Objectives. The aim of this study was to review the impact of smoking tobacco on the musculoskeletal system, and on bone fractures in particular. Methods. English-language publications of human and animal studies categorizing subjects into smokers and nonsmokers were sourced from MEDLINE, The Cochrane Library, and SCOPUS. This review specifically focused on the risk, surgical treatment, and prevention of fracture complications in smokers. Results. Smokers have an increased risk of fracture and experience more complications with delayed bone healing, even if they have already stopped smoking, because some adverse effects persist for a prolonged period. Some risks can be reduced during and after surgery by local and general prevention, and smoking cessation is an important factor in lessening this risk. However, if a patient wants to stop smoking at the time of a fracture, the cessation strategies in reducing tobacco use are not easy to implement. The patient should also be warned that using e-cigarettes or other tobaccos does not appear to reduce adverse effects on health. Conclusion. The evidence reviewed in this study shows that smoking has a negative effect in terms of the risk and treatment of fractures. Cite this article: J. Hernigou, F. Schuind. Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know. Bone Joint Res 2019;8:255–265. DOI: 10.1302/2046-3758.86.BJR-2018-0344.R1

Introduction

Intraarticular calcaneal fractures often need open reduction and internal fixation (ORIF) with plate osteosynthesis. The wound complication is one of the common problems encountered following this and affects the outcome adversely. Our study was done to assess how far postoperative slab/cast can avert wound complications.

Aims. To explore individuals’ experience of a scaphoid waist fracture and its subsequent treatment. Methods. A purposive sample was created, consisting of 49 participants in the Scaphoid Waist Internal Fixation for Fractures Trial of initial surgery compared with plaster cast treatment for fractures of the scaphoid waist. The majority of participants were male (35/49) and more younger participants (28/49 aged under 30 years) were included. Participants were interviewed six weeks or 52 weeks post-recruitment to the trial, or at both timepoints. Interviews were semistructured and analyzed inductively to generate cross-cutting themes that typify experience of the injury and views upon the treatment options. Results. Data show that individual circumstances might exaggerate or mitigate the limitations associated with a scaphoid fracture, and that an individual’s sense of recovery is subjective and more closely aligned with perceived functional abilities than it is with bone union. Misconceptions that surgery promises a speedier and more secure form of recovery means that some individuals, whose circumstances prescribe a need for quick return to function, express a preference for this treatment modality. Clinical consultations need to negotiate the imperfect relationship between bone union, normal function, and an individual’s sense of recovery. Enhancing patients’ perceptions of regaining function, with removable splints and encouraging home exercise, will support satisfaction with care and discourage premature risk-taking. Conclusion. Clinical decision-making in the management of scaphoid fractures should recognize that personal circumstances will influence how functional limitations are experienced. It should also recognize that function overrides a concern for bone union, and that the consequences of fractures are poorly understood. Where possible, clinicians should reinforce in individuals a sense that they are making progress in their recovery. Cite this article: Bone Jt Open 2022;3(8):641–647

The aims of this study were i) to see if there is an association between poorly applied plasters and redisplacement of paediatric forearm fractures, and ii) to define reliable radiographic measurements to predict redisplacement of these fractures. The two radiographic measurements which were assessed were Cast Index and Padding Index which are a guide to plaster moulding and padding respectively. The sum of these was termed as the Canterbury Index.

Case records and radiographs of 142 children who underwent a manipulation for a displaced fracture of forearm were studied. Angulation, translation displacement, Cast index and Padding index were measured on radiographs.

Redisplacement was seen in 44 cases (32.3%). The means and 95 % Confidence intervals for cast index and padding index were 0.87 (0.84, 0.90) and 0.42 (0.39, 0.62) in the redisplacement group whereas were 0.71 (0.69, 0.72) and 0.11 (0.09, 0.12) in the group with no redisplacement respectively. Initial displacement, Cast index, Padding index and Canterbury Index were significantly greater in the redisplacement group (p< 0.005). No statistically significant difference was seen for age, fracture location, initial angular deformity and seniority of the surgeon. We suggest that Cast Index > 0.8, Padding Index > 0.3 and Canterbury Index > 1.1 are significant risk factors for redisplacement of conservatively treated paediatric forearm fractures.

Objectives. The aim of this study was to review the current evidence and future application for the role of diagnostic and therapeutic ultrasound in fracture management. Methods. A review of relevant literature was undertaken, including articles indexed in PubMed with keywords “ultrasound” or “sonography” combined with “diagnosis”, “fracture healing”, “impaired fracture healing”, “nonunion”, “microbiology”, and “fracture-related infection”. Results. The use of ultrasound in musculoskeletal medicine has expanded rapidly over the last two decades, but the diagnostic use in fracture management is not routinely practised. Early studies have shown the potential of ultrasound as a valid alternative to radiographs to diagnose common paediatric fractures, to detect occult injuries in adults, and for rapid detection of long bone fractures in the resuscitation setting. Ultrasound has also been shown to be advantageous in the early identification of impaired fracture healing; with the advent of 3D image processing, there is potential for wider adoption. Detection of implant-related infection can be improved by ultrasound mediated sonication of microbiology samples. The use of therapeutic ultrasound to promote union in the management of acute fractures is currently a controversial topic. However, there is strong in vitro evidence that ultrasound can stimulate a biological effect with potential clinical benefit in established nonunions, which supports the need for further investigation. Conclusion. Modern ultrasound image processing has the potential to replace traditional imaging modalities in several areas of trauma practice, particularly in the early prediction of impaired fracture healing. Further understanding of the therapeutic application of ultrasound is required to understand and identify the use in promoting fracture healing. Cite this article: J. A. Nicholson, S. T. J. Tsang, T. J. MacGillivray, F. Perks, A. H. R. W. Simpson. What is the role of ultrasound in fracture management? Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection. Bone Joint Res 2019;8:304–312. DOI: 10.1302/2046-3758.87.BJR-2018-0215.R2

Aims

The aim of this study was to describe the incidence of refractures among children, following fractures of all long bones, and to identify when the risk of refracture decreases.

Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery.

Cite this article: Bone Joint J 2023;105-B(5):471–473.

Aims

The risk of mechanical failure of modular revision hip stems is frequently mentioned in the literature, but little is currently known about the actual clinical failure rates of this type of prosthesis. The current retrospective long-term analysis examines the distal and modular failure patterns of the Prevision hip stem from 18 years of clinical use. A design improvement of the modular taper was introduced in 2008, and the data could also be used to compare the original and the current design of the modular connection.

Aims

Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters.

Background. The molecular mechanisms underlying non-union bone fractures largely remain elusive. Recently, spatial transcriptomics approaches for musculoskeletal tissue samples have been developed requiring direct placement of histology sections on barcoded slides. However, Formalin-Fixed-Paraffin-Embedded (FFPE) bone sections have been associated with limited RNA quality and read depth compared to soft tissue. Here, we test spatial transcriptomics workflows based on transcriptomic probe transfer to characterize molecular features discriminating non-union and union bone fractures in mice. Method. Histological sections (n=8) used for spatial transcriptomics (Visium CytAssist FFPE; 10x Genomics, n=4 on glass slides, n=4 on hydrogel-coated slides) were obtained from a fracture healing study in female 20-week-old C57BL/6J mice receiving either a femur osteotomy (0.7mm) or a segmental defect (2.4mm) (license 22/2022, Grisons CH). Sequence alignment and manual segmentation of different tissues (bone, defect region/callus, bone marrow, muscle) were performed using SpaceRanger and LoupeBrowser (10x Genomics). Differential gene expression was performed using DESeq2 (Seurat) followed by Gene-Set-Enrichment-Analysis (GSEA) of Gene Ontology (ClusterProfiler). Group comparison of quality measures was done using a Welch's t-test. Results are given as mean±standard deviation. Result. The quality measures, mean counts, and genes per spot, were significantly ~10× higher for sections on hydrogel slides (counts: 4700±1796, genes: 2389±1170) compared to glass slides (counts: 463±415, genes: 250±223). In challenging tissues like cortical bone, we reached high counts+genes in comparison to published data. Direct comparison of a non-union and union section showed a total of 432 differentially regulated genes, 538 in the defect region/callus. GSEA revealed differential regulation of pathways involved in muscle organ morphogenesis, cartilage development and endochondral ossification. Conclusions. Optimized spatial transcriptomics workflows based on transcriptomic probe transfer enable for improved read depth in musculoskeletal tissue enabling the characterization of molecular features discriminating non-union and union bone fractures. Acknowledgements. AO Foundation (AOTRAUMA), SNSF (PhD salary)

Aims

The aim of this study was to report a complete overview of both incidence, fracture distribution, mode of injury, and patient baseline demographics of paediatric distal forearm fractures to identify age of risk and types of activities leading to injury.

Abstract. Objective. Bi-condylar tibia plateau fractures are one of challenging injuries due to multi-planar fracture lines. The risk of fixation failure is correlated with coronal splits observed in CT images, although established fracture classifications and previous studies disregarded this critical split. This study aimed to experimentally and numerically compare our innovative fracture model (Fracture C), developed based on clinically-observed morphology, with the traditional Horwitz model (Fracture H). Methods. Fractures C and H were realized using six samples of 4th generation tibia Sawbones and fixed with Stryker AxSOS locking plates. Loading was introduced through unilateral knee replacements and distributed 60% medially. Loading was initiated with six static ramps to 250 N and continued with incremental fatigue tests until failure. Corresponding FE models of Fractures C and H were developed in ANSYS using CT scans of Sawbones and CAD data of implants. Loading and boundary conditions similar to experimental situations were applied. All materials were assumed to be homogenous, isotropic, and linear elastic. Von-Mises stresses of implant components were compared between fractures. Results. Fracture C showed 46% lower static stiffness than Fracture H, and it was 38–59% laxer than Fracture H during cyclic loading. Fractures C and H failed at 368±63N and 593±159N, respectively. Von-Mises stress distributions of locking plates indicated that for Fracture C peak stresses, observed around the proximal-inferior and proximal-threadless holes, were 55% higher than Fracture H's, which occurred around the kick-stand hole. The Kick-stand screw of Fracture C demonstrated 65% higher stress than Fracture H's. Conclusions. Experimental outcomes revealed that coronal splits significantly reduced structural stability. Von-Mises stress distributions demonstrated that potential fatigue failure points of implant components depend on the fracture geometry. Therefore, coronal fracture lines should be counted to precisely assess different fixation methods and find the optimum option for this problematic trauma

Aims. Though most humeral shaft fractures heal nonoperatively, up to one-third may lead to nonunion with inferior outcomes. The Radiographic Union Score for HUmeral Fractures (RUSHU) was created to identify high-risk patients for nonunion. Our study evaluated the RUSHU’s prognostic performance at six and 12 weeks in discriminating nonunion within a significantly larger cohort than before. Methods. Our study included 226 nonoperatively treated humeral shaft fractures. We evaluated the interobserver reliability and intraobserver reproducibility of RUSHU scoring using intraclass correlation coefficients (ICCs). Additionally, we determined the optimal cut-off thresholds for predicting nonunion using the receiver operating characteristic (ROC) method. Results. The RUSHU demonstrated good interobserver reliability with an ICC of 0.78 (95% CI 0.72 to 0.83) at six weeks and 0.77 (95% CI 0.71 to 0.82) at 12 weeks. Intraobserver reproducibility was good or excellent for all analyses. Area under the curve in the ROC analysis was 0.83 (95% CI 0.77 to 0.88) at six weeks and 0.89 (95% CI 0.84 to 0.93) at 12 weeks, indicating excellent discrimination. The optimal cut-off values for predicting nonunion were ≤ eight points at six weeks and ≤ nine points at 12 weeks, providing the best specificity-sensitivity trade-off. Conclusion. The RUSHU proves to be a reliable and reproducible radiological scoring system that aids in identifying patients at risk of nonunion at both six and 12 weeks post-injury during non-surgical treatment of humeral shaft fractures. The statistically optimal cut-off values for predicting nonunion are ≤ eight at six weeks and ≤ nine points at 12 weeks post-injury

Aims

To evaluate the impact of negative pressure wound therapy (NPWT) on the odds of having deep infections and health-related quality of life (HRQoL) following open fractures.

There is still no consensus on which concentration of mesenchymal stem cells (MSCs) to use for promoting fracture healing in a rat model of long bone fracture. To assess the optimal concentration of MSCs for promoting fracture healing in a rat model. Wistar rats were divided into four groups according to MSC concentrations: Normal saline (C), 2.5 × 106 (L), 5.0 × 106 (M), and 10.0 × 106 (H) groups. The MSCs were injected directly into the fracture site. The rats were sacrificed at 2 and 6 자 post-fracture. New bone formation [bone volume (BV) and percentage BV (PBV)] was evaluated using micro-computed tomography (CT). Histological analysis was performed to evaluate fracture healing score. The protein expression of factors related to MSC migration [stromal cell-derived factor 1 (SDF-1), transforming growth factor-beta 1 (TGF-β1)] and angiogenesis [vascular endothelial growth factor (VEGF)] was evaluated using western blot analysis. The expression of cytokines associated with osteogenesis [bone morphogenetic protein-2 (BMP-2), TGF-β1 and VEGF] was evaluated using real-time polymerase chain reaction. Micro-CT showed that BV and PBV was significantly increased in groups M and H compared to that in group C at 6 wk post-fracture (P = 0.040, P = 0.009; P = 0.004, P = 0.001, respectively). Significantly more cartilaginous tissue and immature bone were formed in groups M and H than in group C at 2 and 6 wk post-fracture (P = 0.018, P = 0.010; P = 0.032, P = 0.050, respectively). At 2 wk post fracture, SDF-1, TGF-β1 and VEGF expression were significantly higher in groups M and H than in group L (P = 0.031, P = 0.014; P < 0.001, P < 0.001; P = 0.025, P < 0.001, respectively). BMP-2 and VEGF expression were significantly higher in groups M and H than in group C at 6 wk postfracture (P = 0.037, P = 0.038; P = 0.021, P = 0.010). Compared to group L, TGF-β1 expression was significantly higher in groups H (P = 0.016). There were no significant differences in expression levels of chemokines related to MSC migration, angiogenesis and cytokines associated with osteogenesis between M and H groups at 2 and 6 wk post-fracture. The administration of at least 5.0 × 106 MSCs was optimal to promote fracture healing in a rat model of long bone fractures

Most patients with a nightstick fracture of the ulna are treated conservatively. Various techniques of immobilisation or early mobilisation have been studied. We performed a systematic review of all published randomised controlled trials and observational studies that have assessed the outcome of these fractures following above- or below-elbow immobilisation, bracing and early mobilisation. We searched multiple electronic databases, related bibliographies and other studies. We included 27 studies comprising 1629 fractures in the final analysis. The data relating to the time to radiological union and the rates of delayed union and nonunion could be pooled and analysed statistically. We found that early mobilisation produced the shortest radiological time to union (mean 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures treated with above- or below-elbow immobilisation and braces had longer mean radiological times to union (9.2 weeks, 9.2 weeks and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1% and 0.8%, respectively). There was no statistically significant difference in the rate of non- or delayed union between those treated by early mobilisation and the three forms of immobilisation (p = 0.142 to p = 1.000, respectively). All the studies had significant biases, but until a robust randomised controlled trial is undertaken the best advice for the treatment of undisplaced or partially displaced nightstick fractures appears to be early mobilisation, with a removable forearm support for comfort as required. Cite this article: Bone Joint J 2013;95-B:952–9

This study was conducted to investigate the characteristics, complications, radiologic features and clinical course of patients undergoing reduction of forearm fractures in order to better inform patient prognosis and postoperative management. We conducted a retrospective cohort study of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. A preoperative radiological assessment and chart review was performed. Percent fracture displacement, location, orientation, comonution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Angle of angulation and percent fracture displacement were calculated by averaging AP and lateral radiograph measurements. 80 cases, averaging 13.5±8.3 years, were identified as having a complete fracture of the radius and/or ulna with 69 receiving closed reduction and 11 receiving fixation via an intramedullary device or percutaneous pinning. Eight patients (10%) experienced complications with four resulting in a refracture and four resulting in significant loss of reduction (LOR) without refracture. Fractures in the proximal ⅔s of the radius were associated with a significant increase in complications compared to fractures in the distal ⅓ of the radius (31.6% vs 3.4%) (P=.000428). Likewise, a higher percent fracture displacement was associated with a decreased risk of complications (28.7% vs 5.9% displacement)(P=0.0403). No elevated risk of complications was found based on fracture orientation, angulation, fracture line visibility, forearm bone(s) fractured, sex, age or arm affected. Our result highlights radius fracture location and percent fracture displacement as markers with prognostic value following forearm fracture. These measurements are simply calculated via pre-reduction radiographs, providing an efficient method of informing risk of complications following forearm fracture

Aims. To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment. Methods. Patients were recruited from seven UK NHS centres and randomized to a three-arm pilot trial if aged older than 60 years and had a displaced acetabular fracture. Feasibility outcomes included patients’ willingness to participate, clinicians’ capability to recruit, and dropout rates. The primary clinical outcome measure was the EuroQol five-dimension questionnaire (EQ-5D) at six months. Secondary outcomes were Oxford Hip Score, Disability Rating Index, blood loss, and radiological and mobility assessments. Results. Between December 2017 and December 2019, 60 patients were recruited (median age 77.4 years, range 63.3 to 88.5) (39/21 M/F ratio). At final nine-month follow-up, 4/60 (7%) had withdrawn, 4/60 (7%) had died, and one had been lost to follow-up; a 98% response rate (50/51) was achieved for the EQ-5D questionnaire. Four deaths were recorded during the three-year trial period: three in the non-surgical treatment group and one in the fix-and-replace group. Conclusion. This study has shown a full-scale RCT to be feasible, but will need international recruitment. The Acetabular Fractures in older patients Intervention Trial (AceFIT) has informed the design of a multinational RCT sample size of 1,474 or 1,974 patients for a minimal clinically important difference of 0.06 on EQ-5D, with a power of 0.8 or 0.9, and loss to follow-up of 20%. This observed patient cohort comprises a medically complex group requiring multidisciplinary care; surgeon, anaesthetist, and ortho-geriatrician input is needed to optimize recovery and rehabilitation. Cite this article: Bone Joint J 2024;106-B(4):401–411

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls. Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively. Cite this article: Bone Joint J 2014;96-B:366–72

Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were