Fracture Grade Research Articles

Unreamed Intra-Medullary Nail Versus Half Pin External Fixator in Grade III [A & B] Open tibia fractures

BackgroundTibia fracture is the most common long bone fracture. The fractures of tibia are commonly open fractures due to subcutaneous position of the tibia. The choice of technique for stabilization of open tibia fractures includes - External fixation, unreamed intra-medullary nails [URTN], Reamed intra-medullary nails, ORIF with Plating. ObjectivesTo evaluate & compare the results of Unreamed Intra-Medullary Nail Versus Half Pin External Fixator in Grade III [A & B] Open tibia fractures. MethodsThis prospective clinical study [Randomized chit box] was done on 50 patients presenting to our institute within 24 h of injury. Only those who were skeletally mature with open tibia fracture Grade IIIA & IIIB [Gustilo-Anderson] were included in this study. After initial management, radiological assessment was done. Following this adequate wound debridement, skeletal stabilization with either primary URTN or external fixator was done. Inspection and debridement were repeated at 48-h intervals until the wound was considered clean. Results50 cases [25 each group] were compared in terms of - Final Alignment of the Fracture, Presence of Infection/Non-union/Mal-union, Hardware failure, Time to Bone Union, Number of Operative Procedures after index admission. Mean time to full weight bearing was 20.96 weeks in URTN group versus 24.8 weeks in Ex-fix group. 5 in URTN group required further surgery for non-union versus 11 patients in Ex-fix group. There were 6 significant pin track infection. Removal of nail was required in 1 case of deep infection. ConclusionThis study supports the use of the URTN over External fixator in the treatment of severe open tibia fractures.

Influence of Hip Fracture on Knee Pain During Postoperative Rehabilitation.

ObjectiveTo investigate whether fracture type, surgical procedure, or fracture grade affect knee pain during postoperative rehabilitation after a hip fracture.MethodsWe conducted a retrospective case-controlled study of 139 patients during postoperative rehabilitation after surgery for hip fractures. Patients were divided into two groups: patients experiencing knee pain during the first week of postoperative rehabilitation, and patients without knee pain. We compared the types of fracture, surgical procedure, and fracture grade between the two groups.ResultsWe enrolled 52 patients (37.4%) with knee pain during the first weeks of postoperative rehabilitation. For type of fracture, knee pain was more common with intertrochanteric fracture than with femur neck fracture (48.8% vs. 21.1%, respectively; p=0.001). For the surgical procedure, there was no significant difference between the groups. For the fracture grade, the grades classified as unstable fractures were more common in the group of intertrochanteric fracture patients with knee pain than in those without knee pain (74.1% vs. 36.4%, respectively; p=0.002).ConclusionIntertrochanteric fracture affected knee pain after hip fracture surgery more than did femur neck fracture, particularly in unstable fractures. Furthermore, there was no difference in each fracture type according to the surgical procedure. Careful examination and management for knee pain is needed in patients with hip fracture surgery.

Evaluation of functional result in different grades of compound tibial fractures by intramedullary nail

Background: The purpose of the present study was to evaluate the outcomes of compound fractures of tibia shaft managed by interlocking intramedullary nailing. Methods: This is a retrospective study of 20 patients with open fractures of tibia shaft operated primarily by tibia interlocking nail. Results: In Our Study we had 20 patients with open tibial fractures. Majority of patients in our series were under 40 years of age with an average age of 28.6 years. The youngest patient was 17 years old and the eldest patient was 55 years. Majority (80%) of our cases sustained Tibial shaft fracture in road traffic accidents. Out of 20 cases in our series in 7 cases (35%) middle 3rd of tibia was involved and in 9 cases (45%) it was lower 3rd. Most common radiological pattern of fracture in our series was transverse (55%) followed by oblique in 30% and communited in 15%. In Patel series most common pattern was oblique 50%, transverse in 31% and communited in 19%. In our study, 70% cases were operated within 2 weeks of injury. Earliest case was operated on 3rd day of injury. Supplementary / secondary procedure required in our series were dynamization (required in 15% of our cases) and bone grafting (5%), none of our cases required nail removal with plating and bone grafting or exchange nailing. One patient required nail removal as he developed deep infection. 75% of our patients were ambulatory within 2 weeks of operation in the form of non weight bearing crutch walking. Of the remaining 5 patients 2 had shaft Femur fracture, one had contralateral both bone leg, one had surgical neck of Humerus with undisplaced Tibial plateau and last one had wound complication. In our series 75% cases showed signs of satisfactory radiological union by 20 weeks. In 50% of our cases clinical and radiological union occurred in 20 weeks’ time. There was no incidence of non union in our series. Our series did not include compound grade III fracture rest all series mentioned here included this in their study. Average time of union came out to be 24.8 weeks with minimum of 16 weeks and maximum of 30 weeks. In 10 patients union occurred in >20 weeks (delayed union). 2 were those patients who underwent dynamization, one had underwent bone grafting, one patient had contralateral both bone leg and one patient was 55 years old. In rest 5 patients no obvious cause was found. Delayed union was more in distal1/3rd fracture due to precarious blood supply. In our study out of 20 patients operated by Tibia interlocking nail 4 (20%) excellent, 6(30%) Good, 10(50%) fair functional results. Conclusions: Treatment of open tibial fracture remains controversial. But the early debridement, primary wound closure and interlock nail is a good option in compound tibia fractures.

Prospective study on functional outcome and role of hybrid external fixators in complex tibial plateau fractures

Introduction: Tibial plateau fractures are common due to high energy injuries. The principles of treatment include respect for the soft tissues, restoring the congruity of the articular surface and reduction of the anatomic alignment of the lower limb to enable early movement of the knee joint. There are various surgical fixation methods that can achieve these principles of treatment. Aim: To study the functional outcome and role of hybrid external fixators in complex tibial plateau fractures.Methods: 50 Patients with Schatzker type V fractures and Schatzker type VI closed plateau fractures and Compound tibial fracture Grade I and IIIB were treated with both closed reduction and hybrid external fixation or with minimal open reduction and a hybrid system. Functional outcome were assessed with NEER’s scoring system. Results: Out of 50 cases 20 cases were type 5 and 30 cases were type 6 Schatzker and the average NEER scoring for them were 17.50 and 14.25 respectively. Most common complication is pin site infection, overcame by regular dressing and Knee stiffness. NEER’s Rating score rating system for knee the 52% patients had excellent and 36% patients had good outcome. Conclusion: The hybrid external fixator method we had applied is safe as regards of soft tissue healing and the limited number of complications associated directly to this method of application.

Le fratture di avambraccio

Fractures of the forearm in the growing skeleton in a common event, accounting for 10% of the overall fracture and at the third place for long bone fractures. Most of these fractures present a simple line. There are several classification but the most widely use is the anatomo-radiological one. The majority of the fracture require closed reduction and immobilization in a long arm cast, with the elbow flexed at 90°, since residual defect that can occur are well tolerate. Under the age of nine angulation deformities lesser than 15° have the possibility to remodell completely. Over the age of nine the toleration is lower than 10°. The time of immobilization has to be at least of 8 weeks, in order to reduce the high risk of refracture. The surgical management of these fracture must to be reserved in case of unstable fractures or impossibility to gain good reduction by closed means. The best surgical solution nowadays is stabilization with elastic stable intramedullary nail. Open reduction and plate osteosynthesis must to be reserved for late adolescent, very near to skeletal maturity. External fixation has limited indication, expecially in politrauma and very high grade of open fractures.

Osteoporosis and vertebral fracture are associated with deterioration of activities of daily living and quality of life in patients with type 2 diabetes mellitus.

Patients with type 2 diabetes mellitus (T2DM) have an increased risk of fragility fracture. However, whether diabetes-related osteoporosis independently contributes to the deterioration of activities of daily living (ADLs) and quality of life (QOL) is unclear. This cross-sectional study investigated the association between osteoporosis, ADLs, and QOL in 309 patients with T2DM. ADLs and QOL were assessed using Barthel Index (BI) and a SF-36 questionnaire. Multiple logistic regression analyses adjusted for age, gender, T2DM duration, body mass index, hemoglobin A1c, estimated GFR, diabetic neuropathy, retinopathy, nephropathy, cardiovascular disease, cerebrovascular disease, peripheral artery disease, and anti-diabetic treatments were conducted. The number of patients with osteoporosis or vertebral fracture was 166 (53.7%) and 118 (38.2%), respectively. Osteoporosis was significantly associated with lower general health (GH), social functioning (SF), and role emotional (RE) (OR 2.56, 1.79, and 1.92, respectively; all p values < 0.05 at least) and marginally associated with lower BI (OR 2.39, p = 0.068). Moreover, the presence of vertebral fracture grade 2 or 3 was significantly associated with lower BI, bodily pain (BP), GH, vitality, SF, and RE (OR 2.58, 2.01, 3.64, 1.99, 2.18, and 1.97, respectively; all p values < 0.05 at least). Osteoporosis and severe vertebral fracture were associated with the deterioration of ADLs and QOL independently of other diabetic complications. Therefore, the management of diabetes-related osteoporosis is an important strategy to avoid the deterioration of ADLs and QOL in T2DM.

Dilution of Open Fracture Grade IIIA of the Lower Leg Using Normal Saline 0.9% Mixed with Honey Compared With Normal Saline 0.9% to the Bacterial Growth

Dilution of Open Fracture Grade IIIA of the Lower Leg Using Normal Saline 0.9% Mixed with Honey Compared With Normal Saline 0.9% to the Bacterial Growth

Clinical Results of Mean GTV Dose Optimized Robotic-Guided Stereotactic Body Radiation Therapy for Lung Tumors.

We retrospectively evaluated the efficacy and toxicity of gross tumor volume (GTV) mean dose optimized stereotactic body radiation therapy (SBRT) for primary and secondary lung tumors with and without robotic real-time motion compensation. Between 2011 and 2017, 208 patients were treated with SBRT for 111 primary lung tumors and 163 lung metastases with a median GTV of 8.2 cc (0.3-174.0 cc). Monte Carlo dose optimization was performed prioritizing GTV mean dose at the potential cost of planning target volume (PTV) coverage reduction while adhering to safe normal tissue constraints. The median GTV mean biological effective dose (BED)10 was 162.0 Gy10 (34.2-253.6 Gy10) and the prescribed PTV BED10 ranged 23.6-151.2 Gy10 (median, 100.8 Gy10). Motion compensation was realized through direct tracking (44.9%), fiducial tracking (4.4%), and internal target volume (ITV) concepts with small (≤5 mm, 33.2%) or large (>5 mm, 17.5%) motion. The local control (LC), progression-free survival (PFS), overall survival (OS), and toxicity were analyzed. Median follow-up was 14.5 months (1-72 months). The 2-year actuarial LC, PFS, and OS rates were 93.1, 43.2, and 62.4%, and the median PFS and OS were 18.0 and 39.8 months, respectively. In univariate analysis, prior local irradiation (hazard ratio (HR) 0.18, confidence interval (CI) 0.05-0.63, p = 0.01), GTV/PTV (HR 1.01-1.02, CI 1.01-1.04, p < 0.02), and PTV prescription, mean GTV, and maximum plan BED10 (HR 0.97-0.99, CI 0.96-0.99, p < 0.01) were predictive for LC while the tracking method was not (p = 0.97). For PFS and OS, multivariate analysis showed Karnofsky Index (p < 0.01) and tumor stage (p ≤ 0.02) to be significant factors for outcome prediction. Late radiation pneumonitis or chronic rip fractures grade 1-2 were observed in 5.3% of the patients. Grade ≥3 side effects did not occur. Robotic SBRT is a safe and effective treatment for lung tumors. Reducing the PTV prescription and keeping high GTV mean doses allowed the reduction of toxicity while maintaining high local tumor control. The use of real-time motion compensation is strongly advised, however, well-performed ITV motion compensation may be used alternatively when direct tracking is not feasible.

Update in Therapeutics: Prophylactic Antibiotics in Open Fractures.

Acute management of open fractures is associated with high morbidity and mortality. Recommended antibiotic regimens for all Gustilo-Anderson fracture grades include first-, second-, and third-generation cephalosporins. Expanded gram-negative coverage is recommended for Grade II and III fractures if a first- or second-generation cephalosporin is selected, and additional anaerobic coverage is required if the open fracture is contaminated with organic or farm-related material. Open fractures endure a high rate of bacterial contamination, and antibiotics have demonstrated effectiveness at reducing infection rates when initiated early. Provided that the expected microbial spectrum is covered, antibiotics should be selected on the basis of patient-specific factors and hospital protocols.

Use of intramedullary implants in adult diaphyseal fracture both bone forearm

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Fractures of the forearm bones are very common. The most common form of stabilization is plate and screw fixation. The role of Intramedullary nailing of fractures of the shafts of the adult radius and ulna is still to be defined. This study was perform to analyze anatomical and function outcome of the patients treated by Talwarkar square nail.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;We evaluated 46 patients (29 males and 17 females) had fracture both bone forearm treated by intramedullary nail. We analyzed patients in two broad group one with close fracture or grade I, II open fracture (34 patients) and other have open fracture grade IIIA or IIIB (12 patients). First group patients further analyzed weather close (22 patients) or open reduction (8 patients) required. Functional outcome was calculated by Grace and Eversman system&lt;/span&gt;.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Out of 32 patients of close fracture or open grade 1 or 2 fracture, 29 (90.62%) have excellent or acceptable result. All the patients (100%) in whom close reduction succeeds achieved excellent result. 22 (64.70%) patients close nailing possible.12 patients in whom open reduction required 9 (75%) goes into union. Close nailing have overall success rate is 90.62% where it fail and open nailing require success rate bring down to 75%.. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;IM nailing gives satisfactory results. Advantages of close nailing are- early union, low incidence of infection, small scars, less blood loss, short operating time with minimal surgical trauma, easier implant removal. Even though plate and screw fixation is the gold standard for stabilization of both bone forearm fracture but intramedullay implant can be used in selected cases with good result. To achieve acceptable result – early surgery, proper selection of the case, pre-operative planning, proper assessment of diameter, length and radial bowing of the nail, is required.&lt;/span&gt;&lt;/p&gt;

Proximal tibia stress fracture with Osteoarthritis of knee - Radiological and functional analysis of one stage TKA with long stem.

Introduction: Proximal tibia stress fractures with knee osteoarthritis pose a challenging situation. We evaluated the radiological and functional outcome of one-stage total knee arthroplasty (TKA) and long stem for patients with varied grades of knee arthritis and proximal tibia stress fractures. Methods: We analysed 20 patients from April 2012 to March 2017 with proximal tibia stress fractures associated with knee osteoarthritis of varied grades. Out of 20 patients, five were acute fresh fractures. The mean age was 64 years (range, 52–78) which includes three men and 17 women. Previous surgery in the same limb, rheumatoid arthritis, valgus deformity were excluded. All patients were treated with posterior stabilised TKA with long stem, of which, four patients had screw augmentation for medial tibial bone defect and two patients with malunited fracture at stress fracture site required osteotomy, plating and bone grafting. Two patients had two level stress fracture of tibia in the same leg.Results: The mean follow-up period was 28 (range, 6–60) months. The mean tibiofemoral angle improved from 18.27° varus to 1.8° valgus. The mean knee society score improved from 21.9 (range, −10 to 45) to 82.8 (range, 15–99) [p < 0.05]. The mean Knee Society functional score improved from 15.5 (range, −10 to 40) to 76.8 (range, 10–100) [p < 0.05]. All fractures got united at the last follow-up. One patient had infection and wound dehiscence at six months for which debridement done and had poor functional outcome.Conclusion: TKA with long stem gives excellent outcome, irrespective of severity of arthritis associated with stress fracture. By restoring limb alignment and bypassing the fracture site, it facilitates fracture healing. Early detection and prompt intervention is necessary to prevent the progression to recalcitrant non-union or malunion.

Antibiotics and open fractures of the lower extremity: less is more.

Infectious complications in open lower extremity fractures contribute to significant morbidity. Historically, orthopedic guidelines have recommended Grade III fractures receive a first generation cephalosporin and an aminoglycoside. Despite these guidelines, few studies have evaluated the utility of adding an aminoglycoside in this patient population. At our trauma center, we have a unique trauma service where half of our surgeons treat Grade III open fractures with a cephalosporin alone and half use a cephalosporin + aminoglycoside. We hypothesized that our outcomes were the same between the two groups. We identified all Grade III fractures of the lower extremity admitted to our urban Level I Trauma Center over the 5-year study period. Charts were retrospectively reviewed to identify demographic information, injury severity score (ISS), fracture location, grade of fracture, type of antibiotic administered, incidence of acute kidney injury (AKI), surgical site infection (SSI), hardware removal, hospital length of stay (HLOS), and disposition. Patients were classified into two groups: those treated with a cephalosporin alone (CEPH) or cephalosporin + an aminoglycoside (CEPH + AG). A total of 126 grade III fractures of the lower extremity were admitted our Trauma Center during the 5-year study period. There were 65 (52%) patients in the CEPH group and 61 (48%) in the CEPH + AG group. Demographics, ISS, fracture location, grade of fracture, rate of SSI, need for hardware removal, and disposition were not different between the two groups. In contrast, patients in the CEPH group had a 4% incidence of AKI, while the incidence was 10% of patients in the CEPH + AG group (p < 0.05). The addition of an AG to antibiotic prophylaxis in open lower extremity fractures was associated with a significant increase in AKI with no change in the incidence of wound infection or hardware removal. Cephalosporins alone may be sufficient for prophylaxis in Grade III open fractures of the lower extremity. A large-scale prospective randomized trial is needed to confirm these findings and inform clinical practice.

Restrictive pulmonary dysfunction is associated with vertebral fractures and bone loss in elderly postmenopausal women.

Association between bone metabolism and pulmonary function in the general population is controversial. The aim of this study was to investigate relationship between lung and bone parameters in elderly postmenopausal women. One hundred and six postmenopausal women (75.6 ± 8.0years old) who underwent spirometric tests were examined for prevalent vertebral fractures, bone mineral density (BMD), bone metabolic markers, and other metabolic indices such as urinary pentosidine. Multivariable logistic regression analyses revealed that forced vital capacity (FVC) (OR = 0.063, 95% CI: 0.011-0.352, p = 0.002) and urinary pentosidine (OR = 1.067, 95% CI: 1.020-1.117, p = 0.005) were associated with the presence of vertebral fractures after adjustment for height loss, age, and BMD at femoral neck. Moreover, vital capacity (VC) or FVC as well as body mass index and age was among independent determinants of BMD after adjustment for height loss and the number and grade of vertebral fractures in forced multiple linear regression analysis (VC: β = 0.212, p = 0.021, FVC: β = 0.217, p = 0.031). Urinary pentosidine was negatively correlated with pulmonary function parameters such as FVC and forced expiratory volume in 1s (FEV1.0), although these correlations appeared dependent on age. Diminished FVC was associated with prevalent vertebral fractures and decreased BMD in Japanese postmenopausal women without apparent pulmonary diseases. Mechanism of such association between pulmonary function and bone status remains to be determined.

Flora bacteriana en fracturas abiertas de grado III ocasionadas por traumatismo de guerra

BackgroundWar injuries such as those produced by modified antipersonnel mines generate extensive soft tissue damage and traumatic amputations, which are severely contaminated with soil, vegetation, faecal components, and even the tissues of other victims. The objective of the study is to establish the type of microorganisms that are isolated in these types of injuries. Materials and methodsA case series was conducted between January 2012 and December 2014, which included all patients with wounds from gunshots, fragmentation weapons, or antipersonnel mines, who had bone-tissue involvement, bacteriological cultures of bone and / or soft tissues with definitive reports, and antibiotic sensitivity tests on isolated germs. ResultsOf the126 patients included, it was found that 72% had an open fracture grade IIIA, and 28% a grade IIIB fracture. Gram negative bacteria were the most isolated in cultures (41%). Enterococcus faecalis was the most frequently isolated bacterium (15%), followed by Pseudomonas aeruginosa (13%). DiscussionIt was shown that 52% of isolated germs had some type of resistance to the empirical antibiotic management that was applied as a protocol at the time of admission (cephalosporin+aminoglycoside and ciprofloxacin+clindamycin in case of fragmentation weapons). This sets a new medical and surgical challenge for all those responsible for the integral management of these kinds of patients. Evidence levelIII.

Why a surgically treated humeral shaft fracture became a nonunion: review of 11 years in two trauma centers

The aim of this study was to evaluate nonunion causes of surgically treated humeral shaft fractures in two different trauma centers. A total of 327 cases of humeral shaft fractures were treated in 11years in two trauma centers. We retrospectively reviewed in detail some factors in order to understand the reasons for nonunion: (1) fracture type, according to the AO classification, (2) grade of open fracture, according to Gustilo-Anderson, (3) timing, (4) reduction and (5) fixation. We observed 19 nonunions, 10 women and 9 men, with an average age of 57years. Fractures were 1 A1 case, 2 A2 cases, 4 B2 cases, 6 B3 cases, 2 C1 cases, 1 C2 case and 3 C3 cases. Three cases had a simple fracture with two fragments; all the other were comminuted. Fifteen cases were closed, four open. The major criticalities observed were fracture comminution, exposure, unstable fixation and bone resorption. All 19 patients with nonunion underwent surgical fixation with compression plate and frozen cortical bone graft. A 4.5 LCP plate was used in 17 cases. The remaining 2 cases had an anatomical site-specific proximal humeral 3.5-mm LCP plate (Synthes, Paoli, PA, USA). In 17 patients, the nonunion healed: 15 cases treated with a 4.5 straight plate, and 2 cases with an anatomical site-specific proximal humeral 3.5mm LCP plate, at a mean of 5months. In 2 cases, consolidation was not reached. We believe that humeral diaphyseal fractures should be treated surgically to avoid many complications. Our retrospective analysis indicates that factors that lead to a fixation failure are fracture comminution, open fracture, unstable fixation. The 19 nonunions treated with compression plating and frozen bone graft demonstrated consolidation in almost 90% of the cases.

Assessment of a Modified Antibiotic Prophylaxis Open Fracture Protocol

Background National guidelines support antibiotic prophylaxis for open fracture with cefazolin +/− aminoglycoside based on fracture grade and contamination. The purpose of this study was to assess a modified adult antibiotic prophylaxis open fracture protocol (AOFP) which recommended weight-based cefazolin for low-grade fractures or ciprofloxacin plus vancomycin for high-grade fractures.Methods Adult patients with open fractures admitted to Palmetto Health Richland between January 2012 and December 2016 were screened for study inclusion. Exclusion criteria were receipt of antibiotics for reasons other than open fracture, death prior to wound closure, and local admission time >48 hours after time of injury. Compliance to all elements of AOFP was assessed. Clinical endpoints including open fracture infection rates, epidemiology, and drug-related adverse events were compared between pre-implementation (January 2012 – December 2012) and post-implementation period (November 2015 – December 2016). χ 2 and t-tests as appropriate were used to compare outcomes between groups.ResultsFollowing exclusions 189 patients were included in the analysis (90 pre- vs. 99 post-AOFP, respectively). Post-AOFP, a 17% (16/93) adherence rate to all AOFP elements was found. Appropriate agents were selected in 82.8% (77/93). The most common reasons for non-adherence were incorrect dosing and prolonged antibiotic duration. Fracture site infection rates were 23.3% (21/90) and 7.1% (7/99) in pre- and post-AOFP groups, respectively (P = 0.001). Infections primary caused by Gram-negative pathogens in pre-AOFP and Gram-negative organisms comprised 62 and 40% of open fracture site infections in pre- and post-AOFP groups, respectively. Incidence of acute kidney injury, Clostridium difficile-associated diarrhea, and other antibiotic-associated AEs were rare and comparable between groups. Change in median days to infection (55.6 days vs. 56.55 days, P = 0.71) and median duration of antibiotics in hours (48.0 vs. 54.7, P = 0.59) was not significantly different post implementation.Conclusion Local adherence to all elements of the modified AOFP was low, yet the appropriate agent(s) was used in majority of cases. The modified AOFP was associated with a numerical decrease in infection rates post-open fracture and comparable AEs.Disclosures P. B. Bookstaver, Rock Pointe: Content Developer, Consulting fee

Volar locking plate in intra-articular fracture lower end radius

Introduction: Fractures of the distal radius recently have become the focus of an intense resurgence in interest regarding optimal management. The overly optimistic attitude that a favourable outcome will eventuate, despite residual deformity must be tempered by the realization that the common factor predisposing to a suboptimal recovery is malunion. Moreover for the most frequently occurring intra-articular fractures, an increasing consensus exists that preservation of distal radial articular contours, that in many cases can be achieved only be open treatment, is an absolute prerequisite for successful recovery. Aim: To evaluate the outcome of volar plating using locked plates in intra articular fractures of lower end radius. Materials and Methods: This is prospective all inclusive study for outcomes of intra articular fracture lower end radius using locked plates as a type of implant for open reduction and internal fixation of the fracture fragments. All patients included for this study sustained distal radius fracture grade III to grade VIII according to Frykmann classification. At the final follow up patients were assessed using Gartland and Werley’s Demerit Scoring System6 for the result of plating of intra articular fracture of lower end radius. Results and Discussion: The results of present study were assessed using using Gartland and Werley’s Demerit Scoring System. We observed that 60.47% patients showed excellent result, 34.89% patients showed good and 4.65% patients showed fair results. These results were quite comparable with other studies performed in the past. Conclusion: Based on our study, we conclude that plating in unstable intra articular fracture of distal end radius using locked plates had become an effective tool in the management of difficult injuries. With the development of volar fixed angle locking plates, this technique is advantageous in intra articular lower end radius fractures.

Comparison of outcome of unilateral plating and dual plating in treatment of bicondylar tibia plateau fractures

Introduction: Fractures of the proximal tibia, particularly those that extend into the knee joint are termed as tibial plateau or tibial condylar fractures. It results from indirect coronal or direct axial compressive forces. Overall worldwide, it comprises of 1% of all fractures & 8% of the fractures in elderly. In the past two decades, with improvements in surgical techniques and implants, there has been a growing trend towards surgical management of these injuries. Thus we have advanced from the conservative approach to internal fixation in fractures as an acceptable mode of treatment. No proven uniform successful method of treatment. Nevertheless, tibial plateau fractures remain challenging because of their number, variety and complexity.Aim: To study the surgical management in terms of unilateral and dual plating for bicondylar intraarticular fractures of proximal tibia to obtain a stable, pain free, mobile joint, to prevent the development of osteoarthritis and to correlate the radiological findings with the type of fracture and the functional end result. Materials and Methods: This was a prospective study of 44 cases. All patients included in this study sustained tibial plateau fracture grade V and VI according to Schatzker Classification. We used Rasmussen’s functional and radiological scoring system for the comparison of outcome of plating. In the surgical group 20 patients were treated by unilateral plating and 24 patients were with dual plating. These patients were followed up for an average period of 13 months. Results and discussion: In our study according to Rasmussens functional scoring4, we have achieved excellent outcome in 43%, good in 50%, fair in 7%, which is comparable to the standard studies. These studies suggest that while isolated lateral locked plating may offer a more biological approach to bicondylar fractures, and may provide a viable alternative for open fractures with a medial wound or fractures with tenous soft tissues, classical dual plating remains the most rigid construct. Conclusion: The surgical management of tibial bicoondylar fracture is challenging and dual plating gives excellent anatomical reduction and rigid fixation to restore articular congruity, facilitate early knee motion by reducing post-traumatic osteoarthritis and thus achieving optimal knee function.

Therapeutic Ultrasound in Navicular Stress Injuries in Elite Track and Field Athletes.

To ascertain whether therapeutic ultrasound (TUS) can be used to assess the progression of conservative management in navicular stress injuries. This is a prospective, clinical case series. Level of evidence IV. All participants were examined and followed up in a private Sports Injury Clinic. Ten elite track and field athletes with severe dorsal midfoot pain over the navicular bone participated in this study. All patients underwent both TUS and magnetic resonance imaging (MRI) evaluation. The painful threshold of TUS on initial evaluation was a mean of 0.707 ± 149 W/cm, and MRI detected a navicular stress injury in all patients. The athletes received conservative treatment and underwent sequential TUS evaluations at 4, 8, 12 and 16 weeks. Therapeutic ultrasound pain threshold values were recorded, and the patients were additionally asked to grade local tenderness on a Visual Analogue Scale. Time to return to play was also recorded. The level of pain produced by the application of TUS on a navicular stress fracture seemed to correlate well with Visual Analogue Scale scores and the grade of fracture demonstrated on MRI. The initial low TUS painful mean value increased to a normal mean value of 1.97 ± 0.067 W/cm by 16 weeks. When clinical and TUS findings had returned to normal, the patients were allowed to return to sports activities, with no recurrences experienced during the study period. The production of pain associated with the application of TUS on a navicular stress fracture is a safe and reproducible method of monitoring the resolution of these fractures. We have used it successfully in making return-to-play decisions for elite level track and field athletes.

Neck of femur fractures in the elderly: Does every hour to surgery count?

ObjectivesTo determine if early surgery before 12h confers a survival or length of stay benefit for patients with neck of femur (NOF) fractures. DesignRetrospective review of prospectively collected data. SettingDistrict general hospital. Patients1913 patients aged over 60 admitted with a fractured NOF who underwent surgery between 2011 and 2015. Mean age was 83.9 years. 73.7% were female. InterventionPatients had surgery for fractured NOF with data collected on demographics, mortality and length of stay. Main outcome measurementsData collected included gender, age, ASA grade, fracture anatomy, surgery, time to surgery, days spent in acute hospital and rehabilitation settings and 30-day mortality. Statistical analysis was used to identify independent predictors of mortality and length of stay. Results30-day mortality was 6.1% and the mean hospitalisation time was 13±11.3days for the acute hospital and 20.2±17.2days for the trust. Operations were performed at a mean of 23.8±14.8h after presentation. Age, gender, ASA grade and type of fracture were independent predictors of either mortality or length of stay. Timing of surgery had an association with mortality but this only reached statistical significance at 24h.In line with previous studies we analysed time to surgery in 12h blocks. We also used logistic regression, recognizing time as a continuous variable, which revealed that every hour of delay to surgery increased the mortality risk by 1.8%. ConclusionsWhile every hour of delay increased mortality risk, the association with mortality only became statistically significant when delaying over 24h. This supports a pragmatic approach, with surgery as soon as medically possible without a race to theatre. Level of evidenceLevel III retrospective cohort study.