Alan J. Johnstone

DIAGNOSING ACUTE COMPARTMENT SYNDROME

Compartment syndrome has been defined as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space”.1 It is most commonly seen after injuries to the leg2-5 and forearm6-8 but may also occur in the arm,9 thigh,10 foot,11-13 buttock,14 hand15 and abdomen.16 It typically follows traumatic injury, but may also occur after ischaemic reperfusion injuries,17 burns,18 prolonged limb compression after drug overdose19 or poor positioning during surgery.20-24 Furthermore, subclinical compartment syndromes may explain the occurrence of a variety of postoperative disabilities which have been identified after the treatment of fractures of long bones using intramedullary nails.25 Approximately 40% of all acute compartment syndromes occur after fractures of the tibial shaft26 with an incidence in the range of 1% to 10%.26-30 A further 23% of compartment syndromes are caused by soft-tissue injuries with no fracture and fractures of the forearm account for 18%.26 Acute compartment syndrome is seen more commonly in younger patients, under 35 years of age31 and therefore leads to loss of function and long-term productivity in patients who would otherwise contribute to the country’s workforce for up to 40 years.

Local anaesthetic infiltration increases the accuracy of assessment of ulnar collateral ligament injuries

Objective:  To assess the effectiveness of a systematic examination of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint (MCPJ) prior to and post infiltration of local anaesthetic.

Displaced distal radial fractures treated using volar locking plates: maintenance of normal anatomy.

BACKGROUND The objective is to assess the ability of volar locking plates to maintain fracture reduction when used to treat dorsally displaced extra- and intra-articular distal radial fractures. METHODS This prospective study was conducted over an 12-month period. Consenting patients who had sustained a closed, dorsally displaced distal radial fracture, treated by open reduction and internal fixation using a volar distal radial locking plate were included in the study. Radial inclination, volar tilt, and ulnar variance were measured from radiographs taken at least 3 months after surgery and compared with radiographs of the uninjured side. Only two of the eight participating surgeons have a specialist interest in upper limb surgery. RESULTS Thirty-three patients were included in the study. There were 23 women and 10 men. The mean age was 49.5 years (range, 26-82 years). According to the Orthopaedic Trauma Association (OTA) classification, there were 19 Type A, 1 Type B, and 13 Type C fractures. The average restoration of volar tilt was 1-degree angle of under correction with a range of 7.3-degree angle of under correction to 3.7-degree angle of over correction, when compared with the uninjured side. The mean restoration of radial inclination was 1.9-degree angle of under correction with a range of 10-degree angle of under correction to 8.4-degree angle of over correction. As a group, the mean ulnar variance was 0 mm with a range of 2 mm of relative ulnar shortening to 3.5 mm of ulnar prominence when compared with the uninjured side. CONCLUSION In the hands of general trauma surgeons, the volar approach combined with the application of a suitable volar locking plate is a good treatment for restoring and maintaining the anatomy of dorsally displaced intra- and extra-articular distal radial fractures.

The Floating Shoulder Redefined

Features suggestive of a “floating shoulder” include a displaced fracture of the scapular neck combined with the following: ruptures of the coracoacromial (CA) and coracoclavicular (CC) ligaments; disruption of the acromioclavicular (AC) joint; or a fracture of the clavicle.1,2 Recently, this loose definition has been expanded to include disruption of the attachments of the distal fragment to the proximal fragment and the axial skeleton in addition to having a displaced scapular neck fracture.3 However, patients can present with features out with these paradigms, thereby significantly increasing the diagnostic difficulty of these uncommon injuries. We present a patient who suffered a fracture of the surgical neck of the scapula with relative anteromedial displacement in association with a fractured acromion, resulting in significant anterior displacement of the shoulder despite having an intact clavicle, AC joint, and CA and CC ligaments. The patient clearly had a fracture through the neck of the scapula, but with only minimal medial and inferior displacement of the humeral head with respect to the acromion. As a result, the degree of instability was initially underestimated, especially because an acromial fracture, located at the angle of the acromion, was not readily seen on the anteroposterior radiograph and was also difficult to visualize on the scapular lateral radiograph.

Do trauma systems work? A comparison of major trauma outcomes between Aberdeen Royal Infirmary and Massachusetts General Hospital

Trauma is an important matter of public health and a major cause of mortality. Since the late 1980s trauma care provision in the United Kingdom is lacking when compared to the USA. This has been attributed to a lack of organisation of trauma care leading to the formation of trauma networks and Major Trauma Centres in England and Wales. The need for similar centres in Scotland is argued currently. We assessed the activity of two quite different trauma systems by obtaining access to comparative data from two hospitals, one in the USA and the other in Scotland. Aggregate data on 5604 patients at Aberdeen Royal Infirmary (ARI) from 1993 to 2002 was obtained from the Scottish Trauma Audit Group. A comparable data set of 16,178 patients from Massachusetts General Hospital (MGH). Direct comparison of patient demographics; injury type, mechanism and Injury Severity Score (ISS); mode of arrival; length of stay and mortality were made. Statistical analysis was carried out using Chi-squared and Cochran-Mantel-Haenszel. There were significant differences in the data sets. There was a higher proportion of penetrating injuries at MGH, (8.6% vs 2.6%) and more severely injured patients at MGH, patients with an ISS>16 accounted for nearly 22.1% of MGH patients compared to 14.0% at ARI. ISS 8-15 made up 54.6% of ARI trauma with 29.6% at MGH. Falls accounted for 50.1% at ARI and 37.9% at MGH. Despite the higher proportion of severe injuries at MGH and crude mortality rates showing no difference (4.9% ARI vs 5.2% MGH), pooled odds ratio of mortality was 1.4 (95% confidence interval 1.2-1.6) showing worse mortality outcomes at ARI compared to MGH. In conclusion, there were some differences in case mix between both data sets making direct comparison of the outcomes difficult, but the effect of consolidating major trauma on the proportion and number of severely injured patients treated in the American Level 1 centre was clear with a significant improvement in mortality in all injury severity groups.

The Role of Total Elbow Arthroplasty in Complex Distal Humeral Fractures

Fractures of the distal humerus are routinely treated by open reduction and internal fixation in an attempt to retain a painless, stable and functional joint. However, results of fixation, even with advances in plate technology, are still dependent on screw purchase and bone quality. Reported results, over the past decade, now support consideration of primary total elbow arthroplasty, in cases of highly comminuted distal humeral fractures, especially in the elderly who have low physical demands, or in those who have significant pre-existing inflammatory joint disease resulting in marked joint destruction.

Assessment Following Distal Radius Fractures: A Comparison of 4 Scoring Systems, Visual Numerical Scales, and Objective Measurements.

PURPOSE To compare 4 recognized upper-limb scoring systems that are regularly used to assess wrist function after injury. METHODS We reviewed 116 patients 6 months after volar locking plate fixation for distal radius fractures. Two purely subjective and 2 composite scoring systems composed of both subjective and objective components were compared along with visual numerical scores for pain and function and objective measures of function. Each score was standardized into a scale from 0 to 100. RESULTS The distribution of the standardized total scores was statistically significantly different and indicated marked variability between scoring systems and therefore the information provided. Overall, the subjective scoring systems correlated well with each other and with both visual numerical scores for pain and function. However, the composite scores and objective measures of function correlated poorly with the subjective scores including the visual numerical scores. CONCLUSIONS Results from wrist scoring systems should be interpreted with caution. It is important to ensure that the component parts of each score are taken into consideration separately because total scores may be misleading. CLINICAL RELEVANCE Composite scores may be outdated and should be avoided.

Primary screw perforation or subsequent screw cut-out following proximal humerus fracture fixation using locking plates: a review of causative factors and proposed solutions

The surgical treatment of proximal humerus fractures remains controversial primarily due to the high complication rate associated with the available fixation methods. In an attempt to reduce the incidence of serious complications and subsequent poor clinical outcomes, proximal humerus locking plates have become popular but even these implants cannot overcome the risk of complications, especially those associated with loss of fracture reduction and screw cut-out/migration through the humeral head. In an attempt to address these issues, we have reviewed the literature, investigating the most likely causes for these predominantly mechanical complications and propose technical solutions.

Distal Ulna Fractures

Isolated fractures of the distal ulna are relatively rare and usually result from a direct force or crush injury. However, ulna fractures do occur more commonly in association with fractures of the distal radius, with up to 65% of fractures of the distal radius having associated distal ulna fractures. In this chapter distal ulna reduction and fixation techniques are discussed.

Comparing the costs and outcomes of an integrated twin compression screw (ITCS) nail with standard of care using a single lag screw or a single helical blade cephalomedullary nail in patients with intertrochanteric hip fractures

BackgroundSurgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows for early rehabilitation and functional recovery. The purpose of the study was to assess the cost-effectiveness of commonly used cephalomedullary nails for the treatment of unstable intertrochanteric hip fractures.MethodsA decision analytic model was developed from a US payer’s perspective using clinical data from a pairwise meta-analysis of randomised controlled trials (RCTs) and comparative observational studies comparing the integrated twin compression screw (ITCS) nail versus two single-screw or blade cephalomedullary nails [single lag screw (SLS) nail and single helical blade (SHB) nail]. The model considered a cohort of 1000 patients with a mean age of 76, as reported in the clinical studies over a 1-year time period. Cost data was obtained from the Center for Medicare and Medicaid Services website and published literature and adjusted for inflation. One-way and probabilistic sensitivity analyses were conducted to assess the effect of uncertainty in model parameters on model conclusions.ResultsThe model estimated 0.546 quality-adjusted life years (QALYs) and 0.78 complications avoided by using the ITCS nail and 0.455 QALYs and 0.67 complications avoided for the standard of care, using SLS or SHB nails. The cost per patient was