BackgroundTo describe the patient population, etiology, and complications associated with thigh compartment syndrome (TCS). TCS is a rare condition, affecting less than 0.3% of trauma patients, caused by elevated pressure within a constrained fascial space which can result in tissue necrosis, fibrosis, and physical impairment in addition to other complications. Compartment releases performed after irreversible tissue ischemia has developed can lead to severe infection, amputation, and systemic complications including renal insufficiency and death.MethodsThis study examines the course of treatment of 23 consecutive patients with 26 thigh compartment syndromes sustained during an eight-year period at two Level 1 trauma centers, each admitting more than 2,000 trauma patients yearly.ResultsPatients developing TCS were young (average 35.4 years) and likely to have a vascular injury on presentation (57.7%). A tense and edematous thigh was the most consistent clinical exam finding leading to compartment release (69.5%). Average time from admission to the operating room was 18 +/- 4.3 hours and 8/23 (34.8%) were noted to have ischemic muscle changes at the time of release. Half of those patients (4/8) developed local complications requiring limb amputations.ConclusionTCS is often associated with high energy trauma and is difficult to diagnose in uncooperative, obtunded and multiply injured patients. Vascular injuries are a common underlying cause and require prompt recognition and a multidisciplinary approach including the trauma and orthopaedic surgeons, intensive care team, vascular surgery and interventional radiology. Prompt recognition and treatment of TCS are paramount to avoid the catastrophic acute and long term morbidities.

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. Transverse or short oblique shaft fractures in patients < 12 years may be treated with elastic intramedullary nails. Bridge plating will provide better stability in complex fractures. Children > 12 years have less risk of vascular disturbance to the proximal physis, and should have lateral transtrochanateric entry locked rigid nails. Fractures with severe soft tissue injuries could be temporized with external fixation. Distal physis and epiphyseal injuries require anatomical reduction and smooth wires and/or screw fixation (placed in such a way as to minimize further damage to the physis) and need to be augmented with a brace. Leg-length discrepancy is not a significant clinical problem in operatively treated patients. 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).

The use of computer navigation in orthopedic surgery allows for real time intraoperative feedback resulting in higher precision of bone cuts, better alignment of implants and extremities, easier fracture reductions, less radiation and better documentation than what is possible in classical orthopaedic procedures. There is no need for direct and repeated visualization of many anatomical landmarks (classical method) in order to have good intraoperative orientation. Navigation technology depicts anatomy and position of "smart tools" on the screen allowing for high surgical precision (smaller number of outliers from desired goal) and with less soft tissue dissection (minimally invasive surgery - MIS). As a result, there are more happy patients with less pain, faster recovery, better functional outcome and well positioned, long lasting implants. In general, navigation cases are longer on the average 10 to 20 minutes, special training is required and equipment is relatively expensive. CAOS applications in knee and hip joint replacement are discussed.

The large spectrum of open fractures is an amalgamation of injuries with the single variable in common of communication of the fractured bone with the outside environment, and thus an increased risk for infection. Contributing to the presence of bacteria within the fracture site is devascularized soft tissue, the degree of which can be directly attributed to the amount of energy imparted to the tissues. The currently used classification system aids in defining the degree of severity of these injuries and their subsequent risk for infection. The basic management principal for all of these injury patterns remains essentially the same, however: prevention of infection through debridement, wound management, antibiotic usage, and fracture stabilization. Frequently multiple surgical procedures will be required in order to obtain an infection free, united fracture with adequate soft tissue coverage (1).

The large spectrum of open fractures is an amalgamation of injuries with the single variable in common of communication of the fractured bone with the outside environment, and thus an increased risk for infection. Contributing to the presence of bacteria within the fracture site is devascularized soft tissue, the degree of which can be directly attributed to the amount of energy imparted to the tissues. The currently used classification system aids in defining the degree of severity of these injuries and their subsequent risk for infection. The basic management principal for all of these injury patterns remains essentially the same, however: prevention of infection through debridement, wound management, antibiotic usage, and fracture stabilization. Frequently multiple surgical procedures will be required in order to obtain an infection free, united fracture with adequate soft tissue coverage (1).

Brachial plexus injuries are devastating injuries that affect primarily young healthy males. For the total plexus injury, current surgical treatments have failed to achieve normal restoration of limb function but some practical goals are obtainable. This review article summarizes existing logic and approach for managing these catastrophic injuries.

This article reviews the history and current management concepts of flexor tendon lacerations. Classic and contemporary repair techniques are discussed. The most popular rehabilitation protocols are also reviewed.