Fracture neck of femur with delayed presentation in young patients can be a surgical challenge. Such scenarios are rare in the developed world but not uncommon in developing countries.

To present the medium term results of open reduction and internal fixation accompanied by Quadratus Femoris muscle pedicle grafting in young patients who presented with a delay after sustaining a fracture neck of femur, 42 patients with fracture neck of femur with delayed presentation were treated with open reduction and internal fixation and supplemented with Quadratus Femoris muscle pedicle graft. A posterior approach was used in all cases. The patients were advised not to bear weight until there was clinical and radiological union. Functional recovery was assessed by gait and ability to squat on the floor.

The age of the patients, predominantly male, ranged from 24 yrs to 50 yrs. Radiological union occurred on average at 6 months. Thirty-six patients proceeded to union; six patients had non-union and needed revision surgery. Complications included varus union in 9 cases; shortening greater than 2 cms occurred in 6 cases.

Quadratus Femoris muscle pedicle grafting described by Meyer in the 1970s is useful in treating fracture neck of femur. Open reduction and internal fixation of the fracture neck of femur when supplemented with Quadratus Femoris muscle pedicle graft fixation promoted the union of fracture and preserved the head the femur.

Aim: To quantify changes in epidemiology, in-patient treatment and outcome of hip fracture patients over seven-year period.

Subjects and methodology: Retrospective randomised analysis of in-patient charts of patients with hip fractures admitted to a large 650-bed Acute District General Hospital in 1996 compared with 2003. The following data is gathered: Epidemiological data, baseline test data for anaemia and renal function, time to surgery from admission, post-operative complications, time to discharge from ward and functional outcome.

Results: In 1996, the total number of admissions over 6 months was 144 compared to 160 in 2003 for the same time period. The mean age has increased from 83 years compared to 85 years in 2003. Median mental test score declined from 9 in 1996 to 6 in 2003. The mean co-morbidities rose from 1.7 in 1996 to 2.8 in 2003. 11% of patients were medically unfit for surgery in 1996 compared to 30% in 2003 resulting in delay in time to theatre. 33% of patients were admitted from nursing homes in 2003 compared to 22% in 1996. The mortality rate was 12% in 1996 compared to 18% in 2003.

Conclusion: This study demonstrates that deteriorating pre-operative status in terms of age, ASA, mental test score and co-morbidities seems to have negated any of the system changes we introduced to improve our service. As patients with neck of femur fractures are often already suffering from other significant co-morbidities, the improvements in the overall health care system may not have an impact on the outcome of the patients concerned.

Aim: To quantify changes in epidemiology, in-patient treatment and outcome of hip fracture patients over seven-year period. This data has provided a baseline of our local changes and provided information for local planning of health care provision for these patients, in terms of improved care pathways, treatment protocols, management with geriatricians, provision for discharge in the future.

Subjects and methodology: Retrospective randomised analysis of in-patient charts of patients with hip fractures admitted to a large 650-bed Acute District General Hospital in 1996 compared with 2003. The following data is gathered: Epidemiological data, baseline test data for anaemia and renal function, time to surgery from admission, post-operative complications, time to discharge from ward and functional outcome. During this time interval we introduced a number of changes to our system of care such as: more junior doctors on the wards, more access to emergency operating time, better post-operative monitoring and care, and a move to a new hospital.

Results: In 1996, the total number of admissions over 6 months was 144 compared to 160 in 2003 for the same time period. The mean age has increased from 83 years compared to 85 years in 2003. Median mental test score declined from 9 in 1996 to 6 in 2003. The mean co-morbidities rose from 1.7 in 1996 to 2.8 in 2003. 11% of patients were medically unfit for surgery in 1996 compared to 30% in 2003 resulting in delay in time to theatre. 33% of patients were admitted from nursing homes in 2003 compared to 22% in 1996. The mortality rate was 12% in 1996 compared to 18% in 2003.

Conclusion: This study demonstrates that deteriorating pre-operative status in terms of age, ASA, mental test score and co-morbidities seems to have negated any of the system changes we introduced to improve our service. Some of our results are at variance with some national trends, highlighting the importance of undertaking this type of study locally. In our situation this was all the more surprising, given that demographically we have a relatively young population in Swindon compared to the national statistics. Performance and National League table results must take into account these demographic variances.

Background: Fracture neck of femur with delayed presentation in young patients can be surgical challenge to any Orthopaedic surgeon. Such scenarios are rare in developed world, but are not uncommon in developing countries.

Aim: To present the medium term results of open reduction and internal fixation accompanied by Quadratus femoris muscle pedicle grafting in young patients who presented at least 3 months after sustaining a fracture neck of femur

Materials and Methods: 42 patients with ununited fracture neck of femur with delayed presentation were treated with open reduction and internal fixation and supplemented with Quadratus Femoris muscle pedicle graft. With patient in lateral position, posterior approach was used in all cases. The patients were advised not bear weight till there was clinical and radiological union. Functional recovery was assessed by gait and ability to squat on the floor.

Results: The delay in presentation ranged from 3 months to 1year after sustaining the intracapsular fracture. The age of the patients ranged from 24 yrs to 50 yrs. There was male predominance. Radiological union occurred on average at 6 months. 36 patients proceeded to union. 6 patients had non-union and needed revision surgery. Complications included varus union in 9 cases, shortening greater than 2.5 cms in 6 cases.

Conclusion: The two staged technique described by Meyer was modified into a single stage open reduction and internal fixation of the fracture neck of femur with quadratus femoris muscle pedicle graft fixation. This helped in promoting the union of the fracture and also preserve the head of the femur (avoiding arthroplasty).

Aim: To propose new guidelines in the management of supracondylar fractures treated by percutaneous Kirschner wires

Subjects and Method: We audited 62 children with displaced, unstable supracondylar fractures of the humerus, which were fixed with Kirschner wire over a period of 2 years. The fractures were classified according to the Wilkins modification of the Gartland system. 10% were type II and 90% type III. The protocol followed was that all unstable fractures that required closed or open reduction must be stabilised with Kirschner wires of adequate thickness used in a crossed configuration and supplemented with back slab. They were then followed up mostly weekly, often with multiple check X-rays until 3 weeks, and for wire removal at 3 weeks. The parameters studied are level of surgeon, adequacy of intra operative reduction, re operation rate, adequacy of intra operative X-rays, out of hour operations, number of post operative X-rays, number of follow ups and any complications.

Results:

Two patients had re operation due to poor intra operative reduction which were performed by junior grade surgeon without supervision during out of hours.

Conclusions: Unnecessary radiation can be avoided by obtaining adequate intra operative X-rays and avoiding check X-ray as no fracture had displaced at follow up.

New guidelines proposed:

Patients with no N-V complications can wait till the morning trauma list.

Background: Hip fractures are common in the elderly population accounting for 20–30% of acute trauma admissions and usually requiring operative treatment. With increasing age the risk of comorbidity increases reflected in higher ASA grades.

Aim: The aim of this study was to evaluate the correlation between ASA grading, morbidity, mortality and functional outcome within one- year from surgery in patients admitted with hip fractures.

Design: A retrospective study in a District General Hospital.

Methods: 155 patients with a mean age 83 years (60 to 102 years) were admitted with hip fractures between June 2001 to May 2002. There were 126 females 29 males. They were assessed for ASA grade, comorbidities, mental test score(MTS), complications and mortality at one year post admission.

Results: ASA 1: 15 patients mean age 79 years – MTS of 8.3, had no postoperative complications, and no mortality in this group.

ASA 2: 66 patients mean age 82 years – MTS 6.3, comorbities 1.8, average time to theatre 36 hours. 15% had injury/implant related complications, one year mortality rate was 4.5%.

ASA 3: 64 patients mean age of 84 years – MTS 3.9, comorbidities 2.7, average time to theatre of 3 days. 6.25% had injury specific complications, one- year mortality rate was 28.13%.

ASA grade 4: 6 Patients mean age 83 years – MTS 5, comorbidities 3. The one-year mortality rate was 83.33%.

Four patients were medically unfit to undergo any form of surgical intervention.

Overall 9% of patients had complications related to the injury/implant that occurred exclusively in ASA 2 and 3 groups and the one year mortality rate was 17.22% for the entire group.

Conclusions: The higher ASA grade in patients admitted with hip fractures results in increased postoperative mortality and morbidity. Despite recent advances in the standards of health care, the comorbid conditions in this aged population will place an ever increasing burden on the health services in the near future.