Seamus Morris

Birth-associated femoral fractures: Incidence and outcome

Femoral fractures resulting from birth injuries are rare. The authors undertook a study to assess their incidence and outcome. Seven patients from a total of 55,296 live births suffered 8 femoral fractures (incidence 0.13 per 1,000 live births). Twin pregnancies, breech presentations, prematurity, and disuse osteoporosis were associated with the occurrence of a fracture. The typical injury pattern was a spiral fracture of the proximal half of the femur, which was held in an extended position. A variety of treatment modalities were used, including gallows traction, spica cast, and Pavlik harness. All patients in this study, regardless of treatment, had a satisfactory clinical outcome, with no evidence of limb length discrepancy or angular deformity on follow-up.

Clavicle hook plate fixation for displaced lateral-third clavicle fractures (Neer type II): a functional outcome study

BACKGROUND Controversy exists with the use of the acromioclavicular hook plate for the treatment of lateral-third clavicle fractures (Neer type II). This is thought to stem from problems associated with the hook plate causing impingement symptoms, which can cause long-term limitation of movement and pain. Our aim was to evaluate the functional outcomes of patients with lateral-third clavicle fractures treated with the hook plate. METHODS We prospectively reviewed all patients who underwent surgery from July 2005 to August 2009 using our prospectively recorded electronic patient information database. All patients were assessed in the clinic to determine both Oxford and Constant shoulder scores. RESULTS We identified 36 patients who underwent surgery with the hook plate, 26 men and 10 women. The mean age was 36.2 years (range, 22-60 years). Of the patients, 46% were smokers. The median length of hospital stay was 2 days (interquartile range [IQR], 1-3). The median follow-up was 28 months (IQR, 23-37). The median time from date of injury to surgery was 7 days (IQR, 4-76). The mean time to union was 3 months (IQR, 2-4), and the union rate was 95%. In total, 92% of plates were removed. The median time to removal was 4.5 months (IQR, 3-8.75). There were no complications. Two patients presented months later after falls with fractures around the medial end of the hook plate. CONCLUSION Hook plates are an effective form of treatment for lateral third clavicle fractures. The best outcomes occur with plate removal before 6 months postoperatively, provided that the fracture has healed.

Complications in the management of metastatic spinal disease

Metastatic spine disease accounts for 10% to 30% of new cancer diagnoses annually. The most frequent presentation is axial spinal pain. No treatment has been proven to increase the life expectancy of patients with spinal metastasis. The goals of therapy are pain control and functional preservation. The most important prognostic indicator for spinal metastases is the initial functional score. Treatment is multidisciplinary, and virtually all treatment is palliative. Management is guided by three key issues; neurologic compromise, spinal instability, and individual patient factors. Site-directed radiation, with or without chemotherapy is the most commonly used treatment modality for those patients presenting with spinal pain, causative by tumours which are not impinging on neural elements. Operative intervention has, until recently been advocated for establishing a tissue diagnosis, mechanical stabilization and for reduction of tumor burden but not for a curative approach. It is treatment of choice patients with diseaseadvancement despite radiotherapy and in those with known radiotherapy-resistant tumors. Vertebral resection and anterior stabilization with methacrylate or hardware (e.g., cages) has been advocated.Surgical decompression and stabilization, however, along with radiotherapy, may provide the most promising treatment. It stabilizes the metastatic deposited areaand allows ambulation with pain relief. In general, patients who are nonambulatory at diagnosis do poorly, as do patients in whom more than one vertebra is involved. Surgical intervention is indicated in patients with radiation-resistant tumors, spinal instability, spinal compression with bone or disk fragments, progressive neurologic deterioration, previous radiation exposure, and uncertain diagnosis that requires tissue diagnosis. The main goal in the management of spinal metastatic deposits is always palliative rather than curative, with the primary aim being pain relief and improved mobility. This however, does not come without complications, regardless of the surgical intervention technique used. These complication range from the general surgical complications of bleeding, infection, damage to surrounding structures and post operative DT/PE to spinal specific complications of persistent neurologic deficit and paralysis.

Skype: a tool for functional assessment in orthopaedic research

Skype is a free program which enables PC users to make video calls to other users with Internet access. We carried out a prospective review of all acromioclavicular joint hook plates for lateral-third clavicle fractures over a five-year period. Functional assessment with Oxford and Constant shoulder scores were carried out using Skype and compared to outpatient review using the Bland-Altman method. Of 36 patients (mean age 36 years), 33 had a computer with a video camera, all 33 had Internet access and 22 were already users of Skype. In total 29 patients were happy to take part in Skype assessment (83%). In comparison with outpatient review, there was a mean difference in the Oxford score of −0.48 (95% confidence interval −0.84, −0.12); the mean difference for the Constant score was −0.68 (95% confidence interval −1.08, −0.29). These differences were not clinically significant, confirming that Skype can be used as an alternative to goniometry in this clinical setting. A survey showed that 93% of 29 patients surveyed preferred the use of Skype for follow-up, mainly due to the convenience and cost-saving involved. The study demonstrates the potential for this new technique in providing patients with more options for follow-up.

Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle.

The medial deltoid ligament is the primary stabilizing structure in the ankle joint following lateral malleolar fracture. However, medial deltoid ligament ruptures are difficult to diagnose using current imaging modalities. We hypothesized that ultrasonography can be used to accurately allow early clinical assessment of ankle fracture stability, thereby negating the need to perform plain film stress views of the acutely injured ankle. This prospective study included 12 patients (age range, 18-72) with supination external rotation fractures requiring operative fixation. Following induction of anesthesia, ultrasonography examination was performed, followed by an arthrogram under fluoroscopic screening. Radiographs, ultrasonography, and arthrographic findings were compared. There was 100% correlation between ultrasonography and arthrogram findings. Ultrasonography accurately diagnosed medial deltoid rupture with a sensitivity of 100% and specificity of 100%. Plain film radiographs of the ankle had a sensitivity of 57.1% and a specificity of 60%. The difference between these was significant (χ(2)=.0091). This study demonstrates diagnostic ultrasonography to be an accurate diagnostic modality in assessing medial deltoid ligament integrity in patients with supination external rotation fractures. It offers the same sensitivity and specificity as arthrography without the need for additional invasive procedures. Its relative ease of use and lack of ionizing radiation make it a potentially useful tool, particularly in a busy trauma service.

A new technique for treatment of a non-union of a lateral humeral condyle

1. Summary We present the case of a 4 year old boy who presented with a displaced lateral humeral condyle fracture which was treated within 24 h with open reduction and internal fixation with two Kirschner wires. Four weeks post-operatively the patient developed a superficial infection at the pin sites, which settled following removal of the wires. It was noted on subsequent follow up that he had a limited range of motion with an extension block of approx. 208. On follow up over the following year it became evident that this patient had developed a non-union of the lateral humeral condyle which was giving rise to a limited range of motion and discomfort (Fig. 1). This was subsequently treated with a novel technique: percutaneous insertion of a cannulated lag screw across the fracture site (Fig. 2). At 18 months follow up the patient’s fracture had proceeded to union and the patient had regained a full range of motion in his elbow (Fig. 3).

Risk factors for surgical site infection following operative ankle fracture fixation

BackgroundAnkle fracture is a common injury and there is an increasingly greater emphasis on operative fixation.AimThe purpose of the study was to determine the complication rate in this cohort of patients and, in doing so, determine risk factors which predispose to surgical site infection.MethodsA prospective cohort study was performed at a tertiary referral trauma center examining risk factors for surgical site infection in operatively treated ankle fractures.ResultsUnivariate and multivariate analysis was performed. Female gender and advancing age were determined to be the risk factors in univariate analysis. Drain usage and peri-operative pyrexia were found to be significant for infection in multivariate analysis.ConclusionThis study allows surgeons to identify those at increased risk of infection and counsel them appropriately. It also allows for a high level of vigilance with regard to soft tissue handling intra-operatively in this higher risk group.

Strong similarities in the creep and damage behaviour of a synthetic bone model compared to human trabecular bone under compressive cyclic loading.

Understanding the failure modes which instigate vertebral collapse requires the determination of trabecular bone fatigue properties, since many of these fractures are observed clinically without any preceding overload event. Alternatives to biological bone tissue for in-vitro fatigue studies are available in the form of commercially available open cell polyurethane foams. These test surrogates offer particular advantages compared to biological tissue such as a controllable architecture and greater uniformity. The present study provides a critical evaluation of these models as a surrogate to human trabecular bone tissue for the study of vertebral augmentation treatments such as balloon kyphoplasty. The results of this study show that while statistically significant differences were observed for the damage response of the two materials, both share a similar three phase modulus reduction over their life span with complete failure rapidly ensuing at damage levels above 30%. No significant differences were observed for creep accumulation properties, with greater than 50% of creep strains being accumulated during the first quarter of the life span for both materials. A significant power law relationship was identified between damage accumulation rate and cycles to failure for the synthetic bone model along with comparable microarchitectural features and a hierarchical composite structure consistent with biological bone. These findings illustrate that synthetic bone models offer potential as a surrogate for trabecular bone to an extent that warrants a full validation study to define boundaries of use which compliment traditional tests using biological bone.

A parametric finite element analysis of the compacted bone-cement interface following balloon kyphoplasty.

Treating fractures of the spine is a major challenge for the medical community with an estimated 1.4 million fractures per annum worldwide. While a considerable volume of study exists on the biomechanical implications of balloon kyphoplasty, which is used to treat these fractures, the influence of the compacted bone–cement region properties on stress distribution within the vertebral body remains unknown. The following article describes a novel method for modelling this compacted bone–cement region using a geometry-based approach in conjunction with the knowledge of the bone volume fractions for the native and compacted bone regions. Three variables for the compacted region were examined, as follows: (1) compacted thickness, (2) compacted region Young’s modulus and (3) friction coefficient. Results from the model indicate that the properties of the compacted bone–cement region can affect stresses in the cortical bone and cement by up to +28% and −40%, respectively. These findings demonstrate the need for further investigation into the effects of the compacted bone–cement interface using computational and experimental methods on multi-segment models.

Impact of road traffic "penalty points" on high energy pelvic trauma

Background: The penalty points system (PPS) was introduced in 2002 in an attempt to reduce the increasing rate of road traffic accident (RTA) related fatalities and serious injuries. Points are awarded based on the severity of the offence and are cumulative. A total of 12 points results in the disqualification from driving. Objective: A few studies have looked at the immediate or short term impact of PPS on trauma services or specific injuries such as spine trauma in Ireland. Little data is available on the long term effect of the PPS. The aim of this study is to see if the PPS system has had an influence on the number of pelvic injuries referred to our unit for surgical intervention and if this influence is sustained in the longer term. Materials and Methods: A retrospective review of all pelvic and acetabular injuries admitted to our unit from 1999 to 2008 was undertaken. The mechanism of injury, the site and patient demographics were noted. Results: A total of 467 patients were identified over the ten year period. 454 patients were included in the study. There was a significant male preponderance of 76%. Mean age was 36.5 years (range 16 to 83). RTAs were the cause in 74% (n = 335) of the cases. The annual work load remained similar over the years. There has been a reduction in the number of RTA related pelvic injuries. There have been notable drops in the number of these cases corresponding to the introduction of the PPS and its subsequent expansion. The number of pelvic injuries due to falls continues to rise. Conslusion: The introduction of the PPS and its subsequent expansion has had a positive influence on the number of RTA related pelvic trauma. Continued surveillance and enforcement of the PPS is important for a sustained benefit from it in the long term.