicotine” with the terms “fracture,” “nonunion,” delayed union,” and “healing.” Articles and citations were evaluated for relevance. Inclusion and exclusion criteria were established to maintain data quality for analysis. Relevant information was independently extracted and compared to ensure agreement. The methodological quality of the studies was determined. A random-effects model was used. The adjusted odds ratios (ORs) and frequency-weighted means for the primary and secondary outcome measures were calculated.

Results: 

Our initial search identified 7110 articles. Of the 237 articles that underwent further evaluation of the abstract, nineteen (seven prospective and twelve retrospective cohort studies) were included. The adjusted OR of nonunion in the smoking group compared with the nonsmoking group was 2.32 (95% confidence interval [CI], 1.76 to 3.06; p < 0.001). An increased nonunion rate was observed in smokers with a tibial fracture (OR, 2.16; 95% CI, 1.55 to 3.01; p < 0.001) and those with an open fracture (OR, 1.95; 95% CI, 1.3 to 2.9; p < 0.001). For all fractures, the mean healing time was longer for smokers (30.2 weeks; 95% CI, 22.7 to 37.7 weeks) than for nonsmokers (24.1 weeks; 95% CI, 17.3 to 30.9 weeks) (p = 0.18). Trends toward more superficial and deep infections of postoperative or traumatic wounds in smokers were noted; however, the differences in superficial and deep infection rates were not significant (p = 0.13 and p = 0.33, respectively).

Conclusions: 

Smoking significantly increased the risk of nonunion of fractures overall, tibial fractures, and open fractures. Nonsignificant trends toward increased time to union in all fractures and toward increased postoperative rates of superficial and deep infections were noted in smokers compared with nonsmokers.

Level of Evidence: 

Prognostic Level III