SYNOPSISThe clinical course and prognosis of 282 cases of acute post-traumatic coma have been studied. Death occurred in 140 cases (49%o), and, of survivors, about two-thirds achieved complete social reintegration, while one-third were partially reintegrated or not at all. The quality of survival did not depend only on the nature of the physical sequelae, but also on other factors, particularly social ones. With regard to early prognosis, the authors believe it is possible to predict the final outcome of the patient by using the indices of age, level of coma, and the nature of the intracranial lesions.

Highlights Tumor-transmitted osteomalacia is a rare FGF 23 transmitted phosphaturic disease. Delay of diagnosis is common due to small and clinically silent underlying tumors. The most sensitive imaging modality is 68 Ga-DOTA-TOC-PET/CT-scan. Complete resection of the tumor mass cures this paraneoplastic disease.

Aims Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making. Methods A total of 163 shoulders in 162 patients with conservatively treated isolated proximal humeral fractures were included. The fractures occurred between January 2015 and May 2018. The mean age of the patients was 69 years (26 to 100) and the mean follow-up was 144 days (42 to 779). The fractures were classified according to Neer. Scores for osteoporosis (Tingart, Deltoid Tuberosity Index (DTI)) and osteoarthritis (OA) of the glenohumeral joint were assessed. Translation of the head on follow-up radiographs of more than 10 mm was defined as displacement. Eccentric head index (EHI) describes the offset of the humeral head centre in relation to the diaphyseal axis. The ratio was estimated on anteroposterior (AP) and Neer views. Medial hinge was considered intact if the medial cortex proximal and distal to the fracture was in line on AP view. Results Secondary fracture displacement occurred in 41 patients (25.2%). Clinical risk factors were alcohol abuse (odds ratio (OR) 6.8; 95% confidence interval (CI) 1.3 to 36; p = 0.025) and previously diagnosed osteoporosis (OR 4.6; 95% CI 0.6 to 34; p = 0.136). Age (OR 1.1; 95% CI 1.0 to 1.1; p = 0.003) and sex (OR 0.9; 95% CI 0.3 to 2.8; p = 0.867) were not independent factors. Radiological risk factors were OA grade 3 (OR 16.4; 95% CI 0.25 to 37.6; p = 0.107) and osteoporosis with the DTI (OR 10; 95% CI 0.8 to 250; p = 0.031) being more predictive than the Tingart score (OR 2.3; 95% CI 0.8 to 4.7; p = 0.041). A high EHI (AP/Neer > 0.4, OR 18.9; 95% CI 2.1 to 30.9/3.0; 95% CI 1.1 to 8.0; p = 0.002/p = 0.033) and a disrupted medial hinge (OR 3.7; 95% CI 1.1 to 12.6; p = 0.039) increased the risk of secondary displacement significantly. Neer classification had no influence. Conclusion During conservative treatment, a quarter of patients showed secondary fracture displacement of at least 10 mm. Patients with alcohol abuse, severe OA, and osteoporosis are at risk. Newly defined EHI and disrupted medial hinge are relevant predictors for secondary displacement. Cite this article: Bone Joint J 2020;102-B(7):881–889.

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Zusammenfassung. Gelenkinfektionen stellen einen orthopädischen Notfall dar. Eine verzögerte Diagnose oder Behandlung kann zu schweren Schädigungen im betroffenen Gelenk führen. Zudem stellt die Abgrenzung zu anderen entzündlichen Arthritiden eine Herausforderung dar. Um sowohl eine Verzögerung der Therapie als auch eine Überbehandlung beziehungsweise vorschnelle Operation zu vermeiden, ist die frühzeitige, interdisziplinäre Kooperation zur Planung von Diagnostik und Therapie unerlässlich. Die rechtzeitige Zuweisung in ein Zentrum, welches auf muskuloskelettale Infektionen spezialisiert ist, ist zu empfehlen. Abstriche oder probatorische Antibiotikagabe verfälschen und verzögern die Diagnostik und sollten daher nicht durchgeführt werden.