The clinical characteristics and management of paediatric pelvic fractures: a changing landscape based on skeletal maturity

INTRODUCTION

Paediatric pelvic fractures (PPFs) are uncommon but signify serious trauma. A comprehensive multidisciplinary approach is needed due to a high number of associated injuries. This study aims to retrospectively analyse PPFs over a 5-year period and evaluate how advancing skeletal maturity changes fracture patterns and management plans.

METHODS

The trauma database was retrospectively reviewed for pelvic fractures in patients aged ≤ 18 years. Radiographs and CT scans were used to classify pelvic injuries according to the modified Torode classification and determine the status of the triradiate cartilage (open: skeletally immature; closed: skeletally mature). Data collected also included the mechanism of injury, clinical and functional outcomes, and associated injuries. Logistic regression analysis was performed to identify risk factors for associated abdominal injuries.

RESULTS

65 PPFs (2.8% of paediatric trauma admissions during the study period) were classified as type I (3.1%), type II (7.7%), type IIIa (32.3%), type IIIb (38.5%), type IV (18.5%) according to the modified Torode classification. The mean age was 13.41 ± 3.82. Skeletally immature children were more likely to be hit by a motor vehicle as a pedestrian (p < 0.001), be intubated (p = 0.009), acquire Torode type II (p = 0.047) and rami fractures (p = 0.037), and receive chest (p = 0.005) and head injuries (p = 0.046). Skeletally immature children were also less likely to acquire Torode type IV fractures (p = 0.018), receive surgical treatment for their pelvic injuries (p = 0.036), and had a faster time to full weight bearing (p = 0.013). Pelvis AIS score ≥ 4 (OR 5.3; 95% CI 1.3-22.6; p = 0.023) and a pedestrian accident (OR 4.9; 95% CI 1.2-20.7; p = 0.030) were risk factors for associated abdominal injuries. There was a strong association between a higher pelvic fracture grade and the proportion of patients with closed triradiate cartilage (p = 0.036), hospital length of stay (p = 0.034), mean pelvic AIS score (p = 0.039), a pelvis AIS score of ≥ 4 (p = 0.022), mean ISS (p = 0.003), an ISS score between 25 and 75 (p = 0.004), average time to FWB (p = 0.001), requirement of blood products (p = 0.015), and a motor vehicle accident (p = 0.037).

CONCLUSION

PPFs occurring in skeletally mature and immature patients are significantly different in terms of mechanism of injury, fracture severity, fracture pattern, and management strategy. There is a high rate of associated injuries, necessitating an integrated multidisciplinary approach in paediatric trauma centres.

Increasing the use of perioperative risk scoring in emergency laparotomy: nationwide quality improvement programme

Background

Emergency laparotomy is associated with high morbidity and mortality. The early identification of high-risk patients allows for timely perioperative care and appropriate resource allocation. The aim of this study was to develop a nationwide surgical trainee-led quality improvement (QI) programme to increase the use of perioperative risk scoring in emergency laparotomy.

Methods

The programme was structured using the active implementation framework in 15 state-funded Irish hospitals to guide the staged implementation of perioperative risk scoring. The primary outcome was a recorded preoperative risk score for patients undergoing an emergency laparotomy at each site.

Results

The rate of patients undergoing emergency laparotomy receiving a perioperative risk score increased from 0–11 per cent during the exploratory phase to 35–100 per cent during the full implementation phase. Crucial factors for implementing changes included an experienced central team providing implementation support, collaborator engagement, and effective communication and social relationships.

Conclusions

A trainee-led QI programme increased the use of perioperative risk assessment in patients undergoing emergency laparotomy, with the potential to improve patient outcomes and care delivery.

1022 Equivalent Management for All Fragility Fractures Occurring in The Older Patient

Aim

Neck of femur fractures (NOFs) are painful and occur in a vulnerable group of our population. Complications occur if their pain is under treated. Optimal management in the United Kingdom is governed by Best Practice Tariff (BPT). This was extended in 2020 without supporting published evidence to include all femur fractures (ROFs).

We sought to compare PRPS for NOFs and ROFs throughout hospital admission.

Method

We performed a retrospective matched analysis of all isolated osteoporotic ROFs to NOFs at our centre between 2018-2019. We analysed electronic patient records for relevant data. Matching criteria included Age +/- 2 years; cognition; walking aids; ASA; and social residence. Primary outcome measure was patient-reported pain scores (PRPS) at set time points. Secondary outcome measures were peripheral nerve blocks (PNB); patient controlled analgesia (PCA); time to surgery; anaesthetic type; length of stay (LOS); weightbearing status and 30-day mortality. Data was statistically analysed.

Results

11 ROFs were matched to 104 NOFs. There was no statistical difference between the two groups for age, sex, nor cognition and no difference in time to surgery; anaesthetic type; LOS; nor 30-day mortality. ROFs were more painful at all time points although not statistically significant. ROFs were more likely to have traction; PCA both pre- and post-operatively and not to weight bear. NOFs were more likely to have a PNB.

Conclusions

ROFs are as painful if not more so than NOFs. Few ROFs receive PNB and require PCA. Better control of symptoms may improve outcomes. We support the extension of BPT.

1514 Higher Mortality in Pelvic Acetabular Fractures Is Associated with Lower Body Mass Index

Aim

Fractures of the pelvis and acetabulum can be life-threatening or life changing injuries. Multiple factors can contribute to outcome including age, frailty, and baseline nutritional status. The aim of this study was to identify if low BMI (&lt;18.5) was a predictor of outcome for patients with such injuries in terms of morbidity and mortality.

Method

We retrospectively analysed 1033 patients with pelvic or acetabular fractures referred to a single level 1 major trauma centre over a 4.5-year period (August 2015 - January 2020). Of these patients, 569 were admitted to the centre and included in our analysis. Data was collected on demographics, injury pattern, operative intervention, and complications. Comparison was made between patients that were underweight (BMI&lt;18.5) and patients that were not, for in-hospital and post discharge complications including pulmonary embolus (PE), deep venous thrombosis (DVT), ileus, infection, loss of reduction and mortality at 6 months.

Results

Underweight patients had a statistically significant increase in mortality both in-hospital (p = 0.019) and at 6 months post injury (p = 0.039) when compared to other BMI groups. No statistical significance was found between these BMI groups comparing morbidity: DVT (p = 0.712), PE (p = 0.736) nor ileus (p = 0.149). Covariate analysis showed that a low BMI was associated with 3 times increased in-hospital mortality after correction for age and energy of injury (adjusted OR 3.028, 95% CI 1.059-8.659).

Conclusions

This study suggests increased mortality in patients with pelvic or acetabular fractures who are underweight. Surgeons should consider these findings in initiating appropriate peri-operative optimisation for these patients.

1550 Experience from A Level-1 Major Trauma Centre in England of Trauma Epidemiology After Easing of Lockdown Restrictions

Aim

The COVID-19 pandemic transformed trauma care. We examined the effect of lockdown easing on trauma presentation and management.

Method

Data was retrospectively analysed from Trauma Audit and Research Network (TARN) on patients presenting to one Major Trauma Centre in the East of England with trauma. The first 47 days of lockdown (23rd March-9th May 2020, period 1) were compared with the next (10th May- 26th June 2020, period 2) and last 47 (27th June- 13th August 2020, period 3). Data collected included demographics, mechanism and severity of injury, management, and length of stay.

Results

1,249 patients were included; 62.2% were male with a mean age of 57.73. Footfall declined in April 2020 compared with 2019 (56 vs 143) but rebounded by May (123 v 120 patients). Road traffic collisions increased over periods 1-3 (18.8% v 23% v 30.1%, p = 0.038); deliberate self-harm (DSH) increased in period 2 compared with 1 and 3 (6.3% v 3.4% v 1.4%, p = 0.03) respectively. The 2020 patient age was younger than 2019, with less trauma relating to alcohol (7.3% v 13.2%, p = 0.009). Compared with 2019 reductions in total length of stay (14.1 v 17.4 days, p = &lt;0.001), critical care length of stay (2.3 v 2.9 days, p = 0.04) and consultant driven care (54.9% v 64.9%, p &lt; 0.001) were noted in lockdown.

Conclusions

Our study suggests that after lockdown easing, trauma footfall rapidly rebounded to 2019 levels. This should be acknowledged in resource allocation decisions if future lockdowns are necessitated.

1036 Operative Versus Non-Operative Management of Osteoporotic Femoral Fractures

Background

he incidence of diaphyseal and distal osteoporotic femoral fractures (OFFs) is increasing. This cohort of patients is often frail with multiple medical co-morbidities. No published data exists neither reporting severity of pain associated with these fractures nor pain in managing their fractures. There are no comparative studies investigating outcomes between conservative (CM) and surgical management (SM). We investigated pain and outcomes between CM and SM OFFs.

Method

We retrospectively analysed all OFFs admitted to our unit between 2018-2019. We analysed electronic patient records including patient-reported pain scores (PRPS). PRPS were calculated for set time periods: admission; 0-24hours CM versus day 1 post-operative; day 2-3; day 4-5. Primary outcome measure was PRPS. Secondary outcome measures included use of traction; PCA use; weightbearing status; length of stay (LOS); 30 day and 1 year mortality. Data was statistically analysed using SPSS software.

Results

22 patients were recruited (11CM, 11SM). There was no statistical difference between groups in terms of age; sex; cognition; Charlson Index; nor pre-morbid mobility status. There was no statistical difference for pain at admission nor PCA use. SM were less painful in the first 24-hour period postoperatively and in the first 3-day postoperative period compared to the same time period in CM. There was no difference in PRPS for the 72–120-hour period. There was no statistical difference between LOS; NWB status; 30 day nor 1 year mortality.

Conclusions

Operating on OFFs reduces pain in the perioperative period without increasing mortality or LOS in this frail population.

Access and feasibility of orthopaedic training in the independent sector - A Deanery's experience

Introduction

Coronavirus (COVID-19) has negatively impacted healthcare around the world. It has had a major impact on orthopaedic training. The independent sector has been proposed as a facility for future training. Our aim was to provide an overview of the current higher surgical trainees’ experience in the independent sector.

Method

Training orthopaedic registrars within the East of England deanery were asked to complete an electronic questionnaire of their training experience in the independent sector between 5th November to 2nd December 2020.

Results

57 of 64 registrars (89%) from across all thirteen regional training hospitals responded. 44% attended the independent sector, but 7 only assisted (28%). No third year trainees went, but there was an even spread of other training years attending a mean of four sessions. Sixty-six indicative procedures were performed, all with supervisors scrubbed. Second year trainees performed the most cases with 4 on average. Completion of work based assessments was low. 20% trainees reported a negative experience. 80% enjoyed themselves. 52% felt they achieved their goals. 29% trainees felt that independent sector operating would compensate for the shortfall in training brought about by COVID-19. The main obstacles to independent sector training were lack of access and opportunity (51%) and poor induction and paperwork issues (22%)

Conclusion

This is the first deanery-wide assessment of access to and training within the independent sector due to COVID-19. Independent sector operating for orthopaedic trainees is feasible on scale and should be embedded to supplement training in the future. In their current state independent sector facilities are not easily and universally accessible to fulfil training needs.

Novel techniques demonstrate superior fixation of simple transverse patella fractures - A biomechanical study

INTRODUCTION

Traditional tension band wiring (TBW) remains the gold standard treatment for simple transverse patella fractures. Challenges include appropriately siting and bending Kirschner wires without damaging surrounding soft tissues. Damage to soft tissues and malposition of metalwork can lead to complications. We propose three novel techniques for fixation of simple transverse patella fractures to ease application without additional resources to traditional TBW. We tested their biomechanical integrity against traditional TBW.

METHOD

Four configurations were tested; two with longitudinal Kirschner Wires (LKW) and two with cross Kirschner Wires (CKW) fixed with either standard figure-of-eight (AO) or side TBW (STBW). An initial proof of concept human cadaveric study was conducted to ensure real world application of the constructs was feasible. The fracture fixations were tested in a biomechanical study using porcine knees. The knees were cyclically loaded in a specially designed test rig through flexion from 90 to 45 degrees. Fracture gap displacement was measured and data blindly analyzed for all tests reaching 100 cycles.

RESULTS

17/22 specimens reached 100 cycles with peak loading ranging from 75 to 80 N. CKW with STBW performed best with average fracture displacement of 0.43 mm. LKW with STBW performed worst with average fracture displacement of 1.93 mm. The incremental displacement/cycle for both CKW configurations was 0.27 mm compared to 0.41 & 0.60 mm for both LKW constructs showing that the CKW configuration conferred greater fixation stiffness under cyclic loading.

DISCUSSION

Previous studies have compared alternative methods of patella fracture fixation to TBW through biomechanical superiority often requiring new resources. The methods tested here utilize the same resources as those for standard AO TBW. Reorientating the plane of the wires and position of the cerclage TBW may reduce iatrogenic soft tissue injury; reduce operating time and the risk of complications.

CONCLUSION

This study shows biomechanical superiority for CKW with either AO or STBW compared to LKW.

Quantifying the contribution of pincer deformity to femoro-acetabular impingement using 3D computerised tomography

OBJECTIVE

To provide a simple, reliable method for the three-dimensional quantification of pincer-type hip deformity.

MATERIALS AND METHODS

Computerised tomography scans of 16 normal female hips and 15 female hips with clinical femoro-acetabular impingement (FAI) and radiographic signs of pincer secondary to acetabular protrusio were analysed. After orientating the pelvis in the anterior pelvic plane, the acetabular centre was determined, and the ratios of its coordinates to the corresponding pelvic dimensions were calculated. Acetabular coverage of the femoral head and centre-edge angles were also measured for the two groups.

RESULTS

In hips with a pincer, the hip was medialised by 37 % (p = 0.03), more proximal by 5 % (p = 0.05) and more posterior by 9 % (p = 0.03) compared with the normal hips. Coverage of the femoral head in protrusio hips was significantly greater than normal (average 71 % vs 82 %, p = 0.0001). Both the lateral centre-edge angle and the combined anterior-posterior centre-edge angle were greater in protrusio hips than in the normal ones (48° vs 37 °, p < 0.001; and 216° vs 176°, p < 0.0001 respectively).

CONCLUSION

Displacement in acetabular protrusio occurs in all planes. This CT-based method allows for the accurate and standardised quantification of the extent of displacement, as well as 3D measurement of femoral head coverage. In the adult female population, a combined centre-edge angle of over 190° suggests an acetabulum that is too deep and a potential cause of symptoms of femoro-acetabular impingement. Conversely, an acetabulum that has a combined centre-edge angle of less than 190° may be considered to be of normal depth, and therefore not contributing a pincer to FAI should it occur.