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Single-bone fixation of paediatric both-bone diaphyseal forearm fractures: A systematic review
Injury, Int. J. Care Injured 43 (2012) 1623–1625
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Abstracts from the 2012 Meeting of the British Trauma Society, 17 & 18th May 2012
The following seven abstracts, presented during the 2012 Annual Meeting of the British Trauma Society, were the winners of the Injury Journal Awards. ELSEVIER WINNERS 1st Prize – 1A.5 2nd Prize – 2A.16 3rd Prize – 2B.5 BTS WINNERS 1st Prize Best Clinical Paper – 1B.18 2nd Prize Best Clinical Paper – 1B.1 Best Paper Presented by a Junior – 1B.13 Best Poster – P 1.3
ELSEVIER WINNERS
failure and transfusion were used to produce the final risk score. The score was statistically significant (p < 0.0001) and highly predictive (ROC analysis, AUC = 0.76) of SVTE. The score was separately validated in two cohorts from different centres. In one prospective consecutive cohort of 1000 NOF patients all components of the NotSVTE score were found to be individually statistically significant (p < 0.0045). The score was further validated in a separate cohort of 3200 patients undergoing elective hip surgery. The score was found to be statistically significantly predictive of SVTE as a whole, and three of the four components were individually predictive. Conclusion: Balancing risks and benefits for thromboprophylaxis is key to reducing the risk of SVTE, minimising bleeding and other complications associated with the therapy. Our study of 13,367 prospective patients is the largest of its type and we have successfully constructed and validated a scoring system that can be used to inform patient treatment decisions.
1A.5 Nottingham trauma symptomatic venous thromboembolism risk score (notsvte). Predicting venous thromboembolism in fractured neck of femurs. A multi-centre validated risk score based on 13,347 serial admissions
http://dx.doi.org/10.1016/j.injury.2012.06.017
2A.16
B.J. Ollivere , K.E. Rollins , P. Johnston , J.B. Hunter , E.P. Szypryt 2, C.G. Moran (Prof)2
Single-bone fixation of paediatric both-bone diaphyseal forearm fractures: A systematic review
1
D.J. Westacott, E.J. Dickenson, N.A. Smith
1
2
2
2
2
Queens Medical Centre, Nottingham Addenbrooke’s Hospital, Cambridge
Purpose: Symptomatic venous thromboembolism (SVTE) is a potentially significant complication which may occur following injury or surgery. The NICE framework was established despite a complete lack of evidence with no studies investigating the risk factors for or incidence of SVTE in NOF. We aim to produce a validated risk score to inform clinical practice. Data from a prospective series of 9167 consecutive patients with a diagnosis of fractured neck of femur (NOF) at a single institution were used to construct a risk score for SVTE. All patients were treated with in-patient anticoagulation. Twenty three factors were screened with pairwise analysis for potential association with SVTE. The cohort had an event rate of 1.4%. A multiple logistic regression model was used to construct a score and correct for confounding variables from nine significant factors in the pairwise analysis. Four factors; length of stay; chest infection; cardiac
West Midlands Deanery
Purpose: This systematic review aimed to establish if fixation of a single bone is a suitable treatment option in both-bone forearm fractures and, if so, which method of fixation of which bone provides the best results. Methods: A systematic review of the published literature was performed, searching Medline for English language studies that reported functional or radiographic outcome following singlebone fixation of either bone by any method in patients less than 18 years old with both-bone diaphyseal forearm fractures. Results: 11 studies met the inclusion criteria. They were all retrospective studies (Level of Evidence III or IV). Five studies compared single- with both-bone fixation and reported similar outcomes in general. Redisplacement of the radius fracture was common following fixation of the ulna, especially when intramedullary Kirschner wires were used. Outcome was good following
1624
Abstracts / Injury, Int. J. Care Injured 43 (2012) 1623–1625
radius fixation with ORIF or nailing. Flexible nails were generally superior to Kirschner wires for intramedullary stabilisation. Conclusions: Single-bone fixation is a viable treatment option. Although more technically-demanding, this review suggests single-bone fixation of the radius provides better outcome in these injuries, regardless of fixation method.
BTS WINNERS 1B.18 The open blast pelvis: The significant burden of management S. Evans, A. Ramasamy, J. Cooper, J. Kendrew Queen Elizabeth Hospital, University Hospitals Birmingham, England
http://dx.doi.org/10.1016/j.injury.2012.06.018
2B.5 Vitamin D levels in hip fractures: Rationale and guidelines for rapid substitution therapy A. de Jong, K. Woods, M. Suresh, M. Porteous West Suffolk Hospital NHS Trust, UK
Introduction: Assessment for and treatment of osteoporosis is recommended following hip fracture. However, all forms of osteoporosis treatment assume that those who receive it have an adequate calcium intake and are vitamin D replete. This study initially assessed vitamin D levels in patients with femoral neck fractures and from that we have developed guidelines on how to safely and effectively manage low vitamin D levels with high dose oral vitamin D3 (cholecalciferol). Materials and methods: Circulating 25-hydroxyvitamin D levels were measured in consecutive patients admitted with a hip fracture over an 18-month period. Substitution therapy with high dose oral vitamin D3 was started in two selected cohorts; one group received substitution therapy for 3 days, the second group for 7 days. Exclusion criteria for substitution were prior vitamin D substitution and corrected calcium > 2.60 mmol/L. Results: 381 patients with 387 hip fractures were included (95 men, 286 women, mean age = 83 years, range 34–97 years). Only 27 patients had sufficient (>75 nmol/L) circulating vitamin D levels (mean 91.2 nmol/L, SD 20.0 nmol/L, range 75.6–171 nmol/L), and of these 22 were taking vitamin D supplements. The remainder, 354 patients, had abnormally low vitamin D levels, with a mean value of 26.4 nmol/L (SD = 17.9 nmol/L, range < 10– 74.4 nmol/L). Substitution with 50,000 IU cholecalciferol daily for 3 days in 14 patients resulted in a rapid increase in circulating vitamin D levels from 29.6 nmol/L to 81.4 nmol/L (SD = 15.8 nmol/ L, range 47.4–108.0 nmol/L, p < 0.0001), at a mean of 14 days. 71% of patients achieved levels above the desired threshold of 75 nmol/ L. Substitution with 50,000 IU cholecalciferol for 7 days in 24 patients resulted in an increase in circulating vitamin D levels from 15.8 nmol/L to 128.4 nmol/L (SD = 29.8 nmol/L, range 85.6– 185.0 nmol/L, p < 0.0001), at a mean of 16 days. 100% of patients achieved levels above the desired threshold of 75 nmol/L. Calcium levels increased from a low value of 2.17 mmol/L to a normal value of 2.29 mmol/L (SD = 0.15 mmol/L, range 1.98–2.48 mmol/L, p < 0.0001). No clinical or biochemical side effects were reported. Discussion: This study shows that virtually all patients who are not taking vitamin D supplements and sustain a hip fracture have abnormally low circulating vitamin D levels and that they all require substitution before osteoporosis treatment can be initiated. This finding seems unaffected by the age of the patient. The routine measurement of vitamin D levels in patients with a corrected calcium < 2.60 mmol/L would seem unnecessary. Substitution with 50,000 IU oral cholecalciferol daily for 7 days increases vitamin D levels rapidly, safely and consistently in all of these patients. http://dx.doi.org/10.1016/j.injury.2012.06.019
The open blast pelvic fracture is said to represent the most severe injury within the spectrum of battlefield trauma. We report our unique experience of 29 consecutive patients treated from 2008 to 2010. All patients were serving soldiers who were injured on operations in Afghanistan. The median New Injury Severity Score (NISS) was 41. Mean blood requirement in the 1st 24 h was 60.3 units. In addition to their orthopaedic injury, 6 (21%) had an associated vascular injury, 7 (24%) had a bowel injury, 11 (38%) had a genital injury and 7 (24%) had a bladder injury. 8 (28%) fractures were managed definitively with external fixation, and 7 (24%) fractures required ORIF. Of those patients who underwent ORIF, 4 (57%) required removal of metalwork for infection. Faecal diversion was performed on 9 (31%) casualties. Median length of stay was 70.2 days, and mean total operative time was 29.6 h. At a mean 20.3 months follow-up, 24 (83%) were able to ambulate, and 26 (90%) had clinical and radiological evidence of pelvic ring stability. The ‘‘Global War on Terror’’ has resulted in incidents that were previously confined exclusively to conflict areas can now occur anywhere, and surgeons who are involved in trauma care may be required to manage similar injuries from terrorist attacks. Our study clearly demonstrates that the management of this injury pattern is extremely resource intensive with the need for significant multidisciplinary input. Given the nature of the soft tissue injury, we would advocate an approach of minimal internal fixation in the management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is mandated in all cases. http://dx.doi.org/10.1016/j.injury.2012.06.020
1B.1 The Masquelet technique induces the formation of a mesenchymal stem cell rich periosteum like membrane R.J. Cuthbert, E. Jones, D. McGonagle, P.V. Giannoudis University of Leeds, England
The purpose of this study was to analyse the structural composition and regenerative potential of the induced membrane formed as a result of the Masquelet technique. The structural and phenotypical characteristics of five induced membranes formed as a result of the Masquelet technique was compared to neighbouring healthy periosteum. Following removal of the cement spacer 6–8 weeks after initial implantation, a small section (<2 cm2) of the induced membrane was harvested with a comparable section of healthy periosteum from the same limb. These were then bisected, one half was processed for histology and immunohistochemistry, the second half was enzymatically digested into a single cell suspension in preparation for flow cytometry. Basic structural composition of the membrane was assessed using a haematoxylin/ eosin and Masson’s Trichrome stains, the localisation of cytokines (BMP-2, VEGF and SDF-1) and cell lineage markers (CD31, CD271
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Abstracts from the 2012 Meeting of the British Trauma Society, 17 & 18th May 2012
The following seven abstracts, presented during the 2012 Annual Meeting of the British Trauma Society, were the winners of the Injury Journal Awards. ELSEVIER WINNERS 1st Prize – 1A.5 2nd Prize – 2A.16 3rd Prize – 2B.5 BTS WINNERS 1st Prize Best Clinical Paper – 1B.18 2nd Prize Best Clinical Paper – 1B.1 Best Paper Presented by a Junior – 1B.13 Best Poster – P 1.3
ELSEVIER WINNERS
failure and transfusion were used to produce the final risk score. The score was statistically significant (p < 0.0001) and highly predictive (ROC analysis, AUC = 0.76) of SVTE. The score was separately validated in two cohorts from different centres. In one prospective consecutive cohort of 1000 NOF patients all components of the NotSVTE score were found to be individually statistically significant (p < 0.0045). The score was further validated in a separate cohort of 3200 patients undergoing elective hip surgery. The score was found to be statistically significantly predictive of SVTE as a whole, and three of the four components were individually predictive. Conclusion: Balancing risks and benefits for thromboprophylaxis is key to reducing the risk of SVTE, minimising bleeding and other complications associated with the therapy. Our study of 13,367 prospective patients is the largest of its type and we have successfully constructed and validated a scoring system that can be used to inform patient treatment decisions.
1A.5 Nottingham trauma symptomatic venous thromboembolism risk score (notsvte). Predicting venous thromboembolism in fractured neck of femurs. A multi-centre validated risk score based on 13,347 serial admissions
http://dx.doi.org/10.1016/j.injury.2012.06.017
2A.16
B.J. Ollivere , K.E. Rollins , P. Johnston , J.B. Hunter , E.P. Szypryt 2, C.G. Moran (Prof)2
Single-bone fixation of paediatric both-bone diaphyseal forearm fractures: A systematic review
1
D.J. Westacott, E.J. Dickenson, N.A. Smith
1
2
2
2
2
Queens Medical Centre, Nottingham Addenbrooke’s Hospital, Cambridge
Purpose: Symptomatic venous thromboembolism (SVTE) is a potentially significant complication which may occur following injury or surgery. The NICE framework was established despite a complete lack of evidence with no studies investigating the risk factors for or incidence of SVTE in NOF. We aim to produce a validated risk score to inform clinical practice. Data from a prospective series of 9167 consecutive patients with a diagnosis of fractured neck of femur (NOF) at a single institution were used to construct a risk score for SVTE. All patients were treated with in-patient anticoagulation. Twenty three factors were screened with pairwise analysis for potential association with SVTE. The cohort had an event rate of 1.4%. A multiple logistic regression model was used to construct a score and correct for confounding variables from nine significant factors in the pairwise analysis. Four factors; length of stay; chest infection; cardiac
West Midlands Deanery
Purpose: This systematic review aimed to establish if fixation of a single bone is a suitable treatment option in both-bone forearm fractures and, if so, which method of fixation of which bone provides the best results. Methods: A systematic review of the published literature was performed, searching Medline for English language studies that reported functional or radiographic outcome following singlebone fixation of either bone by any method in patients less than 18 years old with both-bone diaphyseal forearm fractures. Results: 11 studies met the inclusion criteria. They were all retrospective studies (Level of Evidence III or IV). Five studies compared single- with both-bone fixation and reported similar outcomes in general. Redisplacement of the radius fracture was common following fixation of the ulna, especially when intramedullary Kirschner wires were used. Outcome was good following
1624
Abstracts / Injury, Int. J. Care Injured 43 (2012) 1623–1625
radius fixation with ORIF or nailing. Flexible nails were generally superior to Kirschner wires for intramedullary stabilisation. Conclusions: Single-bone fixation is a viable treatment option. Although more technically-demanding, this review suggests single-bone fixation of the radius provides better outcome in these injuries, regardless of fixation method.
BTS WINNERS 1B.18 The open blast pelvis: The significant burden of management S. Evans, A. Ramasamy, J. Cooper, J. Kendrew Queen Elizabeth Hospital, University Hospitals Birmingham, England
http://dx.doi.org/10.1016/j.injury.2012.06.018
2B.5 Vitamin D levels in hip fractures: Rationale and guidelines for rapid substitution therapy A. de Jong, K. Woods, M. Suresh, M. Porteous West Suffolk Hospital NHS Trust, UK
Introduction: Assessment for and treatment of osteoporosis is recommended following hip fracture. However, all forms of osteoporosis treatment assume that those who receive it have an adequate calcium intake and are vitamin D replete. This study initially assessed vitamin D levels in patients with femoral neck fractures and from that we have developed guidelines on how to safely and effectively manage low vitamin D levels with high dose oral vitamin D3 (cholecalciferol). Materials and methods: Circulating 25-hydroxyvitamin D levels were measured in consecutive patients admitted with a hip fracture over an 18-month period. Substitution therapy with high dose oral vitamin D3 was started in two selected cohorts; one group received substitution therapy for 3 days, the second group for 7 days. Exclusion criteria for substitution were prior vitamin D substitution and corrected calcium > 2.60 mmol/L. Results: 381 patients with 387 hip fractures were included (95 men, 286 women, mean age = 83 years, range 34–97 years). Only 27 patients had sufficient (>75 nmol/L) circulating vitamin D levels (mean 91.2 nmol/L, SD 20.0 nmol/L, range 75.6–171 nmol/L), and of these 22 were taking vitamin D supplements. The remainder, 354 patients, had abnormally low vitamin D levels, with a mean value of 26.4 nmol/L (SD = 17.9 nmol/L, range < 10– 74.4 nmol/L). Substitution with 50,000 IU cholecalciferol daily for 3 days in 14 patients resulted in a rapid increase in circulating vitamin D levels from 29.6 nmol/L to 81.4 nmol/L (SD = 15.8 nmol/ L, range 47.4–108.0 nmol/L, p < 0.0001), at a mean of 14 days. 71% of patients achieved levels above the desired threshold of 75 nmol/ L. Substitution with 50,000 IU cholecalciferol for 7 days in 24 patients resulted in an increase in circulating vitamin D levels from 15.8 nmol/L to 128.4 nmol/L (SD = 29.8 nmol/L, range 85.6– 185.0 nmol/L, p < 0.0001), at a mean of 16 days. 100% of patients achieved levels above the desired threshold of 75 nmol/L. Calcium levels increased from a low value of 2.17 mmol/L to a normal value of 2.29 mmol/L (SD = 0.15 mmol/L, range 1.98–2.48 mmol/L, p < 0.0001). No clinical or biochemical side effects were reported. Discussion: This study shows that virtually all patients who are not taking vitamin D supplements and sustain a hip fracture have abnormally low circulating vitamin D levels and that they all require substitution before osteoporosis treatment can be initiated. This finding seems unaffected by the age of the patient. The routine measurement of vitamin D levels in patients with a corrected calcium < 2.60 mmol/L would seem unnecessary. Substitution with 50,000 IU oral cholecalciferol daily for 7 days increases vitamin D levels rapidly, safely and consistently in all of these patients. http://dx.doi.org/10.1016/j.injury.2012.06.019
The open blast pelvic fracture is said to represent the most severe injury within the spectrum of battlefield trauma. We report our unique experience of 29 consecutive patients treated from 2008 to 2010. All patients were serving soldiers who were injured on operations in Afghanistan. The median New Injury Severity Score (NISS) was 41. Mean blood requirement in the 1st 24 h was 60.3 units. In addition to their orthopaedic injury, 6 (21%) had an associated vascular injury, 7 (24%) had a bowel injury, 11 (38%) had a genital injury and 7 (24%) had a bladder injury. 8 (28%) fractures were managed definitively with external fixation, and 7 (24%) fractures required ORIF. Of those patients who underwent ORIF, 4 (57%) required removal of metalwork for infection. Faecal diversion was performed on 9 (31%) casualties. Median length of stay was 70.2 days, and mean total operative time was 29.6 h. At a mean 20.3 months follow-up, 24 (83%) were able to ambulate, and 26 (90%) had clinical and radiological evidence of pelvic ring stability. The ‘‘Global War on Terror’’ has resulted in incidents that were previously confined exclusively to conflict areas can now occur anywhere, and surgeons who are involved in trauma care may be required to manage similar injuries from terrorist attacks. Our study clearly demonstrates that the management of this injury pattern is extremely resource intensive with the need for significant multidisciplinary input. Given the nature of the soft tissue injury, we would advocate an approach of minimal internal fixation in the management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is mandated in all cases. http://dx.doi.org/10.1016/j.injury.2012.06.020
1B.1 The Masquelet technique induces the formation of a mesenchymal stem cell rich periosteum like membrane R.J. Cuthbert, E. Jones, D. McGonagle, P.V. Giannoudis University of Leeds, England
The purpose of this study was to analyse the structural composition and regenerative potential of the induced membrane formed as a result of the Masquelet technique. The structural and phenotypical characteristics of five induced membranes formed as a result of the Masquelet technique was compared to neighbouring healthy periosteum. Following removal of the cement spacer 6–8 weeks after initial implantation, a small section (<2 cm2) of the induced membrane was harvested with a comparable section of healthy periosteum from the same limb. These were then bisected, one half was processed for histology and immunohistochemistry, the second half was enzymatically digested into a single cell suspension in preparation for flow cytometry. Basic structural composition of the membrane was assessed using a haematoxylin/ eosin and Masson’s Trichrome stains, the localisation of cytokines (BMP-2, VEGF and SDF-1) and cell lineage markers (CD31, CD271