Abstracts from the 2001 Meeting of the British Trauma Society

Injury, Int. J. Care Injured 33 (2002) 847–883

Abstracts

Abstracts from the 2001 Meeting of the British Trauma Society Pathological fractures—the trauma surgeons workload

Percutaneous manipulation of an osteoarthritic hip for femoral nailing

A.D. Toms, G. Cribb, G. Prosser, A.P. Thomas, B. Isgar

A.B.Y. Ng, M.S. Binns

New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton, UK In 1999 the British Association of Surgical Oncology published guidelines on the management of metastatic bone disease. This is the first study to look at the Orthopaedic workload and implications of multidisciplinary working since the introduction of these guidelines. We prospectively collected data on all patients with skeletal metastases, seen in a large district hospital (a recognised cancer centre) over a 6-month period. Data was recorded from three main sources the Oncology department, the multidisciplinary meetings and the Orthopaedic team. During the study period the Oncology department saw 1119 new referrals and only 40 patients with proven bony metastasis, the multidisciplinary breast meeting discussed 18 patients and the Orthopaedic team had 39 patients who were admitted under their care for the management and investigation of skeletal secondaries. Interestingly there was little overlap between these three groups, with the Oncology department rarely requiring an Orthopaedic opinion and the patients discussed at the multidisciplinary meeting rarely requiring Orthopaedic intervention. The Orthopaedic group consisted of mainly breast and bronchial bony secondaries, with 5 biopsies, 10 intramedullary nails and 5 hemiarthroplasties being performed. Three patients were referred to the regional Orthopaedic Oncology service. All Orthopaedic referrals were seen by a Consultant within 24 h. In cases with no previously diagnosed primary the absence of a cancer specialist to act as lead clinician, was seen to delay patient treatment and discharge. In conclusion patients with metastatic bone disease do require multidisciplinary input to all levels of their care, irrespective of how they present, although the numbers of patients actually requiring Orthopaedic surgical intervention are small.

PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 2 7 8 - 4

Department of Orthopaedic Surgery and Trauma, Pontefract General Infirmary, Pontefract, UK An increasing number of elderly patients with femoral shaft fractures also have coexisting osteoarthritis of the hip. This proves to be difficult both in fracture reduction and localisation of the point of entry into the piriform fossa. To facilitate guide wire entry in a patient with osteoarthritis of the hip, considerable adduction of the hip may be required during conventional closed antegrade femoral nailing. We described a technique using a Steinman pin on a T-clamp to facilitate localisation of the piriform fossa.

Spontaneous healing of a large tibial diaphyseal cortical defect: a case report and review of literature A.B.Y. Ng, P.V. Giannoudis, A.L. Putnis, A.F. Hinsche, S.J.E. Matthews, R.M. Smith Department of Orthopaedic Surgery and Trauma, St. James’s University Hospital, Leeds, UK Post-traumatic bone defects present a difficult treatment problem for the orthopaedic trauma surgeons. The use of Ilizarov method of distraction osteogenesis is widely used in limb lengthening procedures and treatment of post-traumatic bone defects. Recently the introduction of bone segment transport over an unreamed intramedullary nail has produced good results in the management of large diaphyseal osseous defects. Other treatment options include massive autologous bone grafting procedures, free fibula transfer, as well as tibiofibular synostosis. We present a unique case in which a 14 cm diaphyseal tibia defect proceeded to spontaneous osseous filling without the need of any surgical reconstruction procedures.

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Abstracts / Injury, Int. J. Care Injured 33 (2002) 847–883

Ipsilateral epiphyseal injuries to the distal femur and proximal tibia in a child A. Ng, R.N. Prasad, S. Gopal, J.L. Brown, P.V. Giannoudis, R.M. Smith Department of Orthopaedic Surgery and Trauma, St. James’s University Hospital, Leeds, UK Isolated epiphyseal injuries of the distal femur and proximal tibia are relatively rare. They account for only 7 and 3%, respectively, of the epiphyseal injuries of the lower extremity in three large series [1–3]. The mechanism of injury is usually a hyperextension force that dissipates to the knee. We report a case of simultaneous, ipsilateral epiphyseal injuries to the distal femur and proximal tibia in a child. We believe this is the first ever case of such injuries and no previous reports were seen in the literature.

Adequacy of lateral views in trochanteric fractures, does the time at which it is taken matter—an audit D. Sunderamoorthy, G. Zafiropolous 4 Lakeside Gardens, Merthyr Tydfil CF48 1EN, UK Aim: To assess the adequacy of lateral views in trochanteric fractures and correlate with the time at which it is done. Method: We retrospectively reviewed radiographs of patients who had trochanteric fractures in the year July 1998–June 1999. Of the 79 patients who had trochanteric fractures only 52 patients radiographs were available for review. The radiographs were assessed for the degree of the exposure, the centring of the hip and the information available from the X-ray. The radiographs were correlated with the time at which they were taken. Results: Only 50% of the lateral views were found to be adequate and 30% of the radiographs done were inadequate. The rest of the 20% of the patients did not have a lateral view done at the time of first X-ray. Ten percent of the patients had a repeat radiograph of the lateral view done as they were inadequate or not done. Correlating the time at which these radiographs were done it was found that of the inadequate films done 35% were done during the normal working hours and 25% during the out of hours. Conclusion: Lateral views are essential in trochanteric fractures to assess the type of fracture and to determine they type of treatment for such fractures. The above audit shows that the standard (everyone with trochanteric fracture should have a lateral done at the time of the fracture and it should be adequate) had not been met and the inadequate radiographs were done mostly during the normal hours where there is adequate manpower. This audit proves that lateral views are essential and it should be done adequately at whatever time done.

Management of severe bony defect in III-B open tibial fractures using a monorail system and free flap coverage A. Dosani, P.V. Giannoudis, S.J. Matthews Department of Trauma and Orthopaedics, St. James’s University Hospital, Leeds, UK Introduction: Gustilo III-B fractures of the tibia are caused by high energy trauma and often associated with extensive soft tissue injury. The management of these fractures becomes more demanding and controversial when it is associated with a significant amount of cortical bone loss. Treatment modalities for bone defect includes, autologous bone grafting, free vascularised bone grafting, bone transport and bone shortening. We report two cases where initial stabilisation of a Gustilo grade III-B open tibial fracture associated with segmental defect was achieved using a solid tibial nail. The large soft tissue defect was filled with a combination of a pedicled and a free flap, following which an Ilizarov frame was applied to achieve callus distraction over the nail for the treatment of the bone defect. Case report 1: A 40-year-old male presented to our casualty department following a head on collision with a car. Primary survey was unremarkable but secondary survey revealed a Gustilo III-B fracture of the right tibia with no distal neurovascular deficit. Initial stabilisation of the tibia was achieved with an unreamed solid tibial nail after extensive soft tissue debridement. Thirteen centimetres of the tibia was devascularised and was discarded. A further 5 cm fragment with soft tissue attachment was transfixed with the nail. Definitive cover was provided 36 h later with a combination of a pedicled gastrocnemius flap and a free latissmus dorsi flap with split skin graft cover. He was discharged 18 days after the injury. The soft tissues healed without evidence of infection. Soon after this he was re-admitted for the application of an Iliazarov frame and proximal corticotomy. Distraction was commenced after 2 weeks, but revision corticotomy was required after 2 weeks of distraction. There were minimal problems with pin site sepsis during transport and 2 weeks later the fragment docked. At recent review (42 months following bone transport) the patient was fully weight bearing without crutches, with union at all levels and no sepsis. Case report 2: A 36-year-old male was transferred to our accident and emergency department following collision of his motorcycle with a trailor. Secondary survey revealed Gustilo III-B fracture of the right tibia with normal circulation and sensation of the foot. He was operated by combined Ortho-Plastic team. The tibia was initially stabilised with an unreamed solid tibial nail after debridement. Definitive soft tissue covered was provided with a combination of a free latissmus dorsi flap with split skin graft. The patient developed pseudomonas infection and he was treated successfully with intravenous antibiotics and discharged, 20 days after the injury. He was readmitted after 3 months for the application of an Ilizarov frame and corticotomy for the bone transport. Distraction was commenced, although

Abstracts / Injury, Int. J. Care Injured 33 (2002) 847–883

fragment did docked but remained hypoplastic even after iliac crest bone graft but united on re-application of the frame for compression of the fracture. At 30 months follow-up, the patient was mobilising full weight bearing without crutches, with clinical and radiological union of the fracture. Conclusion: The management of open tibial fractures is difficult and challenging problem for the orthopaedic surgeons. Immediate management requires aggressive and repeated debridement of necrotic tissue and fracture stabilisation. The combined bone and soft tissue defect demands a team approach between orthopaedic and plastic surgeons to provide an early and healthy soft tissue envelope for a delayed, staged skeletal reconstruction. The Iliazarov method of segmental bone transport has been a successful alternative treatment option modality as seen in these two cases. An unusual elbow dislocation D. Sunderamoorthy, A. Smith, D.A. Woods Department of Trauma and Orthopaedics, Merthyr Tydfil, UK A 58-year-old lady presented to the Accident and Emergency (A&E) department following a fall in the garden injuring the right elbow joint. The elbow was very much swollen and there was extensive bruising of the forearm and the arm with restriction of the elbow movements. There was no distal neurovascular deficit. Radiograph of the elbow showed a normal elbow joint. She was then discharged with analgesics and limb elevation. Three weeks later the general practitioner requested the on call orthopaedic doctor to review the patient. At review the bruise had settled but there was persistent swelling and deformity of the elbow with restriction of the joint motion. Radiograph taken then showed a posterior dislocation of the elbow. The elbow was reduced in the A&E and the patient was followed up in the fracture clinic. At 2 weeks follow-up in the fracture clinic, the elbow had dislocated again, she was then admitted. The elbow was reduced and stabilised with a transarticular pin and an external fixator. Four weeks later the external fixator and the transarticular pin was removed, the elbow was found to be stable and the patient was discharged for outpatient follow-up. This case stresses the importance that elbow dislocation can present late and they can be quite unstable. It is important that such patients in whom it is difficult to assess clinically at the time of presentation be followed up in the clinic to rule out a late dislocation. An uncommon fracture dislocation of the knee D. Sunderamoorthy, S. Parekh Department of Trauma and Orthopaedics, Merthyr Tydfil, UK Fracture dislocation of the knee involving the tibial side had been very well reported in the literature. There had been

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very few reports of fracture dislocation of the knee involving the femoral side. We wish to report such a case with an ipsilateral fracture shaft of femur. A 20-year-old Caucasian was involved in a train traffic accident. He was brought to the A&E department with a partial amputation of the right leg and a grade III open dislocation of the left knee. Radiograph taken showed communitted fracture of the right tibia and fibula and a posterior dislocation of the left knee with fracture of the medial condyle and avulsion of the tibial tuberosity. He also had a fracture of the shaft of the femur with an intact pelvis. He was resuscitated in the A&E department and taken to theatre. Pre-operatively his left knee was very unstable with a torn ACL and PCL and intact meniscus. He knee was debrided, the ACL and the PCL were repaired and the tibial tuberosity and medial condyle fracture were fixed with screws. He had a below knee amputation of the right leg and his fracture femur was fixed later with a plate osteosynthesis. Post-operatively he was mobilised with a left knee brace and prosthetic limb on the right leg. He had an arthroscopic assessment of his knee and the screws on the femoral condyles were removed in a years time. He had a stable knee with good function in the left knee and healed fracture femur. AO dynamic condylar screw in the management of subtrochanteric fractures K.A. Ryding, V. Bhalaik, J.C. Kaye Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral CH49 5PE, UK The AO dynamic condylar screw (DCS) was used for operative treatment of 23 patients, between 1990 and 2000, with subtrochanteric fractures of the femur. The aim of the study was to determine the union and complication rates of the DCS in subtrochanteric fractures of the femur. The age range of the patients was between 51 and 95 years, there were 9 males and 14 females. Six patients died post-operatively from medical complications. The union rate was 64.8% (11/17). The complication rate was 35.2% (6/17). These included three broken plates, two plates that pulled-off the femur and one screw that cut out of the femoral head. The suitability of the use of the AO device in subtrochanteric fractures is discussed. References: [1] Warwick DJ, Crichlow TPKR, Langkamer VG, Jackson M, The dynamic condylar screw in the management of subtrochanteric fractures of the femur Injury 1995:26(4);241–4. [2] Nungu KS, Olerud C, Rehnberg L, Treatment of subtrochanteric fractures with the AO dynamic condylar screw. Injury 1993:24(2);90–2.

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Complex trauma, are we treating enough? L.R. Cutler, D.A. Boot Warrington General Hospital, Warrington, UK Objectives: To assess the average number of complex fractures being operated on per consultant per year in three hospitals in the Mersey region. Methods: All cases of possible complex trauma over a period of 1 year in two hospitals and 6 months in another hospital were identified from theatre records. The X-rays were reviewed by two orthopaedic surgeons and classified according to the AO fracture classification system where appropriate. Hand, spinal and solely soft tissue trauma were not included in this study. We defined a complex fracture as (a) many B and C fractures according to the AO classification and (b) fractures acknowledged to require significant experience to treat. This study has been completed for two District General Hospitals and one Central University Hospital. Results: Most consultants operated on less than 12 complex fractures per year, an average of less than 2 of any type of fracture by anatomic region. Where surgeons had developed an area of interest and cross referrals were encouraged, individual surgeons were operating on up to 25 similar cases per year. Conclusion: Individual complex fractures were uncommon. This finding raises questions about the optimal management of such fractures. Are we maintaining a sufficient level of expertise, or should there be more referrals to surgeons with a specific interest, either in trauma or in that particular anatomical site, e.g. shoulder?

Development of novel fixation device from concept to clinical use: the ‘cruciate’ retrograde nail for internal fixation of condylar and supracondylar fractures of the distal femur M.G. Matthews Wycombe Hospital, Queen Alexandra Road, Buckinghamshire HP11 2TT, UK It has for some time been the practice for new joint replacements to have to undergo rigorous biomechanical testing and clinical trials before being licensed for general use. Trauma products have until recently escaped such close scrutiny, however this is no longer acceptable. We describe a novel implant for secure internal fixation for condylar and supracondylar fractures of the distal femur. This involves a retrograde intramedullary nail with a unique “cruciate” configuration of distal locking bolts, which stabilise the femoral condyles in relation to the shaft. The optimal geometrical configuration of the distal locking bolts has been developed with the aid of cadaver studies. After finalisation of the design, a protocol for testing and clinical evaluation was agreed with the Medical Devices Agency.

Mechanical testing of fixation of both segmental defects and “T” fractures of the distal femur using the “cruciate” retrograde nail compares favourably with fixation using a DCS screw/plate implant. Use of the nail in clinical practice in a series of patients over a limited 2-year trial period has confirmed ease of use and the effectiveness of jigs for both distal and proximal locking. Following completion of testing and clinical trials, the Medical Devices Agency has now granted approval for general use of the implant. It is anticipated that this will greatly facilitate the management of distal femoral fractures. Intramedullary nail infection and union rates at a district accident unit M.H.A. Malik, P. Harwood, S.A. Khan, D.R.M. Redfern 9 Woodacre, Off Alexandra Road South, Whalley Range, Manchester M16 8QQ, UK We performed a retrospective 5-year survey (1995–1999) of occurrence of infection and non-union after intramedullary nail insertion in long bones (122 femoral, 75 tibial and 23 humeral nails) at The Royal Preston Hospital, a designated district accident centre. Indications for insertion were trauma (165 cases), pathological fracture/metastasis (29 cases) and non-union (25 cases). There were 18 open tibial fractures, 12 open femoral fractures and 1 open humeral fracture. An overall infection rate of 10.9% was found and a non-union rate of 11.0%. Our data was analysed to quantify relationships between intramedullary nail infection and non-union with patient age, use of pre-operative antibiotics, whether the fracture was open at time of injury or surgery, operative time, grade of surgeon and medullary reaming. Our experience is compared to previously published data from teaching hospital units. Diagnosing shoulder dislocations: time for a change of view M.P. Espag, D.L. Back, M. Baroni, T.J. Peckham, A.R. Bennett Basildon General Hospital, Basildon, Essex, UK Posterior shoulder dislocations are uncommon, with frequent delays in the diagnosis. Three missed posterior dislocations within our hospital caused us to review the standard radiographs taken and the knowledge of this condition. Forty radiographers and 40 casualty officers were surveyed. Sixty-three percent of radiographers felt it unnecessary to perform two views, they complained that laterals were difficult to obtain because of patient distress. All the radiographers surveyed knew of alternative views, but would not perform them unless specifically requested. Casualty officers claimed to always request two views, but did not in 75% of cases. Only 20% were aware of alternative views,

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all would accept one view for exclusion of a dislocation and none were aware of the radiographic signs associated with a posterior dislocation. Increased education and a change of view would assist in decreasing the rate of missed diagnoses. Smelly plaster casts—adding triclosan does not help: a prospective, double blind, randomised, parallel group study M.R. Reed, C. Fleming, J.L. Sher Department of Orthopaedics, Wansbeck Hospital, Ashington NE63 9JJ, UK Objectives: To evaluate the efficacy of adding triclosan to fracture cast padding in order to reduce cast odour. Design: Randomised, double blind, parallel group trial. Setting: Two outpatient fracture clinics in the UK. Participants: One hundred and thirty-nine patients with closed fractures treated in a forearm or below knee cast. Interventions: Patients were randomly assigned to receive one of two cast paddings. One of these cast paddings, with added triclosan, was claimed to have a reduced risk of unpleasant odours beneath the cast during treatment. Main outcome measures: The mean total cast odour was determined by an electronic nose “sniffing” each cast using 32 sensors, each of which measured different odorous compounds. Results: There was no statistically significant effect in odour intensity between casts made with standard padding or that with added triclosan (P = 0.464). Padding derived from forearm casts (P = 0.0042), males (P = 0.0352) and younger patients (P = 0.0006) had significantly increased odour. Conclusions: The addition of triclosan to cast padding does not reduce odour. Treatment for proximal femoral fractures and pathological lesions management using proximal femoral nail M. Ramakrishnan, S. Prasad, R.W. Parkinson Department of Musculoskeletal Surgery, Arrowe Park Hospital, Wirral CH49 2SP, Merseyside, UK Introduction: The surgical stabilisation of pertrochanteric and subtrochanteric fractures is technically demanding with a high risk of failure. Management of the pathological fractures and lesions is also associated with similar problems. We present our experience in a District General Hospital with the use proximal femoral nail (PFN) with particular emphasis on fracture union and complications. Patients and methods: Between April 2000 and June 2001, 30 patients were treated with PFN. We divided our patients into three groups. Group 1 consisted of 10 patients with proximal femoral fractures primarily stabilised with PFN. Group 2 consisted of six patients who had PFN for failed

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proximal femoral fixation with other implants. Group 3 consisted of 14 patients with pathological femoral lesions and fractures. We had 100% union rate with PFN as primary stabilising implant in proximal femoral fractures. Bony union was 75% with revision of failed implants to PFN. We had no complications associated with nailing in pathological conditions. One patient had broken PFN due to technical reasons, which was revised. Conclusions: Our result shows PFN is a reliable implant for proximal femoral fractures and pathological conditions with high success rate and very low incidence of complications. The current management of tibial fractures: are clinical guidelines effective? A.D. Toms, A.L. Green, S. Giles, P.B.M. Thomas North Staffordshire Royal Infirmary, Princess Road, Hartshill, Stoke on Trent, Staffordshire, UK The production of clinical guidelines is increasing and will continue to do so with the introduction of clinical governance. In 1997 the British Orthopaedic Association (BOA) and the British Association of Plastic Surgeon (BAPS) published joint guidelines on the management of open tibial fractures. It is not known whether these guidelines reached their target audience, or indeed influenced clinical practice. We determined the effectiveness of these guidelines by sending a postal questionnaire survey to 170 orthopaedic surgeons. Only 57% of consultants were aware of the guidelines, 70% of registrars and 25% of staff grades. Less than 29% of orthopaedic consultants would choose to consult the plastic surgical team preoperatively in the management of an open tibial fracture and only 43% would seek plastic surgical involvement at all. The primary aim of increasing multidisciplinary communication has clearly not been achieved. We conclude that the awareness of and adherence to these guidelines is sub optimal. This clearly has implications for both the future management of open tibial fractures and the further production of guidelines. Provision of pre-hospital analgesia: current UK practice A. Smith, W.F. De-Mello Anaesthetic Department Pinderfields General Hospital, Aberford Road, Wakefield WF1 4EE, UK Introduction: A paramedic involved in the Selby train crash felt that provision of analgesia at the scene was inadequate. This prompted us to investigate current practice of pre-hospital analgesia provision in the UK. Method: A questionnaire∗ (see annexe) was sent to all 37 ambulance trusts in the UK. Results: Replies were received from 34 trusts (response rate 92%). A selective summary of the results follow: Assessment of pain: Only 65% (21/34) assessed pain using a visual analogue scale of 0–10 (n = 20) or 0–4 (n = 1).

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Current analgesics available: Entonox and Nalbuphine (14), Nalbuphine (12), Entonox and Tramadol (2), Tramadol (2), Entonox, Nalbuphine and Morphine (2), Entonox (1), Diamorphine (1). Current anti-emetics available: Only 11 (32%) stocked anti-emetics, which included metoclopromide (n = 8), cyclizine (n = 1) and not specified (n = 2). Other drugs: Diazepam (62% n = 21) and naloxone (91% n = 31) were the most common drugs in stock. Audit of practice: Just 22 (65%) trusts audited the efficacy of analgesia provision. Other comments: “need central guidelines, e.g. JRCALC” (n = 14), “concerns about the safety of ambulance crew carrying morphine” (n = 5), “nalbuphine may interfere with the provision of analgesia subsequently” (n = 3), “adoption of morphine for paramedic use is a significant step forward” (n = 3), “need a trial on the efficacy of various agents” (n = 2), “choice of analgesic should depend on clinical need” (n = 1). Discussion: The survey reveals a considerable variation in the provision of analgesia in pre-hospital care in the UK. Although the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) have made recommendations [1] it will be sometime before these are adopted. If morphine is the golden standard choice of opioid we are disappointed to find just three (9%) trusts carried morphine or diamorphine. However, at least 13 (38%) other trusts were hoping to stock morphine in the near future. The reasons for not stocking morphine is complex. In addition to opioiphobia (real or perceived) and legal constraints [2,3], in this survey at least five trusts had concerns about the safety of ambulance crews if they were to carry morphine. The analgesics stocked in descending order were nalbuphine (n = 28), Entonox (n = 19), Tramadol (n = 4) and morphine/diamorphine (n = 3). Given the popularity of nalbuphine, we would welcome further evidence on its efficacy, side effect profile and proof that subsequent use of morphine in hospital is unaffected [3,4]. Depending on the resources and expertise available it is possible to have guidelines for the use of morphine on its own [4] or as part of a multimodal analgesic approach [5]. Conclusion: There is considerable variation in the provision of pre-hospital analgesia in the UK. It will be sometime before adoption of JRCALC recommendations, which may standardise current practice. Further work is needed to derive analgesic provision guidelines that are evidence based and adaptable to local needs. Until then provision of analgesia in pre-hospital care in the UK will be a lottery depending on the postal code. Acknowledgements: The authors wish to thank the staff of the ambulance trusts who took part in the postal survey. References: [1] Joint Royal Colleges Ambulance Liaison Committee (JRCALC) recommendations. . [2] Misuse of Drug Regulations 1985, Br Natl Formulary 2001:41;6–8.

[3] Eaton CJ. Essentials of immediate medical care. 2nd ed. Edinburgh. 2000 [4] Houlihan KP, et al. Excessive morphine requirements after pre-hospital nalbuphine analgesia. Emerg Med J 1999:16(1);29–31. [5] Hocking G, de Mello WF. Battlefield analgesia: a basic approach. JR Army Med Corps 1996:142;101–2. [6] Hocking G, de Mello WF. Battlefield analgesia: an advanced approach. JR Army Med Corps 1999:145;116–8. Annexe: Questionnaire: Does your ambulance crews assessment involve pain assessment/score? Yes/no. What are the current pre-hospital analgesics and antiemetics and stock levels used by your ambulance service? (a) Analgesics (b) anti-emetics. Does your ambulance crews stock morphine? Yes/no. Please explain your decision to stock/not stock morphine? What are the routes of administration preferred/allowed for these drugs? Do your crews carry sedatives? Yes/no. If yes please provide details. Do your crews carry any antidotes (e.g. Naloxone) for the agents discussed above? Yes/no. Please provide details. Have you developed protocols/guidelines for prescribing of analgesia and anti-emetics by your ambulance crews? Yes/no. If yes please supply a copy. Please provide details of how your protocols for the prescribing/delivery of analgesics and anti-emetics were derived. Please provide details of the personnel/experts who were involved in the derivation of these protocols. Do you routinely audit the prescribing/delivery of analgesics and anti-emetics by your ambulance crews? Yes/no. Please provide details. When was your last review of polices for the use of these drugs? When is your next review? Do you liase with other trusts to consider their policies on these agents? Would you prefer a centralised policy/protocol for the delivery of such drugs? Yes/no. Please explain. Please provide details of any major problems you’ve experience with these drugs, e.g. anaphylaxis, over dose, robbery, handling errors, etc. Please provide any further comments. Choice of arthroplasty for proximal hip fractures—a meta-analysis of randomised trials from world literature D.T. Rajan, M.J. Parker Department of Orthopaedics, Peterborough District Hospital, Peterborough PE3 6DA, UK Introduction: Various arthroplasties are used in the surgical treatment of a proximal hip fracture. Are there

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well-conducted randomised trials to support the conventional teaching that cementing prostheses in place reduces post-operative pain and improves mobility? Purpose of study: To review all randomised trials from world literature, to find out if there is any advantage of unipolar hemiarthroplasty/bipolar hemiarthroplasty/total hip replacement and to find out if there is any evidence to support the conventional teaching “cemented hemiarthroplasty reduces post-operative pain and improves mobility”. Summary of methods used and selection criteria: A search strategy was evolved. Trials were identified from the Cochrane Musculoskeletal Injuries Group’s specialised register for reference lists of relevant articles, conference proceedings, and contact with trialists. All randomised and quasi-randomised trials comparing different arthroplasties (and or cement), for the treatment of hip fractures were selected for the study. Two reviewers independently extracted data from the trials and further evaluated the trial quality by use of a 10-item checklist. Results: Thirteen trials involving 1353 patients were identified. Four studies f 355 patients compared various un-cemented prostheses with cemented prostheses and noted reduced pain at follow-up and a tendency to improved mobility for those treated with a cemented prosthesis. Mortality and other outcomes were poorly reported. Six studies of 628 patients compared various unipolar hemiarthroplasties with bipolar hemiarthroplasties. Four of these showed no significant difference between implants, and two small studies on younger patients showed a tendency to more favourable results with the bipolar hemiarthroplasty. Two studies of 269 patients compared different types of hemiarthroplasty with total hip replacement, but because of the limited number of cases and the use of different prostheses no definite conclusions could be made. Conclusions: A bipolar prosthesis is superior to a unipolar prosthesis in younger patients. The role of total hip replacement in surgical treatment of a proximal hip fracture is uncertain. A review of all randomised trials from world literature that compare different arthroplasties for treatment of proximal hip fractures in adults does not support conventional teaching that cementing prostheses in place reduces post-operative pain and improves mobility.

Outcome of periprosthetic fracture of femur in hip replacement G.K. Singh, B.A. Clift, R.G. Deshmukh Staff Residences, Pilgrim Hospital, Boston, Lincolnshire, UK Periprosthetic fracture of the femur around a femoral arthroplasty component is seen with increasing frequency. These days, it is often dealt with at a district general hospital (DGH) level by an orthopaedic surgeon with a special interest. It is a serious injury with a high mortality and morbidity

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rate, which is surprisingly almost uniform in publications on the topic. This is a series of 40 such fractures presenting consecutively between July 1998 and January 2001 at a district general hospital in England. The outcome and complications are analysed according to Tower and Beal’s criteria (1999). The mortality rate within the first 6 months after injury was 35% (14 cases) and 26 cases progressed to clinical and radiological union at an average of 5 and 9 months, respectively, after injury. The results are comparable to those in the literature. If certain principles of treatment are adhered to, such injuries can be treated at district general hospitals, as successfully as at teaching hospitals or specialised referral centres.

The role of external fixation in the treatment of unstable fractures of the distal radius: is the type of comminution important? R.V. Chari, G.J. Packer No. 5 Fenstanton Avenue, North Finchley, London N12 9HA, UK Aim: To demonstrate that external fixation cannot be used solely to treat unstable distal radial fractures with a combination of dorsal and volar comminution. Seventeen patients (8 males and 9 females) with a mean age of 47.5 years (range = 28–64 years), sustaining Frykman grades VII and VIII fractures of the distal radius associated with high energy trauma between 1996 and 1998, treated solely with external fixation were assessed. The mean time to operation was 3.4 days (range = 1–13 days). The mean time to review was 15.8 months (range = 7–31 months). There was dorsal comminution in 7 patients with additional volar comminution in 10 cases. Excellent functional outcome results were obtained with a mean mass grip strength of 79.6% (range = 35.7–95%). However, when comparing patients with a combination of dorsal and volar comminution with those sustaining dorsal comminution alone, loss of radiographic parameters resulted at review. Post-operative and review mean volar tilt values were +1.5 and −3.6◦ , respectively, cf. +2.3 and +6.6◦ , whilst the mean post-operative and review radial length values were 13.9 and 10.7 mm, respectively, cf. 11.6 and 11.4 mm. Comparison of the two groups for volar tilt and radial length gave P values of 0.004 and 0.02. External fixation is not an effective sole modality of treatment in cases associated with both dorsal and volar comminution. It is also highly recommended that when considering the use of external fixation as the sole procedure for these inherently unstable distal radial fractures, the degree and type of comminution is appreciated on the pre-operative radiographs.

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Dorsal wedge cortico-cancellous bone grafting for the treatment of unstable fractures of the distal radius in the younger population R.V. Chari, G.J. Packer No. 5 Fenstanton Avenue, North Finchley, London N12 9HA, UK Aim: To demonstrate that open reduction and dorsal wedge cortico-cancellous bone grafting is an effective modality of treatment in the younger population with inherently unstable distal radial fractures sustained by high-energy trauma. We reviewed the outcome, clinically and radiologically, of 19 patients (8 men and 11 women) with a mean age of 52.9 years (range = 22–70 years) sustaining Frykman grade VII and VIII fractures of the distal radius, associated with high energy trauma between 1994 and 1999, all having undergone open reduction and dorsal wedge cortico-cancellous bone grafting. There was dorsal comminution in 11 wrists with additional volar comminution in the remaining 8 cases. The mean review time was 16.6 months (range = 7–48 months). The mean time to operation was 6.2 days (range = 1–21 days). Good functional outcome results with a mean mass grip strength of 70% (range = 40–100%) and 95% patient satisfaction were obtained. A significant improvement of radiographic parameters were observed post-operatively (mean radial length = 11.4 mm; mean volar tilt = +1.4◦ ; mean radial inclination = 24.1◦ ) and remained so at the time of assessment (mean radial length = 10.9 mm; mean volar tilt = +0.1◦ ; mean radial inclination = 23.9◦ ), indicating structural support of the cortico-cancellous graft. Open reduction and dorsal wedge cortico-cancellous bone grafting is an effective modality of treatment of unstable fractures of the distal radius in the younger population. Donor site morbidity was not a problem.

Fracture dislocation of base of fifth metacarpal—a missed injury S. Kapoor, R.G. Simpson Glasgow Royal Infirmary, Glasgow, UK Introduction: Fracture dislocation of the base of fifth metacarpal is a commonly missed injury even in the experienced hands as it is difficult to assess clinically and radiographically. Materials and methods: Nineteen cases of fracture dislocation of base of fifth metacarpals were treated surgically in hand unit in last 3 years. The fractures were subdivided into subtypes described by Igor Niechajev. The fractures were reduced either by closed or open reduction and held by transfixation of hamato-metacarpal joint. Results: All except one patient were young males and punching injury accounting for most of the cases. The in-

jury was missed in the Accident and Emergency department in three-fourths of the cases. The injury was not obvious on standard AP and lateral radiographs in 65% cases. But oblique radiographs with hand in either supination or pronation picked up the dislocation in all the patients. Closed reduction was achieved in 73% cases and open reduction was usually required when injury was missed for more than 3 weeks. The outcome was excellent to good in 68% cases, fair in 26% cases and poor in 6% cases using Mayo modified score. Conclusion • Fracture dislocation of base of fifth metacarpal is a commonly missed injury. • Oblique radiographs with hand in 60◦ of supination and pronation gives best projection to visualise these fractures. • Transfixation of hamato-metacarpal joint is a simple method of treatment with few complications and good results.

Effect of delay on patient mortality and morbidity in hip fracture surgery S. Kapoor, C.S. Kumar Royal Alexandra Hospital, Paisley, UK The timing of surgery for patients with fractures of the hip is a subject of controversy. Although it is generally recommended that the patients with femoral neck fractures undergo surgical repair within 24 h after admission, some authors have shown that this practice may not have any significant effect on mortality. We conducted a retrospective analysis of data collected on 600 patients who underwent surgery over a 3-year period to study the effect of delay in surgery on patient mortality and morbidity in comparable groups of patients. Mortality at 4 months and duration of postoperative stay (as an indicator or morbidity) were measured in matched groups of age, sex, fracture type and source of admission. Approximately half of the patients waited for more than 24 h for their surgery. The difference in 4-month mortality (52 out of 228 and 42 out of 225, respectively) was not significant when operated earlier and later than 24 h. However, the average postoperative stay was significantly longer (18 days versus 12 days) in patients who were operated after 24 h. In our study, delaying surgery by 24 h had no effect on 4-month mortality but duration of postoperative hospital stay increased significantly in patients who underwent surgery later than 24 h after admission to hospital.

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A review of the adequacy of cervical spine radiology within the Accident and Emergency department S. West, A. Grant Department of Orthopaedics, Royal Gwent Hospital, Newport, South Wales, UK Objectives: To review the adequacy of the cervical spine radiographs in trauma patients attending and A&E department of a large DGH, noting specifically the visualisation of the C7–T1 junction. Method: One hundred sequential patients admitted to the A&E who had cervical spine radiographs were selected retrospectively. The casualty notes and X-rays were reviewed and data recorded. Results: Of the 100 patients 34 were found to have inadequate views of the C7–T1 junction. Swimmers views had been obtained in 12 of these patients. The age range was 9–83 years. Twenty-one of the 34 had been involved in RTA, 7 in a fall, 4 in sport, 1 in an assault and 1 of sudden onset neck pain. Diagnoses included neck sprain in 17, bruising in 3, whiplash in 3 and no diagnosis offered in 11. No specialist opinion was requested for any patient discharged without adequate visualisation of the C7–T1 junction. Fifty-six of the 100 patients had satisfactory radiographs. Films were unavailable for nine patients. Conclusions: Visualisation of the C7–T1 junction in the A&E can be difficult. The use of swimmers view is often a helpful adjunct but may be difficult to interpret. In the absence of adequate views of the cervical spine, injury cannot be excluded. A specialist or senior opinion should be requested with recourse to CT or MRI imaging once C-spine pathology has been suspected, but not excluded with initial radiographs.

Circular frame modifications to prevent flexion contracture M.R. Williams, A.P. O’Gorman, R. Persad, M. Barry Department of Trauma and Orthopaedics, Barking, Essex, UK The use of circular frames in the treatment of traumatic, infective and congenital conditions is becoming more commonplace in orthopaedics. The advantages of this method in the management of complex, malunited and nonunited fractures, in long bone transfer and lengthening are apparent. However, complications have been reported, including flexion contracture deformity and joint stiffness. This has most commonly been reported in the foot, where an equinus deformity is seen. This may be due to soft tissue tethering or connective tissue remodelling as a result of prolonged immobility and absence of tensile forces. A variety of strategies have been employed to prevent soft tissue contractures. Aggressive physiotherapy has been used

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but requires a highly motivated patient and the short periods of forceful stretching may lead to tissue damage and further contracture. Wire fixation of the dorsiflexed foot to the frame is used but requires further surgery and limits mobility of the ankle joint. Commercially available orthoses are available but expensive. As an alternative to these methods, our department have developed a foot plate that is attachable to the frame during the initial surgery and a removable thermoplastic splint that can be exchanged for the plate when the patient starts to mobilise. The foot plate maintains the ankle in the dorsiflexed position in the immediate post-operative period and can be adjusted or removed in the ward or outpatient setting as required. As the patient begins to mobilise, a thermoplastic splint attached to the frame by simple elastic bands can be substituted. The force applied to the foot can be varied, the splint is easily removable, and the patient can even wear the device with a shoe to encourage weight bearing. These modifications have been used on a number of patients with favourable results and provide an inexpensive and effective method to prevent flexion contracture associated with the use of circular frames, and can be easily reproduced in any orthopaedic department.

Tibial gap fractures reconstructed by ipsilateral vascularised fibular transfer N.D. Downing, J. Carmichael, K. Lam, A.P.J. Henry Department of Orthopaedic Surgery, Derbyshire Royal Infirmary, NHS Trust, Derby, UK Introduction: Ipsilateral vascularised fibular transposition was performed on eight patients with segmental tibial defects following injury. Method and results: We report these cases with a minimum follow-up of 2.5 years. All the tibial defects were the result of severe open fractures (Gustilo Grade III) and either bone loss or infected non-union, and ranged in size from 1 to 12 cm. The patients had an average of seven procedures and a delay of 33 months before fibular transfer. The procedure was successful in achieving fracture union in all cases, with an average time to union of 15 months (range 5–33 months). Shortening of up to 3 cm and some residual ankle stiffness was found, but all patients were ambulating bearing full weight and six had returned to their previous occupation by their final follow-up. Only one patient had significant pain affecting function. Conclusions: This is a successful and relatively simple technique compared to microvascular and bone transport procedures for reconstructing segmental tibial defects with relatively avascular graft beds.

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Outcome following Gartland type III supracondylar fractures in children: district hospital experience N. Tellisi, A. Hamid, K.H.A. Wahab 28 Warwick Road, Sutton Coldfield, Birmingham B73 6ST, UK This is a retrospective study into the outcome of treatment following displaced supracondylar fractures in children, conducted at a district general hospital. During the period between January 1995 and December 1999, 50 patients with displaced supracondylar fractures were admitted to the unit and treated by either closed reduction and cast immobilisation, closed reduction and K wire fixation or open reduction and K wire fixation. We performed an outcome study on Gartland type III displaced supracondylar fractures in children admitted over 5 years, in order to assess the outcome of management. A total of 50 patients with a mean age of 6.4 years, were included in the study. Flynn criteria were used to assess the functional and cosmetic outcome. An excellent outcome was seen in 35 patients (70%), a good outcome in 10 patients (20%), a fair outcome in 3 patients (6%) and a poor outcome in 2 patients (4%). The incidence nerve injury was assessed and seven patients developed nerve injury as result of the injury (14%). None of the patients had vascular complications.

Application of halo traction: a survey of trainees’ experience and training P.A. Davey, P. Reilly, M.C. Flannery Department of Trauma and Orthopaedics, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, UK There is a learning curve associated with any surgical procedure. The low frequency of application of halo traction among orthopaedic trainees results in them remaining on the steep part of this curve from a protracted period. We carried out a survey of the experience of orthopaedic trainees in two regions and assessed the influence of training on their confidence to perform this procedure. We also determined what type of equipment was available for the procedure in the training hospitals. Fifty-four trainees from two regions participated in the survey and completed the questionnaire. The mean length of higher surgical training completed was 3 years 4 months. The mean number of procedures performed was 2.5 per trainee. Sixty-one percent of trainees indicated that they would be confident in applying halo traction unsupervised while 39% were not confident. Two-thirds of trainees had been trained in the application of halo traction. Training improved the confidence of trainees to carry out the procedure from 28 to 78%. This is highly significant using a Chi-squared test (P < 0.0003). Among the 25 hospitals that make up the two training regions we were able to identify 12 different products for this

procedure. In addition to this some hospitals were unable to identify what product was actually available. On the basis of these results we propose that there is a case for standardising the equipment available for this infrequently performed procedure across each training region. We also propose that there should be regional based training with the chosen equipment to accelerate trainees up the steepest part of the learning curve to improve our standards of patient care.

Underestimation of severity of injury in major trauma R. Owens, I. Pallister 13 Gaulden Grove, Pontprennau, Cardiff CF23 8SD, UK Introduction: Underestimation of injury adversely affects outcome in major blunt trauma. We wished to evaluate any difference extant between the clinical assessment of injury in the Accident and Emergency department with those injuries identified at post mortem in non-survivors of major blunt trauma in order to assess any areas in which trauma care could be improved. Methods: Retrospective data was collected from all non-survivors of blunt injury trauma treated in Accident and Emergency department between January 1998 and December 2000. Those dead on arrival and deaths due to drowning or hanging were excluded. Each patient was scored according to the Abbreviated Injury Scale (AIS90) from Accident and Emergency records and from post mortem reports. Results: The data shows a statistically significant difference in the injury severity score observed in A&E and those calculated from post mortem report. (P = 0.01 Mann–Whitney U-test, N = 21). The greatest discrepancy lies in assessment of face, abdominal and thoracic injuries. Conclusion: In 1988 major trauma was identified as an area where underestimation of injury was common and adversely affected outcome. Despite undertakings by the Royal College of Surgeons to improve trauma care in the UK the severity of injury sustained in major blunt trauma is still significantly underestimated within the Accident and Emergency department in particular injuries to face abdomen and thorax. Accurate assessment of injury severity is crucial to survival in major trauma. This study was undertaken in a department where completion of Advanced Trauma and Life Support courses is actively encouraged for surgical trainees, but lacks a consultant led trauma team. Comparison of our UK data is currently being made with that of a Level 1 Trauma centre. This study identifies a need to reassess management of major injury in our institution.

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Radial head fractures: a randomised controlled trial of immediate versus delayed mobilisation R.Y.L. Liow, A. Cregan, R. Nanda, R.J. Montgomery R.Y.L. Liow, 39 Bradman Drive, Riverside, Chester Le Street, Durham DH3 3QS, UK Aim: We have compared the outcome of immediate with delayed mobilisation for Masons 1 and 2 radial head fractures through a single-blinded, prospective randomised controlled trial. Methods: Sixty consecutive patients attending the fracture clinic with Masons 1 and 2 radial head fractures were randomly allocated to have either immediate or delayed mobilisation. Delayed mobilisation entailed 5 days in a broad arm sling before a programme of supervised exercises, identical to the immediate group, was commenced. Patients were reviewed at 7 days, 4 weeks and 3 months after their injuries. A blinded independent observer assessed each patient at the follow-up appointments for pain, range of motion, strength and elbow function (Morrey score). Radiographs were obtained at the 4-week and 3-month appointments to assess fracture union. Results: The two groups were comparable in age, sex and hand dominance. There were more Mason 1 in the immediate mobilisation group (60% versus 42%) but this difference was not statistically significant. All the fractures united by the third month. At the end of the first week, the mobilisation group had less pain (VAS 6 versus 7.6, P = 0.002); greater flexion (mean 112◦ versus 98◦ , P = 0.0004); greater strength in supination and pronation (Mann–Whitney P < 0.001) and better elbow function (Morrey score 54 versus 43, P = 0.005). By the fourth week, both groups were comparable in all parameters and improvement continued into the third month. Mean limit of extension at the third month were 2.3◦ in the immediate mobilisation group and 1.8◦ in the delayed group (NS). All patients had excellent function on the basis of the Morrey score. Conclusion: Immediate mobilisation did not adversely affect the outcome in Masons 1 and 2 radial head fractures; in fact, they experienced less pain and attained better elbow function at 1 week post-injury. Pain, ranges of movement and function were similar by the fourth week post-injury.

Subluxation of tibialis posterior tendon— a case report and discussion of management R. Dharmarajan, M.J. Aldridge Department of Trauma and Orthopaedics, Coventry, UK We report an interesting case of subluxed tibialis posterior tendon in a 21-year-old gymnast. To our knowledge only 35 cases have been reported in the literature. The patient presented with ankle instability while doing his tumble. The diagnosis was not made initially due to not recognising the problem and hence the delay in referral to our specialist Gymnast clinic.

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We discuss the presentation, clinical diagnosis and operative management of this uncommon but well recognised problem. Education and new labour in Accident and Emergency: is it working? S.P.R. Macleod, J. Ferguson Department of Oral and Maxillofacial Surgery, Accident and Emergency Department, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB9 2ZX, UK Junior staff in Accident and Emergency may be called upon to assess patients with injuries which they have not had training in. This can have clinical governance implications. In recognition of this there has been a move to increased didactic training of junior staff and competency based assessment, but their effectiveness has not been well evaluated. The knowledge base of a new intake of Accident and Emergency junior staff in the assessment of maxillofacial emergencies was evaluated. This is an area that receives scant attention in the undergraduate curriculum, yet can account for 10% of trauma consultations. Only 30% of injuries presented during the initial evaluation were correctly diagnosed. The response to didactic teaching and supervised practice was assessed. The results of the exercise and a discussion of the development of competencies for Accident and Emergency junior staff will be presented. Correction of complex deformities using Taylor-Spatial Frame S.Z.H. Naqui, G. Tselentakis, J. Day Royal Manchester Children’s Hospital, Booth Hall, UK The Taylor-Spatial Frame (TSF) is a sophisticated external fixator system which can be used to treat simple to complex multi-apical skeletal deformities. The authors describe it’s use in over 20 cases in a variety of pathologies and demonstrate it’s ease of use and versatility. The TSF incorporates two ring fixators connected by 6 struts. A software programme supplied performs all the calculations required to manipulate the struts over any given time. In this way deformities can be corrected and residual deformities can be further corrected without further surgery. We demonstrate its ease of use for both surgeon and patient and it’s versatility in the variety of pathologies in our series. Knee dislocation associated with ipsilateral femoral shaft fracture: a rare injury with significant morbidity S. Agarwal, D.A. Macdonald, P.V. Giannoudis Department of Trauma and Orthopaedics, St. James University Hospital, Leeds, UK Introduction: Knee dislocations are uncommon injuries with most series reporting only few cases over a period of many years. The association of knee dislocations with

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femoral shaft fractures is exceedingly rare and further complicates the management of this injury. We describe four patients managed at our tertiary care trauma centre and evaluate the outcome. Patients and methods: Out of 187 femoral fractures treated in our institution over a period of 6 years (1994–1999), four patients with five femoral fractures and ipsilateral knee dislocations were identified. All four patients (two females) were in early twenties and involved in high energy road traffic accidents. One woman had bilateral knee dislocation with fractures of both femora and tibiae. None of these four patients had head, chest or major visceral injury. No patient had neurovascular damage or compartment syndrome. All were managed by immediate relocation of the knee, angiography, locked intramedullary nailing of femur and post-operative bracing of the knee for 6 weeks—either by external fixator or hinged brace. Following discharge from the hospital they were followed up regularly in the fracture clinic. Secondary reconstructive procedures were planned depending on the severity of injury and patient demands. The minimum follow-up was 2 years. Results: Four of five femoral fractures united within expected time scale. One with non-union had exchange nailing twice and is presently under follow-up. Out of the five knees, four underwent a secondary reconstructive procedure. One patient had an open dislocation of the knee with loss of quadriceps tendon, part of patella and patellar tendon, which was reconstructed with Leeds–Keio ligament strips and a free flap. One other patient required an ACL reconstruction 2 years after injury and finally had a stable painless knee. The lady with bilateral injury had reconstruction of both PCL 2 years after injury. At the final follow-up 7 years later, there was residual PCL laxity in one knee and she was mobile with one stick. At final follow-up all the patients were assessed by the American knee score. Conclusion: Femur fractures with knee dislocations are orthopaedic emergencies. These injuries should be treated by immediate relocation of the knee, stabilisation of the femoral fracture and ensuring normal distal circulation. In our patients, we have braced the knee initially and symptomatic instability was later on managed by appropriate ligament reconstruction procedures. Gross instability may require application of bridging external fixator to facilitate knee ligament healing. Two patients in this series had a good outcome with stable painless knees. The treatment has to be individualised in each situation to achieve an optimum result.

A review and suggestions for management of minor head injuries Simon West, Peter Evans, David Shewring Department of Orthopaedics, Royal Glamorgan Hospital, NR Llantrissant, South Wales, UK Objectives: To review the aetiology of head injury, the Glasgow coma scale (GCS), relation to alcohol consump-

tion and self-discharge rate among patients admitted to the Cardiff Royal Infirmary. Methods: A basic questionnaire was designed to include all the study parameters. This was completed at the time of admission. All patients admitted over an 11-week period were included. Results: There were 45 admissions for minor head injury during the study. Of these 4.5% were related to sport, 8.9% to road traffic accidents, 24.5% to falls in the home, 26.6% were intoxicated with alcohol but not related to assault and, 35.5% followed alleged assaults. Overall, we found 60% of admissions were intoxicated with alcohol. Admissions rose steadily through the week. Alcohol levels followed a similar pattern. In all cases the CGS was never lower than 14. Only one case required further investigation. Associated injuries were trivial in all but two cases. Self-discharge was not found to be common, but those who did had either been assaulted or were intoxicated. Irrespective of the aetiology of admission no patients stayed longer than 18 h. Conclusions: We feel the results support the use of short stay wards for the management of minor head injuries. He use of such wards may reduce the burden on main hospital wards.

A unique case of the fracture chasing the implant ! Vishal Sahni, Pydisetty Ravi Kumar, Richard W. Parkinson Orthopaedic Department, Whiston Hospital, Prescot, Merseyside, UK SL, a 68-year-old lady weighing 16 stones, underwent a left total knee replacement in May 1999. Four months following this she sustained a trivial injury and had a peri-prosthetic fracture just proximal to the femoral prosthesis. The knee prosthesis being well fixed this fracture was treated with an interlocked supracondylar nail. Again 4 months following this she had a trivial fall and sustained a fracture just proximal to the proximal tip of the supracondylar nail. This time she underwent a second generation conventional interlocked nail spanning from the knee to the proximal femur. About 14 months following this she again fell and sustained a fracture of the proximal femur just proximal to the nail. Finally she underwent fixation by a third generation “Proximal Femoral Nail” with fixation by screws in the head and neck of femur and distally around the distal femur. An intensive search did not reveal any such case of sequential peri-implant fractures reported in literature to date. It appears to be a truly a case of the fracture chasing the implant. This case raises several important issues. More such cases are expected in future because in the western world the total number of patients with either a hip or knee prosthesis may soon be around 40 million. In this particular case the fractures were short oblique at the tip of the implant due to a

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stress riser effect between the prosthesis and the bone. Other contributing factors here could be osteopenia, increased body weight and unsteadiness of gait. We have to look more closely at the option of conservative treatment. Also, if fixation has to be undertaken then we should be seeking to devise implants which are bio-mechanically isoelastic to prevent the sudden change in the elasticity of the nail to bone. Training and use of compartment pressure monitoring devices W. Kim, R. Chandru, J. Doyle 14 Croftleigh Close, Whitefield, Manchester M45 7DL, UK Compartment syndrome if an orthopaedic emergency. The diagnosis is made principally from the history and clinical examination. The use of a compartment pressure monitoring device is a useful adjunct in instances where the history and examination is unreliable for example in young children, in the multiply injured and in unconscious patients. Availability, competence in the use of the device, knowledge of values indicative of compartment syndrome are therefore essential. A telephone survey was conducted of 96 teaching and district general hospitals in the UK. Ninety-one (95%) of the respondents were of specialist registrar grade or equivalent. Thirty-seven (39%) of the respondents had equipment within their hospital with which to perform measurements of compartment pressures. Nineteen had the Stryker hand held monitor, 11 had a modified arterial monitor and transducer, 7 had other monitoring devices. Twenty-one (22%) of the respondents received formal training in the use of the monitoring device including teaching of safe and appropriate insertion sites. There is a variety of opinion as to values of pressure which are significant in making or excluding the diagnosis of compartment syndrome. Only 9 (9%) of the respondents used a differential pressure of 30 mmHg between monitored and diastolic pressures as the threshold for emergency fasciotomy. We conclude that there is a lack of availability of compartment pressure monitoring devices in hospitals in the UK. Furthermore, many trainees have not received formal training in the safe and competent use of compartment pressure monitoring devices. Knowledge of values of compartment pressures that are significant are also important including the concept of differential values between measured values and diastolic blood pressure. Is the grip strength of dominant hand affected after simple elbow dislocation? K. Chirputkar, K.S. David-West, S. Smith Department of Trauma and Orthopaedics, Renfrew, UK Aim: To compare the grip strength of the dominant to the non-dominant hand after simple elbow dislocation of the dominant elbow.

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Introduction: The function of the elbow is to position the hand in space. The position of the elbow effects grip strength. Simple dislocation is associated with complete rupture of medial and lateral ligaments. The risk of re-dislocation correlates with muscular injury to the flexor pronator and extension origins at the humeral epicondyle. Flexor digitorum superficials is an important muscle for grip. Bechol has reported the dominant hand being 5–10% stronger grip than the non-dominant. We compared the grip strength of the dominant to the non-dominant limb after conservatively treated simple elbow dislocation. Method and result: All records and radiograph of simple dislocations of the elbow between 1997 and 2000 were reviewed. Patients were invited to the clinic for examination. A “Jamar” dynamometer was used, and the mean of three readings at position 3 was taken. Seventeen patients records were reviewed, three patients declined to take part in the study and two had changed address. Twelve patients took part in the clinical examination (five females and seven males). Mean age was 44.36 years (17–59 years) and mean follow-up of 24.7 months (9–48 months). Ten right hand dominant and two left had dominant. Mean grip strength in the dominant hand was 27.7 kg force (kgf) and in the non-dominant hand was 24.7 kgf. The difference was not statistically significant. Elbow extension was restricted in eight (mean restriction 10◦ , range 5–30◦ ), two patients had full extension. None had changed their occupation. Conclusion: The grip strength in the dominant hand after simple elbow dislocation was stronger than the non-dominant hand but the difference was not statistically significant. Most of the patients had loss of extension but none had changed their occupation. Epidemiology and outcome following supracondylar fractures of the humerus in children Kapil Kumar, Nicola Maffulli Department of Trauma and Orthopaedics, Aberdeen, UK Supracondylar fracture of the humerus is one of the most common injuries in children. In this study, we looked at the epidemiology and outcome following supracondylar fractures of the humerus in children. We identified all orthopaedic inpatients during the period 1991–1996 with supracondylar fractures from ward and theatre records. Case notes and radiographs of these patients were reviewed. A total of 83 patients were admitted with supracondylar fractures. Majority of the injuries occurred during the period May–September. There were 5 Gartland I injuries, 26 Gartland II, and 49 Gartland III fractures. In three patients, the fracture was displaced anteriorly. Nerve injuries were seen in 11 patients, but all recovered. Majority of Gartland III fractures (61%) were treated by open reduction and internal

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F.S. University College London Hospitals, London, UK

its effects on outcome in patients, with non pathological intra-capsular fractures of the neck of femur. Methods: Two hundred and twenty-six patients underwent Austin Moore uncemented hemiarthroplasty. The immediate post operative X-rays were assessed. All patients were followed up for 1 year. Significant pain at 1 year and revision of the prosthesis for loosening were considered as unfavourable outcomes. Results: Inadequate calar seating was significantly associated with pain and revision of the prosthesis (P = 0.04 and 0.01, respectively). Length of the neck remnant was also significantly associated with the two outcomes (P = 0.05 and 0.023, respectively). Difference in head size was associated with pain but not with loosening (P = 0.01 and 0.08, respectively). The rest of the parameters were not significantly associated with outcome. Conclusion: Adequate planning and attention to the proper insertion of this prosthesis, particularly the seating of its collar on the calcar is essential to ensure a favourable outcome.

The Royal National Orthopaedic Hospital Trust, Stanmore, UK

Hybrid fixation for tibial shaft fractures

fixation. The most common long term complication was loss of motion, and most commonly seen in the group treated by open reduction and internal fixation. Residual angular deformities were seen in those with Gartland II, and Gartland III injuries. Cubitus varus occurred in eight patients while one had cubitus valgus. Supracondylar fracture is the most common elbow injury during childhood. Its incidence seems to be related to daylight hours which provide children increased opportunities for outdoor activities. Nerve injuries are common and need to be identified at initial assessment. Displaced supracondylar fractures need to be reduced accurately and stabilised to prevent residual angular deformities. However, operative intervention increases the incidence of long term stiffness. Micro-scooters: an alternative mode of transport not without risks K.I. Eleftheriou, Hashemi-Nejad, A. Haddad

A rapid increase in the use of lightweight foot-propelled scooters has been observed in the last few years. The considerable risks involved in their use have been described in the United States. We prospectively identified scooter related injuries at a local level in the United Kingdom. We describe 23 such injuries. The majority of rider injuries (14) occurred in children under 15-years of age with fractures, soft-tissue injuries and lacerations predominating. Four of the eight adults involved were injured in collisions with scooters. There were no fatalities. Our results follow a similar pattern to that previously reported in the United States. We saw very little supervision of or education on scooter use, and the use of safety equipment was minimal. In view of the widespread use of such scooters in the United Kingdom, we suggest that they pose a substantial risk of injury and are likely to become an increasing drain on resources across the country. The use of scooters must be carefully viewed and both legislative and educative efforts made to ensure their safe operation. Austin Moores hemiarthroplasty procedures. Technical aspects and their effects on outcome, in patients with fractures of the neck of femur Khalid M. Sharif, Martin J. Parker Orthopaedic Department, Peterborough Hospital, Peterborough, UK Objective: To study the technical aspects of Austin Moore’s hemiarthroplasty procedure (alignment of insertion of the prosthetic stem, calcar seating, length of the neck remnant, leg length discrepancy and size of the head of the prosthesis compared to the contralateral femur) and

M. Oleksak, A. Metcalfe, M. Saleh Academic Orthopaedic and Traumatic Surgery Unit, University of Sheffield, Northern General Hospital, Sheffield, UK Hybrid fixation is now an established modality of treatment for articular fractures of the proximal and distal tibia. There is, however, lack of consensus over the management of non-articular fractures within the metaphysis extending into the diaphysis. Intra-medullary nailing, despite more sophisticated application techniques, remains a difficult technique to perform with relatively high rates of mal-union and non-union. Plate fixation may produce satisfactory results but is limited where there is a major extension into the diaphysis or the soft tissues are compromised. Since 1995 we have used hybrid external fixation for the management of such fractures. There have been 43 patients, 25 male and 18 female with an average age of 45 years (9–90 years). The majority of these fractures were high energy injuries as a result of road traffic accidents, with 27 closed and 16 open fractures. These consisted of 28 distal tibial, 6 proximal and 9 tibial shaft fractures. Twenty-seven patients were treated with hybrid fixation as a primary procedure, 16 patients as a secondary procedure within 12 weeks of injury. All patients completed their treatment and achieved union, although 11 required additional procedures such as bone-grafting and soft tissue procedures to achieve this goal. Five patients had a residual mal-union requiring further treatment, there were four pin-track infections and one deep infection which resolved after sequestrectomy. Conclusion: Hybrid fixation is a satisfactory method of managing comminuted and unstable fractures of the tibial metaphysis and diaphysis.

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Enteral feeding after hepatic artery ligation: no need to delay N.A. Stassen, M.J. Scott, J.K. Lukan, W.G. Cheadle Department of Surgery, University of Louisville, Kentucky, USA Early enteral feeding of critically ill patients has been shown to be beneficial. Enteral feeding has been shown to decrease septic morbidity, preserve gut mucosal integrity and attenuate hypermetabolic responses to injuries. Portal blood flow increases with feeding but the oxygen content of this blood is decreased. It has, therefore, been suggested that early enteral feeding after hepatic artery ligation or embolisation will lead to increased hepatocellular injury secondary to hepatic ischaemia. The aim of this study is to demonstrate that early enteral feeding is safe and does not increase hepatocyte damage. Methods: The medical records of trauma patients, who underwent hepatic artery ligation or embolisation for isolated hepatic injury between January 1995 and June 2000, were reviewed. Data on patient demographics, mechanism and severity of hepatic injury, results of blood liver enzyme analysis from injury to 28 days post-operatively, type, timing and tolerance of enteral feeds and post operative complications were collected. Results: Seven patients were identified. Ages ranged from 16 to 54 years (average 29 years) with an average hepatic injury grade of IV. Five patients underwent right hepatic artery ligation, one patient underwent right hepatic artery embolisation, and one patient underwent left hepatic artery embolisation. Enteral feeding was started between 2 and 25 days post operatively. Liver enzyme levels peaked after 3 days post-injury and normalised by day 6. There was no increase in hepatic enzyme level after the initiation of feeding. Conclusion: Enteral feeding after hepatic artery ligation or embolisation does not increase hepatic enzyme levels. This suggests that there is no increased hepatocellular injury due to enteral feeding. These patients benefit from early enteral feeding and this study has found no justification for delaying feeding. The use of hybrid circular frame fixation in the management of complicated lower limb trauma P. Thomas, M. Dobson, S. Jennings Department of Orthopaedics, Whittington Hospital, London, UK Complicated lower limb trauma is a significant problem for orthopaedic surgeons, as it poses a number of difficult management decisions in dealing with the primary injury and any subsequent complications. There are numerous reports in the literature demonstrating the use of Ilizarov external fixation in the treatment of complex lower limb trauma, especially from centres with great experience of treating war injuries, but this specialised tech-

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nique is not available in many centres. There is, however, very little reported highlighting the use of hybrid circular frame fixation in complex trauma. One published paper has shown its use in high energy elbow fractures, but no one has outlined its use in complicated lower limb trauma. We would like to present a review of our experience of managing these injuries with hybrid circular frame fixation. We have identified six patients with complicated tibial fractures that we have managed with hybrid circular frame fixation and retrospectively reviewed the case notes, categorising the injuries according to the AO classification of tibial fractures and Gustillo classification of open fractures and outlined the operative details, duration of time fixator applied, time to walking normally and time to discharge (this being our end point of successful management). All complications were also identified. Our results demonstrate that this method of fracture fixation has good rates of healing of both proximal and distal tibial fractures and, thus, getting patients back to their premorbid state, with no increase in complication rates as compared with other methods of fixation. We, therefore, feel that this method of fracture fixation for complicated lower limb trauma is a useful weapon in the orthopaedic surgeons arsenal. A new generic database for trauma audit and research P.A. Oakley, A.P. Oakley, T.A. Holland, K. Wilson, S. Davies Trauma Research Department, North Staffordshire Hospital, Stoke-on-Trent, UK Two years ago at the British Trauma Society meeting at Crewe Hall, the need for an improved database for trauma care was debated. At the same time, a set of guidelines to promote uniform reporting of trauma data was published simultaneously in Resuscitation, Prehospital and Disaster Medicine, European Journal of Emergency Medicine, Trauma and Emergency Medicine Journal, JEUR, Notfall und Rettungsmedizin and TraumaCare.1 Following the working party report Better Care for the Severely Injured2 from the Royal College of Surgeons of England and the British Orthopaedic Association, the Trauma Audit and Research Network (TARN) has extended the type of information collected in a pilot study. This aimed to set the standards of care agreed by the working party in a clinical governance framework in order to improve trauma care. We have developed a generic trauma database with sufficient flexibility to address the needs of the various data requirements above. Moreover, the data structures have been generalised in an object-oriented model to facilitate complex analysis. The generic design allows individual research projects to be integrated seamlessly with the routine data collection for audit purposes. 1

Supplement to TraumaCare, Vol. 9, No. 2, October 1999. Better Care for the Severely Injured, Royal College of Surgeons, London, July 2000. 2

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In the model, the patient moves through a series of locations (e.g. scene, land ambulance, emergency department, imaging suite, operating theatre, intensive care unit and acute ward), representing a care pathway. In each location, the patient is attended by a set of personnel with generic attributes such as specialty, grade and role. Timed assessment information is collected in each location as observations, imaging or other investigations. Timed interventions including drugs, fluids, operations and other procedures are recorded. Injuries and complications are documented in a similar location-specific manner. A range of scoring methods and validity checks are incorporated into the database. Individual patient information and periodic summaries (e.g. quarterly) are instantly available. In addition to patient data, there is a facility for tracking trauma system concerns (including adverse incidents) to provide a mechanism for improving performance in a non-threatening way. The database has been developed using Microsoft® SQL Server on a standard 1 GHz PC. Microsoft® access is used as a front end to enter and query the data remotely over an Ethernet. The software design and programming has been funded by a grant from the North Staffordshire Medical Institute, Stoke-on-Trent. Neurological deficit following acetabular fractures: the double crush syndrome P.V. Giannoudis, T. De Costa, A. Ng, A. Hinsche, S.J. Matthews, R.M. Smith Department of Orthopaedic Surgery, St. James’s university Hospital, Leeds, UK Purpose: To document the incidence of neurological lesions and functional outcome following displaced acetabular fractures. Patients and methods: Prospective review of patients who underwent stabilisation of acetabular fractures in a University Hospital trauma centre. From December 1994 to November 2000, 136 patients were identified with acetabular fractures. The open reduction and internal fixation of the acetabular fixation was performed by standard operative techniques. The time from the initial injury to the operation ranged from 24 h to 14 days. Patients with sciatic nerve injuries were prospectively followed up and long-term outcome recorded. Weakness or absence of dorsiflexion or plantar flexion was graded according to the standard Medical Research Council. Abnormalities of sensation, including absent or diminished sensation to light touch and pinprick as well as dysesthesia or hyperesthesia of the dorsal and plantar aspects of the foot were recorded. None of the patients had an injury of the spinal cord. Intra-operative monitoring was performed in most cases, and routine electromyography and nerve-conduction studies were done post-operatively and at least on one more occasion to record the level and severity of the lesion and to monitor progress of recov-

ery. All the patients were followed up clinically in the trauma clinics and functional improvement was routinely assessed. The mean follow-up of the patients was 3.4 years (range 1.5–6 years). Results: Out of 136 patients who underwent stabilisation of acetabular fractures there were 27 (19.8%) cases of neurological lesions. In 12 cases, the femoral head was dislocated posteriorly. Twenty were men and eight were woman. The mean age was 33.8 years (range 16–66 years). Fifteen patients had associated injuries. The mean ISS was 12.6 years (range 9–34 years). At initial presentation there were 13 patients with a complete dropped foot lesion, 10 patients with foot weakness and 4 patients with burning pain and altered sensation over the dorsum of the foot. Intra-operative monitoring was performed in 16 cases. All the patients had EMG studies for neurophysiological assessment of the lesion. EMG studies revealed sciatic nerve lesions in all the cases but in nine patients with a dropped foot there was evidence of a proximal (sciatic) and distal (neck of fibula) lesion, “double crush syndrome”. Only in three of these cases there was documentation of an ipsilateral knee injury. In two patients there was deterioration of foot function after surgery due to iatrogenic damage. At final follow-up, clinical examination and associated EMG studies revealed full recovery in five cases with initial muscle weakness (mean time 4.2 years (2–5 years)) and complete resolution of sensory symptoms (burning pain and hyposthesia) in four cases (mean time 3 years (2–4 years)). There was improvement of functional capacity (motor and sensory) in two cases with initially complete drop foot and in four cases with muscle foot weakness (mean time 3.6 years (range 2–6 years)). In 11 of the cases with dropped foot (all nine with “double crush”) at presentation, there was no improvement in function, (mean time 3.9 years (range 2–6 years). Conclusion: Acetabulum fractures associated with sciatic nerve injuries continue to be a significant cause of long-term morbidity in trauma patients. In cases where there is evidence of “double crush lesions” the prospect of functional recovery is low as seen in this group of patients. Single lesions appear to be associated with a more favourable prognosis. Metacarpal fractures are patients telling the truth about causation P.W.A. Goodyear, M.E. Lovell, M.H.A. Malik Wythenshawe Hospital, Manchester, UK Metacarpal (MC) fractures are very common, often sustained in the act of punching another person. This study looks at the reasons why people fight. Generally, a history is taken and although this injury is caused by punching, the majority of patients do not admit an aggressive role on their part. We wished to quantify this further. One hundred and fifty-five patients were interviewed prospectively between August 2000 and June 2001, who sustained a fractured

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metacarpal as a result of a fight with another person. Patients simply asked “Who started the fight? Responses were grouped into three categories. (1) started the fight, (2) self defence or (3) defending someone/something. The 155 patients in the series sustained a total of 175 fractures. A total of 52.3% of the series were in category 2, 29.7 in 3 and 18.1% in 1.60% of the females admitted to starting the fight. Statistical analysis comparing started the fight/self defence, with a null hypothesis that numbers in each group should be equal (Mann–Whitney) showed a high significance level, P < 0.0001. The authors believe this study quantifies the high level of dishonesty or poor recall in this population. Fixclip fixation of fractures in children R. Vadivelu, A.S. Baker Department of Trauma and Orthopaedics, Bedford, UK Fixclips have been used for a variety of applications to internally fix bones over 8 years. Functioning as a biological internal fixator, the system is modular and adjustable. The system uses smooth stainless steel wires held together by a range of clips of various sizes for use with screws from the mini fragment, small fragment and basic fragment sets. The flexibility of such a modular system allows fixation of fractures of bones from the size of a phalanx through to a femur. We show how the system has been used successfully to treat fractures in 62 children. Their mean age was 10.87 years (range 3–17 years). Ten were open fractures, seven Gustillo and Anderson Grade 1 and three Grade 2. Sixteen were physeal injuries, six Salter–Harris Type 1, four Type 2 and four Type 3. Four were intra-articular fractures. All the fractures united without the complications of delayed union, mal-union or non-union. Two patients had superficial infections. On three occasions, one or more wires escaped from the clips and required revision surgery before they united. We wish to illustrate its features anecdotally in a number of applications. Seven of the fractures were in the proximal femur, 2 in the femoral shaft, 4 in the distal femur, 19 in the tibial shaft and tibial plateau, 5 in the ankle, 4 in the proximal humerus, 12 in the distal humerus, 3 in the Olecranon and 6 the forearm. As it stands slightly off the bone, for the main part, it has been used effectively to fix across a growth plate. Modularity allows flexibility and has obvious economic benefits in that only a limited range of sizes of components are required. Flexibility and adaptability have the possible disadvantage of putting the surgeon in the driving seat of fracture surgery. Our success in two centres has encouraged us to advocate use of this system.

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Biomechanical evaluation of the new biological ‘Fixclip’ internal fixation system R. Vadivelu, A.S. Baker, J. Clegg, D. Chetwynd University Hospital of Coventry and Warwickshire, NHS Trust and University of Warwick, Coventry, UK Wires, clips and screws have been used for many years to fix a wide range of osteotomies and fractures. The new Fixclips are used with 0.8–3.0 mm diameter wires and screws to fix osteotomies and fractures. This study deals with the biomechanical properties of the fixclip system. The range of normally accepted screw tightness was established by using a torque screwdriver at surgery. The mechanical grip-strength over this torque range was measured using a Hounsfield Tensometer in the laboratory. The fixation was simulated using Tufnol material and the effect of additional clips on the grip strength and the stability of the construct was assessed. Pull out force depends on the wire size and varied linearly over the clinical range of screw torque (0.25–3 Nm) with values from 50 to 900N. An additional clip increases the pullout force upto 3000N and the adjusting the distance also affects the test results. The strength increased with the distance between the clips and a maximum was obtained at a distance of 4.5 cm between the clips. The system is modular and is designed to lie slightly off the bone causing minimal damage to the underlying periosteum and hence less disturbance to blood supply. The system is cost effective, less time consuming and mechanically reliable and stable for the given clinical situations. It has significant advantage over the existing methods of fixation especially in paediatric orthopaedic and trauma situations. Management of displaced hip fractures: cemented or uncemented hemiarthroplasty? R.J.K. Khana , A MacDowella , P. Crossmanb , N. Jallalia,b , A. Dattaa , G.S. Keeneb a Department

of Trauma and Orthopaedic surgery, Bedford Hospital, Bedford MK47 9DU, UK b Department

of Trauma and Orthopaedic Surgery, Addenbrooke’s Hospitals, Cambridge CB2 2QQ, UK The best management of displaced intra-capsular femoral neck fractures in the elderly remains undecided. Most are treated by hemiarthroplasty. The aim of this study was to establish whether the advantages of cement outweigh the disadvantages. All patients with displaced intra-capsular femoral neck fractures treated with hemiarthroplasty between January 1997 and May 1998, in two hospitals within the same Deanery, were reviewed. The same prosthesis was used, but in Hospital A they were uncemented, and in B cemented. There were 122 patients in Hospital A and 123 in B. We conducted a detailed retrospective analysis of hospital notes.

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All surviving patients (50 and 56, respectively) were interviewed to obtain pre-fracture and current scores of pain, walking ability, use of walking aids, activities of daily living (ADL) and accommodation status, using validated scoring systems. The relative deterioration over the follow-up period (32–36 months) was determined and the groups compared. Patient demographics confirmed comparability of groups. There was no greater incidence of intra-operative fall in diastolic blood pressure, or oxygen saturation in the cemented group. Cemented procedures were on average 15 min longer. Median in-patient stay was the same. Significantly fewer of the cemented group had been revised or were awaiting revision (P = 0.036). There was no difference in mortality rates at any point between surgery and follow-up. Prospective assessment of surviving patients revealed highly statistically significant greater deterioration in pain (P = 0.003), walking ability (P = 0.002), use of walking aids (P = 0.003) and ADL (P = 0.009) in the uncemented group. The trend for more dependent accommodation in the uncemented group failed to reach statistical significance (P = 0.14). In conclusion, the cemented group faired significantly better than the uncemented group. Our findings suggest the advantages of cement outweigh the disadvantages, and we support the use of cemented hemiarthroplasty for the displaced intra-capsular femoral neck fracture in the elderly patient. “A systematic review of cemented versus uncemented hemiarthroplasty of the hip” R.J.K. Khana , A. MacDowella , P. Crossmanb , G.S. Keeneb a Departmant

of Trauma and Orthopaedic Surgery, Bedford Hospital, Bedford MK47 9DU, UK b Department

of Trauma and Orthopaedic Surgery, Addenbrooke’s Hospitals, Cambridge CB2 2QQ, UK Displaced intra-capsular femoral neck fractures in the elderly are most often treated by hemiarthroplasty, with or without cement. The aim of this study is to review the literature to establish which results in a better outcome. Eighteen studies comparing cemented with uncemented hemiarthroplasty were identified. The majority suggested lower revision rate, less thigh pain and better mobility in the cemented group; however, operative time and blood loss were increased. There was no difference in general complication rate, or mortality rates after 3 months. We conclude, the literature supports use of the cemented hemiarthroplasty for these fractures. Further research is needed. Spinal injury patterns in road crashes: cars and motorbikes A. Robertson, T. Branfoot, I. Barlow, S.J. Matthews, R.M. Smith, P.V. Giannoudis Department of Orthopaedic Surgery, St. James’s University Hospital, Leeds, UK

Objectives: To determine spinal injury patterns and clinical outcomes in patients involved in automotive accidents. Patients and methods: Retrospective analysis of 22,858 patient records collected prospectively by the Trauma Audit Research Network (UK) (1993–2000) identified 1121 (4.9%) motorcyclists and 2718 (11.9%) car occupants who sustained injuries as a result of road traffic accidents in the North Yorkshire region. Results: Spinal injury occurred in 126 (11.2%) motorcyclists and 383 (14.1%) car occupants. Victims were predominantly young ( mean age motorcycle 30.2, car 37.8 years) and male ( motorcycle 88.9%, car 60.6%). Mean Injury Severity Scores (ISS) were 18.8 and 15.1, respectively. Spinal injuries occurred in isolation in 30 (23.8%) motorcyclists and 130 (33.9%) car occupants the remainder sustaining associated injuries. The thoracic spine was most commonly injured in motorcyclists (54.8%) and the cervical in car occupants (50.7%). Twenty-five (19.8%) motorcyclists and 54 (14.1%) car occupants had neurological sequelae. Eleven (8.7%) motorcyclists and 44 (11.5%) car occupants underwent spinal surgery whereas 53 (42.0%) motorcyclists and 77 (20.1%) car occupants underwent surgery for associated injuries. Median hospital stays were 11.5 (0–235) and 10 (0–252) days, respectively. There were 13 (10.3%) motorcycle and 26 (6.8%) car related deaths. Conclusions: Spinal injury patterns may reflect differing mechanisms of injury between the restrained car occupant and unrestrained motorcyclist. The latter were more severely injured, had more extremity trauma, a higher mortality and a spinal injury pattern consistent with forced flexion of the thoracic spine resulting from force at the cervico–thoracic junction. The predominance of cervico–lumbar injuries and higher incidence of neck and facial injuries in car occupants might reflect abdomino–thoracic seat belt restraint. The high frequency of multiple level injury re-affirms the need for vigilance in the assessment of this group of patients. The functional outcome of severe open tibial fractures managed with a radical fix and flap protocol S. Gopal, A. Murray, P.V. Giannoudis, S.J. Matthews, R.M. Smith Department of Trauma and Orthopaedic Surgery, St. James’s University Hospital, Leeds, UK Thirty-three patients with Gustilo Grades IIIb and IIIc severe open tibial fractures were reviewed with regard to their functional status. All patients had been treated a fix and flap protocol consisting of radical debridement, immediate bony stabilisation and early soft tissue coverage using muscle flaps. The review included completion of the SF-36, and the Euroqol forms, standardised measures assessing health related quality of life and measurement of the following parameters: Gait; use of walking aids; limb length discrepancy; knee and ankle joint function; muscle wasting; and cosmetic

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appearance of the limb. Personal comments and overall patient satisfaction were also recorded. There were 34 fractures in the study, comprising of 30 Gustilo Grade IIIb and 4 Grade IIIc fractures. Twenty-nine patients had primary internal fixation and four had external fixation. Thirty-four patients required a further bone stimulating procedure and two patients had bone transport to reconstruct large segmental defects. The mean time to bony union was 41 weeks (12–104 weeks). Only two patients developed deep infection (6.6%) that resolved with treatment. For the SF-36 the mean physical score was 49 and the mean mental score 62. The mean state of health score for the Euroqol was 68/100. Both sets of questionnaires revealed that patients with isolated tibial fractures appeared to score better than those with other associated injuries. Knee stiffness was noted in 7 (21%) patients and ankle stiffness in 19 (56%). Twelve patients (41%) returned to work. Overall our results compare favourably with previous outcome measures published for both limb salvage and amputations. However, all our patients expressed their satisfaction of retaining their own limbs. A cannulated conundrum S. Jones, R. Bhatia, M.W. Jones Royal Gwent Hospital, Newport, Wrexham Maelor Hospital, Gwynedd Bangor, UK An assessment of internal fixation of undisplaced femoral neck fractures, with respect to cannulated screw placement, number and orientation. A retrospective analysis of 309 patients with undisplaced subcapital hip fractures was performed. All had AO cannulated screw fixation performed between 1 January 1996 and 31 December 1999 at one of three DGH’s within Wales. The patients had a mean age of 75.2 years (range 65–94 years). Post-operative X-rays were assessed and the fixation considered in terms of: Entry point of screws with respect to the lesser trochanter. Compliance with the lag screw principal. Screw number and when three screws used the orientation of the triangular arrangement. A successful outcome measure was taken if the patient required no further surgery. Follow-up information was gained from the notes and/or telephone conversation. Results showed 91% of the fixations considered were satisfactory and complied with the lag screw principal. Forty-six patients (15%) had screws that were inserted at a point distal to the lesser trochanter and therefore potentially at subsequent risk of subtrochanteric fracture due to stress raiser effect. The mean follow-up period was 21 months (range 12–46 years) during which time 29 patients (9%) required a further surgical procedure. One patient had their screws removed, there were 16 failures sec-

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ondary to AVN and 12 non-unions. Analysis of our results showed that a successful outcome was independent of screw number and orientation (Fisher’s exact probability test P < 0.05). Cannulated screw insertion provides a successful fixation for the treatment of undisplaced femoral neck fractures. The clinical outcome following fixation in our series was unaltered whether two or three screws are utilised, and when three screws were inserted orientation does not influence re-operation rate. Epidemiology of femoral fractures in children in the west midlands S.A. Bridgman, R. Wilson School of Postgraduate Medicine, University of Keele, Thornburrow Drive, Hartshill, Stoke-on-Trent, Staffs ST15 0PZ, Keele Objective: To investigate the epidemiology of paediatric femoral fractures and their treatment in the West Midlands during 1991/1992 to 1998/1999. Methods: Cases were ascertained through the West Midlands hospital episode statistics for years 1991/1992 to 1998/1999. Cases were defined as West Midlands residents aged under 16 years, first episode in an admission (an episode of care is “time a patient spends continuously in the care of one consultant”), femoral fracture (ICD 9 820 or 821, ICD 10 S72) coded in any diagnostic field. Cause of injury was obtained from ICD external cause codes. The mid year population estimate for 1999 for children under 16 years in the West Midlands was used as denominator (575,600) to create age-specific rates. During the time period rates of fractures have been gradually decreasing. The number of femoral fractures in males is about twice that of females. A total of 2507 fractures were recorded. The highest rate was seen in boys aged 0–4 years, and these varied from 0.4 to 0.6 fractures per 1000 boys per year. The lowest rates were in girls aged 5–14 years and varied from 0.1 to 0.2 fractures per 1000 girls per year. There were twice the number of fractures in boys aged 2 years as in the next highest age. About half the fractures were from falls, a quarter from traffic accidents, but only 1.4% from maltreatment. Ninty-three percent of cases were first admitted to orthopaedics and 4% to paediatrics. From age 2 to 9 years the percentage of femoral fractures that were shaft fractures was steady at 70%, but then this gradually fell to around 35% between 13 and 15 years. In different years 40–65% of fields for operation were filled in. Conclusions: The rate of femoral fractures in children is gradually decreasing. The greater risk in young boys, and the high number in 2-year-old boys in particular are unexplained and are an indication of important areas for more detailed research. The percentage of cases recorded as maltreatment is very low compared to some other countries, and may indicate under-reporting.

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Mortality following fracture neck of femur in elderly patients on long term warfarin S.C.M. Srinivasan, S. Sinha, A. Aladin, R. Pande, D. Calthorpe Department of Orthopaedics, Derby, UK The presence of serious co-morbidity makes fracture neck of femur (#NOF) a potentially life threatening injury in elderly patients. A review of the literature failed to reveal any previous series reporting the outcome of hip fracture patients on long term warfarin therapy or prophylaxis for various medical conditions. The medical records of consecutive series of 19 patients who presented with #NOF and on long term warfarin (19 out of 840 #NOF, 2.26%), admitted over 18 month period in our hospital were retrospectively reviewed. The average age 72 years (range 68–89 years). Anticoagulation was not actively reversed in 16 of them. The average waiting time prior to surgery was 3.6 days (range 2–8 days). The mortality rate at 1 and 6 months, respectively, was 32 and 63.2%. When compared with over 1000 hip fracture patients of all ages in previous prospective studies, the patients in this series were found to have significantly higher mortality at 1 month ([95% CL (0.040, 0.512)], P < 0.001), and 6 month ([95% CL (0.156, 0.6470)], P < 0.001). The high mortality in this group of patients is expected due to the associated cardio-vascular morbidity but a significant proportion (86%, six out of seven deaths) of the early post-operative death was due hypostatic pneumonia probably related to delay in surgery and recumbency. A standardised warfarin reversal protocol should be in place in every unit. Early reversal of coagulopathy and avoidance of delay of >48 h to surgery and a co-ordinated multidisciplinary approach might improve the outcome in elderly patients with high co-morbidity. Wire slip in an Ilizarov external fixator frame: a comparison between slotted and cannulated bolts, with and without lubricant T. Opluschtil, T. Branfoot, Z.M. Jin Department of Trauma and Orthopaedics, Northern General Hospital, Sheffield, UK Introduction: Experiments show that slip between the wire bolt interfaces is a reason for the loss of wire tension in a ring fixator. Wire tension may be a critical factor for fracture healing in these devices. A loss of tension results in more inter-fragmentary motion that may compromise fracture healing. Study design: This study examined wire slippage of two different bolt designs in different conditions; with 20 or 10 Nm bolt tightening torque, and with or without lubricant (simulating blood and fat contamination of the wire surface). A tension-testing machine was used to load the wire-clamp interface. The changes in the load-extension curve indicated the load dynamics, and demonstrated slip.

Results: The tests show wire slip in the clamps. A significant difference between the type of bolts used and the different environments could be found. A torque of 10 Nm allows slip at 1400N using clean bolts of either type, using 20 Nm torque the slip occurs at nearly 2000N using slotted bolts and exceeds 200N using cannulated bolts. With contaminated surfaces and a torque of 10 Nm both types of bolts demonstrated a reduced slip at 1200N, with a torque of 20 Nm the slotted bolts showed reduced slip at 1850 Nm, but cannulated bolts showed no such variation. These properties are statistically significant (P < 0.005). Conclusions: Clinically important, is that a 10 Nm tension is adequate with either bolt type with clean surfaces, but a higher torque of 20 Nm is significantly more effective. In simulated operative conditions where biological contamination is present, a torque of 20 Nm shows a more effective holding power than 10 Nm. Differences between the clamp types are also shown, cannulated bolts being more resistant to slip. This study has significant practical lessons for users of Ilizarov frames. The effect of increased hydrostatic pressure on the diffusion of endotoxin across human peritoneum T.P. Beresford, M.S. Walsh, S.F. Purkiss Department of Trauma and Orthopaedics, Essex, UK Background: Raised intra-abdominal pressure (IAP) is reported to be associated with the development of both Multiple Organ Failure and the Systemic Inflammatory Response Syndrome (SIRS), although there is no evidence of causation. To investigate a possible causative mechanism, we studied the effect of increased hydrostatic pressure on the diffusion of endotoxin across human peritoneum in vitro. Methods: With full regional ethics committee approval, specimens of normal human peritoneum were taken from hernia sacs excised during elective inguinal hernia repair procedures and placed in an Ussing chamber with circulating fluorescein-labelled endotoxin solution (2 mcg/ml) facing the parietal surface and phosphate buffered saline (PBS) flowing (0.05 ml/min) past the serosal surface of the peritoneal membrane. Samples of the outflowing PBS solution were collected over each hour for 4 h and the concentration of endotoxin estimated using fluorometry. The diffusion rate was estimated as change in relative fluorescence at atmospheric pressure plus 5 cm H2 O (ATM + 5 cm H2 O), ATM + 10 cm H2 O, and ATM + 25 cm H2 O. Results: Eleven specimens were taken. Mean and standard deviation of rates of diffusion of endotoxin (in units of change in relative fluorescence) across peritoneum at ATM+5, ATM+10, and ATM+25 were 0.9±0.44 (n = 8), 0.64 ± 0.38 (n = 8), 1.54 ± 0.93 (n = 16). Using the two sample student t-test there is no significant difference in endotoxin diffusion across peritoneum as a result of increasing

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hydrostatic pressure to ATM + 10 cm H2 O or +25 cm H2 O (P > 0.1 and P > 0.05, respectively). Conclusion: Increased pressure has no independent effect on the diffusion of endotoxin across human peritoneum. Management of displaced intra-capsular femoral neck fractures in the elderly; time to rethink our strategy? Vishal Sahni, Ashutosh Acharya, Eugene Toh, Gunasekaran Kumar Orthopaedic Department, Whiston Hospital, Prescot, UK Treatment of displaced fractures of the femoral neck in the elderly is controversial. For fear of non-union and avascular necrosis leading to multiple surgeries, primary prosthetic replacement of the femoral head has been advocated and followed in most hospitals in UK. This strategy is based on the incidence of non-union and avascular necrosis reported in literature (10–30 and 15–33%, respectively).The operation for fixation is shorter with less “surgical stress” and blood loss and the long term results of a healed fracture are much better than a hemiarthroplasty. We reviewed 100 adult patients who have had a traumatic intra-capsular femoral fracture. These patients were randomly selected from a group of patients who had undergone fixation for an intra-capsular femoral fracture and had full clinical and radiological data available up-to one of the end points.. The end points were complete clinical and radiological union of the fracture, non-union, avascular necrosis or failure of fixation. Results: The following factors do not influence the development of avascular necrosis or non-union—displacement of the fracture, number of screws (two or three), grade of osteoporosis, parallelism of screws, presence of screws in each “quadrant”, experience/seniority of the surgeon. The factors that definitely influence the development of non-union and avascular necrosis are—gap at fracture site, alignment after reduction of the fracture especially on AP view, all screw threads crossing the fracture site. Conclusions: (1) The incidence of non-union and avascular necrosis following fixation of femoral neck fractures, in our study, is significantly less than most series reported in literature and is not statistically different between displaced and un-displaced fractures. (2) Majority of patients having a displaced fracture intra-capsular femur should be considered for fixation and hemiarthroplasty should be reserved only for the very elderly, high risk patients with a limited life expectancy. Surgically managed distal humerus fractures in children; a comprehensive analysis Vishal Sahni, Ashutosh Acharya, Colin Bruce Department of Trauma and Orthopaedics, Liverpool, UK Distal humeral fractures are the second most common cause of inpatient orthopaedic trauma treatment in the pae-

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diatric population. These include the medial and lateral condyle fractures and supracondylar fractures in increasing order of frequency. We undertook a study, in a Children’s Hospital, to find out details of the fracture pattern, demographics, complications and outcome of these fractures. The study group included 61 cases of supracondylar fractures treated over a period of 15 months with mean age of patients being 7.6 years. Since our study was aimed at outcome of surgically managed fractures we excluded all Type I fractures. Fifty-four percent of the cases were Type II whereas 46% of the cases were Type III supracondylar humeral fractures. Maximum number of cases were in July–August which coincides with the summer vacations. Closed reduction was successful in a vast majority of cases (82.14% in Grade II and 57.57% in Grade III fractures) despite the severity of displacement. Open reduction was more common in older children and in Grade III fractures. Sixteen lateral condylar fractures with mean age of 6.5 years and four cases of medial condylar fractures were also treated during the same time period and they had results comparable to those reported in contemporary literature. Five cases of preoperative and two cases of postoperative nerve injury were noted. All these cases resolved spontaneously. Apart from this four cases of superficial and two cases of deep infection were encountered. Conclusions: (1) Surgical management of distal humeral fractures is a safe and consistently reliable treatment option with uniformly gratifying results and a low rate of complications. (2) Mini-open technique of medial wire insertion has helped further reduce the incidence of iatrogenic ulnar nerve injury. (3) The incidence of superficial and deep wound infection has been reduced with weekly care of the pin sites. Paediatric femoral fracture and associated injuries in a university hospital V. Veysi, S.J. Matthews, P.V. Giannoudis Department of Trauma and Orthopaedics, St. James University Hospital, Leeds, UK Purpose: To determine the epidemiology of femoral fractures in children and their associated injuries. Patients and methods: We reviewed 475 consecutive children admitted over a 7-year-period (1992–1999) to a university hospital. Such details were recorded and analysed as—mechanism of injury, ISS, GCS, ICU stay, total hospital stay, operations performed, presence or absence of femoral fracture, complications and mortality. Results: Out of 475 children admitted, 57 had a femoral fracture (12%). Fourteen were girls and 43 were boys. The mean age was 5.1 years (range 1–14 years) and the mean ISS was 6.9 years (4–36 years). The mean GCS was 14 years (range 5–15 years). The commonest cause of injury was a fall from a height 21/57 (37%) followed by road traffic accidents 20/57 (35%), 11 cases were pedestrians. Six cases were recorded as

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non-accidental injuries. Eight children underwent operative treatment whereas the rest were treated conservatively. In 36 children, the femoral fracture was an isolated injury. The remaining 21 (37%) had two or more injuries. The most common associated injury was a head injury of varying severity 10 (50%) followed by fracture tibia 7 (33%) followed by fracture pelvis 4 (19%). Other associated injuries included a splenic laceration, one pancreatic injury, three humerus fractures and three forearm fractures. None of the children sustained a chest or spinal injury. The mean hospital stay was 22 days (1–67). Four children were admitted to the intensive care unit (two had head injuries) and the mean ICU stay was 3 days (2–5). There was no mortality in these series. Two children underwent fasciotomies for tibial compartment syndrome. Conclusion: The incidence of associated injuries in children with femoral fractures appears to be 35% with head injury being the commonest. The overall prognosis is favourable as seen in these series of patients with nil mortality. Scapula fracture in polytrauma patients: is it an indicator of increased morbidity and mortality?

tion as compared to 3% in group 2. There were four brachial plexus injuries in group 1 (5.1%) versus nil in group 2. In group 1, 32 (40.5%) patients had sustained associated abdominal injuries mean AIS 3.1 versus 190 (34.6%) in group 2 with a mean AIS of 2.9. In the scapula group there were 31 clavicle fractures, 12 humerus fractures and 4 shoulder dislocations. In the non-scapula group there were 137 clavicle fractures, 93 fractures of the humerus and 2 shoulder dislocations. The mean hospital stay in both groups was 22 days (range 5–153 days). In group 1, the mortality rate was 11.4% (9 patients) mean ISS 48 days (range 24–75 days) versus 25% (136 patients) mean ISS 41.3 days (range 17–75 days) in group 2. Conclusion: Patients with scapular fractures were found to have a higher chest and abdominal AIS. Overall, the scapular fracture was not associated with higher ISS or higher mortality and does not correlate with a poorer outcome. Cannulok hip problems: its role in periprosthetic hip fractures A.A. Syed, H. Williams

V. Veysi, S. Agarwal, R.M. Smith, P.V. Giannoudis

5 Pickard Bank, Meanwood LS6 2SJ, UK

Department of Orthopaedic Surgery, St. James’s university Hospital, Leeds, UK

Periprosthetic hip fractures are a surgical challenge. There is no ideal way of treating these difficult fractures. We analysed the results of treating these fractures in one region of UK using a single implant. Between 1996 and 2001, 17 uncemented long stem Cannulok hip prosthesis were used for this purpose. Five patients had died at the time of review. The 12 remaining patients underwent clinical and radiological examination and assessment using the Merle d’Aubigne Postel score. The average age at the time of surgery was 77.3 years. There were equal numbers of fractures associated with loose total hip replacements and hemiarthroplasties. The average follow-up was 20.4 months. All fractures united radiologically. The average duration to union was (13.3 weeks). According to the Merle d’Aubigne Postel score there were eight good to excellent results. Two patients are wheelchair bound, one due to unreduced dislocation and second due to CVA and psychiatric problems. Two other patients are awaiting revision due to prosthesis subsidence. Overall our experience using this prosthesis has been very satisfactory. We feel that this implant is an important addition to treating these difficult fractures.

Purpose: To determine any relation between scapular fracture, severity of chest injury and mortality in patients with multiple injuries. Patients and methods: We reviewed 621 consecutive patients admitted over a 5-year-period (1995–1999) with multiple injuries. All had an associated chest injury. Such details were recorded and analysed as—mechanism of injury, ISS, AIS for chest, GCS, ICU stay, total hospital stay, operations performed, presence or absence of scapular fracture, complications and mortality. Patients with chest injury but without scapula fracture formed the control group of the study. Results: Out of 621 patients with multiple injuries (mean ISS 27.5), 79 (17 women) (12.72%)—group 1 were identified with scapular fractures. A total of 542 (122 women) patients with chest injury but no scapular fracture formed the control group—group 2. The mean age of group 1 was 42 years versus 40 years of group 2 and the mean ISS was 27.12 (S.D. 15.13) and 28.41 (S.D. 14.21) in group 1 and group 2, respectively (P-value > 0.05). In group 1 the chest AIS was 3.46 (S.D. 1.10) and 3.18 (S.D. 1.06) in group 2 (P-value < 0.05). The most common associated chest injury in group 1 was pneumothorax (28%) followed by pulmonary contusion (15.2%) whereas in group 2 it was likewise pneumothorax (20%) followed by pulmonary contusion (21%). There were 8 (10.1%) flail segments in the scapula group, versus 50 flail segments (9%) in the non-scapula group. In group 1, there was an incidence of 3.8% associated thoracic vertebral fractures compared to 8.3% in group 2. 2.6% of patients in group 1 had major vessel injury or cardiac lacera-

Mountain biking injuries in rural England A.D. Toms, L.M. Jeys, G. Cribb, S.M. Hay Orthopaedic Surgery Deptarment, Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury Off road mountain biking is now an extremely popular recreation and a potent cause of serious injury. This is the

Abstracts / Injury, Int. J. Care Injured 33 (2002) 847–883

first study to look at morbidity associated with the sport in the UK. Data was collected prospectively over a 12 month period, on all patients presenting with an injury caused by either recreational or competitive off-road mountain biking. Eighty-four patients were identified, 70 males and 14 females, with a mean age of 22.5 years (8–71 years). Most accidents occurred during the summer months, most frequently in August. Each patient had an average of 1.6 injuries (n = 133) and these were divided into 15 categories, ranging from minor soft tissue to potentially life threatening. Operative intervention was indicated for 19 patients (22.6%) and several required multiple procedures. The commonest injuries were clavicle fractures (13%), shoulder injuries (12%) and distal radial fractures (11%). However, of a more sinister nature, one patient had a C2/3 dislocation requiring urgent stabilisation, one required a chest drain for a haemo-pneumothorax and another required an emergency and life-saving Nephrectomy. This sport carries a significant risk of potentially life threatening injury, across all levels of participation. Trauma and emergency doctors need to be aware that these are often high velocity injuries requiring careful assessment and treatment. Trauma in pregnant women: analysis of patterns and outcomes A. Ng, R.N. Prasad, P.V. Giannoudis, D.A. Macdonald, S.J.E. Matthews, R.M. Smith Department of Trauma and Orthopaedic Surgery, St. James’s University Hospital, Leeds, UK Purpose: To evaluate the patterns and outcomes of pregnant women following trauma. Design: Retrospective review of a consecutive series of 17 patients between 1992 and 2000. Setting: Academic teaching hospital. Patients and methods: From 1992 to 2000, data were retrieved from sophisticated hospital computer system of all pregnant women who presented to Trauma Unit following a wide range of blunt trauma. Data collection included demographic details of the victims, obstetric history of the patients, injuries severity scores (ISS), Glasgow Coma Scores (GCS), clinical information, resuscitation requirements, surgical interventions, obstetric consultations, maternal and foetal mortalities. All patients received initial resuscitation according to ATLS protocol. We analysed the patterns, outcomes and epidemiology of trauma in pregnancy. Results: Out of 19,600 trauma admissions 17 traumatised pregnant women (0.08%) were identified over a period of 8 years. Mean age was 28 years (range: 17–37 years). Gestation period ranged from 7 to 36 weeks (mean: 23.88 weeks), with majority of the victims (52.9%) being in the third trimester. The two commonest mechanism of injury were simple fall (47%) and road traffic accidents (35.3%). Two

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patients (11.6%) presented following deliberate self-harm. Mean ISS was 10 (range: 4–45); mean GCS was 13.6 (range: 3–15). At admission, four (23.5%) patients were haemodynamically unstable and required immediate resuscitation. Three patients (17.6%) presented with vaginal bleeding but only one of them presented with unstable vital signs. Two patients (11.6%) needed blood transfusion of six and two units, respectively. Maternal mortality was 1 (5.88%) and foetal mortality was 4 (23.5%). Mean hospital stays was 10.5 days (range: 1–26 days). This included the stay of one patient who died on the same day of admission. Two patients (11.6%) required admissions to ICU for 2 days. The pattern of injuries included head injury and skull fracture (17.6%), facial fracture (11.7%), spine fracture (5.88%), chest trauma (17.6%), pelvis fracture (17.6%), lower limb fracture (47%), upper limb fracture (11.7%), intra-abdominal trauma (23.5%) and vascular injury (5.88%). Conclusion: Trauma during pregnancy is uncommon but it places the mother and foetus at risk. Haemodynamic stability on admission does not predict foetal mortality. However, high scores in ISS increases the likelihood of both maternal and foetal mortality. Close maternal and foetal monitoring is justifiable regardless of maternal haemodynamic presentation or severity of injury. Increase vigilance of those pregnant patients with pre-existing psychiatric illnesses is recommended as these patients are at risk of deliberate self-harm. Injuries in motorcycle racing A. Packham, W.M. Harper, D. Quinton 254 Knighton Lane East, Leicester LE2 6LU, UK Motorcycle racing is perceived as a dangerous sport and yet thousands of amateur riders take part each weekend. The medical service at one motor racing circuit is described. Advanced medical care is provided in a pre-hospital setting. There is little published information on the epidemiology of injuries in motorcycle racing. This information would be of use in predicting the likely injuries from accidents. Medical staff receive no feedback about patient outcomes with which to evaluate and improve their care. A prospective observational study was conducted at one circuit during the 2000 racing season. Information was collected on-site about all riders involved in racing accidents. Riders referred for further medical attention were followed up to determine the definitive diagnosis and subsequent clinical course. Although accidents were common (1.3 per 1.000 km), severe injury was rare (0.01 per 1.000 km). There were no fatalities. The pattern of injuries is described along with the treatment given. The most common significant injuries (AIS > 1) were limb fractures and minor head injuries. Limb fractures were the most common reason for hospital admission and surgical intervention. They were also associated with a longer time off work compared to other injuries.

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Although accidents occur more frequently in racing than on roads, the risk of severe injury and death in an accident are reduced. This is due to a reduction in secondary collisions with other vehicles and roadside objects; higher standards of protective equipment and the provision of immediate medical care at the trackside. Exeter cemented bipolar hip arthroplasty for fracture neck of femur A. Pardiwala, R.D. Perkins, A. Choksey 12A Meadow Croft Park, Eaton Road, Liverpool L12 3HU, UK We studied the results of Exeter cemented bipolar hip arthroplasty with a mean follow-up of 6 years in a selected group of patients with a fracture neck of femur. We reviewed 42 patients with the Exeter bipolar components. There were 31 females and 11 males with a mean age of 72 years at the time of surgery. Of the 42 hips, 35 were independently mobile and 7 used a stick for mobilisation before the fracture. Forty-one returned to the pre injury state. One, who was independently mobile, used a stick for mobility later on. One hip had an early post-operative dislocation. None showed acetabular migration or infection. Two had anterior thigh pain. Our studies show that excellent results can be achieved with cemented Exeter bipolar hemi-arthroplasty for physiologically active patients who are independent and mobile as they return to their pre fracture level of activity, as the quality of life is important in this age. If in future they do develop acetabular hip pain, the acetabular component can be easily revised. Ilizarov wire tensioning and holding methods: a biochemical study A.W. Davidson, M. Mullins, D. Goodier, M. Barry The Orthopaedic and Trauma Department, The Royal London Hospital, Whitechapel, London E1 1BB, UK Aim: To investigate and compare two specific methods of Ilizarov wire tensioning and hold. Method: This study utilised the Vertical Hounsfield Test Machine H25KS, a hydraulic stress/strain device with a load-cell linked to a computer program. Firstly, the departments present mechanical tensioners were assessed. Secondly, the method of twisting the three designs of wire holding bolts to achieve wire tension, as described by Ilizarov, was assessed. These bolts are described as “cannulated”, “slotted” and “Russian” (which are hexagonal headed with a slot down one side). Results: The mechanical tensioners were found to be accurate, if inefficient, with a maximum produceable tension of 133ON. The most effective bolts for creation of tension were the Russian, which produced mean wire tensions of 785N at 45◦ ; 1200N at 90◦ ; 1695N at 135◦ . The

cannulated and slotted bolts regularly broke the wires at 90◦ twist. Conclusion: The findings demonstrated two effective methods. The present tensioners were found to be inefficient when compared to the simple twisting of the wire holding bolts, which created equivalent tensions with ease and are capable of producing greater wire tensions. The Russian bolts are recommended for use when wire tension is created by bolt twisting. Locoregional muscle transfer for open tibial fractures should be the responsibility of the treating surgeon A.J. Andrade, N.U.O. Jeelani, S.M. Lambert Orthopaedic Trauma Unit, Southampton General Hospital, Southampton, UK Locoregional soft tissue cover has been more traditionally within the remit of Plastic Surgeons. Soft tissue cover, thus, often requires patient transfer between hospitals, with associated significant delays to surgery. In Southampton, 21 patients with a mean age of 44 years (range 7–87 years) have had locoregional soft tissue cover surgery since 1996. Of these 15 had open tibial fractures; one was a Gustillo IIIc and 14 were Gustillo IIIb. Three patients (16%) went on to require an amputation at a mean of 10 months after injury (range 2–21 months). Their mean age was 48 years (range 25–61 years). The mean delay between injury and soft tissue cover for the open fracture group was 9 days (range 0–51 days). Fourteen cases have gone on to union at a mean of 9.8 months (range 4–27 months). Once case was lost to follow-up. Of the 22 flaps carried out there were only two flap failures. One we revised successfully with a gastrocnemius flap, whilst the other required a free latissimus dorsi flap elsewhere, which also failed requiring an above knee amputation. An association was found between smoking and a higher incidence of deep infection (P = 0.046), and smoking and a greater number of operations until union (P = 0.0209). Our results are comparable to those published from Plastic Surgical units. We, therefore, believe that locoregional soft tissue cover in the lower limb should be within the remit of the Orthopaedic Trauma Surgeon. Tibial fractures treated with hybrid fixation: do olive wires through the fracture site improve healing? A.J. Metcalfe, T. Branfoot, K. Shelbrooke, M. Oleksak, M. Saleh Clinical Sciences Centre, Northern General Hospital, Sheffield, UK Introduction: Clinical experience and published studies suggest oblique fractures of the tibia are associated with delayed healing and non-union. Experimental studies have

Abstracts / Injury, Int. J. Care Injured 33 (2002) 847–883

attributed this to increased shear at the fracture site. We have managed these fractures in hybrid fixators using additional olive wires placed through the fracture site to reduce the shear. Design: We retrospectively reviewed a consecutive series of 52 of these complex fractures treated in our unit with hybrid fixation. This was to establish differences in time to healing in cases with and without transfixing olive wires. Definitive fixation was achieved within 6 weeks of injury in all cases. Sub-group analysis was performed to consider the influence of factors including energy level of the fracture, open or closed fracture type and smoking. Age, gender, site and intra-articular extension were also considered. The sub-grouping was performed by an assessor blinded to the outcomes. Results: Comparing equivalent sub-groups, the use of transfixing olive wires improved healing time for low energy injuries (non-olives—mean 32 weeks, olives—mean 22 weeks). No difference was apparent between the groups when high energy fractures were considered (non-olives— mean 44 weeks, olives—mean 44 weeks). Overall, there were no prolonged healing times (>18 months) in the olive group compared to three in the non-olive group. Smoking and the energy of injury were the most important factors influencing healing in this review. Conclusion: Our results suggest that olive wires placed to reduce shear at the fracture site improve healing times of low energy oblique tibial fractures treated with hybrid fixation, but this effect is not seen in the higher energy injuries. No additional problems were apparent using this technique. The use of fracture transfixing wires should be considered when managing oblique fractures using circular external fixation. Failure of closed reduction after Austin Moore dislocation—an analysis of risk factors A.O. Odumala, M.I. Iqbal, R.G. Middleton Department of Orthopaedics, Belfast, UK Objectives: The aim of this study was to determine the failure rate of this procedure, identify risk factors contributing to this and make suggestions on alternative treatment. Methods: We retrospectively analysed consecutive forty patients with Austin Moore dislocations over a 6-year-period (1995–2000). Clinical and demographic data was recorded in a structured proforma. Austin Moore dislocation accounted for 1.7% of all Austin Moore procedures, (total 2336 patients). Results: The study comprised of 28 females and 12 males, with a mean age of 85.6 years (95% CI = 82.7–91.6). Twenty-six patients (65%) dislocated within 7 days of the primary procedure. Closed reduction failed in 32 patients (80%) and off this group one third of patients (11) required more than one closed reduction. All but four of these dis-

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located patients were subsequently treated by girdlestone arthroplasty. Six-month mortality rate was 58%. Dementia was identified as a significant risk factor associated with a higher failure rate, (P = 0.03). Age, sex, pre-operative mobility, pre-operative morbidity (American Society of Anaesthesiology—ASA grade) and operation to dislocation interval (in days) did not have a significant effect on failure rate of closed reduction (P > 0.05). There was no difference in the 6-month mortality rate between failed and successful closed reduction, (P = 0.7). Conclusion: Closed reduction after Austin Moore dislocations have a high failure rate and particularly in patients with dementia. Immediate girdle should be considered a treatment option in this group of patients to avoid unnecessary repeated procedures. Determinants of oxidative stress in Trauma A.O.E. Obayan, B.H.J. Juurlink, R.G. Keith Department of Surgery, University of Saskatchewan, Saskatoon, Canada Animal studies suggests that free radicals and neutrophils play important roles in the pathophysiology of oxidative stress after trauma, shock and burns. Antioxidants in the body have a primary role of quenching free radicals, while glutathione in erythrocytes regenerate other antioxidants such as ascorbic acid. There has been no human study examining antioxidant changes following trauma. Our study is aimed at determining the impact of trauma on GSH in erythrocytes, total antioxidants in plasma, determining the optimal time for evaluating blood GSH and examining the possible role of white cells in the pathophysiology of oxidative stress. Entry criteria for the study included all multiply injured patient at the Royal University Hospital, Saskatoon, Saskatchewan. Patients were subsequently divided into three groups based on the injury severity score and fourth group on premorbid medical problems. GSH was measured, using a modification of the Brigelius method, in packed cell samples taken at 0, 6, 12, 24, 72 h and at day 7. While the total antioxidant was measured using FRAP method developed by Benzie et al. (1996). The results show a correlation between severity of injury and the degree of depletion of erythrocyte GSH and the total antioxidants with maximal correlation seen at 24–30 h following admission. There is also a good correlation between the severity of trauma and the neutrophil count. We conclude that the severity of injury, premorbid medical problems and increased white cell count play a significant role in depletion of erythrocyte GSH and plasma total antioxidant capacity at 24–30 h. We suggest that degree of depletion of erythrocyte GSH, plasma antioxidant and neutrophil count could be used as an index of injury severity. Research supported by the Department of Surgery, University of Saskatchewan and by the Medical Research Council of Canada.

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Improving reliability in the classification of fractures of the acetabulum B.A. Petrisor, Mohit Bhandari, R. Douglas, Scott Mandel, Desmond C. Kwok, Emil H. Schemitsch Division of Orthopaedics, McMaster University, Ontario, Ont., Canada Plain radiographs of the pelvis are routinely used in the initial assessment of patients with suspected fractures of the acetabulum. It is necessary for orthopaedic resident trainees, emergency physicians as well as orthopaedic surgeons who infrequently treat trauma patients to reliably describe these fracture patterns to traumatologist orthopaedic surgeons who ultimately take over patient care. Our purpose was two-fold: (1) to determine reliability of the component parts of the Letournel classification of acetabular fractures—6 AP radiographic lines, and (2) to examine whether the addition of oblique radiograph views (Judet views) improved reliability. Thirty sets of AP and oblique radiographs (Judet views) of the pelvis were selected from a hospital database to represent various types of acetabular fractures. Six reviewers (three orthopaedic trainees and three community orthopaedic surgeons) independently reviewed the radiographs. For each radiograph, the reviewer classified the acetabular fracture according to the Letournel classification. In addition, each reviewer utilised a simplified classification scheme using six radiographic lines on the AP pelvic radiograph. Inter-observer reliabilities among reviewers were reported with intra-class correlation coefficient (ICC) and kappa (κ) values. Agreement for the Letournel classification increased with increasing physician experience (trainees ICC = −0.14 and community surgeons ICC = 0.56). Inter-observer reliability between trainees and community surgeons improved when the six radiographic lines were used (range κ = 0.09–0.89). The oblique pelvic radiographs (Judet views) did not significantly improve reliability among physicians. In this study, we report the following: (1) the reliability of the classification of Letournel improves with level of training, (2) physicians with less experience with acetabular fractures have significantly better agreement in radiograph is not improved with additional oblique (Judet) views). Identifying fractures using the six radiographic lines on the AP film than the Letournel classification and (3). Agreement among the reviewers for the AP pelvic. An easy pre-operative method to determine the length of tibial intra-medullary nail B. Venkateswaran, R. Warner, N. Tulwa, P. Deacon Pinderfields Hospital, NHS Trust, UK Solid Tibial nails need a pre-insertion estimate of size to ensure adequate working length. We felt in our unit that there was some wastage of nails due to discarding of nails that were inserted only to be found to be of inappropriate

length. There was no standard technique amongst surgeons to determine tibial nail length. Literature review showed that most are not accurate. Further, some add on to the operative time. Anthropometric techniques like joint line to joint line in the leg, tibial tuberosity to medial malleolus, joint line to medial malleolus and even a regression equation to body height have been used. We felt that the joint line to joint line would yield the closest estimate of tibial length. Though there is mention in the literature of the same, it has not been determined whether the same length has to be used or if a constant measure has to be deducted from it. We retrospectively reviewed 13 patients with tibial nails. We measured their normal leg’s length from joint line to joint line. We also compared it to the nails used. We also determined ideal nail lengths for each of these patients. From the data, we arrived at a constant to detect from our leg measurement and found a high correlation (0.978). We then used the same prospectively on six patients and noted reduction in the operative time and no wastage of nails. We also validated this measurement by using 10 surgeons including junior trainees measuring on the same 10 patients a week apart. The negative effect of litigation on the recovery from ankle sprains B.C. Knight, M.E. Lovell, P.W.A. Goodyear Department of Trauma and Orthopaedics, Wythenshawe Hospital, Manchester, UK The primary objective of this study is to assess the effect of litigation on the long-term outcome and recovery of ankle inversion injuries. One hundred and sixty-seven patients from an accident and emergency database were contacted by telephone. Thirty participants were litigating and these candidates were randomly matched with 30 non-litigating patients with respect to mechanism of injury. Each group had 27 patients with ankle sprains because of falls/trips and three after RTAs. Radiographs when available, of each participant were examined and the degree of soft tissue swelling over the lateral malleolus was assessed. A total of 76.6% of litigants reported incomplete recovery compared to 26.7% of non-litigants. The median period of sleep disturbance, swelling, limping and non weight bearing was 1.5 days, 2.0 weeks, 2.0 weeks and 1.0 weeks for the non-litigants. This compares to 3.5 days, 10.0 weeks, 8.0 weeks and 8.0 weeks for the litigants using the same variables (P < 0.0001 in all cases). Where ankle radiographs had been taken swelling was equal in each group (9.0 mm over lateral malleolus (30% of litigants incorrectly suggested and ankle X-ray had been taken, when it had not)). The majority of litigants (65%) thought that physiotherapy would not be beneficial in rehabilitating their ankle (35% non-litigants). It appears that litigation has a negative effect on the outcome and recovery of ankle sprains

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Removal of metalwork—a national survey of practising consultant orthopaedic surgeons C.F. Mann, M. Allami, T.K. Bagga 2 Wharfedale Terrace, Linton Road, Collingham, Wetherby LS22 5BT, UK Aim: Routine removal of limb trauma metalwork is controversial, with major cost implications. Our aim was to estimate the current state of practice of UK orthopaedic consultants. We are not aware of any similar orthopaedic research. Method: A postal questionnaire with an explanatory covering letter assuring anonymity was sent to 500 UK Orthopaedic Consultants, chosen at random from the current BOA official consultant mailing list of nearly 1500. Funding was from the Wishbone Trust. Statistical advice was followed including aiming for a minimum useful response rate of 40%. Most questions concerned a particular region of the appendicular skeleton in adults, all regions being covered, and had ‘yes’ or ‘no’ responses. Others considered children, the retention of metalwork for 10 years or more, and on any personal or departmental policies on metalwork removal. Replies were analysed on a computer spreadsheet. Results: The response rate was 237/500 (47%). After excluding replies from retired consultants or those not involved in limb trauma, 205 replies (41%) were analysed. Ninty-five percent of all questions had been answered. Overall, 92% of consultants do not routinely remove metalwork in asymptomatic adults, and 5% do. Metalwork is most frequently routinely removed from the clavicle and acromioclavicular joint (27%), and least frequently from the carpus (0%). Sixty percent of consultants routinely remove metalwork in those aged 16 or under, 37% do not. 87% feel it is reasonable to leave metalwork in for 10 years or more, 11% do not. Concerns include stress shielding, possible toxicity or carcinogenesis, and potential difficulty in future removal. Seven percent have personal or departmental policies concerning removal of metalwork, and these vary. Conclusions: We infer that the majority of UK orthopaedic consultants do not routinely remove metalwork from asymptomatic adults, but the majority do so in patients aged 16 or younger. Less than 10% of consultants have departmental or personal policies. Interleukin 13 and inflammatory markers in human sepsis N. Collighan, O. Koureaki, S. Perry, RM Smith, MC Bellamy, PV Giannoudis Departments of Anaesthetics, Orthopaedics and Trauma, St. James’s University Hospital, Leeds, UK Background: Interleukin-13 (IL-13) is an anti-inflammatory cytokine whose effects include inhibition of the production of inflammatory cytokines, including TNF-␣, IL-1␤, IL-6, IL-8, by LPS-stimulated monocytes, prolongs survival

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of human monocytes and increases surface expression of MHC class II molecules and CD23. It strongly inhibits tissue factor expression induced by LPS and protects endothelial and monocyte surfaces. It has been shown in mice to protect against sepsis and is necessary for survival after CLP in mice. To date, there are few reports of IL-13 in human sepsis. Therefore, we have assayed this cytokine, together with other markers of inflammation in human sepsis, to characterise its pattern of expression. Methods: Thirty-one patients with sepsis or septic shock were recruited. Blood samples were taken from each patient on admission, days 1, 3, 5, and 7. Routine blood results were noted as well as descriptive data. A clotted sample was centrifuged at 500G for 20 min and the serum frozen to allow later analysis. A high-sensitivity ELISA was used to quantify TNF-␣. IL-13 and IL-2 were assayed by standard ELISA, and HLA-DR on CD-14 positive monocytes measured by flow cytometry after labelling with immunofluorescent monoclonal antibodies. Results: Patients had a median age 56 (45–69, interquartile range). APACHE II score was 17.5 (15–23). There were 24 men and 7 women. Twenty of the 31 patients developed septic shock. Patterns of expression of HLA-DR were characteristic of previous reports of similar patient populations, showing greater depression and slower recovery in the shocked than the non-shocked patients. IL-13 was detected in the plasma of 24 of the 31 patients at baseline. From admission to day 3 IL-13 was significantly greater in the shocked patient group than in the non-shocked group. In days 5 and 7 the levels of IL-13 in the shocked group decreased to levels similar to the non-shocked group. TNF-␣ was elevated in all patients but more so in those with septic shock. There was a negative correlation between TNF-␣ and IL-13 expressions. IL-2 was expressed in only one sample. Conclusions: We have characterised patterns of IL-13 expression in human sepsis and septic shock. There is an inverse correlation with TNF-␣ expression. IL-13 may also presage the recovery in HLA-DR expression on CD-14 positive monocytes. These results may have further implications for regulation of mediators in human septic shock and requires further investigation. Treatment of the neck of femur fracture: is a lateral radiograph required? D.A. Jones, A. Chougle, R. Krishna, N. Clay Glan Clwyd Hospital, Bodelwyddan, North Wales, UK Introduction: During the development of the critical pathway for femoral neck fractures at Glan Clwyd Hospital, the question arose whether a lateral radiograph was necessary to help in the diagnosis of the femoral neck fracture and was it needed in the critical pathway. Methods: One hundred patients admitted with femoral neck fractures were reviewed. The A.P. and lateral radiographs were evaluated using the Garden classification for

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intra-capsular fractures and the Evans classification for extracapsular fractures. There were 96 available lateral radiographs for review; four were missing from the extracapsular group. The operative treatment planned was noted after review of the A.P. and then again after review of the lateral. These results were then compared to the actual operation carried out from the case notes. All displaced fractures were to have a cemented hemiarthroplasty and undisplaced fractures AO screws. Results: There were 56 intra-capsular and 44 extracapsular fractures. Using Garden’s classification on the A.P. film there were 4 Type I, 14 Type II, 27 Type III and 11 Type IV fractures. We forecasted 18 patients for AO screws and 28 patients for hemiarthroplasty. On review of the lateral radiograph the groups altered to 4 Type I, 14 Type II, 32 Type III and 6 Type IV, i.e. five radiographs, all of which were displaced changed groups. Again this would result in 18 patients for AO screws and 28 for hemiarthroplasty. In the extracapsular group there were 7 undisplaced, 9 displaced-reduced, 9 displaced-unreduced and 19 communited fractures. All of these fractures underwent dynamic hip screw regardless of the lateral radiographic appearance. Conclusions: We found it difficult to accurately distinguish between Types I and II and Type III and IV on the lateral radiograph as other studies have done. All pre-operative fractures were correctly diagnosed and appropriate operative intervention planned regardless of the lateral radiograph. Therefore, from this study the routine taking of the lateral radiograph was unnecessary with regard to planning operative intervention for patients with femoral neck fracture detectable on the A.P. pelvic radiograph. This would save the patient marked discomfort during its undertaking, reduce the patient’s radiation exposure and save approximately £30 per radiograph. This would equate to £1.8 million per-annum at our present incidence of femoral neck fractures. We do not reject its use if the diagnosis is unclear from the A.P. film. A new use for an old implant: Zickel supracondylar femoral nails for fixation of complex tibial fractures D. Clark, K.M. Porter, J. Marshall Department of Orthopaedics, Torbay Hospital, Torquay We present a new technique using an old implant. Not all fractures of the tibia are suitable for internal fixation using standard intra-medullary nails or plates. This can be due to fracture configuration and is particularly true of proximal tibial metaphyseal fractures. Soft tissue injury over the anterior aspect of the tibia may also preclude the use of routine internal fixation techniques. We have been using Zickel supracondylar femoral nails for such difficult cases, inserting the nails through short (3 cm) medial and lateral proximal tibial incisions. For 11 fractures (three open) treated using this technique all fractures united; mean time to union 16 weeks. The average op-

erating time was 45 min. The locking screws backed out in three cases necessitating removal but this did not affect outcome. There was one infection, which responded promptly to appropriate therapy. We commend this technique as a useful addition to the Trauma Surgeon’s armamentarium for the fixation of tibial fractures when the fracture pattern or soft tissue damage dictate that standard intra-medullary nails cannot be used. Inversion injuries of the ankle—what walks through the emergency department doors Darren John Clement, Gayle Walley, Stephen Bridgman, Nicola Maffulli Academic Department of Trauma and Orthopaedics, Stoke-on-Trent, UK Purpose: To quantify the work load of an Accident and Emergency Department (A&E) as a result of ankle sprain. Materials and methods: During May 2001 data on all patients presenting to A&E with a suspected ankle sprain was prospectively abstracted from the A&E records and recorded using a standard proforma. Data was collected on bony tenderness, fracture status, weight-bearing status at presentation, treatment and subsequent follow-up. Results: During May 2001, 8530 patients presented to the A&E Department. Of these, 335 (4%) patients presented with a suspected ankle sprain (median age at presentation was 25 (range 3–86). Of these, 51% (172/335) where male and 47% (157/335) females with gender not recorded for 2% (6/335). One hundred and fifty-nine were left ankle sprains, 157 right and four bilateral. The side of injury was not recorded for 15 patients. The weight bearing status of 66 patients was unknown. Of the remaining 269, 90 (33%) had been non-weight bearing since injury. Plain radiographs taken on 228 (68%) of the 335 patients confirmed a fracture in 42 of them. Twenty-nine patients had both lateral and medial malleolar tenderness. Management of these patients varied. A total of 194 (58%) received tubigrip and elevation, while 46 (14%) had a plaster of Paris cast. Seventy-nine (24%) patients received crutches. One hundred and seventy-eight had no follow-up, with 57 being seen as a physiotherapy out patient, 46 in a fracture clinic, 15 with their GP, 12 were admitted. Twelve patients declined to wait and were not seen by a doctor and follow-up on six patients was not recorded. Three patients were followed up in a soft tissue clinic, three as an orthopaedic out-patient, two had an orthopaedic consultation in A&E and one was sent for medical assessment. Conclusions: This study confirms that ankle sprains are a major source of workload for a busy A&E Department. This study also highlights the considerable variation in the care pathway for ankle sprains. Physiotherapists play a key role in the subsequent management of these patients. This variation in treatment and follow-up of ankle sprains requires further investigation.

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Incidence and functional outcome of complex tibial plateau fractures (Schatzker Types 5 and 6) A. Dosani, P.V. Giannoudis, S.J. Matthews, R.M. Smith Department of Trauma and Orthopaedics, St. James’s University Hospital, Leeds, UK Purpose: To determine the incidence and functional outcome of complex tibial plateau fractures (Schatzker Types 5 and 6) in our institution. Patients and methods: From January 1993 to December 2000, 176 consecutive adult patients with tibial plateau fractures were treated in our unit. Among them there were 22 patients (14 male and 8 female) with Schatzker Types 5 and 6 fractures (12.5%). Details such as patients age, sex, ISS, type of fractures, whether the fracture was open or closed, method of fixation, incidence of delayed union, the time to union, necessity for additional procedures, complications and hospital stay were recorded and analysed. Following discharge from the hospital all the patients were followed up in the outpatient fracture clinic having regular clinical and radiological assessment. The mean follow-up was 16.8 months (ranges from 6–48 months). Functional assessment of the patients was performed using the American Knee score. Results: The mean age of the patient was 52 years (range from 25 to 76 years) and the mean ISS was 15.5 years (9–44 years). There was one patient with head injury. Seven patients had associated injuries. Eighteen fractures were closed and four were open (one Gustilo Grade 1, one Grade IIIa and two Grade IIIb). Twelve fractures were stabilised initially with AO hybrid frame and cannulated screws, eight cases were treated with internal fixation with buttress plate, one case was treated with double plating and one case with combination of internal fixation and Hoffman external fixator. Intra-operatively a bone graft from iliac crest was used in three patients. Soft tissue coverage was required in four cases. There were two cases of compartment syndrome, eight cases of superficial infection and five cases of deep infection. Overall eight patients were subjected to a second operative procedure (three patients underwent removal of metal work, one case underwent removal of metal work and application of hemicallotasis device and three patients underwent for arthroscopic procedures, two for the wash out, and one for the excision of the bone fragment respectively). Six patients underwent a third procedure (three patients underwent removal of metal work, one patient underwent for the application of hemicallotasis device and two patients underwent for the debridement and curettage of the discharging sinus). The mean time in hospital was 3.5 weeks (range 1–12 weeks). In two cases, there was a 2.5 and 2 cm leg length discrepancy. There were five cases of residual varus deformity. All the fractures but two progressed to union. Functional assessment according to American Knee assessment score was good in 16 cases (72.77), fair in 5 cases (22.72) and poor in 1 case (7.69%). Evidence of radiological OA was present

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in 16 out of cases (72.7%). Correlation of radiological and functional outcome was poor. Overall functional score was 91.49%. Conclusion: The treatment of complex tibial plateau fractures possess many problems to the surgeon due to the nature of the injury and serious damage to the surrounding soft tissues. The incidence of OA was 72.7%. Twenty-one of patients had a good or fair outcome. Complex tibial plateau fractures continue to cause a high incidence of morbidity. The denis classification and prognosis in spinal injury M.H. Kasseem, S. Cutts, E.K. Alpar, W. El-Masry, V.V. Killampall 3 Watchets Green, Lyppard, Habington, Worcester WR4 0RT, UK We present a retrospective study of 87 patients with spinal injuries in the thoracolumbar region. All patients were admitted to the Oswestry Spinal injuries unit between January 1990 and December 1998. Following a review of their notes, CT scans and radiographs, we attempted to classify their injuries according to the Denis (three column) classification of spinal injuries. The objective of the study was to assess the correlation between the Denis classification and clinical outcomes. The patients were assessed both at the time of presentation and on subsequent follow-up. Neurological function was assessed using the Frankel classification. The results of the study show that the correlation between Denis classification and clinical outcome is poor. In addition, the relative proportion of the two most common Major Injury types described by Denis were reversed in our study with Burst fractures forming the majority of injuries. This difference in out come was attributed primarily to the increased use of CT scanning in our study. It appears that Denis misdiagnosed a significant number of burst (two column) fractures as compression (anterior column) fractures. Our findings showed no correlation between the degree of instability and the number of columns disrupted. In addition, our results support the practice of treating vertebral fractures by conservative means with no apparent correlation between treatment modality and neurological outcome at long term follow-up. A new technique for reconstruction of chronic ruptures of the Achilles tendon using the Leeds–Keio connective tissue prosthesis F. Osman, S. Kuruvath, M.L. Rawes Department of Orthopaedic Surgery, Pinderfields General Hospital, Wakefield Many techniques have been described for the reconstruction of chronic ruptures of the Achilles tendon often using

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the patient’s own tissues yet not guaranteeing a good result. We have assessed a new technique using the Leeds–Keio connective tissue prosthesis. Patients presenting with chronic ruptures of the Achilles tendon confirmed on ultrasound have been treated by reconstruction using the Leeds–Keio connective tissue prosthesis. Post-operative management involved immobilisation in a below knee plaster of Paris for 6 weeks followed by physiotherapy. Two females aged 63 and 66 and one male aged 66 with unilateral chronic ruptures of the Achilles tendon have been treated. The surgical wounds all healed by 2 weeks. All had a nearly normal range of movement of their ankle with full power on removal of the plaster cast at 6 weeks. At 3 months all patients were delighted with the result and two were discharged with normal function. The third patient had minor weakness on take-off at 3 months but at 6 months following further physiotherapy had a normal gait and was discharged. The Leeds–Keio connective tissue prosthesis is a simple and effective treatment for repair of chronic ruptures of the Achilles tendon allowing a rapid return to a normal lifestyle. Wither partial patellectomy G. Bedi, C.H. Curwen

reliable and reproducible classification it has been noted that non-union of the middle third is significantly more prevalent with displaced, segmental or comminuted fractures (5.8–15%). What is more, compared to those at the lateral end of the clavicle these non-unions are more often symptomatic for pain and loss of function. Over a 3-year-period we stabilised 12 diaphyseal claviclar non-unions in patients that had failed to unite after conservative treatment. All were plated and augmented with autologous bone graft. There were 10 men and 2 women, median age 31, in whom the majority sustained a direct blow to the clavicle. Surgery was undertaken on average at 34 weeks from injury. All fractures have united with range of movement and shoulder function improved. Seven patients report united with range of movement and shoulder function improved. Seven patients report residual skin numbness caudal to the skin incision and two dislike the palpable metalwork enough for it to be removed. One patient was diagnosed with a subclavian vein thrombosis 2 years post fixation and one patient has an unsatisfactory bone donor site scar. We feel plate fixation is a reliable procedure with good patient satisfaction and functional improvement. Patients should be warned of skin hypoaestesia, palpable metalwork and donor site morbidity pre-operatively.

Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK Patellar fractures are common fractures and the success of treatment depends on adequate restoration of articular fragments and early mobilisation. They are often, however, comminuted and difficult to fix adequately. Complication rates from 0 to 25% have been quoted in different series. We wish to discuss our results managing a rather difficult subset of this fracture, inferior pole fractures. The previous option for some of these would have been partial patellectomy. We have used the load sharing wire technique with or without additional fixation in these fractures. This technique was used in 13 cases and we did not have to revise the fixation or have any case of non-union in this series. All the patients were allowed early mobilisation and regained early knee movement. We have found this technique to be easy to use, cause no additional bone devitalisation and give dependable results in difficult fractures. We have now extended the use of this technique to very comminuted fractures where other conventional fixations do not provide adequate stability and the previous option would have been total patellectomy. The results of open reduction and internal fixation and autologous bone grafting for non-union of fractures of the middle third of the clavicle T.G. McWilliams, S.M. Hatcher, M.L. Rawes Department of Orthopaedics, Pinderfields General Hospital, Wakefield, UK Most fractures of the clavicle have a good prognosis. The non-union rate for all fractures is 0.1–0.8%. With

Audit of management of blunt traumatic pneumothoraces T.G. McWilliams, A.P. Cohen, P. Jellicoe, P. Campbell York District Hospital, Wigginton Road, York A review of management of blunt traumatic pneumothoraces was in our institution was undertaken. A literature search was undertaken and guidelines drawn up. A prospective audit has been set up to investigate the rational for tube thoracostomy in blunt trauma and develop guidelines for safe tube management. Between 1 January 1998 and 31 December 1998, 20 patients were admitted with a diagnosis of blunt traumatic pneumothorax. A total of 16 (80%) had associated injuries. Ninteen (95%) underwent tube thoracostomy (80%) inserted in A/E). Six patients needed IPPV for a surgical procedure, three had respiratory compromise and two had increasing size of pneumothorax on a serial chest X-ray. Following tube thoracostomy 15 of the 19 patients demonstrated an uncomplicated course. Mean length of admission was 9 days (3–69) and the mean number of chest X-rays was 4 (3–7). Associated injury was responsible for delayed discharge in six patients, but in nine no clear reason for prolonged admission was evident. There were four complications; one patient complains of persistent pain at the drain site, three patients required specialist referral; one required suction for delayed re-inflation (8 days), one required further tube thoracostomy for recurrence and one patient required thoracotomy for repair of a parenchymal tear. One patient died (ISS 38).

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Blunt traumatic pneumothoraces are now treated conservatively unless (1) size greater than 1.5 cm measured from the anterior bony end of the third rib to the lung border, or more than half way to the heart border, (2) respiratory compromise, (3) enlargement on CXR after 6 h, (4) or smaller pneumothoraces if bilateral, pre-existing lung disease, other injuries compromising ventilation or need for subsequent IPPV. The drain was removed as soon as radiological expansion and cessation of bubbling had occurred (delayed 12 h if suction used) and a check X-ray performed to ensure re-expansion was maintained. Specialist referral is recommended for persistent bubbling with or without re-expansion, and recurrent pneumothorax following tube removal. Otherwise follow-up is at 7–10 days with further X-ray. In our original series, seven cases had tube insertion, which did not meet our guidelines. Since these have been implemented seven patients have been admitted with traumatic pneumothoraces. One has been successfully managed conservatively and the rest have undergone tube thoracostomy. Blunt traumatic pneumothoraces fulfilling the criteria stated can be managed conservatively. The average time taken for drain removal has decreased from 4.5 to 2.5 days and the amount of ionising radiation to which patients are exposed has been reduced. Don’t trash the TOMO G. Bedi, A. Port, A.T. Cross Department of Orthopaedics, Southmead Hospital, Bristol, UK Tibial plateau fractures are one of the more complex injuries encountered by Orthopaedic surgeons. They are difficult to manage and the inability to get satisfactory fixation often leads to poor results. Computerised tomograms have in most places replaced conventional tomography. We, however, still believe that tomography remains an indispensable investigation giving a very vivid image of the fracture pattern due to its finer resolution, which is much easier to interpret. The depression of fragments is much simpler to assess in relation to the joint line compared to axial cuts provided by conventional CT scan images. The overall cost of tomography as well as the radiation exposure may also be less compared to CT scans. We currently use tomograms as a standard investigation for pre-operative planning and have not had to resort to any other imaging modality. The advantages of tomography will be discussed in the presentation. A radiological assessment of the injury is indispensable because this is the only means available that leads to an accurate evaluation of the fracture pattern and its severity. Frequently the standard exposures are inadequate, and it is necessary to resort to tomogaphy in order to be able to evaluate accurately the fracture pattern. Tomography shows

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the extent and position of the fracture, the degree of comminution and the presence and extent of articular surface depression. It allows a decision to be made of the approach and its operability. It is important to ensure that both antero-posterior and lateral tomographic cuts are obtained. These compliment one another and permit the surgeon to get a much more accurate three-dimensional concept of the fracture. Compartment pressure monitoring—update of current UK practice and comparison between consultants and trainees views Graham D. Smith, Ranjan Vhadra Department of Trauma and Orthopaedics, Royal Bolton Hospital, UK Controversy remains over the use of compartment monitoring in the diagnosis of acute compartment syndrome. Attitudes differ between clinicians. A survey of UK trauma and orthopaedic surgeons conducted 4 years ago showed that less than half of trauma centres had equipment available for compartment monitoring. We have conducted a survey of UK consultants and trainees investigating current attitudes to, and availability of compartment monitoring equipment. One hundred and fifty consultants and 110 trainees were sent a simple email questionnaire. Of those who replied, 89% have had experience of using compartment pressure monitoring, and 78% of these are confident in its use. Seventy-two percent of the respondents have facilities for compartment monitoring available in their unit. Only 17% of those surveyed feel that compartment pressure monitoring is an essential tool in the diagnosis of compartment syndrome. However, a similar number think that it is of little practical use. Interestingly, more trainees than consultants are skeptical about its use, even thought a higher percentage of trainees have had experience in using compartment monitoring. In conclusion, we found that although the availability of compartment monitoring has significantly increased over the last 4 years, there is great polarity in the views of UK orthopeadic surgeons as to its usefulness. Perhaps this is a reflection of the relative lack of evidence that compartment monitoring is of significant benefit in diagnosing and managing acute compartment syndrome. The use of SPECT in predicting post traumatic avascular necrosis of the femoral head G.L. Eastwood, W.M. Harper, D.B. Finlay Department of Orthopaedics, Manchester Royal Infirmary, Manchester, UK Avascular necrosis(AVN) of the femoral head remains a major cause of morbidity following hip trauma. The aim of

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this retrospective study was to review the outcome of patients who underwent single photon emission computerised tomography (SPECT) at Leicester Royal Infirmary following hip trauma (intra-capsular fracture or hip dislocation) between the years 1992 and 2000, looking specifically for AVN. The notes, radiographs and SPECT scans of 60 patients were reviewed. Eight patients had died, 12 had undergone total/hemi-arthroplasty, and three were excluded from the study on clinical grounds, leaving 37 patients who were invited to attend the orthopaedic outpatients for assessment of their hips. This consisted of visual analogue pain score, Harris hip score, plain radiographs and simple gait assessment. Nineteen (51%) of eligible patients responded. Outcome measures were then evaluated in relation to previous SPECT scan results. Of the 57 scan results reviewed, 15 were positive for AVN, 39 negative, and three results were unobtainable (all deceased patients). Of the 15 with positive results, 9 (60%) underwent arthroplasty for AVN, compared to 3 (8%) with negative scans. Only one of those three had changes in the femoral head consistent with AVN at the time of surgery. Three of the 19 patients reviewed in clinic had positive scans; no difference was found in gait, pain or Harris hip scores compared to those with negative scans. We conclude that while SPECT is not an absolute predictor of outcome following hip trauma, it can be a useful tool in predicting the likelihood of arthroplasty requirement secondary to post traumatic AVN. Results of the long Gamma nail in complex proximal femoral fractures H. Pervez, M.J. Parker Department of Orthopaedics, Peterborough Hospital, UK The results for a series of 35 patients with complex proximal femoral fractures treated with the long Gamma nail are presented. Fracture healing occurred in all surviving patients, but there were four technical problems associated with the implant. Two nails broke associated with delayed union of the fracture necessitating revision of the implant, one fracture of femur at the site of distal locking occurred during surgery and there was one later fracture at the tip of the nail. All failures of fixation were revised with another gamma nail and healed uneventfully. Overall the number of fracture healing complication compares favourable to contemporary implants and improvements to the design and strength of the nail may further improve results. Although number of fracture healing complication is similar to that reported with a short gamma nail, long gamma nail gives a similar risk of operative fracture of femur (23/741 = 3.1%) and later fracture around the tip of implant (16.741 = 2.2%). The additional complication that has not been so well reported for the gamma nail is breakage of the nail for which there were two cases in this series.

Classification of trochanteric fractures of the proximal femur: a study of the reliability of the current systems H. Pervez, M.J. Parker, G.A. Pryor Department of Orthopaedics, Peterborough Hospital, UK The radiographs of 88 trochanteric hip fractures were classified by five observers using the Jensen modification of Evans classification and the AO classification. Each observer classified the radiographs independently on two occasions 3 months apart. They were not allowed to see how the fracture has been treated or discuss their observations with other investigators. Kappa statistical analysis was used for determination of intra- and inter-observer variation. For the intra-observer variation the mean kappa value was 0.52 (range 0.44–0.60) for the Jensen classification and 0.42 (range 0.20–0.65) for the AO system with sub groups. For inter-observer variation the mean kappa value was 0.34 (range 0.17–0.38) for the Jensen system and 0.33 (range 0.14–0.48) for the AO with subgroups. For the AO classification system without subgroups, mean kappa value for intra-observer reliability was 0.71 (range 0.60–0.81) and kappa value for inter-observer reliability was 0.62 (range 0.50–0.71). These results indicate that neither the Jensen classification nor the full AO classification with sub groups is an acceptable classification systems for trochanteric hip fractures, but the basic AO classification in to three groups is acceptable and we recommend classifying trochanteric fractures into three groups stable trochanteric, unstable trochanteric and trans-trochanteric. Tip apex distance (TAD) in predicting fixation failure of sliding screws H. Pervez, M.J. Parker Department of Orthopaedics, Peterborough Hospital, UK Cut-out is the most commonest way of sliding screw fixation failure. A number of technical aspects of surgery have been used to asses the risk of cut-out. This study was to determine which of these indicators was the most reliable predictor of cut-out. The anterior–posterior and lateral post-operative radiographs of 20 cases of cut-out were compared with those of 81 cases of uneventful fracture healing. The TAD with correction for magnification was found to be the most reliable predictor of cut-out (P-value = 0.05), followed by the uncorrected Tip-Apex distance (P = 0.09). Predicative factors of mortality after successful tran-sarterial immobilisation in patients with severe pelvic trauma Akiyoshi Hagiwara, Kenji Yamada, Hideki Fukushima, Hiroharu Matsuda, Atsuo Murata, Shuji Shimazaki Department of Traumatology and Critical Care Medicine, Kyorin University, Shinkawa, Mitaka-shi, Japan

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Object: To determine the predictive factors of mortality in patients with severe pelvic trauma after successful trans-arterial embolization (TAE). Methods: This study was based on the following protocol. (1) Of patients without hemoperitoneum, when patients with unstable pelvic fracture were in shock on admission, angiography was performed immediately. Patients without shock underwent angiography only when CT showed hematoma in the pelvis. For patients with stable fracture, only when they were in shock and had the hematoma on CT, they underwent angiography. (2) When patients had hemoperitoneum, either of angiography or laparotomy was firstly selected according to our previously reported protocol. When laparotomy was chosen first to patients with unstable fracture, angiography was immediately performed after laparotomy. All the patients who underwent TAE were enrolled in this study. Result: Of 234 patients with pelvic fracture, 51 patients with unstable fracture and 30 with stable underwent angiography. Sixty-one patients had the extravasation in the pelvis, underwent TAE. Seventeen patients had TILE A, 19 had B, and 25 had C. TAE was successfully performed for all the patients. Arteries and bones of the pelvis were divided into two components of anterior and posterior. The ratios of the extravasated arteries per one bone fracture were TILE A: 0.87 (anterior comportment) versus 1.55 (posterior), B: 0.56 versus 1.25, and C: 0.67 versus 0.91. These ratios in posterior component were significantly higher than those in anterior. Thirteen died in this study. The damages which the patient sustained were divided into two types of anatomical and physiological. Factors of anatomical damage included location of arterial injury, fracture types and ISS. The physiological damage was used for APACHE II score. Only APACHE II had significant odds ratio of 13.75 (95% CI: 2.7–70.1). Conclusion: The determined predictive factor of mortality after successful TAE was the physiological damage that the patient sustained. Foot injuries in motorcycle crashes—patterns and outcomes Hiang Boon Tan, A. Dosani, R. Kammath, P.A. Millner, R.M. Smith, P.V. Giannoudis Department of Trauma and Orthopaedics, St. James’s University Hospital, Leeds, UK Purpose: To determine the pattern of foot injuries following motorcycle trauma. Patients and methods: From January 1993 to December 1999 (data were collected from all motorcyclists presenting to Trauma Units in the Yorkshire Region following a road traffic accident. Collection of data included demographic details of the patients, the use of protective device (helmet), injuries severity scores, Glasgow Coma Scores, clinical details, therapeutic interventions, resuscitation requirements, duration of hospital stay and mortalities. All patients received initial resuscitation according to ATLS protocol. Overall,

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data were collected on 1239 motorcyclists. From this population, we identified those who have sustained foot injuries. Results: Out of 1239 patients 53 (4.7%) sustained foot injuries. Forty-nine were males and four females. The mean age was 31.7 years (range 18–79 years). Fifty-two patients were drivers and one was a pillion passenger. The mean ISS was 6.9 (range 4–33). The mean GCS was 14.7 (range 13–15). There was one death in this series of patients (ARDS, ISS 33). Only seven patients (13.2%) sustained isolated foot injuries. The most common foot injury was a metatarsal fracture (26 cases, 49.1%), followed by fracture of the talus (14 out of 53 cases, 26.4%). Seven patients sustained fracture of the oscalcis (13.2%) and six patients sustained toe fractures (11.3%). Three patients suffered partial foot amputation and in four cases a Lisfranc’s dislocation was present. There were three cases of foot compartment syndrome. Associating injuries included 22 ankle fractures (41.5%), 15 tibial fractures (28.3%), 6 femoral fractures (11.3%), 5 pelvic ring injuries (9.4%) and 23 upper limb injuries (43.4%). Three patients sustained chest trauma (5.7%). It is of note that none of the patients sustained any abdominal trauma or head injuries. In nine patients a pattern of complex limb injuries was observed having sustained foot injuries with associated ipsilateral limb injuries. All patients required operative stabilisation of the fractures sustained. The mean hospital stay was 10.6 days (range 1–35). Conclusion: Motorcycle accidents continue to be a source of severe foot injuries. The most common foot injury appears to be a metatarsal fracture. Although these injuries are associated with low mortality rate require treatment in specialised trauma units to limit long-term morbidity and disability. Audit of open orthopaedic injuries at a city trauma centre H.P. Bhinda, D. Goodier Department of Orthopaedics, Royal London Hospital, London, UK Since November 2000, we have been conducting a prospective data collection of all open orthopaedic injuries presenting to our unit. During the first 6 months there were 51 open fractures, occurring among 44 patients of whom there were 35 males and 9 females with an age range of 7–78 years. Of the 44 patients, 16 presented with polytrauma and the majority of these (12) were brought in by air ambulance. All of the open fractures were assigned a preliminary (pre-operative) and a definitive (intra-operative) grading according to the Gustilo and Anderson classification and the results compared. There was 16% disagreement between pre and intra-operative grading. Of the 18 open tibial shaft fractures in the series, 7 were Grades 3B or 3C. These were stabilised with either an external fixator or a reamed intra-medullary nail, and soft tissue coverage was achieved within the recommended 5 days. There was one case of compartment syndrome.

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We compared the management of our open fractures with studies published by other units and with the guidelines of the British Orthopaedic Association and the British Association of Plastic Surgeons. Overall 64% of cases underwent debridement within 6 h of injury, and 75% within 6 h of admission. All received appropriate antibiotics at a mean of 39 min after arrival, and the majority were given tetanus cover and dressed with an iodine swab. Several further areas for improvement were highlighted. Only 39% of the cases were referred for a plastic surgical opinion, although 85% of the Grades 3B and 3C injuries were referred. Sixteen percent of the wounds underwent primary closure after the initial debridement, and only 5% of the wounds were photographed on presentation. These issues have been addressed and we are currently re-auditing our performance. A study has now been initiated to assess the outcome of these injuries. Evaluating premorbidity modifications to the revised trauma index J. Gaboury, A. Obayan, R. Keith Department of Surgery, Royal University Hospital, Saskatoon, Canada Trauma indexes have been in use since the early 1970s to assist both physicians and non-physicians in the evaluation of injured patients. Various revisions of the trauma index have also occurred over this time, with Smith and Bartholomew’s Revised Trauma Index in 1990. However, the assessment of pre-existing medical conditions has not been routinely incorporated in trauma indexes. In 1993, Osler concluded that the outcome of traumatised patients with pre-existing medical conditions is often dictated by the pre-existing medical disability. Therefore, we have incorporated pre-existing medical conditions into the retrospective evaluation of trauma patients who presented to the Royal University Hospital in Saskatoon, Saskatchewan, Canada between March and September 2000 to determine if this is a better predictor of outcome. Forty patients were assessed using the revised trauma index (RTI). Pre-existing medical problems were then included in the evaluation of these same patients. We were able to improve upon the predictive outcome of the RTI from 32 to 78% as determined by the Kappa score. Our results suggest that pre-existing medical problems play a significant role in determining the outcome of trauma patients. Moreover, the addition of pre-existing medical problems to the trauma index improves the accuracy of the trauma index in determining overall outcome. An algorithm to standardise the investigation of the undiagnosed traumatic painful adult hip: results at 1 years J.P. Whittaker, S. Robbins, S.M. Hay Royal Shrewsbury Hospital, The Robert Jones and Agnes Hunt Orthopaedic Hospital

Aim: In response to the often erratic investigation of such patients, we have developed an algorithm to standardise this process in the undiagnosed traumatic painful adult hip. As yet not all district general hospitals have daily magnetic resonance imaging availability and hence for such units an alternative methodology must be adopted. Not only was this designed to improve efficiency but it may also have important prognostic implications. Patients and methods: Prospectively all adult patients referred with trauma related hip pain were included. The algorithm devised represented a stepwise investigation beginning with simple radiographs and gradually progressing to more complex investigations. Results: Thirty-one patients qualified for the algorithm and amongst these 42% (n = 13) had fractures. Of these 38% (n = 5) required operative treatment. These included four undisplaced intra-capsular fractures and two extracapsular fractures. In addition three patients had fractured pubic rami, three had acetabular fractures and one had an isolated greater trochanteric fracture. Sixteen had a diagnosis of degenerative disease or soft tissue injury. Finally, one patient had femoral neuralgia with low back pain and one patient required further investigation for neoplastic disease. In particular no hip fractures were missed and none changed prognostic grade during this period. Conclusion: The introduction of this simple algorithm has focused attention on this group of patients in a productive way. Investigation and management has become more streamlined and efficient thereby optimising resources. For orthopaedic units without rapid access to MRI, we would advocate this methodology. This approach towards a challenging diagnostic problem has been successful in identifying all hip fractures, and no fracture has deteriorated to a worse prognostic group. A study of the treatment of whiplash injuries in accident and emergency departments in the UK J.R. Andrews, P.M. Alderman Department of Orthopaedics, Royal Gwent Hospital, Newport, Gwent Method: In order for the variations in the treatment of whiplash injuries to be studied a short postal questionnaire was sent to every Accident and Emergency department in the UK. A literature search was then performed in order to determine how much of this treatment is evidence based. Results: We present date from 186 Accident and Emergency units. The use of cervical collars in whiplash treatment is widespread. In the literature no study has shown a therapeutic benefit from collars. The majority of studies comparing early mobilisation with immobilisation in a collar show a prolongation of symptoms, an increase in pain and a decrease in range of movement from treatment

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in collars. Physiotherapy is also provided by a number of units. Evidence for its efficacy is not supported in the literature. There is certainly evidence that early mobilisation is better than rest but no evidence that physiotherapy is superior to self-mobilisation after advice and prescribed exercise programs. Conclusion: A large proportion of Accident and Emergency units are providing treatment that is at best ineffective and in some cases detrimental to patients. This is at a significant cost to the NHS and we suggest treatment protocols should be reviewed. The use of laparoscopy to evaluate the diaphragm in penetrating trauma John Raj, Micheal Walsh Department of Surgery, The Royal London Hospital, London, UK The incidence of diaphragmatic injuries in trauma is estimated to be about 10%. Late recognition is associated with complications with a higher morbidity and mortality. Early recognition of diaphragmatic injuries is, therefore, important to prevent complications and reduce morbidity and mortality. Imaging with the CT scan is useful only if there is associated herniation. It is not accurate in diagnosing diaphragmatic injuries alone. We advocate a diagnostic laparoscopy in all patients with penetrating injuries involving the lower costal or upper abdominal regions, where the diaphragm is more likely to be injured. We present the preliminary results of our experience. Between January 2000 and July 2001, a total of 157 patients were admitted with trauma. Of these, 23 (14.6%) were admitted with penetrating injuries to the chest and/or abdomen. Eleven patients had penetrating injuries to either the lower chest or upper abdomen, with a risk of injury to the diaphragm. All eleven underwent operative procedures. Two patients needed emergency room clamshell thoracotomy to control bleeding. One patient underwent a laparotomy for associated stomach and liver injuries. Eight patients underwent diagnostic laparoscopy. Two patients were found to have associated diaphragmatic injury, giving an incidence of 18.1%. One was detected at laparotomy and the other at laparoscopy. One patient who had a thoracotomy died before the bleeding could be controlled. There was no morbidity associated with laparoscopy. All patients who had laparoscopy were discharged either the same day or the next day. These preliminary findings suggest that diagnostic laparoscopy is useful in evaluating diaphragmatic injuries in patients with penetrating trauma, especially when the injury is in an area where the diaphragm could be potentially injured. The procedure, in our experience, has not increased morbidity or mortality.

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Fixation of the lateral malleolus in unstable ankle fractures: is a neutralisation plate always necessary? J.C. McGregor-Riley, R. Pacheco, A.K. Chaudhary, R.A. Bajekal Department of Orthopaedics and Trauma Surgery, Bassetlaw Hospital, UK Unstable ankle fractures are invariably treated by internal fixation to restore articular anatomy and stabilise the mortise. Anatomical fixation of the lateral malleolus is paramount; usually achieved by inter-fragmentary compression screws supplemented by a neutralisation plate in accordance with AO/ASIF guidelines. The authors present a retrospective review of eight oblique lateral malleolar fractures treated by inter-fragmentary screws without a plate. Objective: To determine the efficacy of fixation of the lateral malleolus, in unstable ankle fractures, by lag screws alone. Design: Retrospective clinical study. Methods: Eight ankle fractures in six men and two women (mean age 31.3 years) were treated by open reduction and inter-fragmentary screw fixation of the lateral malleolus in combination with various medial procedures. All fractures were closed, supination-external rotation stage III or IV (one dislocated). At least two screws were inserted perpendicular to the fracture. Patients were mobilised non-weight bearing in a cast for a minimum of 4 weeks. Mean patient follow-up was 13 months with none lost to follow-up. Results: All fractures united with mean time to permitting full weight bearing of 7 weeks. There were no complications and no re-operations. Conclusion: Oblique lateral malleolus fractures can be adequately fixed with inter-fragmentary screws without a neutralisation plate, provided patients are immobilised in a cast and do not weight bear. This is potentially advantageous as the amount of soft tissue stripping, and the risk of postoperative metalwork problems will be minimised. A larger prospective randomised study is required to compare this method with conventional AO technique. Are fingertips of orthopaedic surgeons in danger? M.A. Hafeza , R.M. Smitha , S. Matthewsa , N. Kalapb , K.P. Shermanb a Orthopaedic

Department, St. James’s University Hospital,

Leeds, UK b Orthopaedic

Department, Hull Royal Infirmary, Hull, UK

Introduction: The number of orthopaedic operations requiring fluoroscopy is rising. The risk from radiation exposure needs to be re-estimated. Previous studies were reassuring that the radiation dose to the hand is far below the yearly limit. However there was no consistency among

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authors with regards to the part of hand that was monitored and the dose to fingertips has not been measured before. Aim: To re-estimate the risk of radiation exposure and to determine the most sensitive part of the hand that should be used for monitoring. Material and methods: We have performed a prospective two-centre study to estimate the risk of radiation exposure of both hands including fingertips. Two consultants and two trainees were monitored over a total period of seven months while performing 47 orthopaedic trauma procedures. Validated thermoluminescent dosimeter (TLD) rings were used to monitor radiation exposure to both hands. A new TLD fingerstall was employed to monitor fingertip exposure. Body, thyroid and control dosimeters were also used. Results: The tip of the finger recorded a relatively very high dose compared with that of the base. If the finger tip dose had not been measured in our study, the results would have been reassuring. Trainees were at higher risk of radiation exposure specially while performing certain procedures e.g. distal locking of intra-medullary nailing. Conclusion: These results, contrary to previous studies, are not reassuring. Fingertips are at risk of receiving higher dose of radiation and should, therefore, be monitored in forthcoming studies. Trauma surgeons are advised to estimate their yearly radiation dose. Keywords: Dosimeter; Hand; Fingertip; Radiation; Orthopaedic; Trauma

Spinal injuries in children: neurological injury may not correlate with injury mechanism or X-ray findings R. Mittal, P.A. Millner, G. Verghese, P. Robinson Spinal Unit, St. James’s University Hospital, Leeds LS9 7TF, UK Introduction: Spinal cord injuries in children are relatively uncommon accounting for <10% of all spinal cord injuries [1,5,10,11]. In children, following spinal cord injury, the neurological status may not correspond with the mechanism of injury or with X-ray findings. Low energy injuries can be associated with severe neurological deficit, whilst some high energy injuries have a benign neurological outcome. With advent of sophisticated imaging techniques, structural abnormalities of the spinal column are often revealed even if initial plain X-rays appear normal. To emphasize on these points, we present two cases. Case 1: JB, 7 years old boy sustained injury to his back and face after he was knocked down to the ground after being hit by the open door of the car which accidentally reversed from stationary position. Clinically, he had complete paraplegia, areflexia in both lower limbs, complete sensory loss below T4 level and priapism. His X-rays of the spine were apparently normal. He had MRI of the spine soon after admission which showed haemorrhage and oedema of the cord at T2–T4 level and central disc bulge at T4/T5 level

causing posterior displacement but no compression of spinal cord. Later, CT scan of dorsal spine was also done which showed fracture through both superior facets and spine of T4 (AO Type B Injury) [7]. He underwent posterior stabilization and fusion from T2–T6 using paediatric ISOLA instrumentation. Recovery from surgery was uneventful but no neurological recovery ensued. From a rehabilitation point of view, the child was fully mobile in a wheelchair. Case 2: VB, 14 years old girl, sustained injury to her back when the car in which she was a backseat passenger crashed into a wall at a speed of 60–70 miles/h. She was wearing only a lap strap seatbelt. On examination, she had significant angular kyphosis at thoraco-lumbar junction. She had no neurological deficit except for hypoaesthesia in L1 dermatome on left side. Her X-rays and CT scan of the spine showed AO Type B injury of L1 vertebra with marked anterior translation of D12 vertebra on L1 vertebra [7]. The patient underwent open reduction, posterior stabilization and fusion of T12–L2 using AO USS/Fixateur interne system on the day of injury. She made uneventful recovery from surgery and the hypoaesthesia in L1 dermatome on left side resolved spontaneously in next few days. In addition, she had a small left sided haemothorax secondary to broken ribs which resolved spontaneously. The patient underwent contrast CT scans for any associated intra-abdominal injury. She did develop mild abdominal symptoms in the postoperative period but these resolved in next few days without operative intervention. Discussion: The first case had a low energy injury and had apparently normal X-rays but his CT scan of spine showed fracture of both the superior facets and spine of T4. He was paraplegic below T4. On the other hand, second case suffered a high energy injury. She did not have any neurological deficit except for transient hypoaesthesia in L1 dermatome on left side. She had significant (almost 100%) anterior translation of D12 over L1. So, low energy injuries can be associated with severe neurological deficit, while some high energy injuries may have no neurological damage. Also, with new imaging techniques, structural abnormalities of the spinal column are often seen even if initial plain X-rays appear normal. Brief information about spinal cord injury without radiological abnormality (SCIWORA) • SCIWORA is closed spinal injury with significant neurological sequelae but without bony injury [6]. • Potential mechanisms of SCIWORA include hyperextension, flexion, longitudinal distraction, crushing and ischaemia of the cord [6,8,9]. • Depending upon the age group, 15–66% of children with spinal injury have SCIWORA [2–4,8,11]. • The ultimate outcome in children with SCIWORA is mainly determined by neurological status on admission [3,8]. Conclusion: In children with spinal injuries, the neurological status may not correspond with the mechanism of

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injury or with X-ray findings. Low energy injuries can be associated with severe neurological deficit, whilst some high energy injuries have a benign neurological outcome. New sophisticated imaging modalities often reveal structural abnormalities of the spinal column even if initial plain X-rays appear normal. References: [1] Babcock JL. Spinal injuries in children. Pediatr Clin North Am 1975;22:487–500. [2] Dickman CA, Rekate HL, Sonntag VK, Zabramski JM. Pedriatic spinal trauma: vertebral column and spinal cord injuries in children. Pedriatr Neurosci 1989;15:237–56. [3] Dickman CA, Zabramski JM, Hadley MN. Pediatric spinal cord injury without radiographic abnormalities: report of 26 cases and review of literature. J Spinal Disord 1991;4:296–305. [4] Hadley MN, Zabramski JM, Browner CM, Rekate H, Sonntag VK. Pediatric spinal trauma: review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg 1988;68:18–24.

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[5] Kewalramani LS, Kraus JF, Sterling HM. Acute spinal cord lesions in pediatric population: epidemiological and clinical features. Paraplegia 1980;18: 206–19. [6] Kriss VM, Kriss TC. SCIWORA (spinal cord injury without radiographic abnormality) in infants and children. Clin Pediatr (Phila) 1996;35(3):119–24. [7] Magerl F, Aebi M, Gertbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994;3:184–201. [8] Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children—The SCIWORA syndrome. J Trauma 1989;29:654–64. [9] Pang D, Wilberger JE. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982;57:114–29. [10] Pollack IF, Pang D. Spinal cord injury without radiographic abnormality. In: Pang D, editor. Disorders of pediatric spine. New York: Raven Press; 1995, p. 509–16. [11] Ruge JR, Sinson GP, McLone DG. Pediatric spinal injury: the very young. J Neurosurg 1988;68:25–30.