The Likelihood of an Occult Fracture in Skeletal Surveys Obtained in Children More Than 2 Years Old With Concerns of Physical Abuse

OBJECTIVES

Skeletal surveys are necessary in the evaluation for physical abuse in children less than 2 years old, but when to obtain a skeletal survey in older children is less clear.

METHODS

A retrospective study of patients older than 2 years who underwent skeletal survey over a 3-year period after implementation of an electronic health record physical abuse order set was conducted. Data were analyzed using descriptive statistics and compared with data from a cohort before order set implementation. The radiation dose of a skeletal survey in a 5-year old was calculated using a previously published technique.

RESULTS

There were 325 skeletal surveys, a marked increase in the rate of skeletal surveys compared with before order set implementation. Less than 2% (6/325) of skeletal surveys demonstrated an occult fracture. Of the 6 patients with occult fractures, 4 were physically abused; in each case, the diagnosis of abuse was evident before the skeletal survey. The other 2 patients fell from windows. The radiation exposure was 0.34 mSv.

CONCLUSIONS

The rate of occult fractures on skeletal survey is significantly lower than previously reported. This is likely because our population included all children who underwent skeletal survey and not the subset referred to a child abuse pediatrician. In addition, our data demonstrate that in children older than 2 years, skeletal surveys are unlikely to assist in making a diagnosis of physical abuse. The radiation exposure in a 5-year-old is 70% greater than in an infant, but still a dose, which represents a negligible health risk.

Exposure to risperidone versus other antipsychotics and risk of osteoporosis-related fractures: a population-based study

OBJECTIVE

Antipsychotics may increase serum prolactin, which has particularly been observed with risperidone. Further, hyperprolactinemia has been linked to osteoporosis-related fractures. Therefore, we investigated fracture risk in a nationwide cohort exposed to antipsychotics.

METHODS

Swedish registers were used to identify adults with two consecutive dispensations of risperidone (n = 38 211), other atypical antipsychotics not including paliperidone (n = 60 691), or typical antipsychotics (n = 17 445) within three months between 2006 and 2013. An osteoporosis-related fracture was defined as a non-open hip/femur fracture in primary analyses. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Risperidone users were on average older (mean age of 68, 44, and 63 years for risperidone, other atypical antipsychotics, and typical antipsychotics respectively). Compared with other atypical antipsychotics, there was no association between risperidone and osteoporosis-related fractures in the overall (HR = 1.04, CI: 0.91-1.19) or age-stratified analyses. A significantly increased risk of typical antipsychotics (HR = 1.24, CI: 1.07-1.45) compared with other atypical antipsychotics remained for ages >45 years.

CONCLUSION

Risperidone does not appear to be associated with an increased risk of osteoporosis-related fracture compared with other atypical antipsychotic agents as a group. For typical antipsychotics, a moderately elevated risk of hip fractures was noted compared with other atypical antipsychotics, possibly because of residual confounding.

PREVALENCE OF INJURIES AMONG THE POPULATION OF THE VINNITSA CITY

Purpose - identify, summarize, systematize the causes and factors of injury; to study the state of injury among the population of a large city during 2016-2018 by nature, place and seasonality; analyze patients' case histories by severity of injuries; analyze the dynamics of the occurrence of injuries over time; to develop recommendations for measures to prevent domestic injuries among urban population. Conduct content analysis of scientific sources and methodological recommendations on occupational safety. To analyze 300 case histories of patients who look for some help at the Vinnytsia City Clinical Ambulance Hospital with injuries during 2016-2018. Systematize the information obtained by dividing it into categories such as the nature of the trauma, the time of occurrence, the place of traumatization and the dominant season. The analysis of the study showed that the domestic injury include: accidents in homes, backyards, in gardens, in the area and accounted for in 2018 - 72%; in 2017 - 67.4% and in 2016 - 70.4% of all cases. Injuries suffered by people on the street in 2018 - 25.3%; in 2017 - 25.5%; in 2016 - 22.4% of all cases. In 2016-2018, injuries in the population of Vinnitsa were as follows: in 2018 - 2.7%; in 2017 - 7.1% and in 2016 - 7.2%. By the nature of the injury, closed fractures are most often established. They won first place, second place took wounds. The third place was diagnosed with open fractures. They accounted for 15% in 2018; in 2017 - 9.1% and in 2016 - 4.7%, respectively. We have analyzed the dynamics of the occurrence of injuries over time. From the dynamics we find that the peak of injury occurs from 6.00 am to 12.00 pm. The dynamics of the occurrence of injuries by the seasons of the year were also evaluated. Most often, people are injured in spring.

Occult periprosthetic femoral fractures occur frequently during a long, trapezoidal, double-tapered cementless femoral stem fixation in primary THA

The present study aimed to investigate the prevalence and clinical consequences of occult intra-operative periprosthetic femoral fractures in total hip arthroplasty (THA). Between 2012 and 2017, a total of 113 primary THAs were enrolled. The mean age of the patients was 66.4 ± 7.6 years. We assessed occult intra-operative periprosthetic femoral fractures with the use of computed tomography (CT) and risk factors, including age, sex, body mass index, diagnosis, stem size, and radiographic parameters of proximal femoral geometry were analyzed. We also assessed the differences in thigh pain and stem subsidence and alignment between the patients with and without occult periprosthetic femoral fracture. Occult intra-operative periprosthetic femoral fractures were found in 13 of 113 hips (11.5%). In 9/13 (69.2%) of occult fractures, fracture lines were started from the region below the tip of the lesser trochanter. Six periprosthetic femoral fractures (5.3%) were found during the operation. Out of the five hips that had detected femoral fractures around the lesser trochanter intra-operatively, four hips (80%) showed concurrent occult fractures on different levels. The female sex (P = .01) and canal filling ratio at 7 cm below the tip of the lesser trochanter (P = .01) were significantly different between the patients with and without occult periprosthetic femoral fracture. The sex was significantly associated with an increased risk in predicting an occult intra-operative periprosthetic femoral fracture (odds ratio of male, 0.25 compared with the female; 95% CI, 0.08-0.85; p = .02). There was a significant difference in the incidence of thigh pain between occult fracture group and non-occult fracture group (P < .05). There were no significant differences in stem subsidence and alignment between the patients with and without occult periprosthetic femoral fracture. All 13 cases of occult intra-operative periprosthetic femoral fractures were healed at the final follow-up. Occult periprosthetic femoral fractures are common during a long, trapezoidal, double-tapered cementless femoral stem fixation in primary THA, that CT scans are helpful to identify them, and that these fractures do not adversely affect the implant's survival if a rigid fixation of the implants has been achieved.

Analysing outcomes through orthopaedic trauma registry - A prospective cohort study

OBJECTIVE

To develop a registry for recording injury-specific data to identify gaps and improve care.

Methods

The prospective cohort study was conducted at Aga Khan University Hospital, Karachi, from June 2015 to July 2018 though enrollment of patients with limb trauma is continuing to date. Data on injuries and management related to Tibia shaft fractures was collected from medical records, and outcomes were assessed on follow-up visits. Internationally validated injury-specific scores were utilised for assessing functional, clinical and radiological outcomes. SPSS version 19 was used for data analysis.

Results

There were 763 patients with 825 limb injuries. Of the injuries, 310(37.6%) related to upper limbs and 515(62.4%) to the lower limbs. Management was surgical for 741(89.9%) and conservative for 84(10.1%) injuries. Overall, 12(1.57%) patients died, and in 7(0.91%) cases mortality was unrelated to trauma and its management. There were 105 patients with tibia shaft fractures. Of them, 88(83.8%) were males and 17(16.2%) were females. At one-year follow-up excellent-to-good results were 12(92%) for intramedullary nailing followed by 7(78%) for open reduction and internal fixation.

Conclusion

Registry data can be used to develop preventive strategies and to improve management protocols.

In-Hospital Mortality Following Open and Closed Long Bone Fracture: A Comparative Study

BACKGROUND

Open fracture is a serious orthopaedic injury that can lead to significant patient morbidity and mortality. There is limited data on the mortality risk for open compared to closed long bone fracture.

METHODS

The Nationwide Inpatient Sample was used to identify all patients who were admitted with a long bone fracture in the United States between 1998 and 2010. Cox proportional hazards regression modeling was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) of mortality.

RESULTS

After adjusting for age, gender, race, insurance, and comorbidities, the HR of mortality was 2.89 (95% CI, 2.56-3.28; p<0.001) for open compared to closed fracture. Stratified by anatomical site, the HR of mortality for open compared to fracture was 3.43 for femur (95% CI, 2.78-4.23; p<0.001), 2.81 for tibia or fibula (95% CI, 2.17-3.64; p<0.001), 2.54 for humerus (95% CI, 1.81-3.56; p<0.001), and 1.56 for radius or ulna (95% CI, 1.10-2.23; p=0.014).

CONCLUSIONS

This data suggests that open fracture carries a worse prognosis compared to closed fracture at the same anatomical site.

Cost and management of males with closed fractures

The purpose of this study was to examine the medical costs and the management of osteoporosis in the 12 months after a closed fracture for men aged ≥ 45 years. The mean medical cost per fracture was high ($6,078-$30,900), and osteoporosis management post fracture was inadequate in the majority of men.

INTRODUCTION

This study was conducted in order to examine the medical costs following fracture in males and the management of osteoporosis post fracture.

METHODS

Administrative claims from a large, national health plan were analyzed. Men ≥ 45 years were included if they had ≥ 1 medical claim for a new closed fracture between January 1, 2005 and December 31, 2008. Commercially insured (COM) and Medicare Advantage Plan (MAP) members were analyzed separately. Costs were calculated as paid amounts and adjusted to 2010 dollars. Both the differences between the individual patients' 12-month pre-fracture and 12-month post-fracture costs and the costs directly attributed to the fracture were reported. The prevalence of dual-energy X-ray absorptiometry (DXA) scan and/or osteoporosis pharmacotherapy treatment was evaluated in the 12 months post fracture.

RESULTS

We identified 18,917 (COM, 16,191; MAP, 2,726) men with new closed fractures. Non-hip, non-vertebral fractures (NHNV) were the most common fracture in both COM and MAP populations. Fracture costs ranged from $7,121 to $15,830 for vertebral fractures, from $22,601 to $30,900 for hip fractures, and from $6,078 to $8,344 for NHNV fractures. In the COM and MAP populations, respectively, 8.5 and 15.5 % had a DXA scan and/or osteoporosis pharmacotherapy in the 12 months following the fracture.

CONCLUSIONS

Healthcare costs associated with fractures in men are substantial. About 1 in 12 men ≥ 45 years in the COM population were provided adequate follow-up for osteoporosis post fracture. While this rate improved to about one in six men in the MAP population, osteoporosis management in men post fracture is far from optimal.

Closed midshaft femur fractures: are they only for trauma centers?

Trauma centers are limited resources, particularly in rural areas, and availability of emergency care in some parts of the United States may be inadequate. The declining number of orthopedic surgeons willing to care for injured patients has limited access to fracture repair in some communities. We studied the management of closed midshaft femur fractures in both trauma centers (TCs) and nontrauma centers (NTCs) to evaluate outcome for this common orthopedic injury and determine if these issues have affected fracture care in Kentucky. All patients 16-years-old and older who suffered femur fractures in Kentucky from 2004 and 2005 were identified. There were 334 TC patients and 341 NTC patients with closed, midshaft femur fractures. The mean age of TC patients (33 ± 17 years) was significantly lower than that of NTC patients (59 ± 25 years). TC patients were more likely men (71% vs 44%), had more associated injuries (2.4 ± 2.1 vs 0.5 ± 1.2), and had longer lengths of stay (8.3 ± 9.8 vs 6.4 ± 7.1 days) (TCs vs NTCs, all P < 0.005). Although both groups ultimately underwent internal fixation (97% vs 99%, TCs vs NTCs), TC patients were more likely (2.7% vs 0.3%) to receive external fixation than the NTC patients (P < 0.05). There was no significant difference in the percentage of patients that received only a closed reduction. There was no significant difference in hospital mortality (0.3% vs 0.9%, TCs vs NTCs, P = 0.62). Although differences in patient populations exist between TCs and NTCs, both TCs and NTCs manage substantial numbers of patients with closed, midshaft femur fractures with low mortality in this state database.

Is magnetic resonance imaging (MRI) necessary to exclude occult hip fracture?

The possibility of occult hip fracture in older patients after a fall is a common problem in emergency and orthopaedic departments. Magnetic resonance imaging (MRI) scanning is the best investigation, but is expensive and may be difficult to obtain. The value of various clinical signs to determine which patients are at risk of occult hip fracture has not been reported. We reviewed all patients who had MRI scan for suspected hip fractures but had normal initial X-rays over a 6-year period. We identified 76 patients. Twelve patients were excluded. Two patients had MRI scan for suspected stress fracture and two patients had metastatic fractures. Eight patients had inadequate or untraceable clinical notes. Each patient's personal details, mobility, independence and detail clinical details were recorded. Following case review of 64 patients we excluded 5 patients with associated osteoarthritis of the hip joint, 1 patient with fibromyalgia and 1 patient with pre-existing multiple myeloma. Thirty-five patients had occult proximal femoral fractures. Of them four patients had isolated pubic ramus fractures and five patients had isolated greater trochanter fractures. Twenty-two patients had no fracture. The value of the individual tests was evaluated using Fisher exact and chi square analysis; with Bonferroni correction for multiple comparisons (10 tests) p<0.005 was deemed significant. Pain on axial loading of the limb and pre-fracture restricted patient mobility were both associated with the presence of a fracture (p<0.005). Both factors had identical positive predictive value=0.76, a negative predictive value=0.69 and post-test probability of disease given a negative test=0.30. Predictive values remained the same when both factors were considered together. Patients who were independently mobile before the fall and who do not have pain on axial compression of the limb are less likely to have a fracture, but these signs alone or in combination do not exclude a fracture. The clinical signs investigated cannot distinguish between patients with and without a hip fracture, and MRI scanning is necessary to establish whether some patients have an occult fracture.

Skeletal surveys in children with burns caused by child abuse

OBJECTIVE

To determine the frequency of occult fractures in children with suspicious burns compared with children with other types of physical abuse.

METHODS

Child abuse outpatient clinic reports and inpatient consultations from a midwest urban children's hospital for 1989 to 2000 were reviewed. Demographic and clinical data were abstracted for patients seen because of suspected physical abuse. Patients were classified based on reason seen (burns vs other physical injuries), whether they were diagnosed as abused, and whether they had at least 1 skeletal survey. Positive skeletal surveys were defined as having a fracture that was unexplained, highly specific for abuse, or with a perpetrator confession.

RESULTS

Of 335 patients evaluated, the mean age (+/-SD) was 1.5 +/- 1.9 years, 63% were boys, 64% were white, and 80% had skeletal surveys performed. Reasons for evaluation included 69 (21%) for burns and 266 (79%) for other injuries. After excluding patients without a final diagnosis of abuse and those presenting with obvious fractures, 5 (14%) of 36 burn patients had positive skeletal surveys compared with 45 (34%) of 133 with nonburn injuries (P = 0.02). Burn patients were older compared with those with nonburn injuries (mean ages, 1.8 +/- 1.5 vs. 1.1 +/- 1.6 years; P = 0.03) and were more likely to be nonwhite (69% vs. 32%; P < 0.001).

CONCLUSIONS

Although young children with abusive burns have fewer occult fractures compared with those with other abusive injuries, the frequency of occult fractures is still high enough to warrant the consideration of skeletal surveys in these cases.

[Medical care for mechanical trauma of the chest and abdomen at the prehospital stage]

The authors describe specific features of the diagnosis and emergency medical care at the prehospital period developed on the basis of treatment of more than 5000 patients with isolated and combined injuries of the chest and abdomen. The importance of using the resuscitation-surgical teams, the syndrome diagnostics and stabilization of vital functions at the place of the accident is stressed as well as admittance of the casualties as quickly as possible to an up-to-date specialized multitype traumatology center.

Fractures of the shaft of the humerus

We studied the epidemiology of 401 fractures of the shaft of the humerus in 397 patients aged 16 years or older. The incidence was 14.5 per 100 000 per year with a gradually increasing age-specific incidence from the fifth decade, reaching almost 60 per 100 000 per year in the ninth decade. Most were closed fractures in elderly patients which had been sustained as the result of a simple fall. The age distribution in women was characterised by a peak in the eighth decade while that in men was more even. Simple fractures were by far the most common and most were located in the middle or proximal shaft. The incidence of palsy of the radial nerve was 8% and fractures in the middle and distal shaft were most likely to be responsible. Only 2% of the fractures were open and 8% were pathological. These figures are representative of a population with a low incidence of high-energy and penetrating trauma, which probably reflects the situation in most European countries.

Posterior Malleolar Fracture is Often Associated with Spiral Tibial Diaphyseal Fracture: A Retrospective Study

BACKGROUND

It is known that posterior malleolar fracture is often associated with tibial diaphyseal fractures. However, in literature there are very few studies on tibial shaft fractures with respect to posterior malleolus fragment. We hypothesized that the incidence of posterior malleolar fracture is higher than in previous studies.

METHODS

A total of 74 closed tibial shaft fractures were treated with intramedullary nailing in Turku University Central Hospital between January 1994 and December 1998. There were 55 men and 19 women, with a mean age of 39 years (range, 16 to 58 years). Two cases were excluded and 72 tibial shaft fractures were analyzed retrospectively.

RESULTS

Posterior malleolar fracture was observed in 18 cases (25.0%). Only 10 were observed preoperatively in plain films, seven were detected postoperatively and one was not detected at all during the treatment. Retrospectively, all 18 posterior malleolar fractures were detectable in preoperative plain films.

CONCLUSION

A fracture of the posterior malleolus was involved in every fourth tibial diaphyseal fracture. The fractures of the posterior malleolus were always detected in preoperative plain films and should be suspected, especially in cases of low-energy spiral distal tibial diaphyseal fractures. We recommend additional plain films to be taken at the ankle region to better visualize these fractures.

Nonoperative Management of Vertical C2 Body Fractures

OBJECTIVE:

To estimate the incidence and to describe the clinical results of the nonoperative management of vertical C2 body fractures.

METHODS:

An 8-year retrospective review of upper cervical spine injuries from the registry of a level I trauma center identified 21 patients with a vertical C2 body fracture.

RESULTS:

Sixteen coronally oriented Type 1 vertical C2 body fractures and 5 sagittally oriented Type 2 vertical C2 body fractures were identified. These fractures account for approximately 10% of the upper cervical spine fractures identified over this period of time. One elderly patient with a Type 1 fracture died as a result of pneumonia, and two patients with Type 2 fractures died from severe closed-head injuries. One patient had evidence of spinal cord injury. This was not related to the C2 body fracture but rather to a subaxial cervical spine injury. Of the surviving 18 patients, all were managed nonoperatively (with external orthoses) and showed evidence of fusion (union of fracture fragments) at the time of the last follow-up.

CONCLUSION:

Vertical C2 body fractures are not rare injuries and can account for up to 10% of upper cervical spine injuries. In general, vertical C2 body fractures are amenable to nonoperative treatment with external orthoses.

Atypical distal radial fractures in children

In a prospective study of paediatric injuries secondary to the use of the non-motorized microscooter, we found a high rate of upper limb trauma, and a distinct injury associated with the scooter. The most common single injury was a fracture of the distal third of radius and ulna, characterized by volar angulation of the distal fragment. This injury, akin to the Smiths fracture in adults, was predictive of scooter use in all cases. This pattern of injury was not repeated by any another mechanism of injury during the course of the study period. The mechanism of injury, seemingly specific to the scooter, is produced by a fall while continuing to clutch the handlebars, leading to palmar flexion and pronation of the wrist as they strike the ground. Fourteen children required admission and manipulation under anaesthesia. Four of these patients subsequently needed remanipulation under anaesthesia. This study suggests that the scooter is associated with a forearm fracture which is both distinctive and unstable.

Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study

BACKGROUND

The purpose of this study was to evaluate the incidence and the long-term results of closed uncomplicated Mason type-II and III fractures in a defined population of adults.

METHODS

Seventy women and thirty men who were a mean of forty-seven years old when they sustained a fracture of the radial head or neck (a Mason type-II fracture in seventy-six patients and a Mason type-III fracture in twenty-four) were reexamined after a mean of nineteen years. Radiographic signs of degenerative changes of the elbow were recorded. The fracture had been treated with an elastic bandage or a collar and cuff sling with mobilization for forty-four individuals, with cast immobilization for thirty-four, with resection of the radial head in nineteen, with open reduction of the radial head in two, and with a collateral ligament repair in one. Secondary excision of the radial head was performed because of residual pain in nine patients, and a neurolysis of the ulnar nerve was performed in one patient.

RESULTS

Seventy-seven individuals had no symptoms in the injured elbow at the time of follow-up, twenty-one had occasional pain, and two had daily pain. The injured elbows had a slight flexion deficit compared with the uninjured elbows (mean and standard deviation, 138 degrees +/- 8 degrees compared with 140 degrees +/- 7 degrees ) as well as a small extension deficit (mean and standard deviation, -4 degrees +/- 8 degrees compared with -1 degrees +/- 6 degrees ) (p < 0.001 for both). The prevalence of degenerative changes was higher in the injured elbows than in the uninjured ones (76% compared with 16%, p < 0.001).

CONCLUSIONS

The results following uncomplicated Mason type-II and III fractures are predominantly favorable. A secondary radial head resection is usually effective for patients with an unfavorable outcome (predominantly long-standing pain).

LEVELS OF EVIDENCE

Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Prevalence and Patterns of Occult Hip Fractures and Mimics Revealed by MRI

OBJECTIVE

The diagnosis of hip fractures can be difficult on radiography alone. MRI is frequently used to confirm or deny the presence of a minimally displaced hip fracture. This study evaluates the patterns of injury seen on MRI that are difficult to diagnose on radiography.

MATERIALS AND METHODS

MRIs of 73 patients who were examined for possible hip fractures and whose radiographic findings were negative or equivocal for hip fracture were reviewed. Seventy-six studies were performed in 73 patients who were between 24 and 102 years old. MRIs were evaluated for the presence and location of bone or soft-tissue injury. Muscle injuries were categorized on the basis of location and type of injury.

RESULTS

Forty-six percent (35/76) of the studies showed subtle fractures. Seventeen fractures were in the proximal femur and 18 in the innominate bone. Soft-tissue abnormalities were common, found in 65% of the studies. Twenty percent of the MRI findings were considered normal because there was no apparent finding on the images to explain the patients' symptoms.

CONCLUSION

Soft-tissue abnormalities are commonly seen alone or in association with subtle fractures on MRI in the evaluation of patients with a clinical suspicion of hip fracture. MRI is recommended for all symptomatic patients whose radiographic findings are negative for hip fracture.

Prevalence and patterns of foot injuries following motorcycle trauma

OBJECTIVES

To determine the prevalence and patterns of foot injuries following motorcycle trauma.

DESIGN

Prospective.

SETTING

Yorkshire Region Trauma Units (Level 1 trauma centers with trauma research).

PATIENTS

Individuals injured in motorcycle road traffic accidents between January 1993 and December 1999.

OUTCOME MEASUREMENTS

Patient demographics, protective devices (helmet) use, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), clinical details, therapeutic interventions, resuscitation requirements, duration of hospital stay, mortality, and type of foot injuries sustained.

RESULTS

The parent population of 1239 contained 53 (4.3%) foot-injured motorcyclists (49 men) with a mean age of 31.7 years (range 18-79 years). Fifty-two were drivers and one was a rear-seat passenger. Mean ISS was 6.9 (range 4-33), significantly lower than the parent population mean of 34.98 (range 9-75) (P = 0.001). Mean GCS was 14.7 (range 13-15). The motorcyclists' injuries included 26 metatarsal fractures (49.1%), 14 talar fractures (26.4%), 7 os calcis fractures (13.2%), and 6 toe fractures (11.3%). Associated foot injuries included three partial foot amputations, four Lisfranc dislocations, three cases of foot compartment syndrome (two crush injuries with no fracture, one open fourth metatarsal fracture with associated Lisfranc dislocation). Forty-six motorcyclists had more than one foot injury. Associated injuries included 22 ankle fractures (41.5%), 15 tibial fractures (28.3%), 6 femoral fractures (11.3%), 5 pelvic ring fractures (9.4%), 23 upper limb injuries (43.4%), and 3 cases of chest trauma (5.7%). No one sustained abdominal trauma or head injury compared with the parent population. All patients required operative stabilization of foot fractures, including their associated injuries. Mean hospital stay was 10.9 days (range 1-35 days). In the parent population, there were 71 deaths (6.0%), whereas there was only 1 death (1.9%) in the foot-injured group (with fractures including open book pelvic, T6-8, unilateral open femur, tibial, ankle, and metatarsal) with an ISS 33, who died of multiorgan dysfunction syndrome. At final follow-up, all patients underwent radiologic and clinical assessment of foot injuries. Forty-three patients returned to their previous occupation and level of mobility. Ten of the more significantly injured patients had to modify their occupation from manual to sedentary-type jobs due to their foot injuries. We noted a pattern of complex ipsilateral foot and limb injury in nine patients, which we postulate was due to the actual mechanism of contact with the road surface.

CONCLUSION

Motorcycle accidents continue to be a source of severe injury, especially to the foot. The most common foot injury is a metatarsal fracture; however, there must be a high index of suspicion for associated injuries. Although these injuries are associated with a low mortality rate, they require prompt assessment and treatment to limit long-term morbidity and disability. The difference in foot injury pattern and mortality between the parent population and our series, among other factors, potentially may be influenced by the actual mechanism of contact with the road surface and the modifying action of the foot during the accident.

Hip fractures in lebanese patients: determinants and prognosis

Hip fractures are the most costly of osteoporotic fractures, but little is known about their epidemiology in the Middle East. Hip fracture patients and controls with osteoarthritis admitted to our institution from 1992 to 2002 were studied. Information on gender, age, type of fracture, comorbid conditions, and medications use was obtained. The mean age for hip fracture patients (n = 274) was 72.1(8.5) yr, and for controls (n = 112), it was 71.1(4.4) yr, two-thirds of fractures occurred in women. Fractures were 59% intertrochanteric, 34% femoral neck, and 7% subtrochanteric, with no gender differences. Hip fracture patients were more likely to have had a prior fracture and to suffer from neurological, gastrointestinal, or renal comorbidities, as compared to controls. Less than 10% of hip fracture patients received any therapy for osteoporosis, either on admission or discharge. In a subset of patients with follow-up, the mortality rate was 47% in subjects with hip fracture, and most deaths occurred within the first year postoperatively. Gender but not fracture type affected mortality. Lebanese patients with hip fractures are younger, more likely to sustain intertrochanteric fractures, and experience higher mortality than Western counterparts. Few subjects received osteoporosis therapy. This study carries important public health implications on the management of hip fracture in subjects from Lebanon and, possibly, the Middle East.

[Epidemiological survey of wrist fractures in children]

PURPOSE OF THE STUDY

The incidence of wrist fractures is increasing in children. We undertook an epidemiological survey in western France to determine characteristic features.

MATERIAL AND METHODS

A prospective multicentric study was conducted over one year in five university hospital centers in western France. The survey included 839 wrist fractures in children aged 6 to 16 years. The following criteria were recorded: age and gender, date and energy of the trauma, side and description of the fracture. Displacement was measured on the AP and lateral radiographs.

RESULTS

The boys were older than the girls at the time of the wrist fractures, generally during the summer season (May to October). The left wrist was involved in 55% of the fractures; 83% were metaphyseal fractures. Fractures with epiphyseal detachment were more frequent in adolescents and occurred after high-energy trauma. Metaphyseal fractures were more common in girls than in boys. Displacement was greater in older children, particularly in case of epiphyseal detachment.

DISCUSSION

We did not observe the male predominance often reported in our country. The girls probably practice sports as much as boys.

Stress fractures in Royal Marines recruits

Data are presented on stress fracture patterns at the Commando Training Center Royal Marines. To reduce the high number of training injuries, including stress fractures, a complete review of the training syllabus was undertaken. Following recommendations from this review, a newly designed, physiologically progressive training program was introduced. The result of this revised training syllabus was a statistically significant reduction in stress fracture incidence. The causes of stress fractures are discussed with particular reference to skeletal adaptation to physical loading and the role of muscular support of the axial skeleton.

Orthopedic pitfalls in the ED: radiographically occult hip fracture

Acute hip fracture is among the most commonly encountered orthopedic injuries seen by the emergency physician. The majority of these fractures can be readily diagnosed on the basis of clinical findings and plain radiographs. When initial films are negative or equivocal, but a high clinical suspicion exists for a hip fracture, additional diagnostic studies need to be performed because significant morbidity can result from ambulation on an unrecognized fracture. The emergency physician needs to remain vigilant for this potential orthopedic pitfall. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.

Fractures in transfusion dependent beta thalassemia--an Indian study

AIM OF STUDY

To analyse the incidence of fractures in beta thalassemia patients and to identify causative factors.

METHODS

We examined all cases of transfusion dependent beta thalassemia (TDBT) seen at our institute over a two-year period. The transfusion records, incidence of fractures, cause of fracture and Hb levels were recorded. Radiographs of the involved parts were taken in cases with fractures only.

RESULTS AND CONCLUSIONS

Amongst 105 cases of TDBT assessed, 14 sustained a total of 28 fractures. Seven patients sustained more than one fracture. Two thirds of these fractures were caused by trivial trauma. All fractures, except one, were of the closed type. Radiologically, fractures frequently showed minimal or no displacement. All fractures were successfully treated by closed modalities of treatment. Majority of the fractures healed within normal union time for a given bone. Permanent deformities and gross limb length discrepancies were uncommon. On reviewing the literature, we noted that the incidence of fractures in our series and in the latest reports was lesser than previously reported. We postulate that this is a result of better and earlier control of hemoglobin status by improved transfusion techniques, and earlier recognition of the disease. Difficulties arise due to inadequate blood transfusion facilities in developing countries.

MR imaging for traumatic tears of the rotator cuff: high prevalence of greater tuberosity fractures and subscapularis tendon tears

OBJECTIVE

The purpose of this study was to determine whether occult bony injuries or other characteristic MR abnormalities are frequent in patients suspected of having traumatic tears of the rotator cuff.

SUBJECTS AND METHODS

MR arthrography of the shoulder was performed in 24 consecutive patients with suspected traumatic tears of the rotator cuff. MR findings were analyzed with regard to abnormalities of the supraspinatus, infraspinatus, and subscapularis tendons; and the humeral head. A comparison group of 24 consecutive patients with symptoms of nontraumatic tears of the rotator cuff was included in the investigation.

RESULTS

Radiographically occult fractures of the greater tuberosity were found in nine (38%) of 24 patients with clinically suspected traumatic tears of the rotator cuff (seven of which occurred in patients <40 years old). Nine partial-thickness and five full-thickness supraspinatus tears were found in the trauma group. In the comparison group, the corresponding numbers were 13 and 10, respectively. Seven partial lesions of the cranial border of the subscapularis and six complete subscapularis tears (all six in patients >40 years old) were found in the trauma group (nine and one in the comparison group).

CONCLUSION

Occult greater tuberosity fractures and complete subscapularis tears are commonly seen on MR images in patients suspected of having traumatic tears of the rotator cuff. Greater tuberosity fractures should be looked for specifically in patients younger than 40 years, and subscapularis tears should be looked for specifically in patients older than 40 years.

Traumatic elbow effusions in pediatric patients: are occult fractures the rule?

OBJECTIVE

Elbow joint effusion with no fracture seen on radiographs of pediatric patients after acute trauma has become synonymous with occult fracture. This study evaluates the incidence of occult fractures in such cases as determined by findings on follow-up radiographs.

MATERIALS AND METHODS

Initial and follow-up radiographs were reviewed for 54 children (mean age, 7 years) with a history of trauma who had joint effusion but no identifiable fracture on initial radiographs. The presence of periosteal reaction or bony sclerosis on follow-up radiographs was considered to be evidence of occult fracture. Mean time between initial and follow-up radiographs was 18 days (range, 14-50 days).

RESULTS

Only nine (17%) of the 54 patients showed evidence of a healing occult fracture on follow-up radiographs. However, we found a statistically significant relationship (p = .001) between persistent joint effusion on follow-up radiographs and occult fracture. Seventy-eight percent of cases with occult fracture, versus 16% of cases without occult fracture, had persistent effusions.

CONCLUSION

Joint effusion without visualized fracture on initial radiographs after trauma does not correlate with the presence of occult fracture in most cases (83%). Therefore, joint effusion as revealed by radiography should not be considered synonymous with occult fracture.

The epidemiology of humeral shaft fractures

We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the Tscherne system. The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most (60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to severe injury in men and a larger peak in the seventh decade after a simple fall in women.

Adult ankle fractures--an increasing problem?

The epidemiology of ankle fractures is changing. Increasing longevity has resulted in the highest age-specific incidence of ankle fractures being in women between 75 and 84 years of age. The introduction of the AO classification has facilitated analysis of the commonest fracture types. This survey of 1,500 ankle fractures, seen in a 3-year period in the Edinburgh Orthopaedic Trauma Unit, shows that the commonest ankle fractures are the B1.1 and A1.2 lateral malleolar fractures. Isolated malleolar fractures accounted for two thirds of the series, with bimalleolar fractures occurring in one fourth of the patients and trimalleolar fractures in the remaining 7%. Open fractures occurred in 2%.

Innominosacral dissociation: mechanism of injury as a predictor of resuscitation requirements, morbidity, and mortality

OBJECTIVES

To assess mechanism of injury as a clinical course predictor in patients with complete anterior and posterior pelvic ring disruptions [innominosacral dissociation (ISD)].

DESIGN

Retrospective review of radiographs and medical data.

SETTING

R Adams Cowley Shock Trauma Center, Baltimore, Maryland, statewide trauma center.

PATIENTS

Forty-three patients with ISD were admitted to our institution between August 1986 and October 1991. Five patients were excluded because of incomplete medical records (4) or refusal of blood transfusion (1).

INTERVENTION

Injuries were grouped according to the Young classification: 18 anteroposterior compression (APC), 14 vertical shear (VS), and 6 other injuries.

MAIN OUTCOME MEASUREMENTS

The mean blood replacement requirements, incidence of multiple organ system failure, mortality rate, and length of hospital stay for each injury classification were compared.

RESULTS

The mean ISS was 34, and the mean 24-hour packed red blood cell transfusion requirement was 12.6 units. Thirteen patients (34.4%) developed multisystem organ failure. Eight patients (21%) died. Patients in the APC group were more likely to require > or = 10 units of blood (15/18, p = 0.001, and those in the VS group were more likely to receive < 10 units (11/14, p = 0.0014). Multisystem organ failure occurred more frequently (11/18 versus 2/14; p < 0.005), mortality was significantly higher (39 versus 0%, respectively; p = 0.01), and mean hospital stay for survivors was longer (48 versus 27 days; p < 0.025) in the APC than in the VS group, respectively.

CONCLUSIONS

These findings suggest that mechanism of injury is an important determinant of clinical behavior in patients with IDS, and that ISD secondary to the APC mechanism is associated with substantially greater resuscitation requirements, morbidity, and mortality than ISD secondary to the VS mechanism.

Acute injuries in orienteerers

The aim of this study was to characterize the type and severeity of acute injuries occurring in Finnish orienteerers in 1987 to 1991. The study is based on the orienteering license insurance records accounting for 2189 orienteering injuries during 69268 person-years of exposure in active orienteerers. Of these orienteerers, 73.0% were male; 73.5% (N = 1608) of all injuries occurred in males, so the injury rate was similar in males and females. The rate was highest in orienteerers 20 to 24 years of age and lowest in children. Injuries occurred most commonly during May to September (78.9% or all injuries), the months which include the orienteering competition season, and were more common during competitions (59.8%) than during training. A high number of the injuries occurred during weekends (58.9% of injuries) including 68.1% of all competition injuries and 44.9% of all training injuries. The lower limbs were involved in 1611 (73.6%) of cases, the ankle (28.7%) and the knee (23.2%) being the two most common injury locations. Sprains, strains and contusions were the most common injuries. Wounds were proportionally more common in males than in females while ankle sprains were more common in females. Fractures, seven open and 94 closed, accounted for 4.6% of injuries; they were most common in the hand/wrist/forearm (N = 44) and ankle (N = 16), and were more frequent during competition (62.3%) than during training. The most important areas for preventive measures seem to be the ankle and the knee.

Changing patterns of scaphoid fractures in adolescents

OBJECTIVE

To determine if the presentation of scaphoid fractures in children has changed.

DESIGN

Case study with a minimum follow-up of 1 year.

SETTING

Outpatient orthopedic clinic in an urban pediatric hospital.

PATIENTS

Twenty-one adolescents (mean age 13.9 years) with scaphoid fractures and an open distal radial growth plate. Fracture healing was assessed at 2-week intervals until union was achieved.

INTERVENTIONS

Immobilization in a short-arm thumb spica cast.

MAIN OUTCOME MEASURES

Fracture union as defined by the absence of pain and obliteration of the fracture line. Active and passive range of motion of wrist as measured with a goniometer.

RESULTS

Only 2 of the 21 patients had avulsed fractures. Twelve fractures were located in the middle one-third of the scaphoid. All fractures healed, but two fractures were in a dorsiflexed position. All patients had full, painless range of wrist motion. No arthrosis was present.

CONCLUSIONS

The presentation of scaphoid fractures in adolescents has changed over the years and now resembles the adult pattern. Malunited scaphoid fractures may be seen. Displaced fractures should be reduced.

Infection after intramedullary nailing of the tibia. Incidence and protocol for management

There is concern about the incidence and serious nature of infection after intramedullary nailing of the tibia, especially for open injuries. We have reviewed 459 patients with tibial fractures treated by primary reamed nailing. The incidence of infection was 1.8% in closed and Gustilo type I open fractures, 3.8% in type II, and 9.5% in type III fractures (5.5% in type IIIa, 12.5% in type IIIb). These incidences appear to be acceptable in comparison with other published results. We describe the different modes of presentation of infection in these cases, and suggest a protocol for its management, which has been generally successful in our series.

[Prognosis and complications of open fractures]

This paper reviews records of Liestal Country hospital, AO Catalogue files and National Swiss Insurance Industry actuarials regarding open fractures. Specific regards are tended toward prognosis forecasting, complications and outcome assessments with respect to industrial "down time" resulting from bone infections and/or pseudarthroses. Evaluation of injuries is contingent upon the Gustilo Classification (1987) which bases prognosis on soft tissue preservation in open fracture injuries. We adhere to well accepted protocols which provide for adequate local primary débridement and stabilization of structural osseous components by means of appropriate fracture fixation. In addition, we have implemented protocols for the preservation of bony vascular elements along with sequential provisions for cancellous bone and soft tissue grafting. Outcome assessments on the range of cases reviewed confirm a traditional perspective that open fractures demonstrate considerably greater morbidity than closed fractures. However, by comparison with previous studies, the results of this series show positive progress toward optimal wound healing. While this more aggressive approach tends initially to be quite expensive, we believe initial costs to the carrier are justified by improved outcome, prognosis and industrial down time.

Incidence, mechanism of injury, and treatment of fractures of the patella in children

Fractures of the patella in skeletally immature patients are rare. The charts of 185 patients treated for patella fractures at the University of Kentucky Medical Center between 1976 and 1988 were retrospectively reviewed. The 12 patients of these 185 aged 8 to 16 years were included in this study. The incidence was calculated to be 6.5% of all patella fractures. All patients studied were male with an average age of 12.7 years. Sleeve fractures were the most common type of patella fracture observed (five), followed by transverse fractures (four). Ten of the 12 cases required operative management ranging from irrigation and debridement to open reduction and internal fixation. Partial patellectomy was performed when indicated. Indications for operative management in this age group were similar to those for adults. As in adults, the mechanism of injury was predominantly motor vehicle and motorcycle crashes. Laws requiring seatbelt restraints for children should have a positive effect on the incidence of such fractures resulting from dashboard injuries. One mechanism of injury not reported previously was that of a flexed knee striking the gym wall after performing a basketball lay-up because the basket was placed flush with the wall.

[The outcomes in crush syndrome of the extremities half a year after the earthquake in Armenia]

Squeezed syndrome affecting various segments of limbs has been identified in 245 of 500 victims randomized for examination 6 months after the earthquake. In 119 cases associated with closed fractures of long tubular bones and in 59 cases with open ones. In 124 cases duration of squeezing was up to 12 h, and in 70 cases--1 day and more. Segmental limb amputation was performed in 113 cases. In 95 cases limbs functions were retained and in 81--lost. Perspectives of more successful outcomes depend on the maximal shortening of rescue period, on rational organization of the treatment process and prolongation of recovery management of squeezed syndrome sequelae.

Brachial-plexus palsy in the newborn

Twenty-one patients who had twenty-three brachial-plexus palsies resulting from trauma at birth were studied over a three and one-half year period, between July 1983 and December 1986. The incidence of this group of injuries was 2.5 per 1,000 live births. There were fourteen palsies of the fifth and sixth cervical nerves; eight of the fifth, sixth, and seventh cervical nerves; and one of the entire brachial plexus. Two patients were lost to follow-up shortly after birth. Of the remaining nineteen patients (twenty-one palsies), fifteen (seventeen palsies) had full recovery at an average of three months (range, two weeks to twelve months), and four (four palsies) had residual paralysis of the upper extremity at more than twenty-six months. We concluded that the newborn who has a brachial-plexus palsy has a favorable prognosis for complete recovery.

Patho-anatomic findings in neck structures in asphyxiation due to hanging: a survey of 80 cases

By examining 80 consecutive cases of death due to hanging, fractures of the thyroid cartilage or the hyoid bone or both, were noted in 45%. Fracture of the cricoid cartilage did not occur. No fracture occurred below the age of 25, and the frequency was slightly increasing with increasing age. There was a preponderance of fractures in males. The highest incidence of fractures was noted in typical hangings, while incomplete hanging to a very great extent was combined with congestion to the face, especially if the location of the ligature was atypical. Typical hanging in general did not produce congestion. The lividity in the declivous areas became fixed at the earliest after 5-6 h suspension time, while after 12 h almost all the cases demonstrated fixed lividity in the distal parts, especially in the legs. There is slight indication that the frequency of fractures increases with the length of suspension time.

Tibial plateau fractures in alpine skiing

Tibial plateau fractures are uncommon in sports. Between 1977 and 1986, the authors studied 18 skiers who suffered tibial plateau fractures. Fracture patterns were diverse and displacement minimal. Hyperextension-valgus displacement caused compression fracture of the anterolateral tibial plateau in a characteristic form in 44%. Detection of these fractures is difficult by clinical and plain radiograph assessment, thus diagnosis may require acute awareness and special imaging tests. Although tibial plateau fractures are uncommon in skiers, early detection and treatment is important for best result in this sports population.

The spectrum of closed-head injuries in facial trauma victims: incidence and impact

Little is known of the incidence of closed-head injury (CHI) associated with facial trauma. To study this problem, we conducted a retrospective review of 200 consecutive admissions to the University of Michigan Medical Center Emergency Department from 1980 to 1985 for treatment of acute facial fractures. All patients were admitted within 48 hours of injury (93% within 24 hours). Medical records were reviewed for age, sex, description, and circumstances of facial injury; assessment of loss of consciousness and anterograde amnesia; and associated intracranial or extracranial injuries. Seventy-three percent of the patients were men (mean age, 27.8 years). Etiologies, in descending order, were road traffic accidents (52%), assaults (22%), sports (14%), falls (7%), other injuries (3%), and gunshot wounds (2%). The incidence rate of CHI in our study was 55%. More than 90% of the head injuries were associated with the loss of consciousness of less than one hour. Risk factor analysis failed to demonstrate that an increased risk of CHI is associated with age, sex, or number of facial fractures. However, there was a one and one-halffold increased risk associated with patients involved in automobile accidents.

Scoliosis and fractures in young ballet dancers. Relation to delayed menarche and secondary amenorrhea

In a survey of 75 dancers (mean age, 24.3 years) in four professional ballet companies, we found that the prevalence of scoliosis was 24 percent and that it rose with increases in age at menarche. Fifteen of 18 dancers (83 percent) with scoliosis had had a delayed menarche (14 years or older), as compared with 31 of 57 dancers (54 percent) without scoliosis (P less than 0.04). The dancers with scoliosis had a slightly higher prevalence of secondary amenorrhea (44 percent vs. 31 percent), the mean (+/- SD) duration of their amenorrhea was longer (11.4 +/- 18.3 vs. 4.1 +/- 7.4 months; P less than 0.05), and they scored higher on a questionnaire that assessed anorectic behavior. The incidence of fractures was 61 percent (46 of 75 dancers), and it rose with increasing age at menarche. Sixty-nine percent of the fractures that were described were stress fractures (mostly in the metatarsals), and their occurrence had an even stronger correlation with increased age at menarche. The incidence of secondary amenorrhea was twice as high among the dancers with stress fractures (P less than 0.01), and its duration was longer (P less than 0.05). In 7 of 10 dancers in whom endocrine studies were performed, the amenorrheic intervals were marked by prolonged hypoestrogenism. These data suggest that a delay in menarche and prolonged intervals of amenorrhea that reflect prolonged hypoestrogenism may predispose ballet dancers to scoliosis and stress fractures.

Slow-pitch softball injuries

A prospective investigation of slow-pitch softball injuries incurred in Hawaii was undertaken to study the nature of these injuries and analyze their causes. The injured players were involved in league softball with referees. There were 83 athletes and 93 injuries. A retrospective review of all Army softball-related admissions was also done. Thirty-five athletes or 42% were injured while sliding, 29 "foot first" and the remainder "hand first". Twenty-five of 27 ankle injuries caused by sliding included 20 fractures, 3 sprains, and 2 complete closed posterior dislocations. Analysis of these injuries suggests that the injury occurs when the individual uses the base to rapidly decelerate and avoid overrunning the base. Eighty-four percent of the athletes were injured from three mechanisms; 42% from sliding, 25% from "jamming" injuries, and 17% from falls. The only preventable group of injuries appears to be the sliding injuries. Recessing the bases, using "quick release" rather than anchored bases, teaching safer sliding techniques, or eliminating the slide are suggested as means of preventing these injuries.

Trauma on eight wheels. A study of roller skating injuries in Seattle

Thirty-five fractures secondary to roller skating accidents from March 15 to October 1, 1979 were treated in the University of Washington-affiliated hospitals. Twenty-eight involved the wrist and elbow. Only three were in skeletally immature individuals. Sixty-three percent of the patients were female with the 20- to 34-year-old age group the most commonly involved. A fall, usually backwards, onto outstretched arms and hands was the most frequent mechanism of injury. A detailed study of the popular outdoor skating area in Seattle, Green Lake, indicated that more than 75% of the injuries occurred on sloped surfaces with otherwise favorable environmental conditions. Most people were either first time skaters or had not skated since childhood. Based on our study, we recommend: (1) skating on level, familiar terrain; (2) learning to skate in a sparsely congested area; (3) skating with experienced partners who can give instructions; and (4) using protective equipment, such as knee and elbow pads and rigid wrist splints.

Spinal fractures and dislocations in children and adolescents

During the years 1962 through 1978 a total of 42 children under the age of 15 years with fractures or dislocations of the spine were admitted to the Royal Brisbane Hospital Complex. Sixty-three percent of these children were males. The predominate causes of injury were fall/jump (40%), road traffic accidents (29%), and water-related injuries (19%). Half the injuries occurred to the cervical spine, while injuries at more than one level occurred in 35% of patients. Cord injuries occurred in 14% of patients, while skeletal and head injuries occurred in over half of the spinal injuries associated with road trauma. The response of the immature spine following trauma differs from that of the adult, especially in respect to a growth potential, ultimate vertebral stability, and neurologic function.

Pattern of bone injury in Ibadan

A series of 1,329 patients with 1,327 fractures and 100 dislocations has been studied. Boys under 10 years of age predominated. The majority of the injuries resulted from falls or road traffic accidents. Upper limb fractures occurred more commonly than those of the lower limbs or axial skeleton. Femoral shaft fractures were 2-1/2 to 5 times more common while femoral neck fractures were three to five times less common than in Americans. Dislocations were most common at the elbow, followed by the shoulder. Only 11.5% of the patients had open operations; the others were treated conservatively. The prognosis as regards survival and functional results was very good, but malunion was the most common complication.