Aims Flail chest from a blunt injury to the thorax is associated with
significant morbidity and mortality. Its management globally is
predominantly non-operative; however, there are an increasing number
of centres which undertake surgical stabilisation. The aim of this
meta-analysis was to compare the efficacy of this approach with
that of non-operative management. Patients and Methods A systematic search of the literature was carried out to identify
randomised controlled trials (RCTs) which compared the clinical
outcome of patients with a traumatic flail chest treated by surgical
stabilisation of any kind with that of non-operative management. Results Of 1273 papers identified, three RCTs reported the results of
123 patients with a flail chest. Surgical stabilisation was associated
with a two thirds reduction in the incidence of pneumonia when compared
with non-operative management (risk ratio 0.36, 95% confidence interval
(CI) 0.15 to 0.85, p = 0.02). The duration of mechanical ventilation
(mean difference -6.30 days, 95% CI -12.16 to -0.43, p = 0.04) and
length of stay in an intensive care unit (mean difference -6.46
days, 95% CI 9.73 to -3.19, p = 0.0001) were significantly shorter in
the operative group, as was the overall length of stay in hospital
(mean difference -11.39, 95% CI -12.39 to -10.38, p Conclusion Surgical stabilisation for a traumatic flail chest is associated
with significant clinical benefits in this meta-analysis of three
relatively small RCTs. Cite this article: Bone Joint J 2016;98-B:1119–25.

Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials.

Peripheral Neuropathies Associated with Total Hip Arthroplasty

Intact abductors of the hip play a crucial role in preventing limping and are known to be damaged through the direct lateral approach. The extent of trauma to the abductors after revision total hip replacement (THR) is unknown. The aim of this prospective study was to compare the pre- and post-operative status of the gluteus medius muscle after revision THR. We prospectively compared changes in the muscle and limping in 30 patients who were awaiting aseptic revision THR and 15 patients undergoing primary THR. The direct lateral approach as described by Hardinge was used for all patients. MRI scans of the gluteus medius and functional analyses were recorded pre-operatively and six months post-operatively. The overall mean fatty degeneration of the gluteus medius increased from 35.8% (1.1 to 98.8) pre-operatively to 41% (1.5 to 99.8) after multiple revision THRs (p = 0.03). There was a similar pattern after primary THR, but with considerably less muscle damage (p = 0.001), indicating progressive muscle damage. Despite an increased incidence of a positive Trendelenburg sign following revision surgery (p = 0.03) there was no relationship between the cumulative fatty degeneration in the gluteus medius and a positive Trendelenburg sign (p = 0.26). The changes associated with other surgical approaches to the hip warrant investigation.

Significant muscle damage after multiple revision total hip replacements through the direct lateral approach

Background:Traumatic brachial plexus injuries (BPIs) disproportionately affect young, able-bodied individuals. Beyond direct costs associated with medical treatment, there are far-reaching indirect costs related to disability and lost productivity. Our objective was to estimate per-patient indirect

/pdf/indirect-cost-of-traumatic-brachial-plexus-injuries-in-the-5bgcnw756y.pdf

Indirect cost of traumatic brachial plexus injuries in the United States

OBJECTIVES Recent evidence to suggest that fixation of clavicle fractures yields better outcomes than conservative treatments has led to an increasing trend toward operative management. There is no evidence, however, to compare early fixation with delayed fixation for symptomatic patients before union. DESIGN Prospective comparative case series. SETTING Level 1 regional trauma center. PATIENTS Displaced clavicle fractures treated operatively in our institution during a 4-year period. Ninety-seven patients were included: 68 with early fixation and 29 delayed. Radiographic and clinical outcomes were available for all patients and scores were available for 62. INTERVENTION Early plate fixation (within 3 weeks) of displaced clavicle fractures compared with delayed (3-12 weeks) fixation of displaced clavicle fractures. OUTCOMES Radiographic union, Oxford Shoulder Score, QuickDASH, EQ5D, and a patient interview. Mean follow-up was to 30 months. RESULTS There were no statistically significant differences in age (P > 0.05), sex (P > 0.05), and energy of injury (P > 0.05) between the 2 groups. The mean QuickDASH was 8.9 early and 9.1 delayed (P < 0.05) and the Oxford Shoulder Score was 44.2 early and 43.9 delayed (P < 0.05). In the early fixation group, there were 5 wound healing complications, and 8 went on subsequently to have removal of prominent metalwork. In the delayed fixation group, 2 had wound healing complications and 4 required removal of prominent metalwork. There were no statistically significant differences in the EQ5D scores. CONCLUSION Our series supports delayed fixation of symptomatic clavicle fractures as results do not differ from early fixation. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Early versus delayed operative intervention in displaced clavicle fractures.

The purpose of this study was to establish whether exploration and neurolysis is an effective method of treating neuropathic pain in patients with a sciatic nerve palsy after total hip replacement (THR). A total of 56 patients who had undergone this surgery at our hospital between September 1999 and September 2010 were retrospectively identified. There were 42 women and 14 men with a mean age at exploration of 61.2 years (28 to 80). The sciatic nerve palsy had been sustained by 46 of the patients during a primary THR, five during a revision THR and five patients during hip resurfacing. The mean pre-operative visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were significantly different (p < 0.001). Based on the findings of our study, we recommend this form of surgery over conservative management in patients with neuropathic pain associated with a sciatic nerve palsy after THR.

Exploration and neurolysis for the treatment of neuropathic pain in patients with a sciatic nerve palsy after total hip replacement.

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5). A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity.

Isolated latissimus dorsi transfer to restore shoulder external rotation in adults with brachial plexus injury

We present our experience of managing patients
with iatropathic brachial plexus injury after delayed fixation of
a fracture of the clavicle. It is a retrospective cohort study of
patients treated at our peripheral nerve injury unit and a single
illustrative case report. We identified 21 patients in whom a brachial
plexus injury occurred as a direct consequence of fixation of a
fracture of the clavicle between September 2000 and September 2011. The predominant injury involved the C5/C6 nerves, upper trunk,
lateral cord and the suprascapular nerve. In all patients, the injured
nerve was found to be tethered to the under surface of the clavicle
by scar tissue at the site of the fracture and was usually associated
with pathognomonic neuropathic pain and paralysis. Delayed fixation of a fracture of the clavicle, especially between
two and four weeks after injury, can result in iatropathic brachial
plexus injury. The risk can be reduced by thorough release of the
tissues from the inferior surface of the clavicle before mobilisation
of the fracture fragments. If features of nerve damage appear post-operatively
urgent specialist referral is recommended. Cite this article: Bone Joint J 2013;95-B:106–10.

Iatropathic brachial plexus injury: A complication of delayed fixation of clavicle fractures

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Papers

Exploration and neurolysis for the treatment of neuropathic pain in patients with a sciatic nerve palsy after total hip replacement.

Isolated latissimus dorsi transfer to restore shoulder external rotation in adults with brachial plexus injury

Iatropathic brachial plexus injury: A complication of delayed fixation of clavicle fractures