Elizabeth Will

Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial.

BACKGROUND Anterior dislocation of the glenohumeral joint in younger patients is associated with a high risk of recurrence and persistent functional deficits. The aim of this study was to assess the efficacy of a primary arthroscopic Bankart repair, while controlling for the therapeutic effects produced by the arthroscopic intervention and joint lavage. METHODS In a single-center, double-blind clinical trial, eighty-eight adult patients under thirty-five years of age who had sustained a primary anterior glenohumeral dislocation were randomized to receive either an arthroscopic examination and joint lavage alone or together with an anatomic repair of the Bankart lesion. Assessment of the rate of recurrent instability, functional outcome (with use of three scores), range of movement, patient satisfaction, direct health-service costs, and treatment complications was completed for eighty-four of these patients (forty-two in each group) during the subsequent two years. RESULTS In the two years after the primary dislocation, the risk of a further dislocation was reduced by 76% and the risk of all recurrent instability was reduced by 82% in the Bankart repair group compared with the group that had arthroscopy and lavage alone. The functional scores were also better (p < 0.05), the treatment costs were lower (p = 0.012), and patient satisfaction was higher (p < 0.001) after arthroscopic repair. The improved functional outcome appeared to be mediated through the prevention of instability since the functional outcome in patients with stable shoulders was similar, irrespective of the initial treatment allocation. The patients who had a Bankart repair and played contact sports were also more likely to have returned to their sport at two years (relative risk = 3.4, p = 0.007). CONCLUSIONS Following a first-time anterior dislocation of the shoulder, there is a marked treatment benefit from primary arthroscopic repair of a Bankart lesion, which is distinct from the so-called background therapeutic effect of the arthroscopic examination and lavage of the joint. However, primary repair does not appear to confer a functional benefit to patients with a stable shoulder at two years after the dislocation.

Elevated intramuscular compartment pressures do not influence outcome after tibial fracture.

BACKGROUND Although the importance of monitoring differential compartment pressures (Delta P) after tibial fractures has been established, many surgeons continue to use intramuscular pressures in diagnosing compartment syndrome, despite the limitations of this strategy. The cited reason for this is concern over leaving high intramuscular pressures untreated. METHODS One hundred one patients with tibial fractures with satisfactory Delta P were studied. Forty-one patients had elevated intramuscular pressures of over 30 mm Hg for more than 6 hours continuously. These patients were compared with a control group of 60 patients who had pressures of less than 30 mm Hg throughout. Outcome was measured prospectively in terms of muscular power and return to function over the year after injury. RESULTS No significant differences were found. CONCLUSION Provided Delta P remains satisfactory, patients with elevated intramuscular pressures after tibial fracture do not have a greater incidence of complications than those with low pressures. These patients can therefore be observed safely.

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.

Locked volar plating for unstable distal radial fractures: Clinical and radiological outcomes

We studied 40 patients treated with locked volar plates for unstable distal radial fractures. Outcome was assessed at a mean of 59 weeks, both radiologically and functionally using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, range of motion and grip strength. The complication rate in our series was 48%. In 11 cases, screw penetration into the radiocarpal joint occurred as a consequence of postoperative collapse. Of these, 25% had malunited and 12.5% ruptured their extensor pollicus longus (EPL) tendon. Functionally, when compared with the contralateral side, 74% of extension, 67% of flexion, 91% of pronation and supination and 81% of grip strength were regained. The mean DASH score was 23. Although locked volar plates can achieve good results in the management of unstable distal radial fractures, there remains a high major complication rate. They should be used with caution particularly in fractures with significant metaphyseal comminution.

Prediction of outcome after humeral diaphyseal fracture.

PURPOSE The aim of this study is to examine the demographic factors, functional outcome and radiological data to predict the outcome of humeral diaphyseal fractures. METHODS We performed a prospective study on a consecutive series of 110 patients of 16 years or over, who had sustained a humeral diaphyseal fracture. There were 42 males and 68 females, with an average age of 59 years (range 16-93 years). A total of 72% sustained low-energy injuries, and 89 patients (81%) were primarily treated non-operatively. Shoulder function was assessed using the Neers and Constants scores at 8 weeks, 3 months, 6 months and 1 year after injury. Muscle strength was determined isokinetically using a Biodex System 2 dynamometer. Non-union was defined as a failure to bridge at least three cortices and persistence of tenderness or mobility at the fracture site 16 weeks after fracture. RESULTS Sixteen patients (17%) had non-union at 16 weeks, while 80 had achieved union and a further 14 were lost to follow-up. After stepwise multiple linear regression was performed to isolate independent factors affecting outcome, only the presence of a proximal diaphyseal fracture was found to predict non-union along with a poor Neers score at 8 and 12 weeks. Poor Neers scores could be predicted at 26 weeks by age (P<0.05), previous stroke (P<0.001) and non-union (P<0.001). At 52 weeks both age (P<0.01) and previous stroke (P<0.01) were independently predictive of poorer Neers scores. Malunion of any degree had no detectable effect on function. CONCLUSIONS Our results indicate that non-union of humeral diaphyseal fractures can be predicted in the presence of a proximal third fracture with a Neers score of less than 45 by 12 weeks after fracture. Early surgery improves early function, but this is not a lasting effect. Poor shoulder function is predicted by increasing age, proximal third fractures and non-union. We recommend that surgery to promote union be considered at 12 weeks after fracture in fit patients with fractures of the proximal third of the humerus, poor Neers scores and no radiographic progression to union.

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 axillary nerve function and functional outcome after fixation of complex proximal humeral fractures using the extended deltoid-splitting approach

BACKGROUND AND PURPOSE The extended deltoid-splitting approach was developed as an alternative to the deltopectoral approach in the treatment of three- and four-part proximal humeral fractures. The aim of our prospective study was to determine whether this approach was associated with evidence of nerve injury, functional deficits or other complications in these cases, during the first year following reconstruction. METHODS Over a 1-year-period, we treated 14 people (median age 59 years) with open reduction and plate fixation using the extended deltoid-splitting approach. All were prospectively reviewed clinically and radiologically during the first year after surgery. Functional testing involved three scoring systems, spring balance testing of deltoid power, dynamic muscle function testing and, at 1 year, electrophysiological assessment of axillary nerve function. RESULTS Of the 14 fractures, 13 united without complications and with comparatively minor residual functional deficits. Of these 13 cases, 1 showed slight neurogenic change in the anterior deltoid but no evidence of anterior deltoid paralysis. In the remaining case, osteonecrosis of the humeral head developed 9 months after surgery and functional scores were poor, but without evidence of nerve injury on electrophysiological testing. CONCLUSIONS This technique is a useful alternative in the treatment of complex proximal humeral fractures, providing good access for reduction and implant placement without adverse effects.

Socioeconomic deprivation predicts outcome following radial head and neck fractures

INTRODUCTION There is increasing evidence demonstrating an association between fracture epidemiology and socioeconomic status. However, the influence of socioeconomic deprivation on fracture outcome has not been documented before. The aim of this study was to determine if socioeconomic deprivation influenced the short-term outcome following a fracture of the radial head or neck. METHODS We identified from a prospective database all patients who sustained a radial head or neck fracture over an 18-month period. The primary outcome measure for this study was the patient-reported short musculoskeletal function assessment (SMFA). The Index of Multiple Deprivation (IMD) was used to quantify deprivation, and any correlation with functional outcome was determined. Multivariate regression analysis was used to determine the influence of deprivation on outcome once other significant demographic and fracture characteristics had been accounted for. RESULTS There were 200 patients in the study cohort, of which 107 (53.5%) were female and the mean age was 44 years (16-83). At a mean follow-up of 6 months the median SMFA score was 0.54 (0-55.4). The SMFA was found to be influenced by the IMD, with increasing deprivation associated with a poorer outcome (p=0.006). On multivariate analysis, the AO fracture classification, compensation and increasing deprivation were the only independent predictors of outcome (all p<0.05). CONCLUSIONS We have a shown a clear correlation between functional outcome and socioeconomic status, with the most deprived patients reporting a poorer outcome. Future work should be aimed at determining which aspects of deprivation influence patient outcome, with modifiable factors targeted in future health-care planning.