Epidemiology, Treatment, and Mortality of 3,983 Scapula Fractures from the Swedish Fracture Register

BACKGROUND

Scapula fractures are relatively uncommon, accounting for <1% of all fractures and approximately 3-5% of shoulder girdle fractures. This study comprehensively describes the epidemiology, fracture classification, treatment, and mortality associated with scapula fractures within a large adult Swedish population.

METHODS

This observational study included all patients ≥18 years old at the time of injury with a scapula fracture (ICD S42.1) registered in the Swedish Fracture Register between March 2011 and June 2020. Variables studied were age, sex, and injury mechanism, including energy level, fracture classification, associated fractures, treatment, and mortality.

RESULTS

We included 3,930 patients (mean age 58 years, SD 18, 64% men) with 3,973 scapula fractures. Some 22% of the fractures were caused by high-energy trauma and 21% had at least one associated fracture. High energy-injuries were most common in glenoid neck (44%) and scapular body (35%) fractures. However, same-level falls were the most common cause of glenoid rim (62%) and intra-articular glenoid (55%) fractures. Clavicle fractures (9%) and proximal humerus fractures (5%) were the most commonly associated fractures. The most common fracture types were the glenoid rim (n=1,289, 32%) and scapular body (n=1,098, 28%) fractures. Nonoperative treatment was performed in 81% of patients. Glenoid rim and intra-articular glenoid fractures were treated operatively in over 30% of cases. The mortality rate for the whole cohort was 4% at 1 year.

CONCLUSIONS

Scapula fractures are predominately sustained by men. High energetic injuries and associated fractures are present in one in five patients. Nonoperative treatment is chosen in four of five patients, but for some fracture types one in three undergo surgery.

GEC-ESTRO ACROP recommendations on calibration and traceability of HE HDR-PDR photon-emitting brachytherapy sources at the hospital level

The vast majority of radiotherapy departments in Europe using brachytherapy (BT) perform temporary implants of high- or pulsed-dose rate (HDR-PDR) sources with photon energies higher than 50 keV. Such techniques are successfully applied to diverse pathologies and clinical scenarios. These recommendations are the result of Working Package 21 (WP-21) initiated within the BRAchytherapy PHYsics Quality Assurance System (BRAPHYQS) GEC-ESTRO working group with a focus on HDR-PDR source calibration. They provide guidance on the calibration of such sources, including practical aspects and issues not specifically accounted for in well-accepted societal recommendations, complementing the BRAPHYQS WP-18 Report dedicated to low energy BT photon emitting sources (seeds). The aim of this report is to provide a European-wide standard in HDR-PDR BT source calibration at the hospital level to maintain high quality patient treatments.

Implementation of a novel MRI protocol for diagnosing femoral neck fractures in high energy femoral shaft fractures: One year results

INTRODUCTION

Preliminary results using a novel rapid-sequence MRI to diagnose ipsilateral femoral neck fractures in patients sustaining high-energy femoral shaft fractures have been favorable compared to radiographic and CT imaging alone. To evaluate and optimize this new institutional imaging protocol further, we reviewed our results one year after implementation.

METHODS

Rapid-sequence MRI was added to the imaging evaluation of patients with high-energy femoral shaft fractures without femoral neck fractures identified on radiographs or CT imaging. Data was retrospectively reviewed from a consecutive series of patients who met inclusion criteria.

RESULTS

From September 2018 through September 2019, 114 patients sustained 121 high-energy femoral shaft fractures. The average patient age was 29.9 years, 73.7% (84/114) of patients were male, and 16.5% (20/121) were open fractures. Of patients indicated for a rapid-sequence MRI, 86% (92/107) underwent MR imaging. 5% (6/121) of patients had an ipsilateral femoral neck fracture identified on radiographs alone. Three additional femoral neck fractures were identified with CT imaging for an initial incidence of 7.4% (9/121). MRI identified 10 additional non-displaced femoral neck fractures, three complete and seven incomplete fractures, for an incidence of 15.7% (19/121). All identified femoral neck fractures were stabilized.

DISCUSSION/CONCLUSION

The addition of rapid-sequence MRI of the pelvis in patients with high-energy femoral shaft fractures reliably increases the diagnosis of ipsilateral femoral neck fractures not identified with standard imaging. There were no cases of missed/delayed femoral neck fractures in patients with a negative MRI. This new imaging protocol effectively and safely improves the diagnosis of this injury pattern.

Syndesmosis injury associated with high-energy tibial shaft fractures: Case series of a misdiagnosis rupture

INTRODUCTION

Ankle syndesmosis injuries can be associated with a spiral mechanism on tibial shaft fractures. We are not aware if there is evidence of the incidence of ipsilateral syndesmotic lesson associated to high-energy tibial shaft fracture mechanisms. The aim of this study was to analyze the incidence of syndesmotic injuries associated with high-energy tibial shaft fractures.

METHODS

233 diaphyseal tibial fractures operated between January 2007 and January 2017, the fracture patterns were analyzed, they were classified according to AO, the talocrural angle was measured, they analyzed failures and reoperations and described a novel failure method.

RESULTS

From a total of 234 fractures that met the inclusion criteria, 159 (64.96%) suffered closed fractures and 75 (32.05%) where open fractures. According to the AO classification system: 152 (64.10%) were simple patterns 42.A; 49 (20.94%) wedge type patterns 42.B and 33 (14.10%) complex patterns 42.C. Ten patients, a 4.27% of the sample, shown an increased talocrural angle in the postoperative radiographs, evidencing shortening of the fibula. Nine patients underwent surgery, the remaining patient was lost to follow-up. All the treated patients presented restoration of the normal talocrural angle.

CONCLUSION

The incidence of syndesmotic injuries associated with high-energy tibial shaft fractures reaches 4.27%. We think that is necessary to evaluate the ankle and syndesmosis in all tibial shaft fractures, even with high-energy patterns, not only in spiral patterns.

Open reduction and navigated Iliosacral screws for vertically unstable pelvic fractures

AIMS

To evaluate clinical and radiological results of vertically unstable pelvic fractures managed by open reduction and navigated iliosacral screws.

PATIENTS AND METHODS

The study included eleven patients with complex posterior ring fractures with vertical instability admitted to our hospital and managed with CT navigated iliosacral screws. There were 7 type C1, 2 C2 and 2 C3, according to Tile classification. Three patients presented a spino-pelvic dissociation and four a vertical sacral fracture affecting the foramina (Denis 2). Vertical displacement, pelvic deformity and asymmetry were measured. Tornetta and Matta criteria were used to assess the quality of pelvic reduction.

RESULTS

An excellent reduction was achieved in 9 fractures and a good reduction in two. Asymmetry index improved from 13.18 to 2.72. Deformity index improved from 0.049 to 0.010. Only two patients with a Denis 2 fracture showed secondary displacement during follow-up. Four patients presented neurological complications due to their initial injuries. Seven patients were able to resume their previous activities.

CONCLUSION

CT navigated IS screws provide enough stability after an anatomic reduction of the fracture. There was no complication related to screw insertion and adequate screw positioning was achieved in all the cases.

Interaction of supplementary L-carnitine and dietary energy levels on feed utilization and blood constituents in New Zealand White rabbits reared under summer conditions

In the summer season, the harmful effects of high ambient temperatures on rabbit productivity have attained global interest. Therefore, the use of new nutritional strategies to improve heat tolerance in rabbits has become highly needed. In the current experiment, the effect of the addition of L-carnitine (LC) to normal (NE) or high-energy (HE) diets of growing rabbits reared under summer conditions on their productive performance, physiological indicators, and carcass characteristics was assessed. For this purpose, a 2 × 2 factorial arrangement of treatments was used with two dietary levels of energy of 10.00 and 11.22 MJ kg^-1 diet of NE and HE, respectively, which was fortified with 0 or 50 mg of LC kg^-1 of diet (LC0 and LC50, respectively). The feeding trial was conducted using 80 male rabbits (initial body weight, 630.7 ± 1.3 g; 35-day-old), and it lasted for 56 days. Throughout the experiment, the average temperature humidity index was 35.49 reflecting very severe heat stress conditions. Rectal temperature, heart rate, and respiration rate decreased significantly in rabbits fed NE+LC50, HE+LC0, and HE+LC50 diets compared with those fed NE diets without supplementation. Simultaneously, growth indices and feed conversion ratio were enhanced significantly. Rabbits fed NE+LC50, HE+LC0, and HE+LC50 diets showed significantly higher blood hemoglobin, white blood cell counts, total protein, glucose, and red blood cell counts, compared with those fed a NE+LC0 diet. Rabbits fed NE+LC50 and HE+LC50 showed higher economic efficiency. In conclusion, growing rabbits reared under summer conditions responded positively to LC supplementation and HE diets, in terms of the highest growth performance, feed conversion, and physiological and biochemical indicators, making them potentially safe to use.

Theoretical design of novel high energy metal complexes based on two complementary oxygen-rich mixed ligands of 4-amino-4H-1,2,4-triazole-3,5-diol and 1,1'-dinitramino-5,5'-bistetrazole

In this study, 16 new energetic metal complexes [M(DNABT)(ATDO), M=Cu, Ni] were designed using the mixed complex construct strategy, which was based on two complementary oxygen-rich high-energy ligands of 1,1'-dinitramino-5,5'-bistetrazole (DNABT) and 4-amino-4H-1,2,4-triazole-3,5-diol (ATDO), then combined with metals Cu and Ni, and further adjusted by the introduction of NO₂ and NH₂. The molecular and electronic structures, heat of formation (HOF), density, detonation velocity, detonation pressure, and sensitivity were investigated by the density functional theory method. The results showed that in metals, the position and amount of NO₂/NH₂ have great effects on the structure and property of metal complexes, and these effects coupled with each other. N-NO₂ bond is the relatively weak bond, and its max length is related with the sensitivity closely. The designed metal complexes all have high HOF (673~868 kJ mol^-1), high density (2.06~2.14 g cm^-3), and ideal oxygen balance (- 19.2~- 6.7%), which further make them have higher detonation velocity (8.76~9.84 km s^-1) and detonation pressure (37.4~46.6 GPa) than three famous high-energy compounds 1,3,5-trinitro-1,3,5-triazine (RDX); 1,3,5,7-tetranitro-1,3,5,7-tetrazocine (HMX); or even 2,4,6,8,10,12-hexanitro-2,4,6,8,10,12-hexaazaisowurtzitane (CL-20). At the same time, they are less sensitive than RDX, HMX, and CL-20, making them potential candidates for high-energy density compounds.

CT based management of high energy tibial plateau fractures: A retrospective review of 53 cases

OBJECTIVES

The management of high energy tibial plateau fractures is a surgical challenge. Recently described Luo's classification is based on CT scans and is more objective with a better inter-observer agreement as compare to Schatzker and AO/OTA classifications. We describe the functional results of a series of 53 cases classified and managed according to the Luo's column concept.

METHODS

A retrospective review of 53 high energy tibial plateau fractures, operated between January 2012 and March 2015 at a Level I trauma center, was performed. CT scans were used to classify these injuries based on the number of columns involved. Plating configuration and surgical approach were chosen based on the number of independent articular fragments on axial sections at the level of fibular head.

RESULTS

1 one-column, 51 two-column and 1 three-column fractures were studied. Triple plating was done in 5 patients. Mean follow-up was 2.7 years and mean Insall Knee score was 95.42. Four patients had varus malalignment and 1 had joint depression in the post-operative period. These were due to imperfect reduction during the surgery itself, and no case of late collapse was detected.

CONCLUSION

Utilizing Luo's classification for treating these complex injuries will assist in better understanding of fracture pattern and hence help in achieving a better functional outcome. Each fractured column needs to be independently addressed.

Predictors of amputation in high-energy forefoot and midfoot injuries

INTRODUCTION

High energy injuries to the midfoot and forefoot are highly morbid injury groups that are relatively unstudied in the literature. Patients sustaining injuries of this region are challenging to counsel at the time of injury because so little is known about the short and long term results of these injuries. The purpose of this study was to investigate injury specific factors that were predictive of amputation in patients sustaining high energy midfoot and forefoot injuries.

PATIENTS AND METHODS

137 patients with 146 injured feet [minimum of two fractures located in the forefoot and midfoot, excluding phalanges, talus, calcaneus, with a high energy mechanism].

RESULTS

121 of 146 feet (83%) were treated operatively; 27 patients sustained 34 total surgical amputation events. 30-day amputation rate was 13.9% and 1-year amputation rate was 18.9%; 27 of 146 feet ultimately sustained amputation with 23 of 27 sustaining a below the knee amputation (BKA) and 17 of 23 (73.9%) received a BKA as their first amputation. Statistically significant predictors of amputation included the number of bones fractured in the foot (p=0.015), open injury to the plantar or dorsal surfaces of the foot, Gustilo grade, vascular injury, and complete loss of sensation to any surface of the foot (all p<0.001). Specific fracture patterns predictive of any amputation were fracture of all five metatarsals (p<0.001) and fracture of the first metatarsal (p=0.003). Presence of a dislocation or fracture of the distal tibia were not predictive of amputation. Midterm patient-reported-outcomes (N=51) demonstrated no difference in physical function for patients with and without amputations.

CONCLUSIONS

High-energy forefoot and midfoot injuries are associated with a high degree of morbidity; 1/5th of patients sustaining these injuries proceeded to amputation within 1year. Injury characteristics can be used to counsel patients regarding severity and amputation risk.

Influence of short-term energy supplementation on estrus, ovarian activity, and blood biochemistry in Ossimi ewes synchronized with fluorogestone acetate in the subtropics

The objective of this study was to evaluate if short-term high-energy diet treatments have any overstimulatory effects on ovarian function and metabolic status in Ossimi ewes synchronized with progesterone sponge. Thirteen ewes were divided into high-energy (HEG; n = 7) and normal-energy or control (NEG; n = 6) groups. Progesterone sponges were placed intravaginally for 14 days during the winter breeding season (December-February). Four days before the removal of the sponges, a high-energy diet (130% of maintenance) was fed to HEG, whereas NEG was offered maintenance diet throughout the experiment. Ovarian performance and progesterone, estradiol, and blood metabolites were assessed daily starting from the day of removal of the sponges. Estrus period was longer in HEG (P < 0.05) when compared with NEG. Ovulation took place considerably longer with larger ovulatory follicles in HEG (P < 0.05). A marked increase in the level of total protein, albumin, glucose, and blood urea during the first 2 days following the removal of progesterone sponge was noticed in HEG when compared with NEG ewes. Eighty-five percentage (85.7%; 6/7) and 66.6% (4/6) had ovulation for the HEG and NEG, respectively. Dietary energy had a nonsignificant effect on the number of the recruited follicles, whereas a significant effect was observed for the diameter of the ovulatory follicle and ovulation rate (HEG, 2.3 ± 0.1 vs. NEG, 1.2 ± 0.3). It is concluded that short-term energy supplementation improves estrus expression and ovarian activity in fluorgestone acetate (FGA)-synchronized Ossimi ewes.

High-energy injuries of the wrist

High-energy injuries to the wrist gather complex fractures of the distal radius, radiocarpal dislocations, perilunate dislocations, and other intracarpal dislocations. Depending on the energy of the injury and the position of the wrist at the time of impact, the patient, often a young male with a high functional demand, presents one of these injuries associating fracture(s) and ligament injury. The trauma is often bilateral, with proximal lesions (elbow) very often associated with contusion or compression of the median nerve. Diagnosis is confirmed by wrist X-rays, which are sufficient to determine treatment for radiocarpal and perilunate dislocations. In cases of distal radius fractures or other intracarpal dislocations, a preoperative CT is necessary. Reduction of the dislocation and relief of neurovascular compression are performed immediately. The final treatment of each lesion (bone fixation, ligament repair) can be undertaken simultaneously or delayed, depending on the patient and the lesions. Cartilage lesions, resulting from the high-energy injury, can be estimated using arthroscopy but cannot be repaired and determine the prognosis. The surgeon's objective is to restore joint congruence, which does not prevent stiffness, the main complication of these rare injuries, which the surgeon must know how to recognize and treat.

Effect of feeding greater amounts of dietary energy for a short-term with or without eCG injection on reproductive performance, serum metabolites and hormones in ewes

This study was conducted to compare the effect of transient high-energy diet in a short-term period with or without eCG injection on ovarian follicle development, twining rate, serum metabolites and hormones in ewes. A total of 45 estrous cyclic Naeini ewes were randomly assigned to three experimental groups: 1-Control (control), 2-High energy short-term feeding (HE), and 3-high energy short-term feeding + eCG injection (HEe). Ewes were housed in individual pens with free access to feed and water. The stage of the estrous cycle of all ewes was synchronized by insertion of intravaginal progesterone sponges. Focus feeding started from 4 days before until 1 day after sponge removal. Follicle development was monitored from 4 days before until 1 day after sponge removal and blood samples were taken during this time. Results showed that ewes fed high energy diets (HE and HEe) had greater (P < 0.05) large follicle numbers compared with the control group. Feeding high energy diets increased (P < 0.05) serum glucose, cholesterol and insulin, but had lesser (P < 0.05) serum urea nitrogen concentrations near the time of ovulation. After the start of experiment, ewes fed high energy diets had less (P < 0.05) serum estradiol. However, 1 day after sponge removal, serum estradiol in HE and HEe groups increased (P < 0.05). It was concluded that short-term (6-day) changes in amount of dietary energy with or without eCG injection increased twin births and had beneficial effects on the blood metabolites and hormone concentrations in Naeini ewes.

Clinical effects of omeprazole vs famotidine for treatment of stress-induced gastrointestinal bleeding in patients with high energy multiple fractures

AIM: To compare the clinical effects of famotidine and omeprazole in the treatment of stress-induced gastrointestinal bleeding in patients with high energy multiple fractures.

METHODS: Ninety patients with high energy multiple fractures who had stress-induced gastrointestinal bleeding and were treated at the Second People's Hospital of Xining City from January 2012 to December 2013 were randomly and equally divided into two groups: A and B. Group A was given omeprazole, and group B received famotidine. Clinical effects were compared for the two groups.

RESULTS: The effective rate was significantly higher in group A than in group B (91.1% vs 71.1%, P < 0.05). The bleeding time was significantly shorter in group A than in group B (8.2 h ± 2.4 h vs 14.5 h ± 3.4 h, P < 0.05). The incidence of adverse reactions was significantly lower in group A than in group B (11.1% vs 26.7%, P < 0.05).

CONCLUSION: Omeprazole is superior to famotidine in the treatment of stress-induced gastrointestinal bleeding in patients with high energy multiple fractures in terms of better clinical efficacy and fewer adverse reactions.