Clavicle fractures are common, accounting for 2.6% of all adult fractures. We describe a most unusual segmental fracture pattern of the clavicle with concurrent disruption of acromioclavicular (AC) joint. We were unable to find any publications or reports describing this fracture pattern. During surgery for a medial one-third shaft of clavicle fracture and AC joint dislocation, the medial clavicle was exposed, leading to the discovery (on table) of a previously unidentified additional undisplaced fracture of the medial clavicle cleaving the bone into three distinct fragments. An anatomical plate was successfully applied, fixing both fractures. The AC joint was then reduced with a hook plate. At 8 months, after removal of the hook plate, the patient has an excellent outcome with an Oxford Shoulder Score of 45/48 and a full range of movement without instability of the AC joint. We describe the operative management of this rare fracture pattern. This also highlights that segmental fractures of the clavicle are easily missed. It was successfully treated with a medial anatomic plate and lateral hook plate. We were unable to find any publications or reports describing the fracture pattern in this case.
Aims With resumption of elective spine surgery services in the UK following the first wave of the COVID-19 pandemic, we conducted a multicentre British Association of Spine Surgeons (BASS) collaborative study to examine the complications and deaths due to COVID-19 at the recovery phase of the pandemic. The aim was to analyze the safety of elective spinal surgery during the pandemic. Methods A prospective observational study was conducted from eight spinal centres for the first month of operating following restoration of elective spine surgery in each individual unit. Primary outcome measure was the 30-day postoperative COVID-19 infection rate. Secondary outcomes analyzed were the 30-day mortality rate, surgical adverse events, medical complications, and length of inpatient stay. Results In all, 257 patients (128 males) with a median age of 54 years (2 to 88) formed the study cohort. The mean number of procedures performed from each unit was 32 (16 to 101), with 118 procedures (46%) done as category three prioritization level. The majority of patients (87%) were low-medium “risk stratification” category and the mean length of hospital stay was 5.2 days. None of the patients were diagnosed with COVID-19 infection, nor was there any mortality related to COVID-19 during the 30-day follow-up period, with 25 patients (10%) having been tested for symptoms. Overall, 32 patients (12%) developed a total of 34 complications, with the majority (19/34) being grade 1 to 2 Clavien-Dindo classification of surgical complications. No patient required postoperative care in an intensive care setting for any unexpected complication. Conclusion This study shows that safe and effective planned spinal surgical services can be restored avoiding viral transmission, with diligent adherence to national guidelines and COVID-19-secure pathways tailored according to the resources of the individual spinal units. Cite this article: Bone Jt Open 2021;2(12):1096–1101.
To review the current knowledge surrounding degenerative disc disease focusing on the changes taking place in the end plate and trabecular bone. A narrative review of the current literature. An age-related reduction in blood supply to the disc contributes to tissue degradation. Degeneration, separate from this process, represents a disruption of the normal homeostasis. A process of vascular and sensory nerve in-growth in the annulus and localised areas of the end plate is associated with markers of inflammation and may represent a pain source. Treatment with local anti-inflammatories has, at best, mixed results. Bone mechanical indentation testing has been used to classify changes in ageing and degeneration demonstrating a location-dependant reduction in strength specific to each process. Modic changes include a process of inflammation, alteration of the mechanical and chemical environment and changes in bone turnover. The underlying cause for their development has multiple explanations including mechanical overload and microfracture, infection and inflammation in response to herniation of disc material through the end plate. We do know, however, that they seem to be at least partially reversible and not all are symptomatic. This reversibility potentially indicates an avenue of exploration for therapy. Restoring the complex balance of disc homeostasis may hold some promise and will rely on greater understanding of the pathological and material changes occurring at the disc-bone interface and their correlation with clinical imaging. Current treatment may be optimised with an understanding of the mechanical environment of the disc in patient subgroups.
Background: Documentation of the neurological status is vital in the clinical management of fracture patients. It is also important for medico legal reasons. Inadequate pre-operative evaluation and documentation can lead to dilemma in the post-operative management if a patient is then found to have a neurological deficit.Aims: To identify the current standard of documentation of preoperative and post-operative neurological status in upper limb fracture patients in this tertiary trauma centre and compare it with the accepted guidelines/practice.Methods: A retrospective audit was performed in this unit between September 2009 and April 2010 to evaluate the documentation in the notes of all patients admitted with upper limb fractures necessitating a surgical intervention. The A&E, pre-operative and post-operative Orthopaedic documentation was reviewed.Results: 100 case notes of patients admitted with an upper limb fracture were reviewed. 15% patients had no documentation of the neurological status in the pre-operative notes and 16% patients had no documentation in the post-operative notes. Neither preoperative nor post-operative documentation of neurological status was present in 3 notes. 3 patients were found to have a neurological deficit post-operatively but had no clear pre-operative documentation.Conclusion: It is considered unacceptable to have no documentation of neurological status of a limb following trauma. It is surprising that there was a failure of documentation in our study in spite of three separate occasions when a doctor would have assessed these patients. This raises questions about the emphasis on clinical method teaching in the undergraduate curriculum as well as decreasing attachments in many trauma and orthopaedic attachments.Given the shorter attachments in the trauma unit for the junior trainees, neurological assessment of injured limb should form a part of the induction/teaching program. Our unit now uses a defined proforma in the clerking sheet for all limb injury patients to enable improved outcomes.
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