The aim was to predict the number and incidence of distal radius fractures in Scotland over the next two decades according to age group, categorised into under 65yrs(<65) and 65yrs and older (≥65), and estimate the potential increased operative burden of this.

The number of distal radius fracture in Scotland was isolated from the Global Burden of Disease database and this was used, in addition to historic population data and population estimates, to create a multivariable model allowing incorporation of age group, sex and time. A Negative Binomial distribution was used to predict incidence in 2030 and 2040 and calculate projected number of fractures according to the population at risk. A 20.4% operative intervention rate was assumed in the ≥65 group (local data).

In terms of number of fractures, there was a projected 61% rise in the ≥65 group with an overall increase of 2099 fractures per year from 3417 in 2020 (95% confidence interval (CI) 2960 – 3463) to 5516 in 2040 (95% CI 4155–5675). This was associated with 428 additional operative interventions per year for those ≥65yrs. The projected increase between 2020 and 2040 was similar in both sexes (60% in females, 63% in males), however the absolute increase in fracture number was higher in females (2256 in 2020 [95% CI 1954–2287] to 3620 in 2040 [95% CI 2727–3721]) compared to males (1160 [95% CI 1005–1176] to 1895 [95% CI 1427–1950]). There was a 4% projected fall in the number of fractures in those <65.

Incidence of distal radius fractures is expected to considerably increase over the next two decades due to a projected increase in the number of fractures in the elderly. This has implications for the associated morbidity and healthcare resource use.

The aim of this study was to determine the floor and ceiling effects for both the QuickDASH and PRWE following a fracture of the distal radius. Secondary aims were to determine the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and if there were patient factors associated with achieving a floor or ceiling effect.

A retrospective cohort study of patients sustaining a distal radius fracture and managed at the study centre during a single year was undertaken. Outcome measures included the QuickDASH, the PRWE, EuroQol-5 Dimension-3 Levels (EQ-5D-3L), and the normal wrist score.

There were 526 patients with a mean age of 65yrs (20–95) and 421 (77%) were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs (4.3–5.5). A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the minimum clinical important difference of the best available score, the ceiling effect increased to 62.8% for the QuickDASH and 60% for the PRWE. Patients that achieved a ceiling score for the QuickDASH and PRWE subjectively felt their wrist was only 91% and 92% normal, respectively. On logistic regression analysis, a dominant hand injury and better health-related quality of life were the common factors associated with achieving a ceiling score for both the QuickDASH and PRWE (all p<0.05).

The QuickDASH and PRWE demonstrate ceiling effects when used to assess the outcome of fractures of the distal radius. Patients achieving ceiling scores did not consider their wrist to be ‘normal’. Future patient-reported outcome assessment tools for fractures of the distal radius should aim to limit the ceiling effect, especially for individuals or groups that are more likely to achieve a ceiling score.

This systematic review and meta-analysis aimed to compare the outcome of operative and non-operative management in adults with distal radius fractures, with an additional elderly subgroup analysis. The main outcome was 12-month PRWE score. Secondary outcomes included DASH score, grip strength, complications and radiographic parameters.

Randomised controlled trials of patients aged ≥18yrs with a dorsally displaced distal radius fractures were included. Studies compared operative intervention with non-operative management. Operative management included open reduction and internal fixation, Kirschner-wiring or external fixation. Non-operative management was cast/splint immobilisation with/without closed reduction. Version 2 of the Cochrane risk-of-bias tool was used.

After screening 1258 studies, 16 trials with 1947 patients (mean age 66yrs, 76% female) were included in the meta-analysis. Eight studies reported PRWE score and there was no clinically significant difference at 12 weeks (MD 0.16, 95% confidence interval [CI] −0.75 to 1.07, p=0.73) or 12 months (mean difference [MD] 3.30, 95% CI −5.66 to −0.94, p=0.006). Four studies reported on scores in the elderly and there was no clinically significant difference at 12 weeks (MD 0.59, 95% CI −0.35 to 1.53, p=0.22) or 12 months (MD 2.60, 95% CI −5.51 to 0.30, p=0.08). There was a no clinically significant difference in DASH score at 12 weeks (MD 10.18, 95% CI −14.98 to −5.38, p<0.0001) or 12 months (MD 3.49, 95% CI −5.69 to −1.29, p=0.002). Two studies featured only elderly patients, with no clinically important difference at 12 weeks (MD 7.07, 95% CI −11.77 to −2.37, p=0.003) or 12 months (MD 3.32, 95% CI −7.03 to 0.38, p=0.08).

There was no clinically significant difference in patient-reported outcome according to PRWE or DASH at either timepoint in the adult group as a whole or in the elderly subgroup.

To compare the long-term outcomes of fibular nailing and plate fixation for unstable ankle fractures in a cohort of patients under the age of 65 years.

Patients from a previously conducted randomized control trial comparing fibular nailing and plate fixation were contacted at a minimum of 10 years post intervention at a single study centre. Short term data were collected prospectively and long-term data were collected retrospectively using an electronic patient record software.

Ninety-nine patients from one trauma centre were included (48 fibular nails and 51 plate fixations). Groups were matched for gender (p = 0.579), age (p = 0.811), body mass index (BMI)(p = 0.925), smoking status (p = 0.209), alcohol status (p = 0.679) and injury type (p = 0.674). Radiographically at an average of 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p = 0.851). Both groups had 1 tibio-talar fusion (2% of both groups) secondary to osteoarthritis with no statistically significant difference in overall re-operation rate between groups identified (p = 0.518,). Forty-five percent (n=42) of patients had so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=19, plate fixation n=23). No significant difference was found between groups at 10 years for the Olerud and Molander Ankle Score (p = 0.990), the Manchester-Oxford Foot Questionnaire (p = 0.288), Euroqol-5D Index (p = 0.828) and Euroqol-5D Visual Analogue Score (p = 0.769).

The current study illustrates no difference between fibular nail fixation and plate fixation at a long-term follow up of 10 years in patients under 65 years old, although the study is currently under powered.

COVID-19 confers a three-fold increased mortality risk among hip fracture patients. The aims were to investigate whether vaccination was associated with: i) lower mortality risk, and ii) lower likelihood of contracting COVID-19 within 30 days of fracture.

This nationwide cohort study included all patients aged >50 years with a hip fracture between 01/03/20-31/12/21. Data from the Scottish Hip Fracture Audit were collected and included: demographics, injury and management variables, discharge destination, and 30-day mortality status. These variables were linked to population-level records of COVID-19 vaccination and testing.

There were 13,345 patients with a median age of 82.0 years (IQR 74.0–88.0), and 9329/13345 (69.9%) were female. Of 3022/13345 (22.6%) patients diagnosed with COVID-19, 606/13345 (4.5%) were COVID-positive within 30 days of fracture. Multivariable logistic regression demonstrated that vaccinated patients were less likely to be COVID-positive (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.34–0.48, p<0.001) than unvaccinated patients. 30-day mortality rate was higher for COVID-positive than COVID-negative patients (15.8% vs 7.9%, p < 0.001). Controlling for confounders (age, sex, comorbidity, deprivation, pre-fracture residence), unvaccinated patients with COVID-19 had a greater mortality risk than COVID-negative patients (OR 2.77, CI 2.12–3.62, p < 0.001), but vaccinated COVID19-positive patients were not at increased risk (OR 0.93, CI 0.53–1.60, p = 0.783).

Vaccination was associated with lower COVID-19 infection risk. Vaccinated COVID-positive patients had a similar mortality risk to COVID-negative patients, suggesting a reduced severity of infection. This study demonstrates the efficacy of vaccination in this vulnerable patient group, and presents essential data for future outbreaks.

The primary aim was to assess the reliability of ultrasound in the assessment of humeral shaft fracture healing. The secondary aim was to estimate the accuracy of ultrasound assessment in predicting humeral shaft nonunion.

Twelve patients (mean age 54yrs [20–81], 58% [n=7/12] female) with a non-operatively managed humeral diaphyseal fracture were prospectively recruited and underwent ultrasound scanning at six and 12wks post-injury. Scans were reviewed by seven blinded observers to evaluate the presence of sonographic callus. Intra- and inter-observer reliability were determined using the weighted kappa and intraclass correlation coefficient (ICC). Accuracy of ultrasound assessment in nonunion prediction was estimated by comparing scans for patients that united (n=10/12) with those that developed a nonunion (n=2/12).

At both six and 12wks, sonographic callus was present in 11 patients (10 united, one developed a nonunion) and sonographic bridging callus (SBC) was present in seven patients (all united). Ultrasound assessment demonstrated substantial intra- (6wk kappa 0.75, 95% CI 0.47-1.03; 12wk kappa 0.75, 95% CI 0.46-1.04) and inter-observer reliability (6wk ICC 0.60, 95% CI 0.38-0.83; 12wk ICC 0.76, 95% CI 0.58-0.91). Absence of sonographic callus demonstrated a sensitivity of 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (accuracy 92%). Absence of SBC demonstrated a sensitivity of 100%, specificity 70%, PPV 40% and NPV 100% (accuracy 75%). Of three patients at risk of nonunion based on reduced radiographic callus formation (Radiographic Union Score for HUmeral fractures <8), one had SBC on 6wk ultrasound (and united) and the other two had non-bridging or absent sonographic callus (both developed a nonunion).

Ultrasound assessment of humeral shaft fracture healing was reliable and predictive of nonunion, and may be a useful tool in defining the risk of nonunion among patients with reduced radiographic callus formation.

The aims of this study in relation to distal radius fractures were to determine (1) the floor and ceiling effects for the QuickDASH and PRWE, (2) the floor and ceiling effects when defined to be within the minimal clinically important difference (MCID) of the minimal or maximal scores, (3) the degree to which patients with a floor or ceiling effect felt that their wrist was ‘normal’, and (4) patent factors associated with a floor or ceiling effect.

A retrospective cohort study of patients sustaining a distal radius fracture during a single year was undertaken. Outcome measures included the QuickDASH, PRWE, EQ-5D-3L and normal wrist score.

There were 526 patients with a mean age of 65yrs and 77% were female. Most patients were managed non-operatively (73%, n=385). The mean follow-up was 4.8yrs. A ceiling effect was observed for both the QuickDASH (22.3%) and PRWE (28.5%). When defined to be within the MCID of the best score, the effect increased to 62.8% for the QuickDASH and 60% for PRWE. Patients that achieved the best functional outcome according to the QuickDASH and PRWE felt their wrist was only 91% and 92% normal, respectively. Sex (p=0.000), age (p=0.000), dominant wrist injury (p=0.006 for QuickDASH and p=0.038 for PRWE), fracture type (p=0.015), and a better health-related quality of life (p=0.000) were independently associated with achieving a ceiling score.

The QuickDASH and PRWE demonstrated ceiling effects following a distal radius fracture. Patients achieving ceiling scores did not consider their wrist to be ‘normal’ for them.

This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture.

A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period.

The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p<0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction.

Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures.

Multiligament knee injuries (MLKI) are associated with significant morbidity and healthcare requirements. The primary aim of this study is to report the patient reported outcomes measures (PROMs) after reconstructive surgery.

Patients undergoing surgery for MLKI between 2014 and 2018 in the single large-volume trauma centre were included. Electronic patient records were reviewed for demographic data, details of surgery and complications. PROMs collected were EQ-5D-5L, Lysholm Knee Score (LKS), UCLA Activity and Sport and patient satisfaction.

Thirty-five patients were included. Mean age was 31 years (range 16-66), and 71% were male. The most common mechanism of injury was sports-related (71%). Obesity was present in eight (23%) patients. No vascular injuries were recorded and four patients sustained nerve injuries. PROMs were available for 18 patients (51%) with a median follow up of 4.5 years. Median EQ-5D-5L was 0.78 (IQR 0.14). Median LKS was 84.5 (IQR 21) and there was no correlation with time to surgery (p=0.43). Grade of MLKI did not impact LKS (p=0.09). Fifteen patients (83%) saw a reduction in their activity level. All patients were satisfied with their surgical treatment. Recurrent instability was noted in four patients (11%). Three patients (8%) required further surgery (one revision reconstruction, one meniscectomy, one conversion to a hinged knee replacement.

This study demonstrates two groups of patients who sustain MLKI: the sporting population and obese patients. Health related quality of life, functional outcomes and satisfaction are high after surgery. Time to surgery did not impact on functional outcomes.

The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the cost-effectiveness of using a Radiographic Union Score for HUmeral fractures (RUSHU)<8 to facilitate selective fixation for patients at risk of nonunion.

From 2008-2017, 215 patients (mean age 57yrs [17–81], 61% female) with a non-operatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n=165/215) after non-operative management, with 23% (n=50/215) uniting after nonunion surgery. The EuroQol Five-Dimension (EQ-5D) Health Index was obtained via postal survey. An incremental cost-effectiveness ratio (ICER) <£20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective.

At a mean of 5.4yrs (1.2–11.0), the mean EQ-5D was 0.736. Multiple regression demonstrated that uniting after nonunion surgery was independently associated with an inferior EQ-5D (beta=0.103, p=0.032). Routine fixation for all patients to reduce the nonunion rate would be associated with increased treatment costs (£1,542/patient) but confer a potential EQ-5D benefit of 0.120/patient. The ICER of routine fixation was £12,850/QALY gained. Selective fixation, based upon a RUSHU<8 at 6wks post-injury, would be associated with reduced treatment costs (£415/patient) and confer a potential EQ-5D benefit of 0.335 per ‘at-risk patient’.

Routine fixation for patients with humeral shaft fractures, to reduce the nonunion rate observed after non-operative management, appears to be cost-effective at 5yrs post-injury. Selective fixation for patients at risk of nonunion based upon the RUSHU may confer greater cost-effectiveness, given the potential savings and improvement in EQ-5D.

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period.

All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures.

6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%).

Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources.

The aim of this study was to identify factors independently associated with symptomatic venous thromboembolism (VTE) following acute Achilles tendon rupture (ATR), and to suggest a clinical VTE risk assessment tool for patients with ATR.

From 2010–2018, 984 consecutive adults (median age 47yrs, 73% male) sustaining an ATR were retrospectively identified. There were 95% managed non-operatively (below-knee cast 52%, n=507/984; walking boot 44%, n=432/984), with 5% (n=45/984) undergoing primary operative repair (<6wks). VTE was diagnosed using medical records and national imaging archives, reviewed at a mean of 5yrs (1–10) post-injury. Regression was performed to identify factors independently associated with VTE.

Incidence of VTE within 90 days of ATR was 3.6% (n=35/984; deep vein thrombosis 2.1% [n=21/984], pulmonary embolism 1.9% [n=19/984]). Age ≥50yrs (adjusted OR [aOR] 2.3, p=0.027), personal history of VTE/thrombophilia (aOR 6.1, p=0.009) and family history of VTE (aOR 20.9, p<0.001) were independently associated with VTE. These non-modifiable risk factors were incorporated into a VTE risk assessment tool. 23% of patients developing VTE (n=8/35) had a relevant personal or family history, but incorporating age into the tool identified 69% of patients with VTE (n=24/35). Non weight-bearing ≥2wks after ATR was also independently associated with VTE (aOR 3.2, p=0.026).

Age ≥50 years, personal history of VTE/thrombophilia and a positive family history were independently associated with VTE following ATR. Incorporating age into our suggested VTE risk assessment tool enhanced sensitivity in identifying at-risk patients. Early weight-bearing in an appropriate orthosis may be beneficial in VTE risk reduction.

This international multicentre retrospective cohort study aimed to assess: 1) prevalence of COVID-19 in hip fracture patients, 2) effect on mortality, and 3) clinical factors associated mortality among COVID-19-positive patients.

A collaboration among 112 centres in 14 nations collected data on all patients with a hip fracture between 1st March-31st May 2020. Patient, injury and surgical factors were recorded, and outcome measures included admission duration, COVID-19 and 30-day mortality status.

There were 7090 patients and 651 (9.2%) were COVID-19-positive. COVID-19 was independently associated with male sex (p=0.001), residential care (p<0.001), inpatient fall (p=0.003), cancer (p=0.009), ASA grade 4–5 (p=0.008; p<0.001), and longer admission (p<0.001). Patients with COVID-19 had a significantly lower chance of 30-day survival versus those without (72.7% versus 92.6%, p<0.001), and COVID-19 was independently associated with increased 30-day mortality risk (p<0.001). Increasing age (p=0.028), male sex (p<0.001), renal (p=0.017) and pulmonary disease (p=0·039) were independently associated with higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders.

The prevalence of COVID-19 in hip fracture patients was 9% and was independently associated with a three-fold increased 30-day mortality risk. Clinical factors associated with mortality among COVID-19-positive hip fracture patients were identified for the first time. This is the largest study, and the only global cohort, reporting on the effect of COVID-19 in hip fracture patients. The findings provide a benchmark against which to determine vaccine efficacy in this vulnerable population and are especially important in the context of incomplete vaccination programmes and the emergence of vaccine-resistant strains.

The primary aim was to determine the rate of complications and re-intervention rate in a consecutive series of operatively managed distal radius fractures.

Data was retrospectively collected on 304 adult distal radius fractures treated at our institution in a year. Acute unstable displaced distal radius fractures surgically managed within 28 days of injury were included. Demographic and injury data, as well as details of complications and their subsequent management were recorded.

There were 304 fractures in 297 patients. The mean age was 57yrs and 74% were female. Most patients were managed with open reduction and internal fixation (ORIF) (n=278, 91%), with 6% (n=17) managed with manipulation and Kirschner wires and 3% (n=9) with bridging external fixation. Twenty-seven percent (n=81) encountered a post-operative complication. Complex regional pain syndrome was most common (5%, n=14), followed by loss of reduction (4%). Ten patients (3%) had a superficial wound infection managed with oral antibiotics. Deep infection occurred in one patient. Fourteen percent (n=42) required re-operation. The most common indication was removal of metalwork (n=27), followed by carpal tunnel decompression (n=4) and revision ORIF (n=4). Increasing age (p=0.02), male gender (p=0.02) and high energy mechanism of injury (p<0.001) were associated with developing a complication. High energy mechanism was the only factor associated with re-operation (p<0.001).

This study has documented the complication and re-intervention rates following distal radius fracture fixation. Given the increased risk of complications and the positive outcomes reported in the literature, non-operative management of displaced fractures should be considered in older patients.

Correct femoral tunnel position in anterior cruciate ligament reconstruction (ACLR) is critical in obtaining good clinical outcomes. We aimed to delineate whether any difference exists between the anteromedial (AM) and trans-tibial (TT) portal femoral tunnel placement techniques on the primary outcome of ACLR graft rupture.

Adult patients (>18year old) who underwent primary ACLR between January 2011 – January 2018 were identified and divided based on portal technique (AM v TT). The primary outcome measure was graft rupture. Univariate analysis was used to delineate association between independent variables and outcome. Binary logistic regression was utilised to delineate odds ratios of significant variables.

473 patients were analysed. Median age at surgery was 27 years old (range 18–70). A total of 152/473, (32.1%) patients were AM group compared to 321/473 (67.9%) TT. Twenty-five patients (25/473, 5.3%) sustained graft rupture. Median time to graft rupture was 12 months (IQR 9). A higher odds for graft rupture was associated with the AM group, which trended towards significance (OR 2.03; 95% CI 0.90 – 4.56, p=0.081). Older age at time of surgery was associated with a lower odds of rupture (OR 0.92, 95% CI 0.86 – 0.98, p=0.014).

There is no statistically significant difference in ACLR graft rupture rates when comparing anteromedial and trans-tibial portal technique for femoral tunnel placement. There was a trend towards higher rupture rates in the anteromedial portal group.

Whilst emergency fasciotomy for acute compartment syndrome (ACS) of the leg is limb and potentially lifesaving, there remains a perception that such surgery may result in excessive morbidity, which may deter surgeons in providing expeditious care. There are limited long-term studies reporting on the morbidity associated with fasciotomy.

A total of 559 patients with a tibial diaphyseal fracture were managed at our centre over a 7-year period (2009–2016). Of these patients, 41 (7.3%) underwent fasciotomies for the treatment of ACS. A matched cohort of 185 patients who did not develop ACS were used as controls. The primary short-term outcome measure was the development of any complication. The primary long-term outcome measure was the patient reported EQ-5D.

There was no significant difference between fasciotomy and non-fasciotomy groups in the overall rate of infection (17% vs 9.2% respectively; p=0.138), deep infection (4.9% vs 3.8%; p=0.668) or non-union (4.9% vs 7.0%; p=1.000). There were 11 (26.8%) patients who required skin grafting of fasciotomy wounds. There were 206 patients (21 ACS) with long-term outcome data at a mean of 5 years (1–9). There was no significant difference between groups in terms of the EQ-5D (p=0.81), Oxford Knee Score (p=0.239) or the Manchester-Oxford Foot Questionnaire (p=0.629). Patient satisfaction on a linear analogue scale was reduced in patients who developed ACS (77 vs 88; p=0.039).

These data suggest that when managed with urgent decompressive fasciotomies, ACS does not appear to have a significant impact on the long-term patient reported outcome, although overall patient satisfaction is reduced.

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after non-operative management. The secondary aim was to determine the effect of management (operative/non-operative) on nonunion.

Over a ten-year period, 734 humeral diaphyseal fractures (732 consecutive patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients; median age 57yrs [16–96], 54% female [n=359/662]) which formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed non-operatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs.

Median follow-up was five months (1.2–74). Nonunion occurred in 22.7% of non-operatively managed injuries (n=119/524). Multivariate analysis demonstrated pre-injury NSAIDs (adjusted OR [AOR] 40.8, 95% CI 2.6–632.3; p=0.008), being underweight (BMI <18.5kg/m2; AOR 7.3, 95% CI 1.3 to 40.2; p=0.022), overweight (BMI 25–29.9kg/m2; AOR 2.5, 95% CI 1.1 to 5.9; p=0.034) and class II obesity (BMI 35–39.9kg/m2; AOR 4.5, 95% CI 1.4 to 15.5; p=0.014) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n=4/139) than non-operative management (AOR for non-operative/operative 11.0, 95% CI 2.8 to 43.6; p=0.001). Based upon these results, five patients would need to undergo operative fixation to avoid one nonunion.

Pre-injury NSAIDs and BMI were independently associated with nonunion following non-operative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion.

The evidence for treatment of acute complex radial head fractures with radial head replacement (RHR) predominantly comprises short to mid-term follow-up. This study describes the complications and long-term patient reported outcomes following RHR.

From a single-centre trauma database we retrospectively identified 119 patients over a 16-year period who underwent primary RHR for an acute complex radial head fracture. We reviewed electronic records to document post-operative complications, including prosthesis revision and removal. Patients were contacted to confirm complications and long-term patient reported outcomes. The primary outcome measure was the QuickDash (QD).

The mean age at injury was 50 years (16–94) and 63 (53%) were female. Most implants were uncemented ‘loose-fit’ monopolar prostheses; 86% (n=102) were metallic and 14% (n=17) silastic. Thirty patients (25%) required revision surgery (n=3) or prosthesis removal (n=27). Five patients underwent arthrolysis and there were four cases of infection. In the long-term, 80% (80/100; 19 deceased) were contacted at a mean of 12 years (7.5–23.5). The median QD was 6.8 (IQR, 16.8), the median EQ-5D was 0.8 (IQR, 0.6) and the median Oxford Elbow Score was 46 (IQR, 7). Overall satisfaction was high with a mean of 9.4/10 (2–10). There was no significant difference in any outcome measure for those patients requiring revision or removal surgery (all p>0.05).

This is the largest series in the literature documenting the long-term patient reported outcome after RHR. Despite a quarter of patients requiring further surgery, RHR is supported by positive long-term results for the treatment of complex radial head fractures.

The aim of the study was to describe the failure rate of locking plates used for internal fixation of distal femoral fractures and to identify independent predictors of failure.

A consecutive series of 147 patients presenting to the study unit during an 8 year period with a distal femoral fracture were identified from a prospectively compiled trauma database. There were 117 females and 30 males, with a mean age of 70.7 years (13 to 99 years), of which 77 were periprosthetic fractures and 70 were supracondylar fractures around native knees.

There were 35 failures of fixation. The commonest cause was non-union (n=31). The survival of the plate 2 years post-surgery was 74percnt; (95percnt; CI 64percnt; to 84percnt;), which remained static to a mean follow of 5 years. There was no difference in failure of fixation according to gender (p=0.32) or if there was a periprosthetic fracture (p=0.8). Younger age (61.8 vs. 73.6 years, p=0.004), increasing level of comorbidity (p=0.02), and fracture comminution (p=0.001) were all significant predictors of failure of fixation. Cox regression analysis confirmed younger age (p=0.04), increasing comorbidity (p=0.002), and fracture comminution (p=0.002) as independent predictors of failure of fixation and non-union after adjusting for confounding.

The failure of locking plates for distal femoral fractures occurs in more than one in five patients. The independent predictors could be used to identify those patients at greatest risk of failure of the locking plate, who may benefit from alternative methods of fixation, primary bone grafting, or interventions that may aid union.

The aim of this prospective randomized controlled trial was to compare patient reported and functional outcomes, complications and costs for displaced olecranon fractures managed with either tension band wire (TBW) or plate fixation. We performed a registered prospective randomized, single blind, single centre trial in 67 patients aged between 16–74 years with an acute isolated displaced fracture of the olecranon. Patients were randomised to either TBW (n=34) or plate fixation (n=33). The primary outcome measure was the Disability Arm Shoulder and Hand (DASH) score at one-year.

The baseline demographic and fracture characteristics of the two groups were overall comparable. The one-year follow-up was 85percnt;. There was a significant improvement in elbow function over the 12 months following injury in both groups (p<0.001). At one-year following surgery the DASH for the TBW group was not statistically different to the plate fixation group (12.8 vs 8.5; p=0.315). There was no significant difference between groups in terms of range of movement, Broberg and Morrey Score, Mayo Elbow Score or the DASH at all assessment points over the one-year following injury (all p≥0.05). Complication rates were significantly higher in the TBW group (63percnt;vs38percnt;; p=0.042), predominantly due to a significantly higher rate of symptomatic metalwork removal (50percnt;vs22percnt;; p=0.021).

In active patients with an isolated displaced fracture of the olecranon, no difference was found in the patient reported outcome between TBW and plate fixation at one year following surgery. The complication rate is higher following TBW fixation due to a high rate of symptomatic metalwork removal.