- Email: [email protected]
OTA Classification
S14
Oral presentations / Injury, Int. J. Care Injured 42 (2011) S3, S1–S24
tibia sites and the volume harvested was not significantly larger than these latter two sites. A50 Talar body fracture with pantalar extension/subluxation/ dislocation: Modification of Muller ¨ AO/OTA Classification K.S.R.K. Prasad, B.K. Dayanandam, G. Clewer, R. Kumar, K. Karras. Prince Charles Hospital, Merthyr Tydfil, United Kingdom Aim: Fractures of talar body are high energy injuries with controversial definition, classification and outcomes. Our purpose is to present combination of fractures of talar body and pantalar extension/subluxation/dislocation, clinical pathodynamics and modification of M¨ uller AO/OTA Classification. Material & Methods: A 63-year old man was admitted with comminuted coronal shear fracture of talar body with subluxation of ankle, subtalar and talonavicular joints. Closed anatomical reduction and stable osteosynthesis was accomplished with two percutaneous cannulated screws from posteromedial and anterolateal approaches. Talonavicular joint was stable. A 43-year old man was admitted with polytrauma including head and facial injuries, comminuted fracture of posterior part of right talar body with pantalar dislocation and fractures of left radius and navicular. Open reduction of pantalar dislocation and K-wire stabilisation was performed. A 77-year old diabetic lady with CT evidence of comminuted fracture of talar body with pantalar extension and fracture of navicular and chronic circulatory insufficiency on delayed presentation one month after injury was treated conservatively. Results: Two cases of talar body fractures with pantalar dislocation, treated by open reduction, were previously reported. M¨ uller AO/OTA Classification comprises CI – Ankle joint involvement, C2 – Subtalar joint involvement, C3 – Ankle and subtalar joint involvement. We extend the classification to include C4 – Ankle, subtalar and talonavicular joint involvement. Conclusions: Our patients have association of fracture of talar body with pantalar extension/subluxation/dislocation. Our modification fills the void in M¨ uller AO/OTA Classification by inclusion of C4. A51 Conservative treatment of fresh scaphoid fractures supplemented with pulsed electromagnetic fields. A prospective randomized double-blind placebo controlled multi centre trial 1 K.W.A. Gottgens ¨ , P. Hannemann1 , P.R.J. Brink1 , B.J. van Wely2 , K.A. Kolkman3 , A.J. Werre4 . 1 Maastricht University Medical Centre, Maastricht, 2 Radboud University Nijmegen Medical Centre, Nijmegen, 3 Rijnstate Hospital, Arnhem, 4 Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
Aims: Failure of treatment of scaphoid fractures can result in longer immobilization as well as avascular necrosis, non-union, early osteo-arthritis and can seriously impair wrist function with significant psychosocial and financial consequences. Previous data indicate that bone healing of acute scaphoid fractures may be improved using physical forces. Aim of the study was to improve healing of fresh scaphoid fractures using Pulsed Electromagnetic Fields (PEMF). Materials and Methods: A multi-centre, prospective, double-blind, placebo controlled, randomized trial was conducted on the effects of PEMF on fresh scaphoid fractures. Half of all applied devices were disabled at random. Investigators as well as patients were unaware of the device’s functionality. Clinical and X-ray follow occurred at 4, 6, 9, 12, 24 and 52 weeks. Results: Duration of radiological consolidation as well as clinical consolidation did not show a significant difference between both groups at log rank analysis. Secondary outcome parameters indicated that at 6 weeks local pain at the anatomic snuffbox (p = 0.03) as well as tenderness at longitudinal compression of the scaphoid (p = 0.008) differed significantly in favor of the placebo-
group. No difference was seen in wrist movement and grip strength between both groups. The number of nonunions in both groups was low, one patient in each group (4.2 vs. 3.4%). Conclusion: Pulsed electromagnetic fields bone growth stimulation seems to have no additional value in conservative treatment of acute scaphoid fractures as determined by plain X ray and physical examination. The number of nonunions was too low to make any conclusions. A52 Incidence and diagnosis of heparin-induced thrombocytopenia (HIT) in patients with traumatic injuries treated with unfractioned or low-molecular-weight heparin: a literature review A. Bloemen, M.J.G. Testroote, M.L.G. Janssen-Heijnen, H.M.J. Janzing. VieCuri Medical Centre, Venlo, The Netherlands Aim: Traumatic injuries are associated with a high incidence of thromboembolic complications (<50%). Therefore, thromboprophylaxis by low-molecular-weight heparin (LMWH) or unfractioned heparin (UH) is routinely administered in these patients and also in patients with below-knee immobilization after trauma. Heparininduced-thrombocytopenia (HIT) is a rare but very serious immunemediated complication of treatment with LMWH, which can cause fatal thromboembolism. Little is known about the incidence of HIT and value of screening in trauma patients and in isolated lower extremity injuries. Materials and Methods: Online databases Medline and EMBASE were searched independently by two authors. Quantitative and qualitative selection took place. After eliminating duplicate and irrelevant articles, seven relevant papers on HIT in trauma were identified and two studies on HIT in patients with lower leg immobilisation (table 1). Table 1. Results of systematic search for studies reporting the incidence of HIT in trauma and lower leg injuries Study
Design
Level of Intervention No. of Used definition evidence patients for HIT
Reported cases of HIT
Haentjens 1996
Randomized Fixed dose LMWH vs adjusted dose LMWH Orthopaedic trauma
1b
Nadroparin
283
Decreased platelet count >50%
2
Geerts 1996
Randomized UH 5000u sc 2×/day vs LMWH 30 mg sc 2×/day Multitrauma, ISS >9
1b
Enoxaparin
171
Immunoassay for 2 HIT antibodies
Lubenow 2010 Randomized 1b 3000u daily sc vs 5000iu UH 3×/day Major trauma
Certoparin
291
Immunoassay for 1 HIT antibodies and HIPA
Thaler 2001
2b
Enoxaparin
897
Decreased platelet count >50%
2b
Enoxaparin
234
Immunoassay for 1 HIT antibodies
Cohort 40 mg daily sc 5 weeks Surgically treated traumatic hip injury
Schwarcz 2001 Retrospective cohort LMWH 30 mg sc 2×/day Multitrauma
0
Worley 2008
Retrospective cohort 2b UH 5000u 2×/day vs LMWH 5000u daily Spinal cord injury
Dalteparin
43
Unknown
Barnes 2005
Case report Unknown dose Blunt multisystem trauma
Dalteparin
1
Immunoassay for 1 HIT antibodies
Certoparin
76
Immunoassay for 0 HIT antibodies and HIPA
various
750
unknown
4
Studies reporting isolated lower leg injuries Lubenow 2010 Randomized 1b 3000u daily sc vs 5000iu UH 3×/day Injury lower leg/foot Testroote 2008 Meta-analysis; 6 RCTs pooled 1a
0
0
Abbreviations: u unit, sc subcutaneous, LMWH low-molecular-weight heparin, UH unfractioned heparin, HIT heparin-induced thrombocytopenia
Results: These papers varied in study design: three randomised controlled trials, three cohort studies and one case report. The methodological quality of the studies varied. In a total population of 1920 patients, HIT was identified in seven patients (0.36%). Pooling of data was impossible due to heterogeneity in study design
Oral presentations / Injury, Int. J. Care Injured 42 (2011) S3, S1–S24
tibia sites and the volume harvested was not significantly larger than these latter two sites. A50 Talar body fracture with pantalar extension/subluxation/ dislocation: Modification of Muller ¨ AO/OTA Classification K.S.R.K. Prasad, B.K. Dayanandam, G. Clewer, R. Kumar, K. Karras. Prince Charles Hospital, Merthyr Tydfil, United Kingdom Aim: Fractures of talar body are high energy injuries with controversial definition, classification and outcomes. Our purpose is to present combination of fractures of talar body and pantalar extension/subluxation/dislocation, clinical pathodynamics and modification of M¨ uller AO/OTA Classification. Material & Methods: A 63-year old man was admitted with comminuted coronal shear fracture of talar body with subluxation of ankle, subtalar and talonavicular joints. Closed anatomical reduction and stable osteosynthesis was accomplished with two percutaneous cannulated screws from posteromedial and anterolateal approaches. Talonavicular joint was stable. A 43-year old man was admitted with polytrauma including head and facial injuries, comminuted fracture of posterior part of right talar body with pantalar dislocation and fractures of left radius and navicular. Open reduction of pantalar dislocation and K-wire stabilisation was performed. A 77-year old diabetic lady with CT evidence of comminuted fracture of talar body with pantalar extension and fracture of navicular and chronic circulatory insufficiency on delayed presentation one month after injury was treated conservatively. Results: Two cases of talar body fractures with pantalar dislocation, treated by open reduction, were previously reported. M¨ uller AO/OTA Classification comprises CI – Ankle joint involvement, C2 – Subtalar joint involvement, C3 – Ankle and subtalar joint involvement. We extend the classification to include C4 – Ankle, subtalar and talonavicular joint involvement. Conclusions: Our patients have association of fracture of talar body with pantalar extension/subluxation/dislocation. Our modification fills the void in M¨ uller AO/OTA Classification by inclusion of C4. A51 Conservative treatment of fresh scaphoid fractures supplemented with pulsed electromagnetic fields. A prospective randomized double-blind placebo controlled multi centre trial 1 K.W.A. Gottgens ¨ , P. Hannemann1 , P.R.J. Brink1 , B.J. van Wely2 , K.A. Kolkman3 , A.J. Werre4 . 1 Maastricht University Medical Centre, Maastricht, 2 Radboud University Nijmegen Medical Centre, Nijmegen, 3 Rijnstate Hospital, Arnhem, 4 Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
Aims: Failure of treatment of scaphoid fractures can result in longer immobilization as well as avascular necrosis, non-union, early osteo-arthritis and can seriously impair wrist function with significant psychosocial and financial consequences. Previous data indicate that bone healing of acute scaphoid fractures may be improved using physical forces. Aim of the study was to improve healing of fresh scaphoid fractures using Pulsed Electromagnetic Fields (PEMF). Materials and Methods: A multi-centre, prospective, double-blind, placebo controlled, randomized trial was conducted on the effects of PEMF on fresh scaphoid fractures. Half of all applied devices were disabled at random. Investigators as well as patients were unaware of the device’s functionality. Clinical and X-ray follow occurred at 4, 6, 9, 12, 24 and 52 weeks. Results: Duration of radiological consolidation as well as clinical consolidation did not show a significant difference between both groups at log rank analysis. Secondary outcome parameters indicated that at 6 weeks local pain at the anatomic snuffbox (p = 0.03) as well as tenderness at longitudinal compression of the scaphoid (p = 0.008) differed significantly in favor of the placebo-
group. No difference was seen in wrist movement and grip strength between both groups. The number of nonunions in both groups was low, one patient in each group (4.2 vs. 3.4%). Conclusion: Pulsed electromagnetic fields bone growth stimulation seems to have no additional value in conservative treatment of acute scaphoid fractures as determined by plain X ray and physical examination. The number of nonunions was too low to make any conclusions. A52 Incidence and diagnosis of heparin-induced thrombocytopenia (HIT) in patients with traumatic injuries treated with unfractioned or low-molecular-weight heparin: a literature review A. Bloemen, M.J.G. Testroote, M.L.G. Janssen-Heijnen, H.M.J. Janzing. VieCuri Medical Centre, Venlo, The Netherlands Aim: Traumatic injuries are associated with a high incidence of thromboembolic complications (<50%). Therefore, thromboprophylaxis by low-molecular-weight heparin (LMWH) or unfractioned heparin (UH) is routinely administered in these patients and also in patients with below-knee immobilization after trauma. Heparininduced-thrombocytopenia (HIT) is a rare but very serious immunemediated complication of treatment with LMWH, which can cause fatal thromboembolism. Little is known about the incidence of HIT and value of screening in trauma patients and in isolated lower extremity injuries. Materials and Methods: Online databases Medline and EMBASE were searched independently by two authors. Quantitative and qualitative selection took place. After eliminating duplicate and irrelevant articles, seven relevant papers on HIT in trauma were identified and two studies on HIT in patients with lower leg immobilisation (table 1). Table 1. Results of systematic search for studies reporting the incidence of HIT in trauma and lower leg injuries Study
Design
Level of Intervention No. of Used definition evidence patients for HIT
Reported cases of HIT
Haentjens 1996
Randomized Fixed dose LMWH vs adjusted dose LMWH Orthopaedic trauma
1b
Nadroparin
283
Decreased platelet count >50%
2
Geerts 1996
Randomized UH 5000u sc 2×/day vs LMWH 30 mg sc 2×/day Multitrauma, ISS >9
1b
Enoxaparin
171
Immunoassay for 2 HIT antibodies
Lubenow 2010 Randomized 1b 3000u daily sc vs 5000iu UH 3×/day Major trauma
Certoparin
291
Immunoassay for 1 HIT antibodies and HIPA
Thaler 2001
2b
Enoxaparin
897
Decreased platelet count >50%
2b
Enoxaparin
234
Immunoassay for 1 HIT antibodies
Cohort 40 mg daily sc 5 weeks Surgically treated traumatic hip injury
Schwarcz 2001 Retrospective cohort LMWH 30 mg sc 2×/day Multitrauma
0
Worley 2008
Retrospective cohort 2b UH 5000u 2×/day vs LMWH 5000u daily Spinal cord injury
Dalteparin
43
Unknown
Barnes 2005
Case report Unknown dose Blunt multisystem trauma
Dalteparin
1
Immunoassay for 1 HIT antibodies
Certoparin
76
Immunoassay for 0 HIT antibodies and HIPA
various
750
unknown
4
Studies reporting isolated lower leg injuries Lubenow 2010 Randomized 1b 3000u daily sc vs 5000iu UH 3×/day Injury lower leg/foot Testroote 2008 Meta-analysis; 6 RCTs pooled 1a
0
0
Abbreviations: u unit, sc subcutaneous, LMWH low-molecular-weight heparin, UH unfractioned heparin, HIT heparin-induced thrombocytopenia
Results: These papers varied in study design: three randomised controlled trials, three cohort studies and one case report. The methodological quality of the studies varied. In a total population of 1920 patients, HIT was identified in seven patients (0.36%). Pooling of data was impossible due to heterogeneity in study design