Konrad I. Gruson

The relationship between admission hemoglobin level and outcome after hip fracture

Objective: To determine the effect of admission hemoglobin level on patient outcome after hip fracture. Study Design: Prospective, consecutive. Patients: From July 1991 to June 1997, 395 communitydwelling patients sixty‐five years of age or older who had sustained an operatively treated femoral neck or intertrochanteric fracture were prospectively followed up. Main Outcome Measurements: Postoperative complications, in‐hospital mortality rate, hospital length of stay, hospital discharge status, place of residence at one year, and mortality and recovery of ambulatory ability and activities of daily living status at three, six, and twelve months. Results: Women with admission hemoglobin levels below 12.0 grams per deciliter and men with admission hemoglobin levels below 13.0 grams per deciliter were classified as anemic. One hundred eighty patients (45.6 percent) were considered anemic on admission. Patients who were anemic were more likely to have an American Society of Anesthesiologists rating of III or IV and have sustained an intertrochanteric fracture. Hospital length of stay and mortality rate at six and twelve months were significantly higher for patients who were anemic on admission. There were no differences in the incidence of postoperative complications, hospital discharge status, place of residence at one year, in‐hospital mortality rate, and three‐month mortality rate between patients who were and were not anemic on admission. In addition, there were no differences in the recovery of ambulatory ability and of basic and instrumental activities of daily living status at three, six, and twelve months between the two patient groups. Conclusions: Patients at risk for poor outcomes after hip fracture can be identified by assessing hemoglobin levels at hospital admission.

Isolated tuberosity fractures of the proximal humerus: Current concepts

Despite the relatively common occurrence of fractures of the proximal humeral amongst the elderly, the subgroup of isolated greater and lesser tuberosity fractures have remained less well understood. While the majority of two-part fractures result from a standing-height fall onto an outstretched hand, isolated tuberosity fractures are also commonly associated with glenohumeral dislocations or direct impact to the shoulder region. Inasmuch as isolated greater tuberosity fractures are considered uncommon, isolated lesser tuberosity fractures are generally considered exceedingly rare. Non-operative treatment including a specific rehabilitation protocol has been advocated for the majority of non-displaced and minimally displaced fractures, with generally good outcomes expected. The treatment for displaced fractures, however, has included both arthroscopically assisted fixation and open or percutaneous reduction and internal fixation (ORIF). The choice of fixation and approach depends not only on fracture type and characteristics, but also on a multitude of patient-related factors. With an expected increase in the level of physical activity across all age groups and overall longer lifespans, the incidence of isolated tuberosity fractures of the proximal humeral is expected to rise. Orthopaedic surgeons treating shoulder trauma should be aware of treatment options, as well as expected outcomes.

Subacromial corticosteroid injections

The use of subacromial injections to treat shoulder pain has remained one of the most common procedures for the practicing orthopedist, rheumatologist, and general practitioner. Despite this, many prospective studies have questioned the efficacy of corticosteroid injections compared with nonsteroidal anti-inflammatory drugs or injections of local anesthetics alone, or both, when used for the treatment of symptomatic rotator cuff disease. Accurate diagnosis of the etiology of a patients shoulder pain and proper injection technique are important in achieving satisfactory clinical outcomes. Both extrinsic as well as intrinsic etiologies for rotator cuff disease should be considered and must be elucidated with appropriate physical examination techniques. Although subacromial injections appear straightforward, more recent cadaveric, radiographic, and clinical studies have demonstrated variable accuracy rates using the two common techniques. In addition, absolute sterile technique must be used because infections of the subacromial space after injections, although uncommon, have generally led to debilitating conditions. This article reviews the etiology and pathophysiology of rotator cuff disease and the indications and techniques for subacromial corticosteroid injections.

Injury of the Femoral Nerve Associated with Acetabular Fracture

Background: The purpose of the present study was to document the prevalence of, and recovery from, injuries of the femoral nerve associated with displaced acetabular fractures. Methods: From 1986 to 2001, 726 acetabular fractures were treated with open reduction and internal fixation. Four patients who had an injury of the femoral nerve associated with a displaced acetabular fracture were identified and were followed for a mean of 3.4 years. The nerve injury was iatrogenic in two patients and traumatic in two patients. Results: Clinically detectable quadriceps femoris motor function returned at an average of eighteen weeks (range, four to fifty-two weeks). All patients had satisfactory recovery of nerve function with a return of grade-4 or 5 motor power (the level of motor power needed to allow a normal gait) by an average of ten months (range, three to twenty-four months). Sensory recovery was incomplete but not debilitating. Conclusions: Preoperative examination of a patient who has an acetabular fracture should include an assessment of femoral nerve function. Regardless of whether the injury is traumatic or iatrogenic in origin, recovery of motor and sensory function without surgical exploration can be expected. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.