Kate E. Bugler

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 treatment of unstable fractures of the ankle using the Acumed fibular nail: Development of a technique

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion. Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

Nonoperative Management of Displaced Olecranon Fractures in Low-Demand Elderly Patients

BACKGROUND The aim of this study was to document both the short and the long-term outcomes following primary nonoperative management of isolated displaced fractures of the olecranon. METHODS We identified, from our prospective trauma database, all patients who had been managed nonoperatively for a displaced olecranon fracture over a thirteen-year period. Inclusion criteria included all isolated fractures of the olecranon with >2-mm displacement of the articular surface. The primary short-term outcome measure was the Broberg and Morrey Elbow Score. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS There were forty-three patients with a mean age of seventy-six years (range, forty to ninety-eight years) in the study cohort. A low-energy fall from a standing height accounted for 84% of all injuries, and one or more comorbidities were documented in thirty-eight patients (88%). At a mean of four months (range, 1.5 to ten months) following injury, the mean Broberg and Morrey score was 83 points (range, 48 to 100 points), with 72% of the patients having an excellent or good short-term outcome. No patient underwent surgery for a symptomatic nonunion. At a mean of six years (range, two to fifteen years) postinjury, the mean DASH score was 2.9 points (range, 0 to 33.9 points) and the mean Oxford Elbow Score was 47 points (range, 42 to 48 points); 91% (twenty-one) of twenty-three patients available for follow-up expressed satisfaction with the result of the procedure. CONCLUSIONS We found satisfactory short-term and long-term outcomes following the nonoperative management of isolated displaced olecranon fractures in older, lower-demand patients.

A prospective randomised controlled trial of the fibular nail versus standard open reduction and internal fixation for fixation of ankle fractures in elderly patients

AIMS The fundamental concept of open reduction and internal fixation (ORIF) of ankle fractures has not changed appreciably since the 1960s and, whilst widely used, is associated with complications including wound dehiscence and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using a fibular nail, wires or screws is biomechanically stronger, requires minimal incisions, and has low-profile hardware. We hypothesised that fibular nailing in the elderly would have similar functional outcomes to standard fixation, with a reduced rate of wound and hardware problems. PATIENTS AND METHODS A total of 100 patients (25 men, 75 women) over the age of 65 years with unstable ankle fractures were randomised to undergo standard ORIF or fibular nailing (11 men and 39 women in the ORIF group, 14 men and 36 women in the fibular nail group). The mean age was 74 years (65 to 93) and all patients had at least one medical comorbidity. Complications, patient related outcome measures and cost-effectiveness were assessed over 12 months. RESULTS Significantly fewer wound infections occurred in the fibular nail group (p = 0.002). At one year, there was no evidence of difference in mean functional scores (Olerud and Molander Scores 63; 30 to 85, versus 61; 10 to 35, p = 0.61) or scar satisfaction. The overall cost of treatment in the fibular nail group was £91 less than in the ORIF group despite the higher initial cost of the implant. CONCLUSION We conclude that the fibular nail allows accurate reduction and secure fixation of ankle fractures, with a significantly lower rate of soft-tissue complications, and is more cost-effective than ORIF. Cite this article: Bone Joint J 2016;98-B:1248-52.

Changing epidemiology of adult fractures in Scotland

Background Fracture epidemiology in adults is changing but there is very little information about the rate of change or whether the change affects males and females equally. Methods We have compared fracture incidence in two similar populations 50–60 years apart. A study of fractures in Dundee, Scotland and Oxford, England, in 1954–1958, was compared with a similar cohort of fractures in Edinburgh, Scotland, in 2010–2011. Fracture incidence in patients >35 years was recorded in both time periods. Results The incidence of fractures increased by 50% between the two time periods, although the increase in males was only 5% compared with 85% in females. The spectrum of fractures has changed considerably, and there has been an increase in the incidence of both fragility and non-fragility fractures. Analysis showed an increased incidence of fall-related fractures in all age groups in both males and females. Interpretation There has been a substantial change in the incidence of fractures in the last 50–60 years. These have been caused by greater longevity and by considerable social and economic changes.

Open fractures in the elderly. The importance of skin ageing.

Open fractures in the elderly are rare and there is little information about them. We have reviewed 484 open fractures in patients aged ≥65 years over a 15-year period and compared them with 1902 open fractures in patients <65 years treated in the same period. The incidence of open fractures increased significantly with age. The incidence of open fractures in patients aged <65 years was 296.6/10(6)/year compared which increased to 332.3/10(6)/year in patients aged ≥65 years and further still to 446.7/10(6)/year in the super-elderly aged ≥80 years The fracture distribution curves show that males aged 15-19 years and females aged ≥90 years have a very similar incidence of open fractures. In males the incidence declines almost linearly, whereas in females there is a steady increase in fracture incidence with age until the 7th decade of life when the incidence rises sharply. About 60% of open fractures in the elderly follow a fall and most fractures are caused by low energy injuries. Despite this there is a high incidence of Gustilo Type III fractures, particularly in females. The commonest open fractures in females are those of the distal radius and ulna, fingers, tibia and fibula and ankle, all fractures with subcutaneous locations. It has been shown that ageing alters the mechanical properties of skin and we believe that this accounts for the increased incidence of open fractures in elderly females which occurs about 1 decade after the post-menopausal increase in fracture incidence.

The spectrum of open fractures of the foot in adults.

Background: Open foot fractures are rare, and few surgeons see the whole spectrum of these injuries. There has been no previous study of the epidemiology and severity of open foot fractures. Methods: A 23-year study of the epidemiology of open fractures was undertaken in a hospital with a catchment area of about 530 000 adults. The results were used to calculate the incidences of open foot fractures and to study their epidemiology and severity. Results: In 23 years, 348 open foot fractures were treated. Analysis showed 3 levels of severity with the least severe fractures being isolated open forefoot fractures, which occurred in 69% of the patients. Patients with multiple forefoot fractures had a higher Injury Severity Score (ISS), prevalence of Gustilo type III fractures, and amputation rate. The most severely injured patients presented with open hindfoot and midfoot fractures. They had an average ISS of 12, and 65.9% had Gustilo type III fractures. In patients with open hindfoot fractures, the amputation rate was 17.1%. This rose to 30% in patients with open midfoot fractures. Open foot fractures tended to occur in younger patients, and only 13% were in patients aged at least 65 years. Conclusions: Open foot fractures are uncommon. There were 3 levels of injury. Level 1 injuries were isolated fractures of the forefoot. Level 2 injuries were multiple forefoot fractures, and level 3 injuries were open fractures of the midfoot and hindfoot. These were severe injuries with a high amputation rate. They should be treated in level 1 trauma centers. Level of Evidence: Level III, retrospective comparative series.

Open Finger Fractures: Incidence, Patterns of Injury and the Influence of Social Deprivation

BACKGROUND This study investigates the patterns and epidemiology of open finger fractures. There is little good data about these injuries. METHODS Data were collected prospectively in a single trauma unit serving a well-defined population. RESULTS Over a 15 year period 1090 open finger fractures were treated in 1014 patients. These made up the vast majority of open fractures treated in the trauma unit during this period. The incidence of open finger fractures was 14.0 per 100,000 patients per year. Deprivation did not influence the incidence of open finger fractures but did affect treatment choices for women. Most open finger fractures resulted from crush injuries or falls and required only simple operative treatments: debridement, lavage and early mobilization. CONCLUSIONS Open finger fractures formed the majority of the workload of open fractures at our trauma centre but usually required simple treatments only. Social deprivation was not shown to influence the patterns or epidemiology of these injuries but did affect treatment choices for women.