Functional management of Achilles tendon rupture: A viable option for non-operative management.

BACKGROUND: Functional management of the ruptured Achilles tendon can be effective using orthoses like the removable walker boot (Foam Walker Boot, Air Cast UK Limited, Lincolnshire, United Kingdom). We conducted this study to look at the outcome of our protocol using this orthosis. MATERIALS AND METHODS: We retrospectively reviewed 107 non-operatively managed Achilles tendon ruptures over the last 5 years. Case notes were analyzed for demographics and immediate outcomes. Long term outcomes were assessed by a postal questionnaire using the Achilles Tendon Total Rupture Score (ATRS). RESULTS: Of the 107 tendons (male:female=71:36, mean age=50 years), 105 tendons (98%) healed with an average discharge time of 22 weeks. Six patients reported major complications and 6 reported minor complications. We received 56 questionnaires with a mean ATRS score of 21. Seventy-seven percent returned to pre-injury level of activity. CONCLUSION: Functional management of Achilles tendon rupture, under appropriate supervision, provides a viable option for non-operative management.

Serum osteocalcin, total and bone-specific alkaline phosphatase following isolated tibial shaft fracture.

We report the changes in osteocalcin concentrations and in total and bone specific alkaline phosphatase activity occurring in the twenty week period following tibial shaft fracture in 20 subjects. Bone formation during the healing process is reflected by progressive increases in the concentration of osteocalcin and bone specific alkaline phosphatase after week 5 and the latter correlated with the height and weight of the subject. In the early post injury period, total alkaline phosphatase activity increased whereas that of the bone isoenzyme initially fell, starting to rise again during the second week. After an immediate post injury rise, osteocalcin concentration also decreased, reaching a nadir by week 5. As only three of our subjects demonstrated delayed union, we have not been able to demonstrate that biochemical monitoring of the healing process can provide an indication of prognosis in tibial shaft fracture.

The Ilizarov method in nonunion, malunion and infection of fractures.

We have reviewed a series of 56 consecutive patients treated by the Ilizarov circular fixator for various combinations of nonunion, malunion and infection of fractures. We used segmental excision, distraction osteogenesis and gradual correction of the deformity as appropriate. Treatment was effective in eliminating 40 out of 46 nonunions and all 22 infections. There were two cases of refracture some months after removal of the frame, both of which healed securely in a second frame. Correction of malunion was good in the coronal plane but there was a tendency to anterior angulation, often occurring in the regenerate bone rather than at the original fracture site, after removal of the frame. This was associated with very slow maturation of regenerate bone in some patients, occurring largely, but not exclusively, in those who smoked heavily. Patients expressed high levels of satisfaction with the outcome, despite relatively modest improvements in pain and function, presumably because their longstanding and intractable nonunion had been treated. None the less, the degree of satisfaction correlated strongly with the degree of improvement in pain and function. We emphasise the importance of a multidisciplinary team in the assessment and support of patients undergoing long and demanding treatment. The Ilizarov method is valuable, but research is needed to overcome the problems of delayed maturation of the regenerate and slow or insecure healing of the docking site.

Serology of abnormal fracture healing: the role of PIIINP, PICP, and BsALP.

OBJECTIVE: To determine whether poorly healing tibial shaft fractures exhibit a serological response of bone-specific alkaline phosphatase (BsALP), collagen I carboxy-terminal propeptide (PICP), collagen III amino-terminal propeptide (PIIINP), and collagen I carboxy-terminal telopeptide (ICTP) different from that of normally healing fractures. DESIGN: Prospective. PARTICIPANTS: Twenty consecutive patients with isolated tibial shaft fractures with or without fracture of the fibula. MAIN OUTCOME MEASUREMENTS: Assays of BsALP, PICP, PIIINP, and ICTP were performed with serum samples taken at standard intervals from twenty-four hours to twenty weeks after fracture. Fracture healing was assessed at five, ten, fourteen, and twenty weeks for clinical and radiological evidence of union. RESULTS: Seventeen fractures united within the twenty-week study period. The three fractures exhibiting delayed union demonstrated significantly lower PICP levels and marginally lower BsALP levels at twenty weeks. PIIINP levels were significantly higher in these three fractures at ten weeks. There was no difference in ICTP between the seventeen united and the three ununited fractures. CONCLUSIONS: This study identified three serological features of a poor healing response in tibial shaft fractures. First, matrix collagen I and III production in the first ten weeks of healing was adequate, with evidence of significantly increased production of type III collagen. Second, there was no serological evidence of a deficient osteoblast response, as indicated by normal levels of BsALP and PICP, during this early period. Third, evidence of a deficient osteoblast response appeared only at twenty weeks after injury.

Serology of collagen types I and III in normal healing of tibial shaft fractures.

OBJECTIVES: To establish that serological indicators of synthesis of collagens I and III in humans with normally healing tibial shaft fractures will display a temporal pattern consistent with the sequence of expression of these collagens observed histologically in animal models of fracture healing. DESIGN: Prospective. SETTING: Four district general hospitals in the United Kingdom supported by an academic unit. PARTICIPANTS: Twenty consecutive patients with isolated tibial shaft fractures were studied. On clinical and radiological grounds, seventeen of the cases united within twenty weeks; these seventeen cases formed the material for this review. INTERVENTIONS: Nineteen patients were treated conservatively, and a functional brace was applied at five weeks. One patient treated with an external fixator had a functional brace applied at twelve weeks. MAIN OUTCOME MEASURES: Assays of collagen I carboxy-terminal propeptide (PICP), collagen III amino-terminal propeptide (PIIINP), and collagen I carboxy-terminal telopeptide (ICTP) were made in serum samples taken at standard intervals from twenty-four hours to twenty weeks after fracture. RESULTS: PICP showed a significant, transient early drop, whereas ICTP rose, indicating early breakdown with uncoupling of collagen I formation and degradation. PIIINP levels rose significantly from day eight to week five, in keeping with early expression of collagen III in experimental fracture callus. PICP levels showed a gradual rise, consistent with later expression of collagen I. CONCLUSIONS: The changes observed are in keeping with previous histological work on animal fracture models, suggesting that serological measures may reflect events occurring at the fracture site and thus offer a means for noninvasive and dynamic observation of collagen synthesis after fracture. Final proof that such measurements reflect bony healing per se, as opposed to events in other tissues, would require comparison with similar data from a soft tissue injury model.

The assessment of cutaneous blood flow with transoxode probe.

An experimental study on 12 healthy individuals was conducted over a period of six months, using the transoxode probe to assess cutaneous blood flow via measurements of transcutaneous oxygen tension (TcpO2) and relative heat power input (R.H.P.). The possible clinical use of the probe in peripheral vascular ischaemia was re-evaluated. The results were controlled with those of venous occlusion plethysmography, being a reliable means of assessing peripheral blood flow. The study revealed that changes in TcpO2 did not correlate significantly with alterations in skin perfusion mainly due to the lack of probe sensitivity. The clinical implications of such methods are discussed.

Traumatic radial head dislocation in children--a missed injury.

The purpose of this article is to remind accident and emergency doctors of an easily missed injury-isolated traumatic radial head dislocation in children. We present two such cases. This is a very uncommon injury and the diagnosis was overlooked in both cases. A high index of suspicion is necessary and careful examination of the radiographs is mandatory. The radiographic appearance of this injury is explained.

ABC of emergency radiology. The wrist.

History including detailed mechanism of injury. Meticulous clinical examination. Appropriate radiograph and systematic assessment.

Irreducible dorsal radiocarpal fracture dislocation with dissociation of the distal radioulnar joint: a case report.

We report a case of dorsal radiocarpal fracture dislocation with dissociation of the distal radioulnar joint. Closed reduction was unsuccessful due to interposition of the osteochondral fragments and open reduction and fixation was carried out with a satisfactory end result. The advantages of volar approach and use of external fixator in the management of this injury are discussed.

Compression stockings in the management of fractures of the ankle: a randomised controlled trial.

In this randomised controlled trial, we evaluated the role of elastic compression using ankle injury stockings (AIS) in the management of fractures of the ankle. A total of 90 patients with a mean age of 47 years (16 to 79) were treated within 72 hours of presentation with a fracture of the ankle, 31 of whom were treated operatively and 59 conservatively, were randomised to be treated either with compression by AIS plus an Aircast boot or Tubigrip plus an Aircast boot. Male to female ratio was 36:54. The primary outcome measure was the functional Olerud-Molander ankle score (OMAS). The secondary outcome measures were; the American Orthopaedic Foot and Ankle Society score (AOFAS); the Short Form (SF)-12v2 Quality of Life score; and the frequency of deep vein thrombosis (DVT). Compression using AIS reduced swelling of the ankle at all time points and improved the mean OMAS score at six months to 98 (95% confidence interval (CI) 96 to 99) compared with a mean of 67 (95% CI 62 to 73) for the Tubigrip group (p < 0.001). The mean AOFAS and SF-12v2 scores at six months were also significantly improved by compression. Of 86 patients with duplex imaging at four weeks, five (12%) of 43 in the AIS group and ten (23%) of 43 in the Tubigrip group developed a DVT (p = 0.26). Compression improved functional outcome and quality of life following fracture of the ankle. DVTs were frequent, but a larger study would be needed to confirm that compression with AISs reduces the incidence of DVT.

Accessory muscles around the foot and ankle presenting as chronic undiagnosed pain. An illustrative case report and review of the literature.

The differential diagnosis of ankle pain is extensive. Pathology may be classified as intra- or extra-articular. Additionally, ankle pain may be traumatic or non-traumatic. One of the unusual differential diagnoses for pain in the ankle is an accessory muscle. Magnetic resonance imaging is the radiological investigation of choice. However, this is invariably reported as normal unless one specifically looks for an accessory muscle. The purpose of this report is to highlight important features of these muscles and to draw attention to this uncommonly reported condition.

Transfusion needs in hip and knee arthroplasty.

A 12 months retrospective study of cross-match and transfusion practice in hip and knee arthroplasty in a general orthopaedic unit was carried out aiming to assess the transfusion needs for these procedures prior to enrolling future patients in a pre-donation program for autologous transfusion. The study revealed acceptable transfusion practice in the unit. For both procedures, over 75% of all transfusions were carried out in the peri-operative period. Eighty-nine percent of patients undergoing hip arthroplasty required transfusion with a maximum of three units, while a maximum of only two units were needed to meet the transfusion requirements of 86% of patients undergoing knee arthroplasty. In hip arthroplasty, the overall transfusion index (Ti), was 2.05, and this value did not vary significantly according to preoperative haemoglobin values. This was in contrast to knee arthroplasty, where the Ti was 2.9 in patients with preoperative haemoglobin value less than 11 g/dL compared to only 0.6 for haemoglobin value greater than 13 g/dL. In conclusion, in an autologous transfusion program, the availability of three units would satisfy the transfusion needs in 89% of hip arthroplasties, while the availability of two units would satisfy the needs in 86% of knee arthroplasties. Preoperative donation for knee arthroplasty with a haemoglobin level over 13 g/dL may prove wasteful as in our current practice, the transfusion index in this group of patients was only 0.6.

Painless limp as a presentation of pelvic eosinophilic granuloma in a child.

Painless limp in children continues to pose a diagnostic challenge. In the majority of the cases transient synovitis of the hip is the cause. However, bone tumours should be considered as a possibility and specifically looked for when a child continues to have ongoing symptoms. Failure to diagnose tumours at an early stage can lead to a poorer outcome. This case report describes a child with eosinophilic granuloma who presented with a progressive painless limp. It emphasises the need to look carefully at the pelvic bones when evaluating a hip radiograph.

A cross-matching policy for fractures of the proximal third of the femur.

Cross-matching and transfusion policies for patients with a fracture of the proximal third of the femur are poorly formulated. A series of 90 patients who underwent operation for such fractures at a district general hospital were evaluated. Unnecessary cross-matching was most frequent in intracapsular fractures, and discrepancies in indications for postoperative transfusions were demonstrated. If postoperative transfusion is indicated for haemoglobin levels of less than 9 g/dl, we recommend routine preoperative cross-matching only for patients admitted with trochanteric fractures and haemoglobin levels between 10 and 12 g/dl. This practice is safe and is a potential area for savings in cost and resources.

Fixation of closed metacarpal shaft fractures. Transverse K-wires in 22 cases.

22 patients who had closed displaced metacarpal shaft fractures, treated by transverse percutaneous K-wire fixation were reviewed. In 11 cases, 1 distal and 1 proximal wire were inserted and in the rest, 2 distal and 1 proximal wire were used. The results in patients treated with a single distal wire were unsatisfactory due to pivoting of the distal fragment on the wire with consequent angulation and cosmetic deformity. In those who had 2 wires inserted distally, the reduction position was maintained throughout.

A new osteotome for performing chevron trochanteric osteotomy.

We report on the use of a new modified osteotome for performing chevron trochanteric osteotomy during hip arthroplasty. It is easy to use and the apex of the chevron is directed distally, thus producing a large segment of osteotomized trochanter, while avoiding the problems of fragmentation and splintering. At the end of the procedure, the trochanter is easily seated back within its concave bed, automatically achieving anatomical reduction and allowing easier fixation using the cruciate wiring technique. In a series of 77 primary hip arthroplasties, bony trochanteric union was achieved within 6 months in all patients.

Widening of the mediastinum following a sternal fracture.

Sternal fractures, once thought of as uncommon, occur with increasing frequency, parallelling the incidence of motor vehicle accidents. A fractured sternum can produce a widening of the mediastinum even in the absence of an aortic injury. The Advanced Trauma Life Support course teaches that a widening of the mediastinum after blunt chest injury is an indication for aortography. In this case report we recommend computerised axial tomography (CT) scan of the chest as the investigation of choice in the non-hypotensive patient who has sustained a fractured sternum after a blunt chest trauma, and who has widening of the mediastinum on the chest X-ray, with no other radiological features suggesting traumatic aortic rupture.

Acrylic bone-cement. Influence of mixer design and unmixed powder.

The effects of hand mixing with two different mechanical mixing systems (fixed versus rotating central axis) on unmixed powder content, macroporosity, density, and bending strength of acrylic bone-cement are compared. The effects of voids and unmixed powder on cement bending strength are also evaluated. In acrylic cement, both unmixed powder monomer and voids 1 mm and larger can be easily visualized and analyzed on radiographs of 3-mm-thick samples. Image analysis allowed demonstration of a significant increase in unmixed powder content (P < .0001), in cement prepared using a vacuum mixing system with a fixed central axis compared with both the rotating axis system and hand mixing. The rotating-axis system produced cement of higher density compared with hand mixing only (P = .004). There was a significant correlation between the number of voids measured per square centimeter and cement bending strength (P < .0001), as well as an independent and significant correlation between unmixed powder content and cement bending strength (P < .0001). Mechanical mixing using a fixed central axis produced significantly weaker cement compared with both hand mixing (P < .015) and the rotating-central-axis system (P < .0001). A 15% drop in strength between the two mechanical mixing systems was observed. It is therefore concluded that the use of different rotating systems in mechanical mixers can influence void and unmixed powder content and, consequently, the mechanical properties of acrylic cement, and that unmixed powder is an independent factor affecting the bending strength of the cement.