Injury

Editorial Board

2010-02-01

Restricted duty hours and implications on resident education—Are different trauma systems affected in a different way?

H.-C. Pape — 2010-02-01

Many clinicians throughout the western societies have been worried over the last few years about the changes in resident education and its effect on clinical patient care. While the incentive to change these work rules certainly is honorable and thoughtful (nihil nocere, “first, do no harm”), it has been questioned whether these goals can be achieved with the measures installed. This is true both for European countries and for the United States. The European law about regulations has been vigorously implicated over the last few years. Chairmen of clinical departments were personally fined if the new rules for duty hours were not followed. Administrations have installed duty shifts without integrating physicians in order to follow these rules. In the USA, work-hour limitations have been implemented by the Accreditation Council for Graduate Medical Education (ACGME) in July 2003. In the US, the chairman is also directly responsible for the implementation of the rules and residency programs can be terminated if the rules are not followed.

The influence of hydroxyapatite coating of external fixator pins on pin loosening and pin track infection: A systematic review

Adnan Saithna — 2010-02-01

Abstract: Objective: The primary objective of this systematic review of published randomised controlled trials was to evaluate whether there was a clinical benefit in terms of pin loosening and pin track infection, or deep infection, associated with hydroxyapatite coating of external fixator pins. The secondary objective was to evaluate whether there was a clinical benefit in terms of loss of alignment or malunion associated with hydroxyapatite coating of external fixator pins.Methods: Studies included were identified by a PubMed search for relevant randomised controlled trials on the 20th of December 2007. A systematic review was performed.Results: All of the studies concluded that there was significantly less pin loosening in the HA-coated groups although the definition of loosening was based on different criteria. However, there was insufficient evidence to properly evaluate the clinical benefit in terms of the numbers needed to treat to avoid premature pin removal. There was also insufficient evidence to evaluate whether any clinical benefit is gained by using HA-coated pins with respect to deep infection and malunion.Conclusion: A well designed large randomised controlled trial is required to determine the numbers needed to treat with HA-coated pins to reduce the incidence of clinically relevant pin loosening, axial deformity and pin track or deep infection.

Compartment syndrome of the thigh: A systematic review

Nwakile I. Ojike, Craig S. Roberts, Peter V. Giannoudis — 2010-02-01

Abstract: Introduction: Thigh compartment syndrome is a surgical emergency with risk of high morbidity and mortality rates. The purpose of this study was to review the available evidence regarding the causes of thigh compartment syndrome, techniques of fasciotomy (specifically, one versus two incisions), methods of wound closure, and complications.Methods: This institutional review board-exempt study was performed at a level-one trauma centre. PubMed and Medline OVID databases in the English language were searched for case series of two or more cases of compartment syndrome of the thigh. Cases were reviewed and analysed for causes of thigh compartment syndrome, number of fasciotomy incisions, methods of wound closure, and complications.Results: A total of 9 papers met our criteria. All were retrospective case studies comprising a total of 89 patients. The most common cause was blunt trauma (90%). Motor vehicle accidents accounted for 36% of cases whilst motorcycle accidents were involved in 9%. Associated injuries included femur fractures in 48%, other limb fractures, renal, cardiovascular and head insults. Eighty-six percent of fasciotomies were performed through a single incision. Fifty-nine percent of fasciotomy wounds were closed by delayed primary closure, 26% had split-thickness skin grafts, and 15% had primary wound closure. Neurological deficits were the most common complications.Conclusion: There are limited data on thigh compartment syndrome with respect to cause, use of one versus two incisions for fasciotomy, methods of wound closure, and complication rates. Prospective studies are required to better define these variables in order to optimise the management of this problem.

Epidemiology of foot injury in a high-income developing country

Ayman M.A. Tadros, Hani O. Eid, Fikri M. Abu-Zidan — 2010-02-01

Abstract: Objectives: To study the epidemiology of foot injuries and factors predicting their severity in a high-income developing country so as to define prevention priorities.Patients and Methods: All patients admitted to Al-Ain Hospital with foot injury between March 2003 and March 2006 were identified from a prospectively collected Trauma Registry. Injuries were scored using foot and ankle severity scale (FASS). Bilateral, multiple or segmental injuries, open fractures or those with FASS score higher than 3 were included in severe foot injury group and compared with simple foot injury group regarding patients’ demography, co-morbidities, trauma mechanism and energy, incident location, number of associated injuries, Injury Severity Score (ISS) and hospital stay using a univariate analysis. A logistic regression model was then used to study factors predicting severity of foot injury.Results: 171 patients (156 males) were studied. The average (range) age was 34 (2–75). 95 had right foot injury, 66 had left, and 10 had both. Fall from height was the most common mechanism. 105 (61%) had work-related injuries. 130 (76%) had isolated foot injury. 151 (88%) had 212 foot fractures. 20 (12%) had soft tissue injuries. 70 (41%) had severe injuries while 101 (59%) had simple ones. The multiple logistic model was highly significant (p=0.002). Number of associated injuries (p=0.025) and location of trauma (p=0.044) were significant while the amount of energy (p=0.054) showed a strong trend to predict severity.Conclusions: Fall from height is the most common mechanism of foot injury in United Arab Emirates. The number of associated injuries, high-energy trauma, and being work related are predictors of foot injury severity. Prevention priorities include counteractions against falling from height and falling heavy objects as occupational hazards.

“No one has ever asked for it back!” A survey assessing the fate of reusable external fixation equipment in mortuaries

A. Timms, T. Sorkin, H. Pugh, M. Barry, W.D. Goodier — 2010-02-01

Abstract: Technicians from one hundred and eighteen Human Tissue Authority (HTA) approved mortuaries licensed to perform post-mortems in England completed a telephone interview. All were questioned on whether they had contact with reusable external fixators, who was responsible for the removal, the number removed annually, and the destination of the fixator post-removal. Opinion was sought on how the return of the equipment could be better facilitated.Seventy-four of the technicians interviewed could remember seeing external fixation devices, but were unable to quantify how many were removed annually. Sixty-one of those questioned stated that they personally removed the fixator, three always requested an Orthopaedic surgeon to remove the device and five contacted a Nurse Specialist. Forty-eight stated that they returned the devices to their local Sterile Services Department or Orthopaedic department. Nine technicians always discarded the fixators, eight always left them with the body and two stored them in the mortuary.Many reusable external fixation devices are inappropriately disposed of each year due to a lack of knowledge and communication with Orthopaedic departments. Confusion also exists among some technicians over whether external fixation components should be treated as ‘implants’.There is a need for clear guidelines to raise awareness and ensure the appropriate return of these high cost devices.

Can patients with low energy whiplash associated disorder develop low back pain?

Nicholas Beattie, Martyn E. Lovell — 2010-02-01

Abstract: 800 consecutive claimant generated medicolegal reports were analysed for symptomatology of whiplash associated disorder (WAD) including the presence of mid and low back pain. We aimed to establish whether the two were linked and if so if there were correlations between accident vector and severity. We also aimed to establish if a low back injury could result from a vehicular accident in the absence of a neck injury. In addition we examined if occupant bracing and occupant neutral position at the time of the accident affected symptom patterns. We found that a claimed back injury following WAD was independent of both accident severity and accident vectors, approximately 40% claiming injury in low, medium and high violence groups and with rear, frontal and side impact. We established that it was unusual to have a back injury in the absence of a neck injury (18 out of 325, 5.5%) without a past medical history of back pain (72.2% of this group having previous back pain). Occupant bracing was not protective. We also showed that occupant neutral position was not protective against a back injury. We were surprised that patients with next to no car damage had the same incidence of back pain as those involved in more violent crashes when biomechanically unlikely. The complex biopsychosocial response and the relationship to constitutional factors are discussed. The literature concerning forces across the lumbar spine and possibilities of injury is reviewed.

The “Good, Bad and Ugly” pin site grading system: A reliable and memorable method for documenting and monitoring ring fixator pin sites

S.A. Clint, D.M. Eastwood, M. Chasseaud, P.R. Calder, D.R. Marsh — 2010-02-01

Abstract: Although there is much in the literature regarding pin site infections, there is no accepted, validated method for documenting their state. We present a system for reliably labelling pin sites on any ring fixator construct and an easy-to-remember grading system to document the state of each pin site. Each site is graded in terms of erythema, pain and discharge to give a 3-point scale, named “Good”, “Bad” and “Ugly” for ease of recall.This system was tested for intra- and inter-observer reproducibility. 15 patients undergoing elective limb reconstruction were recruited. A total of 218 pin sites were independently scored by 2 examiners. 82 were then re-examined later by the same examiners. 514 pin sites were felt to be “Good”, 80 “Bad” and 6 “Ugly”. The reproducibility of the system was found to be excellent.We feel our system gives a quick, reliable and reproducible method to monitor individual pin sites and their response to treatment.

Causes of scapula fractures differ from other shoulder injuries in occupants seriously injured during motor vehicle crashes

Raul Coimbra, Carol Conroy, Gail T. Tominaga, Vishal Bansal, Alexandra Schwartz — 2010-02-01

Abstract: Purpose: Current motor vehicle safety systems primarily focus on preventing life-threatening and serious injury during crashes, but occupants may still sustain less serious injury. Upper extremity injury is common in occupants involved in motor vehicle crashes. The purpose of this study was to compare occupants with scapula fractures to occupants with other shoulder injuries.Methods: We used data from the Crash Injury Research and Engineering Network (CIREN) database (1997–2008) to compare two groups of occupants: (1) occupants with only scapula fractures and (2) occupants with shoulder injury not involving the scapula. We hypothesised that there were no differences in demographics, vehicle, crash characteristics and causes of shoulder injury in these two groups.Results: Of the 3370 occupants studied, 54 occupants (1.6%) had only a scapula fracture in the shoulder region and 342 (10.1%) occupants had other shoulder injuries. There were significant differences between gender, height and weight, maximum Abbreviated Injury Scale (AIS) severity and the crash type. Occupants with scapula fractures were 3 times more likely to be male (odds ratio (OR)=3.30) and were significantly taller and weighed more than occupants with other shoulder injuries. Occupants with other shoulder injuries had significantly greater injury severity (based on maximum AIS for any injury) than those with scapula fractures. There was a significant difference between scapula fractures and clavicle fractures (OR=1.87) and joint dislocations/separations (OR=2.79) comparing the cause of injury (vehicle side interior vs. other causes). Safety belts are the single most important safety system in motor vehicles and should always be worn. However, we found no differences in the cause of scapula fractures comparing occupants wearing their safety belt with those not wearing the belt.Conclusion: This study provides information showing that scapula fractures occur during different types of impacts and have different causes other than shoulder injuries.

Biomechanical comparison of tension band- and interfragmentary screw fixation with a new implant in transverse patella fractures

J. Dargel, S. Gick, K. Mader, J. Koebke, D. Pennig — 2010-02-01

Abstract: Aim: The aim of the present study was to compare the primary fixation stability and initial fixation stiffness of two established fixation techniques, the tension band wiring technique and interfragmentary screw fixation, with a mini-screw fragment fixation system in a model of transverse patella fracture. It was hypothesised that the biomechanical loading performance of the fragment fixation system would not significantly differ from the loading characteristics of the two established methods currently investigated.Materials and methods: Ninety-six calf patellae were used in this biomechanical model. A standardized transverse patella fracture was induced and three different fixation methods, including the modified tension band wiring technique, interfragmentary screw fixation, and the mini-screw fragment fixation system, were used for fragment fixation. Specimens were mounted to a loading rig which was secured within a material testing machine. In each fixation group, eight specimens were loaded to failure at a simulated knee angle of either 0° or 45°. Another eight specimens were submitted to a polycyclic loading protocol consisting of 30 cycles between 20N and 300N at a simulated knee angle of 0° or 45°. The residual displacement between the first and the last cycle was recorded. Differences in the biomechanical performance between the three fixation groups were evaluated.Results: No significant differences between the three fixation groups were observed in the parameters maximum load to failure and linear fixation stiffness with monocyclic loading. Specimens being loaded at 45° showed significantly lower maximum failure loads and linear stiffness when compared with 0°. During polycyclic loading, no significant differences in the residual displacement were observed between the groups at 0° loading angle, while at 45°, residual displacement was significantly higher with tension band fixation when compared with interfragmentary screw fixation or the fragment fixation system.Conclusion: The biomechanical performance of the fragment fixation system was comparable to interfragmentary screw fixation and superior to the tension band wiring technique. Given the advantages of a system which provides interfragmentary compression and which simplifies fracture fixation after open or closed reduction, we believe the fragment fixation system to be an adequate alternative in the osteosynthesis of transverse patella fractures.

Alternative fixation method for open femoral fractures from a damage control orthopaedics perspective

2010-02-01

Abstract: A decision for immediate versus delayed fixation in a polytrauma patient mainly in cases of open femoral fracture depends upon time elapsed since injury, duration of stay in intensive care, soft tissue status, probable intra-operative difficulties and presence of systemic complication. We studied the outcome of the Taylor Spatial Frame (TSF) as a solution in the role of primary and definitive fixator for patients in whom definitive osteosynthesis with intramedullary nailing (IMN) can be associated with higher rate of complications. In view of damage control orthopaedics (DCO), we found that TSF is an effective technique compared to internal nails and earlier external fixator devices, attributable to its advantages such as continuity of frame till union, preventing any second-hit phenomenon, early mobilisation and restoration of primary defect due to bone loss by differential distraction osteogenesis without additional surgery. According to the Paley and Maar's evaluation criteria, 11 patients had an excellent result with clinical and radiological union; the functional result was excellent in three patients, good in five, fair in two and poor in one.

Danger zone for locking screw placement in minimally invasive plate osteosynthesis (MIPO) of humeral shaft fractures: A cadaveric study

T. Apivatthakakul, S. Patiyasikan, S. Luevitoonvechkit — 2010-02-01

Abstract: Several recent reports have described the minimally invasive plate osteosynthesis (MIPO) technique in the treatment of humeral shaft fractures by the anterior approach. The purpose of this study is to identify the danger zone for locking screw placement to avoid musculocutaneous nerve injury in the anterior compartment and radial nerve injury in the posterior compartment of the humerus relative to the humeral length. Eighteen arms of fresh cadavers were fixed with 10-hole locking compression plate (LCP) by anterior approach using the MIPO technique. Two locking screws on each end were fixed by the open technique; the rest of the screws were inserted percutaneously. The arms were dissected both anterior and posterior to identify musculocutaneous and radial nerve injuries. Humeral length with a simple palpable bony landmark was measured from the posterior tip of the acromion process to the lateral epicondyle. Damage or direct contact of the locking screws to the musculocutaneous or radial nerve was recorded, and the distance between the screws and the radial nerve was measured.The average humeral length was 29.71cm (99% confidence interval (CI): 28.54–30.86cm). The danger zone for the musculocutaneous nerve averaged 18.37% (99% CI: 17.06–19.60) to 42.67% (99% CI: 42.33–43.03) of the humeral length from the lateral epicondyle. The danger zone for the radial nerve averaged 36.35% (99% CI: 35.81–37.07) to 59.20% (99% CI: 59.00–59.46) of the humeral length, and the most dangerous screws that penetrated or touched the radial nerve lay 47.22% (99% CI: 45.27–49.17) to 53.21% (99% CI: 51.16–55.33) of the humeral length from the lateral epicondyle. An anteroposterior locking screw placed percutaneously endangered the musculocutaneous and radial nerves.From this cadaveric study, the danger zone for the musculocutaneous and radial nerves could be determined as a percentage of the humeral length. Since the zone with radial nerve injuries shows a large variation, this procedure should only be done by experienced surgeons.

Classification systems for tibial plateau fractures; Does computed tomography scanning improve their reliability?

2010-02-01

Abstract: Introduction: The purpose of this study was to evaluate the impact of computed tomography scanning on the inter- and intra-observer reliability of the OTA/AO, the Schatzker, and the Hohl classifications in the assessment of tibial plateau fractures.Methods: Four independent observers classified 45 consecutive fractures of the tibial plateau according to the criteria of the OTA/AO system, the Schatzker classification, and the Hohl classification. Two sessions of readings were compared; first, the use of plain anterior–posterior and lateral X-rays alone was evaluated, then 4 weeks later the combination of plain X-rays and two-dimensional computed tomography scans were evaluated. The readings were repeated 8 weeks later to evaluate intra-observer reliability.Results: The three classification systems showed “moderate” inter-observer reliability and “good” and “moderate” intra-observer reliability when classified solely on the basis of plain radiographs. After the addition of computed tomography scans inter-observer reliability significantly improved to “good” in all classifications. Likewise, intra-observer reliability improved to “good” in all classifications after the addition of CT-scans. Statistical analysis showed no significant difference regarding inter- and intra-observer agreement between the three classifications.Conclusions: Computed tomography scanning improved the inter- and intra-observer reliability of the OTA/AO, the Schatzker, and the Hohl classification. Overall, all three classification systems showed “good” inter- and intra-observer reproducibility when classified with CT-scans.

Holding power of variable pitch screws in osteoporotic, osteopenic and normal bone: Are all screws created equal?

Rajesh Ramaswamy, Samuel Evans, Yona Kosashvili — 2010-02-01

Abstract: Introduction: Biomechanical properties of four different commercially available small fragment cannulated screws (Twin fix (Stryker, Freiburg, Germany), Herbert, (Zimmer, Warsaw, USA), Omnitech (Unimedical, Torino, Italy), Barouk (Depuy, Warsaw, USA)), with variable pitch, used for fracture fixation were compared.Materials and methods: Polyurethane foam blocks of three different densities with mechanical properties similar to osteoporotic, osteopenic and normal bones were used to conduct the tests. Each screw was tested for pushout and pullout holding power after a primary insertion and for pullout after a repeated insertion into the respective foam blocks.Results: The mean pullout and pushout strengths of all screws correlated to the foam density, and were significantly (p<0.001 and <0.001, respectively) better in foam with higher density.The mean pullout strength of each screw was consistently lower after reinsertion into the osteoporotic, osteopenic and normal bone densities by 4–30%, when compared to the index insertion (Fig. 4b). Yet, this difference was not found to be statistically significant (p=0.23).The Barouk screw performed significantly (p<0.0001) better than the other screws in all three different densities of foam for both for pushout and pullout after index insertion as well as for pullout tests after reinsertion.Conclusion: The holding power of screws is directly correlated to bone density, thread design and number of threads engaging the bone. Reinsertion through the same hole could reduce the ultimate pullout strength. The surgeon should consider the advantages and disadvantages of each implant, depending on the clinical situation and choose accordingly.

Locked volar plating for unstable distal radial fractures: Clinical and radiological outcomes

Dominique Knight, Carol Hajducka, Elizabeth Will, Margaret McQueen — 2010-02-01

Abstract: We studied 40 patients treated with locked volar plates for unstable distal radial fractures. Outcome was assessed at a mean of 59 weeks, both radiologically and functionally using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, range of motion and grip strength.The complication rate in our series was 48%. In 11 cases, screw penetration into the radiocarpal joint occurred as a consequence of postoperative collapse. Of these, 25% had malunited and 12.5% ruptured their extensor pollicus longus (EPL) tendon. Functionally, when compared with the contralateral side, 74% of extension, 67% of flexion, 91% of pronation and supination and 81% of grip strength were regained. The mean DASH score was 23.Although locked volar plates can achieve good results in the management of unstable distal radial fractures, there remains a high major complication rate. They should be used with caution particularly in fractures with significant metaphyseal comminution.

Staged external and internal less-invasive stabilisation system plating for open proximal tibial fractures

Ching-Hou Ma, Chin-Hsien Wu, Shang-Won Yu, Cheng-Yo Yen, Yuan-Kun Tu — 2010-02-01

Abstract: High-energy proximal tibial fractures are complex injuries that may lead to significant complications. Staged treatment of these injuries using a spanning external fixator across the knee joint in the acute setting decreases the incidence of complications. This article is a prospective evaluation of outcomes using a two-stage procedure for treatment of 15 patients who sustained open proximal tibial fractures between April 2006 and January 2008. In the first stage, we used low profile, less-invasive stabilisation system (LISS) plates for temporary external fixation to immobilise the fractures after anatomic reduction, followed by soft-tissue reconstruction. In the second stage, we applied LISS plates for definitive internal fixation, using minimally invasive percutaneous osteosynthesis. All fractures were monitored for a mean of 20.4 months (range, 12–32 months). All fractures united at a mean of 38.6 weeks (range, 18–66 weeks). Knee motion ranged from a mean of 1° (range, 0° to 5°) to 125° of flexion (range, 100° to 145°). The reduction was scored as good in 13 patients and fair in two patients. At follow-up, 10 patients had excellent, and five had good knee scores. The complications included minor screw-track infections in three patients. In conclusion, the two-stage technique was well suited for treating these difficult injuries, and for patients who needed longer periods of external fixation. Surgeons were able to achieve gross anatomy restoration, soft-tissue reconstruction, stable fixation and high union rates. Patients obtained good-to-excellent motion, function and comfort after treatment.

Three-point index in predicting redisplacement of extra-articular distal radial fractures in adults

2010-02-01

Abstract: Introduction: In distal radial fractures in adults, factors affecting instability have been investigated in many studies in an effort to shorten the preoperative waiting period for the fractures requiring surgery. Numerous factors, aside from the alignment-related indices, have been searched to predict redisplacement. Unlike as in paediatric counterparts, the casting technique and casting-related indices have not been appropriately considered in adults. The aim of this study was to determine the impact of the various previously investigated factors in addition to casting technique-related indices such as three-point index, cast index, padding index and gap index, in predicting the risk of redisplacement of extra-articular distal radial fractures in adults and the presence of the ulnar deviation of the cast.Patients and methods: Seventy-five patients over 18 years who were treated with a cast in our emergency department within 24h after a displaced distal radial fracture, were recruited into the study. Age, alignment-related indices, cast-related indices, extent of the ulnar deviation of the cast, having a non-anatomical reduction, co-existing ulnar fracture, dorsal comminution and obliquity of the fracture line were investigated. Casting technique according to three-point index, obliquity of the fracture line, degree of the ulnar deviation of the cast, and reduction accuracy were the significant factors affecting redisplacement.Results: The three-point index had a sensitivity of 95.8%, specificity of 96.1%, positive predictive value of 92%, and negative predictive value of 98% in predicting redisplacement. Logistic regression revealed that having an inadequate cast according to the three-point index (p<0.001), degree of obliquity of the fracture line (p=0.018), decreased ulnar deviation of the cast (p=0.002), and having a non-anatomical reduction (p=0.029) were the significant predictive factors in redisplacement.Conclusions: Our results suggest that the casting technique plays a major role in the success of conservative treatment, which can best be examined with the three-point index. Ulnar deviation of the cast and fracture obliquity are the other dominant factors affecting redisplacement.

A novel non-bridging external fixator construct versus volar angular stable plating for the fixation of intra-articular fractures of the distal radius—A biomechanical study

Markus Windolf, Karsten Schwieger, Ben Ockert, Jesse B. Jupiter, Georg Gradl — 2010-02-01

Summary: Non-bridging external fixation has recently been introduced as an alternative to volar angular stable plating for the fixation of unstable intra-articular distal radial fractures. The purpose of this study was to biomechanically compare a new non-bridging external fixator construct to volar angular stable plate fixation in a dorsally comminuted intra-articular fracture model of the distal radius.Materials and methods: Five pairs of fresh frozen human cadaveric radii were randomly supplied with either a non-bridging external fixator or a stainless steel volar locking plate. A three-fragmental AO 23–C2.1 fracture was created by removing a 15° dorsal wedge with remaining volar cortical contact and by an intra-articular osteotomy lateral to the lister-tubercle. Physiological load transfer via the wrist was simulated by means of a custom-made seesaw. For biomechanical testing, the bones were loaded in cyclic axial compression. Starting at 100N, the load was monotonically increased at 0.025°N per cycle until failure of the construct. Motion of the lunate and scaphoid fragments with respect to the radial diaphysis was acquired by optical three-dimensional (3D) motion tracking. Plastic wedge deformation was determined after 2000, 4000 and 6000 cycles.Results: The amplitude of wedge motion at the beginning of the test as a measure for construct stiffness was significantly lower for the fixator group (P=0.003, power=0.99). Plastic wedge deformation after 2000, 4000 and 6000 cycles was found significantly lower for the external fixator (repeated measures analysis of variance (ANOVA), P=0.009, power=0.86). Displacement of the intra-articular gap was found below 0.6mm (mean) for both groups (P>0.05).Conclusion: The study revealed superior biomechanical properties of the proposed non-bridging external fixation compared to volar locked plating in an unstable intra-articular fracture model with volar cortical support. However, both fixation techniques seem to apply sufficient stabilisation to restore and retain anatomy after fracture of the most distal part of the radius and should be individually chosen according to distinct criteria.

Incidence and significance of injuries to the foot and ankle in polytrauma patients—An analysis of the Trauma Registry of DGU

2010-02-01

Abstract: Background: Injuries to the foot and ankle are often missed or underestimated during the initial care for polytraumatized patients. Nonetheless, injuries to the lower extremity exert significant influence on long-term outcome after discharge from the acute care facility. Since the mortality of trauma decreased in the last decades, these injuries gain more effect on the overall outcome. We analysed foot and ankle injury patterns, associated procedures and special characteristics of this population during early care.Methods: Multiply injured patients of the Trauma Registry of DGU (TR-DGU; Injury Severity Score, ISS≥16) with injuries to the foot and ankle (group F&A) were compared to the remaining TR-DGU population (group Non-F&A) for differences in injury characteristics, surgical treatment and early outcome. A detailed comparative statistic is provided.Results: Demographic data and injury severity were comparable between the groups. The group F&A showed significantly more falls from a height above 3m and suicidal injuries. Their overall injury severity to the extremities, especially to the regions different from the foot and ankle, was significantly higher compared to group Non-F&A. Group F&A patients had more surgeries and less intensive care complications. Mortality was 11.6% (F&A) and 16.2% (Non-F&A). Concerning initial outcome when discharged from the acute care facility, group F&A patients more commonly were moderately or severely disabled in everyday life.Conclusions: Our data enhance the need for a meticulous search for injuries to the foot and ankle in patients with falls, comparably light injuries to the trunk and head and especially in patients with multiple and severe injuries to the skeletal system. Since 88.4% of patients with foot and ankle injuries are discharged alive, early appropriate care should be given to these injuries that significantly affect long-term outcome.

Quantitative fit assessment of tibial nail designs using 3D computer modelling

B. Schmutz, K. Rathnayaka, M.E. Wullschleger, J. Meek, M.A. Schuetz — 2010-02-01

Abstract: Intramedullary nailing is the standard fixation method for displaced diaphyseal fractures of the tibia in adults. The bends in modern tibial nails allow for an easier insertion, enhance the ‘bone–nail construct’ stability, and reduce axial malalignments of the main fragments. Anecdotal clinical evidence indicates that current nail designs do not fit optimally for patients of Asian origin. The aim of this study was to develop a method to quantitatively assess the anatomical fitting of two different nail designs for Asian tibiae by utilising 3D computer modelling.We used 3D models of two different tibial nail designs (ETN (Expert Tibia Nail) and ETN-Proximal-Bend, Synthes), and 20 CT-based 3D cortex models of Japanese cadaver tibiae. With the aid of computer graphical methods, the 3D nail models were positioned inside the medullary cavity of the intact 3D tibia models. The anatomical fitting between nail and bone was assessed by the extent of the nail protrusion from the medullary cavity into the cortical bone, in a real bone this might lead to axial malalignments of the main fragments. The fitting was quantified in terms of the total surface area, and the maximum distance by which the nail was protruding into the cortex of the virtual bone model.In all 20 bone models, the total area of the nail protruding from the medullary cavity was smaller for the ETN-Proximal-Bend (average 540mm2) compared to the ETN (average 1044mm2). Also, the maximum distance of the nail protruding from the medullary cavity was smaller for the ETN-Proximal-Bend (average 1.2mm) compared to the ETN (average 2.7mm). The differences were statistically significant (p<0.05) for both the total surface area and the maximum distance measurements.By utilising computer graphical methods it was possible to conduct a quantitative fit assessment of different nail designs. The ETN-Proximal-Bend shows a statistical significantly better intramedullary fit with less cortical protrusion than the original ETN. In addition to the application in implant design, the developed method could potentially be suitable for pre-operative planning enabling the surgeon to choose the most appropriate nail design for a particular patient.

Intramedullary nailing of proximal tibia fractures—An anatomical study comparing three lateral starting points for nail insertion

2010-02-01

Abstract: Introduction: Intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. To date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures.Materials and methods: 18 fresh-frozen cadaver lower extremities were used to simulate an AO/OTA 41-A3 fracture. Six nails (Expert Tibial Nailing System, Synthes, Salzburg, Austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. After nail insertion, alignment in the coronal plane was recorded.Results: Mean varus malalignment was dependent on the entry point at the lateral tibia plateau. Mean varus malalignment was 16° if nails were inserted at the lateral third, 10° at the middle third and 4° after nail insertion at the medial third. If nails were inserted from the medial third, valgus malalignment was recorded in two specimens.Discussion: The effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. Primary valgus deformation up to 20° can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. Surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion.

Factors that predict poor outcomes in patients with traumatic vertebral body fractures

Zi Yang, Adrian J. Lowe, David E. de la Harpe, Martin D. Richardson — 2010-02-01

Abstract: Study design: Prospective cohort study.Objective: To identify factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit.Summary of background data: There is a paucity of information on factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit.Methods: Patients were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). VOTOR includes all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria, Australia. Patient-reported outcomes and data on possible predictive factors, including demographic details, injury-related and treatment-based factors, were obtained from the VOTOR database. Patient-reported outcomes were measured at 12 months post-injury using the 12-Item Short-Form Health Survey (SF-12), a Numerical Rating Scale (NRS) for pain, global outcome questions and data was collected on return to work or study. For the identification of predictive factors, univariate analyses of outcome vs. each predictor were carried out first, followed by logistic multiple regression.Results: 344 patients were eligible for the study and data were obtained for 264 (76.7%) patients at 12 months follow-up. Patients reported ongoing pain at 12 months post-injury (moderate–severe: 33.5%), disability (70.1%) and inability to return to work or study (23.3%). A number of demographic, injury-related and treatment-based factors were identified as being predictive of poor patient-reported outcomes. Patients who had associated radius fracture(s) were more likely to have moderate to severe disability (odds ratio (OR)=3.85, 95% confidence interval=1.30–11.39), a poorer physical health status (OR=3.73, 1.37–10.12) and moderate to severe pain (OR=3.23, 1.22–8.56) at 12 months post-injury than patients without radius fracture. Patients who did not receive compensation for work-related or road traffic-related injuries were less likely to report moderate to severe pain (OR=0.45, 0.23–0.90) or have a poorer mental health status (OR=0.17, 0.04–0.70) at 12 months post-injury than those who received compensation.Conclusions: The prognostic factors identified in this study may assist clinicians in the identification of patients requiring more intensive follow-up or additional rehabilitation to ultimately improve patient care.

Odontoid fracture in severe ankylosing spondylitic patient

2010-02-01

Patients with ankylosing spondylitis (AS) are at increased risk of spine fractures because of the lack of mobility of the spinal column. The fractures occur most frequently in the cervicothoracic junction, and mid thoracic spine. These fractures are particularly unstable, as many of the soft tissue support and ligaments are calcified and also fracture at the time of injury.

Thermal tibial osteonecrosis: A diagnostic challenge and review of the literature

Josh E. Schroeder, Yoram A. Weil, Amal Khoury, Meir Liebergall, Rami Mosheiff — 2010-02-01

Intramedullary nail (IMN) is a common treatment for tibial shaft fractures. It has been shown that reamed intramedullary nails are advantageous over non-reamed nails in reducing the number of non-union and hardware breakdown. However, soft tissue damage as well as bone injury may occur during the reaming process. These include deep infection, patellar tendon injury and damage to intra-articular structures. In addition, reaming has been associated with increase in the core temperature of the tibial shaft. This may lead to alter the endosteal architecture and eventually can result in thermal necrosis. Ultimately, this complication may lead to devastating clinical results such as recalcitrant non-union and hardware failure. Despite our understanding of the mechanism leading to this devastating complication only a few case reports dealing with this entity were described in the literature mainly dealing with combined soft and osseous tissue complication. We present here a case of an isolated thermal osteonecrosis of the tibia.

Penetrating pelvic battlefield trauma: Internal use of chitosan-based haemostatic dressings

2010-02-01

Penetrating pelvic injuries are a significant problem during armed conflicts, with an overall mortality of 21%. Those with rectal injuries have a higher mortality of 33%. The high energy nature of these injuries, frequently combined with damage to multiple viscera, makes this injury complex particularly challenging. Exsanguinating haemorrhage from fracture sites and severed pelvic veins is the leading cause of death, so rapid control of bleeding is vital. We report on 2 patients who sustained complex ballistic pelvic injuries on the battlefield, with pelvic fracture combined with visceral injuries and major haemorrhage. Both patients underwent initial damage control surgery, involving control leakage from damaged viscera, and pelvic packing to control life-threatening haemorrhage. A chitosan-based dressing (Hemcon™) was used over the fracture sites to augment the pelvic packing.

Surgical techniques: How I do it? Bone graft harvest from the proximal lateral tibia

C.P.C. Mauffrey, D. Seligson, S. Krikler — 2010-02-01

Bone grafting is a procedure that has steadily increased in frequency over the years from 246 cases in the 20 years preceding 1910 to an estimated 200,000 every year in the USA. ENT, Orthopaedic and maxillo-facial surgeons use it to augment bone-healing, arthrodese, treat non-unions, lengthen bones or fill defects. No bone substitutes have shown better results then autologous bone graft. The harvesting of bone from any site cannot be accomplished without some morbidity. In addition to the need for an additional surgical site, pain, gait disturbances sensory deficits and other serious complications have been associated with bone graft procurement. The most frequently used site of harvest is the iliac crest. It offers the advantage of harvesting large amounts of both cortical and cancellous bone. However this procedure carries significant co-morbidities such as donor site pain, post-operative local haematoma, paraesthesia in the area supplied by the lateral femoral cutaneous nerve or damage to the femoral nerve, hernia and fracture of the iliac crest. The total complication rate is reported as high as 10%. For the above reasons some authors have shifted to alternative donor sites associated with less morbidity. Autologous bone harvest from the proximal lateral tibia has been described in the maxillo-facial literature and more recently in the orthopaedic literature. There is an overall lack of morbidity and a favourable quality and quantity of bone available from this site. In fact, O’Keefe et al. followed up a group of 230 harvest of proximal tibia cancellous bone and concluded that the volume was satisfactory, the surgical site was easy to access, and the morbidity was low. In clinical practice, several studies showed that the amount of bone graft taken intra operatively from the proximal tibia is approximately 10–15cm3. Likewise; Catone et al. took an average volume of 25cm3 of cancellous bone intra operatively from the proximal tibia metaphysic, comparable to the volume harvested from the iliac crest. In this ‘how I do it’ section, we focus on the description of our surgical technique to harvest cancellous bone graft from the lateral proximal tibia metaphysis.