Session 14: Trauma II

Mette Sørensen Studstrup, Simon Hestbech Lundorff, Lenike Jeppesen, Niels Krarup Jensen, Thomas Jakobsen
Department of Orthopaedic Surgery, Regional Hospital Viborg; Department of Anesthesia abd Ubtebsive Care, Aalborg University Hospital; Department of Orthopaedic Surgery, Regional Hospital Viborg; Department of Orthopaedic Surgery, Regional Hospital Viborg; Department of Orthopaedic Surgery, Aalborg University Hospital


Background: Routinely kirshner wires are left above skin level to facilitate removal once the fracture is sufficiently healed. In children wire removal may be associated with pain and discomfort. The procedure is frequently done in the outpatient clinic without any anesthesia or analgesia.
Purpose / Aim of Study: Prior to implementing topical analgesia as a standard procedure, we wanted to evaluate potential benefits of topical analgesia on pain associated with wire removal. We conducted a study comparing the intensity of pain with or without topical analgesia.
Materials and Methods: The study was conducted as a prospective study with 81 patients included in two consecutive groups. Mean was age 8.5 years (range 4-14). The first 40 patients were allocated to wire removal without analgesia. The following 41 patients underwent removal after topical application of Emla (lidocaine, prilocaine) around the wires one hour prior to the procedure. Pain scores were recorded prior to wire removal/application of Emla and after wire removal using FPS-R (4-12 years) and a numerical scale (1-10) (12-17 years) indicating baseline pain and the maximum level of pain. Data were normally distributed and evaluated using student's t-test.
Findings / Results: We found no statistically significant effect of topical analgesia vs. no topical analgesia. Both groups had similar baseline scores; mean 1.1 vs. 1.2 (p=0.78). Increase in the level of pain was 3.7 vs. 2.9 (p=0.28).
Conclusions: Based on this study, topical analgesia does not provide any positive effect on pain related to wire removal. Besides the expenses related to acquisition, application of Emla prolongs the stay in the outpatient clinic for these young patients and may also cause local side effects. Therefore, topical analgesia with Emla is not warranted as a standard procedure for children undergoing wire removal.

stud med Linea H Lundholm, Bjørn L Madsen, Kim Holck, stud med Lucy H Olsen, Andrew D Ducksworth, Tim O White
OrthopedicSurgery, Hvidovre University Hospital; OrthopedicSurgery, Hvidovre University Hospital; OrthopedicSurgery, Hvidovre University Hospital; OrthopedicSurgery, Edinburgh Royal Infirmary; OrthopedicSurgery, Edinburgh Royal Infirmary; OrthopedicSurgery, Edinburgh Royal Infirmary


Background: The standard treatment for lateral malleolar fractures has for a long period been ORIF with screws and plates. In recent years a new fixation, fibular nail, has been developed for treating the fractures in a less invasive manner. An RCT study in the age group above 65 did show an advantage in the form of significantly fewer wound complications and deep infections.
Purpose / Aim of Study: The purpose of this is to compare the outcomes of fibular nailing vs standard ORIF of ankle fractures in patients under the age of 65.
Materials and Methods: The study was conducted as a multicenter, RCT study including Hvidovre University Hospital and Edinburgh Royal Infirmary. All patients between the age of 18-65 suffering a lateral malleolar fracture were included after oral and written consent, independently of an eventual medial malleolar fracture. All patients were followed for two years. The outcome was evaluated as a combination of radiographic results, PROM and a clinical examination including wound appearance.
Findings / Results: A total of 127 patients were included. Three patients withdrew their consent during the course of the study, two with plate and 1 nail. In terms of wound complications, the groups were similar, though there was a tendency towards more wound pain in the plate group. One severe wound breakdown occurred in the plate group. In the nail group five patients had to be treated with a plate, in four due to narrow fibular canal and one due to comminuted distal fracture.
Conclusions: In young patients fibular nailing is a reliable method of fixation, as the ORIF and nail showed equivalent clinical outcomes. Unlike in the elder age group, the nail did not show any significant advantage in preventing wound complications. The nail is an addition to the armoury in the treatment of ankle fractures.

Morten Tange Kristensen , Buket Öztürk , Niels Dieter Rock, Annette Ingeman, Henrik Palm , Alma Becic Pedersen
Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Departments of Physical Therapy and Orthopedic Surgery, Amager-Hvidovre University Hospital, Copenhagen, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Denmark; Department of Orthopedic Surgery O , Odense University Hospital, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Denmark; Hip Fracture Unit, Department of Orthopedics , Hvidovre University Hospital, Copenhagen, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Denmark


Background: The regain of pre-fracture basic mobility status at acute hospital discharge is considered an important first step for patients recovering from a hip fracture (HF). The Cumulated Ambulation Score (CAS) is a validated measure of basis mobility used in all patients with hip fracture in Denmark and registered in the nationwide Danish Multidisciplinary Hip Fracture Database (DMHFD).
Purpose / Aim of Study: The aim of the study was to examine the association between the regain of pre-fracture basic mobility at the time of acute hospital discharge, and mortality and readmission within 30 days post-discharge in patients with HF.
Materials and Methods: Using the DMHFD we identified 5,554 patients, aged ≥ 65 years admitted with an acute HF from Dec.1, 2015 to Nov. 30, 2016, at all the 25 Danish HF operating hospitals, and with both a pre-fracture and discharge CAS score. Regain of basis mobility was defined as achieving the same or above the total pre-fracture CAS score at discharge.
Findings / Results: Only 37.9% (n=2,107) patients regained their pre-fracture basic mobility level, and with a 30-day mortality of 2.3% (n=48) compared with 7.2% (n=246) of patients who did not regain their pre-fracture basic mobility level (p<0.001). Correspondingly, 14.5% (n=300) and 17.8% (n=599) of patients were readmitted within 30 days of discharge (p<0.001). Crude and adjusted odds ratio for death and readmission will be presented during the DOS Congress.
Conclusions: In this large national HF registry study of 5,554 Danish patients we found that the regain of pre-fracture basic mobility level before acute hospital discharge was strongly related to both 30-day mortality and readmission. This indicates the importance of basic mobility independence as a primary early rehabilitation goal, and that the CAS could be considered as an outcome parameter in other HF registries.

Jesper Stork-Hansen, Rajzan Joanroy, Kristine Bollerup Arndt, Anders Jordy, Bjarke Viberg
Department of Orthopaedic Surgery and Traumatology, Kolding Hospital – part of Hospital Lillebaelt; Department of Orthopaedic Surgery and Traumatology, Vejle Hospital – part of Hospital Lillebaelt; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital – part of Hospital Lillebaelt; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital – part of Hospital Lillebaelt; Department of Orthopaedic Surgery and Traumatology, and Institute for Regional Health Research, Kolding Hospital – part of Hospital Lillebaelt, and University of Southern Denmark


Background: Ankle fractures treated with open reduction internal fixation (ORIF) have a high percentage of wound complications. By reducing the oedema, the wound complications might be lowered.
Purpose / Aim of Study: To investigate the influence of compression stocking (CS) on complications after primary ankle fractures treated with open reduction internal fixation (ORIF).
Materials and Methods: February 1st 2013, CS was introduced as a standard treatment for all patients after surgical treatment with ORIF for ankle fractures for minimum duration of 6 weeks. Data was retrieved from the hospital database 2 years prior and after the introduction date. All health records were reviewed for type of procedure, age, sex, diabetes, smoking, Gustilo-Anderson classification, American Society of Anaesthesiologists (ASA) score, use of tourniquet, suture type, and complications. All x-ray images were classified according to AO- classification.
Findings / Results: 187 patients were included, 74 in the CS group and 113 in the control group. The median (InterQuartile Range – IQR) age was 52.0 (38.8-63.3) years. There were no baseline differences in age, sex, diabetes, smoking, ASA score or open/closed wounds. However, there was a higher percentage in the CS group of tourniquet use (p<0.001), monocryl sutures (p<0.001), and complex fractures (p<0.002). 23.0% had wound healing complications after 6 weeks in the CS group compared to 13.3% in the control group (p<0.001). In total, there were 19.5% complications in the CS group and 33.8% in the control group. The were 2.7% major complications within 1 year in both groups (p<0.765).
Conclusions: There may be bias in the CS group due to higher rate of tourniquet use, monocryl sutures and complex fractures but CS does not seem to lower the wound complications within 6 weeks after surgery.

Nikolaj Erin-Madsen, Bjarke Viberg, Tobias Kvanner Aasvang, Thomas Bloch, Michael Brix, Peter Toft Tengberg
Department of Orthopedic Surgery, Herlev Hospital; Department of Orthopedic Surgery, Kolding Hospital; Department of Orthopedic Surgery, University Hospital of Hvidovre; Department of Orthopedic Surgery, Slagelse Hospital; Department of Orthopedic Surgery, University Hospital of Odense; Department of Orthopedic Surgery, University Hospital of Hvidovre


Background: The treatment of choice for unstable diaphyseal fractures in the tibia is reamed insertion of an intramedullary nail (IMN) with the additional placement of interlocking screws. The most common complication after insertion of an IMN as treatment of tibial shaft fractures is chronic knee pain with reported rates between 10 % and 87 % with a mean of 47,4 % in metaanalyses.
Purpose / Aim of Study: The primary objective of this study is to evaluate the long-term outcome after inserting an IMN in patients with a tibial shaft fracture using an injury-specific questionnaire.
Materials and Methods: This study includes patients operated on five Danish hospitals. A database search was made using operational codes for insertion of an IMN in a five- year period. All patients who had undergone surgery with the insertion of an IMN in the tibia were included. Patients then received a KOOS- questionnaire by mail with questions regarding knee-specific symptoms, stiffness, pain, function and life quality. Questionnaires were filled out and returned to the corresponding physician for further analyze.
Findings / Results: A total of 351 patients were found eligible to enter the study. Questionnaires were sent out and 236 patients responded. 13 did not meet the inclusion criteria and were excluded. 223 (63,5%) patient questionnaires were analyzed. Mean age was 47,9 years at the time of surgery. 63 % were men and 37% women. Follow-up time ranged from 1,7 to 6,7 years. Patients in this study reported worse KOOS- scores than the reference population in all subscales.
Conclusions: With a follow-up time of over 6 years after IMN of tibia shaft fractures, patients experience more knee- specific symptoms, pain, limitations in sports and daily living and the study population reported lower scores of quality of life compared with a reference population.

Kathrine Rasch, Jens-Christian Beuke, Frank Damborg
Ortopædkirurgisk afdeling, Esbjerg; Ortopædkirurgisk afdeling, Aabenraa; ortopædkirurgisk afdeling, Kolding


Background: Previous studies have shown a preponderance of deep infections and lack of healing in the dual plating treatment, compared to lateral plating in tibial plateau fractures.
Purpose / Aim of Study: To compare the number of complications after osteosynthesis of tibial plateau fractures by dual plating vs. isolated lateral plating.
Materials and Methods: We performed a retrospective cohort study of all patients at Kolding hospital that underwent ORIF for proximal tibia fractures by lateral or dual plating during all of 2010 through 2014. Data was collected by electronic journal review including radiology, physiotherapy and final ambulatory appointment. 107 patients were identified. 18 patients were excluded. Of the remaining 89 patients 11 were treated with dual plating. The mean follow-up time was 10.4 months. We compared both major complications (deep infection, insufficient osteosynthesis, Non-union, post-traumatic arthrosis and other serious complications) and minor complications (superficial infection, wound healing problems, discomfort from implanted material and arthroscopy surgery) between the two groups.
Findings / Results: We found no significant differences in the number of minor and major complications between the two groups. We found a high overall complication rate of 45% compared to earlier studies. Excluding the patients re-operated due to discomfort from the implanted material the rate drops to 37%. For major complications alone, the rate is 21.3%. The deep infections rate (n=4) is 4.5% which equals the rate found in other studies.
Conclusions: Operating a tibial plateau fracture with plating comes with a high risk of complications. Deep infections overall are rare. We observed a high rate of overall complications but no differences between the two groups.

Martin Corÿdon Hochheim, Jonas Vestergård Iversen
Medicine, University of Copenhagen; Department of orthopedic surgery, Nordsjællands Hospital, Hillerød


Background: Quadriceps tendon rupture(QTR) is an invalidating injury typically in need of surgical reinsertion. When dealing with ruptures at the tendon-bone junction either transosseous sutures or anchor fixation are the most well described methods for repair.
Purpose / Aim of Study: The aim of this study was to compare these two surgical methods by reviewing the current literature.
Materials and Methods: A systematic search of the literature was performed using MEDLINE, EMBASE and The Cochrane Central Register of Controlled Trials to identify studies using either transosseous sutures or anchor fixation for patients with QTR, with outcome measures being either extension lag, range of motion, re-rupture or Lysholm score.
Findings / Results: 31 studies containing 163 patients were included, and divided in to two groups based on surgical intervention, 10 studies containing 45 patients regarding anchor fixation and 22 studies containing 118 patients regarding transosseous sutures. One study contained both interventions. In the anchor fixation group 3 out of 46 QTRs (6.5%) had an extension lag. No patients had a range of motion <120° postoperatively and no re- ruptures were reported. Average Lysholm score was 91,4. In the transosseous suture group 10 out of 83 QTRs (12.1%) had an extension lag, and 29 out of 95 QTRs (30.5%) had a range of motion <120° postoperatively. 3 re-ruptures out of 145 QTRs (2.1%) were reported. Average Lysholm score was 86.9.
Conclusions: This study may indicate a slight advantage postoperatively regarding extension lag, range of motion, re-ruptures and Lysholm score when operating QTR with suture anchors opposed to transosseous sutures. Given a low patient count, mainly low evidence studies, and a differing amount of patients in the two groups, further studies, preferably randomized controlled studies, must be conducted.

Julie Odgaard Vedel, Sabina Vistrup, Peter Larsen, Rasmus Elsøe
Department of Orthopedic Surgery, Aalborg University Hospital; Department of Orthopedic Surgery, Aalborg University Hospital; Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital; Department of Orthopedic Surgery, Aalborg University Hospital


Background: The literature lacks studies providing long- term patient-reported, functional and radiological outcomes on patients with patella fractures treated with modern treatment modalities.
Purpose / Aim of Study: The primary aim was to investigate the long- term health-related quality of life (HRQOL) in adult patients treated for traumatic patella fractures. The explorative aim was to report the associations between HRQOL and knee osteoarthritis, muscle strength and gait function.
Materials and Methods: The study was designed as a cohort study. All patients treated for patella fractures at Aalborg University Hospital between January 2006 and December 2009 were identified. Patients between 18 and 80 years were considered for inclusion. All fractures were either treated with splinting or open reduction and internal fixation. Data were collected by retrospective chart review and clinical examination of patients. 
 The main outcome measure for HRQOL was the EQ5D-5L index score. The classifications by Sperner and Kellgren/Lawrence were applied to evaluate osteoarthritis. Knee and associated knee problems were evaluated with KOOS. Muscle strength was measured with a dynamometer. Gait was analyzed using a pressure-sensitive mat.
Findings / Results: 49 patients were included with a mean follow-up time of 8.5 years (range 7-10) and a mean age of 53.9 years. The mean EQ5D-5L index value was 0.741 (95% CI 0.675-0.807), being significantly worse compared to an established reference population. Knee osteoarthritis, muscle strength and gait patterns were not associated with HRQOL, except for gait speed, which was found to have a weak positive correlation to HRQOL (P=0.03).
Conclusions: At 8.5 years following a patella fracture, HRQOL was significantly worse compared to an age-matched reference population.

Nissa Khan, Gerhard Tiwald
Ortopædkirurgisk Afdeling, Køge Sygehus ; Akutafdeling , Holbæk Sygehus


Background: To investigate the chance to adopt ultrasonography (US), a non-invasive technique entailing no exposure to ionizing radiation, for diagnosing fractures performed by non-radiologist physicians.
Purpose / Aim of Study: To compare diagnostic accuracy of radiography and US for diagnosis of suspected extremity fractures. An emergency physician received minimal standardised training in the use of US to evaluate fracture suspicion in extremities. Results were compared with routine radiography. The patient was treated according to the latter. The hypothesis was that US is as sensitive and specific as conventional radiography in diagnosing fractures in extremities.
Materials and Methods: The study was conducted over a 3-month period and included 25 patients with a clinical suspicion of an extremity fracture. The inclusion criteria were a clinical trauma history and a suspected extremity fracture on objective examination. The exclusion criteria were fractures not localised in an extremity, hemodynamic instability, open fractures, neurovascular lesions, deformities indicative of fractures and bones containing orthopaedic hardware. The X-rays were analysed by a radiologist while a blinded emergency physician performed the US.
Findings / Results: Prevalence of fractures was 44%. The sensitivity of US in detecting fracture was 63.64% (95% CI: 30.79;89.0) and the specificity was 100% (95% CI: 76.84;100). The positive predictive value of US was 100% and the negative predictive value was 77.78% (95% CI: 61.56;88.44).
Conclusions: US of suspected extremity fractures is useful and accurate to invalid a fracture suspicion but not reliable to diagnose a fracture. However, due to the small study population, more studies are required before US can be recommended as a screening modality. For future studies, a higher level of training of the ER doctors should be considered.

Catarina Malmberg, Peter Toft Tengberg, Ilija Ban, Morten Grove Thomsen, Søren Kring, Mads Terndrup
Department of Orthopaediac Surgery, Copenhagen University Hospital, Hvidovre; Department of Orthopaediac Surgery, Copenhagen University Hospital, Hvidovre; Department of Orthopaediac Surgery, Copenhagen University Hospital, Hvidovre; Department of Orthopaediac Surgery, Copenhagen University Hospital, Hvidovre; Department of Orthopaediac Surgery, Copenhagen University Hospital, Hvidovre; Department of Orthopaediac Surgery, Copenhagen University Hospital, Hvidovre


Background: The posterolateral approach to the distal tibia is reported to be safe, allowing anatomical reduction of posterior malleolar fractures improving outcome
Purpose / Aim of Study: To examine postoperative complications within the first 3 months following posterior fragment fixation using variable angle locking plates (VA-LCP) through the posterolateral approach
Materials and Methods: Adult patients with trimalleolar fractures treated with variable angle plate fixation of the posterior fragment through a posterolateral approach, as dictated by a standardized algorithm in our clinic, were included prospectively from June 2016 to January 2017. Radiological and clinical follow-up was performed in a dedicated ankle fracture out-patient clinic as part of the “PRO-Malleol Algorithm study” (clinicaltrials NCT03107767)
Findings / Results: 42 patients with mean age 55y (range 26-79) were included. Thirty patients had AO/OTA fracture type 44B3, and twelve 44C-type (8C1, 3C2, 1C3). 71% of patients were allowed full weight bearing from day one. Two patients had severe complications, one requiring reoperation due to deep infection and one patient suffered severe pain with suspected complex regional pain syndrome. Two patients had superficial wound infection requiring only oral antibiotics. Five patients had superficial wound problems/minor defects without infection, which were managed with conservative treatment in the out-patient clinic and all healed. There were no cases of thromboembolic events
Conclusions: Complications were seen in 21% of patients, 4.7% having severe complications requiring either reoperation, readmission to hospital or with severe impairment of everyday life 3 months after surgery. We believe that the posterolateral approach is safe and that a severe early complication rate <5% can be tolerated for patients with complex trimalleolar fractures

Mads Terndrup, Ilija Ban, Morten Grove Thomsen , Søren Kring, Peter Toft Tengberg
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre ; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre ; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre


Background: Operative treatment of isolated lateral malleolar fractures is often considered if fracture displacement is >2mm, combined with apparent rotation of the distal fibular fragment
Purpose / Aim of Study: To examine functional outcome after 3 months and need of secondary surgery in a prospective cohort
Materials and Methods: Adult patients with isolated lateral malleolar fractures, without talar shift or observed ankle displacement, were allowed full weight bearing in a walker boot. Patients were reassessed with weight bearing radiographs after 1 week. At follow up (6 and 12 weeks) questionnaires including satisfaction, VAS and Olerud Molander ankle scores (OMAS) were completed. Follow up was set in a dedicated ankle fracture out-patient clinic as part of the "PRO-Malleol algorithm" study
Findings / Results: In 31 of 102 patients treated non-operatively, fractures were displaced >2mm and with apparent rotation of the distal fragment. All 31 patients had AO 44B1/B2.1 type fractures. At 6 weeks all reported to be satisfied, with median VAS score 1.4 and OMAS 43 (fair) [5 – 75]. However, at 3 months 4 patients were not-satisfied, median VAS increased to 1.9 and three patients had persisting pain, no signs of union and later required surgery. Two patients reported decreased sensibility corresponding to the deep peroneal nerve. Median OMAS was 63 (good) [30 – 100] at 3 months. No secondary talar shift or thromboembolic events were observed
Conclusions: 28/31 patients (90.3%) with >2 mm displacement and apparent rotation of the distal fibula were successfully managed non-operatively at 3 months follow up. If long term functional outcome is satisfactory, non-operative treatment should be considered for displaced isolated lateral malleolar fractures, despite a non-union rate of 9,7%, as primary surgical treatment for these patients is also not without risk