X-Bolt unforeseen placement complication: case report.

With the introduction of the World Hip Trauma Evaluation Four clinical trial, fixation of pertrochanteric neck of femur fractures is becoming a hot topic. In this trial, the novel X-Bolt expanding bolt implant is being compared with the current gold standard of a sliding hip screw. We present a previously undescribed complication when inserting the bolt into the femoral head, where the expandable wings penetrate the femoral neck due to misplacement of the bone crusher or the X-Bolt prosthesis. This unforeseen complication required the introduction of several additional corrective intraoperative steps.

Pre-operative analgesia for patients with femoral neck fractures using a modified fascia iliaca block technique.

Adequate pre-operative analgesia for elderly patients with femoral neck fractures is difficult to assess and is often an overseen aspect of their care. We aimed to assess the efficacy of fascia iliaca blocks inserted via plexus blockade catheters in the pre-operative period. Our simple technique allowed the block to be administered safely without the need for a nerve stimulator. We assessed the effectiveness of the block with a novel objective sitting score and by assessing the degree of passive hip flexion that could be achieved comfortably. Visual analogue scores were also used. We studied 30 consecutive patients, regardless of their mental state. One hour following the block, there was a significant improvement in the sitting scores as well as the passive hip flexion (mean increase 44 degrees ). Visual analogue scores also score improved significantly from 7.2 to 4.6 (S.D. 2.4) in the 18 patients without cognitive impairment. We conclude that fascia iliaca blocks can provide significant benefit in the pre-operative period and allow patients to sit up more comfortably while they await surgery.

Weight-bearing radiographs in thoracolumbar fractures: do they influence management?

STUDY DESIGN: Prospective observational study. OBJECTIVE: Our objective was to compare supine and erect (weight-bearing) radiographs in patients with thoracolumbar fractures without a neurologic deficit and to determine whether the erect radiographs alter the deformity and the management plan. SUMMARY OF BACKGROUND DATA: Nonoperative treatment for thoracolumbar fracture without a neurologic deficit is safe and effective. There are some guidelines in the literature that provide objective standards to identify the patients that are suitable for nonoperative treatment. These guidelines are based on measurements on supine radiographs. The role of weight-bearing radiographs in influencing the management plan of these injuries has not been explored. METHODS: Fractures between T11 and L2 in 28 patients were considered suitable for nonoperative treatment initially. Radiographic measurements included anterior and posterior vertebral body heights, interpedicular distance, and the Cobb angle on the supine and erect radiographs. A change in the treatment from the initial nonoperative management plan, based on the radiographic findings, was recorded. RESULTS: Mean supine Cobb angle of 11 degrees increased to 18 degrees on weight-bearing films. The mean anterior vertebral compression increased from 34% to 46%. No change was noted between the posterior vertebral heights and the interpedicular distance. Seven of the 28 patients were subjected to surgical stabilization based on these findings. CONCLUSION: Performing erect radiographs in patients with thoracolumbar fractures without a neurologic deficit provides additional information and did alter the management plan in a significant proportion (25%) of our patients.

Osteomyelitis of the scaphoid with sequestration of the primary ossification centre.

An 8-year-old boy presented with Staphylococcus aureus osteomyelitis affecting the left (non-dominant) scaphoid. Surgical drainage resulted in the expulsion of the primary ossification centre as a sequestrum. Seven years later the wrist function was minimally impaired and X-rays showed complete ossification of the cartilage remnant with a relatively normal scaphoid.

Comparison of two conservative methods of treating an isolated fracture of the lateral malleolus.

We compared two conservative methods of treating Weber B1 (Lauge-Hansen supination-eversion 2) isolated fractures of the lateral malleolus in 65 patients. Treatment by immediate weight-bearing and mobilisation resulted in earlier rehabilitation than immobilisation for four weeks in a plaster cast. There was no significant difference in the amount of pain experienced or in the requirement for analgesics and early mobilisation was not associated with any complications. We therefore advocate early mobilisation for these stable ankle fractures.