Impaired vascularity of the skin in elderly ankle fracture patients causes the skin and wound complications. This is part of a RCT comparing ORIF and close contact casting (CCC) for isolated unstable ankle fractures in patients >
60 years. Assessments over 6-months
trans-cutaneous O2 saturation (TcP02) of medial and lateral ankle skin Ankle-Brachial Pressure Index (ABPI). 3-vessel arterial duplex scan distal calf perforator artery patency. The uninjured limb was the control. Eighty-nine patients eligible; 59 participated (76% female). 30 randomised to ORIF; 29 to CCC. Each had one death and one withdrawal. Vascular data available on 55. Two patients had delays in wound healing (>
25% for >
6-weeks). Two further developed wound infections. No skin breakdowns in CCC group. There was a reduced TcP02 on day-3 in the injured limb. The TcP02 rose at 6-weeks compared to day-3 (medial 58mmHg; lateral 53mmHg, p=0.002) in the injured leg. At 6-months the TcP02 measurements were not different to uninjured leg. A critical TcP02 (<
20mmHg) found in 4, correlated with skin problems (p=0.003). Two of these had the only major delays in wound healing and one of the two wound infections. 94% of participants had normal ABPI’s (>
1.0). There was no difference between patients with or without an impaired ABPI (<
0.7 mm Hg) and wound problems (p=0.20). There was no difference in patent perforators between the injured and uninjured (p=0.39). Occult vascular insufficiency is present but at low incidence. ABPI and Duplex-US are insensitive for predicting infection or delayed healing. The ankle fracture injury does not disrupt the local perforators. TcPO2 is sensitive and specific for predicting skin problems. Impairment of skin oxygenation is transient. Current TcPO2 technology however is impractical as a clinical tool.
This study aims to determine, by outcome analysis, the appropriateness of current criteria employed to select patients for total hip arthroplasty (THA) as the primary treatment for displaced intracapsular hip fracture (DICHF) and to inform prospective randomised controlled trials investigating the efficacy of THA as a primary treatment. Contemporary THA eligibility criteria were derived from recent publications relating to pre-fracture residence, mobility and independence. Outcome data were analysed for 96 patients (19% of 506 consecutive patients with DICHF between 2003–2005) who fulfilled those criteria. The variables analysed included age, gender, co-existing injuries, co-morbidities, social circumstances, mobility, independence, delay to surgery, readmission, and death. Patients were followed for three years. The primary outcome was the combined achievement of home or warden-assisted accommodation at three months, no re-admission within 6 weeks and survival to 1 year. Secondary outcome was survival to three years. At 3-months 86 patients (90%) had returned home, three (3.1%) required nursing or residential home placement, four (4.2%) were still resident in a community hospital, and three (3.1%) had died. Eight patients (8.3%) were re-admitted within 6-weeks. Mortality was 8.3% at 1-year and 25% at 3-years. Patients not achieving return to home were older (84.8 years vs. 79.7 years, p=0.19), were more likely to use a walking aid (OR 2.35) or required home support (OR 1.74) prior to fracture. The number of co-morbidities was not an association. Backward selection identified age as a significant variable in patients successfully discharged home (OR 1.12, CI 1.01 – 1.21). If maintaining a high level of activity and independence is the expectation for hip fracture patients considered for THA then current selection criteria appear appropriate in identifying those 15% capable of returning home, remaining independent and surviving to one year.
A retrospective cohort – data from all emergency dispatches from a UK county ambulance service was linked to the Patient Admission System at local hospitals. All emergency dispatches for immediately life-threatening events (designated as Code Red) between 01/01/1995 and 31/06/2006 were tracked to death or discharge. Main Outcome Measures:
Mortality (at scene, at emergency department, and during hospitalisation), admissions (to the emergency department (ED), inpatients care, and the intensive care unit (ICU)) and mean lengths of stay were analysed by initial exposure (MP versus landline) using multi-variant analysis with logistic regression controlling for potential confounding variables. 354,199 ambulances were dispatched in the 11.5 years. Mobile phone use rose to 25% by study end. 66% of ambulances subsequently transferred patients to hospital. MP compared to landline reporting of emergencies resulted in significant reductions in the risk of death at scene for medical events (OR 0.74; 95% CI 0.65 to 0.85), but not for trauma (OR 1.04). ED medical deaths were higher (OR 1.33; 95% CI 1.33 to 1.72) as were in-patient (OR 1.19). There was no effect on ED or hospital trauma deaths (ORs 0.81, 0.84). The probability of being admitted to hospital and ICU was higher with MP call for trauma (ORs 1.22, 1.44). There was no difference in mortality between mobile or landline calls from either urban or rural areas. There is little evidence to suggest a lower threshold to make an emergency call from a MP. The potential advantages of MP use of ease of access, supplying bystander/patient advice and shortening the ‘golden hour’ appear confined to non-trauma emergencies.
Spiral fractures are one of the most common fractures seen in non-accidental injury. In such cases, with radiographic evidence for the mechanism of injury, the physician is more capable of identifying any inconsistencies in the offered explanatory history. The objectives of the study were to detail and differentiate the fracture patterns created by rotation forces in different directions and to determine the reliability of that recognition method applied to standard radiographs. Twenty rabbit femurs were fractured using a torque transducer and imaged using standard anterior-posterior and lateral radiographs. The radiographic interpretation skills of paediatric, radiology, orthopaedic and emergency room doctors were assessed before and after being given the findings of this study. The radiographic propagation of the spiral fractures was consistent and followed six simple principles. There was a statistically significant difference in the numbers of correctly diagnosed radiographs, before and after the explanation of our findings, by these doctors (chi-squared=14.06, df=1, p=0.002). The direction of the torsional force producing spiral fractures can be determined from characteristic features on routine radiographs but does not seem to be intuitive. These derived six principles will be a useful aid to physicians who manage paediatric spiral fractures where non-accidental injury is being considered.
In 2006 the standard prosthesis for hip hemiarthroplasty in our unit was changed from the traditional Thompson prosthesis used for over 20 years to the monobloc Exeter Trauma Stem (ETS). The principle anticipated advantages were ease of stem implantation, improvement of orientation positioning and a consistency with modern proven femoral THR stem design. All patients selected for hemiarthroplasty replacement for a displaced subcapital fracture of the hip were eligible for inclusion. Failed previous surgical cases were excluded. The last 100 Thompson’s prostheses used before and the first 100 Exeter Trauma Stems undertaken after the changeover date were studied. Outcomes measured included surgical complications including infection, dislocation, fracture, necessity to ream etc. and technical adequacy of implant positioning based upon post-operative radiographs. Surgeon grade was recorded. There were no changes in surgical personnel. 206 consecutive patients were included in the study (age range 76–96); 67 men and 139 women. Data were collected prospectively as part of a comprehensive hip fracture audit. Initial results show that the rate of surgical complications is similar in both prosthesis groups. Radiographs demonstrate the presence of a learning curve in the use of the new prosthesis. On six occasions after December 2006 the Thompson prosthesis was used – this was due to unavailability of ETS prosthesis or where a very large femoral head (56mm) was required. The introduction of the ETS for hip hemiarthroplasty was successful. Initial conversion problems involved maintaining sufficient stock of the most commonly used size of prosthesis. Advantages were a low dislocation rate despite the greater potential for erroneous implant version and a reduction in the amount of femoral preparation required including reaming. Limitations of this study are the lack functional outcome and long term survivorship analysis.
Demographics: The mechanism of injury was a road traffic accident in 80% and the mean ISS was 24.1. There were 95 patients (10.9%) with a cervical spine fracture, 96 (10.8%) with a fracture in either / both thoracic and lumbar regions. Spine clearance: Mean intubation (7.1 days), time to spine clearance (mean 0.4 days). In 318 patients, clearance was performed with the patient conscious (284 prior to intubation, 34 after intubation of <
24hrs). 42 patients (4.6%) died before spine clearance. In 10 patients, the protocol was not followed. Inclusions: 434 patients underwent CT. 10 of the 95 cervical fractures were deemed stable and underwent DS (n = 349). Missed Cases: CT missed 2 cases of instability, one of these (an atlanto-occipital dislocation) was also missed by DS. Critical analysis revealed a Powers ratio calculation would have diagnosed this injury on CT. Sensitivity (CT 97.7% vs DS 98.8%), specificity (100% CT and DS). There were no complications from either procedure.
A modern craze is the Harry Potter series of books. UK sales of the latest book, The Half-Blood Prince, are estimated to reach 4 million. Given the lack of horizontal velocity, height, wheels or sharp edges we were interested to investigate the impact the books had on children’s traumatic injuries.
The launch dates of the most recent two books (Order of the Phoenix and The Half-Blood prince) were identified and the admissions for these weekends were compared to surrounding summer weekends and those dates in previous years. Data were obtained from MetOffice (
MetOffice data suggested no confounding effect of weather.
The purpose of the study was to ascertain whether there were benefits from surgical treatment of acetabular fractures within 3 days of injury, as opposed to within a 2–3 week time period as stated in the current literature. This is a matched-pair, retrospective study, using prospectively entered data from 2 trauma units’ databases, of patients with acetabular fractures treated operatively between 1991 and 1996. Patients were matched for age, acetabular fracture pattern and associated injuries. One group of patients had surgery within 3 days of injury (median time to surgery 1. 5 days), the other group had surgery at 4 or more days post-injury (median 8 days, range 4–19 days). There were 128 patients, 64 per group. The proportion of patients with complications was higher in the later surgery group (relative risk 2. 1, CI 0. 24–0. 87). Median lengths of stay were significantly shorter in the early surgery group, 11 days compared to 22 days (p<
0. 001 Mann-Whitney-U test). The rate of HO in the early surgery group was 2% compared with 14% in the later surgery group. The rate of good or excellent results was 81% in patients with earlier surgery, and 72% in the later surgery group, in those with median follow-up time of 24 months. Surgery for acetabular fractures can and should be undertaken as soon as possible. In the setting of our Trauma Units, this seems to confer lower risks of early and late complications, shorter inpatient stay and may improve long-term outcome.