Transient peroneal nerve palsies from injuries placed in traction splints

Traction Splinting for midshaft femoral fractures in the pre-hospital and Emergency Department environment-A systematic review

INTRODUCTION

Pain and hemorrhage are common in midshaft femoral fractures. Traction splints (TSs) can reduce pain and control hemorrhage, but evidence of their effectiveness in femoral fractures is still lacking. Through a systematic review, we aimed to analyze and discuss the potential role of TSs in the prehospital and emergency department (ED) setting.

METHODS

The Embase, CINAHL, Cochrane, and PubMed databases were searched up to January 2022. All studies on femoral fractures in the prehospital or ED setting that compared TSs with immobilization or no intervention were included. Articles not written in English, German, or Dutch were excluded. Two authors screened all articles, assessed their quality, and included them if both agreed on their inclusion. The risk of bias was assessed using the modified Methodological Index for Non-Randomized Studies (MINORS). The primary outcome measures were pain and hemorrhage control, while the secondary outcome measures were survivability, morbidity, and complications.

RESULTS

A total of 1,248 articles matched the search strategy, 24 articles were assessed for eligibility based on their abstracts, resulting in 20 articles being included in the synthesis. Ten articles reviewed the effects of TSs on pain, while five reported that the use of a TS was appropriate. All five articles that reviewed blood loss found benefits from the use of a TS. One study found significantly fewer pulmonary complications in patients who were splinted earlier at the scene of injury (level III). No difference was found in complications or mortality between prehospital patients receiving a TS or no TS (level III). None of the studies noted that TSs were a necessity in the ED setting; however, some argued that a TS is a necessary and useful prehospital tool in rural or military areas.

CONCLUSION

TS use is associated with a decreased necessity for blood transfusions and fewer pulmonary complications. No favorable effects were found in terms of pain relief. We recommend the use of TSs in situations where one is likely to encounter a femoral fracture as well as when the time to definitive treatment is long. Further well-designed studies are required to validate these recommendations.

Preventable iatrogenic cause of foot-drop in knee injuries with literature review

PURPOSE

Common peroneal nerve palsy is quite disabling and every effort should be made to prevent its injury during the treatment.

METHODS

We retrospectively reviewed the prospectively collected data of 7 cases of tibial plateau fractures in association with proximal fibula fracture from January 2019 to September 2019 who presented to emergency room of our hospital.

RESULTS

In addition to fibular neck fracture, the first case had type 6 tibial plateau displaced fracture and the second case had displaced acetabular fracture with instability of knee with tibial tuberosity avulsion. common peroneal nerve palsy developed following application of distal tibial skeletal traction in both the cases. Other 6 such cases remained neurologically intact as traction was not applied to them.

CONCLUSION

Such iatrogenic complication could have been prevented if the injury pattern of "concomitant medial and lateral columns" of the proximal leg is kept in mind by the treating surgeon before applying skeletal traction.

Medical management and rehabilitation in posttraumatic common peroneal nerve palsy

Introduction. The common peroneal nerve and the tibial nerve are the two major components into which the sciatic nerve divides. The severity of common peroneal nerve damage depends on the aetiopathogenic mechanism and the place of injury. The peroneal ram of the sciatic nerve injury is the most common cause of mononeuropathy of the lower limb which can cause a signi-ficant disability if is not properly diagnosed and treated. Material and method. We present the case of a 40-year-old patient who suffered a polytrauma by road accident resulting in left tro-chanteric-diaphyseal femoral comminuted open fracture, lacerated wound on the posterolateral middle third of the left thigh, left sacral wing fracture without displacement, left L1, L2, L3 tran-sverse apophyseal fractures and splenic laceration, treated surgically and orthopedically. The pa-tient was admitted to the Medical Reabilitation Department of Sibiu for left leg motor deficit, mechanical pain and functional deficit of the left hip and ankle, gait disorders. Complex rehabi-litation treatment was initiated 3 months after the accident. Results and discussion. Common pe-roneal nerve palsy was confirmed following neurological consultation the day after admission to Orthopaedics-Traumatology Department of Sibiu where continuous extension-traction was performed in order to relax the fracture and subsequent osteosynthesis surgery of the femur fracture. The presence of a deep and lacerating wound on the posterolateral left thigh caused the nerve injury. The coagulase-negative Staphylococcus aureus overinfection of the wound required secondary suturing and subsequently led to fibrous scar formation, adversely affecting the post-injury repair of the common fibular nerve. Conclusions. In patients with posttraumatic common peroneal nerve palsy, early diagnosis and appropriate treatment, including medical rehabilitation, are essential. Medical rehabilitation should be continued on a sustained basis be-cause nerve regeneration occurs slowly. The prognosis mainly depends on the severity of the initial nerve injury. Keywords: common fibular nerve injury, polytrauma, medical rehabilitation

Prehospital Traction Splint Use in Midthigh Trauma Patients

Context

Traction splint (TS) use during emergency medical system transport has been theorized to relieve pain, limit continued injury from loose bone fragments, and decrease potential bleeding space in the injured thigh.

Aims

This study aimed to evaluate the benefit of prehospital TS (PTS) application, using data from the trauma registry at a large Level 1 trauma center.

Methods

A retrospective review of patients from the NTRACS^© and Trauma One^© registry at an American College of Surgeons-verified Level 1 trauma center was conducted. All patients treated between the years 2001 and 2011 who were assigned a diagnosis International Classification of Diseases-9 code of 821.01 (closed fracture of shaft and femur) and 821.11 (open fracture of shaft and femur) (femur fracture [FF]) were included.

Statistical Analysis

All categorical variables between the first groups were compared using Pearson's Chi-square and Fisher's exact test analysis. Comparisons were made using unpaired t-tests and Mann-Whitney test or Kruskal-Wallis one-way ANOVA, followed by Dunn's post hoc pairwise comparisons.

Results

Patients with a TS and those without indicated that the patients with no traction split (NTS) had sustained injuries beyond a FF (14.43 ± 9.740 vs. 18.59 ± 12.993, P < 0.001). The three groups of TS placement (PTS, hospital, and NTS) only used patients with Injury Severity Score < 9 (n = 218). Hospital length of stay (LOS) was found to be significant (P = 0.05) between the patients who received a hospital TS (3.10 ± 1.709) and NTS (5.42 ± 5.144).

Conclusion

PTS can lower LOS and mortality. Further research is needed to confirm these findings.

Iatrogenic Peroneal Nerve Palsy Rates Secondary to Open Reduction Internal Fixation for Tibial Plateau Fractures Using an Intraoperative Distractor

OBJECTIVE

To report the rate of peroneal nerve palsy after routine use of intraoperative distraction during open reduction internal fixation (ORIF) for lateral unicondylar and bicondylar tibial plateau fracture (TPF) repairs.

DESIGN

Retrospective chart review.

SETTING

Level I trauma center.

PATIENTS

Patients with traumatic TPF treated with ORIF between 2007 and 2017.

INTERVENTION

ORIF for lateral unicondylar and bicondylar TPF.

MAIN OUTCOME MEASUREMENT

Presence and resolution of neurovascular injury.

RESULTS

There were a total of 21 lateral unicondylar and 40 bicondylar TPFs repaired through ORIF in 60 patients identified during the study period with 1-year follow-up and complete records for review. Thirty-six patients had staged external fixation before ORIF while 24 were treated with ORIF initially. Of the staged patients, 9 of 36 (25%) developed nerve palsy while those undergoing initial ORIF (not staged) developed palsy in only one case (1 of 24, or 4%). Of the patients who developed nerve palsy, 9 of 10 (90%) were staged with an initial external fixator before ORIF. The incidence of iatrogenic peroneal nerve palsy secondary to intraoperative distraction was 16.4% (10 of 61). Only 60% (6 of 10) of peroneal nerve palsies recovered clinically with a mean recovery time of approximately 14 weeks. Comparison of demographics in patients with peroneal nerve palsy versus those without yielded no significant difference by sex (P = 0.08), age (P = 0.27), fracture type (P = 0.29), tobacco use (P = 0.44), or alcohol use (P = 0.78).

CONCLUSIONS

Peroneal nerve palsy is a common sequela of ORIF for TPFs involving the lateral compartment using an intraoperative distractor. Staged external fixation followed by definitive ORIF using intraoperative distraction was associated with significant risk for developing nerve palsy (9/10). Many patients (40%) who develop peroneal nerve palsies do not recover, leading to permanent loss of motor and/or sensory function for 7% of patients studied. None of the epidemiologic variables evaluated yielded predictive value for development of peroneal nerve palsy or subsequent resolution. Caution should be exercised in avoiding overdistraction when using intraoperative distraction, especially in those cases that had staged fixation, most notably bicondylar injuries.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prehospital use of the traction splint for suspected mid-shaft femur fractures

Introduction:

A retrospective audit of electronic patient care records (ePCRs) highlighted the infrequent use of the traction splint for the management of femur fractures. The aim of this study was to improve the use of the traction splint for patients presenting with a mid-shaft femur fracture in the absence of contraindications, by means of introducing a purpose-designed trauma CPD training course.

Methods:

An intervention consisting of a simulation-based mandatory trauma CPD training session for all operational prehospital care providers was implemented over a 3-month period, supported by a pre- and post-implementation staff survey regarding staff perceptions of using a traction splint. Following the intervention period, a repeat retrospective audit of the ePCR database was conducted to identify any improvement in the use of the traction splint.

Results:

The use of the traction splint for a femur fracture in the pre-intervention stage was found to be underutilised (Median 16%). Following the intervention period, however, traction splint use increased significantly (Median 50%). An improvement was also noted in staff perception and understanding of the management of femur fractures.

Conclusion:

This study found that focused trauma training is an effective means to improve patient care. Training should be ongoing in order to maintain skills and knowledge needed for management of femur fractures.

A Descriptive Analysis of Traction Splint Utilization and IV Analgesia by Emergency Medical Services

Study Objectives Traction splinting has been the prehospital treatment of midshaft femur fracture as early as the battlefield of the First World War (1914-1918). This study is the assessment of these injuries and the utilization of a traction splint (TS) in blunt and penetrating trauma, as well as intravenous (IV) analgesia utilization by Emergency Medical Services (EMS) in Miami, Florida (USA).

METHODS

This is a retrospective study of patients who sustained a midshaft femur fracture in the absence of multiple other severe injuries or severe physiologic derangement, as defined by an injury severity score (ISS) <20 and a triage revised trauma score (T-RTS)≥10, who presented to an urban, Level 1 trauma center between September 2008 and September 2013. The EMS patient care reports were assessed for physical exam findings and treatment modality. Data were analyzed descriptively and statistical differences were assessed using odds ratios and Z-score with significance set at P≤.05.

RESULTS

There were 170 patients studied in the cohort. The most common physical exam finding was a deformity +/- shortening and rotation in 136 patients (80.0%), followed by gunshot wound (GSW) in 22 patients (13.0%), pain or tenderness in four patients (2.4%), and no findings consistent with femur fracture in three patients (1.7%). The population was dichotomized between trauma type: blunt versus penetrating. Of 134 blunt trauma patients, 50 (37.0%) were immobilized in traction, and of the 36 penetrating trauma victims, one (2.7%) was immobilized in traction. Statistically significant differences were found in the application of a TS in blunt trauma when compared to penetrating trauma (OR=20.83; 95% CI, 2.77-156.8; P <.001). Intravenous analgesia was administered to treat pain in only 35 (22.0%) of the patients who had obtainable IV access. Of these patients, victims of blunt trauma were more likely to receive IV analgesia (OR=6.23; 95% CI, 1.42-27.41; P=.0067).

CONCLUSION

Although signs of femur fracture are recognized in the majority of cases of midshaft femur fracture, only 30% of patients were immobilized using a TS. Statistically significant differences were found in the utilization of a TS and IV analgesia administration in the setting of blunt trauma when compared to penetrating trauma. Nackenson J , Baez AA , Meizoso JP . A descriptive analysis of traction splint utilization and IV analgesia by Emergency Medical Services.Prehosp Disaster Med. 2017;32(6):631-635.

Femoral Traction Splints in Mountain Rescue Prehospital Care: To Use or Not to Use? That Is the Question

OBJECTIVES

To determine the incidence of femur fractures in mountain rescue in England and Wales. To investigate the attitudes of rescuers toward the use of femoral traction splints. To review the literature for evidence on the use of traction splints in prehospital medicine and test the hypothesis that femoral traction splints reduce morbidity and mortality in patients with a fractured femur.

METHODS

The Mountain Rescue England and Wales database was searched for cases of suspected fractured femur occurring between 2002 and 2012, a questionnaire was sent to all mountain rescue teams in England and Wales, and a literature review was performed. Relevant articles were critically reviewed to identify the evidence base for the use of femoral traction splints.

RESULTS

Femur fractures are uncommon in mountain rescue, with an incidence of suspected femur fractures on scene at 9.3 a year. Traction splints are used infrequently; 13% of the suspected femur fractures were treated with traction. However, rescuers have a positive attitude toward traction splints and perceive few disadvantages to their use. No trials demonstrate that traction splints reduce morbidity or mortality, but a number describe complications resulting from their use.

CONCLUSIONS

Femur fractures are rare within mountain rescue. Traction splints may be no more effective than other methods of splinting in prehospital care. We failed to identify evidence that supports the hypothesis that traction splints reduce morbidity or mortality. We advocate the use of a femoral traction splints but recognize that other splints may also be appropriate in this environment.

J-splint use for temporizing management of pediatric femur fractures: a review of 18 cases

OBJECTIVES

Pediatric femoral fractures are common injuries encountered in the field and in emergency departments. Currently described temporizing management strategies include skeletal traction, skin traction, traction splinting, and posterior splinting, all of which are suboptimal in some instances. J-splinting femur fractures may be advantageous in temporizing management of pediatric femur fractures. The objective of this study was to evaluate the safety and effectiveness of J-splint use for temporizing management of pediatric femur fractures.

METHODS

This study used a retrospective review of 18 pediatric patients with femur fractures treated with J-splinting in the emergency department. Patient age, weight, and presplinting and postsplinting pain scale ratings were recorded, as well as presplint and postsplint anteroposterior and lateral radiographic fracture angulation. Pain before and after J-splinting was compared using a paired t test.

RESULTS

The mean age of this cohort was 5.4 years (range, 6 months-13 y), with a mean weight of 21.1 kg (range, 7.7-57 kg). In this cohort, there was a significant reduction in pain after reduction and splinting from a mean of 6 to a mean of 1 (P < 0.001). No significant difference in fracture alignment was noted after J-splinting. No complications were noted.

CONCLUSIONS

The J-splint is a reliable, simple, and rapidly applied splint that prevents many of the complications and downfalls of other described temporizing measures and helps to provide excellent pain management in the acute setting.

Temporizing management of pediatric femur fractures using J-splints

This article describes a novel splinting technique for the temporizing management of pediatric femur fractures. The J-splint is a reliable, simple, and rapidly applied splint that prevents many of the complications and pitfalls of other described temporizing measures, such as skeletal traction, skin traction, traction splinting, and posterior splinting. This technique of J-splinting femur fractures has low morbidity and provides many advantages in the temporizing management of pediatric femur fractures.

Transient common peroneal nerve palsy following skeletal tibial traction in a morbidly obese patient - case report of a preventable complication

Today, skeletal tibial traction remains a mainstay of initial management following high-energy, major orthopaedic lower extremity trauma. Historically utilized as definitive fracture management, recent advances in surgical technology have moved skeletal tibial traction into the realm of temporary management, with benefits including fracture reduction, pain relief, and restoration of disturbed surrounding soft tissues, lowering wound complication and compartment syndrome rates. However, no procedure is without its risks. Here, we present a case of common peroneal palsy following skeletal tibial traction placement, which resolved with subsequent pin removal. Indications, proper placement, potential etiologies, and a review of the literature are also discussed.

Safety of amide local anesthetics: new trends

IMPORTANCE OF THE FIELD

Local anesthetics have become one of the most common drugs used in daily practice worldwide. Neurologic and cardiovascular events are the most frequent adverse reactions related to local anesthetics use. Recently, new trends have been developed on this topic.

AREAS COVERED IN THIS REVIEW

We performed an overview of the data available so far on local anesthetics adverse reactions. Relevant literature was identified using PubMed search of articles published up to November 2009, including experimental studies, case reports or clinical studies when available. Search terms included: 'local anaesthetics', 'adverse drug reaction', 'pharmacovigilance' and 'complication'.

WHAT THE READER WILL GAIN

Neurologic, cardiovascular and allergic reactions remain the most frequent adverse drug reactions related to local anesthetics in the literature. Studies based on pharmacovigilance systems have highlighted the frequency of adverse reactions little known until now, such as failure of block. Lipid emulsions are included into algorithm for cardiac resuscitation. Recent studies have demonstrated the myotoxicity and chondrotoxic effects of long-acting local anesthetics.

TAKE HOME MESSAGE

Physicians must keep in mind all these adverse reactions to better prevent their occurrence and give the most appropriate treatment.

Traction splint: to use or not to use

Traction splints are widely used for immobilisation of fractures of the lower limb. There is brevity of evidence-based research on their efficacy. We present a case of skin complication following traction splint for spiral fracture of femur. It is prudent to identify patients at higher risk of developing complications of immobilisation. In circumstances where delays are inevitable, the indication and appropriateness of continuation of traction splint should be re-evaluated.