If a trauma patient is tachycardic, should we call for a counsellor?

BACKGROUND: It has been suggested in the literature that raised heart rate in the early period after trauma is associated with the development of post-traumatic psychopathology, but little account has been taken of the potential confounding effect of injury severity. MATERIALS AND METHODS: A cohort of 154 patients, studied as part of a wider investigation of trauma outcomes, was included. Initial heart rate in the accident & emergency department, and injury severity score and new injury severity scores were recorded. Patients completed the General Health Questionnaire (GHQ-28) as a measure of psychopathology at presentation and again at two- and six-month follow-up. RESULTS: There was no relationship between psychopathology at presentation and initial heart rate or injury severity. Raised heart rate was associated with post-traumatic psychopathology at two months but not at six months. When the potential confounding effect of injury severity was controlled for, there was no independent correlation between heart rate and post-traumatic psychopathology. Injury severity score and new injury severity scores were strongly associated with GHQ-28 caseness. CONCLUSION: Post-traumatic tachycardia is not associated with development of psychopathology, but injury severity is. Previous studies that have suggested a link between tachycardia and development of psychopathology are flawed because they have not considered the confounding effect of severity of injury.

Is Anterior Cruciate Reconstruction Superior to Conservative Treatment?

Not all patients who have a rupture of the anterior cruciate ligament (ACL) elect to have surgical reconstruction. The aim of this study was to assess the short-to-medium-term results of patients who chose conservative management in comparison to patients who had reconstructive surgery within the same time period. Sixty-three patients with an ACL injury were retrospectively studied. Forty patients were managed, according to patient choice, with ACL reconstruction and 23 conservatively. Four validated questionnaires were used to assess general and knee-specific function in a cohort with a median age of 32 years and a median follow-up period of 38 months. Patients were matched on demographic variables except for gender. There were no statistically significant differences in the outcome measures, and the majority of patients would proceed with the same treatment in the event the control leg became injured. Patients who elect to have conservative management of an ACL rupture can achieve similar function and satisfaction to those who elect to have reconstruction. Until a large randomized controlled trial is conducted, patients need to be made aware of the merits of both management strategies and the lack of evidence of superiority of one over the other.

Bioelectrical impedance analysis is more accurate than clinical examination in determining the volaemic status of elderly patients with fragility fracture and hyponatraemia.

OBJECTIVES: Management of hyponatraemia depends crucially on accurate determination of volaemic (hydration) status but this is notoriously challenging to measure in older people. Bioelectrical impedance analysis (BIA) provides a validated means of determining total body water (TBW), but its clinical utility in determining volaemic status in hyponatraemia has never been tested. This study assessed the utility of BIA in the clinical management of hyponatraemia in elderly patients with fragility fractures (EPFF), a group at high risk of hyponatraemia. DESIGN: Prospective observational study of consenting patients ≥65 years with fragility fractures (N=127). SETTING: University teaching hospital in Scotland. PARTICIPANTS: Patients ≥665 years with fragility fractures with capacity to consent to participation. MEASUREMENTS: BIA and standard clinical examination procedures (jugular venous distension, skin turgor, mouth and axillary moistness, peripheral oedema, capillary refill time, overall impression) were performed daily throughout each participant's hospital stay. Volaemic status of hyponatraemia was determined by an expert panel using clinical data (history, examination, nursing observations and laboratory tests) blinded to TBW readings. Cohen's kappa was calculated to assess the level of agreement between the expert panel and both BIA and standard clinical examination measures in determining the volaemic state of hyponatraemia. RESULTS: 26/33 (79%) cases of hyponatraemia had sufficient clinical information to allow determination of volaemic status by BIA. There was moderate level of agreement between BIA and the expert panel, kappa 0.52 (p<.001). All kappa values for standard clinical assessments of volaemic status neared zero, indicating nil to slight agreement. CONCLUSION: BIA outperformed all aspects of the standard clinical examination in determining the volaemic status of hyponatraemic EPFF, suggesting it may be useful in clinical practice.

The importance of epidemiological fracture data: injury epidemiology for the non-epidemiologist.

Epidemiological studies enhance clinical practice in a number of ways. However, there are many methodological difficulties that need to be addressed in designing a study aimed at the collection and analysis of data concerning fractures and other injuries. Most can be managed and errors minimised if careful attention is given to the design and implementation of the research.

Age-related differences in the neck strength of adolescent rugby players: A cross-sectional cohort study of Scottish schoolchildren.

OBJECTIVES: To evaluate the neck strength of school-aged rugby players, and to define the relationship with proxy physical measures with a view to predicting neck strength. METHODS: Cross-sectional cohort study involving 382 rugby playing schoolchildren at three Scottish schools (all male, aged between 12 and 18 years). Outcome measures included maximal isometric neck extension, weight, height, grip strength, cervical range of movement and neck circumference. RESULTS: Mean neck extension strength increased with age (p = 0.001), although a wide inter-age range variation was evident, with the result that some of the oldest children presented with the same neck strength as the mean of the youngest group. Grip strength explained the most variation in neck strength (R(2) = 0.53), while cervical range of movement and neck girth demonstrated no relationship. Multivariable analysis demonstrated the independent effects of age, weight and grip strength, and the resultant model explained 62.1% of the variance in neck strength. This model predicted actual neck strength well for the majority of players, although there was a tendency towards overestimation at the lowest range and underestimation at the highest. CONCLUSION: A wide variation was evident in neck strength across the range of the schoolchild-playing population, with a surprisingly large number of senior players demonstrating the same mean strength as the 12-year-old mean value. This may suggest that current training regimes address limb strength but not neck strength, which may be significant for future neck injury prevention strategies. Age, weight and grip strength can predict around two thirds of the variation in neck strength, however specific assessment is required if precise data is sought.

Anterior cruciate ligament integrity in osteoarthritis of the knee in patients undergoing total knee replacement.

BACKGROUND: Anterior cruciate ligament (ACL) rupture has been implicated in the development of knee osteoarthritis (OA). This study aimed at determining the incidence of prior ACL deficiency in patients undergoing total knee replacement (TKR), the effect of prior ACL deficiency on function and the macroscopic and microscopic appearance of the ligament. MATERIALS AND METHODS: A total of 95 patients undergoing elective TKR for OA were recruited. Pre-operative knee assessment included questionnaires and KT1000 testing. The ACL was examined macroscopically at TKR in all patients, and 10 ACL specimens were examined histologically. RESULTS: The ACL was absent in 12% of the patients. There was no significant correlation between the pre-operative assessment or function and operative findings. The ACL samples all demonstrated degenerative change of varying severities. CONCLUSION: ACL deficiency is uncommon in patients undergoing TKR for OA, and does not worsen pre-operative function.

Change in long-term mortality associated with fractures of the hip: evidence from the scottish hip fracture audit.

We investigated the excess mortality risk associated with fractures of the hip. Data related to 29 134 patients who underwent surgery following a fracture of the hip were obtained from the Scottish Hip Fracture Audit database. Fractures due to primary or metastatic malignancy were excluded. An independent database (General Register Office (Scotland)) was used to validate dates of death. The observed deaths per 100 000 of the population were then calculated for each group (gender, age and fracture type) at various time intervals up to eight years. A second database (Interim Life Tables for Scotland, Scottish Government) was then used to create standardised mortality ratios. Analysis showed that mortality in patients aged > 85 years with a fracture of the hip tended to return to the level of the background population between two and five years after the fracture. In those patients aged < 85 years excess mortality associated with hip fracture persisted beyond eight years. Extracapsular hip fractures and male gender also conferred increased risk.

The strange case of Sir Henry Gray.

Sir Henry Williamson Gray was a prominent Aberdeen surgeon who took up the post of Chief of Surgery at the Royal Victoria Hospital, Montreal in 1923. In what subsequently became known as "The Sir Henry Williamson Gray Affair" in the annals of McGill University, his career was ruined and his reputation left in tatters. The authors examine the available evidence and conclude that Gray was treated unfairly. They hope they have helped restore his name and reputation.

Changes in population demographics and the future incidence of hip fracture.

BACKGROUND: During the first three decades of the 21st century the combination of increasing life expectancy and falling birth rates will result in substantial demographic changes within the population of the United Kingdom. A large increase in the elderly population is likely to have significant effects on the number of patients who sustain a hip fracture. AIM: To predict future changes in hip fracture burden in Scotland. MATERIALS AND METHODS: Data was obtained from the Scottish Hip Fracture Audit database for a 12 month period between April 2004 and March 2005. All orthopaedic units in Scotland participated in the audit during this period. This data was used to calculate the incidence of hip fracture by 5 year age/gender cohorts. Outcome data was analysed in a similar manner. Population prediction data obtained from the Registrar General's Office was then used to predict hip fracture numbers for the year 2031. Two separate prediction models were used. The first model assumed that the age/gender specific incidence of hip fracture observed in 2004 would remain constant. Between 1999 and 2004, a 9.6% decrease in the population incidence of hip fracture was observed. Therefore a second prediction model was used which assumed a continuation in the fall in population incidence of hip fracture between 2004 and 2031. RESULTS: The population aged 50 years and above is predicted to increase 28% by 2031, with the most significant increases occurring in the over 1980s. The number of hip fractures is predicted to rise by 45% to 75% (from 6164 to 8829-10756 cases per annum) requiring an additional 287-474 hospital beds. By 2031 approximately 45% of fractures will occur in those aged 85 years and above, compared to 34% in 2004. Predicted changes in population demographics are highly variable by region and so local planning of resource provision will be essential. CONCLUSION: Changes in population demographics will have significant implications for health care provision for the care of hip fracture patients. An increase in the capacity of acute orthopaedic care and a review of care models will be required to ensure adequate resource provision.

Outcome after surgery for the treatment of hip fracture in the extremely elderly.

BACKGROUND: As a consequence of changes in population demographics, the extremely elderly represent one of the fastest growing groups in Western society. Previous studies have associated advanced age with increased mortality after hip fracture; however, this finding has not been consistent. METHODS: The Scottish Hip Fracture Audit is a prospective, national, multicenter study that collects data on patients over the age of fifty years who are admitted to the hospital with a hip fracture. For the present study, we used data collected from twenty-two acute-care orthopaedic units between January 1998 and December 2005. The extremely elderly cohort consisted of 919 individuals with an age of ninety-five years or more. Case-mix variables and outcomes were compared with those for a modal control group of 15,461 individuals who were seventy-five to eighty-nine years of age. Outcome measures included thirty and 120-day mortality rates, the length of the hospital stay, the place of residence, and mobility. A multivariable logistic regression model was used to compare outcomes between groups while controlling for significant case-mix variables. RESULTS: The extremely elderly presented with poorer indicators of health status as demonstrated by higher American Society of Anesthesiologists scores. In addition, this group was less likely to be independently mobile and more likely to be in institutional care at the time of the fracture (p < 0.001). Mortality at thirty and 120 days was higher in the extremely elderly even after adjusting for case-mix variables. The extremely elderly also were less likely to return home or to return to previous levels of mobility. CONCLUSIONS: Although the extremely elderly exhibited a higher prevalence of prefracture indicators of poor outcome, statistical control for these case-mix variables showed further age-related deterioration in survival and outcomes after surgery for the treatment of a hip fracture.

Epidemiology and outcome after hip fracture in the under 65s-evidence from the Scottish Hip Fracture Audit.

AIM: To report the epidemiology and outcomes after hip fractures in the patients under 65 years of age. PATIENTS AND METHODS: We performed a prospective, multi-centre observational study using the Scottish Hip Fracture Audit Database. Case-mix, process and outcome data was collected by dedicated coordinators on site at the time of admission, at 120 days after the injury and on any re-operations within 12 months. The study cohort consisted of 1896 individuals aged 50-64 years. Patient variables and outcomes were compared to a control group of 15,461 individuals aged 75-89 years of age. The control group consisted of three modal 5-year age groups centred about a median age of 83 years, equal to the database value, excluding the effects of the extreme elderly who may act as confounders. Outcomes measures included 30- and 120-day mortality, length of hospital stay, place of residence and ambulatory status. A multivariate logistic regression model was used to compare outcome between groups while controlling for significant case-mix variables. RESULTS: Patients in the study cohort presented with lower ASA scores and were more likely to be independently mobile and live in their own home at the time of fracture (p<0.001). Pathological fractures were more common in younger patients and accounted for more than 1 in 20 fractures. Mortality at 30 and 120 days was significantly lower (p<0.0001) in the study cohort, however it was increased compared to age and gender adjusted mortality rates for the general population (p<0.001) Younger patients were more likely to recover independent mobility and living. CONCLUSION: Patients aged 50-64 years have significantly better outcome measures after surgery for hip fracture in terms of survival and function. Such differences exist even after controlling for differences in patient case-mix variables.

Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit.

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders. Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered.

Nineteenth century medical education for tomorrow's doctors.

Many of the ideas contained within the GMC's 'Tomorrow's Doctors' could be considered as old ideas reworked for modern medical education. Sir John Struthers, a pioneer in the field of medical education, touched on many of the issues in 'Tomorrow's Doctors' in his writings published over one hundred years ago. The study of the history of medicine, often neglected by members of our profession in the search for new ideas, is not only of interest, but is valuable to current and future medical education. History illustrates the mistakes of the past, but also helps highlight the successes and insights that remain applicable and relevant today.

Sir John Struthers MD FRCS Edin LLD Glasg: anatomist, zoologist and pioneer in medical education.

Sir John Struthers (1823--1899), a past president of the Royal College of Surgeons of Edinburgh and Regius Professor of Anatomy at the University of Aberdeen, was an accomplished scientist and medical educator. Much of his career was spent in shaping the medical curriculum of the nineteenth century. He was a strong proponent of a sound basic science education as preparation for a career in medicine, but was also central in developing more formal clinical teaching for medical students. His interest in comparative anatomy and evolution has provided a rich legacy of human and zoological specimens that remain of value in everyday teaching. Much of his work on educational theory and the place of basic sciences in the medical curriculum remains relevant to this day, and is of particular interest given the ongoing debate regarding the place of the basic medical sciences in the undergraduate medical curriculum

Disturbance of pro-inflammatory cytokines in post-traumatic psychopathology.

BACKGROUND: Post-traumatic psychopathology (PTP) is important to the orthopaedic surgeon as it may complicate the recovery from musculoskeletal injury. PTP is associated with a disturbance of the hypothalamic-pituitary-adrenal axis, and may lead to impaired healing. We have investigated the relationship between PTP and pro-inflammatory markers of the metabolic response to trauma. MATERIALS AND METHODS: A prospective cohort study of 82 patients with musculoskeletal injuries, correlating development of psychopathology (measured by general health questionnaire) and pro-inflammatory markers (CRP, IL-6, sIL-6r, TNF-alpha) two and six months after their injury. RESULTS: Psychological disturbance was found in 39% of patients at two months and 18% at six months. This disturbance was associated with significantly increased levels of IL-6 at two months and of sIL-6r and TNF-alpha at six months. CRP levels were not related to the development of PTP. CONCLUSIONS: The relationship between PTP and disturbances of pro-inflammatory markers needs further exploration, but may explain in part the impaired functional recovery when musculoskeletal trauma is complicated by psychological disturbance.

Association between COLIA1 Sp1 alleles and femoral neck geometry.

Genetic factors play an important role in the pathogenesis of osteoporosis by affecting bone mineral density and other predictors of osteoporotic fracture risk such as ultrasound properties of bone and skeletal geometry. We previously identified a polymorphism of a Sp1 binding site in the Collagen Type 1 Alpha 1 gene (COLIA1) that has been associated with reduced BMD and an increased risk of osteoporotic fractures in several populations. Here we looked for evidence of an association between COLIA1 Sp1 alleles and femoral neck geometry. The study group comprised 153 patients with hip fracture, and 183 normal subjects drawn at random from the local population. Femoral neck geometry was assessed by analysis of pelvic radiographs in the fracture patients and DXA scan printouts in the population-based subjects. The COLIA1 genotypes were detected by polymerase chain reaction and were in Hardy Weinberg equilibrium: "SS" = 222 (66%); "Ss" = 105 (31.3%); and "ss" = 9 (2.7%). There was no significant difference in hip axis length or femoral neck width between the genotype groups, but femoral neck-shaft angle was increased by about 2 degrees in the Ss/ss genotype groups (n = 114) when compared with SS homozygotes (n = 222) (P = 0.001). Previous studies have suggested that an increased femoral neck-shaft angle may increase the risk of hip fracture in the event of a sideways fall by influencing the forces that act on the femoral neck. The association COLIAI genotype and increased femoral neck angle noted here may therefore contribute to the BMD-independent increase in hip fracture risk noted in previous studies of individuals who carry the 's' allele.

Osteoarthritis as a systemic disorder including stromal cell differentiation and lipid metabolism.

For many years articular cartilage has been the focus of research aimed at improving understanding of and treatment for osteoarthritis. Although much is known about the tissue, research has had little success in elucidating the pathogenesis of generalised osteoarthritis. A new hypothesis is required. Substantial changes in many tissues, including bone, muscle, ligaments, and joint capsule, as well as cartilage, are increasingly recognised in this disease, and not all these changes are localised to the affected joints. There is also a well established link with obesity. These observations, the common origins of the mesenchymal cells that maintain these tissues, and the possible role of neuroendocrine factors that can regulate bone mass, result in the hypothesis that systemic factors that include altered lipid metabolism could explain the diversity of physiological changes in generalised osteoarthritis. If proven, this hypothesis could have important implications for a new approach to pharmacological intervention in the early stages of the disease.

C-reactive protein and interleukin 6 receptor in post-traumatic stress disorder: a pilot study.

BACKGROUND: it has been reported that psychological stress in humans is associated with a derangement of biological homeostasis. This pilot study aimed to examine the inflammatory response to post-traumatic stress disorder (PTSD) through measurements of the serum levels of the receptor to interleukin 6 (sIL-6r) and C-reactive protein (CRP), in relation to measures of psychological disturbance. METHODS: 15 patients with established PTSD and eight control patients with musculoskeletal injuries were studied at least three months after their index trauma. All completed revised impact of events scale (RIES), Davidson's trauma scale (DTS) and the general health questionnaire (GHQ), and gave blood samples that were assayed for CRP and sIL-6r. Statistical analysis was by the Mann-Whitney U-Wilcoxon rank sum tests. RESULTS: positive relationships were found between sIL-6r and the RIES intrusion score (P=0.026), and between CRP and DTS intrusion scores (P=0.016), GHQ depression (P=0.028), and RIES intrusion (P=0.044) in the case group. DISCUSSION: we have demonstrated a relationship between post-traumatic psychological and biological disturbance, which provides the basis for further research on the effects of psychological disturbance on physical recovery after injury.

Optimizing the configuration of cement keyholes for acetabular fixation in total hip replacement using Taguchi experimental design.

Cement fixation of the acetabular component is increasingly recognized as a common site of loosening when hip replacements fail. Cement keyholes drilled into the acetabulum have been recommended to improve this fixation but little is known of the optimum positions or sizes of these holes. This study investigates the diameter, depth and number of keyholes to be drilled to maximize the failure torque in a model system. A Taguchi experimental design was used to identify the most significant factors and to predict the best configuration of keyholes within the constraints of the experimental test rig. One hole at each of the pubic, iliac and ischial sites, of 12 mm diameter and 6 mm depth, was found to be the optimum configuration. The failure torque was most strongly dependent on the hole diameter in the pubic region, decreased with increasing hole depth and was not sensitive to the number of holes.