Salter-Harris II injury of the proximal tibial epiphysis with both vascular compromise and compartment syndrome: a case report

We present a case of a Salter-Harris II injury to the proximal tibia associated with both vascular compromise and compartment syndrome. The potential complications of this injury are limb threatening and the neurovasular status of the limb should be continually monitored. Maintaining anatomic reduction is difficult and fixation may be needed to achieve optimal results

Polytrauma in the elderly: predictors of the cause and time of death

<p>Abstract</p> <p>Background</p> <p>Increasing age and significant pre-existing medical conditions (PMCs) are independent risk factors associated with increased mortality after trauma. Our aim was to review all trauma deaths, identifying the cause and the relation to time from injury, ISS, age and PMCs.</p> <p>Methods</p> <p>A retrospective analysis of trauma deaths over a 6-year period at the study centre was conducted. Information was obtained from the Trauma Audit and Research Network (TARN) dataset, hospital records, death certificates and post-mortem reports. The time and cause of death, ISS, PMCs were analysed for two age groups (<65 years and ≥ 65 years).</p> <p>Results</p> <p>Patients ≥ 65 years old were at an increased risk of death (OR 6.4, 95% CI 5.2-7.8, p < 0.001). Thirty-two patients with an ISS of >15 and died within the first 24 hours of admission, irrespective of age, from causes directly related to their injuries. Twelve patients with an ISS of <16, died after 13 days of medical conditions not directly related to their injuries (p = 0.01). Thirty four patients had significant PMCs, of which 11 were <65 years (34.4% of that age group) and 23 were ≥ 65 years (95.8% of that age group) (p = 0.02). The risk of dying late after sustaining minor trauma (ISS <16) is increased if a PMC exists (OR 5.5, p = 0.004).</p> <p>Conclusion</p> <p>Elderly patients with minor injuries and PMCs have an increased risk of death relative to their younger counterparts and are more likely to die of medical complications late in their hospital admission.</p

The Edinburgh variant of a talar body fracture: a case report

We describe a novel closed pantalar dislocation with an associated sagittal medial talar body and medial malleolus fractures. Closed reduction was attempted unsuccessfully. Open reduction was performed, revealing a disrupted talonavicular joint with instability of the calcaneocuboid joint. This configuration required stabilisation with an external fixator. There were no signs of avascular necrosis, or arthrosis at 15 months follow but is currently using a stick to mobilise

Higher rate of complications with uncemented compared to cemented total hip arthroplasty for displaced intracapsular hip fractures: A randomised controlled trial of 50 patients

Marietta van der Linden - ORCID: 0000-0003-2256-6673 https://orcid.org/0000-0003-2256-6673Replaced AM with VoR 2020-10-26Background The primary aim of this study was to compare the functional outcome of uncemented with cemented total hip arthroplasty (THA) for displaced intracapsular hip fractures. The secondary aims were to assess length of surgery, blood loss, complications and revision rate between the two groups.Methods A prospective double-blind randomised control trial was conducted. Fifty patients’ staining an intracapsular hip fracture meeting the inclusion criteria and were randomised to either an uncemented (n=25) or cemented (n=25) THA. There were no differences (p>0.45) in age, gender, health status or preinjury hip function between the groups. The Oxford hip score (OHS), Harris Hip score (HHS), EuroQol 5-dimensional (EQ5D), timed get up-and-go (TUG), pain and patient satisfaction were used to assess outcome. These were assessed at 4, 12 and 72 months after surgery, apart from the TUG which as only assessed as 6 months.Results The study was terminated early due to the significantly (n=8, p=0.004) higher rate of intraoperative complications in the uncemented group: three fractures of the proximal femur and five conversions to a cemented acetabular component. There were no significant (p≥0.09) differences in the functional measures (OHS, HSS, EQ5D, TUG and pain) or patient satisfaction between the groups. There was no difference in operative time (p=0.75) or blood loss (p=0.66) between the groups. There were two early revisions prior to 3-months postoperatively in the uncemented group and none in the cemented group, but this was not significant (Log Rank p=0.16).Conclusion There was a high rate of intraoperative complications, which may be due to poor bone quality in this patient group. There were no ergonomic or functional advantages demonstrated between uncemented and cemented THA. Cemented THA should remain as the preferred choice for the treatment of intracapsular hip fractures for patients that meet the criteria for this procedure.https://doi.org/10.1007/s00590-020-02808-x31pubpu

Routine fixation of humeral shaft fractures is cost-effective:cost-utility analysis of 215 patients at a mean of five years following nonoperative management

Aims: The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion. Methods: From 2008 to 2017, 215 patients (mean age 57 yrs (17 to 18), 61% female (n = 130/215)) with a nonoperatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n = 165/215) after initial nonoperative management, with 23% (n = 50/215) uniting after surgery for nonunion. The EuroQol five-dimension three-level health index (EQ-5D-3L) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury, and management factors upon the EQ-5D-3L. An incremental cost-effectiveness ratio (ICER) of < £20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective. Results: At a mean of 5.4 yrs (1.2 to 11.0), the mean EQ-5D-3L was 0.736 (95% confidence interval (CI) 0.697 to 0.775). Adjusted analysis demonstrated the EQ-5D-3L was inferior among patients who united after nonunion surgery (β = 0.103; p = 0.032). Offering routine fixation to all patients to reduce the rate of nonunion would be associated with increased treatment costs of £1,542/patient, but would confer a potential EQ-5D-3L benefit of 0.120/patient over the study period. The ICER of routine fixation was £12,850/QALY gained. Selective fixation based on a RUSHU < 8 at six weeks post-injury would be associated with reduced treatment costs (£415/patient), and would confer a potential EQ-5D-3L benefit of 0.335 per ‘at-risk patient’. Conclusion: Routine fixation for patients with humeral shaft fractures to reduce the rate of nonunion observed after nonoperative management appears to be a cost-effective intervention at five years post-injury. Selective fixation for patients at risk of nonunion based on their RUSHU may confer even greater cost-effectiveness, given the potential savings and improvement in health-related quality of life. Cite this article: Bone Jt Open 2022;3(7):566–572

A Technique of Predicting Radiographic Joint Line and Posterior Femoral Condylar Offset of the Knee

Purpose. To describe a reliable method of predicting native joint line and posterior condylar offset (PCO) using true lateral digital radiographs of the distal femur. Methods. PCO was measured relative to a line drawn parallel to the posterior cortex of the distal femur and the joint line was measured from the posterior condylar flare to the articular surface. A ratio was then calculated for these measurements relative to the width of the femur at the level of the flare. Two independent observers measured PCO and joint line ratio for 105 radiographs of the different knees and one repeated these measurements after one week. Results. There was a significant correlation between the width of the femoral diaphysis at the level of the posterior condylar flare with joint line (P = 0.008) and PCO (P = 0.003). Joint line and PCO could be predicted within 4?mm and 2?mm, respectively, using the identified ratio between the width of the femoral diaphysis at the level of the posterior condylar flare with measured joint line and PCO. The inter- (P &lt; 0.001) and intra- (P &lt; 0.001) observer reliability for these ratios were high. Conclusion. These ratios could be used to predict the native joint line and PCO

Surgical Versus Nonsurgical Management of Humeral Shaft Fractures:a systematic review and meta-analysis of randomised trials

Introduction: The aim was to compare operative and non-operative management for adults with humeral shaft fractures, in terms of patient-reported upper limb function, health-related quality of life (HRQoL), radiographic outcomes and complications.Methods: MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), ClinicalTrials.gov, ISRCTN (International Clinical Trials Registry) and OpenGrey (Repository for Grey Literature in Europe) were searched in September 2021. All published prospective randomised trials comparing operative and non-operative management of humeral shaft fractures in adults were included. Of 715 studies identified, five were included in the systematic review and four in the meta-analysis. Data were extracted by two independent reviewers according to the PRISMA statement. Methodological quality was assessed using the revised Cochrane risk-of-bias tool for randomised trials. Pooled data were analysed using a random-effects model.Results: The meta-analysis comprised 292 patients (mean age 41yrs [18-83], 67% male). Surgery was associated with superior DASH and Constant-Murley scores at six months (mean DASH difference 7.6, p=0.01; mean Constant-Murley difference 8.0, p=0.003) but there was no difference at one year (DASH, p=0.30; Constant-Murley, p=0.33). No differences in HRQoL or pain scores were found. Surgery was associated with a lower risk of nonunion (0.7% versus 15.7%; odds ratio [OR] 0.13, p=0.004). The number-needed-to-treat (NNT) with surgery to avoid one nonunion was 7. Surgery was associated with a higher risk of transient radial nerve palsy (17.4% versus 0.7%; OR 8.23, p=0.01) but not infection (OR 3.57, p=0.13). Surgery was also associated with a lower risk of re-intervention (1.4% versus 19.3%; OR 0.14, p=0.04).Conclusions: Surgery may confer an early functional advantage to adults with humeral shaft fractures, but this is not sustained beyond six months. The lower risk of nonunion should be balanced against the higher risk of transient radial nerve palsy.<br/