Adverse Effects of Smoking on Musculoskeletal Health.

Smoking remains a prevalent part of present day society, with over 42 million Americans who continue to use cigarettes. Smoking is strongly associated with a variety of conditions that result in increased morbidity and mortality. Research also indicates that smoking has an adverse effect on surgical outcomes. Its effect on the musculoskeletal system is evident and results in postoperative complications such as infection, nonunion, and malunion. These complications also come with a price, as there are severe economic implications of smoking. Patients who smoke may benefit from a period of perioperative cessation to help diminish some of these negative outcomes. It is the physician's duty to educate patients preoperatively about these outcomes and the potential benefit of smoking cessation.

Epidemiology and management of maxillofacial fractures in an Australian trauma centre.

BACKGROUND AND AIM: Trauma is a leading cause of morbidity and mortality, with a considerable proportion of trauma patients sustaining concomitant maxillofacial (MF) injuries. The purpose of this study was to review and analyse the epidemiology, management and complications of patients with MF fractures managed by the Faciomaxillary Surgery Unit at the Alfred Trauma Hospital in Melbourne. The secondary objective of the study was to determine the risk factors for developing postoperative complications. METHODS: A retrospective records review was performed for 980 patients who were treated for MF fracture(s) from January 2009 to December 2011. Descriptive statistics were used and independent demographic and injury-related factors assessed for association with outcome using multivariate logistic regression. RESULTS: A total of 1949 MF fractures from 980 patients were treated over the study period. Males (n = 785, 80.10%) and patients aged 15-24 years (n = 541, 55.20%) were the most frequently affected (mean age (standard deviation, SD) 27.69 (19.22)). The most common aetiology was assault (n = 293, 29.90%). The majority presented with fractures of the orbit (n = 359, 36.33%). In total, 803 fractures from 500 patients were treated operatively. Mandibular fractures were most commonly treated surgically (79.82%). Postoperative complications occurred in 69 of 500 patients treated surgically (13.8%), most commonly due to infected metalware (n = 16, 3.20%). Multiple fractures were associated with a higher probability of requiring surgery (p < 0.001) and developing postoperative complications (p < 0.001) compared to isolated fractures. CONCLUSION: MF fractures most commonly affected young males, often as a result of an assault. Per bony injury, mandibular fractures had the greatest proportion that was managed operatively. High-energy injuries were associated with an increased risk of sustaining multiple MF fractures and developing postoperative complications.

Pediatric clavicular fractures: assessment of fracture patterns and predictors of complicated outcome.

BACKGROUND: Clavicular fractures are the most common pediatric long-bone fracture, and although the vast majority heal with supportive treatment, complications do occur and can lead to pain and disability. Although many studies have characterized adult complication rates and risk factors, to our knowledge no comparable studies to date have looked at clavicular fractures in the pediatric population. STUDY OBJECTIVES: The study aim was to identify the radiological and clinical variables that increase the complication rate of clavicular fractures. Identification of these variables would help emergency physicians identify patients who require more thorough follow-up or surgical intervention. METHODS: We analyzed radiographs of 537 clavicular fractures on initial presentation to the Pediatric Emergency Department at the Children's Hospital at London Health Sciences Center over a 4-year period, collecting data on variables such as displacement, angulation, and comminution, as well as demographic data such as age and gender. We then determined the outcome of each fracture by reviewing each patient's chart, and through a logistic regression analysis, determined the variables associated with complications. RESULTS: Of all the fractures treated supportively (i.e., non-operatively), only 2.5% resulted in a complication. Our analysis determined that patient age was an independent predictor of complications, with each year past zero conferring an 18.1% increase in risk of complication. Furthermore, completely displaced fractures were shown to increase the odds of complication by a factor of 3.2. CONCLUSION: These findings help the emergency physician identify a group of high-risk pediatric patients with clavicular fractures for which more thorough follow-up should be considered.

A systematic review of the treatment of acute fractures of the scaphoid.

A systematic review of the literature identified eight trials comparing surgery with cast treatment and found no significant difference in pain, tenderness, cost, functional outcome or patient satisfaction. In the group treated surgically, the rate of non-union was three times less, there was a quicker return to function and grip strength and range of movement was also transiently better. There were, however, more complications among those treated surgically. No significant differences were reported in the two trials that compared above and below elbow casts or the trial that compared scaphoid and Colles' casts.

National hardware removal rate associated with internal fixation of facial fractures.

PURPOSE: There has not been a broad national examination of complications and demographics of facial trauma reduction procedures. The literature has reported acceptable and unacceptable hardware removal rates in localized populations. MATERIALS AND METHODS: The 2007 Nationwide Inpatient Sample was used to determine all plate removal procedures associated with common complications from facial reductions. Statistical analysis was used to compare the differences in demographics of the reduction procedure and removal procedure groups. RESULTS: Some form of open fixation was reported in 4,879 patients. Plate removals associated with complications were reported in 246 patients. The "failure" removal rate as a percentage of the total number of open procedures for the year was 5.0%. Gender, race, age, primary payer, and median income of the patient were determined to significantly affect the likelihood for hardware removal due to complications. CONCLUSION: These results suggest that decreased lower bone quality and ability to pay affect the chances that a particular patient will undergo a hardware removal procedure. There is a strong possibility that the reported removal rate underestimates the actual failure rate of the procedures and devices used to treat facial trauma.

Assessment and correction of femoral malrotation following intramedullary nailing of the femur.

Rotational deformity is a more common problem than one might expect in the treatment of femoral shaft fractures. This review presents two cases of femoral malrotation following intramedullary nailing of the femur. The presentation, importance of early recognition, investigation with a CT scan, and the technique of correction is discussed in detail. The importance of intra-operative assessment to avoid this complication is highlighted and a review of the current literature on this problem and its treatment is presented.

A lack of consensus in the assessment of fracture healing among orthopaedic surgeons.

BACKGROUND: The assessment of fracture healing is both a clinically relevant and frequently used outcome measure following lower extremity trauma. However, it remains uncertain whether there is a consensus in the assessment of fracture healing among orthopaedic surgeons. Variability in the assessment of healing may have important implications in surgeons' decisions to intervene when they perceive fracture healing is slow to progress. OBJECTIVE: To identify surgeons' approaches in the assessment of tibial fracture healing and the definitions of a delayed union, nonunion, and malunion among orthopaedic surgeons. STUDY DESIGN: Cross-sectional survey of 577 orthopaedic surgeons. METHODS: Focus groups, key informants, and sampling to redundancy strategies were used to develop a survey to examine surgeons' opinions in the assessment of tibial shaft fractures. Surgeons were asked how often the following variables were used in the assessment of fracture healing: (a) callus size; (b) cortical continuity; (c) progressive loss of fracture line; (d) pain with weight bearing; and (e) pain to palpation at the fracture site. Further, surgeons were asked to provide a time point beyond which a delayed union becomes a nonunion. Finally, surgeons specified their limits of acceptable fracture alignment (translation, shortening, rotation, varus/valgus, and procurvatum/recurvatum). The survey was pilot tested for clarity and content validity. This survey was mailed to 577 orthopaedic surgeons who were members of the Orthopaedic Trauma Association, American Academy of Orthopaedic Surgeons, and European-AO International-affiliated trauma centers. RESULTS: Responses were obtained from 444 surgeons (response rate 77%). For each variable, the proportion of surgeons who always used the criterion ranged from 39.7% to 45.4%, and those who occasionally or never used the criterion ranged from 20.7% to 26.9%. Surgeons' definitions of delayed union ranged from 1 to 8 months, whereas definitions of nonunion ranged from 2 to 12 months. There was also variability in definitions of fracture malunion. Acceptable degrees of fracture shortening and translation ranged from less than 5 mm to greater than 15 mm. Surgeons' definitions of acceptable angular malunions (rotational, varus/valgus, and procurvatum/recurvatum) ranged from less than 5 degrees to 20 degrees. CONCLUSIONS: There is a lack of consensus in the assessment of fracture healing in tibial shaft fractures among orthopaedic surgeons. Varying definitions of nonunion and malunion may influence the decision to intervene in an effort to promote fracture healing and/or realign the fracture.

Three-dimensional assessment of tibial malunion after intramedullary nailing: a preliminary study.

OBJECTIVES: The purpose of this study was twofold: (a) to introduce a new three-dimensional digital assessment technique for the estimation of angular and rotational malunion and (b) to determine if an association exists between tibial malunion and functionally defined post-traumatic degeneration at the knee and ankle joint. DESIGN: Nonrandomized, cohort study, with 5.46 years (range 2 to 10 years) of follow-up. Subjects underwent a novel three-dimensional technique to determine the functional mechanical axis of both the knee and tibiotalar joints. Both the affected and unaffected limbs were tested. Differences between both limbs provided assessment of malunion in three planes with 1.8 +/- 0.1 percent (mean +/- SD) reliability. Patients completed the Western Ontario McMaster University Osteoarthritis Index, the Lower Extremity Functional Scale, and the Assessment System of Lower Extremity Function. Standard postoperative radiographs were also examined for evidence of malunion. SETTING: University-based Level 1 trauma center. PATIENTS: Seventy-one subjects with an isolated tibial fracture repaired with intramedullary nails were identified; thirteen met eligibility criteria for study inclusion. RESULTS: A total of 77 percent of the patients (mean follow-up 5.5 years, range 2 to 10 years) were malaligned in one or more of the three planes examined (malunion conventionally defined as >or=10 rotation, >or=5 varus-valgus, and >or=10 procurvatum-recurvatum). Mean varus-valgus deformity was 11.8 +/- 6.3 degrees, mean procurvatum-recurvatum deformity was 3.2 +/- 2.5 degrees, and medial-lateral rotational deformity was 9.6 +/- 4.7 degrees. There was no significant correlation (p > 0.05) between the overall alignment of the involved leg (intertibial difference) in any of the three directional planes and the subject's response to any of the three functional outcome scales used. Three-dimensional analysis differed significantly from radiographic interpretation when malunion occurred in the coronal plane (p = 0.0003). CONCLUSIONS: This study suggests that failure to meet conventionally accepted standards for tibial alignment might be common. Fortunately, these values were not associated with adverse functional outcomes. A three-dimensional system, which determines the functional mechanical axis of the knee and tibiotalar joints, may be a valuable and reliable method by which to determine malunion after fracture fixation.

The complications seen from the treatment by traditional bonesetters.

Traditional bone setters are rampant in the West African subregion but the atrocities committed by them have never been reported hence the need for this article that deals with the menace caused by them. All patients referred to the University College Hospital between 1996 and 2001 were included in this study. Only a few number of the patients have been selected just to illustrate the menace caused by the traditional bonesetters in so many African societies. The deformities, financial loss and amputations resulting from the management by traditional bonesetters have been highlighted. Suggestions are made on how to improve awareness in the way of adequate communications through televisions, radio and the press. Much need to be done in the society as it was found in the study that poverty or lack of education alone is not the major cause of the society seeking the help of the traditional healers, but probably the culture and traditional beliefs of the society.

The treatment of femoral shaft fractures in children: a systematic overview and critical appraisal of the literature.

OBJECTIVE: Through a critical systematic overview of the literature on the treatment of pediatric femoral shaft fractures to determine if any method of treatment can be recommended over others. DATA SOURCES: A MEDLINE search was performed for all cohort and randomized clinical trials for the years 1966 to 1996. STUDY SELECTION: Of 1217 identified articles, 15 cohort studies (where 2 or more treatments were compared in the same study) reported the treatment of children with femoral fractures. DATA EXTRACTION: Information was abstracted and articles rated for quality blind to author, institution and journal. DATA SYNTHESIS: Children having early application of a hip spica cast had an average hospital stay of 11 days (range from 5 to 29 days), average charges of $5784 (range from $590 to $11,800), average rates of limb-length discrepancy (greater than 2 cm) of 3% (range from 0 to 25%), angulatory malunion rates (greater than 10 degrees) of 8% (range from 0 to 19%), and rotational malunion rates (greater than 10 degrees) of 13% (range from 0 to 5%). The costs and malunion rates of early application of a hip spica cast were lower than for traction. Internal fixation (including intramedullary nails) had low angulatory malunion rates compared with early application of a hip spica cast but higher over-lengthening rates (greater than 2 cm) of 25% (range from 5% to 100%) and mean rotational malunion rates (greater than 10 degrees) of 25% (range from 11% to 32%). CONCLUSION: Early application of a hip spica cast had lower costs and malunion rates than traction.