We aimed to perform a randomized prospective study to determine the outcome of Buried versus Exposed K wire placement.
Patient details were collected and follow up was performed at 2 and 6 weeks post op. Infection at pin sites was measured on a 0 to 6 point scale. Superficial radial nerve was assessed with light touch and 2 point discrimination. EPL tendon was also assessed for damage.
No damage to EPL tendon was recorded in either group at 6/52 follow up. There was a slight increased rate of superficial infection at exposed pin sites noted at 2/52 follow up however this was not seen at the 6/52 follow up. Superficial radial nerve damage was noted in one case only. This was in the buried k wire group and occurred following removal of the radial wire.
We aimed to perform a randomized prospective study to determine the outcome of Buried versus Exposed K wire placement.
Patient details were collected and follow up was performed at 2 and 6 weeks post op. Infection at pin sites was measured on a 0 to 6 point scale. Superficial radial nerve was assessed with light touch and 2 point discrimination. EPL tendon was also assessed for damage.
No damage to EPL tendon was recorded in either group at 6/52 follow up. There was a slight increased rate of superficial infection at exposed pin sites noted at 2/52 follow up however this was not seen at the 6/52 follow up. Superficial radial nerve damage was noted in one case only. This was in the buried k wire group and occurred following removal of the radial wire.
Thus it would appear that leaving k wires exposed is the safer and more convenient method of K wiring the displaced distal radius fracture.
In a prospective randomized trial, we divided a group of patients with a clinically suspicious, although radiographically normal, acute fracture of the scaphoid into 2 groups, 1 treated with a cast (group I), the other with a splint (group II). There were 14 patients in group I, and 18 in group II. Patients were reviewed at 2,6, and 12 weeks for range of movement, grip strength, pain and satisfaction rating. Work disability costs were also calculated for both groups. Patients in group II had better range of movement and grip strength at 2 weeks, although complained of more pain. There was no difference in range of movement, grip strength, or pain at 6 or 12 weeks. Group II was more satisfied at 2 weeks, although not at 6 or 12 weeks. Group I required more time off work, and disability costs were significantly higher [€15,209 per person compared to €3,317 per person]. We recommend that all patients, with only a clinical suspicion of a fractured scaphoid, should have a short period of splint immobilization until symptoms resolve, or until further investigations reveal a fracture which can be appropriately treated. This policy is cost efficient and improves the short term outcome.
Overnight fasting can induce post operative insulin resistance. Insulin resistance is related to infectious morbidity and increased hospital length of stay (HLOS). Previously this concept was only important in diabetic patients. Surgery places the body under metabolic stress and even a short period of fasting will change the metabolic state of the patient. Indeed physical trauma can cause a triad known as the “diabetes of injury”: insulin resistance, hyperglycaemia and glucose intolerance. Preparation for surgery by maintaining a fasted state and catabolic metabolism may have deleterious consequences for the patient. Previous studies on elective patients has shown that pre operative carbohydrate loading can reduce insulin resistance and mitigate the inflammatory response by immunomodulation. It has not previously been shown to have an effect in the hip fracture population. This particular group of patients are often elderly and require medical and anaesthetic work up. This delay can mean that the patient is kept fasting for prolonged periods and often overnight.
The records of these 28 patients were reviewed. Twenty three were male. Ages ranged from 19 to 83 years old. Eight patients had open fractures and 20 had closed fractures. Seven patients (25%) had difficulties with communication which could have impeded or delayed the diagnosis of a compartment syndrome.
However, due to the ease of use and the low cost involved, we recommend that all patients with tibial fracture should have continuous compartment pressure monitoring performed.
With the increasing availability of magnetic resonance imaging, there is potentially less emphasis being placed on making a definitive clinical diagnosis. Changes in the undergraduate curriculum have also reduced the emphasis on orthopaedic clinical evaluation. This aim of this study was to evaluate the predictability of clinical examination alone in comparison with arthroscopic findings in 50 consecutive patients presenting for arthroscopy to our service. Four trainees examined each patient; each examiner was blinded to the clinical diagnosis made by their colleagues. All patients were examined in the ward and subsequently underwent examination under anaesthesia and arthroscopy. Of the tests for meniscal injuries joint line tenderness was the most sensitive (77%) and specific (68%). Apley’s and McMurray’s test while specific (92%, 98%) lacked sensitivity (9%, 30%). Overall the tests for anterior cruciate ligament (ACL) disruption were more reliable than the tests for meniscal injuries. The anterior drawer and Lachmann tests had high specificity (90%, 75%) and sensitivity. The pivot shift test also had very high specificity (75%) and sensitivity (98%) for detecting ACL injuries. These data demonstrate that joint line tenderness is the most reliable sign of menis-cal injury. In the absence of joint line tenderness Apley &
McMurray’s tests have little role in routine clinical examination. Clinical tests and signs of ACL deficiency are consistently reliable in diagnosing ACL rupture.
The conservative management if isolated humeral shaft fractures is a long, drawn out, painful process for the patient. For the clinician, it involves multiple clinic attendances and repeated radiographic assessment and brace alteration. The primary reason for conservative management is the excellent results, but a very definite secondary consideration is the high incidence of shoulder pathology after I.M. nailing. This is thought to be due to rotator cuff pathology at the time of surgery. We question the validity of this second argument. Ten consecutive humeral shaft fractures attending our unit had an MRI of both shoulders carried out during the initial stages of their injury. Two of the ten had retrograde nailing and the remainder was managed conservatively. While there was no patient with an occult coracoid fracture in association with the shaft fracture. We found eight out of ten to have significant signal changes in the subacromial space on the side of the fracture only. We conclude that there is a significant occult injury to the shoulder at the time of humeral shaft fracture and this may in fact represent a cause for the high incidence of shoulder pain post fracture.