Does weight-bearing assignment after intramedullary nail placement alter healing of tibial shaft fractures?

INTRODUCTION: There is no consensus regarding postoperative weight-bearing (WB) assignment after treatment of tibial shaft fractures with an intramedullary nail. This study aims to determine if the postoperative WB assignment after tibia intramedullary nail placement alters healing. METHODS: Closed AO type 42A fractures treated with a reamed statically-locked intramedullary nail over a 10-year period were retrospectively reviewed from injury at 2, 3, 6, 9 and 12 month intervals until union or revision. Patients were categorized according to postoperative weight-bearing assignment: weight-bearing-as-tolerated (WBAT) or non-weight-bearing (NWB). Patients with additional diagnoses that confound routine fracture healing were excluded. Postoperative radiographic union scores for tibial fractures (RUST), coronal/sagittal angulations, and length were compared between different weight-bearing groups. Union was defined as a RUST≥10 at a painless fracture site. RESULTS: A total of 83 patients achieved union (32 WBAT, 51 NWB). Both WB groups had similar preoperative demographics. Average age was 37±13 years and follow-up averaged 1.3±0.2 years. There were no significant differences in average time to radiographic union between NWB versus WBAT groups (5.5 vs. 6.1 months, respectively; P=0.208) nor radiographic healing at 2, 3, and 6-month intervals (P=0.631). There were two nonunions and one fracture shortened in the NWB group. There were no reoperations for symptomatic or broken hardware in either cohort. CONCLUSION: Immediate WBAT after statically-locked intramedullary nail placement in simple tibial shaft fractures does not alter the time until or course of radiographic union. LEVEL OF EVIDENCE: IV.

Perceived relationships with parents among adolescent inpatients with depressive preoccupations and depressed mood.

Hypothesized that two types of "depressogenic" preoccupations (self-critical and interpersonal), measured by the Depressive Experiences Questionnaire for adolescents (DEQ-A; Blatt, Shaffer, Bars, & Quinlan, 1992), would mediate associations between perceived difficulties with parents and adolescent depression. Adolescent inpatients between 11 and 17 years of age (N = 295; 158 girls) in an acute-care psychiatric hospital completed the DEQ-A, a Reynolds (1986, 1989) depression questionnaire, and measures that assess experiences of alienation (vs. dependency) and separation-individuation conflicts in the adolescent-parent relationship. Alienation and counterdependency in relation to parents were associated with self-critical concerns; excessive closeness and dependency with interpersonal concerns; and separation-individuation conflicts with both types of concerns. Self-critical and interpersonal concerns were linked to adolescent depression and accounted for most of the variance initially explained by difficulties with parents.

"Playing God" and the removal of life-prolonging therapy.

"Playing God" is the charge frequently leveled when physicians and patients agree to withdraw life-sustaining medical treatments and let the patient die. The accusation rings hollow in the context of four hundred years of moral reflection on the duty of an individual to undergo medical treatments to preserve life. From the teachings of Soto and Banez in the 16th century through the President's, Commission 1983 report 'deciding to forego life-sustaining treatments' there is a clear and constant teaching that though life is sacred it is not an absolute and our moral duty to preserve it is limited and based on rational reflection. No patient need undergo any treatment of procedure that is "disproportionately" costly, burdensome, or painful. The assessment of whether to accept or reject a proposed treatment is in part subjective and belongs to the individual patient. The only remaining issue is how to make that judgement for those unable to speak for themselves.