Andrew D. Duckworth

The epidemiology of open fractures in adults. A 15-year review

There is little information available about the epidemiology of open fractures. We examined 2386 open fractures over a 15-year period analysing the incidence and severity of the fractures. The majority of open fractures are low energy injuries with only 22.3% of open fractures being caused by road traffic accidents or falls from a height. The distribution curves of many open fractures are different to the overall fracture distribution curves with high-energy open fractures being commoner in younger males and low energy open fractures in older females. The mode of injury and the different demographic characteristics between isolated and multiple open fractures are also discussed.

The Epidemiology of Radial Head and Neck Fractures

PURPOSE The aim of this study was to define the epidemiological characteristics of proximal radial fractures. METHODS Using a prospective trauma database of 6,872 patients, we identified all patients who sustained a fracture of the radial head or neck over a 1-year period. Age, sex, socioeconomic status, mechanism of injury, fracture classification, and associated injuries were recorded and analyzed. RESULTS We identified 285 radial head (n = 199) and neck (n = 86) fractures, with a patient median age of 43 years (range, 13-94 y). The mean age of male patients was younger when compared to female patients for radial head and neck fractures, with no gender predominance seen. Gender did influence the mechanism of injury, with female patients commonly sustaining their fracture following a low-energy fall. Radial head fractures were associated more commonly with complex injuries according to the Mason classification, while associated injuries were related to age, the mechanism of injury, and increasing fracture complexity. CONCLUSIONS Radial head and neck fractures have distinct epidemiological characteristics, and consideration for osteoporosis in a subset of patients is recommended. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.

The epidemiology of fractures of the proximal ulna

INTRODUCTION The aim of our study was to report the epidemiological characteristics of fractures of the proximal ulna. METHODS From our prospective trauma database of 6872 fractures, we identified all acute fractures of the proximal ulna from a 1-year period between July 2007 and June 2008. Age, gender, mode of injury, fracture classifications, associated injuries and treatment were the factors documented and analysed. RESULTS There were 78 fractures of the proximal ulna with a mean age of 57 years (15-97). Males (n=35) sustained their fracture at a significantly younger age than females (p=0.041), with no gender predominance seen (p=0.365). The overall fracture distribution was a unimodal older male and unimodal older female type-F curve. The most common mode of injury was a simple fall from standing height (n=52, 67%), with younger patients more likely to sustain their injuries following a high-energy mechanism such as sports or a motor vehicle collision (p<0.001). Seventeen (22%) patients sustained associated injuries to the ipsilateral limb, with an associated proximal radial fracture most frequent (n=13, 17%). Open fractures were seen in five (6.4%) patients. A total of 64 patients had a fracture of the olecranon, with the Mayo 2A most frequently seen (n=47, 60%). CONCLUSIONS Fractures of the proximal ulna are fragility fractures that predominantly occur in elderly patients. Given the number of elderly patients sustaining these injuries, research is needed to determine the role of non-operative treatment for these fractures, particularly in patients with multiple co-morbidities and low functional demands.

Radial head and neck fractures: functional results and predictors of outcome.

BACKGROUND The purpose of this study was to determine the functional outcomes and predictive factors of radial head and neck fractures. METHODS Over an 18-month period, we performed a prospective study of 237 consecutive patients with a radiographically confirmed proximal radial fracture (156 radial head and 81 radial neck). Follow-up was carried out over a 1-year period using clinical and radiologic assessment, including the Mayo Elbow Score (MES). Multivariate regression analysis was used to determine significant predictors of outcome according to the MES. RESULTS Of the 237 patients enrolled in the study, 201 (84.8%) attended for review, with a mean age of 44 years (range, 16-83 years; standard deviation, 17.3). One hundred eighty-seven (93%) patients achieved excellent or good MESs. The mean MES for Mason type-I (n = 103) and type-II (n = 82) fractures was excellent, with only two patients undergoing surgical intervention. For Mason type-III (n = 11) and type-IV (n = 5) fractures, the flexion arc, forearm rotation arc, and MES in the nonoperatively treated patients were not significantly different (all p ≥ 0.05) from those managed operatively. Regression analysis revealed that increasing age, increasing fracture complexity according to the AO-OTA classification, increasing radiographic comminution, and operative treatment choice were independently significant predictors of a poorer outcome (all p < 0.05). CONCLUSIONS A majority of radial head and neck fractures can be treated nonoperatively, achieving excellent or good results. Age, fracture classification, radiographic comminution, and treatment choice are important factors that determine recovery.

Radial head replacement for acute complex fractures: what are the rate and risks factors for revision or removal?

BackgroundWhen treating complex radial head fractures, important goals include prevention of elbow or forearm instability, with restoration of radiocapitellar contact essential. When open reduction and internal fixation cannot achieve this, radial head replacement is routinely employed, but the frequency of and risk factors for prosthesis revision or removal are not well defined.Questions/purposesWe determined (1) the frequency of prosthesis revision or removal after radial head replacement for acute complex unstable radial head fractures, (2) risk factors for revision or removal, and (3) functional outcomes after radial head replacement.MethodsWe identified from our prospective trauma database all patients over a 16-year period managed acutely for unstable complex radial head fractures with primary radial head replacement. Of the 119 patients identified, 105 (88%) met our inclusion criteria; mean age was 50 years (range, 16–93 years) and 57 (54%) were female. All implants were uncemented monopolar prostheses, of which 86% were metallic and 14% silastic. We recorded further procedures for prosthesis revision or removal for any cause, with a minimum followup of 1 year (n = 105). Cox regression analysis was used to determine independent factors associated with revision or removal when controlling for baseline patient (age, sex, comorbidities) and fracture (location, classification, associated injury) characteristics. Short-term functional outcomes (Broberg and Morrey score, ROM) were determined from retrospective review of clinic followup (n = 74), with a minimum followup of 3 months.ResultsTwenty-nine patients (28%) underwent prosthesis revision (n = 3) or removal (n = 26) at a mean of 6.7 years (range, 1.8–18 years) after injury. Independent risk factors for removal or revision were silastic implant type and lower age. At a mean of 1.1 years (range, 0.3–5.5 years) after surgery, mean Broberg and Morrey score was 80 out of 100 (range, 40–99). Mean elbow flexion was 133° (range, 90°–159°; SD, 13°), extension 21° (range, 0°–80°; SD, 17°), flexion arc 112° (range, 10°–140°; SD, 25°), pronation 84° (range, 0°–90°; SD, 18°), supination 73° (range, 0°–90°; SD, 28°), and forearm rotation arc 156° (range, 0°–180°; SD, 38°).ConclusionsWe demonstrated a high removal or revision rate after radial head replacement for acute unstable complex fractures, with lower age and silastic implants independent risk factors. Younger patients should be counseled regarding the increased risk of requiring further surgery after radial head replacement. Future work should focus on long-term patient-reported outcomes after these injuries.Level of EvidenceLevel IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Scaphoid Fracture Epidemiology

Background: The current available literature related to scaphoid fracture epidemiology is inconsistent. The aim of this study was to describe the epidemiology of true scaphoid fractures in a defined adult population. Methods: Using a prospective database, we identified all patients who sustained a radiographically confirmed acute fracture of the scaphoid over a 1-year period. Age, gender, mechanism of injury, the Herbert fracture classification, and associated injuries were recorded and analyzed. Results: There were 151 scaphoid fractures diagnosed giving an annual incidence of 29 per 100,000 (95% confidence interval, 25–34). The median age of males was significantly younger when compared with females (p = 0.002), with a male (n = 105) predominance seen (p < 0.001). Low-energy falls from a standing height were most common (40.4%), but with males being significantly more likely to sustain their fracture after a high-energy injury (p < 0.001). The most common fracture was Herbert classification B2 (n = 55, 36.4%), with unstable fractures more common in younger patients (p = 0.025) following a high-energy injury (p = 0.042). Conclusions: We have reported the epidemiology of true scaphoid fractures, with young males at risk of sustaining a fracture. Knowledge of the true incidence of scaphoid fractures and an understanding of the demographic risk factors are essential when assessing the suspected scaphoid fracture, particularly when considering further imaging modalities.

Fractures of the radial head

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred. This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Deep infection after hip fracture surgery: Predictors of early mortality

INTRODUCTION This study analysed the predictors of mortality in patients who are diagnosed with deep infection following hip fracture surgery. METHODS Data were prospectively collected for 3 years from all patients undergoing hip fracture surgery and who had developed a subsequent deep infection. Infection was defined as positive microbiology culture from deep tissue or fluid samples. Demographic data, treatment, complications and subsequent surgeries were analysed. Potential predisposing factors including chronic medical co-morbidities, American Society of Anesthesiologists (ASA) grade, alcohol excess and smoking were assessed. The main outcome measures were 30-day and 1-year mortality. RESULTS There were 2718 consecutive operations performed for a fracture of the proximal femur over a 3-year period. Forty-three (1.6%) patients had a deep postoperative infection diagnosed on fluid and/or tissue sampling. The mean age was 73 years (25-94) and 65% were female. Of the 43 patients who developed deep infection, the primary procedure in 25 (58%) patients was reduction and internal fixation, with 18 (42%) undergoing hemi-arthroplasty. The most common causative organism was Staphylococcus epidermidis (n=13, 30%), with methicillin-resistant Staphylococcus aureus (MRSA) accounting for 23% (n=10). The 30-day mortality was significantly higher than that of patients with no deep infection (19% vs. 6.5%; p=0.004). On univariate analysis, increasing age, dementia and diabetes were predictive of both 30-day and 1-year mortality (all p<0.05). S. aureus (sensitive or resistant) was approaching significance at 1 year (p=0.065). On multivariate analysis, dementia and diabetes were independent predictors of 30-day mortality, with dementia and S. aureus predictive at 1 year. CONCLUSIONS The 30-day mortality rate in patients diagnosed with deep infection following hip fracture surgery is higher than those without infection. Dementia, diabetes and S. aureus infection are independent predictors of mortality following deep infection.

Radial shortening following a fracture of the proximal radius

Background and purpose The Essex-Lopresti lesion is thought to be rare, with a varying degree of disruption to forearm stability probable. We describe the range of radial shortening that occurs following a fracture of the proximal radius, as well as the short-term outcome in these patients. Patients and methods Over an 18-month period, we prospectively assessed all patients with a radiographically confirmed proximal radial fracture. Patients noted to have ipsilateral wrist pain at initial presentation underwent bilateral radiography to determine whether there was disruption of the distal radio-ulnar joint suggestive of an Essex-Lopresti lesion. Outcome was assessed after a mean of 6 (1.5–12) months using clinical and radiographic results, including the Mayo elbow score (MES) and the short musculoskeletal function assessment (SMFA) questionnaire. One patient with a Mason type-I fracture was lost to follow-up after initial presentation. Results 60 patients had ipsilateral wrist pain at the initial assessment of 237 proximal radial fractures. Radial shortening of ≥ 2mm (range: 2–4mm) was seen in 22 patients (mean age 48 (19–79) years, 16 females). The most frequent mechanism of injury was a fall from standing height (10/22). 21 fractures were classified as being Mason type-I or type-II, all of which were managed nonoperatively. One Mason type-III fracture underwent acute radial head replacement. Functional outcome was assessed in 21 patients. We found an excellent or good MES in 18 of the 20 patients with a Mason type-I or type-II injury. Interpretation The incidence of the Essex-Lopresti lesion type is possibly under-reported as there is a spectrum of injuries, and subtle disruptions often go unidentified. A full assessment of all patients with a proximal radial fracture is required in order to identify these injuries, and the index of suspicion is raised as the complexity of the fracture increases.

Assessment of the suspected fracture of the scaphoid

A suspected fracture of the scaphoid remains difficult to manage despite advances in knowledge and imaging methods. Immobilisation and restriction of activities in a young and active patient must be balanced against the risks of nonunion associated with an undiagnosed and undertreated fracture of the scaphoid. The assessment of diagnostic tests for a suspected fracture of the scaphoid must take into account two important factors. First, the prevalence of true fractures among suspected fractures is low, which greatly reduces the probability that a positive test will correspond with a true fracture, as false positives are nearly as common as true positives. This situation is accounted for by Bayesian statistics. Secondly, there is no agreed reference standard for a true fracture, which necessitates the need for an alternative method of calculating diagnostic performance characteristics, based upon a statistical method which identifies clinical factors tending to associate (latent classes) in patients with a high probability of fracture. The most successful diagnostic test to date is MRI, but in low-prevalence situations the positive predictive value of MRI is only 88%, and new data have documented the potential for false positive scans. The best strategy for improving the diagnosis of true fractures among suspected fractures of the scaphoid may well be to develop a clinical prediction rule incorporating a set of demographic and clinical factors which together increase the pre-test probability of a fracture of the scaphoid, in addition to developing increasingly sophisticated radiological tests.