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Alternative tension band technique for olecranon fractures: A biomechanical study
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Abstracts from the 2015 Meeting of the British Trauma Society, 4th–5th November 2015 / Injury, Int. J. Care Injured 47 (2016) 293–295
TLA prize Abstract 5 Current practice of consent for trauma surgery: A time for change? Steven Churchill*, Cezary Kocialkowski, Ladan Hajipour, Anand Pillai University Hospitals of South Manchester, United Kingdom *Corresponding author. Objectives: The ruling of the Montgomery case this year emphasised the importance of explicit and legally defensible consent in the modern era; the particular nuances relating to informing patients of risks specifically relevant to them. We performed an audit of the current consenting standards in our trauma department to ascertain what can be done to make the consenting process more consistent and justifiable. Methods: We audited 68 consent forms for patients having elective orthopaedic and trauma procedures between February and April 2015. Specifically looking at who consented the patient, the procedure, as well as each risk/complication identified on the form. We also noted any key differences in the way people consented. Results: Consent for 31 trauma procedures were assessed in the audit: 26 neck of femur (NOF) repairs, three ORIFs and two hip revisions; all of the consent forms were completed by SHO grade doctors. The median day of consent was 1 day pre-procedure. For NOF patients, the proportion consented for specific risks were: pain (53.8%), infection (100%), bleeding (96.2%), leg length discrepancy (11.5%), neurovascular (NV) injury (88.5%), MI (42.3%), DVT/PE (84.6%), fatal PE (3.8%), death (36.4%). Conclusions: Some risks are being well consented consistently such as infection, bleeding and NV injury. However, even though the evidence tells us that the risk of PE following a NOF fracture is around 5% with a 1-year mortality of 20–35%, these are not being consented for universally. This would suggest a more reliable form of consenting maybe appropriate, either through consenting ‘‘stickers’’ or by standardised consent forms. http://dx.doi.org/10.1016/j.injury.2015.12.006
Best Student Prize Abstract 17 Relationship of vitamin D with bone mineral density, fracture type and social deprivation in neck of femur fractures Emma Formoy*, Ekemini Eko, Timothy Thomas, Cezary Kocialkowski, Anand Pillai Department of Trauma and Orthopaedics, University Hospital of South Manchester, United Kingdom *Corresponding author. Objectives: Reduced bone mineral density is recognised as a risk factor for hip fractures and fragility fractures in general. Vitamin D is important in maintaining healthy bone mineral levels and can therefore affect risk of hip fracture. We investigated the correlation between vitamin D levels and bone mineral density, as well as fracture type, in neck of femur fractures and also assessed the relationship of vitamin D and social deprivation. Methods: We included all patients admitted to our department, with a neck of femur fracture over one year (October 2013–October 2014). We analysed vitamin D levels for all patients during
admission and compared these to bone mineral density scores, based on DEXA scan results, hip fracture type and comminution, based on admission radiographs; and levels of social deprivation, based on the patient’s address. Results: In total 360 patients were admitted over the study period, with a neck of femur fracture, of which 298 had vitamin D assessed and 76 had DEXA scans. Of these cohorts, 71% were found to be vitamin D deficient and 7% had osteoporosis. No significant correlation was found between vitamin D scores and bone density, or with level of vitamin D deficiency and fracture type or comminution. A significant correlation was however identified, between low vitamin D levels and decreasing levels of social deprivation (R = 0.11, p = 0.04). Conclusions: No relationship was identified between vitamin D levels and hip fracture type, suggesting that vitamin D cannot be used to predict patients at risk of more comminuted fractures. Although no relationship was also identified for bone mineral density and vitamin D, this may be because the sample size of DEXA scans was relatively small. Interestingly the relationship between vitamin D and social deprivation was the reverse of what was expected and suggests that affluent individuals may be at greater risk of low vitamin D. http://dx.doi.org/10.1016/j.injury.2015.12.007
1st Best Scientific Presentation Abstract 35 Alternative tension band technique for olecranon fractures: A biomechanical study Sanjit Singh1,*, Jan Kuiper2, Abol Behzadian2, T. Madhusudhan1, Amit Sinha1 1
Glan Clwyd Hospital, Rhyl, United Kingdom Keele University, United Kingdom *Corresponding author. 2
Objectives: To investigate whether an alternative tension band wire technique will produce greater compression and less displacement at olecranon (elbow) fracture sites compared to a standard figure of eight tension band technique. Olecranon fractures are commonly treated with tension band wiring using stainless steel wire in a figure of eight configuration. Tension band wiring is intended to produce compression across the fracture even during active flexion and extension of the elbow thus allowing early rehabilitation of the injured elbow. However recently published studies have raised doubts over the validity of the tension band concept proving that the standard figure of eight configuration does not provide fracture compression when the elbow is flexed. We propose an alternative tension band technique where the figure of eight is applied in a modified configuration. Methods: An artificial elbow joint was simulated using artificial forearm (ulna) and arm (humerus) bones. The design simulated the action of the muscles around the elbow joint to produce flexion and extension. An intra-articular fracture was created in the ulna with a saw. Two 1.6 mm Kirshner wires were inserted to hold the reduced fracture fragments. This was followed by application of the tension band. There are two arms to this investigation: (1) Standard tension band wire configuration with stainless steel (2) Modified tension band wire configuration with stainless steel The simulated elbow was put through a range of movement and sensors measured the compression at the fracture site. Measurements were taken for compression both at the articular and the
Abstracts from the 2015 Meeting of the British Trauma Society, 4th–5th November 2015 / Injury, Int. J. Care Injured 47 (2016) 293–295
non-articular aspect of the fracture. Three different weights were applied to challenge both the techniques of tension band wiring. Results: Measurements from the non-articular surface of the fracture demonstrated greater compression with alternative tension band technique. However it was not statistically significant (ANOVA). Compression at the articular surface of the fracture exhibited statistically significant (p < 0.05) greater compression with the alternative technique. Neither technique produced greater compression during flexion of the simulated elbow. Conclusions: The alternative tension band wiring technique proved superior in providing greater compression over the fracture site and smaller displacement. Clinical studies required to investigate whether this translates into higher union rates and lower metal work loosening. http://dx.doi.org/10.1016/j.injury.2015.12.008
2nd Best Scientific Presentation Abstract 11 Pelvic pressure changes after a fracture: A pilot cadaveric study assessing the effect of pelvic binders and limb bandaging Rhys Morris1,2,*, Andrew Loftus1,2, Anna Lygas1,2, Rozina Mahmood1,2, Ian Pallister2,3 1
College of Medicine, Swansea University, SA2 8PP, UK Queen Elizabeth University Hospital Birmingham, B15 2TH, UK 3 Morriston Hospital, Swansea SA6 6NL, UK *Corresponding author. 2
Objectives: Pelvic binders are a life-saving intervention for hypovolaemic shock following displaced pelvic fractures, thought to act through increasing intra-pelvic pressure to reduce venous bleeding. This cadaveric study assesses changes in intra-pelvic pressure with different binders augmented by bandaging the thighs to recruit the femora as levers to close the pelvis. Access to femoral vessels via an in situ binder was also assessed. Methods: Two embalmed cadavers were used with unstable pelvic injuries (OA/OTA 61-C1) created through disrupting the pelvic ring anteriorly and posteriorly. To measure intravesical pressure, which reflects intra-pelvic pressure, a supra-pubic catheter was inserted and connected to a water manometer whilst a spigot was placed in a urethral catheter to reduce leakage of fluid. The common and superficial femoral arteries were dissected in the left groin for each specimen prior to any intervention to allow inspection following binder application. A SAM pelvic sling II, Trauma Pelvic Orthotic Device (T-POD), Prometheus pelvic splint and an improvised pelvic binder were used on each cadaver, with each applied following lower limb bandaging with the knees slightly flexed. The groins were then inspected to assess if the femoral vessels were visible. Statistical analysis was performed in SPSS using a paired samples t test to determine if any difference existed between initial pelvic pressure in specimens compared to pressures with bandaging on and binders applied. Results: Bandaging the lower limbs alone produced a significant increase in both peak and steady mean intra-pelvic pressure, 15.69 cmH2O and 12.38 cmH2O, respectively, compared to the baseline pressure, 8.73 cmH2O (p = 0.002 and p = 0.001, respectively). Applying the pelvic binder with the bandaging in place increased intra-pelvic pressure compared to the baseline (peak pressure of 25.38 cmH2O (p < 0.001) and steady pressure of 15.13 cmH2O
295
(p = 0.003)). Steady mean pressures between bandaging alone and bandaging with the binder applied were not significantly different (p = 0.09), whilst the peak pressures were significantly greater when the binder was applied (p = 0.005). The improvised binder and T-POD both required cutting to access the femoral vessels which resulted in decreasing efficacy. Conclusions: Intra-pelvic pressure was significantly increased through bandaging the lower limbs alone, and this represents a simple measure to increase intra-pelvic pressure and therefore efficacy of the binder. Access to the femoral vessels varied with binder type and represents an important consideration in polytrauma patients. http://dx.doi.org/10.1016/j.injury.2015.12.009 Poster 23 Are stainless steel elastic nails the solution to heavier children with femoral shaft fractures? Richard Hutchinson*, Sam Evans Cardiff University, United Kingdom *Corresponding author. Objectives: The use of titanium elastic intramedullary nails for the treatment of femoral shaft fractures, in children weighing 45 kg, has been questioned due to the increased rates of malunion. Our aim was to see if the mechanical properties of stainless steel elastic nails provided enough fracture stability to justify their use in heavier children. Methods: 20 synthetic paediatric-sized femoral Sawbones1, with mid-shaft fractures, fixed with either titanium or stainless steel elastic nails, were tested using a four-point bending set-up. The bending stiffness and bending moments of the constructs were calculated at increasing loads, along with the angle of fracture deformation. From this estimates of maximum permitted body weight for each nail type could be extrapolated. Results: Stainless steel nails created significantly stiffer constructs than titanium in both the coronal and sagittal planes (p < 0.0001). Steel nails required much bigger bending moments (19.1 Nm) before loosing acceptable alignment, than titanium (14.2 Nm), in the sagittal plane (p < 0.0001). However, despite steel just out performing titanium in the coronal plane, this difference was not statistically significant. The estimated body weights extrapolated in the sagittal plane were 45 kg and 61 kg, in titanium and steel, respectively (p < 0.0001). In the coronal plane they were 42 kg and 44 kg, in titanium and steel, respectively (p = 0.457). Conclusions: As stainless steel has nearly twice the Young’s modulus of titanium, it seems logical that fractures fixed with steel nails would be stiffer and fail at higher loads. However it is unclear why steel did not out perform titanium in the coronal plane. A theory was proposed that unequal nail slip from the insertion sites might be a contributing factor to these findings. Current evidence suggests neither stainless steel nor titanium elastic nails are suitable for stabilizing femoral shaft fractures in children 45 kg, due to risk of malunion. Further research into the use of end caps is needed to see if they provide the added stability needed in heavier children. http://dx.doi.org/10.1016/j.injury.2015.12.010
Abstracts from the 2015 Meeting of the British Trauma Society, 4th–5th November 2015 / Injury, Int. J. Care Injured 47 (2016) 293–295
TLA prize Abstract 5 Current practice of consent for trauma surgery: A time for change? Steven Churchill*, Cezary Kocialkowski, Ladan Hajipour, Anand Pillai University Hospitals of South Manchester, United Kingdom *Corresponding author. Objectives: The ruling of the Montgomery case this year emphasised the importance of explicit and legally defensible consent in the modern era; the particular nuances relating to informing patients of risks specifically relevant to them. We performed an audit of the current consenting standards in our trauma department to ascertain what can be done to make the consenting process more consistent and justifiable. Methods: We audited 68 consent forms for patients having elective orthopaedic and trauma procedures between February and April 2015. Specifically looking at who consented the patient, the procedure, as well as each risk/complication identified on the form. We also noted any key differences in the way people consented. Results: Consent for 31 trauma procedures were assessed in the audit: 26 neck of femur (NOF) repairs, three ORIFs and two hip revisions; all of the consent forms were completed by SHO grade doctors. The median day of consent was 1 day pre-procedure. For NOF patients, the proportion consented for specific risks were: pain (53.8%), infection (100%), bleeding (96.2%), leg length discrepancy (11.5%), neurovascular (NV) injury (88.5%), MI (42.3%), DVT/PE (84.6%), fatal PE (3.8%), death (36.4%). Conclusions: Some risks are being well consented consistently such as infection, bleeding and NV injury. However, even though the evidence tells us that the risk of PE following a NOF fracture is around 5% with a 1-year mortality of 20–35%, these are not being consented for universally. This would suggest a more reliable form of consenting maybe appropriate, either through consenting ‘‘stickers’’ or by standardised consent forms. http://dx.doi.org/10.1016/j.injury.2015.12.006
Best Student Prize Abstract 17 Relationship of vitamin D with bone mineral density, fracture type and social deprivation in neck of femur fractures Emma Formoy*, Ekemini Eko, Timothy Thomas, Cezary Kocialkowski, Anand Pillai Department of Trauma and Orthopaedics, University Hospital of South Manchester, United Kingdom *Corresponding author. Objectives: Reduced bone mineral density is recognised as a risk factor for hip fractures and fragility fractures in general. Vitamin D is important in maintaining healthy bone mineral levels and can therefore affect risk of hip fracture. We investigated the correlation between vitamin D levels and bone mineral density, as well as fracture type, in neck of femur fractures and also assessed the relationship of vitamin D and social deprivation. Methods: We included all patients admitted to our department, with a neck of femur fracture over one year (October 2013–October 2014). We analysed vitamin D levels for all patients during
admission and compared these to bone mineral density scores, based on DEXA scan results, hip fracture type and comminution, based on admission radiographs; and levels of social deprivation, based on the patient’s address. Results: In total 360 patients were admitted over the study period, with a neck of femur fracture, of which 298 had vitamin D assessed and 76 had DEXA scans. Of these cohorts, 71% were found to be vitamin D deficient and 7% had osteoporosis. No significant correlation was found between vitamin D scores and bone density, or with level of vitamin D deficiency and fracture type or comminution. A significant correlation was however identified, between low vitamin D levels and decreasing levels of social deprivation (R = 0.11, p = 0.04). Conclusions: No relationship was identified between vitamin D levels and hip fracture type, suggesting that vitamin D cannot be used to predict patients at risk of more comminuted fractures. Although no relationship was also identified for bone mineral density and vitamin D, this may be because the sample size of DEXA scans was relatively small. Interestingly the relationship between vitamin D and social deprivation was the reverse of what was expected and suggests that affluent individuals may be at greater risk of low vitamin D. http://dx.doi.org/10.1016/j.injury.2015.12.007
1st Best Scientific Presentation Abstract 35 Alternative tension band technique for olecranon fractures: A biomechanical study Sanjit Singh1,*, Jan Kuiper2, Abol Behzadian2, T. Madhusudhan1, Amit Sinha1 1
Glan Clwyd Hospital, Rhyl, United Kingdom Keele University, United Kingdom *Corresponding author. 2
Objectives: To investigate whether an alternative tension band wire technique will produce greater compression and less displacement at olecranon (elbow) fracture sites compared to a standard figure of eight tension band technique. Olecranon fractures are commonly treated with tension band wiring using stainless steel wire in a figure of eight configuration. Tension band wiring is intended to produce compression across the fracture even during active flexion and extension of the elbow thus allowing early rehabilitation of the injured elbow. However recently published studies have raised doubts over the validity of the tension band concept proving that the standard figure of eight configuration does not provide fracture compression when the elbow is flexed. We propose an alternative tension band technique where the figure of eight is applied in a modified configuration. Methods: An artificial elbow joint was simulated using artificial forearm (ulna) and arm (humerus) bones. The design simulated the action of the muscles around the elbow joint to produce flexion and extension. An intra-articular fracture was created in the ulna with a saw. Two 1.6 mm Kirshner wires were inserted to hold the reduced fracture fragments. This was followed by application of the tension band. There are two arms to this investigation: (1) Standard tension band wire configuration with stainless steel (2) Modified tension band wire configuration with stainless steel The simulated elbow was put through a range of movement and sensors measured the compression at the fracture site. Measurements were taken for compression both at the articular and the
Abstracts from the 2015 Meeting of the British Trauma Society, 4th–5th November 2015 / Injury, Int. J. Care Injured 47 (2016) 293–295
non-articular aspect of the fracture. Three different weights were applied to challenge both the techniques of tension band wiring. Results: Measurements from the non-articular surface of the fracture demonstrated greater compression with alternative tension band technique. However it was not statistically significant (ANOVA). Compression at the articular surface of the fracture exhibited statistically significant (p < 0.05) greater compression with the alternative technique. Neither technique produced greater compression during flexion of the simulated elbow. Conclusions: The alternative tension band wiring technique proved superior in providing greater compression over the fracture site and smaller displacement. Clinical studies required to investigate whether this translates into higher union rates and lower metal work loosening. http://dx.doi.org/10.1016/j.injury.2015.12.008
2nd Best Scientific Presentation Abstract 11 Pelvic pressure changes after a fracture: A pilot cadaveric study assessing the effect of pelvic binders and limb bandaging Rhys Morris1,2,*, Andrew Loftus1,2, Anna Lygas1,2, Rozina Mahmood1,2, Ian Pallister2,3 1
College of Medicine, Swansea University, SA2 8PP, UK Queen Elizabeth University Hospital Birmingham, B15 2TH, UK 3 Morriston Hospital, Swansea SA6 6NL, UK *Corresponding author. 2
Objectives: Pelvic binders are a life-saving intervention for hypovolaemic shock following displaced pelvic fractures, thought to act through increasing intra-pelvic pressure to reduce venous bleeding. This cadaveric study assesses changes in intra-pelvic pressure with different binders augmented by bandaging the thighs to recruit the femora as levers to close the pelvis. Access to femoral vessels via an in situ binder was also assessed. Methods: Two embalmed cadavers were used with unstable pelvic injuries (OA/OTA 61-C1) created through disrupting the pelvic ring anteriorly and posteriorly. To measure intravesical pressure, which reflects intra-pelvic pressure, a supra-pubic catheter was inserted and connected to a water manometer whilst a spigot was placed in a urethral catheter to reduce leakage of fluid. The common and superficial femoral arteries were dissected in the left groin for each specimen prior to any intervention to allow inspection following binder application. A SAM pelvic sling II, Trauma Pelvic Orthotic Device (T-POD), Prometheus pelvic splint and an improvised pelvic binder were used on each cadaver, with each applied following lower limb bandaging with the knees slightly flexed. The groins were then inspected to assess if the femoral vessels were visible. Statistical analysis was performed in SPSS using a paired samples t test to determine if any difference existed between initial pelvic pressure in specimens compared to pressures with bandaging on and binders applied. Results: Bandaging the lower limbs alone produced a significant increase in both peak and steady mean intra-pelvic pressure, 15.69 cmH2O and 12.38 cmH2O, respectively, compared to the baseline pressure, 8.73 cmH2O (p = 0.002 and p = 0.001, respectively). Applying the pelvic binder with the bandaging in place increased intra-pelvic pressure compared to the baseline (peak pressure of 25.38 cmH2O (p < 0.001) and steady pressure of 15.13 cmH2O
295
(p = 0.003)). Steady mean pressures between bandaging alone and bandaging with the binder applied were not significantly different (p = 0.09), whilst the peak pressures were significantly greater when the binder was applied (p = 0.005). The improvised binder and T-POD both required cutting to access the femoral vessels which resulted in decreasing efficacy. Conclusions: Intra-pelvic pressure was significantly increased through bandaging the lower limbs alone, and this represents a simple measure to increase intra-pelvic pressure and therefore efficacy of the binder. Access to the femoral vessels varied with binder type and represents an important consideration in polytrauma patients. http://dx.doi.org/10.1016/j.injury.2015.12.009 Poster 23 Are stainless steel elastic nails the solution to heavier children with femoral shaft fractures? Richard Hutchinson*, Sam Evans Cardiff University, United Kingdom *Corresponding author. Objectives: The use of titanium elastic intramedullary nails for the treatment of femoral shaft fractures, in children weighing 45 kg, has been questioned due to the increased rates of malunion. Our aim was to see if the mechanical properties of stainless steel elastic nails provided enough fracture stability to justify their use in heavier children. Methods: 20 synthetic paediatric-sized femoral Sawbones1, with mid-shaft fractures, fixed with either titanium or stainless steel elastic nails, were tested using a four-point bending set-up. The bending stiffness and bending moments of the constructs were calculated at increasing loads, along with the angle of fracture deformation. From this estimates of maximum permitted body weight for each nail type could be extrapolated. Results: Stainless steel nails created significantly stiffer constructs than titanium in both the coronal and sagittal planes (p < 0.0001). Steel nails required much bigger bending moments (19.1 Nm) before loosing acceptable alignment, than titanium (14.2 Nm), in the sagittal plane (p < 0.0001). However, despite steel just out performing titanium in the coronal plane, this difference was not statistically significant. The estimated body weights extrapolated in the sagittal plane were 45 kg and 61 kg, in titanium and steel, respectively (p < 0.0001). In the coronal plane they were 42 kg and 44 kg, in titanium and steel, respectively (p = 0.457). Conclusions: As stainless steel has nearly twice the Young’s modulus of titanium, it seems logical that fractures fixed with steel nails would be stiffer and fail at higher loads. However it is unclear why steel did not out perform titanium in the coronal plane. A theory was proposed that unequal nail slip from the insertion sites might be a contributing factor to these findings. Current evidence suggests neither stainless steel nor titanium elastic nails are suitable for stabilizing femoral shaft fractures in children 45 kg, due to risk of malunion. Further research into the use of end caps is needed to see if they provide the added stability needed in heavier children. http://dx.doi.org/10.1016/j.injury.2015.12.010