Rate Of Secondary Displacement Research Articles

THE NATURAL HISTORY OF UNDISPLACED LISFRANC-TYPE INJURIES INITIALLY TREATED CONSERVATIVELY

BackgroundUndisplaced Lisfranc-type injuries are subtle but potentially unstable fracture-dislocations with little known about the natural history. These injuries are often initially managed conservatively due to lack of initial displacement and uncertainty regarding subsequent instability at the tarsometatarsal joints (TMTJ). The aim of this study was to determine the secondary displacement rate and the need for delayed operative intervention in undisplaced Lisfranc injuries that were managed conservatively at initial presentation.MethodsOver a 6-year period (2011 to 2017), we identified 24 consecutive patients presenting to a university teaching hospital with a diagnosis of an undisplaced Lisfranc-type injury that was initially managed conservatively. Pre-operative radiographs were reviewed to confirm the undisplaced nature of the injury (defined as a diastasis< 2mm at the second TMTJ). The presence of a ‘fleck’ sign (small bony avulsion of the second metatarsal) was also noted. Electronic patient records and sequential imaging (plain radiographs/CT/MRI) were scrutinized for demographics, mechanism of injury and eventual outcome.ResultsThe mean age of the patients at the time of injury was 42 years (19 Female). 96% (23/24) were low energy injuries and 88% (21/24) had a positive ‘fleck sign’. The secondary displacement rate in this group of patients was 62.5% (15/24) over a median interval of 14 days (range 0 to 482 days). 12 patients underwent open reduction internal fixation after a median interval of 29 days (range 1 to 294 days) from their initial injury. One patient required TMTJ fusion at 19 months and two patients were managed non-operatively. The injury remained undisplaced in 37.5% patients (9/24) with only one patient requiring subsequent TMTJ fusion at 5 months.ConclusionUndisplaced Lisfranc injuries have a high rate of secondary displacement and warrant close follow-up. Early primary stabilisation of undisplaced Lisfranc injuries should be considered to prevent unnecessary delays in surgical treatment.

Posterior pelvic ring involvement detected with CT taken within a week of admission in acute fragility fractures of the pelvis (FFP) does not predict failure of conservative treatment: a retrospective cohort study

BackgroundAcute low energy pubic rami fractures in the elderly receive primarily conservative treatment. There is debate to what extent posterior ring involvement, which is detected superiorly by CT compared to X-ray, has an impact on outcome and may require modified treatment. We want to demonstrate if posterior ring involvement has an influence on different types of outcome in primarily conservatively treated acute FFP, questioning the usefulness of early CT. Additionally we analysed the early fracture pattern in cases where conservative treatment failed with need for secondary surgery.MethodsA retrospective cohort study of 155 consecutive patients, recruited between 2009 and 2016, aged over 65 years diagnosed with an acute LE-PFr on X-ray at the emergency department of a single, level-one trauma centre and receiving an early CT. A set of outcome parameters was compared between patients with an isolated pubic rami fracture (CTia) and patients who had a combined posterior pelvic ring fracture (CTcp).ResultsThere were 155 patients of whom 85.2% were female with a mean age of 83 years. 76.8% of patients living at home returned home and 15.5% moved to a nursing home. Mortality rate during hospitalisation was 6.4% and 14.8% at one year post-trauma. Secondary fracture displacement occurred in 22.6%. Secondary surgery was performed in 6 cases (3.9%). Median hospitalisation length of stay was 21 days (range 0 to 112 days). There was no significant association between the subgroups and change in residential status (p = 0.65), complications during hospitalisation (p = 0.75), mortality rate during admission (p = 0.75) and at 1 year (p = 0.88), readmission within 30 days (p = 0.46) and need for secondary surgery (p = 0.2). There was a significant increased median length of stay (p = 0.011) and rate of secondary displacement (p = 0.015) in subgroup CTcp. Secondary displacement had no impact on in-hospital complications (p = 0.7) nor mortality rate during admission (p = 0.79) or at 1 year (0.77). Early CT in patients who underwent secondary surgery showed stable B2.1 lesions in 4 of 6 cases.ConclusionsOur data suggest that early CT in patients with conservatively treated acute LE-PFr in order to detect posterior lesions, has limited value in predicting failure of conservative treatment.

The Effect of Surgeon Experience on Short- to Medium-Term Complication Rate Following Operative Fixation of Acetabular Fractures

Operative management of acetabular fractures is technically challenging, but there is little data regarding how surgeon experience affects outcomes. Previous efforts have focused only on reduction quality in a single surgeon series. We hypothesized that increasing surgeon experience would be associated with improved acetabular surgical outcomes in general. Retrospective cohort study. Urban academic level-I trauma center. Seven hundred ninety-five patients who underwent an open reduction internal fixation for an acetabular fracture. There was a significant association between surgeon experience and certain outcomes, specifically reoperation rate (16.9% overall), readmission rate (13.9% overall), and reduction quality. Deep infection rate (9.7% overall) and secondary displacement rate (3.7% overall) were not found to have a significant association with surgeon experience. For reoperation rate, the time until 50% peak performance was 2.4 years in practice. Surgeon experience had a significant association with reoperation rate, quality of reduction, and readmission rate after open reduction internal fixation of acetabular fractures. Other patient outcomes were not found to be associated with surgeon experience. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Secondary displacement in distal forearm fractures in children: adequate positioning of the wrist in the cast is more important than cast index.

The objective of this study was to assess whether the positioning of the wrist joint in the cast in such a manner that it counteracts the direction of angulation of fragments is more important than the cast index in the prevention of secondary displacements in distal forearm fractures. A retrospective review of all pediatric patients (0-16 years of age) who were hospitalized in our institution with displaced fractures of the distal forearm (either isolated fractures of the distal radius or both bone fractures) who underwent subsequent closed reduction and splinting in the period from August 2018 to October 2020. Patients with physeal fractures and open fractures, and skeletally mature patients were excluded from the study. Patients were divided into two categories - the first one in which the cast index was below 0.9 and the second in which it was above 0.9. In each category, we have identified two groups of patients - the first one in whom the wrist joint was positioned in such a manner that it counteracts the direction of angulation of fracture fragments and the second one in whom the wrist joint was in a neutral position. The two groups in each category have been compared according to age, sex, initial angulation, fracture type (isolated radius or both bone fractures), displacement type (angulation or complete dislocation) and the rate of secondary displacement. In both categories, the two groups were comparable according to age, sex, initial angulation, fracture and displacement type. In both categories (cast index below 0.9 and cast index above 0.9), a statistically significant higher portion of patients with secondary displacement was identified in the group of patients who had the wrist joint in a neutral position ( Z = -2.1997; P = 0.0278 - for cast index <0.9 and Z = -2.1672; P = 0.030216 for cast index >0.9). Our research supports the notion that positioning of the wrist joint in the position that counteracts the force that leads to angulation of fracture fragments is more important than the cast index in the prevention of secondary displacements in pediatric distal forearm fractures.

Trochanteric fractures treated by internal fixation using short intramedullary nails: Does the visual intraoperative estimation of the Tip-Apex Distance (TAD) concur with its digital postoperative measurement?

IntroductionThe tip-apex distance (TAD) is the only predictor for mechanical failure after internal fixation of trochanteric fractures. The main objective of our study was to assess whether the intraoperative visual estimation of the TAD concurred with the measurement taken on postoperative digital X-rays. We hypothesized that there was a good concordance between these 2 different methods of measurement. Materials and methodsPatients with an isolated trochanteric fracture were included in our study. A hardcopy of the intraoperative X-rays were printed, and the TAD was calculated manually. Radiological and clinical follow-ups were scheduled at 6 weeks, 3 months and 6 months during which numerical measurements of the TAD were taken. We also recorded the fracture type (AO/OTA classification), degree of osteoporosis (Singh index), surgeon experience, age and ASA score. ResultsA total of 98 patients were included in our study. Of these, 70 had a 6-month follow-up and interpretable postoperative X-rays. The mean age was 87 years, with 77.14% women and a mean ASA score of 3. The coefficient of concordance between the intra and postoperative TAD was 0.7202 (95% CI=0.4905–0.9499). The secondary displacement rate was 3.28%. The univariate analysis showed no statistically significant association between an intraoperative TAD>25mm and fracture type (p=0.7290), degree of osteoporosis (p=0.5701) and surgeon experience (p=1). Discussion/ConclusionsThere was a high degree of concordance between intraoperative visual estimation of the TAD and its measurement on postoperative digital X-rays. The treatment of unstable fractures in osteoporotic bone by junior surgeons was not a risk factor for intraoperative TAD>25mm. It is therefore important to educate young surgeons on the concept of TAD and its intraoperative visual estimation technique as it ensures that the cephalic screw is positioned properly during the fixation of trochanteric fractures. Level of EvidenceII.

Prevention of secondary displacement and reoperation of distal metaphyseal forearm fractures in children

BackgroundMetaphyseal distal forearm fractures are common in paediatric patients and treating these fractures by reduction and cast immobilization alone is under debate, since secondary displacement is a frequent complication that often warrants re-intervention. This study was conducted to invest the incidence of secondary displacement and re-intervention for non-displaced and displaced fractures, with or without fixation. Material and methodsA retrospective cohort study was conducted analysing all consecutive paediatric patients under the age of 16 with distal metaphyseal forearm fractures throughout a 2-year period. Data were recorded on radiographic characteristics, OTC/AO-classification, type of treatment, reduction technique, surgical interventions and removal of hardware and complications. Results200 Patients with displaced metaphyseal forearm fractures were included of which 139 were primarily treated in the emergency room, the other 61 patients were primarily treated in the operating room. 83% Of the patients had a satisfactory reduction in the emergency room and 94% of these patients were treated successfully with casting alone. A total of 84 patients were treated in the operating room of whom 30% underwent reduction and K-wire fixation, and 70% underwent reduction and casting only. 47% Of the patients treated with closed reduction without K-wire fixation in the operating room suffered from secondary displacement, of which 80% needed re-intervention. ConclusionMetaphyseal forearm fractures can be treated with a very high success rate by closed reduction and casting alone in the emergency room. Reduction and casting of displaced metaphyseal forearm fractures in children that needed treatment in the operating room however, resulted in unacceptable high rate of secondary displacement and commonly required re-intervention. Those patients should therefore be treated by reduction and K-wire fixation.

Partially Healed Malaligned Distal Radius Fracture. Surgical Treatment in Patients older than 70 Years

Abstract Introduction Management of distal radius fractures remains controversial despite their high frequency. Elderly patients specifically present a high rate of secondary displacement, sometimes requiring a complex reconstructive surgery. The surgical treatment of displaced fractures evolving for several weeks in elderly patients has not been clearly reflected in the literature. This study aims to show clinical and radiological outcomes from this particular situation. Material and Methods Retrospective study of 31 cases of distal radius fractures with more than 2 weeks of evolution. Fractures were graded according to the Fernández's classification. Pre- and postoperative radiological studies were carried out to evaluate the degree of correction achieved. A clinical evaluation was performed using the Mayo Wrist Score. Data on arthroscopy and bone substitutes use, specific surgical tips and complications were also collected. Results Thirty-one patients with a mean age of 76 years old were operated for distal radius fracture with a delay in surgical treatment of 22 days. The most frequent fracture pattern was Fernández type III (38.7%). The clinical outcome according to the Mayo Wrist Score was 81.94 points with no relationship to fracture pattern or arthroscopic assistance. A statistically significant improvement was achieved for the correction of radial inclination, joint gap and ulnar variance. No statistically significant improvement was achieved in volar tilt correction. Complications were observed in 12.9% of the cases. Conclusions Delayed surgical treatment of distal radius fracture in elderly patients provides similar results to those observed in other age groups and time of evolution. Despite not being the ideal scenario for the surgeon, it should be considered to avoid functional deterioration in this fragile age group.

Does cement augmentation of the screws in angular stable plating for proximal humerus fractures influence the radiological outcome: a retrospective assessment

BackgroundScrew-tip augmentation in angular stable plating offers new possibilities for the treatment of complex proximal humerus fractures. This retrospective analysis was performed to evaluate the radiological outcome of proximal humerus fractures treated with angular stable plates and additional screw-tip cement augmentation in patients over the age of 60.Materials and methodsA retrospective single centre analysis was conducted from June 2013 to December 2016. The minimum follow-up time was set to 6 months after surgery. Anatomical reduction and fixation were evaluated in respect to reattached tuberosities to the head fragment and the adequate restoration of the calcar area not showing any valgus or varus malalignment. Complete fracture healing was determined 3 months after surgery. Any failures such as secondary displacement, primary screw perforation, intraarticular cement leakage and avascular necrosis of the humeral head with concomitant screw cut-out were assessed.ResultsIn total, 24 patients (21 females; 3 males) at a median age of 77.5 (62–96) years were included. Five 2-part, twelve 3-part and seven 4-part fractures were detected. The measured median BMD value of 23 patients was 78.4 mg/cm3 (38.8–136.9 mg/cm3). Anatomical reduction was achieved in 50% of the patients. In most cases, the A level screws and the B1 screw were augmented with bone cement by a median of 7 (5–9) head screws used. Postoperative varus displacement was not detected in any of the patients. One patient (4.2%) sustained an early secondary displacement. Intraarticular cement leakage was detected in 3 patients (2 head-split fractures). Avascular necrosis of the humeral head was observed in 4 patients (16.7%). Revision surgery was necessary in four cases, using hemiarthroplasty twice and reverse shoulder arthroplasty the other two times.ConclusionScrew-tip augmentation in angular stable plating for proximal humerus fracture treatment showed a low secondary displacement rate of 4.2% in patients suffering from poor bone quality. Nevertheless, the occurrence of avascular necrosis of the humeral head with mainly severe fracture patterns observed in this study was higher compared to previously reported results in the literature. Cement augmentation in head-split fractures is not recommended, considering the high risk of an intraarticular cement leakage.

Early displacement of two part proximal humerus fractures treated with intramedullary proximal humeral nail

IntroductionProximal humerus nails (PHN) are commonly used for the treatment of simple proximal humerus fractures, and have a reported malunion rate of about 10%. The surgeons who used PHN in one medical institution have noticed a high rate of fracture re-displacement in the early post-operative period. This study's aim is to evaluate the rate of secondary displacement and malunion of patients treated for two part proximal humerus fractures with an angle-stable PHN (MultiLoc), and to assess possible risk factors for this secondary displacement. MethodsA retrospective study comprised of 25 consecutive patients with 2 part surgical neck or metaphysis displaced proximal humerus fracture, treated with PHN between the years 2014–2017. Results assessed included radiographic measures (neck-shaft angle) and clinical data: range of motion (ROM) and functional scores (Constant, DASH, SSV). A univariate regression analysis was used to assess possible risk factors for secondary displacement. ResultsMean age was 66.6 (range 17–93), and mean follow up was 20 months (range 6–40). Mean neck shaft angle (NSA) changed from 139.1° post operatively to 122.6° at last follow up, with 6 patients (24%) having a NSA change larger than 20°. Two patients (8%) ended up with NSA less than 90°, defined as malunion. The deltoid tuberosity index was found to correlate with the degree of displacement (−0.41, p = 0.04). ConclusionsPHN for simple displaced proximal humerus fractures was associated with fair clinical results but an unacceptable rate secondary displacement. The deltoid tuberosity index was found to correlate with the degree of this secondary displacement.

Comparison between absorbable pins and mini-screw fixations for the treatment of radial head fractures Mason type II-III

BackgroundThe treatment of comminuted radial head fractures can include prosthetic replacement or open reduction and internal fixation. The purpose of this study is to evaluate the results of two different internal fixation systems for Mason type II-III radial head fractures.MethodsBetween 2005 and 2015, 82 patients were treated using pins and 65 patients by mini-screws. The follow-up protocol included: a clinical evaluation 15 days after surgery, and clinical and radiographic evaluations performed at 30 and 60 day intervals, unless any complications were reported by the patient. Over a period of at least 12-months of follow-up, patients were checked and interviewed. Clinical examinations included elbow range of motion (ROM), arm, shoulder and hand Disabilities, (DASH), and the Mayo Elbow Performance Score (MEPS).ResultsSixty-one subjects who had been treated with mini-screws were clinically reviewed at a mean 47.3 ± 35.8 month of follow-up; all patients who had been treated using absorbable pins were evaluated at a mean 82.5 ± 20.6 month of follow-up. No significant statistically differences were observed between the two groups in the mean ROM, DASH, and MEPS scores. Residual pain was reported in 15.8%of the patients treated by pins and 9.2% patients treated by mini-screws. Secondary displacement of fracture fragments was observed in 8.5% patients treated by pins and 1.6% using mini-screws.ConclusionsBoth absorbable pins and mini-screws provided adequate strength and rigidity, allowing good clinical and functional scores at a mid-term follow-up. However, a higher rate of secondary displacement of the fracture fragments was reported among subjects who had been treated using absorbable pins.

Full-scale fatigue tests of precast reinforced concrete slabs for railway tracks

This paper describes the experimental part of a research project on the fatigue behavior of precast reinforced concrete slabs for high-speed railway slab track systems, based on the Japanese Shinkansen system. First, characterization tests on the materials and the fastening system were performed, including compressive fatigue tests over cubic specimens carried out in order to get the fatigue parameters involved in probabilistic models of fatigue. Second, three-point bend fatigue tests on the full-scale slabs were conducted. The slabs were placed on two rubber supports, the cyclic sine wave load was applied on its middle section through two rails. The loading frequency was 1.5Hz, the maximum and the minimum load were 220kN and 22kN, respectively. The number of cycles was set 106. Third, the loss of stiffness of the slabs was presented before and after the fatigue tests, and its evolution monitored throughout them. The displacement development of the middle section of the slabs under the maximum load was also stored and plotted in order to calculate the secondary displacement rates. These data enabled us to predict the number of cycles to failure of any concrete slab with only knowing its secondary displacement rate. Furthermore, the damage (cracks) was marked in the slab to show the failure pattern. The testing procedure leads to the mechanical deterioration of the slabs with only 106 fatigue cycles, while reproducing the actual loads would result in longer and more expensive tests. The results allow us to check resistance of the slab design and could be employed to validate numerical models with fatigue failure criteria.

Secondary displacement of distal radius fractures treated by bridging external fixation

Loss of reduction remains an important problem after treatment of distal radius fractures, whatever the type of bone fixation. We assessed retrospectively the rate of secondary displacement after external fixation of distal radius fractures in order to identify possible risk factors for instability. We reviewed the pre-operative and serial post-operative radiographs of a retrospective series of 35 distal radius fractures treated by bridging external fixation. When classified according to the Société Française d'Orthopédie et Traumatologie (SOFCOT) criteria, the rate of secondary displacement was 48.5%. At final follow up, the reduction was anatomical in 12% and acceptable in 83%. There was malunion in 5%. The loss of reduction concerned primarily the distal radius palmar tilt and was moderate. No correlation was found with age, gender, type of fracture, degree of initial displacement, associated ulnar fracture, or seniority of the treating surgeon.

Complete spontaneous improvement of non-displaced femoral neck fracture without any surgery modality

SummaryBackground:Fracture of the femoral neck is still a medical dilemma due to high rates of complications and the choice of treatment. Although rigid internal fixation with cannulated screws through open or percutaneous approaches is the traditional treatment for undisplaced fractures (Garden type I and II) to avoid secondary displacement, considerable controversy still exists regarding the rate of this problem, thus it seems that a new trend in conservative management of this types of femoral neck fracture is emerging.Case Report:Our case is a 46-year-old woman with Garden type II femoral neck fracture, who refused all surgical options and willingly ignored her problem. Six months later she returned to our center with uneventful recovery of her fracture.Conclusions:The previous belief about the absolute poor prognosis of Garden type II with 100% rate of secondary displacement with non-operative management must have been an overestimation or the success histories in the literature about non-operative treatment of these fractures originates from inherited weakness of the Garden classification in differentiating type I from type II. The patient gave the informed consent prior being included into the study.

Initially missed occult fractures of the proximal femur in elderly patients: implications for need of operation and their morbidity

Occult fractures of the proximal femur are not evident on radiographs and the diagnoses are often missed or delayed. We tried to determine whether the delay of diagnosis in elderly patients lead to increased morbidity and increased need for operation. We identified 26 elderly patients (> or =65 years of age) who were diagnosed as having an occult fracture of the proximal femur over a 3-year period. In 17 patients (17 hips, non-delayed group), the occult fracture was suspected at the first visit and the diagnosis was made on CT and/or MR images (MRI). In the remaining nine patients (9 hips, 34.6% delayed group), the diagnosis was delayed by a mean of 8.4 days (range 4-25 days). We compared the occurrence of fracture displacement, need for operation, change in activity level, and mortality between the non-delayed and delayed groups. Displacement of fracture occurred in 4 of 9 delayed patients and none of 17 non-delayed patients. Ten non-delayed patients needed operative treatment, whereas eight delayed patients needed operative treatment (p = 0.190). The activity level decreased in 6 of 7 surviving patients of the delayed group, whereas it decreased in 4 of 15 surviving patients of the non-delayed group (p = 0.020). A delayed diagnosis of occult fracture in elderly patients resulted in increased rate of secondary displacement of the fracture and increased morbidity. In patients suspected of having occult hip fractures, additional studies, such as MRI and/or CT scans should be recommended to confirm the presence of hip fracture.

Garden I femoral neck fractures in patients 65 years old and older: Is conservative functional treatment a viable option?

Internal fixation is the preferred treatment of Garden I femoral neck fractures in the elderly. High re-operation rates have however been reported, and the results of arthroplasty performed following internal fixation failure are not as good as those of primary arthroplasty. This is why we are advocating functional treatment. Our hypothesis is that this treatment leads to fewer decubitus complications than strict orthopaedic treatment and no more mechanical complications than internal fixation in a selected population sample. Therefore, the objective of our prospective work was: (1) to assess the results of functional treatment of Garden I femoral neck fractures in elderly subjects, and (2) to investigate predictive factors of secondary displacement. All patients over age 65 years, admitted for a Garden I femoral neck fracture between January 2006 and May 2008, were included in this prospective study representing 56 cases (57 fractures) with an average age of 82 years. Functional treatment was performed, including early weight-bearing mobilisation, followed by radiographic evaluation at days 2, 7, 21 and 45, then at 3, 6 and 12 months. In the absence of displacement, discharge was planned at day 5 (Non-Displaced [ND] group). Otherwise, arthroplasty was performed (Displaced [D] group). Parker score and Harris Hip Score (HHS) were used for functional evaluation. The observed displacement rate was 33.3% (19 patients) within an average period of 10 days. In the ND group, one case of osteonecrosis was observed and treated by arthroplasty. The average Parker score was 6.9 and the HHS 82 in the ND group, and 7 and 85, respectively, in the D group. None of the factors studied (age, gender, side, fracture type, inclination angle, degree of outward displacement, sagittal displacement, general status) was statistically predictive of final displacement. The medical complication rate was only 7% in our series, which seems to be lower than that resulting from orthopaedic treatment. The observed secondary displacement rate seemed to be higher than the rate found in the literature on surgical treatment (5.4 to 20%), but the osteonecrosis rate appeared to be lower (11 to 25%). In addition, surgical treatment was the purveyor of specific complications in over 10% of cases. The present prospective study with minimum 1-year follow-up shows that functional treatment results in fewer decubitus complications than orthopaedic treatment and a rate of revision surgery comparable to internal fixation since 70% of included patients could have been successfully treated without surgical intervention. However, the investigation of a larger cohort would be necessary to identify predictive factors for the treatment's failure. Level III prospective non-comparative cohort study.

Comminution of the dorsal metaphysis and its effects on the radiographic outcomes of distal radius fractures

Comminution of the dorsal metaphysis is a relatively common feature of distal radius fractures. However, its effects on the radiographic outcomes of these fractures are not entirely understood. One hundred and twenty-four conservatively managed distal radius fractures were analysed retrospectively to assess the effect of dorsal metaphyseal comminution on fracture stability, especially with respect to initial displacement (minimally displaced versus displaced) and age group. Seventy-seven fractures (62%) had radiographic evidence of dorsal comminution. The secondary displacement rate of these fractures was 75%, compared to 45% in non-comminuted counterparts (P<0.001). In minimally displaced fractures, the secondary displacement rate was higher in those with dorsal comminution as compared to those without (57% vs. 31%, P=0.086). Dorsal metaphyseal comminution was found in 75% of fractures in patients 65+years old (P=0.05). Among those with dorsal comminution, the secondary displacement rates were similar for both men and women (63% vs. 79%; P=0.20). In conclusion, distal radius fractures with dorsal metaphyseal comminution had significantly higher rates of secondary displacement compared to non-comminuted counterparts, and there exists a correlation with this displacement and increasing patient age but not gender.

Long-term results after non-plate head-preserving fixation of proximal humeral fractures

A retrospective study was conducted to evaluate displaced proximal humeral fractures treated with a non-plate head-preserving fixation and to detect factors predicting functional outcome. After a median follow-up period of 79.7 months, 105 patients with nine A-fractures, 36 B-fractures and 60 C-fractures (nine two-part-fractures, 41 three-part fractures and 55 four-part fractures) were assessed. Functional outcome was measured based on the Constant and UCLA scores. Of all patients, 70-75% had excellent or good Constant and UCLA scores. In 74% a good or satisfactory quality of initial reduction fracture was achieved. About one-fifth (21%) of the fractures showed a secondary displacement. Twenty-seven percent of the patients had signs of humeral head necrosis and 22% had implant related problems. There were significant correlations between a high final score and young age, low AO fracture severity, good quality of fracture reduction and residual osseous deformity, absence of secondary fracture displacement, implant-related complications, shoulder arthrosis and humeral head necrosis at the time of follow-up. In conclusion, the non-plate head-preserving fixation of proximal humeral fractures is an alternative treatment for displaced proximal humeral fractures. Especially in severely displaced C-fractures in older patients, non-anatomical reduction leads to a high rate of secondary displacement, residual osseous deformity and only a fair shoulder function. For these cases alternative methods such as prosthetic replacement should be chosen.

Effect of Patient Age on the Radiographic Outcomes of Distal Radius Fractures Subject to Nonoperative Treatment

Our study assessed the radiographic outcomes of nonsurgically treated distal radius fractures of patients who were 18 to 44 years old (group 1), 45 to 64 years old (group 2), and 65 years old or older (group 3). All distal radius fractures seen in our emergency department from April 2002 to September 2004 that had nonsurgical management (either casting alone or closed reduction with immobilization) were considered for this study (n = 124; 50 casted, 74 closed reduced). Patients were further classified by age. Change in fracture alignment was assessed at the time of fracture union (approximately 8 weeks) and included measurements of angulation, articular gap/step-off, and radial shortening. When the fractures (n = 124) were evaluated at union, there was an overall secondary displacement rate of 64% (n = 79), with 42% in the group whose fractures were immobilized in a cast and 78% in the group whose fractures were treated by closed reduction and cast. There was an increase in displacement rate that was associated with increasing patient age. Among fractures that were only casted, there was no such age-matched increase in rates of secondary displacement. However, when considering those fractures that were subject to closed reduction (n = 74), rates of secondary displacement significantly increased with age (58% in group 1, 81% in group 2, and 89% in group 3; p = .03). Our study found that secondary displacement of distal radius fractures increased with increasing patient age, primarily among fractures subject to closed reduction. Older patients with these fractures require closer management after initial reduction, therefore allowing for better monitoring of expected subsequent fracture collapse. Further, given these high rates of secondary displacement after nonoperative treatment (58% to 89%), it is also important to consider that surgical treatment of these fractures may be necessary.

Outcome of non-operative management in Garden I femoral neck fractures

We studied the operation rate for secondary displacement in Garden type 1 femoral neck fracture when treated primarily conservatively. We reviewed the records of 115 patients with Garden type 1 femoral neck fractures primarily treated conservatively. Operation for secondary displacement was required in 48 cases (41%); the displacement rate was highest at age 60-80 years. There was significant difference between age and secondary displacement, but none between gender, ASA classification or Pauwels angle and secondary displacement. Garden type 1 femoral neck fractures deserve special attention because of the high rate of secondary displacement when they are conservatively treated, and surgery should therefore considered.

High secondary displacement rate in the conservative treatment of impacted femoral neck fractures in 105 patients

The purpose of this retrospective study was to evaluate the dislocation rate after the conservative treatment of impacted femoral neck fractures in four hospitals with the same treatment protocol of partial weight-bearing when tolerated. We reviewed the records of 105 patients (mean age 78 years) with an impacted femoral neck fracture, all primarily treated conservatively. Patient demographics, ASA classification and radiographic features were scored. Secondary displacement occurred in 48 patients (46%). There was no significant correlation (p > 0.05) between gender, age, ASA classification or Pauwels angle and secondary displacement. In our group of patients, secondary displacement was frequent and unpredictable.