Evidence that L5 transverse process fracture indicates pelvic instability is insufficient and controversial. Because of unstable pelvis fractures have high mortality rate, they require urgent treatment and good follow-up. The lumbar region is also affected by high-energy traumas in the pelvis region, which causes damage to the muscles and ligamentous structures that adhere to the lumbar transverse process. For this reason, L5 transverse process fracture is thought to be an indicator showing pelvic instability. However, our study shows that this is not like that. This study was carried out in order to investigate the effect of L5 transvers process fracture on pelvic instability and lack of sufficient data in the literature. Between 2017–2020, 86 Patient who were hospitalized and treated with a diagnosis of pelvic fracture were retrospectively studied in our clinic. Pelvic X-Ray and tomography was taken pre-op for all patient. Demographic features, pre-op and post-op hemoglobin counts, how many units of blood transfusion needed in total, fixation method, surgical intervention, presence of additional injury, mechanism of injury for all patient were analyzed and the patients were categorized by investigating L5 transvers process fracture in their tomography. Fractures of patients were classified according toTyle classification. The patients were divided into two main groups as who stabil and unstabil pelvic fractures and L5 transvers process fracture and without. On stabil pelvic fractures and unstabil pelvic fractures, in term of instability effects of L5 transvers process fractures and those without were investigated. Also, changes in preop and post op hemoglaobin counts were investigated in pelvis with and without L5 transvers process fractures. With these, in terms of blood transfusion need the patients were evaluated whether there was a difference between those with L5 transvers process fractures and who did not. Again, whether the blood transfusion was statistically different in stable and unstable pelvis fractures was among the parameters looked at. In statistical analysis, no correlation was found between pelvic instability and L5 transvers process fracture. (p=0,933) No statistically significant difference was found in the evalution of blood transfusion between those with and without L5 transvers process fractures. (P=0,409)When the same parameter was evaluated in terms of stability and instability of the pelvis, it was seen that stability did not significantly affect the need for blood transfusion. (P=0,989) Pre-op and post-op hemoglobin changes of the patients who with L5 transvers process fracture and without were also analized. İn the analysis performed, there was no significant difference in patients with and without L5 transvers process fractures on pre-op and post-op hemoglobin values. (p=0.771/p=0.118)However, Postoperative hemoglobin values were significanly lower in patient with L5 transvers process fracture compared to preopetative hemoglobin values. (p=0.001). L5 transvers process fracture is not a parameter to showing pelvic instability. Stabil and unstabil fractures did not change the need for blood transfusion. The literatüre still needs much more study on this topic

Using an osteotomy of the olecranon as a model of a transverse fracture in 22 cadaver elbows we determined the ability of three different types of suture and stainless steel wire to maintain reduction when using a tension-band technique to stabilise the bone. Physiological cyclical loading simulating passive elbow movement (15 N) and using the arms to push up from a chair (450 N) were applied using an Instron materials testing machine whilst monitoring the osteotomy site with a video extensometer. Each osteotomy was repaired by one of four materials, namely, Stainless Steel Wire (7), No 2 Ethibond (3), No 5 Ethibond (5), or No 2 FiberWire (7). There were no failures (movement of > 2 mm) with stainless steel wire or FiberWire and no significant difference in the movements measured across the site of the osteotomy (p = 0.99). The No. 2 Ethibond failed at 450 N and two of the five of No. 5 Ethibond sutures had a separation of > 2 mm at 450 N. FiberWire as the tension band in this model held the reduction as effectively as stainless steel wire and may reduce the incidence of discomfort from the hardware. On the basis of our findings we suggest that a clinical trial should be undertaken

Weber A fractures are a sub-group of ankle fractures parallel or distal to the joint line, below the level of the syndesmosis. Most stable Weber A fractures are managed conservatively with no significant difference in outcome vs. surgical intervention. 1,2. In an effort to ensure staff time was being used as efficiently as possible, a consultant-led virtual fracture clinic (VFC) was introduced to manage Weber A fractures. Patients not requiring immediate surgery were reviewed remotely and, wherever possible, were ‘virtually discharged’ to a nurse-led telephone line. Those with diagnostic uncertainty, unusual features or delayed recovery received a face to face review from a nurse or surgeon. To examine how patients were allocated under this protocol, along with overall patient satisfaction and functional outcome. An audit of satisfaction and outcome was performed of all patients who presented with a Weber A fracture to the ED between October 2011 and October 2012. The minimum follow-up period was two years. A satisfaction and patient reported outcome (5-level-likert-scale, EQ-5D, MOXFQ) measure was conducted via telephone. 3,4. After exclusions, 79 patients were left, of which 63 were successfully contacted (80%). Of the 79 patients included, 33 (42%) required early face-to-face review while 46 (58%) were discharged with advice following discussion at the VFC. Of the 63 successfully contacted, receipt of the information leaflet was recalled by 61 (97%) and 54 (86%) were satisfied with the information they had received. There was no difference in patient satisfaction regarding recovery (p=0.079) or treatment information (p=0.236) provided between avulsion and transverse fractures or in functional outcome according to MOXFQ (p=0.626) or EQ-Vas (p=0.915) scores. Patient satisfaction can remain high without face-to-face consultations following injury. This was demonstrated by the high satisfaction with recovery (83%) and with information provided (86%) and is consistent with current published literature and similar to what would have been achieved with traditional fracture clinic review. 5. The new protocol reduces unnecessary hospital attendances for patients and reduces the burden of unnecessary review in orthopaedic departments. Only 15% of patients required review at a traditional fracture clinic and 27% at a nurse-led clinic, freeing resources for more complex cases

The patella is an important component of the extensor mechanism of the knee. Patellar fractures need to be fixed if displacement occurs more than 2 mm. Transverse fractures comprise the largest category. Several different techniques for internal fixation have been employed. The aim of this work was to evaluate the results of treatment of transverse patellar fractures with figure of eight wiring through cannulated screws. Twenty patients were included in the study, all suffering from displaced transverse patellar fractures. All were treated by open reduction and internal fixation with figure of eight tension band wire through 4.0 mm cannulated screws. All patients were assessed after 1 month, 3 months and 6 months according to a modified Hospital for special surgery (HSS) knee scoring system. Because varus and valgus knee alignment and stability are not affected by patellar fracture fixation, the ten points assigned to these functions are eliminated, making the highest score ninety points. Excellent results are considered with points from 75 to 90, good from 60 to 74, fair from 50 to 59 and poor with points below 50. The final results of the study showed fourteen patients (70%) had excellent results, five (25%) good result, one (5%) fair result and no patient had a poor result. There was a statistically significant improvement of the patients' score throughout the follow up period. The complications occurred included knee pain in one patient (5%), loss of terminal flexion of knee occurred in three patients (15%), one patient lost 30 degrees, another lost 20 degrees while the last lost 10 degrees. There were no cases with extension lag in this series. Treatment of patellar fractures using figure of eight wiring through cannulated screws is an easy technique which gives good stability leading to good results with a low complication rate

Summary Statement. The Dkk3-derived cells represent a branch of the periosteal mesenchymal lineage that produces fibrocartilage as well as regenerating the periosteal structures. Introduction. Mesenchymal progenitor cells are capable of generating a wide variety of mature cells that constitute the connective tissue system. Our Laboratory has been developing SMAA GFP reporter mice to prove to be an effective tool for identifying these cells prior to the expression of markers of differentiation characteristic of bone, fat, muscular blood vessels or fibrocartilage. Dkk3 was chosen as a candidate reporter because microarray of SMAA-sorted cells culture indicated high expression of this non-canonical anti-Wnt factor, which was not anticipated in a culture with strong osteogenic potential. Material and Methods. Fracture healing process was evaluated in 12 week old male mice at 3, 5, 7, 14, 21 and 28days post fracture. A 3 color reporter mouse was generated by crossing SMAA-GFPcherry × Col3.6GFPcyan × Dkk3-eGFP and subjected to tibial fracture. A closed transverse fracture was performed by Einhorn device under isoflurane anesthesia after insertion of intramedullary pinning. Longitudinal 5 mm non-calcified cryosections were stabilised with Cryofilm tape. Results. Three days post fracture, the proliferating SMAA-red cells were also beginning to express either Dkk3 or Col3.6. By day 5 the two populations had diverged with the Dkk3 cells being on the outer surface of the developing callus while the Col3.6 cells were forming bone at the base of the callus. By day 7 when the callus is filled with cartilage, Dkk3 is active in cells that are in transition from elongated cells on the external surface of the callus to fibrocartilagenous cells that now express low levels of Col3.6. The zone of cells that express Dkk3 appear to block the passage of the surrounding vasculature into the underlying cartilage and does not deposit fibronectin. By day 14–21 when the cartilage core is resorbed, the only remaining Dkk3 is located in the newly formed periosteum external to the active endocortical bone forming activity associated with the inward remodeling of the outer cortical shell. Discussion. We interpret these findings that Dkk3 marks a non-osteogenic limb of the SMAA progenitor population that within the fracture partitions the osteogenic signals away from the surrounding skeletal muscle and the underlying differentiating fibrocartilage. It is a progenitor to cells that form fibrocartilage in the fracture zone as well as the tenascin C positive cells that populate the fibrous zone of the periosteum, and it resides in the cambial zone of the periosteum. Knowing the biological and molecular function of these cells should lead to a fuller appreciation of the pro- and anti-osteogenic factors that regulate skeletal repair

Periprosthetic femoral fractures can occur as a complication of total hip arthroplasty and are often challenging to treat as the mechanical scenario is influenced by the presence of the metal prosthesis within the bone. This research focuses on finding the optimum fixation for transverse, Vancouver type B1 periprosthetic fractures, stabilised using locking plates and secured using screws. The aim of this study was to experimentally validate a computer model of a human femur, develop that model to represent a periprosthetic femoral fracture fixation and show how the model could be used to indicate differences between plating techniques. In the first development stage, both a laboratory model and a finite element model were developed to evaluate the mechanical behaviour of an intact composite femur under axial loading. Axial strains were recorded along the medial length of the femur in both cases and compared to provide validation for the computational model predications. The computational intact femur model was then modified to include a cemented total hip replacement, and further adapted to include a periprosthetic fracture stabilised using a locking plate, with unicortical screws above, and bicortical screws below the transverse fracture. For the intact femur case, the experimental and computational strain patterns correlated well with an average difference of 16%. Following the inclusion of the stem, there was a reduction in the strain in the region of the prosthesis reducing by an average of 45%. There was also a large increase in bulk stiffness with the introduction of the prosthesis. When the fracture and plate fixation were included, there was little difference in the proximal strain where the stem dominated, and the strains in the distal region were found to be highly sensitive to the distribution of the screws. The results of this study indicate that screw configuration is an important factor in periprosthetic fracture fixation. A laboratory model of the periprosthetic facture case is now under development to further validate the computational models and the two approaches will then be used to determine optimum fixation methods for a range of clinical scenarios

Summary. We compare the difference in expression profiles of miRNAs during fracture healing between adult and aged female mice. This study reveals the possibility to improve impaired fracture healing in aged females by regulating key miRNAs at early stage. Introduction. Impaired fracture healing in aged female skeleton is still a clinical challenge (Holroyd et al., Best Pract Res Clin Endocrinol Metab, 2008, Virk, Lieberman, Arthritis Res Ther, 2012). Angiogenesis and osteogenesis are the two key stages during fracture healing, which are impaired in aged female (Naik et al., J Bone Miner Res, 2009). MicroRNAs (miRNAs) are key post-transcriptional non-coding regulators of gene expression, which has demonstrated important roles in angiogenesis and osteogenesis (Bae et al., Hum Mol Genet, 2012, Plummer et al., Cancer Res, 2013). Understanding how non-coding regulatory RNA in fracture healing changes with age will help identifying novel therapeutic targets that can be exploited to improve fracture healing in the aged females. Materials and methods. Bilateral femur transverse fractures were created in 9 female 12-month-old mice (Aged Group) and 9 female 12-week-old mice (Adult Group). Three mice in each group were sacrificed at 0, 2 and 4 weeks post fracture, respectively. Total RNA was extracted and hybridised on Agilent 8×60K Mouse miRNA Microarray. Then, differentially expressed miRNAs were identified in adult and aged female fracture mice, respectively (2-vs-0 weeks, 4-vs-0 weeks, P-value <= 0.05 & Fold change >=2.0). With the experimentally validated interactions among miRNAs and their targets, we constructed fracture-healing-related molecular network. Thereafter, we performed topological and dynamic network analysis to find key hub miRNAs in female fracture healing. Person correlation coefficient (r) analysis was performed on the expression data of the miRNAs in all the 18 mice to identify co-expression modules in the female fracture healing progress. Meanwhile, in order to analyze the angiogenesis in the early stage and osteogenesis in the later stage of female fracture healing, we performed microCT-based angiography at 2 weeks post fracture and micro-CT examination at 4 weeks post fracture on the right femur callus samples. Results & Discussion. Angiography showed smaller blood vessel volume in aged mice at early stage when compared to that in the adult mice. Reconstructed calluses showed lower bridging mineralization tissues within the gap in aged mice than that in the adult mice at the later stage. We found that the top hub miRNAs were differentially expressed in adult female mice but not in aged ones during fracture healing. Moreover, the differential expression of the top hub miRNAs was only observed at early stage (2 weeks) during fracture healing in adult female mice. This may help explain the difference of fracture healing between adult and aged female mice. It also indicated the molecular events controlled by the hub miRNAs in early stage could lead to the following differences between the adult and aged female mice at 4 weeks. The person correlation coefficient analysis revealed that there were five co-expression miRNA modules (r>0.8) participated in female fracture healing. The top hub miRNAs in fracture-healing-related molecular network were all included in the two largest modules. These results implied the possibility to improve the aged female fracture healing by regulating key miRNAs at early stage

Rib fractures (RF) represent the most common bone fracture after blunt trauma, occurring in 10–20% of all trauma patients and leading to concomitant injuries of the inner organs in severe cases. However, a standardized classification system for serial rib fractures (SRF) does still not exist. Basic knowledge about the facture pattern of SRF would help to predict organ damage, support forensic medical examinations, and provide data for in vitro and in silico studies regarding the thoracic stability. The purpose of our study was therefore to identify specific SRF patterns after blunt chest trauma. All SRF cases (≥3 subsequent RF) between mid-2008 and end of 2015 were extracted from the CT database of our University Hospital (n=383). Fractures were assigned to anterior, antero-lateral, lateral, postero-lateral, and posterior location within the transverse plane (36° each) using an angular measuring technique (reliability ±2°). Rib level, fracture type (transverse, oblique, multifragment, infracted), as well as degree of dislocation (none, </≥ rib width) were recorded and each related to the cause of accident. In total, 3747 RF were identified (9.7 per patient, ranging from 3 (n=25) to 33 (n=1)). On average, most RF occurred in crush/burying injuries (15.9, n=13) and pedestrian accidents (12.2, n=14), least in car/truck accidents (8.8, n=76). Altogether, RF gradually increased from rib 1 (n=140) towards rib 5 (n=517) and then decreased towards rib 12 (n=49), showing a bell-shaped distribution. More RF were detected on the left thorax (n=2027) than on the right (n=1720). Overall, most RF were found in the lateral (33%) and postero-lateral (29%) segment. Posterior RF mostly occurred in the lower thorax (63%), whereas anterior (100%), antero-lateral (87%), and lateral (63%) RF mostly appeared in the upper thorax. RF were distributed symmetrically to the sagittal plane, showing a hotspot (up to 98 RF) at rib levels 4 to 7 in the lateral segment and rib level 5 in the antero-lateral segment. In the car/truck accident group, 47% of all RF were in the lateral segment, in case of frontal collision (n=24) even 60%. Fall injuries (n=141) entailed mostly postero-lateral RF (35%). In case of falls >3 m (n=45), 48% more RF were detected on the left thorax compared to the right. CPR related SRF (n=33) showed a distinct fracture pattern, since 70% of all RF were located antero-laterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all RF were dislocated (15% ≥ rib width). SRF show distinct fracture patterns depending on the cause of accident. Additional data should be collected to confirm our results and to establish a SRF classification system

This study was designed to test the hypothesis that the sensory innervation of bone might play an important role in sensing and responding to low-intensity pulsed ultrasound and explain its effect in promoting fracture healing. In 112 rats a standardised mid-shaft tibial fracture was created, supported with an intramedullary needle and divided into four groups of 28. These either had a sciatic neurectomy or a patellar tendon resection as control, and received the ultrasound or not as a sham treatment. Fracture union, callus mineralisation and remodelling were assessed using plain radiography, peripheral quantitative computed tomography and histomorphology.

Daily ultrasound treatment significantly increased the rate of union and the volumetric bone mineral density in the fracture callus in the neurally intact rats (p = 0.025), but this stimulating effect was absent in the rats with sciatic neurectomy. Histomorphology demonstrated faster maturation of the callus in the group treated with ultrasound when compared with the control group. The results supported the hypothesis that intact innervation plays an important role in allowing low-intensity pulsed ultrasound to promote fracture healing.

The aim of this study was to validate the use of three models of fracture fixation in the assessment of technical skills. We recruited 21 subjects (six experts, seven intermediates, and eight novices) to perform three procedures: application of a dynamic compression plate on a cadaver porcine model, insertion of an unreamed tibial intramedullary nail, and application of a forearm external fixator, both on synthetic bone models. The primary outcome measures were the Objective Structural Assessment of technical skills global rating scale on video recordings of the procedures which were scored by two independent expert observers, and the hand movements of the surgeons which were analysed using the Imperial College Surgical Assessment Device.

The video scores were significantly different for the three groups in all three procedures (p < 0.05), with excellent inter-rater reliability (α = 0.88). The novice and intermediate groups specifically were significantly different in their performance with dynamic compression plate and intramedullary nails (p < 0.05). Movement analysis distinguished between the three groups in the dynamic compression plate model, but a ceiling effect was demonstrated in the intramedullary nail and external fixator procedures, where intermediates and experts performed to comparable standards (p > 0.6). A total of 85% (18 of 21) of the subjects found the dynamic compression model and 57% (12 of 21) found all the models acceptable tools of assessment.

This study has validated a low-cost, high-fidelity porcine dynamic compression plate model using video rating scores for skills assessment and movement analysis. It has also demonstrated that Synbone models for the application of and intramedullary nail and an external fixator are less sensitive and should be improved for further assessment of surgical skills in trauma. The availability of valid objective tools of assessment of surgical skills allows further studies into improving methods of training.

We studied the effect of vitamin C on fracture healing in the elderly. A total of 80 elderly Osteogenic Disorder Shionogi rats were divided into four groups with different rates of vitamin C intake. A closed bilateral fracture was made in the middle third of the femur of each rat. Five weeks after fracture the femora were analysed by mechanical and histological testing. The groups with the lower vitamin C intake demonstrated a lower mechanical resistance of the healing callus and a lower histological grade. The vitamin C levels in blood during healing correlated with the torque resistance of the callus formed (r = 0.525). Therefore, the supplementary vitamin C improved the mechanical resistance of the fracture callus in elderly rats. If these results are similar in humans, vitamin C supplementation should be recommended during fracture healing in the elderly.

The treatment of fractures of the proximal tibia is complex and makes great demands on the implants used. Our study aimed to identify what levels of primary stability could be achieved with various forms of osteosynthesis in the treatment of diaphyseal fractures of the proximal tibia. Pairs of human tibiae were investigated. An unstable fracture was simulated by creating a defect at the metaphyseal-diaphyseal junction. Six implants were tested in a uniaxial testing device (Instron) using the quasi-static and displacement-controlled modes and the force-displacement curve was recorded. The movements of each fragment and of the implant were recorded video-optically (MacReflex, Qualysis). Axial deviations were evaluated at 300 N.

The results show that the nailing systems tolerated the highest forces. The lowest axial deviations in varus and valgus were also found for the nailing systems; the highest axial deviations were recorded for the buttress plate and the less invasive stabilising system (LISS). In terms of rotational displacement the LISS was better than the buttress plate.

In summary, it was found that higher loads were better tolerated by centrally placed load carriers than by eccentrically placed ones. In the case of the latter, it appears advantageous to use additive procedures for medial buttressing in the early phase.