Aims

The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery.

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

Cite this article: Bone Joint J 2023;105-B(4):361–364.

Open long bone fractures have been considered orthopaedic emergencies requiring immediate irrigation, debridement and stabilization. Concomitant traumatic brain injuries may preclude the immediate operative treatment of open fractures. The purpose of this study was to review patients with open tibial diaphyseal fractures whose operative tibial fracture management was delayed because of a concomitant traumatic brain injury to determine if there is an increased rate of infection or non-union. After obtaining IRB approval, the trauma registry was scanned for patients who sustained both traumatic brain injury with an Abbreviated Injury Scale (AIS) equal to two or greater and an open tibial diaphyseal fracture. From January 1, 1996 to June 1, 2001, 28 patients with 31 open tibial shaft fractures were identified (Grade I=1, II=6, IIIA=17, IIIB= 7). There were 24 males and 4 females with an average age of 35 years (range 13–69 years of age). The mechanism of injury was motor vehicle collision or pedestrian versus motor vehicle accident for all patients. The mean time to operative irrigation, debridement, and stabilization was 11 hours (range 2–152 hours). Thirteen patients underwent operative orthopaedic treatment within 8 hours (mean 4.4 ± 1.3 hours), and 15 patients underwent delayed debridement (mean 35 ± 35 hours). Twenty fractures were stabilized with intramedullary nailing, 9 fractures were stabilized with external fixation, one fracture was stabilized with a compression plate, and one fracture treated in a cast. A review of clinic records and telephone follow-up interviews was used to determine the rates of infection or non-union. Infection was defined as a positive deep surgical culture for bacteria upon repeat irrigation and debridement. Non-union was defined as any clinically and radiographically unhealed fracture requiring further operative procedures. The average length of follow up was 2.9 years (range 1 month to 6.5 years). Of the 31 open tibial diaphyseal fractures, four fractures (12.9%) were complicated by infection and four fractures (12.9%) went on to non-union. There was no statistical difference in the rates of infection or non-union in patients who underwent irrigation and debridement within eight hours and those that underwent irrigation and debridement after eight hours from the time of initial presentation (odds ratio=1.02, p=0.15). Furthermore there was no correlation between the ultimate presence of infection/non-union and grade of open tibial shaft fracture, initial method of fixation, timing of wound closure (immediate, delayed primary closure, or split-thickness skin graft or flap), severity of overall injury, and epidemiological characteristics. In this subset of 28 patients with 31 open tibial shaft fractures and concomitant traumatic brain injuries, there was no difference in the incidence of infection or non-union in patients who underwent operative treatment within eight hours of admission to hospital and those who underwent operative treatment after eight hours. The results of this study should be considered in the prioritization of care for the multiply injured trauma patient

BACKGROUND: Complex tibial peri-articular fractures are known to be challenging with high complication rates. Techniques are evolving to assist the management of these injuries and this study looks at a Trauma unit’s experience to help evaluate indications, short and mid-term outcomes and complications. METHOD: 4 year retrospective analysis of prospectively enrolled patients diagnosed with complex peri-articular fractures. Definitive treatment with Less Invasive Stabilisation System (LISS), low contact peri-articular plates and locking condylar plates, using minimally invasive percutaneous osteosynthesis (MIPO), irrespective of initial operative management were included. Follow up:until discharge from clinic with union and full weight bearing. Outcome: peri- and post-operative complications, loss of fixation, radiographic union, and range of motion. RESULTS: 25 (15 proximal,10 distal tibial) operations by senior authors (RAB, SDD) over 4 years with a 16–88 year age (mean 44). Poly-trauma:7 (28%) of cases and 6 (24%) of the entire group were open fractures. Ten patients (40%): preceding damage-limitation procedure prior to definitive treatment (MIPO) and found to be over twice as likely to experience a complication compared to patients who did not. 3 (12%) of 10 had failed those alternative modalities. Overall infection rate was 24% (6 patients:2 deep wound infections; 4 open fracture wound infections). Infection was successfully managed with the use of debridement, flaps and antibiotics in 2 patients (8%); antibiotics alone on one (4%); in 3 patients with the delayed plate removal (12%), usually after union (1 revised with an intramedullary nail). Six plates (24%) were removed: 3 (12%) for infection; 2 (8%) for pain; 1 (4%) for plate fracture (revised). Other complications:2 (8%) significant wound breakdowns, one of whom required local flap cover. No mal-alignment issues; 1 patient developed common peroneal nerve neuropraxia. Patients who were operated after a week or more from injury were half (33%) as likely to suffer from a complication than those operated within a week (57%); P < 0.05 Chi-Square. All progressed to union with 5 patients (20%) having metal work out at that end point and 8 (32%) healing without complication, further surgery or irritation. There were 18 re-operations in total in 9 (36%) of the patients. CONCLUSION: Complex peri-articular fractures of the tibia continue to have a high re-operation rate with significant infection risk especially in open injury. Such techniques do provide a lower morbidity and short-term complication profile when compared with frames/hybrids and formal open fixation. The timing of minimal approach surgery is crucial and has yet to be fully defined. Within a department this type of fixation should be restricted to those with a specific interest, experience and training

Aim and Methods

The goals of this study were to define the risk factors, nature, chronology, and treatment strategies adopted for periprosthetic femoral fractures in 32 644 primary total hip arthroplasties (THAs).

There is little information available at present regarding the mechanisms of failure of modern metallic radial head implants. Between 1998 and 2008, 44 consecutive patients (47 elbows) underwent removal of a failed metallic radial head replacement. In 13 patients (13 elbows) the initial operation had been undertaken within one week of a fracture of the radial head, at one to six weeks in seven patients (seven elbows) and more than six weeks (mean of 2.5 years (2 to 65 months)) in 22 patients (25 elbows). In the remaining two elbows the replacement was inserted for non-traumatic reasons. The most common indication for further surgery was painful loosening (31 elbows). Revision was undertaken for stiffness in 18 elbows, instability in nine, and deep infection in two. There were signs of over-lengthening of the radius in 11 elbows. Degenerative changes were found in all but one. Only three loose implants had been fixed with cement. Instability was not identified in any of the bipolar implants.