Hip fracture patients are often subjected to fasting for extended periods. We hypothesise that a pre operative high carbohydrate drink permitted prior to surgery would mitigate the post operative diabetic state.
We reviewed 600 children with 640 sites of acute haematogenous osteomyelitis treated between 1983 and 2002. Neonates and patients with septicaemia were excluded. The mean age of the children was 7 years (3 months to 13 years). The male to female ratio was 2.3:1. The diagnosis was made clinically and with the help of special investigations. The while cell count was elevated in 75% and the ESR in 98%. Blood cultures were positive in 79%. Radiographs showed metaphyseal rarefaction and/or periosteal reaction in 19% and isotope scan was positive in 43%. No aspiration was done to establish the diagnosis. In nine sites (1.5% of operated sites) the diagnosis was regarded as incorrect (no growth or subsequent bony changes on radiographs). The distal femur was the most common site (25%), followed by the distal tibia (20%), proximal tibia (19%), proximal femur (7%), proximal humerus (5%), forearm (5%), distal fibula (4%), pelvis (4%), calcaneum (3%) and other (8%). Staphylococcus aureus was cultured in 89% of sites. Treatment was with intravenous cloxacillin, followed by oral flucloxacillin for 6 weeks. Surgery was performed at 94.5% of sites. The 5.5% sites that were not operated upon were in the pelvis or were early limb sites with no swelling. At surgery, 21% of sites were found to have intra-osseous pus. In the remaining 79%, there was subperiosteal pus at 41% of sites and extraperiosteal pus at 38%. Patients were followed up until adequate bone stock was present on radiographs and no sinus or sequestrum was present. Poor results (sequestrum and/ or pathological fracture) occurred in 8.3% (53 sites). Poor results were not site-specific, but 99% occurred in patients with subperiosteal or extraperiosteal pus.
We reviewed 821 children with 869 sites of septic arthritis treated from 1983 to 2002. Neonates and patients with septicaemia and penetrating injuries were excluded. There were two age groups: 46% of the children were two years or younger (mean 1.1 years) and 54% were between 3 and 12 years (mean 6.8 years). The male to female ratio was 1.7:1. The diagnosis was made clinically and with the help of special investigations. The white cell count was elevated in 67% and the ESR in 96%. Blood culture was positive in 28%. Radiographs demonstrated widening of joint spaces in 19% and isotope bone scan was positive in 11% of sites, mainly in the hip. No diagnostic joint aspiration was done. In 42 sites (4.6%) the diagnosis was regarded as incorrect because there was no growth or white cells. The most common site of septic arthritis was the knee (37%), followed by the hip (30%), ankle (14%), elbow (10%), shoulder (5%), wrist (3%) and subtalar joint (1%). Treatment was with open arthrotomy and antibiotics (cloxacillin and/or ampicillin). Bacteriologically the most common finding was no growth (50% in each age group). In the younger group the most common finding was Haemophilus influenzae (24.5%). Staphylococcus aureus was found in 37% of the older group. From 2000 the incidence of H. influenzae declined, probably owing to the introduction of vaccine in 1998. Results at 30 sites (3.5%) were poor. There was avascular necrosis in 18 hips, chondrolysis in five hips and three ankles, and stiffness in two knees, an ankle and a subtalar joint. Further analysis showed that poor results were more likely to occur in older patients with S. aureus and where there was a delay in treatment. Where good results were achieved, the mean delay was 3.5 days. It was 9.3 days where results were poor.
To study the outcome of stabilisation of humeral shaft fractures using an elastic retrograde humeral nail that is self-locking proximally and easily locked distally. 20 closed humeral shaft fractures were stabilised in 19 patients between 1996 and 1999. There were three acute fractures, nine cases of failed non-operative treatment (three cases of loss of fracture position and six cases of non-union), five established pathological fractures and three impending pathological fractures. The average age of the patients in the acute/failed non-operative treatment group was 43. 6 years (range 18 to 83 years) and in the established/impending pathological fracture group was 73. 6 years (range 60 to 81 years). Patients in the acute/failed non-operative treatment group were followed until fracture union. This occurred without further intervention in 83% of cases at a mean of 11. 8 weeks (range 10 to 16 weeks). Shoulder and elbow movement were rated by determining the percentage loss of movement compared to the other side. Almost all these patients regained a full range of elbow and shoulder movement without residual pain or disability. Two cases needed further surgery to achieve union and it was noted that nail removal in these patients was difficult. In one of these cases the original injury was a floating elbow. All of the pathological fractures were successfully stabilised with good pain relief. Four of the five patients with established fractures survived to fracture union. This occurred at a mean of 12. 5 weeks (range 10 to 16 weeks) without the need for further procedures. There were few complications. We have obtained encouraging results with both pathological and non-pathological fractures using this nail with good preservation of both shoulder and elbow movement. We have continued to use the nail routinely.
