Fragility Fractures of the Pelvis: Current Practices and Future Directions

PURPOSE OF REVIEW

To summarise the current evidence and clinical practices for patients with fragility fractures of the pelvis (FFP).

RECENT FINDINGS

FFPs are an increasingly prevalent and recognised problem in the elderly population. Recent evidence indicates they have a significant impact on function, morbidity and mortality. While traditional management of FFPs was predominantly non-surgical, surgical options have been increasingly used, with a range of surgical methods available. To date, limited consensus exists on the optimal strategy for suitable patient selection, and clinical trials in this population have proved problematic. The management of FFPs requires a multi-faceted approach to enhance patient care, including adequate pain control, minimisation of complications and optimisation of medical management. Early return to mobilisation should be a key treatment goal to maintain functional independence. The selection of patients who will maximally benefit from surgical treatment, and the most appropriate surgical strategy to employ, remains contentious.

The treatment of stable paediatric forearm fractures using a cast that may be removed at home

We investigated whether, in the management of stable paediatric fractures of the forearm, flexible casts that can be removed at home are as clinically effective, cost-effective and acceptable to both patient and parent as management using a cast conventionally removed in hospital. A single-centre randomised controlled trial was performed on 317 children with a mean age of 9.3 years (2 to 16). No significant differences were seen in the change in Childhood Health Assessment Questionnaire index score (p = 0.10) or EuroQol 5-Dimensions domain scores between the two groups one week after removal of the cast or the absolute scores at six months. There was a significantly lower overall median treatment cost in the group whose casts were removed at home (£150.88 (sem 1.90) vs £251.62 (sem 2.68); p <  0.001). No difference was seen in satisfaction between the two groups (p = 0.48).

Cite this article: Bone Joint J 2013;95-B:1714–20.

Proximal femoral fractures in the elderly: how are we measuring outcome?

INTRODUCTION

Patients with proximal femoral fractures present a difficult problem to health care systems in view of their complex presentations and co-morbidities. Traditionally, the focus of outcome measurement for this patient group has been on mortality and surgical implant success. Increasing recognition of the need to diversify outcome measurements has led to the creation and use of a number of outcome scales. We sought to examine how these scales are being used in the current literature.

METHODS

Abstracts to over 4000 papers related to proximal femoral fracture research were screened to identify commonly used scales in the five main categories of general quality of life measures (QoL), Activities of Daily Living scales (ADL), mobility and physical performance scales, disease-specific scales and hip-specific scales. The 14 identified scales were then searched for directly, and papers analysed for scale usage, timing and interpretation.

RESULTS

ADL scales were the most commonly used group, followed by QoL measures, which are validated for elderly patients. Scale timing and use varied widely between studies. A large number of scales were found in addition to the 14 identified scales. None of the 14 identified scales were validated for the proximal femoral fracture population.

DISCUSSION

A good scale must be appropriate in content, method and clinical utility. Its method of application must be reliable, responsive, and validated for the population in question. Outcome scale usage was difficult to assess in proximal femoral fracture research due to difficulties in isolating the relevant research, and in differences in scale timing and interpretation. Scale prevalence was skewed by use by specific research groups.

CONCLUSION

There is no single unifying scale in widespread use for proximal femoral fracture patients. We would recommend the validation of commonly used scales for this population, and would advise the use of scales from more than one category to assess outcome.

Clearing the cervical spine in children

Increasing evidence from adult trauma patients has allowed the formation of some international consensus on clearance protocols. The evidence for paediatric trauma remains more fragmented, making the creation of definitive protocols difficult. Spinal injury in children differs from that in adults by injury distribution and prevalence, as well as anatomical and radiological differences. This complicates the process of clearance of the cervical spine in children. The evidence for clearance can be considered in terms of three groups of patients – the alert and asymptomatic child, the conscious child with high-risk criteria and the unconscious or obtunded child. This systematic review summarises the available evidence to clarify the current best practice for each group of patients.

Factors affecting the physical and chemical stability of morphine sulphate solutions stored in syringes

The stability of morphine sulphate solution (2mg/ml in 0.9 per cent w/v saline) was determined after storage in two brands and two sizes of polypropylene syringes, with or without 0.1 per cent w/v sodium metabisulphite. The suitability of plastic syringes for the long term storage of morphine solutions was further investigated by an assessment of sorption onto or into the syringe, vapour loss and oxygen permeability. A comparison was also made with storage in glass syringes. Measurement of morphine sulphate was by a stability-indicating high performance liquid chromatographic assay. After six weeks, a small loss (&lt;5 per cent) in potency was detected due to oxidation in polypropylene syringes without antioxidant. Polypropylene syringes showed little resistance to oxygen permeation. Oxidation was greater in glass syringes compared with polypropylene syringes, possibly due to release of caustic material. Although inclusion of sodium metabisulphite 0.1 per cent w/v offered protection against oxidation, and the breakdown product pseudomorphine was not detected, the antioxidant was incompatible with morphine under these conditions, resulting in the formation of an unknown substance or complex. To summarise, an acceptable level of stability was observed after storage of morphine solutions in 30ml or 50ml three-piece polypropylene syringes in the dark, at room temperature, for six weeks. While such syringes are not protected from oxygen permeation and are susceptible to oxidation over the longer term, all attempts at using glass syringes or an antioxidant were unsuccessful due to a number of factors.

Angiotensin-converting enzyme genotype and successful ascent to extreme high altitude

Interindividual variation in acclimatization to altitude suggests a genetic component, and several candidate genes have been proposed. One such candidate is a polymorphism in the angiotensin converting enzyme (ACE) gene, where the insertion (I-allele), rather than the deletion (D-allele), of a 287 base pair sequence has been associated with lower circulating and tissue ACE activity and has a greater than normal frequency among elite endurance athletes and, in a single study, among elite high altitude mountaineers. We tested the hypothesis that the I-allele is associated with successful ascent to the extreme high altitude of 8000 m. 141 mountaineers who had participated in expeditions attempting to climb an 8000-m peak completed a questionnaire and provided a buccal swab for ACE I/D genotyping. ACE genotype was determined in 139 mountaineers. ACE genotype distribution differed significantly between those who had successfully climbed beyond 8000 m and those who had not (p = 0.003), with a relative overrepresentation of the I-allele among the successful group (0.55 vs. 0.36 in successful vs. unsuccessful, respectively). The I-allele was associated with increased maximum altitudes achieved: 8079 +/- 947 m for DDs, 8107 +/- 653 m for IDs, and 8559 +/- 565 m for IIs (p = 0.007). There was no statistical difference in ACE genotype frequency between those who climbed to over 8000 m using supplementary oxygen and those who did not (p = 0.267). This study demonstrates an association between the ACE I-allele and successful ascent to over 8000 m.

Drug combinations in syringe drivers: the compatibility and stability of diamorphine with cyclizine and haloperidol

The compatibility and stability of 2B combinations of diamorphine hydrochloride (5-100 mg/ml) with cyclizine lactate (5-50 mg/ml), eight combinations of diamorphine (10-100 mg/ml) with haloperidol (2-4 mg/ml) and eight combinations of all three drugs was assessed after storage in 1 ml polypropylene syringes. Samples were stored for periods up to seven days in the light and at room temperature (22 degrees C). Five combinations of diamorphine with cyclizine precipitated immediately upon preparation. After analysis and determination of t90% values (the time taken for 10% degradation). 16 of the remaining 23 combinations were judged to be compatible (no signs of crystallization or precipitation) and stable (less than 10% loss of potency of either drug) after storage for 24 h. After seven days storage only four remained compatible and stable. The results indicate that ratios of diamorphine to cyclizine of 1:1 are stable at concentrations up to 20 mg/ml. An increase in diamorphine concentration necessitates a reduction in cyclizine to 10 mg/ml, and an increase in cyclizine concentration necessitates a reduction in concentration of diamorphine to 15 mg/ml to maintain stability over 24 h. All the combinations of diamorphine with haloperidol remained compatible and stable for seven days. The addition of haloperidol (2 mg/ml) to the diamorphine and cyclizine combinations had no detrimental effect on their compatibility and stability. A stability curve is included as an easy way for palliative care personnel to avoid potential problems with incompatibilities and reduced stability when using these combinations. Furthermore, to reduce the possibility of precipitation with mixtures containing cyclizine, the use of 0.9% sodium chloride should be avoided.