Aims. Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically. Methods. This is a prospective series of 156 proximal hamstring surgical repairs, with a mean age of 48.9 years (21.5 to 78). Functional outcomes were assessed preinjury, preoperatively, and postoperatively (six months and minimum three years) using the Sydney Hamstring Origin Rupture Evaluation (SHORE) score. Operating time was recorded for every patient. Results. Overall, significant improvements in SHORE scores were seen at both six months and mid-term follow-up. Preoperatively, acute patients (median score 27.1 (interquartile range (IQR) 22.9)) reported significantly poorer SHORE scores than chronic patients (median score 42.9 (IQR 22.1); p < 0.001). However, this difference was not maintained postoperatively. For partial tears, acutely repaired patients reported significantly lower preoperative SHORE scores compared to chronically reapired partial tears (median score 24.3 (IQR 15.7) vs median score 40.0 (IQR 25.0); p < 0.001) but also significantly higher SHORE scores at six-month follow-up compared to chronically repaired partial tears (median score 92.9 (IQR 10.7) vs. median score 82.9 (IQR 14.3); p < 0.001). For complete tears, there was only a difference in preoperative SHORE scores between acute and chronic groups. Overall, acute repairs had a significantly shorter operating time (mean 64.67 minutes (standard deviation (SD) 12.99)) compared to chronic repairs (mean 74.71 minutes (SD = 12.0); t = 5.12, p < 0.001). Conclusion. Surgical repair of proximal hamstring avulsions successfully improves patient reported functional outcomes in the majority of patients, irrespective of the timing of their surgery or injury classification. However, reducing the time from injury to surgery is associated with greater improvement in patient outcomes and an increased likelihood of returning to preinjury functional status. Acute repair appears to be a technically less complex procedure, as indicated by reduced operating times, postoperative neurological symptoms and number of patients requiring bracing. Acute repair is therefore a preference among many surgeons. Cite this article: Bone Joint J 2020;102-B(10):1419–1427

Stable thoracolumbar fracture is a common injury. The factors that determine its outcome are unclear. Aspects of injury severity were analysed for their ability to predict outcome by controlling other outcome-affecting factors (patient's pre-injury health status, legal aspects, associated injuries, etc.). No reliable disc injury severity grading system was available and therefore a new system was developed.

A prospective observational study of 44 conservatively treated patients with stable fractures between T11 and L5 was conducted. Bony injury severity was scored based on comminution, apposition and kyphosis parameters. Disc injury severity was scored by the new scale based on variables – Herniation, Indentation, Height decrease and Signal change – seen in MRI. Ten outcome domains (five domains of pain and function each) were assessed at 1 to 2 years from injury. The data was analysed by non-parametric correlation and stepwise-linear regression analysis to assess the predictive value of different variables (patient factors, injury factors and social factor) to outcome.

The correlation coefficients between injury severity and outcome were consistently higher with disc injury severity than bony. Disc injury severity showed highest predictive value for both pain (29%) and functional (16%) outcomes, whereas the bony injury severity parameters (kyphosis, etc.) and the posterior ligament injury severity provided no prediction of outcome. According to AO classification, the fractures were A1, A2, A3 and B1; in this spectrum of injuries, the AO classification had no prediction of outcome. The disc injury score also had a good predictive value for final disc degeneration.

Disc injury severity should be gauged in advising prognosis and treatment. The new disc injury severity grading system showed good construct validity.

Introduction. Open fractures are complex injuries associated with substantial morbidity. These injuries are associated with harm to both physical and emotional health as well as preclusion of work, social, and leisure activities. Patient reported outcome measures (PROMs) and health related quality of life are critical indicators of successful rehabilitation following open fracture treatment. This study aimed to measure the PROMs for patients with open lower limb fractures and investigate the relationship with injury severity. Materials & Methods. A retrospective cohort study was performed at a single major trauma centre in the UK. All adult patients with an open lower limb fracture were eligible for inclusion. Patients were identified through a search of a local Open Fracture Database. Epidemiological, clinical, and fracture classification data were obtained by reviewing case notes. Lower Extremity Function Scale (LEFS) and EQ5-D were used as PROMs and measured by a postal questionnaire, alongside return to employment data. Results. A total of 73 patients responded to the questionnaire. Median LEFS was 42 (IQR 26.5 – 59.5), and median EQ5-D was 0.69 (IQR 0.48 – 0.89). There was no significant association between open fracture classification and PROMs. Over 40% of patients reported a change in employment due to their injury. Those who changed jobs had a statistically significant reduction in the EQ5-D of 0.12 (p = 0.021); no significant difference existed in LEFS. Conclusions. This study demonstrates the devastating functional impact of open fractures. This cohort of open injuries reported lower functional and quality-of-life measures compared to population norms. Injury classification was not a valuable predictor of PROMs. A substantial proportion of patients were forced to change employment due to their injury, and these patients reported a significantly lower quality of life. Further work is required to understand the factors contributing to open fracture PROMs

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

Introduction. As modern day lifestyle is becoming more active so is the incidence of meniscal injuries on rise. An injury to the meniscus is a common orthopedic problem with the incidence of meniscal injury resulting in meniscectomy of 61 per 100,000 populations per year. The common practice in diagnosis of the meniscal injury involves clinical examination followed by radiological or arthroscopic confirmation. The clinical tests commonly performed are joint line tenderness (JLT), McMurray's Test (Non-weight bearing test) and Childress Test (Weight Bearing Test). Aim. In our study, we performed the comparative analysis of the validity parameters for components of clinical examination in form of Joint line tenderness, McMurray's test and Childress Test. Methodology. A retrospective analysis was performed on the database established using Orchard Sports Injury Classification System-8. Codes KC2 and KC3 (Meniscal injuries) were identified for single examiner for duration from 2004–2007. Out of 88 patients considered for the study, 62 patients were stratified in whom only clinical examination was performed followed by arthroscopic evaluation. The validity parameters considered were accuracy, specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV). Results. Joint line tenderness had accuracy of 85.47%, sensitivity of 89.09%, and specificity of 57.14%, PPV of 94.23% and NPV of 40%. McMurray's test yielded a accuracy of 88.7%, sensitivity of 89.65%, specificity of 75%, PPV of 98.11%, NPV of 33.33% while Childress test accurately predicted meniscal injury 87.09% and was sensitive for 94.73% with specificity of 40%, PPV of 94.73% and NPV of 40%. Conclusion. We can summarise that though the JLT, McMurray's Test and Childress Test provide a variable yet effective diagnostic value, all through can provide a composite diagnostic yield improving the outcome of clinical examination in meniscal injuries

Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports. A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted. Demographic data were recorded prospectively for each patient with an acute clavicle fractures including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson system. A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. More than half of simple fall fractures affected the lateral clavicle. The incidence of clavicle fractures has risen over a twenty year period, and a greater proportion of older adults are now affected. Overall, type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing. We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region

Background. A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. Aims. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports. Methods. A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted over a 12 month period, beginning July 2007. Demographic data were recorded prospectively for each patient presenting with an acute clavicle fracture including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson Classification system. Results. A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. An association between age, mode of injury and fracture type was observed, with younger patients sustaining high energy injury associated with majority of the Type II midshaft fractures; whilst more than fifty-nine percent of Type III lateral one third fractures occur in elderly patients as a result of simple fall. Overall, Type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing. Conclusions. We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of Type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region