A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion. Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed.Objectives
Methods
The August 2015 Shoulder &
Elbow Roundup360 looks at: Clavicular fractures are being fixed – but how?;
We retrospectively reviewed 89 consecutive patients
(45 men and 44 women) with a mean age at the time of injury of 58
years (18 to 97) who had undergone external fixation after sustaining
a unilateral fracture of the distal humerus. Our objectives were
to determine the incidence of heterotopic ossification (HO); identify
risk factors associated with the development of HO; and characterise
the location, severity and resultant functional impairment attributable
to the presence of HO. HO was identified in 37 elbows (42%), mostly around the humerus
and along the course of the medial collateral ligament. HO was hazy
immature in five elbows (13.5%), mature discrete in 20 (54%), extensive
mature in 10 (27%), and complete bone bridges were present in two
elbows (5.5%). Mild functional impairment occurred in eight patients,
moderate in 27 and severe in two. HO was associated with less extension
(p = 0.032) and less overall flexion-to-extension movement (p =
0.022); the flexion-to-extension arc was <
100º in 21 elbows
(57%) with HO compared with 18 elbows (35%) without HO (p = 0.03).
HO was removed surgically in seven elbows. The development of HO was significantly associated with sustaining
a head injury (p = 0.015), delayed internal fixation (p = 0.027),
the method of fracture fixation (p = 0.039) and the use of bone
graft or substitute (p = 0.02).HO continues to be a substantial
complication after internal fixation for distal humerus fractures. Cite this article:
Flail chest from a blunt injury to the thorax is associated with
significant morbidity and mortality. Its management globally is
predominantly non-operative; however, there are an increasing number
of centres which undertake surgical stabilisation. The aim of this
meta-analysis was to compare the efficacy of this approach with
that of non-operative management. A systematic search of the literature was carried out to identify
randomised controlled trials (RCTs) which compared the clinical
outcome of patients with a traumatic flail chest treated by surgical
stabilisation of any kind with that of non-operative management.Aims
Patients and Methods
Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck. The trial manual illustrated the Neer classification of proximal humeral fractures. However, in addition to surgical neck displacement, surgeons assessing patient eligibility reported on whether either or both of the tuberosities were involved. Anonymised electronic versions of baseline radiographs were sought for all 250 trial participants. A protocol, data collection tool and training presentation were developed and tested in a pilot study. These were then used in a formal assessment and classification of the trial fractures by two independent senior orthopaedic shoulder trauma surgeons.Objectives
Methods
This article presents a unified clinical theory
that links established facts about the physiology of bone and homeostasis,
with those involved in the healing of fractures and the development
of nonunion. The key to this theory is the concept that the tissue
that forms in and around a fracture should be considered a specific
functional entity. This ‘bone-healing unit’ produces a physiological
response to its biological and mechanical environment, which leads
to the normal healing of bone. This tissue responds to mechanical
forces and functions according to Wolff’s law, Perren’s strain theory
and Frost’s concept of the “mechanostat”. In response to the local
mechanical environment, the bone-healing unit normally changes with
time, producing different tissues that can tolerate various levels
of strain. The normal result is the formation of bone that bridges
the fracture – healing by callus. Nonunion occurs when the bone-healing
unit fails either due to mechanical or biological problems or a
combination of both. In clinical practice, the majority of nonunions
are due to mechanical problems with instability, resulting in too
much strain at the fracture site. In most nonunions, there is an
intact bone-healing unit. We suggest that this maintains its biological
potential to heal, but fails to function due to the mechanical conditions.
The theory predicts the healing pattern of multifragmentary fractures
and the observed morphological characteristics of different nonunions.
It suggests that the majority of nonunions will heal if the correct
mechanical environment is produced by surgery, without the need
for biological adjuncts such as autologous bone graft. Cite this article:
External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF). A fracture gap model was created to simulate comminuted mid-shaft tibia fractures using synthetic composite bones. Fifteen constructs were stabilised with ET-LCP, ESS-LCP or UEF (five constructs each). The constructs were loaded under both axial and torsional directions to determine construct stiffness.Objectives
Methods
The management of children’s fractures has evolved
as a result of better health education, changes in lifestyle, improved
implant technology and the changing expectations of society. This
review focuses on the changes seen in paediatric fractures, including
epidemiology, the increasing problems of obesity, the mechanisms
of injury, non-accidental injuries and litigation. We also examine
the changes in the management of fractures at three specific sites:
the supracondylar humerus, femoral shaft and forearm. There has
been an increasing trend towards surgical stabilisation of these
fractures. The reasons for this are multifactorial, including societal
expectations of a perfect result and reduced hospital stay. Reduced hospital
stay is beneficial to the social, educational and psychological
needs of the child and beneficial to society as a whole, due to
reduced costs. Cite this article:
The December 2014 Trauma Roundup360 looks at: infection and temporising external fixation; Vitamin C in distal radial fractures; DRAFFT: Cheap and cheerful Kirschner wires win out; femoral neck fractures not as stable as they might be; displaced sacral fractures give high morbidity and mortality; sanders and calcaneal fractures: a 20-year experience; bleeding and pelvic fractures; optimising timing for acetabular fractures; and tibial plateau fractures.
Free vascularised fibular grafting has been used for the treatment
of large bony defects for more than 40 years. However, there is
little information about the risk factors for failure and whether
newer locking techniques of fixation improve the rates of union.
The purpose of this study was to compare the rates of union of free
fibular grafts fixed with locking and traditional techniques, and
to quantify the risk factors for nonunion and failure. A retrospective review involved 134 consecutive procedures over
a period of 20 years. Of these, 25 were excluded leaving 109 patients
in the study. There were 66 men and 43 women, with a mean age of
33 years (5 to 78). Most (62) were performed for oncological indications,
and the most common site (52) was the lower limb. Rate of union
was estimated using the Kaplan-Meier method and risk factors for
nonunion were assessed using Cox regression. All patients were followed
up for at least one year.Aims
Patients and Methods
Total wrist arthrodesis (TWA) produces a spectrum of outcomes.
We investigated this by reviewing 77 consecutive TWA performed for
inflammatory and post-traumatic arthropathies, wrist instability
and as a salvage procedure. All operations were performed by a single surgeon using a specifically
designed pre-contoured dorsally applied non-locking wrist arthrodesis
plate at a single centre. Aims
Patients and Methods
The August 2014 Trauma Roundup360 looks at: On-table CT for calcaneal fractures; timing of femoral fracture surgery and outcomes; salvage arthroplasty for failed internal fixation of the femoral neck; screw insertion in osteoporotic bone; fibular intramedullary nailing on the ascendant; posterior wall acetabular fractures not all that innocent; bugs, plating and resistance and improving outcomes in olecranon tension band wiring.
The February 2015 Shoulder &
Elbow Roundup360 looks at: Proximal Humerus fractures a comprehensive review, Predicting complications in shoulder ORIF, The Coronoid Revisited, Remplissage and bankart repair for Hill-Sach’s lesions, Diabetes and elbow arthroplasty, Salvage surgery for failed bankart repair, Sternoclavicular Joint Reconstruction, Steroids effective in the short-term for tennis elbow
Small animal models of fracture repair primarily investigate
indirect fracture healing via external callus formation. We present
the first described rat model of direct fracture healing. A rat tibial osteotomy was created and fixed with compression
plating similar to that used in patients. The procedure was evaluated
in 15 cadaver rats and then Objectives
Methods
