Effects of vehicle bumper height and impact velocity on type of lower extremity injury in vehicle-pedestrian accidents

In nonfatal passenger vehicle-pedestrian accidents, the lower extremities are the most commonly injured body parts. The European Enhanced Vehicle-safety Committee Working Group 17 (EEVC/WG17) pedestrian subsystem test method using a legform impactor has been developed mainly for evaluation of aggressiveness of the front bumper of passenger vehicles. However, in recent years the number of sports utility vehicles (SUV) with a high bumper has been rapidly increasing. Since the bumper height is different between a passenger vehicle and an SUV, the type of lower extremity injury may be different. The type of lower extremity injury caused by this different bumper height should be clarified, because the test method and vehicle safety countermeasure must take into account a certain type of injury. Furthermore, the effect of vehicle impact velocity on the type of lower extremity injury in vehicle-pedestrian accidents has not been investigated so far. Therefore, the objective of this study is to clarify the effect of vehicle bumper height and vehicle impact velocity on the type of lower extremity injury in vehicle-pedestrian accidents. The Pedestrian Crash Data Study (PCDS), an in-depth accident database in the USA, was used for the current analyses. The results indicate that the type of injury, i.e., to the tibia and knee ligament, could become an injury to the femur with an increase in bumper height. Furthermore, the main injury at an impact velocity of around 20-30km/h is to the knee ligament. On the other hand, the main injury at an impact velocity of around 40km/h is a fracture of the lower extremities.

The most frequent traumatic orthopaedic injuries from a national pediatric inpatient population

Pediatric trauma remains a leading cause of morbidity and mortality of children in the United States and entails exorbitant costs. A 1997 national pediatric inpatient database, the Kids' Inpatient Database, was reviewed for current trauma and practice patterns and was found to contain over 84,000 patients admitted for orthopaedic trauma. These patients accrued an estimated 932.8 million dollars in hospital charges. Femur fracture was the most frequent injury among this patient group (21.7% of orthopaedic trauma), followed by tibia and/or fibula fracture (21.5%), humerus fracture (17.0%), radius and/or ulna fracture (14.8%), and vertebral fracture (5.2%). While the majority of pediatric orthopaedic trauma was treated at non-children's hospitals (70.4%), patients with certain diagnoses such as femur, humerus, vertebral, pelvic, or hand/finger fracture or a back sprain/strain were directed to children's hospitals more frequently compared with the total number of pediatric orthopaedic trauma patients. Practice patterns varied for certain subgroups (eg, femoral shaft fractures) of patients, depending on the type of hospital where the child was treated. Children who sustained a femoral shaft fracture in the 6-to-10-year age group were significantly more likely to receive internal fixation versus casting or traction if they were treated at a children's hospital. Understanding the patterns in which traumatic injuries occur in children is paramount to establishing effective injury prevention, as well as adapting treatment to optimize outcomes.

Minimal internal fixation augmented by small wire transfixion frames for high-energy tibial plateau fractures

PURPOSE

To evaluate the outcome of bicondylar tibial plateau fractures treated with minimal internal fixation augmented by small wire external fixation frames and to assess the necessity of bridging the knee joint by extending the external fixation to the distal femur.

METHODS

This is a retrospective study of 48 tibial plateau fractures. There were 40 (83.5%) Schatzker type VI fractures, 8 Schatzker type V fractures, and 18 (37.5%) fractures were open. A complex injury according to the Tscherne-Lobenhoffer classification was recorded in 30 (62.5%) patients. All fractures were treated with combined minimally invasive internal and external fixation. Closed reduction was achieved in 32 (66.6%) of the fractures. Extension of the external fixation to the distal femur was done in 30 (62.5%) fractures. Results were assessed according to the criteria of Honkonen-Jarvinen.

RESULTS

Follow-up ranged from 28 to 60 months with an average of 38 months. All fractures but 1 united at an average of 13.5 weeks (range 11-18 weeks). One patient developed an infected nonunion of the diaphyseal segment of his fracture. Thirty-nine (81%) patients achieved an excellent or good radiologic result. An excellent or good final clinical result was recorded in 36 patients (76%). Bridging the knee joint did not affect significantly the result (P < 0.418). No significant correlation was found between the type of fracture and the final score (P < 0.458).

CONCLUSIONS

Hybrid internal and external fixation combined with tibiofemoral extension of the fixation is an attractive treatment option for complex tibial plateau fractures.

Epidemiology of fractures in people with severe and profound developmental disabilities

Fractures are more prevalent among people with severe and profound developmental disabilities than in the general population. In order to characterize the tendency of these people to fracture, and to identify features that may guide the development of preventive strategies, we analyzed fracture epidemiology in people with severe and profound developmental disabilities who lived in a stable environment. Data from a 23-year longitudinal cohort registry of 1434 people with severe and profound developmental disabilities were analyzed to determine the effects of age, gender, mobility, bone fractured, month of fracture, and fracture history upon fracture rates. Eighty-five percent of all fractures involved the extremities. The overall fracture rate increased as mobility increased. In contrast, femoral shaft fracture risk was substantially higher in the least mobile [relative risk (RR), 10.36; 95% confidence interval (CI), 3.29-32.66] compared with the most mobile group. Although the overall fracture rate was not associated with age, the femoral shaft fractures decreased but hand/foot fractures increased with age. Overall fracture risk declined in August and September (RR, 0.70; 95% CI, 0.55-0.89), being especially prominent for tibial/fibular fractures (RR, 0.31; 95% CI, 0.13-0.70). Gender was not a factor in fracture risk. Two primary fracture mechanisms are apparent: one, largely associated with lack of weight-bearing in people with the least mobility, is exemplified by femoral fractures during non-traumatic events as simple as diapering or transfers; the other, probably due to movement- or fall-related trauma, is exemplified by hand/foot fractures in people who ambulate. The fracture experience of people with severe and profound developmental disabilities is unique and, because it differs qualitatively from postmenopausal osteoporosis, may require population-specific methods for assessing risk, for improving bone integrity, and for reduction of falls and accidents.

The risk of child abuse in infants and toddlers with lower extremity injuries

PURPOSE

The aim of this study was to assess the risk of child abuse in children younger than 18 months admitted to a pediatric trauma service with lower extremity injuries.

METHODS

An Institutional Review Board-approved retrospective case series of children admitted to a regional pediatric trauma center with lower extremity injuries from 1998 to 2002 (n = 5497) was performed. Factors analyzed included age, injuries, and injury mechanism.

RESULTS

Among 5497 trauma patients, the incidence of abuse was 104 (2%) of 4942 children 18 months or older and 175(32%) of 555 children younger than 18 months (odds ratio [OR], 21.4 +/- 2.9, P < .001). There were 1252 (23%) patients with lower extremity injuries in the entire sample, and 66 of these were younger than 18 months. In the extremity trauma group, for patients 18 months or older, 16 (1%) of 1186 were abused compared with 44 (67%) of 66 patients younger than 18 months (OR, 146 +/- 53, P < .001). Among all trauma patients younger than 18 months, 41 of 55 lower extremity fractures were linked to abuse, whereas 134 of 500 other injuries were caused by abuse (OR, 8.0 +/- 2.6, P < .001). Among the 41 abuse-related fractures, femur fracture was the most common (22), followed by tibia fracture (14).

CONCLUSIONS

Among children 18 months or older, abuse is an uncommon cause of lower extremity trauma. In children younger than 18 months, lower extremity injuries, particularly fractures, are highly associated with child abuse. Clinicians must thoroughly investigate lower extremity injuries in this age group.

Does the crack silently break the back? Long-term follow-up and assessment of risk factors for regional osteoporosis following tibial shaft fractures

The aim of this study is to determine the incidence and to quantify the risk factors for developing long-term regional osteopenia/osteoporosis (RO) following tibial fractures. We studied 42 adult subjects (8 females and 34 males) who had sustained a tibial fracture 16 yr prior to the study. Mechanism and type of injury, method of treatment, length of immobilization, weight-bearing status, and healing time were determined from the patient records. A questionnaire covering known causes of generalized osteoporosis (GO), including history of smoking, alcohol consumption, medications, other fractures, thyroid/parathyroid disorders, epilepsy, and renal disorders, was answered by all the subjects. Bone mineral density (BMD) of lumbar vertebrae 1-4 and both proximal femurs was assessed using dual-energy X-ray absorptiometry (DXA) scanning. T- and Z-scores were generated. Assessment of risk factors was done by calculating the odds ratio (OR) and 95% confidence interval (CI). The incidence of significant loss of BMD as defined by the World Health Organization (T-score <-1) of the ipsilateral neck of femur and/or lumbar spine was found to be 40%. None of our subjects had any known cause for GO. The following risk factors were found to be statistically significant in unadjusted models: smoking (OR 22, 95% CI = 4 - >40), alcohol >20 units/wk (OR 11, 95% CI 2 = 2-54), open fracture (OR 17, 95% CI = 2.9 - >40), nonweight bearing >4 wk (OR 15, 95% CI 2.9- >40), and delayed union defined as healing time more than 6 mo (OR 15, 95% CI 1.54 - >40). Permanent regional loss of BMD occurs in a significant proportion of tibial shaft fracture patients. Modern fracture management should include identifying "at-risk" patients and appropriate preventive measures to prevent fragility fractures.

Does right leg require extra protection? Five-year review of type 3 open fractures of the tibia

INTRODUCTION

Open fracture of the tibia is very common among motorcyclists. The morbidity associated with this injury is well-documented as treatment of severe open fractures is very difficult. There is currently no study done in the literature to see the relationship between fracture severity and the side of the injury.

METHODS

We reviewed 239 patients with open fractures of the tibia admitted to our institution from 1998 to 2002.

RESULTS

From 241 tibias studied, 150 (62.2 percent) involved the right side and 91 (37.8 percent) involved the left side. Statistical analysis showed that there was a significant difference in the severity of open fracture between the sides of fracture. Less severe injury (grades 1 and 2 fractures) was associated with injury of the left tibia and severe injury (grades 3A, B and C fractures combined) was associated with right tibia fracture.

CONCLUSION

Since the right leg was more exposed to the injury, it is imperative to protect the limb. This may reduce the overall incidence and severity of tibia fractures.

Biological Osteosynthesis Versus Traditional Anatomic Reconstruction of 20 Long-Bone Fractures Using an Interlocking Nail: 1994-2001

OBJECTIVE

To observe differences in surgical and healing times as well as complication rates in dogs with a comminuted long-bone fracture stabilized with an interlocking nail (IN) using either anatomic or biologic repair.

STUDY DESIGN

Retrospective study.

ANIMALS

Twenty client-owned dogs with comminuted long-bone fractures.

METHODS

Medical records for dogs with fractures repaired during a 7-year period were reviewed; 20 dogs had repair with an IN nail and radiographic evidence of healing. These 20 dogs where divided into 2 groups, anatomic (11 dogs) and biological (9) repair, for statistical evaluation. Surgical and healing time and complication rates were compared between groups.

RESULTS

Median surgical times were: anatomic (95 minutes) and biologic (110 minutes; P=.06). Median healing times were anatomic (8 weeks) and biologic (6 weeks; P=.04). No statistical differences were observed in complication rates (the likelihood that a case required a second surgery [P=.58], the likelihood of a complication that was managed non-surgically [P=.27]). Use of a bone graft did not shorten healing times (P=.55).

CONCLUSIONS

Biological osteosynthesis provides clinical advantages over anatomic reconstruction with respect to a reduction in surgical and healing time without increasing complication rates.

CLINICAL RELEVANCE

Highly comminuted long-bone fractures can be successfully repaired using an IN without reconstructing the fracture fragments in dogs.

[Monitoring of uncooperative, polytraumatized patients with tibial shaft fractures for acute compartment syndrome]

BACKGROUND

The results of intracompartmental pressure monitoring were assessed in uncooperative, polytraumatized patients with tibial shaft fractures.

METHODS

The study included 29 tibial fractures of 26 polytraumatized patients (9 females, 17 males; mean age 36 years; range 15 to 75 years) admitted to the intensive care unit. The fractures were on the right side in eight patients, on the left in 15 patients. Three patients had bilateral involvement. All the patients were unconscious. Following trauma, absolute compartment pressures and ΔP (diastolic blood pressure - absolute compartment pressure) were monitored at 12-hour intervals for 72 hours via the intracompartmental pressure monitoring system. Patients whose ΔP values were 30 mmHg or below underwent fasciotomy. The mean follow-up period was 21.2 months (range 18 to 25 months).

RESULTS

The overall mean absolute compartment pressure was 30.25 mmHg, and the mean ΔP was 48.47 mmHg at the end of 72 hours. Fasciotomy was performed in two patients (7%) in whom a diagnosis of acute compartment syndrome was made depending on ΔP values less than 30 mmHg. None of the patients had complications associated with acute compartment syndrome. Union was achieved in all the patients without an additional intervention. The mean time to union was 5.21 months (range 3 to 9 months).

CONCLUSION

Intracompartmental pressure monitoring should be considered for an early diagnosis of acute compartment syndrome in uncooperative, polytraumatized patients with tibial shaft fractures.

[Early treatment results with expandable intramedullary nails in lower extremity shaft fractures]

BACKGROUND

We investigated the use of expandable intramedullary nails, their efficacy, and short term results in the treatment of lower extremity shaft fractures.

METHODS

The study included 23 patients (10 females, 13 males; mean age 33 years; range 17 to 60 years) who were treated with expandable intramedullary nails (the Fixion nail) for the lower extremity shaft fractures. Fourteen patients had femoral, nine patients had tibial fractures, all of which were closed. Eight patients had associated injuries. The mean duration from injury to surgery was 3.2 days (range 24 hours to 14 days). The results were evaluated using the Kalström-Olerud criteria. The mean follow-up was 15.3 months (range 10 to 20 months) for tibial fractures, and 13.1 months (range 10 to 19 months) for femoral fractures.

RESULTS

Union was achieved in all the patients. In tibial fractures, the mean operation time was 50 minutes (range 25 to 90 min) and the mean time to union was 12 weeks (range 8 to 24 weeks). The results were excellent in six patients, and good in three patients. In femoral fractures, the mean operation time was 83.5 minutes (range 55 to 120 min) and the mean time to union was 13.2 weeks (range 10 to 20 weeks). The results were excellent in eight patients, good in three patients, fair in two patients, and poor in one patient. No complications were seen such as delayed union, early or late infections, compartment syndrome, or bone necrosis.

CONCLUSION

Expandable intramedullary nails offer advantages in terms of ease of application and are less invasive than static nails and reamed applications. However, they may not provide adequate stability in metadiaphyseal regions and in fractures with fragments larger than 50 per cent.

Treatment of canine and feline diaphyseal radial and tibial fractures with low-stiffness external skeletal fixation

The healing of 62 cases of radial and tibial fractures treated with low-stiffness Kirschner-Ehmer external skeletal fixation frames (frame types 1a, 1a plus intramedullary pin [1aIMP], 1b and 2b) was evaluated. The mean time to clinical union was 65 days. All cases treated with 1b, 2b or 1aIMP frames healed. Four of 25 cases treated with 1a frames failed to heal due to premature pin loosening; these failures were in heavier patients than 1a cases which healed (P=0.041). Complications occurred in 40 of 62 cases, and were more common in cases treated with type 2b frames. Pin loosening was the most frequent complication (35 cases) and most commonly involved the most proximal pin (P<0.001). In type 2b frames, full pins loosened more frequently than half pins (P<0.001). This study indicates that canine and feline fractures can heal readily when treated with these frames, suggesting that more rigid type 2a or type 3 frames are unnecessary in the majority of cases. Increased morbidity compared with the use of more rigid frames need not be expected, but 1a frames should be avoided in heavier patients.

Descriptive epidemiology of fractures occurring in British Thoroughbred racehorses in training

REASONS FOR PERFORMING STUDY

Musculoskeletal injury is the major cause of days lost from training and wastage in Thoroughbred racehorses. Little scientific information is available on the majority of injuries occurring in training.

OBJECTIVES

To estimate the incidence of fractures in British racehorses in training and describe the occurrence of different fracture types and bones involved.

METHODS

Thirteen UK racehorse trainers participated in a prospective study, providing data on horses in their care for 2 years. Details on horses, their daily exercise and fracture occurrence were recorded.

RESULTS

A total of 1178 horses provided 12,893 months at risk. Nontraumatic fracture incidence was 1.15/100 horse months (95% CI = 0.98, 1.35) and 78% of fractures occurred during training. A wide variety of fracture types and bones were involved, although at least 57% were stress fractures. Pelvic and tibial stress injuries accounted for 28% of fractures diagnosed.

CONCLUSIONS

It is important to study injuries in training as well as in racing. The number of stress fractures suggests that training regimes for young Thoroughbreds could often be improved to create a more robust skeleton, able to withstand injury.

POTENTIAL RELEVANCE

Studying injuries in racehorses in training can provide a scientific basis for the design of safer training regimes.

Periprosthetic fractures of the tibia and patella in total knee arthroplasty

Periprosthetic fractures of the tibia and patella associated with total knee arthroplasty are less common than periprosthetic fractures of the distal femur and therefore have been less frequently reported in the literature. Because more total knee replacements are now being performed and implant and patient survival has improved, periprosthetic fractures of the tibia and patella may be recognized more frequently in association with both primary and revision total knee replacement. Several risk factors associated with both types of fractures have been identified, and addressing patient factors, surgical techniques, and implant designs that may contribute to increased risk is an important aspect of management.

The effect of smoking on clinical outcome and complication rates following Ilizarov reconstruction

OBJECTIVE

To determine the effect of smoking on outcome and complication rates following Ilizarov reconstruction.

DESIGN

We performed a retrospective review of 84 adult patients (86 limbs) who underwent Ilizarov reconstruction. There were 39 "limbs" in nonsmokers and 47 "limbs" in active smokers. Complications and an outcome score based on ASAMI (Association for the Study and Application of the Methods of Ilizarov) criteria were recorded for each patient. DATA ANALYSIS AND RESULTS: There were 35 major complications including 15 malunions/nonunions, 7 refractures, 8 persisting infections, and 5 amputations. Results were measured using the ASAMI outcome scale. There were significantly more poor results in the smoking group than in the nonsmoking group (18/47, 38% versus 4/39, 10%; P = 0.003). Seven of eight patients with persisting infection were smokers (P = 0.049). There was a higher incidence of nonunion in the smoking group (P = 0.031). All five amputations were in smokers (P = 0.035).

CONCLUSION

Smokers had a higher percentage of poor results (P = 0.01), due primarily to higher complication rates. Smoking is a significant, potentially remediable risk factor for failure following Ilizarov reconstruction, and cessation strategies are of paramount importance prior to initiating treatment.

Stress fractures in athletes: review of 196 cases

The purpose of this study was to investigate the association of stress fractures with age, sex, sport level, sporting activity, and skeletal site in athletes seen at our sports medicine clinic between September 1991 and May 2001. During these 10 years, 10 726 patients (6415 males, 3861 females) visited our clinic because of sport-related injuries, and 196 patients [125 males (1.9%), 71 females (1.8%)] sustained stress fractures. The average age of the patients with stress fractures was 20.1 years (range 10-46 years); 84 patients (42.6%) were 15-19 years of age, and 68 (34.7%) were 20-24 years of age. Altogether, 74 patients (37.8%) were active at the high recreational level and 122 (62.2%) at the competitive level. The sites of the stress fractures varied from sport to sport. The ulnar olecranon was the most common stress fracture site among baseball athletes and the rib among the rowing athletes. Classical ballet, aerobics, tennis, and volleyball athletes predominantly sustained stress fractures of the tibial shaft. Basketball athletes predominantly sustained stress fractures of the tibial shaft and medial malleolus and the metatarsal bone, whereas track and field and soccer athletes predominantly sustained stress fractures of the tibial shaft and pubic bone. Our results show that stress fractures are seen even in high-level adolescent athletes, with similar proportions for males and females, and that particular sports are associated with specific sites for stress fractures.

Acute tibial tubercle avulsion fractures

Acute tibial tubercle avulsion fractures are uncommon, and these injuries typically occur in mature-appearing adolescent boys involved in jumping sports, particularly basketball. The developmental anatomy of the tibial tuberosity and the changes surrounding normal physiologic epiphysiodesis render this structure susceptible to acute avulsion fractures. Possible associated injuries include patellar and quadriceps avulsions, collateral and cruciate ligament tears, and meniscal damage. The treatment of this injury is based on the amount of displacement and associated injuries. Nondisplaced fractures are treated nonoperatively with cast immobilization. Displaced fractures require open reduction and internal fixation. Even in Type III injuries, the outcome is usually excellent.

[The value of laser Doppler examination of differential diagnosis of the Sudeck syndrome with local osteoporosis after tibia fracture]

The fractures of the shaft of the tibia were analyzed in 120 cases. The level of the osteoporosis in the radiological examination was assessed in comparison to the healthy limb. Osteoporosis was recorded in 60.6% of the cases. The clinical symptoms of the Sudeck syndrome was recorded in 11.25% of the cases. The Laser-Doppler examination was carried out in 120 cases. A standard 3 points measurement was employed: the apex of the toe, the flexion-dorsal part of the foot, and the medial part of the mid tibia length. The examination was done comparatively on both limbs. The pressure used in the occlusion, was 100 mm Hg higher than the pressure on the humeral artery. A faster and higher amplitude post-occlusion circulation reaction in the affected limb, among the patients with an early stage of the clinically diagnosed Sudeck syndrome had been recorded. The outcome is significant statistically. The Laser-Doppler measurement of the microcirculation is a new method and definite conclusions must be draw with caution. However, these results encourage further research.

The axial injury tolerance of the human foot/ankle complex and the effect of Achilles tension

Axial loading of the foot/ankle complex is an important injury mechanism in vehicular trauma that is responsible for severe injuries such as calcaneal and tibial pilon fractures. Axial loading may be applied to the leg externally, by the toepan and/or pedals, as well as internally, by active muscle tension applied through the Achilles tendon during pre-impact bracing. The objectives of this study were to investigate the effect of Achilles tension on fracture mode and to empirically model the axial loading tolerance of the foot/ankle complex. Blunt axial impact tests were performed on forty-three (43) isolated lower extremities with and without experimentally simulated Achilles tension. The primary fracture mode was calcaneal fracture in both groups. However, fracture initiated at the distal tibia more frequently with the addition of Achilles tension (p < 0.05). Acoustic sensors mounted to the bone demonstrated that fracture initiated at the time of peak local axial force. A survival analysis was performed on the injury data set using a Weibull regression model with specimen age, gender, body mass, and peak Achilles tension as predictor variables (R2 = 0.90). A closed-form survivor function was developed to predict the risk of fracture to the foot/ankle complex in terms of axial tibial force. The axial tibial force associated with a 50% risk of injury ranged from 3.7 kN for a 65 year-old 5th percentile female to 8.3 kN for a 45 year-old 50th percentile male, assuming no Achilles tension. The survivor function presented here may be used to estimate the risk of foot/ankle fracture that a blunt axial impact would pose to a human based on the peak tibial axial force measured by an anthropomorphic test device.

[The extraarticular proximal tibial fractures]

Operative stabilization of proximal tibial fractures by use of conventional osteosynthesis is still problematic. The choice of the osteosynthetic treatment is strongly influenced by the situation of the surrounding soft tissue. Additional problems in this particular location may occur with malalignment in the fracture site after operation. Primary intraoperative malalignment may occur due to dislocating muscle forces or to the operative approach itself. Secondary dislocation is mainly due to the unstable fixation of the proximal fragment by the implant. Today many different implants with specific biomechanical properties are available. Each system requires a particular operative technique and can lead to individual implant-related problems. The new angle stable implant systems (e. g. LISS = "less invasive stabilization system"), offer significant advantages over conventional plate osteosyntheses and external fixation systems. Improvement of the geometry of standard intramedullary osteosyntheses and introduction of angle stability in the proximal interlocking screws (PTN = "proximal tibial nail") seemingly make this system the optimal solution, concerning biomechanics. On the background of our own clinical experiences and biomechanical investigations, the article discusses solutions for this particular problem.

Impact of MRI on treatment plan and fracture classification of tibial plateau fractures

OBJECTIVE

To evaluate the interobserver agreement for both treatment plan and fracture classification of tibial plateau fractures using plain radiographs, computed tomography (CT) scan, and magnetic resonance imaging (MRI).

DESIGN

Prospective study to assess the impact of an advanced radiographic study on the agreement of treatment plan and fracture classification of tibial plateau fractures among three orthopaedic surgeons.

SETTING/PARTICIPANTS

Patients presenting with tibial plateau fractures to a level I trauma center were evaluated with plain knee radiographs (anteroposterior, lateral, two oblique views), CT scan, and MRI. Three experienced attending orthopaedic trauma surgeons were randomly presented three sets of studies for each injury: radiographs alone, radiographs with CT, and radiographs with MRI (including soft tissue injuries documented by an experienced MRI radiologist). The surgeons were asked to render fracture classification and treatment plan based upon the blind reading of each individual radiographic set.

MAIN OUTCOME MEASURES

Agreement among the three surgeons was measured using kappa coefficients.

RESULTS

For fracture classification, radiographs alone yielded a mean kappa coefficient of 0.68, which increased to 0.73 for radiographs with CT scan and 0.85 for radiographs with MRI. Fracture classification (Schatzker) was changed an average of 6% with the addition of the CT scan and 21% based on radiographs with MRI. For the fracture management plan, the mean interobserver kappa coefficient for radiographs alone was 0.72, which increased to 0.77 for radiographs with CT scan and 0.86 for radiographs with MRI. MRI changed treatment plan in 23% of the cases.

CONCLUSION

Magnetic resonance imaging increases the interobserver agreement on fracture classification and operative management of tibial plateau fractures.

Tibia fracture after fibula resection for distal peroneal bypass

The lateral approach to the distal peroneal artery has been used by vascular surgeons for 25 years. No complications specifically related to this approach have previously been reported. We reviewed 18 cases of peroneal bypass for limb salvage using the lateral approach with fibula resection and found that two of these cases had ipsilateral tibia fractures within 1 year of the bypass. Eight out of 18 cases were women, and two of these eight had tibia fracture. Both women suffered from osteoporosis. We conclude that tibia fracture is a possible complication of this approach, especially in elderly women with osteoporosis.

Stress fractures of the tibia: can personality traits help us detect the injury-prone athlete?

One of the few serious drawbacks associated with running is overuse injuries such as stress fractures of the tibia, which cause local pain and swelling, often resulting in a temporary cessation of training. Whereas some runners rarely become injured, others experience recurrent injuries even during fairly short periods of time. The aim of the present study was to compare selected personality traits in a group of runners who had sustained a previous tibial stress fracture (n=17), with a matched group of runners (n=17) who had never experienced stress fractures. The results indicated that the injured runners, especially the women, scored higher than the non-injured runners did on inventories measuring both the Type A behavior pattern and exercise dependency. Since motivation, ambitiousness, and competitiveness are integral parts of these inventories, high scoring individuals might be part of a high-risk population for running injuries, the more so if the individual also feels dependent on regular running for managing stress related mood states, which was the case particularly for the injured women in the present study. However, the somewhat limited number of runners who had had a confirmatory scintigram, which was a criterion for inclusion in the study, warrants a cautious interpretation of the results. The findings nevertheless suggest that in order to prevent recurrent injuries, health education professionals and clinicians ought to focus on conveying the importance of detecting precursors of injury, and the subsequent steps which should be taken to avoid developing a serious injury.

One-year outcome after tibial shaft fractures: results of a prospective fracture registry

OBJECTIVES

To describe the outcome in a consecutive series of patients with tibial shaft fractures and to determine whether prospective registration of fracture care produces useful data for clinical purposes.

DESIGN

A prospective follow-up study.

SETTING

A large teaching hospital in Stockholm, Sweden.

PATIENTS

Sixty-four consecutive patients with a tibial shaft fracture.

INTERVENTION

Patients were surgically treated according to the protocols at our institute and were followed up prospectively for one year.

MAIN OUTCOME MEASUREMENTS

Clinical outcome, functional results, Short Form 36 Health Survey, Olerud Molander Ankle score, visual analogue scale.

RESULTS

The fractures were classified as 42A (61 percent), 42B (31 percent), and 42C (8 percent). Forty-three (67 percent) patients were treated with an interlocked tibial nail. The complication rate was low and associated with high-energy trauma. The quality of life according to the Short Form 36 Health Survey was diminished at four and twelve months after the injury, as compared with the preinjury status. Twelve months after the injury, 44 percent had not regained full function of the injured leg, although all but two of the patients had returned to preinjury working status.

CONCLUSIONS

Although the complication rate was low, twelve months after the injury, nearly half the patients still experienced functional limitations related to the fracture, which was also reflected in the quality-of-life parameters. There were difficulties in retrieving data for this registry. We think that periodic, rather than continuous, registration of patient-related outcome after fracture treatment is more beneficial from a clinical and economic point of view.

Flexural wave propagation velocity and bone mineral density in females with and without tibial bone stress injuries

STUDY DESIGN

Case-control nonexperimental design.

OBJECTIVES

To compare flexural wave propagation velocity (FWPV) and tibial bone mineral density (BMD) in women with and without tibial bone stress injuries (BSIs).

BACKGROUND

Physical therapists, particularly in military and sports medicine settings, routinely diagnose and manage stress fractures or bone stress injuries. Improved methods of preparticipation quantification of tibial strength may provide markers of BSI risk and thus potentially reduce morbidity.

METHODS AND MEASURES

Bone mineral density, FWPV, bone geometry, and historical variables were collected from 14 subjects diagnosed with tibial BSIs and 14 age-matched controls; all 28 were undergoing military training.

RESULTS

No difference was found between groups in FWPV and tibial BMD when analyzed with t tests (post hoc power = 0.89 and 0.81, respectively). Furthermore, no difference was found in tibial length, tibial width, femoral neck BMD, and lumbar spine BMD among the groups. There were no differences between the 2 groups in smoking history, birth control pill use, and onset of menarche. Finally, sensitivity and positive likelihood ratios for FWPV (0.14 and 0.63), tibial BMD (0.0 and 0.0), and lumbar BMD (0.18 and 2.0) were low, while specificity was high (0.77, 0.93, and 0.91, respectively).

CONCLUSION

Current bone analysis devices and methods may not be sensitive enough to detect differences in tibial material and structure; local stresses on bone may be more important in the development of BSIs than the overall structural stiffness.

The epidemiology of diaphyseal fractures of the tibia

AO Documentation collected reports of nearly five thousand diaphyseal tibial fractures occurring in the 1980s. The following conclusions can be drawn: i. The number of fractures affecting men is twice that affecting women. ii. These fractures occurred mainly in younger people (under 40 years of age) and no increase occurred in elderly people. iii. Most bending fractures occurred in young men (20-30 yrs) and the torsion fractures affected men and women of about 40 equally. iv. The number of simple fractures (type A) is about the same as for fractures with one fragment (type B).

Complications of tibial shaft soccer fractures

A retrospective study of AO type 42 tibial diaphyseal fractures that presented to a teaching hospital over a 54 month period was made to identify the proportion sustained whilst playing soccer, determine their characteristics and report treatment and outcome. Sport accounts for 73/329 (22.1%) of these fractures and soccer 58/73 (79. 5%) of these. All patients were male with mean age of 24.3 years (range 8-48). Fifty-four fractures were closed and 93.1% (54/58) were situated in the middle third or at the junction of the middle and distal thirds of the diaphysis. Fifty-six (96.6%) had simple or wedge patterns and 45 (77.6%) were right sided. Forty-four (76.2%) were treated non-operatively in plaster, 12 (20.3%) by intramedullary nails and two (3.4%) with external fixators. Two patients were lost to follow-up and the remaining 56 fractures united at a mean of 6.5 months. There were 21 complications in 19/56 (33.9%) patients which included 8/56 (14.3%) delayed/non-unions requiring surgery. There was a significantly higher complication rate for operated fractures (p<0.005) but no significant link to AO fracture type. Thus we cannot assume that treatment of these common fractures is without risk, especially if they are treated operatively.

Inhibitors of hydroxymethylglutaryl-coenzyme A reductase and risk of fracture among older women

BACKGROUND

Inhibitors of hydroxymethylglutaryl-coenzyme A reductase (statins) increase new bone formation in rodents and in human cells in vitro. Statin use is associated with increased bone mineral density of the femoral neck. We undertook a population-based case-control study at six health-maintenance organisations in the USA to investigate further the relation between statin use and fracture risk among older women.

METHODS

We investigated women aged 60 years or older. Exposure, outcome, and confounder information was obtained from automated claims and pharmacy data from October, 1994, to September, 1997. Cases had an incident diagnosis of non-pathological fracture of the hip, humerus, distal tibia, wrist, or vertebrae between October, 1996, and September, 1997. Controls had no fracture during this period. We excluded women with records of dispensing of drugs to treat osteoporosis.

FINDINGS

There were 928 cases and 2747 controls. Compared with women who had no record of statin dispensing during the previous 2 years, women with 13 or more statin dispensings during this period had a decreased risk of non-pathological fracture (odds ratio 0.48 [95% CI 0.27-0.83]) after adjustment for age, number of hospital admissions during the previous year, chronic disease score, and use of non-statin lipid-lowering drugs. No association was found between fracture risk and fewer than 13 dispensings of statins or between fracture risk and use of non-statin lipid-lowering drugs.

INTERPRETATION

Statins seem to be protective against non-pathological fracture among older women. These findings are compatible with the hypothesis that statins increase bone mineral density in human beings and thereby decrease the risk of osteoporotic fractures.

Impact of the Ottawa Ankle Rules in a U.S. Army troop medical clinic in South Korea

The impact of the Ottawa Ankle Rules on radiograph-ordering behavior was assessed. Medical records and radiology reports for 80 consecutive patients who presented with the complaint of acute ankle pain were retrospectively reviewed for 18 variables. Twenty-two patients met the rules criteria and 45 did not. There were 10 fractures in the study group (N = 67), 3 of which were missed by the rules. All 3 fractures were 1-mm avulsion fractures of the fibula and are considered not clinically significant. Application of the Ottawa Ankle Rules by all clinic providers would have decreased the number of radiographs at our facility by 68%. The rules had sensitivity and specificity of 70% and 73%, and positive and negative predictive values of 31.8% and 93.3%, respectively. Providers at our facility did not routinely use the rules. Although the incorporation of these rules into our practice would have been significant, we recommend their use cautiously for a military population, which maintains a high intensity of physical training.

Childhood accidental spiral tibial (CAST) fractures

OBJECTIVE

To further define and describe the spectrum of presentations for accidental spiral tibial fractures of childhood.

DESIGN

A retrospective review.

METHODS

Children 8 years of age or younger who had sustained a tibial fracture within the last five or ten years were collected from the patient populations of two large tertiary medical centers in Southern California, Riverside General Hospital (RGH) and Loma Linda University Medical Center (LLUMC). A total of 189 tibial fractures were documented from both locations. Of the 189 patients, the 55 children with isolated spiral tibial fractures and no criteria for exclusion were selected for further review and analysis. These patients were reviewed for age at time of injury, gender, specific extremity involved, mechanism of injury, fracture location, degree of displacement, and whether child protective services involvement occurred.

RESULTS

Patients with isolated spiral tibial fractures ranged in ages from 12 months to 94 months (7 years 10 months). The mean age was 50.7 months. Eighteen (32.7%) of the patients were less than or equal to 36 months of age. No patient was under one year of age. Males (38/55 or 69%) sustained the fracture slightly more frequently than females. The right extremity was injured slightly less frequently (45.5%) than the left extremity (54.5%). Overall, the lower two thirds of the tibia contained the fracture in 95% of the injuries. Displacement of the fracture segments was most frequently none or minimal. While Child Protective Service referrals or investigations were not accomplished on the majority of the children, no injury was confirmed to have occurred as a result of non-accidental trauma.

CONCLUSION

Isolated spiral tibial fractures are a common injury of children less than 8 years of age and are most frequently accidental. The original description of a distinct clinical entity matching the original definition of the toddler's fracture does not appear to exist. Instead, the previously defined toddler's fracture is simply part of a spectrum of presentations of childhood accidental spiral tibial, or CAST, fractures. Consequently, our findings further support new nomenclature suggested for this fracture (1, 2).

Tibial plateau fractures in the older patient

The epidemiology and management of 151 tibial plateau fractures in patients aged over 60 years of age were reviewed. There were 115 females and 36 males. The usual mode of injury was a simple fall (88 fractures, 58%). The most common pattern of injury observed was the split depression variety, which accounted for 48 (32%) cases, followed by central depression fractures, which occurred in 31 (20%) cases. Non-operative management was used in 103 (68%) of fractures, open reduction and internal fixation in 40 (26%) fractures and external fixation in 8 (5%) fractures. Functional outcome in 67 patients assessed by the Hohl plateau evaluation score was similar in all 3 groups and was more closely related to initial fracture pattern. Forty-six (68%) of these 67 patients had evidence of osteoarthritic change on follow-up radiographs, but only 2 patients in the entire series went on to have a knee replacement. Degenerative change and a mediocre functional outcome are a common occurrence following tibial plateau fractures in patients over 60 years of age.

Descriptive analysis of tibial pseudarthrosis in patients with neurofibromatosis 1

Five percent of individuals with neurofibromatosis type 1 (NF1) present with congenital long bone pseudarthrosis (PA). In large series, 50-80% of patients with congenital long bone PA also have NF1. Very little information exists on the natural history and pathogenesis of PA in NF1. This report is a descriptive analysis of a large series of patients with NF1 and tibial bowing or PA. Study A is a case-control study using the National Neurofibromatosis Foundation International Database (NNFFID). Eighty-five patients with PA were compared to a control group from the same database. There was a statistically significant male predominance of NF1 cases with PA (54 males to 31 females), compared to controls (85 males to 87 females) (chi2 = 4.0, P = 0.046, using a two-tailed test with Yates' correction). There was no significant difference in the clinical presentation of NF1 manifestations in NF1 patients with PA than in NF1 patients without PA. Of the affected individuals with PA, there were 24 de novo cases and 21 familial cases (9 through maternal and 12 through paternal inheritance). Questions that could not be answered by Study A were addressed by a partially overlapping case-series report, Study B, in which data on 75 cases ascertained through questionnaires completed by NF center directors were collected. From Study B we determined that half of the patients who had a fracture sustained it before age 2, and approximately 16% of the pseudarthrosis patients had an amputation. Our data indicate a male predominance and no parent-of-origin effect. Male gender may be a susceptibility factor for pseudarthrosis in NF1.

Congenital pseudarthrosis of the tibia. Treatment and outcome at skeletal maturity in 10 children

We present the clinical characteristics of 14 children with congenital pseudarthrosis of the tibia (CPT) treated in northern Finland at Oulu University Hospital during the years 1968-1996. The incidence of CPT in northern Finland was 3.5/10(5) during years 1962-1996, which is higher than in previous reports. The estimated prevalence of pseudarthrosis was 1.8/10(5). The first 10 children with a mean follow-up time of 19 years from the first grafting procedure and 14 years from the last grafts, all had a solid bony union and could walk without external support at the last follow-up. The best treatment, especially in unfavorable types, seems to be a radical resection of the pseudarthrosis and reconstruction with a free vascularized fibular graft.

The epidemiology of open long bone fractures

Open long bone fractures occur with a frequency of 11.5 per 100,000 persons per year. They are more common in males and they have a bimodal age distribution. Open fractures of the tibial diaphysis are the commonest, but open femoral diaphyseal, distal femoral and proximal tibial fractures tend to occur in the most seriously injured patients. Lower limb open fractures are more severe than open fractures of the upper limbs. Not only is the soft tissue damage less in open upper limb fractures, but there are fewer associated musculoskeletal injuries.

A model for the prediction of time to union in fractures of the tibia

BACKGROUND AND PURPOSE

This report covers the second arm of a trial, the main focus of which was to assess the effect of interferential currents (IFCs) on time to union in tibial fractures. No significant improvement was found with the use of IFCs for the parameters employed (Fourie & Bowerbank, 1997).

METHODS

The focus of this study is the development of logistic regression models which used subject characteristics to predict non-union of fracture within 24, 32 and 40 weeks. Such models could be used to identify clients for consideration of alternative interventions, for example, electric current stimulation, bone grafting or the injection of bone morphogenic proteins (BMPs). The usefulness of such models would depend on their ability to correctly identify subjects whose fractures do or do not unite. These models were validated with respect to their sensitivity and specificity to predict non-union for a separate data set.

RESULTS

The results indicated, for instance, that use of a model to predict non-union of fracture within 24 weeks would lead to 27% of subjects being correctly classified (as union or non-union), 51% of subjects whose fractures did not unite within 24 weeks were identified and 65% of subjects (diagnosed as non-union) whose fractures did not unite within 24 weeks (the closer these values are to 100% the more accurate the model).

CONCLUSIONS

The conclusion reached was that the models may have value for low-cost, non-invasive interventions, but that they could not be used to predict those cases where surgical involvement would be necessary, due to the high false-positive rate.

Limb salvage with osteoarticular allografts after resection of proximal tibia bone tumors

A retrospective study was performed between 1980 and 1995 on 38 recipients of proximal tibial allografts after wide resection of benign and malignant tumors. Twenty-one (55%) patients experienced one or more complications. Of the 26 patients who received chemotherapy, 15 (58%) experienced one or more complications, whereas of the 12 patients who did not receive chemotherapy, six (50%) experienced one or more complications. In the chemotherapy group, there were 12 (46%) fractures, four (15%) infections, three (12%) nonunions, and four (15%) instabilities. In the nonchemotherapy group there were three (25%) infections, two (17%) fractures, one (8%) instability, and one (8%) nonunion. These complications were managed adequately with multiple subsequent surgical procedures. Three patients underwent amputations for deep wound infections. Twelve (32%) patients underwent removal of the allograft, and the limb was salvaged by reallografting or by total knee arthroplasty. The results of both groups were 66% (25 of 38 patients) satisfactory (good or excellent). The chemotherapy group had a significantly higher incidence of fractures. All other complication rates and functional outcomes were not significantly different between these groups.

A retrospective review of the incidence and rehabilitation outcome of concomitant traumatic brain injury and ligamentous knee injury

OBJECTIVES

To estimate the incidence of ligamentous knee injuries in patients with traumatic brain injury (TBI) involved in pedestrian versus motor vehicle collisions (PVMVC), to identify associated risk factors, and to compare rehabilitation outcomes and costs in TBI patients with and without ligamentous knee injury.

DESIGN

Retrospective, case control.

SETTING

An academic rehabilitation hospital with a large metropolitan referral base.

PATIENTS

Twenty-three consecutive adolescent and adult subjects admitted for acute inpatient rehabilitation after a PVMVC from January 1, 1994, to January 1, 1996.

RESULTS

Five subjects (22%) were found to have a ligamentous knee injury, one with bilateral injuries. Two of these six injuries were diagnosed only after presentation to the rehabilitation setting. The most common injury was an anterior cruciate ligament (ACL) disruption in 5 of 6 knees. A coupled ACL and medial collateral ligament injury was identified in 4 of 6 injured knees. The risk of ligamentous knee injury was most closely associated with the presence of a tibial plateau fracture (n=3) (chi2=12.420, p < .001). There was no statistical difference between groups with and without ligamentous knee injuries with respect to age, gender, inpatient acute or rehabilitation length of stay, admission, discharge, or change in motor Functional Independence Measure (FIM) interval measures, or rehabilitation costs. Four of the 5 patients with ligamentous knee injuries were successfully managed nonoperatively. A case illustrating longitudinal management is presented.

CONCLUSIONS

TBI and ligamentous knee injuries, in particular ACL injuries, are common comorbidities after PVMVC. Physicians must maintain a high index of suspicion for ligamentous knee injuries in this population, particularly when a tibial plateau fracture is present. TBI patients with and without ligamentous knee injuries can have comparable functional outcomes when the ligament injuries are identified and appropriately managed, without incurring undue cost or length of inpatient rehabilitation.

Effect of cage area, cage height and perches on feather condition, bone breakage and mortality of laying hens

1. The health of 2 flocks of 896 ISA Brown laying hens were studied successively over the years 1995 and 1996 under different caging conditions. Hens were kept in groups of 4 in a total of 224 cages. The treatments (7 different types of cages) differed in area per hen (450, 600 or 800 cm2) and height (40 or 60 cm). In the large (800 cm2/hen) and high (60 cm cage) treatment, half of the cages were equipped with perches (20 cm/hen). Each study lasted 48 weeks. 2. Feather condition was found to be independent of cage type. 3. No differences were apparent between the 7 treatments in tibia breaking strength (using the 3-point breakage technique). A significant increase in humerus breaking strength was observed in the high cages. The frequency of broken wings recorded after slaughter was lower in high cages (23%) than in low ones (36%). 4. Mortality was different between treatments. This was explained by a higher proportion of birds killed by 'body cannibalism' in the 60 cm high cages, and by a higher proportion of birds killed by 'vent cannibalism' in the cages with perches.

Epidemiology of fractures in 15,000 adults: the influence of age and gender

We report a prospective study of the incidence of fractures in the adult population of Edinburgh, related to age and gender. Over a two-year period, 15,293 adults, 7428 males and 7865 females, sustained a fracture, and 5208 (34.0%) required admission. Between 15 and 49 years of age, males were 2.9 times more likely to sustain a fracture than females (95% CI 2.7 to 3.1). Over the age of 60 years, females were 2.3 times more likely to sustain a fracture than males (95% CI 2.1 to 2.4). There were three main peaks of fracture distribution: the first was in young adult males, the second was in elderly patients of both genders, mainly in metaphyseal bone such as the proximal femur, although diaphyseal fractures also showed an increase in incidence. The third increase in the incidence of fractures, especially of the wrist, was seen to start at 40 years of age in women. Our study has also shown that 'osteoporotic' fractures became evident in women earlier than expected, and that they were not entirely a postmenopausal phenomenon.

Skiing injuries in children, adolescents, and adults

We prospectively gathered data on skiing injuries that had been sustained at the Sugarbush North ski area since 1972 and at the Sugarbush South ski area since 1981. The purpose of the current study was to document the overall rates of injury in children, adolescents, and adults participating in alpine skiing. We also sought to determine the ten most common injuries in each age-group. Finally, we analyzed short-term and long-term trends to determine if changes in equipment had had an effect on the frequency or pattern of injury. From the 1981-1982 to the 1993-1994 season, there were 2.79 injuries per 1000 skier days: 4.27 injuries in children, 2.93 in adolescents, and 2.69 in adults. During the last eight years of the study, the most common injuries were a contusion of the knee in children, a sprain of the ulnar collateral ligament of the thumb in adolescents, and a grade-III sprain of the anterior cruciate ligament in adults. The short-term trends revealed that, in children, the frequency of tibial fractures decreased 10 per cent while that of fractures of the upper extremity increased 8 per cent. The long-term trends showed that, in adults, the rate of tibial fractures decreased 89 per cent while that of injuries of the anterior cruciate ligament increased 280 per cent. The overall rate of injury decreased 43 per cent from the beginning of the study in 1972 to the end of the study in 1994; the decrease was 58 per cent in children, 45 per cent in adolescents, and 42 per cent in adults. Data on the types of equipment and the binding-release values were collected prospectively from injured skiers and from 2083 non-injured skiers. Of the fifty-nine skiers who sustained a spiral fracture of the tibia, forty-two (71 per cent) had binding-release values that were higher than the average for the uninjured group. We believe that the use of properly functioning modern equipment will decrease the rate of injury, particularly in children.

Conservatively managed tibial shaft fractures in Nottingham, UK: are pain, osteoarthritis, and disability long-term complications?

OBJECTIVES

To investigate longterm pain and disability subsequent to a tibial shaft fracture treated conservatively.

DESIGN AND SETTING

Subjects who had sustained a tibial shaft fracture more than 27 years ago were compared with those who had not.

SUBJECTS

572 fracture patients (identified from the records of the plaster room) aged over 16 at the time of injury were contracted and were compared with 2285 randomly selected subjects matched for age, sex, and general practice.

MAIN OUTCOME MEASURES

Self reported knee pain; self reported GP's diagnosis of osteoarthritis; ability to climb stairs, walk 100 yards, to bend, kneel, or stoop; and SF-36 physical functioning score.

RESULTS

Subjects were reviewed between 27 and 41 years after tibial shaft fracture (mean 35 years). Fracture patients were more likely to suffer chronic knee pain (odds ratio 1.23; 95% confidence interval (CI) 1.00, 1.51) and report being given a diagnosis of osteoarthritis by their GP (odds ratio 1.46; 95% CI 1.08, 1.97). The ability to climb stairs, walk 100 yards, and bend, kneel, or stoop was less in the fracture group than the other subjects. The SF-36 physical function score was significantly lower in the fracture group.

CONCLUSIONS

More than 27 years after a tibial shaft fracture, subjects have more knee pain than the rest of the population. They also have greater difficulty performing everyday physical activities. The excess morbidity may be due to injury factors or treatment factors, and further research is needed to investigate this important association further.

A report by the British Orthopaedic Association/British Association of Plastic Surgeons Working Party on the management of open tibial fractures. September 1997

We congratulate the authors of this excellent combined report. What a pleasure it is to find two surgical specialties cooperating in this way. The working party has carefully analysed the available data, considered the various options for management and proffered clear advice which we hope will be useful for all surgeons managing these difficult injuries. The message of collaboration was conveyed in the first edition of the report. This stressed that, in order to avoid repeated surgery and long term disability, it is necessary to evaluate each injury and to establish communication between the two disciplines as soon as possible, with the aim of providing optimal conditions for wound and fracture healing. The working party feels that this message now needs re-emphasising and it is our hope that this latest report, by up-dating and repeating the principles of management, will lead to a further improvement in outcomes.

Extra-articular fractures of the proximal tibial diaphysis: their epidemiology, management and outcome

In a study of 523 consecutive tibial fractures, 33 were located in the proximal extra-articular segment. There were two fracture groups with different epidemiological characteristics and prognoses: group 1 fractures were metaphyseal in location, follow low-velocity injuries and have a good prognosis with non-operative treatment; group 2 injuries are high-energy diaphyseal fractures. Treatment of these latter fractures proved difficult, with all methods showing significant complications. Overall there was a 26% incidence of malunion, 7% deep infection and 7% compartment syndrome. Only 44% of patients with group 2 fractures returned to full function. Epidemiological analysis showed that proximal tibial fractures are closer to comminuted and segmental fractures in severity than to middle- and distal-third fractures. It is suggested, on the basis of our results, that they should be treated with either compression plating or closed external fixation.

Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures

OBJECTIVE

To evaluate the interobserver and intraobserver agreement for both treatment plan and fracture classification of tibial plateau fractures using plain films alone and with computed tomography (CT) scans.

DESIGN

Prospective study to assess the impact of an advanced radiologic study on the agreement of treatment plan and fracture classification of tibial plateau fractures.

SETTING/PARTICIPANTS

Two orthopaedic traumatologists, two orthopaedic residents, and two skeletal radiologists were presented with twenty-one cases of tibial plateau fractures imaged with plain films and with CT scans.

MAIN OUTCOME MEASURES

Agreement was measured using kappa coefficients.

RESULTS

Using plain films alone, the mean interobserver kappa coefficient for classification was 0.62, which decreased to 0.61 after addition of CT scans. Using plain films alone for formulating a treatment plan, the mean interobserver kappa coefficient was 0.58, which increased to 0.71 after addition of CT scans. The mean intraobserver kappa coefficient for fracture classification using plain films was 0.70, which increased to 0.80 with addition of CT scans. The mean intraobserver kappa coefficient for treatment plan based on plain films alone was 0.62, which increased to 0.82 after addition of CT scans. Class was changed in an average of 12 percent of cases after addition of CT scans. Treatment plan was changed an average of 26 percent of the time after addition of CT scans.

CONCLUSION

Addition of CT scans to plain roentgenograms increases the interobserver and intraobserver agreement on treatment plan.

Epidemiology and outcome of tibial diaphyseal fractures in footballers

A retrospective analysis of tibial diaphyseal fractures caused by football was undertaken to establish the epidemiology and severity of these common injuries. Analysis showed that the commonest fracture types were Tscherne C0 and C1 fractures and that only 73.9 per cent of the patients had unimpaired sporting function after the injury. The time to return to football was significantly related to the severity of the fracture but there was no correlation with the skill of the player. The time to return to football for the C0 fractures averaged 7-8 months and it is therefore suggested that it is unlikely that any player will return to football in the same season.

Microdamage of human cortical bone: incidence and morphology in long bones

Increased bone fragility and osteoporotic fracture in human bone has been attributed to the accumulation of microdamage. According to Martin and Burr (J Biomech 15:137-139; 1982), microcracks from interstitial bone propagate to the cement line or concentric lamellae and debond or separate the Haversian canal from the surrounding bone which leads to repair of the damaged region. If this is true, we would expect to find a greater incidence of microdamage existing at the cement line than at other locations within the bone microstructure. The incidence of such an occurrence, however, is not established. The purpose of this investigation was to determine the incidence and morphology of microcracks in human cortical bone from the midshaft of the tibia and proximal femur. We investigated the hypothesis that osteons arrest and trap microcracks in bone. We were also interested in determining if relationships exist between microdamage and bone type (tibia or femur), cortex location (anterior, posterior, medial, and lateral), gender, and donor age. It was found that 62.4% of all microcracks run between the surrounding interstitial bone and the cement line supporting the hypothesis by Martin and Burr. It was also found that microdamage increased with age, was significantly greater in females than males, and was significantly greater in the proximal femur than the midshaft of the tibia.

Ipsilateral knee ligament injuries and open tibial diaphyseal fractures: incidence and nature of knee ligament injuries sustained

Fifty patients with isolated open tibial shaft fractures were reviewed to determine the incidence and type of knee ligament injuries sustained. Eighteen patients (36 per cent) had at least one ligament injury in the ipsilateral knee; eight had multiple ligament injuries. Only four patients (22 per cent) were diagnosed as having a ligament injury at the time of initial management and the remaining 14 patients were diagnosed at the time of review for this study. There is a high incidence of ipsilateral knee ligament injuries in open tibial shaft fractures; the knee should be thoroughly examined at the time of initial fracture management.