Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

The aims of this study was to determine the incidence of malnutrition in children with supracondylar fractures. It was hypothesised that the presence of malnutrition will increase the severity type of fractures. The study was a retrospective, cross-sectional study at a single institution. Children between 0 years and 12 years of age, who sustained documented supracondylar fracture treated surgically as a result of low velocity trauma were included in the study. Patients who sustained high velocity trauma, who had known bone disorders or had incomplete chart data, were excluded from the study Data was captured from children's’ notes who have been treated surgically for supracondylar fractures from casualty, theatre and the clinic notes. The nutritional status of children and fracture grade were identified and the two sets of data were compared against each other to try to identify a possible relation between fracture severity and malnutrition. Data was analysed in STATA and 5% level of significance was used to signify statistically significant associations. 150 patients were identified and included in the study. The majority of patients reviewed were in the normal nutritional range according to their z-scores. The severity of the fracture was not only associated with a poorer nutritional status however children with high and low z-scores (over weight as well as undernourished children) had the more severe fracture patterns, while children with normal z-scores had a fracture patterns of varying severity. Children who were malnourished were more likely to sustain more severe fracture types. The results highlighted the need for all children to have a good nutritional status as this may play a role in preventing more complex fractures

Aims

COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department (ED) presentations, using the same period in 2019 as reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography.

Aims. Cementless acetabular components rely on press-fit fixation for initial stability. In certain cases, initial stability is more difficult to obtain (such as during revision). No current study evaluates how a surgeon’s impaction technique (mallet mass, mallet velocity, and number of strikes) may affect component fixation. This study seeks to answer the following research questions: 1) how does impaction technique affect a) bone strain generation and deterioration (and hence implant stability) and b) seating in different density bones?; and 2) can an impaction technique be recommended to minimize risk of implant loosening while ensuring seating of the acetabular component?. Methods. A custom drop tower was used to simulate surgical strikes seating acetabular components into synthetic bone. Strike velocity and drop mass were varied. Synthetic bone strain was measured using strain gauges and stability was assessed via push-out tests. Polar gap was measured using optical trackers. Results. A phenomenon of strain deterioration was identified if an excessive number of strikes was used to seat a component. This effect was most pronounced in low-density bone at high strike velocities. Polar gap was reduced with increasing strike mass and velocity. Conclusion. A high mallet mass with low strike velocity resulted in satisfactory implant stability and polar gap, while minimizing the risk of losing stability due to over-striking. Extreme caution not to over-strike must be exercised when using high velocity strikes in low-density bone for any mallet mass. Cite this article: Bone Joint Res 2020;9(7):386–393

Background. Cementless acetabular cups rely on press-fit fixation for initial stability; an essential pre-requisite to implant longevity. Impaction is used to seat an oversized implant in a pre-prepared bone cavity, generating bone strain, and ‘grip’ on the implant. In certain cases (such as during revision) initial fixation is more difficult to obtain due to poorer bone quality. This increases the chance of loosening and instability. No current study evaluates how a surgeon's impaction technique (mallet mass, mallet velocity and number of strikes) may be used to maximise cup fixation and seating. Questions/purposes. (1) How does impaction technique affect a) bone strain & fixation and b) seating in different density bones? (2) Can an impaction technique be recommended to minimize risk of implant loosening while ensuring seating of the acetabular cup?. Methods. A custom drop tower was used to simulate surgical strikes, seating acetabular cups into a synthetic bone model (Fig. 1). Strike velocity (representing surgeon strike level) and drop mass (representing mallet mass) were varied through representative low, medium and high levels. Polar gap between the implant and bone was measured using optical tracking markers. Strain gauges were used to measure acetabular rim strain. Following seating, cup pushout force was measured in a materials testing machine. Both measurements were used to quantify the level of fixation of the implant for two conditions: For the first, the cup was optimally seated (moving no more than 0.1mm on the previous strike, representing ideal conditions); For the second the cup was impacted 10 times (excessively impacted). Repeats (N = 5) were conducted in low and high density bone; a total of 180 tests. Results. For ideally impacted cups, increasing mallet mass and velocity improved fixation and reduced polar gap. However a phenomenon of bone strain deterioration was identified if an excessive number of strikes were used to seat a cup, resulting in loss of implant fixation. This effect was most severe in low density bone (Fig. 2). For high strike velocity and mallet mass, each excessive strike halved the measured bone strain (78 ± 7 με/strike). This reduced fixation strength from 630 ± 65 N (optimally seated) to just 49 ± 6 N at 10 strikes (Fig. 3). Discussion. These results identify a possible mechanism of loss of implant stability with excessive acetabular impaction. A high mallet mass with low strike velocity resulted in satisfactory fixation (442 ± 38 N) and polar gap (1 ± 0.1 mm) whilst minimizing the fixation deterioration due to excessive mallet strikes. Extreme caution must be exercised to avoid excessive impaction high velocity strikes in low density bone for any mallet mass. Conclusion & Clinical relevance. As it may be difficult for a surgeon to accurately infer when an implant is optimally seated, this study informs surgeons of the effects of different impaction techniques, particularly in lower density bones. For any figures or tables, please contact the authors directly

Aims

Osteolysis, secondary to local and systemic physiological effects, is a major challenge in total hip arthroplasty (THA). While osteolytic defects are commonly observed in long-term follow-up, how such lesions alter the distribution of stress is unclear. The aim of this study was to quantitatively describe the biomechanical implication of such lesions by performing subject-specific finite-element (FE) analysis on patients with osteolysis after THA.

Purpose of study:

The treatment goals in diaphyseal radius fractures are to regain and maintain length and rotational stability. Open reduction and plating remains the gold standard but carries the inherent problems of soft tissue disruption and periosteal stripping. Intramedullary nailing offers advantages of minimally invasive surgery and minimal soft tissue trauma. The purpose of this study is to describe the results of locked intramedullary nailing for adult gunshot diaphyseal radius fractures.

We report the outcome of 39 patients who underwent a modified Pauwels’ intertrochanteric osteotomy for nonunion of a femoral neck fracture following failed osteosynthesis. There were 31 men and eight women with a mean age of 47.2 years (34 to 59). By Pauwels’ classification, there were 11 Type II fractures and 28 Type III fractures. The mean follow-up was 7.9 years (2 to 19). In the 11 patients whose initial treatment had been osteotomy, union was achieved in nine (81.8%). In 28 patients whose initial treatment had been with a lag screw or a dynamic hip screw, union was achieved in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients (87.5%) with pre-operative shortening. The mean neck-shaft angle improved significantly from 100.5° (80° to 120°) to 131.6° (120° to 155°) (p = 0.004). The mean modified Harris hip score was 85.6 points (70 to 97) and the mean modified Merle d’Aubigné score was 14.3 (11 to 18). Good to excellent functional outcomes were achieved in 32 patients (88.8%). A modified Pauwels’ intertrochanteric osteotomy is a reliable method of treating ununited fractures of the femoral neck following failed osteosynthesis: coxa vara and shortening can also simultaneously be addressed.

Cite this article: Bone Joint J 2014;96-B:1198–1201.

Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors

Introduction. The emergence of a new variant of subtrochanteric stress fractures of the femur affecting patients on oral bisphosphonate therapy has only recently been described. This fracture is often preceded by pain and distinctive radiographic changes, and associated with a characteristic fracture pattern. We undertook a review of this cohort of patients in our service. Method. A retrospective review was carried out looking for patients with subtrochanteric fractures who were taking oral bisphosphonates presenting with a low velocity injury over a two year period. Clinical data and radiographs were assessed. Results. 11 fractures were found in 10 patients matching the inclusion criteria outlined. All were female, and taking bisphosphonates for a mean of 4.3 years. 5 of the 10 patients described prodromal symptoms, for an average of 7.8 months before fracture. Although all fractures were deemed low velocity, 5 of 11 were atraumatic. 3 patients have had bilateral subtrochanteric fractures. Presence of the distinctive radiological ‘bleb’ was common. Surveillance on 2 patients shows lateral cortical blebs on the contralateral femur which merit close follow up. Conclusion. Patients taking oral bisphosphonate therapy may be at risk of a new variant of stress fracture of the proximal femur. Awareness of the symptoms is key to ensure appropriate investigations are undertaken. Following such a fracture surveillance of the contralateral femur is recommended, and the option of discontinuing bisphosphonates should be discussed

Introduction. Isolated trochlea fractures are very rare and have only been described previously as case reports. Aims. To report on a case of isolated trochlea fracture and to present a review of the literature. Results. There have only been four previous reports of isolated trochlea fracture. Our fifth case is included in the analysis of the literature given below. Average age 26 (Range 12–33). 60% female, 80% left sided. Dominance only stated in 40% of cases- 50% dominant side. Mechanism of injury: 60% low velocity fall onto an outstretched hand, 40% high velocity- RTA & fall off horse- exact mechanism of injury unknown. Patients all presented with elbow held in flexion, pain and swelling over the medial aspect and a painfully reduced range of motion. Diagnosis made on plain radiographs in 80%, tomograms required in 20%. AP noted to be essential to differentiate from more common capitellum fracture. 20% of fractures associated with comminution. Management consisted of open reduction through a medial approach and internal fixation in 80% (20% headless screw, 20% k-wire, 40% 4.0mm partially threaded cancellous screws) and olecranon traction in 20%. Elbows were immobilised from 3 to 8 weeks. Time to union ranged from 6 weeks (80%) to 13 weeks (20%). Outcomes were uniformly excellent with 40% being asymptomatic with a FROM, 20% asymptomatic with 10 degrees loss of extension and 40% asymptomatic with 5–20 degrees loss of flexion. There were no reported complications. Conclusion. These are rare injuries and can occur through high and low energy mechanisms. They tend to occur in younger age groups. Diagnosis can be made readily with plain radiographs- the AP is essential in differentiating it from the more common capitellum fracture. The prognosis for this intra-articular fracture is good to excellent

Background. Fractures of the odontoid peg are one of the commonest cervical spinal injuries in the elderly population. In this population there is a higher risk of morbidity and mortality as a result of the injury. The magnitude of the mortality risk has not been quantified in the literature. Aim. To show a survivorship analysis in a cohort of elderly patients with odontoid peg fractures. Method & Materials. A 6-year retrospective analysis was performed on all patients >65 years old with isolated odontoid peg fracture. Kaplan-Meir curve was used to estimate survivorship from the date of fracture. Results. A total of 32 patients witha mean age of 82.1 years were analysed. There were 17 male and 15 female with an average follow-up of 20.4 months. A low velocity mechanical fall was the commonest cause for the injury in 93.7% of cases. 81% of cases were treated with rigid collar immobilsation. Overall, it was estimated that only 62.5 % would be alive by one year. The period of greatest mortality was within the first 12 weeks, a lesser contribution from then to one year, and had no impact on mortality thereafter. Multivariate logistic regression demonstrated that age (P= 0.02) was significant factor with an odds ratio of 1.2. There was no significant relationship among gender or treatment with the occurrence of an adverse event. Conclusion. We observed a 3 month and one year mortality rates of 255 and 37.5% respectively. Odontoid peg fractures in the elderly are not benign injuries and are a cause of high mortality rates within the first three months of the injury. Patients who survived to one year following the injury were observed to have their risk return to age and sex matched rates for this population

Background. Fractures of the odontoid peg are one of the commonest spinal injuries in the elderly population. In this population there is a higher risk of morbidity and mortality as a result of the injury. The magnitude of this risk has not been quantified in the literature. Aim. To show a survivorship analysis in a cohort of elderly patients with odontoid peg fractures. Method and Materials. A 6-year retrospective analysis was performed on all patients >65 years old admitted to a spinal unit with an isolated odontoid peg fracture. Actuarial (Life-Table) analysis was used to estimate survivorship from the date of fracture. Results. A total of 32 patients > 65 years of age with isolated odontoid peg fractures were identified. There were 17 male and 15 female. A low velocity mechanical fall was the commonest cause for the injury. The average age for the females was 86.7 years and for the males 78 years. The age distribution was unimodal in both sex, the greatest number occurring for the females in the 85-94 year age group and 75-84 years for the males. Overall, it was estimated that only 62.5 % would be alive by one year. The period of greatest mortality was within the first 12 weeks, a lesser contribution from then to one year, and had no impact on mortality thereafter. Males appeared to suffer a heavier mortality than females within the first year. At one year the male survival rate had fallen to 58.8% compared with a female rate of 66.6%. Conclusion. We observed that odontoid peg fractures in the elderly are not benign injuries and are a cause of high mortality rates within the first three months of the injury. Patients who survived to one year following the injury were observed to have their risk return to age and sex matched rates for this population

Royal Liverpool University Hospital, Liverpool, UK. To retrospectively review outcomes in patients who underwent vertebroplasty in Liverpool in response to recent level 1 publications claiming vertebroplasty to be no better than sham procedure assessed using 2 criteria. We reviewed cases between 2006 and 2009 looking at 5 criteria for procedure. Visual Analogue Score (VAS). Oswestry disability index scores (ODI). 96 patients identified. 10 patients excluded (inadequate data recorded) (n=86). Operated levels n=134 (thoracic n=61, lumbar n=71, sacral n=2). Presenting symptoms included back pain (86/86) and point tenderness was present in 90% (77/86). Average length of symptoms was 11.50 months with 28% reporting greater than 12 months. 72% recalled definite onset of symptoms with 90% being associated with a low velocity injury. Radiological findings showed an average of 54% height collapse and 91% showing high signal on STIR MRI sequences. Number of levels operated – 3 or more (n=9 VAS 5.3 ODI 10.6); 1 to 2 levels (n= 77 VAS 3.7 ODI 13.9). Average improvement in VAS score was 3.8.and ODI 13.6. 47% (40/86) of patients met all 5 current criteria recommended for operation (VAS 3.7, ODI 14). 53% (46/86) of patients met 2-5 criteria (VAS 3.8, ODI 13.4). There was improvement in pain scores in 91% of patients with an average pre-op VAS 7.8 and post-op VAS 4.0. There was no significant difference in patients meeting all 5 criteria compared to those meeting 2-5 criteria

The most common injury in rugby resulting in spinal cord injury (SCI) is cervical facet dislocation. We report on the outcome of a series of 57 patients with acute SCI and facet dislocation sustained when playing rugby and treated by reduction between 1988 and 2000 in Conradie Hospital, Cape Town. A total of 32 patients were completely paralysed at the time of reduction. Of these 32, eight were reduced within four hours of injury and five of them made a full recovery. Of the remaining 24 who were reduced after four hours of injury, none made a full recovery and only one made a partial recovery that was useful. Our results suggest that low-velocity trauma causing SCI, such as might occur in a rugby accident, presents an opportunity for secondary prevention of permanent SCI. In these cases the permanent damage appears to result from secondary injury, rather than primary mechanical spinal cord damage. In common with other central nervous system injuries where ischaemia determines the outcome, the time from injury to reduction, and hence reperfusion, is probably important.

In order to prevent permanent neurological damage after rugby injuries, cervical facet dislocations should probably be reduced within four hours of injury.

Purpose: Traumatic knee dislocations are complex injuries. A thorough knowledge of the pattern of ligament damage is essential to plan for definitive treatment. Injuries to the structures of the posteromedial corner (posterior oblique ligament, the semi-membranosus tendon and its expansions, the meniscofemoral and meniscotibial ligaments, posterior horn of the medial meniscus and posterior reflections of the deep and superficial medial collateral ligament) can contribute to rotational laxity and have not been previously described in the setting of knee dislocations. We set out to evaluate the injury patterns of the posteromedial corner in a series of traumatic knee dislocations. Method: A radiographic (MRI) study was conducted on 22 multi-ligament knee injuries in 22 patients, managed at a level one trauma centre by a single surgeon between July 2006 and May 2008. Results: There were 14 male and 6 female patients with an average age of 29. The mechanism of injury was high velocity in 10 cases, and low velocity in 12 cases. One case (ACL/PCL/posterolateral corner injury) was associated with a vascular injury. While the incidence of MCL injury was 59%, injury specific to the PMC was evident on MRI in 81.8% (18/22) of cases. The deep and superficial MCL were involved in 13/18 and 12/18 PMC injuries, respectively. The posterior oblique ligament was injured in 11/18 cases and the semi-membranosus and its expansions were injured in 10/18 cases (all distal). Injuries to the posterior horn of the medial meniscus (9/18 cases) were associated with a tear of the menisco-femoral/meniscotibial ligaments in all cases. Conclusion: Injury to the PMC was common with high-grade multi-ligament knee injuries in this series. PMC injuries were more common than MCL injuries alone. Injury to the posterior horn of the medial meniscus was predictive of more extensive PMC injury in all cases. The posteromedial corner of the knee is an under recognized area where important injuries can occur in the setting of a dislocatable knee. Future research will involve the correlation of the injury patterns described in this series to clinical measures of knee instability and laxity

The Quebec Task Force defined whiplash as “an acceleration–deceleration mechanism of energy transfer to the neck”. It is logical that the lower the velocity change following impact, the lower the risk of injury. The accepted velocity change (delta-v) for whiplash injuries following rear impact has been quoted as 5 mph. There is some debate as whether this is valid in the clinical setting. We aimed to investigate this further.

A series of low speed controlled crash simulations were undertaken. There were a total of 27 runs on 23 individuals. Accelerometers were placed on the head and chest of the volunteers. Video recordings were analysed to assess relative displacement of the head and chest. The presence of symptoms was documented over a period of 7 days. The volunteers consisted of 23 males and 1 female with an average age of 38 (range 20–56). The average delta-v achieved was 2.3 mph (range 1.8–3.1 mph). The average maximum accelerations recorded were 3.46g at the chest and 2.93g at the head. The average difference was 0.53g. There was no significant displacement between the head and body. No symptoms were reported beyond 1 hour.

Whiplash is triggered if the disparity between movements of the head and neck is of sufficient magnitude. It seems logical that there is a threshold below which whiplash will not occur. Our results have shown that below a delta-v of 3 mph there is little difference in the magnitude and timing of the movements of the head and chest.

Therefore the whiplash mechanism of injury does not occur at these changes of velocity.

Introduction: We conducted a prospective study on 29 patients comparing the medium-term outcome between intramedullary nail fixation and plate fixation in paediatric forearm fractures. Materials and Methods: The criteria were patients who had a nail (10) or plate fixation (19) for a single or both bones forearm fracture between 2004 and 2006. All these patients were recalled following ethical approval for assessment of their grip strength using a hand dynamometer, forearm and elbow range of movements, scar assessment, POSNA outcome questionnaire and new radiographic views of the forearms. Results: Mean age of 10.4 years for both groups (4–16), All fractures were caused by low velocity falls. Grip strength is reduced in 83% of patients, comparable in both groups. Elbow flexion is more reduced in the plating group but more reduction in extension in the nailing group. The reduction in forearm pronation (69% of patients) and supination (61%) were comparable in both groups. Using the ‘Manchester scar proforma’; the plating group scored worse with 14/21; nail 11/21. ‘POSNA outcome questionnaire’ score showed the nailing group had 90% excellent or good result and plating group 74%. The moderate and poor POSNA outcome (26% plate, 10% nail) were associated with pain, restricted rotation, bad scarring and difficulty lifting heavy objects. Nails were removed after bony healing but all plates were left in situ. Complete remodeling of forearm bones were seen in all radiographs in both groups. One case of non-iatrogenic ulnar nerve injury and two cases of wound infection were noted; all made full recovery. Conclusion: The medium-term outcome at 2.5 years following either fixation method is generally comparable and good. The obvious differences were; a higher (better) POSNA score in the nailing group, larger scar formation in plating, elbow extension restriction in nailing and elbow flexion restriction in plating group. Factors that were comparable were grip strength, forearm rotation and radiographic remodeling and outcome

We describe a case of type-I Arnold-Chiari malformation in a 27-year-old woman who presented on two separate occasions with an apparent whiplash injury. She developed debilitating symptoms after two apparently low velocity vehicle collisions. MRI revealed a type-I Arnold-Chiari malformation. She was referred for consideration of neurosurgical decompression. Type-I Arnold-Chiari malformation is the downward herniation of the cerebellar tonsils through the foramen magnum. It is usually asymptomatic but may present after apparently insignificant trauma with a wide range of possible symptoms. The protean nature of its presentation and the similarity of the symptoms to those of a whiplash injury mean that it is easily overlooked. It is, however, important that it is detected early

Aim: To determine whether timing of intervention affects neurological outcome after spinal cord injury resulting from rugby cervical facet dislocations. Methods: An observational study on 57 rugby players who were admitted to a Spinal Cord Injuries Unit from 1988 to 2000 with cervical spine facet dislocations. Experienced medical officers, an orthopaedic specialist and physiotherapists determined the admission and discharge Frankel grades (A to E). The time was recorded from the actual injury to successful reduction in hours. The usual method of reduction was by Rapid Incremental Traction on an Awake Patient. Statistical analysis was performed using parametric and non-parametric tests (Mann Whitney). Results: 14 patients were treated within 4 hours of injury and 43 were treated after 4 hours. The median Frankel gain for patients reduced within 4 hours was 5 but only 2 for those reduced after 4 hours (p= 0.0002). Conclusion: Time from injury to intervention does significantly affect neurological outcome in a homogenous group of spinal cord injuries in fit young males as a result of low velocity trauma mechanisms. Spinal cord injuries secondary to cervical facet dislocations in these patients should be regarded as an absolute emergency