Mortality in elderly patients after cervical spine fractures

BACKGROUND

Despite an increased risk of cervical spine fractures in older patients, little is known about the mortality associated with these fractures and there is no consensus on the optimal treatment. The purposes of this study were to determine the three-month and one-year mortality associated with cervical spine fractures in patients sixty-five years of age or older and to evaluate potential factors that may influence mortality.

METHODS

We performed a retrospective review of all cervical spine fractures in patients sixty-five years of age or older from 1991 to 2006 at two institutions. Information regarding age, sex, race, treatment type, neurological involvement, injury mechanism, comorbidity, and mortality were collected. Overall risk of mortality and mortality stratified by the above factors were calculated at three months and one year. Cox proportional-hazard regression was performed to identify independent correlates of mortality.

RESULTS

Six hundred and forty patients were included in our analysis. The mean age was eighty years (range, sixty-five to 101 years). Two hundred and ninety-four patients (46%) were male, and 116 (18%) were nonwhite. The risk of mortality was 19% at three months and 28% at one year. The effect of treatment on mortality varied with age at three months (p for interaction = 0.03) but not at one year (p for interaction = 0.08), with operative treatment being associated with less mortality for those between the ages of sixty-five and seventy-four years. A higher Charlson comorbidity score, male sex, and neurological involvement were all associated with increased risk of mortality.

CONCLUSIONS

Operative treatment of cervical spine fractures is associated with a lower mortality rate at three months but not at one year postoperatively for patients between sixty-five and seventy-four years old at the time of fracture.

Brigham fracture intervention team initiatives for hospital patients with hip fractures: a paradigm shift

We designed, implemented, and revised the Brigham Fracture Intervention Team (B-FIT) initiatives to improve in-hospital care of fracture (Fx) patients. Effectiveness was evaluated for 181 medical records of 4 cohorts in four successive years of consecutive patients who were admitted with a fragility hip Fx. The Discharge Initiative (DI) (computer-based) includes 1200 mg calcium and 1000 IU vitamin D(3) daily. The Admission Initiative (AI) was introduced one year later with reminders for serum 25OHD measurement, initiation of daily calcium (1200 mg) and vitamin D (800 IU), and an order for Endocrinology consultation, with an amendment for a computer-assisted reminder and a dose of D(2) (50 000 IU). Initially, the computer-based DI was more effective (67%) than the surgeon-driven AI (33%, P < .001). After introduction of a computer-assisted reminder, AI effectiveness increased to 68%. The marked prevalence of vitamin D insufficiency reaffirms the importance of incorporating vitamin D recommendations in Fx care pathways.

Subchondral cysts of the atlantoaxial joint: a risk factor for odontoid fractures in the elderly

BACKGROUND CONTEXT

Scholars have postulated that cervical degeneration can predispose the upper cervical spine to injury after minor trauma. Subchondral cysts have previously been recognized as potentiators of fracture in the hip and knee but no cases of cervical degenerative cysts contributing to fracture have been reported.

PURPOSE

This report documents a case series in which patients sustained significant injury to the upper cervical spine in the setting of subchondral cervical cysts.

STUDY DESIGN/SETTING

Case series/academic level I trauma center.

METHODS

Between 2004 and 2008, six patients (ages 73-91 years) with cervical pathology were admitted to the trauma service at our Level I trauma center. The most common mechanism of injury was a low velocity fall, which occurred in 5 out of 6 patients. All patients suffered an odontoid fracture. In all cases, there was radiographic evidence of cyst formation, and computed tomographic imaging demonstrated fracture communication with the subchondral cyst.

RESULTS

Of the six cases, four were treated definitively with immobilization in a cervical orthosis and two required surgery. One patient was treated with an occipital-cervical fusion, whereas the other underwent Brooks wiring. All patients ultimately went on to heal their fractures.

CONCLUSIONS

Degenerative changes in the cervical spine have previously been recognized to potentiate injury. This report raises the question of whether degenerative processes at the C1-C2 articulation predispose elderly patients to injury at this level. The presence of cystic degeneration at the atlantoaxial joint should be recognized as a potential risk factor for cervical injury after relatively minor trauma.

The evolution of thoracolumbar injury classification systems

BACKGROUND CONTEXT

An ideal classification system for thoracolumbar (TL) spine fractures should facilitate communication between treating physicians and guide treatment by means of outlining the natural history of injuries. The classification scheme should also be comprehensive, intuitive, and simple to implement. At the present time, no classification system fully meets these criteria. In this review, the authors attempt to describe the evolution of TL fracture classification systems from their inception to the present day.

PURPOSE

To review the evolution of TL injury classification schemes, particularly in regard to the progression of thought on the importance of biomechanical stability, injury mechanism, and neurologic status.

STUDY DESIGN

Review article.

METHODS

The article reviews the salient classification systems that have addressed TL injuries since Boehler's first attempt in 1929. This progression culminates in the Thoracolumbar Injury Severity Score/Thoracolumbar Injury Classification and Severity Score (TLISS/TLICS), a system which incorporates features from earlier scales and represents the most comprehensive grading scale to date.

RESULTS

Each successive system played an important role in advancing contemporary understanding of TL injuries. Most classifications were, however, based on a single individual's, or a comparatively small group's, retrospective review of a case series. In most instances, these grading systems were never validated or modified by their original developers, a shortcoming that prevented their continued evolution. Despite the many advantages of the TLISS/TLICS system, more work in terms of refining the classification and defining its validity remains to be performed.

CONCLUSIONS

The classification of TL injuries has evolved significantly over the course of the last 75 years. Most of these schemes were limited by their complexity, relevance, and/or poor reliability. The TLISS classification system represents the most recent evolution as it combines several important factors capable of guiding the management of TL injuries. Nonetheless, more research regarding this rating scale remains to be performed.

Lung respiratory rhythm and pattern generation in the bullfrog: role of neurokinin-1 and mu-opioid receptors

Location of the lung respiratory rhythm generator (RRG) in the bullfrog brainstem was investigated by examining neurokinin-1 and mu-opioid receptor (NK1R, muOR) colocalization by immunohistochemistry and characterizing the role of these receptors in lung rhythm and episodic pattern generation. NK1R and muOR occurred in brainstems from all developmental stages. In juvenile bullfrogs a distinct area of colocalization was coincident with high-intensity fluorescent labeling of muOR; high-intensity labeling of muOR was not distinctly and consistently localized in tadpole brainstems. NK1R labeling intensity did not change with development. Similarity in colocalization is consistent with similarity in responses to substance P (SP, NK1R agonist) and DAMGO (muOR agonist) when bath applied to bullfrog brainstems of different developmental stages. In early stage tadpoles and juvenile bullfrogs, SP increased and DAMGO decreased lung burst frequency. In juvenile bullfrogs, SP increased lung burst frequency, episode frequency, but decreased number of lung bursts per episode and lung burst duration. In contrast, DAMGO decreased lung burst frequency and burst cycle frequency, episode frequency, and number of lung bursts per episode but increased all other lung burst parameters. Based on these results, we hypothesize that NK1R and muOR colocalization together with a metamorphosis-related increase in muOR intensity marks the location of the lung RRG but not necessarily the lung episodic pattern generator.

Emergency evaluation, imaging, and classification of thoracolumbar injuries

Thoracolumbar injuries usually are the result of high-energy trauma and frequently are associated with multisystem concomitant injuries. Whenever a thoracolumbar injury is suspected, a prompt and thorough evaluation should be performed in the emergency department, using the guidelines of the American College of Surgeons and including full primary and secondary surveys as well as resuscitation. Protection of the spine and spinal cord is of paramount importance during the initial evaluation. A careful and complete neurologic examination is warranted as part of the secondary survey. Plain radiography, CT, and MRI studies are useful in diagnosing and classifying thoracolumbar injuries. At many trauma centers, CT has become the standard imaging technology for the initial evaluation of the spine. MRI is particularly accurate in detecting injury to the posterior ligamentous complex of the thoracolumbar spine. Classification and treatment of thoracolumbar injuries are controversial. The comprehensive, reproducible classification system of the Spine Trauma Study Group has prognostic significance and can guide treatment decisions. The Thoracolumbar Injury Classification and Severity scale classifies thoracolumbar injures based on three pivotal characteristics: the morphology of the injury, the integrity of the posterior ligamentous complex, and the patient's neurologic status. A total severity score is used in conjunction with the classification system to determine the treatment.

Sacral fractures

Sacral fractures are a treatment challenge for the orthopaedic surgeon. The relative rarity of sacral fractures limits physician exposure to these injuries and has resulted in questions regarding their optimal treatment. Proper diagnosis and classification also are subjects of considerable debate. Studies of sacral fractures have been mainly retrospective in nature and have involved heterogeneous and small patient populations. The current literature is, therefore, limited.

Nonsurgical treatment of thoracolumbar spinal fractures

The transitional anatomy of the thoracolumbar spine makes it vulnerable to injury from high-energy vehicular crashes and falls. The definitive management of patients with thoracolumbar spinal fractures is dependent on the presence and extent of neurologic injury, the presence and magnitude of acute deformity, and an estimate concerning spinal stability. It is well established that neurologic deficits generally improve without surgery. Nonsurgical treatment leads to decreased pain and improved function. Although there is a dearth of high-quality studies comparing surgical with nonsurgical treatment, the natural course of thoracolumbar fractures usually is benign, and nonsurgical methods should be the standard treatment with few exceptions.

Osteogenic potential of reamer irrigator aspirator (RIA) aspirate collected from patients undergoing hip arthroplasty

Intramedullary nailing preceded by canal reaming is the current standard of treatment for long-bone fractures requiring stabilization. However, conventional reaming methods can elevate intramedullary temperature and pressure, potentially resulting in necrotic bone, systemic embolism, and pulmonary complications. To address this problem, a reamer irrigator aspirator (RIA) has been developed that combines irrigation and suction for reduced-pressure reaming with temperature modulation. Osseous particles aspirated by the RIA can be recovered by filtration for use as an autograft, but the flow-through is typically discarded. The purpose of this study was to assess whether this discarded filtrate has osteogenic properties that could be used to enhance the total repair potential of aspirate. RIA aspirate was collected from five patients (ages 71-78) undergoing hip hemiarthroplasty. Osseous particles were removed using an open-pore filter, and the resulting filtrate (230 +/- 200 mL) was processed by Ficoll-gradient centrifugation to isolate mononuclear cells (6.2 +/- 5.2 x 10(6) cells/mL). The aqueous supernatant contained FGF-2, IGF-I, and latent TGF-beta1, but BMP-2 was below the limit of detection. The cell fraction included culture plastic-adherent, fibroblastic cells that displayed a surface marker profile indicative of mesenchymal stem cells and that could be induced along the osteogenic, adipogenic, and chondrogenic lineages in vitro. When compared to outgrowth cells from the culture of osseous particles, filtrate cells were more sensitive to seeding density during osteogenic culture but had similar capacity for chondrogenesis. These results suggest using RIA aspirate to develop improved, clinically expeditious, cost-effective technologies for accelerating the healing of bone and other musculoskeletal tissues.

Surgical treatment of thoracolumbar fractures

Surgical management of a thoracolumbar fracture varies according to many factors. Fracture morphology, neurologic status, and surgeon preference play major roles in deciding on an anterior, a posterior, or a combined approach. The goal is to optimize neural decompression while providing stable internal fixation over the least number of spinal segments. Short-segment constructs through a single-stage approach (anterior or posterior) have become viable options with advances in instrumentation and techniques. Unstable burst fractures can be treated with anterior-only fixation using a strut graft and a modern thoracolumbar plating system or with a posterior-only construct using pedicle screws and possibly hooks. A circumferential construct is considered for extremely unstable injuries.

Trends in surgical management of femoral neck fractures in the United States

We examined trends in utilization of open reduction and internal fixation (ORIF), THA, and hemiarthroplasty (HA) for femoral neck fractures. Closed femoral neck fractures managed with ORIF or hip arthroplasty (n = 162,257) were extracted from 1990 to 2001 Nationwide Inpatient Samples. Trends were examined during three periods (1990-1993 [Period I], 1994-1997 [Period II], and 1998-2001 [Period III]). Utilization of HA increased from 67.8% in Period I to 75.3% in Period III. In the same period, utilization of THA decreased from 11.6% to 6.6%. The trend of decreased use of THA was consistent regardless of age, hospital, or surgeon volume. In Period III, 28.7% of patients were managed at urban teaching hospitals as compared with 19.6% in Period I. Increased utilization of HA conforms with recent evidence that arthroplasty has better outcomes than ORIF. However, the decrease in THA is contrary to what was expected, and its impact on patient outcomes needs to be evaluated. The increase in the proportion of femoral fractures managed at urban teaching hospitals may reflect a change in the organization of trauma systems during the last decade.

LEVEL OF EVIDENCE

Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Case report: nonoperative treatment of an unstable Jefferson fracture using a cervical collar

The treatment of unstable burst fractures of the atlas (Jefferson fractures) is controversial. Unstable Jefferson fractures have been managed successfully with either immobilization, typically halo traction or halo vest, or surgery. We report a patient with an unstable Jefferson fracture treated nonoperatively with a cervical collar, frequent clinical examinations, and flexion-extension radiographs. Twelve months after treatment, the patient achieved painless union of his fracture. The successful treatment confirms prior studies reporting unstable Jefferson fractures have been treated nonoperatively. The outcome challenges the clinical relevance of treatment algorithms that rely on the "rules of Spence" to guide treatment of unstable Jefferson fractures and illustrates instability may not necessarily be present in patients with considerable lateral mass widening. Additionally, it emphasizes a more reliable way of assessing C1-C2 stability in unstable Jefferson fractures is by measuring the presence and extent of anterior subluxation on lateral flexion and extension views.

Importance of vitamin D in hospital-based fracture care pathways

OBJECTIVES

This project was developed to identify ways to support hospital-based improvements for the identification and management of osteoporosis following treatment of a fragility fracture.

DESIGN

This is a retrospective review of medical records of sets of consecutive patients who were admitted for surgical treatment of fragility fracture following introduction of several versions of admission and discharge care pathways. Effectiveness of the admission pathway was defined as % subjects with measurement of serum 25- hydroxyvitamin D (25(OH)D) during hospitalization; effectiveness of the discharge pathway was defined as % subjects with documentation of instructions for calcium and/or vitamin D supplementation.

SETTING

This study reviewed medical records of patients admitted to hospital for surgical treatment of a fragility fracture.

PARTICIPANTS

Medical records were evaluated for 98 patients older than 50-years who were admitted with a fragility fracture of the hip or femur.

MEASUREMENTS

Medical records were reviewed for the % subjects with documentation of an in-hospital order for serum 25(OH)D and with documentation of instructions to patients upon discharge concerning calcium and vitamin D intake. Median value of serum 25(OH)D was calculated.

RESULTS

In accordance with the admission pathway, serum 25(OH)D was measured in 37% (36/98). The median 25(OH)D level was 19.5 ng/mL; 78% were vitamin D insufficient [serum 25(OH)D < or = 32 ng/mL] and 58% were vitamin D deficient [serum 25(OH)D < or = 20 ng/mL]. In accordance with the discharge pathway, 74% (71/96) were discharged on calcium and/or vitamin D.

CONCLUSION

The high prevalence of vitamin D insufficiency (78%) observed in this study affirms the importance of incorporating vitamin D supplementation in hospital-based fracture care pathways. The discharge pathway was more effective than the newer admission pathway, a finding attributable to effects of familiarity, retraining, and introduction of computer-prompts. These evolving pathways represent a much-needed paradigm shift in the care of fragility fracture patients.

Spinal cord compression in patients with advanced metastatic cancer: "all I care about is walking and living my life"

As 1 of the 12,700 US cancer patients who, each year, develops metastatic spinal cord compression, Ms H wishes to walk and live her life. Sadly, this wish may be difficult to fulfill. Before diagnosis, 83% to 95% of patients experience back pain, which often is referred, obscuring the site(s) of the compression(s). Prediction of ambulation depends on a patient's ambulatory status before therapy and time between developing motor defects and starting therapy. Ambulatory patients with no visceral metastases and more than 15 days between developing motor symptoms and receiving therapy have the best rate of survival. To preserve ambulation and optimize survival, magnetic resonance imaging should be performed for cancer patients with new back pain despite normal neurological findings. At diagnosis, counseling, pain management, and corticosteroids are begun. Most patients are offered radiation therapy. Surgery followed by radiation is considered for selected patients with a single high-grade epidural lesion caused by a radioresistant tumor who also have an estimated survival of more than 3 months. Team discussions with the patient and support network help determine therapy options and include patient goals; assessment of risks, benefits, and burdens of each treatment; and discussion of the odds of preserving prognosis of ambulation and of the effect of therapy on the patient's overall prognosis. Rehabilitation improves impaired function and its associated depression. Clinicians can help patients cope with transitions in self-image, independence, family and community roles, and living arrangements and can help patients with limited prognoses identify their end-of-life goals and preferences about resuscitation and entering hospice.

Bone tissue engineering and repair by gene therapy

Many clinical conditions require the stimulation of bone growth. The use of recombinant bone morphogenetic proteins does not provide a satisfying solution to these conditions due to delivery problems and high cost. Gene therapy has emerged as a very promising approach for bone repair that overcomes limitations of protein-based therapy. Several preclinical studies have shown that gene transfer technology has the ability to deliver osteogenic molecules to precise anatomical locations at therapeutic levels for sustained periods of time. Both in-vivo and ex-vivo transduction of cells can induce bone formation at ectopic and orthotopic sites. Genetic engineering of adult stem cells from various sources with osteogenic genes has led to enhanced fracture repair, spinal fusion and rapid healing of bone defects in animal models. This review describes current viral and non-viral gene therapy strategies for bone tissue engineering and repair including recent work from the author's laboratory. In addition, the article discusses the potential of gene-enhanced tissue engineering to enter widespread clinical use.

Activation of 5-HT1A receptors in the paragigantocellularis lateralis decreases shivering during cooling in the conscious piglet

Activation of 5-HT1A receptors in the medullary raphé decreases sympathetic outflow to thermoregulatory mechanisms, including brown adipose tissue (BAT), thermogenesis, and peripheral vasoconstriction when these mechanisms are previously activated with leptin, prostaglandins, or cooling. These same mechanisms are also inhibited during rapid eye movement (REM) sleep. It is not known whether shivering is also modulated by medullary raphé neurons. We previously showed in the conscious piglet that activation of 5-HT1A receptors with 8-OH-DPAT (DPAT) in the paragigantocellularis lateralis (PGCL), a medullary region lateral to the midline raphé that contains 5-HT neurons, decreases heart rate, body temperature and muscle activity during non-rapid eye movement (NREM) sleep. We therefore hypothesized that activation of 5-HT1A receptors in the PGCL would also attenuate shivering and peripheral vasoconstriction during cooling. During REM sleep in a cool environment, shivering, carbon dioxide production, and body temperature decreased, and ear capillary blood flow and ear skin temperature increased. Shivering associated with rapid cooling was attenuated after dialysis of DPAT into the PGCL. In animals maintained in a continuously cool environment, dialysis of DPAT into the PGCL attenuated shivering and decreased body temperature, but there were no significant increases in ear capillary blood flow or ear skin temperature. We conclude that both naturally occurring REM sleep and exogenous activation of 5-HT1A receptors in the PGCL are associated with a suspension of shivering during cooling. Our data are consistent with the hypothesis that 5-HT neurons in the PGCL facilitate oscillating spinal motor circuits involved in shivering but are less involved in modulating sympathetically mediated thermoregulatory mechanisms.

Assessment of injury to the thoracolumbar posterior ligamentous complex in the setting of normal-appearing plain radiography

BACKGROUND CONTEXT

The posterior ligamentous complex (PLC) is thought to contribute significantly to the stability of thoracolumbar spine. Obvious translation or dislocation of an interspace clearly denotes injury to the PLC. A recent survey of the Spine Trauma Study Group indicated that plain radiographic findings, if present, are most helpful in determining PLC injury. However, confusion exists when plain radiography shows injury to the anterior spinal column without significant kyphosis or widening of the posterior interspinous space.

PURPOSE

The objective of this study is to identify imaging parameters that may suggest a disruption of the posterior ligamentous complex of the thoracolumbar spine in the setting of normal-appearing plain radiographs. This study was performed, in part, as a pilot study to determine critical imaging parameters to be included in a future prospective, randomized, multicenter study.

STUDY DESIGN/SETTING

Survey analysis of the Spine Trauma Study Group.

PATIENT SAMPLE

None.

OUTCOME MEASURES

Compilation and statistical analysis of survey results.

METHODS

Based on a systematic review of the English literature from 1949 to present, we identified a series of traits not found on plain X-rays that were consistent with PLC injury. This included five imaging findings on either computed tomography (CT) scans or magnetic resonance imaging (MRI) and several physical examination features. These items were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important in representing an injury to the PLC in the setting of normal-appearing plain radiographs.

RESULTS

Thirty-three of 47 surveys were returned for final analysis. Thirty-nine percent (13/33) of the members ranked "disrupted PLC components (i.e., interspinous ligament, supraspinous ligament, ligamentum flavum) on T1 sagittal MRI" as the most important factor in determining disruption of PLC. When analyzed with a point-weighted system, "diastasis of the facet joints on CT" received the most points, indicating that this category was ranked high by the majority of the members of the group. The members were also given freedom to add other criteria that they believed were important in determining PLC integrity in the setting of normal-appearing plain radiograph. Of the other criteria suggested, one included a physical finding and the other a variant of MR sequencing.

CONCLUSIONS

In a setting of normal-appearing plain radiographs, PLC injury as displayed on T1-weighted MRI and diastasis of the facet joints on CT scan seem to be the most popular determinants of probable PLC injury among members of the Spine Trauma Study Group. Between MRI and CT scan, most members feel that various characteristics on MRI studies were more helpful.

Incisional vacuum-assisted closure therapy

Postoperative swelling and prolonged drainage from surgical incisions result in both practical and medical burdens, such as increased need for dressing changes and potentially higher rates of surgical wound infection. This article presents a technique to apply a vacuum-assisted closure therapy sponge as a postoperative dressing to provide a clean, dry wound environment in the immediate postoperative period.

Assessment of injury to the posterior ligamentous complex in thoracolumbar spine trauma

BACKGROUND CONTEXT

Posterior ligamentous complex (PLC), consisting of supraspinous ligament (SSL), interspinous ligament (ISL), ligamentum flavum (LF), and the facet joint capsules is thought to contribute significantly to the stability of thoracolumbar spine. Currently, no consensus exists on radiographic imaging parameters that may indicate injury to the posterior ligamentous complex.

PURPOSE

To identify imaging parameters that may suggest a disruption of the PLC of the thoracolumbar spine.

STUDY DESIGN/SETTING

A survey analysis of members of the Spine Trauma Study Group.

PATIENT SAMPLE

None.

OUTCOMES MEASURES

Compilation of survey results.

METHODS

An extensive review of the literature from 1949 to the present was performed to identify key radiographic elements that have been suggested as indicators of PLC injury. Twelve items identified as such were placed on a survey and sent to the members of the Spine Trauma Study Group. They were asked to rank the items from most important to least important, and the results were compiled for analysis.

RESULTS

Twenty-eight surveys were returned for final analysis. Fifty-percent (14/28) of the members ranked "vertebral body translation" on plain radiographs as the most important factor in determining disruption of PLC. Plain radiographic signs were ranked higher than computed tomography or magnetic resonance imaging indicators, and history of the mechanism ranked lowest. The members were also given freedom to add other criteria that they felt were important in determining PLC integrity. "Interspinous spacing 7 mm greater than that of level above or below on antero posterior plain X-rays" was the only new category that was suggested.

CONCLUSION

Plain radiographic findings were felt to be most helpful in determining PLC injury by the members of the Spine Trauma Study Group. Physical examination findings and history of the mechanism of injury were ranked lower than imaging studies. Future analysis should focus on indicators of PLC injury when plain radiographic findings are either subtle or not present.

The initial assessment and management of the multiple-trauma patient with an associated spine injury

STUDY DESIGN

Review and summary of the relevant literature from multiple disciplines.

OBJECTIVE

Provide the readership with evidence-based guidelines on the initial assessment and treatment of the multiple-trauma patient with an associated spinal column injury.

SUMMARY OF BACKGROUND DATA

Early operative stabilization of the isolated spinal column injury has decreased hospital and intensive care unit length of stay. Early intervention has not provided consistently improved neurologic outcomes. The timing of spinal column stabilization in the multiple-trauma patient continues to be a source of discussion.

METHODS

Review of published English literature from 1990 to present using key words: spinal trauma, multiple-trauma with spinal injury; timing of spinal injury treatment; spinal fracture management; and Advanced Trauma Life Support.

CONCLUSIONS

The treatment of the poly-trauma patient with an associated spinal column injury requires strict adherence to Advanced Trauma Life Support principles. Once life and limb-threatening injuries have been identified and addressed, spinal column assessment and neurologic protection must be maintained at the highest priority. Early spinal stabilization can be performed safely in the multiple-trauma patient in medical centers, in which medical and ancillary staff is available on a 24-hour basis and is familiar with these procedures.

Case reports: pathologic fracture of the patella from a gouty tophus

Fracture of the patella is a relatively common condition seen in patients with trauma. We report one patient with known gout who sustained relatively minor trauma that resulted in a patellar fracture. An intraoperative biopsy confirmed that much of the patella had been replaced with gouty tophus. Gout is a rare cause of patellar fracture, with few documented cases. Postoperative management of patients with patella fractures secondary to gout may be routine with the addition of medical management for the underlying pathologic process.

Are Plain Radiographs of the Spine Necessary during Evaluation after Blunt Trauma? Accuracy of Screening Torso Computed Tomography in Thoracic/Lumbar Spine Fracture Diagnosis

BACKGROUND

Fracture of the thoracolumbar (TL) spine is reported in 8 to 15% of victims of blunt trauma. Current screening of these patients is done with conventional radiography. This may require repeated sets of films and take hours to days. It is imperative that these patients get timely, accurate evaluation to allow for treatment planning and early mobilization; alternatives to plain films would aid in this. The objective of this study is to determine whether the data obtained from admission chest/abdomen/pelvis (CAP) computed tomography (CT) scans after blunt trauma has utility in thoracolumbar spine evaluation.

METHODS

The records of all patients admitted to a Level I trauma center over a 2-month period who underwent CAP CT were reviewed for the presence of TL spine fracture, time to completion of plain film evaluation, and clinical course. Admission CT scans were reviewed by an attending radiologist who was blinded to any previously diagnosed spine fractures. The two tests were compared for diagnostic accuracy and their discriminatory ability was compared using receiver operating characteristic (ROC) curves. Significance was defined as p < 0.05.

RESULTS

In all, 103 patients were admitted from January 1, 2003 to February 28, 2003 and underwent CAP CT scan as part of their initial trauma evaluation. Of these, 26 (25%) had thoracolumbar fractures. Seven (27%) thoracolumbar fractures were not seen on plain radiographs taken during the trauma evaluation. Average time until plain film completion in this group was 8 hours (range, 44 minutes to 38 hours). All 26 (100%) patients with fractures, however, were diagnosed on CT scan performed shortly after admission. Of the remaining 77 patients, two (2.6%) were falsely read as positive for fracture on CT. Sensitivity and specificity of CT scan for thoracolumbar fracture were excellent at 100% and 97%, respectively, with a negative predictive value of 100%. Plain radiographs were 73% sensitive, 100% specific, and had a negative predictive value of 92%. Area under the ROC curve for CT was 0.98, but for plain film was 0.86 (p < 0.02).

CONCLUSION

Admission CAP CT obtained as part of the routine trauma evaluation in these high-risk patients is more sensitive than plain radiographs for evaluation of the TL spine after blunt trauma. In addition, CAP CT can be performed faster. Omission of plain radiographs will expedite accurate evaluation allowing earlier treatment and mobilization.

The medical-legal aspects of informed consent in orthopaedic surgery

BACKGROUND

Orthopaedic surgeons routinely obtain informed consent prior to surgery. Legally adequate informed consent requires a thorough discussion of treatment options and risks and proper documentation; however, there is little data to guide orthopaedic surgeons regarding effective methods of obtaining informed consent.

METHODS

We performed a closed claims analysis on malpractice claims involving an allegation of inadequate informed consent brought during a twenty-four-year period with two malpractice insurers. Relevant malpractice claims were reviewed, and data were abstracted. We then performed statistical analyses to identify factors that positively correlated with a successful defense.

RESULTS

We identified twenty-eight lawsuits that included a claim of inadequate informed consent. All of the cases involved elective orthopaedic surgical procedures; there were no emergent cases. Three cases involved a disputed surgical site; all three cases involved foot and ankle surgery and resulted in an indemnity payment. Documentation of appropriate informed consent in the office notes of the surgeon was associated with a decreased indemnity risk (p < 0.005). Obtaining the informed consent on the hospital ward or in the preoperative holding area was associated with an increased indemnity risk (p < 0.004). When informed consent was obtained in the office by the operating surgeon, the risk of malpractice payment was significantly decreased (p < 0.004).

CONCLUSIONS

Surgeons may be able to decrease the risk of a malpractice claim by obtaining informed consent in their offices, rather than in the preoperative holding area, and by documenting the informed consent discussion within their dictated office or operative notes.

Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma

BACKGROUND

Contemporary understanding of the biomechanics, natural history, and methods of treating thoracolumbar spine injuries continues to evolve. Current classification schemes of these injuries, however, can be either too simplified or overly complex for clinical use.

METHODS

The Spine Trauma Group was given a survey to identify similarities in treatment algorithms for common thoracolumbar injuries, as well as to identify characteristics of injury that played a key role in the decision-making process.

RESULTS

Based on the survey, the Spine Trauma Group has developed a classification system and an injury severity score (thoracolumbar injury classification and severity score, or TLICS), which may facilitate communication between physicians and serve as a guideline for treating these injuries. The classification system is based on the morphology of the injury, integrity of the posterior ligamentous complex, and neurological status of the patient. Points are assigned for each category, and the final total points suggest a possible treatment option.

CONCLUSIONS

The usefulness of this new system will have to be proven in future studies investigating inter- and intraobserver reliability, as well as long-term outcome studies for operative and nonoperative treatment methods.