Eric G Puttler's research while affiliated with Good Samaritan Hospital and other places

With continued improvement in body armor and ballistic helmets as well as advances in modern combat casualty care, more and more combat casualties will survive following injury long enough to be resuscitated; therefore, the severity of extremity injuries among survivors of combat injuries will likely continue to increase. The primary mechanism for these injuries is blast and penetrating trauma, which is an unusual mechanism of injury in civilian medicine, even at Level I trauma centers. This must be understood in the context of overall patient management due to the systemic effects of blast and also in the management of the traumatic amputation when assessing the zone one injury in the injured extremities. Trauma surgery in a combat zone requires adaptation to a different injury paradigm.

We present a series of distal clavicle fractures in which the coracoclavicular ligaments remain intact to the proximal segment, but the distal aspect of the clavicle is displaced superiorly. The fractures sustained in this series are not described in any of the multiple classification systems currently in use for clavicular fractures. We present a series of 2 active-duty patients who sustained nearly identical distal clavicle fractures during Army combatives training. A 23-year-old male was treated successfully with nonoperative therapy and returned to deployment within 2 months. A 23-year-old female failed nonoperative treatment and was successfully treated with an operative open distal clavicle resection. This rare fracture attributed to a specific mechanism of injury has a potential to be commonly encountered in active-duty patients taking part in mandatory combatives programs.

With the ongoing improvement in body armor and ballistic helmets, as well as advances in modern combat casualty care, more and more combat casualties will survive following injury long enough to be resuscitated. As such, the severity of extremity injuries among survivors of combat injuries is increasing. Such injuries rarely occur in the context of civilian medicine, even at Level I trauma centers. So the first thing you have to do when you enter a combat zone is realize you are in a combat zone: the game is changed and you need to adapt to a different injury paradigm.

The incidence of nonunion after humeral shaft fractures is low with both operative and nonoperative interventions. However, when a delayed union or nonunion occurs, it can be a very debilitating, leading to limited function and pain. Several methods have been described for the management of humeral diaphyseal nonunions. We present 11 cases managed with a transverse, shortening osteotomy and compression plating with or without bone grafting. Of the 11 cases, 10 had prior surgical treatment of open reduction and internal fixation. Union was achieved in all 11 humeri.

Braces are commonly used to treat progressive adolescent idiopathic scoliosis. Several previous studies have reported a correlation between the success of brace treatment and skeletal maturity markers. These studies have not focused on the status of the triradiate cartilage (TRC) as it relates to successful brace treatment for adolescent idiopathic scoliosis. The authors retrospectively evaluated all patients at their institution from 1990 to 1997 with a diagnosis of adolescent idiopathic scoliosis who were treated in a Boston brace. Sixty-two patients met inclusion criteria. At presentation, the average age was 12.87 years, the average Risser sign was 0.56, and 45% of patients had an open TRC. The average follow-up was 2.92 years. Greater than 5 degrees of progression at discontinuation of bracing was considered a failure. Curves with a closed TRC failed bracing 21% of the time, whereas those with an open TRC failed 54% of the time (P = 0.0069). Those curves with a closed TRC progressed 3.12 degrees on average, whereas curves with an open TRC progressed 6.86 degrees. Curves associated with a closed TRC at initiation of bracing progressed less frequently and to a lesser degree than those associated with an open TRC (P = 0.027). Although the TRC is not an independent predictor of curve stability, it is an additional indicator of skeletal maturity and may prove most useful in patients with otherwise borderline indications for brace treatment.