Showing papers in "Injury-international Journal of The Care of The Injured in 1993"

Pathogenesis and clinical relevance of bone marrow embolism in medullary nailing — demonstrated by intraoperative echocardiography

Abstract: For the clarification of pulmonary impairment after medullary nailing of femoral fractures, the intramedullary pressure in the femoral cavity during the operative procedure was investigated In addition, an intraoperative transoesophageal echocardiography was performed which revealed two phenomena occurring once the intramedullary pressure had increased: snow-flurry and configured emboli An experimental study in sheep was performed in order to define the substrata of the sonographic echoes The level of intrafemoral pressure which would result in bone marrow intravasation and the substrata of the echocardiographic echoes were studied in sheep by applying pressure to the femoral cavity Sonography of the distal vena cava by laparotomy and macroscopic and histological investigation of the venous blood received throughout a proximal subdiaphragmal venotomy were undertaken The intrafemoral pressure peaks correlated with the appearance of sonographic echoes in both patients and sheep Snow-flurry is an indication of small amounts of bone marrow and already appears at an intramedullary pressure of 50 mmHg, which can easily occur during movement of non-stabilised fractures (values up to 90 mmHg were observed) — configured emboli consist of a core of bone marrow surrounded by thrombotic aggregate and only appeared at pressure increases of over 200 mmHg in the animal experiments During medullary nailing in patients the intrafemoral pressure increases up to 200–600 mmHg in all reaming procedures Configured emboli were seen in 8 of 20 patients being treated with reamed nailing In five nailing procedures performed using the unreamed technique, no pressure increases greater than 70 mmHg and no configured emboli were observed Iv injected bone marrow results in pulmonary impairment In non-stabilised fractures intramedullary pressure peaks constantly press small amounts of bone marrow into the circulation This process helps to explain the benefit of early operations in multiply injured patients During reaming large amounts of bone marrow pass into the circulation and may contribute to pulmonary damage and ARDS (adult respiratory distress syndrome) if cofactors are present (volume deficit, shock, thoracic trauma and preexisting restrictive lung disease) In patients with these conditions, nailing should be performed without reaming In the case of a narrow medullary cavity in which nailing without reaming is impossible other forms of stabilisation (plate or external fixator and later nailing) should be applied

Fractures of the os calcis : improved results with internal fixation

Abstract: A prospective study of 24 patients with displaced intra-articular fractures of the os calcis was performed to compare operative with non-operative treatment. Twelve patients were treated by internal fixation followed by early mobilization, and 12 were managed non-operatively. The patients were assessed 15 months later using eight parameters. Of the 12 patients who were treated by internal fixation, eight had returned to work. Walking distance was significantly longer (4 km) in this group and only one patient needed a change in shoe size. Of the 12 patients who were managed non-operatively, only three had returned to work and eight had a change in shoe size, while the average walking distance without pain was only 1 km. The mean range of subtalar movement was 24 ° in the operated group but only 12 ° in the other group (P

Neck sprains after road traffic accidents: a modern epidemic

Abstract: This study was carried out to determine the incidence of soft tissue injuries of the cervical spine after road traffic accidents and to assess whether the incidence had changed with time The results show that there has been a progressive increase since 1982 in the number of patients seen in accident and emergency departments with a neck sprain after road traffic accidents The results suggest that the increase is not necessarily due to the introduction of seat belts, but that the relentless increasing epidemic may be due to other factors

Influence of thoracic trauma and primary femoral intramedullary nailing on the incidence of ARDS in multiple trauma patients

Abstract: In multiple trauma patients the development of pulmonary complications (pneumonia, posttraumatic adult respiratory distress syndrome (ARDS)) represents a major problem and can have a substantial impact on the duration of intensive care treatment as well as on outcome. An association between the timing of stabilisation of long bone fractures and the incidence of pulmonary complications has been discussed. In several studies, primary fracture stabilisation of femoral shaft fractures, preferably by intramedullary stabilisation (Lhowe and Hansen, 1988), was shown to reduce the incidence of pneumonia and ARDS and was therefore advocated (Goris et al., 1982; Tscherne, 1983; Kwasni et al., 1986; Ruedi and Wolff, 1975; Bone et al., 1989; Johnson et al., 1985; Behrmann et al., 1990). Some authors generally recommend primary intramedullary femoral nailing in multiple trauma patients (Bone, 1993).

Intra-articular fractures of the distal tibia: surgical management by limited internal fixation and articulated distraction

Abstract: A series of 12 patients with severe intra-articular (pilon) fractures of the distal tibia were treated by open reduction and internal fixation of the principal articular fragments. Tibial length was restored and maintained by an articulated external fixator which allowed early mobilization of the joint, and associated fibular fractures were fixed internally. Of the patients, nine have been followed up for an average of 33 months (range 18-60 months); three are still undergoing active treatment. Results have been assessed using the scoring system devised by Karlsson and Peterson. Four patients had scores > 80, four had scores between 50 and 79, and one had a score < 50. This technique is less invasive than conventional open procedures that require the use of a tibial plate and may be of particular value in the management of open fractures.

Measurement of intramedullary pressure in an animal experiment and propositions to reduce the pressure increase

Abstract: 1. During reaming of the medullary cavity prior to nailing, hydraulic pressure builds up in the cavity which far exceeds that of blood pressure. The peak values for 29 sheep clearly exceeds 2.5 bar. The highest values for individual reamers average 1.3 bar. The differences between the various reamers are only small. Intraoperative measurements on patients have confirmed these results. 2. The reamer acts as a hydraulic piston in a piston sleeve which is filled with a mixture of medullary fat, blood, blood clots and bone debris. The level of pressure depends on the flow rate of the medullary cavity contents between the reamer and the bone according to the gap formula. This is particularly dependent on the gap height which is to the third power in the gap equation. 3. The pressure rise can be most effectively prevented by reducing viscosity of the medullary content using the irrigation-suction technique. The reaming rod is cannulated and is continuously filled with Ringer solution in the distal part of the medullary cavity. This is then drawn off proximally after rinsing the reamer. Experimental measurements on 19 sheep did not produce high pressures, but rather negative pressures. 4. Venting holes in the bone only have little effect because their diameter is too small and local peak values must be assumed during the passage of the reamer. 5. Reaming the medullary cavity less does not prevent pressure increase. Pressure is high even for reamers of small diameter. 6. The unreamed insertion of a solid nail into the medullary cavity cannot prevent pressure increase. 7. Intramedullary pressure leads to an infiltration of medullary fat, blood clots and bone debris into the bone canals. This consequently damages the blood supply to the cortex which adds to the inevitable destruction of the medullary vessels. The necrotic bone is revitalised slowly by way of Haversian remodelling from the periphery to the central zones. When using the irrigation-suction technique in the sheep, this necrosis is significantly smaller (n = 35, p 8. The physiological systolic intramedullary pressure is 30–60 mmHg; diastolic values are 10–20 mmHg lower. The theory of the transport mechanism of the canaliculi is important. As a result of the pressure in the medullary cavity, pressure is transferred from the vessels of the Haversian canals to the osteocytes. The tubular system of the canaliculi can be regarded as a closed hydraulic system and the transport extends centrifugally beyond the boundaries of the osteons. 9. The pressure-induced infiltration of medullary cavity contents into the circulation can increase the risk of ARDS in the lung if other toxins are present.

Ankle fractures in the elderly: MUA versus ORIF

Abstract: A series of 80 patients over the age of 60 years with ankle fractures were reviewed retrospectively. 'Pilon' and talar fractures were excluded; 41 were treated conservatively (MUA) and 39 by operation (ORIF). The mean follow-up was 28 months (range 18-38 months) in the ORIF group and 25.5 months (range 12-40 months) in the MUA group. A statistically significant proportion of patients were satisfied with regard to pain, swelling, stiffness, instability and ranges of movement after ORIF. Anatomical congruity of the ankle mortice was better maintained following ORIF. Poor subjective and objective end results correlated with malalignment of the ankle mortice on the final radiograph at follow-up.

Neck injuries from rear impact road traffic accidents: prognosis in persons seeking compensation

Abstract: We studied the natural history and prognostic factors in 100 patients who had sustained neck sprains in rear impact road traffic accidents, and who had all originally been seen for medicolegal reports. They were seen for clinical and radiological review at a mean of 8 years after injury. The detailed medicolegal reports from the early years were available on all patients, and were used to supplement the information obtained at review. Of the patients, 50 per cent had significant pain at 8 months, decreasing to 22 per cent at 2 years and 18 per cent at 3 years. At review, 45 per cent were free of pain, and 14 per cent had significant pain. Front seat position, pain within 12 h of injury, past history of neck pain and degenerative changes on radiographs were associated with a longer duration of significant pain (P < 0.05). Early onset of pain was also associated with a worse level of pain at review. The timing of compensation was not associated with improvement in symptoms. The injury had not accelerated the development of degenerative changes.

Comparing the mortality and morbidity of cemented and uncemented hemiarthroplasties

Abstract: A series of 207 consecutive patients admitted to Aberdeen Royal Infirmary over a 1-year period with a diagnosis of displaced subcapital fracture of the neck of the femur were treated by hemiarthroplasty with either a cemented Hasting or an uncemented Monk bipolar prosthesis. Patients were reviewed at an average of 19 months and differences in mortality and morbidity assessed. We found that there was a significant perioperative mortality in the cemented group and no perioperative mortality in the uncemented group. There was no significant difference in the morbidity or complication rate in the two groups, although surviving patients appeared significantly more satisfied with the cemented Hasting prosthesis.

Gradual closure of fasciotomy wounds using a vessel loop shoelace

Abstract: Acute compartment syndrome is reported to occur in 1.5 per cent of patients with closed tibia1 fractures treated with intramedullary nailing (McQueen et al., 1990). Treatment of acute compartment syndrome should include dermotomy as well as fasciotomy (Gaspard and Kohl, 197.5) and most of these open fasciotomies are treated by skin grafting because delayed primary closure is usually not possible (Sheridan and Matsen, 1976). Skin grafting, however, gives poor coverage and sensation to the wound, often requires immobilization of the limb and to the patient and is less appealing cosmetically. Several techniques have been described to aid closure of the wound in an attempt to avoid skin grafting (Patman and Thompson, 1970; Miller, 1990). These involve placement of static tensioning devices across the wound (paper tape or sutures) which are replaced or tightened at appropriate intervals. An alternative technique using an elastic ‘shoelace’ is described which has the advantages of providing a continuous pull on the wound edges and may be tightened without replacement and without the need for anaesthesia. Although this technique is becoming popular it has remained unreported in the literature.

Locked intramedullary nailing of humeral fractures.

Abstract: Of 46 patients, 30 with fresh fractures of the humerus, nine with non-unions and seven with pathological fractures were treated with a new locked intramedullary nail. Of 30 patients with a fresh humeral fracture, three were lost to follow-up. All fresh fractures healed within 4 months. Functional results of the fresh fracture group were excellent in eighteen patients and satisfactory in three patients. Two patients with Neer type 6 fractures had unsatisfactory shoulder function; in the four other patients poor shoulder function resulted from a pre-existing condition. Out of nine non-unions, six united within 6 months. The three other patients with atrophic non-union required bone-grafting later, after which consolidation was obtained. The long functional recovery period of the non-union group was related to the pre-existing limited shoulder function. The seven patients with a pathological fracture died within 8 months of operation. While alive they were free from pain and could be nursed well.

Patterns of meniscal tears associated with anterior cruciate ligament lesions in athletes.

Abstract: In this study, 400 clinically anterior cruciate ligament (ACL) deficient knees were arthroscoped and studied prospectively in the period January 1986 to April 1992. An ACL tear was always confirmed, and 41 per cent of these patients did not have an associated meniscal tear. In 30.25 per cent the lateral meniscus was torn; in 21.25 per cent the ACL tear was associated with a medial meniscus tear, and in the remaining 7 per cent both menisci were torn. The most frequently associated meniscal injury was the bucket handle tear of the medial meniscus (9 per cent), followed by the posterior horn tear of the lateral meniscus, which showed the same frequency as the ragged (or degenerated) tear of the lateral meniscus (6 per cent). The horizontal tear of the posterior part of the lateral meniscus showed a prevalence of 4.3 per cent. This picture is probably dependent on a secondary referral nature of the centre surveyed, in which the average time between injury and arthroscopy was 23.3 months.

A review of 40 acetabular fractures: the importance of early surgery

Abstract: This study demonstrates the importance of early surgery in the management of acetabular fractures. A total of 40 acetabular fractures in 39 patients was treated by open reduction and internal fixation over a 5-year period. Of these, 26 fractures were assessed at over 1 year and up to 4.25 years postoperatively by the Merle D'Aubigne/Postel hip score. Sixteen patients (61.5 per cent) had a good result (16–18), five patients (19.25 per cent) a moderate result (11–15) and five (19.25 per cent) a poor result (0–10). The quality of the clinical result correlated closely with the quality of the reduction of the fracture. The timing of surgery was found to be directly related to the quality of the clinical result. Patients with poor results had been operated on at an average of 17 days after injury, while those with good results had undergone an operation at an average of 11 days. Rapid referral to a regional centre with the necessary facilities and expertise to manage these fractures is recommended in those patients where an operation may be indicated.

Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care.

Abstract: From 1978 to 1991, 126 multiply-injured patients of 65 years and over were admitted to the Department of Traumatology and Emergency Surgery of the University Hospitals of Leuven. The seriousness of the injury was evaluated using the Injury Severity Score (ISS) and the Glasgow Coma Scale (GCS). Traffic accident (57 per cent) and a simple fall at home (30 per cent) were the main causes of injury. The overall mortality rate within 6 months was 17 per cent. Multiple system organ failure (MSOF) was responsible for the fatal outcome in 48 per cent of the cases and in 71 per cent of the deaths more than 7 days after trauma. Of the survivors still living at home before injury, 78 per cent were able to go back to their normal surroundings. Survivors were compared with non-survivors. There was no significant difference in age or in ISS, nor in pre-existing diseases. On the other hand, the GCS was of important prognostic value, both for survival and functional recovery (P < 0.001). Also, the need for early intubation and continued ventilation were predictive of survival (P < 0.001). Nevertheless, this need for respiratory assistance was not an indication for withdrawing support as 9 per cent of the survivors also required endotracheal intubation for 5 days or longer. In our opinion, aggressive trauma care for the elderly is justified.

Effect of flexible drive diameter and reamer design on the increase of pressure in the medullary cavity during reaming.

Abstract: Reaming the medullary cavity before insertion of an intramedullary nail, results in an increase in both temperature and pressure. This may lead to aseptic necrosis of the cortex and to fat embolism, whereby the increased pressure in the medullary cavity plays a significant role. This paper aims to determine whether a reduction of the drive diameter combined with a different reamer design reduces the amount of intramedullary pressure. The pressure levels were measured in plexiglass tubes filled with a mixture of vaseline and paraffin. The viscoelastic properties of this mixture at 20 degrees C were equivalent to those of bovine medullary fat at 36 degrees C. In comparison with the conventional reamer system (9.0 mm drive + 9.5 mm AO reamer), the 7.0 mm drive+AO reamer and the 7.0 mm drive+hollow reamer, the pressure values were reduced as follows: 1. 9.0 mm drive + 9.5 mm hollow reamer: diaphyseally by 19%, metaphyseally by 21% 2. 7.0 mm drive + 9.5 mm AO reamer: diaphyseally by 48%, metaphyseally by 49% 3. 7.0 mm drive + 9.5 mm hollow reamer: diaphyseally by 61%, metaphyseally by 66%. If the gap between the flexible shaft and the wall of the plexiglass tube became large enough, only small pressure values were recorded for all three types of reamer. In summary, it can be stated that the reduction of the drive diameter causes a sustained reduction in the intramedullary pressure, but that the newly developed hollow reamer only leads to a further reduction in pressure in combination with a thin flexible drive.

Hemiarthroplasty of the hip — the anterior or posterior approach? A comparison of surgical approaches

Abstract: A series of 531 patients presenting with a displaced subcapital femoral fracture treated by hemiarthroplasty, were studied prospectively to determine the optimal approach for surgery. A total of 302 prostheses were inserted by an anterolateral approach and 229 by a posterolateral approach. Complications in these two broadly comparable groups are discussed. Dislocation and thrombosis were more common after a posterior approach. Operative time, blood loss, and infection, were greater after an anterior approach. There was no significant difference in the length of hospital stay or mortality. Our findings suggest that favoured approach should be that at which the surgeon feels more competent.

Holding power of the 4.5 mm AO/ASIF cortex screw in cortical bone in relation to bone mineral.

Abstract: To obtain basic data about the holding power of a 4.5 mm AO/ASIF cortex screw in cortical bone in relation to bone mineral as expressed by densitometric methods, uniaxial pull-out tests were performed on 14 human cadaver femurs. The mechanical parameters were correlated with bone mineral which was assessed by quantitative computed tomography (QCT) and dual energy X-ray absorptiometry (DXA). High correlations were found between the QCT mass, the DXA density and content values and the holding power of the screw. The QCT density values, expressing the physical density of the bone, did not correlate similarly well.

Intramedullary pressure, strain on the diaphysis and increase in cortical temperature when reaming the femoral medullary cavity — a comparison of blunt and sharp reamers

Abstract: Clinical application has shown intramedullary nailing to be a safe therapeutic procedure, although damage to the vascular system and fat embolism have been demonstrated in animal experiments. The main negative factors were presumed to be the increase in intramedullary pressure and the increase in cortical temperature. In this study, the effect of the blunting of the reamers on the increase in intramedullary pressure, the tangential strain on the diaphysis and the increase in cortical temperature was to be clarified. The measurements were carried out on pairs of human femora reamed with sharp and blunt AO reamers. The pressure was measured in the middle of the diaphysis and in the metaphysis, the strain in the middle of the femur and the temperature on four aspects of the femur. The femora were reamed with identical compression and traction forces in a water bath at 37 °C. In comparison with the sharp reamer, the blunt reamer develops 2.1 times the positive diaphyseal pressure, 1.7 times the positive metaphyseal pressure, 1.6 times the negative diaphyseal pressure, 1.5 times the positive tangential strain, 55 times the negative tangential strain and 2.8 times the increase in cortical temperature. There is no difference in the negative metaphyseal pressure. Since blunt reamers produce greater intramedullary pressure values, greater tangential strain on the diaphysis and a greater increase in cortical temperature, the attention of surgeons and operating staff must be drawn to the fact that they should treat the reamers gently and replace them whenever necessary.

Treatment of intra-articular fractures with shape memory compression staples

Abstract: The management of intra-articular fractures remains difficult. Shape memory compression staples fulfil nearly all the special treatment requirements of intra-articular fractures. Early bone union and 93.5 per cent satisfactory function were achieved in a series of 121 cases. Stable fixation, ‘early’ movement and continuous compressive force produced by the staple are the main factors contributing to good results.

Victims of our climate

Abstract: In order to test the hypothesis that the volume of paediatric orthopaedic trauma is related to the weather, we analysed all children with fractures admitted to our unit over a 3-year period and correlated this information with local meteorological data. The average number of children admitted per month with fractures showed a strong positive correlation with mean monthly sunshine hours (Pearson correlation coefficient 0.91) and a weak negative correlation with mean monthly rainfall (-0.24). The summer peak in the incidence of fractures persisted when the effect of school holidays was eliminated. Fractures involving the radius accounted for 48.7 per cent of all fracture admissions and correlation with sunshine hours was highest in this group. Almost two-thirds of all fracture admissions were male and these had a slightly higher mean age (8.2 years) than females (7.6 years). This data has implications for bed management and staffing levels in a paediatric orthopaedic unit.

Intramedullary pressure in reamed and unreamed nailing of the femur and tibia — an in vitro study in intact, human bones

Abstract: The generation of intramedullary pressure during nailing of the femur and the tibia using reamed and unreamed nailing techniques was investigated and compared in an in vitro study in intact, cadaveric human bones. The pressure was assessed by distal supracondylar measurements via a small hole in the metaphyseal cortex. No significant difference in the intramedullary pressure increase was seen in the femur whether a reamed or unreamed nailing technique was used in contrast to the tibia (p = 0.01). A distal venting hole in the femur did not lower the increase in pressure during insertion of an unreamed nail. Using the cannulated cutter to open the medullary canal showed a significant increase in pressure compared to the use of the awl in the femur (p = 0.01), but not in the tibia.

Treatment of subtrochanteric fractures with the AO dynamic condylar screw

Abstract: The AO/ASIF dynamic condylar screw (DCS) was used for the operative treatment of 15 patients, nine women and six men, with subtrochanteric fractures of the femur. The mean age was 70 years (range 20-95 years). The patients were followed for 18 to 30 months. Three patients developed healing disturbances, two of whom had an insufficient medial cortical bone support. The fixation device failed in two hips and it loosened in one. We conclude that the DCS is an alternative to the 95 degrees angled blade-plate in the operative treatment of subtrochanteric fractures of the femur. We also stress the importance of an adequate medial bone support.

Internal fixation of metacarpal and phalangeal fractures with AO minifragment screws and plates: a prospective study

Abstract: In a prospective study, 43 patients with 47 metacarpal or phalangeal fractures with significant displacement, rotation, angulation and/or instability were treated with internal fixation using AO minifragment screws and plates. In all fractures an anatomical reduction was achieved. Postoperatively all metacarpal fractures were protected by means of a plaster, in which motion was allowed, whereas all phalangeal fractures were treated by means of a soft bandage. At a review after a mean period of 28 months, 31 patients with 35 fractures out of 34 patients with 38 fractures had regained excellent recovery of total active flexion (92 per cent). Three patients had a poor recovery of total active flexion; one had an infection, the other two were operated on 6 and 14 days after their injury, whereas the mean delay between injury and operation was 3 days. All patients not reviewed had regained good or 100 per cent function.

A new solid unreamed tibial nail for shaft fractures with severe soft tissue injury.

Abstract: In a prospective study, 51 tibial shaft fractures with severe open or closed soft tissue damage were treated with a new, thin (8 mm or 9 mm) solid locking nail, inserted without reaming. At 6 months or more after trauma, 43 cases were reviewed. Fractures were classified according to Muller with six type A, 25 type B, and 12 type C fractures. In 13 cases there was group II ( n = 8) or group III ( n = 5) closed soft tissue damage (Tscheme). Of 30 open fractures, 16 were group OII, six were group OIIIA and eight were group OIIIB (Gustilo). Postoperative treatment in 42 of 44 cases was possible without additional cast or brace. Full weight bearing was achieved in 26 cases within 12 weeks, and in 42 cases within 26 weeks. In 43 cases, fracture healing occurred with a mean of 21.9 weeks (range 12–40 weeks). There was one case with valgus of 6 ° and three cases with anterecurvatum deformities of 5 ° to 10 °. In four cases there was an external rotation malalignment between 10 ° and 20 °. In three cases we found an internal rotation deformity of 10 ° to 20 °. Shortening between 0.5 and 1.0 cm was found in five cases, and in one case shortening was 1.5 cm. None of the patients had an osteomyelitis.

Prehospital surgical airway management: 1 year's experience from the Helicopter Emergency Medical Service.

Abstract: Advanced Trauma Life Support requires surgical airway techniques to be used in patients when oral or nasal intubation is impossible or contraindicated. Few reports have examined the results of surgical cricothyroidotomy in prehospital trauma management. During a 12-month period, 600 patients were seen and treated by the Helicopter Emergency Medical Service medical team. Advanced airway techniques were performed at the scene in 143 cases (24 per cent). Of these cases, orotracheal intubation was performed in 132 (92.3 per cent) and surgical criothyroidotomy in 11 (7.7 per cent). The indications for cricothyroidotomy were: (1) failed intubation in patients with facial injuries, (2) intubation impossible due to patient position during entrapment, and (3) severe burns. Four patients, who were already in cardiopulmonary arrest, succumbed in the field despite cricothyroidotomy. Three patient later died in hospital and four (37 per cent) survived. Three of the survivors made a good recovery, including one who was in cardiorespiratory arrest at the scene, and one remains severely disabled. Surgical cricothyroidotomy is a life-saving procedure in prehospital trauma management that must be performed without delay or hesitation if conventional airway manoeuvres are impossible or fail.

Valgus reduction of trochanteric fractures

Abstract: A total of 663 patients in whom a Dynamic Hip Screw was inserted for internal fixation of an intertrochanteric femoral fracture were studied prospectively to determine the optimum position of reduction. Results show that those fractures in which a valgus reduction was performed had a reduced incidence of fixation failure. For those fractures fixed in a varus position, 28 per cent of screws cut-out from the femoral head. A valgus reduction is, therefore, to be recommended in preference to fixation in an anatomical position and a varus position must be avoided.

The two-part proximal humeral fracture: a review of operative treatment using two techniques

Abstract: A review of 45 patients who have undergone surgery for two-part fractures of the proximal humerus (Neer Group III) is reported using two operative techniques, AO plating and intramedullary Rush pins. Good functional results were obtained using the former technique in seven out of eight of the patients under the age of 50 years who mainly sustained their original injury as a result of high-energy motor vehicle accidents. However, in the more common low-energy, osteoporotic fracture in the elderly population, results were unsatisfactory in 12 out of 14 cases where AO plating was used, usually as a result of fixation failure. The Rush pin technique produced more reliable results in this age group, with satisfactory functional scores being obtained in 16 out of 23 patients. It is suggested that the Rush pin technique is preferable to plate fixation in the more common osteoporotic insufficiency fracture in the elderly.

Interobserver variation using the AO/ASIF classification of long bone fractures.

Abstract: A comprehensive classification system has been proposed by the AO/ASIF Foundation for the classification of long bone fractures. After an explanatory talk and with the aid of an illustrated pamphlet, 18 orthopaedic surgeons were asked to classify 10 long bone fractures according to the AO system. Three of the participating surgeons had previous experience of the classification system. After individual classification, a consensus classification was derived and the results of the individual and consensus codings were compared. Only 32 per cent of all codings agreed with the final consensus. There was no difference between the surgeons with previous experience of the system (66 per cent) and novice coders (69 per cent) in the number of inaccurate codes when compared with the consensus codes. Reasons for error in coding are discussed. It is recommended that if the AO system is used for the purposes of research and computer-based audit, a consensus of opinion is used as the basis of classification.

Garden grading of intracapsular fractures: meaningful or misleading?

Abstract: A prospective study of 186 displaced intracapsular fractures treated by reduction and internal fixation found that the division into Garden grade 3 or grade 4 fractures had no predictive value in determining the quality of the reduction achieved, or the incidence of non-union. The value of the Garden classification of intracapsular fractures is questioned.

Hazard of ionizing radiation to trauma surgeons: reducing the risk

Abstract: A study aimed to establish the level of radiation exposure to orthopaedic surgeons involved in the care of injured patients; parts of the body most at risk, and to establishing whether surgeon control of X-ray image intensification reduced the risk. This was conducted on five orthopaedic surgeons regularly involved in musculoskeletal care. Radiation dosage (in millisieverts (mSv) to the body, neck, eyes and hands, was measured by means of dosimeters applied to these areas, before and after surgeon-controlled use of X-ray image intensification. Although all doses measured were within current safety guidelines (1.25 mSv total body dose/month, 3.75 mSv eye dose/month and 12.5 mSv extremity dose/month), the hands were most at risk (maximum recorded dosage 3.95 mSv/month). Control by the surgeons of X-ray image intensification significantly reduced exposure of the hands (P < 0.05).