Trends in the incidence of hip fractures.

UNLABELLED: Hip fracture incidence in the capital city of Serbia was assessed over a period of 10 years (2000-2009). Crude annual incidence rates increased significantly for all ages and both sexes (p = 0.002). Age-adjusted rates also showed a steady increase. The mean rate of annual change for age-adjusted rates was 8.6 % (95 %CI 7.5-9.7) in males, 8.0 % (95 %CI 7.4-8.6) in females, and 8.2 % (95 %CI 7.7-8.7) in the total population. INTRODUCTION: The aim of this study was to estimate the incidence rate and trend of hip fractures in the population of Belgrade, the capital of Serbia. METHODS: Data sources were the official statistics of the Public Health Institute in Belgrade. The patient's age, gender, residence, hospital admission, and diagnosis were registered for each hospital admission. Population estimates were based on census data from 2002 and on published estimates for the intercensus years. The annual incidence (crude) rates and age- and sex-specific incidence rates were calculated with 95 % confidence intervals (CI) and age-adjusted incidence rates for persons over the age of 50 years were computed. RESULTS: A significantly increasing trend of crude incidence rates for all ages was observed in males (p = 0.002), females (p = 0.001), and overall (p = 0.002). The proportion of trochanteric fractures rose significantly with age in women (p < 0.0001), whereas it decreased nonsignificantly in men ≥70 years (p = 0.44). The age-adjusted incidence rates (per 100,000 in subjects ≥50 years old) showed a steady increase. The mean rate of annual change for age-adjusted rates was 8.6 % (95 %CI 7.5-9.7) in males, 8.0 % (95 %CI 7.4-8.6) in females, and 8.2 % (95 %CI 7.7-8.7) in the total population. CONCLUSION: Hip fracture incidence continues to increase. In view of the rapid aging of the population, it is necessary to implement a comprehensive preventive policy in our community.

Pelvifemoral external fixation for the treatment of open fractures of the proximal femur caused by firearms.

Seventeen patients with open fractures of the upper third of the femur were treated using a pelvifemoral external fixation device. All of them had grade III open fractures resulting from high-velocity missile and explosive injuries with massive foreign body contamination. Sciatic nerve injury was present in five (29.4%); abdominal viscera and thoracic wall injuries were present in two patients (11.8%). There were no major arterial injuries. Full weight bearing was allowed after clinical and radiological bone healing (average 11.5 months). Chronic osteitis with fistula and sequestra developed in two (11.8%) patients. There were no nonunions and no refractures. Minor painless limitation of hip motion persisted in all patients. Upper-third femoral open fractures due to firearms are a unique type of open fractures. They are usually highly comminuted; therefore, stable fixation is difficult or impossible to achieve using external fixation with transfixation of the fracture site. On the other hand, the risk of infection is high following intramedullary nailing. Pelvifemoral external fixation allows adequate management of the soft tissue wounds, provides stable bone fixation and allows early patient mobilization.

[Incidence and severity of degenerative changes in the wrist in pseudoarthrosis of the scaphoid bone]]. / Ucestalost i intezitet degeneracionih promena zgloba rucja u pseudoartrozi skafoidne kosti.

INTRODUCTION: In patients with symptomatic scaphoid nonunion there was an increased evidence of progressive osteoarthrosis expressed as instability of the wrist [1, 2]; it is defined as a scapholunate angle of more than 70 degrees or a radiolunate angle of more than 10 degrees. Intercarpal instability causes unnatural joint movement of the wrist. This disorganization of the wrist mechanism associated with hypermobility of the schapoid bone induces degenerative changes [3]. Arthritic changes begin at the distal scaphoid-radial styloid joint and later progress to the capitolunate joint. A similarity was noted with rotatory instability of the scaphoid bone associated without fracture [2]. If mid-carpal joint exists the joint becomes unstable, the lunate rotates backwards and carpal bones show the so-called concertina deformity [4] or dorsal intercalated segment instability pattern [5]. AIM: We tried to determine the factors of risk and prognostic indicators of degenerative arthritis. METHOD: In this study 40 patients with painful nonunion of the scaphoid bone were analysed. Duration of nonunion was 1.43 year (range from 8 months to 15 years). Roentgenograms of the hand were done in anteroposterior, lateral and oblique projections. Fracture location and configuration were determined as described by Russe. Instability was determined by measuring the scapholunate and radiolunate angle in the lateral roentgenogram. Scapholunate angle more than 70 degrees and radiolunate angle more than 10 degrees were considered abnormal. To asses the amount of carpal collapse the carpal index was determined as described by Youm [6]. Abnormal value was 0.50 or less (normal value: 0.54 +/- 0.03). Four roentgenographic groups were established based on the extent of degenerative changes [7]. Group I showed no sign of degenerative changes. Group II had sclerotic lesions in fracture margins with or without a cystic formation. Group III showed lesions of radioscaphoid arthritis, including joint-space narrowing and pointing the radial styloid. Group IV had lesions of generalized arthritis of the wrist. RESULTS: Duration of nonunion was not in correlation with development of osteoarthritic changes (p = 0.644, p > 0.05) (Table 1). Progressive degenerative changes correlated well with radiolunate angle (p = 0.398, p < 0.05), capitolunate angle (p = 0.381, p < 0.05) and carpal index (p = 0.392, p < 0.05) (Table 2). The average values of intercarpal angles increased with progression of osteoarthritic changes (Table 3). There were 14 (35%) proximal third located fractures and 26 (65%) in the middle third or waist. There was a statistically strong correlation between location of the fracture in proximal third and presence of degenerative changes (p = 0.341, p < 0.01) (Table 4). Intensity of arthritic changes showed no statistically significant correlation regarding untreated fractures (p = 0.665, p > 0.05). DISCUSSION: In our study the most significant factors associated with arthritis were instability of the wrist and fracture location at the proximal third of the scaphoid bone. Mack [7] reviewed forty-seven symptomatic nonunions of the scaphoid and found a correlation between the presence of arthritis and the duration of nonunion. Also, he concluded that instability of the wrist can occur as late phenomenon in previously stable nonunion. Similar results were noted by Ruby [8] in his series. Conclusion of these authors was that the incidence of degenerative changes increased with the time after fracture of the scaphoid bone occurred [8-12]. We demonstrated that in untreated fractures associated with carpal instability, arthritis developed much earlier. Fourteen (35%) patients in our study were not treated and 92.8% belonged to Group II and Group III, with average time of nonunion duration of 27.2 months. Lunate dorsiflexion is a useful guide to carpal instability. In our experience the lunate silhouette is easily visualized on a lateral roentgenogram even in the presence of degenerative arthritis. There is a high probability that degenerative changes will occur. We recommend that a scaphoid nonunion associated with carpal instability should be operated before degenerative changes develop.

[Computer tomography in the diagnosis and therapy of acetabular fractures]. / Znacaj kompjuterizovane tomografije u dijagnostici i lecenju preloma acetabuluma.

INTRODUCTION: Acetabular fractures and fracture dislocations of the hip joint are frequently complex, and the precise pathological anatomy is not easily demonstrated by routine radiographs. Conventional radiographs are often supplemented by oblique views [1]. The most commonly used classification of acetabular fractures has been based on conventional radiographs which are, in majority of cases, sufficient to determine the type of acetabular injuries [1-3]. It has been shown that computed tomography is useful method in precise evaluation of the fracture type the soft-tissue damage and integrity of joint space [4-6]. AIM: The aim of the study was to evaluate advantages of computed tomography in diagnosis of complex acetabular fractures. METHODS: We studied 737 patients with acetabular injuries over the period from 1989 to 1998. Five hundred and seventy five (78%) were males and 162 (22%) females. Eighty patients with acetabular fractures, with and with out hip dislocation, underwent pelvic CT following AP and 45 degrees oblique pelvic radiographs. Each patient was studied while supine, using 5 mm slice thickness at the acetabulum level and 10 mm at other parts of pelvis. Sections were obtained from the iliac crest to the greater trochanter [7]. RESULTS: The causes of acetabular fractures were: 621 (84.3%) patients participated in traffic accidents, 103 (14%) fell from a height, 7 (0.9%) covered in a mine and 6 (0.8%) were wounded. Femur was the most frequently associated injuries of all bones--155 (66.5%) (Graph 1). Permanent growth of acetabular fractures was noted from 1989 to 1993 regarding gender and years (Table 1), but that growth declined in 1993. It can be explained by a lower number of traffic accidents. Traffic, as an aetiological factor is nearly related with economic and energy crisis in our country (Graph 2). There were 176 (23.8%) fractures of the posterior wall, 23 (3.1%) fractures of the posterior column, 14 (1.9%) fractures of the anterior wall, 29 (3.9%) fractures of the anterior column. Transverse fractures were present in 61 patients (8.3%), "T" fractures in 51 (6.9%) patients and 383 (52.1%) were combined fractures. Of 80 patients loose bodies within the hip joint were noted on the CT scan in 77 (96%) patients, and only in 19 (24%) on radiographs. There was a statistically strong difference between methods (chi 2 = 12.376; p < 0.01). There was no significant difference between two methods in fracture of the femoral head detecting (chi 2 = 1.905; p > 0.05), but it has to bee noted that only two patients had fracture of the anterior aspect of the femoral head, both noted on CT but not on radiographs. In 78 (98%) versus 53 (66%) patients chondral defect of acetabulum was detected on radiografs. Difference was significant (chi 2 = 4.372; p < 0.05). Also, stability of the hip joint regarding size and location of the posterior wall fragment was better seen on CT than on radiographs (chi 2 = 5.555; p < 0.05). DISCUSSION: Our series demonstrates that in many cases details of acetabular fractures are not well visible on conventional radiographs. Because of the complexity of acetabular fractures, precise pathological anatomy is not easily demonstrated by routine radiographs. In a series of Pearson and Shirkhoda et al. [12,13], one third of acetabular fracture was not apparent on the initial radiographs; however, additional views taken three months later demonstrated a fracture. Mossed fractures should decrease with using the CT, which can also reveal the loose bodies in the joint space, occult femoral haed and chondral acetabular impaction. The size of the posterior wall fracture, and thus the stability of the hip, could be better determined by the CT scan than by a conventional radiograph. In conclusion, the information obtained from CT can help the surgeon to decide whether the surgery is necessary, and, if so, the proper approach. We believe that CT is a very helpful supplement to routine AP and 45 degrees oblique views when surgery of acetabular fractures is in question.

[Pseudoarthrosis of the scaphoid bone associated with carpal collapse: factors in choice of surgical approach]. / Pseudoartroze skafoidne kosti udruzene s kolapsom rucja: faktori od znacaja za izbor operacionog postupka.

INTRODUCTION: The most common fracture involving the wrist is a fracture of the scaphoid bone [1], and only 5% to 10% of these fractures proceed to nonunion. Although not symptomatic initially, most (if not all) nonunions later produce a painful wrist with impaired function, clinically significant loss of motion, increased weakness and degenerative arthritis. Nonunion of the scaphoid bone should be treated by open reduction and internal fixation. Many surgical procedures have been advocated to achieve union. Most widely used technique for the treatment of scaphoid nonunion was described by Russe [2], but this method may overcome the flexion deformity of the scaphoid and carpal deformities. The ununited scaphoid usually undergoes resorption of the fractures surfaces, principally over the anterolateral aspect of the fracture, so that the scaphoid becomes misshapen. The restoration of the exact length and form is enabled by insertion of a tight-fitting trapezoidal corticocancellous graft, a technique described by Fernandez [11]. AIM: We analysed the results of treatment of scaphoid nonunion utilized by two bone-grafting techniques and pointed out the need of choice of the best operative method. METHODS: From 1977 to 1993, at the Institute of Orthopaedic Surgery and Traumatology in Belgrade, 40 patients were surgically treated for symptomatic nonunion of the scaphoid bone. The mean duration of follow-up was 10.2 years (range, from 6 to 22 years). Eighteen (45%) patients were operated by Fernandez technique and 22 (55%) patients were operated using Russe's technique. Volar approach and Kirschner's wire fixation were performed in both operative methods. We used two rating scales proposed by Cooney [13] to evaluate the results. Objective scale (Table 1a) included the radiographic appearance of the wrist, the range of motion and grip strength. Subjective scale (Table 1b) comprised function, pain perception of a decrease in performance because of limited motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had postoperatively carpal collapse with the results in patients who had not such deformity. RESULTS: The union rate was 92.5% in both methods. Russe's technique resulted in union in 20 (91%) of 22 cases with two ununited. Fernandez technique achieved union in 17 (94%) of 18 cases. Fracture union was determined by both clinical and roentgenographic examinations. Correction of the lateral interscaphoid angle was obtained in 14 (82%) patients operated by Fernandez technique and 9 (45%) patients operated by Russe's technique. Correction of dorsal tilt of the lunate were achieved in 6 (30%) patients operated by Russe's technique, and 13 (76.6%) patients operated by Fernandez technique. There was a highly significant correlation (p < 0.01) between increased deformity of the scaphoid and extent of carpal collapse (Graph 1). Also, there was significant difference between two operative techniques regarding correction of lateral interscaphoid angle (p < 0.05). Arthrosis of the wrist was present in all patients. We could not demonstrate a significant difference (p > 0.05) between intensity of degenerative changes and increase of lateral interscaphoid angle, but obviously, the large flexion deformity of the scaphoid the worse intensity of degenerative changes (Graph 2). The grip strength significantly increased after Fernandez technique (p > 0.05) (Graph 3), but wrist motion changed a little. The average objective score was 71 points for the patients in whom the lateral interscaphoid angle was 45 degrees or less, and 63 points for those in whom the angle was more than 45 degrees. This difference was significant (p < 0.05), but we could not demonstrate a significant difference between the two groups in terms of the average subjective score. DISCUSSION: In our series, both procedures provided a high union rate [2]. In cases with severe scaphoid shortening and flexion deformity, Russe's procedure has proved to be insufficient to restore anatomic length and correction of carpal alignment [6, 11, 17]. Previous authors have reported that the progression in degenerative changes was slower in patients who had a lateral interscaphoid angle less than 45 degrees [13]. Also, grip strength and range of motion increased in patients in whom flexion deformity of the scaphoid had been corrected [2, 4, 6, 16, 17]. Our study supports these findings, except results regarding the movement. We believe that this was due to postoperative scarring. Discrepancy between the subjective and objective results may have been due to postoperative relief of pain obtained by increased carpal stability or decreased range of motion of the carpal joints due to postoperative scarring. If pain is relieved, patients readily adapt to the functional deficit of decreased range of motion. We concluded that angulatory collapse of the scaphoid resulted in nonunion as well as malunion with secondary functional loss. Recognition and avoidance in acute fractures were important. When recognised late, volar wedge grafting appeared to be a satisfactory method of treatment.

[Role of wrist instability in the onset of pseudoarthrosis of the scaphoid bone]. / Uloga nestabilnog rucja u nastanku pseudoartroza skafoidne kosti.

INTRODUCTION: The most common fracture involving the wrist is a fracture of the scaphoid bone. Fracture of the scaphoid most frequently occurs in young adult male and usually involves the wrist of the scaphoid. There is a universal agreement that the majority of these fractures will heal if immobilized property and for a long period of time [1, 2]. In the treatment of these fractures much attention has been payed to bone damage and not to associated ligament injury. It is reported that the incidence of nonunion of scaphoid fractures is ten per cent and that the frequency of this complication remains essentially unchanged [3, 4]. Failure to improve the outcome suggests that the mechanisms and causes of this complication are poorly understood. Explanations of nonunion or delayed union of scaphoid bone are: poor initial treatment or even no treatment [3], delayed diagnosis [5], fragments displacement [5-8], improper immobilization [9], site and direction of the fracture [3] and wrist instability [8, 10]. AIM: The study was undertaken to analyse the influence of carpal instability on the development of scaphoid nonunion. METHOD: The study concerned 40 patients with painful nonunions of the scaphoid bone. Duration of nonunion was 1.43 year. There were 37 (92%) male and 3 (8%) female patients. Site and direction of the fracture, initial treatment and carpal collaps were analysed. Data processing was done for all examined patients (Table 1). RESULTS: Dominant hand was involved in 24 (60%) patients and nondominant hand in 16 (40%) subjects. Carpal collaps was present in 68% of patients. There were 14 (35%) untreated patients (Graph 1). Untreated fractures were statistically insignificant regarding the intensity of carpal collaps (p = 0.101; p > 0.05). The physical examination usually revealed focal tenderness, a palpable click with ulnar deviation, abnormal antero-posterior mobility with passive range of motion or a combination of these findings. Standard X-rays evaluated fracture location and carpal instability or collaps. There were 14 (35%) proximal third located fractures and 26 (65%) in the middle third of wrist (Graph 2). There was no statistically significant correlation between location of the fracture and presence of carpal collaps (p = 0.081; p > 0.05). DISCUSSION: There were 35 per cent overlooked fractures. Delay in diagnosis of a scaphoid fracture has been suggested as a significant factor in the development of nonunion [5, 7]. However, in our series of nonunions, non treatment does not occur frequently enough to be the critical factor. Most series report about 2/3 of nonunions occurring at the wrist [7, 9]. Our series shows a similar distribution, arguing against site as a critical factor. There appears to be a nearly uniform rate of nonunion in most of the reported series [7, 15, 16], regardless of the position of the wrist, whether or not the thumb was immobilized. Evidence of ligamentous injury in our series led us to conclude that scaphoid nonunion is consistently associated with carpal instability pattern. In our series 68% of nonunions associated with carpal collaps were present. We found no statistically significant correlation between carpal collaps and nontreated fractures or location of fracture site. Therefore, we concluded that carpal collaps was consistently present and, thus the critical factor in wrists with ununited scaphoid fractures.