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Introduction Understanding the different opioid pain relief requirements between patients with upper limb fractures can be useful in forming specific evidence-based guidelines and balancing patient-clinician prescribing discussions with opioid stewardship. We investigated the predictors for opioid requirements in upper limb fractures. Methods We retrospectively investigated all upper limb fractures from the shoulder to the wrist treated at a major trauma center from January 2015 to January 2022. The data collected consisted of fracture location, demographics, comorbidities, and management options. Post-injury opioid prescriptions in the first post-injury year were calculated every month up to six months and then grouped from the seventh to the 12th month and converted to morphine milligram equivalents (MMEs). We then calculated days requiring at least one medication (representing the "coverage") and relative "strength" in each time period. Results Six thousand four hundred thirteen patients sustaining a combined 9125 fractures were included in the study, with an MME mean of 436. Fracture locations of the scapula, proximal humerus, humeral shaft, distal humerus, and proximal ulna all had significantly higher MME requirements (p<0.05) at the one-year level. The radius shaft and distal radius had significantly lower MME requirements (p<0.05). The patients with depression, diabetes, drug abuse history, obesity, pulmonary circulatory disorder, and rheumatological conditions required higher strength of opioids at the one-year level (p<0.05). The patients with chronic kidney disease, depression, pulmonary circulation disorder, and rheumatological conditions required higher coverage of opioids at the one-year level (p<0.05). Conclusion Our study presents a high-resolution breakdown of the post-injury opioid requirements for patients with upper limb injuries. Fractures of the scapula, proximal humerus, and shaft of the humerus were associated with increases in both opioid strength and coverage. Depression, pulmonary disease, and rheumatological conditions were all associated with increased opioid strength and coverage. This provides a framework for which clinicians and patients can more accurately anticipate the course of the rehabilitation journey and risk stratify appropriately at the outset of injury.
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Introduction Understanding the incidence and epidemiology can inform clinicians and policymakers about the population's needs. Our study reports on upper limb fractures treated at a major trauma center over 7.5 years. Methods We collected data on fracture locations, age, gender, Charlson Comorbidity index (CCI), and treatment options of all upper limb fractures treated at a Level I Trauma Centre from January 1, 2015 to June 30, 2022. Humerus, radius, and ulna fractures were each classified as proximal, diaphyseal, and distal. Results About 9,915 patients sustained 12,790 fractures, given an overall incidence of 303.2 fractures per 100,000 patients per year. The most common fracture site was the distal radius (60.1 fractures per 100,000 patients per year, whereas carpal and metacarpal bones had the lowest incidence. The mean age and CCI were 46.4 years and 1.54, respectively. 58.1% of patients were male. All bone fractures distal to the elbow were associated with an age younger than the mean (all p<0.001), with humerus fracture patients having the oldest mean age (54.6 years). Compared to the mean gender ratio, except for ulna (no association), humerus (55% female), and radius (51% female), all other locations showed significantly higher incidences of males (all p<0.001). When plotting the incidence based on the age of injury, the entire cohort, along with radius and ulna fracture subgroups, demonstrated a bi-peak distribution. This pattern revealed that younger males and older postmenopausal females had the highest incidence rates. Conclusion To our knowledge, this represents the first study of this type in the UK since 2006. We sought to elucidate relative incidence and demographic associations with fractures to highlight changing population needs and allow policymakers and services at a regional and national level to operate with up-to-date information.
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Non-ossifying fibromas (NOFs) are common lesions most frequently found in the growing bones of children and adolescents. Although NOFs are benign, their presence as incidental findings often triggers further investigation as they are sometimes mistaken for more sinister bone lesions such as aneurysmal bone cysts. NOFs can also pose an increased risk of pathological fractures. However, there are currently no guidelines on the follow-up of NOFs. We present a case series of five patients from Addenbrooke's Hospital with NOFs illustrating their morphological features on plain radiographs and highlighting specific characteristics to support clinicians in diagnosing and managing NOFs.
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Complex tibial plateau fractures (TPFs) represent a significant treatment challenge for any Orthopaedic surgeon. Current literature suggests that significantly displaced TPFs in the elderly require operative fixation, an operation that is associated with serious complications including septic and post-operative arthritis. As a result, these patients are five times more likely to require a total knee replacement (TKR). We present a case series of five elderly patients with complex TPFs who made serendipitous recoveries while awaiting operations. Their fractures were deemed so severe that they were being considered for TKR instead of fixation. We discovered their surprising functional improvements while they were being reviewed pre-operatively and decided to delay operating. We are currently unaware of any cases in the literature that have reported such findings. In total, five patients presented in 2019 with closed, varus/valgus stable fractures. They were managed non-operatively in hinged-knee braces, progressively weight-bearing with a minimum follow-up of 10 months. Oxford Knee Scores (OKS) were recorded at zero and four months after their injury. All patients were female with an average age of 69 years. Average fracture depression - 8.48mm, average fracture split - 8.66mm, average OKS reduction - 19%. All patients were able to mobilise independently at four months follow-up. Our results suggest that non-operative management can be considered as primary management in elderly patients with significantly displaced TPFs. Should this fail, or they develop arthritis, a TKR can be performed. This carries two benefits: the patient avoids the significant complications associated with fixation and should a TKR be required, it can more easily be performed in a patient without metalwork in-situ. We feel that the results from this case series might offer insight into a new treatment strategy and continue to closely follow these patients.
