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Letters to the Editor / Injury, Int. J. Care Injured 45 (2014) 2110–2119 b
Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, PR China
*Corresponding author at: Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, PR China. Tel.: +86 0311 8860 3682; fax: +86 0311 8702 3626 E-mail addresses: [email protected] (Y. Liu), [email protected] (H. Li), [email protected] (Y. Zhang).
authors enlarge the sample size to conduct another wonderful study to show clinical researchers more perfect data in future. Lastly, we think that it would be wonderful to show some postoperative radiogram pictures from the last follow-up to elucidate the different fracture healing states of small- and large-gap groups. We declare that there is no conflict of interests about our letter. Qikui Wang1 Junlin Zhou* Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, Gong Ren Ti Yu Chang Nan Rd, Chaoyang District, 100020 Beijing, China *Corresponding author. Tel.: +86 13911591377
http://dx.doi.org/10.1016/j.injury.2014.05.021
E-mail addresses: [email protected] (Q. Wang), [email protected], [email protected] (J. Zhou).
Letter to the Editor The butterfly fragment in comminuted femoral shaft fracture may be movable following intramedullary nail treatment
1
Tel: +0086 15611357720. Received 16 June 2014
http://dx.doi.org/10.1016/j.injury.2014.06.020 A B S T R A C T
The gap among fracture fragments is an important factor which influences the healing of bone fracture, and it may be changeable during the early phase of bone healing. In this letter, we pointed out our view that the gap between the butterfly fragment, and the shaft in femoral shaft fractures can easily be changed, so it is hard to study the potential correlation between the size of the gap and fracture healing. ß 2014 Elsevier Ltd. All rights reserved.
Letter to the Editor To ‘‘the outcome of patients sustaining a proximal femur fracture who suffer from alcohol dependency’’ Sir,
Dear Editor, Recently, we have interestingly read a paper finished by WeiHsiu Hsu and his colleagues, ‘‘Effect of fragmentary displacement and morphology in the treatment of comminuted femoral shaft fractures with an intramedullary nail’’ presented on the 10th issue of volume 44 in 2013. We absolutely agree with this argument that a larger fracture gap has a higher potential to interfere with bone healing; however, the gap between a fragment and the femoral shaft is mainly formed as a result of haematoma expansion, soft tissue interposition and traction of muscles attached on the fragment. So with the absorption of haematoma, necrosis or contraction of muscles and postoperative activities of the patient, the fragments which have not been fixed in intramedullary nail treatment may not be maintained still; their positions can easily be changed especially during the early phase of bone fracture healing. So we think that it may be critical to show a relevant evidence to support the conclusion or give some explanations in the discussion section. Second, in our experience, a larger butterfly fragment tends to form a greater gap. Because a fracture with a larger butterfly fragment is always caused by more powerful axial compression besides a bending stress, the fracture is more unstable in this situation. A larger fragment may have a higher probability to develop haematoma expansion, soft tissue or muscle contraction, so it is easy to be kept away from its original anatomic location to form a greater gap. Furthermore, a few data in this study show that ‘‘the mean size of fragments in the small- and large-gap groups was 64.7 mm and 78.5 mm, respectively (p = 0.059)’’, the two values of the mean size really shows a relatively significant difference, and the p value is close to 0.05; so we hope that the
Faroug et al. [1] performed an interesting study on the outcome of patients sustaining a proximal femur fracture who suffer from alcohol dependency. They found that the one year mortality rate of such patients was as high as 29%. What is more, the failure rate of intra-capsular fractures fixed with cannulated screws was 56% at a median time of 43 days. In our opinion, the high rate of complications with fracture fixation and high one year mortality may be related with improper surgical method. For such patients with ASA grade 2 or more, hemiarthroplasty was the preferred surgical method, even for the undisplaced femoral neck fractures and intertrochanteric fractures. Through this treatment principles, we have a relatively low rate of complications and mortality one year later, which was nearly 12% and 11% respectively. So we want to know the answer to the question ‘‘Are there significant differences in postoperative morbidity and mortality one year later between patients with different levels of ASA in the author’s study?’’ [1]. Conflict of interest None declared. Reference [1] Faroug R, Amanat S, Ockendon M, Shah SV, Gregory JJ. The outcome of patients sustaining a proximal femur fracture who suffer from alcohol dependency. Injury 2014;45:1076–9.
Yueju Liua,b,* Yingze Zhanga,b a Third Hospital of Hebei Medical University, Shijiazhuang 050051, PR China
Letters to the Editor / Injury, Int. J. Care Injured 45 (2014) 2110–2119 b
Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, PR China
*Corresponding
author at: Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, PR China. Tel.: +86 0311 8860 3682; fax: +86 0311 8702 3626 E-mail addresses: [email protected] (Y. Liu), [email protected] (Y. Zhang). http://dx.doi.org/10.1016/j.injury.2014.07.024
Letter to the Editor Disability after nondisplaced and minimally displaced radial head fractures: Misleading conclusions Smits and colleagues [1] assume that upper extremity symptoms and disability (DASH scores) an average of 3.8 years following nonoperative treatment of nondisplaced and minimally displaced radial head fractures relate directly to impairment resulting from that injury. In doing so, they ignore extensive evidence that symptoms and disability have limited correlation with pathophysiology and impairment and are most highly correlated with mood, coping strategies, and circumstances [2–4]. We know that nondisplaced and occult fractures of the radial head without associated ligament injury or other fractures result in minimal impairment, mostly a very slight loss of extension. We would not expect this to create substantial symptoms or disability. This paper represents both a missed opportunity to clarify this for orthopaedic surgeons as well as an unfortunate reinforcement of the myth that there is a direct correspondence between disease (pathophysiology) and illness (symptoms and disability). Conflict of interest None declared. References [1] Smits AJ, Giannakopoulos GF, Zuidema WP. Long-term results and treatment modalities of conservatively treated Broberg–Morrey type 1 radial head fractures. Injury 2014. http://dx.doi.org/10.1016/j.injury.2014.05.034. [2] Bot AG, Doornberg JN, Lindenhovius AL, Ring D, Goslings JC, van Dijk CN. Longterm outcomes of fractures of both bones of the forearm. J Bone Joint Surg Am 2011;93:527–32. [3] Lindenhovius AL, Doornberg JN, Ring D, Jupiter JB. Health status after open elbow contracture release. J Bone Joint Surg Am 2010;92:2187–95. [4] Menendez ME, Bot AG, Hageman MG, Neuhaus V, Mudgal CS, Ring D. Computerized adaptive testing of psychological factors: relation to upper-extremity disability. J Bone Joint Surg Am 2013;95:e149.
Mariano E. Menendez David Ring* Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Suite 2100, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA *Corresponding author. Tel.: +1 617 643 7527; fax: +1 617 726 0460 E-mail addresses: [email protected] (M.E. Menendez), [email protected] (D. Ring). http://dx.doi.org/10.1016/j.injury.2014.07.023
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Letter to the Editor Iatrogenic lung injury on radiological evidence: Is it always wise to blindly follow the image? Dear Editor, I read with interest the article by Kong and Clarke [1]. The authors have done a great service in publishing the mistakes made by medical professionals in attempting to address chest injuries and pleural pathologies. I wanted to, if I may, make a more general point regarding the incidence and management of iatrogenic injuries in the chest. Those of us in the cardiothoracic surgical community regularly encounter referrals of unfortunate patients with chest drains in the wrong place. However, we have also encountered instances where an iatrogenic injury has been reported on Computer Tomography (CT) scanning as a result of chest drain malposition but which have in fact turned out to be false. In the last year for instance we have had a radiologically reported case whereby a large-bore chest drain had been inserted into a large bulla inadvertently and another whereby a large-bore chest drain had been inserted into lung parenchyma. Both indications for drainage were pneumothoraces. Both reports turned out to be inaccurate upon surgical confirmation. This is highly unfortunate as patients would have unnecessary procedures based upon the CT report of an iatrogenic injury. The cases illustrate that iatrogenic injuries may actually be over-reported as artefacts may be present on the CT which inadvertently give the impression of something more sinister [2]. These ‘pseudo iatrogenic injuries’ have been reported elsewhere. A rather incisive German paper reported numerous instances whereby large bore chest drains appear to enter the lung parenchyma but in actual fact do not [3]. Their explanations for the discrepancy include the fact that firstly the chest drain is in a fissure and this may not be obvious on the CT. Secondly, large bore drains may cause a ‘sinking’ effect of the surrounding parenchyma to deceive one into thinking that the drain is going through the lung. It is worth noting that large-bore drains should be inserted using an open technique. If this is the case and one bluntly dissects down to the intercostal space, opens the parietal pleura, removes any adhesions with their finger and only then introduces the chest drain, the chances of that drain going into the lung are almost impossible. The exception would be the blind introduction of a large chest drain via a trocar which the authors correctly highlight. The 19th century Danish philosopher, Søren Kierkegaard, once said ‘‘There are two ways to be fooled. One is to believe what isn’t true; the other is to refuse to believe what is true’’ [4]. The intelligence and ability to critically differentiate what is presented in front of them and not be fooled is the unnerving skill of the surgeon. Hence, whilst I acknowledge the importance of identifying and treating iatrogenic injuries following chest drains, we must be equally cautious in blindly following CT reports which suggest iatrogenic injury without assessing the patient clinically and making a more prudent diagnosis which can otherwise result in unnecessary distress for the patient. Conflict of interest The author declares no conflict of interest. References [1] Kong VY, Clarke DL. The spectrum of visceral injuries secondary to misplaced intercostal chest drains: experience from a high volume trauma service in South
Letters to the Editor / Injury, Int. J. Care Injured 45 (2014) 2110–2119 b
Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, PR China
*Corresponding author at: Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, PR China. Tel.: +86 0311 8860 3682; fax: +86 0311 8702 3626 E-mail addresses: [email protected] (Y. Liu), [email protected] (H. Li), [email protected] (Y. Zhang).
authors enlarge the sample size to conduct another wonderful study to show clinical researchers more perfect data in future. Lastly, we think that it would be wonderful to show some postoperative radiogram pictures from the last follow-up to elucidate the different fracture healing states of small- and large-gap groups. We declare that there is no conflict of interests about our letter. Qikui Wang1 Junlin Zhou* Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, Gong Ren Ti Yu Chang Nan Rd, Chaoyang District, 100020 Beijing, China *Corresponding author. Tel.: +86 13911591377
http://dx.doi.org/10.1016/j.injury.2014.05.021
E-mail addresses: [email protected] (Q. Wang), [email protected], [email protected] (J. Zhou).
Letter to the Editor The butterfly fragment in comminuted femoral shaft fracture may be movable following intramedullary nail treatment
1
Tel: +0086 15611357720. Received 16 June 2014
http://dx.doi.org/10.1016/j.injury.2014.06.020 A B S T R A C T
The gap among fracture fragments is an important factor which influences the healing of bone fracture, and it may be changeable during the early phase of bone healing. In this letter, we pointed out our view that the gap between the butterfly fragment, and the shaft in femoral shaft fractures can easily be changed, so it is hard to study the potential correlation between the size of the gap and fracture healing. ß 2014 Elsevier Ltd. All rights reserved.
Letter to the Editor To ‘‘the outcome of patients sustaining a proximal femur fracture who suffer from alcohol dependency’’ Sir,
Dear Editor, Recently, we have interestingly read a paper finished by WeiHsiu Hsu and his colleagues, ‘‘Effect of fragmentary displacement and morphology in the treatment of comminuted femoral shaft fractures with an intramedullary nail’’ presented on the 10th issue of volume 44 in 2013. We absolutely agree with this argument that a larger fracture gap has a higher potential to interfere with bone healing; however, the gap between a fragment and the femoral shaft is mainly formed as a result of haematoma expansion, soft tissue interposition and traction of muscles attached on the fragment. So with the absorption of haematoma, necrosis or contraction of muscles and postoperative activities of the patient, the fragments which have not been fixed in intramedullary nail treatment may not be maintained still; their positions can easily be changed especially during the early phase of bone fracture healing. So we think that it may be critical to show a relevant evidence to support the conclusion or give some explanations in the discussion section. Second, in our experience, a larger butterfly fragment tends to form a greater gap. Because a fracture with a larger butterfly fragment is always caused by more powerful axial compression besides a bending stress, the fracture is more unstable in this situation. A larger fragment may have a higher probability to develop haematoma expansion, soft tissue or muscle contraction, so it is easy to be kept away from its original anatomic location to form a greater gap. Furthermore, a few data in this study show that ‘‘the mean size of fragments in the small- and large-gap groups was 64.7 mm and 78.5 mm, respectively (p = 0.059)’’, the two values of the mean size really shows a relatively significant difference, and the p value is close to 0.05; so we hope that the
Faroug et al. [1] performed an interesting study on the outcome of patients sustaining a proximal femur fracture who suffer from alcohol dependency. They found that the one year mortality rate of such patients was as high as 29%. What is more, the failure rate of intra-capsular fractures fixed with cannulated screws was 56% at a median time of 43 days. In our opinion, the high rate of complications with fracture fixation and high one year mortality may be related with improper surgical method. For such patients with ASA grade 2 or more, hemiarthroplasty was the preferred surgical method, even for the undisplaced femoral neck fractures and intertrochanteric fractures. Through this treatment principles, we have a relatively low rate of complications and mortality one year later, which was nearly 12% and 11% respectively. So we want to know the answer to the question ‘‘Are there significant differences in postoperative morbidity and mortality one year later between patients with different levels of ASA in the author’s study?’’ [1]. Conflict of interest None declared. Reference [1] Faroug R, Amanat S, Ockendon M, Shah SV, Gregory JJ. The outcome of patients sustaining a proximal femur fracture who suffer from alcohol dependency. Injury 2014;45:1076–9.
Yueju Liua,b,* Yingze Zhanga,b a Third Hospital of Hebei Medical University, Shijiazhuang 050051, PR China
Letters to the Editor / Injury, Int. J. Care Injured 45 (2014) 2110–2119 b
Key Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, PR China
*Corresponding
author at: Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, PR China. Tel.: +86 0311 8860 3682; fax: +86 0311 8702 3626 E-mail addresses: [email protected] (Y. Liu), [email protected] (Y. Zhang). http://dx.doi.org/10.1016/j.injury.2014.07.024
Letter to the Editor Disability after nondisplaced and minimally displaced radial head fractures: Misleading conclusions Smits and colleagues [1] assume that upper extremity symptoms and disability (DASH scores) an average of 3.8 years following nonoperative treatment of nondisplaced and minimally displaced radial head fractures relate directly to impairment resulting from that injury. In doing so, they ignore extensive evidence that symptoms and disability have limited correlation with pathophysiology and impairment and are most highly correlated with mood, coping strategies, and circumstances [2–4]. We know that nondisplaced and occult fractures of the radial head without associated ligament injury or other fractures result in minimal impairment, mostly a very slight loss of extension. We would not expect this to create substantial symptoms or disability. This paper represents both a missed opportunity to clarify this for orthopaedic surgeons as well as an unfortunate reinforcement of the myth that there is a direct correspondence between disease (pathophysiology) and illness (symptoms and disability). Conflict of interest None declared. References [1] Smits AJ, Giannakopoulos GF, Zuidema WP. Long-term results and treatment modalities of conservatively treated Broberg–Morrey type 1 radial head fractures. Injury 2014. http://dx.doi.org/10.1016/j.injury.2014.05.034. [2] Bot AG, Doornberg JN, Lindenhovius AL, Ring D, Goslings JC, van Dijk CN. Longterm outcomes of fractures of both bones of the forearm. J Bone Joint Surg Am 2011;93:527–32. [3] Lindenhovius AL, Doornberg JN, Ring D, Jupiter JB. Health status after open elbow contracture release. J Bone Joint Surg Am 2010;92:2187–95. [4] Menendez ME, Bot AG, Hageman MG, Neuhaus V, Mudgal CS, Ring D. Computerized adaptive testing of psychological factors: relation to upper-extremity disability. J Bone Joint Surg Am 2013;95:e149.
Mariano E. Menendez David Ring* Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Suite 2100, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA *Corresponding author. Tel.: +1 617 643 7527; fax: +1 617 726 0460 E-mail addresses: [email protected] (M.E. Menendez), [email protected] (D. Ring). http://dx.doi.org/10.1016/j.injury.2014.07.023
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Letter to the Editor Iatrogenic lung injury on radiological evidence: Is it always wise to blindly follow the image? Dear Editor, I read with interest the article by Kong and Clarke [1]. The authors have done a great service in publishing the mistakes made by medical professionals in attempting to address chest injuries and pleural pathologies. I wanted to, if I may, make a more general point regarding the incidence and management of iatrogenic injuries in the chest. Those of us in the cardiothoracic surgical community regularly encounter referrals of unfortunate patients with chest drains in the wrong place. However, we have also encountered instances where an iatrogenic injury has been reported on Computer Tomography (CT) scanning as a result of chest drain malposition but which have in fact turned out to be false. In the last year for instance we have had a radiologically reported case whereby a large-bore chest drain had been inserted into a large bulla inadvertently and another whereby a large-bore chest drain had been inserted into lung parenchyma. Both indications for drainage were pneumothoraces. Both reports turned out to be inaccurate upon surgical confirmation. This is highly unfortunate as patients would have unnecessary procedures based upon the CT report of an iatrogenic injury. The cases illustrate that iatrogenic injuries may actually be over-reported as artefacts may be present on the CT which inadvertently give the impression of something more sinister [2]. These ‘pseudo iatrogenic injuries’ have been reported elsewhere. A rather incisive German paper reported numerous instances whereby large bore chest drains appear to enter the lung parenchyma but in actual fact do not [3]. Their explanations for the discrepancy include the fact that firstly the chest drain is in a fissure and this may not be obvious on the CT. Secondly, large bore drains may cause a ‘sinking’ effect of the surrounding parenchyma to deceive one into thinking that the drain is going through the lung. It is worth noting that large-bore drains should be inserted using an open technique. If this is the case and one bluntly dissects down to the intercostal space, opens the parietal pleura, removes any adhesions with their finger and only then introduces the chest drain, the chances of that drain going into the lung are almost impossible. The exception would be the blind introduction of a large chest drain via a trocar which the authors correctly highlight. The 19th century Danish philosopher, Søren Kierkegaard, once said ‘‘There are two ways to be fooled. One is to believe what isn’t true; the other is to refuse to believe what is true’’ [4]. The intelligence and ability to critically differentiate what is presented in front of them and not be fooled is the unnerving skill of the surgeon. Hence, whilst I acknowledge the importance of identifying and treating iatrogenic injuries following chest drains, we must be equally cautious in blindly following CT reports which suggest iatrogenic injury without assessing the patient clinically and making a more prudent diagnosis which can otherwise result in unnecessary distress for the patient. Conflict of interest The author declares no conflict of interest. References [1] Kong VY, Clarke DL. The spectrum of visceral injuries secondary to misplaced intercostal chest drains: experience from a high volume trauma service in South
