Intracapsular neck of femur fractures secondary to civilian gunshot injuries: an inter- and intra-observer agreement study on classification and treatment using the AO/OTA classification.

PURPOSE: Numerous classification systems have been developed for neck of femur fractures, but none have been tested for reliability in gunshot injuries. Our primary objective was to assess the inter-observer and intra-observer reliability of the AO/OTA classification system when applied to intracapsular neck of femur fractures secondary to low-velocity civilian gunshots wounds (GSWs). Our secondary objective was to test the reliability of the AO/OTA classification system in guiding surgeon treatment choices for these fractures. PATIENTS AND METHODS: Eighteen reviewers (six orthopaedic traumatologists, six general orthopaedic surgeons and six junior orthopaedic fellows) were given a set of 25 plain radiographs and CT scans of femur neck fractures secondary to GSW. For each clinical case, all reviewers selected a classification as well as treatment option from a list of given options. Inter-observer reliability was measured at the initial classification. The exercise was repeated 10-12 weeks later by the same 18 reviewers to test intra-observer reliability. RESULTS: The Fleiss kappa values indicate only slight agreement amongst raters, across all experience levels, for both injury classification and treatment. Intra-observer agreement was fair across all experience levels for both injury classification and treatment. CONCLUSION: The AO/OTA classification showed only slight reliability in classification of gunshot fractures of the femur neck. With only fair reliability, it also failed to guide surgical treatment thus rendering its routine use in daily clinical practice of questionable value.

Optimising the Orthopaedic Trauma Society Open Fracture Classification system: a proposal for modification in the context of high civilian gunshot fractures.

OBJECTIVES: Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures. METHODS: From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System. RESULTS: One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%). CONCLUSION: We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively.

Orthopaedic trauma residency programs: Perspectives from different countries across the world.

The ability to manage the myriad of musculoskeletal conditions successfully requires multiple years of training. Access to and completion of orthopaedic surgical training entails an often grueling, highly regulated path to certification to practice. Although the world is more connected than ever, the question is whether the local certification criteria for medical specialists leads to a generic residency program and a similar training in all countries. This report from eight nations on five continents details the distinctive features of that training, including the number of positions available, the examinations required, the gender distribution of residents, and available possibilities once the residence period is complete. This analysis shows a wide variation in the orthopaedic trauma training program worldwide, with emphasis on different skills per country.

Surgical management of distal humerus gunshot fractures: descriptive case series.

PURPOSE: The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa. METHODS: A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification. RESULTS: Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months. CONCLUSIONS: These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management. LEVEL OF EVIDENCE: IV.

Conservative Management of Stable, Minimally Displaced Pertrochanteric Fractures: A Case Series.

Background: Hip fractures are common, and account for significant morbidity and mortality. While surgical intervention remains the gold standard, nonoperative treatment protocols are seldom analysed and may be of value in select settings. Objectives: We sought to review our conservatively treated pertrochanteric fractures and present a case series that outlined indications, treatment protocol and early outcomes. Materials and Methods: A retrospective review of medical records and radiographic imaging of all patients who presented with stable pertrochanteric fractures and were treated nonoperatively, from September 2017 to February 2021, at a Level 2 District Hospital in South Africa. Results: Of the 242 patients who were admitted with pertrochanteric fractures, 12 (4.9%) fractures were radiographically classified as AO 31A1.2 (stable, minimally displaced) and eligible for active nonoperative management. Within 6 weeks of injury, 10 (84%) of the patients who received active nonoperative treatment achieved union. Two patients (16%) failed the treatment protocol and required surgery, with one failing during the hospital phase of the treatment protocol and the other on follow up. In the group of united fractures, the neck shaft angle was on average within 3 degrees of the contralateral hip with a range of 0 to 5 degrees. At follow-up, two (16%) patients had a measurable shortening of 5 mm at union. There was no medical morbidity associated with this protocol. Conclusions: In our case series, the active nonoperative management protocol, involving early mobilisation and serial radiographs, in select cases of stable pertrochanteric fractures yielded acceptable outcomes. This is of relevance in low-middle income countries with limited surgical capacity.

Establishing a consensus on research priorities in orthopaedic trauma within South Africa.

BACKGROUND: Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low- and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK healthcare practitioners within SA. METHOD: Members from the Orthopaedic Research Collaboration in Africa (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. RESULTS: Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups-clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. CONCLUSION: This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts.

Return to Work Following Intramedullary Nailing of Lower-Limb Long-Bone Fractures in South Africa.

BACKGROUND: Injuries are one of the leading causes of global death and disability and commonly have substantial economic implications. The economic impact of injuries is particularly pronounced in low- and middle-income countries, where 90% of injuries occur. In this study, we aimed to assess return-to-work rates of individuals who sustained a lower-limb long-bone fracture in South Africa and to identify factors that influence the ability to return to employment. METHODS: This prospective cohort study was conducted across 2 tertiary trauma centers in Cape Town, South Africa. Adults who received intramedullary nail fixation for a lower-limb fracture between September 2017 and December 2018 were recruited and followed for 18 months postoperatively. The participants' return to employment was assessed at 6 and 18 months post-injury. Multivariate logistic regression was used to identify factors that influence post-injury employment. RESULTS: Of the 194 participants enrolled, 192 completed follow-up. The study population had a median age of 33.0 years, and most of the participants (76.6%) were male. Seventy-five percent of the participants were employed before their injury. At 6 and 18 months post-injury, 34.4% and 56.3% of participants, respectively, were employed. Of those employed pre-injury, 70.1% had returned to work at 18 months. Multivariate regression identified increasing age, unemployment prior to injury, and working in the informal employment sector as factors that impede an individual's likelihood of working 18 months post-injury. For those in employment prior to injury, increasing age was the only factor found to impede the likelihood of returning to work following an injury. CONCLUSIONS: This study highlights the profound effect that lower-limb long-bone fractures may have on an individual's ability to return to work in South Africa, with the potential to cause substantial economic impact on an individual's livelihood and that of their dependents. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Radiographic union score for tibia (RUST) scoring system in adult diaphyseal femoral fractures treated with intramedullary nailing: an assessment of interobserver and intraobserver reliability.

OBJECTIVES: The Radiographic Union Score for Tibia (RUST) scoring system has been validated in multiple studies assessing the healing of tibial fractures. Our objective was to assess the interobserver and intraobserver reliability for the RUST in diaphyseal femoral fractures treated with intramedullary (IM) nailing. PATIENTS AND METHODS: A total of 60 sets of anteroposterior (AP) and lateral radiographs of diaphyseal femoral fractures treated by reamed IM nailing were randomly selected from a prospectively collected database. The 60 sets of radiographs were then scored by three reviewers using the RUST system. Interobserver reliability was measured at initial scoring. The 60 sets of radiographs were scored again by the three reviewers to calculate the intraobserver reliability. RESULTS: The RUST scores ranged from 4 to 12 with a mean score of 11.3 ± 1.3. The interobserver intraclass correlation coefficient (ICC) was 0.87 (95% CI, 0.81-0.92) and the intraobserver ICC was 0.91 (95% CI, 0.88-0.94), which indicated excellent agreement. CONCLUSION: This study demonstrated that the RUST system can be used reliably in the assessment of healing in diaphyseal femur fractures treated by reamed intramedullary nailing, with excellent interobserver and intraobserver reliability.

Train related injuries: A descriptive analysis highlighting orthopaedic injuries and management.

INTRODUCTION: Orthopaedic injuries constitute a major aspect of morbidity and mortality following train accidents. The pattern of orthopaedic/musculoskeletal injuries sustained following these accidents has not been fully characterised. The main aim of this study is to describe the range of orthopaedic injuries reported in a major trauma centre and evaluate their management, as well as reporting mortality and amputation rates. Further aims are to identify the social and demographic background of the patients to suggest treatment and prevention strategies. METHODS: This study is a retrospective observation of all clinical files of patients presented to Level 1 Trauma Centre in Cape Town, South Africa, as "train casualty" from January 2013 to July 2019, which were reviewed and evaluated. A total of 174 patients were included, of which 92 were orthopaedic referrals. The average age was 29 years, and 87% were male. RESULTS: Tibial fractures were most common (N = 19), 38% of patients sustained open fractures, and 68% of patients (in total) underwent surgery. Wound debridement was the most common operation, followed by open reduction internal fixation (ORIF). Twelve patients (13%) underwent amputation to 14 body parts. Eight patients (4.6%) (in total) died in the trauma unit. DISCUSSION: This study provides insight into train accident victims and their orthopaedic injuries and management patterns. The victims are largely young males. The majority of orthopaedic injuries require surgical intervention, and those who make it to the hospital have a good chance of survival and limb salvage. It appears that in addition to early hospital access and specialised updated treatments, morbidity and mortality in train accidents could be reduced by improving safety measures and social awareness to reduce railway violence and accidents.

Bibliometric analysis of research on the effects of human immunodeficiency virus in orthopaedic and trauma surgery.

BACKGROUND: There is little research investigating how human immunodeficiency virus (HIV) affects outcomes in orthopaedic surgery. With advances in treatment, HIV has become a chronic health problem and the chance of orthopaedic surgeons encountering it in clinical practice is increasing. AIM: To ascertain the quantity and quality of peer-reviewed publications in orthopaedic journals about HIV. METHODS: A search of the Web of Science database was carried out, identifying any articles relating to HIV published in orthopaedic journals. These were assessed for geographic origin and level of evidence. RESULTS: Of 48.7% of orthopaedic journals listed on the Web of Science database had published articles relating to HIV. There were 168 articles about HIV in orthopaedic journals with only 40.5% (n = 68) published in the time frame we analysed (January 2007 to September 2017). Very few articles came from low-income countries and any articles published from that setting were collaborations. All of the articles were low level of evidence. CONCLUSION: There is a need for more high level orthopaedic and trauma research investigating the effects of HIV, particularly research from low-income countries, where higher level research will help to guide improvements in their treatment of its musculoskeletal manifestations and complications.

Civilian gunshot injuries in orthopaedics: a narrative review of ballistics, current concepts, and the South African experience.

The incidence of civilian gunshot injuries is on the rise worldwide.Unfortunately, there is a lack of high-level evidence guiding management. The treatment of orthopaedic injuries from gunshots is complex and requires consideration of multiple aspects, including energy transfer to the tissue, severity of the wound, possible contamination, presence of fractures and associated injuries. With this narrative review we aim to discuss some of the relevant ballistics, current concepts, and controversies in the general management of civilian gunshot-related orthopaedic injuries based on the available evidence and personal experience. Important points which will be highlighted are the initial management in the emergency room, the assessment and management of soft tissue injuries, associated injuries, use of antibiotics, indication and techniques for fracture fixation, and gunshot injuries to joints.

Effects of Covid-19 on orthopaedic trauma services: early experiences in South Africa and Israel.

South Africa and Israel have significantly different health systems. As South Africa is geographically 500 times as large and has a population nearly 7 times as large as the state of Israel, major differences in the challenges and subsequent handling of the pandemic between these countries were to be expected. South Africa's challenges included being under-resourced, particularly related to trauma, and severe and radical measures had to be undertaken that included extended strict lockdowns, bans on alcohol sales, and cancellation of the majority of the elective surgery during this initial period of the pandemic. Although Israel is much smaller and thereby theoretically easier to control, a complex political situation created difficulties and delays in controlling the pandemic after the initial response, leading to a second wave and additional lockdown. Although massively engaged initially, the Israeli trauma systems had continued functioning almost normally throughout the COVID-19 crisis.

Gunshot Wounds to The Hip.

Gunshot wounds to the hip region are likely to cause complex peritrochanteric fracture. The fracture patterns are often highly comminuted and accompanied by injuries to local structures and abdominal viscera. Our case series analyses 25 orthopaedic procedures performed. The overall union rate for primary fixation was 66%. Two patients underwent revision surgery for failed primary fixation. Two cases where fixation had failed were revised to total hip replacement successfully. These types of injuries present a formidable challenge. Preservation of the femoral head should be prioritised to avoid arthroplasty. Long-term follow-up is necessary in assessing the success of these procedures.

Hip fracture care and national systems in Israel and South Africa.

Despite the same latitude on earth, Israel and South Africa have a wide variety of healthcare systems and approaches. Israel is a developed country with life expectancy within the first decile of the modern world. South Africa is a developing country where available resources and health care varies greatly across the country. Israeli policy makers have realized in 1999 the importance of early surgery for hip fractures as the single most important factor contributing to decreased mortality. After an introduction of a newer reimbursement system in 2004, and public advertising of early hip fracture treatment as a quality tag for hospitals, in more than 85% of the cases patients are operated on early (within 8 hours) with a significant decrease in mortality. However, other issues such as patient preparation, rehabilitation, and prevention are still at their beginning. South Africa deals with significant challenges with high energy hip fractures in a younger population, although osteoporosis is on the rise in certain parts of the country. Due to limited resources and distances, time to surgery differs among hospital systems in the country. In public hospitals, a delay up to a week may be common, whereas in private hospitals most patients are operated early within 48 to 72 hours. Due to decreased life expectancy, arthroplasty is more aggressively used in displaced femoral neck fractures. Rehabilitation is mostly done within the families. Prevention and orthogeriatric teamwork are not being commonly practiced. Generally speaking, more attention to hip fractures is needed from healthcare funders.

Treating fractures in upper limb gunshot injuries: The Cape Town experience.

BACKGROUND: Upper extremity gunshot fractures are generally treated conservatively or surgically using open reduction and internal fixation (ORIF), intramedullary nails (IM) or external fixators. However, there is no gold standard for the management of these complex, multi-fragmentary upper extremity fractures. The aim was to describe and identify the injury patterns, management, complications and associated risk factors for upper extremity gunshot fractures. PATIENT AND METHODS: Data of patients with upper extremity gunshot injuries that presented to a Level I Trauma Unit in Cape Town, South Africa was collected prospectively over a ten-month period from June 2014 to April 2015. Clinical notes and radiographs were reviewed retrospectively. RESULTS: Fifty-one of 90 patients (56.7%) with ballistic injuries had fractures, 30% had neurovascular injuries and 75% had additional injuries to other anatomical structures including head, neck, spine, chest, abdomen, pelvis and urogenital tract. Most fractures were diaphyseal, multi-fragmentary and extra-articular. Fractures were treated conservatively in more than half of the cases. Median fracture length was 5.5 centimetres. A longer fracture zone was statistically associated with surgical treatment. When surgically treated, open reduction and internal fixation was most often performed. Median hospital stay was six days. Infection and injury severity prolonged hospital stay. DISCUSSION: In contrast to studies from the USA and Europe, most fractures in this study were managed conservatively. High quality prospective controlled trials are required to evaluate radiographic and clinical outcomes of treatment methods for upper extremity gunshot injuries. LEVEL OF EVIDENCE: IV, case series.

A meta-analysis of synovial biomarkers in periprosthetic joint infection: Synovasure™ is less effective than the ELISA-based alpha-defensin test.

PURPOSE: (1) To determine the overall accuracy of synovial alpha-defensin, synovial C-reactive protein (sCRP), interleukin-6 (sIL-6), and leukocyte esterase (sLE) as diagnostic markers for periprosthetic joint infection (PJI) and (2) to independantly evaluate the accuracy of both the laboratory-based ELISA alpha-defensin test and the Synovasure™ alpha-defensin test kit. METHODS: An EMBASE and MEDLINE (PubMed) database search was performed using a set of professionally set search terms. Two independent reviewers rated eligible articles. Sensitivity and specificity were meta-analysed using a bivariate random-effects model. RESULTS: Accuracy values were extracted from 42 articles. Pooled sensitivity and specificity of the represented biomarkers were: alpha-defensin ELISA 0.97 (95% CI 0.91-0.99) and 0.97 (95% CI 0.94-0.98), respectively; Synovasure™ test kit assay 0.80 (95% CI 0.65-0.89) and 0.89 (95% CI 0.76-0.96), respectively; sLE 0.79 (95% CI 0.67-0.87) and 0.92 (95% CI 0.87-0.92), respectively; sIL-6 0.76 (95% CI 0.65-0.84) and 0.91 (95% CI 0.88-0.94), respectively; sCRP 0.86 (95% CI 0.81-0.91) and 0.90 (95% CI 0.86-0.93), respectively. CONCLUSION: The labararory-based alpha-defensin ELISA test showed the highest ever reported accuracy for PJI diagnosis. However, this did not apply for the Synovasure™ alpha-defensin test, which was comparable in its overall diagnostic accuracy to sCRP, sIL-6 and sLE. The later biomarkers also did not yield an overall diagnostic accuracy higher than that previously reported for synovial white cell count (sWBC) or culture bacteriology. Based on current evidence, no synovial biomarker should be applied as a standalone diagnostic tool. Furthermore, the use of the laboratory-based alpha-defensin ELISA test should be encouraged, still, the Synovasure™ alpha-defensin test kit should be critically appreciated. LEVER OF EVIDENCE: III.

The burden of gunshot injuries on orthopaedic healthcare resources in South Africa.

BACKGROUND: Injuries inflicted by gunshot wounds (GSWs) are an immense burden on the South African (SA) healthcare system. In 2005, Allard and Burch estimated SA state hospitals treated approximately 127 000 firearm victims annually and concluded that the cost of treating an abdominal GSW was approximately USD1 467 per patient. While the annual number of GSW injuries has decreased over the past decade, an estimated 54 870 firearm-related injuries occurred in SA in 2012. No study has estimated the burden of these GSWs from an orthopaedic perspective. OBJECTIVE: To estimate the burden and average cost of treating GSW victims requiring orthopaedic interventions in an SA tertiary level hospital. METHODS: This retrospective study surveyed more than 1 500 orthopaedic admissions over a 12-month period (2012) at Groote Schuur Hospital, Cape Town, SA. Chart review subsequently yielded data that allowed analysis of cost, theatre time, number and type of implants, duration of admission, diagnostic imaging studies performed, blood products used, laboratory studies ordered and medications administered. RESULTS: A total of 111 patients with an average age of 28 years (range 13 - 74) were identified. Each patient was hit by an average of 1.69 bullets (range 1 - 7). These patients sustained a total of 147 fractures, the majority in the lower extremities. Ninety-five patients received surgical treatment for a total of 135 procedures, with a cumulative surgical theatre time of >306 hours. Theatre costs, excluding implants, were in excess of USD94 490. Eighty of the patients received a total of 99 implants during surgery, which raised theatre costs an additional USD53 381 cumulatively, or USD667 per patient. Patients remained hospitalised for an average of 9.75 days, and total ward costs exceeded USD130 400. Individual patient costs averaged about USD2 940 (ZAR24 945) per patient. CONCLUSION: This study assessed the burden of orthopaedic firearm injuries in SA. It was estimated that on average, treating an orthopaedic GSW patient cost USD2 940, used just over 3 hours of theatre time per operation, and necessitated a hospital bed for an average period of 9.75 days. Improved understanding of the high incidence of orthopaedic GSWs treated in an SA tertiary care trauma centre and the costs incurred will help the state healthcare system better prioritise orthopaedic trauma funding and training opportunities, while also supporting cost-saving measures, including redirection of financial resources to primary prevention initiatives.

Surgical hip dislocation for removal of retained intra-articular bullets.

INTRODUCTION: Surgical hip dislocation with trochanteric osteotomy was introduced for the treatment of femoroacetabular impingement and other intra-articular pathologies of the hip. We expanded the indications to include removal of retained bullets in the hip joint as an alternative to hip arthroscopy. PATIENTS AND METHODS: We present a prospective case series of ten patients that were treated with a surgical hip dislocation for removal of retained bullets in the hip joint between January 2014 and October 2015 in a Level 1 trauma centre. The main outcome measurements were successful bullet removal, blood loss, surgical time and intraoperative complications. RESULTS: There were 8 males and 2 females with a mean age of mean age 27.3 years (range 20-32). All patients had one whole retained bullet for removal (right side: 8; left side: 2). In all cases the bullet could be removed in its entirety. The average surgical time was 73min (range 55-125) and the average blood loss 255ml (range 200-420). CONCLUSIONS: Surgical hip dislocation provides an unlimited view of the acetabulum and femoral head and neck and it therefore allows for easy removal of retained bullets. Osteocartilaginous lesions and concomitant fractures of the femoral head can be simultaneously evaluated and treated.

Early versus delayed application of Thomas splints in patients with isolated femur shaft fractures: The benefits quantified.

AIMS: To investigate and quantify the clinical benefits of early versus delayed application of Thomas splints in patients with isolated femur shaft fractures. MATERIALS AND METHODS: Level IV retrospective clinical and radiological analysis of patients presenting from January to December 2012 at a Level 1 Trauma Unit. All skeletally mature patients with isolated femur shaft fractures independently of their mechanism of injury were included. Exclusion criteria were: ipsilateral fracture of the lower limb, neck and supracondylar femur fractures, periprosthetic and incomplete fractures. Their clinical records were analysed for blood transfusion requirements, pulmonary complications, surgery time, duration of hospital stay and analgesic requirements. RESULTS: A total of 106 patients met our inclusion criteria. There were 74 males and 32 females. Fifty seven (54%) patients were in the 'early splinted' group and 49 patients (46%) were in the 'delayed splinted' group (P>0.05). The need for blood transfusion was significantly reduced in the 'early splinted' group (P=0.04). There was a significantly higher rate of pulmonary complications in the 'delayed splinted' group (P=0.008). All other parameters were similar between the two groups. CONCLUSION: The early application of Thomas splints for isolated femur fractures in non-polytraumatised patients has a clinically and statistically significant benefit of reducing the need for blood transfusions and the incidence of pulmonary complications.

Angular stable fixation of displaced distal-third clavicle fractures with superior precontoured locking plates.

HYPOTHESIS: We reviewed the outcome of angular stable plates in addressing displaced lateral-third clavicle fractures. We investigated union, shoulder function, request for implant removal, and return to sport. Our hypothesis was that these implants provide predictable union and return to sports without the negative consequence of leaving plates in situ, reducing the requirement for a second surgery. METHODS: We undertook a retrospective review of a consecutive series of patients who underwent this surgery between 2007 and 2010. Nineteen patients with a mean follow-up of 25 months were included. Postoperative follow-up was performed at 2 weeks and monthly thereafter until union was assessed as achieved clinically and radiographically. Two telephone interviews at a mean of 7 months and 25 months postoperatively assessed shoulder function by Oxford Shoulder Score, presence of any plate or scar discomfort, need for implant removal, and return to sport. RESULTS: Nineteen patients achieved union by 4 months (median, 12 weeks; range, 6-16 weeks). The mean Oxford Shoulder Score was 46 (range, 41-48) at a mean of 7 months (range, 3-18 months) and 47 (range, 44-48) at 25 months (range, 18-48 months). Initially, 2 patients requested implant removal; later, however, both declined surgery. No plates have been removed. Four patients complained of mild plate discomfort but did not wish removal. All patients had returned to sporting activities. CONCLUSION: Angular stable plate fixation of Neer group II, type II clavicle fractures resulted in a 100% union rate with excellent return of function with no mandatory need for removal.