Taxonomy and treatment – a classification of fracture classifications

The Copenhagen Classification System for Distal Humeral Fractures is useful to identify patients who may require treatment with hemi- or total elbow arthroplasty

Background

Classification systems are only useful if there is agreement among observers. The purpose of this study is to introduce a simple and clinically applicable classification system - The Copenhagen Classification System for Distal Humeral Fractures (CCDHF) and to compare the interobserver and intraobserver agreement for this classification with the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA), and the Sheffield classification systems. The primary objective of the new classification system is to distinguish fractures that may not be suitable for open reduction and internal fixation, necessitating treatment options such as elbow hemiarthroplasty or total elbow arthroplasty (TEA).

Methods

Five consultant elbow surgeons assessed a consecutive series of 105 sets X-rays of distal humeral fractures on 2 occasions with at least 10 weeks interval. All X-rays were classified according to AO/OTA, Sheffield, and the CCDHF systems. The CCDHF system has been developed collaboratively by a panel of five experienced elbow surgeons. Based on consensus, the surgeons identified specific fracture characteristics where elbow hemiarthroplasty or TEA might be needed.

Results

The mean interobserver agreement was fair for AO/OTA and moderate for Sheffield and the CCDHF. The mean intraobserver agreement was moderate for AO/OTA and substantial for Sheffield and the CCDHF. The observers were uncertain about the classification in 29% of the cases with the AO/OTA classification, 15% with the Sheffield classification, and 12% with CCDHF.

Conclusion

The CCDHF demonstrated validity and clinical applicability and can assist surgeons in identifying fractures that may require hemiarthroplasty or TEA treatment.

Using the Equatorial Talar Line as a Radiographic Predictor of Sanders Type 3 and 4 Calcaneus Fractures and Lateral Wall Blowout

OBJECTIVE

To assess the equatorial talar line (ETL) as a sensitive radiographic parameter to predict Sanders type III and IV fractures and the presence of lateral wall blowout.

METHODS

Reliability of the ETL was assessed using the intraclass correlation coefficient (ICC) and receiver operating curve (ROC) to predict sensitivity. Using lateral ankle radiographs, raters determined whether the calcaneal tuberosity was "above" (predicting Sanders type I or II) or "below" (predicting Sanders type III or IV and lateral wall blowout).

RESULTS

In determining the "above" or "below" location of the ETL, the calculated ICC was 1.0 for each session. As a predictor of Sanders fracture classification type, the calculated ICC was 0.93 for the first session and 0.89 for the second session for an overall ICC of 0.91. As a predictor of Sanders fracture type, ROC analysis yielded an overall sensitivity of 0.82. As a predictor of lateral wall blowout, ROC analysis yielded an overall sensitivity of 0.81.

CONCLUSION

The ETL is a reproducible radiographic parameter that can be reliably used to crudely predict between Sanders type I or II (ETL is "above") and Sanders type III or IV (ETL is "below") calcaneus fractures as well as the presence of lateral wall blowout.

ASSESSMENT OF INTEROBSERVER RELIABILITY FOR THE LETOURNEL AND JUDET CLASSIFICATION

Introduction

The Judet and Letournel classification is the most widely used classification system for acetabular fractures. Some complex fractures couldn't be classified according to this classification. The main purpose of this study was to evaluate the reliability of the Letournel and Judet classification system for acetabular fractures.

Material and methods

10 acetabular fractures were analyzed among 17 orthopedic surgeons. The surgeons were asked to classify the fractures according to the Judet and Letournel classification. Their experience, the number of surgeries, and the incision type that the surgeon uses for the anterior part of the acetabulum were recorded.

Results

The overall interobserver agreement for the Letournel classification was found to be poor, with a Kappa value of 0.287. The Kappa value for interobserver agreement was 0.224 for plain radiographs, 0.293 for 2D-CT, and 0.321 for 3D-CT scans. There was no significant difference between the incision types used by the surgeons. The highest reliability was determined among the surgeons who operate on 10-20 acetabular fractures per year, with a Kappa value of 0.309.

Conclusion

This results revealed that the Judet and Letournel Judet classification is not sufficient to classify acetabular fractures because of unclassified fractures and the complex algorithm of the system. Level of Evidence III; Comparative Retrospective Study.

CT-Based Classification Systems for Intra-Articular Calcaneal Fractures: The Inter- and Intraobserver Variations as well as Integrality

The aim of this study was to measure the inter- and intraobserver variations as well as integrality of the Zwipp, Crosby-Fitzgibbons, Sanders, and Eastwood-Atkins classification systems based on more accurate CT scans. Five hundred and forty-nine patients with intra-articular calcaneal fractures from January 2018 to December 2019 taken from a database in our level-I trauma center (3 affiliated hospitals) were included. For each case, normative CT (1 mm slices) scans were available. Four different observers reviewed all CT scans 2 times according to these 4 most prevalent fracture classification systems (FCSs) within a 2-month interval. For these 4 FCSs, the kappa [κ] coefficient was used to evaluate interobserver reliability and intraobserver reproducibility, and the percentage that can be classified was used to indicate integrality. The κ values were measured for Zwipp (κ = 0.38 interobserver, κ = 0.61 intraobserver), Crosby-Fitzgibbons (κ = 0.48 interobserver, κ = 0.79 intraobserver), Sanders (κ = 0.40 interobserver, κ = 0.57 intraobserver), and Eastwood-Atkins (κ = 0.44 interobserver, κ = 0.72 intraobserver). Furthermore, the integralities were calculated for Zwipp (100%), Crosby-Fitzgibbons (100%), Sanders (92%) as well as Eastwood-Atkins (89.6%). Compared with previous literatures, CT scanning with higher accuracy can significantly improve intraobserver reproducibility of Zwipp and Eastwood-Atkins FCSs, but it has no positive effect on variability of Sanders FCS and interobserver reliability of Crosby-Fitzgibbons FCS. In terms of integrality, Zwipp and Crosby-Fitzgibbons FCSs appear to be superior to the other 2 FCSs.

The Evolution of Olecranon Fractures and Its Fixation Strategies

INTRODUCTION

Olecranon fractures are a common fracture of the upper extremity. The primary aim was to investigate the evolution of olecranon fractures and fixation method over a period of 12 years. The secondary aim was to compare complication rates of Tension Band Wiring (TBW) and Plate Fixation (PF).

MATERIALS AND METHODS

Retrospective Study for all patients with surgically treated olecranon fractures from 1 January 2005 to 31 December 2016 from a tertiary trauma center. Records review for demographic, injury characteristics, radiographic classification and configuration, implant choices and complications. Results grouped into three 4-year intervals, analyzed comparatively to establish significant trends over 12 years.

RESULTS

262 patients were identified. Demographically, increasing mean age (48.7 to 58.9 years old, p value 0.004) and higher ASA scores (7.1% ASA 3 to 21.0% ASA 3 p value 0.001). Later fractures were more oblique (fracture angle 86.1-100.0 degrees, p value 0.001) and comminuted (Schatzker D type 10.4-30.0%, p value 0.025, single fracture line 94.0-66.0%, p value 0.001). Implant choice, sharp increase in PF compared to TBW (PF 16.0% to PF 80.2%, p value 0.001). Complication-wise, TBW had higher rates of symptomatic implant, implant and bony failures and implant removal.

CONCLUSION

Demographic and fracture characteristic trends suggest that olecranon fractures are exhibiting fragility fracture characteristics (older age, higher ASA scores, more unstable, oblique and comminuted olecranon fractures). Having a high index of suspicion would alert surgeons to consider use of advanced imaging, utilize appropriate fixation techniques and manage the underlying osteoporosis for secondary fracture prevention. Despite this, trends suggest a potential overutilization of PF particularly for stable fracture patterns and the necessary precaution should be exercised.

Fractures around Trochanteric Nails: The "Vergilius Classification System"

INTRODUCTION

The fractures that occurred around trochanteric nails (perinail fractures, PNFs) are becoming a huge challenge for the orthopaedic surgeon. Although presenting some specific critical issues (i.e., patients' outcomes and treatment strategies), these fractures are commonly described within peri-implant ones and their treatment was based on periprosthetic fracture recommendations. The knowledge gap about PNFs leads us to convene a research group with the aim to propose a specific classification system to guide the orthopaedic surgeon in the management of these fractures.

MATERIALS AND METHODS

A steering committee, identified by two Italian associations of orthopaedic surgeons, conducted a comprehensive literature review on PNFs to identify the unmet needs about this topic. Subsequently, a panel of experts was involved in a consensus meeting proposing a specific classification system and formulated treatment statements for PNFs. Results and Discussion. The research group considered four PNF main characteristics for the classification proposal: (1) fracture localization, (2) fracture morphology, (3) fracture fragmentation, and (3) healing status of the previous fracture. An alphanumeric code was included to identify each characteristic, allowing to describe up to 54 categories of PNFs, using a 3- to 4-digit code. The proposal of the consensus-based classification reporting the most relevant aspects for PNF treatment might be a useful tool to guide the orthopaedic surgeon in the appropriate management of these fractures.

Fixation of the Various Coronal Plane Fracture Fragments, Including the Entire Coronoid Process, in Patients with Mayo Type IIB Olecranon Fractures - Four Methods for Fixation

BACKGROUND

We introduce several methods for fixation of unique Mayo type II olecranon fractures with the coronal plane fragment (CPF) including the entire coronoid process and report the radiological and clinical results through a case series.

MATERIALS AND METHODS

12 patients were operated using this method with a mean age of 44 years. CPFs were fixed with concurrent fixation by a locking plate screw for the olecranon in three patients (method 1), cerclage wiring in six patients (method 2), a mini plate in two patients (method 3), and a double-locking plate (method 4) in one patient. We accessed the fragment through an additional medial coronoid approach after identifying the olecranon fragment through a dorsal approach (methods 1-3). In method 4, the CPF was fixed through a dorsal approach between the comminuted metaphyseal fragments.

RESULTS

With the exception of one patient with delayed union, all patients had achieved union at 3-month followup. The mean flexion extension arc was 125°. The mean pronation/supination was 72.5°/71.7° (range, 60-80°/60-80°). The mean visual analog scale score for elbow pain was 0.92 (range, 0-2), and the mean Mayo Elbow Performance Score was 86.7 (range, 80-90). The mean Disabilities of the Arm, Shoulder, and Hand score was 10.2 (range, 4-14). There were no major complications.

CONCLUSION

A thorough preoperative understanding of the fragment patterns and preparation of tools for adequate reduction and fixation are necessary for satisfactory clinical and radiological outcomes. However, further comparative trials of conservative management versus surgery for CPF fixation, and any differences in outcomes according to the CPF fixation options, are required.

Management of Proximal Interphalangeal Joint Fracture Dislocations

Fracture dislocations of the proximal interphalangeal (PIP) joint of the finger are often caused by axial load applied to a flexed joint. The most common injury pattern is a dorsal fracture dislocation with a volar lip fracture of the middle phalanx. Damage to the soft-tissue stabilizers of the PIP joint contributes to the deformity seen with these fracture patterns. Unfortunately, these injuries are commonly written off and left untreated. A late-presenting PIP joint fracture dislocation has a poor chance of regaining normal range of motion. The provider must be suspicious of these injuries. Treatment options and algorithm are reviewed.

Management of type IIB and IIIB olecranon fractures. Case series

•

Management of type IIB and IIIB olecranon fractures.

•

Report and evaluate the functional outcome of plate fixation.

•

Oxford elbow score.

•

Rotational range of movement and flexion arc.

Objectives

to report and evaluate the functional outcome of plate fixation in comminuted olecranon fractures (Mayo types IIB and IIIB).

Method

23 consecutive patients with comminuted fractures of the olecranon presenting to our unit Between Feb 2011 and Jan 2015, at a mean follow-up of thirty-six months. Main outcome measurements include radiographic healing, post-operative range of motion, complications, outcome score and patient satisfaction.

Results

Our study included thirteen females and ten males with a mean age of 55(18–97). Fourteen were Mayo type IIB and nine were Mayo type IIIB. Eighteen patients had no complications post-operatively with good outcome with mean oxford score of 45, full rotational ROM and mean flexion arc of 20–130 °. Five patients had range of motion between 40–90 ° with full rotational ROM and mean oxford score of 24. Two patients out of five required metal work removal. No non-unions were noted in our series.

Conclusion

Plate fixation of complex olecranon fracture is an effective, reliable method of treatment with low risk of non-union. Restoration of a functional flexion arc of movement can be expected with application of correct technique.

Association of Body Mass Index With the Pattern of Surgically Treated Ankle Fractures Using Two Different Classification Systems

The present retrospective cohort study assessed the association of body mass index (BMI) with the pattern of ankle fractures using 2 classifications systems. Of the 1011 consecutive patients who underwent surgery for ankle fractures in 2 hospitals from January 2009 to December 2011, 837 had a classifiable fracture according to 1 of 2 classification systems and complete information available for covariates. The association of BMI, adjusted for age, sex, corticosteroid use, diabetes, and smoking status with having a more proximal fibula fracture (Weber class A to C) and an increasing number of malleoli involved (uni-, bi-, or trimalleolar) was assessed using multivariable ordered logistic regression analysis. The mean age of the patients was 50.9 ± 16.9 years, and 461 (55%) were female. On multivariable analysis, BMI and male sex were associated with having a more proximal fibula fracture using the Weber classification, with an odds ratio (OR) of 1.07 (95% confidence interval [CI] 1.04 to 1.11; p < .001) per 1 kg/m² increase and OR of 2.96 (95% CI 2.13 to 4.11; p < .001) compared with female sex, respectively. Age was not associated with this fracture classification. In an analysis of uni-, bi-, and trimalleolar fractures, age per 10 years showed higher odds (OR 1.24, 95% CI 1.14 to 1.36; p < .001) and male sex lower odds compared with female sex (OR 0.36, 95% CI 0.27 to 0.48; p < .001) of having trimalleolar fractures than uni- or bimalleolar fractures. An increasing BMI did not seem to be a risk factor, although an inverse U-shaped relationship was seen between quintiles of BMI and the OR of having trimalleolar versus uni- or bimalleolar fractures. Corticosteroid use, diabetes, and smoking status were not significantly associated with the pattern of the ankle fractures using either classification system. In conclusion, an increasing BMI and male sex were risk factors for proximal fibula fractures, and female sex and age were risk factors for bi- and trimalleolar fractures.

The reliability and reproducibility of the Hertel classification for comminuted proximal humeral fractures compared with the Neer classification

INTRODUCTION

The Neer classification is the most commonly used fracture classification system for proximal humeral fractures. Inter- and intra-observer agreement is limited, especially for comminuted fractures. A possibly more straightforward and reliable classification system is the Hertel classification. The aim of this study was to compare the inter- and intra-observer variability of the Hertel with the Neer classification in comminuted proximal humeral fractures.

MATERIALS AND METHODS

Four observers evaluated blinded radiographic images (X-rays, CT-scans, and CT-scans with 3D-reconstructions) of 60 patients. After at least two months classification was repeated.

RESULTS

Inter-observer agreement on plain X-rays was fair for both Hertel (κ = 0.39; 95% CI 0.23-0.62) and Neer (κ = 0.29; 0.09-0.42). Inter-observer agreement on CT-scans was substantial (κ = 0.63; 0.56-0.72) for Hertel and moderate for Neer (κ = 0.51; 0.29-0.68). Inter-observer agreement on 3D-reconstructions was moderate for both Hertel (κ = 0.60; 0.53-0.72) and Neer (κ = 0.51; 0.39-0.58). Intra-observer agreement on plain X-rays was fair for both Hertel (κ = 0.38; 0.27-0.59) and Neer (κ = 0.40; 0.15-0.52). Intra-observer agreement on CT-scans was moderate for both Hertel (κ = 0.50; 0.38-0.66) and Neer (κ = 0.42; 0.35-0.52). Intra-observer agreement on 3D-reconstructions was moderate for Hertel (κ = 0.55; 0.45-0.64) and substantial for Neer (κ = 0.63; 0.48-0.79).

CONCLUSIONS

The Hertel and Neer classifications showed a fair to substantial inter- and intra-observer agreement on the three diagnostic modalities used. Although inter-observer agreement was highest for Hertel classification on CT-scans, Neer classification had the highest intra-observer agreement on 3D-reconstructions. Data of this study do not confirm superiority of either classification system for the classification of comminuted proximal humeral fractures.

Is it time to revisit the AO classification of fractures of the distal radius? Inter- and intra-observer reliability of the AO classification

We conducted an observational radiographic study to determine the inter- and intra-observer reliability of the AO classification of fractures of the distal radius. Plain posteroanterior and lateral radiographs of 456 patients with an acute fracture of the distal radius were classified by a consultant orthopaedic hand specialist and two specialist trainees, and the k coefficient for the inter- and intra-observer reliability of the type, group and subgroup classification was calculated. Only the type of fracture (A, B or C) was found to provide substantial intra-observer reliability (k type 0.65). The inclusion of 'group' and 'subgroup' into the classification reduced the inter-observer reliability to fair (kgroup 0.29, ksubgroup = 0.28) and the intra-observer reliability to moderate (kgroup 0.53, ksubgroup 0.49). Disagreement was found to arise between specific subgroups, which may be amenable to clarification.

Fixation of posterior process fractures of the olecranon using a modified suture bridge technique: report of 2 cases

We encountered 2 patients with posterior process fractures of the olecranon and fixed the fragment using a modified suture bridge method without a metallic implant. The suture anchor was inserted distally through the fracture plane, and the small tip of proximal olecranon was reduced to the ulna. Computed tomography revealed bony union 4 and 5 months later. At the 1-year postoperative follow-up examination, the clinical outcomes were satisfactory in both patients. This suture bridge technique was reliable for small fragment fixation in posterior process fracture of the olecranon based on the tension band theory with no problems induced by metallic hardware.

Novel classification system of rib fractures observed in infants

Rib fractures are considered highly suspicious for nonaccidental injury in the pediatric clinical literature; however, a rib fracture classification system has not been developed. As an aid and impetus for rib fracture research, we developed a concise schema for classifying rib fracture types and fracture location that is applicable to infants. The system defined four fracture types (sternal end, buckle, transverse, and oblique) and four regions of the rib (posterior, posterolateral, anterolateral, and anterior). It was applied to all rib fractures observed during 85 consecutive infant autopsies. Rib fractures were found in 24 (28%) of the cases. A total of 158 rib fractures were identified. The proposed schema was adequate to classify 153 (97%) of the observed fractures. The results indicate that the classification system is sufficiently robust to classify rib fractures typically observed in infants and should be used by researchers investigating infant rib fractures.

New classification system for long-bone fractures supplementing the AO/OTA classification

This article describes a novel, clinically oriented classification system for long-bone fractures that is simple, reliable, and useful to predict treatment method, complications, and outcome. The reliability and memorability of the new classification were statistically tested and compared with the AO-Müller/Orthopaedic Trauma Association (AO/OTA) long-bone fracture classification. The proposed classification system was also clinically validated with a targeted pilot study designed for content and clinical outcome retrospectively reviewing 122 closed tibial shaft fractures, which were used as a representative paradigm of long-bone fractures. Statistical evaluation showed that the proposed classification system had improved inter- and intraobserver variation agreement and easier memorability compared with the AO/OTA classification system. The clinical validation study showed its predictive value regarding selection of treatment method, complication rate, and injury outcome.The proposed classification system proved simple, reliable, and memorable. Its clinical value appeared strong enough to justify the organization of larger studies for a complete assessment of its clinical usefulness for all long-bone fractures.

Anterior approach for posteromedial tibial plateau fractures

Fractures of the posteromedial tibial plateau are rare and their treatment is not well established. Between January 2004 and December 2008, eight patients with fractures of the posteromedial tibia plateau were identified. All patients were treated with fracture reduction using an anterior approach. After a mean follow-up of 21 months, the average range of knee motion was 0-123 degrees of flexion. Seven patients had been injured in motor-scooter accidents, in which the protective front plate of the scooter had hit the knee while it was in the 90 degrees -flexion position. At the final follow-up, 87.5% (7/8) patients had satisfactory reductions of the articular surface, and all patients had acceptable alignments. There were no neural or vascular injuries following surgery, and no superficial or deep infections. The average Hospital for Special Surgery Knee Score was 89. In conclusion, fracture reduction using the anterior approach is associated with fewer complications than the posterior approach, and good functional recovery can be expected.

Calcaneal fracture classification: a comparative study

Comparing different types of calcaneal fractures, associated treatment options, and outcome data is currently hampered by the lack of consensus regarding fracture classification. A systematic search for articles dealing with calcaneal fracture was performed, and the prevalence of use of each classification system determined. Twelve observers classified 30 intra-articular calcaneal fractures according to the 3 most prevalent classification systems; interobserver reliability (kappa [kappa] statistic) and the correlation of the system with the choice of treatment and clinical outcomes were calculated. Forty-nine conventional and 15 computerized tomographic scan classification systems were identified. The most prevalent systems were the Essex-Lopresti, Zwipp, Crosby, and Sanders classifications; and none of these showed a direct correlation with treatment, although each of these systems showed positive correlations with outcome. Moderate interobserver agreement and variability were found for the Crosby and Sanders classifications (overall kappa = 0.48), whereas interobserver reliability among radiologists was poor for the Essex-Lopresti classification (overall kappa = 0.26). Four classifications systems showed positive correlations with outcome, but no correlation with choice of treatment. The Sanders and Crosby classifications displayed comparable, moderate interobserver variability among surgeons and radiologists, and both of these systems are likely to be useful for classification of intra-articular calcaneal fractures.

LEVEL OF CLINICAL EVIDENCE

5.

Milch's classification of paediatric lateral condylar mass fractures: analysis of inter- and intraobserver reliability and comparison with operative findings

This study aimed to test the usefulness and validity of two versions commonly quoted in the literature of the Milch classification of paediatric supracondylar mass fractures. Anteroposterior and lateral elbow radiographs of 10 consecutive acute paediatric lateral condylar mass fractures requiring open surgical reconstruction were presented to six observers in order to assess inter- and intraobserver reliability of both versions. Accuracy of classification was compared with intraoperative findings. Observers agreed with the operative findings in only 50% of cases. There was poor interobserver (kappa<0.2) and moderate intraobserver agreement (kappa<0.6) for both versions. Thus Milch's classification was not found to be a useful tool.

A clinically applicable fracture classification for distal humeral fractures

The purpose of this study was to design a clinically applicable classification for distal humeral fractures that would provide guidance to the surgeon with regard to surgical approach and operative management. The new classification was assessed by use of the original radiographs from a study comparing distal humeral fracture classifications undertaken in Oxford, England, and was validated by use of the exact methodology of that study. Nine independent assessors were asked to classify 33 sets of radiographs on 2 separate occasions using the classifications of Riseborough and Radin, Mehne and Jupiter, and the AO, as well as the new classification system. With the use of the kappa statistic, the level of interobserver and intraobserver agreement was determined. The new classification system was found to be both substantially reliable (kappa, 0.664) and reproducible (kappa, 0.732). The new classification achieved superior interobserver and intraobserver agreement compared with the other 3 classification systems, with a low proportion of unclassifiable fractures. Used in conjunction with a management algorithm, we believe that the new classification aids the surgical decision-making process for these complex fractures.

A concept for the validation of fracture classifications

The fracture classification systems currently used most frequently were not developed or validated by rigorous scientific evaluation methods. This paper discusses the classification of fractures from an epidemiological and clinical decision-making perspective and proposes a standardized methodological concept for their development and scientific validation. Classification categories are clinically relevant entities that surgeons should be able to use for diagnosis with sufficient confidence to limit misclassification and associated treatment errors. The process of validation should assess the value of specific clinical information (eg, the use of radiographs or computed tomography scans) in increasing the probability of a correct diagnosis. A 3-phase validation concept is proposed where: 1) classification categories are defined and the classification process using specific diagnostic images is evaluated by experts in a series of agreement studies (reliability, accuracy, likelihood ratios); 2) a multicenter agreement study is conducted among a representative group of future users of the classification; and 3) the classification proposal is applied in the context of a prospective clinical study to assess its clinical usefulness.

Treatment of Complex Subtrochanteric Fracture with the Long Gamma AP Locking Nail: A Prospective Evaluation of 64 Cases

BACKGROUND

Complex subtrochanteric fractures are uncommon injuries and challenging to manage. We elucidate the role of the Long Gamma AP Locking Nail (LGAPN) in the management of such fractures in the acute stage.

METHODS

Between 1992 and 2002, 64 consecutive cases with nonpathologic complex subtrochanteric fractures managed with the LGAPN were enrolled in this study. Associated injuries were present in 16 cases. The average follow-up period was 68 months.

RESULTS

Mean time to union was 14 weeks. There were two complications (one wound infection and one delayed union). The time to union and functional results were not statistically different between different ages (below 50 years old, or older than 50 years) and the number of distal locking screws used (one or two). Longer time to union is noted in patients with a longer operation time and a more comminuted fracture pattern by the AO classification.

CONCLUSION

Closed reduction and internal fixation with the LGAPN were proven to be safe and effective in the treatment of complex traumatic subtrochanteric fractures in all age groups, and one distal locking screw is sufficient for distal fixation.

Gunshot femoral shaft fractures: is the current classification system reliable?

The reliability of the AO/Orthopaedic Trauma Association classification system has not been evaluated for diaphyseal fractures or fractures attributable to gunshot injuries. Therefore, the current authors assessed its reliability for diaphyseal femur fractures and investigated the effect of a gunshot mechanism of injury. Forty-seven diaphyseal femur fractures, 23 caused by gunshots and 24 caused by blunt trauma, were classified by four observers on two occasions. The interobserver and intraobserver reliability of each level of the AO/Orthopaedic Trauma Association classification was assessed with kappa statistics. Determination of fracture type had substantial interobserver and intraobserver reliability for gunshot and blunt injuries. Reliability decreased at the subsequent levels of the classification. Fractures caused by gunshots compared with those caused by blunt trauma were characterized by significantly lower interobserver agreement on fracture group (k = 0.26 versus 0.45) and subgroup (k = 0.21 versus 0.38). The AO/Orthopaedic Trauma Association classification system has substantial interobserver and intraobserver reliability when evaluating the type of diaphyseal femur fractures. Determination of fracture group and subgroup, however, progressively reduces the reliability of the classification, especially for fractures caused by a gunshot. Diaphyseal femur fractures caused by gunshots, by means of their fracture patterns, cannot be classified reliably with the AO/Orthopaedic Trauma Association classification system.

Population based epidemiologic and morphologic study of femoral shaft fractures

The epidemiologic and morphologic features of all femoral shaft fractures in skeletally mature patients treated during a 10-year period in a semi-urban county were analyzed. Among an average adult population of 202,592 residents, 192 people sustained 201 traumatic femoral shaft fractures during the study period. The incidence was 9.9 fractures per 100,000 person-years. The highest age and gender specific incidences were seen in males from 15 to 24 years of age and in females 75 years of age or older. Seventy-five percent (151) of the fractures were the result of a high-energy trauma, 131 of which occurred in road traffic accidents. Unexpectedly, there were 50 low-energy fractures. Fractures of the middle 1/3 of the diaphysis were 79%. The majority, 155 (77%), of all fractures were transverse, oblique, or oblique transverse. Regarding the degree of comminution, the Winquist and Hansen Grade 0 (noncomminuted) fracture was the most common. Forty-eight percent of fractures were AO Type A, 39% were Type B, and 13% were Type C fractures. Of the 25 open fractures, 14 were Gustilo Type II. All six Type III open injuries were Type IIIA. Based on the data from the current study, most of the femoral fractures in this community might be treated adequately with conventional intramedullary nails, rather than using interlocking nails, provided the stability of fixation and fracture alignment can be maintained. Preventive measures against femoral shaft fractures should focus on protection of automobile drivers, especially young men, and on effective treatment of osteoporosis in elderly women.

Assessment and management of three-and four-part proximal humeral fractures

Three-and four-part comminuted fractures of the proximal humerus are difficult and technically demanding to treat. The various treatment methods reported in the literature are reviewed. It is recommended that three-part fractures be treated with open reduction and internal fixation. Four-part fractures in the younger, active patient also can be treated successfully with open reduction and internal fixation. However, in the elderly and in the patient with osteoporosis, a hemiarthroplasty is the treatment of choice. There is a need for universal agreement on a scoring system for measuring outcome in these fractures to allow a meaningful comparison between reported treatment methods.