Antero-posterior (AP) pelvis and lateral x-rays are routinely prescribed for the positional diagnosis of proximal femoral fractures, however; the usefulness of the lateral x-ray has not been previously presented in the literature. In addition, the clinical advantage of internally rotated AP views has also not been tested. This study aims to define the value of the lateral x-ray, and the internally rotated AP view, in the assessment and treatment planning of proximal femoral fractures. X-rays from 359 consecutive patients with proximal femoral fractures were divided into: ‘un-positioned’ AP (greater trochanter overlying the lateral femoral neck), clear neck AP (internally rotated to show the lateral femoral neck), and lateral views. Three blinded reviewers independently assessed the x-rays in sequence and noted the positional diagnosis and displacement. This was then compared with the intra-operative diagnosis used as gold standard. The addition of a lateral x-ray to an AP view significantly increased the rate of the correct diagnosis made by the reviewers when compared to an AP view alone, in intracapsular fractures only (p <
0.013), but not for extracapsular fractures (p = 0.27). The use of clear neck AP views did not increase the rate of correctly diagnosing the type of fracture when compared to unpositioned AP views. This applies for both intracapsular (p = 0.57), and extracapsular fractures (p <
0.823). Although orthopaedic rote dictates that every fracture should be visualised in two views, this study has shown with that for the majority of hip fractures one view is adequate and safe. The lateral x-ray is only required for intracapsular fractures that appear undisplaced on the AP view and should not be performed routinely. Specially positioned AP views are not required and should be avoided due to the unnecessary pain caused and the needless cost.
The aims of this study were to determine union rates and hardware complications, and to assess whether the “non-toggle” proximal locking option prevented screw back-out.
Thirty-six fractures (95%) went on to unite following treatment with the Polarus nail. Of the two fractures that failed to unite one had an infective non-union and the other developed avascular necrosis with non-union of the surgical neck. Twelve patients (32%) developed post-operative hardware complications. In nine (24%) there was backing out of the proximal locking screws, but only two patients had symptoms requiring screw removal. In five patients (13%) the nail was prominent proximally, causing impingement. In one patient (3%) the proximal screws penetrated the gleno-humeral joint, although this was asymptomatic. There was backing-out in six of the 21 patients (29%) in which the standard 5.0 mm proximal locking screws were used. This compared with three out of 14 patients (21%) in which the 5.3 mm “non-toggling” screws were used. The difference in the rate of screw backing-out between the two groups was significant (P = 0.0474, Fisher’s Exact test). In three patients a mixture of 5.0 and 5.3 mm screws was used.
We present one of the largest reported series of such fractures in which we have explored the above statements.
The patients were followed up in the outpatients clinic for a mean period of 2 months (group 1) and 16 months (group 2). The distance of the fracture site from the proximal tip of the metatarsal was measured on the radiographs.
All group 1 fractures healed well following symptomatic management and none required surgical intervention. Acute fractures in group 2 did better with non-weight bearing mobilization. Stress related fractures in group 2 took longer to heal when managed non-operatively. In group 2 patients, the difference in the site of acute &
stress fractures was not statistically significant. No statistically significant correlation between distance from the proximal tip of the fifth metatarsal to the fracture site and union.
A standardized classification is important because there is great variability in the types of fractures and appropriate treatment. Nonunion in fractures distal to the tuberosity is not related to the distance of the fracture from the metaphyseal-diaphyseal region Acute and stress fractures distal to the tuberosity do not occur at different anatomic sites.
The aim of this work was to define the tensile material properties of the glenoid labrum. Previous SEM studies of the labrum have observed three definitive layers, with a densely packed circumferentially orientated collagen core layer. The glenoid labrum from ten cadaveric shoulders were dissected out and divided into eight equal sections. Each section was cut to produce specimens from the core layer using a microtome and a specifically designed cryo-clamp resulting in uniform specimens with dimensions of 1mm x 1mm x 8mm. All of the tensile testing was performed within a controlled-environment unit of 38°C and 100% relative humidity. Each specimen was precycled to a quasi-static state to alleviate the effects of deep-freezing, prior to final testing. The elastic modulus was calculated for each specimen before and after a 5-minute period of stress relaxation and before failure initiation. The mean age of the specimens was 61 years (range 47–70). Load to failure was 2.7N (1.0–7.0). The mean modulus was 10.2MPa (3.0–22.3) before stress relaxation, 18.0MPa (5.8–36.7) immediately after stress relaxation and 22.3MPa (8.4–66.4) before failure initiation. The 1 and 2 o’clock specimens had lower moduli than the 4 and 5 o’clock specimens (p=0.01). These results can aid in explaining the differing pathologies encountered around the circumference of the labrum. The high moduli at the 4 and 5 o’clock positions may reflect the ability of this portion of the labrum to accommodate forces and thus resist anteroinferior subluxation. The lower moduli at the 1 and 2 o’clock positions suggest that this portion of the labrum is less apt to accommodate tension; this might explain the higher incidence of labral foramen observed in this area and the anatomical variant of the Buford complex.