Background. This is a continued assessment of the effectiveness of a locked intramedullary device in the treatment of acute clavicle shaft fractures. Results of patients treated thus far were assessed, including patients reported on previously. Description of methods. Patients admitted with midshaft clavicle fractures were assessed to determine whether operative fixation of the fracture was required. Indications for surgery were midshaft clavicle fractures with 100% displacement; more than 1.5 cm of shortening, presence of a displaced butterfly segment, bilateral clavicle fractures, ipsilateral displaced glenoid neck fractures, skin and neurovascular compromise. Patients that matched the criteria for surgery were treated operatively with an intramedullary locked device by the author. Post-operatively, patients were kept in a shoulder immobilizer for a period of 6 weeks. Patients were invited to attend a scheduled follow-up visit where the data was collected that comprised the review. All patients were assessed by the surgeon, a radiologist, a physiotherapist and an occupational therapist. Scar size and quality, Dash score, Constant Shoulder score, complications and the radiological picture were assessed. Summary of results. 50 patients (52 clavicle fractures – 2 patients sustained bilateral fractures), 28 males and 22 females with a mean age of 30 attended the schedule data collection visit and were included in the study. 48 clavicles achieved complete union with the remaining 4 fractures progressing normally to union at 10 and 12 weeks post surgery. No additional complications than those reported on previously were encountered. Conclusion. Locked intramedullary fixation of clavicle shaft fractures that match the criteria for operative fixation continues to give good results. No non-unions were found and a high level of patient satisfaction was achieved. The operative technique continues to be refined leading to less fixation related complications. MULTIPLE DISCLOSURES

Background. To determine the relative contributions of bilateral versus unilateral femoral shaft fracture plus injuries in other body regions to mortality after injury. Study design. A retrospective analysis of the prospectively recorded Trauma Registry data (TARN) from 1989 to 2003. Methods. Patients were divided into groups UFi (isolated unilateral femur injury),BFi (isolated bilateral femur injury) and UFa and BFa if an associated injury was present. Data collected for each patient included age, Injury Severity Scores, Glasgow Coma Scale, mortality, physiological parameters, the timing and extent of prehospital care, the time to arrival at the hospital, initial treatments, time to and type of surgery, length of ICU and hospital stay. Logistic regression data analysis was performed to determine variables that were associated with increased mortality. Results. Patients in group BFa had a significantly higher ISS (23 vs 9),reduced GCS (12 vs 15) and increased mortality rate (31.6% vs 9.8%) than patients in group BFi. Group BFa patients had an increased number of associated injuries than group UFa. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures with associated injuries and mortality. However bilateral fracture, even in isolation significantly increased the odds of mortality by 3.07(1.36-6.92). Intramedullary nailing (IMN) was the method of fracture fixation associated with the lowest patient mortality overall. However, when assessing patient mortality in the BFa group with an ISS of more than 40, three other fracture fixation regimens were associated with a lower mortality rate than the IMN group. Conclusions. The increase in mortality with bilateral femoral fractures is more closely associated with the presence of associated injuries and poor physiological parameters than to the presence of the bilateral femoral fracture alone. However contrary to ISS scoring the latter does convey a significant additional risk of mortality. The presence of bilateral femoral fractures should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential

When fixing a mid or distal periprosthetic femoral fracture with an existing hip replacement, creation of a stress-riser is a significant concern. Our aim was to identify the degree of overlap required to minimise the risk of future fracture between plate and stem.

Each fixation scenario was tested using 4th generation composite femoral Sawbones®. Each sawbone was implanted with a collarless polished cemented stem with polymethyl methacrylate bone cement and cement restrictor. 4.5mm broad Peri-loc™ plates were positioned at positions ½, 1 and 2 shaft diameters (SD) proximal and distal to the tip of the femoral stem. Uni-axial strain gauges (medial and lateral longitudinal gauges, anterior and posterior torsional gauges) measured microstrain at tip of the femoral stem with a standard load of 500N in axial, 3-point lateral and composite torsion/posterior loading using an Instron machine.

With axial loading fixation with 2SD proximal resulted in the least amount of strain, in both tension & compression, at the tip of the femoral stem. Fixation with 4 unicortical screws was significantly better than 2 alternating unicortical screws (mean microstrain difference 3.9 to 15.3, p<0.0001). With lateral 3-point loading fixation with 2SD proximal overlap and 2 alternating unicortical screws resulted in the least amount of strain, in both tension and compression, at the tip of the femoral stem (p<0.0001). With torsion & posterior displacement 2SD proximal fixation resulted in the least amount of rotational strain. There was no significant difference between 4 unicortical screws compared to 2 alternating unicortical screws (p>0.05 in 3 of 4 gauges).

Fixation of midshaft or distal femoral fractures with a well-fixed total hip arthroplasty should have at least 2 shaft diameters of proximal overlap with a 4.5mm broad plate. It is not clear if 4 unicortical screws or 2 alternating screws are optimal.

The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions.

Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant.

11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery.

All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function.

A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems.

This study aimed to investigate the outcomes of open tibia shaft fractures at a level one trauma center in a developing world setting. Specific objectives were to determine the association of time delay to antibiotic administration, surgical debridement, definitive skeletal stabilisation and soft tissue reconstruction, and the development of fracture-related infection (FRI). A retrospective cohort study included all adult patients with open tibia shaft fractures from July 2014 to June 2016 and January 2018 to December 2019. Patients who were skeletally immature at the time of injury, those with pathological fractures and who did not complete follow-up of at least three months were excluded. Patients were identified from hospital records. Data was captured in Microsoft Excel and analysed using STATISTICA. A Chi-squared was used to detect significant differences between groups. No association between infection and antibiotic administration was observed when patients were treated within or after 3 hours (p=0.625) or if patients had their first surgical debridement in theatre before or after 24 hours (p=0.259). Patients who waited more than five days for definitive skeletal fixation or soft tissue reconstruction had a significant increase in FRI (OR 4.7, 95% CI 2.0 – 10.9 and OR 4.7, 95% CI 2.0 – 11.0, respectively). Patients who underwent more than two formal debridements had a higher risk of developing FRI (OR 15.6, 95% CI 5.8 – 41.6). Whilst administration of antibiotics within 3 hours of presentation to the emergency unit had no impact on the development of FRI, time delays in managing open tibia shaft fractures are associated with an increased risk for FRI. Definitive soft tissue reconstruction and skeletal stabilization should not be delayed for more than five days

Femoral shaft fractures are fairly common injuries in paediatric age group. The treatment protocols are clear in patients of age less than 4 years and greater than 6 years. The real dilemma lies in the age group of 4–6 years. The aim of this study is to find whether a conservative line should be followed, or a more aggressive surgical intervention can provide significantly better results in these injuries. This study was conducted in a tertiary care hospital in Bhubaneswar, India from January 2020 to March 2021. A total of 40 patients with femur shaft fractures were included and randomly divided in two treatment groups. Group A were treated with a TENS nail while group B were treated with skin traction followed by spica cast. They were regularly followed up with clinical and radiological examination to look out for signs of healing and any complications. TENS was removed at 4–9 months’ time in all Group A patients. Group A patients had a statistically significant less hospital stay, immobilisation period, time to full weight bearing and radiological union. Rotational malunions were significantly lower in Group A (p-value 0.0379) while there was no statistically significant difference in angular malunion in coronal and sagittal plane at final follow up. Complications unique to group A were skin necrosis and infection. We conclude that TENS is better modality for treatment of shaft of femur fractures in patients of 4–6 years age as they significantly reduce the hospital stay, immobilization period and rotational malalignment

The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow function for IMN and PF respectively. A prospective cohort study following up all the cases treated surgically for middle third humeral fractures from 2016 to 2022 at a single centre. Telephonically an analogue pain score, an American Shoulder and Elbow Society (ASES) score for shoulder function and the Oxford Elbow score (OES) for elbow function were obtained. One hundred and three patients met the inclusion criteria. Twenty four patients participated in the study, fifteen had IMN (62.5%) and nine had PF (37.5%.). The shoulder function outcomes showed no statistical difference with an average ASES score of sixty-six for the IMN group and sixty-nine for the PF group. Women and employed individuals expressed greater functional impairment. Hand dominance has no impact on the scores of elbow and shoulder function post operatively. The impairment of abduction score post antegrade nailing was higher in the antegrade nailing group than the plated group. The OES demonstrated greater variance in elbow function in the PF group with the IMN group expressing greater elbow disfunction. This study confirms that treatment of middle third humerus shaft fractures by plate fixation is marginally superior to antegrade intramedullary nailing in preserving elbow function and abduction ability

Delayed management of high energy femoral shaft fractures is associated with increased complication rates. It has been suggested that there is less urgency to stabilize lower energy femoral shaft fractures. The purpose of this study was to evaluate the effect of surgical delay on 30-day complications following fixation of lower energy femoral shaft fractures. Patients ≥ 18 years who underwent either plate or nail fixation of low energy (falls from standing or up to three steps' height) femoral shaft fractures from 2005 – 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) via procedural codes. Patients with pathologic fractures, fractures of the distal femur or femoral neck were excluded. Patients were categorized into early (< 2 4 hours) or delayed surgery (2–30 days) groups. Bivariate analyses were used to compare demographics and unadjusted rates of complications between groups. A multivariable logistic regression was used to compare the rate of major and minor complications between groups, while adjusting for relevant covariables. Head injury patients and polytrauma patients are not included in the NSQIP database. Of 2,716 lower energy femoral shaft fracture patients identified, 2,412 (89%) were treated within 1 day of hospital admission, while 304 (11.2%) were treated between 2 and 30 days post hospital admission. Patient age, American Society of Anesthesiologists (ASA) classification score, presence of diabetes, functional status, smoking status, and surgery type (nail vs. plate) were significantly different between groups (p After adjusting for all relevant covariables, delayed surgery significantly increased the odds of 30-day minor complications (p=0.02, OR = 1.48 95%CI 1.01–2.16), and 30-day mortality (p < 0 .001), OR = 1.31 (95%CI 1.03–2.14). The delay of surgical fixation of femoral shaft fractures appears to significantly increase patients' risk of minor adverse events as well as increase mortality. With only 89% of patients being treated in the 24 hour timeframe that constitutes best practice for treatment of femoral shaft fractures, there remains room for improvement. These results suggest that early treatment of all femoral shaft fractures, even those with a lower energy mechanism of injury, leads to improved outcomes

Māori consistently have poorer health outcomes compared to non-Māori within Aotearoa. Numerous worldwide studies demonstrate that ethnic minorities receive less analgesia for acute pain management. We aimed to compare analgesic management of a common orthopaedic injury, tibial shaft fracture, between Māori and non-Māori. A retrospective cohort study from January 1. st. , 2015, to December 31. st. 2020 inclusive. Eligible patients were 16–65 years old and had isolated closed tibial shaft fractures. 104 patients were included in the study, 48 Māori and 56 Non-Māori. Baseline demographics were similar between the 2 cohorts. The primary outcome measure was type of analgesia charted on the ward. Secondary outcome measures were pre-hospital medications given, pain scores on arrival to the emergency department (ED) and the ward, time to analgesia in ED and type of analgesia given in ED. Statistics were calculated using Fisher's exact test, Pearson's chi-squared test or Wilcoxson's rank sum test as appropriate. No statistically significant differences were found in opiates or synthetics charted to Māori vs Non-Māori (83% vs 89% and 77% vs 88% respectively), opiates given in ED, time to analgesia in ED or ED and ward arrival pain scores. Of statistical significance is that Māori were less likely to receive pre-hospital medication compared to Non-Māori (54% vs 80% respectively, p=0.004). Māori were significantly less likely to receive pre-hospital pain medication compared to Non-Māori. However no other statistically significant findings were found when comparing pain scores, time to analgesia or type of pain relief charted for Māori vs non-Māori. The reasons for Māori receiving significantly less prehospital medication were not explored in this study and further investigation is required to reduce the bias that exists in this area

Timely and competent treatment of paediatric fractures is paramount to a healthy future working population. Anecdotal evidence suggests that children travel greater distances to obtain care compared to adults causing economic and geographic inequities. This study aims to qualify the informal regionalization of children's fracture care in Ontario. The results could inform future policy on resource distribution and planning of the provincial health care system. A retrospective cohort study was conducted examining two of the most common paediatric orthopaedic traumatic injuries, femoral shaft and supracondylar humerus fractures (SCH), in parallel over the last 10 years (2010-2020) using multiple linked administrative databases housed at the Institute for Clinical Evaluative Sciences (ICES) in Toronto, Ontario. We compared the distance travelled by these pediatric cohorts to clinically equivalent adult fracture patterns (distal radius fracture (DR) and femoral shaft fracture). Patient cohorts were identified based on treatment codes and distances were calculated from a centroid of patient home forward sortation area to hospital location. Demographics, hospital type, and closest hospital to patient were also recorded. For common upper extremity fracture care, 84% of children underwent surgery at specialized centers which required significant travel (44km). Conversely, 67% of adults were treated locally, travelling a mean of 23km. Similarly, two-thirds of adult femoral shaft fractures were treated locally (mean travel distance of 30km) while most children (84%) with femoral shaft fractures travelled an average of 63km to specialized centers. Children who live in rural areas travel on average 51km more than their adult rural-residing counterparts for all fracture care. Four institutions provide over 75% of the fracture care for children, whereas 22 institutions distribute the same case volume in adults.?. Adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. There is an unplanned concentration of pediatric fracture care to specialized centers in Ontario placing undue burden on pediatric patients and inadvertently stresses the surgical resources in a small handful of hospitals. In contrast, adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. Patient care equity and appropriate resource allocation cannot be achieved without appropriate systemization of pediatric fracture care

The purpose of this project was to evaluate North American trauma surgeon preferences regarding patient positioning for antegrade fixation of mid shaft femoral shaft fractures. This project was a cross sectional survey taken of orthopaedic fellows and staff surgeons, belonging to three organizations across North America. An estimated sample size was calculated a priori, while various online techniques were utilized to reduce non responder and fatigue bias. The survey was distributed multiple times to optimize yield. Two hundred twelve (212) participants responded in full, 134 (56%) of whom practiced in Canada. The majority of surgeons worked in level one trauma centres (74%), while 72% treated more than one femoral shaft fracture per week. The most common patient position for mid shaft fixation amongst all surgeons was lateral positioning with manual traction (68%), however community surgeons were significantly more likely to use a fracture table. The most common difficulties faced with using a fracture table were inability to achieve fracture reduction and peroneal nerve palsies. The majority (64%) of surgeons quoted a complication rate with fracture tables of greater than 1 per 100 cases. Lateral position with use of manual traction is the preferred set up for antegrade fixation of femoral shaft fracture in this large North American cohort of trauma surgeons. However, a large subset of community and non academic surgeons still prefer use of the fracture table. Amongst all respondents, a high rate of fracture table complications, including malreduction, were quoted. To date, there is no prospective data comparing these two options for patient positioning, and a randomized controlled trial may be an appropriate next step

Operative management of clavicle fractures is increasingly common. In the context of explaining the risks and benefits of surgery, understanding the impact of incisional numbness as it relates to the patient experience is key to shared decision making. This study aims to determine the prevalence, extent, and recovery of sensory changes associated with supraclavicular nerve injury after open reduction and plate internal fixation of middle or lateral clavicle shaft fractures. Eighty-six patients were identified retrospectively and completed a patient experience survey assessing sensory symptoms, perceived post-operative function, and satisfaction. Correlations between demographic factors and outcomes, as well as subgroup analyses were completed to identify factors impacting patient satisfaction. Ninety percent of patients experienced sensory changes post-operatively. Numbness was the most common symptom (64%) and complete resolution occurred in 32% of patients over an average of 19 months. Patients who experienced burning were less satisfied overall with the outcome of their surgery whereas those who were informed of the risk of sensory changes pre-operatively were more satisfied overall. Post-operative sensory disturbance is common. While most patients improve, some symptoms persist in the majority of patients without significant negative effects on satisfaction. Patients should always be advised of the risk of persistent sensory alterations around the surgical site to increase the likelihood of their satisfaction post-operatively

Motorcycle accident-related traffic accidents contribute significantly to the burden of orthopaedic injuries seen in the South African Healthcare system. Subsequent to the Covid-19 pandemic, there has been an increase in the number of delivery drivers on the roads of South Africa. Many of these delivery drivers have no formal employment contracts. We aim to describe the demographics and injury patterns in motorcyclists involved in time dependent delivery work in South Africa; and to quantify the cost to the state of their orthopaedic surgeries. We performed a consecutive case series study at all of the hospitals draining the study region over the period of one year. Epidemiological, clinical and cost to hospital data was collected from medical records, digital radiographs, theatre invoices and a dedicated patient questionnaire. Provisional. So far 41 delivery drivers were captured by the study over a period of 11 months. All drivers were male and the vast majority foreign nationals. 11 patients were polytraumatised and 5 required admission to an intensive care unit. The most common injury patterns were closed femur fractures (17) followed by tibial shaft fractures (13). The average cost of surgery was R35 049 and average cost of ward stay R44 882 at an average of 10 days admission in a general ward. Overall, an estimated total of R 3.1 million rand was spent on these injuries. Informally employed “app users” performing delivery work on motorcycles in South Africa have added a significant burden to the cost of state healthcare since 2020. The vast majority of these patients are foreign nationals who do not hold South African licences or health insurance. They are sustaining high energy injuries typical of motorcycle-car accidents and many of them are left with lifelong loss of function

The purpose of this study was to determine whether there have been changes in the complexity of femoral fragility fractures presenting to our Dunedin Orthopaedic Department, New Zealand, over a period of ten years. Patients over the age of 60 presenting with femoral fragility fractures to Dunedin Hospital in 2009 −10 (335 fractures) were compared with respect to demographic data, incidence rates, fracture classification and treatment details to the period 2018-19 (311 fractures). Pathological and high velocity fractures were excluded. The gender proportion and average age (83.1 vs 83.0 years) was unchanged. The overall incidence of femoral fractures in people over 60 years in our region fell by 27% (p<0.001). Intracapsular fractures (31 B1 and B2) fell by 29% (p=0.03) and stable trochanteric fractures by 56% (p<0.001). The incidence of unstable trochanteric fractures (31A2 and 31A3) increased by 84.5% from 3.5 to 6.4/10,000 over 60 years (p = 0.04). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 8% to 37% (p <0.001). Fewer intracapsular fractures were treated by internal fixation (p<0.001) and the rate of acute total hip joint replacements increased from 13 to 21% (p=0.07). The incidence of femoral shaft fractures did not change significantly with periprosthetic fractures comprising 70% in both cohorts. While there has been little difference in the numbers there has been a decrease in the incidence of femoral fragility fractures likely due to the increasing use of bisphosphonates. However, the incidence of unstable trochanteric fractures is increasing. This has led to the increased use of IM nails which are increasingly used for stable fractures as well. The increasing complexity of femoral fragility fractures is likely to have an impact on implant use, theatre time and cost

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Introduction of the National Hip fracture database, best practice tariff and NICE guidelines has brought uniformity of care to hip fracture patients & consequently improved outcomes. Low energy femoral shaft fractures of the elderly are not within these guidelines, but represent a similar though significantly smaller patient cohort. A retrospective review was performed at Huddersfield Royal Infirmary using theatre, coding & hip fracture databases. Data was filtered to include patients ≥75, excluding non-femoral injuries. Imaging & notes were then reviewed confirming femoral shaft fractures; excluding open, peri-prosthetic & high energy fractures. Between September 2008 and July 2016 24 patients were identified and split into two equal cohorts, before June 2011 NICE Guidelines and after. The groups were equal in terms of age (Mean: 85.25:84.67, P=0.) & sex (12 females Pre-NICE, 9 Post-Nice, P= 0.22). Our main outcome measures of length of stay were 31.89 days:26 days (p=0.38), time to surgery was 29.8hours: 28.4 hours (p=0.8) and 1-year survival rate conditional odds ratio of 1.48 (p=1.00). A secondary measure demonstrated a significantly higher proportion of post-NICE patients receiving surgery after midday 5/12:11/12 (P= 0.03). The infrequency of low energy femoral shaft fractures makes them difficult to study and production of an adequately powered study in a single centre impossible. The authors hope this work can inspire discussion and a coordinated multicentre approach to answer this question. These patients could easily be treated with the same level of enthusiasm as hip fractures

Introduction. Fracture related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and healthcare costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications. Materials and Methods. 56 adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (FRI, non-union surgery and re-fracture) with a mean of 3 prior surgical interventions. 51 patients had an open fracture as their index injury. We report on patient characteristics and outcomes including radiological/clinical union and deep infection. The one-year minimum follow-up rate was 87.5%. Results. One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the 5 patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring further treatment. Conclusions. Use of the ETN PROtect® nail in high-risk patients in the acute trauma setting demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost

Abstract. Background. With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods. A retrospective cohort analysis of 58 patients. 34 SP tibial nails over 3 years versus 24 IP tibial nails over a similar time frame. We compared; radiation exposure, patient positioning time (PPT), non-union rate and follow-up time. Knee pain in the SP group was evaluated, utilising the Hospital for Special Surgery (HSS) Knee injury and Osteoarthritis outcome score (KOOS). Results. 58 patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78cGy (range 11.60 to 156.01cGy) vs 121.09cGy (range 58.01 to 18.03cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow-up was 5.5 months vs 11 months in the SP and IP group respectively. Mean KOOS was 7 (range 0 to 22) at 6 months for the SP group. Conclusion. The semi extended position (SP group) leads to reduced radiation exposure because of ease of imaging. All Patients in the SP group showed improved outcomes, with shorter follow-up and fracture union. The KOOS revealed SP nail patients had minimal pain and good knee function. This study establishes a management and PROMs baseline for ongoing evaluation of SP nails

Introduction:. Displaced and shortened clavicle shaft fractures can be treated operatively by intra- or extramedullary fixation. The aim of the study was to compare the effectiveness of these two treatment modalities. Methods:. Forty seven patients with acute displaced and shortened clavicle shaft fractures were randomly assigned to either an intramedullary locked fixation group or an anatomically contoured locked plating group. All patients were operated by the same surgeon and had identical post-operative treatment regimes. The effectiveness of both treatment regimens were assessed based on; incision length, operative time and union rate. Disabilities of the Arm, Shoulder and Hand Score (DASH) and Constant Shoulder Score were assessed one year post-operatively. Results:. Twenty-five patients were included in the plating group and twenty-two in the intramedullary fixation group. No differences between the two groups were found for age, gender, fracture comminution and/or displacement. Incision size was significantly (p<0.0001) smaller in the nailing group (38±9 mm) than in the plating group (118±19 mm). In line with this the operating time was also shorter in the nailing group than in the plating groups (43±8 min and 60±19 min, respectively (p=0.0029)). One year postoperatively a 100% union rate was achieved in both groups. Lower DASH scores (2±5 vs 16±18 (p=0.0071)) and higher Constant Shoulder scores (96±6 vs. 90 ± 18 (p=0.0122)), were found in the nailing group. Conclusion:. Both anatomically contoured locked plating and locked intramedullary fixation resulted in successful treatment of displaced and shortened clavicle shaft fractures. Intramedullary fixation however was associated with shorter operating times and smaller incision sizes. In addition, better DASH and Constant Shoulder scores were found in the nailing group one year post operatively. Based on these finding and the absence of prominent subcutaneous hardware necessitating removal of the nail, the intramedullary device is a good alternative to treat displaced clavicle shaft fractures