The August 2024 Trauma Roundup. 360. looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis

The August 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Comparing augmented and nonaugmented locking-plate fixation for proximal humeral fractures in the elderly; Elevated five-year mortality following shoulder arthroplasty for fracture; Total intravenous anaesthesia with propofol reduces discharge times compared with inhaled general anaesthesia in shoulder arthroscopy: a randomized controlled trial; The influence of obesity on outcomes following arthroscopic rotator cuff repair; Humeral component version has no effect on outcomes following reverse total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial; What is a meaningful improvement after total shoulder arthroplasty by implant type, preoperative diagnosis, and sex?; The safety of corticosteroid injection prior to shoulder arthroplasty: a systematic review; Mortality and subsequent fractures of patients with olecranon fractures compared to other upper limb osteoporotic fractures.

Aims. Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room. Methods. A randomized controlled trial was conducted. A total of 255 patients were included, aged five to 17 years, who needed plaster treatment for a fracture of the upper or lower limb. Randomization was stratified for age (five to 11 and 12 to 17 years). The intervention group was distracted with VR goggles and headphones during the plaster treatment, whereas the control group received standard care. As the primary outcome, the post-procedural level of anxiety was measured with the Child Fear Scale (CFS). Secondary outcomes included the children’s anxiety reduction (difference between CFS after and CFS before plaster procedure), numerical rating scale (NRS) pain, NRS satisfaction of the children and accompanying parents/guardians, and the children’s heart rates during the procedure. An independent-samples t-test and Mann-Whitney U test (depending on the data distribution) were used to analyze the data. Results. The post-procedural CFS was significantly lower (p < 0.001) in the intervention group (proportion of children with no anxiety = 78.6%) than in the control group (56.8%). The anxiety reduction, NRS pain and satisfaction scores, and heart rates showed no significant differences between the control group and the intervention group. Subanalyses showed an increased effect of VR on anxiety levels in young patients, females, upper limb fractures, and those who had had previous plaster treatment. Conclusion. VR effectively reduces the anxiety levels of children in the plaster room, especially in young girls. No statistically significant effects were seen regarding pain, heart rate, or satisfaction scores. Cite this article: Bone Joint J 2024;106-B(7):728–734

Aims

Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma.

The February 2024 Trauma Roundup³⁶⁰ looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years.

Intimate partner violence (IPV) causes significant morbidity and its unlikely to be reported compared to other forms of gender-based violence (GBV). For early detection, understanding Orthopaedic injuries from GBV is vital. This study assesses the pattern of musculoskeletal injuries from GBV and determines the factors associated with it. It is a retrospective observational study of patients aged ≥18 years, with GBV-related acute Orthopaedic injuries. Data was reviewed from January 2021 to December 2021, including, demographic information, soft tissue and bony injuries, relationship to assailant, substance abuse and the day and time of injury. Frequencies and percentages for categorical data were analysed. Chi-square test was used to calculate association. T-test was used to compare groups for continuous & categorical variables. Multivariate analysis was conducted to find the odds ratio and a p-value <0.05 was statistically significant. 138 patients were included, the mean age at presentation being 35.02 years (SD=11). 92.75% of GBV victims were females. Most were unemployed (66.7%). 30.43% (n-42) had a soft tissue injury; superficial laceration being the most common (23.1%), flexor tendon injury (10.87%), hand abscess (5.8%), and extensor tendon injury (5.07%). 71.02 % (n=98) sustained appendicular fractures. 51.45% (n=71) sustained upper limb fractures; distal radius fractures (10.86%) and distal 3rd ulnar fractures (9,42%). 19.57% (n=27) had lower limb fractures; 7.25% (n=10) had lateral malleolus ankle fractures. 63.7% (n=80) of cases were by an intimate partner on weekends (50.73%). 62.31% occurred between 16h00 and 0h00. 41.1% (n=65) reported alcohol abuse. 63.04% had surgery. GBV likely occurs in early middle-aged females by intimate partners influenced by alcohol over the weekends between 16h00 to 0h00. Distal radius/distal 3rd ulnar fractures are the most common bony injuries. Superficial wrist laceration is the commonest soft tissue injury. These findings may assist with early detection and intervention to prevent adverse outcomes in GBV

Child abuse is an essential discussion within society and poses many challenges. The international literature describes patient and family based risk factors and suspicious injuries. We have created a protocol for the identification and investigation of children with suspected non-accidental injuries. The paediatric orthopaedic ward experiences many children being delayed in the ward once fit for discharge. This study aimed to quanitify those delayed discharges and describe the demographics and risk factors for abuse within the local population. After obtaining ethics clearance, we conducted a retrospective review of records from the Teddy Bear Clinic, as well as admission records. The study examined demographic characteristics, family, injury characteristics and referral to Child Welfare. The delay of discharge from hospital was quantified and was compared to those characteristics. Records were collected from 1 January 2015 to 31 December 2021. Seventy-nine complete records were included. There were 40 males and 39 females with an average age of 20 months. 75.9% were under 36 months old. 94.1% of the cases sustained lower limb fractures. Fifty-two cases had a delayed discharge. The delay ranged from 1 to 233 days. There was an association between an age less than 36 months and delayed discharge. There were no significant correlations between caregiver characteristics and delayed discharge. The later the completion of investigations, the more likely there would be a delay. There was also a significant correlation between referral to Child Welfare and delayed discharge. Children under 36 months on this remain at highest risk for non-accidental injury. Delayed discharge was associated with age less than 36 months, upper limb fractures and referral to Child Welfare. Despite the delayed discharge, most children returned to the same home environments

Aims

Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

Aims

The aim of this study was to report the patterns of symptoms and insufficiency fractures in patients with tumour-induced osteomalacia (TIO) to allow the early diagnosis of this rare condition.

Australian Football (AF) is a popular sport in Australia, with females now representing one-third of participants. Despite this, the injury profiles of females versus males in largely unknown. The current study investigated fractures, dislocations and tendon ruptures in females versus males presenting to emergency departments (ED) with an AF injury. All patients, regardless of age, presenting to one of 10 EDs in Victoria, Australia, with an AF injury were included. Data were prospectively collected over a 10-month period, coinciding with a complete AF season. Data were extracted from patient medical records regarding injury-type, body-part injured and treatments required. Female and male data were compared with chi-squared tests. Of the 1635 patients presenting with an AF injury, 595 (36.0%) had a fracture, dislocation or tendon rupture, of whom 85 (14.3%) were female and the average age was 20.5 years (SD 8.0). Fractures accounted for most injuries (n=478, 80.3% of patients had a fracture), followed by dislocations (n=118, 19.8%) and tendon ruptures (n=14, 2.4%). Upper limb fractures were more common than lower limb fractures (71.1% v 11.5% of fractures). Females were more likely to fracture their hands or fingers than males (45.7% v 34.3%). Males were more likely to fracture ribs (5.4% v 0%). Most fractures (91.2%) were managed in the ED, with the remainder being admitted for surgery (GAMP/ORIF). Males were more likely to be admitted for surgery than females (11.2% v 5.9%). Regarding dislocations (n=118), females were more likely to dislocate the patella (36.8% v 8.1% of dislocations). Only males sustained a tendon rupture (n=14): finger extensor or flexor (57.1%), achilles tendon (28.6%) and patella tendon (14.3%). Orthopaedic AF injuries are common presentations to EDs in Victoria, though few require specialist orthopaedic intervention. Injury profiles differed between genders suggesting that gender specific injury prevention and management might be required

Aims

This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons?

Distal radius fractures (DRFs) are common injuries that represent 17% of all adult upper extremity fractures. Some fractures deemed appropriate for nonsurgical management following closed reduction and casting exhibit delayed secondary displacement (greater than two weeks from injury) and require late surgical intervention. This can lead to delayed rehabilitation and functional outcomes. This study aimed to determine which demographic and radiographic features can be used to predict delayed fracture displacement. This is a multicentre retrospective case-control study using radiographs extracted from our Analytics Data Integration, Measurement and Reporting (DIMR) database, using diagnostic and therapeutic codes. Skeletally mature patients aged 18 years of age or older with an isolated DRF treated with surgical intervention between two and four weeks from initial injury, with two or more follow-up visits prior to surgical intervention, were included. Exclusion criteria were patients with multiple injuries, surgical treatment with fewer than two clinical assessments prior to surgical treatment, or surgical treatment within two weeks of injury. The proportion of patients with delayed fracture displacement requiring surgical treatment will be reported as a percentage of all identified DRFs within the study period. A multivariable conditional logistic regression analysis was used to assess case-control comparisons, in order to determine the parameters that are mostly likely to predict delayed fracture displacement leading to surgical management. Intra- and inter-rater reliability for each radiographic parameter will also be calculated. A total of 84 age- and sex-matched pairs were identified (n=168) over a 5-year period, with 87% being female and a mean age of 48.9 (SD=14.5) years. Variables assessed in the model included pre-reduction and post-reduction radial height, radial inclination, radial tilt, volar cortical displacement, injury classification, intra-articular step or gap, ulnar variance, radiocarpal alignment, and cast index, as well as the difference between pre- and post-reduction parameters. Decreased pre-reduction radial inclination (Odds Ratio [OR] = 0.54; Confidence Interval [CI] = 0.43 – 0.64) and increased pre-reduction volar cortical displacement (OR = 1.31; CI = 1.10 – 1.60) were significant predictors of delayed fracture displacement beyond a minimum of 2-week follow-up. Similarly, an increased difference between pre-reduction and immediate post reduction radial height (OR = 1.67; CI = 1.31 – 2.18) and ulnar variance (OR = 1.48; CI = 1.24 – 1.81) were also significant predictors of delayed fracture displacement. Cast immobilization is not without risks and delayed surgical treatment can result in a prolong recovery. Therefore, if reliable and reproducible radiographic parameters can be identified that predict delayed fracture displacement, this information will aid in earlier identification of patients with DRFs at risk of late displacement. This could lead to earlier, appropriate surgical management, rehabilitation, and return to work and function

Timely and competent treatment of paediatric fractures is paramount to a healthy future working population. Anecdotal evidence suggests that children travel greater distances to obtain care compared to adults causing economic and geographic inequities. This study aims to qualify the informal regionalization of children's fracture care in Ontario. The results could inform future policy on resource distribution and planning of the provincial health care system. A retrospective cohort study was conducted examining two of the most common paediatric orthopaedic traumatic injuries, femoral shaft and supracondylar humerus fractures (SCH), in parallel over the last 10 years (2010-2020) using multiple linked administrative databases housed at the Institute for Clinical Evaluative Sciences (ICES) in Toronto, Ontario. We compared the distance travelled by these pediatric cohorts to clinically equivalent adult fracture patterns (distal radius fracture (DR) and femoral shaft fracture). Patient cohorts were identified based on treatment codes and distances were calculated from a centroid of patient home forward sortation area to hospital location. Demographics, hospital type, and closest hospital to patient were also recorded. For common upper extremity fracture care, 84% of children underwent surgery at specialized centers which required significant travel (44km). Conversely, 67% of adults were treated locally, travelling a mean of 23km. Similarly, two-thirds of adult femoral shaft fractures were treated locally (mean travel distance of 30km) while most children (84%) with femoral shaft fractures travelled an average of 63km to specialized centers. Children who live in rural areas travel on average 51km more than their adult rural-residing counterparts for all fracture care. Four institutions provide over 75% of the fracture care for children, whereas 22 institutions distribute the same case volume in adults.?. Adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. There is an unplanned concentration of pediatric fracture care to specialized centers in Ontario placing undue burden on pediatric patients and inadvertently stresses the surgical resources in a small handful of hospitals. In contrast, adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. Patient care equity and appropriate resource allocation cannot be achieved without appropriate systemization of pediatric fracture care

Abstract. Introduction. Vitamin D deficiency in the UK is well documented − 30–40% of the population. It is an essential component of calcium metabolism and adequate levels are important for bone healing. Studies have demonstrated an overall prevalence of vitamin D deficiency/insufficiency at 77% in trauma patients aged >18, deficiency alone was 39%. Adequate vitamin D levels have a positive effect on bone mineral density and callus formation at fracture sites. Methods. We conducted a retrospective consecutive case series of all patients aged 0–50 undergoing surgical management for any fracture in October 2021 to March 2022. We assessed if vitamin D levels were checked and if patients were prescribed replacement as per local guidelines. Results. A total of 131 patients were identified, (mean 29 years; 83 male and 48 female). Most cases were upper limb fractures (n=78, 60%), as opposed to lower limb (n=53, 40%). Only 20 (15%) had their levels checked, of which 13 (65%) were insufficient/deficient (10 insufficiency, 2 deficiency, 1 severe deficiency). Of these 13 patients, only 3 (23%) were prescribed replacement therapy. Conclusions. Only a small proportion of patients had their levels checked, however the majority were insufficient/deficient. The prevalence in our study is consistent with larger epidemiology studies, which reflect a higher rate of deficiency in fracture patients compared to the general population. Thus, we propose that all patients in this age group should undergo a vitamin d level check upon time of clerking and this should be accurately treated as per trust guidance

Aims. Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters. Methods. We searched PubMed, EMBASE, Scopus, and Web of Science databases using variations of the term “electric scooter”. We excluded studies conducted prior to 2015, studies with a population of less than 50, case reports, and studies not focused on electric scooters. Data were analyzed using t-tests and p-values < 0.05 were considered significant. Results. We studied 5,705 patients from 34 studies. The mean age was 33.3 years (SD 3.5), and 58.3% (n = 3,325) were male. The leading mechanism of injury was falling (n = 3,595, 74.4%). Injured patients were more likely to not wear a helmet (n = 2,114; 68.1%; p < 0.001). The most common type of injury incurred was bony injuries (n = 2,761, 39.2%), of which upper limb fractures dominated (n = 1,236, 44.8%). Head and neck injuries composed 22.2% (n = 1,565) of the reported injuries, including traumatic brain injuries (n = 455; 2.5%), lacerations/abrasions/contusions (n = 500; 7.1%), intracerebral brain haemorrhages (n = 131; 1.9%), and concussions (n = 255; 3.2%). Standard radiographs comprised most images (n = 2,153; 57.7%). Most patients were treated and released without admission (n = 2,895; 54.5%), and 17.2% (n = 911) of injured patients required surgery. Qualitative analyses of the cost of injury revealed that any intoxication was associated with higher billing costs. Conclusion. The leading injuries from e-scooters are upper limb fractures. Falling was the leading mechanism of injury, and most patients did not wear a helmet. Future research should focus on injury characterization, treatment, and cost. Cite this article: Bone Jt Open 2022;3(9):674–683

Aims

The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland.

Mirels’ score predicts the likelihood of sustaining pathological fractures using pain, lesion site, size and morphology. The aim is to investigate its reproducibility, reliability and accuracy in upper limb bony metastases and validate its use in pathological fracture prediction. A retrospective cohort study of patients with upper limb metastases, referred to an Orthopaedic Trauma Centre (2013–18). Mirels’ was calculated in 32 patients; plain radiographs at presentation scored by 6 raters. Radiological aspects were scored twice by each rater, 2-weeks apart. Inter- and intra-observer reliability were calculated (Fleiss’ kappa test). Bland-Altman plots compared variances of individual score components &total Mirels’ score. Mirels’ score of ≥9 did not accurately predict lesions that would fracture (11% 5/46 vs 65.2% Mirels’ score ≤8, p<0.0001). Sensitivity was 14.3% &specificity was 72.7%. When Mirels’ cut-off was lowered to ≥7, patients were more likely to fracture (48% 22/46 versus 28% 13/46, p=0.045). Sensitivity rose to 62.9%, specificity fell to 54.6%. Kappa values for interobserver variability were 0.358 (fair, 0.288–0.429) for lesion size, 0.107 (poor, 0.02–0.193) for radiological appearance and 0.274 (fair, 0.229–0.318) for total Mirels’ score. Values for intraobserver variability were 0.716 (good, 95% CI 0.432–0.999) for lesion size, 0.427 (moderate, 95% CI 0.195–0.768) for radiological appearance and 0.580 (moderate, 0.395–0.765) for total Mirels’ score. We showed moderate to substantial agreement between &within raters using Mirels’ score on upper limb radiographs. Mirels’ has poor sensitivity &specificity predicting upper limb fractures - we recommend the cut-off score for prophylactic surgery should be lower than for lower limb lesions

Aims

Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort.

Aims. The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures. Methods. A four-phase study was conducted to agree a set of core outcome domains. Identification of candidate outcome domains were identified through systematic review of trials, and outcome domains relevant to families were identified through semi-structured interviews with 20 families (parent-child pairing or group). Outcome domains were prioritized using an international three-round Delphi survey with 205 panellists and then condensed into a core outcome set through a consensus workshop with 30 stakeholders. Results. The systematic review and interviews identified 85 outcome domains as relevant to professionals or families. The Delphi survey prioritized 30 upper and 29 lower limb outcome domains at first round, an additional 17 upper and 18 lower limb outcomes at second round, and four additional outcomes for upper and lower limb at the third round as important domains. At the consensus workshop, the core outcome domains were agreed as: 1) pain and discomfort; 2) return to physical and recreational activities; 3) emotional and psychosocial wellbeing; 4) complications from the injury and treatment; 5) rturn to baseline activities daily living; 6) participation in learning; 7) appearance and deformity; and 8) time to union. In addition, 9a) recovery of mobility and 9b) recovery of manual dexterity was recommended as a core outcome for lower and upper limb fractures, respectively. Conclusion. This set of core outcome domains is recommended as a minimum set of outcomes to be reported in all trials. It is not an exhaustive set and further work is required to identify what outcome tools should be used to measure each of these outcomes. Adoption of this outcome set will improve the consistency of research for these children that can be combined for more meaningful meta-analyses and policy development. Cite this article: Bone Joint J 2021;103-B(12):1821–1830

Aims

Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.