Nationwide study on open tibial fractures in the Netherlands: Incidence, demographics and level of hospital care

OBJECTIVES

Open tibial fractures are relatively common injuries following traffic accidents. The vulnerability of the soft tissues surrounding the tibia increases the susceptibility to complications, including infection and nonunion. To minimize complications, a multidisciplinary, timely approach is crucial. To date, the Dutch incidence and level of hospital treatment remain unknown due to a lack of condition-specific nationwide registries. This study aimed to estimate the incidence and management of open tibial fractures in the Netherlands, providing essential information for public health policymaking and guideline development.

METHODS

The 2018 and 2019 Dutch National Hospital Care Basic Registration data, provided by the Dutch Hospital Data Foundation, were utilized to identify all patients admitted to Dutch hospitals with tibial fractures. Incidence rates, patient demographics, primary diagnoses, fracture classification, level of hospital, and length of hospital stays were analyzed using descriptive statistics.

RESULTS

1,079 ICD-10 codes for closed and open tibial fractures were identified in patients that were admitted to a Dutch hospital. Thirty-four percent were classified as open tibial fractures, accounting for an estimated incidence rate of 1.1 per 100,000 person-years (95 % CI 0.97-1.12). When categorized by age, the calculated incidence rate was higher in males for all age categories up until the age of 70. Notably, the overall highest incidence rate was found for females aged 90 and above (6.6 per 100,000 person-years). Open tibial fractures were predominantly treated in general or top clinical hospitals (comprising 69 % of open all tibia fractures). Notably, the minority (31 %) presented at university medical centers, all Level-1 trauma centers, equipped with orthoplastic teams.

CONCLUSION

This is the first study to report the nationwide incidence rate of open tibial fractures in the Netherlands; 34 % of tibial fractures were registered as open. Notably, a limited proportion of open tibial fractures underwent treatment within Level-1 trauma centers. Consequently, in the majority of cases, the implementation of an orthoplastic team approach was unattainable. This study underscores the need for more comprehensive data collection to assess and improve the current treatment landscape.

Clinical Characteristics and Treatment Patterns of Open Hand Fractures in the Pediatric Population

BACKGROUND

Open hand fractures are one of the most common injuries in the pediatric population. These injuries are at higher risk of infection, especially in cases of frank contamination. Several studies on adult hand fractures are available in the literature; however, pediatric open hand fractures have yet to be extensively studied. This study aimed to define pediatric open hand fracture's demographics, clinical characteristics, and treatment patterns.

METHODS

Using the Protected Health Information database, pediatric patients (<18 y old) with the diagnosis of open hand fracture from June 2016 to June 2018 were extracted. Demographic, treatment, and follow-up data were collected. Clinical outcomes included readmission and postoperative infection rates.

RESULTS

There were a total of 4516 patients who met the inclusion criteria; the median age was 7 years (interquartile range: 3 to 11); 60% males; 60% white. Displaced fractures occurred in 74% of patients, with the right hand (52%) and middle finger (27%) predominance. The most common mechanism of injury was a crushing injury in-between objects (56%). Associated nerve injury occurred in 78 patients (4%) and vascular injury in 43 patients (2%). Open reduction and internal fixation were performed in 30% of patients. Cephalosporins were the most commonly prescribed antibiotics (73%), followed by aminopenicillins (7%). Nine patients had complications related to surgical intervention (0.2%), and postoperative infection occurred in 44 patients (1%).

CONCLUSIONS

Pediatric open hand fractures most often occur during childhood and more frequently in males. These fractures tend to be more distal and displaced; reduction and fixation are required in one-third of the cases. Despite the absence of treatment guidelines and variability, this injury exhibits low complication rates.

LEVEL OF EVIDENCE

Level III, retrospective study.

Epidemiology, Etiology, Timing and Severity of Open Fracture - a Five Years Review From a Tertiary Trauma Center, Eastern Province, Saudi Arabia

Background

Open fractures are severe injuries resulting from the bone breaking through the skin, and they have a negative impact on patients' physical, mental, and financial well-being as well as that of the healthcare system. The incidence of open fractures varies globally. These injuries can lead to prolonged disability, increased healthcare costs, and psychological distress. The Gustilo-Anderson classification system is used to classify open fractures into three categories which surgeons use as an index for the severity of an injury and as a prognostic tool. Management involves a multidisciplinary approach, focusing on preventing infection, promoting wound healing, and restoring function.

Objective

The objective of this study is to provide statistics on the epidemiology of open fractures presented to the emergency department to be used later to create management protocols.

Methods

This 5-year retrospective observational analysis of open fracture patients at King Fahad Hospital, a tertiary trauma care institute in Alkhobar from 2018-2023, aimed to understand socio-demographics, injury mechanisms, fracture patterns, and timing. Data were collected electronically, and found 373 cases which were reviewed, and only 138 open fractures fit our inclusion and exclusion criteria and were added to the study.

Results

The study analyzed 138 openly fractured bones in 132 patients aged 2 to 68. Most bones affected were in the lower extremities, the most common being the forefoot bones. The most common mode of injury was a motorbike, followed by MVA. The most common Gustilo type was type 2, with no significant correlation between gender and severity. Musculoskeletal system injury was the highest associated system. Furthermore, we observe a slight increase in cases in Winter/Fall weather seasons.

Conclusion

Total amount of 84.8% of patients with open fractures are men, compared to 15.2% of women. The average age of patients is 25.6 ± 15.6 years. Motorbike accidents, then MVA, are the two leading causes of open fractures. Weather seasons, especially in fall and winter, may also contribute to an increase in open fractures. We found that type 2 is the most common Gustilo type among the injured bones (59.1%).

Patient Comorbidities Associated With Acute Infection After Open Tibial Fractures

INTRODUCTION

Open tibial shaft fractures are high-risk injuries for developing acute infection. Prior research has focused on injury characteristics and treatment options associated with acute inpatient infection in these injuries without primary analysis of host factors. The purpose of this study was to determine the patient comorbidities associated with increased risk of acute infection after open tibial shaft fractures during initial hospitalization.

METHODS

A total of 147,535 open tibial shaft fractures in the National Trauma Data Bank from 2007 to 2015 were identified that underwent débridement and stabilization. Infection was defined as a superficial surgical site infection or deep infection that required subsequent treatment. The International Classification of Diseases, ninth revision codes were used to determine patient comorbidities. Comparative statistical analyses including odds ratios (ORs) for patient groups who did develop infection and those who did not were conducted for each comorbidity.

RESULTS

The rate of acute inpatient infection was 0.27% with 396 patients developing infection during hospital management of an open tibial shaft fracture. Alcohol use (OR, 2.26, 95% confidence interval [CI], 1.73-2.96, P < 0.0001), bleeding disorders (OR, 4.50, 95% CI, 3.13-6.48, P < 0.0001), congestive heart failure (OR, 3.25, 95% CI, 1.97-5.38, P < 0.0001), diabetes (OR, 1.73, 95% CI, 1.29-2.32, P = 0.0002), psychiatric illness (OR, 2.17, 95% CI, 1.30-3.63, P < 0.0001), hypertension (OR, 1.56, 95% CI, 1.23-1.95, P < 0.0001), obesity (OR, 3.05, 95% CI, 2.33-3.99, P < 0.0001), and chronic obstructive pulmonary disease (OR, 2.09, 95% CI, 1.51-2.91, P < 0.0001) were all associated with increased infection rates. Smoking (OR, 0.957, 95% CI, 0.728-1.26, P = 0.722) and drug use (OR, 1.11, 95% CI, 0.579-2.11, P = 0.7607) were not associated with any difference in infection rates.

DISCUSSION

Patients with open tibial shaft fractures who have congestive heart failure, bleeding disorders, or obesity are three to 4.5 times more likely to develop an acute inpatient infection than patients without those comorbidities during their initial hospitalization. Patients with diabetes, psychiatric illness, hypertension, or chronic obstructive pulmonary disease are 1.5 to 2 times more likely to develop subsequent infection compared with patients without those comorbidities. Patients with these comorbidities should be counseled about the increased risks. Furthermore, risk models for the infectious complications after open tibial shaft fractures can be developed to account for this more at-risk patient population to serve as modifiers when evaluating surgeon/hospital performance.

CONCLUSION

Patient comorbidities are associated with increased risk of acute inpatient infection of open tibial shaft fractures during hospitalization.

Epidemiology of Open Tibia fractures presenting to a tertiary referral centre in Southern Malawi: a retrospective study

BackgroundRoad traffic accidents in Malawi have increased in recent years resulting in a high incidence of trauma seen in the hospitals as well as a high prevalence of musculoskeletal impairment in the community. Open fractures are a common consequence of road traffic accidents and the tibia is the most common long bone open fracture.ObjectiveEpidemiology of open tibia fractures at the largest tertiary level hospital in Malawi and incidence of infections of open fractures managed at the institution.Methodology This was a retrospective study of consecutive open tibia fracture patients seen and admitted to Queen Elizabeth Central Hospital’s (QECH) orthopedic department from 1st January 2019 to 31st December 2019. Patients with life-threatening head, chest, or abdominal injuries were excluded as management takes priority over any limb-threatening injury.Results There were 72 open tibia fractures screened, and 60 of these met our entry criteria; 6 patients did not, while 6 patient files were missing. The median age of patients was 36 years, IQR (27-44.75) with Males making up 82%(n=49) of open fractures. Most of the open tibia fractures were caused by road traffic accidents 63%(n=38), followed by assaults 18%(n=11), falls 17%(n=10), and industrial accidents 2%(n=1). 26.7% (n=16) of open tibia fractures developed an infection. We found that patients’ average length of stay was 16. 9(IQR 9.5-31.25) days. Most of the injuries (68.3%, n=41) were moderate to high energy injuries being Gustilo et al. grade II and III open tibia fractures. Conclusion This study identified that open tibia fractures were common in our hospital and that were often high energy injuries requiring an extended hospital stay to manage. The infection rate noted was higher than that reported on average in lower- and middle-income countries. There is a need to do more robust prospective studies in the area to gather more information.

Incidence, characteristics, and treatments of traumatic open fractures in children and adolescents: A retrospective observational study

We aimed to investigate the incidence, characteristics, and treatments of open fractures in children and adolescents (≤18 years old). We retrospectively reviewed the records of 2418 children and adolescents who presented with traumatic fractures and were admitted to our university-affiliated hospitals, among which 206 patients (8.5%) presented with open fractures. The patients' clinical and radiographic records were reviewed, and the age, gender, cause of injury, injury season, injury week, associated injuries and complications were collected. This study enrolled 1789 males (74.0%) and 629 females (26.0%) with an average age of 11.2 ± 5.0 years. The patients were divided into an open fracture group (OF group, n = 206) and a group with no open fracture (No-OF group, n = 2212). There were 206 patients (8.5%) who presented with open fractures and the most common fracture sites were the tibia (31.1%, 64/206) and fibula (20.9%, 43/206). The patients in the OF group presented with higher frequency of emergency admission (P < 0.001), self-supporting medical insurance (P < 0.001), MVCs (P < 0.001), wounded by machine (P < 0.001), struck by object (P < 0.001), hurt/cut by others (P < 0.001), lower limb fractures (P < 0.001), multiple fractures (P = 0.010), associated injuries (P < 0.001) and wound infection (P = 0.003) then the patients in the No-OF group. The most common complication were wound infection (5.8%) and pneumonia (1.0%) in the OF group, wound infection (2.1%) and pressure sores (2.0%) in the No- OF group. Multivariate logistic regression analysis indicated that mechanical trauma (OR = 64.229, P < 0.001), being hurt/cut by others (OR = 26.757, P < 0.001), and being struck by an object (OR = 15.345, P < 0.001) were stronger risk factors for open fracture than were low falls; additionally, lower limb fractures (OR = 5.970, P < 0.001), upper limb fractures (OR = 5.865, P < 0.001) and multiple fractures (OR = 5.414, P < 0.001) were stronger risk factors than craniofacial fractures for open fractures. The frequency of surgical treatment for the patients with traumatic open fractures (87.9%, 181/206) was significantly higher than those without open fractures (72.2%, 1596/2212) (P < 0.001). The hospital stays and fees for surgical treatment for the patients with traumatic open fractures were significantly higher than those without open fractures (P < 0.001). Etiology (especially being injured by a machine or being hurt/cut by others) and the fracture site (including lower limb fractures and upper limb fractures) were independent risk factors for open fractures. Traumatic open fractures presented with higher surgical treatment rate, hospital stays and fees.

Agricultural Trauma Causing Open Fractures: Is Antibiotic Coverage Against Anaerobic Organisms Indicated?

OBJECTIVE

To compare deep infection rate and causative organisms in open fractures of the lower extremity from agricultural trauma with similar injuries in nonagricultural trauma.

DESIGN

Retrospective.

SETTING

Two tertiary care institutions.

METHODS

Open lower extremity fractures sustained between 2003 and 2018 caused by agriculture-related trauma in adult patients were reviewed. A nonagriculture open fracture control group (NAG) was identified for comparison. Patient demographics and injury characteristics were assessed. Outcomes included occurrence of deep infection and causative organisms.

RESULTS

One hundred seventy-eight patients were identified in the agriculture (AG) (n = 89) and control (NAG) (n = 89) groups. Among patients with agricultural injury, farm machinery was the most common mechanism in 69 (77.5%) of them. Open injuries of the foot (38.2%) and tibial shaft injuries (25.8%) were the most common in the AG and NAG groups, respectively. Deep infection was seen in 21% of patients in the AG group compared with 10% in the NAG group (P < 0.05). In the AG group, anaerobic infection occurred in 44% of patients with deep infection compared with 9.1% in the NAG group (P < 0.05). The most common anaerobic organisms included enterococci, Pseudomonas aeruginosa, and Clostridium perfringens.

CONCLUSIONS

This study supports that open fractures due to agricultural trauma have a high infection rate, with anaerobic infection occurring at higher rates than in injuries due to nonagricultural trauma. Prophylactic treatment with antibiotics directed against anaerobes is indicated in these injuries.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Infections After Open Fractures in Pediatric Patients: A Review of 288 Open Fractures

We reviewed pediatric open fractures treated at a large Level 1 children's trauma center to determine the rate of infection after open fractures, potential risk factors for infection, and the rate of infection caused by antibiotic-resistant organisms. A retrospective review identified 288 open fractures in children 1 to 17 years of age. Post-traumatic infections developed in 24 (8.3%) open fractures. There was no significant association between the development of infection and mechanism of injury (p = 0.33), time to surgical debridement (p = 0.93), or type of empiric antibiotic given (p = 0.66). Infection occurred more frequently in overweight and obese patients (odds ratio = 2.22; 95% confidence interval: 0.93, 5.46, p = 0.07). There was one infection (4.2%) caused by methicillin-resistant staphylococcus aureus (MRSA). The most commonly identified organisms on culture were methicillin-sensitive staphylococcus aureus (n = 3) and pseudomonas (n = 3). Obesity is a significant risk factor for the development of infection after an open fracture in the pediatric population. (Journal of Surgical Orthopaedic Advances 31(2):073-075, 2022).

The association of socioeconomic deprivation and paediatric open tibia fractures

The primary aim of this study is to test the association of open tibial fractures (OTF), in a paediatric age group, with socioeconomic deprivation. The secondary objectives are to more clearly define the epidemiological characteristics of these high-energy injuries. A consecutive series of patients with OTF presenting to a major trauma centre at a children's hospital in Liverpool had age, gender, fracture pattern, mechanism, timing of the injury and their postcode of residence recorded. Those cases outside Liverpool, Sefton and Knowsley local authorities were excluded from incidence calculations. Postcodes were used to generate deprivation scores (Index of Multiple Deprivation, 2010) based on census data (2011). Cases were ranked and allocated to deprivation quintiles. A comparison to the normal population within Merseyside was undertaken using regression analysis. There were 71 cases over a 9-year period. Fifty cases resided within the geographical limits of Merseyside and were included in the incidence calculations. The annual incidence of paediatric OTF is 3.09 per 100 000 children (0-16 years). The median age at injury was 11 years (range 2-16) and this occurred most usually during term-time between 3 and 5 p.m. from road traffic collisions. Paediatric OTFs are strongly associated with socioeconomic deprivation. The association with deprivation reflects an exposure to unsafe roads in busy urban areas with limited access to safe playing spaces. Socioeconomically deprived men are most at risk from this injury. The links between deprivation and outcomes of treatment or long-term prospects are unclear.

The Pediatric Open Supracondylar Fracture: Associated Injuries and Surgical Management

BACKGROUND

While supracondylar (SC) fractures are relatively common in children, the incidence of open injuries is believed to be only 1%. Two prior studies on open SC fractures in children reported an increased incidence of vascular injuries. The purposes of our study were to clarify the incidence, associated conditions, and current treatment for open SC fractures.

METHODS

The Pennsylvania Trauma Outcome Study database was queried. Subjects age 25 to 156 months old admitted to trauma centers between January 2000 and December 2015 with a SC fracture were included. Controls were those with closed fractures and the study group, those with open injuries. Study variables were age, sex, weight, injury severity score, length of stay (LOS), nerve injury, ipsilateral forearm fracture, compartment syndrome/fasciotomy, requirement for a vascular procedure. Other variables were mode of treatment, provisional reduction, repeat reduction, time interval between referring facility admission and operation, and time from emergency department admission to operation.

RESULTS

A total of 4308 subjects were included, 104 (2.4%) of whom had an open SC fracture. LOS was 2 days for the study group versus 1 day for controls (P<0.001). Open SC fractures were more likely than closed to be associated with a nerve injury (13.5% vs. 3.7%), ipsilateral forearm fracture (18.3% vs. 6.4%) and/or a vascular procedure (6.7% vs. 0.3%) (P<0.001). 5.9% of those in the study group required repeat surgery compared with 0.4% for controls (P<0.001). Time from emergency department admission to operation was 3.2 versus 10.3 hours (P<0.001).

CONCLUSIONS

We report the largest series to date of open SC fractures in children. Surgeons caring for such patients should be aware of their increased risks for both associated injuries and potential requirement for vascular reconstruction. The majority of children with an open SC fracture are managed with 1 operation and in the absence of vascular injury, seldom require an extended LOS.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Can infection be predicted after intramedullary nailing of tibial shaft fractures?

Despite the progress in tibial fracture care, some patients contract infection following intramedullary nailing. We analyzed which risk factors could predict infection in 171 tibial fractures. The independent variables included age, gender, body mass index, and comorbidities, along with external factors of fracture pattern, nailing settings, and treatment processing time. A multiple logistic regression was used to identify infection risk factors. The risk of infection significantly increased according to the open grading, the fractures' classification, time until antibiotic administration, and time until nailing. Gustilo type I fractures presented a higher rate of infection than expected, explained by a longer delay before surgery. The probabilistic equation allows infection prediction with high sensitivity and specificity. In total, we showed that no antibiotics' prescription in emergency service and a transverse fracture pattern were predictors of infection. An infection risk score can be computed, aiding surgeons in decision making. Outcomes could improve keeping these observations in mind. Level of evidence: Retrospective cohort study. Level iii.

Epidemiology of hand fractures at a tertiary care setting in Saudi Arabia

Objectives:

To examine the epidemiology of hand fractures including common bones affected, causes, interventions, outcomes, and complications.

Methods:

This retrospective records-based study included patients who were admitted to King Saud Medical City, Riyadh, Kingdom of Saudi Arabia, with traumatic metacarpal or phalangeal fractures between January 2016 and September 2017. Carpal fractures, wrist fractures, and all pathological fractures were excluded.

Results:

A total of 82 patients (90.2% of them men with an average age of 27.6±13.4 years) with 101 fractures were included. The fifth (25.5%) and first (24.5%) rays were the most commonly affected ones. The fifth finger (27.8%) and first metacarpal (28.9%) were the most commonly affected finger and metacarpal bone. Approximately 32.7% of the fractures were open fractures. The most frequent causes of hand fractures included falls (40.5%), road traffic accidents (20.3%), crushing injuries (9.5%), and machinery injuries (9.5%). Approximately 90.1% of the patients underwent operative interventions including open reduction (50.5%) and closed reduction (34.3%). The majority of fractures (79.2%) healed, and only 14.7% of fractures developed complications.

Conclusion:

In this study of hand fractures, patients were predominantly males and the main causes of fractures were falls and road traffic accidents.

Open tibial fractures in major trauma centres: A national prospective cohort study of current practice

AIMS

To assess current national practice in the management of severe open tibial fractures against national standards, using data collected by the Trauma and Audit Research Network.

MATERIALS AND METHODS

Demographic, injury-specific, and outcome data were obtained for all grade IIIB/C fractures admitted to Major Trauma Centres in England from October 2014 to January 2016.

RESULTS

Data was available for 646 patients with recorded grade IIIB/C fractures. The male to female ratio was 2.3:1, mean age 47 years. 77% received antibiotics within 3 h of admission, 82% were debrided within 24 h. Soft tissue coverage was achieved within 72 h of admission in 71%. The amputation rate was 8.7%. 4.3% of patients required further theatre visits for infection during the index admission. The timing of antibiotics and surgery could not be correlated with returns to theatre for early infection. There were significant differences in the management and outcomes of patients aged 65 and over, with an increase in mortality and amputation rates.

CONCLUSIONS

Good outcomes are reported from the management of IIIB/C fractures in Major Trauma Centres in England. Overall compliance with national standards is particularly poor in the elderly. Compliance did not appear to affect rates of returning to theatre or early infection. Appropriately applied patient reported outcome measures are needed to enhance the evidence-base for management of these injuries.

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.

The changing epidemiology of open fractures in vehicle occupants, pedestrians, motorcyclists and cyclists

AIMS

To investigate the changing epidemiology of open fractures in vehicle occupants, pedestrians, motorcyclists and cyclists.

MATERIALS AND METHODS

Data on all non-spinal open fractures admitted to the Royal Infirmary of Edinburgh after a road traffic accident between 1988 and 2010 were collected and analysed to provide information about the changing epidemiology in different patient groups. Demographic information was collected on all patients with the severity of injury being analysed with the Injury Severity Score (ISS), Musculoskeletal Index (MSI) and the number of open fractures. The severity of the open fractures was analysed using the Gustilo classification. The 23-year study period was divided into four shorter periods and the results were compared.

RESULTS

There were 696 patients treated in 23 years. Analysis showed that the incidence of RTA open fractures initially fell in both males and females and continued to fall in females during the 23 years. In males it levelled off about 2000. The age of the female patients also fell during the study period but it did not change in males. The only patient group to show an increased incidence of open fractures were cyclists. In vehicle occupants the incidence fell throughout the study period but it levelled off in pedestrians and motorcyclists. There was no difference in the severity of injury in any group during the study period. The most severe open fractures were those of the distal femur and femoral diaphysis although open tibial diaphyseal fractures were the most common fracture in all patient groups.

CONCLUSIONS

Improved car design and road safety legislation has resulted in a reduction in the incidence of open fractures in vehicle occupants, pedestrians and motorcyclists. The most obvious group to have benefitted from this are older female pedestrians. The only group to show an increase in age during the study period were male motorcyclists.

Efficacy And Safety Of Interlocked Intramedullary Nailing For Open Fracture Shaft Of Tibia

BACKGROUND

Due to increasing population and changing human habits the number of accidents and high energy trauma is rising. Management of open fracture tibia is a complex problem and is a challenge for both orthopaedic and plastic surgeons. The study was carried out to ascertain the efficacy and safety of interlocked intra-medullary nailing for open shaft tibial fractures in patients presenting at or after 24hr of injury.

METHODS

In this descriptive case series, over a period of 6 moths, 163 consecutive cases of open fracture of tibial shaft were reviewed in terms of clinical profile, time of presentation, and gender distribution.

RESULTS

In this study mean age was 30±0.02 years. Males comprised 85% of study population while 15% were females. Gustilo-I type fracture and Gustilo-II type fracture was diagnosed in 90% and 10% patients respectively. Thirty three percent patients had wound infection while fracture union was found in 15% cases. Moreover interlocked intramedullary nailing for open fracture shaft of tibia was safe in 80% patients while this procedure was effective in 85%.

CONCLUSIONS

Un-reamed, interlocked intra-medullary nailing may be considered as a suitable option for treatment of open fractures of tibia.

Contemporary demographics and complications of patients treated for open ankle fractures

Open ankle fractures are rare injuries with a high likelihood of wound complications and subsequent infections. There is limited information about the complications and outcomes of these injuries in different age groups. The aim of this study was to assess the contemporary demographics and complications related to this injury. We performed a chart review of all the 3030 patients treated for ankle fractures at a Level 1 trauma centre from 2006 to 2011. 137 (4.5%) patients had an open ankle fracture. The demographic data, injury mechanism, comorbidities, and fracture type were collected. Treatment, complications, length of stay and number of outpatient visits were also recorded. The mean age of the patients was 60 years and 56% were women. Most fractures were Weber type B with a medial sided wound (93%). Only 20% of the fractures were the result of high-energy trauma, and 31% were Gustilo grade III injuries. Immediate internal fixation was performed in 82% of patients, and the wound was primarily closed in most cases (80%). The incidence of postoperative wound necrosis and deep infection was 18% and 17%, respectively. There were more deep infections if pulsatile lavage was used during the wound debridement (p=0.029). About 14 (10%) patients required a flap reconstruction to cover the soft-tissue defect. Every other patient (54%) had a complication, and 21 patients (15%) suffered a long-term disability related to the injury. The number complications did not differ for nighttime and daytime operations (p=0.083). High-energy injuries were more common in younger patients (p<0.001) and these patients also had more lateral sided open wounds than older patients (p=0.002). Interestingly, younger patients also had significantly more complications (p=0.024), suffered more often from chronic pain (p=0.003), and required more flap reconstructions (p=0.026), reoperations (p=0.026), and outpatient clinic visits (p=0.006). Open ankle fractures have a high complication rate and often require multiple surgical procedures. In young patients these injuries are more likely to be the consequence of high-energy trauma leading to more complications and subsequently increased healthcare resource utilisation.

A descriptive study on the surgery and the microbiology of Gustilo type III fractures in an university hospital in Switzerland

OBJECTIVE

To describe the epidemiology, the surgical treatment, the microbiology, the antibiotic prophylaxis and the outcome of patients with the most severe type of open fractures.

METHODS

Retrospective chart reviews of patients with Gustilo type III open fracture admitted to an university hospital in Switzerland between January 2007 and December 2011. The patient's and fracture's characteristics, surgery, antibiotic prophylaxis, and microbiology findings at the initial and at the revision surgery were described.

RESULTS

Thirty patients were included (83% male, mean age 41 years). More than half of the patients had polytrauma. In all patients, debridement and stabilization surgery (70% using external fixation) were performed at admission. Soft tissue reconstruction was performed in 87% and in 23% immediate bone graft was performed. Antibiotic prophylaxis were given in all patients for a median duration of 9 days (60% received amoxicillin/clavulanic acid). Positive bacterial culture was found in 53% of the patients at initial surgery and in 88% at revision surgery. At initial and revision surgery, 47% and 88% of the pathogens were amoxicillin/clavulanic acid-resistant. Treatment outcome was favorable in 24 of 30 patients (80%) and in six cases (20%) an amputation had to be performed. None of the patients had chronic bone infection.

CONCLUSIONS

Positive cultures were found often in open fractures. Amoxicillin/clavulanic acid which is often mentioned in many guidelines as prophylaxis in open fractures does not cover the most common isolated organisms. The combination of surgery and antibiotic prophylaxis leads to good outcome in Gustilo type III fracture.

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.

Prevalence and patterns of fractures in children

OBJECTIVE

To study the prevalence, patterns, and causes of fractures in children at Siriraj Hospital in the years 2006, 2009, and 2012.

MATERIAL AND METHOD

Patient records, files, and radiographs of all children under 16 years of age who had sustained a fracture and came to Siriraj Hospital in the years 2006, 2009, and 2012 were collected. The prevalence and patterns of fractures were reviewed for details, such as age at time of injury, gender, side, location, types, and causes offractures.

RESULTS

The prevalence of the fractures in children seen in the trauma unit at Siriraj Hospital were 4.7% in 2006, 5.3% in 2009, and 5.8% in 2012. There were 716 children with 718 fractures in three one-year periods, as follows: 222 in 2006, 234 in 209, and 262 in 2012. The children consisted of 68% boys and 32% girls, of which boys represented a statistically significant difference (p = 0.013). The most common and dominant age group for fractures was 10-16 years for both boys and girls, at 47.4%. The mean age± +SD of the children was 7. ± +4.6 years old. The rate o ffracture increased with the age of the children-a statistically significant difference (p = 0.001). The rate o fopen fracture was 6.7%. The rate o fphyseal fracture was 12.4%, o fwhich type 2 was the most common at 11.3%. Fractures to the right side occurred in 53.8% o fcases, as compared to 46.2% on the left side (p = 0.031). The most common fracture in children was dista lforearm at 18.87%. The most common causes of fracture were falling (34.6%), road accident (28.4%), and falling from height (24.1%). These top three most common accounted for 87.1% o fall causes o ffractures.

CONCLUSION

The present study described the prevalence, types, patterns, and causes of fractures in children. The results of the present study may be useful in the planning of management and prevention of fractures in children.

Risk factors associated with infection in tibial open fractures

BACKGROUND

The objective of the treatment of open fracture is to prevent infection, stabilize the bones, and restore function. However, infection is the most important step in achieving the latter aims.

OBJECTIVE

The objective of the current paper is to find risk factors associated with infection in a sample of tibial open fractures.

PATIENTS AND METHODS

A retrospective analysis was carried out. The study included all patients who underwent to tibial open fracture treatment in the Hospital Geral Roberto Santos-HGRS, Salvador, Bahia, Brasil, from March to October, 2009. Patients under the age of eight, with multiple fractures or suffering from systemic or bone disease were excluded. Clinical and demographic data were collected and Patient outcomes were divided into two groups: Group 1 comprises those without infection whereas group 2 comprises those with lesions which became infected. The two groups were evaluated in search for associated factors that could lead to infection.

RESULTS

We studied 50 patients. Our overall infection rate was 14 (28%; CI95%=15.5-40.5). Infection was significantly associated with place of trauma (OR 3.78; CI95%=1.4-5.5; p=0.02), and time delay superior to 24 hours (OR 3.4; CI95%=1.4-20.8; p=0.03). Fractures graded as Gustilo I, II and IIIA had a lower chance for infection compared to Gustilo IIIB and IIIC (OR 4.32; CI95%=1.3-19.1; p=0.01). Fractures graded Tscherne III and IV had a higher chance for infection, and it was the most significant isolated factor (OR 8.07; CI95%=2.4-47.1; pp<0.00).

CONCLUSIONS

We confirmed the relationships between infection with Gustilo classification and as well as between infection and trauma from the countryside of Bahia State. We also presented a new relationship between soft tissue and infection, and another relating time delay of more than 12 hours with infection.

[Osteoporotic fractures of the distal radius. What is new?]

The demographic development will result in an increase of up to 30 % of distal radius fractures. There are various therapy options but what is new? Conservative therapy: conservative therapy is reserved for stable fractures only. Osteosynthesis by K-wires: due to low biomechanical stability in older patients, insufficient functional and radiological results were achieved. External fixator: external fixators are used in compound and complex fractures and show better results than K-wire osteosynthesis. Angular stable plate osteosynthesis: with angular stable plates it is possible to achieve good results with complex fractures and they are currently the method of choice. Intramedullary osteosynthesis: intramedullary nails result in a faster functional improvement than angular stable plates but have limitations. New is that 90% of osteoporotic distal radial fractures are treated with angular stable plates which have shown good results in single study groups.

Epidemiological analysis of outcomes in 323 open tibial diaphyseal fractures: a nine-year experience

INTRODUCTION

Open fractures of the tibia pose a challenge to orthopaedic and plastic surgeons. A retrospective observational review was conducted to evaluate the epidemiological factors and fracture outcomes in the Singapore context.

METHODS

A nine-year period of open tibial shaft fractures presenting to our institution was reviewed. Demographic and management data were recorded. Statistical analysis was performed on the outcomes of length of hospital stay, number of operations, time to union and infection rates.

RESULTS

323 fractures met our inclusion criteria (Gustilo [G] 1=53, G2=100, G3=170). Mean age of patients was 36.5 years, 91.3% were male and 40.9% were non-Singaporeans. 69.3% of fractures occurred from road traffic accidents and 21.7% from industrial accidents. Mean length of hospital stay was 28.7 days and number of operations was 4.29. Time to union was 10.7 months and overall infection rate was 20.7%. Infection rates were significantly higher in G3b/G3c compared to G3a (45.7% vs. 21.1%) patients. There was no significant reduction in infection rates when open tibial fractures were operated on within six hours of admission. Multiple injured patients required a longer time to union and hospital stay. There was an exponential cost increase with greater severity of fracture.

CONCLUSION

High Gustilo and AO classification injuries positively correlate with high non-union and infection rates, requiring multiple operations and long hospital stay. There is no benefit in performing surgery on open tibial fractures within six hours of presentation. A significant proportion of these patients would be polytraumatised, indirectly affecting fracture union.

Feline combined diaphyseal radial and ulnar fractures. A retrospective study of 28 cases

Feline combined diaphyseal radial and ulnar fractures were reviewed in a retrospective study of cases that were admitted to two university teaching hospitals. A high incidence of complications was noted, with 6/26 (23.1%) of cases requiring revision surgery. Open fractures were significantly more likely to require revision surgery. The two main repair methods were external skeletal fixation (ESF) or radial plating. The success rate was greater for radial plating, with only 1/10 (10%) cases requiring revision versus 4/14 (28.6%) for ESF. However, ESF tended to be applied to the more complicated fractures. Stabilisation of both bones proved to be an effective repair strategy with only 1/8 cases (12.5%) requiring revision versus 5/18 cases (27.8%) where only one bone was stabilised. Synostoses and radiohumeral luxation were noted as complications associated with the fractures stabilised by ESF. Final limb function following recovery was assessed as 'good' or 'excellent' in 93.3% of cases.

Open depressed and penetrating skull fractures in Port Moresby General Hospital from 2003 to 2005

BACKGROUND

Open wounds to the head with skull bone depression pose the potential for serious injuries to the brain parenchyma and an increased risk of infection. The treatment of these injuries aims to repair the breached dura as well as remove any nidus for infection. Open wounds to the head due to bullets pose special problems and have a high fatality rate.

AIM

To review the presentation, management and outcome of depressed and penetrating open fractures of the skull in Port Moresby.

METHOD

All cases seen from 2003 to 2005 were included. All were managed without a CT (computed tomography) scan. Their Glasgow Outcome Scale (GOS) was documented on discharge.

RESULTS

There were 340 traumatic brain injury (TBI) cases over a period of 3 years between 2003 and 2005 managed by the Neurosurgery Unit of Port Moresby General Hospital. The open depressed and penetrating skull fractures seen in these cases numbered 46 (14%), of which 42 were males and 4 females. The weapons most commonly used were blunt objects (16), knives (11), guns (6) and axes (4). Gunshots contributed to 4 of the 7 deaths. 4 out of the 7 deaths were due to primary brain injury and 3 were due to infection.

CONCLUSION

Open depressed fractures and penetrating injuries form a small but significant group in the management of head injuries. The use of blunt objects, firearms and arrows coupled with increasing urban violence is responsible for most of these injuries. The outcome of patients admitted who are fully conscious is expected to be good. They can be managed by prompt debridement of the wound, elevation of the fracture and removal of fragments as appropriate. However, the mortality rate is high in those with a Glasgow Coma Score of 8 or less on admission, a finding indicative of the severity of brain injury beneath the wound.

Risk factors for development of infection in patients with mandibular fractures located in the tooth-bearing area

PURPOSE

The aim was to identify the main risk factors for infection in patients with mandibular fractures located in the tooth-bearing area.

MATERIAL AND METHODS

Seven hundred and eighty-nine case histories were retrospectively reviewed regarding treatment results and nature of complications developed. The data concerning possible risks were analysed statistically to find out those factors that seemed to have a significant influence on the development of infection.

RESULTS

The incidence of infection in patients with mandibular fractures located in the tooth-bearing area was determined by the following risk factors: social and organizational conditions of medical care, trauma pattern, preexisting medical status and treatment tactics. The main contributory factors were delayed medical care, accompanying pathological disorders, angular location, multiple and comminuted fractures and the type of antibiotic used.

Open clavicle fractures and associated injuries

OBJECTIVES

To describe the associated injuries, demographic distribution, and management of patients sustaining open clavicle fractures.

DESIGN

Retrospective case series.

SETTING

A single level-1 trauma center.

PATIENTS

Twenty patients with open clavicle fractures were identified from a prospectively collected orthopaedic trauma registry.

INTERVENTION

All patients were managed with surgical irrigation and debridement with or without internal fixation.

RESULTS

Thirteen patients (65%) had a closed head injury. Fifteen patients (75%) had a significant associated pulmonary injury. In that group, there were 10 patients who had a pneumothorax (7 bilateral). Additionally, 12 patients had rib fractures and 11 had documented pulmonary contusions or effusions. Seven patients (35%) had a cervical or thoracic spine fracture or dislocation. Eight patients (40%) had concomitant scapula fractures. Six patients (30%) had additional ipsilateral upper extremity injuries remote from the shoulder girdle. One patient had a scapulothoracic dissociation. Eleven patients (55%) sustained significant facial trauma including fractures (5 patients), lacerations, and hematomas. Fourteen patients (70%) were treated with open reduction internal fixation. Fifteen patients (75%) were followed to healing (mean: 111 wk, median: 56 wk, range: 13 to 333 wk). There were no other complications related to the operative fixations. There were no known infections or nonunions.

CONCLUSIONS

Open clavicle fractures are a rare injury. Patients often have associated pulmonary and cranial injuries. Ipsilateral upper extremity and shoulder girdle injuries are common, whereas concomitant neurologic and vascular injuries are infrequent. The majority of patients have rapid and uneventful healing of their fractures after surgical treatment.

Pediatric fractures during skateboarding, roller skating, and scooter riding

BACKGROUND

Skateboarding, roller skating, and scooter riding are popular recreational and sporting activities for children and adolescents but can be associated with skeletal injury. The purpose of this study is to describe the frequency and characteristics of fractures resulting from these activities.

PURPOSE

Fractures from skateboarding, roller skating, and scooter riding compose a considerable proportion of pediatric musculoskeletal injuries.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Demographic data and injury characteristics were analyzed for all patients who presented to the pediatric fracture clinic of the level I trauma center from January 2001 to May 2002 after sustaining fractures due to skateboarding, roller skating, and scooter riding.

RESULTS

Among a total of 2371 fractures, the authors identified 325 fractures (13.7%) that occurred during one of these activities. There were 187 patients (mean age, 13 years; 95% male) who sustained 191 skateboard-related fractures, 64 patients (mean age, 10.8 years; 54% male) who sustained 65 fractures while roller skating, and 66 patients (mean age, 9.7 years; 64% male) who sustained 69 fractures while riding a scooter. The forearm was fractured most often, composing 48.2% of skate-boarding fractures, 63.1% of roller-skating fractures, and 50.7% of fractures due to scooter riding. Of the forearm fractures, 94% were located in the distal third. In the skateboarding group, 10 of 191 (5.2%) fractures were open injuries of the forearm, compared to 6 of 2046 (0.3%) fractures caused by other mechanisms of injury (significant odds ratio, 18.8).

CONCLUSIONS

Skateboarding, roller-skating, and scooter-riding accidents result in a large proportion of pediatric fractures. An open fracture, especially of the forearm, was more likely to be caused by skateboarding than by other mechanisms of injury. Use of wrist and forearm protective equipment should be considered in all children who ride a skateboard.

Management of shotgun induced open fractures of the humerus with Ilizarov external fixator

BACKGROUND

Our aim was to evaluate the clinical efficacy of Ilizarov external fixator used for the management of shotgun induced open humeral fractures with special emphasize on neurovascular sequelae.

METHODS

The authors retrospectively reviewed eleven shotgun induced open humeral fractures managed with emergent application of Ilizarov external fixator. No patient had associated neurovascular injury. All fractures were stabilized with Ilizarov external fixator immediately after meticulous debridement and irrigation under emergent conditions.

RESULTS

With Ilizarov fixation technique complete bony union occurred in all patients within 14 to 44 weeks (average, 21 weeks) postoperatively. One patient required a second intervention in order to adjust the external fixator rings. Two patients required a rotational fasciocutaneous flap so as to handle the soft tissue coverage problem. Superficial pin tract infection was present in eight patients, however in none of the patients deep tissue infection or osteomyelitis has been observed. Good to excellent results were achieved in 10 patients with Ilizarov fixation technique according to the rating system proposed by Smith and Cooney.

CONCLUSION

Emergent Ilizarov external fixation is a safe method of obtaining a functional limb in the management of shotgun induced open humeral fractures with severe soft tissue damage.

Open pelvic fractures: epidemiology, current concepts of management and outcome

Open pelvic fractures constitute one of the most devastating injuries in musculo-skeletal trauma and must be treated aggressively, incorporating a multidisciplinary approach. Early treatment, focusing on prevention of haemorrhage and sepsis, is essential. The management of associated soft tissue injuries must also be aggressive, including early administration of broad-spectrum antibiotics and repeated, meticulous wound debridement and irrigation. Selective faecal diversion, based on wound location, is compulsory and safe, minimising the risk of sepsis and reducing mortality rates.

Does right leg require extra protection? Five-year review of type 3 open fractures of the tibia

INTRODUCTION

Open fracture of the tibia is very common among motorcyclists. The morbidity associated with this injury is well-documented as treatment of severe open fractures is very difficult. There is currently no study done in the literature to see the relationship between fracture severity and the side of the injury.

METHODS

We reviewed 239 patients with open fractures of the tibia admitted to our institution from 1998 to 2002.

RESULTS

From 241 tibias studied, 150 (62.2 percent) involved the right side and 91 (37.8 percent) involved the left side. Statistical analysis showed that there was a significant difference in the severity of open fracture between the sides of fracture. Less severe injury (grades 1 and 2 fractures) was associated with injury of the left tibia and severe injury (grades 3A, B and C fractures combined) was associated with right tibia fracture.

CONCLUSION

Since the right leg was more exposed to the injury, it is imperative to protect the limb. This may reduce the overall incidence and severity of tibia fractures.

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.

Open fractures of the calcaneus: soft-tissue injury determines outcome

BACKGROUND

Studies of open calcaneal fractures have been limited and have not analyzed results according to wound location, severity of soft-tissue disruption, fracture type, or treatment method. In this study, results were evaluated on the basis of the hypothesis that early surgical intervention was indicated.

METHODS

Between 1989 and 1997, 503 calcaneal fractures were treated at our institution, and forty-three of these fractures, in forty-two patients, were open (8.5%). According to the Gustilo classification there were nine type-I, eight type-II, twelve type-IIIA, and thirteen type-IIIB open fractures as well as one type-IIIC open fracture. All fractures were treated according to the same protocol, consisting of intravenous administration of antibiotics chosen on the basis of the wound type, irrigation and débridement in the operating room, temporary wound coverage, and initial stabilization of the limb. Definitive final fixation was performed after the wound was clean, and soft-tissue swelling was minimal. The final follow-up examinations were performed at a minimum of two years after treatment. Clinical results were graded with use of the AOFAS (American Orthopaedic Foot and Ankle Society) score.

RESULTS

An infection developed at the sites of 37% of the forty-three fractures, with osteomyelitis developing at the sites of 19%. Seven of the nine type-I open fractures were treated with open reduction and internal fixation or with primary fusion, with no major complications and a good-to-excellent short-term result. Three of the eight type-II open fractures were complicated by an infection. Three of the twelve type-IIIA open fractures and ten of the thirteen type-IIIB open fractures were complicated by an infection. Six of the infections associated with a type-IIIB open fracture progressed to osteomyelitis, and three of those cases led to an amputation. Overall, thirteen (50%) of the twenty-six type-III open fractures were complicated by an infection, with osteomyelitis occurring in seven (27%). Thirty-three patients with a total of thirty-four open calcaneal fractures were available for follow-up at a minimum of two years, and an average of fifty-five months. The average AOFAS hindfoot score for the twenty-seven patients who had not undergone amputation was 71 points.

CONCLUSIONS

Open calcaneal fractures have a high propensity for deep infection despite the use of an aggressive treatment protocol to prevent it. It appears that type-I and type-II open fractures associated with a medial wound can be treated with open reduction and internal fixation. Type-II fractures associated with a wound in another location should be treated with limited or no internal fixation. Type-III open fractures, and especially type-IIIB open fractures, require extensive débridement and prompt soft-tissue coverage as soon as possible. Early internal fixation should be avoided in this subgroup because of the high rates of osteomyelitis and subsequent amputation.

Open ankle fractures in patients with diabetes mellitus

Complications after surgical treatment of closed ankle fractures in patients with diabetes previously have been well documented. The purpose of this study was to evaluate the union rate, infection rate, and soft tissue complication rate in open ankle fractures in patients with diabetes. Between January 1, 1981 and December 31, 2000, 14 open ankle fractures in 13 patients with diabetes were treated. The mean followup was 19 months (range, 6-84 months). All patients were followed up until union, amputation, or for at least 6 months. Nine of 14 extremities (64%) had wound healing complications. Ultimately, five patients (six extremities; 42%) had below the knee amputation. Only three of 14 fractures in three patients healed without complications. Open ankle fractures in patients with diabetes are limb-threatening injuries with high amputation and infection rates despite contemporary techniques of open reduction and internal fixation, intravenous antibiotics, and emergent irrigation and debridement.

The relationships of skeletal injuries with trauma score, injury severity score, length of hospital stay, hospital charges, and mortality in children admitted to a regional pediatric trauma center

Thirty-four-hundred and seventy-two children were consecutively admitted for acute traumatic injuries over a 34 month period to the Children's National Medical Center. The study comprised 805 patients who sustained 953 fractures and dislocations. The male to female ratio was 2:1. Age at the time of admission was evenly distributed over 16 years, with a mean of 8.3 years. Pedestrian accidents and falls each accounted for 34% of the musculoskeletal injuries, whereas motor vehicle accidents accounted for an additional 13%. The femur was the most commonly fractured bone, representing 22% of all fractures and dislocations, followed by the humerus (16%), tibia/fibula (12%), ankle/foot (13%), and radius/ulna (8%). Nine percent of the fractures were open. The average length of hospital stay was 8.6 days, and the average cost per hospital admission was $8,765. The mortality rate was 3%. Central musculoskeletal injuries (spine, clavicle/scapula, and pelvis) in our hospitalized patients were associated with the longest hospital stays and intensive care unit admissions, and lowest Trauma Scores, as well as the highest Injury Severity Scores, hospital charges, and mortality rates.

Open fractures of the forearm in children

OBJECTIVE

To describe the epidemiology, early results of treatment, and complications associated with open fractures of the forearm in children.

DESIGN

Retrospective review of patients treated according to protocol.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

All children with an open fracture of the forearm during a four-year period (n = 76). Fourteen patients were excluded because of inadequate follow-up or incomplete medical records.

INTERVENTION

All fractures were treated with irrigation and debridement, and parenteral antibiotics. Twenty-five patients were managed with cast immobilization only, and the remaining thirty-seven, with internal fixation either with transcutaneous pins, intramedullary pins, or plates and screws, followed by immobilization in a cast.

MAIN OUTCOME MEASUREMENTS

Time to union, angular alignment at union, and incidence of complications.

RESULTS

The average time to union was 8.9 weeks (median, eight weeks; range, 6 to 17 weeks). There were no nonunions, but three of the sixty-two fractures had delayed union. Eight of the sixty-two fractures healed with an angular deformity of more than 10 degrees, and two developed infections, one deep and one superficial. There were three preoperative and four postoperative nerve palsies, which all resolved spontaneously.

CONCLUSIONS

Open fractures of the forearm in children, treated with prompt administration of parenteral antibiotics followed by debridement, were associated with a fairly low incidence of complications. Although we found that the use of some form of internal fixation tended to reduce both the need to remanipulate these fractures (p = 0.08), and to minimize the incidence of angular deformity greater than 10 degrees (p = 0.16), these findings did not reach statistical significance.

Management of lawnmower injuries to the lower extremity in children and adolescents

Lawnmower-associated trauma remains a substantial source of extremity injury in the pediatric and adolescent patient populations, producing complex wounds that require a combined orthopedic and plastic surgical approach. The authors review their experience with 16 patients, 2 to 17 years of age (mean age, 6.2 years), who were admitted to Duke University Medical Center for lower extremity lawnmower trauma between January 1988 and December 1999. The average hospitalization time was 13.5 days, and an average of 2.9 surgical procedures per patient were performed. Early debridement and bony fixation were carried out in all patients; 8 patients sustained traumatic amputations. Fifteen of 20 nonamputation fractures involved the foot and were managed with either closed reduction or K-wire fixation. Three of five long-bone fractures underwent external fixation. Wound closure was achieved with direct closure or skin grafting in the majority of patients. However, five microsurgical free flap transfers were required for extensive defect reconstruction of the foot (N = 4) and knee (N = 1). Adequate immediate debridement, fracture reduction, and early primary or if necessary secondary wound coverage including microsurgical free tissue transfer to prevent further damage and long-term disability in these type of devastating injuries is recommended.

The epidemiology of open long bone fractures

Open long bone fractures occur with a frequency of 11.5 per 100,000 persons per year. They are more common in males and they have a bimodal age distribution. Open fractures of the tibial diaphysis are the commonest, but open femoral diaphyseal, distal femoral and proximal tibial fractures tend to occur in the most seriously injured patients. Lower limb open fractures are more severe than open fractures of the upper limbs. Not only is the soft tissue damage less in open upper limb fractures, but there are fewer associated musculoskeletal injuries.

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%.

A report by the British Orthopaedic Association/British Association of Plastic Surgeons Working Party on the management of open tibial fractures. September 1997

We congratulate the authors of this excellent combined report. What a pleasure it is to find two surgical specialties cooperating in this way. The working party has carefully analysed the available data, considered the various options for management and proffered clear advice which we hope will be useful for all surgeons managing these difficult injuries. The message of collaboration was conveyed in the first edition of the report. This stressed that, in order to avoid repeated surgery and long term disability, it is necessary to evaluate each injury and to establish communication between the two disciplines as soon as possible, with the aim of providing optimal conditions for wound and fracture healing. The working party feels that this message now needs re-emphasising and it is our hope that this latest report, by up-dating and repeating the principles of management, will lead to a further improvement in outcomes.

Epidemiology and management of open fractures of the lower limb

Epidemiological analysis indicates that 40% of open fractures occur in the lower limb and that the tibial and femoral diaphyses are most commonly affected. Recent advances in fracture stabilization and soft tissue reconstruction technique have improved the outcome of these fractures.

Ipsilateral knee ligament injuries and open tibial diaphyseal fractures: incidence and nature of knee ligament injuries sustained

Fifty patients with isolated open tibial shaft fractures were reviewed to determine the incidence and type of knee ligament injuries sustained. Eighteen patients (36 per cent) had at least one ligament injury in the ipsilateral knee; eight had multiple ligament injuries. Only four patients (22 per cent) were diagnosed as having a ligament injury at the time of initial management and the remaining 14 patients were diagnosed at the time of review for this study. There is a high incidence of ipsilateral knee ligament injuries in open tibial shaft fractures; the knee should be thoroughly examined at the time of initial fracture management.

[Epidemiology of supracondylar fractures of the humerus in children in Bangui, Central African Republic]

The purpose of this retrospective study was to evaluate the epidemiological, clinical, and anatomical aspects of supracondylar fractures of the humerus in children treated at the National University Hospital Center (NUHC) of Bangui, Central African Republic. Between January 1992 and March 1995 a total of 119 documented cases involving children between the ages of 0 and 15 years were treated. Most patients were boys (62%) between 3 and 8 years of age. Fracture occurred during play in 74% of cases on the left side (92 cases) more often than the right. The mechanism of fracture was extension in 115 of the 119 cases with only four open fractures. Most fractures (68.1%) were severe (Lagrange Grade 3 and 4). These findings which are comparable to those reported in other countries confirm the high incidence of supracondylar fracture of the humerus and need for appropriate treatment in African orthopedic facilities.

Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons

The system of Gustilo and Anderson for the classification of open fractures is commonly used as a basis for treatment decisions and for comparison of the published results of treatment. The reliability of this classification system was tested on the basis of the responses of 245 orthopaedic surgeons to a survey. The respondents were asked to provide data about their age, type of practice, and type of training; the number of open fractures of the tibia that they treated each year; and their use of the Gustilo-Anderson classification system. They were also asked to classify twelve open fractures of the tibia on the basis of a series of videotaped case presentations. Each case presentation on the color videotape included demographic data on the patient, a history of the injury, the results of the physical examination, the appearance and dimensions of the open wound before the operation, preoperative radiographs, and selected portions of the operative débridement with narration. The level of agreement for the classification of each fracture was determined according to the largest percentage of observers who chose a single classification type. The average agreement among the observers for all twelve fractures was 60 percent. The over-all agreement for each fracture ranged from 42 to 94 percent. The average agreement in the subgroup of surgeons who were considered to have the least experience (residents and fellows) was 59 per cent (range, 33 to 94 percent).(ABSTRACT TRUNCATED AT 250 WORDS)

[A three-year aid program for plastic surgery in Peshawar (Pakistan). Ongoing management of severely injured patients of the Afghanistan war: 1,528 large operations, 5,171 smaller interventions, 15,932 patients examined]

Since 1980 Interplast Germany has sent many plastic surgeons to developing countries. In 1989 a new Interplast Germany program for helping Afghan refugees in Pakistan's Peshawar was started. The Federal Republic of Germany financed the first two years; thereafter, the European Community and Help supported the project. Twenty-four teams with 123 nurses, surgeons and anesthesiologists operated on 1,528 patients in two hospitals. In the same period 5,171 smaller operations have been performed and 15,932 patients have been examined. Low expense for the teams, good support by officials, and professional administration have made this project highly effective for 3 years.

Interobserver reliability in the Gustilo and Anderson classification of open fractures

The Gustilo and Anderson classification system is widely used to categorize open fractures. To assess its interobserver reliability, 10 patients with open fractures had photographic slides taken of their wound before and after operative treatment. These slides were then shown to a group of orthopaedic surgeons. After an explanation of the Gustilo and Anderson classification system and each patient's pertinent history and physical examination, the physicians were asked to classify the fracture. Agreement among the various raters was determined by Kappa analysis, which is the preferred measurement of interobserver reliability for nominal data such as classification schemes. Kappa analysis demonstrated only moderate agreement among the observers classifying open fractures using the Gustilo and Anderson system. This seems to indicate that, although useful, the Gustilo and Anderson open fracture classification system does have limitations; studies and treatment recommendations based on it should be interpreted with caution.

Treatment of open tibial fractures with Ender rods

In a retrospective, nonrandomized study from 1980 until 1988, 43 patients with 46 open tibial fractures were treated with Ender rods. The configuration of each fracture was classified using the Orthopaedic Trauma Association's (OTA) tibial fracture guidelines, and the extent of soft-tissue damage was graded using the Gustilo classification of open fractures. The OTA classification was further divided into stable, unstable, and highly unstable fracture configurations. Ender rods were placed immediately into 90% of fractures; and within one week of initial injury in the remainder. Follow-up evaluation of four patients (six fractures) could not be completed. The average time to union was 22.1 weeks, and there was a low incidence of complications. Otherwise there was a 40% incidence associated with early rod removal. Most complications occurred in those fractures that had extensive soft-tissue damage, and minimal or no inherent axial stability (unstable and highly unstable OTA classes). Except for the above-noted complications, Ender rods provide effective fixation for open tibial fractures with some degree of axial and rotational stability. In fractures with minimal or no inherent axial stability (OTA Classes IIIC, D; IVA, B), and in Grade IIIB or IIIC open tibial fractures, Ender rods have a higher incidence of complications and should be used with caution.