Margaret M. McQueen

The epidemiology of proximal humeral fractures

We present a 5-year prospective study of the epidemiology of 1,027 proximal humeral fractures. These fractures, which tend to occur in fit elderly persons, have a unipolar age distribution and the highest age-specific incidence occurs in women between 80 and 89 years of age. The commonest was the B1.1 impacted valgus fracture, found in one-fifth of the cases in this series, a type that is not included in the Neer classification. We used both Neer and AO classifications. The AO classification proved to be more comprehensive because in the Neer classification, half of the fractures are minimally displaced and almost nine-tenths fall into only three categories. In the AO classification, the B1.1, A2.2, A3.2 and A1.2 sub-groups comprise over half of all proximal humeral fractures, while the AO type C fractures occur in only 6%. We suggest that the literature does not adequately reflect the spectrum of proximal humeral fractures.

Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture

BACKGROUND Nonunion is a rare complication of a fracture of the clavicle, but its occurrence can compromise shoulder function. The aim of this study was to evaluate the prevalence of and risk factors for nonunion in a cohort of patients who were treated nonoperatively after a clavicular fracture. METHODS Over a fifty-one-month period, we performed a prospective, observational cohort study of a consecutive series of 868 patients (638 men and 230 women with a median age of 29.5 years; interquartile range, 19.25 to 46.75 years) with a radiographically confirmed fracture of the clavicle, which was treated nonoperatively. Eight patients were excluded from the study, as they received immediate surgery. Patients were evaluated clinically and radiographically at six, twelve, and twenty-four weeks after the injury. There were 581 fractures in the diaphysis, 263 fractures in the lateral fifth of the clavicle, and twenty-four fractures in the medial fifth. RESULTS On survivorship analysis, the overall prevalence of nonunion at twenty-four weeks after the fracture was 6.2%, with 8.3% of the medial end fractures, 4.5% of the diaphyseal fractures, and 11.5% of the lateral end fractures remaining ununited. Following a diaphyseal fracture, the risk of nonunion was significantly increased by advancing age, female gender, displacement of the fracture, and the presence of comminution (p < 0.05 for all). On multivariate analysis, all of these factors remained independently predictive of nonunion, and, in the final model, the risk of nonunion was increased by lack of cortical apposition (relative risk = 0.43; 95% confidence interval = 0.34 to 0.54), female gender (relative risk = 0.70; 95% confidence interval = 0.55 to 0.89), the presence of comminution (relative risk = 0.69; 95% confidence interval = 0.52 to 0.91), and advancing age (relative risk = 0.99; 95% confidence interval = 0.99 to 1.00). Following a lateral end fracture, the risk of nonunion was significantly increased only by advancing age and displacement of the fracture (p < 0.05 for both). On multivariate analysis, both of these factors remained independently predictive of nonunion (p < 0.05), and, in the final model, the risk of nonunion was increased by a lack of cortical apposition (relative risk = 0.38; 95% confidence interval = 0.25 to 0.57) and advancing age (relative risk = 0.98; 95% confidence interval = 0.97 to 0.99). CONCLUSIONS Nonunion at twenty-four weeks after a clavicular fracture is an uncommon occurrence, although the prevalence is higher than previously reported. There are subgroups of individuals who appear to be predisposed to the development of this complication, either from intrinsic factors, such as age or gender, or from the type of injury sustained. The predictive models that we developed may be used clinically to counsel patients about the risk for the development of this complication immediately after the injury.

Prospective Randomized Controlled Trial of an Intramedullary Nail Versus Dynamic Screw and Plate for Intertrochanteric Fractures of the Femur

Objectives To compare the surgical complications and functional outcome of the Gamma nail intramedullary fixation device versus the Richards sliding hip screw and plate device in intertrochanteric femoral fractures. Design A prospective, randomised controlled clinical trial with observer blinding. Setting A regional teaching hospital in the United Kingdom. Patients All patients admitted from the local population with intertrochanteric fractured femurs were included. There were 400 patients entered into the study and 399 followed-up to one year or death. Intervention The devices were assigned by randomization to either a short-type Gamma nail (203 patients) or a Richards-type sliding hip screw and plate (197 patients). Main Outcome Measurements The main surgical outcome measurements were fixation failure and reoperation. A functional outcome of pain, mobility status, and range of movement were assessed until one year. Results The requirement for revision in the Gamma nail group was twelve (6%); for Richards group, eight (4%). This was not statistically different (p = 0.29; odds ratio, 1.48 [0.59–3.7]). A subcapital femoral fracture occurred in the Richards group. Femoral shaft fractures occurred with four in the Gamma nail group (2%) and none in the Richards group (p = 0.13). Three required revision to another implant. Lag-screw cut-out occurred in eight patients in the gamma nail group (4%) and four in the Richards group (2%). This was not statistically significant (p = 0.37; odds ratio, 2.29 [0.6–9.0]). The development of other postoperative complications was the same in both groups. There was no difference between the two groups in terms of early or long-term functional status at one year. Conclusions The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications. Routine use of the Gamma nail in this type of fracture cannot be recommended over the current standard treatment of dynamic hip screw and plate.

Closed intramedullary tibial nailing. Its use in closed and type I open fractures

We present the results of using the Grosse-Kempf interlocking nail in the management of 125 closed and type I open tibial fractures. The mean time to union was 16.7 weeks and no fracture required bone grafting. Mobilisation of the patient and the range of joint movement were better than with other methods of treating tibial fractures. There was a 1.6% incidence of infection; 40.8% of patients had knee pain and 26.4% needed to have the nail removed. Other complaints were minor. We suggest that closed intramedullary nailing with an interlocking nail system is an excellent method of treating closed and type I open tibial fractures.

Prediction of instability in distal radial fractures.

BACKGROUND Effective methods of treating an unstable distal radial fracture are described in the literature, but there is no reliable method of identifying an unstable fracture in time to initiate appropriate treatment. The purposes of this study were to identify the predictors of fracture instability and to construct a method of prospectively predicting the radiographic outcome. METHODS Data on approximately 4000 distal radial fractures were prospectively recorded over a 5.5-year period. The database was validated by reexamining a sample of it. Demographic data on the patients and mode of injury, as well as the fracture classification and measurements, were recorded at the time of presentation. Outcome measures consisted of radiographic measurements made at one week and six weeks and assessment of carpal alignment at six weeks. Univariate and multiple logistic regression analyses were performed to identify the significance of the data obtained at presentation in the prediction of early and late instability as well as the risk of malunion and carpal malalignment. RESULTS The predictors of early and late instability and malunion differed according to the displacement of the fracture at presentation. Patient age, metaphyseal comminution of the fracture, and ulnar variance were the most consistent predictors of radiographic outcome. Dorsal angulation was not found to be significant in the prediction of radiographic outcome for displaced fractures. The degree to which the patient was independent was predictive of malunion in minimally displaced and displaced fractures. Formulas that are predictive of each of the seven radiographic outcome measurements were constructed. CONCLUSIONS The study succeeded in identifying the factors that are prognostic of the radiographic outcome for distal radial fractures. Formulas to predict the radiographic outcome were constructed as the independent prognostic significance of these factors was quantified. These formulas can be used to inform the surgeons decision about the nature of primary treatment of fractures of the distal aspect of the radius. However, they must be validated by further studies before they are used to impact the management of distal radial fractures. LEVEL OF EVIDENCE Prognostic Level I.

REDISPLACED UNSTABLE FRACTURES OF THE DISTAL RADIUS: A PROSPECTIVE RANDOMISED COMPARISON OF FOUR METHODS OF TREATMENT

We performed a prospective, randomised trial on 120 patients with redisplaced fractures of the distal radius comparing four methods of treatment. The four treatment groups, each containing 30 patients, were remanipulation and plaster, open reduction and bone grafting, and closed external fixation with and without mobilisation of the wrist at three weeks. The radiological results showed improvement in angulation of the distal radius for the open reduction and bone grafting group. Functional results at six weeks, three and six months and at one year, however, showed no difference between any of the four groups. The main influence on final outcome was carpal malalignment which had a statistically significant negative effect on function.

Acute compartment syndrome

We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure.

The translated two-part fracture of the proximal humerus: EPIDEMIOLOGY AND OUTCOME IN THE OLDER PATIENT

We have undertaken a five-year prospective study of 126 translated two-part fractures of the proximal humerus and present an analysis of the epidemiology and of the factors which affect outcome in elderly patients. The fracture has a unimodal age distribution and rarely affects adults under the age of 50 years. Analysis showed that patients with two-part translated fractures of the surgical neck tended to be independent and relatively fit, despite the fact that their mean age was 72 years. Outcome was determined by the age of each patient and the degree of translation on the initial anteroposterior radiograph. Surgery did not improve the outcome, regardless of the degree of translation.

Locked intramedullary nailing of open tibial fractures

We report the use of Grosse-Kempf reamed intramedullary nailing in the treatment of 41 Gustilo type II and III open tibial fractures. The union times and infection rates were similar to those previously reported for similar fractures treated by external skeletal fixation, but the incidence of malunion was less and fewer required bone grafting. The role of exchange nailing is discussed and a treatment protocol is presented for the management of delayed union and nonunion.

Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period

We report the results of locked Seidel nailing for 30 fractures of the humerus. There were frequent technical difficulties at operation especially with the locking mechanisms. Protrusion of the nail above the greater tuberosity occurred in 12 cases, usually due to inadequate locking, and resulted in shoulder pain and poor function. Poor shoulder function was also seen in five patients with no nail protrusion, presumably because of local rotator cuff damage during insertion. Our results suggest that considerable modifications are required to the nail, and possibly to its site of insertion, before its use can be advocated.