Does standardized rehabilitation and discharge planning improve functional recovery in elderly patients with hip fracture?

OBJECTIVE: To determine whether standardized early rehabilitation and discharge planning increase risk-adjusted function and reduce risk-adjusted institutionalization in the first 6 months after hip fracture. DESIGN: Pre-post study of 2 independent population-based inception cohorts. SETTING: Two tertiary hospitals in an urban health region. PARTICIPANTS: Patients with hip fracture (N=919) 65 years and older. INTERVENTION: Subjects were enrolled before (control) and after (intervention) implementation of standardized rehabilitation and discharge planning. MAIN OUTCOME MEASURES: Function and institutionalization status were assessed at time of fracture and 3 and 6 months postfracture. Administrative databases provided length of stay (LOS) data. RESULTS: After risk-adjustment, the Barthel Index score was significantly lower 3 months postfracture in control patients with low social support compared with those with higher social support (P<.05). Social support did not affect 3-month function in the intervention cohort. Control subjects with low social support were also significantly more likely to reside in long-term care by 6 months postfracture than intervention subjects with similar social support or those with higher social support (odds ratio=3.3; 95% confidence interval, 1.4-7.5). Total LOS did not change between cohorts. CONCLUSIONS: Overall, standardized rehabilitation and discharge planning did not affect postoperative function or institutionalization in elderly patients with hip fracture. In intervention patients with low social support, function improved and institutionalization was reduced.     

Osteomyelitis after Operative Fracture Treatment: A Report of 62 Cases Treated with Radical Surgery and Lincomycin (Lincocin®)

During the years 1967-1975 a total of 62 patients were treated for postoperative osteomyelitis. The lower extremities had been fractured in 89 per cent of the cases and 54 per cent were closed injuries. The fractures, mostly caused by traffic accidents and falls, had been immobilized by plates in 30 and by intramedullary nails or pins in 25 patients.

Staphylococcus aureus was cultured in 80 per cent, 68 per cent of them were resistant to penicillin, but in 84 per cent the organisms were highly lincomycin sensitive and only three patients with four osteomyelitic lesions presented lincomycin resistance.

The treatment consisted chiefly of sequestrectomies and saucerizations supported by 3-12 months of lincomycin treatment. In 30 operations a closed irrigation-suction technique was used, perfusing the wound with lincomycin solution. Stable implants should be left in place until the fracture is clinically solid whereas unstable osteosyntheses should be replaced by rigid internal or extraskeletal fixation.

At follow-up, the results were judged as good in 74 per cent, fair 8 per cent and poor 18 per cent. The amputation rate was 13 per cent.

Plates should not be used in the treatment of comminuted tibial fractures with considerable soft tissue damage.     

The arteries of the humeral head and their relevance in fracture treatment

Bone vascularisation has gained increased interest in relation to the blood supply of bone fragments during treatment of fractures. In the current study the pattern of vascular supply of the proximal humerus was studied in six cadavers by the corrosion technique. Furthermore, the effect of fractures on the vascular supply was also investigated. In all preparations the intraosseous arteries of the humeral head arose from the circumflex arteries, which surrounded the humerus and dispatched branches towards the proximal end. The main vessel was the branch of the anterior circumflex artery, penetrating the major tubercle in six of six cases. Due to the intraosseous arch shape of this vessel it is referred to as the arcuate artery. Besides other smaller vessels, there was also a vascular network arising from the posterior circumflex artery. Their branches penetrated medially at the cartilage bone interface in five of six preparations. The medial bone arteries appear to gain distinctive importance in humeral head fractures by their impact on the vascularisation of the fracture fragments. After disruption of the arterial supply from the arcuate artery, the vascularisation of the head fragments is most likely ensured by this group of vessels. Therefore, necessary repositioning manoeuvres during open reduction of the fracture should be conducted with care in order to preserve these arteries.     

Osteoporosis at presentation of childhood ALL: management with pamidronate

Vertebral fractures at diagnosis of childhood acute lymphoblastic leukemia (ALL) are an uncommon but recognized problem. Clinical issues associated with pathological fractures in these children include pain control and the potential for further treatment-associated fractures and long-term bony morbidity. The authors report the successful use of pamidronate in two children who presented with vertebral compression fractures at diagnosis of ALL. Both patients had pain and low bone mineral density at baseline. In addition to standard chemotherapy, pamidronate (1 mg/kg, IV) was given bimonthly. Initial rapid symptom relief and gradual improvement of bone mineral density was demonstrated in both patients.     

Talar body fatigue stress fractures: three cases observed in elite female gymnasts

Objective To introduce and emphasize the clinical and radiological findings of three talar body fatigue stress fractures in competitive athletes.Design and patients Clinical and radiographic skeletal records of 24,562 athletes taken between 1962 and 2002 were retrospectively reviewed. Among these, 6851 files related to acute foot and ankle injuries or chronic post-traumatic sequelae were found.Results There were 925 (3.76%) stress fatigue fractures selected from the whole collection. Among these there were three cases (0.32%) of talar body stress fractures diagnosed in elite female gymnasts 1517 years old. The negative first radiograph become positive 4–6 weeks later. Scintigraphy was positive at an early stage and consistent for the diagnosis. CT and MRI gave positive results 1–2 weeks after the beginning of symptoms which were always greatly diagnostic.Conclusions The sports medicine literature lacks reports of talar body fatigue stress fractures. The poor initial sensitivity of radiography makes it problematic to establish an early diagnosis. A wise combination of scintigraphy, CT and MRI has therefore to be relied upon. Familiarity with this rare location for a stress fracture may prevent delayed diagnosis and long-lasting damage, both of which are important factors in competitive athletes.     

Imaging in spinal trauma

Because it may cause paralysis, injury to the spine is one of the most feared traumas, and spinal cord injury is a major cause of disability. In the USA approximately 10,000 traumatic cervical spine fractures and 4000 traumatic thoracolumbar fractures are diagnosed each year. Although the number of individuals sustaining paralysis is far less than those with moderate or severe brain injury, the socioeconomic costs are significant. Since most of the spinal trauma patients survive their injuries, almost one out of 1000 inhabitants in the USA are currently being cared for partial or complete paralysis. Little controversy exists regarding the need for accurate and emergent imaging assessment of the traumatized spine in order to evaluate spinal stability and integrity of neural elements. Because clinicians fear missing occult spine injuries, they obtain radiographs for nearly all patients who present with blunt trauma. We are influenced on one side by fear of litigation and the possible devastating medical, psychologic and financial consequences of cervical spine injury, and on the other side by pressure to reduce health care costs. A set of clinical and/or anamnestic criteria, however, can be very useful in identifying patients who have an extremely low probability of injury and who consequently have no need for imaging studies. Multidetector (or multislice) computed tomography (MDCT) is the preferred primary imaging modality in blunt spinal trauma patients who do need imaging. Not only is CT more accurate in diagnosing spinal injury, it also reduces imaging time and patient manipulation. Evidence-based research has established that MDCT improves patient outcome and saves money in comparison to plain film. This review discusses the use, advantages and disadvantages of the different imaging techniques used in spinal trauma patients and the criteria used in selecting patients who do not need imaging. Finally an overview of different types of spinal injuries is given.     

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.     

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.