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Osteomyelitis developed at closed fracture sites in two children. The infection responded to antibiotic therapy, and the fractures healed without chronic infection developing, impairment of bone growth, or loss of function. It is rare for a closed fracture to develop acute hematogenous osteomyelitis, but the diagnosis should be considered in a child with a closed fracture in whom a fever develops or who complains of increasing pain after the fracture has been reduced and immobilized. In children, the condition has an excellent prognosis.

Thirty-one closed fractures of the lower extremity in diabetics were retrospectively reviewed to determine healing times. There was a prolonged union time overall (163% of expected) and in both insulin and oral hypoglycemic-controlled diabetics (157% and 176% of expected). Displaced fractures showed a prolonged union time, while nondisplaced fractures healed in the normal time period (187% and 96% of expected). Fractures treated by open reduction had a more prolonged healing time than those treated by closed reduction (186% and 142% of expected), but this was primarily related to displacement. Sex and age had no effect on union time. The known effects of diabetes mellitus on bone and mineral metabolism in both experimental animals and humans may explain these prolonged union times.

The study compared the healing of fractures treated with rigid immobilization with the healing of fractures without internal fixation. Comparative studies were made of the cytologic, morphologic and mechanical properties of callus from closed fractures in 2 groups of dogs: one plated, the other not. Significant differences were observed in the 2 groups in early stages of healing. The biomechanical differences between the 2 groups persisted into later stages of healing, even after histologic and electron microscopic appearance of cellular activity and new bone formation had become similar. In general, closed, nondisplaced fractures of dogs' radii treated without surgical procedures and followed by early functional activity demonstrated a cytologically more active endosteal callus and increased biomechanical strength characteristics at the fracture site.

The effectiveness of the Lottes nail was evaluated in 63 consecutive cases of tibia fractures treated by closed intramedullary fixation with image intensification. The procedure was offered to all adults except those with Gustillo and Anderson Type III open wounds and with fractures less than 10 cm from the knee or 5 cm from the ankle. The operations were generally performed within a few days in closed fractures and somewhat later in open fractures. Patellar-tendon-bearing casts were applied five to ten days after operation, and weight-bearing to tolerance was emphasized. All fractures united. Bridging callus was generally seen by seven or eight weeks. Complications not necessarily peculiar to the procedure included one each of delayed wound infection, peroneal neurapraxia, compartment syndrome, heel decubitus, and shortening of more than 2 cm. Technical failures included malunion of fracture, loss of fixation by the nail, backing out of the nail, and penetration into the ankle joint. Most of the complications and technical failures could be remedied and did not influence the ultimate result. The authors recommended the Lottes nail and closed intramedullary nail fixation as the preferred method of treatment of diaphyseal fractures of the tibia in adults.

The charts and roentgenograms of 41 adult patients with severe head injuries who sustained 47 tibial shaft fractures were reviewed. Twenty-seven (57%) of the fractures were open and the incidence of peroneal nerve injury was 17%. The average time to weight-bearing was 3.1 months. Closed fractures united at 5.4 months and open fractures at 5.8 months. Three nonunions (6.5%) occurred in 2 patients. This review failed to demonstrate either an early rate of union or an abnormally high union rate. Furthermore, exuberant callus was not observed roentgenographically. Tibia fractures in adults with head injuries, whether on the normal or paralyzed extremity, appeared to heal in a fashion similar to fractures in normal patients. Conventional methods of treatment render satisfactory results.

Most closed fractures of the shaft of the femur and tibia can be treated successfully with internal fixation with medullary or interlocking nails. Unlike plate fixation, intramedullary nailing does not provide absolutely rigid fixation, so that some motion at the fracture site exists. The process of reaming causes circulatory disturbances in the inner two-thirds of the diaphyseal cortex. However, this does not impede the formation of external callus. The parts of bone that have sustained vascular damage by trauma or surgery are revascularized. Delay in the healing process due to disruption of the blood supply to fracture fragments is not known. The majority of patients are able to weight-bear a few days after surgery.

The role of external fixation in the management of femoral shaft fractures is reviewed based on a study of 24 femoral fractures managed by either an AO or a Wagner external fixator during 1983-1986. Indications included open fractures with soft-tissue injury (13 patients), comminuted shaft fractures (six patients), and unstable operative candidates (five patients). In 14 patients, external fixation was a temporary method (Group I), while in ten patients it was the definitive method of stabilization (Group II). Twenty-one patients achieved solid union, two developed a delayed union, and one had a nonunion. Three patients developed pin-tract infections, and one developed osteomyelitis after intramedullary fixation in Group I. Two patients in Group II developed shortening (2.1 cm and 3.2 cm). Loss of motion occurred in 11 patients, averaging 56 degrees. It is suggested that external fixation be considered in the following types of femoral fractures: open fractures for aggressive management of soft-tissue injuries; closed fractures in severely traumatized, burn, or head injury patients; fractures about the knee resulting in floating knees; and infected femoral nonunions and pseudarthroses.

Most fractures of the clavicle occur as isolated injuries and resolve without complications. A rare case of pneumothorax that complicated a clavicle fracture is reported in a 19-year-old man. The pneumothorax necessitated closed-tube thoracostomy. Six weeks of splint immobilization resulted in satisfactory union of the clavicle fracture. Complete chest and neurocirculatory examinations and careful review of pertinent radiographs enabled an early diagnosis of this rare complication of a fracture of the clavicle.

Aggressive treatment of the multiply injured patient often requires early fixation of many fractures, some of which may be open. Often, patients develop postoperative fevers requiring a thorough workup to rule out infection. Recently, indium-111 white blood cell (WBC) imaging has become a valuable adjunct in the diagnosis of acute infection. The patient described had a simple, closed clavicle fracture with markedly increased activity on an indium-111 WBC scan obtained for fever workup. This subsequently proved to be a normal, healing, noninfected fracture by other diagnostic techniques. Noninfected, simple closed fractures should be added to the list of causes for a false-positive indium-111 WBC scan.

Five cases of acute hematogenous osteomyelitis occurring at the site of closed fractures are reported. This is a serious and potentially lethal complication resulting in directly in the death of 3 of the 5 patients. This is an unusual occurrence seen infrequently, and subsequent delay in diagnosis is frequent. An awareness of this complication (which usually occurs in the face of decreased resistance to infection) coupled with careful inspection of the fracture site, evaluation of the patient as a whole, and a high index of suspicion will allow earlier diagnosis and possibly more successful early treatment. Because of the pathophysiology of this lesion and the usual delay in diagnosis, initial treatment should include wide surgical drainage of the abscess with proper debridement and bony resection. This may involve procedures which at first glance may appear to be mutilating. In these patients with decreased resistance to infection, the initial appropriate choice of antibiotics is essential.

FEVER following fractures of long bones is usually attributed to the resorption of the hematoma and the products of tissue damage. Despite the frequency of trauma and the extensive volume of medical literature on fever, this relationship has been inadequately documented. Knowledge of the frequency, onset, duration, and magnitude would be helpful in accessing the significance of fever in the postinjury period. The purpose of this study is to document this relationship in children. Materials The clinical courses of 78 children who had sustained unilateral closed fractures of the femoral shaft were studied. The children were in good health prior to the injury, and all were treated in either Bryant's or Russell's traction for a mean of 19 days prior to spica cast immobilization and discharge. Ages ranged from birth to 12 years with a peak incidence of fracture at 3 years of age and a gradual decline in frequency

Healing rates of various types of tibial-shaft fractures are compared as to type of treatment. Conservative management in adults is found to have certain advantages and certain limitations. In the case of closed tibial-shaft fractures, no advantage is shown for either open operative or closed treatment. The hazard of introducing infection is considered to be the single greatest deterrent to operative fixation of closed fractures. In this series, primary internal fixation of an open fracture is associated with a very real hazard of infection and with prolongation of the healing rate. Internal fixation of open tibial-shaft fractures should be reserved for those cases with minimal contamination and cases in which stability can be achieved with the least exposure of bone and the least quantity of metal implanted in the limb.

Dr. Turner: A 19-year-old college student was thrown through the rear door of an automobile following a two-car collision. He was admitted to a hospital in a neighboring state and was found to have the following multiple injuries: bilateral fractured pubic rami; bladder and urethral lacerations; bilateral closed femoral-shaft fractures; closed fracture-dislocation of the right ankle; closed fracture of the right medial tibial plateau; right peroneal nerve palsy; open fractures of the left tibia and fibula with gross contamination and loss of approximately five inches of the middle portion of the tibia. Blood supply and sensation were entirely normal in the left foot. After initial management of shock by transfusion with seven units of whole blood, laparotomy was performed to repair the lacerated bladder. He was placed in bilateral balanced suspension with bilateral proximal tibial wires for traction. The left leg wound was debrided and packed open, but became grossly

The authors review 115 fractures of the shaft of the tibia of which 111 were treated by closed conservative measures. Emphasis is placed on the use of the traction hitch for the closed reduction of such fractures. The end-results of all cases were studied to determine the period of healing from immobilization to full weight bearing. The average period was 26 weeks for all cases, with an average of 22 weeks for the closed fractures and 29 weeks for the open fractures. The complications encountered are reviewed. The method of treatment described is not new, but an appeal is made for a reevaluation, by all physicians treating tibial shaft fractures, of the inherent value of conservative means of treating such fractures.

Vascular injuries of the extremities associated with closed fractures in civilian practice have given poor results because of delay in diagnosis or inadequate treatment. Five cases are presented where arteriography defined the site and suggested the type of arterial obstruction. The treatment consisted of arteriolysis, thrombectomy, or intimal repair or some combination of these. Low molecular dextran 40 was used in all cases and heparin sodium in one. A normal functioning limb resulted in all patients.

The early management of fractures embraces both the temporary emergency management and the early definitive management of both open and closed fractures. The temporary emergency management is nothing more than the emergency splinting for transportation to and within the hospital. This is a facet of management of fractures lacking in color, appeal, and, all too often, professional interest. However, it remains an exceedingly important, albeit a frequently neglected, part of early management. Fractures of long bones, particularly those of the lower extremities, must be splinted at the first opportunity if the best interests of the patient are to be served. Emergency Splinting The significance of effective emergency splinting must not be underevaluated. It prevents further damage to soft parts by sharp fragments. In so doing, it may prevent the catastrophe of laceration of a major blood vessel or a peripheral nerve or compounding of a closed fracture. It minimizes pain

"The pendulum has swung too far in the direction of operative treatment of fractures" said Dr. W. B. Coley 1 of New York, last December, at the annual meeting of the Southern Surgical and Gynecological Association. This sentence shall be the motto of the present paper. Because of some unsatisfactory results in the conservative methods, the operative treatment of fractures has gained some ground in the last decade, and has justly become the treatment of choice for a few types of fractures. Unfortunately, many surgeons, following such extremists as Arbuthnot Lane, have attempted to operate on all fractures, without indications of any sort. This policy makes things much easier, of course; it does away with the study of anatomy and the study of the different types of fractures; the surgeon does not have to think any more, not even for the diagnosis, as this is given to him by the Roentgen rays; he

Dr. David Grainger: The patient is a 39-year-old female, physical education instructor whose automobile was involved in a head-on collision while returning from a weekend of skiing. She was unconscious for approximately three minutes but was oriented when she arrived at the local hospital. Her chief complaints were pain in her right hip, abdomen, and chest. Examination and x-ray films at the local hospital revealed the following injuries: (1) closed fracture of right acetabulum with posterior dislocation of right hip (Fig 1), (2) closed fracture of left fifth metacarpal, (3) fracture of left third rib, (4) laceration of right leg, (5) multiple contusions and abrasions, and (6) possible intraperitoneal injury. A Foley catheter was inserted into the bladder without difficulty, and the specimen obtained was within normal limits. The patient was observed closely for several hours while being given appropriate fluid replacement, and gradual stabilization of her vital signs occurred.

Introduction Those concerned with fracture management have frequently implied that closed and uncomplicated fractures may be associated with large losses of blood. A review of the literature, however, has failed to uncover experimental evidence to substantiate this opinion. Accordingly, a series of studies has been carried out in an effort to determine the effects of varying types of fracture upon the circulating red cell mass of the splenectomized dog. The initial study of the experimental program was performed with a series of dogs that were subjected to closed fractures of one or more long bones. Contrary to expectations, such injuries were followed by minimal blood loss at the fracture site and by an increase in the circulating red cell mass as measured with radiochromate.1 The present investigation is concerned with the effect of pelvic fracture upon the circulating red cell mass. Fractures of the pelvis have been produced in

Introduction Fracture of a long bone in the dog produces dramatic alterations in the hemodynamics of the injured region. Widespread vasodilation with accompanying increase in blood flow occurs in the fractured limb. 4 Associated changes in the general circulation have not been clearly demonstrated. Textbooks of surgery and orthopedic surgery imply that extensive blood loss follows fracture of a long bone. 1,2 On the other hand, we have been unable to find documented proof that significant hemorrhage accompanies the usual uncomplicated fracture. The present study was carried out in an effort to estimate, in a reasonably critical fashion, the amount of hemorrhage that accompanies a closed fracture of a long bone. Fracture sites were restricted to areas with relatively little paraskeletal soft tissue, in an effort to separate the effects of skeletal trauma from those of soft tissue injury. The dog rather than the human was employed in this investigation

To the Editor:— In connection with Dr. H. Earle Conwell's communication (The Journal, October 25, p. 531) the following is submitted for the consideration of those concerned with fracture nomenclature. Generally speaking, it is desirable that a nomenclature use terms which are self-explanatory and which need little or no agreement as to what they mean. Consequently, if the terms "simple fracture" and "compound fracture," which are meaningless unless defined and agreed on, could be replaced by better terms much would be gained. Erich Lexer, the late Munich surgeon, was well aware of this; he objected against the corresponding German terms of "einfache" and "komplizierte Fraktur," and he insisted in the use of "geschlossener" and "offener Bruch," i. e. "closed fracture" and "open fracture." Undoubtedly, these terms tell, without any explanation or agreement as to meaning, whether there is or has been contact between the fractured bones and the outside world.

If orthopedic surgery is to contribute anything to the present treatment of fractures, it will be in the direction of greater conservatism in the use of open operations, and in the advance of the use of more perfect methods for the external or closed (mechanical) reduction and fixation of fractures. Accurate manipulative reduction, splinting and extension is a fine art which is not to be replaced by the scalpel, bone plate or bone clamp. Operative intervention in closed fractures is at all times a hazardous and difficult undertaking; volumes have been written, and endless surgical debates are still going on, as to whether it is indicated or justifiable except in unusual cases; but for the purpose of this paper this subject must be left in statu quo. In compound fractures, three additional factors are introduced of such vital import as absolutely to contraindicate, to my mind, all immediate operative intervention

To the Editor:— In many instances, and for years, I have emphasized what misnomers the terms "simple" and "compound" fractures are, especially when one realizes that a simple fracture can be accompanied by the most complicated pathology in surrounding tissues and can be more severe in many instances than the so-called compound fracture. In my opinion, the presently-used terms should be supplanted by the following: (1) closed fracture, in many instances complex closed fracture, and (2) open fracture. "Simple" fracture does not define the injury to the soft tissues, the intramuscular hemorrhage, or the loss of sensation of the parts of the tissue close to the fracture area. Neither does it emphasize the possible marked displacement of bone fragments. Too frequently, if all these exist with no open wound, the term simple fracture is used. I believe it is important that we classify as complex closed fractures those which do

Bone morphogenetic proteins (BMPs) are known to induce new bone formation in vivo but treating trabecular bone defects with a BMP based therapeutic remains controversial. Here, we evaluated the safety and efficacy of a novel Autologous Bone Graft Substitute (ABGS) comprised of recombinant human BMP6 (rhBMP6) dispersed within an autologous blood coagulum (ABC) as a physiological natural carrier in patients with a closed distal radial fracture (DRF). We enrolled 32 patients in a randomized, standard of care (SoC) and placebo (PBO) controlled, double-blinded Phase I First in Human (FiH) clinical trial. ABGS was prepared from peripheral blood as 250 μg rhBMP6/mL ABC or PBO (1 mL ABC containing excipients only) and was administered dorsally via a syringe injection into the fracture site following closed fracture fixation with 3 Kirschner wires. Patients carried an immobilization for 5 weeks and were followed-up for 0 to 26 weeks by clinical examination, safety, serial radiographic analyses and CT. During the 13 weeks follow-up and at 26 weeks post study there were no serious adverse reactions recorded. The results showed that there were no detectable anti- rhBMP6 antibodies in the blood of any of the 32 patients at 13- and 26-weeks following treatment. Pharmacokinetic analyses of plasma from patients treated with ABGS showed no detectable rhBMP6 at any time point within the first 24 h following administration. The CT image and radiographic analyses score from patients treated with AGBS showed significantly accelerated bone healing as compared to PBO and SoC at 5 and 9 weeks (with high effect sizes and P = 0.027), while at week 13 all patients had similar healing outcomes. In conclusion, we show that intraosseous administration of ABGS (250 μg rhBMP6/mL ABC) into the distal radial fracture site demonstrated a good tolerability with no serious adverse reactions as well as early accelerated trabecular bone healing as compared to control PBO and SoC patients.