We present the prevalence of multiple fractures in the elderly in a single catchment population of 780 000 treated over a 12-month period and describe the mechanisms of injury, common patterns of occurrence, management, and the associated mortality rate. A total of 2335 patients, aged ≥ 65 years of age, were prospectively assessed and of these 119 patients (5.1%) presented with multiple fractures. Distal radial (odds ratio (OR) 5.1, p <  0.0001), proximal humeral (OR 2.2, p < 0.0001) and pelvic (OR 4.9, p < 0.0001) fractures were associated with an increased risk of sustaining associated fractures. Only 4.5% of patients sustained multiple fractures after a simple fall, but due to the frequency of falls in the elderly this mechanism resulted in 80.7% of all multiple fractures. Most patients required admission (> 80%), of whom 42% did not need an operation but more than half needed an increased level of care before discharge (54%). The standardised mortality rate at one year was significantly greater after sustaining multiple fractures that included fractures of the pelvis, proximal humerus or proximal femur (p < 0.001). This mortality risk increased further if patients were < 80 years of age, indicating that the existence of multiple fractures after low-energy trauma is a marker of mortality

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls. Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively. Cite this article: Bone Joint J 2014;96-B:366–72

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In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

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Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI.

Introduction and objectives. Intramedullary nailing is indicated to stabilization of tibia shaft fractures. Intramedullary nailing through an infra-patellar incision is commonly the technique of choice. While intramedullary nailing of simple diaphyseal fracture patterns is relatively easy, proximal tibia fractures, extremely comminuted/segmental tibia fractures, politrauma with multiple fractures in both extremities and reconstruction of bone loss segment with stiffness of the knee joint can be very challenging to treat. A novel technique for intramedullary tibia nailing through the patella-femoral joint is described. This technique allow extension tibia during intervention time and it supplies easier reduction of the pattern of fracture above. The purpose of our investigation was to evaluate the use of this new technique in described above pattern fracture and patient situation; because we have thought that new technique can perform better outcomes in this situations. Materials and Methods. An observational study of tibia fractures or bone defect was performed for consecutive patients who presented: proximal tibia fractures, extremely comminuted/segmental tibia fractures, politrauma with multiple fractures in both extremities and reconstruction of bone loss segment in the Trauma unit of our institution from September 2009 to August 2010. A total of 32 were included in our study, which performed surgery intervention with Trigen tibia nail (Smith & Nephew, Memphis) with suprapatelar device. Demographic data, mechanism of injury, fracture classification, ROM (2 and 6 weeks, and 3 months), consolidation rate, reduction fracture quality and knee pain at 3 months were recorded. Results. Male was the gender most frequent (64%), the average age was 39,5 years and the main mechanism of injury was motor vehicle injury (30,6%). There were 7 proximal fractures, 1 bifocal fracture, 6 politrauma and 2 reconstruction bone loss segment, the others were comminuted and segmental tibia fracture. In all the patients, the fracture was consolidated between 8 to 14 weeks with average of 10,6 weeks. The quality of reduction was correct in all patients in different axis. The average of ROM at 2 weeks was (−2°/95°) at 3 months was (−0,4°/133°). The knee pain (VAS) average was 0,6 only in 2 patients were (4). Poller screw was used in 7 patients. Conclusion. The suprapatelar nailing is optimal technique to resolve complex fracture of the tibia (proximal, segmental conminution, politrauma) that perform correct consolidation rate without misalignment in the patients. Concerns about knee pain (VAS) from the technique not appear in our data. Prospective and clinical trials are needed to validate this approach

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There is increasing evidence to support the use of topical antibiotics to prevent surgical site infections. Although previous research suggests a minimal nephrotoxic risk with a single dose of vancomycin powder, fracture patients often require multiple procedures and receive additional doses of topical antibiotics. We aimed to determine if cumulative doses of intrawound vancomycin or tobramycin powder for infection prophylaxis increased the risk of drug-induced acute kidney injury (AKI) among fracture patients.

We conducted a randomised controlled trial to compare external fixation of trochanteric fractures of the femur with the more costly option of the sliding hip screw. Patients in both groups were matched for age (mean 67 years, 50 to 100) and gender. We excluded all pathological fractures, patients presenting at more than one week, fractures with subtrochanteric extension or reverse obliquity, multiple fractures or any bone and joint disease interfering with rehabilitation. The interval between injury and operation, the duration of surgery, the amount of blood loss, the length of hospital stay and the cost of treatment were all significantly higher in the sliding hip screw group (p < 0.05). The time to union, range of movement, mean Harris hip scores and Western Ontario and McMaster University knee scores were comparable at six months. The number of patients showing shortening or malrotation was too small to show a significant difference between the groups. Pin-track infection occurred in 18 patients (60%) treated with external fixation, whereas there was a single case of wound infection (3.3%) in the sliding hip screw group

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To explore staff experiences of a multicentre pilot randomized controlled trial (RCT) comparing intramedullary nails and circular frame external fixation for segmental tibial fractures.

Aim. To review current military orthopaedic experience and establish if there exists a consensus of opinion in how and if to perform fasciotomy of the foot and to guide other clinicians. Method. A questionnaire was sent to 10 DMS orthopaedic consultants to identify their experience with foot compartment syndrome and performing fasciotomies. Results. 50% had performed a foot fasciotomy (average 2, range 1-6) over an average of 6.2 years as consultant and an average of 7.3 months deployed. Most commonly two dorsal and a medial incision were used to decompress the foot, while one advocated not decompressing and accepting the contractures, a view consistent with some civilian literature. Discussion. The debate surrounding decompression stems from the rarity of the condition, the lack of consensus regarding the anatomy of the foot compartments and whether to accept the inevitable contractures by not decompressing. Given that foot compartment syndrome may not be seen during civilian training, then there is a requirement for guidance for the deploying military surgeon. Conclusion. DMS clinicians need to remain vigilant to compartment syndrome of the foot and especially in cases of crush or blast injury or of multiple fractures. If diagnosed or even if an impending compartment syndrome is suspected then the foot should be decompressed and the deployed orthopaedic surgeon should be capable of performing it

Introduction. The main symptoms in multiple myeloma are the result of skeletal destruction mainly the vertebral column. The current treatments for multiple myeloma include radiotherapy and chemotherapy but unfortunately it is still incurable. However, the symptoms and quality of life of these patients can be improved by cement augmentation which has gained popularity in the recent years. Aim. To analyse the efficacy and safety of cement augmentation and to assess the survival and outcome of the patients with vertebral fractures secondary to multiple myeloma. Material and Methods. In this retrospective study, we reviewed the data over the last 3 years. Medical records review included correction of vertebral angle (VA), assessment of disability, survival and postoperative improvement in pain and functional status. Results. We reviewed 12 patients with 48 vertebral compression fractures including 9 male and 3 female patients. Mean age was 62.5 years (41–85). 5 patients had single vertebral involvement while 7 had multiple fractures at different levels in thoracolumbar spine. Average length of follow-up was 20.3 months (14–33 months). Based on Modified Tokuhashi score, the expected survival was less than 12 months in 2 patients and more than 12 months in the remaining patients. 11 patients are alive till date with average survival of 26 months (18–42 months) while 1 patient died, 23 months after the initial correction surgery. Prior to correction, the average vertebral angle (VA) was 10.60 (2.30 to 25.20) and after cement augmentation the average VA was 7.00 (1.60–22.80). Mean correction achieved was 3.60. There was no loss of vertebral height in any patient until their latest follow-up. Karnofsky performance score was more than 70 in 5 patients, 50–70 in 6 and less than 50 in 1 patient preoperatively while it improved to more than 70 in all patients postoperatively which indicates improvement in their functional status. All patients reported improvement in their pain level after surgery. No cement leakage or major complication occurred in these patients. Conclusion. Cement augmentation is a safe and effective way of treating the symptoms of multiple myeloma which occur due to vertebral metastases. It results in excellent pain control and improvement in quality of life

Introduction. In an ageing population the incidence of patients sustaining a neck of femur fracture is likely to rise. Whilst the neck of femur fracture is thought to be a pre-terminal event in many patients, there is little literature following this common fracture beyond 1 year. With improving healthcare and increasing survival rate, it is likely that a proportion of patients live to have subsequent fractures. However little is known about if these occur and what the epidemiology of these fractures are. Aim. To describe the epidemiology of fractures sustained over a ten year period in patients who had an “index” neck of femur fracture. Method. All patients from the Lothian region, who sustained a neck of femur fracture and were admitted to the Royal Infirmary of Edinburgh in Scotland between 01/01/2000 and 31/12/2000 were prospectively identified and had their orthopaedic notes and where appropriate death records retrospectively reviewed in Aug 2010, to identify further fractures and orthopaedic treatments. Patients admitted from without the Lothian region were excluded from the study. Other information regarding their pre-injury medical history, what surgery was performed, age, social status, co-morbidities and where relevant cause and date of death were recorded. Results. In the year 2000 there were 628 patients identified as having sustained a neck of femur fracture giving an incidence of 12/10,000/year. 534 (85%) of the 628 fractures were sustained by falls, with the remainder being direct trauma, pathological or an unknown cause. The mean age of patient at the time of sustaining the neck of femur fracture was 87.5 years old, with a range of 17 to 101 years old. 136 (21.7%) patients went on to sustain further fractures. The top five most frequent fractures involved the contralateral neck of femur (55; 31%), radius (34; 19%), humerus (24; 13.4%), ipsilateral femur (19; 10.6%) and tibia (10; 5.6%). 32 (23.5%) people sustained multiple fractures after the initial hip index fracture. 24% of patients had previously sustained some form of fracture prior to their index neck of femur fracture. Conclusion. Our results demonstrate that over a fifth of patients who sustain a neck of femur fracture will sustain a further fracture in the next ten years. Rather than regarding a neck of femur fracture as a terminal event, resources and support should be directed at preventing further fractures in this high risk population. As patients live longer and health care and the treatment of neck of femur fractures improves it is likely that the incidence of further fractures will rise. We believe our results will be useful for all departments treating neck of femur fractures

Aims

The aims of this study were to investigate the mortality following a proximal humeral fracture. Data from a large population-based fracture register were used to quantify 30-day, 90-day, and one-year mortality rates after a proximal humeral fracture. Associations between the risk of mortality and the type of fracture and its treatment were assessed, and mortality rates were compared between patients who sustained a fracture and the general population.

Aims

Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery.

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In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries.

Aims

To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients.

This study describes the epidemiology and outcome of 637 proximal humeral fractures in 629 elderly (≥ 65 years old) patients. Most were either minimally displaced (n = 278, 44%) or two-part fractures (n = 250, 39%) that predominantly occurred in women (n = 525, 82%) after a simple fall (n = 604, 95%), who lived independently in their own home (n = 560, 88%), and one in ten sustained a concomitant fracture (n = 76, 11.9%). The rate of mortality at one year was 10%, with the only independent predictor of survival being whether the patient lived in their own home (p = 0.025). Many factors associated with the patient’s social independence significantly influenced the age and gender adjusted Constant score one year after the fracture. More than a quarter of the patients had a poor functional outcome, with those patients not living in their own home (p = 0.04), participating in recreational activities (p = 0.01), able to perform their own shopping (p < 0.001), or able to dress themselves (p = 0.02) being at a significantly increased risk of a poor outcome, which was independent of the severity of the fracture (p = 0.001).

A poor functional outcome after a proximal humeral fracture is not independently influenced by age in the elderly, and factors associated with social independence are more predictive of outcome.

Cite this article: Bone Joint J 2014;96-B:970–7.

Paediatric fractures are common and can cause significant morbidity. Socioeconomic deprivation is associated with an increased incidence of fractures in both adults and children, but little is known about the epidemiology of paediatric fractures. In this study we investigated the effect of social deprivation on the epidemiology of paediatric fractures.

We compiled a prospective database of all fractures in children aged < 16 years presenting to the study centre. Demographics, type of fracture, mode of injury and postcode were recorded. Socioeconomic status quintiles were assigned for each child using the Scottish Index for Multiple Deprivation (SIMD).

We found a correlation between increasing deprivation and the incidence of fractures (r = 1.00, p < 0.001). In the most deprived group the incidence was 2420/100 000/yr, which diminished to 1775/100 000/yr in the least deprived group.

The most deprived children were more likely to suffer a fracture as a result of a fall (odds ratio (OR) = 1.5, p < 0.0001), blunt trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7, p < 0.0001) than the least deprived.

These findings have important implications for public health and preventative measures.

Cite this article: Bone Joint J 2015;97-B:240–5.

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Cite this article: Bone Joint J 2013;95-B:583–97.

In patients with traumatic brain injury and fractures of long bones, it is often clinically observed that the rate of bone healing and extent of callus formation are increased. However, the evidence has been unconvincing and an association between such an injury and enhanced fracture healing remains unclear. We performed a retrospective cohort study of 74 young adult patients with a mean age of 24.2 years (16 to 40) who sustained a femoral shaft fracture (AO/OTA type 32A or 32B) with or without a brain injury. All the fractures were treated with closed intramedullary nailing. The main outcome measures included the time required for bridging callus formation (BCF) and the mean callus thickness (MCT) at the final follow-up. Comparative analyses were made between the 20 patients with a brain injury and the 54 without brain injury. Subgroup comparisons were performed among the patients with a brain injury in terms of the severity of head injury, the types of intracranial haemorrhage and gender. Patients with a brain injury had an earlier appearance of BCF (p < 0.001) and a greater final MCT value (p < 0.001) than those without. There were no significant differences with respect to the time required for BCF and final MCT values in terms of the severity of head injury (p = 0.521 and p = 0.153, respectively), the types of intracranial haemorrhage (p = 0.308 and p = 0.189, respectively) and gender (p = 0.383 and p = 0.662, respectively).

These results confirm that an injury to the brain may be associated with accelerated fracture healing and enhanced callus formation. However, the severity of the injury to the brain, the type of intracranial haemorrhage and gender were not statistically significant factors in predicting the rate of bone healing and extent of final callus formation.

There have been many advances in the resuscitation and early management of patients with severe injuries during the last decade. These have come about as a result of the reorganisation of civilian trauma services in countries such as Germany, Australia and the United States, where the development of trauma systems has allowed a concentration of expertise and research. The continuing conflicts in the Middle East have also generated a significant increase in expertise in the management of severe injuries, and soldiers now survive injuries that would have been fatal in previous wars. This military experience is being translated into civilian practice.

The aim of this paper is to give orthopaedic surgeons a practical, evidence-based guide to the current management of patients with severe, multiple injuries. It must be emphasised that this depends upon the expertise, experience and facilities available within the local health-care system, and that the proposed guidelines will inevitably have to be adapted to suit the local resources.