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1.  Risk Factors for Infection after 46,113 Intramedullary Nail Operations in Low- and Middle-income Countries 
World Journal of Surgery  2012;37(2):349-355.
Background
The fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data.
Methods
The SOSD contained 46,722 IM nail surgeries in 58 different LMIC; 46,113 IM nail operations were included for analysis.
Results
The overall follow-up rate was 23.1 %. The overall infection rate was 1.0 %, 0.7 % for humerus, 0.8 % for femur, and 1.5 % for tibia fractures. If only nails with registered follow-up (n = 10,684) were included in analyses, infection rates were 2.9 % for humerus, 3.2 % for femur, and 6.9 % for tibia fractures. Prophylactic antibiotics reduced the risk of infection by 29 %. Operations for non-union had a doubled risk of infection. Risk of infection was reduced with increasing income level of the country.
Conclusions
The overall infection rates were low, and well within acceptable levels, suggesting that it is safe to do IM nailing in low-income countries. The fact that operations for non-union have twice the risk of infection compared to primary fracture surgery further supports the use of IM nailing as the primary treatment for femur fractures in LMIC.
doi:10.1007/s00268-012-1817-4
PMCID: PMC3553402  PMID: 23052810
2.  Global Access to Literature on Trauma 
The trauma pandemic disproportionately kills and maims citizens of low-income countries although the immediate cause of the trauma is often an industrial export of a high income country, such as a motor vehicle. Addressing the trauma pandemic in low-income countries requires access to relevant research information regarding prevention and treatment of injuries. Such information is also generally produced in high income countries. We explored various means of making scientific information available to low-income country surgeons using the internet. If orthopaedic surgeons want to maximize their global impact, they should focus on writing about trauma questions relevant to their colleagues in low-income countries and ensuring these same colleagues have access to the literature.
doi:10.1007/s11999-008-0375-4
PMCID: PMC2584301  PMID: 18663552
3.  Mortality as an indicator of patient safety in orthopaedics: lessons from qualitative analysis of a database of medical errors 
Background
Orthopaedic surgery is a high-risk specialty in which errors will undoubtedly occur. Patient safety incidents can yield valuable information to generate solutions and prevent future cases of avoidable harm. The aim of this study was to understand the causative factors leading to all unnecessary deaths in orthopaedics and trauma surgery reported to the National Patient Safety Agency (NPSA) over a four-year period (2005–2009), using a qualitative approach.
Methods
Reports made to the NPSA are categorised and stored in the database as free-text data. A search was undertaken to identify the cases of all-cause mortality in orthopaedic and trauma surgery, and the free-text elements were used for thematic analysis. Descriptive statistics were calculated based on the incidents reported. This included presenting the number of times categories of incidents had the same or similar response. Superordinate and subordinate categories were created.
Results
A total of 257 incident reports were analysed. Four main thematic categories emerged. These were: (1) stages of the surgical journey – 118/191 (62%) of deaths occurred in the post-operative phase; (2) causes of patient deaths – 32% were related to severe infections; (3) reported quality of medical interventions – 65% of patients experienced minimal or delayed treatment; (4) skills of healthcare professionals – 44% of deaths had a failure in non-technical skills.
Conclusions
Most complications in orthopaedic surgery can be dealt with adequately, provided they are anticipated and that risk-reduction strategies are instituted. Surgeons take pride in the precision of operative techniques; perhaps it is time to enshrine the multimodal tools available to ensure safer patient care.
doi:10.1186/1471-2474-13-93
PMCID: PMC3416713  PMID: 22682470
Patient safety; Errors; Orthopaedics; Trauma surgery; Quality improvement
4.  Injuries in Developing Countries—How Can We Help?: The Role of Orthopaedic Surgeons 
Each year nearly 5 million people worldwide die from injuries, approximately the number of deaths caused by HIV/AIDS, malaria, and tuberculosis combined. Ninety percent of these injuries occur in developing countries and that number is growing. Road traffic accidents account for 1.2 million of these 5 million deaths. For each death from trauma, three to eight more are permanently disabled. Orthopaedic surgeons should consider the victims of this epidemic by using their ability and capacity to treat these injuries. SIGN (Surgical Implant Generation Network, Richland, WA, USA) builds local surgical capability in developing countries by providing training and equipment to surgeons for use in treating the poor. It assists in treating long-bone fractures by using an intramedullary nail interlocking screw system. C-arm imaging, unavailable in many of these hospitals, is not necessary to accomplish interlocking. Surgery is performed primarily by local surgeons who record their cases on the SIGN surgical database. Discussion of these reports provides a means of communication and education among surgeons. This database demonstrates the capability of these surgeons. It also demonstrates that the SIGN intramedullary nail is safe for use in the developing world as it has been successful in treating 36,000 trauma patients.
doi:10.1007/s11999-008-0387-0
PMCID: PMC2584284  PMID: 18685912
5.  Osteosarcoma in the distal femur two years after an ipsilateral femoral shaft fracture: a case report 
Introduction
The duration of symptoms preceding a definitive diagnosis of osteosarcoma is quite long. Pathological radiological signs are often evident by the time of diagnosis. Although several case reports have been published on osteosarcoma of the femur, to the best of our knowledge this report is the first one with such an unusual clinical course.
Case presentation
We describe the case of a 58-year-old Caucasian man who presented with a femoral shaft fracture. Two years post-trauma osteosarcoma in the ipsilateral distal femur was diagnosed. Was it coincidence? We think that the history of the trauma is crucial to answering this question.
Conclusion
This case report underlines the need to keep up awareness of pathological fractures in emergency medicine and trauma surgery. When radiographs do not raise any suspicion but the history of trauma or the physical examination does, we recommend further radiological and/or histological diagnostic examinations.
doi:10.1186/1752-1947-5-198
PMCID: PMC3117825  PMID: 21600008
6.  Steppingstones to the implementation of an inhospital fracture and dislocation registry using the AO/OTA classification: compliance, completeness and commitment 
Background
Musculoskeletal trauma represents a considerable global health burden, however reliable population-based incidence data are scarce. A fracture and dislocation registry was established within a well-defined population. An audit of the establishment process, feasibility of the registry work and report of the collected data is given.
Methods
Demographic data, fracture type and location, mode of treatment, and the reasons for the secondary procedures were collected and scored using recognized systems, such as the AO/OTA classification and the Gustilo-Anderson classification for open fractures. The reporting was done in the operation planning program by the involved orthopaedic surgeon. Both inpatient and day-case procedures were collected. Data were collected prospectively from 2006 until 2010. Compliance among the surgeons and completeness and accuracy of the data was continuously assured by an orthopaedic surgeon.
Results
During the study period, 39 orthopaedic surgeons were involved in the recording of a total of 8,188 procedures, consisting of primary treatment of 4,986 long bone fractures, 467 non long bone fractures, 123 dislocations and 2,612 secondary treatments. In the study period 532 fractures or dislocations were treated at least once for one or more serious complications. For the index year of 2009, a total of 5710 fractures or dislocations were treated in the emergency department or hospitalized, of which the 1594 (28%) were treated at the inpatient or day-case operation rooms, thus registered in the FDR. Quality assurance, educational incentives and continuous feedback between coders and controller in the integrated electronic system are available and used through the features of the electronic database.
Conclusions
Implementing an integrated registry of fractures and dislocations with the electronic hospital system has been possible despite several users involved. The electronic system and the data controller provide for completeness and validity. The FDR has become an indispensable tool for the department for planning and education and will serve as a prerequisite for the conduct and execution of future prospective trials within the department. Further, other departments with similar electronic patient files may fairly easily adopt this system for implementation.
doi:10.1186/1757-7241-18-54
PMCID: PMC2976727  PMID: 20955572
7.  Achieving locked intramedullary fixation of long bone fractures: technology for the developing world 
International Orthopaedics  2012;36(10):2007-2013.
Eighty per cent of severe fractures occur in developing countries. Long bone fractures are treated by conservative methods if proper implants, intraoperative imaging and consistent electricity are lacking. These conservative treatments often result in lifelong disability. Locked intramedullary nailing is the standard of care for long bone fractures in the developed world. The Surgical Implant Generation Network (SIGN) has developed technology that allows all orthopaedic surgeons to treat fracture patients with locked intramedullary nailing without the need for image intensifiers, fracture tables or power reaming. Introduced in 1999, SIGN nails have been used to treat more than 100,000 patients in over 55 developing world countries. SIGN instruments and implants are donated to hospitals with the stipulation that they will be used to treat the poor at no cost. Studies have shown that patients return to function more rapidly, hospital stays are reduced, infection rates are low and clinical outcomes excellent. Cost-effectiveness analysis has confirmed that the system not only provides better outcomes, but does so at a reduced cost. SIGN continues to develop new technologies, in an effort to transform lives and bring equality in fracture care to the poorest of regions.
doi:10.1007/s00264-012-1625-3
PMCID: PMC3460075  PMID: 22847118
8.  Child Abuse: The Role of the Orthopaedic Surgeon in Nonaccidental Trauma 
Background
Child abuse presents in many different forms: physical, sexual, psychological, and neglect. The orthopaedic surgeon is involved mostly with physical abuse but should be aware of the other forms. There is limited training regarding child abuse, and the documentation is poor when a patient is at risk for abuse. There is a considerable risk to children when abuse is not recognized.
Questions/purposes
In this review, we (1) define abuse, (2) describe the incidence and demographic characteristics of abuse, (3) describe the orthopaedic manifestations of abuse, and (4) define the orthopaedic surgeon’s role in cases of abuse.
Methods
We performed a PubMed literature review and a search of the Department of Health and Human Services Web site. The Pediatric Orthopaedic Surgery of North America trauma symposium was referenced and expanded to create this review.
Results
Recognition and awareness of child abuse are the primary tasks of the orthopaedic surgeon. Skin trauma is more common than fractures, yet fractures are the most common radiographic finding. Patients with fractures who are younger than 3 years, particularly those younger than 1 year, should be evaluated for abuse. No fracture type or location is pathognomonic. Management in the majority of fracture cases resulting from abuse is nonoperative casting or splinting.
Conclusions
The role of the orthopaedic surgeon in suspected cases of child abuse includes (1) obtaining a good history and making a thorough physical examination; (2) obtaining the appropriate radiographs and notifying the appropriate services; and (3) participating in and communicating with a multidisciplinary team to manage the patients.
doi:10.1007/s11999-010-1610-3
PMCID: PMC3032840  PMID: 20941649
9.  Lessons from the Severe Acute Respiratory Syndrome Outbreak in Hong Kong 
Emerging Infectious Diseases  2003;9(9):1042-1045.
Severe acute respiratory syndrome (SARS) is now a global public health threat with many medical, ethical, social, economic, political, and legal implications. The nonspecific signs and symptoms of this disease, coupled with a relatively long incubation period and the initial absence of a reliable diagnostic test, limited the understanding of the magnitude of the outbreak. This paper outlines our experience with public health issues that have arisen during this outbreak of SARS in Hong Kong. We confirmed that case detection, reporting, clear and timely dissemination of information, and strict infection control measures are essential in handling such an infectious disease outbreak. The need for an outbreak response unit is crucial to combat any future outbreak.
doi:10.3201/eid0909.030366
PMCID: PMC3016765  PMID: 14519237
Severe acute respiratory syndrome (SARS); Hong Kong; emerging infectious disease; outbreak control
10.  Orthopaedic Surgeons’ Knowledge and Misconceptions in the Identification of Intimate Partner Violence Against Women 
Background
Intimate partner violence (IPV)—physical, sexual, psychologic, or financial abuse between intimate partners—is the most common cause of nonfatal injury to women in North America. As many IPV-related injuries are musculoskeletal, orthopaedic surgeons are well positioned to identify and assist these patients. However, data are lacking regarding surgeons’ knowledge of the prevalence of IPV in orthopaedic practices, surgeons’ screening and management methods, and surgeons’ perceptions about IPV.
Questions/purposes
We aimed to identify (1) surgeon attitudes and beliefs regarding victims of IPV and batterers and (2) perceptions of surgeons regarding their role in identifying and assisting victims of IPV.
Methods
We surveyed 690 surgeon members of the Orthopaedic Trauma Association. The survey had three sections: (1) general perception of orthopaedic surgeons regarding IPV; (2) perceptions of orthopaedic surgeons regarding victims and batterers; and (3) orthopaedic relevance of IPV. One hundred fifty-three surgeons responded (22%).
Results
Respondents manifested key misconceptions: (1) victims must be getting something out of the abusive relationships (16%); (2) some women have personalities that cause the abuse (20%); and (3) the battering would stop if the batterer quit abusing alcohol (40%). In the past year, approximately ½ the respondents (51%) acknowledged identifying a victim of IPV; however, only 4% of respondents currently screen injured female patients for IPV. Surgeons expressed concerns regarding lack of knowledge in the management of abused women (30%).
Conclusion
Orthopaedic surgeons had several misconceptions about victims of IPV and batterers. Targeted educational programs on IPV are needed for surgeons routinely caring for injured women.
doi:10.1007/s11999-012-2749-x
PMCID: PMC3585999  PMID: 23283672
11.  Global Distribution of Outbreaks of Water-Associated Infectious Diseases 
Background
Water plays an important role in the transmission of many infectious diseases, which pose a great burden on global public health. However, the global distribution of these water-associated infectious diseases and underlying factors remain largely unexplored.
Methods and Findings
Based on the Global Infectious Disease and Epidemiology Network (GIDEON), a global database including water-associated pathogens and diseases was developed. In this study, reported outbreak events associated with corresponding water-associated infectious diseases from 1991 to 2008 were extracted from the database. The location of each reported outbreak event was identified and geocoded into a GIS database. Also collected in the GIS database included geo-referenced socio-environmental information including population density (2000), annual accumulated temperature, surface water area, and average annual precipitation. Poisson models with Bayesian inference were developed to explore the association between these socio-environmental factors and distribution of the reported outbreak events. Based on model predictions a global relative risk map was generated. A total of 1,428 reported outbreak events were retrieved from the database. The analysis suggested that outbreaks of water-associated diseases are significantly correlated with socio-environmental factors. Population density is a significant risk factor for all categories of reported outbreaks of water-associated diseases; water-related diseases (e.g., vector-borne diseases) are associated with accumulated temperature; water-washed diseases (e.g., conjunctivitis) are inversely related to surface water area; both water-borne and water-related diseases are inversely related to average annual rainfall. Based on the model predictions, “hotspots” of risks for all categories of water-associated diseases were explored.
Conclusions
At the global scale, water-associated infectious diseases are significantly correlated with socio-environmental factors, impacting all regions which are affected disproportionately by different categories of water-associated infectious diseases.
Author Summary
Water is essential for maintaining life on Earth but can also serve as a media for many pathogenic organisms, causing a high disease burden globally. However, how the global distribution of water-associated infectious pathogens/diseases looks like and how such distribution is related to possible social and environmental factors remain largely unknown. In this study, we compiled a database on distribution, biology, and epidemiology of water-associated infectious diseases and collected data on population density, annual accumulated temperature, surface water areas, average annual precipitation, and per capita GDP at the global scale. From the database we extracted reported outbreak events from 1991 to 2008 and developed models to explore the association between the distribution of these outbreaks and social and environmental factors. A total of1,428 outbreaks had been reported and this number only reflected ‘the tip of the iceberg’ of the much bigger problem. We found that the outbreaks of water-associated infectious diseases are significantly correlated with social and environmental factors and that all regions are affected disproportionately by different categories of diseases. Relative risk maps are generated to show ‘hotspots’ of risks for different diseases. Despite certain limitations, the findings may be instrumental for future studies and prioritizing health resources.
doi:10.1371/journal.pntd.0001483
PMCID: PMC3279334  PMID: 22348158
12.  Low infection rates after 34,361 intramedullary nail operations in 55 low- and middle-income countries 
Acta Orthopaedica  2011;82(6):737-743.
Background
The Surgical Implant Generation Network (SIGN) supplies intramedullary (IM) nails for the treatment of long bone fractures free of charge to hospitals in low- and middle-income countries (LMICs). Most operations are reported to the SIGN Online Surgical Database (SOSD). Follow-up has been reported to be low, however. We wanted to examine the pattern of follow-up and to assess whether infection rates could be trusted.
Patients and methods
The SOSD contained 36,454 IM nail surgeries in 55 LMICs. We excluded humerus and hip fractures, and fractures without a registered surgical approach. This left 34,361 IM nails for analysis. A generalized additive regression model (gam) was used to explore the association between follow-up rates and infection rates.
Results
The overall follow-up rate in the SOSD was 18.1% (95% CI: 17.7–18.5) and national follow-up rates ranged from 0% to 74.2%. The overall infection rate was 0.7% (CI: 0.6–0.8) for femoral fractures and 1.2% (CI: 1.0–1.4) for tibial fractures. If only nails with a registered follow-up visit were included (n = 6,224), infection rates were 3.5% (CI: 3.0–4.1) for femoral fractures and 7.3% (CI: 6.2–8.4) for tibial fractures. We found an increase in infection rates with increasing follow-up rates up to a level of 5%. Follow-up above 5% did not result in increased infection rates.
Interpretation
Reported infection rates after IM nailing in the SOSD appear to be reliable and could be used for further research. The low infection rates suggest that IM nailing is a safe procedure also in low- and middle-income countries.
doi:10.3109/17453674.2011.636680
PMCID: PMC3247895  PMID: 22066554
13.  The effects of delayed physical prompts and reinforcement on infant sign language acquisition. 
Researchers and clinicians have recommended that sign language be taught to typically developing children during their first 2 years of life; however, existing research does not provide adequate information regarding appropriate methods of sign training. We used delayed physical prompting and reinforcement to teach manual signs to 3 children between the ages of 6 and 13 months. Data were collected on the occurrence of prompted and independent signs as well as crying. Sign training was successful in producing independent signing in all 3 children in under 4 hr of training per child.
doi:10.1901/jaba.2004.37-379
PMCID: PMC1284511  PMID: 15529893
14.  Corruption in the health care sector: A barrier to access of orthopaedic care and medical devices in Uganda 
Background
Globally, injuries cause approximately as many deaths per year as HIV/AIDS, tuberculosis and malaria combined, and 90% of injury deaths occur in low- and middle- income countries. Given not all injuries kill, the disability burden, particularly from orthopaedic injuries, is much higher but is poorly measured at present. The orthopaedic services and orthopaedic medical devices needed to manage the injury burden are frequently unavailable in these countries. Corruption is known to be a major barrier to access of health care, but its effects on access to orthopaedic services is still unknown.
Methods
A qualitative case study of 45 open-ended interviews was conducted to investigate the access to orthopaedic health services and orthopaedic medical devices in Uganda. Participants included orthopaedic surgeons, related healthcare professionals, industry and government representatives, and patients. Participants’ experiences in accessing orthopaedic medical devices were explored. Thematic analysis was used to analyze and code the transcripts.
Results
Analysis of the interview data identified poor leadership in government and corruption as major barriers to access of orthopaedic care and orthopaedic medical devices. Corruption was perceived to occur at the worker, hospital and government levels in the forms of misappropriation of funds, theft of equipment, resale of drugs and medical devices, fraud and absenteeism. Other barriers elicited included insufficient health infrastructure and human resources, and high costs of orthopaedic equipment and poverty.
Conclusions
This study identified perceived corruption as a significant barrier to access of orthopaedic care and orthopaedic medical devices in Uganda. As the burden of injury continues to grow, the need to combat corruption and ensure access to orthopaedic services is imperative. Anti-corruption strategies such as transparency and accountability measures, codes of conduct, whistleblower protection, and higher wages and benefits for workers could be important and initial steps in improving access orthopaedic care and OMDs, and managing the global injury burden.
doi:10.1186/1472-698X-12-5
PMCID: PMC3492067  PMID: 22554349
15.  Orthopaedic Web Links (OWL): A Way to Find Professional Orthopaedic Information on the Internet 
Background
Finding useful high-grade professional orthopaedic information on the Internet is often difficult. Orthopaedic Web Links (OWL) is a searchable database of vetted online orthopaedic resources. OWL uses a subject directory (OWL Directory) and a custom search engine (OWL Web) to provide a list of resources. The most effective way to find readily accessible, full text on-subject material suitable for education of an orthopaedic surgeon or trainee has not been defined.
Questions/purposes
We therefore (1) proposed a method for selecting topics and evaluating searches and (2) compared the search results from an orthopaedic-specific directory (OWL Directory), a custom search engine (OWL Web), and standard Google searches.
Methods
A scoring system for evaluation of the search results was developed for standardized comparison. Single words and sets of three words from randomly selected examination questions provided the search strings to compare the three strategies.
Results
For single keyword searches, the OWL Directory scored highest (16.4/50) of the three methods. For the three keywords searches, OWL Web had the highest mean score (26.0/50), followed by Google (22.8/50), and the OWL Directory (1.0/50). OWL Web searches had higher scores than Google searches, while returning 800 times fewer search results.
Conclusion
The OWL Directory of orthopaedic subjects on the Internet provides a simple browsable category structure to find information. The OWL Web search engine scored higher than Google and resulted in a greater proportion of valid, on-subject, and accessible resources in the search results.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-011-1875-1) contains supplementary material, which is available to authorized users.
doi:10.1007/s11999-011-1875-1
PMCID: PMC3111805  PMID: 21455801
16.  Supracondylar skeletal traction and open interlocking nailing for neglected fracture of the shaft of femur – Retrospective study 
Background
Neglected trauma is a common problem faced by Orthopaedic surgeons practicing in developing countries. Nothing much in English literature is available regarding the practical difficulties and guidelines for treating neglected trauma of long bones.
Methods
In our institution from November 2003 to October 2009 we treated 25 cases of neglected fracture of shaft of femur. Patients underwent either of three types of management protocols depending upon the preoperative manual traction radiographs. The fracture was fixed with open interlocking nail. Primary bone grafting and bone shortening procedures were not performed in any of the patient.
Results
The fractures united in all patients at an average duration of 17 weeks. Two patients had limb length discrepancy.
Conclusion
Careful preoperative evaluation is mandatory for good results. Preoperative skeletal traction and two stage surgical procedure may be required to avoid limb length discrepancy and neurovascular complication.
doi:10.1016/j.jcot.2013.05.003
PMCID: PMC3880433
Supracondylar skeletal traction; Neglected trauma; Interlocking nail
17.  STABILIZATION OF DISTAL FEMUR FRACTURES WITH INTRAMEDULLARY NAILS AND LOCKING PLATES: DIFFERENCES IN CALLUS FORMATION 
Objectives
This study compared callus formation in distal femur fractures stabilized with locking plates and intramedullary nails to test the hypothesis that locking plates induce less fracture callus than IM nails.
Design
Retrospective case matched study.
Setting
Two orthopaedic trauma centers.
Patients
174 distal femur fracture were reviewed to extract cases treated with retrograde IM nails (NAIL group, n = 12). These were then individually matched to cases treated with locking plates (Plate group, n = 12).
Intervention
Retrograde IM nailing or locking plate fracture fixation.
Outcome Measures
Periosteal callus was measured on lateral and antero-posterior radiographs taken at 12 weeks after injury using validated software to objectively extract the size of peripheral callus from digital radiographs.
Results
The NAIL group had 2.4 times more callus area per location (231 ± 304 mm2) than the PLATE group (95 ± 109 mm2, p=0.028). Compared to the PLATE group, the NAIL group had 3.4 times more callus anteriorly (p=0.31), 2.6 times more callus posteriorly (p=0.25), and 2.3 times more callus medially (p=0.16). At 12 weeks after injury, no or minimal callus for secondary bone healing (<20 mm2) was present in 20% of callus locations in the NAIL group and in 54% of callus locations in the PLATE group.
Conclusion
Significantly less periosteal callus formed in fractures stabilized with locking plates than with IM nails. This result is likely multifacto-rial and further study of the interaction between construct stiffness and fracture healing in the distal femur is warranted.
PMCID: PMC2958272  PMID: 21045973
18.  Radiographic Prevalence of Femoroacetabular Impingement in a Young Population with Hip Complaints Is High 
Background
Femoroacetabular impingement (FAI) is reportedly a prearthritic condition in young adults that can progress to osteoarthritis. However, the prevalence of FAI is unknown in the young, active population presenting with hip complaints.
Questions/purposes
We sought to determine (1) the prevalence of radiographic findings of FAI in a young, active patient population with complaints localized to the region of the hip presenting to primary care and orthopaedic clinics; (2) the percentage of films with FAI with an official reading suggesting the diagnosis; and (3) whether the Tönnis grades of osteoarthritis corresponded to the findings of FAI.
Methods
We performed a database review of pelvic and hip radiographs obtained from 157 young (mean age 32 years; range, 18–50 years) patients presenting with hip-related complaints to primary care and orthopaedic clinics. Radiographs were analyzed for signs of FAI (herniation pits, pistol grip deformity, center-edge angle, alpha angle, and crossover sign) and Tönnis grade. Radiology reports were reviewed for a diagnosis of FAI.
Results
At least one finding of FAI was found in 135 of the 155 patients (87%). Four hundred thirteen of 487 radiographs (85%) had been read as normal and one read as showing FAI. Tönnis grades did not correlate with radiographic signs of FAI.
Conclusions
Radiographic evidence of FAI is common in active patients with hip complaints. Increased awareness of FAI in primary care, radiology, and orthopaedic clinics and additional research into the long-term effects of management are warranted.
Level of Evidence
Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1233-8
PMCID: PMC3049607  PMID: 20107939
19.  Marked Subchondral Bandlike Osteopenia on Radiography after Trauma and Inactivity: A Report of four Cases 
Case Reports in Orthopedics  2013;2013:234278.
We report about four cases of marked subchondral osteopenia on followup radiography after trauma and prolonged disuse. This localized form of disuse osteopenia has not been reported in details beside the followup imaging of talar neck fractures, where it is known as the “Hawkins sign.” Due to its unique morphology, it can be easily recognized as a benign finding in posttraumatic followup imaging and can be morphologically distinguished from severe complications like complex regional pain syndrome type 1 (Sudeck's disease) or periarticular osteopenia in infectious arthritis. It is important for the radiologist and orthopaedic surgeon to be aware of this form of disuse osteopenia in the proper clinical context.
doi:10.1155/2013/234278
PMCID: PMC3638522  PMID: 23691391
20.  Global Relevance of Literature on Trauma 
The trauma pandemic disproportionately kills and maims citizens of low-income countries although the immediate cause of the trauma is often an industrial export of a high-income country, such as a motor vehicle. Addressing the trauma pandemic in low-income countries requires access to relevant research information regarding prevention and treatment of injuries. Such information is also generally produced in high-income countries. We reviewed two years’ worth of articles from leading orthopaedic and general medical journals to determine whether the scientific literature appropriately reflects the global burden of musculoskeletal disease, particularly that due to trauma. General medical journals underrepresented musculoskeletal disease, but within musculoskeletal disease an appropriate majority of papers were regarding trauma, in particular the epidemiology and prevention of injury. Orthopaedic journals, while focusing on musculoskeletal conditions, substantially underrepresented the global burden of disease due to trauma and hardly consider injury epidemiology and prevention. If orthopaedic surgeons want to maximize their global impact, they should focus on writing about trauma questions relevant to their colleagues in low-income countries and ensuring these same colleagues have access to the literature.
doi:10.1007/s11999-008-0397-y
PMCID: PMC2584287  PMID: 18685910
21.  Acetabular fracture types vary with different acetabular version 
International Orthopaedics  2012;36(12):2559-2563.
Purpose
Acetabular fractures typically occur in high energy trauma. Understanding of the various contributing biomechanical factors and trauma mechanisms is still limited. While several investigations figured out what role femoral position during impact plays in distinct fracture patterns, no data exists on the influence of acetabular version on the fracture type. Our study was carried out to clarify this issue.
Methods
Radiological data sets of 192 patients (145 male, 47 female, age 14–90 years) sustaining acetabular fractures were assessed retrospectively. The crossover ratio of the crossover sign and presence or absence of the posterior wall sign and ischial spine sign were used to determine acetabular retroversion on conventional radiographs. Acetabular version in the axial plane was measured on a computed tomography (CT) scan. Statistics were then performed to analyse the relationship between the acetabular fracture type according to the Letournel classification and acetabular version.
Results
A significant difference (p = 0.029) in acetabular version was found between fractures of the anterior [mean equatorial edge (EE) angle 19.93°] and posterior (mean EE angle 17.53°) acetabulum in the CT scan. No difference was shown on the measurements on conventional radiographs.
Conclusions
Acetabular version in the axial plane has an influence on the acetabular fracture pattern. While more anteverted acetabula were frequently associated with anterior fracture types according to the Letournel classification, retroversion of the acetabulum was associated with posterior fracture types.
doi:10.1007/s00264-012-1687-2
PMCID: PMC3508050  PMID: 23104675
22.  Orthopedic manifestations in patients with mucopolysaccharidosis type II (Hunter syndrome) enrolled in the Hunter Outcome Survey 
Orthopedic Reviews  2010;2(2):e16.
Mucopolysaccharidosis type II (MPS II or Hunter syndrome) is a rare, inherited disorder caused by deficiency of the lysosomal enzyme iduronate-2-sulfatase. As a result of this deficiency, glycosaminoglycans accumulate in lysosomes in many tissues, leading to progressive multisystemic disease. The cardiopulmonary and neurological problems associated with MPS II have received considerable attention. Orthopedic manifestations are common but not as well characterized. This study aimed to characterize the prevalence and severity of orthopedic manifestations of MPS II and to determine the relationship of these signs and symptoms with cardiovascular, pulmonary and central nervous system involvement.
Orthopedic manifestations of MPS II were studied using cross-sectional data from the Hunter Outcome Survey (HOS). The HOS is a global, physician-led, multicenter observational database that collects information on the natural history of MPS II and the long-term safety and effectiveness of enzyme replacement therapy.
As of January 2009, the HOS contained baseline data on joint range of motion in 124 males with MPS II. In total, 79% of patients had skeletal manifestations (median onset, 3.5 years) and 25% had abnormal gait (median onset, 5.4 years). Joint range of motion was restricted for all joints assessed (elbow, shoulder, hip, knee and ankle). Extension was the most severely affected movement: the exception to this was the shoulder. Surgery for orthopedic problems was rare. The presence of orthopedic manifestations was associated with the presence of central nervous system and pulmonary involvement, but not so clearly with cardiovascular involvement.
Orthopedic interventions should be considered on an individual-patient basis. Although some orthopedic manifestations associated with MPS II may be managed routinely, a good knowledge of other concurrent organ system involvement is essential. A multidisciplinary approach is required.
doi:10.4081/or.2010.e16
PMCID: PMC3143973  PMID: 21808707
bone; joint; mucopolysaccharidosis; orthopedic; spine.
23.  Femur Fractures in the Pediatric Population: Abuse or Accidental Trauma? 
Background
Child abuse represents a serious threat to the health and well-being of the pediatric population. Orthopaedic specialists will often become involved when child abuse is suspected as a result of the presence of bony injury. Distinguishing abuse from accidental trauma can be difficult and is often based on clinical suspicion.
Questions/purposes
We sought to determine whether accidental femur fractures in pediatric patients younger than age 4 could be distinguished from child abuse using a combination of presumed risk factors from the history, physical examination findings, radiographic findings, and age.
Methods
We searched our institution’s SCAN (Suspected Child Abuse and Neglect) and trauma databases. We identified 70 patients in whom the etiology of their femur fracture was abuse and compared that group with 139 patients who had a femur fracture in whom accidental trauma was the etiology.
Results
A history suspicious for abuse, physical or radiographic evidence of prior injury, and age younger than 18 months were risk factors for abuse. Patients with no risk factors had a 4% chance, patients with one risk factor had a 29% chance, patients with two risk factors had an 87% chance, and patients with all three risk factors had a 92% chance of their femur fracture being a result of abuse.
Conclusions
Clinicians can use this predictive model to guide judgment and referral to social services when seeing femur fractures in very young children in the emergency room.
Level of Evidence
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1339-z
PMCID: PMC3032851  PMID: 20373153
24.  Femur Fractures in the Pediatric Population: Abuse or Accidental Trauma? 
Background
Child abuse represents a serious threat to the health and well-being of the pediatric population. Orthopaedic specialists will often become involved when child abuse is suspected as a result of the presence of bony injury. Distinguishing abuse from accidental trauma can be difficult and is often based on clinical suspicion.
Questions/purposes
We sought to determine whether accidental femur fractures in pediatric patients younger than age 4 could be distinguished from child abuse using a combination of presumed risk factors from the history, physical examination findings, radiographic findings, and age.
Methods
We searched our institution’s SCAN (Suspected Child Abuse and Neglect) and trauma databases. We identified 70 patients in whom the etiology of their femur fracture was abuse and compared that group with 139 patients who had a femur fracture in whom accidental trauma was the etiology.
Results
A history suspicious for abuse, physical or radiographic evidence of prior injury, and age younger than 18 months were risk factors for abuse. Patients with no risk factors had a 4% chance, patients with one risk factor had a 29% chance, patients with two risk factors had an 87% chance, and patients with all three risk factors had a 92% chance of their femur fracture being a result of abuse.
Conclusions
Clinicians can use this predictive model to guide judgment and referral to social services when seeing femur fractures in very young children in the emergency room.
Level of Evidence
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1339-z
PMCID: PMC3032851  PMID: 20373153
25.  Pneumomediastinum in a High School Football Player: A Case Report 
Journal of Athletic Training  1998;33(4):362-364.
Objective:
To provide athletic trainers with information about the mechanism, evaluation, and treatment of pneumomediastinum.
Background:
This is a case study of a high school football player who suffered pneumomediastinum as a result of a flat-handed thump to his sternal area during a blocking drill. Pneumomediastinum is a relatively rare occurrence in sports. Common mechanisms include direct blunt trauma, vomiting, sneezing, Valsalva maneuver, and forceful coughing. Typical signs and symptoms include chest pain, dyspnea, tenderness, crepitus in the neck that can be aggravated with swallowing, and a positive Hamman's sign with auscultations.
Differential Diagnosis:
Pneumothorax, pneumopericardium, sternal contusion, rib fracture, upper respiratory infection, and myocardial infarction.
Treatment:
Conservative management includes restriction from athletic activities, prophylactic antibiotics, and sleeping in a semireclined position. Surgical repair of the defect may be indicated if repeat radiographs fail to show improvement after 1 week.
Uniqueness:
It is rare that a relatively light blow through shoulder pads would result in a pneumomediastinum. Review of the literature does not include this athlete's symptoms of congestion, nasal voice, or sore throat as typical signs of pneumomediastinum.
Conclusions:
The literature indicates that an uncomplicated pneumomediastinum will typically resolve in 2 weeks' time. In this case, symptomatic evaluation warranted only 1 week of rest before the athlete was allowed to return to full activity.
Images
PMCID: PMC1320589  PMID: 16558536
mediastinal emphysema; football injuries; retrosternal chest pain

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