Objectives Intra-articular fractures predispose patients to post-traumatic osteoarthritis (PTOA), with associated chronic joint pain and decreased function. The success of articular fracture management is dependent on how the fracture is treated and on fracture type and severity. The purpose of the present study was to correlate objective CT-based indices of intra-articular fracture severity with subsequent joint degeneration. It was hypothesized that an injury severity metric that included objective measures of articular disruption, of fracture energy, and of fragment displacement/dispersal would be a useful predictor of PTOA. Methods Novel CT-based image analysis techniques were utilized to quantify acute injury characteristics in a prospective series of twenty tibial plafond fractures managed by articulated external fixation, with later definitive surgical fracture reduction performed after soft-tissue swelling had sufficiently resolved. PTOA severity was assessed two years post-injury using the Kellgren-Lawrence (KL) radiographic grading scale. A predictive model was developed by linearly regressing these two-year KL outcomes on the CT-based severity metrics. Results A combined acute severity score involving articular disruption and fracture energy successfully predicted PTOA severity (R2 = 0.70), whereas fragment displacement / dispersal and surgeon opinion correlated much less well with degeneration (R2 = 0.42 and 0.47). The concordance between the combined metric and PTOA severity was 88%. Conclusions The findings of this study indicate that objective CT-based metrics of acute injury severity can reliably predict intermediate-term PTOA outcomes in this challenging class of articular fractures. Quantitative biomechanical assessment of injury characteristics provides new possibilities to improve fracture management and to guide PTOA research.
The energy of producing a fracture is considered one of the most important factors relating to injury severity, prognosis, and risk of complications, yet there has been no objective way to measure this important variable. The purpose of this study was to compare assessments of fracture severity made using new objective computed tomography (CT)-based methods versus the expert opinion of experienced orthopedic traumatologists. Fracture energy, fragment displacement, and soft tissue swelling were quantified in twenty tibial plafond fractures by analyzing injury CT scans. Three experienced orthopedic traumatologists then independently performed a rank order analysis of fracture severity, using plain radiographs. The concordance among the three clinicians ranged from 87% to 91%. Objective fracture severity measurements made with the CT algorithm agreed well with the clinical assessments (fracture energy concordance from 73% to 76%, fragment displacement from 82% to 89%, and soft tissue swelling from 61% to 65%). These are the first objective, CT-based measures of fracture severity. With further refinement, this conceptually novel method has the potential to serve as a valuable tool to provide objective measurement of fracture severity, allowing one to control for this previously confounding variable in large multicenter studies. ß 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res Keywords: fracture severity; intra-articular; post-traumatic arthritis Intra-articular fractures often portend secondary osteoarthritis (OA), chronic pain, and decreased joint function. The success of periarticular fracture management is dependent not only on how the fracture is treated but also on the fracture type and severity. 1-5 Decision making in treating complex articular injuries with comminution ( Fig. 1) requires that a surgeon assess the relative injury severity of a given case, and with this information, factor in the complexity of available treatment techniques, estimate prognosis, and weigh the risk for complications. Currently, no practical way exists to measure injury severity objectively. Existing methods have generally taken the form of fracture classification systems, based upon visual assessment of specified characteristics. Poor interobserver reliability is a persistent problem for these observer-based techniques, 20,22 with inaccurate identification and inconsistent interpretation of classification guidelines explaining much of the variability. With such poor reliability, comparisons among different studies is reduced to ''apples to oranges,'' hindering the compilation of a collective experience to guide patient care.The concept that ''the extent of bone, cartilage, and soft tissue damage is directly related to the energy imparted to these structures'' 6 is widely accepted among orthopedic traumatologists, and it provides a basis for objectively quantifying injury severity. To assess the mechanical energy involved in a fracture, a new computed tomography (CT)-based methodolog...
Children with brachial plexus birth palsy (BPBP) may have shoulder external rotation and abduction weakness that can restrict activities of daily living (ADLs). Static range of motion measurements may not measure ADL restrictions. Motion analysis has been used to quantify gait limitations and measure changes associated with treatment. The purpose of this study was to determine whether upper extremity motion analysis (UEMA) can measure the differences in shoulder motion during ADLs between children with BPBP and normal children. Following a previously described UEMA protocol, 55 children with BPBP and 51 normal children (control group) were studied. Kinematic data of selected ADLs were collected before surgery. UEMA was used to measure statistically significant differences between children with BPBP and control subjects for all planes of shoulder motion in all activities tested. The authors conclude that UEMA can discriminate between children with BPBP and control subjects during selected ADLs, and suggest that UEMA can also be used to measure the effects of surgical interventions in children with BPBP.
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