Session 3: Trauma I

That Minh Pham , Lonnie Froberg, Lars-Henrik Frich , Søren Overgaard, Hagen Schmal
Orthopedic department, Odense University Hospital ; Orthopedic department, Odense University Hospital ; Orthopedic department, Odense University Hospital ; Orthopedic department, Odense University Hospital ; Orthopedic department, Odense University Hospital


Background: Elevation of synovial cytokines following intra-articular ankle fracture may play an important role in cartilage degeneration leading to osteoarthritis development. Therefore in addiction to fracture reduction, it would be ideal to prevent inflammatory response. However little is known about the composition of the synovial environment and how it correlates to clinical outcomes. may play an important role in cartilage degeneration leading to osteoarthritis development. Therefore in addiction to fracture reduction, it would be ideal to prevent inflammatory response. However little is known about the composition of the synovial environment and how it correlates to clinical outcomes.
Purpose / Aim of Study: 1) Are there differentially regulated c cytokines in ankles with and without a f fracture? 2) Do the identified cytokines correlate with short-term clinical o outcomes?
Materials and Methods: In a prospective cohort study between October 2017 and June 2019 synovial fluid (SF) from bilateral ankle joints and serum were collected from 47 patients with ankle fractures undergoing open reduction and internal fixation in Odense University Hospital. For this preliminary report (n=39/47), the patients (n=39) were followed for 3 months and evaluated using the Foot Function Index (FFI) and the AOFAS. The serum and SF were analyzed for bFGF bFGF, IL-1b, IL-6 and IL-8. Furthermore, the fractures were classified according to AO.
Findings / Results: Typical inflammatory parameters such as IL-1â, IL-6, and IL-8 were found in normal joints with concentrations just above detection level but were highly upregulated in ankles with a fracture. Basic fibroblast growth factor (bFGF), a chondrogenic metabolite, was constitutively expressed, but statistically significant upregulated in ankle joints with a fracture. FFI and AOFAS strongly correlated with age; however, there was no association with either of the initially measured cytokines. The time periods between occurrence of fracture and collection of effusion did not show a statistically significant correlation. .
Conclusions: Elevation of synovial cytokines following intra-articular ankle fracture is characterized by the expression of inflammatory proteins within the first 12 days, however, an association with the short-term follow-up after 3 months could not be found. Further clinical follow-up may be needed to demonstrate a relationship between elevations of synovial cytokines to osteoarthritis development.

Ingunn Lode, Vegard Nordviste, Julie Ladeby Erichsen, Hagen Schmal, Bjarke Viberg
Orthopaedic Surgery and Traumatology, Kolding Hospital; Orthopaedic Surgery and Traumatology, Kolding Hospital; Orthopaedic Surgery and Traumatology, Kolding Hospital; Orthopaedic Surgery and Traumatology, Odense University Hospital; Orthopaedic Surgery and Traumatology, Kolding Hospital


Background: Nonoperative treatment is commonly considered as the gold standard in Denmark for humeral shaft fractures but advantages in certain aspects have been described using operative stabilization.
Purpose / Aim of Study: To conduct a systematic review and meta-analysis to compare operative and nonoperative treatment in adult patients with humeral shaft fractures.
Materials and Methods: A search string was developed using a PICO- model in cooperation with a scientific librarian and was applied to Medline, Embase, Cochrane, and Cinahl on 1st of October 2018 searching for randomized controlled trials (RCT) and cohort studies. Two reviewers screened 8,071 eligible studies using Covidence followed by systematic data extraction. The primary outcome was defined as post-treatment complications concerning nonunion, nerve damage, major reintervention, and infections. The secondary outcomes were functional scores and patient reported outcome measures (PROM). The quality of included studies was assessed using Cochrane tools.
Findings / Results: Twelve studies were included; 1 RCT, 1 prospective cohort and 10 retrospective cohorts with totally 1406 patients, of which 835 were treated operatively and 571 nonoperatively. Mean age ranged from 35 to 64, and 54% of the patients were male. The cohort studies had in general moderate bias while the RCT had low bias. There were statistically significant fewer nonunions in the operative group (8%) compared with the nonoperative group (17%) yielding a Risk Ratio (RR) of 0.5 (0.4-0.7) and a number needed to treat of 12. There were more deep infections (3%) in the operative group than in the nonoperative group (1%) yielding a RR of 2.8 (1.0-7.5) but otherwise no statistical differences concerning malunion or nerve damage. Only one study included PROM data with no differences between treatments.
Conclusions: There were fewer nonunions in the operative group but more deep infections. Due to the lack of studies reporting PROMs, the potential positive effect of operative therapy in early aftercare could not be evaluated. Therefore, PROMs should be mandatory in future comparative studies.

Casper Gronbek, Stig Brorson, Rasmus Nielsen, Peter Soendergaard, Jens Peter Alva-Joergensen, Peter Max Halschou-Jensen
Department of Orthopedic Surgery, Herlev University Hospital, Copenhagen, Denmark ; Department of Orthopedic Surgery, Zealand University Hospital, Denmark; Department of Orthopedic Surgery, Herlev University Hospital, Copenhagen, Denmark ; Department of Orthopedic Surgery, Herlev University Hospital, Copenhagen, Denmark ; Department of Orthopedic Surgery, Herlev University Hospital, Copenhagen, Denmark ; Department of Orthopedic Surgery, Herlev University Hospital, Copenhagen, Denmark


Background: The incidence of hip fractures increases with age and predominantly occurs in a group of patients often suffering from various comorbidities. Hemiarthroplasty is the most used surgical procedure following displaced femoral neck fractures. In Denmark, approximately 90% of hemiarthroplasties are inserted using a posterior approach (PA), and about 8-10 % using an anterolateral approach (AL).
Purpose / Aim of Study: To compare the short-term dislocation rate, revision surgery, fall-related hospital contacts and death between AL and PA in a consecutive cohort treated with hemiarthroplasty.
Materials and Methods: Chart data was retrospectively collected for a consecutive series of hip fracture patients undergoing hemiarthroplasty between June 1st, 2017 and May 31st, 2018 at Herlev University Hospital, Copenhagen, Denmark. We registered gender, age and ASA-score at the time of surgery. Data on dislocation, revision surgery, death and fall- related hospital contacts were recorded. The two populations were compared using an unpaired t-test while gender distribution was compared using the chi-square test. 182 patients with hemiarthroplasties were identified, 139 were operated using PA and 43 using AL. The follow-up period was one year for all patients. The choice of surgical approach was based on the individual surgeon’s preference.
Findings / Results: In the PA group 37 dislocations appeared in 10.1% (14 of 139 patients) compared to zero patients in the AL group (p=0.03). The two groups differed in age with the AL group having a mean age of 82.6 and the PA group of 85.1 (p=0.04). We found a statistically significant difference in fall-related hospital visits with fewer contacts in the AL group compared to the PA group (p=0.47), but no significant difference in the amount of injuries requiring hospitalization (p=0.23). There was no statistically significant difference between the two groups in ASA-score (p=0.8), gender (p=0.64), revision surgery (p=0.56) or mortality (p=0.84).
Conclusions: Postoperative dislocation is a common complication after hemiarthroplasty for displaced femoral neck fractures. In our series, using AL reduced this risk without influencing short-term risk for revision surgery, death or fall-related hospitalizations.

Christian Grundtvig Refstrup Rasmussen, Søren Benfeldt Jørgensen, Peter Larsen, Rasmus Elsøe
Ortopækirurgisk, Aalborg Universitetshospital; Ortopædkirurgisk, Aalborg Universitetshospital; Fysioterapien, Aalborg Universitetshospital; Ortopædkirurgisk, Aalborg Universitetshospital


Background: Fractures of the foot are some of the most common fractures. Resent literature concerning the epidemiologi of foot fractures are scares and there is a lack of coherent data, including distribution of fractures, trauma mechanism and classification.
Purpose / Aim of Study: The aim of the study was to provide up- to-date concerning the incidence of foot fractures in a large and complete population including all age groups spanning 6 years, and report the distribution of fractures, trauma mechanism and patient baseline demographics.
Materials and Methods: Population based epidemiological study including all foot fractures in a 6 year period from 2005 to 2010 in North Region of Denmark. All patient charts and radiology were manually assessed. The average population of North Region of Denmark was 578.000 persons.
Findings / Results: 4,938 patients presenting with 5,912 foot fractures were assessed. The mean age was 36.1 years at time of fracture (female 41.3 years, male 31.3 years). The overall incidence was 142.3/100,000/year (female 130.2/100,000/year, male 185.1/100,000/year). The most common fracture types were fracture of the 5th metatarsal and 1st digit with an incidence of 49.5/100,000/year and 37.6/100,000/year, respectively. Both genders had the highest incidence in the age group 10-19 years (female 201.4/100,000/year, male 296.9/100,000/year). The most common trauma mechanism was low- energy trauma representing 99.2% of all fractures. The predominant mode of injury was distortion, (18.4%) followed by sport, (16.6%).
Conclusions: The incidence of foot fractures was 142.3/100,000/year. The most common fracture types were fracture of the 5th metatarsal and 1st digit with an incidence of 49.5/100,000/year and 37.6/100,000/year, respectively. The predominant mode of injury was distortion (16.6%).

Mads Terndrup, Ilija Ban, Søren Kring, Morten Thomsen, Anders Troelsen, Peter Tengberg
Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital


Background: Operative treatment of isolated lateral malleolar fractures is often considered if fracture displacement is >2mm. However, acute open reduction and internal fixation (ORIF) of this common injury is not without risk
Purpose / Aim of Study: To examine patient reported outcome (PROM) and the need of secondary ORIF in a prospective cohort of adult patients with displaced (>2mm) isolated lateral malleolar fractures
Materials and Methods: The protocol was registered on clinicaltrials.gov (NCT03107767). Adult patients with isolated lateral malleolar fractures were reassessed with weight bearing radiographs 7-10 days after injury. Follow-up was set at 6, 12 and 52 weeks including weightbearing radiographs. At all follow-ups patients reported: pain on weightbearing; satisfaction and Ollerud Molander ankle scores (OMAS). At 52 weeks, patients additionally completed Short Form (SF- 36) Health scores
Findings / Results: 102 of 166 included patients (61%) had fracture displacement (FxDisp) ≥ 2mm, with mean FxDisp of 2,8 mm (CI [2,7- 3,0], Range (2-6mm)). 93% had transsyndesmotic AO44B1 type fractures and 7% suprasyndesmotic AO44C1/2 types, without posterior malleolar involvement. Five patients (4,9%) required secondary ORIF, of which four progressed to union without complication. One patient with FxDisp of 2,1mm suffered non-union with very poor outcome after secondary ORIF. One additional patient required subtalar arthrodesis 1y after injury. Six patients reported substantial persisting pain at 9- 12 months, but progressed to a satisfactory result without surgery. 90 patients completed PROM at 6 weeks, 88% completed PROM at 12 weeks and 66% completed PROM at 52 weeks. Mean 12 week OMAS score was 70 and mean 52 week OMAS score was 89 (Good). SF36 PhysicalFunction score at 52 weeks was 90. The five patients requiring surgery were not included in the total PROM score analysis. 12 patients withdrew consent at 6 week follow-up
Conclusions: Non-operative treatment should be considered safe for displaced isolated lateral malleolar fractures, despite a secondary ORIF rate of 4,9% and delayed-union rate of 5,9%. Functional patient reported outcome was satisfactory in 90% of patients and primary surgical treatment for this common injury is not without risk

Jonas Adjal, Anne Marie Nyholm
Hvidovre Ortopædkirurgisk afd. 333, Hvidovre Hospital; Hvidovre Ortopædkirurgisk afd. 333, Hvidovre Hospital


Background: Background Symptomatic post-traumatic osteoarthrosis of the ankle (PTOA) can be treated with ankle joint fusion (AJF) or arthroplasty (AP). The prevalence of PTOA is currently unknown.
Purpose / Aim of Study: Objectives To estimate the prevalence of secondary surgery (AJF, AP) following surgery for a malleolar fracture.
Materials and Methods: Design and Methods 4195 lower leg fractures (ICD10: DS82.1- 8)) treated with the surgery code KNGJ in a Danish hospital be-tween 01.01.2000- 31.12.2009 were collected from the Civil registrational system. Data included age, gender and any diagnosis of osteoarthrosis (OA) prior to fracture. The fractures were sub-grouped according to fracture diagnosis. Surgeries for proximal tibia or shaft fractures (1636) were excluded. Data on later AJF, AP and amputations at any time until 04.12.2017 was likewise collected.
Findings / Results: Results 2559 patients with a follow up of 7-17 years were included. 959 (37,5%) were female and 1600 (62,5%) male with a mean age of 43. Six sub-groups were analyzed: Bi-or tri malleolar or multiple fractures of the leg or knee (BTM): 1565. Bimalleolar fractures (B): 62. Isolated fibular shaft fractures (F): 246. Isolated frac-tures of the lateral malleolus (L): 297. Isolated fractures of the medial malleolus (M): 72. Unspecified frac-tures in the malleolar region (U): 317. 105 (4.1%) patients underwent secondary surgery: 44 (1.7%) were amputated, 11 (0.4%) had an AP and 50 (2%) had an AJF. 47 (77%) of the AP’s and AJF’s were performed within five years from osteosynthesis. 79 of the 105 surgeries (75%) were performed on patients with a bi- or trimalleolar fracture. Only 11 (1.8%) of 615 uni malleolar fractures underwent AP’s or AJF’s. 4 cases had been diagnosed with OA prior to osteosynthesis. The prevalence of ankle joint surgery secondary to malleolar fracture in patients without OA prior to malleo-lar fracture was 2.33%. The prevalence of AP’s and AJF’s for patients with no former OA in the B/BMT sub-groups was 2.9%.
Conclusions: Conclusions The prevalence of AP’s and AJF’s was 2.4%. Most of these operations occurred within the first 5 years. Fur-thermore, the severity of the ankle fracture seems to further increase the risk of these secondary surgeries.

Henrik Sjølander, Per Hviid Gundtoft, Sune Jauffred, Michael Brix
Orthopedic, Odense Universitetshospital; Orthopedic, Odense Universitetshospital; Orthopedic, Sjællands Universitetshospital, Køge; Orthopedic, Odense Universitetshospital


Background: The standard postoperative regimen for surgically treated fractures of the distal forearm consists of clinical- and x-ray follow-up 2-weeks postoperatively. It is unclear whether the x-ray at time of follow-up has any consequences for the treatment of these patients.
Purpose / Aim of Study: To study whether x-ray at 2 weeks follow-up has any therapeutic consequence for the patients, especially whether these x-ray controls results in any re- operations.
Materials and Methods: This retrospective cohort study was performed at Zealand University Hospital, Køge during 2011 and Odense University Hospital during 2019. We reviewed the medical record and pre-operative, post-operative and follow-up x-rays of patients with a fracture of the distal forearm treated with a volar locking compression plate. Standard aftercare at both departments is 2 weeks in a cast, which is replaced by a removable orthosis for an additional 3 weeks. The cast is replaced at a 2 weeks follow-up visit in the outpatient clinic where x-ray is performed. It was recorded whether the x-ray follow-up resulted in any change of treatment in terms of re-operation, extension of immobilization, additional diagnostic imaging or additional clinical follow-up.
Findings / Results: A total of 525 medical records were screened of which 502 were included in the study. The 2 weeks clinical and x-ray follow-up resulted in a change of the postoperative plan for 11 (2.2%) patients: 3 patients (0.6%) were re-operated (of which one was a patient who did not follow the postoperative regime), for 3 (0.6%) patients the immobilization in a cast was extended. Additional diagnostics imaging was performed for 12 (2.4%) patients, but beside the 6 (1.2%) patients who were re-operated or were immobilized for an extended period of time; this additional diagnostic imaging did not result in a change of the postoperative plan.
Conclusions: The x-ray control at 2 weeks follow-up only resulted in a change of the postoperative plan in 1.2% of the cases. As many other surgically treated fractures are treated without follow-up x-ray it seems fair to conclude that routinely performed 2 weeks follow-up x-ray of surgically treated distal forearm fractures are unnecessary.

Dennis Karimi, Cecilie Mølgaard, Søren Kring, Peter Toft Tengberg
Orthopedic Surgery, Copenhagen Univsersity Hosptal Hvidovre; Orthopedic Surgery, Copenhagen Univsersity Hosptal Hvidovre; Orthopedic Surgery, Copenhagen Univsersity Hosptal Hvidovre; Orthopedic Surgery, Copenhagen Univsersity Hosptal Hvidovre


Background: Humeral shaft fractures are traditionally treated conservatively with a functional prefabricated brace. Historical studies of this method have shown excellent results with high union rates. More recent studies have shown a different story with reported nonunion rates as high as 39%. In our experience, most patients with humeral fractures achieve union with conservative treatment. Some of these patients might have benefitted from surgical treatment as this could have shortened their time to union considerably
Purpose / Aim of Study: To examine the rate of union and time to union of conservative treatment vs surgical treatment of humeral shaft fractures
Materials and Methods: In this retrospective single-center study, all adult patients (≥18 years) treated for a humeral shaft fracture at our facility from 2016 through 2018 were enrolled. Baseline data and radiographs were collected. All radiographs were reviewed for union, fracture location and fracture pattern by AO- classification. Union was defined as callus bridge in at least one radiograph between the two main fragments and no pain. Nonunion was defined as transfer to secondary surgery or the lack of union past one year. Nerve injury was recorded prior to and after treatment
Findings / Results: A total of 117 humeral shaft fractures were treated. Twenty-one patients (18%) were excluded due to loss to follow-up. Of the 96 patients included: 59 were female, mean age was 60 years (SD±18.3) and 73 were treated conservatively. A total of 17 patients went on to nonunion from the conservative treatment, giving an overall union rate of 77% for the conservative treatment. Of the 17 nonunions, 16 were treated with secondary osteosynthesis, one was treated with lifelong bracing. All patients who underwent primary surgery achieved union. Time to union in the conservatively treated group was 81 days (95%CI=62.2-93.4, SD±44.3) without the nonunions vs. 76 days (95%CI=56.1-95.8, SD±45.9) in the surgically treated group (p=0.6). Iatrogenic nerve injury occurred in one patient after surgical treatment and no patients had deep infection
Conclusions: Difference in time to union was not statistically significant between the two treatment modalities, but 23% of the conservatively treated group went on to nonunion

Liv Vesterby, Ilija Ban, Morten Grove Thomsen, Peter Toft Tengberg
Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark


Background: Circular external fixation (CEF) is widely used for both reconstruction and trauma. Many different types of frame constructions are used in trauma making comparison difficult. A standardised stepwise technique for treatment of tibial fractures with an all fine wire CEF have recently been published.
Purpose / Aim of Study: To evaluate the clinical and radiological outcome of a consecutive series of patients with acute tibial fractures treated with an all fine wire CEF applied with a standardised stepwise method.
Materials and Methods: The stepwise CEF method was introduced in August 2017. Basic demographic data, fracture union (evaluated by the RUST score) and complications (all secondary operations, malalignment and infections) were evaluated based on a retrospective inquiry of both patient files and radiographs.
Findings / Results: 25 patients were identified. Median age was 56.9 years [IQR 44.5-69.3], 15 of 25 were males, 1 of 25 had diabetes mellitus and the median ASA- score was 2 [IQR 1-3]. The fractures were divided according to the AO classification (AO 41 A-C (n=4), AO 42 A-C (n=6) and AO 43 A-C (n=15). In 12 of 25 the fracture was classified as open. The standardised step-wise method was applied in all but 1 case. Median operating time was 87 minutes [IQR 72-108]. Median time from frame application to removal was 16.9 weeks [IQR 15.9-19.2]. At time of frame removal the median RUST score was 8 [IQR 7-9]. Union was achieved in all but 1 patient. This single nonunion patient was co-morbid with severe atherosclerosis and amputation was discussed initially. After removal of the CEF he developed deep infection and was above knee amputated. 2 patients had secondary surgery due to complications (pin tract infection not responding to antibiotics (n=1) and malalignment of fracture (n=1)). 1 patient had secondary fracture displacement but did not want to undergo secondary surgery. 15 patients had minor pin tract infection all treated successfully with antibiotics.
Conclusions: The stepwise CEF method is effective and reproducible resulting in relative short operation times, anatomic alignment, high union rate and few major complications. Pin tract infection is still seen in most cases but can be treated successfully with oral antibiotics.

Line Wickstrøm, Julie Erichsen, Rasmus Bendtson, Anders Jordy, Bjarke Viberg
Ortopædkirurgisk afdeling , Kolding SLB; Ortopædkirurgisk afdeling, Kolding SLB; Ortopædkirurgisk afdeling , Kolding SLB; Ortopædkirurgsik afdeling, Kolding SLB; Ortopædkirurgisk afdeling, Kolding SLB


Background: Traditional surgical approach to tibia shaft fractures is through an infrapatellar approach. This method can displace the fracture and tends to make the radiographic imaging during the operation difficult. To avoid the disadvantages of the infrapatellar approach, a suprapatellar technique has been used in recent years.
Purpose / Aim of Study: To compare the operation time, perioperative dose area product (DAP - absorbed x-ray dose multiplied by the area irradiated) and complication frequency in the supra- versus the infrapatellar approach in adult patients with tibia shaft fractures surgical treated with intramedullary nailing.
Materials and Methods: From January 1st 2015 to February 28th 2019 a retrospective cohort was retrieved using the local hospital database. Patients with a tibia shaft fracture, operated with a tibia nail using either a supra- or infrapatellar approach, were included. Data on age, sex, ASA score, fracture classification, operation time, DAP, surgical approach and complications leading to a second operation, were collected by reviewing the patients’ health care files and x-ray images.
Findings / Results: 100 patients were included, 31 with suprapatellar approach and 69 with infrapatellar. The mean age was 49 (SD; 9) with no statistical differences in age, sex, ASA score or fracture classification between groups. There were 16% (5/31) complications in the suprapatellar approach due to screw removal. No other complications were reported. There were 36% (25/69) complications in the infrapatellar approach, 26% (18/69) due to screw removal, 6% (4/69) due to deep infection, 3% (2/69) experienced a malunion, and 1% (1/69) had a nonunion. This leaded to a statistical difference in complications between the two groups (p<0.042). Perioperative DAP was mean 3.12 gycm2 (SD; 5.5) for the suprapatellar and mean 3.38 gycm2 (SD; 8.9) for the infrapatellar approach (p=0.3), operation time was 97 minutes (SD; 0.3) for the suprapatellar and 111 minutes (SD; 0.4) for the infrapatellar approach (p=0.3).
Conclusions: This study indicates the suprapatellar approach for intramedullary nailing of tibia shaft fractures to be superior to the infrapatellar approach.