Forensic & Expert Witness E Mag
Special issue
An insight into: Management of fractures, trauma & medico legal reports Most common fractures caused by accidents
The importance of using the right expert witness THE LONG TERM EFFECT OF FRACTURES
Does your age make a difference ?
Interviews with leading expert witness Professor Charles Court Brown www.forensic&expertwitnessemag.com
Professor Charles Court-Brown Expert Witness in M Orthopaedic Trauma Prof Charles Court-Brown
Professor Charles Court-Brown MB, FRCS Ed (Orth) specialises in orthopaedic surgery including the management of fractures and their complications.
Professor Of Orthopaedic Trauma MD, FRCS Ed (Orth) Attaining his first medical qualification in 1975, Professor Court-Brown is a well respected and highly experienced Orthopaedic Trauma and Orthopaedic Surgeon specialising in musculoskeletal injuries particularly of the lower limb. He also has extensive knowledge of the management of upper limb injuries as well as spinal injuries including whiplash. Professor Court-Brown's expertise covers Trauma emergencies, trauma and intensive Professor of Orthopaedic and care for multiple injury patients. He also has extensive experience in the Orthopaedic Surgeon with particular treatment of fractures and has published extensively on fracture epidemiology and interests fracture trends in in thethe elderly.management Expert Witness instruction of has included cases of personal injury, road traffic accidents slipping and tripping.
orthopaedic injuries encompassing A Fellow of the Royal College of Surgeons of Edinburgh, Professor Court-Brown has a personal chair from Musculo-skeletal injuries and the University of Edinburgh. He has written or edited eight books and over 150 research papers on fractures diseases, ankle, wrist, and their treatment. fractures, He was also thefoot, first non-American surgeon to write a chapter in Rockwood and Green’s Fractures Adultsupper and he limb has been an editor of the last three editions of this book. He has extensive handin and injuries (including medico-legal experience and has been instructed annually to write expert witness reports as well provide whiplash testimony in Court. injuries) and surgery in respect of all of these Career profile Professor of Orthopaedic Trauma, University of Edinburgh
Surgery expertise also covers Training and Clinical Practice Undergraduate Medical training, University of Edinburgh Orthopaedic training, Royal Infirmary of Edinburgh emergency and trauma surgery and Trauma Fellowship, Sunnybrook Hospital, Toronto, Canada intensive for multiple injury MD Thesis. The Hughescare external fixation device. Studies of its biomechanical properties, its effect on fracture healing and its clinical application. patients of personal injury, Road Consultant Orthopaedic Surgeon, Royal Infirmary of Edinburgh. Traffic Accidents and slipping, tripping, falling and other hazards. Publications
About 170 publications in refereed journals 30 invited papers I have writen 8 books and over 82 chapters Books100 papers on my specialities Court-Brown CM, Hughes SPF. A Colour Atlas of External Fixation. and CM. have in ofdepth medico-legal Court-Brown An Atlas Closed Nailing of the Tibia and Femur. Court-Brown CM, McQueen MM and Quaba AA. Management experience, averaging some 300of Open Fractures Court-Brown CM and Pennig D. Tibia and Fibula. instructions annually and Perrynew C, Court-Brown CM. Masterclass. Orthopaedic Trauma. Robinson CM, Alho A,court Court-Brown CM. Femur. including appearances Bucholz R, Heckman J, Court-Brown CM. Rockwood and Green’s Fractures in Adults 6th edition. Court-Brown CM, McQueen MM, Tornetta P. OSE Trauma Bucholz R, Heckman J, Court-Brown CM, Tornetta P. Rockwood and Green’s Fractures in Adults 7th edition. Court-Brown CM, Heckman J, McQueen MM, Tornetta P, McKee M. Rockwood and Green’s Fractures in Adults 8th edition. Court-Brown CM, McQueen MM, Swiontkowski M, Friedmann S, Ring D, Duckworth AD. Musculoskeletal Trauma in the Elderly. In Press.
Contact: Prof C M Court-Brown Craigesk House, Lothianbridge. EH22 4TP. Tel:0131 660 4227. Emailccb@courtbrown.com For further information, please call the Secretary of Professor Court-Brown T:0131 660 4227 E:ccb@courtbrown.com
The epidemiology of fractures
Fractures are extremely common and occur in all age groups and in both males and females. However their distribution changes with age and gender. In males fractures have a bimodal distribution with an increased incidence being seen in both younger and older males. In females there is a unimodal distribution affecting older females. The incidence of fractures is relatively constant until the menopause after which the incidence rises quickly and the spectrum of fractures changes. Table 1 shows the ten most common fractures in different age groups. In children and adolescents (≤ 15 years of age) fractures of the hand and wrist account for about 55% of all fractures with a further 9% occurring in the diaphyses, or mid-section, of the long bones. With increasing age the distribution of fractures changes but in adults, aged 16-64 years, about 47% of fractures are hand fractures and only about 4% are long bone diaphyseal fractures. In older patients (≼ 65 years) the distribution of fractures is different. Only about 29% occur in the wrist and hand and about 5% are long bone diaphyseal fractures. Table 1 shows that there is a considerable increase in fragility fractures with the commonest fracture in the ≼ 65 year age group being the proximal femoral, or hip, fracture. Other fragility fractures that are commonly seen are the distal radius, or distal forearm, fracture and the proximal humeral fracture in the shoulder.
Table 1 shows that fractures of the pelvis and femur are more common. These are often though to be high-energy injuries that occur as a result of road traffic accidents but nowadays they are mainly fragility fractures, occurring in the elderly. Table 1 shows that overall the commonest fracture that presents to orthopaedic surgeons is the distal radius, or wrist, fracture. This is known as the Colles fracture after Abraham Colles who described it. These account for about a third of all childhood and adolescent fractures and about a fifth of all fractures in the elderly. Some fractures, such as the clavicle or collar bone fracture, are more commonly seen in young patients and others, such as the ankle fractures are commoner in young and middle aged adults. Obviously the epidemiology of fractures reflects the condition of the bones but also the activities of the population. Ankle fractures often follow work-place or sports injuries and are therefore more common in young and middle-aged adults.
There are many medical and social factors that influence fracture epidemiology and these are probably best examined by assessing the effect of social deprivation on the incidence of fractures. A study in Scotland showed that in the least affluent 10% of the population the incidence of fractures in males was 4 times higher than in the rest of the population. The equivalent figure for females was 3.5 times.
The epidemiology of fractures is changing very rapidly. A comparison of fracture epidemiology in adults aged > 35 years in the United Kingdom in the 1950s with an equivalent population in 2010 shows that the incidence of fractures in males rose by 4.4% but in females it rose by 85.7%. This illustrates the rapid change in social conditions and the health of the population in the last 60 years. Industrial injuries have declined and fragility fractures have increased.
Table 1 The overall incidence and prevalence of the commonest 10 fractures in three age groups. The data was collected in Edinburgh, Scotland.
Types of fracture Closed fractures Most fractures that occur are closed fractures with an intact soft tissue envelope that occur in healthy bone. There is usually a degree of associated soft tissue damage and the amount of bone damage depends on the force of the injury and the age of the patient. Figure 1 shows a closed femoral diaphyseal fracture with significant bone comminution. This is typical of a high-energy injury such as occurs in a road traffic accident.
Figure 1. An posterior x-ray comminuted femoral fracture young male after traffic accident.
Open fractures Approximately 2% of all fractures are open fractures in which there is extensive soft tissue damage resulting in a soft tissue defect that permits contamination of the fracture by the outside environment (Figure 2). Traditionally it has been assumed that most open fractures result from high energy injuries such as road traffic accidents, falls from a height or war time injuries. This is still the case in many open fractures in young males but recently it has become clear that the incidence of open fractures in elderly females is about the same as in younger males although virtually all are caused by low energy mechanisms such as a standing fall. The explanation is that skin, like bone, thins with age and in fact it has been shown that in elderly females skin thickness is a predictor of osteoporosis. Young patients tend to present with open fractures of the hand and from the knee downwards and they are frequently associated with road traffic accidents. Older patients often present with open fractures of the distal forearm and ankle after a simple fall. Figure 2. An open fracture of the tibia.
anteroof a closed in a a road
Stress fractures These fractures occur as a result of overuse usually in patients who give no history of a specific injury. There are two types these being fatigue fractures and insufficiency fractures. Fatigue fractures occur in normal bone as a result of unaccustomed repetitive loading and insufficiency fractures occur in abnormally weak bone subjected to normal loading. Stress fractures are usually seen in athletes, military recruits (Figure 3) and ballet dancers. Insufficiency fractures are seen in the elderly and in patients with diseases that result in abnormally weak bone. A common locations of fatigue fractures is the proximal femur, or hip, these often being seen in fun runners. They are also seen in the shaft of the femur and they have been reported in most lower limb bones. Insufficiency fractures are essentially fragility fractures and they occur in many locations with increasing age. Spinal fractures are very common.
Periprosthetic fractures Periprosthetic fractures (Figure 4) are becoming commoner with increasing use of total joint replacements and fracture fixation methods. Fractures can occur around prostheses used to treat arthritis or around the implants used to treat fractures. Fractures around prostheses are usually seen in the hip or knee and they are associated with osteoporosis and other bone diseases such as rheumatoid arthritis. They are usually treated by replacement of the prosthetic joint with a larger one or by applying a plate or plates across the fracture.
Figure 4. A lateral x-ray of a periprosthetic fracture above a knee replacement.
Figure 3. An antero-posterior x-ray of femoral fracture in a military recruit. There was no trauma.
Pathological fractures The term pathological fracture is applied to a fracture that occurs through an area of weakness in the bone caused by a benign or malignant tumour or, more commonly, by a secondary metastatic tumour deposit or by bone disease (Figure 5). Primary bone tumours are relatively rare and most pathological fractures are secondary to metastases from another tumour. The commonest tumours to metastasise are those of the breast, prostate, kidney, thyroid and lung. Treatment involves careful investigation to find the primary tumour and radiotherapy and chemotherapy are often used. Extensive bone resection and prosthetic replacement are also often required. Legends
Figure 5. A metastatic deposit and pathological fracture in the humerus. The primary was breast carcinoma.
Outcomes and complications of fractures. It is often assumed that fractures are straightforward to treat and are associated with a good outcome. However, in fact, many fractures are associated with considerable morbidity and mortality which increases with the age of the patient and the severity of the fracture and its associated soft tissue injury. Many younger patients with minor fractures make a full recovery but older patients or patients with severe injuries often complain of residual pain, joint stiffness and impaired function. If the patient has, or develops, psychological dysfunction after the injury these problems are often exacerbated. Impaired function is a particular problem in middle-aged or older manual workers who have severe
There are a number of recognised complications of fractures.
Acute compartment syndrome
Acute compartment syndrome occurs when pressure arises within a conďŹ ned space in the body resulting in a critical reduction of blood ow to the tissues within the space. This is most commonly seen in the lower leg following a tibial diaphyseal fracture but it is also seen in other areas such as the thigh, hand and forearm. The main diagnostic sign is increased pain and if the diagnosis is delayed the patient may develop muscle weakness, paralysis and sensory problems. Treatment is by rapid decompression of the affected compartments. Compartment syndrome is usually secondary to a fracture but about 30% of cases follow a soft tissue injury. It is most commonly seen in young males. There has been debate about the best method of diagnosing compartment syndrome. Traditionally the patient is observed for increasing pain, muscle weakness, paralysis or sensory problems but pain is difďŹ cult to assess and quantify particularly if analgesia is used. Recently direct measurement of the compartment pressure has been shown to be a very useful technique but, as yet, it is not used by all surgeons.
Infection Bone infection is called osteomyelitis. It is usually seen in open fractures and may cause non-union. All open fractures require aggressive tissue clearance to remove all devitalised tissue. They then require soft tissue reconstruction often using plastic surgery techniques. Infected bone is treated similarly. All infected and devitalised tissue is removed and bone grafting and soft tissue reconstruction undertaken. If this is impossible amputation may be necessary.
Non-union Most fractures unite without secondary surgery but union is affected by the severity of the fracture and the associated soft tissue damage. It is also affected by age, smoking, radiation and a number of medical conditions and drugs. Non-unions are more frequent in diaphyseal fractures because the bone blood supply is not as good as at the ends of long bones. Open fractures are particularly susceptible. Thus closed proximal tibial fractures virtually always unite but severe open tibial diaphyseal fractures have a non-union rate of 30 – 35%. Non-unions can be atrophic, with no evidence of healing, or hypertrophic, where the healing process has started but failed. They can also be aseptic, with no infection, or infected. The treatment of non-union depends on the type. Bone grafting is often used with bone commonly taken from the crest of the pelvis. Allograft bone from a bone bank can be used as can a number of synthetic products. The surgeon may also change the method of surgical treatment.
Malunion Surgeons have a responsibility to ensure that bones heal in good alignment. The difficulty is assessing good alignment in all patients and surgeons may well accept a degree of malalignment in old infirm patients. However significant malalignment in younger patients may result in impaired function and should be avoided.
Nerve injury Fractures may damage adjacent nerves. This most commonly seen in proximal humeral, forearm and pelvic fractures. The nerves are usually intact and will recover but if they do not investigation and treatment is required. Unfortunately nerves are sometimes injured by surgery and this is a particular problem with plating. Care must be taken to visualise and protect adjacent problem with plating. A good example is radial nerve damage secondary to plating of a humeral fracture.
Vascular damage
Very severe open fractures may be associated with damage to major blood vessels. This is a major problem in wartime injuries. If possible the artery should be repaired or grafted but if this impossible amputation may be required.
Post-traumatic osteoarthritis Fractures involving joints may cause significant joint damage and result in early arthritic change. In symptomatic patients this is treated by joint replacement or by fusing smaller joints.
Mortality Seriously injured patients may die as a result of their fractures and associated injuries. However there is considerable mortality in isolated, low energy injuries in the elderly and the common proximal femoral, or hip, fracture is associated with an overall mortality of 20-25% which rises to about 45% in patients older than 90 years.
What causes fractures? It is often assumed that most fractures occur as a result of high energy injuries. This is sometimes the case but most fractures actually occur as a result of a low energy injury such as a fall or trip from standing height. The causes of the adult fractures listed in Table 1 in the section on fracture epidemiology are shown in Table 1. It can be seen that 62.5% of fractures are the result of a fall from standing height with a further 4.2% being caused by a low fall such as on stairs. The second most common cause is a direct blow, which may be work-related. Sports injuries are relatively common but only 5.2% of fractures follow road traffic accidents and 2.3% occur as a result of a fall from a height, such as from a ladder.
Falls from a standing height This is the commonest cause of fracture and is responsible for 40.7% of fractures in males and 85.4% of fractures in females. With an increasing elderly population more such fractures will be seen. The commonest fractures resulting from a standing fall are fragility fractures such as proximal femoral, proximal humeral and distal forearm fractures.
Direct blows Table 1 shows that fractures from a direct blow tend to occur in younger patients, usually males. Overall 48% are metacarpal fractures and 27.5% are finger fractures. Industrial hand fractures are now rare because of improved safety legislation and most now occur because of the interaction between testosterone and alcohol.
Sports injuries These are a heterogeneous group of fractures that usually occur in young adults. The causes of sports fractures vary in different countries but in the fractures detailed in Table 1 39.5% were caused by soccer, 13% by rugby, 11,8% by cycling and 10.1% by winter sports.
Road traffic accidents Fractures following road traffic accidents are relatively rare but Table 1 shows that they tend to be more severe with a high prevalence of open fractures and multiple fractures. Table 2 shows the demographic details of people who sustain fractures in road traffic accidents.
Cyclists Cyclists have the highest risk of fractures in road traffic accidents. They occur in young males and females but are five times more common in males. About 90% of fractures occur in the upper limb with fractures of the clavicle (20.8%), proximal forearm (19%) and distal forearm (12.5%) being particularly common. Lower limb fractures are uncommon but if cyclists cannot undo their shoes from the pedals they may fall and sustain a proximal femoral fracture, this being the classic fracture of elderly ladies!
Motorcyclists Table 2 shows that about 22% of road accident fractures occur in motorcyclists who are usually young men. Predictably there is a high prevalence of open and multiple fractures. Analysis shows that 64.1% of fractures occur in the upper limb with the commonest fractures being in the hand (21.8%), distal forearm (17.9%) and clavicle (14.1%).
Pedestrians Pedestrians who present with fractures tend to be older (Table 2) and to be at risk of sustaining multiple fractures. There is a higher prevalence of lower limb fractures (50.8%) and the commonest fractures are those of the metatarsals (23.8%), tibial shaft (11.1%) and the fingers (11.1%). A further 11.1% present with spinal or pelvic fractures.
Vehicle occupants Improved car design and the requirement for seat belts and airbags has reduced the incidence of fractures in vehicle occupants. Passengers are safer than drivers who not infrequently present with open fractures or multiple fractures. The most common fractures are those of the distal forearm (13.3%) and spine (13.3%).
Falls from a height Table 1 shows that fractures resulting from falls from a height (>2-3 meters) tend to be the most severe. People that fall from a ladder are often seriously injured. They tend to occur in younger males and their epidemiology is different. There is a very high prevalence of fractures of the distal tibia, ankle and foot (38.5%) and the commonest fracture is that of the calcaneus or heel bone (23%). Spinal fractures are also very common (17.5%)
Children’s fractures The most common cause of fractures in children is a low fall, from below bed height, or a fall down stairs or a slope (39.8%). Higher falls cause 17.2% of fractures and blunt trauma causes 18.8%. Sports injures cause 12.1% and road traffic accidents 6.7% of fractures.
What causes fractures?
The management of fractures The use of stiffened bandages to treat fractures is attributed to Hippocrates and it lasted until about 200 years ago. However with increased industrialisation and the casualties of the Napoleonic Wars better methods were required. The Plaster of Paris cast and traction became popular but there was increased interest in operative treatment. This accelerated after the 2nd World War and the Vietnam War and now many fractures are treated by internal or external fixation. This has resulted in lower morbidity and mortality and improved patient function. However with the increased number of fractures in the frail elderly population there has been a return to non-operative management for some fractures.
Non-operative management remains the most popular method of treating fractures. A large study of fractures in both children and adults treated in 2000 in a major trauma unit showed that 25.4% were treated with primary surgery. Non-operative management was used in 91.6% of children and adolescents and in 67.6% of adult fractures. It is difficult to know how accurate these figures are 15 years later as there has been increased interest mainly in upper limb fracture surgery but there are
more elderly being treated non-operatively. Operative management is more commonly used in adults, lower limb fractures, high energy fractures, open fractures, displaced fractures and in patients with multiple fractures. Wiring techniques are often used for smaller bones but the most popular operative techniques are plating, intramedullary nailing, external fixation and joint replacement.
Plating
The first plate was used in 1886. Since then it has become very popular and plating can be used to treat most fractures. The classic plate was a straight plate that permitted rigid fracture fixation but recently increased used has been made of location specific plates designed to fit a particular bone (Figure 1). The latest advance in plate use has been the introduction of the locked plate. In this plate the screws are secured in bone but the screws head also screw into the plate. This is thought to be useful in plate fixation of fragility fractures as plate failure will be less frequent. Thus far there is little evidence that this is the case. Plating remains the treatment of choice for many fractures.
Figure 1 An A-P x-ray of a plate designed to be use on the distal femur. This is a locking plate with the screw heads locked into the plate.
Intramedullary nailing Intramedullary nailing is particularly used to treat long bone or diaphyseal fractures. Metal nails were used at the end of the 1st World War and popularised by K端ntscher in the 2nd World war. Since then they have become the treatment of choice for lower limb diaphyseal fractures. The recent development of locking nails has increased their usefulness as proximal and distal screws can be inserted though the nail and bone and a wider range of fractures can be treated (Figure 2). Intramedullary nailing is being used more frequently in adult upper limb diaphyseal fractures and in diaphyseal fractures in children but in children care must be taken not to damage the growth plates. Figure 2 An A-P x-ray of a locking intramedullary tibial nail used in a comminuted fracture. Note the 2 screws used to treat the ankle fractures.
External fixation This technique was first used about 1850. It has been used sporadically since but has become more popular in the last 20 – 30 years, mainly as a result of the work of Ilizarov in Russia. The technique is used for a number of reasons. It is used in open fractures either as definitive treatment of until the soft tissue damage has been treated and internal fixation can be used. It is used as a temporary treatment method in severely injured patients and it can be used to lengthen bone or to transport a segment of bone to encourage fracture union. It can also be used in closed fractures (Figure 3).
Figure 3. An external fixation device used to treat a distal forearm fracture.
Joint replacement Increasingly joint replacement is being used to treat fractures around joints in the elderly. Hip replacement is commonly used to treat proximal femoral fractures (Figure 4) and recently shoulder replacement has become popular for proximal humeral fractures. It is likely that other joint replacement procedures will become popular as the population ages as joint replacement is a definitive procedure that allows early mobility. Figure 4 A hip replacement used to treat a proximal femoral fracture in an elderly patient.
Prof Charles M Court-Brown Professor Of Orthopaedic Trauma MD, FRCS Ed (Orth)
Professor of Orthopaedic Trauma and Orthopaedic Surgeon with particular interests in the management of orthopaedic injuries encompassing Musculo-skeletal injuries and diseases, fractures, foot, ankle, wrist, hand and upper limb injuries (including whiplash injuries) and surgery in respect of all of these Surgery expertise also covers emergency and trauma surgery and intensive care for multiple injury patients of personal injury, Road Traffic Accidents and slipping, tripping, falling and other hazards. I have writen 8 books and over 100 papers on my specialities and have in depth medico-legal experience, averaging some 300 new instructions annually and including court appearances
Contact: Prof C M Court-Brown Craigesk House, Lothianbridge. EH22 4TP. Tel:0131 660 4227. Emailccb@courtbrown.com