The importance of communication in secondary fragility fracture treatment and prevention.

INTRODUCTION: We report on a Canadian longitudinal qualitative case study of midlife women with fragility fractures, their treating orthopaedic surgeons and family physicians. METHODS: Women and their treating physicians were followed for an average of one year post fracture to investigate the health outcomes and what, if any, follow-up occurred aimed at secondary fracture prevention. The final dataset includes 223 interviews gathered from women aged 40 to 65 with fragility fractures, orthopaedic surgeons and family physicians. RESULTS: The circle of care for those with fragility fractures is disrupted at vital communication junctures: (1) the inconsistent flow of information between acute care institutions and family physicians; (2) unidirectional and inconsistent communication from orthopaedic surgeons to family physicians; and (3) competing demands of the cast clinic environment and patient expectations. It is not the lack of will that is undermining the consistent and detailed communication among patients, physicians and institutions. It is the episodic nature of fracture care that makes communication among involved parties difficult, if not impossible. CONCLUSIONS: Communication about events, acuity and clear expectations around roles and follow-up is urgently needed to improve communication throughout the circle of care to support secondary fracture prevention. Fractures from a standing height or similar trauma in women aged 40 to 65 should be treated as suspicious fractures and followed-up to investigate the underlying bone condition. This article reports on challenges and barriers to clear communication among women, their orthopaedic surgeons and family physicians that is necessary for follow-up and prevention of future fractures.

Magnetic resonance diffusion weighted imaging in cerebral fat embolism.

The use of diffusion weighted imaging with apparent diffusion coefficient mapping in the diagnosis of cerebral fat embolism is shown here to demonstrate infarcts secondary to fat emboli more intensely than T2 weighted sequences 24 hours after the onset of symptoms. Embolic foci are hypointense on apparent diffusion coefficient mapping consistent with cytotoxic edema associated with cell death and restricted water diffusion. This technique increases the sensitivity for detecting cerebral fat embolism and offers a potentially important tool in its diagnosis.

Results of spinal cord decompression and thoracolumbar pedicle stabilisation in relation to the time of operation.

Short-segment pedicle stabilisation, transpedicular disc resection and autologous cancellous bone grafting is performed in trauma patients being transferred to our trauma centre with thoracolumbar fracture/dislocations. A follow-up examination of 88 patients, who were operated during the years of 1985-1992, took place after an average time of 5.6 years. Our results suggest that the earlier operative decompression and spine stabilisation takes place, the better is the recovery rate in patients with neurologic deficits. The highest neurologic recovery rates were found in patients operated within 8 h after the initial trauma. High remission rates were still found, if the patients had been operated within 48 h. After this time there was no significant difference in the neurologic outcome compared to the time of operation.

Limited diagnostic value of macroradiography in suspected scaphoid fractures.

In a prospective study 60, patients having suspected occult scaphoid fractures, but with normal conventional scaphoid radiographs, also underwent macroradiography. Clinical and conventional radiographic follow-up examinations and MRI identified 8 occult scaphoid fractures and 23 nonscaphoid lesions. Macroradiography identified only 50% of the occult scaphoid fractures.

Twisting of patellar tendon grafts does not reduce their mechanical properties.

The purpose of this study was to investigate whether the twisting of a patellar tendon (PT) graft improves or reduces its mechanical properties. Twenty-seven pairs of 10 mm cadaveric PT grafts were tested at a strain rate of 10% min(-1). For each pair, the left specimen served as an unmanipulated control while the right specimen was either left untwisted, twisted + 90 degrees, or twisted - 90 degrees. All avulsion failures were excluded from the data analysis, focusing only on pure in-substance tendon ruptures. Higher ultimate load values than previously reported were obtained for both the twisted and untwisted specimens, without a statistical significant difference between the two. The values obtained for the left and right specimens from Group A were 4014+/-319 and 3973+/-245 N, from Group B 3613+/-207 and 3891+/-14 N, and from Group C 3997+/-278 and 4415+/-507 N, respectively. Stiffness and failure strain were not influenced by the twisting. Neither the presence of a twist, nor the direction of the twist were found to increase the ultimate load of the 10 mm cadaveric patellar tendon graft. Therefore, recommendation for twisting cannot be assessed to its mechanical properties.

The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique.

A prospective clinical trial from January 1994 to February 1996 evaluated the efficacy of a vacuum sealing technique in dealing with sacral pressure ulcers, acute traumatic soft tissue defects and infected soft tissue defects following rigid stabilization of lower extremity fractures in 45 patients. Polyvinyl foam under negative pressure generates an area of high contact forces at the wound/foam interface. This situation appears to facilitate granulation tissue production while maintaining a relatively clean wound bed. In 84% (38/45) of the patients the use of the vacuum sealing technique following irrigation and debridement decreased the dimensions of the initial wound, thus facilitating healing time and the eradication of any pre-existing infection. Wound closure by granulation, secondary closure, or split thickness skin grafting was achieved in 35 wounds. The vacuum sealing technique is an effective option in the management of infected wounds.