Review article: A comprehensive review of unusual causes of acute limb compartment syndrome.

Acute limb compartment syndrome (ALCS) is a surgical emergency that can have serious consequences unless promptly diagnosed and treated, which is particularly challenging when there is an unusual cause. This is a comprehensive review of reported causes of ALCS. From 1068 included articles, we found 299 discrete causes of ALCS including toxins, infections, endocrine pathology, haematological emergencies, malignancy and iatrogenic ALCS. Familiarity with this wide range of ALCS causes may assist in early diagnosis of this limb-threatening condition.

Clostridium histolyticum (AA4500) for the Treatment of Adhesive Capsulitis of the Shoulder: A Randomised Double-Blind, Placebo-Controlled Study for the Safety and Efficacy of Collagenase - Single Site Report.

BACKGROUND/HYPOTHESIS: Adhesive capsulitis of the shoulder results in pain and restricted movement of the glenohumeral joint. Hypothesis: There would be a difference in active range of movement in the affected shoulder of patients with adhesive capsulitis after receiving a series of injections of collagenase Clostridium histolyticum (CCH) compared to placebo. METHODS: This study reports the results from a single site that was part of a 321-participant, multicenter, double-blind, prospective parallel-group, randomized controlled clinical trial. Inclusion criteria: over 18 years of age, unilateral idiopathic adhesive capsulitis for >3 months, but <12 months. Exclusion criteria: recent physical therapy, injections, subacromial impingement, calcific tendonitis or glenohumeral joint arthritis in the affected shoulder. Subjects were randomized 3:1 to receive CCH 0.58 mg or placebo under ultrasound guidance. Injections were on days 1, 22, and 43. The primary outcome measure was a functional assessment of active range of movement. RESULTS: Overall, 37 patients were screened, 26 subjects were excluded, and 11 subjects were randomly assigned to the treatment group (n=9) or the control group (n=2). Both control and treatment groups showed improvement in ROM between baseline and day 95. In the treatment group, AROM improved from the baseline of 272.89° (SD 86.25) to 462.11° (SD 96.89) and the control group from 246.00° (SD 5.66) to 451.50° (SD 50.20) at day 95 with no statistical difference between groups p=0.78. Site data were in line with the whole study findings. Treatment-related adverse events at the injection site, including haematoma (bruising) and localised pain and swelling, were common. CONCLUSION: Although the participants showed improvement in function, statistical significance was neither reached in the site nor the overall study cohort. Given the adverse events and the potential risks of the procedure, we would not recommend this drug for the treatment of adhesive capsulitis of the shoulder. LEVEL OF EVIDENCE: 2, cohort from one site of RCT.

Occlusion of the lumbar spine canal during high-rate axial compression.

BACKGROUND CONTEXT: While burst fracture is a well-known cause of spinal canal occlusion with dynamic, axial spinal compression, it is unclear how such loading mechanisms might cause occlusion without fracture. PURPOSE: To determine how spinal canal occlusion during dynamic compression of the lumbar spine is differentially caused by fracture or mechanisms without fracture and to examine the influence of spinal level on occlusion. STUDY DESIGN: A cadaveric biomechanical study. METHODS: Twenty sets of three-vertebrae specimens from all spinal levels between T12 and S1 were subjected to dynamic compression using a hydraulic loading apparatus up to a peak velocity between 0.1 and 0.9 m/s. The presence of canal occlusion was measured optically with a high-speed camera. This was repeated with incremental increases of 4% compressive strain until a vertebral fracture was detected using acoustic emission measurements and computed tomographic imaging. RESULTS: For axial compression without fracture, the peak occlusion (Omax) was 29.9±10.0%, which was deduced to be the result of posterior bulging of the intervertebral disc into the spinal canal. Omax correlated significantly with lumbar spinal level (p<.001), the compressive displacement (p<.001) and the cross-sectional area of the vertebra (p=.031). CONCLUSIONS: Spinal canal occlusion observed without vertebral fracture involves intervertebral disc bulging. The lower lumbar spine tended to be more severely occluded than more proximal levels. CLINICAL SIGNIFICANCE: Clinically, intermittent canal occlusion from disc bulging during dynamic compression may not show any radiographic features. The lower lumbar spine should be a focus of injury prevention intervention in cases of high-rate axial compression.

Analysis of Platelet-Rich Plasma Extraction: Variations in Platelet and Blood Components Between 4 Common Commercial Kits.

BACKGROUND: Platelet-rich plasma (PRP) has been extensively used as a treatment in tissue healing in tendinopathy, muscle injury, and osteoarthritis. However, there is variation in methods of extraction, and this produces different types of PRP. PURPOSE: To determine the composition of PRP obtained from 4 commercial separation kits, which would allow assessment of current classification systems used in cross-study comparisons. STUDY DESIGN: Controlled laboratory study. METHODS: Three normal adults each donated 181 mL of whole blood, some of which served as a control and the remainder of which was processed through 4 PRP separation kits: GPS III (Biomet Biologics), Smart-Prep2 (Harvest Terumo), Magellan (Arteriocyte Medical Systems), and ACP (Device Technologies). The resultant PRP was tested for platelet count, red blood cell count, and white blood cell count, including differential in a commercial pathology laboratory. Glucose and pH measurements were obtained from a blood gas autoanalyzer machine. RESULTS: Three kits taking samples from the "buffy coat layer" were found to have greater concentrations of platelets (3-6 times baseline), while 1 kit taking samples from plasma was found to have platelet concentrations of only 1.5 times baseline. The same 3 kits produced an increased concentration of white blood cells (3-6 times baseline); these consisted of neutrophils, leukocytes, and monocytes. This represents high concentrations of platelets and white blood cells. A small drop in pH was thought to relate to the citrate used in the sample preparation. Interestingly, an unexpected increase in glucose concentrations, with 3 to 6 times greater than baseline levels, was found in all samples. CONCLUSION: This study reveals the variation of blood components, including platelets, red blood cells, leukocytes, pH, and glucose in PRP extractions. The high concentrations of cells are important, as the white blood cell count in PRP samples has frequently been ignored, being considered insignificant. The lack of standardization of PRP preparation for clinical use has contributed at least in part to the varying clinical efficacy in PRP use. CLINICAL RELEVANCE: The variation of platelet and other blood component concentrations between commercial PRP kits may affect clinical treatment outcomes. There is a need for standardization of PRP for clinical use.

Prevalence of non-union and delayed union in proximal humeral fractures.

BACKGROUND: Little is known about the prevalence of proximal humeral non-union. There is disagreement on what constitutes union, delayed union and non-union. Our aim was to determine the prevalence of these complications in proximal humeral fractures (PHFs) admitted to trauma hospitals. METHODS: The Victorian Orthopaedic Trauma Outcomes Registry identified 419 cases of PHFs, of which 306 were analysed. Three upper limb orthopaedic surgeons used X-rays to classify fractures according to the Neer classification and determine union. Twelve-item Short Form Health Survey scores were used to assess patient health and wellbeing. RESULTS: Of 306 cases, 49.4% reached union. Median time to union was 100 days (confidence interval 90-121). Of these, 17.0% united by 60 days, 8.5% united by 89 days and 23.9% united after 90 days, demonstrating 'prolonged delayed union'. There were 25 non-unions with a prevalence of 8.2%, most occurring in two-part surgical neck fractures. CONCLUSION: Our cohort of largely displaced PHFs admitted to trauma hospitals had a non-union prevalence of 8.2% and an overall delayed union prevalence of 32.4%. Consensus is required on definitions of non-union and delayed union timeframes.

Interobserver agreement of Neer and AO classifications for proximal humeral fractures.

BACKGROUND: The classification of proximal humeral fractures remains challenging. The two main classification systems used, the Neer and the AO classification, have both been shown to have less than ideal interobserver agreement. Agreement in classification is required, however, to guide fracture management. METHOD: Data from the Victorian Orthopaedic Trauma Outcomes Registry were collected and the X-rays of 104 proximal humeral fractures were reviewed by three orthopaedic consultants. They classified the fractures according to the Neer and AO classifications, as well as their simplified versions. Interobserver agreement was then assessed using kappa statistics. RESULTS: Interobserver agreement was better overall in the Neer classification, which was moderate (kappa = 0.40-0.58), than the AO classification, which was fair to moderate (kappa = 0.31-0.54). When simplified, the Neer and AO classification interobserver agreement remained similar. CONCLUSION: The classification of proximal humeral fractures with both the Neer and the AO systems remains difficult with minimal improvements seen when reducing the number of categories in each classification system. From these results, the Neer classification system would appear slightly more useful in clinical practice to guide treatment.

Mental imagery and learning: a qualitative study in orthopaedic trauma surgery.

CONTEXT: Good preparation for surgical procedures has been linked to better performance and enhanced learning in the operating theatre. Mental imagery is increasingly used to enhance performance in competitive sport and there has been recent interest in applying this in surgery. OBJECTIVES: This study aims to identify the mental imagery components of preoperative preparation in orthopaedic trauma surgery and to locate these practices in existing socio-material theory in order to produce a model useful for surgical skills training. METHODS: Semi-structured interviews were conducted with nine orthopaedic surgeons. Participants were identified by personal recommendation as regularly performing complex trauma operations to a high standard, and by affiliation to an international instruction course in trauma surgery. Interviews were audio-recorded and transcripts were independently analysed using thematic analysis. RESULTS: Analysis revealed that surgeons interact intensively with multiple colleagues and materials during their preparatory activities. Such interactions stimulate mental imagery in order to build strategy and rehearse procedures, which, in turn, stimulate preparatory interactions. Participants identified the discussion of a preoperative 'plan' as a key engagement tool for training junior surgeons and as a form of currency by which a trainee may increase his or her participation in a procedure. CONCLUSIONS: Preoperative preparation can be thought of as a socio-material ontology requiring a surgeon to negotiate imaginal, verbal and physical interactions with people, materials and his or her own mental imagery. Actor-network theory is useful for making sense of these interactions and for allowing surgeons to interrogate their own preparative processes. We recommend supervisors to use a form of preoperative plan as a teaching tool and to encourage trainees to develop their own preparatory skills. The ability of a trainee to demonstrate sound preparation is an indicator of readiness to perform a procedure.

Arterial supply of the tendinous rotator cuff insertions: an anatomical study.

BACKGROUND: Confirming the presence of arteries crossing the osteotendinous junctions (OTJs) of the rotator cuff may explain why rates of avascular necrosis (AVN) of the humeral head vary between three- and four-part proximal humeral fractures. It is hypothesized that the humeral head remains better vascularized in three-part fractures because one tuberosity with its inserting rotator cuff tendons is still attached to the articular fragment and supplying it with blood. METHODS: Eighty rotator cuff tendons from 20 shoulder girdles of cadavers aged 68-94 years were studied. In six shoulder girdles, the anterior circumflex humeral artery and posterior circumflex humeral artery (PCHA) were injected with ink, and the extra- and intraosseous courses of the vasculature were dissected until the OTJs of the rotator cuff. RESULTS: The rotator cuff insertions received an arterial supply across their OTJs in 50% of cases (75% in supraspinatus, 67% in subscapularis, 33% in infraspinatus and 20% in teres minor). Supraspinatus and subscapularis insertions were vascularized by the arcuate artery, while the insertions of infraspinatus and teres minor were supplied by an unnamed terminal branch of the PCHA. This was named 'posterolateral artery'. CONCLUSION: The presence of arteries crossing the OTJs of the rotator cuff, as well as the differences in the frequency arteries crossed the OTJs of individual rotator cuff tendons, may help explain why there is a lower rate of AVN of the humeral head in thee-part, compared with four-part proximal humeral fractures.

New approach to the study of intraosseous vasculature.

BACKGROUND: The study of intraosseous vasculature has always been challenging due to the hard, calcified structure of bone. Techniques used to study intraosseous vasculature usually involve diaphanization with a Spalteholz technique, followed by X-ray imaging to display the radio contrast-injected blood vessels. These techniques produce results with fine detail when successfully executed. However, high failure rates and the extensive length of time required to perform these techniques are drawbacks. This paper describes a faster, alternative method for the study of intraosseous vasculature. METHOD: Five embalmed and two fresh shoulder girdles were harvested from six cadavers. Cannulas were inserted into the origins of the anterior (ACHA) and posterior (PCHA) circumflex humeral arteries and injected with ink diluted in water or 6% hydrogen peroxide. The arteries and their branches were dissected until they entered their respective bony foraminae. A hammer, chisel, bone nibbler and mounted needles were used to follow the intraosseous course of these arteries and their branches. RESULTS: The intraosseous vasculature was seen in all specimens. The branches of the main nutrient artery to the proximal humerus were followed until they reached articular cartilage or crossed cortical bone again to enter the rotator cuff tendons. DISCUSSION: An innovative, new approach to the study of intraosseous vasculature with direct visualization of the intraosseous arteries of the proximal humerus is described.

Clinical practice guidelines for the management of acute limb compartment syndrome following trauma.

BACKGROUND: Acute compartment syndrome is a serious and not uncommon complication of limb trauma. The condition is a surgical emergency, and is associated with significant morbidity if not managed appropriately. There is variation in management of acute limb compartment syndrome in Australia. METHODS: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma were developed in accordance with Australian National Health and Medical Research Council recommendations. The guidelines were based on critically appraised literature evidence and the consensus opinion of a multidisciplinary team involved in trauma management who met in a nominal panel process. RESULTS: Recommendations were developed for key decision nodes in the patient care pathway, including methods of diagnosis in alert and unconscious patients, appropriate assessment of compartment pressure, timing and technique of fasciotomy, fasciotomy wound management, and prevention of compartment syndrome in patients with limb injuries. The recommendations were largely consensus based in the absence of well-designed clinical trial evidence. CONCLUSIONS: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma have been developed that will support consistency in management and optimize patient health outcomes.

Factors that predict poor outcomes in patients with traumatic vertebral body fractures.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To identify factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit. SUMMARY OF BACKGROUND DATA: There is a paucity of information on factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit. METHODS: Patients were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). VOTOR includes all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria, Australia. Patient-reported outcomes and data on possible predictive factors, including demographic details, injury-related and treatment-based factors, were obtained from the VOTOR database. Patient-reported outcomes were measured at 12 months post-injury using the 12-Item Short-Form Health Survey (SF-12), a Numerical Rating Scale (NRS) for pain, global outcome questions and data was collected on return to work or study. For the identification of predictive factors, univariate analyses of outcome vs. each predictor were carried out first, followed by logistic multiple regression. RESULTS: 344 patients were eligible for the study and data were obtained for 264 (76.7%) patients at 12 months follow-up. Patients reported ongoing pain at 12 months post-injury (moderate-severe: 33.5%), disability (70.1%) and inability to return to work or study (23.3%). A number of demographic, injury-related and treatment-based factors were identified as being predictive of poor patient-reported outcomes. Patients who had associated radius fracture(s) were more likely to have moderate to severe disability (odds ratio (OR)=3.85, 95% confidence interval=1.30-11.39), a poorer physical health status (OR=3.73, 1.37-10.12) and moderate to severe pain (OR=3.23, 1.22-8.56) at 12 months post-injury than patients without radius fracture. Patients who did not receive compensation for work-related or road traffic-related injuries were less likely to report moderate to severe pain (OR=0.45, 0.23-0.90) or have a poorer mental health status (OR=0.17, 0.04-0.70) at 12 months post-injury than those who received compensation. CONCLUSIONS: The prognostic factors identified in this study may assist clinicians in the identification of patients requiring more intensive follow-up or additional rehabilitation to ultimately improve patient care.

The arterial anatomy of the Achilles tendon: anatomical study and clinical implications.

The Achilles tendon is the most frequently ruptured tendon in the lower limb and accounts for almost 20% of all large tendon injuries. Despite numerous published studies describing its blood supply, there has been no uniformity in describing its topography. The current study comprises a detailed anatomical study of both the intrinsic and extrinsic arterial supply of the Achilles tendon, providing the detail sought from studies calling for improved planning of surgical procedures where damage to the vascularity of the Achilles tendon is likely. A dissection, microdissection, histological, and angiographic study was undertaken on 20 cadaveric lower limbs from 16 fresh and four embalmed cadavers. The Achilles tendon is supplied by two arteries, the posterior tibial and peroneal arteries. Three vascular territories were identified, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. The midsection of the Achilles tendon was markedly more hypovascular that the rest of the tendon. The Achilles tendon is at highest risk of rupture and surgical complications at its midsection. Individuals with particularly poor supply of the midsection may be at increased risk of tendon rupture, and approaches to the tendon operatively should consider the route of supply by the peroneal artery to this susceptible part of the tendon.

Predictors of moderate or severe pain 6 months after orthopaedic injury: a prospective cohort study.

OBJECTIVE: To determine predictors of moderate or severe pain 6 months after orthopaedic injury. DESIGN: Prospective cohort study. SETTING: Two adult level 1 trauma centers in Victoria, Australia. PARTICIPANTS: A total of 1290 adults admitted with orthopaedic injuries and registered by the Victorian Orthopaedic Trauma Outcomes Registry. MAIN OUTCOME MEASURES: Participant self-reported pain and health status using an 11-point numerical rating scale and the 12-item Short-Form health survey, respectively. RESULTS: The prevalence of moderate or severe pain was 48% [95% confidence interval (CI), 45-51] at discharge and 30% (95% CI, 28-33) at 6 months postinjury. Failure to complete high school [adjusted odds ratio (AOR) 1.5 (95% CI, 1.1-1.9)], self-reported preinjury pain-related disability [AOR 1.8 (95% CI, 1.3-2.5)], eligibility for compensation [AOR 2.1 (95% CI, 1.6-2.8)], and moderate or severe pain at discharge from the acute hospital [AOR 2.4 (95% CI, 1.8-3.1)] were found to be independent predictors of moderate or severe pain at 6 months postinjury. CONCLUSIONS: Moderate or severe pain is commonly reported 6 months after orthopaedic trauma. Pain intensity at discharge and the effects of a "no-fault" compensation system are potentially modifiable factors that might be addressed through intervention studies to reduce the burden of persistent pain after orthopaedic trauma.

Twelve-month outcomes of serious orthopaedic sport and active recreation-related injuries admitted to Level 1 trauma centers in Melbourne, Australia.

OBJECTIVE: To describe and identify predictors of 12-month outcomes of serious orthopaedic injuries due to sport and active recreation. DESIGN: Prospective cohort study with 12-month follow-up. SETTING: Two Level 1 adult trauma centers in Victoria, Australia. PARTICIPANTS: A total of 366 adults admitted to two Level 1 trauma centers for an orthopaedic sport and active recreation injury between August 2003 and March 2006. Patients were captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), followed up at 12 months, and were free of moderate to severe disability prior to injury. ASSESSMENT OF RISK FACTORS: Independent variables assessed for predictors of outcome were sporting group, age, sex, marital status, education level, Injury Severity Score, injury patterns, and head injury status. MAIN OUTCOME MEASUREMENTS: The 12-item Short Form Health Survey and maximum pain scores. RESULTS: At 12 months postinjury, 22.8% of patients reported moderate to severe physical disability, 12.1% reported moderate to severe mental health disability, and 11.1% reported moderate to severe pain. There were significant differences in physical outcomes between sporting groups, with motor and equestrian sports reporting the worst physical outcomes. Multivariate analysis indentified increasing age (P = 0.010) and patterns of injury (P = 0.040) as significant predictors of a poor physical outcome at 12 months. No significant independent predictors of outcome for mental health and maximum pain at 12 months were identified. CONCLUSION: Almost one-quarter of participants reported moderate to severe physical disability at 12 months postinjury. Increasing age and patterns of injury were found to be significant predictors of a poor physical outcome at 12 months.

Survey of management of acute, traumatic compartment syndrome of the leg in Australia.

BACKGROUND: Acute compartment syndrome is a serious and not uncommon complication of limb trauma. The condition is a surgical emergency and is associated with significant morbidity if not diagnosed promptly and treated effectively. Despite the urgency of effective management to minimize the risk of adverse outcomes, there is currently little consensus in the published reports as to what constitutes best practice in the management of acute limb compartment syndrome. METHODS: A structured survey was sent to all currently practising orthopaedic surgeons and accredited orthopaedic registrars in Australia to assess their current practice in the management of acute, traumatic compartment syndrome of the leg. Questions were related to key decision nodes in the management process, as identified in a literature review. These included identification of patients at high risk, diagnosis of the condition in alert and unconscious patients, optimal timeframe and technique for carrying out a fasciotomy and management of fasciotomy wounds. RESULTS: A total of 264 valid responses were received, a response rate of 29% of all eligible respondents. The results indicated considerable variation in management of acute compartment syndrome of the leg, in particular in the utilization of compartment pressure measurement and the appropriate pressure threshold for fasciotomy. Of the 78% of respondents who regularly measured compartment pressure, 33% used an absolute pressure threshold, 28% used a differential pressure threshold and 39% took both into consideration. CONCLUSIONS: There is variation in the management of acute, traumatic compartment syndrome of the leg in Australia. The development of evidence-based clinical practice guidelines may be beneficial.

The relationship between compensable status and long-term patient outcomes following orthopaedic trauma.

OBJECTIVE: To determine the relationship between compensable status in a "no-fault" compensation scheme and long-term outcomes after orthopaedic trauma. DESIGN AND SETTING: Prospective cohort study within two adult Level 1 trauma centres in Victoria, Australia. PARTICIPANTS: Blunt trauma patients aged 18-64 years, admitted between September 2003 and August 2004 with orthopaedic injuries and funded by the no-fault compensation scheme for transport-related injury, or deemed non-compensable. MAIN OUTCOME MEASURES: 12-item Short Form Health Survey (SF-12) and return to work or study at 12 months after injury. RESULTS: Of 1033 eligible patients, 707 (68.8%) provided follow-up data; 450 compensable and 247 non-compensable patients completed the study. After adjusting for differences across the groups (age, injury severity, head injury status, injury group, and discharge destination) using multivariate analyses, compensable patients were more likely than non-compensable patients to report moderate to severe disability at follow-up for the physical (adjusted odds ratio [AOR], 2.0; 95% CI, 1.3-2.9), and mental (AOR, 1.6; 95% CI, 1.1-2.5) summary scores of the SF-12. Compensable patients were less likely than non-compensable patients to have returned to work or study, even after adjusting for injury severity, age, head injury status and discharge destination (AOR, 0.6; 95% CI, 0.3-0.9). CONCLUSIONS: Patients covered by the no-fault compensation system for transport-related injuries in Victoria had worse outcomes than non-compensable patients.

Outcomes of patients with orthopaedic trauma admitted to level 1 trauma centres.

BACKGROUND: Although orthopaedic trauma results in significant disability and substantial financial cost, there is a paucity of large cohort studies that collectively describe the functional outcomes of a variety of these injuries. The current study aimed to investigate the outcomes of patients admitted with a range of orthopaedic injuries to adult Level 1 trauma centres. METHODS: Patients were recruited from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which included all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria (Australia). Patients were categorised into three groups; isolated orthopaedic injuries, multiple orthopaedic injuries and orthopaedic and other injuries. Demographic and injury data were collected from the medical record and hospital/trauma databases, and functional outcome instruments were given at 6 months post-injury. RESULTS: Of the 1303 patients recruited for VOTOR over a 12-month period, 1181 patients were eligible for the study and a response rate of 75.6% was obtained at 6 months post-injury. Patients reported ongoing pain (moderate-severe: 37.2%), disability (79.5%) and inability to return to work (35.2%). Poorer outcomes were evident in patients with orthopaedic and other injuries than those with single or multiple orthopaedic injuries alone. CONCLUSION: A large percentage of patients have ongoing pain and disability and a reduced capacity to return to work 6 months after orthopaedic trauma. Further research into the long-term outcomes of patients with orthopaedic injuries is required to identify patient subgroups and specific injuries and procedures that result in high morbidity.