Orthopedics
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Case Reports
Post-traumatic cerebral fat embolism prior to operative repair of femoral and tibial fractures.
Rare cases of primary cerebral fat embolism as a postoperative complication have been reported. In addition, cerebral fat embolism occurring before operative repair without shunt lesion are more rarely reported. We report a patient with a posttraumatic cerebral fat embolism resulting in severe neurologic dysfunction without right to left shunt. ⋯ Supportive medical treatment included endotracheal ventilatory support and tracheostomy. The patient was discharged from the hospital 50 days after admission. On follow-up 2 months later, he had returned to activities of daily living, however a speech disturbance remained.
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This study analyzed 14 patients with 17 broken intramedullary nails for the treatment of femoral fractures. Average distance from the fracture site was 7.9 cm in cases in which nail breakage occurred at the junction between the cylindrical and cloverleaf portions and 6.4 cm in cases in which nail breakage occurred at the screw hole. ⋯ Nonunion or delayed union is the main cause of nail breakage. Exchange nailing with bone grafting is a safe and effective method of treatment for a broken intramedullary nail with nonunion.
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Preoperative classification of proximal humeral fractures in addition to thorough knowledge of the specific anatomy and vascular blood supply is more important for successful treatment than the choice of implant. If reduction and fixation is necessary, aggressive reduction maneuvers can compromise humeral head perfusion with subsequent humeral head necrosis regardless of the implant used. Modern implants such as intramedullary proximal humeral nails and anatomically designed proximal humeral angular stable plates offer high primary stability even in osteoporotic bone with preservation of periosteal blood supply to the humeral head. ⋯ Minimally invasive, percutaneous techniques also demonstrate favorable results comparable to those mentioned above, although mean patient age tends to be younger in these studies and complications requiring reoperation tend to be more pronounced in elderly patients due to poor bone quality. Alternatively, nonoperative treatment of displaced two- and three-part fractures in elderly patients with severe morbidity and high perioperative risks should be considered. In elderly patients with selected displaced four-part fractures or fracture dislocations and head-split fractures, hemiarthroplasty offers high subjective patient satisfaction despite moderate function with most of the patients being pain free.
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Femoral neck fractures require urgent evacuation of intracapsular hematoma, anatomic reduction, and secure fixation with screws and cast immobilization. Extracapsular trochanteric and subtrochanteric fractures are best treated by fixed angle devices (locked plates or dynamic screw and side plate). "Length stable" low energy shaft fractures with minimal displacement or < 2 cm of shortening on presentation, are treated with one-leg spica casting (if the patient weighs < or = 50 lb. "transportable"). Unstable, complex (multifragmentary) and significantly displaced high energy shaft fractures are treated operatively. ⋯ We recommend hardware removal after complete fracture healing, usually in 6 to 12 months. Implants left in the growing child could become buried deep inside of the bone, or cause "periprosthetic" fractures and/or eventually impede adult reconstruction. Minimal risks are reported for hardware removal in healthy patients with healed fractures (4 cortices bridged).