The June 2014 Trauma Roundup³⁶⁰ looks at: BMP use increasing wound complication rates in trauma surgery; can we predict re-admission in trauma?; humeral bundle nailing; how best to treat high-angle femoral neck fractures?; hyperglycaemia and infection; simultaneous soft-tissue and bony repair in terrible triad injuries; metaphyseal malunion in the forearm leading to function restrictions; delayed fixation of the distal radius: not a bad option; and fasciotomies better with shoelaces

High-quality randomised controlled trials (RCTs) evaluating surgical therapies are fundamental to the delivery of evidence-based orthopaedics. Orthopaedic clinical trials have unique challenges; however, when these challenges are overcome, evidence from trials can be definitive in its impact on surgical practice. In this review, we highlight several issues that pose potential challenges to orthopaedic investigators aiming to perform surgical randomised controlled trials. We begin with a discussion on trial design issues, including the ethics of sham surgery, the importance of sample size, the need for patient-important outcomes, and overcoming expertise bias. We then explore features surrounding the execution of surgical randomised trials, including ethics review boards, the importance of organisational frameworks, and obtaining adequate funding.

Cite this article: Bone Joint Res 2014;3:161–8.

In light of the growing number of elderly osteopenic patients with distal humeral fractures, we discuss the history of their management and current trends. Under most circumstances operative fixation and early mobilisation is the treatment of choice, as it gives the best results. The relative indications for and results of total elbow replacement versus internal fixation are discussed.

We investigated whether, in the management of stable paediatric fractures of the forearm, flexible casts that can be removed at home are as clinically effective, cost-effective and acceptable to both patient and parent as management using a cast conventionally removed in hospital. A single-centre randomised controlled trial was performed on 317 children with a mean age of 9.3 years (2 to 16). No significant differences were seen in the change in Childhood Health Assessment Questionnaire index score (p = 0.10) or EuroQol 5-Dimensions domain scores between the two groups one week after removal of the cast or the absolute scores at six months. There was a significantly lower overall median treatment cost in the group whose casts were removed at home (£150.88 (sem 1.90) vs £251.62 (sem 2.68); p <  0.001). No difference was seen in satisfaction between the two groups (p = 0.48).

Cite this article: Bone Joint J 2013;95-B:1714–20.

Blast and ballistic weapons used on the battlefield cause devastating injuries rarely seen outside armed conflict. These extremely high-energy injuries predominantly affect the limbs and are usually heavily contaminated with soil, foliage, clothing and even tissue from other casualties. Once life-threatening haemorrhage has been addressed, the military surgeon’s priority is to control infection.

Combining historical knowledge from previous conflicts with more recent experience has resulted in a systematic approach to these injuries. Urgent debridement of necrotic and severely contaminated tissue, irrigation and local and systemic antibiotics are the basis of management. These principles have resulted in successful healing of previously unsurvivable wounds. Healthy tissue must be retained for future reconstruction, vulnerable but viable tissue protected to allow survival and avascular tissue removed with all contamination.

While recent technological and scientific advances have offered some advantages, they must be judged in the context of a hard-won historical knowledge of these wounds. This approach is applicable to comparable civilian injury patterns. One of the few potential benefits of war is the associated improvement in our understanding of treating the severely injured; for this positive effect to be realised these experiences must be shared.

The December 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: Long term-changes in hip morphology following osteotomy; Arthrogrypotic wrist contractures are surgically amenable; Paediatric femoral lengthening over a nail; Current management of paediatric supracondylar fractures; MRI perfusion index predictive of Perthes’ progression; Abduction bracing effective in residual acetabular deformity; Hurler syndrome in the spotlight; and the Pavlik works for femoral fractures too!

Bicondylar tibial plateau fractures result from high-energy injuries. Fractures of the tibial plateau can involve the tibial tubercle, which represents a disruption to the extensor mechanism and logically must be stabilised. The purpose of this study was to identify the incidence of an independent tibial tubercle fracture in bicondylar tibial plateau fractures, and to report management strategies and potential complications. We retrospectively reviewed a prospectively collected orthopaedic trauma database for the period January 2003 to December 2008, and identified 392 bicondylar fractures of the tibial plateau, in which 85 tibial tubercle fractures (21.6%) were identified in 84 patients. There were 60 men and 24 women in our study group, with a mean age of 45.4 years (18 to 71). In 84 fractures open reduction and internal fixation was undertaken, either with screws alone (23 patients) or with a plate and screws (61 patients). The remaining patient was treated non-operatively. In all, 52 fractures were available for clinical and radiological assessment at a mean follow-up of 58.5 weeks (24 to 94). All fractures of the tibial tubercle united, but 24 of 54 fractures (46%) required a secondary procedure for their tibial plateau fracture. Four patients reported pain arising from prominent tubercle plates and screws, which in one patient required removal. Tibial tubercle fractures occurred in over one-fifth of the bicondylar tibial plateau fractures in our series. Fixation is necessary and can be reliably performed with screws alone or with a screw and plate, which restores the extensor mechanism and facilitates early knee flexion.

Cite this article: Bone Joint J 2013;95-B:1697–1702.

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required.

This year is the centenary of the birth of John Charnley. Some of his legacy to Orthopaedic Surgery is described in this editorial.

We compared case-mix and outcome variables in 1310 patients who sustained an acute fracture at the age of 80 years or over. A group of 318 very elderly patients (≥ 90 years) was compared with a group of 992 elderly patients (80 to 89 years), all of whom presented to a single trauma unit between July 2007 and June 2008. The very elderly group represented only 0.6% of the overall population, but accounted for 4.1% of all fractures and 9.3% of all orthopaedic trauma admissions. Patients in this group were more likely to require hospital admission (odds ratio 1.4), less likely to return to independent living (odds ratio 3.1), and to have a significantly longer hospital stay (ten days, p = 0.01).

The 30- and 120-day unadjusted mortality was greater in the very elderly group. The 120-day mortality associated with non-hip fractures of the lower limb was equal to that of proximal femoral fractures, and was significantly increased with a delay to surgery > 48 hours for both age groups (p = 0.04). This suggests that the principle of early surgery and mobilisation of elderly patients with hip fractures should be extended to include all those in this vulnerable age group.

We identified 11 women with a mean age of 74 years (65 to 81) who sustained comminuted distal radial and ulnar fractures and were treated by volar plating and slight shortening of the radius combined with a primary Sauvé-Kapandji procedure.

At a mean of 46 months (16 to 58), union of distal radial fractures and arthrodesis of the distal radioulnar joint was seen in all patients. The mean shortening of the radius was 12 mm (5 to 18) compared to the contralateral side. Flexion and extension of the wrist was a mean of 54° and 50°, respectively, and the mean pronation and supination of the forearm was 82° and 86°, respectively. The final mean disabilities of the arm, shoulder and hand score was 26 points. According to the Green and O’Brien rating system, eight patients had an excellent, two a good and one a fair result.

The good clinical and radiological results, and the minor complications without the need for further operations related to late ulnar-sided wrist pain, justify this procedure in the elderly patient.

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery.

This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

This study assessed whether undergraduate performance improved following the introduction in 2006 of a musculoskeletal teaching programme lasting for seven weeks. Different methods were used to deliver knowledge and skills in trauma and orthopaedic surgery, rheumatology and allied specialties. The programme combined four main elements: traditional firm-based teaching, weekly plenary sessions, a task-based workbook and additional specialist clinics. The block of 139 students who attended in its first year were assessed using a multiple choice question examination just before their final examinations in 2008. They showed a 6% improvement in performance over a control group of 130 students assessed in 2005 before the programme had commenced. There was no difference in performance between the students assessed in 2005 and a second group of 46 students from 2008 who did not attend the new teaching programme. Performance was improved by providing more focused musculoskeletal training using available resources, as well as increasing the length of the programme.

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

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

We studied 11 patients with checkrein deformities of the hallux who underwent surgical treatment. Six had lengthening of the flexor hallucis longus tendon by Z-plasty in the midfoot, and five underwent release of adhesions and lengthening of the tendon by Z-plasty at the musculotendinous junction at the fracture site.

All six patients who underwent Z-plasty at the midfoot showed complete correction of the deformity without recurrence. Of the five who had release of adhesions and Z-plasty of the tendon at the fracture site, two showed partial and one showed complete recurrence.