Subclavian vessel injury from chest-drain malposition in the treatment of a pneumothorax in the presence of a lateral third open clavicular fracture.

Objective: We report the unorthodox injury of the subclavian vessels by the malposition of a chest drain, for the treatment of a pneumothorax in the presence of a lateral third open fracture of the left clavicle. This case presents the first report of a ruptured subclavian vein and cephalic vein after the insertion of a chest drain for a pneumothorax. A systematic search performed in MEDLINE, EMBASE, Cochrane Library, and Web of Science found no similar cases documented in the literature. Methods: A Chest tube was inserted into the second intercostal space mid-clavicular line. Immediately postinsertion the left-hand digits were cyanosed with an absent radial pulse. An intraoperative haematoma was noted surrounding the chest drain insertion point. Vascular surgeons provided assistance and detected ruptured cephalic and subclavian veins and a punctured subclavian artery. The subclavian artery was repaired and both veins tied. The chest drain was re-inserted as per the ATLS protocol into the 4th intercostal space mid-axillary line. Upon healing of vascular repair of the subclavian artery injury the clavicle fracture was treated by use of a hook plate. Results: The patient made a good recovery, follow-up radiographs showed signs of fracture healing with complete resolution of pneumothorax and the patient was discharge from the department of orthopedic care. Conclusion: We believe that strict adherence to ATLS principles is vital as fractures of the lateral third of the left clavicle can distort anatomical landmarks. This can increase the incidence of injury to subclavian vessels due to malposition of the chest drain. Insertion of the chest drain in the fourth intercostal space mid-axillary line provides sound decompression of a pneumothorax as per ATLS protocol and reduces iatrogenic risk.

Antegrade insertion of a retrograde intramedullary femoral nail for treatment of a subtrochanteric pathological femoral shaft fracture in a patient with pre-existing coxa vara.

Objective: We report the unorthodox use of a retrograde intramedullary nail via antegrade technique for the treatment of a subtrochanteric pathological femur fracture in the presence of significant coxa vara. No similar use has been documented previously in literature. Methods: A standard approach to the proximal right femur was performed and standard antegrade technique used to introduce a guide wire into the proximal femur after which the femoral shaft was reamed. A 38-cm long 10 mm diameter retrograde nail was attached to the retrograde insertion and targeting device as if to perform a left sided retrograde femoral nailing. The nail was then inserted antegrade into the proximal right femur and locked. Results: The patient made a good recovery without complications and was followed up regularly at the clinic until complete healing of the fracture. Conclusion: We believe that a retrograde intramedullary nail inserted antegrade, enabling proximal locking with screws passing into the femoral head, provides a mechanically sound fixation of a subtrochanteric fracture, where a reduced neck-shaft angle precludes the use of a standard cephalo-medullary nail.

Outcome of surgery in neck of femur fracture patients with poor pre-fracture mobility.

BACKGROUND: Hip fractures are common with a UK incidence of over 70,000 cases and total healthcare costs of over £2 billion per year. Mortality rates of 10% at 30 days and up to 30% at 1-year have been reported. We wanted to assess the outcome of hip fracture surgery in patients with reduced pre-fracture mobility as this has not been exclusively studied previously. METHODS: We retrospectively reviewed 168 hip fracture patients with reduced pre-fracture mobility (wheelchair bound, bed bound, walking with 2 aids or a frame) who underwent hip fracture surgery at our institution between 2008 and 2013 using case notes, discharge letters, outpatient clinic letters and laboratory test results. Measured outcomes included 30-day renal, cardiac and respiratory morbidity as well as 30-day and 1-year mortality. RESULTS: Our study comprised 27% males and 73% females with a mean age of 82 years. The 30-day chest infection, acute renal failure and acute coronary syndrome rates were 26%, 7.7% and 4% respectively. In those patients who were either wheelchair or bed bound, 30-day and 1-year mortality rates were 11.8% and 52% respectively whereas in those who could mobilise with the help of 2 aids or frame, 30-day and 1-year mortality rates were 4.34% and 39.70% respectively. CONCLUSION: Our study highlighted increased 30-day and 1-year morbidity and mortality rates following hip fracture surgery with notable high rates of respiratory and renal complications in patients with reduced pre-fracture mobility. We would recommend pre- and postoperative optimisation with orthogeriatric review, chest physiotherapy and intravenous fluid hydration to reduce complication rates and improve morbidity and mortality.

Fibula osteotomy using a rib cutter.

We find the use of a rib cutter to be a useful alternative instrument in carrying out a fibular osteotomy.