Aims. Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results. From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion. A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture. Cite this article: Bone Jt Open 2024;5(2):117–122

Introduction. Currently, a validate scale of ankle osteoarthritis (OA) is not available and different classifications have been used, making comparisons between studies difficult. In other joints as the hip and knee, the Kellgren-Lawrence (K&L) scale, chosen as reference by the World Health Organizations is widely used to characterize OA. It consists of a physician based assessment of 3 radiological features: osteophyte formation, joint space narrowing and bone end sclerosis described as follows: grade 0: normal joint; grade 1: minute osteophytes of doubtfull significance; grade 2: definite osteophytes; grade 3: moderate diminution of joint space; grade 4: joint space greatly impaired, subchondral sclerosis. Until now, the K&L scale has never been validated in the ankle. Our objective was to assess the usefulness of the K&L scale for the ankle joint, by determining its reliability and by comparing it to functional scores and to computerized minimal joint space width (minJSW) and sclerosis measurements. Additionally we propose an atlas of standardized radiographs for each of the K&L grades in the ankle. Methods. 73 patients 10 to 20 years post ankle ORIF were examined. Bilateral ankle radiographs were taken. Four physicians independently assessed the K&L grades and evaluated tibial and talar sclerosis on anteroposterior radiographs. Functional outcome was assessed with the AOFAS Hindfoot score. Bone density and minJSW were measured using a previously validated Ankle Image Digital Analysis software (AIDA). Results. The interobserver reliability, for the K&L stages was 0.60 (intraclass correlation coefficient) indicating moderate to good agreement. The mean AOFAS hindfoot score decreased substantially (p = 009) and linearly from 99.3 in K&L grade 0 to 79.5 points in K&L grade 4. The minJSW assessed by AIDA was similar among grades 0 to 2 (between 2 and 2.5mm), but significantly lower in grade 3 (1.8mm) and in grade 4 (1.1mm). A decreased minJSW less than 2mm, commonly used as a threshold for the assessment of hip and knee OA, was found in 77% of K&L grades 3–4 compared to 33% of grades 0–2, sensitivity 77.4% and specificity 66.7%. Physician based assessment revealed that subchondral sclerosis was present in 16% of K&L grade 1 patients, 52% of grade 2, 70% of grade 3 and 100% of grade 4 patients. No correlation could be found between physician based assessment and digital image analysis of subchondral sclerosis. Conclusions. Interobserver reliability in assessment of ankle OA using the K&L scale was similar to other previously described joints. OA progression correlated with functional diminution. Joint space narrowing assessed AIDA as well as the cut-off of 2mm correlated well with the K&L scale. Overall, we recommend the use of the K&L scale for the radiographic assessment of ankle OA

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Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery.

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This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA.

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National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD.

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The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care.

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Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria.

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The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking.

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The modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing.

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Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare surgical wait times, mortality, length of stay (LOS), and healthcare costs for similar hip fracture patients evaluated with and without preoperative echocardiograms.

The management of pelvic fractures remains a challenging problem for orthopaedic surgeons. The prompt recognition of unstable fracture patterns is important in reducing mortality and morbidity. It is perceived wisdom that a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. There is a paucity of evidence in the literature to support this belief. The aim of our study was to determine if a fracture of the transverse process of L5 was a predictor of pelvic fracture instability. The Hospital Trauma database was reviewed. Between 2006 and 2009, 65 pelvic fractures were identified. They were classified according to the Burgess and Young classification. There were 37 stable and 28 unstable fractures. 14 patients had an associated fracture of the transverse process of L5; 9 were associated with an unstable fracture pattern. The odds ratio was 3; the relative risk 1.7. A fracture of the transverse process of L5 is associated with an increased risk of pelvic fracture instability. Its presence should alert the attending physicians to the possibility of an unstable injury

The management of pelvic fractures remains a challenging problem for orthopaedic surgeons. The prompt recognition of unstable fracture patterns is important in reducing mortality and morbidity. It is perceived wisdom that a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. There is a paucity of evidence in the literature to support this belief. The aim of our study was to determine if a fracture of the transverse process of L5 was a predictor of pelvic fracture instability. The Hospital Trauma database was reviewed. Between 2006 and 2009, 65 pelvic fractures were identified. They were classified according to the Burgess and Young classification. There were 37 stable and 28 unstable fractures. 14 patients had an associated fracture of the transverse process of L5; 9 were associated with an unstable fracture pattern. The odds ratio was 3; the relative risk 1.7. A fracture of the transverse process of L5 is associated with an increased risk of pelvic fracture instability. Its presence should alert the attending physicians to the possibility of an unstable injury

The aim of this study was to produce estimates of specificity and predictive value of presenting symptoms and signs of paediatric bone cancer, a rare and frequently misdiagnosed condition, to aid clinical decision-making in primary care. A systematic literature review plus questionnaire to primary care physicians were carried out to determine frequency of bone cancer symptoms in both cancer and the benign conditions as which cancer is misdiagnosed. Literature sources – Ovid MEDLINE (1950-May 2008), EMBASE (1980-May 2008) and AMED (Allied and Alternative Medicine) (1985-May 2008). Literature review methods – We included systematic reviews, cohort studies or case series (where n ≥ 10), reporting frequency of symptoms and signs at initial presentation, as originally recorded in case notes or observed by the authors, in subjects aged 0–18 years. Disease incidence data was taken from retrospective and prospective studies from 1980 onwards which recorded incidence over a defined time period, in a large pre-defined population within Europe, North America or Australia. Questionnaire respondents – 32 general practitioners and paediatric Accident & Emergency physicians throughout Scotland and England. Positive predictive values (PPVs) for bone cancer symptoms range from 0.003 to 0.034% (percentage of children presenting with symptom who have cancer). Specificity (percentage of children without cancer who do not have the symptom) varies considerably between symptoms and ranges from 24% (tenderness) to 95% (weight loss). Specificity can be improved by looking for combinations of symptoms. Weight loss and fever are the features with both highest specificity and highest PPV. Bone cancer symptoms, even those with high specificity for cancer, have low positive predictive value. We suggest that diagnosis based on initial presentation to primary care is intrinsically difficult and that delay in diagnosis is not unreasonable if it is to make use of time as a diagnostic aid

Frail patients with neck of femur fracture often present to Accident & Emergency (A&E) with concomitant medical problems and are frequently fast-tracked to orthopaedic wards to achieve government waiting time targets. This is a second cycle of audit since 2008 examining the safety of fast-tracking following several critical incidents. Data was collected prospectively between March and June 2011 by the first on-call orthopaedic doctor. 56 patients (12 male), average age 81.2y (50–97) were fast-tracked. 52 were correctly referred as having intra/extracapsular fracture; 4 patients did not have neck of femur fracture, but did have other medical problems. On arrival to the ward, 8 patients demonstrated abnormal symptoms, signs and vital observations requiring immediate review from the receiving physicians. For the 56 patients, a total of 448 mandatory points of protocol (e.g. intravenous access) should have been addressed prior to transfer; 150 were omitted (33.5%). Vital observations of patients fast-tracked after 2100h were worse (MEWS range 0 to 11) when compared with those fast-tracked prior to 2100h (MEWS range 0 to 3). Fast-tracking is a common practice amongst many district-general and some teaching hospitals in Scotland. These data support concerns from orthopaedic surgeons and highlight the need for more complete management by A&E and, if necessary, referral to receiving medical staff prior to ward transfer. Early medical optimisation of acute and chronic comorbidities common to these patients is the main facilitator of early surgery. The evidence base demonstrates early surgery is a major variable in reducing post-operative mortality

Introduction. Viscosupplementation is used widely to provide symptomatic relief to patients with knee OA. This study aimed to compare the efficacy and safety of the standard (3×2ml) and single (1×6ml) dosing regimens of hylan G-F 20. Methods. Prospective, randomized, blinded (reviewers), comparative independent study. Inclusion criteria was OA knee pain e 60mm on a 100mm VAS; no prior intra articular (IA) injection. Patients were randomised to recieve 1 × 6mL or 3 × 2mL hylan G-F 20. Follow-up at 1, 6, 12, 26 and 52 weeks. Analgesics prohibited for 24 hours prior to follow-up assessments and NSAID_s for 26 wks. All adverse events (AE) were recorded. Primary outcome measure: Target knee pain (VAS) at 26 weeks. Secondary outcome measures included WOMAC, Oxford knee score, SF12. Results. 412 patients were randomized (1 × 6mL N=194, 3 × 2 mL N=218). There were no significant differences in age, gender or grade of OA. Injection and/or treatment-related AE (all mild/moderate) were reported in 10.5% (3 × 2 mL) and 9.1% (1 × 6 mL) of patients Significant pain reduction was observed in both groups at 26 weeks (3 × 2 mL: 50% (mean) decrease, 1 × 6mL: 45%). There were no significant differences between groups for any of the primary or secondary outcome measures at 26 weeks. Discussion and Conclusion. Single dose of 6 mL hylan G-F 20 offer comparable safety and efficacy to 3 × 2 mL at 26 weeks. It provides both the patients and physicians a choice with the potential additional benefits of reduced operational costs

Patients most at risk of osteoporosis are post-menopausal women. However, for many such women, presentation of osteoporosis is only made following their first fragility fracture. Often in the UK, osteoporosis investigation occurs following discharge, and any subsequent secondary prevention starts in the community. This may result in patients with osteoporosis not being investigated or not receiving correct prophylactic treatment. 143 post-menopausal women (av. age 77.7 years) starting secondary osteoporosis prophylaxis following fragility fractures requiring operative intervention were included in this retrospective study. Osteoporosis was defined by DEXA scan using the WHO criteria (122 hip fractures and 21 wrist fractures), following the UK's national guidelines for osteoporosis prophylaxis. Treatment was started following discussion and explanation of treatment with each patient, and either commenced by the surgical team during the acute hospital admission with the fracture, or in an out-patient setting within 6 weeks of the fracture by an orthopaedic specialist nurse. To check compliance, either the patient themselves or the patients' family physician was contacted. Results showed that 120 of the women (83.9%, 102 hip fractures, and 18 wrist fractures) were still compliant with secondary osteoporosis prophylaxis at an average follow-up of 200 days (5 hip fractures lost to follow-up, 0 wrist fractures). 12 women with hip fractures died (0 wrist fractures), and 6 women stopped taking their prophylaxis (3 hip fractures, 3 wrist fractures): 4 for medical reasons, and 2 for unknown reasons. No women sustained further fractures. Few studies have previously investigated compliance of osteoporosis secondary prevention, and our results compare favorably. We therefore recommend the prompt commencement of secondary prevention treatment by the orthopaedic surgical team following osteoporotic fractures

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Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation.

The reported results of compression fractures are poor. These results are not influenced by the severity of compression, the fracture site or the residual deformity. Otherwise, the factors that determine a patient's recovery are unknown. This study wants to identify the factors determining a patient's recovery after surgical treatment of compression fractures of the thoracolumbar spine. Therefore, in 31 surgically treated patients the pre-injury versus the 12-month follow-up differences in back pain, in global outcome and in participation were prospectively recorded. For this, the visual analogue scale for pain (VAS scale) and the Greenough and Fraser low back outcome scale were used. Of the latter scale, the 3 questions pertaining to participation were combined to create a participation subscale. For these differences and for time lost from work multiple linear regressions with combinations of 16 possible predictors were performed. At one year patients who smoke report a 25% less favorable global outcome and return 2.8 points (out of 10) less closely to their pre-injury pain level than patients who do not smoke. Patients with a fracture at the thoraco-lumbar junction return 3.3 points less closely to their pre-injury level on the VAS scale than those with a lumbar fracture. For each decrease in 1 of the 3 education levels, the patients stay away from work 15 weeks longer. Per degree of sagittal index at follow-up, patients stay 9 days longer at home. For each increase in level of occupation the return to the pre-injury participation level is 10% less favorable. The variability of time lost from work and of recovery of global outcome, pain and participation level explained by our models is 73%, 37%, 25% and 13% respectively. Smoking, localization of the fracture at the thoraco-lumbar junction and a high pre-existent level of occupation are strong negative predictors for recovery. A lower education level and sagittal fracture deformity at follow-up are negative predictors for sick leave but might also reflect the concerns of the physician when deciding about return to work

BACKGROUND CONTEXT. Osteoporosis causes decreased bone mineral density, which predisposes to fragility fractures. Low-energy vertebral compression fractures are the most common type of osteoporotic fragility fracture. Prior studies have shown that only one-quarter of patients diagnosed with an osteoporotic fracture are referred or treated for osteoporosis. PURPOSE. To identify the rate of recurrent fractures after vertebroplasty and after the conservative treatment for patients aged 50 years and older who sustained low impact vertebral compressions fractures over a 6-month period. STUDY DESIGNED/SETTING. Prospective study. PATIENT SAMPLE. The sample included patients 50 years or older who had a low-energy vertebral compression fracture. The patients were divided into two groups: first group (n=24) - patients teated by vertebroplasty and the second group (n=34) - patients treated conservatory. There was no significant difference among the groups in terms of the vertebral levels or BMD. METHODS. Patients records were reviewed for fracture recurrence and in the same time we examined medical records for osteoporotic medication prescriptions, refferals to endocrinology and to dual-energy X-ray absorptiometry (DEXA) scans. RESULTS. Confounding factors of age at the procedure, sex and chronic steroids use were considered and found to have no statistically significant difference between the two groups and between those with fracture recurrence and those without fracture recurrence. Four vertebroplasty procedure resulted in a recurrent fracture within the first 6 months. In the patient group treated conservatory 8 patients sustained recurrent fractures. Patients with recurrent vertebral fracture didn't receive active osteoporosis treatment. Within 6 months after the fracture only 21% of patients were receiving active osteoporosis treatment. CONCLUSIONS. The incidence of recurrent fracture after vertebroplasty or after conservative treatment is substantial but have no statistically significant difference between the two groups. We consider that the recurrence rate is not related with the surgical intervention but is the result of natural history of the patient's osteoporosis because the patients do not understand the importance of initiating active therapeutic intervention for osteoporosis recommended by physicians

Background. Overlooked compartment syndrome represents a devastating complication for the patient. Invasive compartment pressure measurement continues to be the gold standard. However, repeated measurements in uncertain cases may be difficult to achieve. We developed a new, noninvasive method to assess tissue firmness by pressure related ultrasound. Methods. Decreased tissue elasticity by means of rising compartment pressures was mimicked by infusion of saline directly into the anterior tibial compartment of 6 human specimens post mortem. A pressure transducer (Codman) monitored the pressure of the anterior tibial compartment. A second transducer was located in a saline filled ultrasound probe head to allow a simultaneous recording of the probe pressure provoked by the user. The ultrasound images were generated at 5 and 100mmHg probe pressures to detect the tissue deformity by B-mode ultrasound. The fascial displacement was measured before and after compression (d). Subsequently, increments of 5mmHg pressure increases were used to generate a standard curve (0–80mmHg), thus mimicking rising compartment pressures. The intra-observer reliability was tested using 10 subsequent measurements. A correlation was determined between d and the simulated intacompartmental pressure (ICP) in the compartment. The Pearson correlation coefficient (r) was calculated. The reliability determined by the kappa value and a regression analysis was performed. Results. With rising compartmental pressure, a concordant consistent correlation between d and ICP occurred. The Pearson coefficient was significant at r=0.979 and the intra-observer value kappa (k) showed a statistically good reliability (k10=0.73 and k70=0.79). Within a pressure ranging from 5–35mmHg there was an almost linear behavior, with decreasing elasticity and tissue movement in case of raising ICP. Conclusions. Pressure related ultrasound emphasized as a reliable tool to determine the correlation between the measured compartmental displacement and the raising intracompartmental pressures. This may help to improve the clinical assessment of the compartment elasticity by the physician. Further studies are required to investigate whether the good correlation also applies for the clinical scenario. However, this new method may be useful to monitor trends in the compartment pressures and may help to avoid delayed decision of fasciotomy