Hip fractures in nonagenarians--a study on operative and non-operative management.

Hip fractures in nonagenarians represent a special group because of their advanced age and co-morbidities. Surgery is advocated for their younger counterparts but may not appear desirable in nonagenarians. Eighty-four patients were studied over a 2-year period. There were 73 female and 11 male patients. Forty-seven patients sustained an intertrochanteric fracture of the femur. 37 suffered a neck of femur fracture. ASA score of II was the largest group with 51. At least 62 had one co-morbidity or more; 46 were considered demented with a mental test score of less than 7. The mean length of stay was 31 days. Treatment consisted of either traction or surgery. Forty-six patients were managed surgically and 38 non-surgically. Patient review was done 2 years after the fracture. The overall rate of complications was 52% for the operative and non-operative groups. Death outcome at 24 months was not significantly affected by ASA status, number of co-morbidities at admission, or between surgical and non-surgical treatment. However, there was statistical significance between death and the mini-mental test score of less than 7 (P < 0.05). Forty-three patients were still alive after 2 years; of which 27 had been treated surgically and 16 non-surgically. The overall mortality in both operative and non-operative groups is 49%. Surgery significantly increases the ability for independent ambulation (P < 0.01). Therefore the outcome of non-operative and non-operative treatment in nonagenarians with hip fractures is poor due to the high rates of mortality and morbidity.

Galeazzi-equivalent fracture in children associated with tendon entrapment--report of two cases.

INTRODUCTION: This is a report of 2 consecutive cases of the Galeazzi-equivalent fracture in children. CLINICAL PICTURE: In both cases, the mechanism of injury was falls onto the outstretched hand. Radiographs showed fracture of the radius with separation of the distal ulnar physis. TREATMENT: Initial treatment by closed manipulation failed; hence, open reduction and internal fixation was required. The cause of failure of closed manipulation in both cases was interposition of soft tissue into the ulnar fracture site. OUTCOME: Both cases showed good functional outcome after open reduction and internal fixation. CONCLUSION: Recognition of this form of injury is necessary to ensure proper treatment is undertaken to prevent the complications of inadequate reduction and growth retardation.

A retrospective study on elbow function after internal fixation of intercondylar fracture of adult humerus.

Between 1989 and 1993, 20 intercondylar fractures of the distal humerus were treated by open reduction, internal fixation and early postoperative mobilisation. One patient died on the third postoperative day as a result of multiple injuries, leaving 19 patients for evaluation. The mean follow-up period was 4.1 years (range 2.0 to 6.7 years). According to the Muller system, there were 7 type C1 and 12 type C2 fractures. Using the Jupiter criteria, 6 elbows were rated as excellent, 9 good and 4 fair. Complications included late ulnar neuritis in one patient and wound infection in another patient.

Necrotising fasciitis--an old enemy or a new foe.

Necrotising fasciitis when described by Meleney was caused predominantly by Streptococcus pyogenes. Since then, there were several reports which confirmed streptococcus as the main organism identified in this disease entity. However, recently there were reports of necrotising fasciitis caused by organisms other than Streptococcus. We analysed 19 cases of necrotising fasciitis seen in the Department of Orthopaedic Surgery over a period of 24 months to see if this disease entity has changed significantly. The patients in our series were between the ages of 19 to 85 years with an average age of 57.2 years. Males were more often affected (16 out of 19). The majority of the patients have some form of underlying disease (16 out of 19 cases). There was a trend towards polymicrobial infection and many were resistant to standard antimicrobial therapy. The mortality rate was 21.1%. Our results are comparable to many earlier series.

Operative treatment of volar intra-articular fractures of the distal end of the radius.

We retrospectively reviewed the results of operative treatment of forty-nine volar marginal intra-articular fractures of the distal end of the radius. According to the Comprehensive Classification of Fractures, there were two B3.1 fractures (characterized by a small volar fragment, with the sigmoid notch intact), three B3.2 fractures (characterized by a large volar fragment that included the sigmoid notch), and forty-four B3.3 fractures (characterized by comminution of the volar fragment). Although all fractures healed and only nine patients had evidence of osteoarthrosis on follow-up radiographs, there were six early and fourteen late complications, some of which adversely influenced the over-all outcome. After an average of fifty-one months (range, twenty-four to 117 months), there were thirty-one excellent, ten good, and eight fair results according to the system described by Gartland and Werley, and thirty-two excellent, nine good, five fair, and three poor results according to the modified system of Green and O'Brien. Two factors were found to have a significant association with a fair or poor outcome: evidence of osteoarthrosis on the most recent follow-up radiographs and reversal of the normal volar tilt of the distal end of the radius. The age of the patient, the interval from the injury to the operation, a concomitant injury of the ipsilateral upper extremity, an associated fracture of the ulnar styloid process, the radio-ulnar index, ulnar angulation, the classification of the fracture, comminution of the volar fragment, and articular incongruity were not significantly associated with the outcome.

The infected nonunion of the tibia.

Ununited fracture of the tibia complicated by infection is not only a complex surgical problem but also a chronic and at times debilitating condition. The principle methods used to diagnose and stage posttraumatic tibial osteomyelitis are described. Infected nonunions of the tibia are characterized by the extent of bony loss and the presence of a functional ipsilateral fibula. Using this tibial staging criteria, a series of 37 infected nonunions of the tibia are reviewed. Twenty patients were male and 16 were female, with an average age of 33 years. The distal third of the tibia was involved in 19 patients, the middle third in 11, and proximal third in 7. Twenty three of the tibia were infected with > 1 organism. Thirty were Type 3 (tibial defect of 6 cm or less with a long and usable fibula), 4 Type 4 (tibial defect > 6 cm without usable fibula), and 3 Type 5 (tibial defect > 6 cm without usable fibula). The patients were evaluated at an average of 61 months after treatment. Union and eradication of infection were achieved in 35 of 37 patients. The results of the Health Impact Analysis suggest that the infected nonunion of the tibia represented a chronic and debilitating disorder with a lasting impact.

Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus. Methods and results in 13 adults.

We reviewed the results of 13 adults of secondary reconstruction of malunited and ununited intraarticular distal humeral fractures. Their average age was 39.7 years, and preoperatively all had pain, loss of motion and functional disability; the average arc of motion was only 43 degrees and the average flexion contracture was 45 degrees. Nine patients had ulnar neuropathy. Elbow reconstruction, at an average of 13.4 months after the original injury, included osteotomy for malunion or debridement for nonunion, realignment with stable fixation and autogenous bone grafts, anterior and posterior capsulectomy and ulnar neurolysis. The elbows were mobilised 24 hours postoperatively. There were no early complications and all nonunions and intra-articular osteotomies healed. After a mean follow-up of 25 months, the average arc of motion was 97 degrees with no progressive radiographic degeneration. Ulnar nerve function improved in all cases and clinical assessment using the Morrey score showed two excellent, eight good and three fair results. Reconstruction of intra-articular malunion and nonunion of the distal humerus in young active adults is technically challenging, but can improve function by restoring the intrinsic anatomy of the elbow.

Cadaveric study on the vascular anatomy of the ulnar nerve at the elbow--a basis for anterior transposition?

The clinical results of anterior transposition of the ulnar nerve in compressive ulnar neuropathy have been unsatisfactory. This study aims at qualifying and quantifying the vascular anatomy of the ulnar nerve at the elbow so as to enable us to appreciate the possible effects of anterior transposition of the ulnar nerve. In our study of 16 cadaveric limbs, we found that the average number of nutrient vessels supplying the ulnar nerve is 14.3. The main contributing vessel in the arm is the superior ulnar collateral artery, at the elbow, the inferior ulnar collateral artery proximally, and the posterior ulnar recurrent artery distally. In the forearm, the main supply is from the ulnar artery. The average length of the nutrient vessels ranges from 1 cm at the elbow to about 2.6 cm in the arm. The nutrient vessels at the elbow are short, small and numerous. Blood supply to the nerve is segmental in nature. In our histological study of the nerve at the elbow, we found that overall, there are more vascular channels in the intrinsic system than the extrinsic system (statistical significance p < 0.01). From this study, we were able to postulate that there is devascularisation of the ulnar nerve following an anterior transposition. The significance of the devascularisation will require further studies.

Diaphragmatic injuries: why are they overlooked?

Twenty-one cases of diaphragmatic tears (11 blunt and ten penetrating injuries) were reviewed retrospectively. Left-sided diaphragmatic ruptures predominated except for two patients with penetrating injuries and one patient with bilateral tears following blunt trauma. Significant associated injuries (injury severity score greater than 16) were present in 76% of cases: the most common being intra-abdominal visceral injuries of the stomach, spleen and liver. Initial hypotension (systolic pressure less than 100 mmHg) was present in seven patients and respiratory distress (rate greater than 30 per min and/or Pa,O2 less than 70 mmHg) was seen in eight cases. Correct preoperative diagnosis was made in six cases while 12 were only detected during operation. The other three cases were diagnosed late. A variety of reasons accounts for the tendency to overlook diaphragmatic injuries in trauma victims. First, it is an uncommon condition presenting to an unsuspecting clinician. Second, the paucity of pathognomonic clinical signs makes for a difficult diagnosis. Third, the diverting attention of life-threatening visceral injuries accounts for failure to identify patients with the few available clinical and radiological features.