Injury

Editorial Board

2010-08-01

The role of acute total hip arthroplasty in the treatment of acetabular fractures

A.J. Ward, T.J.S. Chesser — 2010-08-01

There is a rising incidence of pelvic and acetabular fractures in the elderly due to the ageing population. As a consequence the average age of patients with acetabular fractures is increasing and the elderly are projected to become the largest subset needing treatment. In younger adults most acetabular fractures result from high-energy trauma, such as road traffic accidents, and have associated injuries, whereas in the elderly most fractures are the result of low-energy trauma, such as a fall from a standing height, and are associated with different injury patterns and a poorer outcome. There is a reported higher incidence in the elderly of displaced anterior fracture types, involving anterior column, anterior wall and quadrilateral plate, and of comminuted, impacted posterior wall fracture types, which are more difficult to reconstruct.

Fix and flap in the era of vacuum suction devices: What do we know in terms of evidence based medicine?

James P. Stannard, Naveen Singanamala, David A. Volgas — 2010-08-01

Abstract: Introduction: The concept of immediate or early fixation and soft tissue coverage of open fractures is frequently referred to as ‘fix and flap,’ and negative pressure wound therapy (NPWT) has had a major impact in this area. This article aims to review concepts and evidence relevant to the use of NPWT in open fractures.Review of open fracture management: Muscle flaps in open fractures do well in part because they improve blood supply to the underlying fracture. Outcomes of muscle flaps are best when done acutely, before bacterial colonisation. The colonised subacute wound is managed with ‘open-wound techniques’ until it becomes a chronic localised wound, when flap coverage is again indicated. NPWT provides a useful adjunct in this process as the zone of injury is determined.Vacuum-assisted closure: review of basic and clinical science literature: Proposed mechanisms of action of NPWT include: increased blood flow, decreased oedema, cytokine release induced by mechanical stretch and increased lactate and oxygen tension in the tissue with induction of collagen transcription and angiogenesis.Vacuum-assisted closure in open fractures: NPWT to open fractures caused early appearance of healthy granulation tissue, a reduction in wound area and allowed simpler soft tissue procedures for wound closure. NPWT also improved clinical survival of muscle flaps despite occluded flap venous outflow.Summary: The aim in open fractures is to stabilize the fracture and achieve soft tissue coverage before infection develops. NPWT, applied as a temporizing dressing, simplifies soft tissue coverage on the ‘reconstructive ladder.’ The only Level-I data on that topic showed a significant decrease in infections. However, NPWT does not allow delay in soft tissue coverage. NPWT increases the ‘take rate’ of skin grafts, skin substitutes and composite skin grafts and allows quicker graft incorporation.

A systematic review of early prognostic factors for return to work following acute orthopaedic trauma

Fiona J. Clay, Stuart V. Newstead, Roderick J. McClure — 2010-08-01

Abstract: Introduction: Acute orthopaedic trauma is a major contributor to the global burden of disease. This study aims to synthesise and summarise current knowledge concerning prognostic factors for return to work and duration of work disability following acute orthopaedic trauma.Methods: A systematic review of prognostic studies was performed. The Medline, Embase, PsychINFO, CINAHL and AMED electronic databases were searched for studies between 1985 and May 2009. Included studies were longitudinal, reported results with multivariate statistical analyses appropriate to prognostic studies, comprised persons employed at the time of the injury, included prognostic factors measured proximal to the injury and focused on upper and lower extremity injuries.Results: Searches yielded 980 studies of which 15 met the inclusion criteria and were rated for methodological quality. Analysis focused on the 14 factors considered in more than one study. There was limited evidence for the role of any factor as a predictor of return to work. There is strong evidence for level of education and blue collar work and moderate evidence for self-efficacy, injury severity and compensation as prognostic factors for the duration of work disability. Significant methodological issues were encountered in the course of the review that limited interpretation of the evidence and the conclusions that could be drawn from the findings.Conclusion: People who have sustained acute orthopaedic trauma regardless of severity experience difficulties in returning to work. Due to the lack of factors considered in more than one cohort, the results of this review are inconclusive. The review highlights the need for more prospective studies that are methodologically rigorous, have larger sample sizes and considers a comprehensive range of factors.

Treatment of severe fractures of the calcaneus by reconstruction arthrodesis using the Vira® System: Prospective study of the first 37 cases with over 1 year follow-up

2010-08-01

Abstract: Purpose: To study the surgical applicability and clinical results of the Vira® System in treatment for severe fractures of the calcaneus.Methods: A total of 37 acute intra-articular fractures of the calcaneus treated by reconstruction and primary fusion with the minimally invasive Vira® System. Of them, 33 patients were analysed over a 2-year period. All fractures were classified, according to the Sanders criteria, as grade IV. The mean age was 42.08 years. Four were bilateral fractures and three were open fractures. All the patients were evaluated, in a prospective manner, using the American Orthopaedic Foot and Ankle Society (AOFAS) scale, plain radiographs and CT scan studies.Results: The average AOFAS score 12 months after surgery was 75.43 points (SD: 13.9). In 31 cases, the result was considered good and very good, and in five and one case mild and poor. Most of the patients (81%) could wear normal shoes; the footprint and the alignment of the heel were considered normal in all cases but seven patients showed a mild valgus deviation. The Böhler angle improvement after surgery was significant (p=0.05) and it did not vary along the follow-up. Subtalar arthrodesis was achieved in all cases. Only one case needed bone grafting. Important post-surgical complications were not registered in this cohort.Conclusions: The Vira® System is a useful option for the surgical treatment of severe fractures of the calcaneus, yielding good clinical and radiological results with a surgical procedure that is only minimally aggressive and has a low rate of complications.

Mid-term outcomes after intramedullary fixation of peritrochanteric femoral fractures using the new proximal femoral nail antirotation (PFNA)

Yake Liu, Ran Tao, Fan Liu, Youhua Wang, Zhenyu Zhou, Yi Cao, Hong Wang — 2010-08-01

Abstract: Background: Controversy persists concerning the preferred treatment of peritrochanteric femoral fractures. The purpose of the present study was to evaluate the mid-term outcomes of the newly developed implants – proximal femoral nail antirotation (PFNA) for the stabilisation of this type of fracture.Methods: Between April 2006 and March 2008, 169 patients with peritrochanteric femoral fractures were treated with PFNA. As many as 26 patients were excluded from the study. According to the Orthopaedic Trauma Association (OTA) classification system, the remaining 143 fractures were classified as 19 cases of AO/OTA 31A1 fractures, 83 cases of 31A2 fractures, 28 cases of 31A3 fractures and 13 cases of 31A combined with proximal 32 fracture or separate proximal 32 fracture. The mean age of these patients was 67 years (range, 20–93 years). The operative time, the overall fluoroscopy time, the duration of hospitalisation and the surgical complications were noted. Patients were followed up for a mean of 21 months (range, 12–36 months). Functional outcomes were assessed according to the Harris hip scoring system.Results: Fifteen patients (10%) required open reduction. The mean duration of surgery (from the beginning of close reduction to wound closure) was 72min with a range between 45 and 170min. The mean fluoroscopy time was 164s with a range between 92 and 396s. The mean time of hospital stay was 15 days. Postoperative X-rays showed a good or acceptable reduction in 134 cases (94%), and an ideal implant position in 131 cases (92%). There were 12 (8%) postoperative complications. All patients except one healed their fractures without any implant-specific complication (bending, breaking of the implant, cut out of the PFNA blade, femoral head penetration of the blade or ipsilateral fractures of the femoral shaft at the tip of the implant). The average time to bone healing was 16 weeks (range, 12–25 weeks). At the time of the latest follow-up, 106 patients (74%) were restored to their preoperative mobility. The mean Harris hip score was 84 points (range, 46–100 points). A total of 106 patients (74%) had an excellent or good outcome. According to the patients and/or their caregivers, outcome was described as satisfactory in 120(84%) of the 143 patients, and 36(90%) of the 40 patients, who were more than 80 years old.Conclusion: The results suggest that PFNA is a very effective and safe method in the treatment of different patterns of peritrochanteric femoral fractures. The fixation is adequate to maintain reduction over time even in osteoporotic bones.

Review of Lodox Statscan in the detection of peripheral skeletal fractures in multiple injury patients

2010-08-01

Abstract: Introduction: As part of the primary survey, polytrauma patients in our emergency department are examined using the new ‘Lodox Statscan’ (LS) digital low-radiation imaging device. The LS provides full-body anterior and lateral views based on enhanced linear slot-scanning technology, in accordance with the recommended Advanced Trauma Life Support (ATLS) Guidelines. This study's objectives were to establish whether LS appropriately rules out peripheral bone injuries and to examine whether LS imaging provides adequate information for the preoperative planning of such lesions.Methods: A total of 245 consecutive polytrauma patients aged 16 years or more undergoing LS imaging were included in this retrospective chart analysis. The results of the LS scans were reviewed and compared to additional plain radiographs or computed tomography scans, whenever further radiological imaging was required to determine consecutive therapy.Results: The sensitivity and specificity of the LS scans were 73% and 100%, respectively, for peripheral skeletal injuries. Additional plain radiographs were performed in 50% of cases for (1) superior focussing and more precise resolution of the affected part of the body, (2) additional second or third plane, (3) additional information about fracture type and planning of the surgical approach and (4) for preoperative planning of implant size and positioning on calibrated digitised films, <1% because of the low quality of the LS scan and <1% because the fracture zone had not been fully captured.Conclusion: The study demonstrates that despite LS's high sensitivity and specificity in the detection of peripheral skeletal injuries, additional radiological imaging for diagnostic or preoperative reasons was required. Our results imply that LS, although efficient for patient screening in the emergency room, cannot always rule out peripheral skeletal injuries.

Chronic complete proximal hamstring injury: The double-window approach for bony avulsions

G. Shyamalan, M. Bircher — 2010-08-01

Abstract: Proximal hamstring injury represents a spectrum of trauma to either the bone or the soft tissues. Injuries can be complete or incomplete. Complete injuries usually require surgical treatment.We discuss the operative management of eight consecutive cases of chronic complete proximal hamstring injuries (injury to surgery >2.5 months). Of the eight patients, three patients had soft tissue avulsions, which were reattached with anchors via a longitudinal buttock crease incision. Five patients had bony avulsions requiring open reduction and internal fixation. In three of these, the retraction of the fragment into the thigh was so great that it was not easily retrievable and fixable through a conventional approach. On the basis of a cadaveric study, a double-window surgical approach was developed to enable us to treat these avulsions with extreme retraction. This approach can be used for other less severe injuries.

Reverse LISS plates for unstable proximal femoral fractures

2010-08-01

Abstract: The best treatment for unstable proximal femoral fractures is controversial. In this prospective study, we assessed the outcomes of reverse less invasive stabilisation system (LISS) plates for treatment of unstable proximal femoral fractures that are expected to be difficult to nail.From April 2004 to January 2007, 20 patients with unstable proximal femoral fractures that were assessed to be difficult to nail were managed with reverse less invasive stabilisation system–distal femur (LISS–DF) plates, which included (1) subtrochanteric fractures with extension into the piriform fossa, (2) short skeletons with narrow femoral canals, (3) adolescents with open physes and (4) severely bowed or deformed femurs. These patients were enrolled in this study. There were 11 females and nine males, with a median age of 58 years (range, 14–95 years).The average follow-up period was 24 (range, 12–32) months. Functional recovery (Parker and Palmer mobility score), pain, bony union, varus deformity, implant failure and leg length discrepancy were assessed. The fractures united at a median of 7 months (range, 3–15 months) postoperatively. Parker and Palmer mobility scores were 9 points for 17 patients and 6 points for three patients. Pain was absent in 15, mild in three, and moderate in two patients. Patients with poor quality of reduction were more likely to have pain results (p=0.009). Although patients with advanced age were not more likely to have pain results, they were more likely to have ‘delayed union’ radiographic results (p=0.033). Two limbs were shortened by 1.5 and 2cm, respectively.Reverse LISS plate fixation led to complete union of unstable proximal femoral fractures without additional procedures. The surgical technique was simple and safe. We recommend considering the use of this locked-plate device as the alternative management of unstable proximal femoral fractures that are unsuitable for nailing procedures.

The epidemiology of sports-related fractures in adolescents

2010-08-01

Abstract: Objective: To examine the epidemiology of sports-related fractures in adolescents aged 10–19 years.Methods: All fractures in adolescents presenting to the Royal Hospital for Sick Children and the Royal Infirmary of Edinburgh in a one-year period were prospectively documented and all sports-related fractures retrospectively examined. These two hospitals have a defined population facilitating epidemiological studies.Results: There were 408 adolescent sports-related fractures giving an overall incidence of 5.63/1000/year. The gender ratio was 87/13% male/female and 84% were upper limb fractures. Thirty sports produced 22 different fracture types. Football, rugby and skiing accounted for 66.2% of the fractures. The commonest fractures were in the finger phalanges (28.7%), distal radius and ulna (23.0%) and metacarpus (12.7%).Conclusions: Sport-related fractures are common in adolescents, particularly in males. They tend to be low-energy injuries affecting the upper limb in particular. Few require operative treatment although their frequency means that they impose significant demands on orthopaedic surgeons and health systems.

Changes in the treatment of acetabular fractures over 15 years: Analysis of 1266 cases treated by the German Pelvic Multicentre Study Group (DAO/DGU)

2010-08-01

Abstract: Epidemiological, clinical and radiological data of 1266 patients with a unilateral acetabular fracture of up to 29 hospitals was reviewed. Three time periods, 1991–1993 (Registry I; n=359), 1998–2000 (Registry II; n=503), and 2005–2006 (Registry III; n=404) were compared with regard to injury pattern and severity, fracture type, and chosen nonoperative vs. operative treatment to elucidate changes over time in the treatment of acetabular fractures. In the operatively treated group, time to operation, surgical approach, fracture fixation implants and fracture reduction quality were examined.641 (50.6%) patients with isolated acetabular fractures, 410 (32.4%) multiple injured and 215 (17.0%) polytrauma patients with 642 (50.7%) simple and 624 (49.3%) associated acetabular fractures were evaluated. In the time period from 1991 to 2006, the rate of operative treatments increased nationwide to 77% (ρ<0.001). The distribution of fracture types involving the anterior and posterior wall changed with age (ρ<0.001). Across all registries, 583 (68.0%) operations were performed within 7 days, 212 (24.7%) operations between 7 and 14 days and 54 (6.3%) operations were performed later than 14 days after injury. An anatomical reduction (0–1mm displacement) was achieved in 551 (64%) acetabular fractures. The obtained reduction quality did not correlate with time to operation, was lower in associated than in simple fracture types, and also lower in patients with isolated acetabular fractures than in polytrauma patients. Most importantly, the fracture reduction quality did not improve over time despite a higher frequency of surgical interventions. The Kocher–Langenbeck approach was preferred in the nineties in nearly three quarters of all operative procedures. Currently, the Kocher–Langenbeck and the ilioinguinal approaches are used equally often. The fracture fixation did not change over time and is achieved in 51% with plates in combination with single screws.This multisurgeon series illustrates a nationwide performance in acetabular fracture management. Despite changes in the chosen approaches and an increased surgical frequency, the operative treatment of acetabular fractures of the last 15 years did not lead to an increased reduction quality. Therefore, the rarity and complexity of acetabular fractures demands further specific teaching by experienced acetabular surgeons, scientific research and clinical outcome evaluation.

Magnetic resonance imaging of clinically suspected Salter–Harris I fracture of the distal fibula

2010-08-01

Abstract: Objectives: In skeletally immature children, isolated lateral ankle injuries without radiograph-visible fractures are often diagnosed with Salter–Harris I fractures of the distal fibula (SH1DF). However, recent magnetic resonance imaging (MRI) evidence in children suggests that sprains may be more common than previously thought. Thus, the main objective of this study was to determine the rate of MRI-confirmed SH1DF among cases where this diagnosis was made presumptively, based on clinical findings. In ankle injuries where there is no MRI evidence of SH1DF, another aim is to detect the pathology which gives rise to this clinical scenario.Methods: This was a prospective cohort study performed at a tertiary care paediatric centre. Eligible patients included skeletally immature children with acute ankle injuries presenting with difficulty weight bearing and maximal tenderness and swelling over the distal fibular growth plate (lateral malleolus). Enrolled patients had ankle radiographs at the Emergency Department (ED) visit, MRI within 1 week of the injury, and repeat ankle X-rays at 4 weeks. All images were reviewed by two radiologists and an orthopaedic surgeon. Discrepancies between reading physicians were resolved by consensus agreement.Results: Eighteen patients were enrolled into the study from September 2008 to August 2009. Mean (SD) age of participants was 8.7 (2.0) years. None of the 18 patients had evidence of fibular growth plate injury on MR imaging. Patients often had more than one abnormal finding on MRI. Fourteen (78%) had evidence of ligamentous sprains, 11 (61%) had bony contusions, one patient (6%) had a subtle fibular avulsion fracture, and another was found to have a minor articular cartilage injury. At 4 weeks, only one patient's radiographs demonstrated a healing fracture, which corresponded with the avulsion fracture case. All patients had returned to full weight bearing by 4 weeks.Conclusions: In this series, the clinical diagnosis of SH1DF was incorrect in 100% of cases. Instead, in almost 90% of these patients, MRI identified ligamentous sprains and/or bony contusions. These results may influence the way children who present with this common clinical scenario are managed since the vast majority of children in this study actually had sprain/contusion injuries and none had SH1DF.

A computed tomography-based analysis of proximal femoral geometry for lateral impingement with two types of proximal femoral nail anterotation in subtrochanteric fractures

Vineet Tyagi, Jae Hyuk Yang, Kwang Jun Oh — 2010-08-01

Abstract: Objective: To evaluate and analyse the geometrical discrepancies between the proximal femur and two types of AO/Association for the Study of Internal Fixation (AO/ASIF) Proximal Femoral Nail Anterotation (PFNA/PFNA-II) using computed tomography (CT)-based analysis in Asian patients, and its implication in lateral cortical impingement during reduction intra-operatively in subtrochanteric fractures.Materials and methods: Coronal CT images of hips in 50 randomly selected healthy cases were analysed using a unique measurement method with respect to the height, diameter, bending angle and inclination angle of lateral cortex of proximal femur. The data were then compared with dimensions of PFNA and PFNA-II.Results: The average height of proximal femur was 61.1±5.2mm, diameter 18.1±1.5mm, bending angle 8.4±2.2° and inclination angle of lateral cortex 11.9±1.1°. The average impingement length of the lateral cortex was 54.2±4.7mm (range 41.4–64.2mm), which was shorter than the height of the proximal femur. On comparison with dimensions of PFNA and PFNA-II, the lateral inclination angle and impingement length were found to be discrepant in PFNA; however, in the latter the flat lateral surface helps avoiding impingement with the lateral femoral cortex.Conclusion: Our study provides clear evidence that the flat lateral shape of PFNA-II is better suited for the femur of Asian patients by reducing the chances of impingement with the lateral proximal femoral cortex during intra-operative reduction in subtrochanteric fractures.

Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults

Eric R. Weinberg, Michael G. Tunik, James W. Tsung — 2010-08-01

Abstract: Introduction: Injury is a major cause of death and disability in children and young adults worldwide. X-rays are routinely performed to evaluate injuries with suspected fractures. However, the World Health Organisation estimates that up to 75% of the world population has no access to any diagnostic imaging services. Use of clinician-performed point-of-care ultrasound to diagnose fractures is not only feasible in traditional healthcare settings, but also in underserved or remote settings. Our objective was to determine the accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults presenting to an acute care setting.Methods: We conducted a prospective cohort study of patients aged <25 years that presented to emergency departments with injuries requiring X-rays or CT for suspected fracture. Paediatric emergency physicians with a 1h training session diagnosed fractures by point-of-care ultrasound. X-rays or CT were used as the reference standard to determine test performance characteristics.Results: Point-of-care ultrasound was performed on 212 children and young adults with 348 suspected fractures. Forty-two percent of all bones imaged were non-long bones. The prevalence rate of fracture was 24%. Overall: sensitivity—73% (95% CI: 62–82%), specificity—92% (95% CI: 88–95%); long bones: sensitivity—73% (58–84%), specificity—92% (86–95%); non-long bones: sensitivity—77% (58–90%); specificity—93% (87–97%); age≥18 years: sensitivity—60% (39–78%), specificity—92% (87–96%); age<18: sensitivity—78 (65–87%), specificity—93% (87–95)%. Majority of errors in diagnosis (>85%) occurred at the ends-of-bones.Conclusions: Clinicians with focused ultrasound training were able to diagnose fractures using point-of-care ultrasound with a high specificity rate. Specificity rates to rule-in fracture were similar for non-long bone and long bone fractures, as well as in skeletally mature young adults and children with open growth plates. Clinician-performed point-of-care ultrasound accuracy was highest at the diaphyses of long bones, while most diagnostic errors were committed at the ends-of-bones or near joints. Point-of-care ultrasound may serve as a rapid alternative means to diagnose midshaft fractures in settings with limited or no access to X-ray.

Comparison of artificial neural network and logistic regression models for predicting mortality in elderly patients with hip fracture

Chen-Chiang Lin, Yang-Kun Ou, Shyh-Huei Chen, Yung-Ching Liu, Jinn Lin — 2010-08-01

Abstract: Purpose: Older patients with hip fracture have a mortality rate one year after surgery of 20–30%. The purpose of this study is to establish a predictive model to assess the outcome of surgical treatment in older patients with hip fracture.Methods: A database of information from 286 consecutive cases of surgery for hip fracture from the Department of Orthopedics, National Taiwan University Hospital Yun-Lin Branch, was utilised for model building and testing. Both logistic regression and artificial neural network (ANN) models were developed. Cases were randomly assigned to training and testing datasets. A testing dataset was utilised to test the accuracy of both models (n=89).Results: The areas under the receiver operator characteristic curves of both models were utilised to compare predictability and accuracy. The logistic regression training and testing datasets had an area of 0.938 (95% CI: 0.904, 0.972) and 0.784 (95% CI: 0.669, 0.899), respectively, below the 0.998 (95% CI: 0.995, 1.000) and 0.949 (95% CI: 0.857, 1.000) of the final ANN model.Conclusion: Overall, ANNs have higher predictive ability than logistic regression, perhaps because they are not affected by interactions between factors. They may assist in complex decision making in the clinical setting.

Complete traumatic hemipelvectomy: Report of a case after 19 years of follow-up

Sandra Lasurt, Andrés Combalia-Aleu — 2010-08-01

Traumatic hemipelvectomy or hindquarter amputation with complete disruption through the symphysis pubis and sacroiliac joint is a very rare injury, an extreme and near-lethal form of an open pelvic fracture caused by a high kinetic energy force. The real incidence is unknown because most of victims die before reaching the hospital. Few victims of traumatic avulsion of the hemipelvis survive the initial resuscitation period. According to Beal and Blaisdell, the first reported survivor of a hemipelvectomy was in February 1915. The mechanism of injury is a hyperabduction coupled with an external rotation. Eighty percent of them are caused by motor vehicle accidents.