Below-elbow cast for metaphyseal both-bone fractures of the distal forearm in children: a randomised multicentre study

IntroductionMinimally displaced metaphyseal both-bone fractures of the distal forearm in children are often treated with an above-elbow cast (AEC). Treatment with a below-elbow cast (BEC) could give more comfort, but might lead to fracture displacement reducing pronation and supination. Because this has not been systematically investigated, we set up a randomised multicentre study. The purpose of this study was to find out whether BEC causes equal limitation of pronation and supination but with higher comfort level, compared with AEC.Patients and methodsIn four hospitals, consecutive children aged < 16 (mean 7.1) years with a minimally displaced metaphyseal both-bone fracture of the distal forearm were randomised to 4 weeks BEC (n = 35) or 4 weeks AEC (n = 31). Primary outcome was limitation of pronation and supination 6 months after initial trauma. The secondary outcomes were cast comfort, limitation of flexion/extension of wrist/elbow, complications, cosmetics, complaints, and radiological assessment.ResultsA group of 35 children received BEC and 31 children received AEC. All children attended for the final examination at a mean follow-up of 7.0 months (range 5.0–11.6 months). Limitation of pronation and supination 6 months after initial trauma showed no significant difference between the two groups [4.4° (±5.8) for BEC and 5.8° (±9.8) for AEC]. Children treated with BEC had significantly higher cast comfort on a visual analogue scale [5.6 (±2.7) vs. 8.4 (±1.4)] and needed significantly less help with dressing (8.2 days vs. 15.1 days). Six complications occurred in the BEC group and 14 in the AEC group. Other secondary outcomes were similar between the two groups.ConclusionsChildren with minimally displaced metaphyseal both-bone fractures of the distal forearm should be treated with a below-elbow cast.     

Single-bone intramedullary fixation of unstable both-bone diaphyseal forearm fractures in children leads to increased re-displacement: a multicentre randomised controlled trial

Introduction

Both-bone diaphyseal forearm fractures in children can be stabilised without cast by a flexible intramedullary nail in both the radius and the ulna. Adequate results with single-bone fixation combined with a complementary cast are also reported. However, because those results are based on a selection of children, this trial investigates whether single-bone intramedullary fixation, compared with both-bone intramedullary fixation, results in similar pronation and supination in children with an unstable diaphyseal both-bone forearm fracture.

Materials and methods

In four Dutch hospitals, 24 consecutive children aged <16 years with a displaced unstable both-bone diaphyseal forearm fracture were randomly allocated to single-bone or both-bone intramedullary fixation. Primary outcome was limitation of pronation and supination 9 months after initial trauma. Secondary outcomes were limitation of flexion/extension of wrist/elbow, complication rate, operation time, cosmetics of the fractured arm, complaints in daily life, and assessment of radiographs.

Results

Between January 2006 and August 2010, 11 children were randomised to single-bone fixation and 13 to both-bone fixation. In the both-bone fixation group, two fractures were stabilized by only one nail. In both groups, median limitation of pronation/supination at 9-month follow-up was 5°–10°. In both groups operation time was similar but in the single-bone fixation group cast immobilisation was longer (median of 37 vs. 28 days). In four children, re-displacement of the fracture occurred in those fractures without an intramedullary nail.

Conclusions

These results caution against the use of single-bone fixation in all both-bone forearm fractures. This method may lead to increased re-displacement and reduced clinical results.     

A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour

BackgroundAfter accidental dural puncture in labour it is suggested that inserting an intrathecal catheter and converting to spinal analgesia reduces postdural puncture headache and epidural blood patch rates. This treatment has never been tested in a controlled manner.MethodsThirty-four hospitals were randomised to one of two protocols for managing accidental dural puncture during attempted labour epidural analgesia: repeating the epidural procedure or converting to spinal analgesia by inserting the epidural catheter intrathecally. Hospitals changed protocols at six-month intervals for two years.ResultsOne hundred and fifteen women were recruited but 18 were excluded from initial analysis because of practical complications which had the potential to affect the incidence of headache and blood patch rates. Of the remaining 97 women, 47 were assigned to the repeat epidural group and 50 to the spinal analgesia group. Conversion to spinal analgesia did not reduce the incidence of postdural puncture headache (spinal 72% vs. epidural 62%, P = 0.2) or blood patch (spinal 50% vs. epidural 55%, P = 0.6). Binary logistic analysis revealed the relative risk of headache increased with 16-gauge vs. 18-gauge epidural needles (RR = 2.21, 95% CI 1.4–2.6, P = 0.005); anaesthetist inexperience (RR = 1.02 per year difference in experience, 95% CI 1.001–1.05, P = 0.043), and spontaneous vaginal compared to caesarean delivery (RR = 1.58, 95% CI 1.14–1.79, P = 0.02). These same factors also increased the risk of a blood patch: 16-gauge vs. 18-gauge needles (RR = 2.92, 95% CI 1.37–3.87, P = 0.01), anaesthetist inexperience (RR = 1.06 per year difference in experience, 95% CI 1.02–1.09, P = 0.006), spontaneous vaginal versus caesarean delivery (RR = 2.22, 95% CI 1.47–2.63, P = 0.002). When all patients were included for analysis of complications, there was a significantly greater requirement for two or more additional attempts to establish neuraxial analgesia associated with repeating the epidural (41% vs. 12%, P = 0.0004) and a 9% risk of second dural puncture.ConclusionsConverting to spinal analgesia after accidental dural puncture did not reduce the incidence of headache or blood patch, but was associated with easier establishment of neuraxial analgesia for labour. The most significant factor increasing headache and blood patch rates was the use of a 16-gauge compared to an 18-gauge epidural needle.     

Polymorphisms in the estrogen receptor genes are associated with hip fractures in Chinese

IntroductionHip fractures (HF) are a major cause of public health burden with strong genetic determination. However, the true causal genes remain largely unknown.Materials and methodsBased on the important biological role of estrogens in bone homeostasis, this study aimed to investigate whether the estrogen receptor genes, ESR1 and ESR2, affect the onset of HF in 700 elderly Chinese subjects (350 with osteoporotic HF and 350 healthy controls). We genotyped 32 SNPs in total and examined their associations both by the single-SNP and haplotype tests.ResultsWe identified two novel SNPs of ESR1, rs3020314 and rs1884051, were significantly associated with HF (rs3020314: P = 0.0004, OR = 1.66, 95%CI: 1.25–2.18; rs1884051: P = 0.0004, OR = 1.46, 95%CI: 1.19–1.81). We firstly detected significant association of ESR2 with HF (rs960070: P = 0.0070, OR = 1.43, 95%CI: 1.10–1.86). Haplotype analyses corroborated our single-SNP results.ConclusionOur findings have important implications for understanding the pathology of osteoporotic fractures. Independent replication studies are needed to validate our results and explore the most possible functional variants for molecular studies.     

The acute compartment syndrome following fractures of the lower leg in children

IntroductionThe acute compartment syndrome (ACS) of the lower leg is a rare but serious complication following either fractures or soft tissue injuries. An acute intervention consisting of fasciotomy is indicated as ACS may cause muscle and nerve damage. The aim of the present study was to evaluate the cause, the incidence, the time to fasciotomy and the outcome of ACS of the lower leg following fractures in a paediatric population.Patients and methodsA retrospective analysis of all patients with ACS following a fracture of the lower leg treated from 1998 to 2010 was performed. The time from admission to occurrence of the ACS, the kind of fracture and surgical treatment was evaluated. Accident mechanisms were recorded.ResultsA total of 1028 fractures of the lower leg were treated. 31 patients (3%) with a median age of 14.6 years (range 7.3–17.1 years) developed an ACS. In the group of patients younger than 12 years the incidence was even lower (1.3%). 81% of injuries leading to ACS were caused by high-energy trauma, with motorcycle accidents being the most common (45%). External fixation was used in 45%, including all open fractures. The diagnosis of an ACS was primarily based on clinical symptoms. In 23 cases an intracompartmental pressure of median 55 mmHg (range 40–100 mmHg) were measured. ACS was diagnosed after 19 h mean (range: 1.5–65 h). There was a tendency that the ACS occurred earlier after high-energy trauma than after low energy trauma (mean 16.9 vs. mean 28 h). No complications linked to the compartment syndrome were observed.DiscussionACS can occur up to 65 h after an accident and therefore clinical monitoring is fundamental in order to be able to surgically intervene as soon as possible when needed. With early decompression complications can be prevented.     

The epidemiology of fractures of the proximal ulna

IntroductionThe aim of our study was to report the epidemiological characteristics of fractures of the proximal ulna.MethodsFrom our prospective trauma database of 6872 fractures, we identified all acute fractures of the proximal ulna from a 1-year period between July 2007 and June 2008. Age, gender, mode of injury, fracture classifications, associated injuries and treatment were the factors documented and analysed.ResultsThere were 78 fractures of the proximal ulna with a mean age of 57 years (15–97). Males (n = 35) sustained their fracture at a significantly younger age than females (p = 0.041), with no gender predominance seen (p = 0.365). The overall fracture distribution was a unimodal older male and unimodal older female type-F curve. The most common mode of injury was a simple fall from standing height (n = 52, 67%), with younger patients more likely to sustain their injuries following a high-energy mechanism such as sports or a motor vehicle collision (p < 0.001). Seventeen (22%) patients sustained associated injuries to the ipsilateral limb, with an associated proximal radial fracture most frequent (n = 13, 17%). Open fractures were seen in five (6.4%) patients. A total of 64 patients had a fracture of the olecranon, with the Mayo 2A most frequently seen (n = 47, 60%).ConclusionsFractures of the proximal ulna are fragility fractures that predominantly occur in elderly patients. Given the number of elderly patients sustaining these injuries, research is needed to determine the role of non-operative treatment for these fractures, particularly in patients with multiple co-morbidities and low functional demands.     

Is softcast (3M) strong enough for potentially unstable paediatric forearm fractures?

IntroductionThe majority of paediatric forearm fractures are treated using a circumferential splint, with prior manipulation as necessary. Plaster of Paris is often chosen for its ease of application, cost and proven reliability.Softcast is an alternative, providing a comfortable and water-resistant splint that can be removed without a plaster saw, and is in widespread use for immobilising buckle fractures. Softcast has not been recommended for acute unstable fractures. We established whether a Softcast splint could provide sufficient mechanical stability to control an unstable paediatric forearm fracture.MethodsA laboratory study was undertaken to compare the 3 point (kinking) and 4 point bending, and torsion loads to defined clinical failure points withstood by standardised 4-wrap POP compared to Softcast splints with 6-wrap, 4 wrap and reinforced 4-wrap configurations.ResultsThe load at clinically relevant failure of a 6-wrap Softcast forearm splint was 504 N in 4 point bending, 202 N in 3 point bending (kinking), and 11Nm in torsion (equalling 30.4%, 26% and 42.2% of the equivalent values for a circumferential 4-wrap POP). The 6-wrap Softcast was however stronger in all modes than a fibreglass-reinforced Softcast splint (previously recommended for acute fractures). Furthermore, the load to failure in all modes exceeds that which can be exerted by body weight in many paediatric patients.Softcast demonstrated complete recovery of its original shape on unloading, whereas POP was permanently deformed. 6-wrap Softcast splints were 4% lighter than POP.ConclusionA 6-wrap Softcast splint provides adequate mechanical stability and protection for paediatric patients up to approximately 20 kg, avoiding high-risk activities. The primary risk is not of fracture angulation and loss of position, but temporary indentation of the splint, causing discomfort or pain. Considering its ease of removal, Softcast may be preferable for younger paediatric patients. Its cost may be offset by reducing the number and duration of hospital visits.     

Calcaneous quantitative ultrasound measurements predicts vertebral fractures in idiopathic male osteoporosis

ObjectivesThe aim of this study was to identify the differences in ultrasound bone variables (QUS) and to test the ability to discriminate male patients with and without vertebral fractures.MethodsWe therefore measured broadband ultrasound attenuation (BUA) and speed of sound (SOS) matched for bone mineral density (BMD) and vertebral deformity in idiopathic male osteoporosis.ResultsOne hundred and seventeen men (age 56.6 range 27–78) were divided into three groups (osteoporosis n = 25, osteopenia n = 58 and age-matched control n = 34) according to BMD T-score by WHO criteria. We found 66 patients (56%) with at least one vertebral deformity during the study. BMD and BUA did not differ, while SOS was lower in osteoporosis (p < 0.001) and control group (p < 0.001) between the patients with and without vertebral compression. Strong positive correlation was demonstrated between BUA and BMD (lumbar spine r = 0.44, p < 0.001, femoral neck r = 0.56, p < 0.001, radius r = 0.40, p < 0.001), while similar association between SOS and BMD values was not shown. There was no relationship between the BUA and vertebral fracture risk (Odds ratio: 1.14 95% CI: 0.80–1.61). However, the relative risk of vertebral fracture by SOS was 1.56 (95% CI: 1.08–2.62). Adjusting for age and BMI the risk of vertebral fracture did not change (odds ratio for SOS 1.50 95% CI: 1.02–2.22). After adjustment for BMD SOS was still associated with fracture risk at all measured sites (odds ratio: 1.43, 95% CI: 1.02–2.22; 1.41, 95% CI: 1.02–2.17 and 1.32, 95% CI: 1.02–2.0).ConclusionOur results suggest that BUA values are more closely related to density and structure while SOS values are able to predict fractures.     

Reamed or unreamed intramedullary nailing for tibial fractures: a meta-analysis

Objective：To compare the treating effects of different intramedullary nailing methods on tibial fractures in adults.Methods：Literature reports in both Chinese and English languages were retrieved （from the earliest available records to October 1,2013） from the PubMed,FMJS,CNKI,Wanfang Data using randomized controlled trials （RCTs） to compare reamed and unreamed intramedullary nailing for treatment of tibial fractures.Methodological quality of the trials was critically assessed,and relevant data were extracted.Statistical software Revman 5.0 was used for data-analysis.Results：A total of 12 randomized controlled trials,comprising 985 patients （475 in the unreamed group and 510 in the reamed group）,were eligible for inclusion in this meta-analysis.The results of metaanalysis showed that there were no statistically significant differences between the two methods in the reported outcomes of infection （RR=0.64; 95％CI,0.39 to 1.07;P=0.09）,compartment syndrome （RR=1.44; 95％CI,0.8to 2.41; P=0.16）,thrombosis （RR=1.29; 95％CI,0.43to 3.87; P=0.64）,time to union （WMD=5.01; 95％CI,-1.78 to 11.80; P=0.15）,delayed union （nonunion）（RR=1.56; 95％CI,0.97 to 2.49; P=0.06）,malunion （RR=1.75; 95％CI,1.00 to 3.08; P=0.05） and knee pain （RR=0.94; 95％CI,0.73 to 1.22; P=0.66）.But there was a significantly higher fixation failure rate in the unreamed group than in the reamed group （RR=4.29; 95％CI,2.58to 7.14; P＜0.00001）.Conclusion：There is no significant difference in the reamed and unreamed intramedullary nailing for the treatment of tibial fractures,but our result recommends reamed nails for the treatment of closed tibial fractures for their lower fixation failure rate.     

A percutaneous reduction technique for irreducible and difficult variant of paediatric distal radius and ulna fractures

Background and aimThe objective of this study is to introduce a novel percutaneous reduction technique for irreducible and difficult paediatric radius and ulna fractures in the distal forearm.MethodsFrom May 2010 to January 2012, the percutaneous joystick technique was conducted in 48 children who sustained irreducible or difficult radius and ulna fractures in the distal forearm. The series comprises 32 male and 16 female patients with an average age of 11 years (range, 7–15 years). Among them, 22 patients were <9 years of age. At the final follow-up, the range of motion of the wrist and grip strength of the hand were assessed. Measurements were compared to those on the opposite side. Wrist function was assessed with Mayo Wrist Score. Appearance and patient satisfaction were assessed using the 10-cm visual analogue scale. A p-value <0.05 was considered statistically significant.ResultsBone healing was achieved in all patients (radius: mean 3.5 weeks, range, 3–4 weeks; ulna: 3.8 weeks, range, 3–4 weeks), respectively. After an average follow-up period of 39 months (range, 36–45 months), patients had an average range of wrist motion of 74° (range, 65–86°) in flexion and 64° (range, 54–78°) in extension. The mean grip strength of the injured side was 33.7 kg (13.8–47.6 kg). The mean Mayo Wrist Score was 97 (range, 85–100), including 44 excellent and four good results. The mean scores of appearance and patient satisfaction on the forearm were 9.7 (range, 9–10) and 9.8 (range, 8–10), respectively. No significant difference was found regarding the range of motion and grip strength (p < 0.05).ConclusionsThe percutaneous reduction technique is a safe and valuable procedure for irreducible and difficult paediatric fractures of distal radius and ulna.     

Minimising the risk of accidental dural puncture with epidural analgesia for labour: a retrospective review of risk factors

BackgroundAccidental dural puncture has a quoted incidence of between 0.19% and 3.6% of obstetric epidurals and is associated with significant morbidity. We set out to determine possible factors associated with an increased risk of accidental dural puncture.MethodsWe performed a retrospective review of 18 385 epidurals, performed over a 15-year period. Factors analysed were: time of day of insertion, loss-of-resistance technique, maternal position, cervical dilatation, grade of anaesthetist and depth to the epidural space.ResultsUsing univariate analyses we found no association between the risk of accidental dural puncture and the following variables: time of day of insertion (P = 0.71), loss-of-resistance technique (P = 0.22), maternal position for insertion (P = 0.83), degree of cervical dilatation (P = 0.41) and grade of anaesthetist performing the epidural (P = 0.34). Conversely, we found that the risk of accidental dural puncture increased with increasing depth to the epidural space. This was confirmed using a logistic regression analysis, from which it was estimated that, for every 1-cm increase in depth, the risk of accidental dural puncture increased by approximately 19% (P = 0.019; 95% CI for OR: 1.029–1.38).ConclusionWe conclude that the risk of accidental dural puncture increases with increasing depth to the epidural space. We suggest further study is required to correlate this risk with increasing body mass index.     

Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate

BackgroundPlate and screw fixation was introduced for complex fractures of the hand. Several risk factors for a poor functional outcome have been identified, but there is a paucity of evidence regarding predictors of finger stiffness in difficult hand fractures. The purpose of this prospective cohort study was to identify independent prognostic factors of the postoperative total active motion (%TAM) in the treatment of metacarpal and phalangeal fractures.MethodsSeventy-two patients (62 males, 10 females; 37 ± 15 years) with periarticular fractures involving metaphyseal comminution and displacement were evaluated at a minimum of 1 year following surgery. There were 49 phalangeal bone fractures, 30 intra-articular fractures and 20 associated soft-tissue injuries. The locations of plate placement were lateral in 42 patients and dorsal in 30. The mean duration from injury to surgery was 7.6 days (range, 0–40 days). There were eight examined variables related to patient characteristics (age, gender and hand dominance), fracture characteristics (fracture location, joint involvement and associated soft-tissue injury) and surgical variables (location of plate placement and duration from injury to surgery). Univariate and multivariate linear regression analysis were used to identify the degree to which variables affect %TAM at the final follow-up.ResultsUnivariate analysis indicated moderate correlations of %TAM with fracture location, associated soft-tissue injury and age. Multiple linear regression modelling including fracture location, age and associated soft-tissue injury resulted in formulae that could account for 46.3% of the variability in %TAM: fracture location (β = ?0.388, p < 0.001), age (β = ?0.339, p < 0.001) and associated soft-tissue injury (β = –0.296, p = 0.002).ConclusionPhalangeal fracture, increasing age and associated soft-tissue injury were important risk factors to identify the postoperative %TAM in the treatment of comminuted periarticular metacarpal or phalangeal fracture with a titanium plate.     

A comparison of paracervical block with single-shot spinal for labour analgesia in multiparous women: a randomised controlled trial

BackgroundEpidural and spinal analgesia may be contraindicated or unavailable in labour. This randomised controlled study examined the suitability of paracervical block as an alternative method of labour analgesia.MethodsMultiparous women in labour were randomised to receive either paracervical block or single-shot spinal analgesia. Pain was quantified using a numerical rating scale. Subsequent analgesia, progress of labour, and mode of delivery were noted. Fetal heart rate patterns were reviewed. Apgar scores and umbilical artery pH measurements were collected. Parturients’ satisfaction and willingness to have the same method of labour analgesia again were recorded.Results122 parturients were randomised with data available on 104. Median pain scores decreased significantly in both groups; this was greater with single-shot spinal analgesia (difference between means 2.7; 95% CI 1.9-3.5; P_g < 0.001). Parturients receiving paracervical block received subsequent analgesia more often (23/56 vs. 3/48, P < 0.001). Progress of labour, instrumental delivery rates, detected abnormal decelerations in cardiotocography and neonatal outcome were similar between groups. Shivering (P < 0.04) and pruritus (P < 0.001) were more common with single-shot spinal analgesia. Parturients in the paracervical block group were less satisfied (median 7.0, IQR 3.0–8.0 vs. median 9.0, IQR 8.0–10.0; P < 0.001) and less willing (28/55 vs. 39/48, P = 0.002) to have the same labour analgesia again.ConclusionsParacervical block was less effective than single-shot spinal analgesia. Both methods were associated with a low incidence of fetal bradycardia but maternal side effects were more common with single-shot spinal analgesia.     

Routine blood tests as predictors of mortality in hip fracture patients

ObjectiveThe aim of this study was to assess the evidence for the association between different biochemical markers at admission and mortality through a meta-analysis.Data sourcesPubMed-, Embase-, Cochran Library and the Web of Knowledge were searched for cohort studies.Study selectionEligible studies were observational studies with a study population larger than 150 subjects, a mean age above 60 years and a study duration below 730 days.Data extractionCharacteristics of studies and outcomes of all-cause mortality were extracted from the retrieved articles. Data were pooled across studies for the individual biomarker using random- or fixed-effect analysis.Data synthesis15 eligible studies of 5 different markers on mortality were studied. The following markers were found to be of prognostic value on mortality in hip fracture patients: low haemoglobin (odds ratio, 2.78; 95% confidence interval, 2.17–3.55; P < 0.00001, 3148 subjects included), low total lymphocyte count, TLC (odds ratio, 2.60; 95% confidence interval, 1.61–4.20; P < 0.00001, 1689 subjects included), low albumin (odds ratio, 1.83; 95% confidence interval, 1.31–2.56; P = 0.0004, 1680 subjects included), low albumin/low TLC (odds ratio, 3.00; 95% confidence interval, 1.81–4.99; P < 0.0001, 704 subjects included), low albumin/high TLC (odds ratio, 3.39; 95% confidence interval, 1.83–6.29; P = 0.0001, 704 subjects included), high creatinine (odds ratio, 1.58; 95% confidence interval, 1.25–1.99; P = 0.0001, 3761 subjects included), and high PTH (odds ratio, 15.43; 95% confidence interval, 3.60–66.14; P = 0.0002, 525 subjects included).ConclusionBiochemical markers at admission are valid predictors of mortality in hip fracture patients.     

Minimally invasive percutaneous compression plating versus dynamic hip screw for intertrochanteric fractures: a randomized control trial

Objective：Intertrochanteric femur fracture is a common injury in elderly patients.The dynamic hip screw （DHS） has served as the standard choice for fixation; however it has several drawbacks.Studies of the percutaneous compression plate （PCCP） are still inconclusive in regards to its efficacy and safety.By comparing the two methods,we assessed their clinical therapeutic outcome.Methods：Atotal of 121 elderly patients with intertrochanteric femur fractures （type AO/OTA 31.A 1-A2,Evans type 1） were divided randomly into two groups undergoing either a minimally invasive PCCP procedure or a conventional DHS fixation.Results：The mean operation duration was significantly shorter in the PCCP group （55.2 min versus 88.5 min,P＜0.01）.The blood loss was 156.5 ml±18.3 ml in the PCCP group and 513.2 ml±66.2 ml in the DHS group （P＜0.01）.Among the patients treated with PCCP,3.1％ needed blood transfusions,compared with 44.6％ of those that had DHS surgery （P＜0.01）.The PCCP group displayed less postoperative complications （P＜0.05）.The mean American Society of Anesthesiologists score and Harris hip score in the PCCP group were better than those in the DHS group.There were no significant differences in the mean hospital stay,mortality rates,or fracture healing.Conclusion：Due to several advantages,PCCP has the potential to become the ideal choice for treating intertrochanteric fractures （type AO/OTA 31.A1-A2,Evans type 1）,particularly in the elderly.     

Incidence and clinical impact of seizures after surgery for chronic subdural haematoma

Background and purposeSeizures can occur in patients who have surgery for a chronic subdural hematoma. However, the incidence of seizures and their impact on the clinical course of patients in the perioperative period is not well known.MethodsIn this retrospective study, we reviewed 161 cases of patients treated for chronic subdural hematoma in our institution. The surgical procedures consisted in trephine craniotomy in 156 cases, burr-hole craniotomy in three cases, and bone flap craniotomy in two cases. All the patients had systematic antiepileptic drug prophylaxis.ResultsIn our patients’ population, the incidence of seizures was 10.6% before surgery and 14.9% after surgery. Low initial score on the Glasgow Coma Scale (P < 0.001) and preoperative cognitive impairment (P = 0.005) were associated with a higher rate of postoperative seizures. In our study, the mortality rate was 14.9%. Low initial score on the Glasgow Coma Scale (P = 0.068) and postoperative seizures (P = 0.002) were associated with a higher mortality rate.ConclusionsWe have shown that patients suffering from seizures may have worse outcome. The benefit of a systematic perioperative prophylaxis using antiepileptic drugs has to be evaluated.     

Closed reduction and internal fixation versus total hip arthroplasty for displaced femoral neck fracture

Objective： To compare the clinical effects between closed reduction and internal fixation （CRIF） and total hip arthroplasty （THA） for displaced femoral neck fracture. Methods： In this prospective randomized study, 285 patients aged above 65 years with hip fractures （Garden III or IV） were included from January 2001 to December 2005. The cases were randomly allocated to either the CRIF group or THA group. Patients with pathological fractures （bone tumors or metabolic bone disease）, preoperative avascular necrosis of the femoral head, osteoarthritis, rheumatoid arthritis, hemiplegia, long-term bed rest and complications affecting hip functions were excluded. Results： During the had significantly higher 5-year follow-up, CRIF group rates of complication in hipjoint, general complication and reoperation than THA group （38.3% vs. 12.7%, P〈0.01; 45.3% vs. 21.7%, P〈0.01; 33.6% vs. 10.2%, P〈0.05 respectively）. There was no difference in mortality between the two groups. Postoperative function of the hip joint in THA group recovered favorably with higher Harris scores. Conclusion： For displaced fractures of the femoral neck in elderly patients, THA can achieve a lower rate of complication and reoperation, as well as better postoperative recovery of hip joint function compared with CRIF.     

Dynamic hip screw with locking side plate: a viable treatment option for intertrochanteric fracture

Objective： Dynamic hip screw （DHS） is recommended for the fixation of stable intertrochanteric fractures. Its postoperative cut-out rate ranges from I% to 6%. In osteoporotic bone, normal screws in DHS blade provide less anchorage compared to locking screws. This study aims to compare DHS with locking side plate and conventional side plate. Methods： Fifty consecutive patients with intertrochanteric fractures were randomly allocated for fixation with a standard DHS （group A） and locking DHS （Combi plate, group B）. We compared the clinical and radiological outcomes for the conventional DHS and locking DHS in intertrochanteric fractures. Functional outcome was evaluated using the Parker mobility score. Results： Coxa valga was found more frequently in group A than in group B （12% vs. 0%, P=0.42）. Coxa vara showed the same trend （12% vs. 8%, P=0.81）. Rate of restoration of postoperative neck-shaft angle within 20° of sound side was higher in group B （8% cases） than in group A （4% cases, P=0.98）. The rate of anteversion angle restoration within 10° of sound side was also higher in group B （100% vs. 88%, P=0.85）. The average lag screw slippage in group A and group B was 3.2 mm and 4.2 mm, the average fracture union duration was 17.1 weeks and 16.4 weeks, and the mean Parker score was 5.6 and 5.8 respectively. Screw cut-out was seen in one patient in group A. No cut-out was seen in any of the patient in group B. No patient developed deep infection, avascular necrosis, deep vein thrombosis or any other significant complications. Conclusion： The present study demonstrated that treating intertrochanteric fracture with a locking DHS allows sound bone healing and is not associated with any major complications. Although this report is promising, it should be interpreted with caution because only a prospective study with a large sample size would allow definitive conclusion.     

Australian epidemic strain pseudomonas (AES-1) declines further in a cohort segregated cystic fibrosis clinic

AimTo evaluate changes in prevalence of an epidemic strain of Pseudomonas aeruginosa (AES-1, Australian epidemic strain, type 1) in a paediatric cystic fibrosis (CF) centre practising cohort segregation, to describe the patients' clinical characteristics at acquisition and observe mortality rates.MethodsCohort segregation was introduced in our paediatric CF clinic January 2000. The prevalence of AES-1 was analysed in 1999, 2002 and 2007. Age at acquisition, lung function, presence of bronchiectasis, hospitalisations, prior P. aeruginosa infection and mortality rates were collected. AES-1 infection was determined by pulse-field-gel-electrophoresis (PFGE) on airway specimen cultures taken three monthly.ResultsThe prevalence of AES-1 declined from 21% in 1999 to 14% in 2002 (risk difference 7% (95% CI 1,13) p = 0.0256) and to 6% in 2007 (risk difference 8% (95% CI 3,13) p = 0.0018). New acquisitions after the introduction of cohort segregation were uncommon (10 by 2002 and another 7 by 2007) with a declining incidence of 3.3 cases/year (1999 to 2002) compared to 1.4 cases/year (2002 to 2007). Twenty-two of 32 (69%) deaths between 1999 and 2007 occurred in patients infected with AES-1.ConclusionCohort segregation has been associated with reductions in the prevalence of AES-1 in our CF clinic. Mortality was higher in patients infected with AES-1 than other organisms.     

Low-dose intravenous ketamine improves postoperative analgesia after caesarean delivery with spinal bupivacaine in African parturients

BackgroundIn the absence of neuraxial opiates, postoperative analgesia after caesarean delivery is limited by the duration of action of bupivacaine. This could be prolonged by the co-administration of adjuvants such as ketamine.MethodsSpinal anaesthesia was performed in 60 parturients using hyperbaric bupivacaine 15 mg. Patients were randomly allocated to receive a 2-mL intravenous injection of either ketamine 0.15 mg/kg (Group BK) or 0.9% saline (Group B) immediately after institution of spinal anaesthesia. Postoperative pain was assessed using a visual analogue scale and the time of first postoperative analgesic administration was noted. Postoperative analgesia was provided with intramuscular pentazocine and diclofenac, the total doses of which were recorded over 48 h.ResultsThe mean (SEM) time of first postoperative analgesic administration was significantly longer in Group BK (209 ± 14.7 min) than in Group B (164 ± 14.1 min) (P < 0.001). Pain scores were significantly lower in Group BK than in Group B for 120 min after surgery (P = 0.022). Patients in Group BK required significantly less diclofenac (P < 0.001) and pentazocine (P < 0.001) on day one after surgery. There was no difference in diclofenac (P = 0.302) and pentazocine (P = 0.092) consumption between the groups on the second postoperative day. The incidence of adverse effects was not different between the groups.ConclusionThe use of intravenous low-dose ketamine as an adjuvant to bupivacaine for spinal anaesthesia for caesarean delivery was associated with longer postoperative analgesia and lower early postoperative analgesia consumption than bupivacaine alone.