Risk of extremity fractures in adult outpatients with epilepsy.

PURPOSE: To study the incidence of extremity fractures in a group of adult patients with epilepsy attending an outpatient clinic compared with the incidence of fractures in the general population in the same geographic area. METHODS: We selected 177 consecutive adult patients with epilepsy attending the outpatient clinic at the Department of Neurology at Karolinska Hospital in Stockholm in 1995. This study population was matched with an Injury Registry to identify those epilepsy patients who during 1991 through 1995 attended the emergency department for an extremity fracture. The observed number of fractures in the epilepsy group was compared with the corresponding number of expected cases based on regional fracture rates. Relative-risk estimates for fractures were calculated with respect to the duration of epilepsy, mono- or polytherapy, and history of tonic-clonic seizures. RESULTS: Twenty (11%) of 177 patients sustained 23 fractures that prompted a visit to the emergency department. The incidence of fractures in the epilepsy patients was 23.8/1,000 person-years. The overall Standardized Morbidity Ratio (SMR) was 2.39 (95% CI, 1.52-3.59). A significantly higher risk for fractures was thus found in patients with epilepsy. Risk factors were age 45 years or older, male sex, and occurrence of generalized seizures. It also was found that the relative risk of fractures was higher during the first and second year compared with >or=5 years after diagnosis (RR, 3.71; 95% CI, 1.20-11.48). CONCLUSIONS: Our results highlight the risk of fractures in outpatients with epilepsy. In this patient group, 43% of the fractures were definitely or possibly seizure related. Males 45 years or older are a particular risk group. Special attention is required for this group of patients who are at higher risk for fractures. The risk is apparently higher in the first 2 years after diagnosis, although potential bias in ascertainment of fracture incidents in our study may have underestimated the long-term risk for fractures.

Improved trauma care after reorganisation: a retrospective analysis.

OBJECTIVE: To shorten the time to make a diagnosis and to begin definitive treatment of severely injured patients, thereby improving their medical care. DESIGN: Retrospective analysis. SETTING: Teaching hospital, Sweden. SUBJECTS: 61 patients who had sustained high-energy injuries, including head injury which required surgical intervention, and fracture of the femoral shaft before (1987-1988 n = 23) and after (1991-1993 n = 38) the reorganisation. INTERVENTION: Trauma care was reorganised during the year 1989-1990 and the concept of early multidisiplinary treatment with the general surgeon as trauma-leader was adopted. MAIN OUTCOME MEASURES: The time required to make a diagnosis and begin definitive treatment as well as the assessment of medical care taking account of the patient's general condition and other injuries. RESULT: The immediate medical care was classified as delayed or inappropriate in 9 of 23 patients before, and in 2 of 38 patients after, the reorganisation (p = 0.001). The time needed to make a diagnosis was less than 4 hours in all cases. The time needed to start definitive treatment of head injuries was less than four hours in 9 of 12 patients before, and in 18 of 21 patients after the reorganisation. The internal fixation of femoral fractures was started within four hours in 2 of 11 femoral fractures before, compared with 12 of 17, after the reorganisation. CONCLUSION: The time to beginning definitive treatment of severe injuries was shorter after the reorganisation, as a result of early participation of members of the trauma team.

Open tibial fractures: faster union after unreamed nailing than external fixation.

Unreamed intramedullary nailing is an alternative to external fixation in the treatment of open tibial fractures. We compared a prospective series of thirty-one patients managed with a solid nail with static interlocking without intramedullary reaming, with a retrospective series of thirty-one patients managed by external fixation. The protocol for soft tissue treatment was the same throughout the study period. Most fractures were caused by high energy trauma and included Grade I to III B injuries. The fracture wound infection rate was equal in both groups; there were two deep and three superficial infections in the nail group and three deep and two superficial infections in the external fixation group. In addition, eleven patients in the external fixation group had severe pin track infections. The mean time to union was five months in the nail group and eight months in the external fixation group. The incidence of delayed union was twice as high in the external fixation group as in the nail group. The number of surgical procedures performed to promote union was three times higher in the external fixation group. The malunion rate did not differ between the groups. Although the treatment groups are not fully comparable, the results indicate that intramedullary nailing is superior to external fixation in the treatment of most open tibial fractures.

The Stockholm County programmes for accident and alcohol prevention and injury surveillance--initial experiences.

A comprehensive programme for accident prevention and injury surveillance was established in Stockholm County in 1988. Its main objective is to reduce the morbidity and mortality of unintentional injuries by 25% by the year 2000, and by more than 25% in the high-incidence groups. An accident prevention unit has been assigned to task of planning and implementing an accident prevention programme, while a programme for prevention of alcohol-related problems was set up later. An injury epidemiological unit at the Karolinska Hospital is responsible for coordinating injury surveillance, which is an important contribution for monitoring and evaluation of the prevention programmes. On injured patients information about type of injury, extent of injury, place, activity, injury mechanism, external cause of injury, treatment and other items is entered on a special registration form. In (10%) of 11,327 injury events alcohol was considered by the physician to be a main or contributory cause of the injury, with a predominance among males. An act of violence was approximately three times as common among males and five times as common among females with alcohol involvement than among cases without alcohol involvement. The injury surveillance can be an important means for evaluation of programmes for prevention of injuries and alcohol-related events.

Major differences in trauma care between hospitals in Sweden: a preliminary report.

The quality of trauma care has been studied at five different Swedish hospitals. The results suggest that improvements in the quality of medical care for patients with severe road traffic injuries can be achieved by reorganizing the highly decentralized trauma care system in Sweden. Above all there is a need for a better structure and organization of the on-call system and of the cooperation of physicians of different specialties within the hospital. The medical care of patients with severe injuries was delayed in 30% and was inappropriate in 7% of cases. Assessment of the quality showed great variation between the hospitals. The medical care was in fact not best at the university hospital but at one well-functioning small hospital. It was an effect of an on-call system at the small hospital, which guarantees rapid participation of senior staff in both general surgery and orthopaedic surgery. The greatest problems arose in early diagnosis and treatment of bleeding in abdominal injuries. This was caused by inexperience in the first on-call team in combination with late assessment by second on-call consultants. Fractures of the femoral shaft in almost half of the cases did not get definitive surgery until several days after the accident.

Injury surveillance at emergency departments in an urban area. Methodology and quality control.

An injury surveillance system has been developed and tested in a pilot study at two emergency departments in the Stockholm area. The object was to develop an all-age, all-injury registration at all hospital emergency departments and primary care units treating injured patients. The information will be used at the local level for preventive measures, and on a national level for comparison with other areas. All injured patients were given a record-sheet that served both as a registration form and a medical record. The NOMESKO-code was used as a basis for classifying intent, activity, type of location, and injury mechanism. Altogether, 11,327 injured patients were registered. One day each month was randomly selected from the registration for control of registry completeness. The drop-out rate was on average 13%. The reasons were that patients had not been provided with the injury form, or that the copy of the form had not been sent to, or had not reached the Epidemiological Unit where data entry was performed. 6% of the injuries occurred in patients living outside the Stockholm area. The average shortfall-rate in filling in the NOMESKO-code on the registration form was 10%. The rate of registry drop-outs and incomplete forms should decrease when registration has become a routine procedure, provided that the staff can be engaged in the preventive work and the registration procedure can be adjusted to the routines of trauma management in each emergency department.

Factors predisposing to healing complications after internal fixation of femoral neck fracture. A stepwise logistic regression analysis.

A stepwise logistic regression analysis was made to assess the influence of various factors on the rate of healing complications after femoral neck fracture. A prospective series comprising 101 patients with fresh fractures treated by closed reduction and internal fixation was included in a roentgenographic follow-up study. The single most important factor was the quality of reduction, followed by the type of fracture, and the position of the internal fixation material. Age, gender, and type of internal fixation device (three screws or three nails) were not found to influence the healing complication rate. The predicted probability of a healing complication for different combinations of the three most important factors ranged from 0.05 to 0.99. The highest value was found for the combination Garden Type IV fracture, which had unacceptable reduction and position of the internal fixation material. The results show that failure to achieve adequate reduction should be a strong argument in favor of primary hip arthroplasty.

Localization of the chromosomal breakpoints of the t(12;16) in liposarcoma to subbands 12q13.3 and 16p11.2.

Short-term cultures of two myxoid liposarcomas and two mixed-type (myxoid and round cell) liposarcomas were cytogenetically analyzed. A t(12;16)(q13;p11) was present in three tumors, whereas the fourth had an unbalanced 12;16-translocation with breaks in 12q13 and 12q22, with loss of the 12q13-q22 segment, and in 16p11. In the two mixed liposarcomas, the breakpoints could be determined at subband level to 12q13.3 and 16p11.2.

Prognostic accuracy of preoperative and postoperative scintimetry after femoral neck fracture.

Forty patients with fresh femoral neck fractures treated with closed reduction and internal fixation were included in a prospective study of nonunion and osteonecrosis by preoperative and postoperative scintimetry. Correlated roentgenographic follow-up studies were continued for two years postoperatively. The aim of the study was to determine the relative prognostic accuracy of preoperative versus postoperative scintimetry. A ratio between the radionuclide uptake over the femoral head on the fracture side and the contralateral side exceeding 1.9 at the preoperative scintimetry and 1.2 at the postoperative scintimetry was associated with a high incidence of union, whereas a lower ratio often predicted subsequent complications (redisplacement, nonunion, or late segmental collapse). Prognostic accuracy was higher for scintimetry of fractures treated with closed reduction and internal fixation (0.70) than for untreated fractures (0.53). These results suggest that scintimetry is useful postoperatively to complement roentgenographic examination in assessing the prognosis of femoral neck fractures.

Arthrodesis of the first carpometacarpal joint. 33 cases of arthrosis.

Thirty-three arthrodeses were performed for arthrosis of the first carpometacarpal joint in 29 patients. The patients were reexamined 5 (2-10) years after the operation. Twenty arthrodeses were clinically satisfactory, although two had failed to unite. Analysis of this group showed that a painless stiff carpometacarpal joint causes some functional impairment, considered negligible by most patients. The remaining 13 cases were unsatisfactory due to pain caused by arthrosis in the peritrapezoidal joints (7 cases), nonunion (4), radial nerve neuroma (1), and unknown reason (1).

Nail versus screw fixation of femoral neck fractures. A 2-year radiological and clinical prospective study.

137 recent femoral neck fractures were randomly allocated in a prospective study to internal fixation with either Nyström nails or Scand screws. A radiological and clinical follow-up was conducted of all survivors one and two years postoperatively. Reduction was unsatisfactory in 15 of 87 patients included in the two-year follow-up study. 13 of them developed complications. The 44 Nyström-nailed fractures included in the two-year follow-up showed sliding of the nail in 22 cases, redisplacement/nonunion in 14, and late segmental collapse in 5. The results of clinical examination were excellent or good in 30 patients and fair or poor in 14. Among the 43 Scand-screwed fractures sliding of the screw occurred in 1 case, redisplacement/nonunion in 14, and late segmental collapse in 4. In 35 patients the result was graded as excellent or good and in 8 as fair or poor. No statistical difference between the groups was found with respect to the incidence of redisplacement, nonunion and late segmental collapse, nor with respect to the results of the clinical assessment at the one-year and two-year follow-up. There was a considerably higher incidence of extrusion of the internal fixation device among the nailed fractures than those treated with screws. The results indicate that Scand screws are a better alternative to Nyström nails in the treatment of femoral neck fractures. If an adequate reduction cannot be achieved, primary hip replacement is recommended.

Consumption versus need of institutional care after femoral neck fracture.

For 137 patients who sustained a femoral neck fracture domiciliary circumstances, ADL functional level and walking ability were recorded during a period of six months in 1983. At the time of injury 71% were living at home or in a so-called service apartment with medical and domestic facilities, and 28% in chronic care institutions (1% were transferred from other acute care units). Of the surviving patients 43% could return directly home or to a service apartment on discharge, 21% were transferred to an orthopedic rehabilitation facility, convalescent home, or other acute care unit, and 36% to chronic care institutions. At the 1-year as well as the 2-year follow-up 39% of the surviving patients were living in chronic care institutions. Analysis of the various parameters for patients having recourse to chronic care facilities at follow-up, showed that almost half of this group might be cared for at home. However, this will only be possible on condition that an extensive and effective home medical care system is developed as a complement to domestic assistance provided by public agencies. It is unrealistic to expect the incidence of patients needing chronic care facilities following femoral neck fracture to subside below a minimum of 20%.

A scintimetric study of Colles' fracture. Comparison between cementation and closed treatment.

In order to study whether bone cement (methylmethacrylate) inserted in the medullary cavity of redisplaced Colles' fractures to fill the dorsal defect arising after repeat reduction is an obstacle to bony union, the course of healing was monitored by scintimetry in fractures thus treated (n = 10), in fractures treated by external fixation (n = 10), and in undisplaced fractures immobilized in a plaster cast. No differences emerged between the three groups. It is therefore assumed that the insertion of bone cement does not disturb the healing process.

Sequential scintimetry after femoral neck fracture. Methodologic aspects and prediction of healing complications.

Forty-five patients with recent cervical hip fractures were included in a prospective, clinical, radiographic and sequential scintimetric study. Striking changes in radionuclide uptake over the entire hip region on the fracture side were found during the first 5 postoperative months. Fractures that healed without complications showed the highest relative femoral head uptake at 1 week and a peak value at 6 weeks, followed by a gradual decline at the subsequent examinations. Fractures with complications (redisplacement, nonunion, or late segmental collapse) showed a lower initial uptake and a more gradual increase and only a slight tendency towards increased uptake after 3 months. The accuracy in predicting nonunion with scintimetric examination alone is high both at 1 and at 6 weeks, and the accuracy is almost equally high with combined scintimetric, radiographic, and clinical assessment 3-5 months postoperatively.

Sequential scintimetry in prediction of healing rate after femoral neck fracture.

Thirty-one femoral neck fractures which united without complications (nonunion or late segmental collapse) were included in a prospective sequential scintimetric study. Roentgenologically, three subgroups with different healing rates could be distinguished: rapid union, normal union, and delayed union. All fractures showed a rapid increase in relative femoral head radionuclide uptake after the 1-week scintimetry, followed by a gradual decline after 6 weeks-3 months. However, both the initial rise in activity and the time for maximal uptake tended to differ between the three groups. For rapid union and normal union the peak activity was registered at 6 weeks and for delayed union at 3 months. It is concluded that sequential scintimetric assessment of femoral head uptake can identify different healing rates and that this difference can be partly explained by a transient impairment of vascular supply to the femoral head in fractures with delayed healing.

Respiratory distress following major trauma. Predictive value of blood coagulation tests.

We have evaluated the use of laboratory parameters to predict the risk of adult respiratory distress syndrome (ARDS) at an early stage after major trauma. Patients with lung contusion were excluded. Five of 29 patients fulfilled our criteria of ARDS, i.e. PaO2/FiO2 less than or equal to 38. They showed lower platelet counts and antiplasmin as well as a tendency to lower antithrombin III, fibrinogen, and plasminogen. These changes indicated activation of the coagulation and fibrinolytic systems by trauma. The most sensitive indicator of ARDS seemed to be the platelet count, although it was also related to blood loss and amount of blood transfused. Hence the platelet count should be considered in relation to blood replacement in the patient with major trauma. Tentative laboratory values are suggested to indicate risk levels of developing ARDS.

Radionuclide scintigraphy of femoral head specimens removed at arthroplasty for failed femoral neck fractures.

In order to determine the value of scintimetry as a tool for quantitative measurement of femoral head vascularity, the results of postoperative scintigraphic and histologic examination of surgically removed femoral head specimens were compared with those of preoperative radionuclide scintigraphy in 19 failed femoral neck fractures. Following intravenous administration of 600 MBq of Tc-99m MDP before hip replacement, the activity distribution in femoral head sections was recorded with a gamma camera and the area of isotope uptake calculated. A correlation was found between the results of preoperative noninvasive radionuclide scintigraphy and the assessment of isotope uptake in the removed femoral head specimens (r = 0.83, p less than .001) and was confirmed by the results of histologic examination. There is a risk, however, of overestimating the ratio of isotope uptake between the femoral head on the fracture side relative to the contralateral side with respect to quantitative assessment of femoral head vascularity, due to the general increase in isotope owing to accumulation in the injured hip region. The calculations, however, reflect the levels of radionuclide uptake and the varying degrees of femoral head vascularity.

Radionuclide scintimetry for diagnosis of complications following femoral neck fracture.

A scintimetric study using Tc-99m MDP was made of 54 patients with delayed union, nonunion, or late segmental collapse of the femoral head, 4-92 months after femoral neck fracture. In radiographically verified collapse, the radionuclide uptake ratio between the femoral head on the fractured and on the intact side (HHR) was significantly higher than in fractures resulting in delayed union or nonunion. On the basis of scintimetric and radiographic findings, the patients with healing disturbances could be divided into three groups, characterized by the following features: Satisfactory post-reduction position of the fracture without subsequent redisplacement and a high HHR, which as a rule turned out to be delayed union; The same radiographic pattern but with a lower HHR, which in most cases resulted in nonunion; Inadequate reduction or early redisplacement of the fracture with a high HHR, which resulted in nonunion. The fractional precision in discriminating between different types of disturbed fracture healing by means of skeletal scintimetry was 0.86 in this study. This non-invasive and technically simple method would therefore be a valuable complement to radiography in the assessment of healing, more than 4 months after fracture of the femoral neck.