Complex fractures, do we operate on enough to gain and maintain experience?

Complex fractures are generally assumed by our profession to require adequate training and continuing practice to treat optimally. The quantity of complex fractures treated in individual hospitals and by or under the care of individual orthopaedic consultants may have implications regarding the quality of care for particular patients and also for the training of specialist registrars.A complex fracture was defined as a comminuted peri- or intra-articular fracture or segmental shaft fracture: fractures acknowledged at specialist fracture courses and by special trauma surgeons to require particular training and experience to treat optimally. The AO classification was used: most fractures were in AO groups B and C [M.E. Muller, S. Narazian, P. Koch, J. Schatzker, The Comprehensive Classification of Longbones, Springer, Berlin, 1990]. Theatre records were used to identify all operated orthopaedic trauma cases over a period of 1 year in one District General Hospital (DGH) and one University Hospital, each serving populations of over 300000 and for 6 months in one DGH (population approximately 300000). Radiographs and hospital records were reviewed by two orthopaedic surgeons and the number and type of complex fractures documented as defined above. In hospital A, 69 complex fracture operations were carried out under the care of six consultants in 12 months. In hospital B, 24 complex fractures were treated by five consultants over a 6-month period and in hospital C, 127 complex fractures were treated by 10 consultants over a 12-month period. Some consultants (different consultants for different fracture regions) did not operate on any complex fracture of the proximal, mid, or distal humerus; proximal, mid, or distal radius or ulna; proximal, mid, or distal femur; proximal, mid, or distal tibia; calcaneum; peri-prosthetic; Lisfranc; or talus fracture during the specific time period. Some consultants only treated one or two such fractures. Where two surgeons had developed an area of special interest and cross-referral were encouraged individual surgeons were operating on up to 25 complex cases in their area of interest.This audit has shown that individual complex fractures present infrequently to particular hospitals and surgeons. This finding raises questions about the optimal management of such fractures: are we maintaining a sufficient level of expertise, or should there be more cross-referrals to surgeons with a specific interest either in trauma or in a particular anatomical region?

An assessment of the POSSUM system in orthopaedic surgery.

We describe the development and validation of a scoring system for auditing orthopaedic surgery. It is a minor modification of the POSSUM scoring system widely used in general surgery. The orthopaedic POSSUM system which we have developed gives predictions for mortality and morbidity which correlate well with the observed rates in a sample of 2326 orthopaedic operations over a period of 12 months.

Head injury in the severely injured: long-term follow-up in 157 patients.

Ninety-two patients with head injury in the context of multiple injury were followed up 5 years after injury. Severe disability in this group of patients was nearly always due to brain/spinal cord injury, rather than musculoskeletal injury. A substantial number of patients with mild or moderate head injuries had significant persisting disability 5 years after injury.

Disability after severe injury: five year follow up of a large cohort.

The early outcome for severely injured patients has improved in the last 20 years, but the level of continuing long term disability in such patients is not known. A large cohort of severely injured patients (ISS > 15) were interviewed and examined approximately 5 years following their injury. We present the preliminary results which show that only 30 per cent had made a full recovery, and that an alarming 47 per cent remain with moderate, severe or very severe disabilities. A large proportion (45%) of the persisting disability is due to pelvic and limb injury (74 per cent if brain and spinal cord injuries are excluded). This study reflects initial treatment in 13 District General Hospitals and one Teaching Hospital in a single geographical region in 1989 and 1990, and is the first such study in the UK. We conjecture whether more aggressive and specialized treatment and rehabilitation, especially of orthopaedic injuries, would improve these disappointing results.

Preventable deaths among major trauma patients in Mersey Region, North Wales and the Isle of Man.

Preventable and unexpected deaths following injury were identified from among 1088 victims of major injuries arising in a defined population and area during a 12-month period. In hospital, 44 (16 per cent) deaths from blunt injury, one death from penetrating injury and one death from drowning were preventable. In patients sustaining blunt injuries, 22 per cent of non-head-injury deaths and 13 per cent of head-injury deaths were preventable. In all preventable head-injury deaths either a delay in operation (35 per cent) or no operation for mass lesions (65 per cent) occurred, often because of misdiagnosis as alcohol intoxication (22 per cent) or CVA (22 per cent). Multiple preventable factors were more likely in non-head-injury deaths and included missed injuries (67 per cent), poor airway care (57 per cent), delayed or no operation (52 per cent), undertransfusion (38 per cent) and inadequate surgery (19 per cent). By TRISS methodology the outcome was unexpected, in 53 per cent blunt injury deaths in hospital and 2.8 per cent of survivors. Three preventable blunt injury deaths (6.8 per cent) had probabilities of survival < 50 per cent and were not, therefore, identified as unexpected by TRISS. A preventable death rate of 16 per cent for blunt injuries equates to 638 preventable blunt injury deaths each year in England and Wales.

Maxillofacial and associated injuries in severely traumatized patients: implications of a regional survey.

The aim of this paper was to study the incidence and causes of facial injuries occurring in conjunction with major trauma, and to examine the role of the maxillofacial surgeon in the management of severely injured patients. A prospective study was undertaken of 1088 patients seen in 16 hospitals over a 1-year period. A total of 161 (15%) patients sustained facial injuries. Of these, 33% died at the scene of the incident and 21% died in hospital. There was poor resuscitation in 32% of patients, and a total of 32 injuries were missed in 19 patients. The involvement of the maxillofacial surgeon in the management of severely injured patients is examined. Our findings emphasize the need for early referral to the maxillofacial surgeon. It is concluded that maxillofacial surgery should be an on-site speciality, closely associated with the neurosurgical centre.

Severe motorcycle injury in Mersey region and North Wales.

Ninety-three patients were involved in serious motorcycle accidents (death or Injury Severity Score more than 15) during a 1-year period among a total of 554 victims of serious road traffic accidents studied at 16 district general and teaching hospitals. There were 91 males and two females. The average age was 29 years (range 15-81 years). Of these, 32 per cent died at the scene of the accident or in transit; 68 per cent arrived alive at the above hospitals. Of the latter, 30 per cent died in hospital. The commonest cause of death was multiple injuries. The Injury Severity Score of patients admitted to hospital was a mean of 32.1. The Glasgow Coma Score was below 9 in 33.8 per cent. Of those admitted to hospital, the average length of stay was 38.7 days. 67 per cent were admitted to intensive therapy unit of whom 41.3 per cent had to be ventilated for an average of 3.55 days. There were four preventable deaths among the patients who died after being admitted to hospital. Many body areas are frequently injured in motorcycle accidents which occur usually in fit males. Careful assessment along with vigorous and aggressive treatment is particularly important for this group. Access to a specialized trauma centre would be beneficial.

The epidemiology of major injuries in Mersey Region and North Wales.

A prospective epidemiological study was undertaken to determine the workload and patient characteristics for a putative trauma centre in a large defined area. One thousand and eighty-eight patients were included: 430 brought in dead, 309 hospital deaths and 349 survivors. Types of injury were: blunt 76 per cent, penetrating 3.6 per cent, burns 5.8 per cent, other 14 per cent. The incidence of blunt injury was 19/100,000 for patients arriving alive at hospital and accounted for 0.08 per cent of new A & E attendances. Eight per cent of blunt injury patients were children, 68 per cent were adults and 24 per cent elderly. Major causes of injury were: road accidents 67 per cent and falls 26 per cent. In patients arriving alive after blunt injuries, those who subsequently died were significantly older, more severely injured and more physiologically impaired. Hospital mortality was 45 per cent for blunt, 43 per cent for penetrating injuries, and 67 per cent for burns. TRISS methodology indicated 53 per cent of hospital deaths from blunt injuries were unexpected. Practically, it is questionable whether the incidence of major injuries is sufficient to provide the volume of patients necessary to sustain a Level I Trauma Centre. Nevertheless, concentration of injury service is essential, since no hospital receives sufficient patients to develop and maintain expertise.

Regional review of blunt trauma in children.

Seventy-five severely injured children (Injury Severity Score greater than 15 or death) were identified during a 1-year prospective audit of all severe trauma in a single region. Fourteen children were admitted primarily to the regional children's hospital, comprising 0.2 per cent of that accident and emergency department workload. Paediatric trauma admissions to the 15 district general hospitals averaged 3.1 children per hospital per year or 0.007 per cent of the accident and emergency department attendances. There were 38 deaths (51 per cent), of which 15 occurred before admission to hospital. Significant deficiencies in acute management were identified at both types of hospital. There is a need to improve trauma management of children at tertiary care level and district general hospitals by developing trauma management protocols. The low number of severely injured children presenting to the district general hospitals suggests the need for a regional trauma system.

Regional audit of pedestrian accident care.

In all, 160 serious pedestrian accidents (ISS > 15 or death), were recorded during a 12-month prospective study of all trauma in a population of 3.2 million. Of these, 35 died at scene, 125 arrived at hospital alive and 68 (54 per cent) subsequently died. There were 35 (22 per cent) children, and 62 per cent (39) were more than 60 years of age. Prehospital care significantly delayed transfer to hospital. In the accident and emergency department, only 38 per cent of those unconscious had a cervical collar applied, and only 67 per cent were intubated. Of those transferred for neurosurgical care, 34 per cent were not intubated. The Median Injury Severity Score for each outcome group was similar between age groups. The Revised Trauma Score and APACHE II score showed significant differences between those who lived and died. TRISS analysis revealed that 32 per cent of deaths and 12 per cent of survivors were unexpected. ATLS treatment protocols should be instituted for prehospital care and in all accident and emergency departments (A&E).

Pedestrian accidents on Merseyside: the case for criminalization of jaywalking.

During a 12-month review within Merseyside, 85 serious pedestrian accidents (ISS > 15 or death), were identified. Analysis of police accident statistics showed that 17 per cent of these cases had not been recorded. Children and the elderly made up 64 per cent of those injured. Accidents were more common in the afternoon and evening and evenly spread throughout the week. There was a low rate of alcohol testing among casualties who died and involved drivers. The majority of accidents occurred in good visibility and weather; 90 per cent were due to pedestrian behaviour.

Radio-lunate arthrodesis.

Radio-lunate arthrodesis has been carried out in 15 rheumatoid patients whose radiographs showed localised arthritis around the radio-lunate joint. Six patients had insertion of a Stanley-Shelley plate. The results were assessed from 1 to 3 1/2 years after operation and were excellent in nine wrists, good in three, fair in one and poor in three wrists. Continued carpal degeneration in 12 wrists suggests that long-term follow-up is required before this procedure can be generally recommended.

The prevention of adhesions after laminectomy. Adverse results of Zenoderm implantations into laminectomy sites in rabbits.

Zenoderm (Ethicon Ltd., Edinburgh, Scotland) is porcine skin dermis specially treated so as to be weakly antigenic when implanted. Its use as an extradural spinal and nerve root membrane to reduce postoperative adhesions after laminectomy was tested in 22 rabbits with laminectomy in the second and fourth lumbar vertebra. The sites were reviewed histologically two to 36 weeks after operation. Histologic sections showed that Zenoderm was initially surrounded by hematoma that organized into fibrous tissue and, later, bone. When Zenoderm was placed immediately adjacent to the dura, dense adhesions formed, which were slower to resolve than those in the control sites. The rate of Zenoderm resorption was variable. In general, Zenoderm did not excite excessive fibrous tissue formation and was slowly replaced by bone. Contrary to the experience of others, it was unusual to find adhesions between the laminectomy site, and the dura began disappearing after six to nine weeks. In rabbits, Zenoderm is unlikely to prevent adhesions forming after lumbar disc surgery. The resorption rate is variable, and laminectomy sites are unsuitable for the investigation of material for the prevention of spinal dural adhesions.

Computed tomogram myelography in cervical spondylosis.

Nine patients with severe and prolonged signs and symptoms due to cervical spondylosis had myelography followed by a CT Scan using the same injection of intrathecal contrast. All patients had radiographic changes of cervical spine degeneration and were being considered for exploration and fusion of the anterior cervical spine. All patients had a full clinical evaluation, EMG studies and plain radiographs taken prior to their CT Scan. EMG readings showed several levels of compression in three patients but did not indicate a single level in any. Plain radiography showed multiple level involvement in every patient. Myelography indicated significant indentation in three of five patients with clinical signs but did not demonstrate root cut off in any case. CT Myelography indicated the degree of Lushka and facet joint involvement, indentation, exit foramen encroachment, and the degree of spinal stenosis at the involved segment. In three patients, the findings at operation correlated closely with the CT Scans. Myelography failed to indicate the presence of significant osteophytes in these two cases.

Fracture dislocation of the calcaneus. A report of two cases.

In two typical cases of calcaneal fracture dislocation, the primary fracture, which runs forward and medially from a point behind the sustentaculum tali, is associated with inversion of the hindfoot. The calcaneus splits into a small anteromedial and a larger posterolateral fragment. Rupture of the lateral collateral ligament allows the posterolateral calcaneal fragment to move laterally to lie immediately subjacent to the distal fibula. Closed reduction is impossible. Open reduction of this rare fracture dislocation is essential. A lateral approach to the calcaneus is generally sufficient, but a second medial incision may be required.

A new directly moulded patellar-tendon-bearing socket.

Silicone rubbers and casting tapes individually have previously been used in the manufacture of sockets (Swanson, 1972; Sweitzer, 1973; Ruder, 1977; Graves, 1980; Aqualite, 1982). The authors believe that the present combination of these materials to manufacture a directly moulded socket with a complete silicone rubber lining of variable thickness has not previously been described. The new socket, after addition of the modular components, allows fitting of an aligned below-knee prosthesis within three hours. The socket (Fig. 1.) is made directly on the below-knee stump, can be completed with experience in an hour and does not require the use of specialized equipment. The socket consists of an outer supportive Scotchflex layer inside which is a lining of soft smooth biocompatible silicone rubber of deliberately variable thickness to allow pressure tolerant areas to accept more load and pressure sensitive areas to accept less load (Fig.2). The thicker areas of silicone are produced by applying carefully cut Plastazote pads to the pressure sensitive areas. The thickness and extent of the pads is individually assessed according to the estimated sensitivity of the particular area (Fig. 3). The Scotchflex socket is then manufactured directly on the below-knee stump with these pads applied. The pads are then removed prior to insertion of a semi-liquid silicone rubber. Thus, when the socket with the liquid silicone rubber is re-applied to the stump, the space produced by the pads is filled by the rubber which then sets at room temperature. In this way a layer of variable thickness is produced.(ABSTRACT TRUNCATED AT 250 WORDS)