Introduction

In an ageing population the incidence of patients sustaining a neck of femur fracture is likely to rise. Whilst the neck of femur fracture is thought to be a pre-terminal event in many patients, there is little literature following this common fracture beyond 1 year. With improving healthcare and increasing survival rate, it is likely that a proportion of patients live to have subsequent fractures. However little is known about if these occur and what the epidemiology of these fractures are.

This study describes the long term clinical and patient reported outcomes following simple dislocation of the elbow.

We identified all adult patients treated at our trauma centre for a simple dislocation of the elbow over 10 years. 140 patients were identified and 110 (79%) patients were reviewed at a mean of 88 (95% CI 80–96) months after injury. This included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, an Oxford Elbow questionnaire and a patient satisfaction questionnaire.

Patients reported long-term residual deficits in range of movement. The mean DASH score was 6.5 (95% CI 4 to 9). The mean Oxford Elbow score was 43.5 (95% CI 42.2 to 44.8). The mean satisfaction score was 85.6 (95% CI 82.2 to 89). Sixty-two patients (56%) reported persistent subjective stiffness of the elbow. Nine (8%) reported subjective instability and 68 (62%) complained of continued pain. The DASH, Oxford Elbow and satisfaction scores all showed good correlation with absolute range of movement in the injured elbow. After multivariate analysis, a larger elbow flexion contracture and female gender were both independent predictors of worse DASH scores. Poorer Oxford Elbow scores and overall satisfaction ratings were predicted by reduced flexion-extension arc of movement.

Patients report good long term functional outcomes after simple dislocations of the elbow. These are not entirely benign injuries. There is a high rate of residual pain and stiffness. Functional instability is less common and does not often limit activities.

Introduction

This study investigates the epidemiology of proximal radial fractures and potential links to social deprivation.

Introduction

The optimal treatment of elderly patients with unstable ankle fractures is a widely contested and as yet unresolved issue. Whereas the AO technique of anatomical reduction and plate fixation has been shown to give good functional results it is associated with a wound complication rate of up to 40%. This has led some surgeons to believe the risks of operative intervention are too great.

The fibula nail is an intra-medullary device with the benefit of requiring minimal soft-tissue dissection. It provides lateral column support over a greater area than the standard plate.

The study aims were to assess the clinical and radiographic outcome of a cohort of patients managed with the Fibula Nail (Acumed).

The purpose of this study was to evaluate the efficacy of autologous cancellous bone grafting (ABG) for the treatment of long bone fracture non-unions. Patients who were treated with ABG for fracture non-unions of the lower extremities were identified from our prospectively entered database. Non-union was defined as failure of the fracture to unite within a period of 9 months. Demographics, comorbidities, medications, complications and surgical outcomes were all recorded and subsequently analysed. Chi square test was used to analyse the results.

In total 82(54 male) patients met the inclusion criteria. The mean age was 43.6 years (range 18–78). Ten patients were diagnosed with femoral and 72 with tibial fracture non-unions. Fifty three (64.6%) were open fractures at presentation. In the tibial non-union group, initially, 67 fractures were stabilised with IM nailing and 5 with plating. During revision surgery, 33 patients underwent exchanged nailing and ABG whereas 34 received ABG without revision of the metal work.

All five tibial plantings required re-plating and ABG. In the femoral non-union group, five fractures were initially stabilised with IM nailing and the rest with plating. During revision surgery, six patients underwent change of fixation (exchange nailing) and ABG and four received only ABG. Overall 73/82 patients progress uneventfully to union and the success rate was 89%. A second and a third attempt of ABG was made for 6/86 patients (7.31%) and 2/82 patients (2.44%) respectively, till clinical and radiological union. All but one of the patients united their fractures. One patient underwent amputation due to underlying osteomyelitis.

The mean time to union following the ABG procedures was 8.4 months (range 3–18). Autologous bone grafting is an effective method of treating fracture non-unions. Success rates of as high as 89% can be achieved as seen in this series of patients.

The epidemiology of adult fractures is changing rapidly. The longevity of the population continues to extend with increasing incidence of fragility fractures. The aim of this study was to map the epidemiology of fractures in patients 90 years and older.

A retrospective review of all orthopaedic trauma patients over the age of 89 years attending Edinburgh Royal Infirmary in 2000 was performed. All inpatients and outpatients were included. These patients were identified using a prospectively complied database held by the senior author. Patient notes were used to confirm place of residence, mobility, co-morbidity, management, length of admission and place of discharge.

236 fractures (4% of all fractures) were identified. There were 209 (89%) female patients. All were secondary to low energy trauma. More than 50% of the patients were admitted from home and mobilised independently or with a stick. 124 (53%) patients had nil or one co-morbidity, the commonest being dementia and hypertension. Of the 133 neck of femur (NOF) fractures 11 (8%) died as inpatients, and of the 66 patients residing independently in their own home only 5 (8%) returned with the other 61 needing step-up care. The average length of stay in hospital for NOF fractures was 13 days.

The majority of patients are female and reside at home, being independently mobile and have limited co-morbidity. The length of stay is relatively long and few patients’ return directly home following a NOF fracture. This, with the ever-growing super-elderly population, will have substantial financial implications in the future.

Mountain biking is increasing in popularity worldwide. The injury patterns associated with elite level and competitive mountain biking are known. This study analysed the incidence, spectrum and risk factors for injuries sustained during recreational mountain biking.

The injury rate was 1.54 injuries per 1000 biker exposures. Males were more commonly injured than females, with those aged 30–39 years at highest risk. The commonest types of injury were wounding, skeletal fracture and musculoskeletal soft tissue injury. Joint dislocations occurred more commonly in older mountain bikers. The limbs were more commonly injured than the axial skeleton. The highest hospital admission rates were observed with head, neck and torso injuries. Protective body armour, clip-in pedals and the use of a full-suspension bicycle confer a significant protective effect.

To illustrate the incidence and epidemiology of fractures due to football.

All inpatient and outpatient fractures from a prospectively collected database for a defined population in 2000 were retrospectively analysed.

There were 396 football fractures, 96% male. Football caused 39% of the 1022 sports fractures in 2000. This represented 5% of the 8151 fractures in total. The incidence was 61/105. 115/105 in males and 5 /105 in females. The average age was 22.9 years; 22.8 in males and 26.6 in females. 77% of fractures were treated as outpatients. The top five fractures representing 84% of the injuries were Radius+Ulna 30%, Phalanx 19%, Tibial+Fibula 18%, Metacarpal 11% and Clavicle 5%. 71% were upper-limb fractures. The busiest two months were October and May 17% and 14% respectively. The quietest two months were February and December at 5%.

Although the epidemiology of football injuries will vary amongst different populations, these results can be generalized to similar population bases. Results will be valuable to medical professionals supporting football teams, enabling them to focus their attention on treating the most common injuries, the majority being treated as outpatients.

Football is the most common cause of fractures in sport. As participation increases, the incidence of fractures is likely to reflect this. Upper limb fractures account for over 2/3 rd of fractures with radius+ulna fractures accounting for up to a 1/3rd of fractures; the majority can be treated as an outpatient. Therefore medical teams should be familiar with standard treatment regimes, possible impact on players’ futures and time out of sport.

Introduction and Aims: The aim was to prospectively assess shoulder hemiarthroplasty for un-reconstructable proximal humeral fractures at a minimum of 12 months and identify factors that aid prognosis.

Method: Inclusion criteria were patients with a displaced fracture requiring shoulder hemiarthroplasty. Constant scoring was done at a minimum follow-up of one year. Patients were treated using a Neer or Osteonics prosthesis, the decision for hemiarthroplasty being made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review establishing a physiological index according to co-morbidities, and radiological analysis were carried out. Survival analysis was performed for one and five-year results and data was analysed by linear regression to identify prognostic factors.

Results: From 163 patients there were 138 fitting the criteria, 42 males and 96 females, average age of 68.5 (range 30–90) years and follow-up of 6.3 (range 1–15) years. The fracture pattern was three and four part in 133 cases and five head split fractures; 58 were associated with dislocation. Survival was 96.4 percent at one year and 93.6 percent at five years, with no significant difference between prostheses. There were eight revisions, (one deep infection, four dislocations and three peri-prosthetic fractures), by 12 months. The average Constant score was 67.1 at one year.

Conclusion: Prognostic factors on presentation were age of the patient and their physiological index, and at three months any complication, the position of the implant, tuberosity union and persistent neurological deficit. Overall optimum outcome was in patients aged 55 to 60, with minimal co-morbidities and uncomplicated recovery.

Introduction The aim of this study was to assess shoulder hemiarthroplasty for non-reconstructable proximal humeral fractures at a minimum of 12 months and identify factors that aid prognosis.

Methods Patients with a displaced fracture requiring shoulder hemiarthroplasty were studied. Patients were treated using the Neer or Osteonics prosthesis and the decision for hemiarthroplasty was made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review creating a physiological index on co-morbidities, and a radiological analysis were carried out. Survival analysis was performed for one and five year results and data was analysed by linear regression to identify prognostic factors. From 163 patients there were 138 fitting the criteria, 42 males and 96 females, average age of 68.5 (range 30 to 90) years and follow-up of 6.3 (range 1 to 15) years. The fracture pattern was three or four part in 133 cases and five head split fractures; 58 were associated with dislocation.

Results Survival was 96.4% one year and 93.6% five years, with no significant difference between prostheses. There were eight revisions, (one deep infection, four dislocations and three peri-prosthetic fractures), by 12 months. The average Constant score was 67.1 at one year. Prognostic factors at presentation were patient age and physiological index. At three months factors were implant position, tuberosity union, persistent neurological deficit and any complication.

Conclusion Overall optimum outcome was in patients aged 55 to 60, with minimal co-morbidities and an uncomplicated recovery.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

Humeral hemi arthroplasty has become widely used as a form of surgical management for severe fractures. However there is still no consensus as to the role for prosthetic replacement in displaced proximal humeral fractures.

The aim was to assess shoulder hemi arthroplasty for un-reconstructable three and four part proximal humeral fractures at a minimum of twelve months and identify factors that guide to prognosis.

Criteria for inclusion were patients with a fracture that went onto shoulder hemi arthroplasty with Constant scoring at a minimum follow up of one year. Patients were treated using a Neer or Osteonics prosthesis, with the decision for hemi arthroplasty being made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review establishing a physiological index according to comorbidities, and a radiological analysis were carried out. A survival analysis was performed for the one and five year results and data was analysed by linear regression to identify prognostic factors.

Of 163 patients there were 138 fitting the criteria, 42 males and 96 females with an average age of 68.5 (range30–90) years and average follow up of 6.3 (range1–15) years. The fracture pattern was three or four part in 133 cases and 5 head split fractures; 58 were associated with a dislocation. Survival was 96.4% at 1 year and 93.6% at 5 years, with no significant difference between prostheses. There were 8 revisions, (1 deep infection, 4 dislocations and 3 peri-prosthetic fractures), most within 12 months. The average Constant score was 67.1 at one year.

Prognostic factors on presentation were the age of the patient and their physiological index. Factors at 3 months were any complication, the position of the implant, tuberosity union and persistent neurological deficit. Overall optimum outcome was gained by patients aged 55–60, with minimal comorbidities and an uncomplicated recovery.

All patients over 65 yrs with an ISS greater than 15 attending Edinburgh Royal Infirmary between 1997 and 2000 were prospectively entered into the study. Patients were followed until death or discharge home. The patients were divided into, group 1 [patients who survived], and group 2 [those who died.]

A total of 72 patients were included in the study, 42 males and 31 females. 42 patients survived, and 31 died.

Group 1 consisted of 29 males and 15 females with an average age of 75.23yrs. Group 2 consisted of 13 males and 18 females with an average age of 78.05yrs. All incidents involved blunt trauma. The three main mechanisms of injury were RTA, Fall less than 2 meters, and Fall greater than 2 meters.

Five patients required intubation in group 1 and 12 patients in group 2.The average GCS was lower in group 1 compared to the group 2. All Injuries with AIS of greater than 3 were analysed. The total number of injuries was greater in the group 2. Group 1 required 214 days in HDU/ITU and a total of 943 in-patient days. Group 2 in comparison needed 62 HDU/ITU days and 169 in-patient days. The major cause of death was head and spinal injury 11 (35%), and Multiple injuries 9 (29%).

A total number of 1952 days were spent in rehabilitation prior to discharge, with an average of 46.48 days. Post trauma the level of independence was significantly reduced.

The injuries are exclusively blunt and in the majority of cases secondary to motor vehicle accidents. Predictors of mortality appear to include, intubation, head and neck injuries, GCS, and chest injuries. Current outcome scores correlate inaccurately. These patients require long hospital stays with a large amount of intensive care input. After discharge rehabilitation is universally required. These patients place a large demand on the NHS and social services; the total cost of their care was approximately £2,500,000.

We reviewed the results of the treatment of 30 tibial fractures with minor to severe bone loss in 29 patients by early soft-tissue and bony debridement followed by primary locked intramedullary nailing. Subsequent definitive closure was obtained within the first 48 hours usually with a soft-tissue flap, and followed by bone-grafting procedures which were delayed for six to eight weeks after the primary surgery. The time to fracture union and the eventual functional outcome were related to the severity and extent of bone loss. Twenty-nine fractures were soundly united at a mean of 53.4 weeks, with delayed amputation in only one patient. Poor functional outcome and the occurrence of complications were usually due to a departure from the standard protocol for primary management. We conclude that the protocol produces satisfactory results in the management of these difficult fractures, and that intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilisation.

We reviewed 63 patients with fractures of the distal tibial metaphysis, with or without minimally displaced extension into the ankle joint. The fractures had been caused by two distinct mechanisms, either a direct bending force or a twisting injury. This influenced the pattern of the fracture and its time to union. All fractures were managed by statically locked intramedullary nailing, with some modifications of the procedure used for diaphyseal fractures. There were few intra-operative complications. At a mean of 46 months, all but five patients had a satisfactory functional outcome. The poor outcomes were associated with either technical error or the presence of other injuries. We conclude that closed intramedullary nailing is a safe and effective method of managing these fractures.

We describe a new technique for open reduction, bone grafting and fixation with a single Kirschner wire of unstable fractures of the distal radius. Of the 83 patients treated by this technique, most had regained volar tilt when seen at an average of 13 months after injury. Malunion was seen in 18 patients due either to poor placement of the graft and Kirschner wire or because of both volar and dorsal comminution. Assessment of hand and wrist function showed an average recovery of 63% of mass grip strength with an excellent return of specialised grip strength and range of movement. The advantages of this technique over closed methods include the ability to regain the volar tilt of the distal radius and to achieve reduction at any time before union of the fracture.

We performed an epidemiological analysis of 523 fractures treated in the Edinburgh Orthopaedic Trauma Unit over a three-year period using modern descriptive criteria. The fractures were defined in terms of their AO morphology and their degree of comminution, location and cause. Closed fractures were classified using the Tscherne grading system and open fractures according to the Gustilo classification. Further analysis of fractures caused by road-traffic accidents and football was carried out. The use of the AO classification allowed the common fracture patterns to be defined. Correlation of the classification systems showed an association between the AO morphological system and the Tscherne and Gustilo classifications. The relative rarity of severe tibial fractures is indicated and it is suggested that in smaller orthopaedic units the infrequency of these fractures has implications for training and the development of treatment protocols.