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Objective To assess the clinical outcomes of open calcaneal fractures with medial wounds treated with one‐stage management, including early modern wound care, sequential reduction, and frame structure fixation using percutaneous Kirschner wires. Methods A total of 19 patients with open calcaneal fractures admitted to our hospital from May 2016 to March 2019 were selected in this study. Twelve type‐II and seven type‐IIIA medial open injuries were identified according to the classification of Gustilo and Anderson. Fractures were stratified by Sanders classification, including nine type‐II fractures, seven type‐III fractures, and three type‐IV fractures. All patients accepted one‐stage irrigation and debridement, sequential reduction of calcaneal fractures through the open medial wound, percutaneous Kirschner wire fixation, and primary closure of wounds covered with vacuum‐assisted closure (VAC) device. The Bohler angle, the Gissane angle, and the width of the calcaneus were compared before and after surgery. The functional results were evaluated according to the Paley and Hall score system, visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Maryland Foot Score, and related complications. Results The follow‐up duration for all patients ranged from 14 to 28 months (mean, 22.7 months). The angle of Bohler and Giasane was increased from (−7.6° ± 15.0°) and (96.6° ± 7.6°) before surgery to (23.7° ± 6.1°) and (124.1° ± 7.1°) postoperatively (P, Open calcaneus fractures with medial wound is treated by one‐stage sequential reduction and frame structure fixation using percutaneous Kirschner wires. This technique allows direct restoration of calcaneal morphology with a minimal invasion of soft tissues at an early stage.

Various open injury scores have been devised to aid the difficult decision of salvage or amputation following open fractures of the lower limb. Our aim of the study was to compare the performance of mangled extremity severity score (MESS), limb salvage index (LSI), orthopaedic trauma association-open fracture classification (OTA-OFC) and Ganga hospital score (GHS) in our population of type IIIB injuries. A total of 219 patients with 225 type IIIB open fractures of the tibia were studied prospectively between July 2016 and June 2017. The decision of salvage or amputation was taken by a combined consensus of senior orthopaedic and plastic surgeons, blinded to the scores. All four open injury scores were calculated by an independent reviewer following initial debridement. The follow-up period was one to two years. After final follow-up, there were 193 (85.7%) successfully salvaged limbs, 19 primary amputations without attempt of debridement (8.4%), three primary delayed amputations within 72 hours (1.3%) and six secondary amputations after 72 hours from initial debridement (2.7%). Of these, four patients died within one year and were excluded. All four scores performed well for salvage, while GHS was superior when considering amputation. MESS, LSI and OTA-OFC underscored amputations, since these scoring systems award more points for vascular injuries. There were both salvaged and amputated patients around the threshold value of amputation for all scores, which was only acknowledged by GHS in its unique ‘grey zone’. It includes patients who are neither easily salvageable nor definitely requiring amputation. The performance of the GHS was superior to MESS, LSI and OTA-OFC in our study, since it was developed for type IIIB injuries and includes the ‘grey zone’, where decisions need to be undertaken on a case to case basis. GHS has an improved ability to determine amputation in IIIB open tibia fractures.

This case report describes the management of a 27-year-old male who, after a quadbike accident, presented with an open, infected, segmental both bone forearm injury with significant bone and soft tissue loss including the radio-carpal joint. Limb salvage was accomplished in the form of a single bone forearm fusion utilising Masquelet's two-stage induced membrane technique to reconstruct the segmental bone defect. The patient proceeded to uneventful bony union by 6 months and returned to driving and riding a quadbike. Despite significant deep infection, successful salvage was achieved using the induced membrane technique. Critical to success was aggressive, repeated debridement alongside restoration of vascular supply and reconstruction of soft tissue defects. We highlight the multidisciplinary approach to management including relevant specialists with a particular interest in limb reconstruction.

Case We report 3 adult men (aged 28, 34, and 71 years) with successfully salvaged mangled injuries around the shoulder with high threshold for amputation. Assessment by Mangled Extremity Severity Score, Ganga Hospital Open Injury Severity Score, and Orthopaedic Trauma Association-Open Fracture Classification open injury scores predicted amputation. However, extended salvage was performed by orthoplastic approach. Two of them had superior shoulder suspensory complex (SSSC) injury. The QuickDASH score was high in 2 patients with SSSC injury and a good score in the third patient who achieved good shoulder motion. Conclusion "Orthoplastic approach" achieves successful limb salvage in severely mangled shoulder injuries. Volume of muscle crush injury and double disruption of SSSC injury were the main determinants of outcome.

Closed pantalar dislocations are a rare variant of an uncommon injury. Pantalar dislocations are typically caused by high-energy trauma resulting in an open injury with associated fracture of the articulating bones. Given its obscurity, the literature on closed pantalar dislocations is scarce, and no standard treatment protocol has been accepted. This case report chronicles the treatment and outcome of a 29-year-old man who presented with a checkrein deformity of all digits after a closed pantalar dislocation with 6-month follow-up. A comprehensive literature review found 28 articles representing 39 patients with closed pantalar dislocations without talar neck or body fractures. Roughly equal numbers of closed and open reduction techniques were performed with avascular necrosis occurring in 7 of 36 patients. Although outcome measures and follow-up were variable, what can be considered a suitable outcome was seen in approximately 83% of patients, with only 3 of 35 requiring a secondary operation. Long-term studies with well-defined outcome measures are needed to adequately predict the prognosis of this rare injury and efficacy of treatment protocols.

Total talar extrusion is a rare injury that most commonly occurs secondary to high-energy trauma. There are few reported cases of open dislocations in literature and still, there is no consensus regarding the appropriate treatment of the extruded talus. In this case report, we present a 12-month follow-up of a patient with an open talar dislocation with extrusion treated with immediate surgical debridement, reduction and temporary fixation with one Steinmann pin. No infection was reported, although the patient developed avascular necrosis.

Introduction and aims Open injuries in children are rare compared to adults. In children with major open injuries, there is no specific scoring system to guide when to amputate or salvage the limb. The use of available adult scoring systems may lead to errors in management. The role of Ganga Hospital Open Injury Severity Scoring (GHOISS) for open injuries in adults is well established and its applicability for pediatric open injuries has not been studied. This study was done to analyse the usefulness of GHOISS in pediatric open injuries and to compare it with MESS(Mangled Extremity Severity Score). Methods All children (0–18 years) who were admitted with Open type IIIB injuries of lower limbs between January 2008 and March 2015 were included. MESS and GHOISS were calculated for all the patients. There were 50 children with 52 type IIIB Open injuries of which 39 had open tibial fractures and 13 had open femur fractures. Results Out of 52 type IIIB open injuries, 48 were salvaged and 4 were amputated. A MESS score of 7 and above had sensitivity of 25% for amputation while GHOISS of 17 and above was found to be more accurate for determining amputation with sensitivity of 75% and specificity of 93.75%. Conclusion GHOISS is a reliable predictor of injury severity in type IIIB open fractures in children and can be used as a guide for decision-making. The use of MESS score in children has a lower predictive value compared to GHOISS in deciding amputation versus salvage. A GHOISS of 17 or more has the highest sensitivity and specificity to predict amputation.

Objective Penetrating trauma to the buttock is relatively common. Because of the location of the trauma and complicated peripheral anatomical structures, surgery to the area can be difficult. We report the cases of 2 patients who sustained penetrating trauma to the buttock and underwent operative treatment assisted by spinal endoscopy. Methods With the rapid development of minimally invasive spine surgery techniques in recent years, especially the wide application of endoscopy, we treated 2 cases of penetrating trauma with endoscopic probing within the wound channel, followed by hemostasis and postoperative irrigation and drainage. Results Drainage tubes were removed from the 2 patients within 7 days after the surgery. Their wounds were healing well and they were discharged from the hospital within 12 days. Conclusions If there is no injury to the large blood vessels, intestines, or urinary system, satisfactory clinical results can be obtained using spinal endoscopy to probe, irrigate, and identify foreign objects, when combined with hemostasis, postoperative short-term irrigation and debridement, and the use of antibiotics.

Knee dislocation with concomitant multiligament injury is a rare and devastating injury. We report the successful repair of a rare case of open knee dislocation with concomitant multiligament injury and patellar tendon rupture of an 18-year-old male due to a motorcycle accident. The patient presented with an open wound running parallel to the knee joint line and patellar tendon rupture with full exposure of the cartilage of the distal femur. Staged surgical management including the application of a ring-type external fixator with a hinged joint, lateral collateral ligament repair, medial collateral ligament reconstruction using autogenous hamstring tendon, and joint release was performed. Range of movement was recovered to 0 degrees of knee extension and 80 degrees of knee flexion, and extension lag was negative. The Lysholm score of the patient was recovered to 92. The patient was able to return to work in the construction field 2 years after sustaining the injury. The patient had no complaint of pain and was able to resume construction work, even though reconstruction of the anterior cruciate ligament and posterior cruciate ligament was not performed. The application of a hinged ring-type external fixation device might play a key role in early range of movement restoration and to maintain the reduced position and acceptable recovery of the posterior cruciate ligament injury without the need for reconstructive surgery. This report is the first to describe the safety and effectiveness of staged surgical management for the repair of open knee dislocation with concomitant multiligament injury and patellar tendon rupture. However, further studies with longer follow-up periods will be needed to observe the development of osteoarthritis or weakness of the knee. Staged surgical management is a safe and effective procedure for repairing an open knee dislocation with concomitant multiligament injury and patellar tendon rupture.

Background: The excellent method for treating fractures of the tibial shaft was the closed intramedullary nailing technique. But because of limited references related to the results, incidence of infection, non-union of open injury. Hence, it was decided to analyse open tibial fractures treatment by primary interlocking nailing.Methods: 50 Patients with open fractures of the tibial shaft which were treated with primary interlocking nail were studied in the period of 14 months.Results: In present study 18 (36%) type I, 22 (44%) type II and 10 (20%) type IIIA Gustilo open fractures were treated. The average duration of time between injury and nailing was 3.5 hours (range was 1.5 hours to 4 hours). After reaming, 40 (80%) fractures were fixed, without reaming, 10 (20%) of fractures were fixed. The average time to union was 27 weeks for type I fractures, 30 weeks for type II fractures and 33 weeks for type IIIA fractures. There was 1 non-union. There were 4 deep infections.Conclusions: The best mode of therapy was primary interlocking intramedullary nailing for open fractures.

Open scapulothoracic dissociation (SD) is a rare injury and an average orthopaedic surgeon might be practically unaware of this entity. To our knowledge, there are hardly any cases of open SD reported in the English literature. We present one such case of open injury associated with total brachial plexus injury, but without any component of vascular injury. The patient was managed by aggressive debridement and fixation of the osseous injury which helped us save the patient from the dreadful complication of sepsis associated with such a severe injury. We briefly review the literature regarding SD and also discuss the management options when encountered with such a severe and rare injury.

Aim: This study was planned to determine the demographic, etiological and clinical characteristics and the treatment costs of the patients with open isolated hand and/or wrist injuries.Material and Methods: In this study, the data of 127 patients who were admitted to the adult emergency department due to hand and / or wrist trauma between 01.01.2018 and 06.30.2018 were examined. Data on demographic data, shape and clinic of injury were summarized as number and percentage. Shapiro Wilk test was used to determine whether the numerical measurements were compatible with the normal distribution and Kruskal Wallis test was used for comparison of cost between groups.Results: Of the patients, 81.1% were male and the most common injury was seen in the age group of 19-64 and workers. Fingers were the most frequently injured areas and the most common injured finger was the index finger. The first two reasons in the aetiology were home and occupational accidents. Penetrating/cutting was the most common injury mechanism. There was no significant difference between occupation groups in terms of cost (p>0.05) but there was a significant difference between diverse treatment methods (p0.0001). Conclusion: Hand and / or wrist open injuries not only represent a significant part of all injuries but also represent a significant economic burden with high health costs. Measures to prevent such injuries could contribute to lowering health expenditures.

Objective: This is the first report of successful allograft mosaicplasty treatment of a large osteochondral lesion of the knee caused by a blast fragment sustained during combat operations. The patient was able to return to active duty following rehabilitation. Methods: An active-duty infantryman sustained an osteochondral lesion of the medial femoral condyle caused by a metallic fragment of an explosively formed projectile. Initial treatment consisted of removal of the foreign body and primary closure. The patient continued to experience pain, mechanical symptoms, and repeated effusions after initial nonoperative treatment. Allograft mosaicplasty of the lesion utilizing two 18-mm-diameter fresh allograft osteochondral plugs was performed at 6 months post-injury. Results: At 2-year follow-up, the patient remains on active duty with marked improvement in symptoms. Two years postoperatively, his outcome scores are 72 of 100 on the Western Ontario and McMaster University osteoarthritis scoring index (WOMAC) and 60 of 100 on the Knee Injury and Osteoarthritis Outcome Score (KOOS). His follow-up x-rays and MRI demonstrate intact articular cartilage and subchondral bone incorporation. Conclusion: Penetrating injuries to joints are commonplace in the battlefield environment. Combat injuries to the knee are frequently associated with articular cartilage injury. While numerous cartilage restoration techniques have been used with success for the treatment of osteochondral injuries to the femoral condyles, no published reports describe the use of allograft mosaicplasty in this location for open, penetrating injuries with focal cartilage loss. This is the first documented use of allograft mosaicplasty for a traumatic osteochondral defect of the medial femoral condyle caused by a metallic projectile. The patient was able to return to active duty following rehabilitation. We demonstrate a high level of functioning is possible following allograft mosaicplasty of a large osteochondral lesion caused by penetrating ballistic trauma.

Infections in and around the calcaneus can be quite challenging for the patients and physicians involved. These infections arise because of multiple potential etiologies including chronic pressure, trauma, and postsurgical wound-healing complications. The impediments to healing can be equally as diverse depending on patients' comorbidities, such as smoking, diabetes, and open injury. In this article the authors review the anatomy of the calcaneus and surrounding soft tissue, patient risk factors, and various treatment options that can be used through a multidisciplinary approach. The common limiting factor for most of these patients is the delicate soft-tissue envelope, and occasionally, the lack thereof. The ultimate goal is an infection-free limb with durable soft-tissue coverage and maximal maintenance of function.

開放性咽頭外傷によって高度舌運動障害を生じた非常にまれな症例を経験した。症例は39歳男性，自宅で転倒し，ガラス戸に頭から突っ込み，頸部に深い裂傷を負った。救急搬送時にはショック状態で気管切開後，閉創した。その後，高度の舌運動障害を認め，構音訓練と嚥下障害を呈した。その後，舌の萎縮を認めるようになったが，構音訓練のリハビリテーションを中心に施行し，発語明瞭度の改善とともに嚥下障害を補うことができた

Extremity damage in disaster as well as combat situation, particularly of the lower limb, is typically a high-energy trauma with open injury [1, 2]. These dramatic conditions confront surgeons among others with significant human and ethical problems [3]. Hereby treatment of severely injured limbs challenges orthopedic surgeons [4]. It is important that in these extreme situations, only surgical specialists and senior trainees should be deployed and not be used as a training field for junior residents [5].

Introduction The standards for the management of open fractures of the lower limb published by the British Association of Plastic, Reconstructive and Aesthetic surgeons (BAPRAS) and British Orthopaedic Association (BOA) were introduced to improve the treatment received by patients after open injury to the lower limb. These Standards were released after BAPRAS/BOA published Guidelines for the management of open tibial fractures. Methods We wished to determine the impact of these Standards upon the surgical management of open tibial fractures by comparing patients admitted to an orthoplastic centre in the 45 months concluding December 2009 (the Guidelines era) with those admitted during 2011 (the Standards era). Surgical procedures required during the first 30 days and 12 months after injury were determined. Cases were divided into ‘directly admitted patients’ (DAP) and ‘transferred patients’ (TP). Standards-era patients were divided further into those who had surgery exclusively at the orthoplastic centre (orthoplastic patients (OPP)) and those transferred after surgery (TASP). Results The number of TP trebled in frequency in the Standards era, 25% of whom were transferred before surgery. Significantly fewer surgical procedures were required for DAP and OPP groups compared with TP (and TASP) groups in both eras (Mann–Whitney U-test, p=0.05). DAP and OPP groups during the Standards era underwent the fewest procedures, with the vast majority of cases treated with two or fewer procedures in the first 12 months (88% and 80%, respectively, compared with 61% in the Guidelines era). In the Guidelines era, 44% of TP cases and in the Standards era 39% of TP and 29% of TASP groups underwent two or fewer procedures. Approximately two-thirds of open tibial fractures managed in our orthoplastic centre were patients transferred after surgery. The greatest impact of the Standards was evident for those who underwent surgery exclusively in the orthoplastic centre, reflecting a more deliberate combined strategy. Conclusion These findings vindicate the Standards as well as mandating reorganisation and resourcing of orthoplastic services to ensure immediate transfer and early combined surgery. By increasing the capacity to deal with time-dependent initial surgery, the surgical burden that the patient must endure, and which the service must provide, are reduced.

Thirty percent of fractures involve the hand with the same proportion involving the metacarpal. Most are treated nonoperatively with the emphasis being on achieving restoration of function for the individual. Biomechanically the index and middle fingers contribute to the central stable section of the hand with the other metacarpals including the thumb forming the mobile units. Fracture angulation, shortening and rotation are poorly tolerated in the fixed metacarpals and may require surgical intervention. Intra-articular fractures in the metacarpal head are relatively uncommon but often are associated with significant soft tissue damage or open injury. Like the more common intra-articular fractures at the base of the metacarpal, restoring large fragments back in place is the key for long term outcome and stability of the involved joint. Open injuries require thorough debridement and procedures to achieve appropriate skin cover. Involvement of specialists in hand therapy and surgery at an early stage is important in order to get those with metacarpal fractures, who are often young, back to function and employment.

Traumatic scapulothoracic dissocation is a rare upper extremity injury caused by massive traction or blunt trauma. Most cases are associated with a large spectrum of concomitant injuries, including severe musculoskeletal injuries and neurovascular injuries around the shoulder. But, it occurs without damaging overlying skin as a closed injury rather than an open injury. We present a case of open scapulothoracic dissociation and describe clinical features with literature review.

This article reports a case of the blunt open injury to the lower extremities resulting from the overextension of the knee joint that, despite it severity, turned out to be a mere accompanying event of a more serious condition. This case is of great interest in the context of forensic medical expertise by virtue of the apparent discrepancy between the extent of the injury and the circumstances of the accident. Clearly, such discrepancy may influence the reliability of the expert conclusion as regards the evaluation of such injury.

The authors conducted a retrospective review at their level I trauma center to assess the outcomes of closed vs open pediatric tibial fractures treated with titanium elastic nails. The study group included 38 pediatric patients (median age, 12 years) treated with titanium elastic nails for tibial fractures during a 5-year period. Patient demographics, closed or open injury, Gustilo-Anderson type for open fractures, fracture location, skeletal maturity, time to union, hospital length of stay, number of procedures performed per patient, and complications were recorded. The main outcome measures were time to union and complications. Average follow-up duration was 13 months. Mean time to union was 4 months for closed and 9 months for open fractures ( P P =.02). Delayed union (>6 months postoperatively) occurred in 1 (6%) of 17 closed fractures compared with 11 (52%) of 21 open fractures. The average number of surgical procedures for closed fractures was fewer than for open fractures (2 vs 3 procedures, respectively; P =.03). Mean hospital length of stay was shorter for closed than open fractures (3 vs 6 days, respectively; P =.03). Two infections occurred in the open fracture group. Closed and open pediatric tibial shaft fractures can be successfully treated with titanium elastic nails. Open fractures treated with titanium elastic nails have a significantly longer time to union, require additional operative procedures, and result in longer hospital stays.

Aim:To report our experience with the Masquelet concept in a pediatric upper extremity following an open injury to the elbow.Methods:A case report and literature review.Results:An 11-year-old boy was transferred to our institution after a motor vehicle collision. There was a primary loss of the ulnohumeral articulation and the surrounding soft tissues as well as the ulnar nerve. Reconstruction used the Masquelet-induced membrane technique and a soft tissue flap. At the 30-month follow-up, the extremity was pain free and functional.Conclusion:This case highlights the value of the Masquelet technique in pediatric extremity injuries, where there is a loss of a major articular segment, as well as significant soft tissue compromise.

Tendon surgery only started in the early 16th century when one differentiated between nerves and tendons as, e.g., depicted by Leonardo da Vinci, Andreas Vesalius, and Rembrandt. The breakthrough, however, was only achieved in the 20th century with the advent of improved suturing material. Horsehair, linen, cotton, and silk threads used until then only poorly glided in the tendon sheath, such that as late as 1916 it was recommended to amputate an injured fi nger so as not to impair the fi nger or indeed the whole hand. Claude Verdan was the fi rst to demonstrate a primary suture of a severed fl exor tendon in 1961. Six years later Harold Kleinert was the fi rst to successfully rejoin tendons in zone 2. In 1973, he furthermore recommended dynamic splinting of the fi nger generally leading to its full functional restitution. Later the secondary suture of the fl exor tendon was abandoned and the delayed primary suture was introduced by Buck-Gramcko et al. (1983).

In the management of Type IIIb injuries, Gustilo's classification has the disadvantages of a poor intra and inter-observer agreement rate, low specificity and sensitivity to salvage and inability to predict functional outcomes. We propose here a validated score which assesses the severity of injury to the covering structures, skeletal structures and functional tissues of the injured limb separately along with providing weightage to the presence of co-morbid factors. A high sensitivity and specificity for amputation was documented when a score of 14 was used as the threshold score. In salvaged limbs, the score was found to offer guidelines in protocols for reconstruction. According to the total score, injuries were treated by 'Fix and close' protocol; 'Fix, Bone Graft and Close' protocol, 'Fix and Flap' protocol or 'Stabilise, Watch, Assess and Reconstruct' protocol. The score was thus found to be useful clinically not only to assess salvage but also to provide guidelines in reconstruction.

We retrospectively reviewed 207 patients suffering from traumatic bone defect who had been treated at our institution between 1973 and 1993. Three types of traumatic bone defects were identified: I, minor; II, major cortical; III, major articular. Each type was further subdivided into: A, open injury; B, closed injury. The proposed treatment modality of each type was included within each classification. Types II and III posed the greatest difficulties in management. However, massive bone allografts can be successfully used in these situations, even in the early phases of treatment, but only given specific prerequisites.

Although dislocations occurring at either the proximal or distal interphalangeal joints of a finger are common, it is rare to encounter simultaneous dislocations of both joints. We report a case of an open double interphalangeal joint dislocation of a little finger. The mechanism of injury is discussed and the role of non-operative treatment evaluated. In 1874 Bartels first described double dislocation in a finger. Since then only five reports of this unusual occurrence have appeared in the English literature. The little finger of the dominant hand is frequently involved (Nathan and Schlein, 1973; Freitag et al., 1977) suggesting it is more injury-prone. This may be due to lack of protection from surrounding fingers which help dissipate the force of a blow, or to its ligaments which are inherently weaker. This case is unusual in that it was an open injury successfully treated by simple manual reduction. All previously reported cases involving the little finger were closed injuries, were easily reduced and have done well following splintage. Case report

CASE REPORT An l&year-old male construction worker fell from a height of 2m and landed on his left hand with outstretched fingers and sustained an acute, hyperextension injury to the MP joints of all fingers. He sustained a transverse wound at the level of the distal palmar crease (Fig. 1). The index, middle and ring fingers were held in extension at the MP joints and these joints could not be flexed. A radiograph showed dorsal dislocation of the MP joint of the index and middle fingers and subluxation of the MP joint of the ring finger (Fig. 2). Two hours after injury a closed manipulation was attempted in the emergency department, by distally directed traction on the fingers and gentle flexion of the MP joints. With this manipulation the MP joints of the middle and the ring fingers were reduced but the MP joint of the index finger proved irreducible. The wound on the palm was excised, cleaned and explored. It was found to communicate with the MP joints.

A case is reported in which a severe open injury of the thigh eventually required amputation of the lower limb. Lengthening of the short proximal femoral stump was achieved by turning over a flap comprising bone and soft tissue, with sensation, from the ipsilateral leg.

This chapter discusses natural disease in glider pilots. A tandem two-seater glider was being flown with a cadet pupil in the front seat and an extremely experienced instructor, aged 43, in the rear. As the machine was turning at a height of about 300–400 ft, it was seen to go into a spin that continued until it struck the side of a hut. The cadet escaped unhurt; the instructor was found dead on the roof of the hut. At autopsy, a gross open injury to the chest was found, the heart was badly lacerated and the left ventricle was found to be avulsed and recovered from outside the body. The combination of all the circumstances of the accident, the instructor's considerable experience, the relative competence of the pupil cadet, and the lack of any acceptable alternative explanation for the loss of control, led to the conclusion that the instructor had probably suffered an acute coronary insufficiency in flight at a low altitude that had caused the accident.