Objective of the study is to correlate between the radiological and functional outcome in patients with pelvic ring fractures postoperatively. Thirty patients who were admitted for pelvic ring fractures treated surgically or by conservative management during 2011 to 2021 were reviewed. The fractures were classified according to the Tile classification. The patients were sent a questionnaire based on the items of the functional pelvic score of Majeed, Orlando score and the SF-12. 8 (26.66%) patients underwent External fixation + iliosacral percutaneous CC screw surgery. ORIF + iliosacral percutaneous CC screw done in 6 (20%) patients. Whereas 4 (13.33%) patients each were underwent for external fixatior – Pelvic and iliosacral percutaneous CC screw management. CRIF with iliosacral percutaneous CC screw done in 2 patients, and Internal Fixation with iliosacral percutaneous CC screw surgery performed in 1 patient. Conservative management done for 5 (16.66%) patients.Quality of reduction was checked by SI joint displacement which was <4mm in 2 patients and 4-10mm in 28 patients. However, Chronic pain was registered for 1 (3.33%) patients and Sexual dysfunction registered for 1 (3.33%) patient. Mean Majeed score was 98.4, 94.2 and 91.65 for Tile Type A, Type B and Type C fracture respectively. Two experienced pelvi-acetabular surgeons and use of a dedicated post-operative rehabilitation protocol, support from the Intensive care , plastic and general surgery were able to achieve good to excellent functional and radiological outcome in all of our patients, with all of them regaining their pre injury occupation.

Background

Pelvic fractures are associated with high energy trauma. This study intends to retrospectively evaluate the 30 day mortality, whilst considering the impact of concomitant injuries.

Method

A consecutive series of 1000 patients were identified within the TARN database for St Mary’s Hospital, London, between 2012 and 2020. Univariate and stepwise multivariate logistic regression were used to determine which of the following factors was associated with 30-day mortality; AO/OTA score, Glasgow Coma Score on admission (15, 10-14, <10), abdominal trauma, haemothorax, long bone fracture, arterial injury and an open pelvis. Additional co-variates included in the final model were age and gender.


Results

The mean age of patients was 52.2 years (SD 23.5), 449 men and 551 women. The risk of 30-day mortality was 5.2% (95% CI: 3.9–6.8). The final multivariate model demonstrated a significant association between the presence of a haemothorax and 30-day mortality (OR 2.4; 95% CI 1.1–5.0). A GCS of less than 15 was associated with 30-day mortality (p< 0.001). The OR for GCS <10 was 27.2 (95% CI; 11.8–62.3).

Conclusion

Pelvic fractures and a concomitant haemothorax injury are significantly associated with an increased risk of 30 day mortality. This shows that urgent identification of a haemothorax and emergent treatment is critical in the management of pelvic fractures. Furthermore, identifying a GCS below 15 was associated with 30 day mortality. Future collaborative investigation of 30 day mortality for major trauma centres may improve risk stratification of concomitant injuries and development of a scoring system for predicting mortality.

Purpose: Coronal shear fractures of the distal humerus involving the capitellum and trochlea are rare injuries. Internal fixation with Herbert screws provides a stable construct facilitating early mobilisation. Our study aimed to identify the key determinants of both radiological and functional outcomes of patients with distal humerus coronal shear fractures treated with internal fixation. Methods: A retrospective analysis of 61 patients with distal humerus coronal shear fractures who were treated surgically was done. Demographics, fracture morphology, time to surgery, operative details such as surgical approach and implant used, quality of reduction, time to union and associated complications from hospital records. Radiological outcomes were assessed using plain radiographs, and the functional outcomes were by Oxford Elbow Score (OES), Mayo Elbow Performance Index
(MEPI). Results: Patients with anatomical reduction of the fracture had better functional outcomes and range of motion. The presence of posterior comminution of capitellum resulted in poorer outcomes (p =0.03). Delayed presentation did not alter the outcome when the anatomical reduction was achieved. Myositis ossificans was noted in 9 patients and non-union in 5 patients. Two patients developed avascular necrosis of the capitellum and arthritis of the elbow joint. Conclusion: Anatomical reduction and posterior comminution are the two key determinants of the functional outcome in these coronal shear fractures of the distal humerus. Early mobilisation following a stable fixation is crucial in achieving a good outcome.

Introduction: Femoral neck fractures are challenging to diagnose and treat in osteogenesis imperfecta (OI) patients. We aim to describe surgical management techniques and outcomes of femoral neck fractures in a cohort of OI. Methods: Between 1976 and 2022, we retrospectively reviewed children's medical records with OI and femoral neck fracture evaluated at our institution. We reviewed their treatment and outcomes. We included patients who had surgical treatment. Results: We found eight patients, five boys, and three girls, with surgical treatment for femoral neck fractures with a minimal follow-up of 24 months. Age varied from seven to eighteen. 6 children had type III, and two had type IV OI. Three patients had medialization subtrochanteric osteotomy, one closed reduction and internal fixation with screws, and four had open reduction and fixation with a valgus effect plate. All patients had fixation of the femoral epiphysis. Four children regained their pre-operative ambulation status six months following the surgery. All patients had achieved bony union after a mean period of 8 months (range 6-12 months). One girl had revision surgery for failure of fixation. After six months, she was reoperated to modify the fixation construct with fibular autograft. She had an excellent result and achieved bony union six months later. One girl developed 24 months later bilateral hip stiffness due to aggravation of her AP. We didn’t observe any infection or malunion. Conclusion: our variety of surgical techniques for femoral neck fractures in OI patients seems appropriate, achieving bony union with good results and outcomes.

Background: Non-union following distal femur fractures treated with lateral locking plates have been associated with various factors. We focussed on construct related variables, mechanical variables, types of fracture and complications that affect the outcome. Methods: A retrospective observational study of 298 distal femur fractures treated with lateral locking plates was performed. We analysed implant and mechanical characteristics of fixation, patient demographics, co-morbidities, injury characteristic (open vs closed, AO type), and complications such as infection. Univariate analysis and multiple logistic regression analysis were performed to analyse the prediction of outcomes. Result: Non-union rate was found to be 19%. Stainless steel implants were a more rigid construct compared to titanium implants. 17.44% of non-union cases were found in comminuted fractures and 1.67% in simple fractures. Fractures with a medial bone gap of more than 10 mm were found to have a high risk of non-union in this study. The number of empty holes near the fracture site was found statistically significant in simple non- union fractures. Open fractures, deep infection, and type C comminuted fractures were also related with non- union with statistically significant value. Conclusion: A locking compression plate is an excellent treatment method for distal femur fractures with good outcomes. Our study showed that stainless steel implants were more rigid compared to titanium implants and the
greater the number of holes near the fracture site in simple fractures resulted in an increased risk of non-union.
Open fractures were found to be the most significant factor in determining outcomes.

Introduction: In patients with Gustilo 3B open fractures of the lower leg who require a free flap, it is unknown whether local blood flow is sufficient for bone reconstruction using the Masquelet induced membrane technique (IMT). This study aims to investigate the outcomes of patients who underwent reconstruction for Gustilo 3B open fractures of the lower leg with IMT. Patients and Methods: We retrospectively investigated the outcomes of 10 limbs that underwent bone reconstruction with IMT for Gustilo 3B tibial open fractures using medical records. Results: The mean age of the patients was 49.2 years, and 7 plates and 3 intramedullary nails were used for internal fixation. Soft tissue defects were reconstructed with 6 free flaps, 3 free muscle flaps, and 1 pedicled muscle flap. The mean Radiographic Apparent Bone Gap (RABG) was 39.7 mm. All autogenous bone was obtained from cancellous bone from the iliac bone, and artificial bone was mixed in 8 cases. Three cases developed deep tissue infection after bone grafting, 2 of which were amputated, and 1 was re-reconstructed with IMT. Only 2 cases were successfully unionized, and the implants were removed. Discussion: In this study, the outcomes of Gustilo 3B patients' bone reconstruction with IMT were less successful than other reports about IMT. This result may be due to insufficient blood flow around the bone or the use of artificial bone. Conclusion: The results of Gustilo 3B open fracture patients' bone reconstruction with IMT were poor.

Purpose: Early excessive neck shortening after internal fixation of trochanteric fracture is associated with a higher risk of cutout. Little is known about the association between nail diameter and the incidence of postoperative excessive neck shortening. Methods: At a single trauma center from July 2010 to August 2017, trochanteric fractures fixed by short femoral nails among the elderly were retrospectively evaluated. We divided the patients into four groups according to the quartile range of nail canal ratio (NCR), defined as the ratio of the nail diameter to the canal diameter at the level of distal locking screw. The primary outcome was the neck shortening of more than 6mm within two weeks of surgery. After stratification with the displaced lesser trochanteric fragment, we estimated the influence of NCR on the primary outcome after adjusting the possible confounding factors by logistic regression model. Results: Of the 949 patients, the outcome was evaluated in 712 patients. Excessive shortening was found in 89 patients (13%). In cases with posteromedial support (n=398), there was no significant difference in the excessive neck shortening between each NCR group (p=0.63 to 0.99). On the other hand, in cases without posteromedial support (n=319), the excessive neck shortening significantly increased in the lowest NCR group (NCR < 0.73) against the highest group (NCR > 0.86) (adjusted odds ratio 2.4, p=0.05). Conclusion: When nailing unstable trochanteric fractures, orthopaedic surgeons should be careful not to choose a narrow-diameter nail to avoid early excessive neck shortening leading higher risk of cut out.

Introduction: Supracondylar fractures are the most common elbow fracture in children. This study aims to compare clinical, functional and radiographic outcomes between patients with Gartland type 2 fractures treated surgically and conservatively. Methods: Patients between 2 and 15 years-old with supracondylar fracture of the humerus were considered from 2010 to 2020. Age, gender, type of fracture, treatment, pre- and post-treatment radiographic parameters and functional outcomes were evaluated. Results: 87 patients were included. The average age was 6-year-old (2-15) and 44 fractures were treated conservatively (group A) with plaster (6-36 days- average 23.89); 43 were treated surgically (group B) with closed reduction and percutaneous pinning (CRPP). Kirschner wires were removed at an average of 24.5 days (p=0.57). Among all, 48 fractures were 2a (Wilkins sublclassification) and only 3 of them were treated surgically. 3 cases of group B required re-operation (3.45%) and 2 had postoperative nerve complications (2,3%). Fractures with better postoperative radiographic criteria (Baumann angle and humero-capitellum distance) had better functional outcome according to Flynn criteria (p<0.05). Conclusions: There is a lack of evidence in the literature to guide the surgeon regarding the correct approach in Gartland type 2 fractures. In the majority of conservatively treated Gartland 2 fractures, good radiographic and functional results were obtained. The fractures surgically treated had more unfavorable radiographic parameters at presentation and this could represent a type of approach for this type of fractures.

Currently, there is growing interest in such a little-studied problem as symphysitis. According to the literature over the past decades, discrepancies and ruptures of the pubic symphysis occur in 0.2–4% of cases. This problem does not have clear development factors, which also poses difficulties in diagnosis and treatment. The main clinical manifestation is pain, often combined with diastasis of the pubic symphysis. In 30% of cases, symptoms include signs of destabilization of the anterior semi-ring of the pelvis, dyspareunia, irritation and signs of bladder overactivity. Methods: In 25 patients, at the initial stage of surgical treatment, to eliminate destabilization of the pelvic ring, fixation of the pubic symphysis with an plate in the anterior part of the pelvic ring was used with resection of the inflammatory process zone of the structure of the pubic symphysis to healthy tissue. The volume of the resulting cavity after resection was filled with granules of a complex alloplastic preparation based on hydroxyapatite. All patients were discharged with improvement for outpatient treatment. Results: the results were assessed 6 months after surgical treatment. According to X-ray data, high reliability of fixation, elimination of pain, expansion of motor activity, orthopedic regimen and improvement in the quality of life of patients were noted. A Russian Federation patent was received for the developed methodology: “Method of surgical treatment of the pubic symphysis of the pelvic ring”. The choice of surgical treatment is determined individually, which requires additional consideration of treatment results

Objective: This study sought to assess the clinical and functional outcomes of acetabulum fracture fixation, utilizing the modified Harris Hip Score as the evaluation tool. Methodology: Conducted at the SMBB Institute of Trauma from 2019 to 2021, this retrospective study focused on 73 patients who underwent acetabular fracture fixation. After excluding those who expired or were lost to follow-up, the final sample comprised 52 patients. Data included patient demographics, injury mechanisms, treatment details, and complications. Acetabulum open reduction and internal fixation were performed by an experienced surgeon in pelvic and acetabulum surgeries. Clinical and functional outcomes were assessed using the modified Harris hip score. Results: The study involved 52 patients with a mean age of 37.5 +/- 11.9 SD years, including 39 men and 13 women. Road traffic accidents were the leading cause of acetabular fractures (90.4%), followed by falls (9.6%). Associated injuries with acetabulum fractures included extremity fractures and chest injuries (13.5%) and hip dislocations (5.8%). The modified Harris hip score at the 2-year follow-up indicated excellent outcomes in the majority of patients (73.1%). Complications included surgical site infections (9.6%), hip osteoarthritis (3.8%), and nerve injuries (3.8%). Conclusion: This study underscores the intricate nature of acetabular fractures and emphasizes the positive outcomes of surgical intervention, as assessed by the Harris Hip Score. Ongoing follow-ups and management are essential for complications such as hip osteoarthritis and nerve injuries. Acknowledging study limitations, including its retrospective design and sample size, this research demonstrated excellent clinical and functional outcomes following acetabular fracture fixation.

70 years old male with history of L4 laminectomy and L4-L5 foraminectomy, dyslipidemia and hypertension, was admitted to the ER in hemorrhagic shock after being struck by a vehicle. Patient was conscious with dyspnea, hypotension, abdominal pain, pelvic instability and visible right lower limb deformity. After resuscitation, CT-scan showed fractures of multiple cervical and lumbar transverses processes, L1 burst fracture without neurological deficits - AO Spine A4, right thorax rib fractures with pneumothorax, hepatic and mesentery lacerations, with laceration of the right renal artery and right iliac fracture showing caecum extrusion, without perforation or ischemia. X-ray of right lower limb showed a femoral segmental fracture (neck and shaft). Patient was taken to the OR with general surgery and orthopedics for exploratory laparotomy, chest tube placement and femoral fracture closed reduction and long intramedullary nailing. Mesentery hemorrhage was controlled, right colon was mobilized and integrity was confirmed. Bone fragments were removed from the iliac and pelvic binder was applied. Patient was admitted to the ICU for 48 days and underwent percutaneous lumbar fixation (D12,L1,L2) on the 17th day of hospitalization. Evolved with prolonged extubation due to muscular weakness, needing tracheostomy. Hospital stay was complicated by blood-stream infection from CVC, cellulitis and abscess superficial to the iliac fracture, upper GI hemorrhage, intubation associated pneumonia, and pressure ulcers. Patient needed a long course of rehabilitation and was discharged two months afterwards able to bear weight in both legs and walk with modified autonomy, with a walker. Follow-up in out-patient setting unremarkable without complications.

Background Treatment escalation plans (TEPs) provide enhanced clarity in planning appropriate decision-making in the management of deteriorating patients by explicitly defining a limit of care. These decisions are discussed with patients or their relatives and mutually agreed upon. We aimed to improve staff adherence to the completion of TEPs upon the admission of patients to the orthopaedics wards in a London teaching hospital. Methods This study employed the Plan-Do-Study-Act (PDSA) methodology to investigate the efficacy of interventions implemented within a hospital setting for adult inpatients receiving orthopaedic treatment. The approach adopted was cross-sectional, where a comprehensive audit was conducted on all adult inpatients admitted to the hospital. The initial cycle of the study was conducted in March 2022, followed by the implementation of interventions in the form of an internal algorithm. Subsequently, the second cycle of the study was conducted in November 2022. Results We sampled a total of 50 patients (PDSA 1, n=27; PDSA 2, n=23). Following the implementation of a designated local TEP pathway, the proportion of patients with incomplete TEPs fell from 30.4% (n=7, PDSA Cycle 1) to 11.76% (n=2, PDSA Cycle 2). Conclusions The study has demonstrated that interventions such as institutional algorithms and departmental meetings can be useful in improving the adherence of staff to complete TEPs. Ongoing training and education can help overcome some of the barriers to TEP completion.