Experience of managing open fractures of the lower limb at a major trauma centre

Introduction

In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network.

Methods

From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC.

Results

Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover.

Conclusions

Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.     

Management of open tibial fractures - a regional experience

INTRODUCTION

The treatment of soft-tissue injuries associated with tibial diaphyseal fractures presents a clinical challenge that is best managed by a combined plastic and orthopaedic surgery approach. The current study was undertaken to assess early treatment outcomes and burden of service provision across five regional plastic surgery units in the South-West of England.

SUBJECTS AND METHODS

We conducted a prospective 6-month audit of open tibial diaphyseal fracture management in five plastic surgery units (Bristol, Exeter, Plymouth, Salisbury, Swansea) with a collective catchment of 9.2 million people. Detailed data were collected on patient demographics, injury pattern, surgical management and outcome followed to discharge.

RESULTS

The study group consisted of 55 patients (40 male, 15 female). Twenty-two patients presented directly to the emergency department at the specialist hospital (primary group), 33 patients were initially managed at a local hospital (tertiary group). The mean time from injury to soft tissue cover was significantly less (P < 0.001) in the primary group (3.6 ± 0.8 days) than the tertiary group (10.8 ± 2.2 days), principally due to a delay in referral in the latter group (5.4 ±1.7 days). Cover was achieved with 39 flaps (19 free, 20 local), eight split skin grafts. Nine wounds closed directly or by secondary intention. There were 11 early complications (20%) including one flap failure and four infections. The overall mean length of stay was 17.5 ± 2.8 days.

CONCLUSIONS

Multidisciplinary management of severe open tibial diaphyseal may not be feasible at presentation of injury depending on local hospital specialist services available. Our results highlight the need for robust assessment, triage and senior orthopaedic review in the early post-injury phase. However, broader improvements in the management of lower limb trauma will additionally require further development of combined specialist trauma centres.     

Critical analysis of tibial fracture healing following unreamed nailing

Purpose

Unreamed nails have revolutionised the treatment of tibial shaft fractures. Many authors, however, have reported increasing bone healing complications with these implants. Unfortunately, few studies have addressed the factors affecting bone healing after unreamed tibial nailing.

Methods

One-hundred and sixty tibial fractures in 158 patients (mean age 39.5 years) fixed using unreamed nails were reviewed. There were 78 AO type-A, 65 type-B and 17 type-C fractures (115 closed and 45 open fractures). Twelve patient, injury and surgery variables were analysed for their influence on fracture healing.

Results

Union occurred in all fractures after a mean time of 24.3 weeks. Additional surgery to achieve union, apart from dynamisation, was done in nine (6%) cases. The most important variables affecting healing were the mechanism of trauma (p = 0.005), fracture site gap (p = 0.01), degree of comminution (p = 0.0003), associated soft tissue injuries (p = 0.02) and the time to dynamisation (p = 0.0001).

Conclusions

High-energy trauma and fracture comminution have a negative impact on bone union and require close follow-up. It is essential to avoid distraction over three millimetres with unreamed nailing. Dynamisation is advised within ten weeks in axially stable fractures to encourage bone healing and avoid failure of the locking screws.     

Fracture healing following high energy tibial trauma: Ilizarov versus Taylor Spatial Frame

Introduction

The optimal treatment of high energy tibial fractures remains controversial and a challenging orthopaedic problem. The role of external fixators for all these tibial fractures has been shown to be crucial.

Methods

A five-year consecutive series was reviewed retrospectively, identifying two treatment groups: Ilizarov and Taylor Spatial Frame (TSF; Smith & Nephew, Memphis, TN, US). Fracture healing time was the primary outcome measure.

Results

A total of 112 patients (85 Ilizarov, 37 TSF) were identified for the review with a mean age of 45 years. This was higher in women (57 years) than in men (41 years). There was no significant difference between frame types (p=0.83). The median healing time was 163 days in both groups. There was no significant difference in healing time between smokers and non-smokers (180 vs 165 days respectively, p=0.07), open or closed fractures (p=0.13) or age and healing time (Spearman''s r=0.12, p=0.18). There was no incidence of non-union or re-fracture following frame removal in either group.

Conclusions

Despite the assumption of the rigid construct of the TSF, the median time to union was similar to that of the Ilizarov frame and the TSF therefore can play a significant role in complex tibial fractures.     

Soft tissue management of children's open tibial fractures �C a review of seventy children over twenty years

INTRODUCTION

The management of open tibial fractures in children represents a unique reconstructive challenge. The aim of the study was to evaluate the management of paediatric open tibial fractures with particular regard to soft tissue management.

PATIENTS AND METHODS

A retrospective case-note analysis was performed for all children presenting with an open tibial fracture at a single institution over a 20-year period for 1985 to 2005.

RESULTS

Seventy children were reviewed of whom 41 were males and 29 females. Overall, 91% (n = 64) of children suffered their injury as a result of a vehicle-related injury. The severity of the fracture with respect to the Gustilo classification was: Grade I, 42% (n = 29); Grade II, 24% (n = 17); Grade III, 34% (n = 24; 7 Grade 3a, 16 Grade 3b, 1 Grade 3c). The majority of children were treated with external fixation and conservative measures, with a mean hospital in-patient stay of 13.3 days. Soft tissue cover was provided by plastic surgeons in 31% of all cases. Four cases of superficial wound infection occurred (6%), one case of osteomyelitis and one case of flap failure. The limb salvage was greater than 98%.

CONCLUSIONS

In this series, complications were associated with delayed involvement of plastic surgeons. Retrospective analysis has shown a decreased incidence of open tibial fractures which is reported in similar studies. Gustilo grade was found to correlate with length of hospital admission and plastic surgery intervention. We advocate, when feasible, the use of local fas-ciocutaneous flaps (such as distally based fasciocutaneous and adipofascial flaps), which showed a low complication rate in children.     

A comparison of surgical delays in directly admitted versus transferred patients with hip fractures: Opportunities for improvement?

Background

The increasing incidence of hip fractures in our aging population challenges orthopedic surgeons and hospital administrators to effectively care for these patients. Many patients present to regional hospitals and are transferred to tertiary care centres for surgical management, resulting in long delays to surgery. Providing timely care may improve outcomes, as delay carries an increased risk of morbidity and mortality.

Methods

We retrospectively reviewed the cases of all patients with hip fractures treated in a single Level 1 trauma centre in Canada between 2005 and 2012. We compared quality indicators and outcomes between patients transferred from a peripheral hospital and those directly admitted to the trauma centre.

Results

Of the 1191 patients retrospectively reviewed, 890 met our inclusion criteria: 175 who were transferred and 715 admitted directly to the trauma centre. Transfer patients’ median delay from admission to operation was 93 hours, whereas nontransfer patients waited 44 hours (p < 0.001). The delay predominantly occurred before transfer, as the patients had to wait for a bed to become available at the trauma centre. The median length of stay in hospital was 20 days for transfer patients compared with 13 days for nontransfer patients (p < 0.001). Regional policy changes enacted in 2011 decreased the median transfer delay from regional hospital to tertiary care centre from 47 to 27 hours (p = 0.005).

Conclusion

Policy changes can have a significant impact on patient care. Prioritizing patients and expediting transfer will decrease overall mortality, reduce hospital stay and reduce the cost of hip fracture care.     

Complications following hemiarthroplasty for displaced intracapsular femoral neck fractures in the absence of routine follow-up

Introduction

Hemiarthroplasty is the most commonly performed surgery for displaced intracapsular femoral neck fractures. At present, it is not routine practice to follow up these patients despite the risk of all the complications associated with arthroplasty. This study aimed to determine the prevalence and nature of complications occurring following hemiarthroplasty that re-presented to this centre in the absence of routine postoperative follow-up.

Methods

Consecutive patients undergoing uncemented hip hemiarthroplasty for displaced intracapsular femoral neck fractures at a district general hospital between 2004 and 2009 were identified. Data were collected from the hospital database on all complications relating to the index procedure, further surgery performed and mortality.

Results

There were 490 hemiarthroplasties performed in 477 patients (mean age: 80 years, 75% female). Of these, 110 (22%) were referred postoperatively for specialist orthopaedic review. The prevalence of any complication following hemiarthroplasty was 12% (n=59) and the prevalence of hemiarthroplasty failure was 8% (n=40). The most common indications for failure were periprosthetic fracture (28%), aseptic femoral loosening (25%) and unexplained pain (25%). Persistent hip pain and poor mobility accounted for most complications not requiring further surgery (n=15). The mortality rate within 30 days and 1 year of hemiarthroplasty was 6% (n=31) and 29% (n=146) respectively.

Conclusions

In the absence of routine follow-up, complications were encountered frequently in patients undergoing hip hemiarthroplasty, with most requiring further surgery. Appropriate services should be implemented to allow timely referral for orthopaedic assessment, and enable the early identification and treatment of postoperative complications.     

External versus internal fixation for bicondylar tibial plateau fractures: systematic review and meta-analysis

Background

It is uncertain whether external fixation or open reduction internal fixation (ORIF) is optimal for patients with bicondylar tibial plateau fractures.

Materials and methods

A systematic review using Ovid MEDLINE, Embase Classic, Embase, AMED, the Cochrane Library, Open Grey, Orthopaedic Proceedings, WHO International Clinical Trials Registry Platform, Current Controlled Trials, US National Institute for Health Trials Registry, and the Cochrane Central Register of Controlled Trials. The search was conducted on 3rd October 2014 and no language limits were applied. Inclusion criteria were all clinical study designs comparing external fixation with open reduction internal fixation of bicondylar tibial plateau fractures. Studies of only one treatment modality were excluded, as were those that included unicondylar tibial plateau fractures. Treatment effects from studies reporting dichotomous outcomes were summarised using odds ratios. Continuous outcomes were converted to standardized mean differences to assess the treatment effect, and inverse variance methods used to combine data. A fixed effect model was used for meta-analyses.

Results

Patients undergoing external fixation were more likely to have returned to preinjury activities by six and twelve months (P = 0.030) but not at 24 months follow-up. However, external fixation was complicated by a greater number of infections (OR 2.59, 95 % CI 1.25–5.36, P = 0.01). There were no statistically significant differences in the rates of deep infection, venous thromboembolism, compartment syndrome, or need for re-operation between the two groups.

Conclusion

Although external fixation and ORIF are associated with different complication profiles, both are acceptable strategies for managing bicondylar tibial plateau fractures.

Level of evidence

II.     

Lower extremity free flaps: a review

Objective

To identify factors related to free-flap coverage of lower extremity fractures that are linked to a negative outcome.

Design

A chart review.

Setting

A large microsurgical referral centre.

Patients

From 1981 to 1989, the records of all patients who underwent free-tissue transfer to the lower extremity with more than 1 year of follow-up were selected. From this was drawn a subgroup of 49 patients (mean age, 36 years) who had tibial fractures (55% were motor vehicle injuries) and in almost all cases established soft-tissue or bony defects. They formed the study group.

Intervention

Free-flap transfer.

Outcome Measures

Factors that might be associated with free-flap failure: mechanism of injury, grade of tibial fracture, history of smoking, diabetes, peripheral vascular disease, ischemic heart disease, vascular compromise in the leg preoperatively, recipient artery used, type of anastomosis, and hypertension or hypotension intraoperatively.

Results

Type IIIB tibial fractures were the most frequent (67%) and carried a significantly (p = 0.02) higher risk of free-flap failure than other types of fracture. Patients underwent a mean of four procedures before referral for free-tissue transfer. The mean time from injury to flap coverage was 1006 days. Stable, long-term coverage of the free flaps was achieved in 78% of patients. Wound breakdown was most often caused by recurrent osteomyelitis (65%). Seventy-four percent of the fractures healed. The amputation rate was 10%. Four patients required repeat free-flap transfer for limb salvage.

Conclusion

Only the grade of tibial fracture could be significantly related to postoperative free-flap failure.     

Management of open fractures of the tibial shaft in multiple trauma

Background:

The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients.

Materials and Methods:

The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years). The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8–10 days after the trauma.

Results:

The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8%) males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation.

Conclusion:

Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8–10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture.     

The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures

Purpose

Despite the high incidence of cases of minimally displaced lateral or posterior malleolus ankle fractures, treatment guidelines are still an issue of controversy. The purpose of this study was to delineate treatment preferences among orthopaedic surgeons in these fractures with and without concomitant posterior malleolus fractures. We hypothesized that concomitant minimally displaced fractures of the posterior malleolus can shift treatment preference towards operative intervention.

Methods

A questionnaire-based study was conducted among orthopaedic surgeons attending the 2012 European Federation of National Associations of Orthopaedics and Traumatology Conference (EFORT) in Berlin, Germany. Treatment preferences were reported for minimally displaced lateral malleolus fractures seen on radiographs and were then compared with treatment preferences when computed tomography (CT) was added revealing a concomitant minimally displaced posterolateral fracture of the posterior malleolus.

Results

The cohort comprised 177 surgeons from all six continents. When radiographs showing a minimally displaced lateral malleolus fracture were presented, nonoperative management was indicated by 35 % (62) of participants, whereas 65 % (115) preferred operative intervention. After CT views were added showing an accompanying minimally displaced posterolateral posterior malleolus fracture, 79 % (140) suggested operative intervention and only 21 % (37) advocated nonoperative management (p = 0.03).

Conclusions

Most surgeons prefer open reduction with internal fixation for minimally displaced lateral malleolar fractures. The presence of concomitant posterior malleolus fractures in these cases shifts treatment preference further towards open reduction with internal fixation. Because the posterior malleolus fragment might not be well delineated on standard ankle radiographs, a high index of suspicion is warranted, and the use of CT should be considered in these cases.     

Impact factors of orthopaedic journals between 2000 and 2010: trends and comparisons with other surgical specialties

Purpose

The impact factors (IF) of orthopaedic journals is an important component in determining the future of orthopaedic research funding. We aim to characterise the trend in journal IF over the last decade and draw comparisons with other surgical specialties.

Methods

We conducted an analysis of impact factors from Journal Citation Reports between 2000 and 2010.

Results

Between 2000 and 2010 the number of orthopaedic journals increased from 24 to 41, more than any other surgical specialty and the mean IF increased from 0.842 to 1.400. Journals printed in the English language had a significantly higher IF in the year 2010 (1.64 vs. 0.33, p = 0.01) than those printed in other languages. English language journals published in the US had significantly higher mean 2010 IF (1.932 vs. 1.243, p = 0.025) than those published in Europe, and this had changed compared with 2000 mean IF (0.978 Vs. 0.704, p = 0.360). Orthopaedics was ranked sixth out of 11 surgical subspecialties in 2000 but dropped to seventh out of 11 in 2010.

Conclusions

The quality of orthopaedic journals has significantly increased over the last decade and this has been accompanied by a rise in mean IF. It is important that orthopaedics continues to improve the quality of research, which may help orthopaedic researchers secure funding in the future.     

Segmental neck of femur fractures: A unique case report of an ipsilateral subcapital,greater trochanteric and intertrochanteric fracture and proposed management algorithm

INTRODUCTION

Neck of femur fractures are now increasingly common in an ageing population. The management is well known and has been described in great detail. Concomitant ipsilateral segmental fractures of the neck of femur (SFNOF) however are rare and their investigation and management is poorly described.

PRESENTATION OF CASE

We present the surgical management of a unique and complex case of an ipsilateral subcapital, greater trochanteric and intertrochanteric fracture sustained in an 87-year-old female following a low trauma injury. This fracture configuration has not been described in the literature to date, neither has our method of reconstruction for this fracture, namely hemiarthorplasty, trochanteric stabilising plate and cerclage wires.

DISCUSSION

15 cases from 1989 to 2011 managed by 8 different fixation devices and followed up for an average of 17 months (2–58 months). There was an initial mortality rate of 13% (n = 2). All associated with low energy trauma occurred in female (n = 8), and most with high energy trauma occurred in males (83%; n = 5). The diagnosis was delayed or missed in 20% of cases, and the most common pattern was a concomitant undisplaced subcapital and intertrochanteric fracture (37.5%, n = 6). The overall risk of avascular necrosis was 20%, with a greater risk in patients greater than 65 years of age (33%).

CONCLUSION

Ipsilateral SFNOF are rare injuries with a bimodal distribution, and carry a greater risk of AVN. We advise that all SFNOF should have pre-operative CT planning and propose an algorithm to treat these patients with a standardised surgical approach.     

Thoracotomy versus VATS: is there an optimal approach to treating pneumothorax?

Introduction

The 2010 British Thoracic Society guidelines recommend that a weighted decision be made by clinicians with regard to surgical intervention for pneumothorax as the video assisted thoracoscopic surgery (VATS) approach is better tolerated by patients but carries a higher rate of recurrence (5% vs 1%).

Methods

Overall, 163 patients underwent surgical intervention for pneumothorax at our institution and data were collected prospectively for almost 7 years. Of these, 86 patients underwent VATS under a single surgeon with extensive VATS experience to compensate for the associated learning curve while 79 patients underwent an open procedure.

Results

There was no statistically significant difference in the recurrence rate between the open and the VATS group (1% vs 3.5%, p=1.0). The VATS group was superior to the open group in terms of reduced postoperative bleeding (7.5% vs 0%, p=0.01), reduced number of intensive care unit admissions (16% vs 0%, p<0.01) and a reduced adjusted length of stay (3 vs 5.5 days, p<0.01).

Conclusions

A comparable recurrence rate is attainable with a VATS approach once the learning curve is surpassed and a reduction in morbidity is an additional merit.     

Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures

Purpose

The aim of this study was to compare the results of a new technique for low, multidirectional locked nailing with closed reduction and minimally invasive plating in the treatment of distal tibial metadiaphyseal fractures.

Methods

Forty-six matched patients were divided according to age, gender, Injury Severity Score, and fracture pattern into group A (expert tibial nailing) and group B (minimally invasive plating). Then, the patients were followed up, and the clinical and radiographic results were retrospectively analysed.

Results

The mean followed-up was 24.7 ± 2.7 months in group A and 25.8 ± 2.8 months in group B. No patient had nonunion, shortening, hardware breakdown, or deep-seated infection. Patients in group A had a significantly shorter mean operating time, hospital stay, full weight-bearing time and union time (76 ± 16.6 vs. 90 ± 20.3 minutes, p = 0.000; 5.8 ± 2.1 vs. 8.9 ± 3.1 days, p = 0.000; 9.0 ± 1.4 vs. 11.1 ± 1.7 weeks, p = 0.000; and 21.3 ± 3.5 vs. 23.1 ± 3.6 weeks, p = 0.047, respectively). Three patients in group A and one patient in group B presented with malalignment (p = 0.608). The mean Olerud-Molander Ankle score was 89.0 ± 7.1 in group A and 87.6 ± 8.4 in group B (p = 0.478).

Conclusions

Distal tibia metadiaphyseal fractures may be treated successfully with low, multidirectional locked nails or plates. However, low, multidirectional locked nailing may represent a superior surgical option, since it offers advantages in terms of mean operating time, hospital stay, full weight-bearing time and union time.     

Minimally Invasive Plate Osteosynthesis for Open Fractures of the Proximal Tibia

Background

Relatively few studies have addressed plate osteosynthesis for open proximal tibial fractures by now. The purpose of this study was to assess the results of minimally invasive plate osteosynthesis (MIPO) for open fractures of the proximal tibia.

Methods

Thirty-four patients with an open proximal tibial fracture were treated by MIPO. Thirty of these, who followed for over 1 year, constituted the subject of this retrospective study. According to the AO Foundation and Orthopaedic Trauma Association (AO-OTA) classification, there were 3 patients of type 41-C, 6 of type 42-A, 8 of type 42-B, and 13 of type 42-C. In terms of the Gustilo and Anderson''s open fracture grading system, 11 patients were of grade I, 6 were of grade II, and 13 were of grade III (III-A, 6; III-B, 6; III-C, 1). After thorough debridement and wound cleansing, when necessary, a soft tissue flap was placed. Primary MIPO (simultaneous plate fixation with soft tissue procedures) was performed in 18 patients, and staged MIPO (temporary external fixation followed by soft tissue procedures and subsequent conversion to plate fixation after soft tissue healing) was performed in 12 patients. Results were assessed according to the achievement and time to union, complications (including infections), and function of the knee joint using Knee Society scores. Statistical analysis was performed to identify factors influencing results.

Results

Primary union was achieved by 24 of the 30 study subjects. Early bone grafting was performed in 6 cases with a massive initial bone defect expected to result in non-union. No patient had malalignment greater than 10°. The mean Knee Society score was 88.7 at final follow-up visits, 23 patients achieved an excellent result, and 7 a good result. There were 3 superficial and 5 deep infections, but none required early implant removal. Functional results were similar for primary and staged MIPO (p = 0.113). Fracture pattern (p = 0.089) and open fracture grade (p = 0.079) were not found to influence the results.

Conclusions

If soft tissue coverage is adequately performed, MIPO could be regarded as an acceptable method for the treatment of open proximal tibial fracture.     

Satisfaction and functional outcome with “self-care” for the management of fifth metacarpal fractures

Background

Fifth metacarpal fractures are common and comprise a significant proportion of traditional orthopaedic fracture clinic workload. We reviewed the functional outcome and the satisfaction of patients managed with a new protocol that promoted “self-care” and resulted in the discharge of most of these patients from the emergency department with no further follow-up.

Methods

A retrospective study was performed of patients discharged with a fifth metacarpal fracture between April 2012 to October 2012. A postal questionnaire was sent to each patient, followed by a telephone call. Patient-reported outcome measures (EQ-5D, QuickDASH) and patient satisfaction were assessed. Of the 167 patients eligible for the study, 5 were excluded. Of the remaining 162, 64 were uncontactable or declined to participate. The mean follow-up time was 21.6 months (SD 1.9, range 18.1 to 24.7).

Results

The median EQ-5D health index score was 0.87 (IQR 0.74 to 1.00), and the median QuickDASH score was 2.3 (IQR 0 to 6.8). Seventy-nine (80.6 %) patients were satisfied with the outcome of their injury, while 83 (84.9 %) reported being satisfied with the process. There was no difference between those with a fracture or those without a fracture in EQ-5D (p = 0.307) or QuickDASH (p = 0.820).

Conclusion

Fifth metacarpal fractures can be managed effectively through an Emergency Department protocol without any formal orthopaedic follow-up. This pathway lead to excellent patient-reported outcome measures and patient satisfaction. This protocol has reduced unnecessary hospital attendances for patients and increased the time available for clinicians to deal with more challenging injuries.

Electronic supplementary material

The online version of this article (doi:10.1007/s11552-015-9749-8) contains supplementary material, which is available to authorized users.     

Bilateral intertrochanteric and femoral diaphyseal fractures with unilateral proximal tibial fracture: A case report and review of the literature

INTRODUCTION

Bilateral intertrochanteric femur fractures are relatively rare injuries. This study aims to present a case of a patient with simultaneous bilateral intertrochanteric femur fractures and femoral diaphyseal fractures and proximal tibial fracture with his twelve years follow-up.

PRESENTATION OF CASE

A 44-year-old man presented to emergency department after a motor vehicle accident. Bilateral intertrochanteric femur fractures (OTA classification – 31A.1.2) and bilateral femoral diaphyseal fractures (OTA classification – 32A.2) and nondisplaced right proximal tibial fracture (OTA classification – 41B.1) were determined in radiographs. Following closed reduction, fractures were fixed with intramedullary nails bilaterally. Proximal tibial fracture was fixed with cannulated screws following open reduction. At twelfth year follow-up he was able to do his daily activities with minimal limitation.

DISCUSSION

High energy traumas, stress fractures, systemic disorders (osteomalacia, chronic renal failure), steroid treatments, seizures and electric injuries are possible causes for bilateral hip factures. However bilateral femoral diaphyseal fractures are mostly due to high energy traumas. Long-term biphosphonate use may also cause bilateral fractures. Single-stage surgery should be performed in order to avoid secondary damages of surgical interventions. All fractures of our patient were fixed in a single session. This prevented further deterioration of patient''s status and made rehabilitation easy.

CONCLUSION

Careful evaluation of all systems should be performed in multi-trauma patients to find out concomitant injuries. Single staged surgical treatment may decrease morbidities.     

Identification of mandibular fracture epidemiology in Canada: Enhancing injury prevention and patient evaluation

BACKGROUND:

Mandibular fractures can lead to significant functional and aesthetic sequelae if treated improperly. They may act as an indicator of concomitant trauma and are very demanding on the public health care system. Thus, knowledge of mandibular fracture epidemiology is critical to effective prevention, as well the establishment of accurate trauma evaluation protocols.

OBJECTIVES:

To identify the epidemiology of mandibular fractures treated at a level 1 Canadian trauma centre, clarify the pathogenesis of these epidemiological patterns and suggest potential targets for preventive efforts.

METHODS:

A retrospective review of all mandibular fracture patients presenting to the Montreal General Hospital between 1998 and 2003 was performed. Medical records and digitized radiographic imaging were used to collect patient demographics and injury data.

RESULTS:

The chart review identified 181 patients with 307 mandibular fractures. Fifty-two per cent of the fractures occurred in individuals 21 to 40 years of age, 78% of patients were male, and there was wide ethnic diversity. Sixty percent of patients had multiple mandibular fractures; 29% were symphyseal/parasymphyseal fractures, 25% were condylar fractures and 23% were angle fractures. Assault was the most common mechanism of injury, with 29% of fractures involving alcohol or illegal drug use. Thirty percent of patients had an associated facial fracture, and more than one-third had another major injury.

CONCLUSIONS:

The present epidemiological review reveals several potential prevention targets as well as significant trends. Further research into the impact of these preventive measures could more objectively identify their impact on mandibular trauma.