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IntroductionA hip fracture carries significant morbidity and mortality—a second fracture of the contralateral hip carries even higher complications. Most second hip fractures occur within 48 months of the first. The aim of this study was to comprehensively analyse all identifiable variables that may increase the risk of a contralateral hip fracture within this time period.MethodsWe retrospectively analysed 1242 consecutive patients with hip fractures presenting to our institution. All patient-related, surgery-related and inpatient variables were collected from the index admission. We then identified patients with a subsequent contralateral hip fracture in the following 2 years. Univariate and multivariate analyses were performed to identify risk factors associated with a second fracture.ResultsA total of 66 patients (5.3%) had a contralateral hip fracture in the 2 years following initial hip fracture. Mean age at first presentation was 81 years, and mean time to second fracture was 305 days. Following multivariate analysis, the patients at highest risk of a second fracture were those with dementia, acute inpatient chest infection, urinary tract infection and multiple comorbidities as measured by the Charlson score. Discharge destination after initial fracture was not associated with the risk of a second fracture.ConclusionsWe have identified a number of discrete risk factors that are associated with a short- to medium-term risk of contralateral hip fracture that may be useful in screening for patients at risk and provide them with focused medical rehabilitation.

Fractures of the proximal humerus are common in the middle age population and usually result from a fall. The fracture may involve the humeral head, lesser tuberosity, greater tuberosity, surgical head or anatomical head of the humerus. Neer’s classification is used to guide treatment and it is based on the number of segments displaced (one to four part fractures). An axillary x-ray is necessary to exclude fracture dislocation. In this chapter the surgical management of proximal humeral fractures is discussed.

BACKGROUND: The UK hip fracture best practice tariff (BPT) aims to deliver hip fracture surgery within 36 h of admission. Ensuring that delays are reserved for conditions which compromise survival, but are responsive to medical optimisation, would help to achieve this target. We aimed to identify medical risk factors of surgical delay, and assess their impact on mortality. MATERIALS AND METHODS: Prospectively collected patient data was obtained from the National Hip Fracture Database (NHFD). Medical determinants of surgical delay were identified and analysed using a multivariate regression analysis. The mortality risk associated with each factor contributing to surgical delay was then calculated. RESULTS: A total 1361 patients underwent hip fracture surgery, of which 537 patients (39.5 %) received surgery within 36 h of admission. Following multivariate analyses, only hyponatraemia was deduced to be a significant risk factor for delay RR = 1.24 (95 % CI 1.06-1.44). However, following a validated propensity score matching process, a Pearson chi-square test failed to demonstrate a statistical difference in mortality incidence between the hypo- and normonatraemic patients [χ (2) (1, N = 512) = 0.10, p = 0.757]. CONCLUSIONS: Hip fracture surgery should not be delayed in the presence of non-severe and isolated hyponatraemia. Instead, surgical delay may only be warranted in the presence of medical conditions which contribute to mortality and are optimisable. LEVEL OF EVIDENCE: III.

Congenital insensitivity to pain is a rare condition that is often undiagnosed until patients present with a variety of musculoskeletal problems. A major sequel of these orthopaedic manifestations is the development of heterotopic ossification and callus formation following fractures, eventually leading to the development of a Charcot's joint. This case reports on a 7-year-old child who was diagnosed with congenital insensitivity to pain type V, after he presented in our clinic with fractures of the metatarsals in his left foot while continuing to weight bear, without any discomfort. The patient failed to attend the follow-up in paediatric neurology clinic despite multiple invitations. This case highlights the importance of establishing an early diagnosis and keeping a close eye on this rare entity, which can present for the first time in a paediatric fracture clinic.

Salmonella osteomyelitis occurs infrequently in healthy children and can manifest in the subacute form. This condition has only been reported in few cases previously. We report the first case of primary subacute haematogenous osteomyelitis of the calcaneum in a healthy 12-year-old child. The patient made uneventful recovery following surgical drainage and antibiotic therapy. Histology of the tissue biopsy confirmed a diagnosis of Salmonella livingstone infection. Although the diagnosis of Salmonella osteomyelitis of the calcaneum can be difficult to establish, it should be considered as an aetiological factor even in healthy children.

The dominant approach in brand-extension research has focused on the role of fit in the extension evaluation process. Overemphasis on fit has resulted in research designs that involve singular evaluation of the extension without considering how competing brands in the target category might affect the evaluation of brand extensions. Singular evaluations are known to result in brand positivity effects; that is, brand extensions are evaluated more favorably than is warranted. This research finds that singular evaluations do indeed lead to brand positivity effects. However, brand positivity effects are mitigated when respondents were provided with competitive information along with target-category structure and comparative/non-comparative brand positioning statements. Results also suggest that parent brand-extension fit, though an important determinant of an extension's assessment, plays a less critical role in a comparative evaluation context when an extension's brand strength is accounted for in relation to its competition in the target category. Therefore, the findings stress the importance of both competition and parent-brand fit in making informed positioning decisions and more realistic predictions of extension success. The research demonstrates when, how and to what extent comparative evaluations result in lower extension ratings and provides managerial strategies to introduce an extension effectively.

Posterior cruciate ligament (PCL) injuries from tibial avulsions are rare in the paediatric setting. One would need a high index of suspicion as clinical examination may be difficult, especially in the early period. Magnetic resonance imaging is an excellent diagnostic modality for this condition and other associated injuries within the knee. We report a rare case in which the patient had a PCL avulsion off the tibial insertion site with an associated posterior horn medial meniscal tear off the posterior capsule. He was treated through open reduction and internal fixation of the avulsed fragment with suture repair of the meniscal tear. We emphasize the importance of diagnosing and managing associated intra-articular injuries when dealing with the rare condition of PCL tibial avulsion in the paediatric setting.

Background A fracture neck of femur is the leading cause of injury-related mortality in the elderly population. The 30-day mortality figure is a well utilised marker of clinical outcome following a fracture neck of femur. Current studies fail to analyse all patient demographic, biochemical and comorbid parameters associated with increased 30-day mortality. We aimed to assess medical risk factors for mortality, which are easily identifiable on admission for patients presenting with a fractured neck of femur. Methods A retrospective review of a prospectively populated database was undertaken to identify all consecutive patients with a fracture neck of femur between October 2008 and March 2011. All factors related to the patient, injury and surgery were identified. The primary outcome of interest was 30-day mortality. Univariate and subsequent multivariate analyses using a backward stepwise likelihood ratio Cox regression model were performed in order to establish all parameters that significantly increased the risk of death. Results A total of 1,356 patients were included in the study. The 30-day mortality was 8.7%. The most common causes of death included pneumonia, sepsis and acute myocardial infarction. Multiple regression analysis revealed male gender, increasing age, admission source other than the patient's own home, admission haemoglobin of less than 10 g/dL, a history of myocardial infarction, concomitant chest infection during admission, increasing Charlson comorbidity score and liver disease to be significant predictors of mortality. Conclusions This study has elucidated risk factors for mortality using clinical and biochemical information which are easily gathered at the point of hospitalization. These results allow for identification of vulnerable patients who may benefit from a prioritisation of resources.

The purpose of this inquiry was to analyze: (a) the extent to which hospitals employed senior citizens as models in their advertisements, (b) the roles of these models and their active-passive status, and (c) the degree to which the advertisements portrayed seniors in a positive or negative status. Content analysis was employed to assess these issues. Hypotheses about the portrayal of senior citizens by hospitals were tested by examining advertisements in newspapers. The analysis provided some findings which should be of value to researchers and practitioners in the health care industry.

Fractures of the distal end of the radius are common injuries and are the commonest bony injury around the wrist. Management of these fractures has remained controversial as far as modality of treatment is concerned. In this study 90 adult cases of acute displaced intra-articular fractures of the lower end of the radius were classified according to Frykman's and AO classifications after obtaining radiographs in antero-posterior and lateral planes. These were randomly treated by one of three methods: (1) closed reduction and plaster immobilisation, (2) external fixation and (3) open reduction and internal fixation, and were followed for an average of 4 yr. In the final functional assessment (Sarmiento) the results were (1) plaster 43% good and excellent, 50% fair and 7% poor, (2) external fixator 80% good and excellent, 20% fair and poor results, (3) open reduction and internal fixation 63% good and excellent, 26% fair, 11% poor. We recommend that displaced severely comminuted intra-articular fractures should be treated with an external fixator.