R.M. Smith

Injury patterns associated with mortality following motorcycle crashes

All patients involved in motorcycle crashes admitted to various hospitals in the Yorkshire region of UK between January 1993 and December 1999 were retrospectively reviewed to identify the factors that are likely to predict a reduced survival. Of the 1239 patients requiring hospital admission, 74 died. The probability of reduced survival was estimated by a logistic regression model using independent variables such as head injury, thoracic trauma, abdominal injury, spinal injury and pelvic fracture and a compound variable of pelvic fracture combined with a long bone fracture. The odds ratio for head injury was 0.349, chest injury 0.39, abdominal injury 0.42, and the compound variable (pelvis plus a long bone fracture) 0.576. The mean injury severity score (ISS) in the fatal group was 35.96 compared to 12.2 in the group that survived (P<0.01). There was a significant difference in the Glasgow coma scale (GCS) between patients wearing a helmet and those that did not wear any protective headgear (P=0.0007). Head injury followed by chest and abdominal trauma were found to predict a reduced survival rate. Use of helmets should continue to be compulsory. Chest and abdominal injuries should be diagnosed and treated early to reduce mortality.

Reamed against unreamed nailing of the femoral diaphysis: a retrospective study of healing time

In order to assess the results of the AO unreamed femoral nail (URFN), and specifically its effects on healing, 147 consecutive patients treated were reviewed. These included 50 reamed femoral nails (RFN) and 97 unreamed femoral nails. Exclusion of pathological fractures, revisions and fractures outside the femoral diaphysis left 51 procedures in which the healing process could be studied. Twenty-four unreamed and 27 reamed femoral nails in patients with diaphyseal fractures AO (32) were followed up by clinical review and radiographically until union or death. There were two deaths from multiple injuries (one in each group) and two non-unions (at 52 weeks), one in each group. There were no cases of infection, angular deformity of leg length discrepancy; two cases required early rotational correction. There was a single broken distal locking screw in the URFN group but no other implant failures. The fractures in the URFN cases took longer to heal with a mean of 26.9 weeks as opposed to 20.5 weeks in the RFN group (P = 0.009). This did not cause a significant clinical problem. The URFN proved easy to use with a much shorter operation time.

Exchange nailing for femoral shaft aseptic non-union

Although rare, non-union of femoral shaft fractures is a cause of significant morbidity. In aseptic non-union, excellent union rates have historically been reported following reamed exchange femoral nailing. However, recently, a high incidence of failure requiring additional procedures has been reported. In light of these concerns and a recent change in our practice to the use of thin solid nails we undertook a retrospective study to determine the efficacy of exchange nailing with these modern nails in our hands. We reviewed records and radiographs of 25 patients who had a reamed exchange femoral nailing for established aseptic non-union. 24 patients (96%) united after exchange without the need for an additional procedure. The mean time to union was 29.75 weeks. Patients who had open bone grafting performed at the same procedure tended to unite quicker, but this did not achieve statistical significance (p = 0.14). Union times were not affected by smoking habits or nail type. This study demonstrates that reamed exchange nailing for aseptic femoral non-union remains an effective treatment. We believe that the nail type is less important than the biological effects of reaming, bone grafting and dynamization.

Heterotopic ossification: a comparison between reamed and unreamed femoral nailing.

Heterotopic ossification in the abductor region of the hip following reamed intramedullary femoral nailing has an incidence as high as 68 per cent. A definitive triggering factor for heterotopic ossification remains obscure, but it has been suggested that there may be both local and systemic influences. Previous work has only been able to show a statistical correlation with systemic factors. Sixty antegrade femoral nailings were performed in 58 patients, of which 32 were unreamed. There was no significant difference between the two groups for systemic risk factors known to have statistical correlation with the formation of heterotopic bone. The incidence of heterotopic ossification in the reamed nail group was 35.7 per cent and 9.4 per cent in the unreamed nail group (P = 0.01). The difference in the incidence of heterotopic bone formation seems to be due to local factors, in particular the generation of osteogenic reaming debris, which are important in the pathophysiology of heterotopic ossification seen in femoral intramedullary nailing.

Segmental tibial fractures: an assessment of procedures in 27 cases

Twenty-seven patients (two women) with segmental tibial fractures (19 open) were treated in our institution with a mean age of 38.9 years (range 22-67 years) and a mean Injury Severity Score of 11.5 (9-34). Sixteen fractures were stabilised initially with an interlocking nail, seven with an external fixator, one with a hybrid external fixator, two cases were plated and one was treated in plaster. The mean size of the segment was 11.5 cm (range 4-20 cm). Soft tissue coverage was required in 17 cases. There were three cases of compartment syndrome, six cases of superficial infection and four deep infection cases (two of which required amputation). In four cases, excision of the non-viable segment was necessary. Overall, 13 patients were subjected to a second operative procedure (OP) (four external fixators were replaced with the AO solid tibial nail, two Ilizarov bone transports following excision of the dead bone segment, 2 below knee amputations, 3 exchange reamed nailings, 1 LISS plate application for stability and 1 ring fixator for compression of a fracture). Five patients underwent third procedure (two Ilizarov for bone transport, two exchange nailing, and one bone grafting). The mean time to union of the proximal segment was 38.8 weeks (range 10-78 weeks) and 41.4 weeks (range 12-65 weeks) for the distal segment, respectively. The treatment of segmental tibial fractures poses many problems to the surgeon due to the precarious blood supply of the intermediate segment. The risk of non-union delayed union, infection and additional procedures is high as seen in this series of patients.

Removal of the retained fragment of broken solid nails by the intra-medullary route

The development of solid nails has not eliminated the risk of occasional nail failure. It has been suggested that subsequent intra-medullary removal of solid nail fragment may be virtually impossible and thus major surgery is required for their revision. We report two cases of hardware failure of a solid intra-medullary nail (Synthes solid femoral and tibial nail) and describe their successful intra-medullary removal using the Synthes extraction kit.

Operative stabilisation of painful non-united multiple rib fractures.

Traumatic rib fractures are very common injuries. They account for 10% of admissions for blunt trauma [1]. Severe chest wall injuries produce significant management problems in the acute stage often requiring admission to intensive care unit for pain management and ventilatory support. Increasing number of rib fractures and advanced age are associated with increasing patient morbidity and mortality after blunt trauma [2]. However, long-term problems are rare, with the majority of rib fractures healing with minimal intervention. We report a case of a painful non-union of several fractured ribs, in a patient who presented to our institution almost a year following spontaneous fracture of the lower ribs. This was treated by means of open reduction and internal fixation using reconstruction plates and screws.

Unusual presentation of sciatica in a 14-year-old girl.

The sciatic nerve can be compressed by a variety of causes, while intervertebral disc herniation is the most common cause of sciatica [Surg. Neurol. 46 (1996) 14], other documented causes include, infection, neoplasm, degenerative disease of a spine, congenital anomalies and traumatic posterior hip dislocation [BMJ 287 (1983) 157]. Sciatic neuropathy in children is uncommon. We present an unusual case of sciatic nerve compression in a 14-year-old-girl that was caused by an avulsion fracture of the ischial tuberosity. The compression was relieved by surgical excision of the avulsed ischial tuberosity.

Post-traumatic giant intraarticular synovial osteochondroma of the knee.

Secondary synovial chondromatosis is a well-recognised cause of intraarticular loose bodies of the knee joint. Although usually associated with degenerative arthritis of the adjacent joint surfaces, the phenomenon is less common following trauma. In addition, giant lesions from any cause are rarely seen in the knee joint. We describe a giant synovial osteochondroma measuring 7.5×5×4 cm following a football injury in which an osteochondral fracture of the medial femoral condyle occurred. The lesion was confirmed arthroscopically, but arthrotomy was required to remove it.

Compartment syndrome following isolated ankle fracture

Abstract We report two cases of compartment syndrome following isolated ankle fractures. Both required decompression of all the compartments following early clinical diagnosis and measurements of the intra-compartmental pressures.Résumé  Nous rapportons deux cas de syndrome de loge qui suit des fractures de la cheville isolées. Les 2 cos ont nécessité une décompression de tous les compartiments aprés un diagnostic précoce et la prise des pressions intra-compartimentales.