Outcome after conservatively managed intracapsular fractures of the femoral neck.

INTRODUCTION: In 2012, 2.6% of hip-fracture patients in the UK were treated conservatively. There is little data on outcome for these patients. However, one study demonstrated that though 30-day mortality is higher, mortality over the rest of the year is comparable with that in surgical groups. Therefore, we assessed conservatively managed patients in our unit. METHODS: Patients with intracapsular fractures of the femoral neck treated by conservative means between 2010 and 2012 inclusive were identified. Data were collected: American Society of Anaesthesiologists (ASA) grade, Nottingham Hip Fracture Score (NHFS), mobility, mortality (30 days and one year) and pain levels. RESULTS: Thirty-two patients formed the study cohort. Mean age was 85.6 years. Median ASA grade was 4. Mortality at 30 days and one year was 31.3% and 56.3%, respectively. There was one case of pneumonia and one of infection. Pressure sores or venous thromboembolism were not documented. Three patients underwent surgery once their health improved. In general, mobility was decreased, but 30.8% of patients could mobilise with two aids or a frame. Only two cases had ongoing problems with pain. CONCLUSIONS: Our data are similar to those published previously. Our patients were likely to have higher mortality data due to selection bias. Thirty-day mortality was significantly higher than the national average, but patients surviving 30 days had a prevalence of mortality similar to those managed by surgical means. Despite mobility decreasing from the pre-admission status, a considerable number of patients were free of pain and could mobilise. These data suggest that conservative management of intracapsular fractures of the femoral neck can produce acceptable results.

Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age. A prospective, randomised study.

Forty-seven patients over the age of 55 years with a displaced fracture of the ankle were entered into a prospective, randomised study in order to compare open reduction and internal fixation with closed treatment in a plaster cast; 36 were reviewed after a mean of 27 months. The outcome was assessed clinically, radiologically and functionally using the Olerud score. The results showed that anatomical reduction was significantly less reliable (p = 0.03) and loss of reduction significantly more common (p = 0.001) in the group with closed treatment. Those managed by open reduction and internal fixation had a significantly higher functional outcome score (p = 0.03) and a significantly better range of movement of the ankle (p = 0.044) at review.

Ankle effusions following acute ankle injury.

We prospectively studied 56 patients with an acute ankle injury and an effusion to determine the significance of the ankle effusion to functional outcome. The average size of effusion was 15 mm. Most injuries occurred following a fall (73%) and most (73%) were inversion injuries. At 6 months all but two patients had returned to their normal activities with no further problems. No correlation was found with size of effusion and the functional and clinical outcome. We conclude that an ankle effusion does not reliably distinguish which injuries require further investigations and unless there are clinical indications further investigations are not indicated.

The effect of leg length discrepancy on foot loading patterns and contact times.

The effect of a simulated leg length discrepancy on foot loading patterns and gait cycle times in normal individuals was investigated. Thirty feet of 15 normal volunteers were evaluated. Leg length discrepancy was simulated using flexible polyurethane soles. As leg length discrepancy increased, the total loading increased from 35.31 to 37.99 kg/cm2/sec, forefoot loading increased from 15.58 to 19 kg/cm2/sec, hindfoot loading remained the same. All subjects, except females with middle loading patterns, demonstrated increased hallux loading. The contact phase of gait decreased from 22% to 13%, the midstance phase remained the same, the propulsion phase increased from 44% to 50%. All findings were statistically significant. Leg length discrepancy has significant effects on the foot. Different adaptive loading patterns amongst subsets of individuals are seen.

Osteotomy of the hallux proximal phalanx.

Osteotomy of the proximal phalanx appears to be used more frequently and with increasing indications. It rarely is indicated as the only surgical procedure and often is combined with a secondary procedure. In hallux valgus surgery, a proximal or distal metatarsal osteotomy often is used, and in hallux rigidus, a cheilectomy usually is added. The advantage of a proximal phalanx osteotomy is that it enables an extra-articular correction, which avoids breaching the metatarsophalangeal joint. This extra-articular correction may prevent joint stiffness and long-term joint changes.

Effect of cotton padding on the setting properties of plaster slabs.

INTRODUCTION: Plaster of Paris (PoP) impregnated bandages have been used to maintain the position of bones and joints for over a century. Classically, wool dressing is applied to the limb before the PoP, which can then be moulded to the desired shape. A modification of this practice is to wrap the PoP bandages circumferentially in cotton before wetting and applying to the patient in an attempt to reduce inhalation of plaster dust and reduce mess. However, this may affect the water content of the cast and therefore also its setting properties and strength. This study compared the setting properties of PoP casts when used with and without cotton wrapping. METHODS: Sixty specimens, compliant with the American Society for Testing and Materials standards for three-point bending tests, were prepared, with thirty wrapped in cotton. All were weighed before and after water immersion, and wrapped around a plastic cylinder to mimic limb application. Bending stiffness and yield strength was measured on a servohydraulic materials testing machine at 2, 6, 12, 24, 48 and 72 hours. RESULTS: The water content of cotton-wrapped plaster was significantly higher (50%) than that of standard plaster. It had significantly lower strength up to 24 hours and significantly lower stiffness up to 72 hours. CONCLUSIONS: The initial decrease in strength and stiffness of the cast wrapped in cotton may comprise the ability of the backslab to hold the joint or bone in an optimal position. Any modification of the standard plaster slab application technique should allow for the potential adverse effects on the plaster setting properties.

Sledging related spinal injuries and fracture patterns: a report on five cases.

The cases are reported of five patients who presented to The Queens Medical Centre, Nottingham after a sledging accident. All five patients presented consecutively during the first weekend in 1997 having sustained the accident in the same public park. The mechanism and subsequent fracture type is described for each. These injuries are preventable, and increasing public awareness of the risk of sledging in public places may reduce the incidence.

Skip metastases in Ewing's sarcoma: a report of three cases.

The accurate pre-operative staging of all potentially malignant tumours of bone is essential. We report three cases of Ewing's sarcoma of bone in which MR imaging identified skip metastases not visualized on either contemporary radiographs or bone scintigraphy. The implications for patient management and possible reasons for the other imaging modalities failing to reveal the skip metastases are discussed.