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.

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

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

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

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. 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

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.