Abstracts from the 2003 Meeting of the British Trauma Society

Injury Extra (2003) 34, 1—85

Abstracts from the 2003 Meeting of the British Trauma Society Do innocuous fractures of the pelvic rami really exist? S.K. Gupta, T.D.A. Cosker, A. Ghandour, K.J.J. Tayton E-mail address: [email protected]. Aim: To investigate the extent of pelvic rami fractures following low energy falls in the elderly. Methods: Fifty consecutive elderly patients with fresh fractures of the pelvis were each investigated with an MRI scan of the pelvis in order to assess the competency of the pelvic ring. The 50 patients consisted of 46 female and 4 males with a mean age of 81 years. Fifteen had isolated superior pubic rami fractures, 6 had isolated inferior pubic rami fractures and 29 had both superior and inferior pubic rami involvement. The mechanism of injury in all cases was a simple fall in the home environment. On admission 80% of the patients complained of sacral pain and were tender in the sacral or posterior pelvic region. On MRI, 92% of patients had a sacral fracture associated with the pubic rami fractures and in all but 2 of these the posterior pelvic pain was directly related to the sacral fracture site. At 6-month follow-up, 80% still complained of anterior pelvic tenderness and 60% of posterior pelvic tenderness. Both areas of tenderness corresponded to the sites of the fractures. Conclusion: The study shows that the apparently benign traumatic pelvic rami fracture in the elderly has a high association with sacral fractures. They should therefore be regarded as a more significant injury, and after discharge from hospital, attention should be paid to treatment of the on-going anterior and posterior pelvic pain. Biomechanical analysis of sliding in keyed and nonkeyed compression hip screws G.L. Eastwood, A.W. Miles E-mail address: [email protected].

Compression hip screws are considered to be the gold standard for treatment of trochanteric proximal femoral fractures. Two implant designs exist; the ‘keyed’ and ‘nonkeyed’ barrel profiles. Many biomechanical studies have been published on the performance of sliding hip screws, but most have used only static testing, and none to our knowledge have sought to compare the two barrel profiles. This study aimed to compare the sliding characteristics of keyed and nonkeyed systems in both static and dynamic loading. Method: Tests were performed on the implants using a multi axis servo-hydraulic testing machine. The machine possessed both linear and torsional actuators, such that hip flexion/extension could be simulated during testing. Load to initiate sliding in both implants was measured in a variety of testing conditions; screw engagement in barrel (20— 38 mm), angle of hip flexion (0—40 degrees), perpendicular loading force (50—190 N), and cycle frequency (0—1 Hz). Results: Results showed a tendency towards greater sliding in the nonkeyed system, although these were significant only for screw engagement testing (P < 0:001). However, load to initiate sliding in both implants was significantly higher in dynamic as compared to static testing (P < 0:001), and increased as torsional frequency increased. The nonkeyed system did not demonstrate any tendency for screw rotation within the barrel during dynamic testing. Conclusion: We conclude that the nonkeyed system does show a trend towards improved sliding characteristics, and does not display the tendency for screw rotation within the barrel under loading, often quoted as a misgiving of this implant. Also, since forces to initiate sliding are significantly higher when these implants are loaded dynamically (which mimics more closely the in vivo performance), future biomechanical studies should include dynamic testing for any hip fracture implant.

0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.10.005

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Abstracts

Pre-operative saline verses gelatin for hip fracture patients; a randomised prospective trial of 396 patients

Drains in orthopaedic surgery: are they necessary? A meta-analysis of 27 studies including 5069 wounds

Humayon Pervez, Martyn J. Parker, Richard Griffiths

Humayon Pervez, Martyn J. Parker

Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK

Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK

E-mail address: [email protected]. A previous study has suggested that hypovolaemia, present in most hip fracture patients at the time of surgery, is best corrected using colloid solution rather than crystalloid which is associated with a reduction in the length of hospital stay. We aim to see if we could demonstrate such benefits in a larger number of patients. Between April 1999 and January 2002, 398 patients presenting with a hip fracture were randomised to receive either 500 ml of normal saline or 500 ml of Gelatin (Gelofusine) pre-operatively. Each of these solutions were in identical containers, enclosed in opaque plastic so neither the patients or attending physicians were aware which solution was administered. All patients also received a standard intravenous fluid regime of saline stated from the time of admission in casualty at a rate of one litre every 8 to 12 h. All surviving patients were followedup to 1 year from injury. The characteristics of the patients in the two groups were similar. Table 1 gives the outcomes for the two groups (198 patients in each group). None of the differences between groups were statistically significant. Table 1. Outcome measures for the two groups (%)

E-mail address: [email protected]. The use of closed suction drainage systems following Orthopaedic surgery is common practice. Theoretical advantages of using drains are a reduction in the occurrence of wound haematomas and wound infection. The aim of this meta-analysis was to determine, based on the evidence from randomised controlled trials, the advantages and adverse effects of surgical drains. All randomised trials comparing the use of closed suction drainage systems with no drain following any Orthopaedic surgical procedures were identified using searches of the Cochrane collaboration. Trials from all languages and sources were included. Two authors independently extracted data from identified trials and all trails were assessed for methodology. Twenty-seven studies involving 4845 patients with 5069 wounds were included in the analysis. Pooling of results indicated no statistically significant difference between drained and un-drained wounds in the incidence of wound infection (53/ 2375 versus 61/2328, Relative risk (RR) 0.84, 95% confidence intervals (CI) 0.59—1.19), wound haematoma (19/944 versus 24/953, RR 0.81, CI 0.47 to 1.42) or wound dehiscence (7/489 versus 7/474, RR 0.85, CI 0.38 to 1.93). There was a tendency to an increased risk of re-operations for wound complications (14/784 versus 5/760, RR 2.25, CI 0.95 to 5.33) and a significantly greater need for transfusion (235/586 versus 176/591, RR 1.34, CI 1.15 to 1.57) in the group with drains. Reinforcement of wound dressings and bruising around the operation site tended to be more common in the group without drains. No difference between groups was seen for limb swelling, venous thrombosis, mortality or hospital stay. Based on the randomised trials performed to date, there is no evidence to support the continued use of closed suction drainage in orthopaedic surgery. The use of drains may even have an overall detrimental effect by increasing the need for additional surgery for wound healing complications.

Saline Gelatin (Crystalloid) (Colloid) 30-day mortality 60-day mortality 90-day mortality 120-day mortality 365-day mortality Intra-operative fall in BP Mean orthopaedic ward stay (days) Mean total hospital stay Myocardial infarction Congestive cardiac failure Cerebrovascular accident Deep vein thrombosis Pulmonary embolism

9 (4.5%) 19 (9.6%) 22 (11.1%) 28 (14.1%) 57 (28.8%) 42 (21.2%) 17.7

19 (9.6%) 25 (12.6%) 30 (15.2%) 31 (15.6%) 52 (26.3%) 29 (14.6% 15.7

22.5 0 8 2 5 2

17.3 1 13 0 5 0

We conclude that the universal use a 500 ml of colloid solution prior to surgical repair of a hip fracture is not justified.

Persistent anterior knee pain following tibial intra-medullary nailing N.A. Quraishi, A. Chaudhury, T.O. Boerger E-mail address: [email protected].

2003 Meeting of the British Trauma Society

We assessed the prevalence of anterior knee pain after tibial intra-medulllary nailing. We compared the prevalence of anterior knee pain, sensory disturbance, pain on kneeling and the Lysholm knee score in patients who had their nails removed with those in whom the implant remained in situ. Methods: This retrospective study assessed 60 patients who had tibial fractures treated using a locked AO nail at a district general hospital between 1990 and 1996 (minimum follow up was 5 years). Patients were asked to complete a questionnaire detailing anterior knee symptoms. Results: At a mean follow up of 66.6 months, 32 patients with an average age of 51 years (range 26— 88) had a tibial nail in situ. Sixty percent had anterior knee pain; 93.7% had anterior knee sensory disturbance; 96.8% had pain on kneeling; the average Lysholm knee score was 83.5. Twenty-eight patients out of 60 had their nail removed in an attempt to reduce knee pain. Of these 53.5% had persistent anterior knee pain; 89.2% had anterior sensory knee disturbance; 71.4% had pain on kneeling and the average Lysholm knee score was 84.4. Discussion: The incidence of anterior knee pain and associated symptoms were found to be similar in the two groups. Metal removal did not facilitate the desired reduction of symptoms. Patients have to be informed of the high incidence of the above symptoms and of an almost 50% chance that anterior knee pain will persist when nail removal is contemplated. Predictors of outcome in shoulder hemiarthroplasty for 3 or 4 part proximal humerus fractures A. Bonshahi, S. Canty, S.P. Hodgson Royal Bolton Hospital, Bolton, Lancashire, UK E-mail address: [email protected]. The purpose of this study was to evaluate patient, fracture and radiological parameters in the operated and normal shoulders against shoulder function with a view to determine factors that could predict unsatisfactory outcomes for hemiarthroplasty of displaced proximal humeral fractures. Methods: We reviewed 15 patients aged over 70 who had a shoulder hemiarthroplasty for 3 or 4 part proximal humerus fractures with a minimum 18 months follow-up. All had standard AP and modified axillary lateral X-rays of both shoulders. Constant score was recorded. Power was measured using a myometer. Radiologic evaluation involved measuring the lateral offset, tuberosity height, radius of head and humeral head version. Each parameter was evaluated against clinical outcomes by linear regression analysis to assess possible relationships.

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Results: The average age of patients was 79.4 years (range 71—88). The average constant score of the normal shoulder was 81.6 (61—98) and 43.6 (31— 68) on the operated side. There was a moderately strong relationship between age and corrected constant score (r ¼ þ 0:75, P ¼ 0:003), between age and flexion (r ¼ 0:65, P ¼ 0:011) and between tuberosity height and pain (r ¼ 0:62, P ¼ 0:023). The corrected lateral offset also had a moderate linear relationship to constant score (r ¼ 0:554, P ¼ 0:049). There was no significant relationship between other radiological parameters and the shoulder function. Conclusion: It is difficult to predict outcomes for shoulder hemiarthroplasty using radiologic parameters. Older patients in our series had better corrected Constant scores. Getting the tuberosity height correct seems to reduce the pain felt post-operatively. This could be as a result of reduced impingement. There may also a beneficial effect on shoulder function by reproducing a lateral offset similar to that in the normal shoulder. Single bone titanium elastic nailing for unstable both bone forearm fractures in children A.Y. Bonshahi, N. Shah, J.J. Henderson Royal Bolton Hospital, Bolton, Lancashire, UK E-mail address: [email protected]. Aims: To present a retrospective review of nine cases of single bone elastic nailing in both bone fractures of the forearm in children and to discuss the results. Methods: Nine children with single bone elastic nailing for both bone forearm fractures were retrospectively reviewed. We recorded demographics, mechanism of injury, fracture type, intra-operative problems, immobilisation time, time to nail removal, and complications. Radiographs were evaluated for alignment, callus formation, and change in nail position. Clinical outcome was graded with a scale used by Price et al. Results: The mean age was 10.1 years. There were 5 mid-shaft, 2 proximal third and 2 distal third closed diaphyseal fractures of the radius and ulna. Seven patients had radius nailing and two had ulna nailing. Only two fractures necessitated open reduction due to difficulty in closed reduction. The average length of immobilisation was 4.2 weeks. Seven patients had the nail removed at an average of 6.9 weeks. All fractures united. One patient had a loss of 20 degrees of forearm supination. Eight patients had excellent results and one was classed as a good result.

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Conclusion: Most forearm fractures in children can be treated by closed reduction and casting. However in a small minority, some form of internal stabilisation is required. Nailing of both bones of the forearm in children is common. Single bone plating or k-wire/rush pin fixation has been reported. There is no report on single bone titanium elastic nailing for forearm fractures in children. The rationale of treatment is to stabilise one bone with fixation and the other is manipulated into reduction. Single bone nailing in children has shown to be an effective and safe alternative in our experience with functional results comparable to both bone fixation and a potential benefit of reduced morbidity. Titanium elastic nailing of diaphyseal fractures in children A.Y. Bonshahi, N.A. Shah, J.J. Henderson Royal Bolton Hospital, Bolton, Lancashire E-mail address: [email protected]. Background: Titanium elastic nailing is well established for stabilising paediatric diaphyseal fractures. The standard of care for most paediatric diaphyseal fractures has been casting or traction. However, surgeons have increasingly recognised the advantages of fixation and rapid mobilisation. An ideal fixation device would act as a load-sharing ‘‘internal splint,’’ maintaining reduction for a few weeks until callus forms. Most important, implantation should endanger neither the physes nor its blood supply. Aims: To review results and complications of titanium elastic nailing of long bone fractures in children. Materials and methods: We performed a retrospective review of 33 diaphyseal fractures which had titanium elastic nails in 32 children (mean age 11.31 years, 23 males, 9 females). Pre-operative data was obtained in all patients by case note review and post-op data by clinical and radiological follow up using a standard proforma. Results: A total of 17 forearm, 7 tibial, 5 femoral, 2 humeral and 2 fibula nailings were performed, 24 by consultants and 8 by middle grade trainees. Mean hospital stay was 3.71 days and mean period of plaster immobilisation 7.7 weeks. All fractures united. Ten complications were noted. Three patients had nail backing out, 2 had superficial infections at nail entry sites, which settled with antibiotics. One patient had terminal restriction of knee movement and two had limited forearm movement, which did not cause any functional disability. One patient had a radial nerve palsy, which recovered fully in 8 months.

Abstracts

One patient suffered a refracture following nail removal, necessitating plate osteosynthesis. Conclusions: To conclude, flexible intramedullary nailing using titanium elastic nails is a reliable, yet less invasive procedure for long bone diaphyseal fractures which are difficult to treat by nonoperative methods. The complications noted are comparable with other series and can be minimised with attention to detail and careful technique. Isolated lesser trochanter fractures in elderly–a case for prophylactic dynamic hip screw (DHS) fixation A. Bonshahi, D. Knowles, S. Hodgson Department of Orthopaedic Surgery Royal Bolton Hospital, Bolton, UK E-mail address: [email protected]. Isolated lesser trochanter fractures are a rare presentation of hip fractures in the elderly. Some lesser trochanter fractures are associated with tumours and result from little or no trauma. Three elderly osteoporotic ladies sustained isolated fractures of the lesser trochanter secondary to a definite history of trauma. Radiologically, none of them showed any evidence of pathological lesions or intertrochanteric fracture extension at presentation. Two patients subsequently developed displaced intertrochanteric fractures, which necessitated internal fixation. In the third patient, a dynamic hip screw (DHS) was inserted before mobilisation. We propose that complete, displaced lesser trochanteric fractures in the elderly need to be carefully observed and managed differently. Perhaps there is a case for performing an MRI scan to rule out any underlying intertrochanteric fracture extension, which may precede the true fracture. Avulsions of the lesser trochanter (especially a large fragment) can weaken the osteoporotic proximal femur and predispose to progression to an intertrochanteric fracture on mobilisation. When the integrity of the proximal femur is in doubt there is a case for stabilising it prophylactically with a dynamic hip screw to avoid the morbidity associated with a displaced intertrochanteric fracture. Bone morphogenic protein 7: the early results following salvage procedures for non-union L.M. Jeys, O. Wall, G. Radcliffe, S.J.E. Matthews Trauma Unit, St. James University Hospital, Leeds, UK E-mail address: [email protected]. Introduction: Human recombinant bone morphogenic protein type 7 (BMP 7) is now available

2003 Meeting of the British Trauma Society

commercially for clinical use. In our trauma unit it has been used since September 2001 for patients with established intractable non-unions. We present the early results. Methods: All consecutive patients receiving BMP 7 were reviewed regularly following treatment. All patients had established non-unions previously treated with a variety of methods. The patients were assessed for clinical evidence of fracture union (using stability and pain). Treatment episodes will be categorised as failures if there is no evidence of fracture union at 1 year following BMP 7 treatment. Plain X-rays were assessed by 2 independent radiologists and categorised into: 1. 2. 3. 4. 5.

Radiological evidence of fracture union Encouraging progression towards union Little evidence of fracture healing Atrophic non union Hypertrophic non union

Results: A total of 12 separate non-union sites have been treated in 10 patients (all male) to date. The mean age of the patients at follow up was 45 years. The series included 5 tibial non-unions, 3 femoral non-unions, 3 ulna non-unions and a clavicular non-union. The patients had several previous treatment regimes with a mean of 3.3 treatments (range 1—7 treatments) and had endured symptoms, from initial injury to treatment with BMP 7, with a mean of 8.3 years (range 2 months—10.4 years). To date, the mean follow-up is 18 weeks (range 6— 48 weeks). Currently, 2 fractures have clinical and radiological union, 2 treatments have failed (implant failure and patient opted for amputation), 3 fractures are below 3 months follow up, 5 fractures have a radiological classification as ‘encouraging progression towards of union’ (4 with clinical union). Conclusion: In a very difficult treatment group, we have encouraging early clinical results. Radiological evidence to compare to initial clinical results will be available shortly. Non-operative treatment of displaced olecranon fractures–—a retrospective single-centre study and literature review Kalpit K. Patel, Avinash Joshi, Ian M. Lowdon E-mail address: [email protected]. Aim: To analyse the functional outcome of non-operatively treated displaced olecranon fractures. Methods: The selection criteria were: biologically elderly patient, medically unfit for surgery, severe osteopenia on X-ray or those thought unsui-

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table for surgery by the surgeon involved. Ten patients were included in the study: 4 males and 6 females with average age of 52 years (range 25— 93). Parkers classification was used for all fractures. Elbow was immobilised by a sling/plaster followed by active mobilisation at a mean of 3 weeks. At F/U major emphasis was on noting any functional disability in performing ADL. Morrey elbow performance score was calculated after examination and X-rays. Results: The mean fracture gap was 6 mm (range 5—9 mm). At F/u 9/10 patients were pain-free. Four out of 10 patients had restricted extension ranging from 10 to 208; none had significant restriction of flexion. One patient had limitation of ADL due to constant pain in elbow and the rest were satisfactorily back to their pre-injury functional status. X-rays revealed 4 cases of pseudoarthrosis but none had changes of osteoarthrosis. There were no complications. Discussion: Literature review shows that there is limited information on the results of conservative treatment of these fractures because conventionally they are treated surgically. Internal fixation has potential complications including infection, implant breakage, etc. These problems are much more relevant in an elderly population who have poor quality skin, porotic bones and medical ailments. Moreover, their functional demands are lesser, and fracture union/anatomic position is perhaps less important than preventing elbow stiffness and avoiding risks of surgery. Loss of flexion is a major disability which none of the patients had in this study. Majority of patients regained full pre-injury functional status and were subjectively satisfied. All achieved good, fair or excellent Morrey scores. Conclusion: Non-operative treatment is a safe and viable treatment in a select group (elderly) of patients. From admission to treatment-delays in acute orthopaedic surgery A. Oliver, M.O. Mathew, G. Tait E-mail address: [email protected]. Objective: This study was designed to ascertain if there was a real increase in delays of acute orthopaedic surgery as had been perceived. It also aimed to identify the demographics of those delayed as well as the reasons, length and waiting time for surgery. Methods and results: This was a retrospective case note review over a 12 month period identifying those who had experienced a delay in their operative treatment. The case notes were scrutinised for documentation of the reasons for delay, the demographics of those delayed, the length

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of the delay and the interval until their surgery. The overall rate of delay was 13% of admissions, in 34% no documentation was entered relating to the delay. Fifty-one percent had a neck of femur fracture, 55% were aged 70 years or more, and 49% had to wait more than 72 h for their operation. Conclusions: The majority of these delays were attributed to patient factors (46%) which may have been avoidable by earlier optimisation of the patients on presentation to the Accident and Emergency Department. The other common reasons were lack of theatre time, which may also be addressed by improved allocation of time slots and resources. The lack of documentation is a worrying trend in these days of increasing litigation and must be improved, as must the length of time elapsed before operation. Welcome to the ‘Wild Wild West Midlands’–—gun shot injuries in trauma and orthopaedics S. Kilia, A.L.R. Michaelb, A Gadgilc, R Diasd a

Specialist Registrar Trauma and Orthopaedics, New Cross Hospital, UK b

Clinical Fellow Trauma and Orthopaedics, New Cross Hospital, UK

Abstracts

Symphyseal diastasis occurs in certain pelvic fractures and open reduction and internal fixation with a symphyseal plate is an accepted mode of treatment. Plating is associated with complications such as plate fractures, screw loosening and instability at the pubic symphysis, which may be symptomatic. In order to eliminate these potential complications, we considered the possibility of fusing the symphysis with bone graft supplemented by a plate. We reviewed 26 patients who underwent symphyseal plating. Equal numbers of bone grafted and non-bone grafted cases were recruited into the two arms of the study and retrospectively analysed for any evidence to suggest that bone grafting was a better mode of treatment. The average age of the patient was 39 years, there were 21 males and five females included and the duration of follow up ranged from 3 months to 5 years. A variety of commercially available plates were used in the study. The analysis was done by assessing radiological evidence of union, comparing complication rates and through patient feedback. Our conclusions are that there is better pain relief, fewer complications and fewer revisions in the bone-grafted group of patients.

c

Specialist Registrar Trauma and Orthopaedics, New Cross Hospital, UK d

Specialist Registrar Trauma and Orthopaedics, New Cross Hospital, UK E-mail address: [email protected]. Orthopaedic surgeons are required increasingly to deal with gunshot wounds as part of their trauma service. With the national increase in gun related violence, we have reviewed a series of 39 consecutive gunshot injuries admitted to New Cross Hospital. The cohort was made up of 36 male and 3 female with a mean age of 25.3 (range 14.6—50). Thirty-six suffered limb injuries and 3 had isolated visceral injuries, all requiring surgical intervention. Interestingly, there were no deaths and 75% were adamant they were innocent bystanders. As the gun and violence culture continues to develop in this country, so too must the orthopaedic surgeon’s skills develop to deal with this new pattern of injury. Pubic symphysis plating with bone graft- is this the way forward? Philip Mathew, A.D. Patel Princess Alexandra Hospital, Harlow, UK E-mail address: [email protected].

Hand washing rituals in trauma theatre: clean or dirty? L. Hajipoura, L. Longstaffb, V. Cleevec, N. Brewsterd, P. Henmane a

SHO III Orthopaedics, Wishaw General Hospital, UK

b

SPR Orthopaedics Year 3, Newcastle General Hospital, UK

c

SPR Microbiology, Newcastle General Hospital, UK

d

Consultant Orthopaedic Surgeon, Newcastle General Hospital, UK

e

Consultant Orthopaedic Surgeon, Newcastle General Hospital, UK E-mail address: [email protected]. Introduction: Between 50 and 67% of gloves are perforated during joint replacement operations. Infection, in these cases, can be directly transmitted from the hands of the surgeon. The Hospital Infection Society Working Group on Infection Control recommends that in operating theatres hand washing should be performed for a set time using chlorhexidine gluconate. It is postulated that alcohol gel or foam can be as effective as more conventional detergents if applied to clean hands. Repeated washing using chlorhexidine gluconate can lead to skin irritation and the development of

2003 Meeting of the British Trauma Society

abrasions. Therefore, the use of alcohol may form a suitable alternative. Aim: The aim of this study is to investigate the degree of contamination of the surgeon’s hand using these 2 different disinfectants. Method: In this prospective randomised trial, orthopaedic surgeons were allocated to one of 2 different hand washing protocols using a randomisation table. The hand washing protocol dictated that all surgeons should wash for 5 min with chlorhexidine for their first case. Thereafter, the surgeon was randomised to wash for 3 min with either alcohol gel or chlorhexidine. At the end of each procedure, the gloves of each surgeon were carefully removed and the fingertips from each hand were placed on an agar plate. The number of bacterial colonies present after 24 and 48 h of incubation were recorded for each agar plate by a microbiologist blinded to the washing protocol used. Results: 41 procedures and 82 episodes of hand washings were included in the study. Two episodes were discarded due to contamination at the time of glove removal. 4 hands (8%) were contaminated in the chlorhexidine group compared to 14 (27%) in the alcohol group. Fisher’s exact test confirmed a significantly higher risk of contamination using alcohol gel compared to chlorhexidine (P ¼ 0:002). In addition, the average bacterial colony count was substantially higher in the alcohol group (20 cfu’s) compared to the chlorhexidine group (5 cfu’s). There was no relationship between the duration of surgery and the degree of contamination (P ¼ 1:12). Conclusion: Alcohol gel disinfectant is not a suitable alternative to chlorhexidine whilst hand washing before surgery. Our study has identified a higher risk of bacterial contamination of surgeon’s hands washed with alcohol. This may lead to higher levels of post-operative infection in event of glove perforation. Evaluation of the long intra-medullary hip screw Ryan Hamilton E-mail address: [email protected]. There have been many publications about second and third generation femoral nails, such as the Russell Taylor nail (Smith & Nephew) and Long Gamma nail (Howmedica), but little work has been published on the long Intra-medullary Hip Screw (Smith & Nephew). We set out to evaluate the effectiveness of the Long IHMS as a device for the fixation of proximal femoral fractures. We retrospectively reviewed 33 patients who had a long IMHS inserted for a sub-trochanteric or proximal femoral

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fracture. Of the 33 patients who had a long IMHS inserted, 6 had died and 6 were lost to follow up, leaving 21, who we reviewed. Of the 21 patients reviewed the mean age was 67 years old and the mean follow up was 31 weeks. Mean time to union was 15.65 weeks, with one nonunion. There were 3 superficial wound infections. In one patient there was loosening of the distal locking screws, requiring removal and there was one case of intra-operative femoral shaft fracture. The distal locking screws had broken in 4 patients but this did no cause any serious problems. We conclude that, the long IMHS is an effective device for the treatment of sub-trochanteric and proximal femoral fractures with a high rate of union achieved and a low complication rate. The spectrum of paediatric pelvic fracture: epidemiology, management and outcome S. Banerjee, M. Barry, J.M.H. Paterson Dept. of Orthopaedics, Royal London Hospital, Whitechapel, London E11BB, UK E-mail address: [email protected]. Introduction: Pelvic fractures in children are uncommon. There is relatively little information in the literature regarding the epidemiology, fracture pattern, management and outcome. This review aims to provide this information. Material and methods: Data was retrospectively collected over the period 1993—2003. Only children admitted through the Helicopter Emergency Medical Service (HEMS) were considered. Other methods of admission were excluded. Age and sex distribution, Injury Severity Score (ISS), Revised Trauma Score (RTS), length of stay, fracture pattern, length of follow up and operative management were noted. Data was collected and analysed with the SPSS software package. Results: A total of 43 records were reviewed, 15 females and 28 males. The age range was 2—16 years, with a mean of 11.44 years. The ISS scores ranged from 6 to 45, the mean ISS in girls was 21.6 and in boys, the mean score was 25.0 (power 1.0). The RTS score ranged from 1.0 to 8.8. The mean RTS in girls was 6.02 and in boys, the mean score was 5.99 (power 0.08). The commonest type of fracture was Zeig and Torodoe type 2. In all but one case, the pelvic fracture was treated conservatively. In one case, stabilisation with an external fixator was required. No pelvis required internal fixation. The mortality in this group of high energy injures was 14% (6/43) Death in all cases was as the result of associated head injuries. In the survivors, the mean length of hospital stay was 18.5 days with a median

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of 12.0 days. Follow up data was available for 35 cases. The mean length of follow up was 18 months. All children were full weight bearing after 3 months and had achieved a full range of pain free movements at the hip by 6 months. Conclusion: Paediatric pelvic fractures are uncommon. In our series of selected high energy injuries admitted through the HEMS service, mortality was relatively high at 14%. In the survivors, a good outcome can be anticipated with full functional recovery by 6 months after injury. ‘War Surgery at Sea’: maritime trauma experience in the Gulf War 2003 J.J. Matthews, A.N. Pandya, A.L. Pimpalnerkar, G. Hill, P. Barker E-mail address: [email protected]. During the second Gulf War in 2003, the Royal Naval hospital facility onboard R.F.A. Argus treated 36 patients with injuries sustained in the conflict. Their injuries and operative management are reported. Eighteen casualties sustained fragmentation injuries, six casualties sustained gunshot wounds and seven casualties suffered a combination of both. In addition to penetrating missile injuries, five casualties from road traffic accidents were treated. All wounds were managed following the established principles of war surgery. The extremities were involved in 28 patients (78%). Nine open, multifragmented, long bone fractures were managed with external fixators. Fourteen split skin grafts and one fasciocutaneous flap were performed. Five limbs were amputated. Two laparotomies and one thoracotomy were performed. Wound debridements including delayed primary closure were the most common operation performed. Of the 34 operations analysed 18 involved surgeons of more than speciality. This was the first time that the Royal Navy’s ‘Primary Casualty Receiving Facility’ had been used to surgically manage war casualties and it fulfilled this role to good effect. The experience gained emphasised the importance of a multidisciplinary surgical team with intensive care and radiological facilities located close to the ‘point of wounding’ in the treatment of war casualties, and showed that this can be achieved effectively at sea. Spontaneous reduction of posterior shoulder dislocation following repeated epileptic seizures F. Ali, A.S. Rameto, B.Y. Ng, M.K. Basu Royal Albert Edward Infirmary, Wigan E-mail address: [email protected].

Abstracts

Epileptic seizures are known cause of posterior shoulder dislocations. Posterior shoulder dislocation is uncommon and accounts for 2—4% of all shoulder dislocations. The injuries are often overlooked resulting in missed diagnosis and delayed in diagnosis. A case is presented of a spontaneous reduction of posterior shoulder dislocation after repeated epileptic seizures. This patient presented to accident and emergency department with a ‘‘normal looking’’ shoulder. His injury was only diagnosed when the axillary view revealed a large reverse Hill-Sachs lesion. In the best of our knowledge this presentation of this rare injury has not been reported previously. Through this case we would like to highlight the importance of obtaining radiographs in at least two views when assessing shoulders and also for the clinicians to be aware of this unusual presentation of shoulder dislocation. Application of Ferrari technology in orthopaedic trauma surgery: a preliminary report Diegomaria Cavallini, Ferdinando Cassese E-mail address: [email protected]. A new external fixation device has been developed using the novel, state-of-the-art Ferrari Engineering concept. The advantages of this device include: 1. The use of Telemetry within the device allows data transfer via radiofrequency. It also allows sequential objective assessment of callus stiffness which is the end point of fracture union. 2. The use of high performance composite material as the central body provides a lighter and stronger external construct without compromising the stability. 3. Radiolucent central body provide excellent radiographic follow-up evaluation of fracture configuration and alignment. The early result of this DTM (Design and Technologies for High Performance Mechanics) device is presented. A modified three-quarter plaster slab for distal radius fractures Anmar K. Alshawi, MRCS Specialist Registrar in Trauma and Orthopaedics; A.G. MacEachern FRCS Consultant Orthopaedic Surgeon E-mail address: [email protected]. Inadequate initial immobilisation of displaced distal radius fractures following closed reduction in the A&E department is a common problem.

2003 Meeting of the British Trauma Society

The plaster ‘‘back’’ slabs used often lack sufficient volar cover and proper moulding. Three-point fixation to maintain the reduction is therefore rarely achieved. We conducted an audit at our District General Hospital assessing the plaster slabs applied in the A&E department both clinically and radiologically. The findings clearly demonstrated the extent of the problem. We describe a simple modification to produce a three-quarter plaster slab that guaranties volar cover similar to a full circular plaster. It addresses the shortcomings of the conventional slab effectively without loosing the advantages and should reduce the re-displacement risk of this common fracture. Penetrating abdominal trauma index, determination of its sensitivity and specificity to discriminate morbidity and mortality by ROC curve analysis Jose ´ Francisco Go ´mez-Leo ´n M.D. E-mail address: [email protected]. Background: When developed in 1981 by Moore and cols. The Penetrating Abdominal Trauma Index (PATI) was used to identify trauma patients in risk of post-operative complications, PATI scores of 25 or more led to that conclusions; methods of trauma quantification have been extensively developed, but their outcomes evaluations have been na½¨ve, subject only to basic statistical analyses, The accuracy of P.A.T.I. was assessed by means of ROC curve analysis. Methods: A prospective study, over a 4-month period, enrolled all patients with penetrating abdominal trauma undertook to laparotomy, initial assessment of patients was taken following ATLS guidelines, patients were stratified on basis of those who developed complications, no complications and post-operative mortality. PATI was calculated based on operative findings and outcomes were measured on basis of complications or mortality in the post-operative period. Results: Eighty-nine consecutive patients underwent laparotomy for abdominal trauma, 49 stabbed wounds and 40 for gunshot wounds. Patients who developed complications scored a mean PATI of 19,78; those who died in the post-operative period scored a mean PATI of 25,29. ROC curve analysis of PAT scores in patients who developed complications results in 57,1% sensitivity and 85,4% specificity. Sensitivity and specificity for mortality prediction is 42,9 and 91,5% respectively. Conclusion: Trauma scores statistical evaluation should be performed using adequate methodology in order to avoid naive evaluations that overcome in loss of information, and therefore, in the bias of

9

conclusions taken from that analysis. ROC curve evaluation of this trauma score index allows comprehensive study of the instrument’s performing, avoids data simplification and permits cross-analysis of different trauma score indexes. A prospective analysis of maxillofacial injuries in 250 consecutive tracheostomy patients Peter S.G.F. Hardee, Iain L. Hutchison, Mike Millwaters, Nick Kalavrezos Helen Drewery Maxillofacial Unit, The Royal London Hospital, Whitechapel, London E1 1BB, UK E-mail address: peter.hardee@bartsandthelondon. nhs.uk. A prospective analysis of Maxillofacial injuries in 250 consecutive patients undergoing tracheostomy yielded 19 who had maxillofacial injuries (1 transected trachea, 1 panfacial laceration, 10 mid-facial fractures, and 7 combined mid-facial and mandibular fractures). Of these, all 10 mid-facial fracture patients, and 6 of the combined mid-facial and mandibular fracture patients had major thoracic, abdominal, or orthopaedic injuries. 6 tracheostomies were placed percutaneously, 12 were placed surgically, and 1 was a cricothyroidotomy placed at the scene of the injury. The indications for tracheostomy were 1 emergency airway, 1 tracheal repair, 8 respiratory weaning, and 9 for respiratory weaning and easier fracture management. Definitive Maxillofacial treatment was performed at the same time as the tracheostomy in 10 patients, at a later date in 5 patients, and no active treatment was required in 4 patients. Three patients were transferred with the tracheostomy tube still in place, and 1 patient died from non-tracheostomy related complications with the tracheostomy tube still in place. There were no complications related to the tracheostomy tube. Complications of temporary and definitive external fixation of pelvic ring injuries W.T.M. Mason, L.T. James, S. Khan, T.J.S. Chesser, A.J. Ward E-mail address: [email protected]. Aim: The aim of this study was to determine the nature and frequency of complications of external fixation in pelvic ring injuries, comparing fixator use for temporary and definitive treatment. Method: The records of 100 consecutive patients treated with pelvic external fixation were reviewed retrospectively. All surgical complications were recorded.

10

Results: In 52 patients external fixation was intended for use as the definitive treatment of the pelvic ring injury and was maintained for a mean duration of 60 days (17—113). In 48 patients it was used temporarily for a mean duration of 8 days (1— 20) before internal fixation of the pelvic ring. The complication rate for definitive and temporary fixators was 62% and 21% respectively. Pin-site infection occurred in 50% of definitive fixators and 13% of temporary fixators but rarely led to more serious complications. Seventeen percent of definitive fixators and 9% of temporary fixators required revision for a complication. In five patients the definitive management was changed as a result of a complication of the external fixator. The commonest cause for revision of either fixator was aseptic pin loosening. Revision for loose pins in eight patients was associated with the use of two pins in each iliac crest rather than three (P ¼ 0:01). Conclusion: The temporary use of external fixation is relatively safe and effective, but use for definitive treatment is associated with a high rate of pin-site infection. Accurate pin placement and the use of three pins in each iliac crest should reduce the number of fixators that require revision for aseptic pin loosening. Close attention to pin site hygiene is paramount in patients with pelvic external fixation as the definitive treatment can be compromised by pin site infection. The use of percutaneous K wires in the fixation of Weber B fractures–—a preliminary report A.D. Tambe (Research fellow in Orthopaedics), K. Swamy (Registrar in Orthopaedics) Wrightington, Wigan and Leigh NHS trust, Royal Albert Edward Infirmary Wigan E-mail address: [email protected]. Introduction: Wound healing problems, because of tense skin and risk of implant failure in osteoporotic bones are problems that worry A surgeon when dealing with ankle fractures. Material and methods: Percutaneous K wire fixation was used in 18 patients with unstable Weber B fractures of the fibula with talar shift. Wires were inserted under image intensifier percutaneously after fracture reduction, into the lateral complex, one intramedullary and one transfixing the syndesmosis through the fibula. These were removed after 8 weeks in the outpatients. Observations: There were 18 patients, 3 of them had a diastasis, 5 had poor skin over the fibula and 13 had very osteoporotic bone. The average age was 49.4 years and mean follow up was for 19 months.

Abstracts

17 fractures united, there were no infections or any late ankle instability. The Olerud and Molander ankle score showed good results in 90% patients. Conclusion: Percutaneous K wire fixation done with a proper technique, is useful in managing unstable Weber type B fibular fractures, with talar shift, in patients with either poor skin condition over the fibula or poor bone stock. Unstable thoracolumbar spinal injuries: is conservative management possible? A.D. Tambe (Research fellow in Orthopaedics) Wrightington, Wigan and Leigh NHS trust, Royal Albert Edward Infirmary Wigan E-mail address: [email protected]. Introduction: Due to the rising incidence of unstable thoracolumbar spinal injuries (TLSI) in developing countries, the lack of trained personnel and adequate facilities many patients get managed conservatively. There is not much literature available on the outcomes of these patients compared to the accepted operative treatment. Materials and methods: A prospective study was done in the Govt Medical College Hospital, Nagpur, India where the outcome of 19 unstable TLSI which were operated (group A) was compared to the outcome of 22 cases which were managed conservatively (group B). Observations: Average follow up was 1.2—2.2 years (average 1.4). There was neurologic recovery in both the groups by two Frankel grades.

DVT Pulmonary complications Bedsores UTI Angle of kyphus (average value) Pre-treatment Post-treatment On follow up

Group A

Group B

2 1 2 5

3 2 3 5

30.7 16.7 18.7

28.1 29 32

The change in the angle was not significant. One patient developed secondary neurodeficit due to internal kyphus in group B. Conclusion: The outcomes of patients with unstable thoracolumbar spinal injuries managed conservatively appear comparable to the operated patients. Hence conservative treatment done properly may be a viable option in managing these patients in centres lacking the resources to operate

2003 Meeting of the British Trauma Society

all cases. Further studies with larger numbers and longer follow up are needed. Acromioclavicular joint reconstruction: analysis of technique and outcome at 2- to 11-year follow-up B.Y. Ng, K. Swamy, A.O. Browne Royal Albert Edward Infirmary, Wigan E-mail address: [email protected]. Aims: To evaluate the functional outcome and patient satisfaction following the modified Weaver—Dunn procedure for the treatment of chronic acromioclavicular joint (ACJ) disruption. Methods: A cohort of 16 patients treated surgically for chronic, symptomatic ACJ disruption (Rockwood type 3 to 5) between 1992 and 2001 is reviewed. The Constant—Murley functional shoulder scoring system and patient satisfaction were assessed at the latest follow-up evaluation. Results: All patients undergone modified Weaver-Dunn procedure which consists of excision of lateral end of clavicle, bone block transfer of coracoacromial ligament stabilised with two 2 mm Kwires and Nylon tape or Ethibond suture to maintain acromioclavicular alignment. There were 13 males and 3 females with a mean age of 36 years (range: 17 to 58). Thirty percent patients had sporting related injury. Mean delay from onset of symptom to surgery was 30 months. Four patients had failed primary operation to the ACJ. Two patients had concomitant fibrous non-union of lateral 1/3 of clavicle. All the patients were re-examined at 2 to 11 years after surgery (mean: 5.8 years). The mean Constant- Murley scores were 86 (range: 70 to 100). Results were good to excellent in 75% of cases. Complications consisted of 1 K-wire migration, 2 superficial wound infections, 1 deep infection and 3 failure of reconstruction. The latter were related to salvage procedure in previous failed primary operations. Conclusions: Acromioclavicular realignment can be achieved using Nylon tape or Ethibond sutures and 2 stout K-wires. The latter appears to enhance the pull-out strength of bone block transfer and allows bone-to-bone union. We recommend this modification of technique to ensure acromioclavicular alignment. This technique is not intended for salvage procedure as failure rate is high.

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Purpose: The purpose of the study is to determine the health-related quality of life of trauma victims 5 years after injury. Methods: 246 patients (15 years when injured) with injuries from blunt or penetrating energy (Injury Severity Score 9) who were injured in 1996 or 1997 received a questionnaire 5 years after injury. The patients quality of life was measured using the SF-36 Health Survey. The result was compared to a reference group and data from a trauma registry. Result: 205 patients (83%) answered the questionnaire. The subjects were predominantly men (74%). The median age when answering the questionnaire was 39 years old (range 20—87). Seven percent of the injuries were caused by penetrating energy. The median value of Injury Severity Score was 14 (range 9—57). Mean SF-36 scores were significantly worse on all SF-36 dimensions compared with the reference group. In comparing patients with blunt or penetrating injuries patients with blunt injuries had significantly worse scores in physical function (P < 0:05) and patients with penetrating injuries had significantly worse scores in mental health (P < 0:05). Patients with high age, hospital complications, some form of operations during care, longer hospitalisation, and longer care in intensive care units were strongly associated with lower SF-36 scores. The mean sick leave was 48 weeks and 73% had returned to work. Sixty-seven percent reported still suffering from physical impairment, 41% from psychological impairment, and 50% thought that the acute health care system could have done more to ease their situation. Discharge Injury Severity Scores did not predict poor health related quality of life 5 years after injury. Conclusion: The study group reported a low health-related quality of life 5 years after injury. Injury Severity Score at hospital discharge may not be predictive of long-term health status. Hemi-arthroplasty for fracture neck of femur: a new method of reference for the femoral cut N.R. Chenthil Kumara (MRCS Ed), M. Maqsoodb (FRCS: Tr & Orth), A.L.R. Michaelc (FRCS Ed), E.M.H. Obeidb (FRCS: Tr & Orth), A.O. Ebizieb (FRCS: Tr & Orth) a

Research in Orthopaedics

Health related quality of life 5 years after trauma

b

Consultant in Orthopaedics

K. Sluys, T, Haggmark, L. Iselius,

c

Clinical Fellow in Orthopaedics

Department of Surgery, Karolinska Hospital, SE-171 76 Stockholm, Sweden E-mail address: [email protected].

E-mail address: [email protected]. Background: Thompson’s hemiarthroplasty is one of the common procedures done for displaced intra

12

Abstracts

capsular fracture of the femoral neck in the elderly. One would want to achieve near anatomical position with this endoprosthesis to attain good stability and to avoid the related complications due to improper placement. However, there is no mention in the literature to our knowledge regarding the technical or operative details about how this could be achieved. Material and methods: This pilot study was undertaken as a prospective and controlled study to find out reference points to make the femoral cut that would allow the Thompson’s prosthesis to be inserted and seated in the near anatomical position. Preliminary studies were done by the main author on dry bones to understand and find out the reference points to guide the femoral cut. Later, this new method of reference points for the femoral cut were applied by three surgeons in different grades in three different hospitals. Results: A total of 75 patients were followed up for an average period of 18 months (range 5—27 months). Post-operative radiograhs showed that the pattern of the femoral cut was reproduced in all the patients achieving near anatomical position and there was no dislocation or other complications noted during the follow up relating to the position of the endoprothesis. Conclusion: The results of our new method are easily reproducible and also reduces the intra operative time by avoiding repeated revision of the femoral cut to achieve the adequate femoral neck length. This is not technically demanding and the learning curve should be shallow. Hence we recommend this new method of reference to make the femoral cut in Thompson’s Hemiarthroplasty.

earlier results. The trauma team was not made aware of the project and the study reflected the existing normal practice. Results: The previous forms did not have the space to document the name of the responsible health professional, job title of consenting doctor, type of anaesthesia and risks of surgery. A copy of documented discussion could not be provided to the patient. Analysis of these forms showed that 76% did not have the date of consent documented by patient, 40% had abbreviations of the procedure and in 4%, operative area was not stated. Four percent had a procedure different from that consented. Seven forms had changes to the initial documentation and 3 of them were not initialled. With the new forms, in 54% of cases patient’s copy was not provided to patient. Other deficiencies included lack of documentation of, responsible healthcare professional in 54%, anaesthesia in 33%, operative area in 2% and risks of operation in 6%. In 20%, the procedure was written in abbreviations. One case had a procedure different from that consented. The legibility was subjectively scored. Conclusions: The new forms have improved the documentation towards the recommended guidelines. However, the current clinical practice is less than satisfactory and healthcare professionals need to be aware that documentation needs to be as complete as possible.

Keywords: Fracture; Neck of Femur; Endoprosthesis; Hemiarthroplasty; Thompson

Haukeland University Hospital, Bergen, Norway

Documentation of consent in trauma surgery R. Bhattacharya, J.E. Sudhakar E-mail address: [email protected]. Purpose of the study: To analyse if level of documentation of consent forms meets recommended national guidelines. Method: The department of health, GMC and the Royal College of Surgeons have published guidelines in obtaining consent for surgery. One hundred and fifty consent forms from case notes were obtained from consecutive emergency trauma admissions in early 2002. The documentation was analysed and several deficiencies were noted. In July 2002, the new consent forms were introduced. One hundred and fifty new forms were similarly analysed and the results compared to the

Trauma outcome in a Norwegian regional hospital Kari Schrøder Hansen MD; Lars Birger Engesæter MD, PhD; Asgaut Viste MD, PhD

E-mail address: [email protected]. Background: The aim of this study was to compare survival of trauma patients in a Norwegian regional hospital to Trauma Audit Research Network (TARN) and Major Trauma Outcome Study (MTOS) by using the TRISS methodology. Methods: During a 2-year period 1126 patients were included in a trauma registry at Haukeland University Hospital. W-, Ws- and Z statistics were used to compare survival in our dataset to the survival in the predicting datasets. We used M statistics to compare the distribution of probability of survival between the datasets. Results: There were significant more survivors at Haukeland University Hospital compared to TARN with a W-value of 3.29 (Z ¼ 5:42) and Ws of 2.76 (CI 1.78—3.73). When comparing to MTOS the W-value was 1.9 (Z ¼ 3:51) and W’s was 2.67 (CI 1.54—3.78).

2003 Meeting of the British Trauma Society

The M values compared to TARN and MTOS were 0.95 and 0.97 respectively. Conclusions: There were an estimated excess number of survivors at Haukeland University Hospital compared to TARN and MTOS. Even though Mvalues showed a good match between the comparing datasets, the results may be explained by differences in the trauma populations.

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team training in trauma care has never been done before in Norway. BEST is a cost-effective improvement tool. The focus on team performance rather than the individual’s is important. Olecranon non-union–—results of elbow function S. Sharma, L.A. Rymaszewski

ATLS is good–—but what is BEST?

Glasgow Royal Infirmary, Glasgow

Kari Schrøder Hansena, MD, Guttorm Brattebøb, MD, Torben Wisborgc, MD

E-mail address: [email protected]. Aim: To test the hypothesis that olecranon nonunions have poor function owing to reduced elbow extension strength. Methods: We examined 15 patients (age range 16—75 years) with established non-unions of their olecranon. Eight of these patients had an osteotomy performed for surgical exposure while 7 were nonunions following a fracture. All patients had their range of movement assessed using a goniometer. Pain was assessed using the visual analogue score, function was assessed using the mayo elbow performance index and isometric elbow extension power tested using a custom-made machine. Results: The average arc of movement was between 25 and 1358. Pain was less than 3 on the visual analogue score. The mayo score for the patients in this series averaged 80/100. The average isometric elbow extension strength was also not significantly different between the affected and the contralateral normal side. Symptomatic elbow extension weakness was noticed in 3 of these patients. They however regained extension power greater than the opposite arm following a 2month period of physiotherapy. Conclusion: Although we agree with the principle of anatomic reduction and rigid internal fixation of olecranon fractures, based on the results of this study we believe that when there are contraindications to surgery, conservative treatment can result in acceptable function.

a

Haukeland University Hospital, Bergen, Norway

b

Haukeland University Hospital, Bergen, Norway

c

Hammerfest Hospital, Hammerfest, Norway

E-mail address: [email protected]. The initial treatment of multiple traumatised patients is a demanding challenge. In Norway, very few hospitals get enough trauma cases to enable the trauma teams to perform optimally just by doing their regular work. From aviation safety it is known that human factors and sub-optimal team co-operation can lead to disasters, and crew resource management (CRM) has been developed to address this. We have developed a multi-professional course called Better & Systematic Trauma Care (BEST), organised locally at each hospital. The 1-day course consists of lectures, followed by practical training with two simulated patients. The hospital’s team set-up, procedures and equipment are used, and team members play their own professional role. During the practical session an instructor gives physiological data to the team but he does not interrupt the team performance. The simulation is videorecorded, and in the subsequent structured debriefing the team is encouraged to focus on areas for improvement in leadership, communication and cooperation. A voluntary network between all hospitals has also been established, as a national quality improvement collaborative. In addition BEST and Haukeland University Hospital have established a course in ‘‘Damage Control Surgery’’ where anaesthetised pigs are used in a pig-model. BEST is now established at 28 of the 48 Norwegian trauma hospitals. More than 2300 professionals have followed the lectures and more than 1000 have simulated. The feedback is overwhelmingly positive; especially many of the health care workers find the local training with their own well-known colleagues, procedures, and equipment very useful. This kind of cross-professional

Flexible intramedullary nailing in displaced diaphyseal fractures in children V. Kapoor, B. Theruvil, S.E. Edwards, G.R. Taylor, M.P. Clarke, M.G. Uglow E-mail address: [email protected]. We report the results of Flexible Intramedullary Nailing (FIN) for displaced diaphyseal fractures of the forearm in 44 children. The average age was 12 years (range 5 to 15 years). The indications for fixation were instability (26), redisplacement (14), and open fractures (4). All 44 patients were reviewed at an average of 15 months and all progressed to bony

14

union. The average union time was 7 weeks with one delayed union. In 34 patients the metal work was removed at an average period of 6 months following bony union. There were entry site problems in four cases necessitating earlier removal of the implants. Nine are awaiting removal and in one patient, the nails were left in situ, as they were deeply buried in the bone. There were no complications associated with removal of metal work. All patients regained full flexion and extension of the elbow and wrist. Pronation was restricted by an average of 208 in 30% patients. There was refracture in one case, which was treated by nail removal and open plating. Two patients developed post-operative compartment syndrome requiring fasciotomy. FIN confers advantages with fewer complications when compared to plating. We therefore recommend FIN for the treatment of unstable middle and proximal third forearm fractures. Stanmore total knee replacement versus internal fixation for supracondylar fractures of the distal femur in elderly patients E.O. Pearse, B. Klass, S.P. Bendall, G.T. Railton E-mail address: [email protected]. Background: Supracondylar fractures of the femur in the elderly are difficult to treat. Total knee replacement is often not considered. The aim of this study was to compare the short to medium term outcome of fixation and total knee replacement in medically fit active elderly patients with no pre-existing arthritis in order to determine whether total knee replacement can be an alternative to internal fixation. Patients and methods: In this retrospective study, we included patients who were aged 75 or over with an ASA grade of 2 or less, walked independently before their injury, sustained a type A or C supracondylar fracture and survived to discharge. Four were treated with internal fixation and 6 with a cemented Stanmore knee replacement. Patients were reviewed clinically and radiographically a minimum of 6 months after surgery. Results: The advantages of TKR were a greater proportion of patients returned to independent walking, rehabilitation was more rapid, and knee flexion was better. The advantages of internal fixation were a decreased need of blood transfusion, a smaller proportion of patients reported knee pain at follow up, and a better mean Oxford knee score at follow up. Anaesthetic time and level of patient satisfaction at follow up were similar. Conclusion: Total knee replacement is an alternative to internal fixation for the treatment of supracondylar fractures of the distal femur in

Abstracts

elderly and could be used more widely in the management of these difficult fractures. General practitioner training in orthopaedics and trauma; is it adequate? D. Morgan, A. Evans, M. Holt E-mail address: [email protected]. Aims: Musculo-skeletal complaints comprise a significant proportion of General Practitioner workload. The aim of this study was to assess whether the training of GP’s is satisfactory given their exposure to orthopaedics and trauma in practice. Methods: A postal questionnaire was sent to 200 local General Practitioners requesting information on their training in musculo-skeletal conditions. Results: The response rate was 58%. The reported estimated proportion of musculo-skeletal problems varied between 10 and 60%. Only 33% of General Practitioners had any formal post graduate training in trauma and orthopaedics. Experience in the related specialities of rheumatology was 12% and A þ E 69%. Thirty-five percent of responding General Practitioners reported a specialist interest in musculo-skeletal conditions although less than 2% have any postgraduate qualifications in this area. Only 23% of GP’s thought that their training in orthopaedics and trauma was adequate. 85% felt that they would benefit from further training. Eighty percent of these felt that clinical teaching would be the best way to achieve this. Conclusions: Musculo-skeletal problems comprise a significant proportion of General Practice workload. Despite this fact formal training in trauma and orthopaedics received by GP’s is minimal. Seventy-seven percent of GP’s feel that their training in the treatment of musculo-skeletal conditions is inadequate and 85% would like further training. Blood transfusion requirements in surgically treated proximal femoral fractures D. Morgan, S. Evans, M. Holt, J. Jones E-mail address: [email protected]. Aims: To assess the transfusion requirements of patients with surgically treated neck of femur fractures and the need for a hospital transfusion policy. Methods: The pre- and post-operative haemoglobin measurements, transfusion requirements and length of stay of 181 consecutive unselected patients who underwent surgical treatment of proximal femoral fracture were determined by a comprehensive review of the medical notes.

2003 Meeting of the British Trauma Society

Results: A total of 76 (42%) patients required transfusion at a mean of 3.07 units per patient.45% of patients undergoing DHS required transfusion as did 33% of hemiarthroplasty patients as did 50% of those who had intramedullary fixation. The average pre-operative Hb was 1.2 g higher in the case of the non-transfused DHS patients 0.5 g higher in the same hemiartroplasty group and 1.2 g higher in the IMN group. The average post-operative Hb in patients requiring transfusion were as follows: DHS Hb ¼ 8:9, hemiarthroplasty Hb ¼ 9:4, IMN Hb ¼ 9:9. Conclusions: A review of 41 sets (54%) of randomly chosen notes showed that the vast majority of transfusions were justified by low Hb alone and not any clinical indication. The average length of stay of the of the transfused patients was 19 days. Despite this there was no common trigger for a transfusion in an individual patient. Length of stay was not affected by transfusion. Given the attendant risks and costs of blood transfusion and the decreasing availability of blood stocks a transfusion policy is suggested on the results of this study. Isolated injury to the lateral antebrachial cutaneous nerve secondary to trauma Rohit Samuel, David Ellis E-mail address: [email protected]. We report a case in which a 28-year-old male sustained an injury to his left arm whilst performing his job involving lifting heavy barrels. One of the barrels slipped and trapped his hand producing a hyperextension force to the wrist and traction injury to the arm. Although suffering no symptoms initially he complained of paraesthesia over the radial aspect of his forearm during the following few months. Clinical examination showed no muscular weakness and reflexes were normal. Nerve conduction studies showed an absence of response for the left lateral antebrachial cutaneous nerve consistent with axonotmesis. Electromyographic examination of biceps brachii and brachialis was normal. On further review, the patient reported that his symptoms were settling spontaneously so it was decided to treat his condition conservatively. Although isolated injuries of the lateral antebrachial cutaneous nerve have been reported previously, there is no report of it occurring secondary to a traction injury. We describe techniques to aid diagnosis on clinical examination, discuss management options, including surgical procedures, and likely outcomes for this rare isolated event.

15

Orthopaedic surgeons in Yorkshire–—are we A.T.L.S. positive? S.P. Kelley, D.H.M. McMurray, A.F. Hinsche, P. Deacon Department of Orthopaedic Surgery, Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, Yorkshire, UK E-mail address: [email protected]. Introduction: In 1993 the Major Trauma Working Group of (region) proposed that hospitals should be accredited as Trauma Reception Hospitals with a policy for the response to the arrival of a trauma patient. These requirements include specific criteria for Orthopaedics. Methods: To evaluate if these criteria are being fulfilled, we carried out an audit comparing the response in the hospitals within the (region) deanery to the arrival of major trauma. All consultant and middle grade orthopaedic surgeons on call for trauma were contacted and questioned as to their ATLS provider status and involvement in the ‘‘trauma call’’. Results: Sixteen hospitals were included. Thirteen have a ‘‘trauma team’’. One hundred and ninety-one surgeons (96% response) were included. One hundred and seventy-five have completed an ATLS course. Of these, 72 (41%) had out of date qualifications. Only 9 (13%) were waiting to revalidate. Variation was seen in the frequency of Accident and Emergency department attendance by different grades of surgeon for major trauma. Discussion: All hospitals have a response for major trauma although variations occur. The vast majority of orthopaedic surgeons in (region) have been adequately trained in ATLS management (more so than any study has previously shown), particularly the middle grades, who are usually first to attend. The level of revalidation is low and reasons for this are discussed with recommendations for revalidation in the future. The benefits of exposure to chronic low dose radiation in the operation theatre-Will Orthopaedic surgeons live longer as their radiology colleagues? A.J.S. Kumar, D.M. Power, K. Mangat E-mail address: [email protected]. Roentgen announced his discovery of X-rays in December 1895. Many studies have shown that the doses received by orthopaedic surgeons fall within the current safety guidelines, but at the same time, emphasises concern over the effects of long term exposure to low dose radiation [7—9]. A revolution-

16

ary 100 year observational study on British Radiologists published in the British Journal of Radiology [14] reveal the health benefits of exposure to chronic low dose radiation. Some authors describe this study as the most important article about the health effects of radiation on humans ever published [17]. The article calls attention to the health benefits of a moderate radiation dose rate. The very significant decrease in the deaths from non- cancer deaths and lack of increase in cancer deaths in radiologists after 1920 makes it apparent that the recommended dose limits for radiation workers are set too low for good health. The most dramatic results are seen in radiologists registered after 1955, who had a 32% lower SMR for deaths from all causes than that of all physicians and the SMR for non- cancer deaths was 36% lower. According to Cameron, this demonstrates a highly significant beneficial effect of radiation at moderate doses of radiation. Cameron concludes that the above studies gives evidence that humans need a level of radiation above natural background radiation and there may be such a thing as radiation deficiency. An orthopaedic surgeon involved in trauma, would definitely be chronically exposed to this level of radiation. Although Roentgen discovered the Xray just more than 100 years back, fluoroscopy in Orthopaedics has increased only in the last 30 years. In all probability, the next time when one hurries to wear a lead apron in the operation theatre we might be able to do that with a smile. Occult fracture of the hip: a clinical and radiological correlation A.C. Maury, W.S. Roy, J. Lewis, C. Carpenter, R. Brown, J. Davies E-mail address: [email protected]. Introduction: Hip fractures are usually evident on plain radiographs. Some are not obvious and require further investigation. A review of the pertinent literature reveals different treatment algorithms for such patients but MRI is recommended as the investigation of choice. Little is stated about the clinical findings in patients with an occult fracture of the hip. Aims: To investigate any correlation between clinical findings and the presence of fracture on MRI in occult fracture of the hip and use this as a means of speeding the diagnosis of such patients. Methods: We report a prospective, multi-centre trial. Twenty-two patients admitted with a suspected occult fracture of the hip were assessed clinically for evidence of resting deformity, ecchymosis,

Abstracts

point tenderness, hip pain on heel percussion or pistoning and ability to straight leg raise (SLR). The same features were assessed in the contralateral limb. All patients were alert and orientated as to comply with examination. Plain radiograph and MRI findings of both hips were recorded in each case. Results: Of 22 patients, 17 were unable to perform SLR on the affected side, 5 were able to do so. Of the 18 patients, all had a fracture of either the acetabulum or proximal femur on MRI. Of the group of 5, 2 had normal MRI scans, 1 had a pubic ramus fracture, 1 had bone marrow oedema secondary to osteoarthritis and 1 patient had a 6 week old valgus impaction fracture. All patients could SLR and had normal MRI of the contralateral hip. Conclusions: Under the conditions of this study straight leg raise test is 95% sensitive and 95% specific for predicting the presence of fracture in either the acetabulum or proximal femur. We recommend that this simple test can be used to help speed up the diagnosis of and further management of occult fractures of the hip. Fracture shaft of clavicle–—an indirect injury from bench pressing: a case report and review of literature Chima Mbubaegbu, FRCS (Orth); Consultant Orthopaedic Surgeon, Inder Gill FRCS; Senior SHO Orthopaedics E-mail address: [email protected]. Weight lifting in its various guises has become common as the society has become more health conscious. The development and hypertrophy of the muscles, which occurs with training, can result in their power being more than the supporting bony structures can cope with. We report a case of fracture of the clavicle occurring due to violent muscle contraction during bench pressing. A 28year-old right hand dominant male was lifting about 100 pounds of weight doing bench presses lying on his back, when he suddenly heard a crack in his right shoulder. Several types of injuries have been reported during weight training. Weight lifters have an increased incidence of both proximal and distal clavicle osteolysis. This is the first report of fracture of the shaft of the clavicle due to a single event of muscle contraction. Our case does not appear to be a problem with technique but rather shear strength overcoming the resistance of the bone. Body builders should be made aware of the risks that are associated with muscle bulk development in bony struts with muscles acting at its ends.

2003 Meeting of the British Trauma Society

Delays in open fracture management: where do they occur? Robert U. Ashford, Antonio Frasquet-Garcia, Kalpit K. Patel, Peter Campbell E-mail address: [email protected]. Six hours (360 min) from injury to surgery is regarded as the gold standard for the management of open fractures. We reviewed the case notes and radiographs of all patients admitted to our hospital with open fractures over a 12-month period to identify where delays occur. Patients were identified from the operating theatre register and data were gathered from ambulance records, emergency department and orthopaedic notes and radiographs. Twenty-nine patients (23 male, 6 female) sustained open fractures necessitating orthopaedic treatment between January and December 2002. The mean age was 41 (range 11 to 90). In 9 patients there were multiple orthopaedic injuries. No data was obtainable on 1 patient because of his transfer to a tertiary centre. The mean time from injury to surgery was 527 min (283—1175) and from arrival in the emergency department to surgery 437 min (192—1047). The mean time from arrival to being seen by an Emergency Department doctor was 21 min (range 0—111). The mean time to obtain limb radiographs was 51 min (0—128), with slightly longer being necessary for the polytrauma patients (mean 65 versus 46 min). The mean time from limb radiography until orthopaedic review was 31 min. However, a mean time of 325 min elapsed between the orthopaedic SHO reviewing the patient and them getting to theatre. There were no significant differences in times for those patients arriving in normal working hours and those arriving out of hours. This study shows delays occur at all stages of open fracture management. The principal delay is between orthopaedic assessment and getting to theatre. The aim must be to improve theatre access, reduce radiographic delays and generally speed patients through the system. A proforma may be the way to achieve this. Paediatric atlas fracture following minor trauma– —delayed displacement through synchondrosis V. Kapoor, B. Theruvil, B. Watts, M.R.N.R. Boeree, J. Fairhurst E-mail address: [email protected]. We present a unique case of a 21-month-old boy with a fracture of the synchondrosis of the atlas. There was history of minor trauma (fall from a

17

cardboard box, the child landing on his bottom with his head flexed forwards) following which the initial radiographs and CT scan did not reveal a fracture. However, 48 h later the child developed cervical muscle spasm and torticollis and subsequent CT scan at 6 days showed synchondral separation of the arch of C1 vertebra. The child was treated in Halter traction for 3 weeks and a repeat CT showed stable appearances. Following traction the child was sent home with a soft collar for 6 weeks. At 1-year follow-up, there was full recovery and the child was discharged. Delayed displacement of paediatric atlas fractures is unusual and to our knowledge this has not been reported in the literature previously. Due to rarity of the fracture and the paucity of literature, experience in treatment is limited. Recommended treatment is immobilisation in a rigid brace. There are however practical difficulties in the use of a rigid brace in a child of only 21 months. In this case halter traction provided the necessary stability and correction and was well tolerated by the child. The potential consequences of missing an injury at this site may suggest that protection, in the form of a collar and further radiological evaluation after a few days may be indicated in suspicious cases. The case also emphasises the strong predictive value for fractures of the atlas, when there is a combination of pain, neck spasm, decreased range of head movement and torticollis. Limitation of non-surgical management using transcatheter arterial embolization (TAE) in patients with severe hepatic injuries–—the efficacy of focused assessment with sonography for trauma (FAST) Akiyoshi Hagiwara, Atsuo Murata, Takeaki Matsuda, Seiki Sakaki, Shuji Shimazaki Department of Traumatology and Critical Care Medicine, Kyorin University School of Medicine, 6-20-2 Shinkawa Mitaka-Shi Tokyo 181-8611, Japan E-mail address: [email protected]. Object: To determine the limitations of nonsurgical management using TAE for a severe blunt hepatic injury. Materials and methods: FAST was performed to all the patients with blunt abdominal injuries. All the patients whose hemodynamics were improved by fluid resuscitation underwent contrast CT, and those who had hepatic injury as defined the American Association for the Surgery of Trauma (AAST) grade > III underwent angiography. The patients who had angiographic evidence of contrast extravasation underwent TAE. Non-surgical management were successfully performed in all the patients who

18

had Grade III hepatic injury. Therefore, in the present study, we focused on patients with Grade > IV hepatic injury to clarify the limitations of nonsurgical management. Results: 70 patients with Grade > III hepatic injury were admitted to our hospital between 1997 and 2002. Among them, 20 had grade > IV hepatic injury and underwent TAE. Six of the 20 patients went into shock after TAE and received emergent laparotomy. Of these 6 patients, 3 had retrohepatic IVC injury. The other 2 had juxtahepatic venous injuries and 1 had an injury at the origin of the posterior portal vein. The two patients who underwent lobectomy died. In all the 6 patients who received emergency laparotomy after TAE, the FAST performed on admission showed diffuse hyperechoic area >10 cm in diameter and fluid collection in Douglas pouch, perisplenic space and Morison’s pouch. The volumes of fluid resuscitation needed from admission until completion of TAE ranged from 2109 to 3500 ml/h. Conclusion: All the patients, in whom hyperechoic area >10 cm and fluid collection in at least 3 anatomical positions were observed on FAST and who required >2,000 ml/h of fluid resuscitation, had AAST Grade > IV hepatic injury with juxtahepatic venous injury or retrohepatic IVC injury. They absolutely should receive emergent laparotomy. A short series of four uncommon cases on complex paediatric elbow trauma H. Sharmaa, G.R. Taylorb a

Specialist Registrar in Trauma and Orthopaedics, Monklands Hospital, Airdrie ML6 0JS, UK b

Consultant Orthopaedic Surgeon, Southampton Gen. Hospital, Southampton SO16 6YD, UK E-mail address: [email protected]. Complex paediatric elbow fractures are quite unusual to encounter. The management of such fractures can be technically demanding. A short series of four cases of complex paediatric elbow trauma comprising of fracture lateral condyle in association with posterior dislocation of elbow (one case), intercondylar—transcondylar fracture of distal humerus (one case), and fracture lateral condyle along with olecranon fracture (two cases) is presented. The average age was 9.25 years. All the patients were male and sustained a direct elbow trauma. The elbow stability was assessed under general anaesthesia. All the patients had closed/open reduction and fracture fixation using kirschner wires. The average life span of k-wire was 4.3 weeks in this series. All the patients in this series had an uneventful recovery with a satisfactory outcome.

Abstracts

In conclusion, open pinning is recommended to anatomically align and restore the growth plate and articular surface. A contralateral comparison elbow radiograph should be ordered by the emergency department in all such cases as the fracture line may be difficult to interpret sometimes and a helpful adjunct in comparing the achieved position after reduction. A clinico-radiologic weekly follow-up post-operatively can help in early diagnosis of loss of reduction. The anatomical reduction and fixation of lateral condyle fracture is of prime importance as it constitutes Salter Harris type IV injury to avoid nonunion, abnormalities in carrying angle, a prominent lateral humeral condyle and tardy ulnar palsy. Blackthorn injury related exploratory findings and clinical outcome H. Sharmaa, A.D. Meredithb a

Specialist Registrar, Department of Trauma and Orthopaedics, Monklands Hospital, Airdrie ML6 0JS, UK b

Consultant, Department of Trauma and Orthopaedics, Bronglais General Hospital, Aberystwyth SY23 1ER, UK

E-mail address: [email protected]. Aims: To analyse various manifestations, and to evaluate the clinical outcome in the patients, who had exploratory procedures following Blackthorn (Prunus spinosus) injury. Design: A retrospective case series. Setting: A District General Hospital of the UK. Participants: A consecutive series of 18 patients admitted between April 1997 to March 2001. Main outcome measures: Final clinical outcome in the patients, who had undergone exploratory procedures following Blackthorn injury. Results: In all the cases, the site of injury was the upper limb. The mean age at presentation was 39.1 years. There was a male predominance (83.33%) and a marginal right side preponderance. The majority of the patients (83.33%) presented between March and August, which correlates with hedge-cutting time. The mean delay in presentation was 3 days (range, 1—14 days). The patients were followed-up for a mean of 18 months (range, 6 months to 4 years). The final post-operative outcome was satisfactory in all cases. We observed joint stiffness in two cases, scar tenderness in one case (had reexploration and digital neurolysis) and minor wound infection in one patient, which were resolved in due course. Conclusions: We conclude that conservative treatment alone failed to resolve the symptoms.

2003 Meeting of the British Trauma Society

We recommend that all patients presenting with a history of Blackthorn injury should undergo an immediate and thorough exploration to avoid undue complications. Bilateral sleeve fracture of the patella in a healthy child H. Sharmaa, S. Goyalb, G.K. Singhb, S. Richardsc, P. Calvertc a

Specialist Registrar in Trauma and Orthopaedics, Monklands Hospital, Airdrie ML6 0JS, UK

b

Department of Trauma & Orthopaedics, St. Richard’s Hospital, Chichester PO19 6SE, UK

c

Department of Trauma & Orthopaedics, St. George’s Hospital, London SW17 0QT, UK E-mail address: [email protected]. Complete avulsion of the proximal insertion of patellar ligament with or without a small fleck of bone and a portion of patellar articular cartilage constitutes a sleeve fracture of the patella. Patellar Sleeve fractures are relatively rare in children. They involve the cartilaginous portion of the patella, and can be missed in the initial evaluation of the knee. Missed diagnosis is not uncommon as extension function of the knee may be intact with minimum radiologic findings. Sinding-Larsen-Johansson disease and Osgood Schlatter disease should be differentiated as these conditions are managed conservatively in contrary to the management of sleeve fractures. A bilateral simultaneous sleeve fracture following trauma in an otherwise fit and healthy 8-year-old girl is presented, who was treated by open reconstitution with a satisfactory outcome. Hadlow and Medlicott (1987) reported a case of bilateral simultaneous sleeve fracture in a child with secondary hyperparathyroidism. To the authors’ best knowledge, a case of bilateral simultaneous sleeve fracture occurring in a healthy child has never been reported. The controversy between the usage of absorbable versus non-absorbable sutures is critically analysed by the available evidences.

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Background and aims: Diagnostic errors in orthopaedics are usually caused by missing a fracture or misreading radiographs. The aim of this study was to document the pick-up rate of the wrong diagnoses by reviewing X-rays and casualty notes in the next day trauma meeting. Methods and materials: The casualty notes and radiographs of five hundred patients were prospectively reviewed in the daily trauma meeting between August 2002 and December 2002 in a district general hospital. These were seen by several members of the orthopaedic department attending the meeting. The relevant data were collected and analysed by a single assessor. Results: The false positive rate for making an orthopaedic diagnosis was 12.6% (i.e. diagnosing a fracture, when none existed). The false negative rate was 4%, while 2.4% incidental findings were missed or at least not documented after reading the X-rays. There were 7.8% wrong diagnoses made. The majority of the patients were seen by the senior house officers. Conclusion: The medicolegal significance of missed diagnoses is obvious. This study shows the importance of final radiological consultant interpretation in a small to medium size accident and emergency units where junior doctors see patients out of office hours. A morning orthopaedic trauma meeting to review radiographs is an effective risk management solution to early detection of missed injuries. Girdlestone resection arthroplasty failed operated hip trauma

following

H. Sharmaa, J. De Leeuwb, D.I. Rowleyc a

Specialist Registrar, Department of Trauma and Orthopaedics, Monklands Hospital, Airdrie ML6 0JS, UK b

Consultant, Department of Trauma and Orthopaedics, Falkirk and District Royal Infirmary, Falkirk FK1 5QE, UK

c

A prospective study on 500 orthopaedic referrals in order to find a cost effective risk management solution for diagnostic errors H. Sharmaa, W. Gaineb a

Specialist Registrar in Trauma and Orthopaedics, Monklands Hospital, Airdrie ML6 0JS, UK b

Consultant Orthopaedic Surgeon, Falkirk and District Royal Infirmary, Falkirk FK1 5QE, UK E-mail address: [email protected].

Professor, Department of Trauma and Orthopaedics, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK E-mail address: [email protected]. Background and aims: Girdlestone resection arthroplasty is well described in the literature as a salvage procedure for control of infection and pain relief in failed total hip arthroplasties. No studies have been published evaluating the outcome of Girdlestone operation following failed operated hip trauma. The aim of this study was to evaluate the mortality characteristics and functional outcome of

20

Girdlestone procedure following failed operated hip fractures. Materials and methods: From 1993 to 2002, the case notes and charts of 22 patients were retrospectively reviewed. The indications were failed osteosynthesis (8), septic hemiarthroplasty (9), aseptic loosening of hemiarthroplasty (3) and recurrent dislocation of hemiarthroplasty (2). Results: Fifteen patients died with an overall mortality of 68.18%. The mean age was 78.8 years with 80% female preponderance in the mortality group. All seven surviving patients had a failed hemiarthroplasty. There were septic hemiarthroplasty (5), sepsis with recurrent dislocation (1) and recurrent dislocation (1). There were five females and two males. The mean age was 78.8 years. The patients were followed-up for a mean 38 months (range, 6 months to 8 years). Pain relief was achieved in 100% patients with none to mild pain in the hip. All the patients had their infection controlled with 85.71% cases needing some kind of walking aid for mobility. Overall 85.71% patients expressed their satisfaction in Girdlestone procedure. Conclusions: This study reiterated that Girdlestone procedure is effective in achieving infection control and pain relief to salvage failed operated hip fractures. We believe a high mortality could be attributed to higher age group, poor general health and highly selected group of patients. Such patients must be warned to expect two to three inches of limb shortening and invariable assisted mobility post-operatively. Future studies with larger number of patients utilising results from multiple centres may reveal more meaningful results. Guided gesture without visual control in trauma T. Gautherona, F. Leitnerb, B. Braunb a

Centre Hospitalier, Moutiers, France

b

Grenoble, France

E-mail address: [email protected]. Introduction: The Orthopilot Trauma Project is a way to navigate a C-arm device in order to align its main axis along some useful structure. For instance, aligning its axis to the locking hole of an intramedullary nail will afterwards permit to navigate a drilling guide. We report a preliminary study with sawbones. Material and methods: The final goal is to provide an easy way to adjust a geometrical model with a standard C-arm without transition of picture as shown before, with fluoronavigation. The system is independent from any image transfer between the C-arm and the OrthoPilot.

Abstracts

Additionally this technique removes all X-ray shots on the surgeon hands. Results: After a phase of training related to the originality of the step to perform at the locking of a tibial or femoral nail, we henceforth manage to carry out the two sequences:  obtaining perfectly circular distal holes,  then installation of one to three screws for distal locking, with only 3 to 4 impulses of the amplifier. Moreover, the exposure of the hands in the primary education beam is no more necessary. Discussion: Results on sawbones validate this original concept of assistance to the distal aiming by clearly decreasing the irradiation. This preliminary experiment on dry bone enabled us to validate the concept of assistance to the orientation of the patient on the operational table to obtain perfectly round holes without using the X-rays intensifier. It is a less complex system than the fluoronavigation. It does not require any image transfer and is easier to implement. Soon we will possibly validate the experiment on corpse and then on wounded people. Conclusion: The locking of a nail does not inevitably require a data-processing platform, but thanks to this module of traumatology this platform brings a global solution to computer-assisted surgery. The use of cortical strut allografts for periprosthetic fractures of the femur R.J. Rees, J. Metcalf, W. Hart, R. Spencer-Jones E-mail address: [email protected]. Introduction: There are approximately 50000 hip and knee arthroplasties performed in the UK every year. With this increasing number the prevalence of periprosthetic fractures is also rising. These are often challenging problems with increased morbidity and mortality. The use of cortical strut allografts in periprosthetic fractures was first reported in the early 90’s with favourable results. The aim of this study was to assess the radiological outcome of cortical strut allografts used as the treatment for periprosthetic fractures of the femur in patients presenting to our institution. Patients and methods: 17 patients with who had received strut allografts as part of their treatment for a periprosthetic fracture of the femur were identified. Thirteen fractures were around a total hip replacement and 4 around other femoral implants (2 long stemmed TKRs and 2 fracture fixation devices). We undertook a radiological evaluation of this technique. We assessed fracture union and strut allograft incorporation using the radiological criteria of Emerson et al. The procedure was deemed a

2003 Meeting of the British Trauma Society

success if the fracture had united, with evidence of graft incorporation with a stable implant. We also undertook a notes review identifying any risk factors and any previous surgery. Results: Two patients died in the early postoperative period. Fifteen patients were available for analysis. The average length of radiographic review was 16 months. Eleven out of fifteen procedures (73%) were deemed a success. All these showed evidence of graft incorporation which was time dependent. There were four failures. In one patient the struts fractured at 2 months. There were three cases of deep sepsis, this required amputation in one and excision arthroplasty in two. Conclusion: Cortical strut allografts are a good technique for the management of periprosthetic fractures of the femur. As well as providing initial support they also become incorporated which improves the host bone stock. Forearm plate removal in children M. Zenios, U. Abdulkadir, A. Kumar, M.A. Pena E-mail address: [email protected]. Plating of forearm fractures is considered the standard method of fixation in adults. In children, even though forearm fractures can be treated by manipulation and plaster application, since a degree of angulation is accepted, a number of unstable fractures are treated by internal fixation either using wires or plates. When plates are used for fixation and once the fracture has healed the surgeon needs to decide whether to remove the plates or not. In the past, high complication rates have been reported following metalwork removal in adults. The aim of this study was to identify whether the same complication rate applies to children. We retrospectively reviewed 45 children who had forearm plates removed following forearm fractures over a 10-year period. All operations were performed as elective procedures once the fractures united. We report three cases of refractures (2 in the same patient), one superficial infection successfully treated with antibiotics and no new neurological injuries. Considering our low complication rate and the fact that leaving forearm plates in situ for the rest of the life of a young patient is not a benign practice we conclude that forearm plates in children should be removed once the fracture has united. Plaster immobilisation in acute metatarsal fractures–—a prospective randomised controlled trial M. Zenios, W. Kim, B.N. Muddu E-mail address: [email protected].

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Fractures of the lesser metatarsals are the commonest injuries in the foot. The existing literature supports early mobilisation and weight bearing for these injuries. The aim of this study was to investigate the need for plaster immobilisation in metatarsal fractures. A randomised prospective controlled trial of all patients over the of 16 seen in the A&E department with an undisplaced fracture of a lesser metatarsal was performed. Forty patients were randomised in two groups. Group 1 received a below-knee weight bearing cast made of light-weight bearing synthetic material and group 2 received tubigrip bandage. The exclusion criteria were: Jones fractures, open fractures, stress fractures, first metatarsal fractures, multiple fractures, pathological fractures and very elderly and infirm patients. All patients were reviewed for 3 months. There was no difference in analgesic requirements between the two groups during the first 7 days. At 3 months all fractures united but patients treated without a plaster had a significantly higher AOFAS mid foot score. We conclude that plaster immobilisation in the treatment of undisplaced metatarsal fractures should be avoided. MRSA wound infection following implant surgeries in trauma patients colonised with MRSA pre-operatively D. Sunderamoorthy, S. Ahuja, A. Grant E-mail address: [email protected]. Introduction: Patients admitted to the trauma wards are routinely screened for MRSA pre-operatively. Majorities of them have implant surgeries performed before the screening results are available. In elective orthopaedic implant surgery MRSA positive swab would mean cancellation of proposed operation till the patient is MRSA negative. Aim: The aim of our study was to identify the incidence of MRSA wound infection in trauma patients who are MRSA positive pre-operatively and their outcome following the infection. Materials and methods: We randomly reviewed 40 trauma patients who were colonised with MRSA pre-operatively and had implant surgeries. The case notes, drug charts and the microbiology reports were reviewed to identify the incidence of MRSA wound infection and its outcome in these patients. The place of residence, site of colonisation and the treatment given were also considered. Results: 70% of the patients were admitted from home and 35% had previous admission within 1 year. The commonest site colonised was the nose (55%) followed by the perineum in 20%. Multiple sites were

22

colonised in 10% of the patients. Only 50% patients with MRSA positive nasal swabs were given nasal bactroban. Chlohexidine wash was given in only 70% of them with MRSA colonisation in other areas. Post-operatively 22.5%% (9/40) of the wound grew MRSA and they were treated with vancomycin or teicoplanin. Wound debridement and washout was needed in 62.5% of the patients. Seventy-five percent of MRSA infected wound healed well with normal swabs after treatment. Twenty-five percent MRSA infected wound had persistent MRSA in the wound. Hand injuries–—how do they happen? D. Sunderamoorthy, A. Sayuti E-mail address: [email protected]. Aim: The aim of our study was to determine the characteristics, causes and disposal of isolated hand injuries that attended the accident and emergency department. Materials and methods: All the patients attending the accident and emergency department with hand injuries during the period December 2001 to middle of February 2002 were studied prospectively. Results: 162 patients with hand injuries attended the A&E. The age range 5—92 years with a mean of 25 years. The male to female ratio was 2.3:1. Ninety-eight percent of them were right handed and the right hand was injured in more than 50% of the patients. The commonest mechanism of injury was fall. Forty percent of the injuries occurred at home and 15% at work. X-rays were done in more than 2/3 of the patients, and there were equal no fractures, lacerations and bruises, i.e. 30%. The thumb, index and the fifth metacarpal were commonly injured. Ninety percent of the injuries were treated in the A&E and 10% were referred to the orthopaedic surgeons. Conclusion: Hand problems are common in A&E practice and doctors in A&E given adequate training; supervision and support can manage most simply and successfully. Risk assessment of IV sedation by non-anaesthetist for fracture reductions and dislocations–—are we following the guidelines? D. Sunderamoorthy, Byreddy E-mail address: [email protected]. Aim: To assess whether proper risk assessment of patients having intravenous sedation for fracture reductions and dislocations in the accident and emergency department by the non anaesthetist are being done in accordance with Royal College Guidelines.

Abstracts

Materials and methods: We did a retrospective audit of intravenous sedation done in the accident and emergency department for reduction of fractures and dislocations during the period February 2002 to May 2002. We looked at the A&E notes to collect the data. Results: 20 patients had intravenous sedation during the above period. The male: female ratio was 1:1. The average age was 39 years with a range of 18 to 82 years. Majority of it was for reduction of shoulder dislocation followed by Colle’s fracture reduction. Midazolam had been used in all patients and morphine in 50% of them in addition to midazolam. Only 50% were consented and the fitness for the procedure recorded in 25% of the patient notes. Vital signs were recorded in the notes in only 75% of patients prior to the procedure. All had supplementary oxygen. The vital signs during the procedure were recorded in 25% of the notes. Ninety-five percent of the patients were not given advice after sedation. Conclusion: The above audit shows that the guidelines for intravenous sedation by the nonanaesthetist in the accident and emergency department have not been followed. We recommend that every attempt should be made to in the future to follow the guidelines and re-audit the same to meet the guidelines. Muller straight stem total hip arthroplasty for fractured neck of femur Kalpit K. Patel, Robert U. Ashford Cath Booth, Antonio Frasquet-Garcia, Steve Joseph, P. DeBoer E-mail address: [email protected]. Although the current belief is that there is a role of total hip arthroplasty for the treatment of displaced intracapsular fractures of the proximal femur; it remains controversial due to the conflicting results of the studies published so far. It has been our experience that Muller hip replacement gives satisfactory results with low complication rates in acute fracture neck of femur patients who are physiologically active. A total of 50 patients (42 females, 8 males) over a 10-year period were treated under a single consultant firm at a district general hospital and were included in this retrospective study. Case notes and radiographs were reviewed for obtaining data. The mean age at the time of operation was 74 years (range 56—90 years). Forty-four percent had enjoyed unrestricted activity before the fracture neck of femur. The operations were performed through a anterolateral approach and a cemented Muller straight stem prosthesis was implanted. Post-operative

2003 Meeting of the British Trauma Society

rehabilitation was routine as for any hip replacement. At a mean follow-up of 59 months 11 patients had died of unrelated causes. The remaining 39 patients were assessed with a standard proforma utilising Merle d’Aubigne- Postel score with particular emphasis on functional outcome and radiographs to ascertain loosening. The early post-operative complications including urinary retention (1), superficial wound infection (1), pulmonary embolism (1), respiratory problems (2) resolved completely with conservative treatment. One patient had an early dislocation; it relocated under anaesthetic and had no subsequent complications. No revision hip operations were performed. This study shows excellent results with very low dislocation rates and survivorship of many Muller hip replacements at 10 years is better compared to previous similar studies. This might be due to larger (28 mm) head size. Hence we believe it to be a safe and a viable treatment option in fracture neck of femur patients. The Kent hip in periprosthetic femoral fractures S. Sinhaa, C.A. Stosselb a

Kent & Canterbury, UK

b

Maidstone Hospital, Kent, UK

E-mail addresses: [email protected]; [email protected]. Periprosthetic fractures are increasing in frequency and in complexity These usually occurs at low energy levels either after falls or spontaneously during activities of daily living. Periprosthetic femoral fractures are technically demanding to treat as well as those of revision arthroplasty. Developed from the idea of the Huckstep femoral interlocking nail, the Kent hip was introduced in 1986 by C.A. Stossel for the treatment of periprosthetic fractures. The Kent hip is fixed to the femoral shaft by interlocking screws. The two objectives of immediate weight bearing and to avoid the need for bone grafting were achieved. Since the introduction of Kent hip, it has been used for more than 400 patients at Maidstone, Kent, UK. Forty percent of those patients were of traumatic periprosthetic femoral fractures. A maximum follow up of 15 years are presented with excellent results. Because of the simplicity of the system and its instrumentations, it has been used in about 40 countries. The goals of treatment in periprosthetic femoral fractures were achieved. In major trauma unit up to 50% of the femoral periprosthetic fractures may require a Kent hip. As such the Kent hip may be regarded as a product for the trauma unit.

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Massive degloving injuries in patients; a management protocol

multi-trauma

B.A. De Souza, A. Ghattaura, C. Nduka, G. Moir, N. Carver, M. Shibu E-mail address: [email protected]. Introduction: Severe multi-trauma injuries which include degloving injuries have not been classified this is important to recognise and hence refer to the appropriate team or treat accordingly. ATLS training provides protocols for the initial management of trauma and is essential for staff dealing with such trauma patients especially in the Accident and Emergency department. However, there is no reference to assessment for degloving injuries or a classification system to indicate severity. Patients: We would like to present 15 cases and summarise their clinical presentations and management procedures. Discussion: Our results show that the outcome of major degloving injuries depends on good thorough debridement and timing of surgery to heal the large raw surfaces. We also advocate the use of vacuum suction therapy as a means of dressing the wounds to act as an intermediate phase for wound closure. We also advocate the use of vacuum suction therapy to hold large areas of skin grafts in place. Finally, we propose that degloving injuries be included in the ATLS secondary survey and put forward a classification system. The islanded gastrocnemius muscle flap in lower limb trauma B.A. De Souza, G. Moir, M. Shibu Department of Plastic Surgery, Royal London Hospital, Whitechapel, London E1 1BB, UK E-mail address: [email protected]. Pedicled gastrocnemius flaps either medial or lateral are used to cover exposed bone around the knee joint, however, in large defects it is not possible to cover the defect unless the two heads of muscle are used. Islanding the muscle flap will give rise to extra length (¼5 cm) of the flap allowing closure of such larger defects. The islanded pedicled gastrocnemius has been used to cover 10 large defects of exposed knee joints. All these cases were due to trauma, the one exception was skin necrosis over the knee joint induced by frequent needle aspirations. The islanded gastrocnemius flap was successful in covering the knee joints in all cases and there was no complication of the muscle flap. The details of the operative procedure and results are discussed.

24

The technique of islanding the gastrocnemius muscle flap is relatively quick, easy to execute and perhaps reduces the necessity of free flaps. To conclude, we have found this reconstructive procedure is relatively quick, simple and cosmetically favourable with minimal donor site morbidity. Perioperative liberation of proinflammatory cytokines in blunt trauma patients-clinical relevance of biochemical markers F. Hildebrand, M. van Griensven, C. Krettek, H.C. Pape Trauma Department, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover E-mail address: hildebrand.frank@mh-hannover. de. Background: The aim of this study is to asses the associations between timing of secondary definitive fracture surgery on inflammatory changes and outcome in polytrauma patients. The study population comprises trauma patients who were managed using a strategy of primary temporary skeletal stabilisation followed by delayed definitive fracture fixation. Methods: In a prospective cohort study, the patient’s injury and operative details as well as immune markers and clinical outcome were studied. The patients were split into an early secondary surgery group (ESS, surgery at days 2—4) and a late secondary surgery group (LSS, surgery at days 5—8). During the posttraumatic course, inflammatory markers (interleukin-6, tumor necrosis factor a) were determined on a daily basis. Perioperatively, these markers were additionally evaluated at 30 min, 7 h and 24 h after initiation of surgery. Results: Secondary surgery on days 2—4 was associated with a higher incidence of post-operative organ dysfunction (n ¼ 33, 46.5%) than secondary surgery on days 5—8 (n ¼ 9, 15.7%, P ¼ 0:01). A significant association between the combination of initial IL-6 values > 500 pg/dl þ surgery on days 2—4 and the development of MOF (r ¼ 0:96, P < 0:001) occurred. A correlation between the initial IL-6 values > 500 pg/dl and surgery on days 5—8 (r ¼ 0:57, P < 0:07) could not be found. IL-6 demonstrated a predictive value for the development of MOF: IL-6 > 500 pg/dl in group ESS, r ¼ 0:96, P < 0:001; IL-6 > 500 pg/dl in group LSS r ¼ 0:57, P<0.07. Conclusions: No distinct clinical advantage in carrying out secondary definitive fracture fixation early could be determined. In contrast, in patients who demonstrated initial IL-6 values above 500 pg/dl, it may be advantageous to delay the interval between

Abstracts

primary temporary fracture stabilisation and secondary definitive fracture fixation for more than 4 days. In trauma patients undergoing primary temporary fixation of major fractures, the timing of secondary definitive surgery should be carefully selected, because it may act as a second hit phenomenon and cause a deterioration of the clinical status. Digital imaging on-call; making everyone’s lives easier Matt Freudmann, M. Arafa E-mail address: [email protected]. Digital Imaging is now commonplace. However, very few trauma departments are using it to their advantage. All you need is a digital camera and Internet access to enable the on-call trauma consultant to view the X-rays of any trauma case from the comfort of their own home. Thus, consultants get to base decisions on visual as well as verbal information and may avoid trips in to hospital. Certain patients can avoid being starved unnecessarily for theatre whilst others may avoid admission to hospital altogether. The more urgent cases may get their operation sooner whilst those operated on by the registrar may get a more appropriate operation. We present one DGHs experience of digital imaging on-call and demonstrate not only how easily it can be done, but also how it benefits the patient, the consultant, the registrar and the hospital. At the end of this presentation, the whole audience will be left wondering why they have not been doing it in their hospital! Traumatic anterior shoulder dislocation in the young patient: what do you do? Matt Freudmann, Stuart Hay E-mail address: [email protected]. Aims: We set out to discover how this common injury is treated by shoulder surgeons in the UK. Methods: 164 consultant orthopaedic surgeons, all members of the British Elbow and Shoulder Society were sent a comprehensive three-page questionnaire asking for details of how they treat these patients. Topics covered included investigations performed, conservative management, indications for and timing of operative intervention, details of preferred stabilisation procedure, postop rehabilitation and more. Results: The response rate was 83%. We identify three schools of thought on stabilisation surgery and highlight the difference between the groups. Conclusions: There is still a lack of consensus on how best to manage these patients. It seems

2003 Meeting of the British Trauma Society

that open stabilisation is still the firm favourite with arthroscopic stabilisation being the operation of choice for only 16% of the UK’s shoulder surgeons Reverse boot traction–—a novel technique for operative management of trochanteric fractures in patients with ipsilateral below knee amputation A. Bhargava, H.V. Nagesh, C. Brooks E-mail address: [email protected]. Aims: Operative treatment of trochanteric fractures in patients with below knee amputation on the same limb is a rare and challenging problem. This is difficult not only because of the absence of foot but also due to coexisting medical problems. The aim of this study was to analyse the problems involved in the treatment of this rare problem. Methods: We reviewed 13 such patients being treated at East kent Hospital Trust over 7 years between Nov 1993 and Dec 2000. All patients were treated by DHS fixation. Six of these had Reverse boot traction applied during surgery and seven of these had upper tibial pin traction. Results: We observed that boot traction is easy and quick method with less complications. Also these patients rehabilitated better than pin traction group. They started using their prosthesis in 3 days as compared to 7 days in pin traction group. Patients in whom Reverse boot technique was used were discharged home earlier (in 14 days as compared to 21 days) than patients who had pin traction applied during surgery. Conclusions: Although this study included a very small number of patients but it is a largest of its type. Based on our results we recommend that reverse boot traction should be used in all such patients. Is there a role for blood products in the initial resuscitation of trauma patients in the prehospital setting? A review of the literature Stephen L. Richey (CRT, EMT-I/D) Respiratory Therapist, Healthsouth Rehabilitation Hospital, Terre Haute, IN, USA Clinical Laboratory Science Student, Indiana State University, Terre Haute, IN, USA E-mail address: [email protected]. Despite the well demonstrated safety of ‘‘universal donor’’ blood product replacement in both civilian and military emergency medicine, patients that emergently need transfusion are forced to wait for hospital to receive this treatment. Leading

25

experts in the care of trauma patients are advocating less aggressive fluid resuscitation because of the potential risk of increased bleeding resulting from dilution of the coagulation factors and from increase in blood pressure prior to control of bleeding. Limited resuscitation to levels recommended in ‘‘permissive’’ hypotension (90 mmHg systolic) can be accomplished in critical trauma victims as effectively with packed red blood cells as it can with any saline or Ringer’s solution. The increase in the availability of point-of-care testing has allowed the capability of monitoring hemoglobin and hematocrit to move from the laboratory to the patient compartment of an ambulance. There is no redistribution of blood products as is seen with other forms of fluid resuscitation thus limiting the volume that must be administered. The risk of transfusion reaction (due to reasons other than misidentification of blood types by lab personnel) is estimated based on retrospective studies at 1 in 250,000 units of blood. This risk can be totally negated by the use of autotransfusion of blood recovered from chest tubes inserted to manage hemothoraces. The capability to administer packed cells is most likely to be of greatest benefit in cases where the transport time to definitive care is greater than 20 min. The use of blood products is already fairly well established amongst aeromedical services in the United States. There is no compelling evidence to prevent to the migration of this capability to ground transport services. Predictors of failure of the sliding hip screw J. Reynolds, J. Brown, B. Squires, T.J.S. Chesser Department of Trauma and Orthopaedics, Frenchay Hospital, North Bristol NHS Trust E-mail address: [email protected]. nhs.uk. Aim: To assess predictors of mechanical failure of the Sliding Hip Screw (SHS), used to treat extracapsular hip fractures, in particular the ‘‘Tip Apex Distance’’ (TAD), fracture pattern, grade of operating surgeon, screw position with-in the head and screw to joint distance. Methods: One hundred and one consecutive patients were reviewed after a mean of 21 months (Range 6 to 24). The outcome was determined for every patient. Data pertaining to residential status, mobility, mental state, hospital stay, pain and reoperation rates were obtained from the patient’s medical records, by telephone follow up or clinical assessment. Radiographs were studied to determine the screw to joint distance, screw position in the head and TAD.

26

Abstracts

Results: At follow-up seven (7%) of screws had cut-out of the femoral head. This correlated with a TAD greater than 25 mm (P ¼ 0:0018), complex fracture pattern (P ¼ 0:0393) and a junior operating surgeon (P ¼ 0:046). Three out of six screws placed anterior in the head had cut-out. Eight percent of patients required re-operation. Conclusion: The results of the SHS in our institution match those in the published literature, cut-outs tended to occur in patients with unstable intertrochanteric hip fractures, treated by junior surgeons, with a TAD exceeding 25 mm. This helps to validate the TAD as a predictor of mechanical failure.

Number ISS

MODS 90 þMODS 20 *

Duration of initial operation (min)

of MODS (MODS/þMODS) (Table 1). IL-6 concentrations were significantly higher in þMODS patients compared to MODS patients from day 0 (þMODS: 1500:6  201:3 pg/dl versus MODS: 322:6  98:6 pg/dl) until day 7 (þMODS: 672:4  99:4 pg/dl versus MODS: 59:4  19:7 pg/dl). In contrast to the MODS group, þMODS patients showed a secondary increase of IL-6 concentrations on day 3. Until day 4, IL-10 concentrations decreased in both groups. From day 4 on, þMODS patients showed a secondary increase until the end of the observation period (significant higher IL-10 concentration in þMODS patients: days 1—3 and days 5—14).

Number of ICU (days) operations days 2 and 3

24.3  8.1* 98.8  55.0 3 32.7  8.7 113.6  69.9 7

Age (years) Male:female Death

15.0  8.9* 33.6  12.4 68:35 26.9  11.8 35.6  13.9 17:6

1 10*

Statistical significance (P < 0:05) MODS versus þMODS.

Systemic cytokine concentrations in blunt trauma- do they indicate surgery induced second hit and development of Multiple Organ Dysfunction Syndrome (MODS)? F. Hildebrand, M. van Griensven, T. Brin, C. Krettek, H.C. Pape Trauma Department, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover E-mail address: hildebrand.frank@mh-hannover. de. Introduction: MODS continues to be a major complication in polytraumatized patients. The pathogenesis is thought to be triggered by the inflammatory response with synthesis of pro-inflammatory cytokines, such as interleukin-6 (IL-6) and the antiinflammatory cytokine IL-10. The objective of this study was to evaluate the pro- and anti-inflammatory response after severe blunt trauma and secondary surgery. Patients and methods: Trauma patients were consecutively included in this prospective study. Inclusion criteria: Injury Severity Score (ISS) >16, age 18—60 years, admission within 6 h after accident, survival >48 h. Blood samples were drawn once daily (14 days) for determination of IL-6 and IL10 levels. The first sample was taken directly after admission, always before the first surgical treatment. The clinical course was recorded once daily. MODS was evaluated using the Marshall-Score. Results: 110 patients were included. Patients were divided in two groups, according to the development

Summary and conclusion: The early increase of IL-6 and IL-10 serum concentrations is trauma induced. Secondary increases of IL-6 and IL-10 were found to occur in association with further surgical procedures. The early increase of IL-6 levels and the secondary increase of IL-10 serum concentrations seem to be associated to the later development of MODS. This study reconfirms systemic IL- 6 levels to represent adequate markers for severity of trauma. For the clinical development of MODS (increase of MODS-score from days 4 to 9), IL-10 appears to play a major role, thus representing a dysergic reaction with an increased anti-inflammatory response in the later course after trauma. Centralised guide wire replacement after DHS reaming S.C.A. Hughes, A.J. Hearnden E-mail address: [email protected]. Very occasionally, after reaming the proximal femur in DHS placement one may unintentionally withdraw the guide wire along with the reamer. This may occur as a result of the guide wire becoming bent on insertion or a small amount of soft tissue can get trapped between the wire and the reamer. One is then left with the problem of accurate replacement. Inaccurate eccentric replacement of the guide wire will lead to difficulties in accurate tapping

2003 Meeting of the British Trauma Society

and/or placement of the cannulated hip screw, consequently altering the angle in relation to the shaft of the femur. This leads to unnecessary additional exposure to radiation, has potential to cause problems and is avoidable. A simple method using the DHS plate and screw is suggested. Management and outcome of paediatric elbow dislocation: a 10-year review A.D. Maclean, M. Abela, P. Tansey E-mail address: [email protected]. Aims: To review paediatric elbow dislocations treated in our institution over a 10-year period and assess outcome. Methods: Prospective data collected on elbow injuries in our unit was used to identify elbow injuries and elbow dislocations over a 10-year period. Thereafter a comprehensive case note and radiological review was performed. Results: 1761 elbow injuries exclusively treated in our unit in a 10-year period. Sixty-three elbow dislocations were identified. Male to female preponderance of around 2:1 (44:19), left more common than right (37:26). There was a seasonal variation. Eighty percent of all dislocations occurred as a result of a low fall or simple sporting injury. Sixty of the 63 dislocations were posterior with 2 anterior and 1 divergent dislocations. Associated fractures were common (46%) with 33% of patients having a medial epicondylar fracture in association with their dislocation, other fractures were rare. Two dislocations were open; there were 2 neuropraxias and no vascular complications. Twelve cases were reduced with sedation and analgesia with the remainder undergoing general anaesthetic. Closed reduction was possible in all cases. Reduction of fracture dislocations under sedation was associated with a higher incidence of medial epicondyle entrapment in the joint compared with general anaesthetic reduction. Post-operative management consisted on average of 3 weeks in plaster. No significant long-term loss of movement occurred in any patient. In the timeframe used there was one re dislocation and no re referrals for ongoing instability. Conclusions: Paediatric elbow dislocations represent around 3.5% of all paediatric elbow injuries. Although closed reduction is almost always possible, fracture dislocations should be reduced under general anaesthesia. Unlike in adults there appears to be no problem with immobilisation for up to 5 weeks and the results of conservative treatment are excellent.

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Photo messaging in orthopaedic trauma K. Cheng, A.D. Maclean, A.C. Chappell Department of Orthopaedics, Inverclyde Royal Infirmary, Greenock, Glasgow, Scotland E-mail address: [email protected]. Purpose: To assess the efficacy and usefulness of photo messaging in orthopaedic surgery, specifically in the assessment of trauma radiology. Methods: Prospectively, 50 sets of X-rays from patients presenting to our emergency dept with a clinical hip fracture were collected. Digital images of theses AP pelvis and lateral hip X-rays were taken using a Panasonic GD87 mobile picture messaging phone by one of the authors using a standard technique. The images were then blindly assessed by two orthopaedic surgeons for the presence of a fracture with the clinical history of a patient with hip pain and inability to weight bear after a fall. Results from the digital imaging were then correlated with the actual X-rays reviewed by the same two surgeons. Results: 28 patients had a hip fracture on plane Xrays, 4 had a pubic ramus fracture, 1 had a cystic abnormality in the femoral head and 17 had normal X-rays. Digital imaging at 640  480 pixel resolution with images 3:2  4:4 cm correctly identified 26/28 fractured hips and 3 of the 4 pubic rami fractures. Digital imaging missed 2 undisplaced fractured hips visible on plane films and the cystic abnormality. Ten out of 17 normal sets of digital images were thought to show possible undisplaced fractures or were inconclusive. Conclusions: Digital images taken and viewed on currently available mobile phone were of sufficient quality to identify most fractures visible on standard plane films. A false positive rate of nearly 50% and a significant false negative rate however mean that this technology is not of sufficient accuracy to allow its safe use in orthopaedic practice. National survey on DVT prophylaxis for patients with fracture neck of femur Rajasundaram Rajaganeshan, Chakravarthy Dussa, Philippa Molyneux, Vishal Sahni E-mail address: [email protected]. Thromboprophylaxis continues to be an ambiguous topic mainly due to the lack of clear answers to pertinent questions. There is no uniformity of its usage across the country and often within the same hospital. In such situations a survey is a very helpful tool as it identifies current practices and how various Orthopaedicians view the available literature.

28

A national survey was done in January 2003 to determine the trends of usage thrombo-prophylaxis following fracture neck of femur. A simple postal questionnaire was sent to 1648 Orthopaedic Consultants. Out of these 718 Consultants replied (44%). Eighty-seven percent Consultants had protocols for DVT prophylaxis. Ninety percent used thromboprophylaxis routinely. Of these, 50% routinely used both chemical and mechanical prophylaxis, 42% used chemoprophylaxis only and 8% used mechanical prophylaxis only. Amongst Consultants using Chemoprophylaxis, 325 use LMW Heparin, 235 use aspirin, 35 use unfractionated heparin and 15 use warfarin. Chemoprophylaxis was started on admission by 62% firms, at induction of anaesthesia by 8%, 6 h post induction by 8% and 24 h post-operative by 4.5%. Forty-five percent discontinued chemoprophylaxis on discharge and 22% discontinued it 6 weeks after discharge. In the mechanical prophylaxis sub-group TED stockings were used by 319 (58%), foot and ankle pumps by 94 (29%) firms and flowtron boots by 60 (19%). Mechanical prophylaxis was discontinued when the patient started mobilisation by 76 firms (24%), upon discharge by 122 (38%) firms and 6 weeks after discharge by 122 (38%) firms. This is the first National Survey in UK to identify current practice in thromborophylaxis in patients with fracture neck of femur. It reveals that 18% of all Consultants do not use any chemoprophylaxis and 10% do not use any thrombo- prophylaxis at all for patients with fracture neck of femur. Fracture’ of forearm elastic nails! R. Mittal, M.A. Hafez, P.A. Templeton Department of Trauma and Orthopaedics Leeds General Infirmary E-mail address: [email protected]. Introduction: The use of Nancy nails is an established modality for treating forearm fractures in children. Nancy nails are usually removed 1 year after surgery. Refracture of forearm bones after the nail removal is a well known complication. Here, we report a case of refracture of the forearm bones with Nancy nails in situ, a previously unreported complication of Nancy nails. The fracture -with the nails in situ- was dorsally angulated to approximately 80 degrees. Closed reduction was difficult as these are elastic nails and resulted in breakage of ulnar Nancy nail. Authors describe the details and outline the management of this unreported complication. Case report: A 14 years old boy sustained fracture of shaft of both radius and ulna while skateboarding.

Abstracts

As the fracture configuration was unstable, he was managed by closed reduction and percutaneous insertion of Nancy nails. Both the fractures united in 8 weeks. Five months following the first injury, he fell down again while skateboarding and refractured both forearm bones. He presented with severe clinical deformity of the forearm with no distal neurovascular deficit. The Nancy nails were bent but not broken. Closed reduction was attempted under general anaesthesia. After the full correction, the ulnar nail broke at the fracture site. Surgical intervention was indicated, as satisfactory position could not be maintained in a long arm cast. At surgery, the radial nail and the proximal fragment of broken ulnar nail were easily removed through the original insertion points. An attempt to pass a new Nancy nail past the broken piece in the distal fragment of the ulna was unsuccessful. The ulnar fracture site was then opened and the medullary cavity was noted to be blocked with sclerotic bone. The proximal end of the broken nail was flush with the fracture surface. A 2.5 mm drill bit was used to drill spaces around the end of the nail. The nail was grasped with a fine endoscopy grasping forceps. Two new Nancy nails (2 mm diameter) were inserted to stabilise both the radius and ulna. The forearm was protected in an above elbow cast for a period of 6 weeks. Both the fractures united well in 8 weeks time. By 3 months after surgery, he had regained almost full movements of elbow and radio-ulnar joints. The nails will be removed 6—9 months after his second surgery. Conclusion: ‘Fracture’ of Nancy nail in situ has not been reported before. This complication may happen again and we suggest that removal of the broken nails and insertion of new ones is a satisfactory option for treatment. The management outlined above can be a useful guide for similar situations. A comparison of different interpretations of intracapsular hip fracture classification Kurinchiselvan Gurusamy John Kendrew, Martyn Parker Orthopaedic Department, Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK E-mail address: [email protected]. The Garden classification subdivided intracapsular fractures into four grades, dependent on the degree of fracture displacement. Whilst this classification is of value for the division of undisplaced (Grades I and II) and displaced fractures (Garden Grades III and IV), the subdivisions of the classification with four groups has been questioned.

2003 Meeting of the British Trauma Society

More recently the American literature has illustrated a different interpretation of the Garden classification, in which displaced fractures are subdivided into two groups dependent on whether the degree of displacement is greater or less than 50%. This study was to determine if this classification was predictive of outcome of fracture healing or if other aspects of fracture displacement and shortening of the fracture were more useful. 435 patients with a displaced intracapsular fracture treated by closed reduction and internal fixation were studied. The mean age was 74 years, 23% were male. Mean X-ray follow-up was 461 days (range 113—2181). Fractures were classified without knowledge of the outcome of treatment using the following factors. 1. A ‘traditional’ Garden grading. 2. Direct observation to estimate the displacement as more or less than 50%. 3. Measuring the vertical displacement using a measure to give a ratio. 4. Vertical shortening of the limb as measured against the contralateral limb on the X-ray. 5. Fracture shortening on the X-rays. The outcome was either non-union or fracture healed. Statistical analysis was by Fisher’s Exact test for binary outcomes and t-test for continuous outcomes. Does delay in management of open tibial fractures affect outcome? Harish. k. shanker, Brigeen Canavan, John Wong, Henry Mc Gee Department of orthopaedic surgery, Altnagelvin Area Hospital, Londonderry, Northern Ireland E-mail address: [email protected]. Open tibial fractures have traditionally been treated as surgical emergencies. However, the ‘‘golden 8 h rule’’ for emergent treatment of these injuries is based more on historic principles and invitro data. A substantial number of open tibial fractures referred to our hospital from peripheral referral units have transport times in excess of 8 h. These circumstances provide the source for the present study of the effect of delay in initial treatment on the final outcome in terms of infection, delayed union, non-union, malalignment and failure of fixation. Between January 1998 and June 2001, 53 open tibial fractures were treated at our institution. The fractures were classified using the Gustilo classification. All patients had a minimum of 1 year’s

29

follow-up. Patients were categorised into 4 groups based on the time delay from injury to surgery, namely those treated within 6 h of injury, 6 to 12 h, 12 to 18 h and >18 h following injury. Following recognised methods of surgical toilet and wound debridement, treatment modalities included intramedullary nailing, external fixation and cast application. There were 22 grade 1, 22 grade 2 and 9 grade 3 open fractures. Twenty-three received treatment within 6 h of injury, 10 between 6 and 12 h, 6 between 12 and 18 h and 14 at more than 18 h following injury. Forty-three percent of cases with complications were in the group of patients treated within 6 h of injury, 29% were in those treated between 6 and 12 h, 7% were in those treated between 12 and 18 h and 21% were those treated at >18 h following injury. Twenty-seven percent of grade 1 open fractures, 14% of grade 2 fractures and 55% of grade 3 fractures developed complications. Our experience indicates that the incidence of complications correlates more with the severity of the injury rather than with time from injury to treatment. In spite of early treatment, fractures treated within 6 h of injury developed more complications in our series. Delays of 6 to 18 h did not reflect a proportional increase in incidence of complications. Internal fixation of distal extra-articular fractures of tibia using ‘Halder’ tibial nail S.S. Kumar, Kevu, Zepeda, Flood, Halder E-mail address: [email protected]. Distal extra-articular fractures of the tibia are sometimes difficult to treat with conventional nails. Distal interlocking is a problem with existing nails, with respect to, difficulty in insertion of screw, breakage of drills and screws and radiation exposure of hands. Since 1994 we have treated 85 patients with our new nail. Our nail is inserted proximal to the Tibial tuberosity, after reaming with flexible reamers. Proximal locking is done as in traditional nails. Distal interlocking is achieved with a unique ‘Trio wire’, which is inserted through the nail itself from the proximal end and fans out distally. Combined with the proximal screw, the Trio wire gives excellent axial and rotational stability. In selected cases early dynamization could be achieved without the need for another operation to remove the screw. In all our cases early pain relief and return of knee and ankle functions were achieved. Complications

30

Abstracts

include Infection (1 case), Mal-union (1 case), Distal protrusion of wire (2 cases) and Non-union (1 case). In our experience, this new nail system is easy to use and provides stable fixation. Radiation exposure to patient and surgeon is reduced and early dynamization could be easily achieved to promote early fracture union. Ankle fractures with diastasis of the inferior tibio-fibular syndesmosis–—radiological outcome and risk factors for loss of reduction R. Anakwe, A. Abraham, C.M. Robinson, J.F. Keating Department of Trauma Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh EH16 4SU, UK E-mail address: [email protected]. We have reviewed 111 ankle fractures associated with a diastasis of the inferior tibio-fibular syndesmosis. The aim of this study was to determine the radiological outcome of ankle fractures with diastasis treated with syndesmosis screws and to assess the impact of previously uninvestigated factors on anatomic reduction of the syndesmosis, before and after removal of the syndesmosis screw. Outcome was either radiological anatomical reduction or malreduction. Risk factors for malreduction were identified from notes and X-rays. Relative risk analysis for these are summarised in the table below.

ments. Minimally invasive plate osteosynthesis is developed on the principles of biological fixation, which gives more importance to biology than mechanical stability. Aim: To evaluate the results of minimally invasive plate osteosynthesis, prospectively, in comminuted long bone fractures. Patients and methods: This is a prospective analysis of 20 patients with comminuted long bone fractures treated by minimally invasive plate osteosynthesis. The study was conducted between October 1998 and January 2001. Age of the patients ranged from 18 to 60 years with mean age of 36.6 years. Minimum follow up period is 12 months with a mean of 17.2 months, Double incision surgical technique was used. Fracture site itself was not exposed. All the fractures were reduced using indirect reduction techniques. A suitable plate is then passed in the sub muscular tunnel to minimise the soft tissue damage and devascularisation of bony fragments. Bone grafting and interfragmentry screws were not used. Results: All these fractures went for solid union. There was no incidence of infection, delayed union or non-union. The functional outcome was also analysed. We had excellent results in 13 patients, good results in 6 patients and fair result in 1 patient. Conclusion: Biological fixation provides an optimum condition for bone healing with reliable clinical

Risk factor

Anatomically reduced

Malreduced

Number of patients Compound injuries Post-operative infection Dislocation at presentation Variation in screw insertion* Deltoid rupture Posterior malleolus fracture High fibular fracture Fibular fracture not stabilised

81 0 3 20 33 58 41 37 42

30 5 3 11 16 20 11 9 13

Relative risk (95% CI)

P-value

4.24 1.94 1.49 1.45 0.80 0.66 0.56 0.71

0.002 0.41 0.31 0.33 0.65 0.27 0.13 0.38

(1.82—1.82) (0.51—3.62) (0.73—2.85) (0.74—2.85) (0.41—1.68) (0.32—1.31) (0.25—1.15) (0.36—1.39)

*

Our results did not achieve statistical significance but are suggestive of a trend towards redisplacement of the syndesmosis with injuries that were compound, presenting with dislocation, had suffered post-operative infections and in which the syndesmosis screw was not parallel to the tibial plafond.

Minimally invasive plate osteosynthesis for comminuted long bone fractures Narayan Hulse, N. Raghunanthan, M. Subramanian E-mail address: [email protected]. Background: Conventional technique of plating may result in significant amount of devitalisation of soft tissues and de-vascularisation of bone frag-

outcome. It reduces the incidence of infection and non-union. Varus impacted intracapsular fractures of the femoral neck D.S. Damany, M.J. Parker E-mail address: [email protected].

2003 Meeting of the British Trauma Society

Aim: We describe a distinct type of intracapsular femoral neck fracture for 12 patients. Radiologically the fracture does not fit into a described pattern, such as Garden’s or the AO classification. The varus impacted group of fractures have a characteristic radiographic feature of impaction in varus on the antero-posterior view, with a triangle of sclerosis seen at the inferior border of the femoral neck denoting this impaction. At the superior border of the neck, the fracture opens up, whilst in the lateral view, the fracture remains undisplaced. Methods: 12 such fractures (0.6% of all intracapsular neck of femur fractures) were recorded between 5 March 1998 and 20 November 2001. Majority of these fractures presented spontaneously without a definite history of trauma. The mean time from symptoms to presentation was 9 days. Eleven of the twelve fractures were treated with AO screw fixation and one with a hemiarthroplasty. Results: Eight of these fractures healed without complications. Two fractures failed to heal and one developed avascular necrosis. Conclusion: This particular fracture pattern we describe is rare and one cannot therefore be precise on the optimum method of treatment. We believe that these fractures should be treated as undisplaced fractures with internal fixation insitu as this is a relatively simple operation with low morbidity and a short hospital stay. This stabilises the fracture from further displacement and reduces pain. Outcomes after intracapsular hip fractures in young adults A meta-analysis of 18 published studies involving 564 fractures D.S. Damany, M.J. Parker, A. Chojnowski E-mail address: [email protected]. Aim: To analyse outcomes following such fractures in patients under 50 years of age with particular reference to the influence of the degree of fracture displacement, timing of surgery, method of reduction (open/closed) on the incidence of non-union and avascular necrosis (AVN). Materials and methods: Relevant studies from 1966 to May 2003 were retrieved using MEDLINE, EMBASE, and CINAHL. Eighteen studies with 564 fractures were included in the analysis. Results: There was a higher risk of developing AVN than non-union following surgery for these fractures (P < 0:0001 considered extremely significant, RR ¼ 0:3846, 95% CI: 0.2836 to 0.5216).

31

The overall incidence of non-union was 8.86% (50/564) and AVN was 23.04% (130/564). There was a higher incidence of non-union following open than closed reduction (P ¼ 0:0417, considered significant, RR ¼ 0:4192, 95% CI: 0.1904 to 0.9230). There was a higher incidence of AVN after closed than open reduction (P ¼ 0:0005 considered extremely significant, RR ¼ 2:759, 95% CI: 1.443 to 5.274). The incidence of AVN after open or closed reduction became not significant when the one study (Zetterberg CH, 1982) which reported a significantly higher rate of AVN (43/93—46.24%) with closed reduction than other studies was disregarded (P ¼ 0:0787, considered not quite significant, RR ¼ 1:837, 95% CI: 0.9217—3.662). The difference in the incidence of non-union and avascular necrosis following early (<12 h) or late (>12 h) surgery was not significant (non-union: P ¼ 0:1789 considered not significant, RR ¼ 2:342, 95% CI: 0.6945 to 7.900, avn: P ¼ 0:8198 considered not significant, RR ¼ 0:9009, 95% CI: 0.4194 to 1.935). There was a higher incidence of non-union and AVN following displaced than undisplaced fractures (non-union: P ¼ 0:0236, considered significant, RR ¼ 7:105, 95% CI: 0.9693 to 52.076, avn: P < 0:0001 considered extremely significant, RR ¼ 3:785, 95% CI: 1.802 to 7.952). Conclusion: It appears that early (<12 h) or open reduction of these fractures may not reduce the risk of non-union or avascular necrosis. There is a suggestion of a higher incidence of non-union following open reduction than closed reduction. Randomised studies or prospective observational studies are required to report on a larger number of patients in this age group before definite conclusions on treatment can be made. Do displaced supracondylar humerus fractures in children have to be reduced in the middle of the night? Andreas Rehmb, William Gainea, Benjamin Almana a

The Hospital for Sick Children, Toronto, Canada

b

Addenbrooke’s Hospital, Cambridge, England

E-mail address: [email protected]. Purpose: To investigate if there is a correlation between timing of treatment of displaced supracondylar humerus fractures in children and the complication and open reduction rate. Method: All supracondylar humerus fractures managed with closed or open reduction and pin fixation at our institution between 1995 and 2002 were retrospectively reviewed.

32

Fractures treated 8 h from injury were considered in the early treatment group while >8 h were considered in the late treatment group. Results: We identified 431 patients with a Gartland grade 3 and 141 patients with a Gartland grade 2b. The time from injury to surgery ranged from 2 h to 13 days. The average time to reduction was 12 h for grade 3 injuries and 21 h for 2b injuries. None of the patients had an initial closed reduction in the emergency department. The early treatment group consisted of 230 patients with two compartment syndromes, six ulnar-, one superficial radial-, one median- and one radial nerve palsy, one septic arthritis, one pin site infection, six open reductions and one re-manipulation was required for loss of reduction. The late treatment group consisted of 342 patients with six ulnar-, three median-, one radial nerve palsy and one lateral cutaneous nerve of the forearm palsy, three pin site infections, five open reductions and re-manipulation was required in one patient. All nerve palsies recovered post-operatively. Conclusion: There was no significant difference in the proportion of complications between the early and late treatment group. Delayed treatment of supracondylar fractures seems to be safe in those patients without neurovascular deficit, and in fact, most of our patients were treated more than 8 h from the injury. Universal precaution compliance by orthopaedic trauma team members in a major trauma resuscitation scenario R.O. Sundaram, N.W. Emms, C.E. Bruce, R.W. Parkinson Department of Orthopaedics, Arrowe Park Hospital, Wirral E-mail address: [email protected]. Introduction: Orthopaedic surgeons managing a major trauma patient may be at risk of exposure to blood borne infections such as Human Immunodeficiency Virus, Hepatitis B and C. Aims: To determine the compliance rates of orthopaedic surgeons on hospital trauma teams in applying Universal Precautions (UP) in major trauma resuscitation scenarios; and the availability of UP in Accident and Emergency (A&E) departments throughout England. Methods: A national telephone survey was implemented contacting the first on-call orthopaedic surgeon and A&E departments in all of the 164 hospital trusts accepting major trauma throughout England. A questionnaire was employed to determine current practice; experience

Abstracts

and availability of UP when managing a trauma patient. Results: One hundred and twelve first on-call orthopaedic surgeons and 99 A&E departments were able to respond. Thirty-five percent of orthopaedic surgeons received formal advice regarding applying UP. Seventy-four percent had high or moderate concern regarding the transmission of blood borne infections. There was good compliance for using gloves (99%) and aprons (86%). There was poor compliance in using goggles (21%), face masks (18%), shoe covers (4%) and head caps (4%). Orthopaedic surgeons applied UP according to the level of risk they subjectively perceived. They would increase UP compliance if the trauma patient was known to be infected with a blood borne infection. One hundred percent of A&E departments had gloves and aprons. The availability of the other UP was less; goggles (94%), face masks (81%), shoe covers (23%) and head caps (27%). Sixty-eight percent of orthopaedic surgeons reported that UP were not available in the A&E department. Conclusion: Orthopaedic surgeons on the trauma team should be more compliant in using UP. UP should be more available in the A&E departments. There should be better communication between A&E departments and the trauma team regarding the availability of UP. Internal fixation of traumatic diastasis of pubic symphysis: is plate removal essential? P.V. Giannoudis, R. Raman, C. Hadjikouti-Dyer, C. Roberts, S.J. Matthews St James’s University Hospital Leeds E-mail address: [email protected]. Purpose: We aim to measure the health status of patients with respect to plating of the pubic symphysis, identify the long-term effects of retaining the plate and address the issue of plate removal. Patient/methods: Amongst 561 patients with pelvic ring injuries treated in our unit, we identified 74 (13.6%) consecutive patients (18 female) with diastasis of the pubis symphysis that required internal fixation. A retrospective chart analysis was performed and at final follow up, clinical and radiological assessment was made and the quality of life of the patients was assessed using the EuroQol EQ-5D generic outcome tool. The incidence of impotence amongst the men was recorded and the women were questioned about dyspareunia, pregnancy, labour and possible future pregnancy. The mean follow up was 40.4 (18—148) months.

2003 Meeting of the British Trauma Society

Results: The mean age of the patients was 40.6 (10—75) years and the median ISS was 25.5 (IQ range 18—34). The fracture types were 12 vertical shear fractures, 8 lateral compression (LC) II fractures, 10 LC-III fractures, 25 antero-posterior compression (APC) II, and 19 APC-III fractures. Eight fractures were open. The pubic symphysis was reduced and stabilised with a single plate in 59 patients and with double plates (superior and anterior) in 15 patients. Of 3 patients who developed local wound infection, 2 settled completely following antibiotic therapy. One patient had the plate removed as a result of deep sepsis (10 months). Implant failure was observed in 4 (5.4%) patients. All these patients had no functional consequences. The plate was removed only in 3 patients. Of the three (4%) men who had erectile impotence, two had associated bladder injury and the other had penile and scrotal injury. One female (1.3%) who had deep dyspareunia had coexistent vaginal and perineal lacerations. Three (4%) females and 7 (9.4%) men who had residual suprapubic pain, had no evidence of implant failure. Three patients were pregnant after the injury (the plate removed in one patient). Six patients expressed their wish to become pregnant and all were concerned about the effects of retaining the plate on pregnancy and labour. The results of the EQ-5D are summarised in Table 1.

33

women of childbearing age requires further investigation. Long-term functional outcome following severe pelvic trauma: A comparison of Vertical shear fractures to APC-III, LC-III, and complex acetabular fractures R. Raman, P.V. Giannoudis St James’s University Hospital, Leeds, UK E-mail address: [email protected]. Purpose: To analyse the long-term functional outcome of vertical shear fractures to other forms of severe pelvic injuries: APC-III, LC-III, and complex acetabular fractures. Patients and methods: We identified 31 vertical shear fractures in 29 consecutive patient and compared with 34 patients with APC—III, 32 patients with LC-III and 32 patients with complex (at least bicolumnar) acetabular fractures to form the control group, who were matched for age and sex with the vertical shear fracture group. The mean follow up was 62 months. Functional outcome was assessed in all patients using the following generic outcome measurement tools: EuroQol EQ-5D, SF36 v2 (Short form), VAS, short musculoskeletal functional assessment (SMFA) and Majeed score. In addition Merle d’ Aubign and Postel scores (Matta, 1986) and radi-

Table 1 Sex/age group

Self-reported description score (mean)

Male

Patients

Sample UK population

<29 years 30—59 years >60 years

0.84 0.49 0.59

0.94 0.87 0.76

Female <29 years 30—59 years >60 years

0.82 0.83 0.69

0.94 0.86 0.74

*

Self-rated valuation score-health thermometer (mean) P-value 0.04* 0.006* 0.01* 0.04* >0.05 >0.05

Patients

Sample UK population

60 56.8 40

87.4 83.5 72.8

88 77.5 75

86.6 80.2 76.1

P-value 0.01* 0.009* 0.005* >0.05 >0.05 >0.05

P < 0:05.

Conclusion: Traumatic diastasis of the pubis symphysis treated by plating results in satisfactory union of the fracture with moderate to good functional results. The residual anterior pubic pain was very minimal and did not correlate with implant failure. This study supports the view that routine removal of the plate is not essential. The issue of whether the implant needs to be removed in

ologic degenerative hip scores (Matta, 1994) were used to assess patients with acetabular fractures. Results: The mean age of all the patients in the study was 43.5 years (16—71) and the median injury severity score was 22 (12—32). All patients had their pelvic ring stabilised at least temporarily within 24 h and all acetabular fractures were reduced and stabilised by 7 days. Functional outcome was

34

Abstracts

assessed in all patients of the control group and in 28/29 patients of the vertical shear fracture group. In the vertical shear fracture group, 35% of the patients have returned to their previous jobs (49% in control group), 30% have changed their professions (30% in control group) and 25% (14% in control group) have retired from regular work. In the acetabular group, 10 (31%) patients had neurologic injury (6 sciatic, 3 common peroneal, 1 femoral). Of these, 4 were iatrogenic. Six patients had complete neurologic recovery. Heterotopic ossification was seen in 19 (59%) patients. Three patients (9%) with acetabular fractures (all had associated posterior wall fracture) had total hip replacements at 29, 40 and 51 months. The clinical outcome of patients in the acetabular fracture group was: 5 excellent (3 THA), 4 good, 13 fair and 10 poor. The radiologic score of degenerative hip disease (Matta 1994) for the acetabular fracture group was: 4 excellent, 8 good, 14 fair and 3 poor. Analysis of the functional outcome is shown in Table 1.

Posterior stabilisation of vertical shear fractures: efficacy of SI screws R. Raman, P.V. Giannoudis, R.M. Smith, S.J. Matthews St James’s University Hospital, Leeds E-mail address: [email protected]. Purpose: Posterior stabilisation of the pelvic ring in vertical shear fractures could be accomplished using screws, plates or both. There has been some controversy in the literature about the efficacy of using SI screws alone as posterior stabilising agents. We have therefore reviewed the patients treated in our institution with vertical shear fractures of the pelvis where posterior stabilisation has been achieved using SI screws and report on our results and long-term functional outcome. Patients and methods: Between Jan 1995 and Jan 2002 we identified patients with vertical shear fractures and data was analysed from medical records and radiographs. Functional outcome

Table 1 VS

EQ-5D Description score Valuation score SF-36 v2 Physical health Mental health SMFA Dysfunction index Bother index

0.43  0.12

LCIII

0.63  0.18

AP III

0.69  0.11

Acet #

VS fractures versus LCIII

AP III

Acet #

Norm

0.49  13

P > 0:05

P ¼ 0:03

P > 0:05

P ¼ 0:001

46.1  19.4

62.3  21.9

78  11.4

51.4  11.2

P > 0:05

P ¼ 0:02

P > 0:05

P ¼ 0:002

44.4  19.3

62.5  11.3

78.3  9.6

54.2  16.3

P ¼ 0:04

P ¼ 0:02

P > 0:05

P ¼ 0:005

46.2  12.1

68  19.2

76.5  15.7

56.3  10.7

P > 0:05

P ¼ 0:03

P > 0:05

P ¼ 0:001

63.3  11.3

44.6  11.2

38.3  17.3

54.1  19.8

P > 0:05

P ¼ 0:01

P > 0:05

P ¼ 0:006

60.5  13

49  13.2

34.2  11.9

57.2  14.3

P > 0:05

P ¼ 0:02

P > 0:05

P ¼ 0:002

VAS and Majeed scores not shown.

Conclusion: Patients with vertical shear fractures represent the spectrum of high-energy pelvic disruption. The functional outcome is significantly better in patients with APC III and LC III fractures when compared to vertical shear and complex acetabular fractures thus reflecting the severity of the injury. Secondary osteoarthritis and neurologic injury appear to contribute to the poor outcome of acetabular fractures. Sound reconstruction of the pelvic ring is not always associated with good results probably due to the extensive pelvic floor trauma.

assessment was performed using: Euroqol 5D (EQ), SF36 v2 (short form), short musculoskeletal functional assessment (SMFA), Majeed score and visual analogue score (VAS). The mean follow up was 39 months (12—101). Results: Out of 380 pelvic ring injuries we identified 31 (8.1%) vertical shear fractures. The mean age was 43.5 (range 16—71). The median ISS was 22 (12—32). There was one open fracture of the sacrum. Additional injuries were identified in the chest (12 patients, 41%), abdomen (8 patients, 27%)

2003 Meeting of the British Trauma Society

and extremities (14 patients, 48%). The mean resuscitation requirements were 4.2 (3—11) litres of intravenous fluids and 6.5 (3—21) units of blood. All patients had their pelvic ring initially stabilised within 12 h of injury. The mean time for definitive posterior ring stabilisation was 3 (0—13) days. The posterior ring was stabilised using SI (sacro-iliac) screws alone in 23 (24 fractures) cases. A single screw was used in (9 fractures) and two screws in the rest (15). All SI screws were inserted percutaneously under fluoroscopy guidance. The screws were supplemented with a plate in 3 fractures and the rest were stabilised with plates. The anterior ring was stabilised using an external fixator in 11 cases and by plating in 18 cases. Systemic complications developed in 6 (20%) patients–—ARDS in 4 (14%) patients and MOF in 2 (6%). All patients where screws were used to stabilise the posterior ring were followed up clinically and radiologically at regular intervals. Iatrogenic nerve injury was identified in 3 (10%) patients post-operatively of which two patients recovered completely. The SI screws had to be repositioned in one patient. Immediate post-operative radiographs revealed satisfactory reduction (gap of less than 1 mm) of the SI joint in 19 cases. In 3 cases, the gap at the SI joint was more than 2 mm and in 2 cases more than 3 mm. At final follow up, radiographic analysis revealed no loss of reduction of the posterior fracture in all patients. The screws were removed in 2 patients at 13 and 19 months due to persisting sacro- iliac pain. However, the pain persisted in one patient even after removal of the implant. There was no radiological evidence of implant failure in all the cases. Analysis of the functional outcome using the Majeed score revealed that 1/3 of the patients did fair, 1/3 poor and 1/3 good. The SF-36 v2 analysis as well as the EQ 5-D revealed a moderate functional outcome, with better results within the younger patients compared to older age group. The SMFA and the visual analogue score also revealed similar outcomes. Thirty-five percent of the patients have returned to their previous jobs, 40% have changed their professions, but still continue to work and 25% have retired from regular work. Conclusion: Patients with vertical shear fractures represent the spectrum of high-energy pelvic disruption. Prompt resuscitation and early temporarily stabilisation of the pelvic ring is frequent necessary as part of the resuscitation process. From our study, stabilisation of the posterior ring using SI screws seems to be a satisfactory method. Sound reconstruction of the pelvic ring is not always associated with good results probably due to the extensive pelvic floor trauma

35

as seen in this series of patients. Younger individuals seem to have a relatively better outcome when compared to the older age group. We are aware of the limits of this study as it describes a small series of patients. However, in our experience, we find stabilisation of the posterior ring using SI screws to be adequate with satisfactory results. Is pre vertebral soft tissue swelling on The Lateral C spine Radiograph a useful predictor of cervical column injury in patients previously intubated by the Helicopter Emergency Medical Service? Adam Pandit, Russell Hawkins, Colin Natali E-mail address: [email protected]. Introduction and aims: It has been shown that the presence of an endotracheal tube invalidates the sign of increased prevertebral soft tissue swelling as a radiographic marker of cervical spine injury. The aim of the study was to assess the strength of this relationship in patients intubated in the field by the Helicopter Emergency Medical Service (HEMS) team. Methods: The trauma radiographs of the lateral c-spine from 22 HEMS patients who had been intubated outside of the hospital and had confirmed cervical spine injuries were studied. The time from intubation to radiograph was calculated and the PVST was then measured at C2 and at C6. Results: The mean time of intubation to radiograph was 48.45 min (16—112) with the mean time of injury to radiograph 89.17 min. Fourteen patients suffered upper cervical spine injuries and 8 had lower cervical spine injuries. Seventy-one percent with upper injuries demonstrated PVSTS whereas only 62.5% of lower injuries showed PVSTS. All those with PVSTS at C2 had upper cervical injuries. None of the patients with a lower injury had PVSTS at C6. Discussion: We postulate that the presence of an ET tube in patients with a lower cervical spine injury masks PVSTS possibly due to a compressive force. To confirm this we are collecting data from non intubated spinal injuries for statistical analysis. Hip fracture in the immobile patient D. Hay FRCS, J. Parker MD, FRCS E-mail address: [email protected]. Immobility has been used as an indication for conservative treatment in hip fracture patients, though there is little in the literature to support this view. We conducted a prospective review of 3515 hip fracture patients over a 12-year period. One hundred and fifty-two (4.3%) patients were

36

immobile prior to the fracture. Nine patients were treated conservatively, the rest by operation. The mean age was 83 (range 42—99). The mean length of hospital stay was 17.8 days. Nineteen (12.5%) patients died before discharge from hospital and 120 (79.0%) went back to their original residence. There were 38 post-operative complications. At 1 year from injury, 79 patients had died. For the survivors 54/73 (74.0%) had none or minimal pain in the hip and 58/73 (80.1%) had the same residential status as before the fracture. Immobility in hip fracture patients is uncommon and is not a valid reason for conservative treatment. Traumatic knee dislocation–—a review of eleven cases T.D.S. Sethi MRCS (Eng.), D. Miller MRCS (Eng.) Department of Trauma and Orthopaedics, University Hospital of North Staffordshire, UK E-mail address: [email protected]. Traumatic dislocation of the knee is a rare but serious injury. Dislocation of the knee almost always results in major disruption of the peri-articular structures and may result in damage to the popliteal artery and peroneal nerve. Most knee dislocations are a result of massive trauma in road traffic accidents or through high energy falls and are often associated with multiple injuries. Eleven knee dislocations over a 10-year period from two centres were reviewed retrospectively. The initial assessment, operative details and postoperative assessment were reviewed. The average follow up was 16 months (Range 2 months to 6 years). The age range was 17—60, with an average age of 32 years. All patients were managed by early closed reduction at the scene of the accident or at the admitting hospital. Twenty-seven of the cases had an associated vascular injury and 9% of cases had peroneal nerve injuries. All patients were assessed for vascular injury by a detailed history and a thorough clinical examination on admission. Three patients, after assessment, were suspected to have sustained a vascular injury and all three had proven vascular injuries on arterial angiogram. Although the remaining eight patients had no clinical evidence of any vascular injury, six underwent arterial angiogram with normal results. We found that if a vascular injury is not clinically suspected, then arterial angiogram may not be mandatory. A detailed history and thorough physical

Abstracts

examination to exclude vascular injuries may make the routine use of arterial angiograms unnecessary. Table 1. Summary of vascular injuries No. of with No. of with no suspected suspected vascular injury vascular injury No Angiogram performed No vascular injury identified on angiogram Vascular injury identified Total

2

0

6

0

0

3

8

3

A picture tells a thousand words Picture messaging in orthopaedic trauma D. Baker, S.M. Sarasin, J.P. Davie E-mail address: [email protected]. Aim: To assess the effectiveness of mobile phone ‘‘picture messaging’’ in orthopaedic trauma practice. Methods: Picture messaging mobile phone technology is a relatively new innovation. An initial pilot study used 50 X-ray images of common fractures seen in orthopaedic trauma surgery. These images were assessed by a senior specialist registrar in trauma and orthopaedics, using a proforma for image quality, adequacy of information displayed, diagnosis, fracture characteristics and management of the injury. The X-ray was then photographed using a digital camera incorporated into a mobile phone and transmitted to another identical phone and assessed by a consultant orthopaedic surgeon using the proforma. We performed studies to assess the inter-observer error in viewing these images. No patient identification data was transmitted and thus the Data Protection Act was not contravened. Results: Image clarity and adequacy of displayed information was good or better in 98% of transmitted images. Correlation between assessors for diagnosis was also 98% and for management was 96%. We found picture imaging to be a useful adjunct to emergency trauma practice The assessment of fracture patterns also showed correlation in excess of 90% for all variables studied. Conclusion: Our initial study shows that picture messaging will allow the immediate assessment of an injury by a consultant who is not readily available. It will also be effective in reducing the need for consultants to return to hospital to review X-rays and thus has implications in the reduction of doctors

2003 Meeting of the British Trauma Society

working hours. We are undertaking a prospective trial to further evaluate the effectiveness of this technique. Fracture fixation in HIV positive patients Ashok Baburam E-mail address: [email protected]. A prospective study involving 45 patients who sustained acute fractures of the femur and/or tibia was undertaken at Durban metropolitan hospitals from April 2002 to June 2003. All patients underwent unreamed intramedullary fixation including debridement if the fractures were compound. Of the 45 patients, 40% (18) were HIV þve with a mean age of 29 years (20—47 years) and 28.5 years (15—56 years) for the HIV ve. There were 12 males and 6 females amongst the HIV þve group and 24 males and 3 females in the HIV-ve group. The majority of the injuries were due to pedestrian-motor vehicle accidents (56%) or gunshot wounds (20%). Associated injuries included fractures of the tibia (3), femur (4), ankle (1), acetabulum (1), head injury (3), and chest trauma (2). None of the patients had other known medical co-morbidities. Amongst the patients with closed fractures, 9 were HIV þve, 7 with femur and 2 with tibia fractures and amongst the HIV ve group 12 patients had femur and 7 tibia fractures. Three of the HIV þve patients had compound fracture of the tibia, each with a Gustilo type II, type IIIA and type IIIB fracture whilst four HIV ve patients had compound fracture of the tibia, two each with grade II and grade IIIB fractures. Amongst the 6 HIV þve patients who had compound fractures of the femur one had a grade I, two grade II, two grade IIIA and two grade IIIB fractures. Four HIV ve patients had compound femoral fractures, three with grade II and one grade IIIA. Two patients had wound infection, a HIV þve male who had a grade IIIA fracture of the femur and a HIV ve female with a grade IIIB fracture of the tibia, resulting in an infection rate 5.5 and 3.7% for the HIV þve and HIV ve patients, respectively. We conclude that the infection rate amongst asymptomatic HIV þve patients with acute long bone fractures treated operatively is comparable to those of HIV ve patients. Mobile non-union of the humeral diaphysis in the elderly results of triple therapy in six patients a 5year follow-up Keith Hayward, Jay Trevedi, James Richardson Robert Jones Agnes Hunt Hospital, Oswestry E-mail address: [email protected].

37

Six elderly patients (average age 74 years) with a mobile non-union of the humeral diaphysis were treated with a modification of the standard technique of plate and screw fixation. The method utilises an adolescent blade plate inserted at the proximal or distal end of the humerus. The blade plate was supplemented with a strut allograft in four patients and a dynamic compression plate in five patients. In addition an intramedullary graft was used in three patients with bone loss at the non-union. A triple fixation was thus applied across the fracture to enhance fixation. All patients had at least one previous operation in an attempt to obtain union across the fracture (average 2.8 operations per patient). The average duration of non-union was 7.5 years (range 1—30 years). The mean follow-up was 62 months for five patients (range 60—65 months). One patient died 3 months after surgery from her co-morbid conditions. All surviving patients had significant improvement in their pre-operative Constant and Murley scores (P < 0:001). The mean preoperative Constant and Murley score was 12.4 (range 5—16) and the mean post-operative score was 42.8 (range 33—48). The method is proposed for stabilisation of mobile non-unions of the humerus in the elderly in whom routine methods of fracture fixation have failed. A prospective consecutive series assessing locking compression plate fixation for comminuted distal radius fractures: The Royal London Experience T. Seepaul, A. Hart, R.J.D. Hewitt, S.C. Ang The Department of Orthopaedics, The Royal London Hospital, Whitechapel, London E1 1BB, UK E-mail address: [email protected]. Comminuted, high energy fractures of the distal radius are a difficult problem and their management is controversial. The goal of treatment is to maintain reduction and allow early mobilisation of the wrist. Problems arise from the paucity of adequately contoured implants; the dorsal approach and sequelae of dorsally placed implants; and the lack of implants with angular stability and the effect of screw toggling or dislodgement. The volar LCP has been developed with these problems in mind and is proposed as a solution for these fractures. This study presents a consecutive series of 9 patients with Fryckman 8, Melone 2B or 3B, or AO type C2 radiologically classified fractures. They were all managed with the volar LCP and iliac crest bone graft. The patients were mobilised early, at 3 weeks, and assessed at 6 weeks with

38

flexion/extension radiographs. The preliminary results were very promising with no early complications or concerns noted. Internal fixation of femoral neck fractures in young adults–—comparison of closed and open reduction: a prospective randomised study Ashish Upadhyay, Pankaj Jain, Puneet Mishra, Lalit Maini, V.K. Gautam Southend Hospital, Westcliff-on-Sea, Essex, UK E-mail address: [email protected]. Background: Displaced intra-capsular fractures of femoral neck in young adults are treated by osteo-synthesis. We compared the results and complications of internal fixation after closed (CRIF) and open reduction (ORIF) in these patients. We also studied the risk factors that influence non-union and avascular necrosis (AVN). Methods: Patients in the age group of 15—50 years, with intracapsular fractures of the femoral neck, who were scheduled for internal fixation within 1 week of injury, were randomised into two groups, one for closed reduction and the other for open reduction. The two groups were compared for factors such as age, gender, time to surgery and posterior comminution as well as union and complications. Using univariate and multivariate methods the factors influencing non-union and AVN were analysed. Results: The results in the 2 groups in terms of union (P ¼ 0:93) and AVN at 2 years (P ¼ 0:85) were comparable. Rates of complications like deep vein thrombosis and infection were also found to be comparable. Guide wire breakage was found in 2 patients undergoing CRIF. Average duration of surgery in CRIF was significantly less than that in ORIF (P < 0:05). Posterior comminution, poor reduction and improper screw placement were the major factors influencing non-union. An accurate reduction in both the planes and placement of screws parallel or slightly divergent to each other had a positive influence on union. An overall incidence for AVN was 16.3% (15/92) and it was not influenced by any of the factors. A delay of more than 48 h in surgery did not influence union or AVN. Conclusions: Both CRIF and ORIF are credible methods of treatment. Although the duration of surgery in CRIF is less than ORIF, the added time taken in achieving the reduction on the fracture table may sometimes make the whole procedure longer than ORIF. Posterior comminution, early loss of reduction and convergent screw placement are leading reasons for non-union.

Abstracts

Basal fractures of the femoral neck: intra- or extra-capsular? A. Mallick, M.J. Parker Orthopaedic Department, Peterborough District Hospital E-mail address: [email protected]. It remains a matter of debate as whether basal fracture neck of femur should be treated as an extra-capsular or an intra-capsular fracture, hence different implants have been used to treat this. The purpose of this study is to give an overview and insight into the management of basal fractures. Out of a consecutive series if 3534 patients, 83 (2.3%) were classified as a basal. Seventy-one had internal fixation with a sliding hip screw for which there was one failure of fixation by cut out. Two had fixation with three screws, one of which healed in varus and the other required re -fixation with sliding hip screw. Five were treated with a hemiarthroplasty and one had total hip arthroplasty. Four were treated conservatively. For the surviving patients at 1 year 88% were in the same residence. Thirty-eight percent used similar walking aids, with the rest being more dependent on walking aids. Six percent of patients has significant residual pain. We conclude that basil fractures should considered as extracapsular fractures and treated surgically with a sliding hip screw. Factors predicting functional recovery following elbow dislocations in a consecutive series of 34 patients David Miller, Will Hart, Stuart Hay E-mail address: [email protected]. Aims: To look at the functional outcome after elbow dislocation. Methods: Patients were identified from a prospectively gathered trauma database. No patients were lost to follow up. Results: 34 patients with a dislocation or fracture dislocation of the elbow were reviewed over a 2year period. There were 24 adults and 10 children (mean age 52.7 range 26—83, and mean 12.8 years range 10—15 respectively). There were 14 female and 20 male with follow up averaging 15.2 months. There were 13 simple dislocations and 21 patients had associated fractures. There were 10 coronoid fractures identified and 11 radial head fractures. We found 4 medial epicondyle fractures and one radial neck fracture. Three cases were open. One patient had a radial nerve neurapraxia. There were no vascular injuries.

2003 Meeting of the British Trauma Society

All dislocations underwent reduction and EUA within 12 h. Seven cases required further surgical treatment. There were 5 radial head replacements, one medial epicondyle ORIF and one external fixator applied. Two adults subsequently required remanipulation for recurrent dislocation during follow up. Both had associated type II coronoid fractures. At follow up 31 (90%) patients were satisfied with their outcome. In these patients the average loss of extension was 19 degrees (range 0—30). Four patients were not satisfied with their outcome (3 children and one adult) with limit to extension of 50 degrees or more. Conclusions: The presence of a coronoid process fracture does not correlate with an unsatisfactory outcome. However, there was an increase in shortterm instability. The short-term expectation for patients requiring radial head replacement is of a good functional outcome although length of recovery was 3 months longer. Time to maximal recovery was on average 5 months. With the data available we have been unable to identify any predictors of unsatisfactory outcome. Long intramedullary hip screw for pathological fractures of the proximal femur M.R. Acharya, C. Wolstenholme, S.C. Williams, W.M. Harper E-mail address: [email protected]. Background: Estimates suggest that 50% of new cases of invasive cancer diagnosed each year will eventually metastasise to bone. The proximal end of the femur is the most common site of long bone involvement by metastatic disease. Accepted principles for the treatment of metastatic disease of the proximal femur have been published. The results of 31 consecutive patients treated with a long intramedullary hip screw for metastatic disease of the proximal femur are reported. Patients and methods: Retrospective case note review of all patients that had a long intramedullary hip screw for metastatic disease affecting the proximal femur over a 4-year period 1998—2002. Results: The case notes of 31 patients (33 femurs) were reviewed. There were 21 females and 12 males with a mean age of 71 years. Thirty-one femurs were Zickel group Ia or Ib, the remaining 2 were impending pathological fractures (Zickel group II) that were fixed prophylactically. Post-operatively all patients were allowed to fully weight bear. Seventy percent of patients regained their initial level of mobility or increased their level of dependence by a factor of one. Mean

39

hospital stay was 20.8 days (mode 7 days). Patients that died post-operatively had a mean survival of 299 days (range 2—1034). Those patients that were still alive at the last follow up had a mean survival of 475 days (range 7—1384). There were no cases of fixation or implant failure. There was one case of deep infection that was treated by implant removal. Conclusion: On the basis of these findings, the long intramedullary hip screw fulfils the principles for treatment of metastatic disease and can be recommended for the treatment of pathological or impending pathological fractures of the proximal femur. Pressure for beds–—does it put our orthopaedic patients at risk? S. Elsayed, T.D.A. Cosker, A.J. Grant E-mail address: [email protected]. Introduction: High occupancy rates of NHS beds has meant that increasing numbers of trauma patients find themselves on non-orthopaedic wards. Nursing staff on these wards may not have the specialist training to nurse such patients and may not recognise complications should they arise. The failure to recognise compartment syndrome was highlighted in a Clinical Governance meeting, leading to an assessment of nursing awareness of this condition. Methods: 50 orthopaedic trained nurses and a matched cohort of 50 non-orthopaedic trained nurses were asked a series of questions relating to compartment syndrome. Results: The majority of non-orthopaedic nurses failed to recognise the signs of early compartment syndrome. Only two (4%) of the non-orthopaedic trained nurses could give an adequate definition of the meaning of the term compartment syndrome. Thirty-two (64%) recognised that they should consult with a surgeon early, but were unable to accurately describe the symptoms for which the surgeon should be alerted. Many were reliant on subjective sensations as experienced by the patient rather than key clinical signs. Forty-four (88%) of the orthopaedic trained nurses were able to give an accurate description of the term compartment syndrome. All knew that as soon as they were suspicious of the diagnosis, they should alert a member of medical staff. All but one was aware of the gravity of a missed diagnosis in this respect. Conclusion: Compartment syndrome is a limbthreatening condition which requires prompt recognition. Patients at risk should be nursed in an appropriate environment.

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Locking plate system in the treatment of displaced proximal humeral fractures R. Chidambaram, T. Stasch, D. Mok, Epsom General Hospital E-mail address: [email protected]. Introduction: The purpose of this study is to evaluate the results of internal fixation of displaced proximal humeral fractures with a locking plate system. Methods: Between 2002 and 2003, 116 patients presented to our shoulder unit with proximal humeral fractures. Of these, 15 healthy active patients with displaced two to four-part fractures underwent open reduction and internal fixation with a locking compression plate system (Philos, Stratec UK Ltd.). Their average age was 60 years. They were evaluated clinically and radiologically at 2, 6, 12, 26 weeks or until union. Objective assessment was measured by the Constant scoring system, subjective assessment by the Oxford shoulder questionnaire. Surgical technique: Through an anterior deltopectoral approach, the fracture was reduced. A titanium plate designed to contour over the lateral aspect of the humeral head was applied with minimum of five locking screws in head fragment and three in the humeral shaft. Tuberosities approximation was reinforced with Ticron sutures through the rotator cuff and the holes in the plate. The shoulder was immobilised in a sling for 2 weeks followed by gradual mobilisation program with the physiotherapist. Results: All fractures united with a mean healing time of 14 weeks. Malunion, non-union or failure of fixation was not observed. One patient had a significant fall 3 months after surgery and sustained an undisplaced fracture of shaft of humerus below the plate. Treated non operatively, both fractures went on to uneventful union. Conclusions: Internal fixation with locking plate system in healthy active patients appears to be a safe and reliable method of treating displaced proximal humerus fractures. The early results show that this technique preserves the humeral head without disruption of the rotator cuff. Superficial radial nerve damage due to Kirschner wiring of wrist S. Singha, SpR Orthopaedics, S.P. Trikhab, MRCS, R. Twymanc a

Epsom Hospital, Dorking Road, Surrey KT18 7EG, UK

b

Orthopaedic Specialist Registrar

c

Consultant Orthopaedic Surgeon, Epsom Hospital, Dorking Road, Surrey KT18 7EG, UK E-mail address: [email protected].

Abstracts

For displaced fractures of the radius the use of Kirschner wires (K wires) is accepted practice either alone or to supplement external fixation. Complications related to K wires include infection, migration, damage to tendons and nerves. We set out to investigate to incidence of superficial radial nerve damage due to radial styloid wires. Fifty-four patients who had K wiring of the distal radius over a 12-month period were identified. Twelve patients were excluded as they did not have a radial styloid wire and a further two patients were not able to be assessed. The procedures were carried out by a number of different surgeons with different techniques. Patients were assessed clinically testing pain, light touch and two point discrimination. The non injured hand was used as control. The presence of neuroma formation was also noted. Four patients (10%) had no sensation in the distribution of the nerve, and three (7.5%) patients had reduced sensation in the distribution of the nerve. Two patients (5%) had a painful neuroma. Certain precautions should be taken to avoid damage to adjacent structures during percutaneous wiring of the distal radius. These include: the use of a tourniquet, a formal incision over where the pin is to be inserted, direct visualisation of the nerve, and if wires are buried under the skin they should be removed with the aid of a tourniquet. Nine patients (22.5%) sustained injury to the superficial radial nerve due to K wiring of the wrist, and we feel that the morbidity associated with K wires is underestimated, and can be avoided. VAlidating data on pre-existing comorbidity to avoid bias in comparative outcome studies A. Mahmood, Peter A. Oakley Department of Trauma Research, North Staffordshire Hospital NHS Trust, Princes Road, Hartshill, Stoke-on-Trent, ST4 7LN, UK E-mail address: [email protected]. The impact of pre-existing co-morbidity on victims of major trauma is well recognised as an influence on outcome. However, there are significant problems with the consistency of recording the pre-morbid state. At the time of presentation the main focus is on acute events and previous medical records are often unavailable. Individual centres record this information in different ways. Many do not make a concerted effort for uniformity in recording. There is no clear vali-

2003 Meeting of the British Trauma Society

dated distinction between past medical conditions that have resolved and on-going disease processes or tendencies. The information systems used for coding pre-existing co-morbidity vary from centre to centre, making direct cross-centre comparison impossible. In preparing data for an international comparison between a centre in the UK and one in Australia, the comparability of pre-morbid data was assessed by an independent review of the patient records. Significant omissions in the original data were evident. The free-text entry with ICD coding used in the relational database of one centre was adapted into the binary fields used by the other centre. The American College of Surgeons data set for pre-existing co-morbidity was agreed as a common platform. We propose a unified approach to acquiring this information in the future and present a strategy for addressing the common issues that prevent this. Combination management of massive tibial defects using contralateral vascularised free fibular transfer, Illazarov fixaton and OP-1 M.B. Rajesh, I. Pallister Department of Orthopaedic Surgery and Trauma, Morriston Hospital, Morriston E-mail address: [email protected]. Limb salvage after loss of bone and soft tissue may require many operations to restore soft-tissue cover and bony continuity. Massive segmental bony defects in open tibial fractures are generally treated with conventional bone grafting, bone transport or a free vascularised fibular graft. The vascularised fibular graft offers certain advantages to other options and can be used in conjunction with a ring fixator as an alternative method using transport of the fibula. Combining vascularised free fibular transfer with circular frame stabilisation and OP-1 confers the potential for rapid union and fibular hypertrophy. It minimises the morbidity of a lengthy cast immobilisation or frame application. Four patients with segmental tibial defects have been managed operatively as described above. Patients were allowed full weight bearing as soon as soft tissue permits. Staged deconstruction of the fixators were commenced after evidence of callus formation on X-ray at an average of 8 weeks, with frame removal completed at 12—16 weeks. The only significant morbidity has been one transient deep peroneal nerve palsy in the donor leg. Illizarov ring fixator therefore lends excellent support in the management of a delicate vascularised fibular graft. The concurrent use of OP-1

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allows for seemingly rapid union and swift progress to fibular hypertrophy and full unprotected weight bearing. The early mortality rate of tibial fractures in the elderly N. Beauchamp (Medical Student), Miss M.M. McQueen (Consultant), C.M. Court-Brown (Consultant) Royal Infirmary of Edinburgh, Orthopaedic Trauma Unit E-mail address: [email protected]. Aim: To define the mortality rates in patients 65 years old, who sustain tibial diaphyseal fractures and to identify high risk factors for mortality in this age group. Methods: Between January 1990 and December 1999, 225 patients aged 65, were treated for 233 tibial diaphyseal fractures. Demographic and descriptive data was obtained from prospectively recorded databases. Tscherne and Gustilo classifications were used for closed and open fractures, respectively. Mortality data was obtained by crossmatching patient information with General Register Office’s database. Hip fracture mortality data was obtained from the national hip fracture audit. Statistical analysis used Kaplan—Meier. Results: 73% of patients were female and 27% male, with an average age of 77.9 years (range 65— 99). Simple falls were the commonest mode of injury (38.6%), pedestrian RTA (29.2%), and falling down a slope (19.3%). One hundred and sixty-four fractures were closed (70.9%) and 69 (29.6%) open. The majority of closed fractures were Tscherne 0 or 1, whereas Gustilo type III predominated in open fractures. Overall mortality rate at 120 days was 17.2%. The mortality rate increased with age to a peak of 31.7% in 85 year olds. The mortality rate was significantly higher in open fractures (33%) compared to closed (10%, P ¼ 0:000). Mortality rates rose with increasing Gustilo grade (I: 27% to IIIC: 50%). In comparison to hip fractures there is a similar 30-day post injury mortality rate (tibia 11%, hip 13%, P ¼ NS), but at 120-days hip fracture mortality is greater (tibia 17%, hip 25%, P ¼ 0:02). However, open tibial fractures have a higher 120day mortality rate than hip fractures (open tibia 33%, hip 25%). Conclusion: There is a significant mortality rate for elderly patients who sustain a tibial fracture. Open tibial fractures in particular have a significant risk of death. This is a higher death rate than that for hip fractures, which are acknowledged as being a high-risk injury for the elderly patient, illustrating

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that injury carries a significant risk for the elderly patient. Should we be giving intravenous fluids to victims of blunt trauma? M.P. Revell, K.M. Porter, O. Bouamra, F.E. Lecky Hope Hospital, Salford, Manchester E-mail address: [email protected]. Objective: To determine whether or not fluid resuscitation impacts on the survival of blunt trauma patients. Subjects: Patients submitted by hospitals through out England and Wales to the TARN database between 1989 and 2000. Patients were injured by blunt trauma and subsequently required surgery for their injuries. Outcome: Odds of death after injury for patients administered 501—1000, 1001—1500, 1501—2000, >2000 ml of fluid resuscitation prior to surgery compared to those receiving <500 ml. Odds of death were adjusted through multiple logistic regression for variation between groups in injury severity score (ISS), age, and revised trauma score (RTS). Results: Three thousand six hundred and eighty four patients met the inclusion criteria. The case mix adjusted odds of death in patients receiving >2000 ml versus <500 ml of fluid prior to theatre was 1.78 (95% CI 119—2.59). No significant survival differences were seen for lesser fluid volumes. Conclusion: High volume fluid resuscitation is associated with greater mortality in blunt trauma patients requiring surgery after adjustments for case mix.

Abstracts

presentation of 29.6 months, and an average gap on the pre-op MRI of 4.2 cm. All six cases underwent open reconstruction of the TA using the Leeds—Keio synthetic ligament, weaving it through the distal and proximal stumps, bridging the gap. An MRI scan was performed at 6 and then 12 months post op. The patients were reviewed by the authors and a senior physiotherapist at 2, 3, 4, 5, and 6 months and at 1 year. At each visit the patients were scored using a modification of the Kaikkonen ankle scoring system, the power of the tendon compared to the contra-lateral side was assessed using a grip dynamometer modified by the author for use with the foot. None of the patients had any wound complications. All patients returned to full activity by 6 months, apart from running which took up to 1 year. The average strength of the TA compared to the other side, was 48% at 2 months, rising to 92% at 6 months (Table 1). The modified Kaikkonen score approached that of the non-affected leg by 6 months (Table 2). The MRI scans show that the bridged gap filled in with scar tissue. Open reconstruction of the TA using the Leeds— Keio synthetic ligament can be used in the treatment of chronic ruptures. In our series, no complications occurred, and good functional outcome was achieved. Table 1

Leeds–Keio synthetic ligament reconstruction of the Tendo Achilles following chronic ruptures; outcome and MRI findings M.J. Ravenscroft (MBBS, BSc, MRCS Specialist Registrar Orthopaedics) M. Sundar (FRCS Consultant Orthopaedic Surgeon) E-mail address: [email protected]. Chronic ruptures of the Tendo Achilles (TA), including late presentations and following failed conservative treatment, can be difficult to identify. Many techniques for repairing chronic ruptures have been described including turn down flaps, V-Y advancement, local tendon transfers, and synthetic grafts. From August 2001 to August 2002, we collected six patients with chronic TA ruptures that were confirmed with an MRI scan. All were male with an average age of 42.5 years, an average delay to

Table 2

2003 Meeting of the British Trauma Society

Initial results using a new humeral fixator plate (the ‘‘PlantTan’’ Plate) for fractures of the proximal humerus L.N. Banks, M.G. Smith, R.S. Bale, L.G.H. Jacobs E-mail address: [email protected]. Aims: To assess shoulder function and pain following open reduction and internal fixation of displaced 2, 3 and 4 part fractures of the proximal humerus, using a new fixation plate designed to provide rotation and angle stability. Methods: Patients treated by open reduction and internal fixation with a PlantTan Plate (PTP) are being followed-up for a period of 2 years from time of surgery. Post-operatively Constant-Murley (CMS) and Visual analogue (VAS) scoring systems are being used to assess function and pain at 2, 6, 12, and 24 months post surgery. Complications have been carefully recorded. Results: Currently 48 patients have been treated with a PTP and followed up beyond 12 months. Mean patient age is 65 (31—89), 17 male, 31 female. Six were undertaken for non-union and 42 for acute fractures. At 6 months post surgery mean CMS was 62 (28—100) on the fractured side compared to 85 (59—100) for the uninjured shoulder, with a mean VAS of 22 (1—85). At 12 months mean CMS was 70 (19—95) for the fractured side compared to 86 (75— 100) for the uninjured side, with a mean VAS of 20 (0—68). Six patients have died (unrelated causes). Screws have cut out in six (12.5%) patients with one requiring implant removal, one requiring revision and one requiring removal of a head screw. One screw cut out was due to the only case of AVN. There have been five (10.4%) superficial wound infections (resolved with oral antibiotics). One patient had a post-operative CVA. One case developed compartment syndrome due to intra-operative vascular injury; treated successfully with fasciotomies and vascular repair. Conclusion: We believe the PTP is a useful implant for the management of displaced proximal humeral fractures. We will report on full 2 year follow-up in the near future. Audit! A life saving tool in fatal road traffic accidents A.A. Abassi, M. Waseem E-mail address: [email protected]. The aims of our study were to assess mortality in road traffic accidents, to ascertain the major causes of deaths and to know the age and sex wise distribution of fatal road traffic accidents in a gulf state. We had a unique opportunity due to the small population of a 2.5 million all in the tertiary referral

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area of Khoula Hospital. Prior to this study there were no mortality and morbidity figures available in the state of Oman. This is an audit conducted at Khoula hospital, Muscat Sultanate of Oman from Jan 1998 to Dec 1999. Khoula Hospital is the national trauma center of Oman. Total road traffic accidents in these 2 years were 4469. The mortality due to Road traffic accidents was 84 (2.9%) and 69 (3.6%) in 1998 and 1999, respectively. The majority of cases who died due to Road traffic accidents were in age group 15— 45 100 (65%) followed by 46—70 28 (18%) years. In this study there were 122 (80%) male while only 31 (20%) were female. Major cause of death was head injury 102 (66%) followed by polytrauma 42 (27%) and blunt abdominal trauma 5 (3%). We conclude from our study that more work is to be done in this respect. Accidents can be reduced by strict enforcement of traffic laws by police. We also recommend that there should be an ambulance service for transferring RTA’s victims from the site of accident, as presently there is no such service. More is needed in pre hospital phase of management of trauma patients. We also made recommendations regarding use of seat belts and safety equipment for children. Since the presentation of this work to local police and health authorities some of these laws have been implemented. An audit is a very powerful tool and in this case a life saving one. Complete statistical analysis of pattern of injuries due to road traffic accidents in a Gulf state A.A. Abbasi, M. Waseem E-mail address: [email protected]. The main aim of our study was to know the pattern of injuries due to road traffic accidents with a view to identifying area’s for future interventions. In Sultanate of Oman data regarding Road traffic accidents was not available but there are approximately 3000 traffic accidents annually of which 500—600 are fatal. This study is meant at filling the gap in statistics of Road traffic accidents in Oman specially the pattern of injuries. Oman is a small country situated in the middleeast with a total population of 2.5 million people. This study was conducted at Khoula Hospital which is the National trauma center of Oman and a tertiary care Hospital. Data was collected retrospectively for 2 years 1998 and 1999. All patients who attended accident and emergency department because of road traffic accidents were included in this study. In our study total injuries due to RTA’s in these two years were 4483, the most common were soft tissue injuries 2145 (49%) followed by skeletal trauma 1017 (25%) and following head injury 943 (17%). In skeletal

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trauma group, lower limb fractures were 563 (34.5%) out of these 203 (36%) were fractures of tibia/fibula, while in upper limb the incidence was 289 (13.4%) of these 87 (30%) patients suffered from fractures of both radius and ulna. One hundred and eighteen (5.5%) of road traffic accident victims had pelvic fracture while 236 (11%) suffered polytrauma. In head injury group 458 (48%) were mild, 129 (13% ) moderate and 356 (38%) suffered severe head injury. This study highlighted the need for further work in this area. We concluded that the Omani Authorities should maintain a database of all RTA victims. Due to a small population this is a realistic aim and will help in future management and safety of RTA’s victims. Differences in outcome of surgical management of acute spinal injury between specialised versus non-specialised units M. Almaiyah, F. Selmi, P. Kluger National Spinal Injury centre (NSIC), Aylesbury, UK E-mail address: [email protected]. Aim: To determine the increased complications of spinal surgery done in non-specialised units for acute spinal injury patients. Methods: Retrospective analysis of all admissions to (NSIC) between February 1999 to August 2000. Results: Two hundred and forty-three patients admitted to NSIC over 18 months. Fifty-five patients underwent surgical interventions. Majority of patients were males, average age 36 years. Commonest cause of injury is RTA (45%). A complete injury (ASIA A) occurred in (54.5%) of patients. Primary interventions were done in NSIC, with no major complication, for 36 patients. Nineteen patients operated on in the referring hospital (non-specialised units) before transfer to our centre. Early corrective surgery required for 10 of the total 19 patients due to spinal instability in 5 patients, non-union in 2 patients, CSF leak, infection in 2 patients and wrong level in one patient. A comparison between primary and corrective surgery performed in NSIC the by the same surgical team. Showed that the average length of corrective surgery was 240 min with 150 min for primary procedure. Blood loss: 1750 ml in average for corrective surgery compared to 600 ml for primary intervention. Post-op mobilisation started in average 5 days after primary surgery and 20 days after corrective surgery. Period of rehabilitation 16 weeks in average after primary surgery in NSIC compared to 40 weeks after corrective surgery. Conclusions: Our results showed that early transfer to spinal injury unit and early spinal decompression and stabilisation performed by an experienced

Abstracts

spinal surgeon, in a spinal injury centre would prevent complications and delays in rehabilitation. Underestimation of previous whiplash injuries S.Z. Naqui, S.J. Lovell, M.E. Lovell E-mail address: [email protected]. In light of the recent suggestion that more significant symptoms may be expressed after second whiplash injuries by a possible cumulative effect, including degeneration 1, we wondered if patients were underestimating the severity of their earlier injury. We studied recent medico legal reports, to assess subjects with a second whiplash injury. Three hundred and ninety-four case sheets were evaluated to obtain 116 subjects with two whiplash injuries. They had been asked whether their earlier injury was worse, the same or lesser in severity. The mean age of the subject was 38 years old, 50 were male and 66 female. The mean duration between injuries was 4 years and 10 months. One hundred and one patients (87%) felt that they had fully recovered from their first injury and 15 (13%) had not. The majority of accidents were rear side impact with most subjects being the driver of the car. Seventy six subjects considered their first injury of lesser severity, 24 worse and 16 the same. The 76 that considered the energy of injury as lesser, suggested lesser symptoms as a result of their earlier injury. Out of the 24 that felt the energy of their first accident was worse, only 8 had worse symptoms, and 16 felt otherwise their symptoms were mainly the same or less than their symptoms from their second injury. Analysing with the null hypothesis that the rates should have been equal this result was highly significant (P < 0:0001). We feel that subjects may underestimate the severity of an earlier injury and associated symptoms. Reasons for this may include secondary gain rather than any proposed cumulative effect. Analysis of results after operative and non-operative treatment of fractures of the distal humerus in the elderly (aged 75–100) K. Srinivasan, M. Agarwal, S.J. Matthews, D.A. Macdonald, P.V. Giannoudis Department of Trauma & Orthopaedics, St. James’s University Hospital, Leeds, UK E-mail address: [email protected]. Purpose: In the younger population there is substantial body of evidence that the outcome is better following open reduction and internal fixation of distal humerus fractures. In the elderly however, there is a need to assess the value of internal

2003 Meeting of the British Trauma Society

fixation of these fractures where osteoporosis is almost a rule than exception and poses considerable challenge to even very experienced trauma surgeon. The purpose of this study therefore was to assess the functional outcome of operative fixation of fractures of the distal humerus in a cohort of elderly patients (aged 75 and above). The reproducibility of four different scoring systems is also evaluated. Patients and methods: Between 1996 and 2000 out 125 patients who were treated in our institution, elderly patients above 75 years of age were studied. Demographic data such as age, sex, associated injuries and the pre-admission elbow function were recorded. All the fractures were classified according to the AO/ASIF system. At final follow-up elbow function was analysed using OTAs rating system and these results were compared using three other scoring systems (Jupiter’s criteria, Aitkin’s and Rorabeck criteria, and the scoring system of Caja et al.). Treatment options, surgical or non surgical was based on the medical condition of the patient and the personality of the fracture. Intra-operative details including ulnar nerve transposition, olecranon osteotomy and quality of fixation were recorded and analysed. Serial radiographs were studied in detail for union, loss of reduction, certain prognostic indicators such as anterior tilt of distal humerus, cubitus angle, any articular step, gap, heterotopic ossification and development of degenerative changes. Radiological analysis was correlated with functional outcome. The minimum follow-up was 16 months (range 16—92). Results: Out of 125 patients, 29 (23.2%) were above the age of 75 (five male). The mean age of the patients was 84.6 years (range 75—100). One patient was lost to follow-up. In total 28 patients were studied with 29 fractures (one bilateral) and 5 open (Gustilo’s grade I). Mechanism of injury included 24 falls and 4 motor vehicle accidents. In seven cases associated injuries (three with ipsilateral upper limb injuries) were noted. Twenty patients (69.8%) had noticeable osteopenia in the X-rays. According to the AO/ASIF classification, there were eight type A, eight type B and thirteen type C fractures. Eight patients were treated nonoperatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. The injurysurgery interval ranged from 6 h to 5 days. An olecranon osteotomy (chevron type, Jupiter’s technique) was performed in 21 cases, 2 underwent Triceps ‘tongue’ reflection and 7 had triceps splitting. Only one case had anterior transposition of the ulnar nerve and none in the series developed ulnar nerve symptoms. Local complications included one case of deep infection (leading to non-union), three cases of superficial infection treated with

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antibiotics, three non-unions (two affecting the fracture and the other one the site of the olecranon osteotomy). The former patients declined further intervention and the latter patient was asymptomatic. One patient needed removal of olecranon metal ware, one developed olecranon bursitis. Heterotopic ossification was present in one patient with no effect on the elbow function. Overall, the mean loss of extension was 22.58 (range 58—408) and the mean flexion 98.68 (ranged 408—1328). In the nonoperative group the mean loss of extension and mean flexion achieved were 33.58 and 70.18 respectively whereas in the operative group were 22.78 and 106.68. OTA grading revealed 3 ‘excellent’, 9 ‘good’, 7 ‘fair’ and 2 ‘poor’ results in the operated group whereas in the non-operative group there were no ‘excellent’, 2 ‘good’, 3 ‘fair’, 3 ‘poor’ results. It is of note that in the non-operative group there was a 37.5% incidence of poor results significantly higher than the operative group. The number of ‘acceptable’ (excellent þ good) results was higher in the surgically treated group (52%) than in the non-surgically treated group (25.0%). The functional outcome was most closely related to anatomical reduction of the fracture (particularly articular step <2 mm) and anterior tilt of the distal humerus and was unaffected by the injury-surgery interval. It was found that the Jupiter score was less rigid for the range of movement but produced similar scores to OTA with less potential inter observer error compared to the two other scoring systems. Eighteen of the 21 (85.7%) the patients had no limitation of rotation. Conclusion and significance: This study supports the view that the functional outcome following distal humerus fractures is better with operative treatment in patients above the age of 75. Out of the four functional assessment scoring systems evaluated only the OTA and Jupiter gave similar results. Assessment of acute endothelial permeability changes following femoral instrumentation in a standardized sheep model: what is the effect of lung contusion and reaming? M. Chawdaa, P.V. Giannoudisa, F. Hildebrandb, M. van Griensvenb, C. Krettekb, H.-C. Papeb a

Department of Trauma & Orthopaedics, St. James’s University Hospital, Leeds, LS9 7TF, UK & Hannover, Germany b

Department of Trauma & Orthopaedics, Hannover Medical School Leeds, LS9 7TF, UK & Hannover, Germany E-mail address: [email protected]. Purpose: We aimed to quantify the development of acute endothelial permeability changes (within

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Abstracts

4 hours from canal instrumentation) with the reamed (RFN) and unreamed (UFN) nailing technique and assess the effect of coexisting lung contusion. Materials and methods: A standardized sheep model (n ¼ 8 animals/group) was used. In the control groups, a thoracotomy without lung injury was performed prior to canal instrumentation. In the study groups a lung contusion of the right middle and lower lobe was induced. Osteosynthesis of the femur was carried out by the reamed (group RFN) and unreamed technique (group UFN). Bronchoalveolar lavage was performed in order to assess the extent of lung parenchymal damage (permeability). Polymorphonuclear leukocyte activation was quantified by chemi-luminescence. IL-8 and coagulatory disturbances (Protein C) were also measured. All animals were sacrificed 4 h following canal instrumentation and histological analysis was performed. Results: The experimental lung contusion induced prior to canal instrumentation caused also a significant increase in pulmonary permeability compared to baseline values. The subsequent canal instrumentation amplified further, significantly so, the degree of pulmonary permeability only in the reamed group (RFN) (Table 1). Both the activation of leukocytes and IL-8 release were also significantly raised following lung contusion and reamed femoral nailing compared to the UFN group with lung contusion (data not shown).

Conclusion: In a standardised sheep model without chest injury, instrumentation of the femoral canal with the reamed and the unreamed nailing techniques induced a rise in pulmonary permeability changes. In the presence of lung contusion, reamed intramedullary femoral nailing provoked a further increase in pulmonary permeability damage, IL-8 release and leukocyte activation. The findings of this study support the view that reaming of the femoral canal should be avoided in polytrauma patients with severe chest injuries as it can act as an additional stimulus for adverse outcome. Prevalence of pelvic ring disruptions, associated injuries and mortality: the United Kingdom perspective P.V. Giannoudis, O. Bouamra, F. Lecky E-mail address: [email protected]. Purpose: We wished to determine the characteristics of patients with pelvic ring fractures (PG) in England and Wales, make comparisons to major trauma patients without pelvic injury (NPG), determine the factors predicting mortality including the impact of presence of pelvic reconstruction facilities in the receiving hospitals on outcome. Patients and methods: Prospectively data from 106 trauma receiving hospitals forming the Trauma

Table 1 Group

Time

Urea (g/l)

Protein (g/l)

Ratio

BAL

SERUM

BAL

SERUM

UFN

Baseline Thoracotomy Fixation (F) 4 h post F

0.013 0.0019 0.0065 0.0075

0.09 0.086 0.085 0.071

0.20 0.048 0.095 0.22

68.75 52.13 67.01 54.06

80.13 108.06 109.80* 105.84

UFN

Baseline Contusion Fixation (F) 4 h post F

0.0343 0.0265 0.0269 0.0174

0.1296 0.0953 0.0874 0.0960

0.1398 0.3838 0.3843 0.1924

79.0648 76.2271 69.7002 56.2467

40.26 105.21* 121.07 110.64

RFN

Baseline thoracotomy Fixation (F) 4 h post F

0.013 0.088 0.0086 0.013

0.127 0.079 0.081 0.08

0.14 0.16 0.22 0.30

62.5 59.86 63.58 56.4

76.8 86.62 130.22* 104.49

RFN

Baseline Contusion Fixation (F) 4 h post F

0.0143 0.0037 0.0057 0.0064

0.0877 0.0661 0.0755 0.0911

0.1284 0.3596 0.2057 0.2833

55.0222 58.4300 65.6325 64.146

42.01 102.71* 178.261 256.671

Statistical significance (P < 0:05). (*) Compared to baseline; 1 compared to contusion.

2003 Meeting of the British Trauma Society

Audit and Research Network were studied. The TARN database includes injured patients arriving alive at hospital who are then admitted for more than 72 h, or who die in hospital from their injuries. Patients aged greater than 65 years with isolated fractures of the proximal femur or pubic ramus and patients with simple injuries are excluded. From this population we identified patients who had sustained pelvic ring injuries (PG) according to Abbreviated Injury Scores (AIS) coding. The database allows analysis in detail of demographic information, scene data, admission physiology, initial resuscitation, inter-hospital transfers and operative intervention. AIS injury codes, and Injury Severity Scores (ISS), duration of intensive care unit stay, length of hospital stay or time of death are also available. These factors were analyzed firstly to compare the demography and injury severity of patients with pelvic ring injuries to patients without pelvic fractures. Following this, univariate analysis was used to identify factors predicting mortality within the PG. Significant variables were used in a backward stepwise logistic regression multivariate analysis to determine relationship with outcome. Results: Between 1989 and 2001 out of 159,746 patients, 12,759 (8%) had sustained a pelvic fracture (PG). However, 1610 patients did not meet the inclusion criteria and were excluded from the final analysis. In total 11,149 patients were studied. The remaining 146,987 formed the non-pelvic group (NPG). The mean age and ISS was 37.9 (range 1—99) versus 40.6 (range 1—108) and 10 (4—75) versus 9 (4—75) in the PG and the NPG, respectively. Thirty-four percent (4335%) patients in the PG had an ISS  16 versus 16.8% (24,764) in the NPG, P ¼ 0:001. The overall mortality rate in the PG was 14.2% (1586 patients) versus 5.6% (7465) in the NPG, P ¼ 0:001. On arrival at the trauma room 21% of the patients in the PG had a GCS < 15 and 7.4% had a systolic blood pressure <90 mmHg. The severity of pelvic fractures according to the AIS was: AIS 2 ¼ 7247 (65%), AIS 3 ¼ 3051 (27.4%), AIS 4 ¼ 627 (5.6%) and AIS 5 ¼ 224 (2%). There was an incidence of associated liver/spleen lacerations in 8% of the patients, chest trauma in 21.2%, head injuries in 15.4%, 2 or more long bone fractures in 7.6 %, spinal fractures in 2.7% whereas a urethra/bladder injury was noted in 519 (3.9%) of the cases. Three thousand seven hundred and twenty-four (28%) of the patients required a surgical intervention within the first 12 h of arrival (8.2% application of external fixator/laparotomy) and the rest thereafter. Analysis of survivors versus non-survivors in the PG group revealed a significant higher ISS 9 (4—75) versus 34 (4—75),

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incidence of systolic blood pressure <90 mmHg, GCS < 15, and higher fluid resuscitation requirements. Non-survivors had a significant higher prevalence of liver/spleen lacerations compared to survivors (29.4% versus 4.7%), chest trauma (61.1% versus 14.6%), head injuries (56.1% versus 8.75%), and two long bone fractures (17.6% versus 6%), P ¼ 0:01. Factors predicting reduced survival estimated by a multiple logistic regression model revealed age, physiological derangement, head injury, chest injury, and associated spleen and liver lacerations having an independent predictive ability of increased mortality (P ¼ 0:001) with a higher odds ratio for liver/spleen injuries. Severity adjusted odds of survival between patients who were treated or transferred to a hospital without facilities for pelvic reconstruction using a multiple regression analysis adjusted for ISS, age and RTS showed an odds ratio (OR) 2.5 (1.45—4.038) for mortality compared to patients treated in hospitals where pelvic reconstruction was available. Conclusions: The presence of liver/spleen lacerations, head and chest injuries were predictive of reduced survival rates as well as the absence of pelvic reconstruction facilities on the receiving hospitals. This study supports the view that level I trauma centers with pelvic reconstruction facilities in the United Kingdom may contribute to improve survival rates in patients with pelvic fractures. A simple method of dressing external fixator pin sites S.R. Annapureddy, N.J. Talbot, G. Becker, N.D. Rossiter E-mail address: [email protected]. We describe a simple method of dressing pin sites, based on the principles developed in the Ilizarov institute, that can be used in the British operating theatres. There are a wide variety of protocols for pin site care but infection rates of up to 80% are reported. The Ilizarov institute in Russia claims low infection rates which may be influenced by their dressing technique. Specially manufactured rubber stoppers are passed over the wires to hold the gauze sponges against the skin. Plastic syringes consist of a barrel and a plunger with a rubber bung. The rubber bung from a 5 ml syringe plunger can be easily removed and slid over the end of a half pin or both ends of a fine wire. At the end of the procedure a cut piece of gauze is applied around the pin site and held in place by the rubber bung, providing a secure non- bulky dressing. The bungs can be slid back up the pin when the

48

dressings are changed and left up if the pin site is to remain uncovered. Should the pin site begin to discharge the bung can again be used to hold the dressings securely. We have found this simple, quick, inexpensive and reliable method of pin site dressing that can be readily used in everyday practice. Clavicular length measurement following trauma Purpose of the study: To identify a simple and reproducible method of measuring clavicular shortening following trauma. Introduction: Clavicular fractures following trauma, account for about 5% of all fractures and about 45% of all shoulder girdle injuries. Loss of clavicular length following fracture (clavicular shortening) has recently been recognised to affect functional outcomes. A recently published report has recommended the use of bilateral clavicular X-rays to measure clavicular lengths. We describe a simple, and reproducible method of measuring clavicular length that can be used for assessing clavicular shortening following trauma. Method: Five different postero-anterior chest X-rays for each of 30 different patients (a total of 150 chest X-rays) were checked by an observer in the first instance to measure the clavicular lengths bilaterally. Only X-rays showing full clavicle on both sides were used. After a gap of 6 weeks, these X-rays were read again by the same observer and then subsequently by another observer independently. Bilateral clavicular lengths along with the inter-pedicular distance and the spino-pedicular distance of T3/T4 vertebrae were measured on each occasion to ascertain the rotation of the film as well as clavicular lengths. Results: Analysis of the results showed that neither the intra- nor the inter-observer variations in any of the measurements were statistically significant (P > 0:1 in both cases). If the chest X-ray was not rotated, as estimated from the inter-pedicular and spino-pedicular distances, then the clavicular length measurements were reproducible in the same patient in different chest X-rays. Conclusions: We have identified a reliable and reproducible method of measuring clavicular lengths using a simple and commonly used technique. We recommend the PA chest X-ray in measuring clavicular shortening following trauma. Ankle arthrodesis with angle blade plate in failed primary fixation of ankle fractures

Abstracts

K.N. Subramanian, A.I. Zubairy. N.P. Geary, M. Hennessy, M. Lwin Southport and Ormskirk District General Hospital, Southport, Merseyside E-mail address: [email protected]. Introduction: Fracture configuration in severe ankle trauma impedes adequate fixation leading on to chronic pain in ankle. We describe our experience of ankle arthrodesis with paediatric angle blade plate in patients with intractable ankle pain after failure of initial fixation in complex ankle fractures. Materials and methods: Ten-ankle arthrodesis were performed in 9 patients. All patients were reviewed independently in special clinics. The objective assessment was performed by detailed clinical examination and the subjective assessment was made including overall patient satisfaction. The American Academy ankle and hindfoot scoring system was used. The technique of ankle arthrodesis was similar in all patients using anteromedial or anterolateral incision, preparation of articular surface, internal fixation with paediatric angle blade plate with or without bone grafting. Similar postoperative protocol was followed in all cases. Time to union was assessed by clinical and radiological examinations. Results: Radiological union was achieved in nine ankles in a mean time of 16 weeks. Fibrous union occurred in one patient. Eight patients were very satisfied with their treatment. The patient with fibrous union had marginal improvement of symptoms with pain score improved from 9 to 7. The mean ankle and hindfoot score was 84. Conclusion: Ankle arthrodesis with paediatric angle blade plate is a valuable method of managing patients with intractable ankle pain after failure of initial fixation in complex ankle fractures. In our series of patients it has success rate of around 90%. Histology of reaming samples of bone in patients undergoing intramedullary stabilisation for metastatic lesions in bone K.N. Subramanian, C. Ramamurthy, M. Ramakrishnan, R.W. Parkinson Southport and Ormskirk District General Hospital, Southport, Merseyside E-mail address: [email protected]. Aim: To report on the bone histology of patients undergoing intramedullary stabilisation for a pathological fracture or a metastatic lesion in long bones.

2003 Meeting of the British Trauma Society

Materials and methods: From 1999 to 2002, 36 long bones in 29 patients (seven had stabilisation of two long bones) were stabilised with an intramedullary nail in patients with a known primary tumour. Prophylactic fixation was performed in 19 bones with metastatic tumour and in 17 for a fracture. Of the 17 fractures, 13 were considered pathological and four were simple fracture unrelated to metastasis. Thirty-three nailings were done for proximal femoral lesions and three were for the humerus. Reaming samples were sent for histological analysis. The various sites of the primary tumour were Breast (13), Myeloma (6), Prostate (5), Lung (4), Unknown (3), Bladder (2), Oesophagus (1), Renal (1), Melanoma (1). The histological results were correlated with the clinical diagnosis. Results: Thirty-six reaming samples were sent for histological analysis. Twenty-two samples correlated with the clinical diagnosis. Of the 22 tissue samples, two did not have a initial confirmed histological diagnosis of primary and the reaming samples helped to achieve this. Fourteen biopsies gave false negative results. Conclusion: Approximately two-thirds of the time the reaming sample has correlated with clinical diagnosis. Sensitivity of this test is 61%. ACL reconstruction: should we forget extraarticular augmentation? R. Anwar, R.P. Mackenney E-mail address: [email protected]. We performed a retrospective review of 139 patients who had surgical stabilization for chronic anterior cruciate ligament instability. Sixty-five patients had intra-articular reconstruction (Group 1) alone, while 74 patients had been treated with a combined intraarticular and extraarticular (Group 2). The same surgeon operated on both the groups. Patients were assessed on the basis of clinical and radiological findings using the Tegner Activity and IKDC scoring methods. The average follow-up period was 49 months in Group 1 and 52 months in Group 2 patients. The average age of patients in both groups of patients was 30 years (28.7–—range 26—32 Group 1 and 29–—range 17—52 in Group 2). Football and other sporting activities were the major cause of injury. IKDC scores were found to be normal or nearly normal only in 47 patients (72.3%) in Group 1 and 89% (66 patients) in Group 2 patients. Group 1 patients exhibited more knee symptoms and these were mainly related to instability. Moreover, only three patients stepped down from IKDC grade A or B in 4 years in Group 2; while this change was more dramatic in Group 1 where eight patients deteriorated considerably in the same time. A long

49

prospective study involving the use of instrumentation (arthrometer) is required for further evaluation. Failure of cannulated hip screws for stabilization of femoral neck fracture: is there a configuration for an optimum fixation? M. Almaiyah, P.J. Gregg, M. Allami, C. Corbin, P. Giannoudis Middlesbrough General Hospital, UK St. James’s University Hospital, Leeds, UK E-mail address: [email protected]. Purpose: To investigate the relevance of different cannulated hip screw configurations on femoral neck fracture’s fixation outcome. Patients and methods: Retrospective study of 169 consecutive patients who underwent cannulated hip screw fixation for fracture neck of femur were examined by three independent reviewers. Data was recorded and analysed as fracture pattern, bone quality, screws’ configuration, radiographic failure, osteonecrosis, union rate, revision rate, systemic and local complications, postoperative pain and patients’ overall satisfaction. The minimum follow-up was 14 months (range 12—60). Statistical analysis at 5% significance level using t-test was performed. Results: Between 1997 and 2000, 169 cannulated hip screws in 167 patients (two bilateral) were performed in our institutions. Twenty-three patients were lost to follow-up. In total 146 (86.4%) patients (37 male) were analysed. The results of the study in order of significance were: the radiographic failure rate was detected in 56 out of 146 patients (38.4%). The revision rate was 21.25% (31/146). The incidence of failure was more common (35/66) with displaced fractures compared to undisplaced fractures (21/80). The triangular configuration with apical screw superior provided a higher success rate, higher union rate and fewer incidences of osteonecrosis compared to other configurations. Apical anterior, linear, and crossed configurations provided less stability for fixation with higher rate of failure and osteonecrosis. Failure rate was more common in men, patients with Parkinson’s disease and in patients on steroids and/or NSAIDs. There was no significant statistical association between the failure and osteoporosis, osteoarthritis of the hip and post-operative protective weight bearing in all groups studied (P > 0:005). Conclusion: This study supports the view that use of triangular configuration with apical superior screw provides better stability of fixation for intracapsular femoral neck fractures. The current

50

practice of favouring triangular configuration with apical inferior screw fixation should therefore be reevaluated. Displaced proximal and distal extra-articular fractures of the humerus treated by a retrograde nailing technique J.E. Kevu, S.S. Kumar, R. Zepeda, K. Murali, T. Chapman, S. Halder E-mail address: [email protected]. Management of displaced proximal and distal extra-articular fractures of the humerus remain a challenge. The increasing tendency towards operative treatment in the young working patient coupled with the various fixation techniques and devices now available place increased demands on the surgeon. Conventional antegrade nailing may damage the rotator cuff and attempts at proximal and distal locking may injure the neurovascular structures, including the axillary nerve. Available retrograde nails may be inadequate for distal fractures. We report results of the first 278 patients treated by our retrograde nailing system. It incorporates a special interlocking device–—‘‘Trio wire’’, that obviates the need for jigs and screws whilst ensuring axial and rotational stability. It therefore eliminates the possibility of cuff and neurovascular damage. Of the 278 patients, 160 were proximal and 118 distal fractures including 17 of the extra-articular type. In all early pain relief with return of full shoulder and elbow function was achieved. By 6 weeks 95% could perform most tasks of daily living. Complications include proximal migration of nail through humeral head (four cases), broken ‘‘Trio wire’’ with resultant non-union (four cases), nonunion successfully treated by revision (six cases) and heterotopic ossification (two cases). All distal fractures healed without complications. In our experience, this retrograde nail is easy to use and provides stable fixation for proximal and distal humeral fractures even in cases of poor quality bone. The effect of a venous filter on embolic load, during medullary canal pressurization: a caninie study K. Mohanty, J.N. Powell, D. Musso, D. Traboulsi, I. Belenkie, B. Mullen, J.V. Tyberg E-mail address: [email protected]. Introduction: Early stabilization of the skeleton in multiply injured patients has shown to reduce mortality and reamed nailing is the ‘gold standard’ method for stabilizing femoral shaft fractures. However, several investigators have highlighted

Abstracts

the adverse effect of early reamed nailing in polytrauma patients. Intravasation of medullary fat has been suspected to produce a ‘second hit’ and trigger pneumonia and ARDS. This study investigates the effect of a filter placed into the ipsilateral common iliac vein during medullary canal pressurization. Methods: Using an established canine model, twelve mongrel dogs were randomized into two groups. Under general anesthesia, cannulations and transesophageal echocardiography was performed in all animals and then a special filter was inserted percutaneously into the left common iliac vein in half the dogs where as the other half served as controls. In all dogs, the left knee was exposed; the femur and tibia were sequentially reamed and than pressurized by injection of bone cement and insertion of intramedullary rods. Hemodynamic measurements and echocardiography images were recorded continuously through out the surgical procedure. After 45 min, the dogs were sacrificed and the lungs were harvested for histological analysis. Results: There was significant difference noticed in the right-sided pressures between the filter and the control groups. The mean pulmonary artery pressure at 3 min of pressurization was 12 mm of Hg in the filter group and 28 mmHg in the control group. Transesophageal echocardiography showed less embolic shower in the filter group and histomorphometry demonstrated much less proportion of lungs to be occupied by fat in the filter group as compared to the control group. Conclusion: This canine study has demonstrated that mechanical blockade by a venous filters can significantly reduce the embolic load on the lungs during canal pressurization. A suitable filter is being designed for possible clinical use. Assessment of reliability of classification systems for trochanteric fractures K. Mohanty, E. Olschewski, J.N. Powell E-mail address: [email protected]. Introduction: Extra capsular fractures of proximal femur account for approximately half of all hip fractures and its incidence is on the rise. There are many classification systems in use for classifying these fractures. An ideal classification system helps in planning treatment, predicting outcome and helps in communication amongst clinician and hence should be reliable. We report on the intra and inter observer reliability of various classification systems and the relationship between classification and choice of implants. Methods: The preoperative radiographs, both anteroposterior and lateral views of 50 cases of

2003 Meeting of the British Trauma Society

trochanteric fractures, were studied by three orthopaedic surgeons. Each rater was required to classify the fractures according to the modified Evans and AO proximal femur classification systems, and additionally as stable or unstable types. Each observer independently classified the fractures and indicated treatment choice on two occasions, 1 month apart. Kappa statistic was used to assess both inter- and intra-observer reliability. Result: Among the 47 fractures, only 10 fractures (21.3%) were classified the same way across all three observers using Evans classification system. Using the AO classification system, 53.2% of the fractures (n ¼ 25) were identically classified across the three raters and when determining stability, they were in agreement for 31 fractures (66.0%). For the Evans classification system, the mean kappa value was 0.69 (range: 0.53—0.87) for intra-rater reliability and 0.34 (range: 0.28—0.43) for inter-rater reliability. For the AO classification system, the mean kappa value was 0.63 (range: 0.29—0.87) for intra-rater reliability and 0.66 (range: 0.57—0.73) for inter-rater reliability. Classification of fracture stability was also assessed resulting in mean kappa values of 0.89 (range: 0.81— 1.0) and 0.75 (range: 0.71—0.80) for intra- and interrater reliability respectively. Conclusion: The intra and interobserver reliability of current systems was found to be poor and agreement was most for classifying these fractures as stable or unstable. Assessment of lower limb alignment after L.I.S.S. fixation K. Mohanty, D. Musso, R. Buckley, J.N. Powell, C. Romano E-mail address: [email protected]. Introduction: With the rising popularity of biological fixation, ‘‘less invasive skeletal stabilisation system’’ (L.I.S.S.) has emerged as a valid option to treat complex fractures around the knee. Published reports have shown good results with shorter healing time and lesser re-operation rates. However as with any close procedure, restoring correct alignment of the limb could be difficult with this system and has not been reported previously. We report the results of CT alignment study in 20 cases of L.I.S.S. fixation. Methods: In a combined retrospective-prospective study, 20 patients, who were treated with L.I.S.S. system for stabilizing either femoral or tibial fractures were enrolled. Patents with only unilateral fractures with a normal contra-lateral lower limb were included. All patients had CT scannograms and limited axial CT cuts of both lower limbs. Axial and rotational alignments were measured and assessed by one consultant radiologist.

51

Result: There were nine cases of femoral and 11 cases of tibial L.I.S.S. The mean total malrotation was found to be 11.978 (2.0—34.5). All femora were found to be malrotated externally with a mean of 11.71 degrees where as for the tibiae the mean internal and external malrotaions were found to be12.53 and 11.74, respectively. Mean coronal malalignment was found to be 3.768. If acceptable alignment was taken as 58 in any plane, then the degree of malrotation in our study was found to be statistically significant. Discussion and conclusion: Malalignment, mainly in the rotational plane has been reported in other closed techniques such as femoral and tibial nailing. As L.I.S.S. is also minimally invasive and done through indirect reduction techniques, restoration of correct alignment could be difficult to achieve. This study is reassuring as we have found that generally, alignment of limb in our study was satisfactory and no corrective surgery was needed. Death in the millenium; an audit of in hospital deaths for the year 2000 in a large teaching hospital trauma unit S.C. Williams, M. Acharya, F. Hussein, W.M. Harper E-mail address: [email protected]. An audit was conducted to determine the causes of in hospital death. There were 133 deaths from 1st January 2000 to the 31st December 2000. The majority of the deaths were from fractured neck of femur cases (83.62%). For all deaths there were 50 (38%) females and 83 (62%) males. The average age of death was 83 years, range 49—97 years. Causes of death as appeared in part 1a of the death certificate were, bronchopneumonia (23% cases), congestive cardiac failure (11%), left ventricular failure (7%), old age (6%), and MI (3%). Death from pulmonary embolism (PE) was uncommon and only occurred as a coroner’s cause of death (4% coroner’s cases). The majority of patients who required surgery were operated upon in less than 2 days. Most deaths occurred within the first 5 days following surgery. For fractured necks of femur, there was no difference in the causes of death between those patients who underwent internal fixation as compared with those who had a hemiarthroplasty. Apart from PE, for those cases referred to the coroner (48/133), the causes of death were no different, in terms of the spectrum and frequency with which they were recorded, than those recorded by the medical practitioner completing the death certificate. Death from respiratory disease and cardiac failure are common, post-mortems do not seem to yield different causes of death. The in hospital death rate for fractured necks of femur was 12.5%. This data is

52

likely to increase awareness, improve care pathway design, and reduce morbidity and mortality by targeting resources. Prophylactic reconstruction of impending metastatic subtrochanteric fractures of femur using long gamma nail S.R. Samsani, V. Pannikar, K.M. Venu, D. Georgionnas, D. Calthorpe E-mail address: [email protected]. Metastases in the subtrochanteric region of the femur can be challenging to treat due to peculiarities in biomechanics and anatomy. The aim of the study is to review the results of prophylactic reconstruction of femur for impending metastatic subtrochanteric fractures using a Long Gamma Nail. Between 1996 and 2002, 28 subtrochanteric metastatic lesions of femur in 25 patients (three bilateral) were treated with Long Gamma Nail. The outcome measures used in this study were pain relief, postoperative mobilization status, complications and survival following surgery. There were 16 female and 9 male patients with an average age of 64 years. Primary source of pathology was breast followed by lung and prostate. Left side was involved in 17 and right in 11. Intra-op blood loss 557 ml (range 400—1000 ml). Average post-op transfusion rate was 2.7 (range 2—4) units. Mean hospital stay was 9 days (range 4—21 days). All patients were followed until death. All patients reported marked pain relief. All but one regained preoperative mobilization status. There were no intra-operative deaths including three bilateral nailings. Significant surgical and implant related complications were seen in three (12%) patients. Postoperative medical complications were seen in three (12%) patients including a death on 4th post-op day. There were no implant failures and reoperations. At the time of study 14 patients died with an average survival of 9 months and 11 patients were alive with an average survival of 16.5 months. Long Gamma Nail is valuable reconstruction device for the prophylactic treatment of the difficult femoral subtrochanteric metastatic bone disease. It provides immediate stability to relieve pain and allows unlimited weight bearing. It is versatile and biomechanically superior to extramedullary devises and compares favourably with other intramedullary devices. Unusual triple lesion S. Sripada, A.J. Quyn, G. Fadel, J.E. Scullion Ninewells Hospital and Medical School, DUNDEE E-mail address: [email protected].

Abstracts

We present a case of type III coracoid fracture associated with grade III acromio-clavicular joint dislocation and Neer II lateral clavicular fracture in a young patient. This patient was successfully treated by open reduction and osteosynthesis. Both the fractures are fully healed at the last follow-up. The patient has a Constant score of 91 at 2 year followup, compared to 96 of the contra-lateral shoulder. A combination of these three injuries in the same shoulder is not described in English literature to our knowledge. Functional outcome following femoral shaft fractures in children J.A. Webb, L. Longstaff, C. Bailey, S. Goodfellow, J.M. Quinby, P.D. Henman Newcastle General Hospital, Freeman Hospital, Newcastle upon Tyne, UK E-mail address: [email protected]. Femoral shaft fractures are common in children, accounting for approximately 2% of all bony injuries. Various treatment strategies have been advocated and these are usually age dependant. Few large studies have been published comparing fracture and treatment patterns in the paediatric population. No studies published to date have analysed functional outcome in this group. Methods: Follow-up data of 73 children with femoral shaft fractures was obtained from hospital notes. X-rays were classified according to the AO system. All patients were subsequently invited to attend clinic where functional outcome was measured using the AAOS/POSNA scoring system. Limb length was measured using graded blocks. Data analysis was performed specifically examining demographic details, treatment and outcome. Results: There was a bimodal distribution of fractures with peaks at 2 and 15 years. Males were more commonly affected than females (50 versus 23). Fractures in younger patients were treated predominantly conservatively; those at 8 years and over predominantly operatively. All fractures united. Mean length of hospital admission was 19 days in the conservative group and 11 days in the operative group. Mean follow-up was 17 weeks. Forty-four patients attended the special assessment clinic at a mean time of 43 months from injury. The overall mean POSNA score was 47.4. Ten patients had a score of less than 1 standard deviation from the standard mean. This indicates that they are experiencing a lower level of global health function than the general paediatric population. The mean POSNA score for the operatively treated group was significantly lower than the conservatively treated group. (40.0 versus 50.7,

2003 Meeting of the British Trauma Society

Fischer’s exact test, P ¼ 0:034). At prolonged followup, there was minimal limb length discrepancy in all groups (mean ¼ 0:28 cm, range 0—2.7 cm). No relationship could be established between this residual limb length discrepancy and functional outcome (Fischer’s exact test, P ¼ 0:299). Conclusion: Existing treatment of paediatric femoral shaft fractures is safe and effective, leading to union with few complications. For most patients, long-term functional outcomes are high and measured limb length discrepancies are low. However, in contrast to the conservatively treated group, patients treated operatively may demonstrate lower long-term functional outcomes when compared to the general paediatric population. Experience with BMP-7: case reviews R. Bommireddy, S. Phillips, A.F.G. Groom E-mail address: [email protected]. The role of bone morphogenetic proteins (BMPs) in osseous repair has been demonstrated in numerous animal models. Recombinant human osteogenic protein-1 (rhOP-1 or BMP-7) has now been produced and was evaluated in a clinical trials. Bone Morphogenetic Protein-7 (recombinant human osteogenic protein-1: OSIGRAFT) was used in 12 selected difficult cases during the past year in our unit. Of these, 10 cases were non-unions with at least one failed previous operation. Iliac autograft along with BMP-7 was used in nine cases. In two cases only BMP-7 and in one case allograft along with BMP-7 was used. We have achieved union in all the cases except one. We conclude that a combination of autograft and BMP-7 appears to enhance bone healing potential with rapid, abundant callus formation in difficult non-unions. Cost and lack of long-term results are the main concerns. Epiphyseal injury of distal femur with a Hoffa’s fracture complicated by common peroneal nerve injury S.R. Samsani, K.M. Venu, J. Chell E-mail address: [email protected]. Hoffa’s fracture in children is rare and has never been reported in the western literature either as an isolated injury or in combination with a distal femoral epiphyseal injury. We report the management and outcome of a rare case of complex distal femoral epiphyseal injury associated with a Hoffa’s fracture of medial femoral condyle and neuropraxia of common peroneal nerve. A 14-year-old girl presented with a painful swollen knee following an injury. Radiographs showed a

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complex distal femoral epiphyseal injury associated with a Hoffa’s fracture of medial femoral condyle. Patient also had symptoms in the distribution of peroneal nerve. Due to the nature of injury and associated neurological involvement operative stabilization of fracture was immediately performed. In view of her age that she had reached menarche and was 165 cm tall, it was considered that her further growth potential was minimal. Therefore, the distal femoral epipyseal injury was stabilized to achieve primary epipysiodesis and the Hoffa’s fracture was fixed with an antero-posterior lag screw. The peroneal nerve symptoms had completely resolved by 3 weeks and there was radiological evidence of growth plate consolidation with good functional outcome at 6 months followup. Prognostic relevance of Salter—Harris classification and incidence of peroneal nerve injuries with reference to distal femoral epiphyseal injuries is also discussed. Traumatic base of the fifth metatarsal fractures–— a new classification system A.P. Kumaaraguru, V. Koo, G. McAlinden E-mail address: [email protected]. Background: There has been much controversy and confusion regarding fractures of the base of the fifth metatarsal since 1902, when Sir Robert Jones first reported this fracture in the literature. This confusion has been augmented by the universal application of the term ‘‘Jones’s fractures’’ to all fractures at the base of the fifth metatarsal. The fractures were vaguely classified and it was not studied properly. We aimed to read the fracture pattern more anatomically to decide best treatment. Method: We individually reviewed plain X-ray films to study the epidemiology and anatomical variations in fifth metatarsal base fractures. Results: According to this radiological review a new classification system is proposed to understand more about this fractures. Based on this classification system a retrospective study was done for a period of one year to look at the way this fractures were treated and to identify potential problems. Conclusion: Types III and IV fractures take long time to heal than other types. It needs a prospective study based on the new classification system. Carpal instability after apparently minor distal radial fracture: a short case series and brief review R.E. da Assunc¸a ˜o, M. Waseem, P. Yates E-mail address: [email protected].

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Introduction: Carpal instability may be a complication of distal radial trauma and, left untreated, may predispose to debilitating osteoarthritis. We present four cases of minor distal radial fracture associated with significant ligamentous disruption, an injury pattern rarely reported. We suggest that these injuries may be under-appreciated and emphasize the need for timely diagnosis, with particular reference to the radiological evidence of injury. Case Reports: All the patients were men aged 19—32. Three injuries were sustained after a fall onto the hand and one injury sustained in a road traffic accident. All were treated initially with plaster cast immobilisation and three treated with subsequent surgery. All the patients had a longitudinal intra-articular split fracture of the distal radius or a radial styloid fracture. All the fractures were identified at initial presentation but ligament injury in all cases was noted only at follow-up and in one case after arthroscopy. Discussion: Radiological signs of carpal instability may be subtle and easily missed, particularly when pain from a distal radial fracture precludes formal examination. However, they are more easily recognised when sought and may provide evidence of ligamentous injury. We briefly discuss the radiological signs of scapholunate instability with reference to the causative pathomechanics. We suggest that minimally displaced split fractures or radial styloid fractures may be associated with scapholunate injury. This injury may be underappreciated and should be actively sought by emergency doctors to ensure prompt referral to a hand specialist. Smoking and acute scaphoid fracture R.E. da Assunc¸a ˜o, D. Higgs, J. Greenslade, D. Hargreaves E-mail address: [email protected]. Purpose of study: To determine the relationship, if any, of acute scaphoid fracture treatment time and smoking. Methods: We identified 42 patients treated with plaster cast immobilisation for acute scaphoid fracture over a 12 month period at our institution. All patients presented within 2 weeks of injury, had undisplaced fractures and were treated with uninterrupted immobilisation. We recorded patient age, gender, position of fracture and time in plaster. Smoking status during treatment was determined by telephone or postal questionnaire and time in plaster was compared between smokers and non-smokers. Radiographs on admission and discharge were independently reviewed in a blinded fashion to establish the

Abstracts

presence of fracture and union respectively, using strictly defined criteria. Results: The mean time in plaster for smokers was 65.9 days (95% confidence interval 56.8—75) versus 51.1 days (95% confidence interval 45.3— 56.9) in non-smokers (two-tailed t-test, P ¼ 0:008). The groups were not significantly different with regard to age, gender and fracture location. Discussion: We discuss in general the problems inherent in establishing scaphoid fracture union and relate this to the results. We suggest that smoking may be associated with longer treatment times for acute scaphoid fracture and support this view with reference to current literature, including the possible pathophysiology. Results of combined open reduction and intramedullay fixation for irreducible subtrochanteric femoral fractures M. Ramakrishnan, G. Kumar, J.C. Kaye E-mail address: [email protected]. Subtrochanteric fractures are often associated with comminution and displacements of fracture fragments due to various muscular pulls around the hip joint. Reconstruction of the postero medial wall is considered essential to reduce the incidence of fixation failure or non-union. Aim: To study the results of open reduction and intramedullary fixation of comminuted subtrochanteric fractures with an irreducible postero medial fragment. Methods: Between April 2000 and August 2002 we treated 18 patients (average age–—58.7 years) with comminuted subtrochanteric fractures where the postero medial fragment failed to reduce by closed manipulation. In all these cases a limited open reduction was performed to reduce the postero medial fragment and was fixed with cerclage cable. Then a long AO Proximal Femoral nail fixation was performed. Results: The average follow-up period was 39.7 weeks. All fractures in our series achieved bony union with an average time to union of 24.5 weeks. There were no incidences of wound problem, deep infection or mechanical failure of the implant noted in this series. Functional results were assessed using traumatic hip score by Sanders R and Regazzoni P. Sixteen patients were scored as excellent to good and two as fair. Conclusions: Open reduction and cerclage cabling is a useful technique when treating irreducible comminuted subtrochanteric femoral fractures. Posteromedial wall reconstruction of the proximal femur, when treating subtrochanteric fractures with Long PFN, reduces the incidence of mechanical failure and non-union.

2003 Meeting of the British Trauma Society

The consequences of blood transfusion in hip fractures D. Chakravarty, A. Boyle, M.J. Parker

55

Conclusion: It appears that blood transfusions are associated with an increased mortality, but when this is adjusted for baseline characteristics and confounding variables this is not significant.

Peterborough Hospitals NHS Trust E-mail address: [email protected]. Introduction: There is controversy whether blood transfusions cause increased mortality in surgical patients. We conducted this study to find out whether blood transfusion was an independent risk factor for mortality and wound infections after hip fracture surgery. Materials and methods: We conducted a prospective cohort study analysing collected data for 3571 hip fracture patients undergoing surgery over the last 15 years at one institution. Out of these 1068 patients underwent blood transfusion. We related mortality at 1, 4 and 12 months to whether the patient was transfused and with confounding predictors of mortality (age, sex, preoperative haemoglobin concentration residential status, ASA grade and mobility). We also determined if there was an increased incidence of wound infection in patients who received a blood transfusion. Results: Three thousand four hundred and sixtyone cases remained after 290(7.7%) cases had to be excluded for missing data in the multivariate analysis. Analysing the data set with and without missing data did not alter the results significantly or change our conclusions. Mortality at 30 days was 181 (7.2%) in the non-transfused group and 95 (8.9%) in the transfused group (P-value non-significant). Mortality at 120 days was 374 (14.9%) in the non-transfused group and 247 (23.1%) in the transfused group (P-value < 0:0001). Mortality at 365 days was 626 (25.0%) in the non-transfused group and 381 (35.7%) in the transfused group (P-value < 0:0001). Blood transfusion was associated with an adjusted hazard ratio of 1.11 (95% CI 0.96—1.29) for mortality at 1 year.

Effect of limb tourniquet on bone temperature during distal fibula drilling G. Whitwell, J. Morley, P. Giannoudis St James Teaching Hospital Leeds E-mail address: [email protected]. We have carried out a prospective randomised study to asses the effect of a limb tourniquet on bone temperature and cooling times in the distal fibula during drilling for plate fixation of ankle fractures. The use of a tourniquet can provide a bloodless field for limb surgery. However, opponents claim that a tourniquet prevents transfer of heat away from the drilling site, increasing the risk of thermal necrosis of the bone. We studied 19 patients undergoing open reduction and internal fixation of the distal fibula. The patients were randomised into two groups: Group 1 had surgery with a lower limb tourniquet inflated and Group 2 had surgery with no limb tourniquet. All holes were drilled using a standard 3.2 mm drill bit. The temperature was recorded immediately after drilling each hole using a thermocouple probe inserted into the centre of the fibula. The probe then continued to record the bone temperature until the temperature returned to the baseline reading. The study is due to run for a further month and therefore analysis of results and subsequent conclusions are not available at the present. The completed study will be ready for presentation on the 1st October 2003. Referral patterns of major pelvic and acetabular trauma in south east england A.H. Sott, J. Bernard, A. Day, M. Bircher

NS: not significant.

E-mail address: [email protected]. The management of complex trauma particularly tertiary referrals is both clinically demanding and costly. Resources are scarce and may have to be reallocated to allow continuation of this valuable work even in today’s NHS- driven by targets which rarely include acute major trauma. We present data from a 6-month audit highlighting the following points:

There appeared to be no significant difference in the sepsis rates in this population, though the numbers of cases of sepsis were small.

1. Number of pelvic/acetabular trauma patients referred to St. George’s Hospital from December 2001 to June 2002. 2. Demographic details of patients.

Rates of sepsis following hip surgery Transfused Nongroup transfused group Superficial sepsis Deep sepsis

P-value

48 (1.9%)

22 (2.0%)

NS

15 (0.6%)

10 (0.9%)

NS

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3. 4. 5. 6.

Abstracts

Location of referring units. Delay between injury/referral/transfer. Details of injuries and management. Lengths of stay and discharge details.

Our results can help to raise awareness of these important issues at local and national level and might persuade Strategic Health Authorities to increase their support for specialist pelvic and acetabular services in South West England. Unreamed Femoral Nail with spiral blade–—our experience in the management of Subtrochanteric Femoral fractures A.L.R. Michael, R. Rajan, K. Luscombe, N. Kumar New Cross Hospital, Wolverhampton E-mail address: [email protected]. Subtrochanteric Femoral fractures are difficult to manage especially in the elderly population and in pathological fractures. The comminution in the cortical bone and large biomechanical stresses can cause failure of internal fixation before bony union thus necessitating further surgery and increasing morbidity. The Dynamic Hip Screw, Dynamic Condylar Screw and Blade plate require a large incision and have a high failure rate. We studied the results of management of traumatic and pathological subtrochanteric Femoral fractures with the AO unreamed titanium nail with spiral blade inserted percutaneously with a small incision. Forty-one consecutive patients were included in the study between February 1998 and November 2001. Thirty-three of these were traumatic fractures through normal bone and eight were fractures through bone rendered weak by various pathological processes. The surgical procedures were undertaken by registrars with and without supervision and by consultants. Patients were followed up till fracture union, notes and radiographs were studied to determine outcome. Age ranged from 27 to 95 years (mean 72 years). There were 10 male and 31 female patients. In the group with pathological fractures six died within 4 months of surgery. Of the remaining patients three required further intervention in the form of dynamisation (2) and revision to a long stem Total Hip Arthroplasty (1). There were no infections or Avascular necrosis of the Femoral head and all other fractures had united at final follow-up. We conclude that percutaneous insertion of the Unreamed Femoral Nail with Spiral blade is adequate for the management of traumatic and pathological Subtrochanteric Femoral fractures.

Training opportunities in paediatric fractures: a district general hospital perspective W.Y. Kim, M. Zenios, T.H. Dunningham E-mail address: [email protected]. Increasing subspecialisation, centralization of hospitals and the reduction of working hours brought about by the European Working Time Directive (EWTD) has direct implications on the training of surgeons in the UK. A retrospective review of procedures for paediatric orthopaedic fractures performed in a district general hospital in a year was conducted. The aim of the review was to determine the range and volume of procedures performed, degree of supervision and possible implications for training. A total of 210 paediatric fracture procedures were performed, including 99 distal radius/ulna procedures, 28 shaft radius/ulna, 25 supracondylar procedures, 15 hand fracture procedures, 14 tibial shaft procedures. Middle grade/ registrars and senior house officers performed 188 (89.5%) of all procedures. Consultant supervision was noted in 29 (13.8%) of all procedures performed. The range and volume of exposure to common as well as unusual injuries was documented. The educational value of a training post may only be confirmed by reliable data which would provide an indication of operative opportunities and degree of supervision available to a trainee. This study provided a model upon which all operative training opportunities in the orthopaedic department is documented. It is suggested that such data should form the basis of the establishment of training posts within a region. The maintenance of such posts, number of trainees and seniority of trainees appointed to any hospital within a training region should be on the basis of data such as reported in this study, to maintain the high standard of orthopaedic training in the UK. The incidence of ipsilateral concomitant femoral neck and shaft fractures in patients bought in via a Helicopter Emergency Medical Service D. Pratt, D. Goodier E-mail address: [email protected]. Introduction: We present a retrospective review of patients with femoral fractures. The reported incidence of ipsilateral concomitant femoral neck and shaft fractures has been reported at 2.5—6%. These injuries are mostly found in patients involved in moving vehicle accidents, falls from a height, or industrial accidents. Method: At our centre we reviewed the case records of 150 consecutive patients diagnosed with 186 fractures of the femur following an admission

2003 Meeting of the British Trauma Society

via HEMS. The majority of these patients had been involved in moving vehicle accidents, falls from a height, or industrial accidents. Results: Two of 150 patients were found to have ipsilateral concomitant femoral neck and shaft fractures and this gives an incidence of 1.3%. Of the other fractures in this study 30 of the fractures involved the femoral neck alone, and 152 involved the femoral shaft. Eighteen patients had bilateral femoral fractures. Forty-one of 186 (22%) fractures were open and 36 (19%) of the fractures were bilateral. Discussion: These results suggest that in patients brought in via HEMS, the frequency of ipsilateral concomitant femoral neck and shaft fractures is considerably less than that reported in the literature. Preliminary experience with the Biomet Cable Plating System: the importance of classification of periprosthetic fractures involving the femur D.A. Pratt, P. Symeonidis, S. Bhagarva E-mail address: [email protected]. Introduction: There are several methods of treatment of periprosthetic fractures, and there are several cable plating systems on the market. We present a retrospective review of 22 patients with periprosthetic fractures sustained between 1999 and 2002 treated with the Biomet Cable Plating System. Method: The periprosthetic fractures of the femur were classified according to the Vancouver Classification described by Duncan and Masri. Those considered suitable for surgery underwent Biomet Cable Plating of the femur with or without revision of the hip prosthesis. Twenty-two patients were treated with the Biomet cable plate system. The operations were performed by seven experienced surgeons. Follow-up time ranged from 3 months to 2 years. Of the periprosthetic fractures, 20 were sustained in relation to hip arthroplasty and the other two were sustained proximal to total knee arthroplasties. Results: There were 15 satisfactory outcomes and 4 poor outcomes. Three patients were lost to followup. There were marked differences in the outcomes of the groups depending on the Vancouver Classification of the femoral fracture. B1 type fractures had the best results along with C type fractures performing marginally less well. Hemiarthroplasty patients did better than total hip replacement patients. Discussion: The Biomet Cable Plating System has proved in our hands to be a useful tool in the management of periprosthetic fractures when used in combination with the Vancouver Classification.

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We believe this is a good system for the fixation of type B1 fractures of the femur and this emphasises the importance of careful patient selection when using this technique. Several different surgeons performed these procedures and it is suggested that in order to achieve the best possible results, every periprosthetic fracture should be managed by a surgeon experienced in the management of periprosthetic fractures. Nurse led ‘‘Back in Trouble’’ clinics–—an effective method of reducing fracture clinic attendances? A.L.R. Michael, R. Dias, A. Kansal, S. Kili, S. Chugh New Cross Hospital, Wolverhampton E-mail address: [email protected]. The back in trouble was started in the department of Trauma and Orthopaedics at New Cross Hospital in 1997 to reduce the ever increasing patient load in the fracture clinics. This clinic is Nurse led with access through protocols to the relevant Medical staff. Prior to the commencement of this clinic, patients with any problems went to the Accident and Emergency department and were promptly booked to attend the next fracture clinic! This Nurse led clinic has reviewed around 5000 patients since its inception allowing the Orthopaedic Medical staff to concentrate on patients that required indepth clinical and radiological assessment at their fracture clinic visits. We have found this approach to managing unscheduled re-attendees very effective in reducing fracture clinic numbers. Most of the problems were associated with tight casts, inflamed wounds etc. Two audits and a patient satisfaction survey showed that patients were satisfied with the attention they received. We recommend such clinics. A simple technique of intraoperative reduction of two column transverse fracture of acetabulum O.N. Paramasivan, S. Raja E-mail address: [email protected]. Techniques of intraoperative reduction of acetabular fracture pose a challenge to the surgeon. Although reduction of transverse fracture using special clamps is an invaluable technique, the clamps are bulky and often difficult to use in limited space and they interfere with plate positioning and fixation. We have used this new technique in reduction of two column transverse fractures. Two 4.5 mm screws are inserted about 1 cm from the fracture line, first one in the proximal fragment and the

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second one in the distal fragment in such a way that the two screws are in straight line after anatomic reduction. The screw insertion points are selected with reference to the acetabular margin. A cerclage wire of 1.5 mm diameter is applied in a figure of eight configuration around the screw heads across the fracture. The wire is tightened using wire tightener. If the reduction is not anatomical the procedure can be repeated by placing the third and fourth screws in different location. Once anatomical reduction is achieved the plate is applied across the fracture over the cerclage wire and fixed with screws. Before the final tightening of the screws over the plate, the cerclage wire and reduction screws are removed. Once the posterior column is hinged the anterior column is addressed through an ilioinguinal approach. The advantage of this technique is that there are no bulky clamps which interfere with the application of plate and screws in a relatively limited space. Perilunate injuries–—MRI assessment of outcome: a prospective study S. Kutty, F. Maleki, J. Mckenna, P. Keogh, S.J. O’flanagan E-mail address: [email protected]. Aim: To assess outcome of perilunate injuries using MRI and score of Herzberg. Materials and methods: Six patients with perilunate injuries were treated in our hospital between June and September 2002. All were followed prospectively. There were two females and four males. The mean age was 33.33 years (range 21—66 years). The mean duration of follow-up was 6.5 months (range 5—7 months). Three patients had a Road Traffic Accident with three patients sustaining falls. Four patients had injury to their dominant hand. There was a delay in the diagnosis in four cases–—a mean of 7.5 days (range 1—16 days). Four patients had a trans-scaphoid type, 1a trans-styloid type and 1 patient had a pure perilunate dislocation. Four patients had other injuries in the same arm–—a dislocated elbow, 2 Bennett’s fractures and a dislocation of the proximal interphalangeal joint. Five patients had the dislocation reduced by closed means and the associated fractures fixed. One patient needed an open reduction. Results and Conclusions: The mean clinical outcome was 75 (range 65—85; 75–—good and 60–— fair). The radiological outcome ranged from A to B (A: normal, B: abnormal). All six patients were able to their pre injury occupation. The outcome in our series has ranged from fair in three patients to good in the rest. The patients who had a fair outcome had an associated fracture in the same hand as against

Abstracts

the rest. MRI assessment showed disruption of the triangular fibrocartilage and the volar radio-ulnar ligament in all three in addition to disruption of the scapholunate ligament in two of them. Those with good outcome showed preservation of the normal alignment and intercarpal ligaments. This study shows that presence of an additional injury in the same hand can influence outcome as can continuing presence of disruption of alignment and ligaments. Intracapsular fractures of the neck of femur in the elderly: an audit of outcome following surgical treatment with Hemiarthroplasty D. McMurray, B. Venkateswaran, V. Wong Bradford Royal Infirmary, Bradford E-mail address: [email protected]. The treatment of Intracapsular Fractures of the Femoral neck in the Elderly with a Hemiarthroplasty is a common procedure in most Orthopaedic Departments. The purpose of this study was to asses the results of those people who had a cemented Thompsons prosthesis and compare them with those who had an Austin—Moore prosthesis for an Intracapsular Fracture of the Femoral neck over the same time period. Information was gained from Medical Records, Xrays and contacting the patient via telephone. We used a patient administered questionnaire, the Euroqol (EQ5D). This assesses changes in quality of life by use of five questions about mobility, self-care, usual activities, pain/discomfort and anxiety/depression. This has good reproducibility, validity and ease of administration. It represents the change in health status but most importantly, a patient’s perspective of outcome. Each patient answered a questionnaire as well as specific questions about pre and post injury mobility, walking aids and daily activities. Fifty-six patients over 66 years of age operated upon for Intracapsular Femoral neck fractures from February 2001 to August 2001 were followed up. Eleven patients were male and 45 were female. The age range was 67—103 years. The mean ASA grade was 3. The mean follow-up was 14.5 months. The majority of patients underwent Austin—Moore Hemiarthroplasty. There was no statistically significant difference in quality of life following surgery between those who had an Austin—Moore prosthesis an those who had a cemented Thompsons prosthesis. There were seven patients who complained of thigh pain, three of which were awaiting revision to a Total Hip Replacement. There was one post-operative dislocation and three wound infections.

2003 Meeting of the British Trauma Society

We found that there was no difference in outcome between the two groups. Re-MUA of forearm fractures in paediatric patients K. Vemulapalli, N. Shah SpR, Royal London Rotation, Associate specialist, Orthopaedics, Oldchurch Hospital, Romford, Essex E-mail address: [email protected]. Aim: To determine the % of Re-MUA of fractures in children. To identify whether operator’s experience and time of operation affects the outcome of fractures in paediatric age group as measured by reMUA rate. Method: Retrospective analysis of 303 children’s records with forearm fractures requiring MUA was carried out. Results: The re-MUA rate for forearm fractures for these 303 children was 7.9% (24/303). There was a significant difference in these fractures requiring re-MUA depending upon the operator’s experience but no difference was noted regarding time of MUA. Amongst all 24 patients who required re-MUA, 67% (16 patients) had index surgery by trainee and 33% (8) by staff surgeon. None of these index operations were performed by consultant. Fifty-four percent (13 patients) were operated between 9:00 and 17:00 h and rest of them had MUA after 17:00 h (46%). At repeat procedure 67% (16 patients) required some sort of definite fixation (K-wiring or ORIF). Conclusion: The current overall re-MUA rate in a district general hospital is same as data published from specialized centers and surgeons, but this is probably more representative of norm, when performed in a general setting. Exact fracture personality should be evaluated carefully to reduce reMUA rate. Open tibial fractures in newcastle–—a review of epidemiology, management and outcome A. Jafri, M. Ragbir, R.H. Milner E-mail address: [email protected]: The aim of this review is to evaluate epidemiology, management and outcome of these injuries in Newcastle. Materials and Methods: A retrospective study of 32 cases (January 2000 to March 2002). Results: Twenty-five were male and seven were female, age range 8—90 years. The commonest aetiology of injury was RTAs (40.6%). Sixty-eight percent of those not documented as being immunised for tetanus received intramuscular Tetanus toxoid, 1 patient received immunoglobulin.

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90.6% of the patients were documented as receiving intravenous antibiotics. Over half the cohort arrived to the A&E department within one hour and 81.8% were in theatre within 6 h. All patients underwent wound excision and bone stabilisation. Twelve had intramedullary nails, 18 had external fixators and 2 were stabilised in cast. The Gustilo & Anderson classification was used for these injuries. I: 12.5%, II: 28.1%, IIIA: 21.9%, and IIIB: 37.5%. Of the GA I and II patients, seven had immediate direct closure following wound excision and six were closed at 48 h. The GA III injuries were all referred to plastic surgery. Thirteen out of the 19 (68%) underwent wound coverage within 5 days, 4 (21%) were during weeks 2—3 and 2 (11%) after week 3. The coverage included skin graft (4), fasciocutaneous flap (8), free flap (5), pedicled myocutaneous flap (1). There was one amputation. The overall complication rate was 21.8%, and for GA type III injuries it was 31.6%. 10.5% infection, 10.5% non-union, 5.3% mal-union and 5.3% infection and mal-union. Conclusion: Our study shows that our complication rates are comparable to other large centres (Court-Brown, Byrd et al. and Gopal et al.). However, wound coverage within 5 days as advocated by BOA/BAPS guidelines should be achieved.

Remanipulation of fractures in children: incidence, reasons, prevention and financial implication for the hospital Dipankar Sen, John Fraser, Hans Fuchs, H. Cabrera Palacios E-mail address: [email protected]. Readmission for Remanipulation of fracture is noted in almost every orthopaedic unit and has significant impact upon the hospital budget. Added upon these is prolonged morbidity due to immobilisation plus loss of attendance in school for the children. We carried out a retrospective study from January 2001 to December 2002 in our hospital on the various aspects of readmission for remanipulation of fractures in children. Out of a total of 726 paediatric admission for fracture disease 44 (6.06%) were readmitted for Remanipulation. Thirty-five (79.5%) were satisfactorily manipulated and nine (20.5%) needed open reduction, percutaneous fixation or external fixation. Most of the readmissions (32 out of 44 or 72.7%) were within 9 days of the initial fixation. The commonest fracture needing remanipulation was fracture distal radius at metaphysis/diaphysis junction (18 cases) about 30— 36 mm from the distal articuar surface. The common

60

reasons for displacement after the primary manipulation were inappropriate assessment of fracture (12 cases), inadequate reduction and immobilisation (28 cases) and following change of plaster (12 cases). On average a child had an extra 16 days of immobilisation due to the fracture displacement. The best way to prevent fracture displacement was accurate assessment of stability at the initial outset, accurate reduction, immobilisation by plaster cast with a longitudinal slit along the length rather than a backslab, which covers half the circumference of the limb. Fractures at metaphysis/diaphysis junction may be considered for primary percutaneous fixation especially in obese child. We calculated the financial impact of a single readmission for remanipulation on the hospital budget considering extra clinic appointment, bed occupancy for 24—48 h, extra theatre time and use of anaesthetic resources. Practice of intravenous fluid administration in the post-operative period following surgical treatment of fracture neck of femur Dipankar Sen, John Fraser, H Cabrera Palacios, Siva K. E-mail address: [email protected]. One of the most important and delicate aspects of postoperative care is maintenance of adequate fluid balance following surgery for fracture neck of femur. However, it is difficult to maintain it, because of various reasons like difficulty in maintaining IV access in dementic patients, inadequate oral intake, existing medical conditions limiting fluid administration, inability to accurately record the output. We audited the fluid administration pattern in 126 patients of fracture neck femur over a period of 1 year (May 2002 to April 2003) to find out whether we are following any particular protocol. On average patients were given IV fluid administration for 2—6 days. A total of 1200—3800 ml of fluid was administered per 24 h. The three common fluids used were Hartman’s, 5% Dextrose and Normal Saline in a completely arbitrary manner. Thirty-five (27.7%) patients had episodes of hypotension/ tachycardia requiring change of fluid ration by the doctor within 48 post-operative hours. We recorded the urine output and the blood Na level during the period of fluid administration and failed to establish any relation between these two variables with the rate of fluid administration. Fortyfour (34.9%) patients had complications like dehydration (29 patients), fluid overload (eight patients) and fluid extravasation (18 patients) in extremities. The inpatient stay for these patients was prolonged by about 2—4 days. Thirty-four patients had no complete record of input output for fluid and 22

Abstracts

of them had complications. We conclude that although a very delicate issue fluid balance is often ignored and IV fluids are prescribed in a completely arbitrary manner, which is grossly inappropriate. We recommend setting up a protocol, which should be strictly adhered for both quality and quantity of fluid to be infused. The utilisation of intraosseous lines in paediatric trauma resuscitation R. Smith (MB ChB FRCS), N. Davis (MB ChB FRCS (Tr & Orth)) E-mail address: [email protected]. Intraosseous lines are a useful, reliable and rapid means of obtaining vascular access in emergency situations, particularly in children. Their use is recommended when intravenous access cannot be easily secured and there is a need for fluid or pharmacological resuscitation. Training in this technique is included in the ATLS and APLS provider courses. The objective of this study is to analyse the national use of intraosseous lines in paediatric trauma in the UK. Data were used from the TARN group, which have been collected longitudinally over fourteen years from 1988 to 2002. From 5232 paediatric trauma cases intraosseous lines were used in only 30 patients. Detailed analysis of the six local cases demonstrated a trend to more recent use, perhaps due to an increase in training, and a high mortality at 67% probably due to the level of injury triggering the use of intraosseous access. There were no pre hospital line placements and all of the lines were used at district general hospitals with none at paediatric hospitals. In 66% of the cases (all of those where it was documented) there was an APLS or ATLS provider present at the resuscitation. It is likely that intraosseous lines are not used frequently enough considering the ease and speed of placement along with the low complication rate. Perhaps local Accident and Emergency department training might increase the awareness of this simple and effective resuscitation tool. Full data from the national patients will soon be available in order to complete this work. Management of pelvic ring injuries N.A. Shah (Specialist Registrar), A.D. Clayson (Consultant Orthopaedic Surgeon) North West Pelvic and Acetabular Trauma Service E-mail address: [email protected]. Aim: To review treatment, results and complications of pelvic ring injuries. Materials and methods: We reviewed 39 pelvic ring injuries, mean age 37 years, referred to a

2003 Meeting of the British Trauma Society

tertiary unit, with mean follow-up 19 months (6— 60). Data regarding type of fracture, associated injuries, treatment, injury surgery interval, complications and outcome was documented. Vehicular accidents in 21 were the commonest mechanism of injury and 30 had vertical shear fractures. There were four associated head injuries, five chest, four maxillofacial, four perineal/vaginal tears, seven urological, one anorectal, two each of abdominal and ophthalmic, and one each of vascular, spine and brachial plexus injuries. Also there were 15 skeletal fractures, 12 soft tissue injuries and 11 associated acetabular fractures of which 8 needed fixation, and 17 had lumbosacral plexus injuries. Six compound pelvic fractures were treated with debridement, fixation and early life saving bowel diversion. Nineteen patients had anterior external fixators, nine were applied elsewhere for resuscitation. Complications: There were 10 systemic complications, 4 ARDS, 2 wound infections and 1 colovesical fistula, 1 infected pubic plate, and 3 late inguinal hernias. Eight patients had pin track infections, and five iatrogenic problems including two nerve lesions, two vascular injuries and one bladder rupture, none of which left any residual problem. Results: Twenty patients had no pain, 31 were fully mobile without aids, and 22 had returned to original level of activity. Six complained of sexual dysfunction, and one had double incontinence. Six patients were on disability allowance, and 10 had full recovery of lumbosacral plexus injury. Conclusion: Severe associated injuries and soft tissue trauma significantly affect outcome and complications, inspite of sound bony fixation and healing, and multidisciplinary management is obligatory. Posterior ring lesions were often underestimated, and anterior external fixation alone can make them worse. Early colostomy is lifesaving in compound pelvic fractures. Early involvement of a specialist surgeon is desirable for optimal outcome, which can be achieved in most patients. AO clavicular Hook Plate fixation for Tossy III ACJ dislocation–—a preliminary report D.S.R. Baiju, R. Chennagiri E-mail address: [email protected]. Treatment of Tossy III acromioclavicular joint (ACJ) dislocation is a much-debated topic. Lack of a satisfactory stabilisation procedure with results comparable to non-operative management has led to the trend towards non-operative management. The AO clavicular hook plate is a recent implant for open reduction and internal fixation of the acromioclavicular joint. We report the early results of acromioclavicular joint stabilisation with this

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implant in patients who have high demand or overhead working jobs. We reviewed 23 patients who had a Tossy III ACJ dislocation reduced with the Hook Plate. The initial injury was 1—3 months prior to fixation. An infra-clavicular approach was used rather than the Sabers’ Approach to the ACJ. All initial insertion of the hook plate was done or supervised by an experienced Orthopaedic Consultant NG. The plate was removed after 3 months and the patient was referred for aggressive physiotherapy. At 3 months following removal of the plate, all 23 patients had returned to normal activity including work. There was no re-dislocations, scar sensitivity or anterior chest wall numbness after 6 months, following removal of the plate. At one year, a direct comparison was made showing the affected shoulder was 100% compared with the normal shoulder in both power and movements. There was one case of a superficial wound infection which cleared with antibiotics, and 23 patients (100%) expressed satisfaction with there operation and post operative care. We are therefore of the opinion, that the Lateral Clavicular Hook Plate is a safe and effective method of treating Tossy III ACJ dislocations in patients with high demand or overhead jobs, where rotation of the clavicle is necessary for daily function. Transverse sacral fractures C.U. Dussa, B.M. Soni E-mail address: [email protected]. Transverse sacral fractures are an uncommon injury as the amount of force required to produce this injury is high. It is very commonly missed at the time of its initial presentation due to lack of suspicion and as the conventional X-rays do not show the fracture. The incidence of neurological deficit in these fractures is very high from 56.7— 63.3%. The neurological deficit produced mimics Cauda Equina syndrome, which is a lower motor neuron type involving the S1—4 nerves depending on the level of fracture of the sacrum. There is no definite method of management of these fractures, which could result in the best possible outcome. We would like to present our experience with six cases of transverse sacral fractures over 15 years; of which 5 had neurological deficit. All were missed at the time of presentation. Five of these fractures were managed conservatively and 1 managed operatively. The fracture united in all the six cases. Though there is good improvement in the motor recovery in neurologically affected patients, the recovery of pelvic visceral functions like bladder

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and bowel is poor and unsatisfactory. The sensory and sexual function recovery is partial. To conclude, transverse sacral fractures are very rare, commonly missed fractures producing cauda equina syndrome like neurological picture. The prognosis and the outcome of these injuries are poor with incomplete recovery especially of bladder and bowel function. Sexual function is also affected to some extent. These disabilities produce tremendous psychological impact hence affecting the personal lives of these affected individuals. This seems to have major implications on the quality of life of these patients. Missed locked posterior shoulder dislocation with a big defect on the humeral head–—successful management by open reduction and fixation of the defect with femoral allograft A. Lakdawala, S. Ansara, S. Geernavar E-mail address: [email protected]. Locked posterior shoulder dislocation is rare injury. We discuss this case of a 23-year-old student, who sustained a posterior shoulder dislocation and was missed in A/E. He is a right hand dominant student. He presented to us at 4 weeks following injury. The right shoulder was dislocated posteriorly and locked with the glenoid rim. There was a defect approximately 30% of the humeral head on the antero-medial side of the humeral head (reverse hill-sach’s lesion). The surgical technique and the evidence based approach to surgical treatment is discussed. Functional outcome following PHILOS Plating for displaced proximal humeral fractures S.J. Haridas, D. Thyagarajan, R. Williams E-mail address: [email protected]. Aim: To assess the functional outcome following internal fixation with the PHILOS plating system for displaced proximal humeral fractures. Background: Controversy exists with regards to the management of displaced proximal humeral fractures and many methods of treatment have been proposed over the years. In particular, the role of surgery has not been clearly defined. The current trend is toward limited dissection of the soft tissues with the use of minimal amounts of hardware to gain stability. Methods: We performed a retrospective analysis of 11 consecutive patients treated surgically with the PHILOS plate for a displaced proximal humeral fracture between Jan 2002 and January 2003. Patients were assessed clinically and radio graphically at an average follow-up time of 9 months.

Abstracts

Functional outcome was determined utilising the American Shoulder and Elbow Society score. The injury was classified using Neer’s four part classification. Results: Average age of the patients was 55 years (20—80). There were three two-part, four threepart and four four-part fractures. All patients united within 10 weeks. The average ASES score was 62 (28—82). One patient required removal of hardware secondary to impingement. Conclusion: Our results show that good fracture stability and functional outcome can be obtained from the use of the PHILOS plate. Early mobilisation of the shoulder can be achieved without compromising fracture union. We would recommend the use of the PHILOS plate for the management of displaced fractures of the proximal humerus. Prehospital trauma death: epidemiology and sentinel events Annalisa Volpi, Antonio Bellini, Francesca Scavetto, Luca Cattani, Antonella Vezzani, Mario Mergoni E-mail address: [email protected]. Background: Trauma is the first cause of death among people under 45; many efforts have been done to improve mortality and morbidity among trauma patients, but economic restraints are the most complained limitations in the development of comprehensive Trauma Systems. Due to this it is very important to evaluate the epidemiology and the pattern of traumatic injury, which is peculiar to each region. Material and methods: We prospectively examined the prehospital trauma care system in Parma. We evaluated all trauma victims during a 6 months period, identifying ‘‘sentinel events’’ and errors during all the phases of the pre-hospital care. The data were collected from the EMS (site of accident, dispatch, on-scene and transportation time), clinical report, and autopsy data. We also calculated RTS, AIS, ISS and TRISS scores. Results: Twenty-eight deaths were reviewed, 20 male (71.5%) and eight female (28.5%) with mean age of 43  21:89 years. Seventy-five percent of the events were due to road accidents, 10.71% to blunt trauma following intentional falls, 7.14% to gun shots, 3.57% to work accidents. Twenty-six patients were declared dead on scene, 1 was found dead and 1 was dead on arrival to the hospital. Two patients used protection devices, as seat belts or helmets. Thirteen patients were tested for blood alcohol or urine metabolites of benzodiazepines, opiates, THC. In 5 (17.85%) we found elevated blood alcohol levels and in 2 elevated urine benzodiazepines

2003 Meeting of the British Trauma Society

levels. All of these patients were driving. Most of the accident happened during day time and there was not a statistically significance difference in the dispatch time between day and night time. Three errors were found, concerning dispatch and onscene time and two deaths were judged as ‘‘sentinel events’’ and needed further evaluation. Conclusions: Priority in our emergency care are: prevention of road accidents, improvement of prehospital care, systematic evaluation of all trauma death. Intrahospital preventable trauma death: an audit of trauma care Annalisa Volpi, Francesca Scavetto, Antonio Bellini, Mario Cavazza, Vincenzo Violi, Nicola Cucurachi, Ermanno Giombelli, Mario Mergoni Io Servizio Anestesia e Rianimazione, Azienda Ospedaliera di Parma, Parma, Italy E-mail address: [email protected]. Background: The effectiveness of well-organized multidisciplinary trauma centre in reducing the mortality and morbidity of injured patients has been documented and is recognised the benefit of a centralized trauma care. As it is well known, trauma death occurs mostly during pre-hospital setting. The timeliness and the efficacy of treatment are essential for patients that arrive to the hospital and is based on priority identification by trained staff. The purpose of this study was to evaluate the in-hospital trauma care examining both the rate of preventable deaths and the critical errors during any phase of care. Material and methods: During a six-month period were prospectively included 15 injured patients, 12 males and 3 females, admitted to the hospital and dead within 48 h, in the ED, in the OR, in the ICU or in other department. A panel of experts reviewed all cases to judge the adequacy of clinical care and to assess whether death could have been prevented. The clinical judgement had been integrated with severity trauma score to achieve a conclusive judgement. Results: Death was found to be not preventable in 11 cases (73.3%), potentially preventable in 4 (26.7%). Failures of treatment in trauma patients were: in pre-hospital setting 2 patients with GCS <9 were not intubated, 2 unstable patients didn’t receive intravenous fluids; delay in performing diagnostic procedures or in transferring to the OR in 4 patients; incompleteness of data obtained in 14. Conclusions: Our study demonstrates three serious deficiencies related to diagnosis and treatment

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of trauma patients: lack of protocols for treatment of injured patients during pre-hospital setting; delay in time of diagnosis and treatment: the organisation of care for injured patients within the hospital need to be assessed; incompleteness of data: we need to train the involved personnel to the importance of data collection. Visual estimate of external blood loss L.A. Sanz (FRCS Orthopaedic SpR), D. Wright (MRCS Surgical BST) Alder Hey Children’s Hospital, Liverpool E-mail address: [email protected]. Background: Estimating external blood loss in the resuscitation room and the trauma theatre is important to plan fluid resuscitation and to predict outcome when using the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) score blood loss component. Such estimate relies on visual inspection of blood spillage around the patient. Aims: The purpose of this study is to determine the accuracy in estimating external blood loss trough visual inspection of simulated clinical scenarios amongst Surgeons, Anaesthetists and Accident & Emergency Doctors. Methods: Simulated clinical scenarios where recreated in which known volumes of blood like (Haemoglobin 12 g/dl and Haematocrit 40%) solution were spilled on the floor of an operating theatre, theatre greens, gauze swabs, impermeable gowns and fluid receivers. Photographs were taken of each subject for a given known volume and then grouped at random in four sets (scenarios) of three. The photographs were shown to Consultants and trainees holding ATLS and a postgraduate exam in the fields of Trauma Surgery, Anaesthesia or Accident & Emergency Medicine and they were asked to fill a proforma with the volume estimates (in ml) corresponding to each of the four scenarios. These were compared to the real volumes (450, 525, 1075 and 900 ml) and correlated to the intervals in the blood loss component of POSSUM (<100, 101—500, 501—999, >1000 ml). Results: The results of the first 52 tests are included in this abstract. Forty (76.9%) participants were trainees and twelve (23.1%) consultants. Volume was underestimated in all four scenarios (average 29.2%) and correlation with the intervals in the blood loss component of POSSUM showed 41% accuracy.

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Conclusions: Our study suggests that visual assessment of external blood loss tends to underestimate its volume by 29.2% and the accuracy of estimating the blood loss component of POSSUM is poor (41%). Current trends of anaesthesia and their efficacy for closed reduction of distal radius fractures N. Kharwadkar, S. Naique, J. Brown, M.S. Hockey E-mail address: [email protected]. Objective: Following the withdrawal of general anaesthetic services to Accident and Emergency Department (as a result of Royal College of Anaesthetists’ guidelines), there has been an increase in number of closed reductions done with regional anaesthesia.Objective of this study was to analyse the current practice of anaesthesia and its efficacy for the closed reduction of displaced distal radius fractures in adults above 50 years of age. Method: Retrospective study was undertaken involving a review of A & E cards and Hospital records of 113 consecutive patients above 50 years of age treated for distal radius fractures between 1st January 2001 and 1st January 2002. Fifty-four patients with undisplaced or minimally displaced fractures were excluded leaving 59 patients with displaced fractures for final review (18 males and 41 females, mean age 71.3 years). Results: 23 out of 59 (39%) fractures were manipulated in A & E under regional anaesthesia. Twenty-one out of 59 (35%) were given Haematoma Block (9 with supplementary IV sedation). Two out of 59 (3%) were given Bier’s Block. Thirt-six out of 59 (61%) were admitted for general anaesthesia on trauma lists. Nine out of 23 (39%) A & E reductions later required re-manipulation. Six out of nine (twothirds) were due to slipped fracture reduction at first follow-up in fracture clinic.The re-manipulation rate was lower (33%) when IV sedation was used in combination with Haematoma Block. Conclusion: Withdrawal of anaesthetic support to A & E Department on safety grounds has led to high admission rates for closed reduction of wrist fractures under general anaesthesia. Those performed in A & E under Haematoma Block, with or without IV sedation, have high re-manipulation rates and require additional procedures. This has significant implications for the cost of this procedure, the interference with overloaded trauma lists and unnecessary admissions of patients. Fracture angulation: do we have an unambiguous definition? G. Kumar, M. Ramakrishnan, A. Thompson, V. Kamath, S. Senthil Kumar, S.R. Murali E-mail address: [email protected].

Abstracts

Aim: The purpose of this study was to compare the fracture angulation description by Orthopaedic trainees with those in standard Orthopaedic textbooks. Methods and materials: Ninety-seven Orthopaedic trainees at various stages of training in the UK and India filled in a questionnaire containing four copies of radiographs. They chose one of the two given fracture angulation descriptions for each radiograph. They also identified the Orthopaedic textbooks on which they based their choices. Fracture angulation description in the direction of the distal fragment was termed as ‘Traditional’ description. While the description in the direction of the apex of the fracture was termed as ‘Standard or Textbook’ description. Results: Ninety-seven trainees made three hundred and eighty eight observations. These fracture descriptions were compared with the descriptions as expected from the textbooks. Four UK and three Indian trainees’ observations correlated with the expected descriptions from the textbooks. Two UK and three Indian trainees’ observations had mixed responses. The rest of the observations were ‘Traditional’ descriptions. More than 90% of responses were opposite of the descriptions stipulated in the common Orthopaedic textbooks. Conclusion: We feel confusion in fracture angulation description exists because as Medical students the first understanding of fracture angulation is ‘Colles’ fracture, which is dorsally angulated. This is extrapolated to describing other fractures. None of the textbooks identify in the Colles’ fracture section that by accepted standards this fracture should be described as volar angulation. All the other fracture angulation descriptions in these textbooks are in terms of direction of the apex of the fracture angle. Clear understanding and teaching of the fracture descriptions is essential to avoid this confusion. Do paediatric orthopaedic hospitals need a good arthroscope? K. Moholkar, S. Ali, N. Davis, T. Meadows, J. Day E-mail address: [email protected]. We report a series of 67 skeletally immature patients (9—16 years age) who underwent knee arthroscopy for sports-related injuries or symptoms. The purpose of the study was to analyse the accuracy of preoperative clinical diagnosis, Magnetic Resonance Imaging (MRI) and the value of arthroscopy in diagnosing acute internal derangements of the knees.

2003 Meeting of the British Trauma Society

The most common arthroscopic finding was Anterior Cruciate Ligament (ACL) and meniscal injury, followed by chondromalacia patellae, plica synovialis, loose bodies, and osteochondritis dissicans. In 67 patients arthroscopy confirmed the clinical diagnosis in 18 patients (27%). The main error tended to be misdiagnosis of meniscal pathology (24 patients–—75%) and over diagnosis (49 negative arthroscopies–—73%). Accuracy of clinical examination in diagnosing medial meniscal tear was 26%, lateral meniscal tear was 16% and Anterior Cruciate ligament was 89%. MRI Scan was performed in 19 patients to aid the clinical diagnosis of meniscal injuries and a highly negative correlation (61%) was found. In our experience, paediatric knee arthroscopy is a safe procedure and is recommended in symptomatic ACL injuries, osteochondritis dissicans and removal of loose bodies. There is only a 27% chance of making a correct diagnosis on clinical grounds, whereas the sensitivity of MRI to aid the diagnosis of knee injuries was found to be poor (39%). The biomechanics of wrist fracture plating A. Hart, T. Seepaul, R. Hewitt, S. Ang E-mail address: [email protected]. The treatment of dorsally comminuted and intraarticular distal radial fractures rarely involves early mobilisation of the wrist and commonly involves loss of reduction of the fracture. This results in poor functional outcome. The use of volarly placed locking plates have theoretically revolutionised the treatment of these fractures. This is controversial because there is very little published data for wrist locking plates. There is only one comparative study of locking plates versus other plating systems. We have compared locking plate fixation to more traditional methods of plate fixation using a synthetic bone model. We created an intra-articular distal radius fracture with dorsal comminution which were plated and tested using the Instrom biomechanical testing machine at Imperial College. The model was axially loaded to 150 Newtons at 1 N/s for up to 500 cycles. Our outcomes were the number of cycles before fixation failure, the mode of fixation failure and the final displacement of the fracture. Our findings suggest that the new volar locking plates are of comparable strength to traditional dorsal plating systems. The locking mechanism accounts for the superiority over traditional volar plating systems.

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Midfoot injuries: the Newcastle experience A case series examining diagnosis, classification and treatment of these rare injuries A.L. Khan, M. Khatri, P.J. Briggs Freeman Hospital, Newcastle upon Tyne E-mail address: [email protected]. Introduction: Midfoot fractures are rare injuries in a trauma unit serving a nearly 260,000, with 95,000 casualty attendances, six patients were seen over a period of three years, compared with Main and Jowett’s review, which found 21 in seven years. These fractures tend to affect young people, and sub-optimal treatment for these injuries results in long term pain, disability and economic loss. Materials and methods: Retrospective case note, radiology and clinic attendance review. Results: We found five examples of fractures affecting the midfoot. These include injuries to the navicular, cuboid, cuneiform and lateral process of os calcis. Sangeorzan’s, and Main and Jowett’s classifications were used to classify these injuries. All patients were pain free. Three had stiffness at the midfoot. One was back playing sport. Discussion: The biomechanical principles used in the treatment of these injuries are discussed. The operative principles are described and anatomical correction is correlated to the restoration of biomechanics of the foot. Conclusion: These injuries must be treated promptly, after adequate and appropriate radiological investigation to enable correct anatomical reduction and fixation, or arthrodeses relying on biomechanical principles. Inadequate or delayed treatment results in long term disability and pain, an unwanted outcome, especially in a young age group. In addition to the treatment of midfoot injuries, these principles may be useful when considering operative intervention for treating Lisfranc injuries, and other injuries to the foot. Radical management of ring sequestrum A. Salama, M. Saleh Orthopaedic and Traumatic Surgery Research Group, University of Sheffield, UK E-mail address: [email protected]. With any screw design cantilever effects lead to breakage of bone threads during the period of treatment. This leads to sequestrum formation and after screw removal it is often described as a ring sequestrum. This type of sequestrum usually

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Abstracts

manifests clinically as an inflamed unstable area of the skin, which may resolve spontaneously, may resolve after discharge of piece(s) of bone or may remain irritable, inflamed and troublesome. In a busy Limb Reconstruction unit like Sheffield four to five patients with ring sequestra come to exploration per annum. This usually involves curettage and irrigation but it is difficult to remove the sequestrum and therefore there is no guarantee for cure. We recommend this conservative surgical procedure in the first instance. However, if a site remains troublesome after curettage a more extensive procedure may be required. We describe a minimally invasive but radical method to excise the screw track with the central sequestrum. Using a wire to localize the track guided by pre operative C T Scan and intra operative imaging, we then use a 7 mm circular saw over the wire to cut out a core of bone including the screw track and its central sequestrum. Unless the overlying tissues are inflamed, direct closure of the wound over Gentamycin fleece is performed. A plaster cylinder may be applied if clinically indicated. We have used this technique in three patients and believe it is a technique worthy of consideration for the resistant case. It is minimally invasive, and may be performed as a day case.

plate use were to avoid extensive soft tissue stripping, peri-prosthetic fractures and high energy closed fractures, which have already resulted in significant soft tissue damage. It was used in periprosthetic fractures of Femur in 4 cases, Spiral fracture of Femoral shaft in an adolescent patient, Femoral diaphyseal fracture in 2 cases, Tibial plateau fracture in 3 cases, Tibial diaphysis and metaphysis fracture in 2 case and distal Tibial fracture in 3 cases. The mean time to radiological union was 17.3 (S:D:  26:5). One femoral L.I.S.S. plate used in a peri-prosthetic fracture had to be revised with a longer L.I.S.S. plate. One Tibial L.I.S.S. plate had to be stabilised by an external fixator following delayed union. Both the cases subsequently achieved full union. Conclusions: L.I.S.S. plate has a role to play in lower limb reconstruction. Early results are promising. However authors feel that the tibial L.I.S.S. plate used in simple diaphyseal fractures, under certain circumstances, lacks sufficient rigidity. Adherence to external fixator’s principles seems essential to achieve good result.

Early result with the use of L.I.S.S. plates in lower limb reconstruction

E-mail address: [email protected]. Traumatic dislocation of knee is a rare but potentially limb threatening injury with significant morbidity and mortality. It should be diagnosed and managed early to prevent disability. Our review aims at identifying the potential complications that may arise in the course of it’s management. We conducted a retrospective review of all patients who had acute high energy knee injuries causing dislocation and subluxation of the knee joint, admitted through our emergency, low energy and post replacement dislocations were excluded. A time period of last two years were considered. Age and sex distribution, mechanism of injury, RTS, ISS, Investigations done, associated injuries, length of stay, operative procedures, complications and final outcome were noted. A total of 10 patients were considered in the study, 9 males (90%) compared to one female noted. Commonest mechanism of injury was road traffic accident, involving motorcyclists; 30% had suspected vascular injury and had angiograms, but only 10% needed intervention one patient ended up with an above knee amputation owing to vascular deficit. CT scan was the most commonly performed investigation and successfully diagnosed tibial plateau fracture in 2 (20%) cases. MRI was done to diagnose

M. Al-Maiyah, A.S. Bajwa, S.L. Papastefanou, P. Patil, R. Liow, A. Rangan, A. Port Middlesbrough General Hospital, Middlesbrough, Cleveland E-mail address: [email protected]. Aims: To evaluate the outcome of L.I.S.S. plates used in lower limb reconstruction. Methods: Patients in whom L.I.S.S. plate was used for lower limb reconstruction, were included in the study. The decision to use L.I.S.S. plate was taken by the Consultant Trauma Surgeon responsible for the patient care. Both the Femoral and Tibial L.I.S.S. plate applications are included. Patients were followed up in the out patient clinics. Indications for the use of L.I.S.S. plate, time to union, clinical result and immediate and intermediate complications were studied. Results are presented as a case series with the use of radiological images. Results: 15 L.I.S.S. plates were applied in 14 patients. Mean age of the patients is 58 years (S:D:  26:5). There were 8 male and 6 female patients. L.I.S.S. plate was used in Tibia and Femur in 8 and 7 cases respectively. Indications for L.I.S.S.

Acute high energy traumatic dislocation of knee: what should we be aware of? S. Banerjee, D.D.M. Spicer

2003 Meeting of the British Trauma Society

knee injuries in one case, in others it posed a problem because of the femoral intramedullary nailing done on the affected leg which was the most commonly associated injury. One patient had a foot drop owing to traction injury to the common peroneal nerve, which was repaired primarily. Structured damaged in the knee included ACL, PCL, MCL, LCL and Posterolateral corner, and in one case a lateral dislocation of patella following retinacular rupture, they were all effectively diagnosed at preoperative examination under anaesthesia, and all were primarily repaired. Superficial wound infection complicated one case, which recovered following antibiotic therapy. In conclusion knee dislocation are rare injuries but with significant proportion of potential disabilities, and adequate examination under anaesthesia is essential to identify the injury as radiology may not be a plausible option. Early operative management is recommended management with a high index of suspicion for neurovascular injury and patellar dislocation. Open reduction and plate fixation of unstable dorsally displaced fractures of the distal radius Brian Rooney, Peter Chan, Tim Hems Department of Orthopaedic Surgery, Victoria Infirmary, Glasgow, UK E-mail address: [email protected]. Aims: The results of open reduction and plate fixation of 24 unstable dorsally displaced fractures of the distal radius are reported. Methods: The fractures occurred in 24 patients (mean age 42 years) and 17 of the fractures were AO Type C. All fractures were treated with open reduction and subperiosteal placement of dorsal 2.0 or 2.7 mm AO mini-fragment plates between 1st and 2nd compartments and beneath the 4th compartment. Additional volar fixation was required in 6 cases. Patients were examined and X-rays performed. Outcome was assessed using the Modified Mayo Wrist Score. Results: At final follow-up (mean 38 months), all fractures united with no superficial or deep infection. Mean range of movement was: flexion 648, extension 788, pronation 838 and supination 848. Grip strength averaged 84% of the unaffected side. There was statistically significant improvement in all ranges of movement and grip strength when compared to those measured at 6 months followup. Radiographic assessment revealed a mean volar angle of 88 and articular step in 3 cases. Osteoarthritis was seen in 10 of the 24 patients, all of whom had greater than 2 years follow-up.

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The final outcome, using the Modified Mayo Wrist Score was excellent in 13 cases, good in 7 and fair in 4 cases. Complications were seen in 3 cases and metalwork has been removed in 8 patients for tendon irritation but there have been no cases of extensor tendon rupture. Conclusions: This initial experience has encouraged the use of open reduction and dorsal plating as the treatment of choice in young patients with unstable/intra-articular dorsally displaced fractures of the distal radius. Range of movement, grip strength and ultimately function continue to improve with time after injury. Radiographic evidence of osteoarthritis does not appear to develop until 2 years post-injury though there is no correlation with functional result. Use of ankle syndesmotic screw–—survey of current practice in the united kingdom R. Samuel, C. Rajasekhar E-mail address: [email protected]. Ankle fractures with a syndesmosis injury are highly unstable injuries. Controversies exist on the indications and use of a positional screw to stabilise the syndesmosis. Debate continues on the type of screw, its method of insertion and removal. Recent clinical and biomechanical studies suggest reduction in the need for syndesmotic stabilisation. A questionnaire was sent to 120 Consultant Orthpaedic surgeons practicing trauma. Eighty replies were obtained (66.6%). 68.5% (55) of the respondents routinely checked syndesmotic stability with the help of a hook after fixation of the ankle fracture and used a screw only if diastasis was noted. Twenty-one (26.25%) would insert a syndesmotic screw if diastasis was evident on the preop Xray without introperative stressing. All the respondents used metallic screws, though use of bioabsorbable screws has been reported. 69.5% used 3.5 mm screws whereas 30.5% used the large fragment 4.5 mm screws. Lagging of the screw was a routine practice in 22% of the surgeons. Majority purchased three cortices with the screw. Ninetyone percent of the surgeons would remove the screw before allowing full weight bearing walking, 70% removing at 6 weeks and 30% at 8 weeks. This survey has established an overview of the current practice in use of syndesmotic screw in common ankle fracture fixation. As more evidence emerges that a positional screw to hold the syndesmosis may not be necessary, the practice may change. This is important as avoiding insertion of the screw would allow early mobilisation with earlier return to function and would avoid unnecessary secondsurgery.

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Factors affecting the outcome of dynamic hip screw fixation D. Sunderamoorthy, A. Slaon, S. Ahuja, S. Gupta, A. Grant E-mail address: [email protected]. Aim: Dynamic hip screw fixation is one the commonest operation done in the orthopaedic practice among trauma patients. The aim of our study was to assess the factors that affect the outcome of dynamic hip screw fixation for intertrochanteric fractures of the femur. Materials and methods: We prospectively reviewed 85 dynamic hip screw fixation done over 10 month period. The fracture pattern, the degree of osteoporosis (Singh index), the fracture reduction, the grade of the operating surgeon, the screw position and the distance of the screw tip from the subchondral bone were considered. The case notes, anteroposterior and lateral radiographs taken at the time of injury, postoperatively and during follow-up were reviewed. Results: The average age was 82 years with a range of 44—104 years. The follow-up was 3—6 months. Sixty-five percent of the fractures were unstable, three or four part complex fractures. The Singh’s index was below 4 in 75% of the patients. The registrars performed 90% of the operations, consultants and SHOs did the remaining. The medial column was restored in 85% and the fracture was reduced in 70% in both planes. The screw position was central/central in 50% followed by superior/ central in 20% and central/posterior or inferior/ central in 10% of the patients. The average distance of the screw tip from the subchondral bone is 5.7 and 6 cm in the anteroposterior and lateral radiographs. Outcome: Three dynamic hip screw fixations failed during the above period of study. All the three fractures were unstable and not reduced in the lateral radiograph taken postoperatively. The screw positions were central/anterior, superior/posterior and superior/central. Two of them had their implant removed and the fracture healed with bed rest, the other patient was on traction and the fracture healed with the implant in situ. Conclusion: Fracture reduction and proper screw positioning were found to be important factors in deciding the outcome of dynamic hip screw fixation in comparison to the other factors considered. Prospective study of such type will ensure that registrars are adequately supervised to prevent implant failures occurring in DHS fixation.

Abstracts

Development, implementation and prospective evaluation of triage guidelines for severely injured children Mal Patterson, Patrick Nee, David, Lloyd Institute of Child Health, Alder Hey Hospital, Liverpool E-mail address: [email protected]. Background: Most injured children are appropriately treated at a District General Hospital (DGH) but some require transfer to a specialist children’s centre. No guidelines existed to enable DGH clinicians to identify children likely to require transfer. Aim: To develop, implement and evaluate triage guidelines for the rapid recognition of injured children requiring transfer to a specialist centre. Design: Prospective, interventional study consisting of a 24-month pre-guidelines period, 3month implementation period, and 24-month post-guidelines period. A multidisciplinary Steering Group, including representatives from participating hospitals, developed and implemented the Guidelines. Setting: Five acute DGHs and two specialist centres (Children’s Hospital and Neurosciences Centre). Population: All seriously injured children aged 16 years and under who presented at regional DGHs. Methods: The Accident & Emergency Department (A&E) records of 320,650 paediatric DGH A&E attenders were reviewed; 12,543 were identified as trauma admissions, transfers or deaths. Serious injuries were defined in the Guidelines and patients were classified as Level I (unstable) or Level 2 (stable). Results: In the post-guideline period there were significant changes in the management of Level I patients, namely: a 29% increase in the proportion of Level 1 transfers to specialist centres (P ¼ 0:001), there were no admissions to a DGH intensive care unit, all operations were done at a specialist centre, and the proportion of Level 1 patients having Computerised Tomography at a DGH prior to transfer decreased significantly by 38%. The management of Level 2 patients did not differ significantly pre and post guidelines. Guideline users indicated a positive attitude towards the guidelines and an understanding of their purpose. Conclusions: An effective communication network for the management of seriously injured children has been established between DGHs and specialist centres in the study Region. The introduction of triage guidelines was associated with positive changes in the management of severely injured children.

2003 Meeting of the British Trauma Society

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Outcome of distal radial fractures: a prospective study

Wound surveillance in patients with fracture neck of femur–—a pilot study

D. Rowland, C. Booth, P. De Boer

D. Sunderamoorthy, D. Thyagarajan, Praveen, A. Johansen

E-mail address: [email protected]. Two hundred fifty-five patients with fractures of the distal radius were recruited from November 2001 to August 2002. Fractures were graded using the AO classification. Treatment was instituted according to the wishes of the Consultant with overall responsibility for each case. All patients were assessed clinically and by questionnaire at initial presentation, 6 weeks, 6 months and 1 year with AP and lateral radiographs at each of these visits. Data were collected for arthritic change, pain, wrist function, deformity and range of movement. Patients also completed SF36 and DASH (Disability of the Arm Shoulder and Hand) questionnaires at one year. We present the findings of our study with the outcomes related to the patients’ age, sex, fracture type and treatment. Please note that as the study is still in progress I am unable to give full results at present. I should be grateful if you could consider the abstract in this state and will submit a complete abstract when the study is completed in August 2003. Follow-up of extra-articular fractures of the distal radius in the elderly population. Does treatment change the outcome? D. Rowland, C. Booth, P. De Boer E-mail address: [email protected]. From November 2001 to August 2002 we recruited patients with extraarticular fractures of the distal radius. These were subclassified according to the AO classification. Treatment was by manipulation if necessary and plaster or K wires according to the Consultant’s assessment of the fracture type. The patients were followed up at clinically and radiologically at 6 weeks, 6 months and 1 year. Our findings suggest that manipulation and/or use of K wires make little difference to the overall outcome since many of the fractures have returned to their original position by the time of their annual review. Despite this, the majority of patients have an excellent functional result. This study is due to be completed in August 2003 and some data are therefore still awaited. I should be grateful if the abstract could be considered in this state and will send an updated abstract once final results are available.

E-mail address: [email protected]. Aim: Wound infection is an important cause of morbidity and mortality in patients with fracture neck of femur. The aim of our study was to identify the incidence of postoperative wound infection (superficial and deep) and their outcome. Materials and methods: We prospectively reviewed 100 consecutive patients admitted with fracture neck of femur to our trauma ward over a period of 2 months. The residential status, mechanism of injury, type of surgery and post operative wound status were documented. The wound status was monitored both by the specialist trauma hip nurses and the surgeons on a regular basis. Surgical site infection was diagnosed based on the ‘Centre for Disease Control’s National Nosocomial Infection Surveillance definition’. Antibiotic were started based on the culture and sensitivity report and out come of the treatment was followed up. Results: The mean age was 81.2 years. Eighty percent of the patients in this study were admitted from their own home, 12% from nursing homes and 8% from residential homes. Forty-five percent of the patients underwent dynamic hip screw, 33% hemiarthroplasty, 11% AO screws, 6% total hip replacements and 5% proximal femoral nailing. Cephradine was given as prophylaxis. 7% developed superficial wound infection and 3% deep wound infection. Out of the superficial infection 1% was MRSA, 3% staph aureus, 1% Coagulase negative staphylococcus, 1% pseudomonas aeurogenosa and 1% streptococci. The superficial MRSA wound infection was treated with vancomycin and rest with appropriate antibiotics. Out of the 3 deep infections, two were MRSA and one was staphylococcus. All patients with deep infection underwent wound debridement and washout. The two patients with MRSA deep wound infection died of sepsis and the one with staphylococcal deep wound infection healed. Totally there were six deaths of which two were related to sepsis and the remaining was due to medical reasons. Conclusion: In our study the incidence of superficial wound infection was 7% and deep infection 3%. The incidence of MRSA was 3%. All the superficial wound infection healed well with antibiotics. The deep wound infections were treated with wound debridement and washout.

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We found that the wound surveillance pilot study to be a useful tool in identifying post operative wound infection in patients with fracture neck of femur treated surgically. This may serve as a platform for setting up data base and policy decisions. Incidence of MRSA colonisation in patients with fracture neck of femur and its influence on postoperative wound infection D. Thyagarajan, D. Sunderamoorthy, S. Haridas, A. Johansen E-mail address: [email protected]. Introduction: Incidence of MRSA has been increasing in the hospital and the community over the last decade. MRSA is one of the commonest hospital acquired infection and is associated with huge economic implications. Aim: The aim of our study is to identify the incidence of MRSA in patients admitted with fracture neck of femur and its implications on the post operative wound. Materials and methods: We prospectively reviewed 100 consecutive patients admitted with fracture neck of femur to our trauma ward. The residential status, previous admission to hospital during the last one year and antibiotic prophylaxis were documented. Surgical site infection was diagnosed based on the ‘Centre for Disease Control’s National Nosocomial Infection Surveillance definition’. Results: The mean age was 81.2 years. Eighty percent of the patients in this study were admitted from their own home, 12% from nursing homes and 8% from residential homes. 5% of the patients admitted with fracture neck of femur were colonised with MRSA from the nose preoperatively and all of them had previous admission to the hospital in the last one year. Out of the MRSA positive patients 40% were admitted from their own home, 40% from nursing homes and 20% from residential homes. All were treated with nasal bactroban and chlorhexidine wash. Two underwent hemiarthroplast and three had dynamic hip screw. Standard antibiotic prophylaxis was given using cephradine. Post operatively the wound healed well in all the patients with preoperative MRSA colonisation. One had persistent colonisation of MRSA in the nose despite local treatment. Conclusion: The incidence of MRSA colonisation in patients admitted with fracture femur to the trauma ward is 5%. With local treatment and isolation procedures we found that there were no post operative MRSA wound infection in these patients.

Abstracts

Early results using the philos plate system for proximal humeral fractures L.M. Longstaff, A.S. Bajwa, P. Patil, R. Liow, A. Port, J.R. Williams E-mail address: [email protected]. Introduction: Fractures of the proximal humerus account for 4—5% of all fractures. Most occur in elderly individuals caused in part by osteoporosis. The treatment of displaced fractures is controversial. Conservative treatment frequently leads to poor outcomes because of malunion and stiffness. ORIF is increasingly advocated. Biomechanical studies suggest that the Proximal Humeral Internal Locking System (PHILOS) provides better fixation than conventional plating devices in osteoporotic bone. Aims: The aim of this study was to assess the early results of surgical treatment of displaced 2—4 part proximal humeral fractures using PHILOS. Methods: All patients who underwent ORIF of their proximal humeral fracture with PHILOS were followed up for a period in excess of 6 months. The initial injury was classified according to the AO system. At follow-up, functional outcome was assessed using the Oxford Shoulder Score and X-rays were performed. Results: 16 patients were included in the study. The mean patient age was 58.9 years (S:D:  20:4) and 11 (69%) were females. All patients underwent treatment for acute fractures. According to AO classification, there were 3 cases of 11C2, one case each of 11C3 and 11B3, and the remainder were 11A3 fractures. All fractures united in less than 6 months, mean time to radiological union was 14.5 weeks (S:D:  6:2). At a mean 23.6 weeks post surgery, the mean Oxford Shoulder score was 24.1 (S:D:  8:3). Complications were few and included 1 death secondary to CCF, and stiffness of shoulder in 2 patients, one of whom needed MUA. None of the patients suffered loss of reduction of the fracture, screw back out or implant failure. Conclusion: The PHILOS plate system is a safe and effective treatment of displaced proximal humeral fractures. Functional outcomes are high and complications after surgery are low. Edinburgh splint-an option for the treatment of proximal phalangeal fractures A. Dosani, T. Jehanzeb, A.A. Faraj E-mail address: [email protected]. Introduction: Closed inherently unstable proximal phalangeal fractures commonly angulate in a volar direction. This usually is treated by surgery.

2003 Meeting of the British Trauma Society

Percutaneous k-wiring or open reduction and internal fixation have the advantage of intra-articular reconstruction but at the cost of damage to the soft tissue envelope, risk of infection, wire loosening and stiffness of the finger. Patients and methods: We describe 15 patients with angulated proximal phalangeal fracture treated with manipulation and Edinburgh cast. The volar part of the cast in relation to the fingers and up to the knuckles was then removed. This is done after a check radiograph of the fracture reduction. This to provide flexion with no extension beyond neutral until union is achieved. The cast was maintained for the period of 3 weeks, mobilisation of the fingers was allowed meanwhile. Fourteen patients had an excellent objective and subjective outcome. Conclusion: The advantage of our technique is early mobilization of the fingers without compromising the position of the fracture and sparing the complications of surgical fixation. This method of treatment should be considered an alternative to other treatment option as it is simple, cheap and effective. Deformed intact femoral intramedullary nail removal with ilizarov transosseous osteosynthesis F.Y. Chan, Smith & Nephew Kurgan Fellow, V.M. Shigarev, Russian Ilizarov Scientific Centre For Restorative Traumatology And Orthopaedics Russian Ilizarov Scientific Centre For Restorative Traumatology And Orthopaedics E-mail address: [email protected]. Intramedullary nailing technique is widely used in the treatment of femoral shaft fractures. Unfortunately, like all the other techniques of fracture management, it has its own complications. Bone re-fracture and nail deformation is one of the rare complications that can occur. When this happens, the nail removal becomes difficult if not impossible. With the current described techniques, the nail removal and fracture stabilization usually involved open procedures that cause significant soft tissue disruption and impairment of subsequent fracture healing. In this article, re-fracture of femoral fracture previously treated with intramedullary nail was described. The nail was deformed but remained intact. The technique of transosseous osteosynthesis used in the Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics is described in the nail removal and fracture stabilization. The fracture was stabilised with the Ilizarov

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frame. Gradual correction of the deformed nail was performed until the deformity resolved. The nail was then removed using the standard technique described in the manufacturer’s literature. The fracture was united in a satisfactory position uneventfully. The transosseous osteosynthesis technique has the following advantages. Biomechanically, it is proven to provide multi-directional stability for fracture healing. It allows fracture healing to occur while the nail being removed. It does not damage the soft tissue envelope at the fracture site. Hence, there is no impairment of the fracture healing process from the technique. It converts a difficult if not impossible deformed nail removal procedure to a standard nail removal procedure. It also allows repeated compression at the fracture site during the treatment period. There is the possibility of limb length correction if required. Hence, it is one of the ideal solutions for this rather difficult problem. Slide plate fixation a study of 36 cases for subtrochanteric & supracondylar fracture femur G. Shah, A.M. Patel E-mail address: [email protected]. A study of 36 patients was carried out (19 distal third/supracondylar fracture femur, 17 subtrochanteric fracture). The study was aimed at preservation of biology at the fracture site by preserving fracture haematoma & preservation of endosteal supply. All the fractures united without any further surgical intervention. The outcome was much better as far as union rate & complications associated with open reduction are concerned. The risk of rotational problems were encountered in 3 patients. One patient required correction of rotation. A study of 43 cases of ruptured extensor mechanism of the knee G. Shah, John Deleeuw E-mail address: [email protected]. A retrospective analysis of 43 patients with post traumatic rupture of extensor mechanism (quadriceps/patellar tendon rupture) was studied from 1992 to year 2000. Study was aimed at understanding of the mechanism of injury, the associated conditions which may modify the treatment options, operative procedures & outcome and patient satisfaction. All the patients were followed up with same post operative regime & were followed up & clinical findings were noted. Knee movements as well as quadriceps mechanism power were also evaluated.

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Clinical out come of distal radial fractures: soft cast versus plaster of paris G. Shah, J.R.L. Lindasy E-mail address: [email protected]. Distal radial fractures are quite common & affects mainly elderly patients. The fracture can have long lasting effects like deformity,reduced mobility & function & complications of the fracture management. In order to assess the efficacy of softcast (combicast) vs plaster of paris, a study of 39 patients have been carried out. The study was aimed at reducing the change of casts, prevention & assessment of complications & patient satisfaction. 19 patients with softcast & 20 patients with plaster of paris treatment were included. The study revealed a slightly lower number of corrective actions required compared to plaster of paris. But there is same risk of plaster complications. The outcome is not affected by change in type of plaster. All the fractures were reduced under haematoma block. The results of distal femoral nail fixation of supracondylar femoral fractures in the elderly M. Ramakrishnan, G. Kumar, R. Sundaram E-mail address: [email protected]. Aim: To study the outcome of distal femoral fractures stabilised with Distal Femoral Nail (DFN) in the elderly. Methods and materials: Between August 2000 and August 2002, 28 patients, average age of 78 years (range 62 to 94 years), with distal femoral fractures (33A1—17, 33A2—1, 33C1—6, 33C2—4) were treated with DFN. All the patients had sustained the injury following a simple fall. Periprosthetic fractures were excluded from this study. Two fractures required additional procedures in the form of circleage wires. Nailing was performed through a midline mini arthrotomy. Post operative protocol was to mobilise the patient weight bearing as tolerated. Results: All fractures healed without the need for secondary procedures. Average period of follow-up was 8.5 months. Average hospital stay was 18 days (range 10 to 34). Post-operative mobility returned to pre operative state in 15 patients. Three patients died within 3 months due to unrelated medical causes. There was no incidence of extension lag or malunion. Knee range of movement was on average 958. Patients with pre existing knee arthritis had slight worsening of the pain. Hospital for Special Surgery knee scores were on

Abstracts

average 78.3. Twenty-three patients were rated as excellent, 4 good and 1 poor. In one patient the distal screws broke without significant functional impairment. Conclusion: We recommend the use of DFN in supracondylar femoral fractures in the elderly as it produced satisfactory results with low operative and post operative morbidity. It can be performed with minimal soft tissue damage with good purchase in the osteoporotic bone which allows early mobilisation. Shorter is better! Change in the flow rate on shortening an intravenous cannula H.V. Dabke, N.V. Jayanthi E-mail address: [email protected]. According to Poiseuille’s law the rate of flow through a tubular structure is directly proportional to its radius and inversely proportional to its length. An in vitro study was performed to assess whether the flow rate of infusion is altered by shortening an intravenous cannula. Method: Using a uroflowmeter the flow rates of 18 G, 16 G & 14 G intravenous cannulae (Venflon) were measured before and after shortening them to 32 mm which is the length of a 20 G cannula. A new one litre bag of saline was used for each measurement and ambient temperature was kept constant. The pressure head of the gravity driven system was kept constant by keeping the lowest end of the fluid bag at 100 cm from the level of the tip of the IV cannula. Three measurements were taken for each type of cannula and the mean calculated. Results: Increase in the flow rate of 15—18% was seen with maximum increase in the 16 G cannula and minimum increase in the 14 G cannula. Average time taken to infuse one litre of saline reduced by 13—15%. Conclusions:* The current in vitro study shows that shortening an intravenous cannula does increase the flow rate by 15—18% (P < 0:05) and reduces the time required for infusion by 13—15% (P < 0:05). This finding may have important implications in resuscitation of a polytraumatised patient. However these results need to be cautiously applied to in vivo conditions because other factors like peripheral venous resistance, venous valves, turbulence in the system (produced by extensions or Luer locks) would influence flow rates in clinical practice. * The length of an intravenous cannula does not appear to have significant effect on flow rates in cannulae of size 14G or larger.

2003 Meeting of the British Trauma Society

Distal radius fracture manipulation in A&E–—do we need to rethink our strategy? H. Mohyuddin, A.H. Shah, S.H. Abdi, N. BartonHanson Department of Orthopaedics, University Hospital Aintree, Liverpool E-mail address: [email protected]. Distal radius fractures are one of the commonest Orthopaedic conditions treated in A&E department. Significantly displaced fractures are generally manipulated in A&E department to improve its position. In this retrospective analysis of 96 consecutive cases of distal radius fractures which attended our A&E department, 26 of them had an MUA performed in A&E. Fourteen out of these 26 patients had a subsequent orthopaedic procedure next day on the trauma list. Three cases required an ORIF of the fracture for stability and/or comminution and hence were excluded from out study. Remaining 11 cases just had a re-MUA. Of the 26 MUAs performed in A&E, 16 cases had Haematoma block, 3 Bier’s block, 4 sedation and in 3 cases it was not documented. Overall, out of 23 cases, 11 (47.8%) required a re-MUA. This re-manipulation rate for Haematoma block is high in our study. It has demonstrated previously that re-manipulation rates are lower with Bier’s block. Our study reinforces this finding. This emphasises the use of proper anaesthetic techniques and training of the personnel doing the manipulation. It also implies that if we are able to achieve a satisfactory MUA in A&E itself, it may save these patients another procedures in theatre and pressure on inhospital trauma admissions. Radiographic assessment of dynamic hip screw fixation K.N. Subramanian, G. Puranik, M.A. Ali, V. Sahni Southport and Ormskirk District General Hospital, Southport, Merseyside E-mail address: [email protected]. Introduction: Dynamic Hip Screw (DHS) fixation is one of the most common orthopaedic surgical procedures. Tip Apex Distance (TAD) is a well-recognised method of evaluating the screw position of the DHS. We studied the adequacy of fixation of DHS by assessing TAD and type of reduction. Materials and methods: We selected a random cohort of 49 patients who had DHS fixation and had the requisite clinico-radiological data. TAD is defined as sum of the distance, in millimetres, from the tip of

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the lag screw to the apex of femoral head, as measured on AP radiograph and lateral radiograph, after correction has been made for radiological magnification. Tip apex distance of 25 mm or less is considered as good, 26—30 mm as acceptable, 31—35 mm as poor and more than 35 mm as unacceptable. Quality of reduction was assessed as per Sernbo. Good, if alignment was normal on AP and maximum 20 degrees angulation on lateral radiograph and less than 4 mm of displacement of any fragment. To be labelled acceptable, a reduction had to meet the criteria of a good reduction with respect to either alignment or displacement, but not both. A poor reduction met neither. Results: Mean TAD in our series was 24 mm (9.84—37.6). Out of this 32(66%) were 25 mm or less indicating good, 12(24%) of them were 26— 30 mm indicating acceptable. One (2%) measured 31.6 indicating poor, 4(8%) were more than 35 mm indicating unacceptable. 26(53%) patients had good reduction. Eighteen (37%) had acceptable reduction and 5(10%) had poor reduction. Conclusion: This study shows that only 66% of all patients having DHS fixation had ‘‘good’’ placement of the fixation device and only 53% had a ‘‘good’’ reduction. We conclude that complacency must not set in on DHS fixation and that we must endeavour for good reduction and placement in as many cases as possible. The relevance of the fourth column in vertebral injuries John F. Quinlan, Mihai Vioreanu, John M. O’byrne E-mail address: [email protected]. Introduction: Fractures of the sternum may result from a direct blow or from an indirect mechanism. Indirect injury occurs with hyperflexion of the spine. The association between spine injury and sternal fractures has been reported but is commonly overlooked and underestimated. Aims: We studies the clinical and radiological effects of an attendant sternal fracture on vertebral fractures. Berg first described the extra stability afforded to the thoracic spine by the sternal-rib complex and the adverse effects of damage to this ‘‘4th column’’ apropos of 2 cases. Materials and methods: Ten patients were admitted to our unit from October 1996 to August 2001 suffering from vertebral fractures and concomitant sternal fractures. The clinical notes and plain film radiographs of these patients were studied. Results: The average age of the 10 patients (6 males and 4 females) was 33 years (range: 21—73).

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Eight had been involved in road traffic accidents and 2 had fallen from a height. Four patients had injuries to their cervical spine, 5 to their thoracic spine and 1 had a lumbar spine fracture. The patients were broken into 2 groups: extra- and intra-thoracic spine fractures. The intra-thoracic spine group all had neurological compromise (3 complete, 2 incomplete), with only 2 in the extra-thoracic group suffering a neurological injury. Furthermore, the intra-thoracic group were associated with lifethreatening chest injuries in 3 cases. Conclusions: It has been traditionally accepted that the sternum is injured only in association with upper thoracic spine. Our findings suggest that spinal injury at lower thoracic, upper lumbar or cervical level may also be associated with sternal injuries. However, the relative severity of the vertebral injury and neurological compromise in the thoracic spine subgroup offers clear support of Berg’s ‘‘4th column’’ theory of thoracic spine fractures when compared to fractures of the cervical or lumbar spine with sternal injuries. The need for combined management of fractures of the upper throacic spine John F. Quinlan, James A. Harty, John M. O’byrne E-mail address: [email protected]. This retrospective medical record-based study analyses the characteristics of the 32 patients who underwent surgery for fractures of their upper thoracic spine (T1—6) in our unit from February 2nd, 1995 to March 21st, 2001. The thoracic spine has always been associated with a stability that is considerably augmented by the rib cage and associated ligaments. Fractures of the thoracic spine require great forces to be applied, causing high levels of other injuries. In addition, the narrow spinal canal dimensions result in high levels of neurological compromise when fractures occur. Using surgical records and then case files, the 32 patients who underwent surgery between February 2nd, 1995 and March 21st, 2001 had their treatment course studied. 26 of the 32 patients were male, with an average age of the entire group of 24.4  11.3 years and an average inpatient stay of 17.5  10.5 days. Twentynine patients suffered fractures at more than one level and 23 patients suffered complete neurological compromise. Only 2 patients were neurologically intact. Ninety-one percent sustained their injuries in road traffic accidents (RTAs), with 54% of the male group being involved in motorcycle accidents. Multiple imaging was required in 30 cases with 20 patients suffering injuries apart from their spinal fracture. Of these, 15 had associated chest

Abstracts

injuries. Consultations from the cardiothoracic surgical service were required in 56% of cases, and from the general surgeons in 38% of patients. Fifty-nine percent of patients required intensive care unit therapy, with another 4 patients going to the high dependency unit. Fractures to the upper thoracic spine are injuries with devastating consequences, both due to high levels of neurological compromise and concomitant injuries. The results of this study show the imperative need for combined management of patients with these injuries. Elastic stable intramedullary nailing of long bone fracture in the upper limb in children Kalid M. Abdlslam, J.A. Fernandes, M.J. Bell, S. Smith, M.J. Flowers Introduction: Long bone fractures of the upper limb in children are commonly treated nonoperatively. However there are definitive indications for operative treatment. This includes situations where the conservative treatment fails to achieve adequate alignment and maintenance of reduction, open fractures and fractures in multiply injured child. Intramedullary fixation of fractures is biomechanically superior to plating. Materials and Methods: Retrospective study of all children who underwent elastic stable intramedullary fixation of upper limb fractures in the Department of Paediatric Orthopaedic at Sheffield Children Hospital over 4.5 years. Results: Fifty-six patients were included in this study. At the end of the follow-up period, 93% had free range of movement. There were no deepseated infections or non-union. No refractures noticed after removal of the nails. Parameters that effect time off work after whiplash injuries K.S. Hagan, M.E. Lovell, S.Z. Naqui Wythenshawe Hospital, Manchester E-mail address: [email protected]. It has been suggested that velocity of injury is not of relevance to severity of whiplash injury. Little has been published about occupational factors. We analysed 800 medicolegal casesheets from a consultant orthopaedic surgeon practice 2001—2003. Of those injured 596 were working, 204 were unemployed or retired. The working group was subanalysed. Severity of injury was estimated by analysing velocity of injury combined with vehicular damage. Mean time off work for a minor injury was 10.6 days; moderate 12.1 days; severe 13.8 and very severe 24.9. (P < 0:05).

2003 Meeting of the British Trauma Society

Looking at work categories as previously described in the literature as heavy manual 20.5 days were taken off:light manual 15.7; driving 13.9; secretarial 9.2 and sedentary 12.8 (P < 0:05). Analysing as per social class showed that professionals required 7.0 days; intermediate 14.7; skilled non-manual 16.1 days; skilled manual 34.2 days and unskilled manual 11.5 days and semiskilled manual 33.2 (P < 0:05). Time off for 52.1% was at the 4 day mark, 90.1% at the 30 day mark: 31.2% required no time off. Time off greater than 12 weeks occurred in 29 cases (4.9%) and was reasonably evenly distributed between each work group–—heavy manual 8.2%; light manual 4.4%; driving 7.1%; secretarial 2.5% and sedentary 4.7% (NS), severity of injury in this subgroup was to a degree also evenly distributed–— mild 1.9%, moderate 3.0%, severe 3.3% and very severe 10.6% (NS). Means were heavily skewed by some subjects (maximum time of 555 days). We conclude that job style, severity of injury and social class/occupation have an effect on time taken off work after road traffic accidents causing the whiplash syndrome. Who gives extra help after wrist fractures N. Copus, M.E. Lovell, S.Z. Naqui Wythenshawe Hospital, Manchester E-mail address: [email protected]. We interviewed 54 fracture clinic patients with wrist fractures, males 13%, females 87%, aged 29— 89 years, mean 64 years. They were at least 4 weeks post injury. They were asked how long tasks were taking and help they received. Patients were asked if they had been offered help, even if they had not taken it. Numbers seeking compensation were limited (3/54). Extra time required for tasks was 76.5 min/day on average, housework an extra 60 min, the rest personal tasks. Help was needed with shopping (75%), getting in and out of bed — 27%. Patients received help from a variety of sources, mainly family and partners, 19% received help from social service, 93% were offered help of some kind, 11% felt they needed more. Partners and family were most likely to help with more personal tasks such as getting dressed and washing, neighbours and friends offered help with shopping and travelling. Despite help from social services being offered to patients, it appeared that those most vulnerable and in need of help, such as elderly people living alone (43%), were least likely to be offered social services support (30% offered), 65% had no nearby relatives. Tasks such as travelling and shopping were more likely to require help, and

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these were often the last tasks managed on recovery. The main carers tended to be family and partners and therefore patients without this support often struggled (43%). Some patients were unhappy with social services help, 33% complained that helpers arrived late on in the day to get them washed and dressed and often failed to do tasks in manner satisfactory to patients. We conclude that some patients do struggle with their injuries and require help that, at present, is not always available to them, the majority seem to cope. The headache of abdominal trauma: a years review of a major trauma centre N.J. Rukin, S. Davis, N. Maffulli, P.A. Oakley Department of Trauma Research, University Hospital of North Staffordshire, Stoke-on-Trent E-mail address: [email protected]. Object: Review of abdominal trauma admissions to a designated trauma centre over a 1-year period. Design: Review of prospectively collected data. Data source: Trauma database established since 1993. Review methods: Abdominal trauma cases, admitted either directly to our centre or transferred form January 1st 2002 to 1st January 2003, with an AIS code of at least 2 were analysed. Results: A total of 51 patients (39 male; 12 female) with AIS score of 2 or more were admitted to the unit in the year 2002. The majority (33) were young adults (16—44 years). Most patients (47) were admitted following blunt trauma. RTA’s were the most common incident types (35), other causes include gunshot wounds (2), stabbings (2), falls (6), direct blows (3) and other (3). Forty-four cases were from so called ‘accidental group’. Mean time from call received to arriving at the unit was 41.9 min, with an average time at scene of 20.9 min. The average ISS was 27.8, with 72.5% having an ISS > 15. There were 2 cases of stomach injuries. There were a total of 16 cases of bowel injury; 10 small and 6 large bowel. The most commonly injured organ was the liver (12 cases) followed by 11 spleen injuries and 9 cases of kidney injuries. There were nine deaths (17.7%), 2 of which were pre hospital cardiac arrests. Of the in hospital deaths (7 cases), 4 had ISS grade 5 head injuries. Other causes were myocardial infarction, sepsis and multiple injuries. Mean ISS for the deaths were 38.5, with one case having an ISS < 15. Conclusion: Moderate to severe abdominal trauma is not particularly common in our unit and has a relatively high mortality. Our data shows that mortality is increased with a concurrent head injury

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and ISS > 15. A review of the deaths highlighted certain training points, with regards to future trauma surgery training. This will have implications on junior training. An audit of the use of trauma theatre time in a district general hospital A. Odumala, J. Williams, R. Kulkarni Royal Glamorgan Hospital, Llantrisant, South Wales E-mail address: [email protected]. Objective: Inefficient use of trauma list time could lead to increased cost from delays and unnecessary overruns. In view of this the aim of this audit was to determine the current use of operating list time and the reasons for inefficient use of time. Methods: We prospectively reviewed the timing of event in a district general hospital’s trauma and emergency list. A total of 120 operated patients that consisted of 72 patients on 27 trauma lists and 48 emergency patients were assessed. Details of each patient and timed events were recorded on a structured proforma. There were seven different time scales from the time patient was sent for till patient was taken to the recovery room. Results: The study consisted of 62 females and 58 males. The mean age of the population was 50.6 years (range 5—99). We found that 77% of the trauma list time was spent operating and 20% of the time for turnover. Average start delay time was 35 min and average pre-operative time 34 min. Time patient seem by the anaesthetist had a significant effect on start time delay (P ¼ 0:01). The pre-operative time was significantly longer in patients who had spinal anaesthesia. However the pre-operative time was similar in both consultant and middle grade anaesthetist. The mean turnover time was 20 min but this was found not to be significantly different whether a consultant orthopaedic surgeon was present or not. (20 min versus 19 min respectively ¼ 0.9) Conclusion: We conclude that the trauma list can be used more efficiently if early preoperative visit is carried out by the anaesthetist and detailed preparation undertaken by theatre and surgical staff. Turnover and wasted time should be addressed and limited as much as possible. Follow-up in fracture clinic after referral to physiotherapy: is it necessary? A. Odumala, H. Dapke, S. Owa, K. Kulkarni. Royal Glamorgan Hospital, Llantrisant, South Wales E-mail address: [email protected].

Abstracts

Objectives: Overbooked fracture clinics are a common NHS problem with resultant dissatisfaction to both patients and hospital staff. The aim of this audit was to determine if patients could be safely discharged from the clinic after physiotherapy referral, and patient satisfaction about the process. Methods: Forty-three (44) patents from four hundred and three (403) new patients referred to the fracture clinic over a 3-month period were discharged to the physiotherapist without follow-up in the fracture clinic. This constituted about 11% of fracture clinic referrals. Patient details, physiotherapy treatment, and patient outcome were entered into a structured proforma. A feedback telephone survey was carried out on patient satisfaction. Results: The study group consisted of 28 females and 16 males. The median age of the study population was 47 years (range 13—88 years). Fractures, dislocations, and soft tissue injuries were the reasons for referrals in 73%, 18% and 9% of cases respectively. Three-quarters of patients had adequate information on their physiotherapy request forms and also spent 12 weeks or less on physiotherapy treatment. Only four (9%) of all patients referred to the physiotherapist were referred back to the fracture clinic further review. All except two patients were satisfied or happy about their physiotherapy treatment and the SOS discharge from the fracture clinic. Conclusion: We conclude that majority of patients referred to the physiotherapist do not need routine follow-up appointments and minority of patients that require follow-up can be referred by the physiotherapist. This will also considerable reduce the volume of patients seen in the followup clinics. Clinical experience with the AO distal tibial anatomical locking screw plate (LCP) Awen Iorwerth, Ian Pallister Morriston Hospital Morriston, Swansea The development of locking screw plate technology offers potential new solutions when applied to previously unsolved peri-articular fractures, such as distal tibial fractures. The concepts of bridging external fixation, minimally invasive articular reconstruction, and stabilisation of metaphysis to diaphysis are now well established. MIPPO techniques have minimised associated problems of wound breakdown. Locking screw plate (LCP) technology affords very sound fixed angle stabilisation, together with anatomical plate design. Our experience of 12 cases of LCP stabilisation for a variety of applications in the distal tibia is

2003 Meeting of the British Trauma Society

encouraging. Cases include 2 extra-articular fractures, 1 nonunion, 7 plafond fractures, and 2 osteotomies for malunions. One case of distal wound dehiscence has occurred, in a non-compliant patient, who admitted to picking at the wound. This case was salvaged with conversion to an Ilizarov frame and split skin grafting. In no other case have there been any wound healing problems. A standard operative technique will be outlined, with rehabilitation consisting of 5 days elevation, non-weight bearing mobilisation for 6 weeks, with ankle exercises, followed by shadow walking for a further 6 weeks. All fractures have united without the need for secondary procedures. In summary, distal tibial anatomical LCP fixation enhances the established strategy for MIPPO stabilisation of the distal tibial fracture. Gustilo 3C open fractures of the lower extremity: analysis of early and late outcomes K. Tzafetta, R. Raman, P.V. Giannoudis St. James’s University Hospital, Leeds E-mail address: [email protected]. Purpose: To assess the early results and late functional outcome of open 3C fractures of the lower extremity. Materials: Between 1990 and 2000, 15 patients with open 3C fractures of the lower extremity were treated at our institution. Demographic data, mechanism of injury, ISS and MESS were ascertained. The patients received combined treatment by the orthopaedic, plastic and when necessary by vascular surgeons. Method of fracture stabilization and type of soft-tissue cover was based on the configuration of the fracture and extent of softtissue damage. The minimum follow-up was 2 years. Functional outcome was assessed using EuroQol 5 D and SF-36 as outcome tools. Results: The mean MESS was 7. The fractures were stabilised initially followed immediately by vascular and soft tissue repair in the same surgical sitting. The Tibia was involved in 2/3 of the patients and in 3 cases there was a combined fracture of both the femur and tibia. The posterior tibial artery was involved 75% of the cases, which was either disrupted or avulsed whilst the superficial femoral artery was thrombosed in a long segment in one case. Limb was salvaged and reconstructed in 13 (77%). Two patients underwent immediate amputation as they had disruption of the posterior tibial nerve, massive contamination with severely segmental fractures with significant loss of soft tissue with a MESS of 10. Fractures were stabilised using intramedullary nails in 6 cases and by plate

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osteosynthesis in the rest. Fasciotomy was performed in all patients due to the nature and extend of the injury. Free latissimus dorsi flap was used in 5 patients (1 bilateral). Regional flaps were used in 3 cases, and one patient with a femoral fracture had a delayed primary closure. All but 2 flaps were applied in the primary surgical sitting. Two were applied in 48 h due to the general condition of patients who suffered also other injuries. The mean total number of operations was 2.6. We had no flap failure. Three patients developed superficial wound infection. Five progressed to non-union (treated with debridement and grafting). In our last follow-up clinic we identified 1 patient with chronic osteomyelitis and 1 patient with significant lymphoedema. The EQ 5D health and thermometer scores were 0.78 and 69 respectively (P > 0:05) and SF 36 physical and mental scores revealed no significant difference from the average population corrected for age. Conclusion: The functional outcome was most closely related to the severity of injury and the injury-surgery interval. Our study showed that improved functional outcome is possible following surgical treatment of these challenging injuries especially when prompt response is instituted by combined ortho/plastic/vascular surgical teams. Management of ipsilateral pilon and calcaneal fractures: a surgeon’s dilemma? Rajnish Mittal, Stuart J. Matthews, T. Dion Zavras, Peter V. Giannoudis St James’s University Hospital, Leeds E-mail address: [email protected]. Introduction: Isolated pilon and calcaneal fractures create a treatment dilemma for most surgeons. This dilemma is even greater when these fractures are sustained simultaneously on the same limb. In that situation, the management of these fractures becomes even more challenging and demands expertise. Besides the restoration of the joint anatomy, other important issues to be considered, for the best possible outcome, include minimising further damage to the soft tissue envelope, positioning of the patient, application of traction and prolonged tourniquet time. With this aim, we present two patients from our tertiary referral trauma centre highlighting the mechanism of these injuries, their management and possible complications of these complex injuries. Patients/Method: Case 1: A 32 year old man, a known case of cystic fibrosis, was involved in a motorcycle accident and sustained AO type 43C2 pilon fracture and Sanders type IIA calcaneus

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fracture on his left lower limb. Both the fractures were temporarily stabilised with an external fixator the next day. Case 2: A 39 year old man fell off a digger which then fell onto him. In the process, the patient sustained multiple injuries including open (grade I) fracture of right calcaneum (Sanders type IIIB), closed right pilon fracture (AO 43 C3). The wound on the right heel was thoroughly debrided the same day and an external fixator was applied to stabilise the fracture and to give time for the soft tissues to heal. Both Cases (1, 2): 12 and 13 days later respectively, once the soft tissue swelling had regressed, had definitive surgery (open reduction and internal fixation of the pilon fracture and the os calcis). Discussion: It is important to appreciate the extensive soft tissue trauma associated with these injuries and to allow adequate time for them to heal before performing surgery. Besides this, other important issues to be considered include inability to insert a pin or to use the universal distractor through the calcaneus to maintain reduction of the pilon fracture, the different positioning of the patient for the fixation of the two fractures and the prolonged tourniquet time. Both of our cases united in 3—3.5 months without any complication except for some restriction of movements of both ankle and subtalar joints in the second case. We feel that by careful planning and using the ‘two stage protocol’ these complex injuries can be managed successfully, as seen in our two cases. Conclusion: The management of ipsilateral pilon and calcaneal fractures is complex and demands expertise tempered by experience and careful planning. The protocol we followed offers the advantages of timely fracture union and good functional results without any complications such as wound dehiscence, infection, DVT, malunion or nonunion. Although further bigger studies are desired, these cases are likely to set up a trend of successful management of these complex and challenging injuries. Less invasive stabilization system (L.I.S.S.) for complex distal femur and priximal tibial fracture–—case series of 22 patients R.S. Pulavartia, A.O. Fellowa, B. Pilkeyb, D. Stephenc, H. Krederd a

Sunnybrooke’s Hospital, Toronto, Canada

b

Orthopaedics And Trauma, Sunnybrooke’s Hospital, Canada

c

Sunnybrooke’s Hospital, Toronto, Canada

d

Sunnybrooke’s Hospital, Toronto, Canada

E-mail address: [email protected].

Abstracts

22 patients with complex distal femur and proximal tibial fractures treated by Less Invasive Stabilization System (L.I.S.S.) have been followed both retrospectively and prospectively. The results analysed with particular reference to operation time, complications, re-operation rates, functional recovery and SF36. The results seem to be interesting and the system seems to be promising especially in patients with osteoporosis and periprosthetic fractures of knee. Terrorist bombing of French nationals: experience of a university hospital in disaster management in a developing country Muhammad Rizwan Khan FRCS (author for presentation/correspondence) Hasnain Zafar, Masood Umar, Riffat Rehmani, Mohsin-e-Azam The Aga Khan University Hospital, Karachi, Pakistan E-mail address: [email protected]. Introduction: Disaster management is multidisciplinary and requires mobilization of manpower and material resources. A Disaster Plan encompasses the advance planning for this mobilization as well as role definition of physicians and ancillary staff. At our hospital, a disaster plan was re-visited and modified in light of the events on 9/11, and the rising tension across Pakistan’s borders. This disaster plan was tested by mock drills on several occasions. On the morning of 8th of May 2002 there was a terrorist bombing of a bus carrying 23 French naval engineers in Karachi. This lead to the activation of the AKUH Disaster Plan. In this paper the experience of implementation of the plan and the simultaneous management of 12 bomb blast victims at a low trauma volume teaching hospital is being presented. Methods: The management of individual patients was reviewed from a pre-printed trauma form. Information on the nature of injuries, operative management and hospital course were recorded and this data analyzed using the Trauma registry (CDC Version 3.0). The process of care and the implementation of the disaster plan were evaluated by an exit interview of the care providers. Results: The victims started to arrive in the Emergency room at AKUH about an hour following the bomb blast; all of them were transferred from various hospitals across the city. Four teams, each comprising of four doctors (residents of surgery, emergency, anaesthesia) and two nurses were formed. The disaster plan coordinator along with physician staff (of anaesthesia and surgery) supervised the teams. All the victims were males with a

2003 Meeting of the British Trauma Society

mean age of 40.5 Years. The average number of injuries was 7.5. The most commonly encountered were injuries were compound fractures of the lower limbs. All patients had tympanic membrane perforations and multiple shrapnel injuries. Three patients had intra-abdominal injury and two required laparotomy. The mean Injury Severity Score (ISS) was 10.4 (range from 5 to 36). Three patients were considered critical with life threatening injuries (ISS > 14) and five had limb threatening injuries. The patients were resuscitated and investigated in the emergency room and underwent a total of 127 X-rays, 15 CT scans and 3 had Focused Abdominal Sonography for Trauma (FAST). Twelve operative interventions were undertaken: five for limb injury, one laparotomy, one laparoscopy and five shrapnel wounds were debrided. The mean ER time was 163 min. All the patients were stabilized and were ready for evacuation within twenty four hours of admission. Conclusions: Advance planning facilitated the care of 12 bomb blast victims. The disaster plan was tested in real-time and worked well on a weekday during working hours. However inter-hospital transfer of victims did contribute to loss of crucial time and difficulty in providing care. An integrated and comprehensive disaster plan involving all the major hospitals of Karachi needs to be developed in the interests of patient care. Radiation exposure to patients in lower limb trauma surgery S. Malek, E. Davies, A. Rawal, A. Singh, R. Harvey Department of Trauma & Orthopaedics, Wirral Hospital NHS Trust, Arrowe Park Hospital, Upton, Wirral, UK Objective: The aim of this study was to determine the average radiation exposure to patients in Dynamic Hip Screw (DHS) fixation, Cannulated Hip Screw (CHS) fixation, intra-medullary(IM) nailing of tibia and femur operations. Setting: Department of Trauma & Orthopaedics of 1000 bed district general hospital. Patients and method: Records of all patients undergoing the above operations between May 2000 and August 2003 were retrospectively reviewed. Total of 670 patients were included. Three hundred and eighty-nine had DHS, 85 had CHS, 125 had femoral nailing and 71 had tibial nailing. Results: Average radiation time was 0.7 (IQR 0.4— 0.8), 1.1 (IQR 0.7—1.3), 2.5 (IQR 1.6—3.0) and 2.1 (IQR 1.2—2.8) min for DHS, CHS, femoral nailing and tibial nailing respectively. Average radiation dose was 196 (IQR 107—244), 356 (IQR 172—387), 548 (IQR 342—672) and 125 (IQR 67—143) cGy cm2 for DHS,

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CHS, femoral nailing and tibial nailing respectively. Compared to registrars, radiation time and dose were higher with consultants in DHS fixation (P ¼ 0:02, 0.02). Radiation dose was higher with SHOs compared to registrars in CHS fixation (P ¼ 0:03). There were no significant differences between consultants and registrars in IM nailing operations. Conclusion: All these operations involved high dose of radiation to patients. IM nailing of femur had four times higher radiation than of tibia and CHS had twice high radiation than DHS. Recommendations: Every effort should me made to reduce the radiation exposure to patients during these operations. Vital organs of the patients, like genitals, thyroid and eyes, should be protected. Adequate precautions should be taken by all the theatre staff involved to minimise radiation exposure to them. Humeral shaft fractures treated with the Marchetti–Vicenzi nail–—a 7-year experience D. Khan, S. Kutty, J. McKenna, I. Sharif, S.O. Flanagan, P. Keogh E-mail address: [email protected]: To assess the use of the Marchetti-Vichenzi nail for the treatment of humeral shaft fractures. Patients and methods: Between 1996 and 2002, 23 acute non-pathological fractures were treated with the retrograde nail. There were 16 males and 7 females. The mean age was 40.08 (range 18—78 years). Four pin nails were used in 20 patients and five pin nails were used in three patients. The fractures were classified according to the AO system. There were six A1, five A2, five A3, four B10 , two B2 and one C1. The approach used in all patients was a paterior triceps splitting. All patients were followed up regularly and until fracture union. A complete physical examination was documented and radiographs evaluated for union. Results: Nineteen patients united without a further procedure. Four patients required removal of the nail, plating and bone grafting as a result of non-union. The type of fractures that resulted in non-union were A2, A3, B1 and C2. There was 1 radial nerve palsy that recovered. One patient needed removal of the nail due to elbow pain. The mean union for the 19 patients was 11.2 weeks (range 8—32 weeks). The mean follow-up was 13 months (range 8—18 months). All patients had good to excellent range of motion of the shoulders and elbows. Conclusions: We feel the Marchetti—Vicenzi nail is a good alternative for treatment of acute humeral shaft fractures with a low complication rate as compared nails inserted in an antegrade manner.

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External fixation fracture shaft femur, a study of 26 cases G. Shah, A.J. Vaishnavi E-mail address: [email protected]. Trauma is a disease of all ages, which is sudden in onset but slow in recovery. We present a study of 26 cases of External fixator shaft femur. The study includes patients from 1991 to 1997 with an average follow up of 25 months. The study was aimed at ease of application, wound management, bony union, range of knee movements, shortening, complications of pin tract, patient’s return to pre injury occupation. The authors suggest that external fixator is a viable option in contaminated wounds as well as severe soft tissue injury. Study also reveals very high incidence of complications associated with external fixator like pin tract infection,loss of range of movements in knee, delayed and non-union, shortening, persistence of infection. The complex mode of injury decides the secondary intervention as well as necessity of different procedures like repeat debridements/soft tissue cover/bone grafting. The intervention in the form of intamedullary nailing/bonegrafting/soft tissue cover was associated with better outcome. Fracture of the distal radius–—role of external fixator Shivashanker Aithal, D.A. Boot, M.P. Manning Royal Preston Hospital, Preston, Lancashire, UK E-mail address: [email protected]. Aim: (1) To retrospectively analyse the functional outcome of comminuted intra-articular fractures of the lower end of the Radius in patients under the age of 65. (2) To evaluate the efficacy of the external fixator in the treatment of these fractures. (3) To evaluate the factors associated with an unsatisfactory outcome. Materials and methods: Twenty-eight patients were included in this study. The average time interval between injury and follow-up was 36 months. Clinical Assessment was performed using the Modified Gartland and Werley scoring system, which is a point system based on the disability evaluation. A subjective assessment of the result by the patient was also recorded. Radiological assessment of the final follow-up radiograph was also performed. Results: The results obtained in this study were as follows: excellent 18%, good 43%, fair 28%, and poor 11%. Six of the patients (21%) were found to have complications–—numbness in the distribution of

Abstracts

the superficial branch of the Radial nerve, Carpal Tunnel Syndrome, Pin track infection. Conclusions: In conclusion, we feel that external fixation is a very useful technique for treating the comminuted intra-articular fractures of the distal end of radius. The severity of the initial injury has a direct relationship to the final outcome. The presence of degenerative changes in the radiocarpal joint did not affect the final outcome. Restoration of the normal palmar tilt has a significant relationship to the outcome. Transitional fracture of the distal tibia S. Aithal, C.E. Bruce Royal Preston Hospital, Preston, Lancashire, UK E-mail address: [email protected]. Aim: (1) To evaluate the functional outcome of treatment of these complex injuries. (2) To identify the causes of poor outcome. Materials and methods: This was a retrospective analysis of twenty five patients with this complex injury. There were thirteen boys and twelve girls in this study. The average age at injury was 13 years and 8 months. Fall accounted for majority of these injuries. Conservative line of management was employed in 4 patients and 21 patients underwent operative intervention. Assessment was performed using the Olerud and Molander scoring system which is a subjective assessment of the ankle function. The assessment was carried out in the form of a questionnaire. Results: The average follow up was 2 years and 6 months. The results were as follows: excellent 44%, good 37% and fair 19%. Complications included, Infection, plaster sore and screw breakage. Conclusions: In conclusion, we feel these are complex injuries which require thorough evaluation by way of a CT scan as the plain radiograph usually under estimates the severity of the injury. Operative line of management gives a better outcome when compared to conservative management. Long-term follow-up of these patients is required to identify any long-term complications. Patients attending fracture clinic–—are they satisfied? S. Sinha, M. Thilagarajah, P. Housden Department of Trauma & Orthopaedics, Kent & Canterbury Hospital, Canterbury CT13NG, UK E-mail address: [email protected].

2003 Meeting of the British Trauma Society

Introduction: Patient satisfaction is at the heart of any clinical problem. A recent BOA letter suggests that there should be 15 min for new and ten minutes for follow up cases. This would mean that in a three hour fracture clinic, with one consultant and two registrars, it would be possible to get through 12 new patients and 36 follow up patients as against an average of 70 patients seen in a normal fracture clinic in DGH setup. Methods: We carried out a prospective study to assess patient satisfaction attending a fracture clinic in one District General Hospital for a period of 4 weeks. We presented them with a set of 12 questions asking about different aspects of their experience in the fracture clinic. Data were then analysed using MS excel. Results: A total of 600 responses were received. Sixty percent (range 52—76%) of patients attending the fracture clinic filled in the questionnaire. Eighty-four percent of these were from patients, while the remaining 16% from either relatives or attendants. Two hundred and fourteen (37%) were attending the clinic for the first time while 358 (62%) were follow-up. The average delay in the fracture clinic was 40 min. One hundred and fifteen (19.5%) patients expected to be seen within ten minutes while 330 patients expected this to be within 30 min from their appointment time. Ninety (16%) patients expected to be seen sometime during clinic, while 42 (8.4%) patients expected to be seen on time. Almost three quarters of patient would be better prepared for the delay if they were pre informed about the same. They would prefer to be called by their names. Conclusion: The main complaints of patients were the delay in seeing the doctor. They were also unhappy about the space in the waiting area and its local condition. Overall 90% patients were satisfied with their visit to the fracture clinic, despite all the factors. Treatment of communited proximal humeral fractures with shoulder hemiarthroplasty in elderly patients S. Neshat Anjum, M. Sohail butt Russells Hall Hospital, Dudley, W. Midlands E-mail address: [email protected]. This is a retrospective study of 22 patients who had hemiarthroplasty of shoulder following comminuted proximal humeral fractures during June 1996 and December 2000. Twenty patients were available for clinical and radiological assessment. The average age was 77.6 years. Male:female ratio was 5:15. In nine patients, dominant side was

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involved. The average follow-up was 33 months (Range 12—50 months). There were four 3-part fracture-dislocation, thirteen 4-part fractures, two 4-part fracture-dislocation and one head splitting fracture. Eleven patients had Nottingham, eight Isoelastic and one Neer II prosthetic replacement. The patients were assessed using Constant Scoring System. Pain was assessed using Visual Analogue Scale. All had radiological assessment at follow up. Median Relative Constant Score (considering age and sex related shoulder function) for all patients was 70. It was 70.5 for Nottingham Prosthesis and 55.5 for Isoelastic Prosthesis. None of the patients had severe pain. Four had moderate and 16 had none or mild pain. The Constant score for pain was better with longer followup. Range of movement was not good. The activities of daily living were significantly reduced in patients with moderate shoulder pain. Sixteen patients (80%) were satisfied with the outcome of the management of shoulder injury. Radiological assessment showed malrotation of prosthesis in one patient and another had ectopic calcification. Three patients with Isoelastic prosthesis had osteolysis around greater tuberosity. Seven patients showed proximal migration of prosthesis on X-ray although there was no significant difference in functional results. Complications included fatal Pulmonary embolism in one patient. Two patients had axillary nerve palsy that was recorded to occur at the time of actual injury. There was no infection. Hemiarthroplasty is a good treatment option in elderly patients with displaced comminuted fracture of proximal humerus. It gives good pain relief but there is only moderate functional improvement. Nottingham prosthesis shows slightly better results than Isoelastic prosthesis. Acute non-traumatic bilateral lower limb compartment syndrome mistaken as paraplegia: case report S.R. Samsani, A. Rahman, K.M. Venu, M. Bankes E-mail address: [email protected]. Acute non-traumatic bilateral lower limb compartment syndrome is uncommon and potentially is a limb and life threatening condition. Early diagnosis and urgent surgical intervention is essential to minimize the complications. The aim this paper is to present and discuss the sub optimal outcome following the delayed surgical intervention in a case of acute non-traumatic bilateral lower limb compartment syndrome initially mistaken as paraplegia. A 20-year-old male schizophrenic was brought to casualty with increasing pain, swelling and

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weakness of both legs. The patient was then admitted under the care of physicians with a diagnosis of paraplegia. Patient had CT scan of head to rule out intra-cranial pathology and was negative for intra-cranial pathology. Subsequently patient developed renal failure due to myoglobinaemia and underwent forced alkaline diuresis. As the pain, swelling and weakness in the legs deteriorated, 36 h after admission, patient was referred to orthopaedics to rule out compartment syndrome. A diagnosis of compartment syndrome of thigh and gluteal region of right leg and left foot was made on clinical grounds. Compartmental pressures were measured using Stryker kit; 45 mmHg in the gluteal and posterior compartment, 38 mmHg in the medial compartment and 26 mmHg in the anterior compartment of the right thigh. Patient refused to have the compartmental pressures of left foot measured. Patient immediately underwent fasciotomy and debridement of thigh and gluteal compartments of right leg and left foot. Patient had delayed closure of wounds and skin grafting by the plastic surgeons. At 3 months follow-up, patient had complete recovery of power and sensation in left, but on right side there was only partial recovery of power and sensation. Our case highlights the consequences of delayed diagnosis with poor outcome in a rare case of bilateral lower limb compartment syndrome. Radiology in paediatric pelvic fractures: what investigations should be done? S. Banerjee, M. Barry, M. Easty, J.M.H. Paterson E-mail address: [email protected]. CT Scan has been used in the diagnosis of adult pelvic fractures but it’s role in paediatric pelvic fracture is not so well established. The paediatric pelvis is very different from the adult pelvis; the cartilaginous component not only raises the possibility of different fracture patterns, but also, in theory make diagnosis on the basis of plain radiographs less accurate. We investigated the use of plain radiography, CT and MRI in our practice of high-energy pelvic trauma. We reviewed the imaging and management of 45 consecutive children with high-energy pelvic fractures admitted through the emergency room at our hospital over the past ten years. Three observers independently classified the fracture as seen on the plain radiograph and, where available CT or MRI scans, according to the classification of Zeig and Torodoe and of Tile. The status of the triradiate cartilage and the Risser grade of maturation were also noted. The subsequent management was recorded.

Abstracts

In 85% of cases, the classification made on plain radiographs correlated with those made on CT or MRI. In the remaining 15%, the CT scan resulted in a different classification to that made on the basis of the plain radiograph. In some of these cases it can be shown that the subsequent clinical management was altered as a result of this change in classification. Inter and intra observer agreement was excellent n contrast to adult fractures, the Tile Classification was found to be relatively non-discriminatory, and the Zeig and Torodoe classification was more helpful. We were not able to identify clinical characteristics of the injuries which would allow pre selection for the CT. In view of the significant number of cases in which important additional information was derived from CT and MRI scanning, we recommend that CT scans should be done in all children with paediatric pelvic fractures to determine the fracture pattern as classified by Zeig and Torodoe. Role of the general surgeon on trauma teams R. Dattani, T. Richards, C. Smith, T. Magee Department of General Surgery, Royal Berkshire Hospital, Reading E-mail address: [email protected]. Introduction: The trauma team constitutes a crucial approach to early management of seriously injured patients. Advanced Trauma and Life Support (ATLS) guidelines state a trauma team should include a general surgeon. Aim: To assess impact of the general surgeon at trauma calls. Methods: (1) prospective study of patients attending A & E who should have a trauma call by ATLS guidelines. (2) Analysis of trauma calls made at a district general hospital (population 460,000) in 2002. Results: (1) Twenty-seven patients fulfilled ATLS criteria for a trauma call, over a 2-month period. Only six trauma calls (22.2%) were made. Sixteen had road traffic accidents (59.3%), five were victims of assault (18.5%), four fell from a height (14.8%) and two had crush injuries (7.4%). Of these, eleven had orthopaedic injuries (40.7%), eight head injuries (29.6%), four facial injuries (14.8%) and one had no significant injuries (3.7%). Twenty-four patients (88.9%) sustained injuries managed by specialties other than general surgery, including all patients that had a trauma call. Only three patients (11.1%) were admitted under general surgery, all had penetrating abdominal trauma. (2) There were 48 trauma calls. Thirty-two had road traffic accidents (66.7%), eight were victims

2003 Meeting of the British Trauma Society

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of assault (16.7%), four fell from a height (8.3%) and four unknown (8.3%). Of these, 20 had orthopaedic injuries (41.7%), 16 head injuries (33%), 4 facial injuries (8.3%) and 4 fatal cardiac arrests (8.3%). Forty patients (83.3%) sustained injuries managed by specialties other than general surgery. Only four patients (8.3%) were admitted under general surgery and all had penetrating abdominal trauma. Conclusion: Most trauma cases in our hospital are currently managed by A&E staff. Attendance by a general surgeon is not essential during a trauma call. Avascular necrosis (AVN) following talar neck fractures: a meta-analysis of studies over the last 25 years in English language peer reviewed journals Vishal Sahni, Pravin Patil, Sanjay Sureen E-mail address: [email protected]. Introduction: Talar neck fractures are rare but serious injuries. Because of its rarity, a meta-analysis is a good tool to assess the rate of AVN. The main goal of meta-analysis is to combine the results of previous studies to arrive a summary conclusion about a body of research. It is most useful in summarizing prior research when individual studies are too small to yield a valid. Inclusion criteria: 1. English language peer reviewed journals. 2. Studies over 25 years from 1977 to 2002. 3. Number of cases per study more than 10. Results: Year Journal 2002 2000 2000 1998 1985 1978 1996

Acta. Orthop. Scand. Foot Ankle Int. J. Foot Ankle Surg. Ann. Acad. Med. Singap. Clin. Orthop. JBJS Am. Orthopaedics

No. of cases

No. and % of AVN

80 60 50 22

9 10 4 2

(11%) (17%) (8%) (9%)

36 71 86 405

12 37 33 107

(33%) (52%) (38%) (26%)

Conclusion: The rate of AVN is directly proportional to the severity of the injury. Interestingly, the studies from 2000 onwards have an AVN rate of 12% only whereas studies from before 2000 have an AVN rate of 39%. This may be related to an actual difference due to better understanding of the anatomy, blood supply, biomechanics, implants or rehabilitation or it could be due to differences in study

design. Our study, like the majority of meta-analyses on orthopaedic-surgery-related topics, has methodological limitations. We also accept that the ultimate quality of a meta-analysis depends on the quality of the primary studies on which it is based. A meta-analysis is most persuasive when data from high-quality randomized trials are pooled. Evaluation of quality of reduction during operative fixation of ankle fractures V. Prasad, S. Deshpande, K. Baloch E-mail address: [email protected]. Introduction: The importance of anatomical reduction following ankle ORIFs is well documented. We have assessed the adequacy of anatomical reduction and the quality of intra-operative radiographs in patients who underwent ankle ORIFs at our trauma unit. We have also looked at the influence of the grade of the operating surgeon and the timing of surgery on our results. Methods: This was a retrospective study of 100 patients who had undergone ankle ORIFs during a 15-month period. The X-rays were analysed against accepted criteria for a satisfactory anatomical reduction. Results: Satisfactory anatomical reduction was obtained in 90% of our cases. However, in fracture dislocations, this was only achieved in 84% of cases. The procedures were consultant led or supervised in 60% of cases. Satisfactory intra-operative radiographs were obtained in only 62.5% of cases. The best results were obtained in ankle fractures without dislocations, which were operated on early, but on a dedicated trauma list, during hours, with adequate Senior supervision. Discussion: Senior Supervision is recommended for ORIF of ankle fracture dislocations. Good quality intra-operative images using the standard image intensifier are imperative for adequate assessment of reduction. We also suggest that departmental radiographs should be obtained in all ankle ORIF patients before discharge. Application of appropriate selection criteria for cervical spine radiography in blunt trauma victims by junior A&E staff Mahmood Bhutta E-mail address: [email protected]. Clinical criteria that have been well validated can be used to exclude cervical spine injury in the blunt trauma victim (NEXUS group study, 2000). However clinical experience suggests that such criteria are not always used in the clinical context, and that radiography of the cervical spine is over-

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Abstracts

utilised. This study looks at the appropriateness of cervical spine X-rays requested in a busy A&E in South East England (Mayday University Hospital). One hundred and forty-five consecutive patient records were retrospectively analysed for documentation of validated exclusion criteria for necessity of X-ray evaluation of the c-spine. It was found that 58% of patients had documented reasons for Xray of the c-spine, 21% had documentation that meant X-ray was not necessary and a further 21% had inadequate documentation and/or assessment of the need for X-ray evaluation. This study concludes that at least 20% and possibly as many as 40% of trauma victims with potential c-spine injury have X-ray evaluation unnecessarily. There is a need for education of junior A&E staff on appropriate evaluation of the c-spine to reduce unnecessary radiation exposure and healthcare costs.

Twenty paediatric forearm radiographs confirmed an approach angle of 20—308. Using a variety of manufactured wires (60—120 degrees) and synthetic and bone surfaces we recorded the maximum angle of approach before test surface penetration. Linear displacement and pressure was recorded on a computer calibrated jig system. Increasing the trocar tip geometry, allows higher approach angles both with drilling or direct linear advancement. We conclude that with particular reference to fractures of the paediatric radius, the wire should be advanced towards the far cortex in a linear manner without drill power and the trocar points should be in excess of those currently commercially available.

Increased kirschner wire trocar angle improves the efficacy of intermedullary passage-with reference to fractures of the paediatric radius

A.J. Pearse, P. Hopgood, P. Wykes, G. Shepard

R. Roach, D. Edwards, A. Ramatalla, Maffulli The Robert Jones and Agnes Hunt Hospital, Oswestry, Shrops E-mail address: [email protected]. Intermedullary wire fixation is a recognised treatment modality for many fractures. The technique invariably fails with sharp K-wires due to penetration of the far cortex. To keep the wire in the intermedullary cavity options include altering the approach angle, entry point, converting to a mini-open technique for a pre-bent or smooth tipped wire. K-wires are supplied with a standard 80 degree offcentred trocar point. We hypothesized that another solution could be to increase this angle, hence mak-

The assessment of lumbar spine fracture stability on plain film

E-mail address: [email protected]. Aim: To assess the accuracy of trauma doctors’ assessment of lumbar spine fracture stability on plain X-rays. Method: Twelve doctors (3 A&E SHOs; 4 orthopaedic SHOs; 2 orthopaedic SpRs; 2 orthopaedic consultants; and 1 radiology consultant) were asked to look at 10 sets of plain films demonstrating lumbar spine fractures. The patients’ details and time of injury were obscured. The participants were all asked to decide whether each fracture was stable or unstable. If they decided the fracture was unstable an explanation was required for their reasoning. Each patient included in the study had undergone CT examination at the time of injury. The scans were used as the gold standard for stability assessment of the fractures.

Results: Participant

Sensitivity

Specificity

Accuracy (%)

Correct reasoning (%)

Consultant radiologist (n ¼ 1) Consultant orthopaedics (n ¼ 2) Registrar orthopaedics (n ¼ 2) SHO orthopaedics (n ¼ 4) SHO A&E (n ¼ 3) Overall results (n ¼ 12)

0.571 0.857 0.929 0.857 0.81 0.833

1 0.667 0.667 0.583 0.778 0.694

70 80 85 77.5 80 79.2

100 91.7 92.3 88.3 35.3 75.7

ing the end appear flatter. The shoulder of the tip would then come into contact with the far cortex first forcing it to remain within the medullary cavity.

Discussion: The results show that there is a significantly low sensitivity to the accurate diagnosis of unstable lumbar fractures on inter- and intra-

2003 Meeting of the British Trauma Society

department testing. Of particular note is the low sensitivity and specificity amongst the ‘‘first-line’’ octors, i.e. SHOs in A&E and orthopaedics, who would see most patients with lumbar fractures and make a decision on further management. Also of note is the low percentage of accurate reasoning amongst the casualty doctors suggesting that they may be, admirably, overcautious based on having little formal training in lumbar fracture assessment. Overall the results would suggest that all practitioners should have a low threshold for CT scans of patients with lumbar spine fractures, as plain films are not sensitive in most hands. This is a pilot study, whereby we intend to increase the number of participants using an Internet site accessible via a link on the World Wide Web (http://www.boltonknees.com). Flexible intramedullary nailing of paediatric tibial fractures S. Platt, S.P. Duckett, N. Garg, C.E. Bruce Department of Paediatric Orthopaedics, Royal Liverpool University Childrens Hospital, Alder Hey, Eaton Road, Liverpool L12 2AP, UK E-mail address: [email protected]. Aim: To review the outcome of treating tibial fractures in children with flexible intramedullary nailing. Methods: Eleven Tibial fractures have been treated with flexible intramedullary nailing at Alder Hey between December 1997 and June 2003. We have reviewed the indications, outcome, and complications from the patients notes and radiographs. Results: Good clinical and functional outcomes were obtained in all cases Conclusions: The technique of flexible intramedullary nailing was used in favour of other open methods due to the relatively small exposure required for nail placement, low complication rate

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and ease of removal. The clinical result is good. The surgical technique is straightforward with relatively few complications. A new clinical mechanism of fracture of the neck of talus: rare combination of fractures of the neck of talus and calcaneus in children Kodali siva, R.K. Prasad, George Zafiropoulos Prince Charles Hospital, Merthyr Tydfil, Mid Glamorgan, UK E-mail address: [email protected]. We are proposing a new clinical mechanism of fracture of the neck of talus- axial compressive loading, based on two cases of an extremely rare combination of fractures of the neck of talus and calcaneus in 2- and 12-year-old children, sustained by different contrasting modes of injury-dorsoplantar and plantodorsal compression, but same mechanism- axial compressive loading. Forced dorsiflexion of talus against the anterior edge of tibia appears to be the accepted common mechanism of injury in all reported major series. Associated fractures of medial malleolus implicate an element of supination in some instances. Peterson and Romanus produced typical patterns of talar neck fractures in cadavers by application of axial loads on plantar aspect, but not by hyperdorsiflexion. No clinical corroborative report, however, exists until now. Our cases provide the first clinical evidence in literature that fractures of the neck of talus can result from axial loads- from dorsal aspect as in the first case (fall of a concrete slab) as well as plantar aspect as in the second case (fall from a height), although in children in association with fractured calcaneus. The dissimilar and diametrically opposite application of axial compressive forces suggests that axial compression, not forced doriflexion, is the primary operative force in fracture of the neck of talus.