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The management of open tibial fractures: The experience of a London Trauma Centre
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Abstracts / Injury Extra 42 (2011) 95–169
2A.18 Radiographic predictors of instability in paediatric diaphyseal forearm fractures L. Tillotson, P.A. McCann Gloucester Royal Hospital, Gloucester, UK Aim: To determine whether radiological criteria can be used to guide the method of treatment of diaphyseal paediatric forearm fractures to MUA only or surgical intervention with either IMN or ORIF. Method: All cases of paediatric diaphyseal forearm fractures in children aged 5–12 presenting to our institution between 2006 and 2010 were reviewed (53 cases). Index radiographs were graded by AO classification, the presence of single or both bone injuries, apex dorsal or volar patterns, degree of cortical contact and fracture angulation. The duration of post-operative immobilisation, surgical complication and final clinical outcome and was also assessed. Results: The predominant fracture pattern was AO type 22-D/4.1. Both bones were involved in 87% of cases, and fractures occurred at the same level in 92%. 91% of fractures were apex volar, and the majority (87%) were complete. 32 fractures were treated with MUA, 16 with IMN, and 5 with ORIF. Sagittal plane deformity was not predictive of treatment method, this was maximal in the cohort treated with MUA only (34◦ vs. 21◦ with IMN and 19◦ with ORIF). Cortical contact was not predictive of treatment method (83% with MUA vs. 49% with IMN and 73% with ORIF). Statistical analysis did not reveal any correlation between the radiographic indices of the fracture and the subsequent surgical treatment. All injuries went onto clinical and radiographic union with minimal complication. Conclusion: No single radiological criterion is predictive of fracture stability. Therefore the surgeon must be prepared to proceed to surgical intervention if MUA fails. This information will aid the planning of trauma lists where a shortfall exists between the ability of the surgeon to perform simple manipulation and the definitive surgical procedure. doi:10.1016/j.injury.2011.06.314 2A.19 The management of open tibial fractures: The experience of a London Trauma Centre D. Williams, J. Stammers, S. Zainul Abidin, O. Berber, J. Hunter, J. Leckenby, M. Vesely, D. Nielson St George’s Healthcare NHS Trust, London, United Kingdom Aims: To determine whether becoming a trauma centre has affected referral patterns, the degree of combined orthoplastic input and the length of stay in patients with open tibial fractures. Methods: Data on patient pathway were obtained prospectively on consecutive open tibial fractures during two 8 month periods: before and after becoming a Major Trauma Centre (May 2009–December 2009 and April 2010–October 2010, respectively). Results: 30 open tibial fractures were admitted during the 8 months after designation as a major trauma centre compared to 17 before (3.75 per month vs. 2.1 per month). Since becoming a trauma centre the average number of operations has reduced from 4.52 to 2.3 (p < 0.01), and the average length of hospital admission fell from 23 to 16 days (p = 0.05). Significantly, all Gustilo & Anderson grade III fractures had combined Orthopaedic and Plastic Surgery input at 1st debridement (previously 8% (p < 0.01)). There has been a reduction in delayed patient transfers from hospitals without plastic surgery from 41% to 30%. Those admit-
ted to SGH directly and hot transfers were in hospital 2 days less (15.4 days vs. 17.8 days), had fewer operations (2 vs. 3.14) and had a reduced time to definitive soft tissue coverage than delayed referrals (57 h vs. 184 h). Conclusions: The BOA/ BAPRAS guidelines for the management of open tibial fractures (2009) recommend early senior combined orthoplastics input and appropriate facilities to manage a high caseload. Since becoming a Major Trauma Centre, St Georges Hospital is managing more open tibial fractures. High turnover and adherence to the suggested guidelines has improved patient care with potential secondary cost benefits. doi:10.1016/j.injury.2011.06.315 2A.20 Posttraumatic proximal tibial valgus deformity: A case series and literature review C.H.M. Bagley, D.H. Park, P.S. Ray Barnet Hospital, Wellhouse Lane, Barnet, Hertfordshire, United Kingdom Introduction: Undisplaced or minimally displaced proximal metaphyseal tibial fractures in children can lead to the development of progressive valgus deformity. The aetiology is not clearly understood and there is no consensus in the literature on the definitive means of prevention or treatment. Aims: We report 3 cases of proximal tibial fractures in children, two of whom developed progressive valgus deformity of the knee following non-operative management. We highlight the importance of counselling parents on the possibility of developing this deformity and to discuss its subsequent management. Methods and results: We reviewed the clinical notes and radiographs of three patients, a 21 month old girl, a 4 year old boy and an 8 year old girl all sustaining an acute minimally displaced traumatic fracture to the proximal tibial metaphysis. They were all treated non-operatively in plaster. Sequential radiographs in plaster showed satisfactory alignment. The plaster was removed at 6 weeks for the 8 year old girl, and at 5 weeks for the other two patients. The 4 years and 21 month old patients developed a valgus deformity at 9 and 6 weeks respectively following initial fracture; they have been referred to a tertiary centre for further management and are being managed expectantly with regular follow-up. The 8 year old girl had no evidence of deformity at 3 months but is being monitored closely as an outpatient. Conclusion: Fracture of the proximal tibial metaphysis in a child can appear innocuous but despite acceptable reduction and satisfactory healing, a valgus deformity can develop. Surgery to correct the deformity is associated with a high chance of recurrence. Overall, studies recommend conservative management due to the regular occurrence of spontaneous correction and an asymptomatic limb. Patients with post-traumatic tibia valga should be followed until skeletal maturity. Operative treatment should be reserved for those who are symptomatic and, where possible, performed after skeletal maturity. It is important that surgeons are aware of the risk of progressive valgus deformity and counsel parents of this complication at an early stage. doi:10.1016/j.injury.2011.06.316
Abstracts / Injury Extra 42 (2011) 95–169
2A.18 Radiographic predictors of instability in paediatric diaphyseal forearm fractures L. Tillotson, P.A. McCann Gloucester Royal Hospital, Gloucester, UK Aim: To determine whether radiological criteria can be used to guide the method of treatment of diaphyseal paediatric forearm fractures to MUA only or surgical intervention with either IMN or ORIF. Method: All cases of paediatric diaphyseal forearm fractures in children aged 5–12 presenting to our institution between 2006 and 2010 were reviewed (53 cases). Index radiographs were graded by AO classification, the presence of single or both bone injuries, apex dorsal or volar patterns, degree of cortical contact and fracture angulation. The duration of post-operative immobilisation, surgical complication and final clinical outcome and was also assessed. Results: The predominant fracture pattern was AO type 22-D/4.1. Both bones were involved in 87% of cases, and fractures occurred at the same level in 92%. 91% of fractures were apex volar, and the majority (87%) were complete. 32 fractures were treated with MUA, 16 with IMN, and 5 with ORIF. Sagittal plane deformity was not predictive of treatment method, this was maximal in the cohort treated with MUA only (34◦ vs. 21◦ with IMN and 19◦ with ORIF). Cortical contact was not predictive of treatment method (83% with MUA vs. 49% with IMN and 73% with ORIF). Statistical analysis did not reveal any correlation between the radiographic indices of the fracture and the subsequent surgical treatment. All injuries went onto clinical and radiographic union with minimal complication. Conclusion: No single radiological criterion is predictive of fracture stability. Therefore the surgeon must be prepared to proceed to surgical intervention if MUA fails. This information will aid the planning of trauma lists where a shortfall exists between the ability of the surgeon to perform simple manipulation and the definitive surgical procedure. doi:10.1016/j.injury.2011.06.314 2A.19 The management of open tibial fractures: The experience of a London Trauma Centre D. Williams, J. Stammers, S. Zainul Abidin, O. Berber, J. Hunter, J. Leckenby, M. Vesely, D. Nielson St George’s Healthcare NHS Trust, London, United Kingdom Aims: To determine whether becoming a trauma centre has affected referral patterns, the degree of combined orthoplastic input and the length of stay in patients with open tibial fractures. Methods: Data on patient pathway were obtained prospectively on consecutive open tibial fractures during two 8 month periods: before and after becoming a Major Trauma Centre (May 2009–December 2009 and April 2010–October 2010, respectively). Results: 30 open tibial fractures were admitted during the 8 months after designation as a major trauma centre compared to 17 before (3.75 per month vs. 2.1 per month). Since becoming a trauma centre the average number of operations has reduced from 4.52 to 2.3 (p < 0.01), and the average length of hospital admission fell from 23 to 16 days (p = 0.05). Significantly, all Gustilo & Anderson grade III fractures had combined Orthopaedic and Plastic Surgery input at 1st debridement (previously 8% (p < 0.01)). There has been a reduction in delayed patient transfers from hospitals without plastic surgery from 41% to 30%. Those admit-
ted to SGH directly and hot transfers were in hospital 2 days less (15.4 days vs. 17.8 days), had fewer operations (2 vs. 3.14) and had a reduced time to definitive soft tissue coverage than delayed referrals (57 h vs. 184 h). Conclusions: The BOA/ BAPRAS guidelines for the management of open tibial fractures (2009) recommend early senior combined orthoplastics input and appropriate facilities to manage a high caseload. Since becoming a Major Trauma Centre, St Georges Hospital is managing more open tibial fractures. High turnover and adherence to the suggested guidelines has improved patient care with potential secondary cost benefits. doi:10.1016/j.injury.2011.06.315 2A.20 Posttraumatic proximal tibial valgus deformity: A case series and literature review C.H.M. Bagley, D.H. Park, P.S. Ray Barnet Hospital, Wellhouse Lane, Barnet, Hertfordshire, United Kingdom Introduction: Undisplaced or minimally displaced proximal metaphyseal tibial fractures in children can lead to the development of progressive valgus deformity. The aetiology is not clearly understood and there is no consensus in the literature on the definitive means of prevention or treatment. Aims: We report 3 cases of proximal tibial fractures in children, two of whom developed progressive valgus deformity of the knee following non-operative management. We highlight the importance of counselling parents on the possibility of developing this deformity and to discuss its subsequent management. Methods and results: We reviewed the clinical notes and radiographs of three patients, a 21 month old girl, a 4 year old boy and an 8 year old girl all sustaining an acute minimally displaced traumatic fracture to the proximal tibial metaphysis. They were all treated non-operatively in plaster. Sequential radiographs in plaster showed satisfactory alignment. The plaster was removed at 6 weeks for the 8 year old girl, and at 5 weeks for the other two patients. The 4 years and 21 month old patients developed a valgus deformity at 9 and 6 weeks respectively following initial fracture; they have been referred to a tertiary centre for further management and are being managed expectantly with regular follow-up. The 8 year old girl had no evidence of deformity at 3 months but is being monitored closely as an outpatient. Conclusion: Fracture of the proximal tibial metaphysis in a child can appear innocuous but despite acceptable reduction and satisfactory healing, a valgus deformity can develop. Surgery to correct the deformity is associated with a high chance of recurrence. Overall, studies recommend conservative management due to the regular occurrence of spontaneous correction and an asymptomatic limb. Patients with post-traumatic tibia valga should be followed until skeletal maturity. Operative treatment should be reserved for those who are symptomatic and, where possible, performed after skeletal maturity. It is important that surgeons are aware of the risk of progressive valgus deformity and counsel parents of this complication at an early stage. doi:10.1016/j.injury.2011.06.316