Surgery versus functional bracing for humeral shaft fractures

English abstrac

Aikuisten olkavarsimurtuman hoito

Vertaisarvioitu. Näin hoidan.Olkavarren murtuma on melko yleinen murtuma aikuisilla. Diagnoosi on yleensä selvä jo kliinisen tutkimuksen perusteella, ja se varmistetaan röntgenkuvalla. Murtuma voidaan yleensä hoitaa menestyksekkäästi konservatiivisesti olkavarren alueelle asetetulla toiminnallisella ortoosilla tai leikkaushoidolla. Leikkaushoito on tavallisesti perusteltua muun muassa avomurtumissa, murtumaa komplisoivien suonivammojen yhteydessä ja monivammautuneiden potilaiden hoidossa. Parin viimeisen vuosikymmenen aikana leikkausmäärät ovat lähteneet nousuun myös komplisoitumattomissa olkavarren murtumissa. Vertailevia tutkimuksia konservatiivisen ja kirurgisen hoidon välillä on kuitenkin vähän. Tuoreen suomalaistutkimuksen perusteella vaikuttaa siltä, että kirurginen hoito tarjoaa nopeamman toipumisen, mutta keskimäärin tulokset ovat kuuden kuukauden kuluttua vammasta yhtä hyvät

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Casting in finger trap traction without reduction versus closed reduction and percutaneous pin fixation of dorsally displaced, over-riding distal metaphyseal radius fractures in children under 11 years old : A study protocol of a randomised controlled trial

Publisher Copyright: ©Introduction Distal radius is the most common site of fracture in children, comprising 23%-31% of all paediatric fractures. Approximately one-fifth of these fractures are displaced. Completely displaced distal metaphyseal radius fractures in children have traditionally been treated with closed reduction. Recent evidence suggests that correcting the shortening in over-riding distal metaphyseal radius fractures is not necessary in prepubertal children. To date, no published randomised controlled trial (RCT) has compared treatment of these fractures in children by casting the fracture in bayonet position to reduction and pin fixation. Methods and analysis We will conduct an RCT to compare the outcomes of casting the fracture in bayonet position in children under 11 years of age to reduction and percutaneous pin fixation. 60 patients will be randomly assigned to casting or surgery groups. We have two primary outcomes. The first is ratio (injured side/non-injured side) in the total active forearm rotation and the second is ratio (injured side/non-injured side) in total active range of motion of the wrist in the flexion-extension plane at 6 months. The secondary outcomes will include axial radiographic alignment, passive extension of the wrists, grip strength and length of forearms and hands, patient-reported outcome QuickDASH and pain questionnaire PedsQL. Patients not willing to participate in the RCT will be asked to participate in a prospective cohort. Patients not eligible for randomisation will be asked to participate in a non-eligible cohort. These cohorts are included to enhance the external validity of the results of the RCT. Our null hypothesis is that the results of the primary outcome measures in the casting group are non-inferior to surgery group. Ethics and dissemination The institutional review board of the Helsinki and Uusimaa Hospital District has approved the protocol. We will disseminate the findings through peer-reviewed publications. Trial registration number NCT04323410. Protocol V.1.1, 29 September 2020.Peer reviewe

Treatment of hallux rigidus (HARD trial) : study protocol of a prospective, randomised, controlled trial of arthrodesis versus watchful waiting in the treatment of a painful osteoarthritic first metatarsophalangeal joint

Introduction Hallux rigidus is a common problem of pain and stiffness of the first metatarsophalangeal joint (MTPJ) caused mainly by degenerative osteoarthritis. Several operative techniques have been introduced for the treatment of this condition without high-quality evidence comparing surgical to non-surgical care. In this trial, the most common surgical procedure, arthrodesis, will be compared with watchful waiting in the management of hallux rigidus. Methods and analysis Ninety patients (40 years or older) with symptomatic first MTPJ osteoarthritis will be randomised to arthrodesis or watchful waiting in a ratio of 1:1. The primary outcome will be pain during walking, assessed using the 0-10 Numerical Rating Scale (NRS) at 1 year after randomisation. The secondary outcomes will be pain at rest (NRS), physical function (Manchester-Oxford Foot Questionnaire), patient satisfaction in terms of the patient-acceptable symptom state, health-related quality of life (EQ-5D-5L), activity level (The Foot and Ankle Ability Measure Sports subscale), use of analgesics or orthoses and the rate of complications. Our null hypothesis is that there will be no difference equal to or greater than the minimal important difference of the primary outcome measure between arthrodesis and watchful waiting. Our primary analysis follows an intention-to-treat principle. Ethics and dissemination The study protocol has been approved by the Ethics Committee of Helsinki and Uusimaa Hospital District, Finland. Written informed consent will be obtained from all the participants. We will disseminate the findings of this study through peer-reviewed publications and conference presentations. Protocol version 21 June 2021 V.2.0.Peer reviewe

BioFACTS : biomarkers of rhabdomyolysis in the diagnosis of acute compartment syndrome - protocol for a prospective multinational, multicentre study involving patients with tibial fractures

Introduction The ischaemic pain of acute compartment syndrome (ACS) can be difficult to discriminate from the pain linked to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is based on clinical findings and performed at a low level of suspicion. Biomarkers of muscle cell damage may help to identify and monitor patients at risk, similar to current routines for patients with acute myocardial infarction. This study will test the hypothesis that biomarkers of muscle cell damage can predict ACS in patients with tibial fractures. Methods and analysis Patients aged 15-65 years who have suffered a tibial fracture will be included. Plasma (P)-myoglobin and P-creatine phosphokinase will be analysed at 6-hourly intervals after admission to the hospital (for 48 hours) and-if applicable-after surgical fixation or fasciotomy (for 24 hours). In addition, if ACS is suspected at any other point in time, blood samples will be collected at 6-hourly intervals. An independent expert panel will assess the study data and will classify those patients who had undergone fasciotomy into those with ACS and those without ACS. All primary comparisons will be perforated between fracture patients with and without ACS. The area under the receiver operator characteristics curves will be used to identify the success of the biomarkers in discriminating between fracture patients who develop ACS and those who do not. Logistic regression analyses will be used to assess the discriminative abilities of the biomarkers to predict ACS corrected for prespecified covariates. Ethics and dissemination The study has been approved by the Regional Ethical Review Boards in Linkoping (2017/514-31) and Helsinki/Uusimaa (HUS/2500/2000). The BioFACTS study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology recommendations.Peer reviewe

Minimal important difference and patient acceptable symptom state for common outcome instruments in patients with a closed humeral shaft fracture - analysis of the FISH randomised clinical trial data

Background: Two common ways of assessing the clinical relevance of treatment outcomes are the minimal important difference (MID) and the patient acceptable symptom state (PASS). The former represents the smallest change in the given outcome that makes people feel better, while the latter is the symptom level at which patients feel well.Methods: We recruited 124 patients with a humeral shaft fracture to a randomised controlled trial comparing surgery to nonsurgical care. Outcome instruments included the Disabilities of Arm, Shoulder, and Hand (DASH) score, the Constant-Murley score, and two numerical rating scales (NRS) for pain (at rest and on activities). A reduction in DASH and pain scores, and increase in the Constant-Murley score represents improvement. We used four methods (receiver operating characteristic [ROC] curve, the mean difference of change, the mean change, and predictive modelling methods) to determine the MID, and two methods (the ROC and 75th percentile) for the PASS. As an anchor for the analyses, we assessed patients'satisfaction regarding the injured arm using a 7-item Likert-scale.Results: The change in the anchor question was strongly correlated with the change in DASH, moderately correlated with the change of the Constant-Murley score and pain on activities, and poorly correlated with the change in pain at I rest (Spearman's rho 0.51, -0.40, 0.36, and 0.15, respectively).Depending on the method, the MID estimates for DASH ranged from -6.7 to -11.2, pain on activities from -0.5 to -1.3, and the Constant-Murley score from 6.3 to 13.5.The ROC method provided reliable estimates for DASH (-6.7 points, Area Under Curve [AUC] 0.77), the Constant-Murley Score (7.6 points, AUC 0.71), and pain on activities (-0.5 points, AUC 0.68).The PASS estimates were 14 and 10 for DASH, 2.5 and 2 for pain on activities, and 68 and 74 for the Constant-Murley score with the ROC and 75th percentile methods, respectively.Conclusion: Our study provides credible estimates for the MID and PASS values of DASH, pain on activities and the Constant-Murley score, but not for pain at rest. The suggested cut-offs can be used in future studies and for assessing treatment success in patients with humeral shaft fracture.Peer reviewe

Humeral Shaft Fractures in Adults : Effectiveness of Surgery versus Functional Bracing

Introduction Humeral shaft fractures account for 1–3% of all adult fractures. They are usually caused by simple falls, traffic accidents, and sports injuries. Historically, the treatment of these injuries has been mainly nonsurgical. However, there has been a marked increase in the rate of surgical treatment for humeral shaft fractures in recent years without high-quality evidence supporting this trend. Aim The Finnish Shaft of the Humerus (FISH) randomized clinical trial was planned to compare the effectiveness of surgery versus nonsurgical care in the treatment of humeral shaft fractures in patients traditionally deemed suitable for nonsurgical care with functional bracing (Study I). Patients and methods Patient recruitment was conducted at the Helsinki and Tampere University hospitals between November 2012 and January 2018. Consenting adult patients with displaced, closed, unilateral humeral shaft fractures were randomized to either surgical care using open reduction and plate fixation or nonsurgical care using functional bracing. Patients with a history or condition affecting the function of the injured upper limb, pathological fracture, other concomitant injury affecting the same upper limb, other trauma requiring surgery (e.g., fracture, internal organ, brachial plexus, or vascular injury), polytrauma, multimorbidity with high anesthesia risk, or inadequate cooperation for any reason were excluded. Altogether, 321 patients were assessed for eligibility and of these 140 were eligible for randomization. After informed consent, 82 were willing to undergo randomization. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score (range, 0 to 100 points; 0 = no disability, 100 = extreme disability). In Study II, the patients were analyzed according to the initially allocated treatment method (surgery group and bracing group). In Study III, the patients were analyzed in three groups according to their final treatment method: 1) initial surgery group, 2) bracing group with successful healing, and 3) secondary surgery group including patients randomized to functional bracing but who underwent late surgery due to fracture healing problems. Results Study II. The mean DASH score was 8.9 (95% confidence interval [CI], 4.2 to 13.6) in the surgery group and 12.0 (95% CI, 7.7 to 16.4) in the bracing group at 12 months. The between-group difference was -3.1 (95% CI, -9.6 to 3.3). This difference was not statistically significant, and it was below the predefined minimal clinically important difference of 10 points. Of the patients allocated to functional bracing, 13/44 (30%) underwent late surgery due to healing problem during the 12-month follow-up. In the post hoc analysis, the results of those with initial surgery were superior to those with late surgery due to healing problem (between-group difference, -11.1; 95% CI, -20.1 to -2.1) at 12 months. Study III. The mean DASH score was 6.8 (95% CI, 2.3 to 11.4) in the initial surgery group (n=38), 6.0 (95% CI, 1.0 to 11.0) in the bracing group (n=30), and 17.5 (95% CI, 10.5 to 24.5) in the secondary surgery group (n=14) at the 2-year follow-up. The between-group difference was -10.7 (95% CI, -19.1 to -2.3) between the initial and secondary surgery groups and -11.5 (95% CI, -20.1 to -2.9) between the bracing and secondary surgery groups. Conclusions Study II. Surgery with plate fixation, compared with functional bracing in the treatment of adult patients with closed humeral shaft fractures, did not significantly improve functional outcomes at 12 months. However, 30% of the patients allocated to functional bracing underwent late surgery due to healing problem. Study III. Shared decision-making between the clinicians and patients with closed humeral shaft fractures should weigh the prospect that 2/3 of patients undergo successful healing and have good functional outcomes using functional bracing against the 1/3 risk of fracture healing problems leading to secondary surgery and inferior outcomes even at 2 years after the injury.Olkavarren murtumat muodostavat 1–3 % aikuisväestön murtumista. Vamman syynä on yleensä kaatuminen, liikenneonnettomuus tai urheiluvamma. Aiemmin näitä murtumia on hoidettu pääsääntöisesti ilman leikkausta käyttäen ns. toiminnallista ortoosia. Viime aikoina näiden vammojen leikkausmäärät ovat kuitenkin selvästi lisääntyneet ilman leikkaushoitoa tukevaa laadukasta tieteellistä näyttöä. Tavoite Tässä satunnaistetussa vertailevassa tutkimuksessa verrattiin kirurgisen hoidon (levykiinnitys) ja ilman leikkausta toteutetun hoidon (ortoosihoito) tuloksia sulkeisen olkavarren murtuman saaneilla aikuispotilailla. Tutkimuksen menetelmät julkaistiin ennalta (Tutkimus I). Aineisto ja menetelmät Tutkimusaineisto kerättiin Helsingin ja Tampereen yliopistollisissa sairaaloissa vuosina 2012–2018. 140 soveltuvasta potilaasta 82 suostui satunnaistukseen, jolloin potilas hoidettiin joko leikkaamalla tai ortoosilla. Päätulosmuuttuja oli potilaan raportoima yläraajan toimintakykyä ja vammaan liittyvää haittaa kartoittava DASH-mittari (asteikko 0–100; 0=paras). Tutkimuksessa II tulokset arvioitiin satunnaistuksen mukaisissa ryhmissä (kirurginen ryhmä vs. ortoosiryhmä). Tutkimuksessa III tulokset arvioitiin kolmessa ryhmässä lopullisen hoitomuodon mukaisesti: 1) välittömän kirurgian ryhmä, 2) ortoosiryhmä (murtuma parani ilman ongelmia) ja 3) myöhäisen kirurgian ryhmä (epäonnistunut ortoosihoito johti myöhäisvaiheen leikkaukseen murtuman paranemisongelman vuoksi). Tulokset Tutkimus II. DASH-pisteiden keskiarvo oli 8.9 kirurgisessa ryhmässä ja 12.0 ortoosiryhmässä 12 kuukauden kuluttua vammasta. Ero oli selvästi alle kliinisesti merkityksellisen 10 pisteen. 30 % ortoosiryhmän potilaista jouduttiin leikkaamaan vuoden kuluessa vammasta paranemisongelman vuoksi ja näiden potilaiden tulokset päätettiin analysoida erikseen 2 vuoden kohdalla vammasta. Tutkimus III. DASH-pisteiden keskiarvo oli 2 vuoden kuluttua vammasta 6.8 välittömän kirurgian ryhmässä, 6.0 ortoosiryhmässä ja 17.5 myöhäisen kirurgian ryhmässä. Yhteenveto Tutkimus II. Kirurgisella hoidolla ei saavutettu parempia tuloksia ortoosihoitoon verrattuna vuoden kuluttua vammasta. Tutkimus III. Olkavarren murtuman saaneen potilaan ja häntä hoitavan lääkärin tulee huomioida hoidosta päättäessään, että 2/3 ortoosihoidolla hoidetuista potilaista paranee hyvin tuloksin, mutta 1/3:lla liittyy ortoosihoitoon paranemisongelmia, minkä vuoksi heidät joudutaan leikkaamaan viivästetysti. Tällöin heidän toiminnalliset tuloksensa ovat vielä 2 vuoden kuluttua vammasta huonommat, kuin heti leikatuilla potilailla sekä niillä potilailla, joilla murtuma paranee ortoosihoidolla ilman leikkausta

Development cooperation, 1958-1992: party politics and a foreign policy débâcle

The chapter investigates Italian foreign aid policy from 1958 to 1992

Epidemiology of 936 humeral shaft fractures in a large Finnish trauma center

Background: Humeral shaft fractures are relatively common injuries and are classified according to location and fracture morphology. Epidemiological studies improve understanding of injury patterns and lay foundations for future research. There are only a few published larger epidemiological studies on humeral shaft fractures. Methods: We retrospectively analyzed the medical records of adult patients having sustained a humeral shaft fracture treated in the Helsinki University Hospital between 2006 and 2016. We recorded patient and fracture characteristics, timing and mechanism of injury, associated injuries, and 1-year mortality. Results: We identified 914 patients (489 females, median age = 61.4 years; 425 males, median age = 50.4 years) with 936 fractures. Over 60% of these fractures were sustained from simple falls. The patient age distribution was bimodal, with highest fracture rates in elderly females and young males. We divided the fractures into typical traumatic, periprosthetic, and pathological fractures. Of the 872 typical traumatic fractures, 3.0% were open. In addition, there were 24 (2.6%) periprosthetic and 40 (4.3%) pathological fractures. An associated injury was found in 24% of patients, with primary radial nerve palsy (PRNP) being the most common (10%). PRNPs were more common in distal shaft fractures and high energy injuries. The 1-year mortality was 9.2%. Conclusions: In this study, the most common injury mechanism was a simple fall. The most common associated injury was PRNP. The observed bimodal fracture distribution is consistent with previous literature. (c) 2022 The Author(s). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).Peer reviewe