displacedSCHFsaretreatedwithsurgery,wouldresultin77%of patientsundergoingunnecessaryoperativetreatment.Moraleda andcolleaguesshowedthatpatientswithatype-IISCHFtreated conservatively had a mild cubitus varus deformity and a mild increaseinelbowextension,butwithexcellentfunctionalresults inthemajorityofpatients[5].
Combinedinterpretation oftheseresultsmaysuggestthat a proportionofthedisplacedSCHFswillhealappropriatelywithout surgical intervention. We therefore believe that a conservative approachtothepostoperativemalalignmentinsomepatientsis acceptable,and protects patients fromundergoingunnecessary secondarysurgeryaftertheindexprocedure.Althoughnotmany complicationsarereported,probablepsychologicaldistressforthe childanditsparentsofasecondinterventionwillbepartofeach re-doprocedure. The conclusionsdrawn by theauthorsin this relevantstudyshouldbeseeninthelightofthesecomments. Conflictofintereststatement
Theauthorsdeclarenoconflictofinterest. References
[1]OrO,WeilY,SimanovskyN,PanskyA,GoldmanV,LamdanR.Theoutcomeof earlyrevisionofmalalignedpediatricsupracondylarhumerusfractures.Injury 2015.pii:S0020-1383(15)00218-1.
[2]RaneyEM,ThielenZ,GregoryS,SobralskeM.Complicationsofsupracondylar osteotomiesforcubitusvarus.JPediatrOrthop2012;32:232–40.
[3]CampJ,IshizueK,GomezM,GelbermanR,AkesonW.AlterationsofBaumann’s anglebyhumeralposition:implicationsfortreatmentofsupracondylar hu-merusfractures.JPediatrOrthop1993;13:521–5.
[4]PersianiP,DiDomenicaM,GurziM,MartiniL,LanzoneR,VillaniC.Adequacyof treatment,boneremodelingandclinicaloutcomeinpediatricsupracondylar humeralfractures.JPediatrOrthopB2012;21:115–20.
[5]MoraledaL,ValenciaM,BarcoR,Gonzalez-MoranG.Naturalhistoryof unre-ducedGartlandtype-IIsupracondylarfracturesofthehumerusinchildren:a twotothirteen-yearfollow-upstudy.JBoneJointSurgAm2013;95:28–34.
A.E.Dekker*
LeidenUniversityMedicalCenter,DepartmentofTraumaSurgery, PostalZoneK6-R,Albinusdreef2,2333ZALeiden,TheNetherlands M.P.J.vandenBekerom OnzeLieveVrouweGasthuis,DepartmentofOrthopaedicSurgery, Oosterpark9,1091ACAmsterdam,TheNetherlands J.N.Doornberga,b,c
aUniversityofAmsterdamOrthopaedicResidencyProgram(PGY4),
TheNetherlands
bTEAMTraumaplatform&OrthopaedicResearchCenterAmsterdam,
TheNetherlands
cOnzeLieveVrouweGasthuis,DepartmentofOrthopaedicSurgery,
Oosterpark9,1091ACAmsterdam,TheNetherlands I.B.Schipper1
LeidenUniversityMedicalCenter,DepartmentofTraumaSurgery, PostalZoneK6-R,Albinusdreef2,2333ZALeiden,TheNetherlands
*Correspondingauthor E-mailaddresses:anne_brittd@hotmail.com(A.E.Dekker), Bekerom@gmail.com(M.P.J.vandenBekerom), jobdoornbergortho@gmail.com(J.N.Doornberg), I.B.Schipper@lumc.nl(I.B.Schipper).
1Tel.:+31715261065;fax:+31715266750.
http://dx.doi.org/10.1016/j.injury.2015.06.021
Letter
to
the
Editor
Femoralveininjuryfromatrochanteric hipfracture
DearEditor,
Wereadwithgreatinterestthecasereportentitled‘‘Femoral veininjuryfromatrochanterichipfracture’’intheissueof2015 Jun; 46 (6): 1171–1173 of Injury, Int. J. Care Injured, and congratulate theauthorson their managementof thecase.We wouldliketocommendtheauthorsfortheirdetailedandvaluable work[1].
Injuryoffemoralvesselsisararecomplicationof intertrochan-teric fractures [1–3]. Complications reported in the English literature specificallydue tomigration of the lesser trochanter fragmentinclude injury totheprofunda femoris artery[4] and femoralnervecompression[5].
However, we believethat some important additional com-mentsseemnecessarytobecontributedthroughthisstudy.In this article, the authors stated that their case was the first description of a common femoral vein injury by a spike of a displaced lessertrochanter[1].Nevertheless,we wouldliketo call theattention ofthe readers tothefactthatthe literature containsanadditionalcasereport.Thus,contrarytotheauthors’ claim,theirsisnotthefirstcaseintheliterature.Choaetal.[2] presented the first case in theEnglish literaturedocumenting damage to the common femoral vein by a displaced lesser trochantericfragment.Asseenintheircase,theysuggestedthat theproximalmigrationof alarge lessertrochantericfragment can lead to significant neurovascular damage. They recom-mended carefulreviewofradiographsinpositionofthelesser trochanterandconcludedthatifthefragmentisfoundunusually proximally migrated, an ultrasound examination of the area shouldbeconsidered[2].
LikeotherauthorsKeelandEyres[3]alsosuggestedthatthe proximalmigrationofalargelessertrochantericfragmentisnot totallybenignandislikelytomigratewithmovementsatthehip duetofunctionofattachediliopsoas.
Againweappreciatetheauthorsontheirworkwhichaddsto ourknowledgetobeabletorecognizeandmanagethisdifficult vascularclinicalproblem.
Conflictofinterest
Theauthorshavenoconflict ofinteresttodeclare,andthere wasnoexternalfundingsourceforthisstudy.
Disclaimer None. References
[1]MedlockG,McCulloughL,BarkerS.Femoralveininjuryfromatrochanterichip
fracture. Injury 2015;46(June (6)):1171–3.
http://dx.doi.org/10.1016/j.inju-ry.2015.03.004.
[2]ChoaRM,ShanmugamS, MolloyA,NarayanB. Femoralveininjuryinan intertrochantericfracture:acasereport.InjuryExtra2009;40(8):155–7.
[3]KeelJD,EyresKS.Vascularinjurybyanintertrochantericfracturefragment. Injury1993;24(5):350–2.
[4]RitchieED,HaverkampD,SchiphorstTJ,BosschaK.Falseaneurysmofthe profundafemorisartery,ararecomplicationofaproximalfemoralfracture. ActaOrthopBelg2007;73(August(4)):530–2.
[5]NielsenKD,DammenI.Latesymptomsafterhipfracturewithdisplacementof thelessertrochanter–acasereport.ActaOrthopScand2003;74(4):500–1.
SelahattinOzyurek* DepartmentofOrthopaedicsandTraumatology,AksazMilitary Hospital,Marmaris,Mugla,Turkey AzizAtik DepartmentofOrthopaedicsandTraumatology, BalikesirUniversityHospital,Balikesir,Turkey SerkanAribal DepartmentofRadiology,AksazMilitaryHospital,Marmaris, Mugla,Turkey *Correspondingauthorat:DepartmentofOrthopaedicsand Traumatology,AksazMilitaryHospital,48700Marmaris, Mugla,Turkey.Tel.:+902524210161 E-mailaddress:fsozyurek@yahoo.com(S.Ozyurek).
http://dx.doi.org/10.1016/j.injury.2015.06.014
Letter
to
the
Editor
Responseto:‘‘CoulibalyM,etal.Resultsof 70consecutiveulnarnightstickfractures’’ [Injury2015]
DearEditor,
With utmostinterestIread thearticle byCoulibalyetal. in which the resultsof operative and non-operative treatment of isolatedulnarshaft fractures(IUSF)werecompared[1].Using a retrospectivecase–controlanalysistheyfound14non-unions(NU) in70patients(20%).Besidessecondarydisplacement>2mm, non-operativetreatmentwasfoundtoberelatedtoNU.Werecently analysedallpatientswithanIUSFwhoweretreatedatourtrauma centreduringtheperiod2004–2012andfoundtheexactopposite, i.e.theonlyfactorassociated withNU wasactually havinghad
surgery.Wewouldliketoaddourdatatothediscussion. Ninety-threepatientswereidentifiedretrospectively:56 males(60.2%), meanage36.8years(SD26;2–87),with54right-sidedfractures (58.1%). Data on fracture type (AO classification), degree of angulation, comminution, displacement, and exact location of thefractureintheulnarbonecanbefoundinTable1.Fivepatients developed a NU; only 1 out of the 83 patients treated conservatively,comparedto4outofthe10patientstreated by open reductionand internal fixation. None of the generally acceptedriskfactorsappliedatalltoourrelativelylargesample ofpatients(Table2).
Inconclusion,clinicalstudiescontinuetoyieldcontradicting results.IllustratedonceagainbythestudyofCoulibalyetal.and ourown,retrospectivestudiesarenotabletosolvethedebate on the optimal treatment of IUSF [1]. Interpretation and generalisationoftheserelativelysmallandretrospectivestudies should bedonewithcaution. Forexample110out ofthe 180 patientsintheaforementionedstudywereexcludedbecauseof inadequate follow-up [1]. Until there is a robust and well-powered RCT, IUSF will remain unpredictable and treatment controversial.
Sincerelyyours, Conflictofinterest
Nonedeclared. Reference
[1]CoulibalyM,JonesCB,SietsemaDL,SchildhauerTA.Resultsof70consecutive ulnarnightstickfractures.Injury2015;46:1359–66.
Sincerelyyours, J.J.Kox AtriumMedicalCentre,Heerlen,DepartmentofTraumaSurgery,Henri Dunantstraat5,6419PCHeerlen,TheNetherlands R.Dinjens AtriumMedicalCentre,Heerlen,DepartmentofOrthopaedicSurgery, HenriDunantstraat5,6419PCHeerlen,TheNetherlands P.A.Hustinx AtriumMedicalCentre,Heerlen,DepartmentofTraumaSurgery,Henri Dunantstraat5,6419PCHeerlen,TheNetherlands W.L.W.vanHemert AtriumMedicalCentre,Heerlen,DepartmentofOrthopaedicSurgery, HenriDunantstraat5,6419PCHeerlen,TheNetherlands G.F.Vlesa,b,* aAtriumMedicalCentre,Heerlen,DepartmentofTraumaSurgery,
HenriDunantstraat5,6419PCHeerlen,TheNetherlands
Table1 Patientcharacteristics. N=93 N(percentage/range) N(percentage/ range) Sex Displacement% Male 56(60.2%) 0% 49 Female 37(39.8%) 0–10% 7 Age 36.8(2–87years; SD26) 11–40% 23 Side 41–70% 8 Right 54(58.1%) 71–90% 1 Left 39(41.9%) 90–100% 2 Angulation 3.78(0–30) Missing 3 Comminution 6(6.5%) Displacementto AOclassification None 48 22-A1.1 30(32.3%) Dorsal 10 22-A1.2 50(53.8%) Volar 15 22-B1.1 7(7.5%) Ulnar 15 22-B1.2 4(4.3%) Radial 5 22-C1.1 2(2.2%) Location
Openfractures 0(0%) Proximalthird 3
Treatment Middlethird 36
Conservative 83(89.2%) Distalthird 53
Operative 10(10.8%) Missing 1
Result
Union 88
Non-union 5
Table2
GenerallyacceptedriskfactorsforthedevelopmentofNUinIUSF.
Riskfactor N Non-union
>50%displacement 11 0 >58angulation 41 0 Proximalthird 3 0 Middlethird 36 4 Distalthird 53 1 Wedge(Btype) 11 1 Complex(Ctype) 2 1 Open 0 NA Operativetreatment 10 4
LetterstotheEditor/Injury,Int.J.CareInjured46(2015)2073–2087
