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Clinical decision analysis in the management of displaced mid-shaft clavicle fractures: the patient's perspective

Authors:
Abstracts / Injury Extra 41 (2010) 131–166 159
the night-patients need to be well motivated and understand its
importance in preventing recurrence.
doi:10.1016/j.injury.2010.07.477
2A.3
Clinical decision analysis in the management of displaced mid-
shaft clavicle fractures: the patient’s perspective
Sukhman Kalra
, Harry Sprot, Sudiptamohan Mukhopadhyay,
K.N. Subramanian, Angus Robertson
Displaced mid-shaft clavicle fractures have traditionally been
treated non-operatively. New evidence supports the use of opera-
tive treatment with better functional results although with some
risk of adverse complications. The patient’s opinion in choosing
one or the other option of treatment is important especially when
a new therapeutic philosophy is introduced. We aimed to obtain
the patients’ preference based on their opinion of various possi-
ble outcomes of each treatment method. A clinical decision tree
was constructed based on probabilities for various outcomes from
the current literature. We used clinical decision analysis based on
Bayesian logic. A similar clinical decision analysis was done for a
cohort of orthopaedic surgeons.
We interviewed 20 patients to obtain their health preferences
on a numerical rating scale for each of the six possible outcomes
for the conservative and operative treatments. Similar health pref-
erences were obtained from 20 orthopaedic surgeons. The cohort
of patients was young (age range: 13–21, mean: 16 years) males
involved in active sport. The results of the decision analysis demon-
strated a strong preference for operativemanagement in this cohort
of patients (combined probability of 0.81 for operative treatment
versus 0.61 for non-operative).
The cohort of orthopaedic surgeons was either career
orthopaedic trainees or qualified orthopaedic surgeons with an
age range of 28–41 years (mean age: 35 years). The results of the
decision analysis demonstrated a weak preference for operative
management in this cohort of surgeons (combined probability of
0.84 for operative treatment versus 0.77 for non-operative man-
agement).
Overall the young active patient is eight times more likely to
prefer operative treatment over non-operative management com-
pared to the well informed orthopaedic surgeon. Patient education
is the key to a better informed patient who can make a balanced
decision. Clinical decision analysis can be a useful tool in this pro-
cess.
doi:10.1016/j.injury.2010.07.478
2A.4
Radiological outcomes of distal radius extra-articular fragility
fractures treated with extra-focal kirschner wires
C. Kennedy (MB, BCh, BAO, MRCS)
a,
, M.T. Kennedy (MB, MCh, BAO,
MRCS)
b
, D. Niall (FRCSI, FRCS (Tr&Ortho))
b
, A. Devitt (MCh, FRCSI,
FRCS (Tr&Ortho))
a
a
Department of Orthopaedic Surgery, University College Hospital, Gal-
way, Ireland
b
Department of Orthopaedic Surgery, Midland Regional Hospital, Tul-
lamore, Co Offaly, Ireland
Introduction: The classical Colles fracture (extraarticular, dor-
sally angulated distal radius fracture) in patients with osteoporotic
bone is becoming increasingly more frequent. There still appears
to be no clear consensus on the most appropriate surgical manage-
ment of these injuries.
Methods: We retrospectively analysed 72 consecutive cases of
Colles fractures treated with interfragmentary K-wire fixation, in
female patients over 60 years of age, in two orthopaedic centres,
under the care of 12 different orthopaedic surgeons. We correlated
the radiographic distal radius measurements (ulnar variance, volar
tilt, and radial inclination) at the pre-operative and intra-operative
stages with the final radiographic outcome.
Result: Mean dorsal angulation was 21
at time of presentation.
Closed reduction significantly improved fracture position to a mean
of 2.7
volar angulation (p < 0.05). Mean angulation at time of K-
wire removal was 1.6
dorsal, this was not significant in comparison
to post-reduction measurements (p < 0.05). Mean ulnar variance at
time of presentation was 2.5 mm (range 7.4 to 4.2). Reduction
improved fracture displacement to a mean of 0 mm, which was
statistically significant (p < 0.05). Mean ulnar variance at time of K-
wire removal was 2.4 mm (p < 0.05). 56.8% of cases demonstrated
radial shortening of 2 mm or more.
Conclusion: In female patients over 60 years of age, the best
predictor of radial length, when K-wire fixation is to be used, is
the radial length prior to fracture reduction. Thus if there is radial
shortening visible in the initial radiographs as measured in terms
of ulnar variance, one should consider a method of fixation other
than inter-fragmentary K-wires.
Conflict of interest: There was no conflict of interest. All the
authors disclose there were no financial or personal relationships
with other people or organizations, that could inappropriately
influence our work. No grant or funding was received for the above
study.
doi:10.1016/j.injury.2010.07.479
2A.5
Inner city gunshot injuries: south London experience
R. Mansouri
, K. Tsitskaris, S. Gudipati, V. Kavarthapu
King’s College Hospital, United Kingdom
Background: The Metropolitan Police figures in 2009 suggest
a 23% decrease in the incidence of injuries related to offensive
weapons in London compared to 2002. We conducted a retrospec-
tive analysis of extremity gunshot injuries over a 1-year period.
Our aim is to report on our (1) incidence, (2) experience in treating
these injuries and (3) complications.
Methods: Over a 1-year period (2008–2009), 27 extremity
gunshot injuries in 23 patients were identified and case notes
reviewed retrospectively. The following were identified and anal-
ysed: fracture patterns (AO classification), treatment (operative/
non-operative), complications and patient compliance.
Results: Our results show a 15% increase the rate of extremity
gunshot injuries compared to data from 2002. Two-third of our
injuries were managed non-operatively. Complications were as fol-
lows: four wound infections, one delayed union, one compartment
syndrome, one vascular injury and three nerve injuries. Outpatient
compliance was below average.
Conclusion: Our data suggests that extremity gunshot injuries
are on an increase in the south London highlighting the need for
trauma surgeons’ knowledge of the management of these injuries.
This group of patients have poor compliance and one should take
this into account when treating these injuries in outpatient setting.
doi:10.1016/j.injury.2010.07.480
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