Injury

Editorial Board

2012-02-01

Classification of patients with multiple injuries—Is the polytrauma patient defined adequately in 2012?

H.C. Pape — 2012-02-01

The face of trauma in Europe continues to be mainly represented by patients with blunt injuries. Even in 2012, multiply injured patients are usually younger and male gender is prevailing. Scoring of these patients is an important factor for clinicians and for reimbursement of care. Anatomic scoring systems continue to be used as gold standard. Despite well described shortcomings, the abbreviated injury scale and the injury severity score continue to be the most relevant scales to assess injury severity. However, since the initial descriptions of the AIS/ISS, there have been significant developments in trauma management techniques, both in the preventive and acute-care phases of trauma management. Since the development of the score, mortality rates dropped from 30% and more to less than 15%. Regardless, major trauma is still defined using an Injury Severity Score (ISS) threshold of 16.

The role of toll-like receptor-4 in the development of multi-organ failure following traumatic haemorrhagic shock and resuscitation

Lee J. McGhan, Dawn E. Jaroszewski — 2012-02-01

Abstract: Haemorrhagic shock and resuscitation (HS/R) following major trauma results in a global ischaemia and reperfusion injury that may lead to multiple organ dysfunction syndrome (MODS). Systemic activation of the immune system is fundamental to the development of MODS in this context, and shares many features in common with the systemic inflammatory response syndrome (SIRS) that complicates sepsis. An important advancement in the understanding of the innate response to infection involved the identification of mammalian toll-like receptors (TLRs) expressed on cells of the immune system. Ten TLR homologues have been identified in humans and toll-like receptor-4 (TLR4) has been studied most intensively. Initially found to recognise bacterial lipopolysaccharide (LPS), it has also recently been discovered that TLR4 is capable of activation by endogenous ‘danger signal’ molecules released following cellular injury; this has since implicated TLR4 in several non-infectious pathophysiologic processes, including HS/R. The exact events leading to multi-organ dysfunction following HS/R have not yet been clearly defined, although TLR4 is believed to play a central role as has been shown to be expressed at sites including the liver, lungs and myocardium following HS/R. Multi-organ dysfunction syndrome remains an important cause of morbidity and mortality in trauma patients, and current therapy is based on supportive care. Understanding the pathophysiology of HS/R will allow for the development of targeted therapeutic strategies aimed at minimising organ dysfunction and improving patient outcomes following traumatic haemorrhage. A review of the pathogenesis of haemorrhagic shock is presented, and the complex, yet critical role of TLR4 as both a key mediator and therapeutic target is discussed.

Multiple trauma induces serum production of host defence peptides

2012-02-01

Abstract: Today multiple trauma still is associated with a high mortality. Although severe open fractures and wounds can give rise to local infections and sepsis, the overall infection rate of multiply injured patients is surprisingly low. We have investigated serum of multiply injured patients with respect to antibacterial properties and screened for host defence peptides (HDP) that constitute a class of fast acting and rapidly available molecules preventing bacterial infection.Serum specimens were obtained from multiply injured patients. Radial diffusion assays were performed to investigate antimicrobial properties. Ultrafiltration and heat-inactivation were used to rule out antimicrobial activity of large proteins i.e. complement factors. ELISA was performed to analyse serum concentrations of the human beta-defensins 2 and 3 (hBD-2 and hBD-3), LL-37 and the proinflammatory cytokines interferon-gamma (IFN-γ) and interleukin-6 (IL-6).Serum of multiply injured patients showed greater zones of inhibition in antimicrobial testing against Gram negative und positive bacteria. This effect was mediated by proteins smaller than 10kDa, inactivation of the complement system does not significantly reduce antibacterial action. hBD-2, hBD-3 and LL-37 concentrations were significantly elevated after trauma and followed different characteristic concentration curves. Similar patterns of concentration profiles were recorded for hBD-2/IL-6 and hBD-3/IFN-γ suggesting a stimulatory influence within their induction process.With this study we provide evidence, that serum of multiply injured patients has by far higher antibacterial capacity than that of healthy donors. As possible mediators we have detected the HDP hBD-2, hBD-3 and LL-37 and their inducers in serum of multiply injured patients.

The effects of a displaced dorsal rim fracture on outcomes after volar plate fixation of a distal radius fracture

Jae Kwang Kim, Sung Whan Cho — 2012-02-01

Abstract: Introduction: The purpose of this study was to determine whether a displaced dorsal rim fracture has an adverse effect on wrist function after volar plate fixation of a dorsally displaced distal radius fracture (DRF).Materials and methods: Two matched cohorts of 23 matched patients, one with a displaced dorsal rim fracture >2mm (group 1), and the other without a dorsal rim fracture (group 2) were analysed in this study of volar locking plate fixation for dorsally unstable DRFs. The two cohorts were analysed for differences in wrist function and wrist pain, radiographic parameters and arthritic grades of radiocarpal joints. Displacement of dorsal rim fragments and diameters of the retained articular portions of dorsal rims in group 1 were measured.Results: No significant difference was found between the two groups in overall wrist function or wrist pain. Mean displacement of dorsal rims in group 1 was 3.0mm and the mean diameter of the retained articular portion of dorsal articular wall was 2.0mm. No significant difference was found between the two groups in terms of any radiographic parameters or the arthritic grading of radiocarpal joints.Conclusion: A displaced dorsal rim fracture does not appear to affect outcomes adversely after volar locking plate fixation of dorsally displaced DRFs.

The use of hook plate in type III and V acromio-clavicular Rockwood dislocations: Clinical and radiological midterm results and MRI evaluation in 42 patients

2012-02-01

Abstract: Background: Acromio-clavicular (AC) joint dislocations are very common following falls on the shoulder or an overstretched hand. The best treatment for such lesions remains a matter of debate. Several studies have, however, lent support to the surgical role of the hook plate in Rockwood type III and V AC dislocations. The aim of this study was to evaluate the midterm clinical results and magnetic resonance imaging (MRI) features of coraco-clavicular ligaments 18 months after an AC dislocation treated with an AC Dreithaler hook plate.Patients and methods: The cohort was made up of a consecutive series of 42 patients, who underwent surgery between November 2002 and December 2006 for an AC dislocation. They were classified, according to the Rockwood classification, as 22 grade III and 20 grade V dislocations. Surgical treatment consisted of open reduction and stabilisation with an AC Dreithaler hook plate. A clinical and radiological follow-up examination was performed 1 and 3 months after surgery, that is, before removal of the plate, and 12 months following removal.Eighteen months after the trauma, an MRI and a clinical examination were performed and the Constant–Murley scores calculated.Results: An acceptable joint alignment was achieved in all the patients after surgery; 1 year after plate removal, five cases (12%) of dislocation recurrence were reported. MRI showed the coraco-clavicular ligaments had healed in the remaining 37 cases (88%).Conclusion: An AC plate is a useful technique in acromio-clavicular dislocations because it is easy to implant, requires mini-invasive access and results in early resumption of normal activity. MRI can be used to evaluate healing of coraco-clavicular ligaments. A long-term follow-up study is, however, warranted to assess the likelihood of recurrence.Level of evidence: Level IV, therapeutic cases series.

Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus

2012-02-01

Abstract: Introduction: Angular stable osteosynthesis has become the gold standard in the operative treatment of proximal humeral fractures. The aim of this article is to determine the indications for osteosynthesis versus primary arthroplasty based on clinical and radiological parameters.Methods: A total of 368 surgically treated proximal humeral fractures were reviewed. Preoperative X-rays were used to evaluate the displacement and vascularity of the humeral head (according to the Hertel criteria) and the AO (Arbeitsgemeinschaft für Osteosynthesefragen) fracture type. Postoperative X-rays were analysed to assess the quality of the reduction, the reconstruction of the medial hinge and the displacement of the tuberosities. Follow-up X-rays were used to evaluate healing progress, the occurrence of avascular necrosis, loss of reduction and implant related failures. The American Shoulder and Elbow Surgeons score (ASES score) was used to evaluate the functional outcome. Correlations between a set of variables, type of treatment and eventual outcome were verified in both univariate and multivariate settings, with the significance rate set at p<0.05.Results: In total, 307 shoulders were evaluated. Mean follow-up was 4.3 years and showed a 15.3% failure rate, a 23.8% re-operation rate and a mean ASES score of 75.3. Better results were noted in patients who were younger at the time of surgery. More displaced fractures, AO type C fractures, varus fracture configuration and reduced head vascularity all led to a worse outcome. Anatomical reduction correlated with better results. Articular fractures had better results when treated with a plate.Conclusion: Surgical treatment of proximal humeral fractures remains difficult, with a failure rate of 15.3% and a re-operation rate of 23.8% at 4.3 years. A significantly displaced varus articular fracture in the older patient results in the worst outcome.

A 2-year experience, management and outcome of 200 clavicle fractures

R. Singh, R. Rambani, N. Kanakaris, P.V. Giannoudis — 2012-02-01

Abstract: Introduction: Clavicle fractures can cause pain and functional impairment if not managed appropriately. This article evaluates the prevalence of clavicular fractures, estimates the number of cases requiring operative treatment, evaluates whether removal of implant is a frequent necessity and compares the final functional outcome of the operative and non-operative groups.Patients and methods: Between November 2005 and November 2007, patients with clavicular fractures were eligible for participation. Patients below 18 years of age and those with pathological fractures were excluded. Demographic details, mechanism of injury, operative versus non-operative treatment, radiographic classification (Allman system), complications, implant removal and functional outcome using the University of California, Los Angeles (UCLA) shoulder-rating score were documented and analysed.Results: Out of 16,280 fractures that presented to our University Teaching Hospitals, 200 (1.23%) met the inclusion criteria. As many as 20 patients were lost due to natural attrition. A total of 159 (88.3%) patients were treated non-operatively and 21 (11.7%) patients were operated upon, over half of them for symptomatic non-union. All clavicles united postoperatively. Eighty-one conservatively managed undisplaced medial, middle and lateral end fractures had excellent mean UCLA shoulder scores. A statistical significance in UCLA scores (p<0.05) was noted between the operative and non-operative patient groups in mid-shaft fractures. There was no statistical difference between the operative and non-operative groups in lateral-end fractures. A total of 42.9% required removal of metal implant due to soft tissue irritation with complete resolution of symptoms.Conclusion: The incidence of clavicle fractures was 1.23%. A small number of patients (11.7%) required operative treatment. We recommend surgical management of symptomatic non-union and removal of metal implant for hardware-related irritation.

Reconstruction of radial capitellar fractures using fine-threaded implants (FFS)

Steffen Heck, Christian Zilleken, Dietmar Pennig, Thomas C. Koslowsky — 2012-02-01

Abstract: Fractures of the capitulum humeri are rare and challenging injuries to the elbow and outcome results are limited to case series, often with different fixation devices. This article aims to present 15 patients with a fracture of the capitulum humeri treated with the same implant, fine-threaded Kirschner wires (FFS). Besides range of motion and grip strength, outcome measurements include the following scores: the Mayo Elbow Performance index (MEPI); the American Shoulder and Elbow Surgeons’ Elbow Assessment (ASES) Form; the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; and the Broberg–Morrey score.Using the modified Bryan and Morrey classification, there were seven type-I injuries, three type-II, two type-III and three type-IV fractures. In addition to fractures of the capitellum, five patients were diagnosed with a complex ligamentous injury and three had suffered radial head fractures. After a minimum follow-up of 12 months, we obtained a range of motion in flexion and extension of 124° and a pro- and supination of 173°. The mean DASH showed 10.84 and the Broberg–Morrey score reached 90.8. ASES and MEPI scores were 91.5 and 90, respectively. The mean grip strength of the injured side was 217.9N versus 236.4N on the healthy side.The use of FFS for capitellar fractures of the humerus achieved good clinical results and these implants can be considered as a treatment option for this fracture entity.

The interpretation of intra-abdominal pressures from animal models: The rabbit to human example

Osamu Yoshino, Anthony Quail, Christopher Oldmeadow, Zsolt J. Balogh — 2012-02-01

Abstract: Introduction: The importance of the abdominal wall characteristics in intraabdominal pressure (IAP), intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are poorly understood. The applicability of laboratory research findings to human scenarios is unknown due to the potential differences in abdominal wall elastance (AWE) amongst species. The aims of the study are to describe the AWE curve in rabbits and to compare it to the available human data.Materials and methods: Prospective experimental animal study in the setting of research laboratory. Male New Zealand White rabbits weighting 2.7kg±0.1kg, were anesthetized and the AWE was determined by infusion of lactated Ringer's solution into the peritoneal cavity whilst the IAP was measured. A meta-analysis of peer-reviewed studies was conducted to define human AWE.Results: The described AWE was lower in the rabbit than in humans. The function comparing human and rabbit was: loge human IAP=(0.58 loge rabbit IAP+1.6).Conclusions: The AWE can vary amongst species. This study determined the relationship to allow the comparison of rabbit and human IAP. The proposed mathematical function is important for the advancement of interpretation and understanding of animal research into IAH and ACS. We recommend developing model-specific functions comparing individual animal models’ IAP and that of humans.

Treatment of complex fractures of the distal radius: A prospective randomised comparison of external fixation ‘versus’ locked volar plating

J. Jeudy, V. Steiger, P. Boyer, P. Cronier, P. Bizot, P. Massin — 2012-02-01

Abstract: The traditional treatment of severely impacted fractures of the distal radius involves bridging external fixation and maintaining reduction by applying continuous traction. The recent technique using fixed-angle screws within volar plates is reported restore the radial length and the articular profile whilst avoiding joint distraction. It is also believed to produce better and quicker clinical results. To test these claims, we carried out a randomised controlled comparison of the efficiency of external fixation (EF) ‘versus’ open reduction and internal fixation (ORIF) in treating severely impacted fractures of the distal radius. A total of 39 patients were treated with EF, eventually associated with percutaneous pinning, whereas 36 underwent ORIF with a locked volar plate. There was no significant difference in the two groups with regard to changes in the ulnar variance. Articular reduction was poor in two patients in the EF group with residual step-offs exceeding 2mm; another patient of the EF group suffered a secondary loss of reduction, healing with a severe articular malunion (>2mm). By contrast, articular reduction was satisfactory in all the patients of the ORIF group. The clinical results on the Green and O’Brien rating were significantly better in the ORIF group than in the EF group (p<0.01 at 6 weeks, p<0.05 at 6 months). Nevertheless, open reduction and volar plating did not yield better subjective results than EF. However, although not statistically significant, patients treated by ORIF seemed to resume their usual activities quicker than those treated with EF, suggesting that this technique may be adapted to a greater extent in the case of active, young individuals.

Circulating cellular and humoral elements of immune function following splenic arterial embolisation or splenectomy in trauma patients

2012-02-01

Abstract: Background: Splenectomy impairs the ability to combat infection, especially with encapsulated organisms. However, there is limited understanding of the impact of splenic arterial embolisation on immune function. Our hypothesis was that embolisation would not impair systemic immune function. This study examines elements of cellular and humoral immunity in patients undergoing splenic embolisation or splenectomy for trauma.Patients and methods: Splenic embolisation (SE) and splenectomy patients (S) were compared to blunt trauma patients without splenic injury (NS). Lymphocyte counts, natural-killer cells, serum complement (C3, C4), and properdin levels were assayed.Results: No significant differences in total, helper, or suppressor T-lymphocytes, complement (C3, C4), or properdin were found. B-lymphocyte counts were higher in S (602±445cells/mm3) than SE (238±114cells/mm3) or NS (293±153cells/mm3) (p=.003 for pairwise comparisons). S also had more natural killer T-cells than NS (325±170cells/mm3 vs. 174±116cells/mm3, p=.004).Conclusion: Splenic embolisation does not alter the measured immunologic parameters. The absence of sensitive markers for splenic immune function limits the ability to assess the impact of embolisation for trauma.

The impact of BMI on polytrauma outcome

2012-02-01

Abstract: Background: Varying results have been reported concerning the effect of body mass index (BMI) on polytrauma outcome. Although most studies focus on obesity and its associated preexisting medical diseases as a predictor for increased mortality rates, there is evidence that polytrauma patients with underweight also face an inferior outcome.Methods: Records of 5766 trauma patients (minimum 18 years of age, Injury Severity Score≥16, treated from 2004 to 2008) documented in the Trauma Registry of the German Society for Trauma Surgery were subclassified into 4 BMI groups and analysed to assess the impact of BMI on polytrauma outcome.Results: Underweight (BMI Group I) as well as obesity (BMI Group IV) in polytraumatized patients are associated with significantly increased mortality by multivariate logistic regression analysis with hospital mortality as the target variable (adjusted odds ratio for BMI Group I, 2.1 (95% CI 1.2–3.8, p=0.015); for BMI Group IV, 1.6 (95% CI 1.1–2.3, p=0.009)). Simple overweight (BMI Group III) does not qualify as a predictor for increased mortality (odds ratio 1.0; 95% CI 0.8–1.3).Conclusions: There is a significant correlation between obesity, underweight, and increased mortality in polytraumatized patients. Efforts to promote optimal body weight may reduce not only the risk of chronic diseases but also the risk of polytrauma mortality amongst obese and underweight individuals.

Early alveolar and systemic mediator release in patients at different risks for ARDS after multiple trauma

2012-02-01

Abstract: Alveolar IL-8 has been reported to early identify patients at-risk to develop ARDS. However, it remains unknown how alveolar IL-8 is related to pulmonary and systemic inflammation in patients predisposed for ARDS. We studied 24 patients 2–6h after multiple trauma. Patients with IL-8 >200pg/ml in bronchoalveolar lavage (BAL) were assigned to the group at high risk for ARDS (H, n=8) and patients with BAL IL-8 <200pg/ml to the group at low risk for ARDS (L, n=16). ARDS developed within 24h after trauma in 5 patients at high and at least after 1 week in 2 patients at low risk for ARDS (p=0.003). High-risk patients had also increased BAL IL-6, TNF-α, IL-1β, IL-10 and IL-1ra levels (p<0.05). BAL neutrophil counts did not differ between patient groups (H vs. L, 12% (3–73%) vs. 6% (2–32%), p=0.1) but correlated significantly with BAL IL-8, IL-6 and IL-1ra. High-risk patients had increased plasma levels of pro- but not anti-inflammatory mediators. The enhanced alveolar and systemic inflammation associated with alveolar IL-8 release should be considered to identify high-risk patients for pulmonary complications after multiple trauma to adjust surgical and other treatment strategies to the individual risk profile.

AIS>2 in at least two body regions: A potential new anatomical definition of polytrauma

Nerida Butcher, Zsolt J. Balogh — 2012-02-01

Abstract: Background: The term ‘polytrauma’ lacks a universally accepted, validated definition. In clinical trials the commonly applied injury severity based anatomical score cut-offs are ISS>15, ISS>17 and a recently recommended AIS>2 in at least two body regions (2×AIS>2).Purpose: To compare the outcomes of clinically defined polytrauma patients with those defined based on anatomical scores.Material and methods: A prospective observational study on all trauma team activation patients over a 7-month period presenting at a level-1 trauma centre were included in the study. The prospective data collection included AIS in each body region, ISS, ICU length of stay (LOS), multiple organ failure (MOF) and mortality.Results: 336 patients met inclusion criteria (age: 41±20, 74% male, ISS: 15±11, NISS: 19±15, MOF: 3%, mortality: 4%, 25% ICU admission). ISS>15: 13 deaths (10%), 71 (54%) required ICU admission and 10 (8%) developed MOF. ISS>17 captured 11 deaths (11%), with 63 (62%) requiring ICU admission and 10 (10%) developing MOF. Defining as (2×AIS>2): 8 deaths (13% of the group), with 43 patients requiring ICU admission (67%) and 9 (14%) developing MOF. When examining the performance of these three approaches, the ISS>15 and the ISS>17 captured statistically the same amount of clinically defined polytrauma patients (p=0.4106), while the 2×AIS>2 definition captured significantly more polytrauma patients than ISS>15 (p=0.0251) and ISS>17 (p=0.0019).Conclusion: 2×AIS>2 captured the greatest percentage of the worst outcomes and significantly larger % of the clinically defined polytrauma patients. 2×AIS>2 has higher accuracy and precision in defining polytrauma than ISS>15 and ISS>17. This simple, retrospectively also reproducible criteria warrants larger scale validation.

Isokinetic evaluation of pronation after volar plating of a distal radius fracture

2012-02-01

Abstract: Introduction: Pronator quadratus (PQ) is an important contributor to forearm pronation, and there is concern that volar plating of a distal radius fracture (DRF) may damage the PQ function. The purpose of this study was to determine whether isokinetic pronation strength would decrease considerably after volar locking plating of a DRF, and whether clinical outcomes would be affected by any pronation strength decrease.Materials and methods: Thirty-four patients of mean age of 55 years (range, 21–74 years) underwent bilateral isokinetic testing at 6 months and 1 year after open reduction and internal fixation using volar plating. Isokinetic pronation and supination strengths were compared between the operated and normal sides. Clinical outcomes such as grip strengths, range of motions and disabilities of the arm, shoulder and hand (DASH) scores were evaluated and analysed for any associations with isokinetic results.Results: At 6 months, peak torque and total work values for both pronation and supination were lower in the operated sides than in the normal sides (all p<0.001). However, at 1 year postoperatively, the differences in pronation strength were not statistically significant (p=0.188 for peak torque and p=0.190 for total work), whilst supination torque and total work were still significantly lower in the operated sides (p=0.015 and p=0.029, respectively). Decreases in pronation strength were found to correlate significantly with decreases in supination strength and grip power. Wrist motion and DASH scores were not found to be correlated with decrease in pronation or supination strengths.Conclusions: In patients with a DRF treated by volar plating, pronation strength was not significantly different between the operated and normal sides at 1 year postoperatively, and decreases in pronation or supination strengths were not found to affect clinical outcomes as assessed by DASH scores. This study suggests that dissection of the PQ may have minimal clinical impact on forearm pronation function.

A biomechanical study on variation of compressive force along the Acutrak 2 screw

Hari Kovilazhikathu Sugathan, Max Kilpatrick, Tom J. Joyce, John W.K. Harrison — 2012-02-01

Abstract: Introduction: Acutrak 2 screws are commonly used for scaphoid fracture fixation. To our knowledge, the variation in compressive force along the screw has not been investigated before. The objectives of our study were to measure variance in compression along the length of the standard Acutrak 2 screw, to identify the region of the screw which produces the greatest compression and to discuss the clinical relevance of this to the placement of the screw for scaphoid fractures.Materials and methods: A laboratory model was set up to test the compressive force at 2mm intervals along the screw, using solid polyurethane foam (Sawbone) blocks of varying width. The Acutrak 2 screws were introduced in the standard method. Forces were measured using a custom-made load cell washer introduced between the Sawbone blocks and were plotted as a graph along the whole length of the screw.Results: Maximum compression was at the mid-point of the screw. Overall compressive forces were higher in the proximal half of the screw by 19% when compared with the distal half. Minimum compression was seen at 4mm or less from either end of the screw.Conclusions: There is variation in compression along the length of the standard Acutrak 2 screw and the maximum compression was obtained at the mid-point of the screw. From this study, we would recommend when using an Acutrak 2 screw for internal fixation of scaphoid fractures, to attain maximum compressive force, place the fracture at the mid-point of the Acutrak screw. If this is not possible, then place the fracture towards the proximal half of the screw.

Optimal positioning of the DVR plate in distal radius fractures: A cadaveric examination of a referencing technique

A.R. Phillips, A. Al-Shawi — 2012-02-01

Abstract: Introduction: Volar locking plates have revolutionised the treatment of distal radius fractures but complications are not uncommon. We present a cadaveric study and a technical tip to assist in the accurate and reproducible placement of one such plate.Study: We placed 25-g needles in the distal radioulnar joint and radiocarpal joint and measured the distance from these needles to a DVR plate in its optimal position. This distance measured 5mm, corresponding to the width of the depth gauge handle. Placing this next to needles in these joints can help pre-plan the most distal and ulnar extent of the plate allowing for reproducible optimal positioning of the DVR plate.Technique: The technique developed uses the existing kit and is simple and easy to build into one's existing fixation technique.

Outcome of conjoined tendon and coracoacromial ligament transfer for the treatment of chronic type V acromioclavicular joint separation

Sae Hoon Kim, Young Ho Lee, Seung Han Shin, Ye Hyun Lee, Goo Hyun Baek — 2012-02-01

Abstract: Background: Numerous surgical methods are used to treat acromioclavicular (AC) joint dislocations, and an anatomical reconstruction using a free tendon graft has attracted considerable attention, particularly for chronic cases. The purpose of this study was to introduce the results of lateral half conjoined tendon (LHCT) and coracoacromial ligament (CAL) transfer for chronic type V injuries.Materials and methods: A retrospective evaluation was performed on the clinical and radiographic outcomes of the 12 patients who underwent LHCT and CAL transfer for chronic type V AC injuries and had been followed for 2 years postoperatively. All 12 patients were males with a mean age of 37.3±7.7 years (range: 26–49 years) at surgery. The causes of the injury were traffic accidents (five), falls (three) and sports injuries (four). The mean time elapsed between trauma and surgery was 12.5±5.4 weeks (range: 7–22 weeks).Results: No reduction loss was observed at the final follow-up. The postoperative coracoclavicular (CC) distance was 8.9±1.6mm, which represented a significant improvement versus the preoperative status (20.3±3.0mm; p<0.001), and no significant difference was observed between the injured and uninjured contralateral sides (8.7±0.8mm), postoperatively (p=0.619). The temporary use of a Steinman pin for AC fixation did not cause any complications. On the other hand, there were eight cases of mild radiographic arthrosis at the AC joint and two cases of heterotopic ossification of the CC space, although neither affected the functional outcomes. The mean modified UCLA score was 18.5±2.1 (range: 12–20), which represented an excellent result in 11 of the 12 cases. The single case with a poorer postoperative score had a pre-existing brachial plexus injury.Conclusions: Despite the small study cohort, the results of LHCT and CAL transfer in chronic type V AC separation are promising. CAL transfer alone has been shown to be biomechanically insufficient for an AC reconstruction, particularly in chronic situations. The advantage of LHCT transfer is that it does not require a distant donor site or incur the costs of an allograft or implant.

Fracture stabilisation in a polytraumatised African population—A comparison with international management practice

Ben Grey, Reitze N. Rodseth, David J.J. Muckart — 2012-02-01

Abstract: Introduction: Fracture management in polytrauma patients has favoured early definitive fracture fixation with some authors advocating a staged management approach in these potentially unstable patients. We aimed to investigate the timing of surgical fracture stabilisation in polytrauma patients with significant orthopaedic injuries in a Level 1 trauma unit in South Africa (RSA) and to compare its performance with Level 1 trauma units in the USA and Europe.Materials and methods: A retrospective review was performed extracting polytrauma patients with a New Injury Severity Score (NISS)≥15, with significant pelvic or long bone fractures managed surgically. We compared these data with recently published data from the USA and Europe.Results: Over a 3 year period pedestrian (46.3%) and motor vehicle or motorcycle accidents (40.7%) were the predominant mechanisms of injury in the 123 eligible patients. Compared to international data, patients were significantly younger (32.41 years (SD 13.4) vs. USA 44.1 years (SD 16.39) and Germany 41.2 years (SD 15.35), p<0.001); and had a higher NISS score (RSA 31.93 (10.3), USA 27.4 (8.65), Germany 29.4 (6.88), p=0.007). Less definitive fixation took place in the first 24h (RSA 37.4%, USA 57.1%, Germany 65.6%, p<0.001), but overall definitive fixation took place earlier (RSA 3.6 days (SD 4.39), USA 5.5 days (SD 4.2), Germany 6.6 days (SD 8.7), p=0.001).Conclusion: In a developing country when compared to international trauma centres, less primary definitive fixation was performed in the first 24h.

Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system?

M. Königshausen, L. Kübler, H. Godry, M. Citak, T.A. Schildhauer, D. Seybold — 2012-02-01

Abstract: Introduction: The surgical treatment of displaced proximal humeral fractures (ORIF) is a perpetual challenge to the surgeon. For this reason, the principle of polyaxiality was developed to provide an improved primary stability of the fracture through better anchorage of the screws, especially in osteoporotic bone. The aim of this study was to present clinical results with the polyaxial locking plate in the operative treatment of proximal humerus fractures in order to determine whether the technique of polyaxiality leads to better functional outcome and lower complication rates in comparison to monoaxial plates in the literature.Patients and methods: Seventy-three patients with displaced proximal humeral fractures were treated surgically with the polyaxial locking Suture Plate™ (Arthrex®) between 03/2007 and 06/2009. Fifty-two of the patients (mean age, 69.9±12.1) were included in a radiographical and clinical examination using the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH).Results: The follow-up examinations were on average 13.9±4.5 months (10–27 months) after surgical treatment. The mean CS of the patients was 66.0±13.7 points, the age- and gender-related CS was 90.9%±20.0% and the mean DASH score was 23.8±19.8 points for the injured side. The patients with a nearly anatomical reduction of their fracture (n=13) reached a significantly higher CS (75.1±8.5; p=0.004) and DASH-score (13.6±11.6; p=0.043) and none of these patients had a complication. The complications were identified in 12 (23.1%) cases, 5 of which involved loss of reduction. All of these 5 cases were lacking of initial medial column support and 4 of which were type C2.3 AO-Classification.Conclusion: The data show that the combination of angular stability with the possibility of variable polyaxial screw direction is a good concept for reduction and fixation of displaced proximal humeral fractures, but anatomical reduction and medial support remain important preconditions for a good outcome. However, a significantly lower rate of complications or better clinical outcome than that reported in the literature could not be found.

Effects of penehyclidine hydrochloride on pulmonary contusion from blunt chest trauma in rats

2012-02-01

Abstract: Background and objective: Toll-like receptor 4 (TLR4) is widely recognised as a pattern recognition receptor (PRR) in the triggering of innate immunity. Lung inflammation and systemic innate immune responses are dependent on TLR4 activation undergoing pulmonary contusion. Therefore, the author investigated the effects of penehyclidine hydrochloride (PHC) on the expression of TLR4 and inflammatory responses of blunt chest trauma-induced pulmonary contusion.Materials and methods: Male Sprague-Dawley (SD) rats were randomly assigned into three groups: normal control (NC) group, pulmonary contusion (PC) group and penehyclidine hydrochloride treatment (PHC) group. Pulmonary contusion was induced in anesthetised rats at fixed chest impact energy of 2.45J. Lung injury was assessed by the histopathology changes, arterial blood gas and myeloperoxidase (MPO) activity of lung. The serum tumour necrosis factor-α (TNF-α) and interleukin-6 (IL-6) levels were measured using enzyme-linked immunosorbent assays (ELISA). The expression of TLR4 was determined by immunohistochemistry.Results: Blunt chest trauma produced leucocytosis in the interstitial capillaries, hypoxemia, and increased MPO activity. The expressions of TNF-α, IL-6 and TLR4 in the lung were significantly enhanced during pulmonary contusion. PHC treatments effectively attenuated pulmonary inflammation responses, as shown by improved pulmonary oxygenation, histopathology damage, decreased the MPO activity, the expressions of TNF-α, IL-6, and TLR4 after lung injury.Conclusion: It might be concluded that PHC exhibit anti-inflammatory and protective effects in traumatic lung injury via the inhibition of the TLR4 pathway.

Vitamin D levels in post-menopausal Korean women with a distal radius fracture

2012-02-01

Abstract: Introduction: The purpose of this study was to investigate serum levels of vitamin D in post-menopausal Korean women with a distal radius fracture (DRF) and to determine if there is any association between vitamin D levels and bone-related variables such as bone mineral densities (BMDs), serum parathyroid hormone (PTH) levels and several bone turnover markers.Materials and methods: The data of 104 postmenopausal women surgically treated for a distal radius fracture (DRF group) and 107 age-matched control patients without a fracture (control group) were compared. Serum vitamin D levels (25-hydroxycholecalciferol, 25(OH)D3) were compared between the groups with consideration of age and seasonal variations. BMDs, serum PTH and several bone turnover markers, including serum osteocalcin, C-telopeptide and urine N-telopeptide, were measured and analysed to find any association with vitamin D levels.Results: The mean 25(OH)D3 level was significantly lower in the DRF group compared to the control group (p<0.001). In particular, patients in their sixth and seventh deciles in the DRF group had significantly lower 25(OH)D3 levels than patients in the control group (p=0.001 and 0.013, respectively). When seasonal variation was considered, significant differences of 25(OH)D3 levels were found between the groups in autumn and winter. Hip BMDs were significantly lower in the DRF group than in the control group, and there was a positive correlation between serum 25(OH)D3 levels and hip BMDs. Bone turnover markers were not significantly different between the two groups, although serum PTH levels were marginally higher in the DRF group (p=0.08).Conclusions: Post-menopausal Korean women with a DRF were found to have significantly lower serum vitamin D levels than the control group, and vitamin D levels were particularly lower in women in their sixth and seventh deciles who may be a good target group for prevention of future fractures. Future investigation should focus on determining whether vitamin D supplementation can be helpful in preventing future fractures in patients with a DRF.

Fractures of the neck of the fifth metacarpal bone. Medium-term results in 28 cases treated by percutaneous transverse pinning

V. Potenza, R. Caterini, F. De Maio, S. Bisicchia, P. Farsetti — 2012-02-01

Abstract: The purpose of this study was to report the medium-term results in 28 patients affected by closed displaced fractures of the neck of the fifth metacarpal bone (boxer's fracture) with an associated severe swelling of the hand, who were treated with percutaneous transverse K-wire pinning, to verify the effectiveness of this surgical treatment. We opted for this treatment in all cases in which malrotation of the fifth finger and volar angulation of the metacarpal head greater than 30° were associated with a severe swelling of the hand. All the patients were reviewed clinically and radiologically at an average of 25 months after surgery. At the final follow-up, no patient reported residual pain. All patients had full extension of the fifth finger, except two in whom we observed a limitation of the extension of the fifth metacarpophalangeal (MP) joint of about 10°, without significant impairment of hand function. All patients had at least 90° flexion of the fifth MP joint and full range of motion of the interphalangeal (IP) joints. No patient had rotational deformity of the fifth finger with a deficit of grip strength. At the final follow-up, a residual palmar angulation of the head of the fifth metacarpal was found in three patients, with a mean of 7°. The disabilities of the arm, shoulder and hand (DASH) scale had a mean value of 5, and all patients considered their result as good or excellent. We recommend percutaneous transverse pinning in all boxer's fractures in which operative treatment is indicated, especially in patients with severe soft-tissue swelling. The surgical procedure is easy to perform, and surgical results are generally good.

Closed reduction intermetacarpal Kirschner wire fixation in the treatment of unstable fractures of the base of the first metacarpal

A.P.A. Greeven, T.D.W. Alta, R.E.M. Scholtens, P. de Heer, F.M. van der Linden — 2012-02-01

Abstract: The purpose of this study was to describe the results of extra-articular and intra-articular fractures, at the base of the first metacarpal, treated with closed reduction and percutaneous fixation with intermetacarpal Kirschner wires. Outcome was evaluated by experienced pain, functional outcome and radiographic indications for arthritis. In total, 25 patients with unstable fractures at the base of the first metacarpal underwent closed reduction and percutaneous fixation of the fracture. Prospectively collected data of 25 consecutive patients were evaluated retrospectively, assessing stability of fixation, operation time and the occurrence of fracture dislocation during and after treatment.All patients were assessed at 1, 3, 6 and 24months. Follow-up included questionnaires: functional tests including grip and pinch measurement and radiographic analysis for post-traumatic arthritis, using the modified Eaton–Littler classification.In total, 15 patients with extra-articular fractures and 10 patients with intra-articular fractures were treated with this technique. In the group of extra-articular fractures of 15 patients, only one patient had loss of grip strength greater than 20% in comparison with the contra-lateral side (corrected for hand dominance). No clinically important difference was found for pinch strength. One patient experienced functional limitations and was unable to return to a previous hobby.In the patients group with intra-articular fractures, seven patients had a Bennett fracture and three a Rolando fracture. One patient with a Bennett fracture had a loss of pinch strength greater than 20% corrected for hand dominance. One of the three patients with a Rolando fracture had grip loss greater than 20%. None of the patients with intra-articular fractures experienced any functional limitations.The described fixation procedure results in a stable fixation of the fracture fragments, and no secondary dislocation of the fracture occurred. Fractures consolidated within 32 (26–50) days and no new fractures were observed.These results suggest that this technique can be safely used in the treatment of extra-articular fractures as well as intra-articular fractures at the base of the first metacarpal.

A contemporary approach to the management of a Bosworth injury

S.E. Wright, A. Legg, M.B. Davies — 2012-02-01

A Bosworth ankle fracture-dislocation is a dislocation of the distal fibular shaft posterior to the posterior tibial tubercle held fixed by an intact interosseous membrane. Approximately 60 cases have been reported in the literature since 1947, either as case reports or as small case series. Variants of this injury pattern include an intact fibula, associated ruptured deltoid ligaments, fractured medial malleolus, fractured posterior tibial tubercle, associated compartment syndrome and vascular injury. In most cases, there is a need to perform an open reduction as closed reduction methods often fail. Rarely, the fibula shaft fragment interposes between the posterior tibial lip fragments necessitating an open reduction and the exertion of ‘considerable force’ in order to achieve reduction.

Combined posterior and medial plate fixation of complex proximal ulna fractures

Alida E.A. Ochtman, David Ring — 2012-02-01

Olecranon fracture dislocations often create complex fractures of the proximal ulna including fragmented coronoid fractures. Olecranon fracture dislocations can occur in an anterior or a posterior direction. In an anterior olecranon (transolecranon) fracture dislocation, the radius and ulna both dislocate anteriorly, the forearm relationships remain intact and the coronoid fracture is usually simple. Posterior olecranon fracture dislocations and varus posteromedial rotational injuries can have greater coronoid fragmentation. Coronoid fragmentation can be difficult to repair with a posterior plate and screws alone.