The advantages of MRI in the detection of occult hip fractures

While the displaced hip fracture can be visualized easily by plain radiography, the non-displaced fracture may be radiographically occult and require different imaging modalities, e.g., MRI for proper visualization. The accuracy of readers and cost advantages of utilizing MRI have not been assessed. Therefore, we undertook a study of these factors. The medical records of all patients who had visited the emergency room from June 2002 until May 2003 with a clinically suspected hip fracture, negative or equivocal plain film and subsequent MRI examination were retrospectively reviewed. Two senior and two junior radiologists independently evaluated both the MR images and radiographs of all 33 patients in a blinded study. One of three possible evaluations was described for the images of each modality: absence, presence or possibility of fracture. The economic consequences of using MRI in the detection of occult hip fractures were calculated. For all four doctors participating in this study, MRI proved to be far more sensitive and specific in the detection of occult hip fractures than radiography. Using the MR images, the senior radiologists identified the occult hip fracture patients with 100% accuracy and were in complete agreement. The agreement between junior and senior radiologists was high (average =0.75). MRI also detected soft tissue injuries in 39% of the patients that could not be identified with radiography. Adoption of the new protocol using MRI saves hospitals from €242 to 627 per patient. By shortening the time to diagnosis and permitting a superior visualization of both bone and soft tissue injuries, MR imaging prevents unnecessary hospitalization and delays in definitive treatment. MR images should be assessed by senior radiologists.     

Soft Drink and Milk Consumption,Physical Activity,Bone Mass,and Upper Limb Fractures in Children: A Population-Based Case-Control Study

Carbonated beverages have been reported to increase fracture risk in children but the mechanism is unclear. The aim of this population-based case-control study was to investigate the association between soft drink and milk consumption, physical activity, bone mass, and upper limb fractures in children aged 9–16 years. A total of 206 fracture cases and 206 randomly selected individually matched controls were studied. There were 47 hand fractures; 128 wrist and forearm fractures, and 31 upper arm fractures. An interviewer-administered questionnaire was utilized to retrospectively assess last-year physical activity (including television, computer, and video watching) and to recall the average weekly consumption of milk, colas, and total carbonated drinks. Bone mass at the spine, hip, and total body was assessed by dual-energy X-ray absorptiometry (DXA) and metacarpal morphometry. For total fractures, none of the above drink types was significantly different between cases and controls. For wrist and forearm fractures, there was a positive association between cola drink consumption and fracture risk (OR 1.39/unit, 95% CI: 1.01, 1.91). Cola consumption was significantly correlated with television, computer, and video watching (r = 0.20, P = 0.001) but not bone mineral density or milk drinks. After adjustment for television, computer, and video watching and bone mineral density, the association between cola drinks and fracture risk became nonsignificant (OR 1.31/unit, 95% CI: 0.94, 1.83). No association with other fracture sites was observed. In conclusion, cola, but not total carbonated beverage consumption, is associated with increased wrist and forearm fracture risk in children. However, this association is not independent of other factors and appears to be mediated by television watching and bone mineral density but not by decreased milk intake.     

Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures

PURPOSE: There have been few prospective studies of elderly patients with conservatively treated distal radius fractures and little is known about the relationship between acceptable radiographic reduction and functional outcomes in this population. We hypothesized that acceptable fracture reduction (according to standard radiographic dorsal/volar tilt criteria) would be associated with better functional outcomes and greater satisfaction. METHODS: Seventy-four patients who were at least 50 years of age with conservatively managed distal radius fractures were recruited from 2 large urban emergency departments from January 2001 to December 2001. Patients with wrist fractures treated in the emergency department and discharged home were included; patients admitted to the hospital or who required surgical reduction were excluded. Standard lateral radiographs were taken after the final cast was removed. These were reviewed independently by a reference-standard musculoskeletal radiologist and the degree of dorsal/volar tilt was recorded. This value was dichotomized according to standard published dorsal/volar tilt criteria as acceptable (dorsal tilt <10 degrees or volar tilt <20 degrees ) or unacceptable (dorsal tilt >10 degrees or volar tilt >20 degrees ). The Medical Outcomes Study Short-Form 12 (SF-12); the Disabilities of the Arm, Shoulder, and Hand questionnaire; and a patient satisfaction survey were used to assess patient-reported outcomes 6 months after the injury. RESULTS: The average dorsal/volar tilt measured by the reference standard radiologist was 3.4 degrees (SD=13.6) dorsal; overall 47 patients (64%) were considered to have an acceptable radiographic reduction. Acceptable radiographic reduction was not associated with better generic physical or mental health status, lesser degrees of upper-extremity disability, or greater satisfaction with outcomes than was unacceptable reduction. Overall 44 of 74 patients (59%) reported being satisfied or very satisfied with their functional status at 6 months. CONCLUSIONS: Contrary to our hypotheses we found that acceptable radiographic reduction (according to dorsal/volar tilt criteria) was not associated with better self-reported functional outcomes or increased satisfaction at 6 months in elderly patients with conservatively treated distal radius fractures.     

Complications of percutaneous vertebroplasty and their prevention

Complications due to vertebroplasty may be divided into two categories whether or not they are related to polymethylmethacrylate (PMMA) cement leakage from the compressed vertebral body. PMMA leakage is a very frequent occurrence in vertebroplasty is also the main source of complications. Neurological complications are due to cement leakage into the spinal canal and less exceptionally into the intervertebral foramen. The transpedicular needle approach reduces the risk of cement leakage into the foramen. Pulmonary embolism of PMMA may occur when there is a failure to recognize venous migration of cement early during the procedure. Cortical destruction, presence of an epidural soft-tissue mass, highly vascularized lesions, and severe vertebral collapse are factors which increase the rate of complications, which is therefore much higher in metastatic than in osteoporotic vertebral collapse. Prevention of PMMA leakage-related complications is a multifactorial issue including procedure preparation, needle approach and placement, and cement application. The technical refinements which may help reduce the risk of PMMA leakage are reviewed in this article. Experimental data have shown that systemic reactions may occur during vertebroplasty in the absence of cement leakage. These reactions may be partly related to vascular embolism of bone marrow fat. Another controversial issue is a possible increase in the risk of vertebral collapse of adjacent vertebrae following vertebroplasty. Prospective randomized studies are needed to resolve this issue.     

Traumatic injuries of the pelvis and thoracic and lumbar spine: does thin-slice multidetector-row CT increase diagnostic accuracy?

The objective is to evaluate different multidetector-row CT (MDCT) strategies for adequate classification of spinal and pelvic injuries. Seventy intubated patients after multiple trauma underwent conventional radiography (CR) and MDCT. Examinations included the pelvis (P), the lumbar spine (LS) and the thoracic spine (TS). Conventional radiographs, 3-mm (CT5) and 5-mm scans (CT3) and 3-mm and 5-mm scans combined with MPR (CT3R/CT5R) were compared to surgery, autopsy and clinical course. MDCT led to significantly better results than CR (P<0.01). Correlation coefficients were r=1.0 (CT3R), r=0.96 [TS] to r=1.0 [P/LS] (CT5R), r=0.8 [P] to r=1.0 [TS] (CT3), r=0.80 [P] to r=0.86 [TS] (CT5) and r=0.3 [TS] to r=0.69 [P] (CR). Fractures were identified by CT3R in 100% of cases, by CT5R in 95%, by CT3 in 90% [P]–100% [TS], by CT5 in 83.3% [LS]–90% [P] and by CR in 57.1% [TS]–87.2% [P]. Unstable fractures were identified in 100% by CT3R, CT5R and CT3, 85.7% [TS]–100% [P/LS] by CT5 and 57.1% [TS]–80% [P] by CR. Only overlapping thin-slice multiplanar reformation allows for an adequate classification of spinal and pelvic injuries and thus is highly emphasized in patients after severe blunt trauma.     

UNIVERS3-D肩关节假体置换治疗创伤后盂肱关节炎

目的评价UNIVERS 3-D 肩关节假体置换治疗创伤后盂肱关节炎的临床效果. 方法 54例创伤后盂肱关节炎患者接受UNIVERS 3-D 假体置换治疗,年龄31～84岁,平均67.07岁.45例术前进行严格的功能评估,32例获得12～68个月严格的功能评估,随访(35.62±15.70)个月;44例术后获得12个月以上的X线随访.功能评估采用Constant评分和Constant修正评分标准;随访X线片包括前后位、轴位和 "Y"形位片. 结果术后疼痛、日常生活、活动范围和肌力较术前有明显的改善;术后Constant评分和Constant修正评分均较术前有明显的提高.全肩关节置换与半肩关节置换其日常生活、活动范围评分前者优于后者(P<0.05),疼痛、肌力评分二者差异无显著性意义;术后Constant评分和Constant修正评分前者优于后者(P<0.05).肱骨假体周围X线透亮带发生率为14%(6/44),透亮带评分系数均<1,无松动;透亮带发生的部位表现为越靠近假体的远端,透亮带发生的机会越多;盂假体周围未发现任何X线透亮带.9例术后并发症依次为肩袖问题、术后不稳和松弛、关节囊纤维化和冻结肩、肩峰下撞击征、肱骨假体头-颈连接部松动和脱位;6例进行了翻修手术,3例效果不满意. 结论 UNIVERS 3-D 假体肩关节置换治疗严重创伤后盂肱关节炎临床效果非常满意,全肩关节置换优于半肩关节置换.X线透亮带发生率、术后并发症及翻修率与第三代假体相比非常低.UNIVERS 3-D 假体的临床效果优于第三代肩关节假体.     

Unreamed femoral nail with spiral blade in subtrochanteric fractures: experience of 55 cases

OBJECTIVE: To evaluate the use of the unreamed femoral nail with spiral blade (UFN-SB) in the treatment of subtrochanteric femoral fractures. DESIGN: A retrospective review of a consecutive series of 55 fractures. Fourteen patients had metastatic disease (four had prophylactic nailing). RESULTS: In five fractures, the UFN-SB failed: there was migration in three cases and breakage of the spiral blade in two cases, with breakage of the nail in two cases. Revision surgery was necessary in four cases. Five out of seven complications related to the spiral blade were seen in patients with a Seinsheimer fracture Type IIC or V. All other fractures healed within 1 year including those that needed revision surgery. In two cases the end result was THR. CONCLUSIONS: No complication was observed in pathological fractures, which may be because of a high mortality in the first 4 months after surgery due to co morbidity. The main advantage of the nail seems to be its ease of use. It can be inserted through a small incision. The options in spiral blade angle insertion make it a very versatile implant. The implant should probably not be used in Type IIC or V (Seinsheimer) fractures.     

Delays in open fracture management: where do they occur?

We audited the delays in the management of 29 patients presenting to our department with 30 open fractures over a 1-year-period to ascertain where the most lengthy delays were occurring. Gold standard treatment is the surgical debridement and stabilisation of the fracture within 6h of injury. In our series only 14 patients achieved this standard. The lengthiest delays were in getting a patient to the operating theatre following orthopaedic assessment. We have introduced an "open fracture proforma" to highlight the time-critical nature of the injury in an effort to speed-up the process.     

Supracondylar Femoral Nail in the management of non-union of humeral shaft fractures

We reviewed seven patients with established non-union of a shaft of humerus fracture, treated by locked intramedullary nailing using the Intramedullary Supracondylar Nail (IMSC Nail; Smith & Nephew Richards, Memphis TN). The mean age of the patients was 65 years (range 48-78 years). Three of the fractures involved the proximal third of the diaphysis while the remaining four involved the middle third. Six of the original fractures were closed and one was an open fracture. The time interval between the original injury and final surgery averaged 9.3 months. All the nailings were done by the ante-grade approach with static locking. Six of the patients had closed nailing and one had open nailing with bone grafting. The mean follow-up was 8 months and osseous union was achieved in all seven cases at a mean of 5.6 months. We conclude that the Supracondylar Femoral Nail is a useful alternative implant in the management of non-union of fractures of the humeral shaft with wide medullary canals.     

Five years' clinical experience with the unreamed humeral nail in the treatment of humeral shaft fractures

With the development of interlocking nail systems especially designed for the upper arm, standards for the operative treatment of humeral shaft fractures have appeared to change. The trumpet-like shape of the medullary cavity does not allow stable splinting with a nail alone, and therefore the bone--nail complex is commonly stabilized with interlocking bolts. Between June 1996 and June 2001, 51 fractures of the humeral shaft were treated operatively at the BG Unfallklinik Ludwigshafen with the unreamed humeral nail (UHN; Synthes). All nails were inserted by the retrograde technique. Ninety-five percent of the patients showed excellent or good shoulder function at follow-up examinations. For elbow function, 91.4% of the patients showed excellent or good results. Three out of four patients with poor elbow function had suffered from an additional injury to the brachial plexus; one patient developed heterotopic ossification. Intraoperative complications were: one iatrogenic lesion of the radial nerve, two intraoperative shaft fractures, one split at the insertion point, and one supracondylar fracture. As implants we used 7.5 mm nails in 36 cases and 6.7 mm nails in 15 cases. Among the 47 patients undergoing follow-up examinations, we found two cases of non-union. All patients were pain-free. Thirty-seven patients were very satisfied, six satisfied and four dissatisfied with the therapy. Decisive criteria for the use of a new implant are a high safety standard and simple reproducibility; these appear to be fulfilled by retrograde nailing of humeral fractures with the UHN. Interlocking nailing with the UHN enriches the range of therapeutic options for humeral shaft fractures.