Proximale Humerusmehrfragmentfrakturen--Misserfolge nach T-Platten-Osteosynthesen [Proximal humeral multiple fragment fractures--failures after T-plate osteosynthesis].

Dislocated compound fractures of the proximal humerus are often difficult to treat. The choice of treatment influences the final functional result. From 1984-1991 108 patients with dislocated compound fractures of the proximal humerus were operated with a T-plate osteosynthesis, retrospectively examined and classified according to the Neer-Classification. At an average follow up time of 5 years 72 patients had a clinical and radiological examination. 68% of these patients with 3-fragment fractures and 80% with 4-fragment fractures showed a modest to unsatisfactory result caused by fracture biology, imprecise fracture reduction or poor surgical procedure. Incorrect position of T-plates and inadequate material were distinguishable. The T-plate which was widely used in the late eighties for internal fixation has to be considered a failure for these particular types of fractures and should be limited for Collum chirurgicum fractures.

Prospective evaluation of risk of vertebral fractures using quantitative ultrasound measurements and bone mineral density in a population-based sample of postmenopausal women: results of the Basel Osteoporosis Study.

OBJECTIVE: Prospective studies have shown that quantitative ultrasound (QUS) techniques predict the risk of fracture of the proximal femur with similar standardised risk ratios to dual-energy x-ray absorptiometry (DXA). Few studies have investigated these devices for the prediction of vertebral fractures. The Basel Osteoporosis Study (BOS) is a population-based prospective study to assess the performance of QUS devices and DXA in predicting incident vertebral fractures. METHODS: 432 women aged 60-80 years were followed-up for 3 years. Incident vertebral fractures were assessed radiologically. Bone measurements using DXA (spine and hip) and QUS measurements (calcaneus and proximal phalanges) were performed. Measurements were assessed for their value in predicting incident vertebral fractures using logistic regression. RESULTS: QUS measurements at the calcaneus and DXA measurements discriminated between women with and without incident vertebral fracture, (20% height reduction). The relative risks (RRs) for vertebral fracture, adjusted for age, were 2.3 for the Stiffness Index (SI) and 2.8 for the Quantitative Ultrasound Index (QUI) at the calcaneus and 2.0 for bone mineral density at the lumbar spine. The predictive value (AUC (95% CI)) of QUS measurements at the calcaneus remained highly significant (0.70 for SI, 0.72 for the QUI, and 0.67 for DXA at the lumbar spine) even after adjustment for other confounding variables. CONCLUSIONS: QUS of the calcaneus and bone mineral density measurements were shown to be significant predictors of incident vertebral fracture. The RRs for QUS measurements at the calcaneus are of similar magnitude as for DXA measurements.

Documentation of fracture severity with the AO classification of pediatric long-bone fractures.

BACKGROUND: The AO comprehensive pediatric longbone fracture classification system describes the localization and morphology of fractures, and considers severity in 3 categories: (1) simple, (2) wedge, and (3) complex. We evaluated the reliability and accuracy of surgeons in using this rating system. MATERIAL AND METHODS: In a first validation phase, 5 experienced pediatric (orthopedic) surgeons reviewed radiographs of 267 prospectively collected pediatric fractures (agreement study A). In a second study (B), 70 surgeons of various levels of experience in 15 clinics classified 275 fractures via internet. Simple fractures comprised about 90%, 99% and 100% of diaphyseal (D), metaphyseal (M), and epiphyseal (E) fractures, respectively. RESULTS: Kappa coefficients for severity coding in D fractures were 0.82 and 0.51 in studies A and B, respectively. The median accuracy of surgeons in classifying simple fractures was above 97% in both studies but was lower, 85% (46-100), for wedge or complex D fractures. INTERPRETATION: While reliability and accuracy estimates were satisfactory as a whole, the ratings of some individual surgeons were inadequate. Our findings suggest that the classification of fracture severity in children should be done in only two categories that distinguish between simple and wedge/complex fractures.

Le traitement des fractures du fémur de l'enfant par enclouage centromédullaire élastique stable (E.C.M.E.S.)

RÉSUMÉ La prise en charge des fractures de l'enfant a beaucoup évolué au cours des quinze dernières années. Les spécificités pédiatriques des mécanismes de réparation osseuse rendaient nécessaires des modalités de traitement se différenciant de l'ostéosynthèse adulte classique qui suivait les principes de réduction anatomique et de stabilité. Chez l'enfant le traitement conservateur des fractures reste le moyen le plus fréquemment employé. Cependant, ce traitement s'avérait imparfait dans le cas de la fracture fémorale car il impliquait une hospitalisation prolongée. Ceci a mené à réaliser des ostéosynthèses classiques et trop invasives chez des patients pédiatriques, entraînant des hyperallongements parfois importants. C'est ainsi que de nouvelles techniques adaptées à l'enfant sont apparues, tels que l'enclouage centro-médullaire élastique stable (ECMES) et le fixateur externe dynamisable (FED). Nous rapportons ici l'expérience du Service de Chirurgie Pédiatrique du CHUV à Lausanne. Entre 1988 et 1996, nous avons recensé 265 cas de fractures fémorales chez des enfants âgés entre 0 et 15 ans : 227 sont diaphysaires, 23 épiphysaires, 8 cervicales, 7 per- ou sous-trochantériennes. Parmi celles-ci, 94 fractures diaphysaires, 11 épiphysaires, 4 trochantériennes et toutes les cervicales ont bénéficié d'un traitement chirurgical. Nous avons étudié rétrospectivement 96 fractures traitées par ECMES, ce qui représente le traitement chirurgical standard de la fracture diaphysaire fémorale dans notre service. La majorité de ces fractures est liée aux accidents de la route (41%) ou au ski (27%). Le collectif comprend 7 enfants polytraumatisés, 3 fractures du membre inférieur controlatéral, 1 fracture du tibia homolatéral et une fracture instable du bassin. Après ECMES, la mobilisation débute généralement entre le troisième et le douzième jour postopératoire selon l'âge de l'enfant, le type de fracture et surtout les lésions associées. La durée moyenne d'hospitalisation est de 12 jours. Le suivi moyen est de 16 à 21 mois selon la catégorie d'âge, le type de fracture et la compliance du patient et des parents. Dans les suites, nous avons pu observer que l'hyperallongement du membre concerné affecte plus souvent les patients les plus jeunes (3-5 ans) tandis que les raccourcissements du membre fracturé concernent les enfants plus âgés (12-15 ans). La complication la plus fréquemment rencontrée est la migration des broches dont la fréquence varie entre 8% et 25% selon l'âge. Un total de 11% tout âge confondu nécessite un traitement ou une reprise. Chez les enfants de moins de 8 ans, avec migration de broches, la moitié des cas nécessite d'une reprise, tandis que le montage est repris dans tous les cas de plus de 8 ans. L'ECMES offre l'avantage d'une technique simple, peu invasive, peu coûteuse, qui utilise les capacités de guérison spécifique de l'enfant. Il permet des séjours hospitaliers courts et favorise une bonne consolidation respectant la biologie de guérison et autorisant une reprise précoce de l'activité physique. Les complications sont peu nombreuses et les résultats orthopédiques, comparables à ceux du traitement conservateur.

Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women.

BACKGROUND: Frailty, as defined by the index derived from the Cardiovascular Health Study (CHS index), predicts risk of adverse outcomes in older adults. Use of this index, however, is impractical in clinical practice. METHODS: We conducted a prospective cohort study in 6701 women 69 years or older to compare the predictive validity of a simple frailty index with the components of weight loss, inability to rise from a chair 5 times without using arms, and reduced energy level (Study of Osteoporotic Fractures [SOF index]) with that of the CHS index with the components of unintentional weight loss, poor grip strength, reduced energy level, slow walking speed, and low level of physical activity. Women were classified as robust, of intermediate status, or frail using each index. Falls were reported every 4 months for 1 year. Disability (> or =1 new impairment in performing instrumental activities of daily living) was ascertained at 4(1/2) years, and fractures and deaths were ascertained during 9 years of follow-up. Area under the curve (AUC) statistics from receiver operating characteristic curve analysis and -2 log likelihood statistics were compared for models containing the CHS index vs the SOF index. RESULTS: Increasing evidence of frailty as defined by either the CHS index or the SOF index was similarly associated with an increased risk of adverse outcomes. Frail women had a higher age-adjusted risk of recurrent falls (odds ratio, 2.4), disability (odds ratio, 2.2-2.8), nonspine fracture (hazard ratio, 1.4-1.5), hip fracture (hazard ratio, 1.7-1.8), and death (hazard ratio, 2.4-2.7) (P < .001 for all models). The AUC comparisons revealed no differences between models with the CHS index vs the SOF index in discriminating falls (AUC = 0.61 for both models; P = .66), disability (AUC = 0.64; P = .23), nonspine fracture (AUC = 0.55; P = .80), hip fracture (AUC = 0.63; P = .64), or death (AUC = 0.72; P = .10). Results were similar when -2 log likelihood statistics were compared. CONCLUSION: The simple SOF index predicts risk of falls, disability, fracture, and death as well as the more complex CHS index and may provide a useful definition of frailty to identify older women at risk of adverse health outcomes in clinical practice.

Long gamma nail in the treatment of subtrochanteric fractures.

INTRODUCTION: The purpose of our study was to retrospectively evaluate the clinical and radiological results of subtrochanteric fractures treated with a long gamma nail (LGN). The LGN has been the implant of choice at our level-1 trauma center since 1992. MATERIALS AND METHODS: Over a period of 7 years, we have treated 90 consecutive patients with subtrochanteric fractures. In order to evaluate the clinical and radiological outcomes, we reviewed the clinical and radiographic charts of these patients followed for a mean time of 2 years (range 13-36 months). RESULTS: We found no intra- or perioperative complications nor early or late infection. Clinical and radiological union was achieved at a mean of 4.3 months in all of the patients (range 3-9 months); in 24 cases (30%) the distal locking bolts were retrieved in order to enhance callus formation and remodeling as a planned secondary surgery. Three patients (3.3%) needed unplanned secondary surgery for problems related to the nailing technique. Two mechanical failures with breakage of the nail were encountered due to proximal varus malalignment, of which one was treated with exchange nailing and grafting and the other one by removal of the broken hardware, blade-plating, and bone grafting. One fracture below a short LGN was treated by exchange nailing. CONCLUSIONS: The minimally invasive technique and simple application of the LGN lead to a low percentage of complications in these difficult fractures after a relatively short learning curve. The biomechanical properties of this implant allow early mobilization and partial weight-bearing even in patients with advanced osteoporosis.

The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women.

SUMMARY: BMD and clinical risk factors predict hip and other osteoporotic fractures. The combination of clinical risk factors and BMD provide higher specificity and sensitivity than either alone. INTRODUCTION AND HYPOTHESES: To develop a risk assessment tool based on clinical risk factors (CRFs) with and without BMD. METHODS: Nine population-based studies were studied in which BMD and CRFs were documented at baseline. Poisson regression models were developed for hip fracture and other osteoporotic fractures, with and without hip BMD. Fracture risk was expressed as gradient of risk (GR, risk ratio/SD change in risk score). RESULTS: CRFs alone predicted hip fracture with a GR of 2.1/SD at the age of 50 years and decreased with age. The use of BMD alone provided a higher GR (3.7/SD), and was improved further with the combined use of CRFs and BMD (4.2/SD). For other osteoporotic fractures, the GRs were lower than for hip fracture. The GR with CRFs alone was 1.4/SD at the age of 50 years, similar to that provided by BMD (GR = 1.4/SD) and was not markedly increased by the combination (GR = 1.4/SD). The performance characteristics of clinical risk factors with and without BMD were validated in eleven independent population-based cohorts. CONCLUSIONS: The models developed provide the basis for the integrated use of validated clinical risk factors in men and women to aid in fracture risk prediction.

La cohorte OstéoLaus: évaluation des outils de routine clinique pour la prédiction de la fracture ostéoporotique [OsteoLaus: prediction of osteoporotic fractures by clinical risk factors and DXA, IVA and TBS].

OsteoLaus is a cohort of 1400 women 50 to 80 years living in Lausanne, Switzerland. Clinical risk factors for osteoporosis, bone ultrasound of the heel, lumbar spine and hip bone mineral density (BMD), assessment of vertebral fracture by DXA, and microarchitecture evaluation by TBS (Trabecular Bone Score) will be recorded. TBS is a new parameter obtained after a re-analysis of a DXA exam. TBS is correlated with parameters of microarchitecture. His reproducibility is good. TBS give an added diagnostic value to BMD, and predict osteoporotic fracture (partially) independently to BMD. The position of TBS in clinical routine in complement to BMD and clinical risk factors will be evaluated in the OsteoLaus cohort.

Calcification des grandes artères et risque de fracture ostéoporotique [Aortic calcification and the risk of osteoporotic fractures].

Osteoporosis and atherosclerosis seem to be epidemiologically correlated. Several medical conditions are risk factors for both osteoporosis and atheromatosis (i.e. age, diabetes, end stage renal disease, sedentarity, smoking), but a common pathogenic link may be present beyond this. The burden of cardiovascular events and of osteoporotic fracture is considerable for the health care system in term of costs and resources. However, both diseases are rarely managed together. This article is a review of the recent studies in this new field.

Is amoxicillin/clavulanic acid sufficient for preemptive antibiotic therapy in type III grade open fractures ?

The risk of infection after type III° open fractures is high (10-50%).Preemptive antibiotic therapy may prevent posttraumatic infection andimprove the outcome. Recommendations about the type and durationof antibiotic vary among the institutions and it remains unclear whethergram-negative bacilli or anaerobs need to be covered. In Europe, themost commonly recommended antibiotic is amoxicillin/clavulanic acid.We retrospectively analyzed microbiology, characteristics and outcomeof patients with open type III° fractures treated at our institution.Methods: Between 01/2005 and 12/2009 we retrospectively includedall type III grade open fractures of the leg at our institution classifiedafter Gustilo into type IIIA, IIIB and IIIC. Demographic characteristics,clinical presentation, microbiology, surgical and antibiotic treatmentand patient outcome were recorded using a standardized case-reportform.Results: 30 cases of patients with type III° open fractures wereincluded (25 males, mean age was 40.5 years, range 17-67 years).27 fractures (90%) were located on the lower leg and 3 (10%) on theupper leg. Microbiology at initial surgery was available for 19 cases(63%), of which 10 grew at least one organism (including 8 amoxicillin/clavulanic acid-resistant gram-negative bacilli [GNB], 7 amoxicillin/clavulanic acid-resistant Bacillus cereus), 11 were culture-negative.Preemptive antibiotics were given in all cases (100%) for an averageduration of 8.5 days (range 1-53 days), the most common antibioticwas amoxicillin/clavulanic acid in 60% (n = 18). 11 cases just receivedpreemptive antibiotic treatment, in 19 of 30 cases the antibiotic therapywas changed and prolonged. Microbiology at revision surgery wasavailable for 25 cases and 22 grew at least one pathogen (including32 amoxicillin/clavulanic acid-resistant gram-negative bacilli and 10amoxicillin/clavulanic acid-resistant Bacillus cereus), 3 were culturenegative.Conclusions: At initial surgery, most common isolated organismswere coagulase-negative staphylococci (43%), Bacillus cereus (23%),and gram-negative bacilli (27%), and others (7%) of which 48% wereresistant to amoxicillin/clavulanic acid. At revision surgery, isolatedorganisms were gram-negative bacilli (64%), Bacillus cereus (20%),and others (16%) of which 88% were resistant to amoxicillin/clavulanicacid. The spectrum of amoxicillin/clavulanic does not cover the mostcommon isolated organisms.FM32

Sexual dimorphism of the human mandible: demonstration by elliptical Fourier analysis.

A new quantitative approach of the mandibular sexual dimorphism, based on computer-aided image analysis and elliptical Fourier analysis of the mandibular outline in lateral view is presented. This method was applied to a series of 117 dentulous mandibles from 69 male and 48 female individuals native of Rhenish countries. Statistical discriminant analysis of the elliptical Fourier harmonics allowed the demonstration of a significant sexual dimorphism in 97.1% of males and 91.7% of females, i.e. in a higher proportion than in previous studies using classical metrical approaches. This original method opens interesting perspectives for increasing the accuracy of sex identification in current anthropological practice and in forensic procedures.

Dorsal fractures of the triquetrum: MRI findings with an emphasis on dorsal carpal ligament injuries.

OBJECTIVE: The objective of our study was to report the MRI findings in dorsal fractures of the triquetrum, with an emphasis on dorsal carpal ligament injuries. MATERIALS AND METHODS: A total of 21 patients (16 men, five women; mean age, 41.9 years) with acute or subacute (≤ 6 weeks) dorsal triquetral fractures on radiography and MRI were included in this two-center retrospective study. MRI of the wrist was performed on 3-T units with transverse T1-weighted, coronal or transverse (or both) fat-suppressed T2weighted, transverse gadolinium-enhanced fat-suppressed T1-weighted turbo spin-echo, and 3D gadolinium-enhanced fat-suppressed T1-weighted gradient-recalled echo sequences. Three musculoskeletal radiologists evaluated the ulnar styloid process index (USPI) on radiographs and the following MRI features: fracture pattern (types 1-6), bone fragment size and displacement, bone marrow edema distribution, and dorsal carpal ligament tears. RESULTS: Eight type 1, one type 2, six type 3, five type 4, and one type 5 fractures were identified. These fractures were associated with 14 (66.7%), 17 (81.0%), and 16 (76.2%) tears of the dorsal radiocarpal, ulnotriquetral, and intercarpal ligaments, respectively. There was no correlation between bone marrow edema distribution and dorsal carpal ligament injuries (all p > 0.05). The mean (± SD) bone fragment volume and displacement were 205 ± 157 mm(3) and 1.0 ± 1.1 mm, respectively. The mean USPI was 0.21 ± 0.10. CONCLUSION: Dorsal fractures of the triquetrum are frequently associated with dorsal carpal ligament injuries. Bone marrow edema distribution is not correlated with these ligament tears.