Managing supracondylar fractures of the distal humerus in children in a district general hospital.

INTRODUCTION: Controversy exists regarding the timing of surgery in children with displaced supracondylar fractures of the humerus. METHODS: We reviewed retrospectively the postoperative outcomes and complications in these children managed in a district general hospital. RESULTS: There were 81 children with displaced supracondylar fractures (64 Gartland type III and 17 type IIA). Of these, 46 children were treated within 6 hours of presentation and 35 were treated later. The rate of open reduction was higher in children treated early (23%) than in late cases (11%). There was no significant difference in the postoperative outcomes and complications between the groups. CONCLUSIONS: In children with a supracondylar fracture, the timing of surgical treatment (before or after six hours from presentation to hospital) had no effect on postoperative complications and outcomes.

Clinical efficacy and cost effectiveness of intraoperative cell salvage in pelvic trauma surgery.

INTRODUCTION: Pelvic acetabular injuries are associated with significant blood loss. This is compounded by multiple surgical interventions including definitive fracture fixation, which put patients at further risk of postoperative transfusion. We use intraoperative cell salvage routinely as a blood conservation strategy to address this issue. This is a prospective evaluation of the clinical efficacy and cost effectiveness of using intraoperative cell salvage in patients with pelvic acetabular injuries. METHODS: Data were collected prospectively for all the patients who underwent pelvic acetabular fracture fixation at our institution. A total of 30 patients (25 men, 5 women) with a mean age of 41 years (range: 31-79 years) were assessed over a period of 10 months. RESULTS: The mean preoperative and postoperative haemoglobin levels were 11.8g/dl and 9.9g/dl respectively. The mean intraoperative blood loss was 1,232.5ml (range: 150-2,693ml). The mean amount of blood salvaged and retransfused through a cell saver was 388ml. Of the 30 patients, 14 (47%) required transfusion after surgery and 26 units of blood were transfused. In terms of cost effectiveness, a total of £2,572 in 30 patients or £86 per patient were saved. CONCLUSIONS: We found intraoperative cell salvage to be clinically efficacious and cost effective in patients with pelvic acetabular injuries.

Management of abductor mechanism deficiency following total hip replacement.

Deficiency of the abductor mechanism is a well-recognised cause of pain and limping after total hip replacement (THR). This can be found incidentally at the time of surgery, or it may arise as a result of damage to the superior gluteal nerve intra-operatively, or after surgery owing to mechanical failure of the abductor muscle repair or its detachment from the greater trochanter. The incidence of abductor failure has been reported as high as 20% in some studies. The management of this condition remains a dilemma for the treating surgeon. We review the current state of knowledge concerning post-THR abductor deficiency, including the aetiology, diagnosis and management, and the outcomes of surgery for this condition.

Acute fractures of the scaphoid bone: Systematic review and meta-analysis.

BACKGROUND: The scaphoid fractures account for 50%-80% of all carpal bone fractures in young individuals. Non-union of the fracture occurs in approximately 5%-10% of undisplaced scaphoid fractures. Current management varies significantly among different places and surgeons. OBJECTIVES: The purpose of this review is to investigate the evidence of the effectiveness and safety of various treatments of acute scaphoid fractures. METHODOLOGY: Systematic review and metanalysis of all the randomised and quasi-randomised trials comparing different treatments of acute scaphoid fractures. RESULTS: Thirteen RCTs (Published 18 times) have met our inclusion criteria. The followings have been investigated: 1. Colles cast versus scaphoid cast. 2. Above elbow versus below elbow scaphoid cast. 3. Colles cast with the wrist in flexion versus Colles cast with the wrist in extension. 5. Operative versus non-operative treatment. 6. Union rate versus time to union. CONCLUSION: Scaphoid fracture can be treated by Colles cast for up to 12 weeks. The wrist should not be in flexion. There is no advantage of an above elbow cast over a below elbow cast. Operative treatment for scaphoid does not provide a higher union rate in undisplaced fractures, but may do in displaced fracture. Open approach seems to be superior to percutaneous fixation.

To what degree is digital imaging reliable? Validation of femoral neck shaft angle measurement in the era of picture archiving and communication systems.

OBJECTIVES: This study investigates the reliability of femoral neck shaft angle (NSA) measurements made with the software and images available in routine clinical practice. METHODS: Using the Centricity Enterprise™ (GE Healthcare Pty Ltd Piscataway, NJ) picture archiving and communication system (PACS), the NSA of the proximal femur was measured from anteroposterior radiographs of adult hips. 3 independent observers, using a standardised technique, performed a total of 120 measurements. RESULTS: The Pearson's correlation coefficient for the intraobserver agreement was 0.98 (p<0.01) and for interobserver measurements 0.86 (p<0.01). Bland-Altman plots revealed the limits of intraobserver agreement to be ±2.5°, but interobserver limits of agreement to be ±6°. The intraclass correlation coefficient (ICC) was also calculated. The interobserver ICC was 0.62 (0.42-0.78, 95% confidence interval (CI); p<0.001). The intraobserver ICC was 0.98 (0.95-0.99, 95% CI; p<0.001). CONCLUSION: PACS software has many advantages, but when using systems that can display angle measurements to one-tenth of a degree caution must be exercised to ensure that reliability of these measurements is not overestimated. We found that in the context of measuring the NSA of the proximal femur the reliability of the measurement, even under the best conditions, is only ±6° for different observers.

Skin puckering as a sign of humeral neck fracture.

To the best of our knowledge, this is the first clinical report of skin puckering associated with fractured neck of humerus. Its significance may vary in different locations and its presence should be added to other physical and radiological signs to aid decision making.