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The Role of Soft Tissues in Rigidity of Fracture Fixation of Upper Extremities; application for battlefield use
E. Anne Ouellette, MD, MBA1; Winston Elliott, BS2; Loren Latta, PhD, PE3; Edward Milne, BS3; David Kaimrajh, MS3; Jason Lowe, MD4; Anna-Lena Makowski1, Eleanor Herndon, BS1; Check Kam, MD5; Prasad J. Sawardeker, MD6
1Physicians For The Hand, Miami, FL, 2University of Colorado, Boulder, CO, 3Max Biedermann Inst for Biomech/University of Miami/Mt. Sinai Medical Center, Miami, FL, 4University of Alabama, Birmingham, AL, 5Indiana Hand to Shoulder Center, Indianapolis, IN, 6Allegheny General Hospital, Pittsburgh, PA

Introduction:Soft tissue compression (STC) in functional braces has been shown to provide rigidity and stability for most closed fractures, selected open fractures and can supplement some other forms of fracture fixation. The rigidity of 3 types of fracture fixation with intact soft tissue (ST), then progressive ST defects & bone loss were tested in the upper extremity.

Methods:A simple, oblique fracture was created in22 humeri and 22 radii and ulnae of intact limb segments. The weight of each intact limb segment was measured. Cyclic axial loads (12 – 120N) were applied for each progressive condition: intact limb, mid shaft osteotomy, a lateral 1/4 circumferential soft tissue defect, 1/3 circumferential defect and finally, 3 cm bone defect. Limbs were randomly assigned to be stabilized be either plate and screw (PS), intramedullary rod (IR) or external fixation (EF). Testing with and without STC in a brace was performed after each condition. ANOVA multi-variant analysis corrected for multiple comparisons was used to compare the axial rigidity between the different conditions tested.

Results:There was no significant difference in axial rigidity for humerus shaft fractures treated by any of the methods related to the degree of soft tissue damage. Humeri with a 3 cm bone defect were best stabilized with IR. Forearms with a 3 cm bone defect were best stabilized with PS. Progressive increase in soft tissue defects did create progressive loss in rigidity in forearms, but the most dramatic loss occurred with the bone defect and ST defect. The rigidity of IR and EF in forearms decreased almost 79%, and about 21% of that was restored with STC.

Conclusions: Invasive types of surgical intervention provide the best rigidity and stability to fractures, regardless of the presence of or size of a soft tissue defect. In general, use of PS and IR and application of conventional types of braces to achieve STC is not practical in the field. EF, however, can be applied quickly and easily with a minimal of facilities in the battlefield and can be applied in such a way that no foreign bodies end up in the contaminated wound. For injuries to the forearm, supplemental support from STC with a splint or brace-like system could be effective.

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