Aim

There is not adequate evidence to establish whether external fixation (EF) of pelvic fractures leads to a reduced mortality. We used the Japan Trauma Data Bank database to identify isolated unstable pelvic ring fractures to exclude the possibility of blood loss from other injuries, and analyzed the effectiveness of EF on mortality in this group of patients.

BACKGROUND. Most closed tibial fractures in children can be treated conservatively. On the occasions that surgical intervention is required, there are various options available to stabilise the fracture. We would like to present our experience of using monolateral external fixators in the management of closed tibial fractures. Aim. We sought to assess the time to healing, limb alignment, and complications observed in a cohort of tibial fractures treated with external fixation. METHODS. Our limb reconstruction database was used to identify patients who underwent monolateral external fixation for a closed tibial fracture between January 2008 and December 2016. Radiographs of all patients were assessed to determine the original fracture pattern. Time to union was assessed as the time when the fixator was removed and the patient allowed to mobilise independently without any further support of the limb. The presence or absence of residual deformity was assessed on final follow-up radiographs. RESULTS. 22 patients fulfilled the inclusion criteria. 78% of patients had both tibial and fibular fracture. The mean age at injury was 12 years. The mean time taken for the fracture to heal was 18 weeks. The total duration of follow-up averaged 9 months. The mean Valgus deformity at the final follow up was 4 degrees and the mean Varus deformity was 4 degrees. The mean procurvatum was 4.2 degrees and the mean recurvatum was 6 degrees. 50% of patients had pin site infection. Two patients had tibio fibular synostosis. None of them had leg length discrepancy or refractures. There were no episodes of osteomyelitis. CONCLUSIONS. Five degree of coronal plane deformity and ten degree of sagittal deformity were considered as acceptable in children due to their potential for remodeling. All our patients had acceptable levels of residual deformity. In our opinion monolateral external fixation represents a safe and effective option

Background. The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications. Aim. To compare outcomes for AO/OTA 42C2 and 42C3 fractures treated using IMN with those treated using EF in a University Teaching Hospital. Methods. Retrospective case note and radiograph review of 31 segmental tibial fractures treated between 2010 and 2017. Results. There were 17 42C2 and 14 42C3 fractures. 17 patients underwent IMN and 14 EF, and were matched for age and gender. 9 fractures in each group were open. Median time to radiological union was 7 months for IMN and 8 months for EF. Revision surgery was needed for 4 IMN patients and 3 EF patients. The mean number of unplanned procedures was 1.46 for IMN and 1.1 for EF (p=0.69). Length of stay was 15.5 days for IMN and 16.2 days for EF (p=0.9). There was one compartment syndrome in each group and 2 cases of deep infection in the IMN group. There was no significant difference in coronal and sagittal plane alignment. Conclusions. Notwithstanding the small numbers and the retrospective design, the results show that the results of IMN may be equivalent to EF. Modern techniques using suprapatellar entry and blocking screws, combined with early plastic surgical coverage in open injuries are likely to have improved outcomes. Implications. Modern IM nailing techniques have produced similar clinical and radiological outcomes to that achieved by external fixation in this series

Patients infected with HIV presenting with an open fracture of a long bone are difficult to manage. There is an unacceptably high rate of post-operative infection after internal fixation. There are no published data on the use of external fixation in such patients. We compared the rates of pin-track infection in HIV-positive and HIV-negative patients presenting with an open fracture. There were 47 patients with 50 external fixators, 13 of whom were HIV-positive (15 fixators). There were significantly more pin-track infections requiring pharmaceutical or surgical intervention (Checketts grade 2 or greater) in the HIV-positive group (t-test, p = 0.001). The overall rate of severe pin-track infection in the HIV-positive patients requiring removal of the external-fixator pins was 7%. This contrasts with other published data which have shown higher rates of wound infection if open fractures are treated by internal fixation. We recommend the use of external fixation for the treatment of open fractures in HIV-positive patients

A minimally-invasive procedure using percutaneous reduction and external fixation can be carried out for Sanders’ type II, III and IV fractures of the os calcis. We have treated 54 consecutive closed displaced fractures of the calcaneum involving the articular surface in 52 patients with the Orthofix Calcaneal Mini-Fixator. Patients were followed up for a mean of 49 months (27 to 94) and assessed clinically with the Maryland Foot Score and radiologically with radiographs and CT scans, evaluated according to the Score Analysis of Verona. The clinical results at follow-up were excellent or good in 49 cases (90.7%), fair in two (3.7%) and poor in three (5.6%). The mean pre-operative Böhler’s angle was 6.98° (5.95° to 19.86°), whereas after surgery the mean value was 21.94° (12.58° to 31.30°) (p < 0.01). Excellent results on CT scanning were demonstrated in 24 cases (44.4%), good in 25 (46.3%), fair in three (5.6%) and poor in two (3.7%). Transient local osteoporosis was observed in ten patients (18.5%), superficial pin track infection in three (5.6%), and three patients (5.6%) showed thalamic displacement following unadvised early weight-bearing. The clinical results appear to be comparable with those obtainable with open reduction and internal fixation, with the advantages of reduced risk using a minimally-invasive technique

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group

We present a prospective study of the treatment of 32 unstable Colles’ fractures by external fixation and cancellous grafting with minimal exposure. We inserted an external fixator between the radius and the second metacarpal, and maintained ligamentotaxis for five weeks. In 27 patients the result was good or excellent, but five fractures healed with malunion. All patients made a satisfactory functional recovery. At a mean follow-up of three years (1 to 5) after injury none had pain in the wrist and all were satisfied with the result. The average grip strength was 95% of normal. Seven patients had algodystrophy with mild impairment of finger movements in four. We conclude that the combination of cancellous grafting and external fixation is effective for the treatment of unstable Colles’ fractures

Introduction. Distal tibial fractures are notoriously difficult to treat and a lack of consensus remains on the best approach. This study examined clinical and functional outcomes in such patients treated definitively by circular external fixation (Ilizarov). Patients and Methods: Between July 2011 and May 2016, patients with fractures extending to within 1 muller square of the ankle were identified from our prospective Ilizarov database. Existing data was supplemented by review of clinical records. Fractures were classified according to the AO/OTA classification. Functional outcome data, including general measures of health related quality of life (SF-12 and Euroqol) and limb specific scores (Olerud and Molander Score and Lysholm scores) had been routinely collected for part of the study period. Patients in whom this had not been collected were asked to complete these by post. Adverse events were documented according to Paley's classification of: problems, obstacles and complications. Results. 142 patients with 143 fractures were identified, 40 (28%) were open, 94 (66%) were intra-articular, 85 (59%) were tertiary referrals. 32% were type 1, 28%, type 2 and 40% type 3 AO/OTA severity. 139 (97%) of the fractures united (2 non-unions, 1 amputation and 2 delayed unions who remain in frames), at a median of 165 days (range 104 to 429, IQR 136 to 201). 62% united by 6 months, 87% by 9 months and 94% by 1 year. Both non-unions have united with further treatment. Closed fractures united more rapidly than open (median 157 vs 185 days; p=0.003) and true Pilon (43C3) fractures took longer to unite other fractures (median 156 vs 190 days; p<0.001). 34% of patients encountered a problem, 12% an obstacle and 10% a complication. Of the complications, 6 (4%) were minor, 5 (3.5%) major not interfering with the goals of treatment and 4 (3%) major interfering with treatment goals (including the 2 patients with non-union and 1 who underwent amputation as well as 1 significant mal-union). This will increase to 4% if the 2 delayed unions fail to unite. Overall 56% reported good or excellent ankle scores at last report, 28% fair and 16% poor. Closed, extra-articular and non-43C3 fractures had better functional outcome scores than open, intra-articular and 43C3 fractures respectively. Conclusions. This study demonstrates a high union and low serious complication rate, suggesting that external ring fixation is a safe and effective treatment for these injuries. *Judged best paper*

We have carried out a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. We describe the heterogeneity of these fractures, their association with multiple injuries and the need for multilevel stability with the least compromise of the biology of the fracture segments. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36). The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients. Two had nonunion at the distal level, one a wire-related infection which required further surgery and another shortening of 15 mm with 8° of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm. This may be explained by the presence of multiple injuries affecting the overall score

We conducted a randomised controlled trial to compare external fixation of trochanteric fractures of the femur with the more costly option of the sliding hip screw. Patients in both groups were matched for age (mean 67 years, 50 to 100) and gender. We excluded all pathological fractures, patients presenting at more than one week, fractures with subtrochanteric extension or reverse obliquity, multiple fractures or any bone and joint disease interfering with rehabilitation. The interval between injury and operation, the duration of surgery, the amount of blood loss, the length of hospital stay and the cost of treatment were all significantly higher in the sliding hip screw group (p < 0.05). The time to union, range of movement, mean Harris hip scores and Western Ontario and McMaster University knee scores were comparable at six months. The number of patients showing shortening or malrotation was too small to show a significant difference between the groups. Pin-track infection occurred in 18 patients (60%) treated with external fixation, whereas there was a single case of wound infection (3.3%) in the sliding hip screw group

We reviewed the clinical details and radiographs of 52 patients with ballistic fractures of the femur admitted to the International Committee of the Red Cross Hospital in Kenya (Lopiding), who had sustained injuries in neighbouring Sudan. In all cases there had been a significant delay in the initial surgery (> 24 hours), and all patients were managed without stabilisation of the fracture by internal or external fixation. Of the 52 patients, three required an amputation for persisting infection of the fracture site despite multiple debridements. A further patient was treated by an excision arthroplasty of the hip, but this was carried out at the initial operation as a part of the required debridement. All of the remaining 48 fractures healed. Four patients needed permanent shoe adaptation because of limb shortening of functional significance. Although we do not advocate delaying treatment or using traction instead of internal or external fixation, we have demonstrated that open femoral fractures can heal despite limited resources

We report the outcome of 19 children aged 5.2 to 13.2 years with 20 fractures of the femoral shaft requiring surgery, who were randomly assigned to have external fixation (EF) or flexible intramedullary nailing (FIN) (10 fractures each). The duration of the operation averaged 56 minutes for the EF group with 1.4 minutes of fluoroscopy, compared with 74 minutes and 2.6 minutes, respectively, for the FIN group. The early postoperative course was similar, but the EF group showed much more callus formation. The time to full weight-bearing, full range of movement and return to school were all shorter in the FIN group. The FIN complications included one transitory foot drop and two cases of bursitis at an insertion site. In the EF group there was one refracture, one rotatory malunion requiring remanipulation and two pin-track infections. At an average follow-up of 14 months two patients in the EF group had mild pain, four had quadriceps wasting, one had leg-length discrepancy of over 1 cm, four had malalignment of over 5°, and one had limited hip rotation. In the FIN group, one patient had mild pain and one had quadriceps wasting; there were no length discrepancies, malalignment or limitation of movement. Parents of the FIN group were more satisfied. We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft which require surgery, and reserve external fixation for open or severely comminuted fractures

There are 33 million people worldwide currently infected with human immunodeficiency virus (HIV). This complex disease affects many of the processes involved in wound and fracture healing, and there is little evidence available to guide the management of open fractures in these patients. Fears of acute and delayed infection often inhibit the use of fixation, which may be the most effective way of achieving union. This study compared fixation of open fractures in HIV-positive and -negative patients in South Africa, a country with very high rates of both HIV and high-energy trauma. A total of 133 patients (33 HIV-positive) with 135 open fractures fulfilled the inclusion criteria. This cohort is three times larger than in any similar previously published study. The results suggest that HIV is not a contraindication to internal or external fixation of open fractures in this population, as HIV is not a significant risk factor for acute wound/implant infection. However, subgroup analysis of grade I open fractures in patients with advanced HIV and a low CD4 count (< 350) showed an increased risk of infection; we suggest that grade I open fractures in patients with advanced HIV should be treated by early debridement followed by fixation at an appropriate time

We performed a prospective, randomised trial in 39 patients with open tibial fractures treated initially by external fixation to compare cast immobilisation (group A) and intramedullary nailing (group B) as a sequential protocol planned from the onset of treatment. The results showed that group B achieved faster union (p < 0.05) than group A with less malunion or shortening and a greater range of movement. Patients treated by intramedullary nailing required fewer radiographs and outpatient visits (p = 0.0015) and had a more predictable and rapid return to full function. We feel that these severe fractures are better treated by delayed intramedullary nailing and that this has an acceptable rate of complications

Our aim was to determine the clinical effectiveness and safety of Ilizarov external fixation for the acute treatment of severely comminuted extra-articular and intercondylar fractures of the distal femur. A total of 14 consecutive patients with complex fractures was treated. There were three type-A3, two type-C2 and nine type-C3 fractures according to the AO/ASIF system. The mean follow-up was 14 months. Most fractures (13) united primarily at a mean of 16 weeks. One patient with a type-IIIA open fracture had infection and nonunion. The mean range of flexion of the knee at the final follow-up was 105° (35 to 130). We conclude that, in the treatment of comminuted fractures of the distal femur, the Ilizarov fixator is safe and effective in providing stability and allowing early rehabilitation

The aim of this study was to investigate the epidemiology of fractures of the distal radius in the Swedish population and to review the methods used to treat them between 2005 and 2010. The study population consisted of every patient in Sweden who was diagnosed with a fracture of the wrist between 1 January 2005 and 31 December 2010. There were 177 893 fractures of the distal radius. The incidence rate in the total population was 32 per 10 000 person-years. The mean age of the patients was 44 years (0 to 104). The proportion of fractures treated operatively increased from 16% in 2005 to 20% in 2010. The incidence rate for plate fixation in the adult population increased 3.61 fold. The incidence rate for external fixation decreased by 67%. The change was greatest in the 50 years to 74 years age group. In Sweden, there is an increasing tendency to operate on fractures of the distal radius. The previously reported increase in the use of plating is confirmed: it has increased more than threefold over a five-year period. Cite this article: Bone Joint J 2014;96-B:963–9

The open blast fracture of the pelvis is considered to be the most severe injury within the spectrum of battlefield trauma. We report our experience of 29 consecutive patients who had sustained this injury in Afghanistan between 2008 and 2010. Their median new injury severity score (NISS) was 41 (8 to 75), and mean blood requirement in the first 24 hours was 60.3 units (0 to 224). In addition to their orthopaedic injury, six had an associated vascular injury, seven had a bowel injury, 11 had a genital injury and seven had a bladder injury. In all, eight fractures were managed definitively with external fixation and seven required internal fixation. Of those patients who underwent internal fixation, four required removal of metalwork for infection. Faecal diversion was performed in nine cases. The median length of hospital stay following emergency repatriation to the United Kingdom was 70.5 days (5 to 357) and the mean total operating time was 29.6 hours (5 to 187). At a mean follow-up of 20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk and 26 (89.7%) had clinical and radiological evidence of stability of the pelvic ring. As a result of the increase in terrorism, injuries that were previously confined exclusively to warfare can now occur anywhere, with civilian surgeons who are involved in trauma care potentially required to manage similar injuries. Our study demonstrates that the management of this injury pattern demands huge resources and significant multidisciplinary input. Given the nature of the soft-tissue injury, we would advocate external fixation as the preferred management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is necessary in all cases

Aims. To explore staff experiences of a multicentre pilot randomized controlled trial (RCT) comparing intramedullary nails and circular frame external fixation for segmental tibial fractures. Methods. A purposeful sample of 19 staff (nine surgeons) involved in the study participated in an interview. Interviews explored participants’ experience and views of the study and the treatments. The interviews drew on phenomenology, were face-to-face or by telephone, and were analyzed using thematic analysis. Results. The findings identify that for the treatment of segmental tibial fractures equipoise was a theoretical ideal that was most likely unattainable in clinical practice. This was conveyed through three themes: the ambiguity of equipoise, where multiple definitions of equipoise and a belief in community equipoise were evident; an illusion of equipoise, created by strong treatment preferences and variation in collective surgical skills; and treating the whole patient, where the complexity and severity of the injury required a patient-centred approach and doing the best for the individual patient took priority over trial recruitment. Conclusion. Equipoise can be unattainable for rare injuries such as segmental tibial fractures, where there are substantially different surgical treatments requiring specific expertise, high levels of complexity, and a concern for poor outcomes. Surgeons are familiar with community equipoise. However, a shared understanding of factors that limit the feasibility of RCTs may identify instances where community equipoise is unlikely to translate into practice. Cite this article: Bone Jt Open 2021;2(7):486–492

The primary aim was to determine the rate of complications and re-intervention rate in a consecutive series of operatively managed distal radius fractures. Data was retrospectively collected on 304 adult distal radius fractures treated at our institution in a year. Acute unstable displaced distal radius fractures surgically managed within 28 days of injury were included. Demographic and injury data, as well as details of complications and their subsequent management were recorded. There were 304 fractures in 297 patients. The mean age was 57yrs and 74% were female. Most patients were managed with open reduction and internal fixation (ORIF) (n=278, 91%), with 6% (n=17) managed with manipulation and Kirschner wires and 3% (n=9) with bridging external fixation. Twenty-seven percent (n=81) encountered a post-operative complication. Complex regional pain syndrome was most common (5%, n=14), followed by loss of reduction (4%). Ten patients (3%) had a superficial wound infection managed with oral antibiotics. Deep infection occurred in one patient. Fourteen percent (n=42) required re-operation. The most common indication was removal of metalwork (n=27), followed by carpal tunnel decompression (n=4) and revision ORIF (n=4). Increasing age (p=0.02), male gender (p=0.02) and high energy mechanism of injury (p<0.001) were associated with developing a complication. High energy mechanism was the only factor associated with re-operation (p<0.001). This study has documented the complication and re-intervention rates following distal radius fracture fixation. Given the increased risk of complications and the positive outcomes reported in the literature, non-operative management of displaced fractures should be considered in older patients

Aims. Pin-site infection remains a significant problem for patients treated by external fixation. A randomized trial was undertaken to compare the weekly use of alcoholic chlorhexidine (CHX) for pin-site care with an emollient skin preparation in patients with a tibial fracture treated with a circular frame. Methods. Patients were randomized to use either 0.5% CHX or Dermol (DML) 500 emollient pin-site care. A skin biopsy was taken from the tibia during surgery to measure the dermal and epidermal thickness and capillary, macrophage, and T-cell counts per high-powered field. The pH and hydration of the skin were measured preoperatively, at follow-up, and if pin-site infection occurred. Pin-site infection was defined using a validated clinical system. Results. Out of 116 patients who were enrolled in the study, 23 patients (40%) in the CHX group and 26 (44%) in the DML group had at least one bad or ugly pin-site infection. This difference was not statistically significant (p = 0.71). There was no significant relationship between pH or hydration of the skin and pin-site infection. The epidermal thickness was found to be significantly greater in patients who had a pin-site infection compared with those who did not (p = 0.01). Skin irritation requiring a change of treatment occurred in four patients (7%) using CHX, and none using DML. Conclusion. We found no significant difference in the incidence of pin-site infection between the CHX and DML treatment groups. Dermol appeared to offer a small but significant advantage in terms of tolerability. We did not find a significant association between patient or treatment related factors and pin-site infection. It is therefore difficult to make specific recommendations based upon these results. The use of either cleaning agent appears to be appropriate. Cite this article: Bone Joint J 2021;103-B(2):279–285