Background

Research on midfoot injuries have primarily concentrated on the central column and the Lisfranc ligament without amassing evidence on lateral column injuries. Lateral column injuries have historically been treated with Kirschner wire fixation when encountered.

Introduction

Treatment pathways of 5^th metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management.

Introduction

Open fragility ankle fractures involve complex decision making. There is no consensus on the method of surgical management. Our aim in this study was to analyse current management of these patients in a major trauma centre (MTC).

Surgical planning is the first step in operative fracture management. Complex situations are often faced which pose difficulties on both technical and logistic fronts. Surgical planning is the first step in operative fracture management. The degree of planning that is required is therefore determined by a number of factors including: the nature of the injury mechanism and its concomitant physiological insult, complexity of the fracture and region, expertise of the surgical team and equipment limitations. This paper explores a novel planning process in orthopaedic trauma surgery based upon British Military Doctrine. The seven questions of surgical planning represent a novel method that draws inspiration from the combat estimate process. It benefits from a global approach that encompasses logistic as well as surgical constraints. This, in turn, allows the surgical team to form an understanding of the nature of the fracture in order to develop, document and deliver a surgical plan. This has benefits for the operating surgeon, operating room practitioners and trainees alike and ultimately can result in improved patient care.

Intramedullary nailing of tibial fractures is commonplace and freehand techniques are increasingly popular. The standard freehand method has the knee of the injured leg flexed over a radio-lucent bolster. This requires the imaging C-arm to swing from antero-posterior to lateral position several times. Furthermore, guide wire placement; reaming and nail insertion are all performed well above most surgeons' shoulder height. If instead the leg is hung over the edge of the table, the assistant must crouch and hold the leg until the nail is passed beyond the fracture.

We describe a method of nailing which is easier both for the surgeons and the (often inexperienced) radiographer and present a series of 87 consecutive cases managed with this technique.

Extensor tendon ruptures have been reported in up to 8.8% of patients after volar plating and long screws have been implicated. The dihedral dorsal surface of the distal radius hinders accurate screw length determination using standard radiographic views (lateral; pronation and supination). A ‘dorsal tangential’ view has recently been described, but has not been validated.

To validate this view, we mounted a plate-instrumented sawbone onto a jig. Radiographs at different angles were reviewed independently by 11 individuals. Skyline views clearly demonstrated all screw tips, whereas only 69% of screw tips were identifiable on standard views.

With screws 2mm proud of the dorsal surface, skyline views detected 67% of long screws (sensitivity). The best of the standard views achieved only 11% sensitivity. At 4mm long, skyline sensitivity was 85%, compared with 25% for standard views. At 6mm long, 100% of long screws were detected on skylines, but only 50% of 8mm long screws were detected by standard views. Inter and intra-observer variability was 0.97 (p=0.005).

For dorsal screw length determination of the distal radius, the skyline view is superior to standard views. It is simple to perform and its introduction should reduce the incidence of volar plate-related extensor tendon rupture.

The results of displaced three part fracture of the proximal humerus treated by retro grade nailing +/− cannulated cancellous screws for fixation of the greater tuberosity was analysed.

Displaced three part fractures of the humerus are unstable and difficult to fix. Different methods of operative treatment available for this type of fracture are Kirschner wires, tension band wiring, hemiarthroplasty and open reduction and internal fixation with plate and screws.

The Halder Humeral Nail was introduced through the olecranon fossa into the head of the humerus, to stabilize the neck of humerus fracture. The displaced greater tuberosity was reduced with a minimal stab incision and fixed with cannulated screws. Compared to other open procedures the proximal exposure was minimal.

47 Patients with displaced three part proximal humeral fractures have been surgically treated since January 1995. 22 Were treated with proximal screws and 25 without proximal screw fixation. There were 32 females and 15 males. The average age was 67.68 years.

Early passive movements were encouraged in the shoulder. Pain was relieved in almost all the patients. 41 Fractures united. 3 Patients had a malunion, 2 had humeral head collapse, and 1 developed AVN of the humeral head.

The authors concluded that displaced three part proximal humeral fractures can be treated using the Halder Humeral Nail, and that this is a simple method of treatment which avoids major surgical exposures.

Retrospective review of eighteen patients with sacral fracture dislocations and cauda equina deficits treated with posterior sacral decompression and lumbopelvic fixation. At mean nineteen-month follow-up, all fractures healed without loss of alignment despite immediate full weight-bearing. Fifteen patients (83%) improved neurologically, and ten patients (56%) had full bowel/ bladder recovery. Complications consisted mainly of infection (17%) and asymptomatic rod breakage (33%). This series demonstrates the clinical effectiveness of lumbopelvic fixation, allowing the application to sacral injuries of decompression and fixation principles commonly used in fractures with neurologic deficits that occur in more rostral areas of the spine.

To evaluate the results of sacral decompression and lumbopelvic fixation for sacral fracture-dislocations with neurologic deficits.

Lumbopelvic fixation provided the stability necessary for full weight-bearing without loss of fracture reduction despite extensive sacral decompression. The functional neurologic improvement in most patients and complete neurologic recovery in all but one patient with intact lumbosacral roots are encouraging. The effectiveness of lumbopelvic fixation facilitates the application of principles of early decompression and stabilization to sacral fracture-dislocations.

Sacral fractures healed in all eighteen patients without loss of reduction. Average sacral kyphosis improved from forty-one to twenty-four degrees. Fifteen patients (83%) had normalization or improvement of bowel and bladder deficits, although only ten patients (56%) had improved Gibbons scores. Average Gibbons type improved from four to 2.8 at nineteen-month average follow-up. Rod breakage (33%) and infection (17%) were the most common complications. Recovery of bowel and bladder function was less likely in patients with disruption of any lumbosacral root (36% vs. 86%, p=.066) and complete deficits (47% vs. 100%, p=.241) although the small cohort size precluded statistical significance.

Retrospective review of medical records, radiographs, and prospectively collected data of eighteen consecutive patients with sacral fracture-dislocations and cauda equina deficits identified between 1997 and 2002 through institutional databases. Treatment consisted of open reduction, sacral decompression and lumbopelvic fixation. Radiographic and clinical results of treatment were evaluated. Neurologic outcome was measured by Gibbons’ criteria.

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Retrospective review of seventeen consecutive survivors of craniocervical dissociation (CCD). Thirteen patients had delay in diagnosis, with associated neurologic deterioration in five. Diagnosis of CCD was entertained after lateral C-spine x-ray in only two patients, and after screening C-spine CT in two others. At fifteen-month average follow-up, mean ASIA motor score improved from fifty preoperatively to seventy-nine postoperatively. One patient had temporary postoperative neurologic decline. There were no pseudarthroses. The diagnosis of CCD is often missed, with potentially severe neurologic consequences. Early diagnosis and stabilization are neuroprotective. A classification that identifies minimally displaced yet unstable injuries may improve diagnostic accuracy.

To identify the timing and method of diagnosis, diagnostic reliability of screening lateral radiographs, effect of delayed diagnosis, complications of treatment, and neurologic outcome of this life-threatening condition.

Diagnosis of craniocervical dissociation (CCD) was frequently delayed, increasing the risk of neurologic decline. Early diagnosis and stabilization protected against worsening spinal cord injury.

This study highlights the importance of disciplined evaluation of the lateral cervical spine radiograph of poly-traumatized patients. Head-injured patients with cranio-facial trauma and asymmetric high cervical spinal cord injuries should heighten clinicians’ suspicion of CCD.

CCD was identified or suspected on two of seventeen (12%) initial lateral cervical spine radiographs, and on screening CT scan in only two additional patients (12%), despite an abnormal dens-basion relationship in 16/17 (94%) patients. Of the thirteen patients with (two-day average) delay in diagnosis, 5/13 (38%) had profound neurologic deterioration. One patient worsened temporarily after fixation. There were no pseudarthroses at fifteen-month average follow-up. Mean ASIA motor score of fifty improved to seventy-nine, and the number of patients with useful motor function (ASIA D or E) increased from seven (41%) preoperatively to thirteen (76%) postoperatively.

Four patients with severe craniocervical instability had < 3 mm displacement. We therefore adopted a classification based on provocative traction testing of minimally displaced injuries.(Table).

Retrospective review of seventeen consecutive CCD survivors identified between 1994–2002 through institutional databases. Radiographic and clinical results were evaluated, emphasizing timing of diagnosis, effect of delayed diagnosis, clinical or radiographic warning signs, and response to treatment.

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Introduction and Aims: The purpose of this study was to analyse the results of a new intramedullary retrograde humeral nail used for fixation of difficult fractures of humerus.

Method: In Airedale NHS Trust and Calderdale hospitals, 282 patients were treated for displaced humeral fractures. The new nail called Halder Humeral Nail (HHN) was inserted from the olecranon roof proximally towards the head of humerus. It had a specialised locking system by opening of a trio wire at the proximal head of humerus and distally near the elbow the nail was locked with the help of a screw on a plate. Patients were mobilised immediately after surgery in a polysling.

Results: At six weeks, 95% of patients were pain free and could perform daily activities comfortably. Average post-operative Constance score was 74.7. Complications included proximal migration of the nail and the trio wire in seven cases; six patients had non-union and one patient had infection. Breakage of trio wire was seen in five cases. This resulted in modification of the nail by introducing an additional screw to lock at proximal humerus around the trio wires.

Conclusion: We concluded that stable internal fixation and a good fracture union could be achieved by this new HHN, especially in a displaced humeral fracture, even in poor quality bone with fracture at different level. Pain-free movements, and early recovery was possible without damaging the rotator cuff and risking the axillary nerve.

Introduction Sacral fracture-dislocations with cauda equina deficits are high-energy injuries, the treatment of which is controversial. The effect of early decompression and stabilization is unclear. Neurologic recovery has not been objectively evaluated in past series, putting into question reported recovery rates. Sacral anatomic constraints make standard principles of fracture reduction, neural decompression and stable fixation difficult to apply. Lumbo-pelvic fixation allows indirect fracture stabilization by transferring loads directly from the acetabulum to the lumbar spine, thus avoiding the difficulties inherent in achieving sacral fixation. The purpose of this study was to determine the results of sacral decompression and lumbo-pelvic fixation for sacral fracture-dislocations, with neurologic deficits, using an objective method to evaluate neurologic recovery.

Methods We have carried out a complete retrospective review of all medical records, original radiographs, and prospectively collected data of 18 consecutive patients with sacral fracture-dislocations and cauda equina deficits identified between 1997 and 2002 through institutional spine and trauma databases. Fractures were classified according to Denis (1), Roy-Camille (2) and Strange-Vognsen (3). All were treated with open reduction, sacral decompression and lumbopelvic fixation. Radiographic and clinical results of treatment were evaluated. Neurologic outcome was measured by Gibbons’ criteria (4).

Results Sacral fractures healed in all 18 patients without loss of reduction. Average sacral kyphosis improved from 41° to 24°. Fifteen patients (83%) had normalization or improvement of bowel and bladder deficits, although only 10 patients (56%) had improved Gibbons scores. Average Gibbons type improved from four to 2.8 at 19 month average follow-up. Rod breakage (33%) and infection (17%) were the most common complications. Recovery of bowel and bladder function was more likely in patients with intact lumbosacral roots (86% vs. 36%,p=.066) and incomplete deficits (100% vs. 47%, p=.241) although the small cohort size precluded statistical significance.

Conclusions Lumbo-pelvic fixation safely and effectively provided the stability necessary for mobilization and weight-bearing without loss of reduction in polytraumatized, neurologically impaired patients undergoing extensive sacral decompression. Although neurologic improvement was noted in 83% of patients only 56% of patients had measurable recovery according to objective criteria. However, the functional improvement noted in most patients and complete recovery of bowel and bladder function in all but one patient with intact sacral roots are encouraging.

Introduciton Diagnosis of cranio-cervical dissociaton is frequently delayed, and neurological consequences may be severe. Our purpose was to identify problems with the diagnosis and treatment of craniocervical dissociation, while reporting the results of early craniocervical fusion with posterior segmental fixation.

Methods We present a retrospective review of 17 survivors of cranio-cervical dissociation identified through institutional spine and trauma registries. Medical records, radiographs, and prospectively collected data were used to identify the timing and method of diagnosis, and the effect of delayed diagnosis. Radiographic and clinical results of treatment were evaluated. Emphasis was placed on identifying missed or delayed diagnoses, decline in neurologic function, potential clinical or radiographic warning signs, and response to treatment.

Results Despite an abnormal Basion-Dens relationship in all but one patient, cranio-cervical dissociation was identified or suspected on the initial lateral cervical spine radiograph in only two patients (12%), and was diagnosed in only four patients (24%) following initial trauma evaluation (lateral radiograph and CT of cervical spine). The two day average delay in diagnosis was associated with profound neurologic deterioration in five patients. One patient had post-operative neurologic worsening. No patients developed craniocervical pseudarthrosis or hardware failure after a 15-month average follow-up period. The mean ASIA motor score of 50 improved to seven, and the number of patients with useful motor function (ASIA D or E) increased from seven patients (41%) pre-operatively to 13 (76%) post-operatively. The typical patient profile was of a polytraumatized patient with associated head injuriy, cranio-facial trauma, and asymmetric motor deficits extending above the C5 level.

Conclusions Better clinician awareness and disciplined review of screening C-spine radiographs are important for prompt diagnosis and stabilization of craniocervical instability. Of 17 patients with CCD necessitating internal fixation (stage two and three), 13 had a delay in diagnosis either at our institution or the transferring hospital, with severe neurological consequences in five patients. Significant recovery of neurologic function was a consistent post-operative finding, confirming the importance of prompt diagnosis and operative stabilization of these devastating injuries.

Introduction A promising new approach in the treatment of osteoporosis is the reinforcement of fractured vertebrae with percutaneous injection of bone cement: percutaneous vertebroplasty. This paper reviews the current state of medical literature on this topic and raises concerns about the rapid acceptance of this procedure despite the poor quality of the evidence relating to its safety and efficacy.

Methods We performed a search and critical formal review of the available literature on percutaneous vertebroplasty listed in the MEDLINE database.

Results We found it difficult to summarize the distinct cases reported in the literature because of duplication of case reports and questionable citation in summary reports. Pain relief within 48 hours of treatment was almost universally reported, although clearly defined outcome measures and long-term follow-up were often not reported. The most common complication was leakage of the cement, with 90 instances reported out of 226 patients treated. The leaks were associated with clinical symptoms in three percent of the instances.

Conclusions New high-tech solutions to difficult medical problems are enticing. We must force new treatments through rigorous assessments before proclaiming them safe and successful. The percutaneous vertebroplasty literature fails in this responsibility.

Aim: Distal extra articular fractures of femur and tibia are difþcult to treat by conventional nails because of inability to use distal locking screws. The aim of this study is to analyse the effectiveness of this new I.M. Nail that does not require the use of distal locking screws for rotational stability. Methods & Material: Since 1994 we have treated a total of 68 such cases. Of these 40 were fractures of distal tibia and 28 were that of femur. Age range was from 11– 92. After insertion of the nail in the usual way, a ÒTrio WireÒ was introduced through the nail. This wire fans out in the distal segment which maintains rotational stability. Patients were mobilised with partial weight bearing within 3 weeks. Results: Most of the fractures were united without any signiþcant problem. Delayed union occurred in 2 cases. Breakage of the trio wire occurred in one case and 1 patient with supra-condylar fracture of femur needed revision for persistent varus deformity. Conclusion: We conclude that this I.M. Nail can be used effectively for þxation of these difþcult fractures. This is does not require X-ray exposure for distal locking. Operative time is thus minimised. This also saves surgeonñs hands from direct exposure to radiation. The þxation also allows for dynamisation of the fracture to promote early union.

Aims: Distal humeral shaft fractures are difficult to treat by antegrade humeral nails. In this study we have used a new retrograde nail to treat these fractures. Methods and Material: Since 1997 we have treated 15 extra articular fractures using this device. The nail is introduced through the roof of the olecranon fossa, thus leaving the rotator cuff of the shoulder free from any iatrogenic injury. Proximal rotational stability is maintained by a unique ‘Trio Wire’, which passes through the nail and fans out in the head of the humerus. Distal rotational stability is maintained by the transverse plate. Results: In all cases early pain relief was obtained with return of shoulder and elbow functions. By 6 weeks 98% of patients could perform the majority of daily tasks. No significant complication was noted except a loss of extension of the elbow by 10–15 degrees. Conclusion: This new nail provides stable fixation of difficult distal humeral fractures, even in cases with poor bone quality. Early pain relief with a rapid return of shoulder and elbow functions denote a successful outcome of these operations.

Displaced fractures of the distal humerus are very difficult to treat. Numerous techniques have been developed for internal fixation, e.g. plating, Rush nail fixation, IM nailing etc. Results are not very good in majority of the cases. Conventional ‘antigrade’ nailing sometimes may not be suitable for these types of fractures. This new nail is inserted by a close retrograde technique using a special interlocking system to avoid axillary nerve and rotator cuff damage. This nail also allows stable fixation of these distal fractures via a plate welded its distal end, which maintain the rotational stability.

Since 1997 we have treated 15 displaced extra particular fractures using this device. 12 of them were widely displaced fractures, some comminuted, and 3 were pathological fractures. The nail is introduced through the roof of the olecranon fossa, thus leaving the rotator cuff of the shoulder free from any iatrogenic injury. Proximal rotational stability is maintained by a unique ‘Trio Wire’, which passes through the nail and fans out in the head of the humerus. Distal rotational stability is maintained by the transverse plate.

In all cases early pain relief was obtained with return of shoulder and elbow functions. By 6 weeks 98% of patients could perform the majority of daily tasks. No significant complication was noted except a loss of extension of the elbow by 10–15 degrees

This new nail provides stable fixation of difficult distal humeral fractures, even in cases with poor bone quality. Early pain relief with a rapid return of shoulder and elbow functions denote a successful outcome of these operations.

We review the results of the Gamma nail fixation to elucidate its effectiveness in the treatment of peritro-chanteric and subtrochanteric fractures of the neck of femur.

We report the result of 718 cases of Gamma nail fixation in all such cases presenting at our institution since 1988. 573 cases of peritrochanteric and 145 cases of sub-trochanteric fractures were treated by means of standard and long Gamma nail. Age groups of the patients are from 33 to 99 years. No distal locking screw was used in cases of standard nails. All grades of surgeons were involved. Full weight bearing was allowed on the first post operative day. Cases were followed up for one year.

No intraoperative iatrogenic fracture was encountered. Minimal post operative pain was experienced and mobility was regained early. All fractures healed satisfactorily except the following: 51 cases developed coxa vera deformity; 37 cases of undisplaced fractures of base of greater trochanter were noticed at 6 weeks follow up - all healed spontaneously; 1 case of external rotational deformity occurred in a long nail where no distal locking screw was used. 2 cases of deep infection were treated successfully by removal of nail and antibiotic treatment; 4 cases of fracture at the level of the distal end of the prosthesis, presented at 6 weeks to 2 year period following a subsequent trauma, were treated with exchange of device with long nail. Upward penetration of hip screw 22. No case of metal failure observed.

Gamma nail provides a stable fixation in both simple and complex fractures of proximal femur with a much less invasive tehcnique which allows minimal disturbance of fracture haematoma, less incidence of wound infection and less amount of postoperative pain. Early mobility is regained with immediate and unrestricted weight bearing. Biomechanically also Gamma nail produces a better means of osteosynthesis.

Purpose of study: General practitioners (GPs) are often asked to recruit patients for research studies. However, a mismatch exists between the numbers of potential patients (estimated from pilot work and reported literature) and actual patients recruited. The purpose of this study was to establish GPs’ perceptions of the reasons for this mismatch.

Background: An OCPS survey reported that 16% of adults consulted their GP with back pain per year. Thus a GP, serving an average population of ~1900 patients, might expect to see around 300 patients with back pain every year, although this estimate includes all causes of back pain. Nevertheless, this represents a significant proportion of a GP’s workload.

In the ‘Back Home’ study, which was a randomised controlled trial of a patient information leaflet for people with acute low back pain (previously presented to this Society), recruitment of patients was problematic. A total of 28/97 GPs in the New Forest area agreed to recruit patients for the study, but in 22 weeks, only 8 patients emerged. Despite extending the catchment area of the study, and having 51 participating GPs, in 2_ years, only 64 patients were entered from 19 of these GPs. Therefore, we decided to investigate GPs’ perceptions of the reasons for such poor recruitment.

Methods: The challenge for this research was identifying how best to gain information from GPs about poor recruitment, recognising that requests for information about poor response rates may yield a limited response! The least intrusive means of accessing information was considered to be a brief questionnaire containing an open question that asked GPs to list any reasons that they thought may have contributed to the slow recruitment of patients into the study. GPs were then asked to rate 12 factors, identified by GPs who had withdrawn from the study. The factors were rated using a Likert scale from 1–4 (1=‘not at all’, 2=‘mildy’, 3=‘moderately’ and 4=‘very significantly’).

Results: Of the initial 51 participating GPs, 11 did not complete the study: 1 left the practice; 2 retired; 7 withdrew (3 of these due to pressure of work); and 1 was asked to leave the study by the research team due to issues of non-conformity with the study protocol.

Forty GPs were sent a questionnaire and 24 responded (60%). They gave 47 unprompted reasons for poor recruitment of patients – the most popular being: pressure of work (n=12); difficulty remembering (n=10); feeling ‘over-researched’ (n=4); and few patients fitted the inclusion criteria (n=4). When GPs rated the 12 listed factors, the maximum score for each item = 96 (24x4). According to the GPs, the top 4 factors were: pressure of work (score=60); forgetting to include suitable patients (52); time-consuming process of entering patients (39); GPs are ‘over-researched’ (31).

Conclusion: Research studies that necessitate GPs accessing patients from their routine surgeries are likely to experience difficulties with recruitment. It is vital that researchers and funding agencies address this issue if research within primary care is to survive.