Historic indications for fixation of posterior malleolus fractures- where did they come from and where are we now?

INTRODUCTION

The indications for reduction and fixation of the posterior malleolus component of rotational ankle fractures have been controversial for nearly a century. This study aims to identify the historical basis for surgical intervention and trace trends in management strategies over time.

METHODS

In March 2023, a systematic review of full-text, English-language articles providing indications for surgical fixation of the posterior malleolus component of rotational ankle fractures was performed. Articles underwent title and abstract screening before undergoing full-text review.

RESULTS

Historical indications for surgical fixation were size-dependent, with fractures comprising 25 % to 33 % of the plafond recommended for internal fixation. Modern studies suggest that nonoperative management of posterior malleolus fractures below this threshold results in residual malreduction of the articular surface, syndesmotic instability, and an increased need for independent fixation of the syndesmosis.

CONCLUSIONS

Size-based indications for posterior malleolus fracture fixation are based on Level V evidence from small retrospective case series published nearly one century ago and should be retired. While the size of the posterior malleolus component cannot be ignored, additional factors like fracture morphology and location within the plafond should guide modern surgical indications. Contemporary studies indicate that reduction and fixation of small posterior malleolus fractures (comprising less than 25 % of the articular surface) are associated with improved articular reductions, tibiotalar contact pressures, syndesmotic stability with decreased need for independent fixation of the syndesmosis, and superior postoperative outcomes.

Meta-analysis of elastic versus rigid fixation in the treatment of acute tibiofibular syndesmosis injury

OBJECTIVE

The objective of this study was to conduct a meta-analysis by synthesizing multiple literature sources to explore whether there are any differences between elastic fixation and rigid fixation in the treatment of acute tibiofibular syndesmosis injuries. The aim was to provide effective guidance for clinical treatment.

METHODS

We conducted a comprehensive search across seven databases, including both Chinese and English, to include all studies related to the treatment of acute tibiofibular syndesmosis injuries with elastic fixation and rigid fixation published between January 1, 2013, and November 15, 2022. Following the PRISMA guidelines, we rigorously screened, assessed, and extracted data from the included studies. The outcome measures included AOFAS scores at 3, 6, and 12 months postoperatively; tibiofibular clear space (TBCS) and tibiofibular overlap distance (TBOL) at the early postoperative and 12-month follow-up; intraoperative blood loss; operative time; time to full weight-bearing postoperatively; and postoperative complications. Meta-analysis was performed using Review Manager 5.4.

RESULTS

A total of 35 studies were included, comprising 16 randomized controlled trials and 19 retrospective cohort studies. The study population included 2120 cases, with 1044 cases in the elastic fixation group and 1076 cases in the rigid fixation group. The elastic fixation group had higher AOFAS scores at 3, 6, and 12 months postoperatively compared to the rigid fixation group. Although the elastic fixation group had a slightly larger TBCS than the rigid fixation group in the early postoperative period, the difference between the two groups became statistically insignificant at 12 months postoperatively. There was no statistically significant difference in TBOL between the two groups in the early postoperative period, but at 12 months, the elastic fixation group had a greater TBOL than the rigid fixation group. Additionally, the elastic fixation group had lower rates of postoperative local irritation, wound infection, and postoperative internal fixation loosening or rupture compared to the rigid fixation group. The rate of postoperative tibiofibular redislocation did not differ statistically between the two groups. The time to full weight-bearing was shorter in the elastic fixation group than in the rigid fixation group. Although the elastic fixation group had a slightly longer operative time, there was no statistically significant difference in intraoperative blood loss between the two groups.

CONCLUSION

Compared to rigid fixation, elastic fixation in the treatment of acute tibiofibular syndesmosis injuries offers several advantages, including better postoperative ankle joint function recovery, more precise anatomical reduction of the syndesmosis postoperatively, a lower incidence of postoperative complications, and shorter time to full weight-bearing postoperatively. These findings provide robust guidance for clinical treatment.

The reliability of posterior malleolar ankle fracture assessment: a unique perspective

AIM

This study aims to elucidate the pathology of PMFs in the South African population, establish correlations between fracture patterns and international classification guidelines and evaluate the interobserver reliability of current classifications.

METHODS

A retrospective review was conducted in a multicentre analysis over a one-year period from January 2019 to December 2019 at our institution. Computer tomography scans for foot and ankle injuries were reviewed, and posterior malleolus fractures were included. Pathoanatomical data was collected and analysed according to known classification systems and subsequent treatment modalities evaluated. A panel of observers individually reviewed radiographic data to determine interobserver reliability.

RESULTS

A total of 71 patients were included with a mean age of 41 ± 13.4 years (range 18-78) and a female predominant population (69%). A greater proportion of injuries were high energy (23.9%), with significant fragment comminution (53.5%), and half (52.1%) of all injuries were subluxated/dislocated at presentation. A total of 93% of injuries were managed operatively, despite theatre access limitations resulting in significant delays to fixation (19.1 days). Despite good pathoanatomical agreement with most international classifications, interobserver reliability was poor (Krippendorff α-coefficient < 0.667). Inconsistent treatment patterns in operative and non-operative strategies are reported.

CONCLUSION

A unique patient population of younger, female individuals incurred posterior malleolar fractures due to higher energy mechanisms of injury. Whilst injury patterns were mostly comparable, significant interobserver variability was noted. Resource limitations, diagnostic challenges, poorly defined and inconsistent treatment strategies, inevitably impact outcomes within the South African population.

LEVEL OF EVIDENCE

Level III.

A novel minimally invasive fixation method for flail chest management in a Canine model: an animal research

BACKGROUND

Multiple rib fractures can lead to flail chest with up to 35% mortality rate due to severe pulmonary complications. Current treatments of flail chest remain controversial. Studies have shown that surgical treatments can improve outcomes and reduce mortality, comparing to non-operative treatments. Current surgical fixation methods focus on stabilization of ribs on the outward facing side, and they require division of intercostal muscles. Damages to surrounding nerves and vessels may lead to chronic pain. This study tests a novel interior fixation method that minimizes neurovascular injuries.

METHODS

Twelve healthy canines were divided in two surgical operation groups for exterior and interior fixation using titanium metal plates. Osteotomy with oblique fractures was prepared under general anesthesia. Exterior fixation was performed in open surgery. Interior fixation was minimally invasive using custom made tools including a flexible shaft extension screwdriver, solid plate stand, guiding wire loop and metal plates with threaded holes.

RESULTS

Respiratory and cardiovascular functions (RR, PO2, PCO2, SpO2, and HR) together with body temperature were measured before anesthesia and within 48 h after surgery. The difference in measurements was not statistically significant between the two groups before surgery with P values greater than 0.05. However, the interior group canines had better RR and PO2 values starting from the 24th hour, and better PCO2, SpO2, and HR values starting from the 48th hour. It took longer operation time to complete the minimally invasive interior fixation surgery (P value less than 0.001), but the total blood loss was less than the exterior fixation group (P value less than 0.001). Results also showed that interior group canines suffered less pain, and they had quicker recovery in gastrointestinal and physical mobility.

CONCLUSIONS

The investigative interior fixation method was safe and effective in rib stabilization on a canine rib fracture model, comparing to the exterior fixation method. The interior fixation was minimally invasive, with less damages to tissues and nerves surrounding the ribs, leading to better postoperative outcomes.

Two-week versus four-week immobilization of stable distal radioulnar joint following surgical fixation of Galeazzi fracture-dislocations: A randomized controlled trial

Background

Postoperative immobilization protocols following surgical fixation of Galeazzi fracture-dislocations (GFD) in adults remain unresolved. This study aimed to compare outcomes of two different immobilization durations (two weeks versus four weeks) in terms of functional outcomes and complications.

Methods

Participants were prospectively and randomly enrolled in two-week versus four-week immobilization after plate fixation of GFD when the distal radioulnar joint (DRUJ) was reducible and stable postoperatively. Immobilization involved an above-elbow splint with the forearm in full supination. Demographic data, including age, gender, mechanism of injury, fracture characteristics, and treatment approach, were recorded. The primary outcome was the abbreviated version of the Disability of Arm, Shoulder, and Hand (DASH) scores at three months post-operation. Secondary outcomes included wrist range of motion, mean grip strength differences between injured and uninjured sides, and complications.

Results

A total of 54 participants were enrolled and randomized into two treatment groups. Demographics were similar between groups, with most participants being male, and the mean age was 35 years (range 18-65). Fractures were generally less than 10 cm. The mean DASH scores were slightly higher in the four-week immobilization group but not statistically significant (1.43 in the two-week immobilization group vs. 2.36 in the four-week immobilization group, p = 0.152). Range of motion and mean grip strength differences were similar between groups. Complication rates were also similar, with recurrent DRUJ dislocation occurring in two participants from each group.

Conclusion

This study found no significant differences in functional outcomes and complications between two-week and four-week immobilization durations after plate fixation of GFD when the DRUJ was reducible and stable postoperatively.

Level of evidence

Therapeutic Level I.

Operative Management for Displaced Distal Clavicle Fractures

This article reviews techniques and outcomes of surgical fixation for distal clavicle fractures. Near 100% union has been reported for several techniques. The most common are locked plating, coracoclavicular fixation and a combination of plating with CC fixation. Hook plates are useful for particular fracture patterns, but there can be complications specific to this implant. Low-profile constructs are favored due to the high rates of symptomatic hardware. Fixation of subacute and chronic injuries can provide reliable functional improvements, but is inferior to acute fixation. Surgery is generally the treatment of choice for displaced fractures in athletes.

Quantitative Evaluation of the Influence of Posterior Malleolus Fracture and Fixation on the Rotational Stability of the Ankle

Background

This study aimed to analyze quantitative correlation between the posterior malleolus fracture and fixation and the rotational stability of the ankle and to explore supplementary surgical indications for posterior malleolus fracture.

Methods

Twenty fresh frozen cadaver specimens were selected and dissected. Based on the tibial insertion of the ligament complex, the model for the supination external rotation stage 3 ankle fracture with a posterior malleolar fragment and syndesmosis diastasis was created. The area threshold of the posterior tibial insertion of posterior malleolus fracture was biomechanically assessed and the difference of the antirotating ability stiffness of the ankle between simple posterior malleolus fixation and simple syndesmotic fixation was analyzed statistically.

Results

The tibial insertion of posterior inferior tibiofibular ligament and inferior transverse tibiofibular ligament complex was relatively broad, and its width decreased as the distance from the joint line increased. Biomechanical analysis showed that: the threshold of posterior area of posterior malleolus fracture was 1/4S; posterior malleolus fixation provided better rotational stability than syndesmotic fixation (P < 0.01).

Conclusion

The surgical indications for posterior malleolus fracture should consider simultaneously the restoration of the axial and rotational stability of the ankle. Simple posterior malleolus fracture fixation is recommended when the syndesmosis is unstable and the area ratio of posterior tibial insertion of posterior malleolus fracture is greater than or equal to 1/4. Syndesmotic fixation is proposed to restore and maintain the rotational stability of the ankle when the syndesmosis is unstable and the area ratio is less than 1/4. Regardless of the area ratio, the surgical indication only depends on the impact of the posterior malleolus fracture on the axial stability of tibiotalar joint, the involved articular surface area, and the displacement degree of posterior malleolus fragment, when the syndesmosis is stable.

Is fixation of both clavicle and scapula better than clavicle alone in surgical treatment of floating shoulder injury? A retrospective study

BACKGROUND & OBJECTIVE

Little research was available to explore which surgical fixation was better between fixation of both clavicle and scapula and clavicle alone in management of floating shoulder injury.

METHODS

Total 69 patients with floating shoulder injury receiving surgery from February 2005 to July 2020 participated in the study. 49 patients underwent fixation of the clavicle alone (Group C) while 20 patients underwent fixation of both clavicle and scapula (Group C + S). They were further divided into subgroups according to age: Group C1, Group C + S1 (age ≤ 55 years old) and Group C2, Group C + S2 (age>55 years old). The radiological parameter (glenopolar angle (GPA)) and clinical outcomes (Herscovici score, Constant-Murley shoulder outcome score (CSS score), and Visual Analogue Scale score (VAS score)) were collected and compared between these groups. The correlation between age and radiological parameter and clinical outcomes was calculated by the Spearman correlation analysis.

RESULTS

All people were followed up for at least 1 year. The degree of change in GPA before and after surgery in Group C + S is significantly better than that in Group C. The Herscovici and CSS score in Group C + S2 were significantly higher than those in Group C2 at 1 month, 3 months and 1 year after surgery. However, no significant difference in Herscovici and CSS score was found at final follow-up (1 year after surgery) between Group C + S1 and Group C1. The VAS score in Group C + S2 at final follow-up was significantly lower than that in Group C2. No significant difference in VAS score at final follow-up was found between Group C + S1 and Group C1. In addition, the VAS score was negatively correlated with Herscovici and CSS score. No correlation was found between VAS score and GPA.

CONCLUSIONS

Both types of surgical fixation are effective in management of floating shoulder injury. For young people with floating shoulder injury, both types of surgical fixation are equally effective. However, for older people with floating shoulder injury, fixation of both clavicle and scapula is better in prognosis than fixation of clavicle alone.

Strategies for fixation of periprosthetic fragility fractures of the neck of femur below a well-functioning hip resurfacing arthroplasty: A case-series

Introduction

Metal-on-metal Hip Resurfacing (HR) was performed in many young individuals as it conserved bone stock and had low wear rates, before it became less popular due to the detection of Adverse Reactions to Metal Debris. As such, many patients in the community have well-functioning HRs and as they age, the incidence of fragility fractures of the neck of femur around the existing implant is expected to increase. These fractures are amenable to surgical fixation as adequate bone stock remains in the head of the femur and the implants are well fixed.

Case-series

We present a series of six cases which were treated by fixation using locked plates (3), dynamic hip screws (2) and cephalo-medullary nail (1). Four cases achieved clinical and radiographic union with good function. One case had a delayed union, though union was finally achieved at 23 months. One case had an early failure necessitating revision to a Total Hip Replacement after 6 weeks.

Discussion

We highlight the geometrical principles of placing fixation devices under an HR femoral component. We have also conducted a literature search and present details of all case reports to date.

Conclusion

Fragility per-trochanteric fractures under a well-fixed HR with good baseline function are amenable to fixation using a variety of methods including large screw devices that are commonly used in this location. Locked plates including variable angle locking designs should be kept available if needed.

Pediatric spinal injuries- current concepts

Spinal injuries in children contribute to the highest mortality and morbidity among all pediatric injuries. Fortunately, these injuries are a rare clinical entity but pose a difficulty in diagnosis due to challenges in neurological evaluation of a child and varied radiological presentation. Anatomical and biomechanical aspects of developing musculoskeletal system, relative plasticity of the pediatric spine make children vulnerable to spine injuries. Though motor vehicle collisions are common, children also suffer non-accidental trauma, falls and sports injuries. More chances of cervical spine involvement, higher susceptibility of spinal cord to tensile forces and associated multisystem injuries result in devastating consequences in children compared to adults. Injuries like SCIWORA, vertebral apophyseal injuries, birth-related spinal cord injuries are more specific injuries in pediatric age group. A vigilant clinical, neurological and radiological evaluation is mandatory in all children with suspected spinal injuries. Normal radiological features like ossification centers, pseudosubluxation and physiological vertebral wedging should be carefully noted as they could be misinterpreted as injuries. While CT scans help in better understanding of the fracture pattern, Magnetic Resonance Imaging in children is beneficial especially in detecting SCIWORA and other soft tissue injuries. Management principles of these pediatric spinal injuries are similar to adults. Literature evidences support conservative management in injuries like SCIWORA, unless there is an ongoing spinal cord compression. As in adults, the role of high dose methylprednisolone is still controversial in pediatric spinal cord injuries. Stable spinal injuries can be managed conservatively using orthosis or halo. Instrumentation by both anterior and posterior techniques has been described, but it is challenging due to smaller anatomy and poor implant purchase. In addition to pedicle screw instrumentation, wiring techniques are very beneficial especially in younger children.

Posterior malleolus fracture: a mid-term follow-up

BACKGROUND

The treatment of posterior malleolar fractures is changing rapidly, and the evidence base is still catching up. This study aimed to assess the mid-term prognosis of posterior malleolar fractures based on different morphological types and provides evidence for the treatment of posterior malleolar fractures.

METHODS

We retrospectively analyzed the data of inpatients with posterior malleolar fractures from 1 January 2012 to 31 December 2019 at one high-volume tertiary trauma center. Fracture morphology was classified into small-shell fragment, single-fragment (small-fragment and large-fragment) and multifragment (double-fragment and compressive-fragment) by computed tomography according to our previous study. All patients were followed up at an average of 5.06 (range, 2.21-8.70) years. The Olerud-Molander Ankle Score (OMAS), EuroQol-5 Dimensions (EQ-5D) and American Orthopedic Foot and Ankle Society (AOFAS) score were recorded.

RESULTS

Seventy-nine patients were included, and 7 patients were classified into the small-shell group, 52 patients into the single-fragment group and 20 patients into the multifragment group. Of all the patients, the average OMAS, EQ-5D and AOFAS scores were 85.9, 82.8 and 92.5, respectively. In the single-fragment group, patients who underwent surgical fixation in the posterior malleolus had significantly better scores (P = 0.037, 0.033 and 0.027). Among the patients with small fragments, the surgical fixation group also had higher OMAS (93.1 ± 7.5 vs. 83.5 ± 19.5, P = 0.042) and AOFAS scores (98.1 ± 3.1 vs. 91.0 ± 14.1, P = 0.028). The mean OMAS, EQ-5D and AOFAS scores were 85.5, 85.7 and 91.7, respectively, in patients with multiple fragments who underwent surgical fixation.

CONCLUSION

This study shows that in fractures with a single fragment, surgical fixation of the posterior malleolar fragment led to a better prognosis in the midterm. All single fragments should be fixed regardless of size. Fixation of the posterior region in all single- and multi-fragments in posterior malleolar fractures led to satisfactory outcomes.

LEVEL OF EVIDENCE

Level III, follow-up study.

The outcomes of surgical treatment for lateral Hoffa fracture nonunions

INTRODUCTION

Lateral Hoffa nonunion are rare injuries. A significant percentage of these nonunions are due to missed acute lateral Hoffa fractures. Operative management of these injuries is difficult and complicated by the presence of bone loss, infection, and soft-tissue contractures. In this study, the aim was to assess clinical and functional outcome in our group of patients with lateral Hoffa nonunion who had undergone operative management and to determine whether variables such as fracture type, infection, and previous surgery affect nonunion/complication rates.

MATERIALS AND METHODS

Data were analyzed for patients with lateral Hoffa nonunion who underwent surgical fixation from January 2008 to December 2020 at a tertiary-care referral center. Patients with lateral condyle Hoffa nonunion and having a minimal follow-up of 1 year were included in this study. Patients with medial Hoffa nonunion, pathological fractures, and children aged less than 16 years were excluded from the study. The fractures were classified by the AO/OTA and Letenneur classification systems. Clinical and functional outcomes were assessed by the Knee society score (KSS) and the lower extremity functional scale (LEFS).

RESULTS

All the 12 patients had united in our series. One patient had reduction failure at 3 months who united after re-fixation. The union rate in our patients was 100%, with a loss of reduction rate of 7.7%, and post-traumatic arthrosis of 7.7%. The average follow-up period was 52.16 ± 27.7 months. The mean knee flexion obtained at the final follow-up was 104.5° (80°-130°). The average KSS clinical score was 80.6 (65-88). The average KSS functional score was 92 (70-100). The average LEFS score was 71 (47-79). There is a statistically significant improvement in the knee range of motion in our patients (p = 0.001). However, no correlation could be detected between variables like type of fracture, infection, and previous surgeries and outcomes.

CONCLUSIONS

Lateral Hoffa nonunion can be managed with careful planning of surgical approaches and fixation techniques.

Surgical versus non-surgical treatment of humeral SHAFT fractures compared by a patient-reported outcome: the Scandinavian Humeral diAphyseal Fracture Trial (SHAFT)-a study protocol for a pragmatic randomized controlled trial

BACKGROUND

The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures.

METHODS

A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality.

DISCUSSION

The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04574336 . Registered on 5 October 2020.

Indications for surgical fixation of low-energy pelvic ring fractures in elderly: a systematic review

INTRODUCTION

There are no generally accepted criteria for when and how to fixate osteoporotic pelvic ring fractures in elderly. This systemic review aims to summarize the currently available literature regarding the indications and methods for surgical fixation of fragility fractures of the pelvic ring in elderly patients after low-energy trauma.

MATERIALS AND METHODS

The Pubmed and Embase databases were searched using the key words pelvic fractures, geriatric, fragility, osteoporosis, and surgical fixation, and their synonyms. Extracted data including the indication, method of operative fixation, and post-operative outcomes (pain levels, mobility, complications and mortality) were analyzed using descriptive statistics. The studies were too heterogeneous to perform a meta-analysis.

RESULTS

Eleven cohort studies (3 comparative and 8 noncomparative) were included. The methodological quality was poor to moderate; the studies were heterogeneous regarding study design and reported outcomes. In all included studies operative treatment for all fracture types was preceded by a period of conservative treatment comprising physiotherapy-guided full weight-bearing. Time to surgery differed widely. For posterior ring fixation, the majority of the included studies used minimally invasive surgery with trans-iliosacral screws. Five studies described a form of additional fixation of the anterior pelvic ring but did not report the indications.

CONCLUSIONS

Fixation of low-energy pelvic ring fractures in elderly is commonly performed after a period of conservative treatment, with persistent pain as the most frequent indication for fixation. Fracture classification based on stability seems to be of secondary importance. Timing for surgical fixation of the pelvic ring fracture in elderly patients remains diverse. Large well-designed comparative prospective studies and randomized controlled trials are needed to provide clearly substantiated guidelines.

Increase in surgical fixation of pediatric midshaft clavicle fractures since 2008

BACKGROUND

Clavicle fractures in children have traditionally been treated non-operatively. In adults, a great increase in operative treatment has been reported. We aimed to analyze the respective trend and potential explanatory factors in children.

METHODS

This is a single-institution retrospective study in a subregion in Northern Finland. The ICD-code S42.0 was used to identify the cases in the hospital registry. Altogether, 214 children, aged < 16, with consecutive clavicle fractures were first enrolled in the area during 2008-2019. Hospital journals and radiographs were reviewed. After lateral and medial fractures and patients living outside the area were excluded, final study population was 172. The respective population at risk was extracted by Statistics Finland. Predictive factors and annual rates of operative treatment as adjusted for 100,000 children at risk were determined.

RESULTS

The rate of the surgical treatment of clavicle fractures increased from zero in 2008 to 10.8 in 2019 per 100,000 age-adjusted children (β = 0.864, 95% confidential intervals (CI) 0.4 to 1.4). There was a rise in the rate of surgery from 2.6% (2014-16) to 16.1% (2017-19) (diff. 13.5, 95% CI 1.7 to 23.3%). A displacement > 15 mm and a shortening of > 15 mm were associated with the increased risk of surgery but did not change during the study period. Age > 9 years increased the risk of surgery; the mean age increased from 5.5 years (2008-10) to 8.5 years (2017-19). There was a 3.6-fold increase in sports-related fractures (95% CI 7.4 to 26.4). The severity of the fractures did not change.

CONCLUSIONS

There has been an increasing trend in the surgical fixation of pediatric middle shaft clavicle fractures since 2008. The available literature does not support the trend.

Diagnostic Accuracy of e-FAST in Stable Blunt Trauma Chest: A Prospective Analysis of 110 Cases at a Tertiary Care Center

Background

Focused assessment with sonography in trauma (FAST) is an important adjunct and an extension of the clinical examination in an emergency setting for the last three decades. e-FAST visualizes the lung bases and injuries related to the lungs in addition to the intra-abdominal and pericardial bleed. In trauma patients, time is precious. Noncontrast computed tomography (NCCT) chest is the gold standard for the evaluation of blunt trauma chest. However, it is cumbersome and time-consuming and leads to increased morbidity and mortality. Therefore, evaluation of trauma patients at the trauma bay with e-FAST which is available at all times will not only save time but also the lives of trauma patients. Our endeavor is to find whether e-FAST can be substituted for NCCT for assessing injuries accurately in a stable blunt trauma patient.

Patient and methods

Prospective observational study was conducted in a tertiary care trauma center during the period of November 2017 to 2019. Of the 197 patients presenting to the trauma surgeon in the trauma center, 110 were included in the study after satisfying the inclusion criteria. Eighty-seven patients being hemodynamically unstable were excluded from the study.

Results

There was no statistical significance in the comparative data between the groups and all with “p” values more than 0.05. This accepts the null hypothesis and establishes the fact that there is no difference between NCCT chest which is the gold standard for chest blunt trauma and e-FAST.

Conclusion

We conclude that e-FAST is a better adjunct to the diagnosis and management of blunt trauma chest patients.

How to cite this article

Devadoss H, Sharma P, Nair VV, Rehsi SS, Roy N, Rao PP. Diagnostic Accuracy of e-FAST in Stable Blunt Trauma Chest: A Prospective Analysis of 110 Cases at a Tertiary Care Center. Indian J Crit Care Med 2021;25(10):1167–1172.

Surgical fixation of isolated greater tuberosity fractures of the humerus- systematic review and meta-analysis

OBJECTIVES

A systematic review was undertaken based on PRISMA guidelines to study the results of surgical treatment of Greater Tuberosity fractures of the Humerus by different techniques (Open, Percutaneous or Arthroscopic) and using different fixation devices (Sutures, Screws and Plates).

DATA SOURCES

Literature searches were performed for studies in English on four online databases (MEDLINE®, Embase®, Ovid® Emcare and CINAHL®) using a pre-planned search strategy.

STUDY SELECTION

Studies were screened against pre-decided inclusion and exclusion criteria. 24 articles were eligible for inclusion involving 562 patients in all.

DATA EXTRACTION

A template was used for collection of relevant data regarding the study design, demographics, fracture characteristics, surgical techniques and implants used, outcomes, complications and re-operations. Methodological quality was assessed using a modified Coleman Methodology Score.

DATA SYNTHESIS

Pooled analysis was conducted for (1) complications/reoperations of different devices; and (2) reported results using standard outcome measures of various techniques. Results were pooled using inverse variance method. When pooling proportions, we used arcsine transformation to account for zero events.

CONCLUSION

Use of screws was associated with higher rates of total complications (23.7%) as well as reoperations (13.2%), compared to sutures (14.2%; 2.6%) and plates (10.6%; 4.1%). In a subgroup analysis, use of low-profile plates (LPPs) was associated with the lowest rates of total complications (4.97%). The superiority of any surgical technique could not be established using the pooled Constant or ASES scores because there was lack of uniformity in the reporting of outcome measures. Our analysis of complications of the various fixation devices dissuades the use of screws and favours the use of low-profile plates. There is a need for prospective studies comparing arthroscopic suture fixation with open low-profile plate fixation of GT fractures.

What's the best surgical repair technique of an ulnar styloid fracture? A biomechanical comparison of different techniques

INTRODUCTION

8-10% of all Ulnar styloid fractures (USF) accompanying distal radius fractures are addressed surgically. The surgical fixation has to counteract forces of translation and rotation acting on the distal radioulnar joint (DRUJ). The different technics used were never compared biomechanically. Our study aims to compare the effects of different techniques of USF fixation on the forearm rotation and the dorsal-palmar (DP)-translation of the DRUJ.

MATERIAL AND METHODS

9 forearm specimens were mounted on a custom testing system. Load was applied for Pronosupination and DP-translation with the forearm placed in neutral position, pronation and supination. The positional change of the DRUJ was measured using a MicroScribe. Six different, sequential conditions were tested in the same specimen: intact, USF and 4 repair techniques (2 K-wire, tension band wiring (TBW), headless compression screw, suture anchor).

RESULTS

The USF significantly increased DP-translation and pronosupination compared to the intact condition. The DP-translation in neutral was reduced significantly with all four techniques compared to the USF condition. TBW and suture anchor also showed a significant difference to the K-wire fixation. In supination only the TBW and suture anchor significantly decreased DP-Translation. The rotational stability of the DRUJ was only restored by the K-wire fixation and the TBW.

CONCLUSIONS

All four USF repair techniques partially restored translational stability; however, only K-wire fixation and TBW techniques restored rotational stability. TBW was biomechanically superior to the other techniques as it restored translational stability and rotational stability.

Current concepts in the management of bisphosphonate associated atypical femoral fractures

Bisphosphonates are a class of drugs used as the mainstay of treatment for osteoporosis. Bisphosphonates function by binding to hydroxyapatite, and subsequently targeting osteoclasts by altering their ability to resorb and remodel bone. Whilst aiming to reduce the risk of fragility fractures, bisphosphonates have been associated with atypical insufficiency fractures, specifically in the femur. Atypical femoral fractures occur distal to the lesser trochanter, until the supracondylar flare. There are a number of the differing clinical and radiological features between atypical femoral fractures and osteoporotic femoral fractures, indicating that there is a distinct difference in the respective underlying pathophysiology. At the point of presentation of an atypical femoral fracture, bisphosphonate should be discontinued. This is due to the proposed inhibition of osteoclasts and apoptosis, resulting in impaired callus healing. Conservative management consists primarily of cessation of bisphosphonate therapy and partial weightbearing activity. Nutritional deficiencies should be investigated and appropriately corrected, most notably dietary calcium and vitamin D. Currently there is no established treatment guidelines for either complete or incomplete fractures. There is agreement in the literature that nonoperative management of bisphosphonate-associated femoral fractures conveys poor outcomes. Currently, the favoured methods of surgical fixation are cephalomedullary nailing and plate fixation. Newer techniques advocate the use of both modalities as it gives the plate advantage of best reducing the fracture and compressing the lateral cortex, with the support of the intramedullary nail to stabilise an atypical fracture with increased ability to load-share, and a reduced bending moment across the fracture site. The evidence suggests that cephalomedullary nailing of the fracture has lower revision rates. However, it is important to appreciate that the anatomical location and patient factors may not always allow for this. Although causation between bisphosphonates and atypical fractures is yet to be demonstrated, there is a growing evidence base to suggest a higher incidence to atypical femoral fractures in patients who take bisphosphonates. As we encounter a growing co-morbid elderly population, the prevalence of this fracture-type will likely increase. Therefore, it is imperative clinicians continue to be attentive of atypical femoral fractures and treat them effectively.

Cost-effectiveness of surgery versus cast immobilization for adults with a bicortical fracture of the scaphoid waist : an economic evaluation of the SWIFFT trial

AIMS

The aim of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was to determine the optimal treatment for adults with a bicortical undisplaced or minimally displaced fracture of the waist of the scaphoid, comparing early surgical fixation with initial cast immobilization, with immediate fixation being offered to patients with nonunion.

METHODS

A cost-effectiveness analysis was conducted to assess the relative merits of these forms of treatment. The differences in costs to the healthcare system and quality-adjusted life years (QALYs) of the patients over the one-year follow-up of the trial in the two treatment arms were estimated using regression analysis.

RESULTS

Our base case analysis found that patients randomized to early surgical fixation had statistically significantly higher mean costs to the NHS of £1,295 more than for the cast immobilization arm (p < 0.001), primarily due to the cost of surgery. They also had a marginally better quality of life, over the period, of 0.0158 QALYs; however, this was not statistically significant (p = 0.379). The mean combined cost per additional QALY was £81,962, well above the accepted threshold for cost-effectiveness used in the UK and internationally. The probability of early surgery being cost-effective in this setting was only 5.6%.

CONCLUSION

Consistent with the clinical findings of SWIFFT, these results indicate that initial cast immobilization of minimally displaced scaphoid fractures, with immediate fixation only offered to patients with nonunion, is the optimal form of treatment, resulting in comparable outcomes with less cost to the healthcare system. Cite this article: Bone Joint J 2021;103-B(7):1277-1283.

Multimodal imaging of composite carbon fiber-based implants for orthopedic spinal fixation

OBJECTIVE

As cancer treatments continue to improve, the incidence of spinal metastases and the need for surgical management of these with fixation procedures are growing rapidly. Traditionally metallic implants, composed of titanium alloy, have been used in surgical fixation of unstable or symptomatic vertebral metastases or traumatic injuries. Metallic implants, however, cause significant artifact on post-operative imaging, degrading image quality and limiting interpretation, and can also impair the planning and delivery of radiotherapy. Composite carbon fiber-based materials, such as carbon fiber-reinforced polyetheretherketone (PEEK), have been developed to overcome these issues and are now available for spinal fixation procedures. We aimed to review the multimodal imaging features of these new implants.

MATERIALS AND METHODS

Current literature and a case example from our institution were used to describe the multimodal imaging characteristics and considerations of new carbon fiber-based spinal fixation implants.

RESULTS

New carbon fiber-based spinal implants allow far greater visualization of surrounding structures on post-operative cross-sectional imaging, significantly improving diagnostic accuracy and precision of radiotherapy planning, and do not significantly absorb or scatter X-ray photons during radiotherapy delivery. There are, however, important surgical and radiologic considerations associated with the use of carbon fiber-based implants which radiologists must be aware of, such as implications for surgical planning and intra-operative fluoroscopic and post-operative plain radiographic imaging.

CONCLUSION

The use of carbon fiber-based implants, rather than traditional metallic implants, for spinal fixation offers significant advantages for post-operative diagnostic imaging and radiotherapy planning and delivery.

Plates versus struts versus an extracortical rib fixation in flail chest patients: Two-center experience

PURPOSES

Notwithstanding advances in medical and surgical management of flail chest, its morbidity and mortality rates are still high. Aim of this study is to compare three approaches for parietal thoracic stabilization by analyzing both early and long-term patient outcomes.

METHODS

A retrospective study from January 2006 to January 2018 involving sixty-five surgical flail chest (25 plates,11 struts and 29 wires fixations) was conducted. A mean Abbreviated Injury Scale (AIS) was 2.38±0.82 and a mean Injury Severity Score (ISS) was 32.02±8.21.

RESULTS

Struts and plates stabilizations compared with wires fixation showed an immediate restoring of the partial pressure of oxygen (90.56 mmHg vs 91.90 mmHg vs 89.23 mmHg, p = 0.021), the carbon-dioxide levels (36.00 mmHg vs 35.03 mmHg vs 38.98 mmHg, p = 0.000) and the oxygen-blood saturation (97.71% vs 98.21% vs 92.12%, p = 0.000) in the early postoperative period. Furthermore, struts and plates ensured a better recovery of daily activities up to the 3rdmonth (QoL=1.0: p<0.001 in lateral flail chest and p<0.02 in anterior and antero-lateral flail chest). At the 12thmonth no difference in QoL was found between the different approaches.

CONCLUSIONS

Plate and strut fixation revealed a lower rate of postoperative morbidity and mortality. Wires stabilization was characterized for a reduction of operative time.

Return to work after surgically treated acetabular fractures in an Asian population

BACKGROUND

Acetabular fractures are rare but are severe injuries that occur in younger patients with a significant economic impact. There is limited evidence describing the return to work rates in this group of patients. The aim of our study was to examine the rate and time to return to work (RTW) after surgical fixation of acetabular fractures.

METHODS

We performed a retrospective study on all patients with surgically treated acetabular fractures at a single institution between 1 July 2010 and 31 December 2018. Medical records were reviewed to analyze demographics such as age, gender, occupation and RTW characteristics.

RESULTS

There were 30 patients, with a mean age of 43.3 ± 12.7 years. There were 26 patients who were employed prior to injury. The most common mechanism of injury was from a road traffic accident (73.3%). The average ISS was 8.9 ± 5.2. The mean follow-up duration was 21.5 months ± 15.7. The rate of RTW was 80.8%. Eighteen patients (85.7%) returned to the same job and duties, while two (9.5%) returned with same job but lighter duties and one (4.8%) had to change job. Three patients (11.5%) retired. The average time to return to work was 8.3 months (range 2-57.5). RTW rates were 15.4%, 61.5%, 69.2% at 3, 6 and 12 months, respectively.

CONCLUSION

Acetabular fractures can lead to loss of economic productivity, with 80.8% of patients returning to work. Work reintegration programs after acetabular fractures are important.

Clinical and radiological mid- to long-term results after direct fixation of posterior malleolar fractures through a posterolateral approach

BACKGROUND

Direct fixation of posterior malleolar fractures has been shown to lead to higher accuracy of fracture reduction compared to an indirect anterior to posterior fixation but lacks long-term clinical results. This study shows the mid- to long-term clinical and radiological outcome after direct fixation of the posterior malleolus through a posterolateral approach.

MATERIALS AND METHODS

Thirty-six patients with an ankle fracture including a posterior malleolar fragment (23 × AO-44C, 12 × AO-44B, 1 × unclassifiable) treated with direct fixation of the fragment through a posterolateral approach were retrospectively evaluated. There were 24 females (67%) with a mean age of 63 (range 34-80) years and a BMI of 28 (range 19-41) kg/m² at the time of surgery. An initial fracture-dislocation was seen in 67%. The clinical outcome was assessed with the Visual Analog Scale (VAS, 0-10 points) and the American Foot and Ankle Society (AOFAS, 0-100 points) score. Posttraumatic osteoarthritis was recorded with the Van Dijk Classification (grade 0-III). Subgroup analyses of patient- and fracture-associated risk factors (age, BMI, smoking, fracture-dislocation, postoperative articular step-off) were assessed to reveal possible negative prognostic predictors.

RESULTS

After a mean follow-up of 7.9 (range 3-12) years, the median VAS was 1 (IQR 0-2) point, and the median AOFAS score was 96 (IQR 88-100) points. Ankle range of motion measurements showed a significant, but clinically irrelevant, difference in plantar- and dorsiflexion between the affected and unaffected ankle. 92% of the patients were very satisfied or satisfied with the postoperative course. 89% had no preoperative signs of ankle osteoarthritis. Osteoarthritis progression was seen in 72%, with 50% showing grade II or III osteoarthritis at the final follow-up. No significant negative prognostic factors for a worse clinical outcome could be detected.

CONCLUSION

Direct fixation of posterior malleolar fractures through a posterolateral approach showed good clinical mid- to long-term results with a high satisfaction rate but substantial development of posttraumatic ankle osteoarthritis. Further studies should include CT analysis of the preoperative fracture morphology and even, perhaps, the postoperative reduction accuracy to evaluate the benefit of posterior malleolar fracture reduction in preventing ankle osteoarthritis in the long term.

LEVEL OF EVIDENCE

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

Pragmatic randomised evaluation of stable thoracolumbar fracture treatment outcomes (PRESTO): study protocol for a randomised controlled feasibility trial combined with a qualitative study and survey

Background

A thoracolumbar fracture is the most common fracture of the spinal column. Where the fracture is not obviously stable or unstable, the optimal management is uncertain. There are variations between surgeons, treating centres and within the evidence base as to whether surgical or non-surgical approaches should be used. In addition, the boundaries of this zone of uncertainty for stability are unclear.

This study has been designed in response to an NIHR HTA commissioning brief to assess the feasibility of undertaking a large-scale trial to evaluate the effectiveness of surgical and non-surgical treatments for thoracolumbar fractures without neurological deficit.

Methods

Assessment of feasibility will be addressed through three elements: a randomised external feasibility study, a national survey of surgeons and a qualitative study.

The external feasibility study is a pragmatic, parallel-group, randomised controlled trial comparing surgical fixation (intervention) versus non-surgical management (control). Recruitment will take place in three secondary care centres in the UK.

The primary outcome is recruitment rate, defined as the proportion of eligible participants who are randomised. Further outcomes related to recruitment, randomisation, drop-out, cross-over, loss to follow-up, completeness of outcome data, study processes and details of the interventions delivered will be collected.

The survey of surgeons and qualitative study of clinicians, recruiting staff and patients will enhance the feasibility study, enabling a broad overview of current practice in the field in addition to perceived facilitators and barriers to running a full-scale trial.

Discussion

PRESTO is a feasibility study which aims to inform methodology for a definitive trial comparing surgical fixation with non-surgical management for patients with stable thoracolumbar fractures.

Trial registration

The trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN12094890). Date of registration was 22/02/2018 (http://www.isrctn.com/ISRCTN12094890).

Predictors of clavicle fixation in multiply injured patients

Introduction

Clavicle fractures account for approximately 10% of all fractures in multiply injured patients. Our study aims to determine factors associated with surgical fixation of the clavicle fracture in multiply injured patients.

Methods

Major adult trauma patients from 2005 to 2014 with a clavicle fracture were included. Multivariate analysis was undertaken to determine the variables associated with fixation.

Results

1779 patients (median age of 47 and a median Injury Severity Score of 17) were included. 273 (15%) patients underwent clavicle fixation. Factors associated with surgical fixation of the clavicle included: year, younger age, ICU admission, or an associated humerus or scapula fracture.

Epidemiology of Distal Radius Fixations and Functional Outcomes in the Superelderly Population

Background: Superelderly patients (defined as 80 years old and older) account for 18% of all distal radius fractures in our institution and this number is increasing with the ageing population. When faced with the option of surgery, patients in this age group have concerns with regards to the long term outcomes including functional outcomes and the time to fracture union. Therefore, the aim of this study was to evaluate the functional outcomes in this specific population. Methods: Patient selection for surgery was determined by the fracture stability, the patient's premorbid function and underlying comorbidities. Post operatively, the time to fracture union after surgical fixation, surgical complications and patients' functional outcome scores were recorded. The method of anaesthesia and any anaesthesia-related complications were also included. Results: There were 76 superelderly patients who underwent surgical fixation of their distal radius fractures identified from our institution's prospective database from 2009 to 2016. Overall there were good functional outcome scores. The DASH scores at 3 months and 6 months were 17 and 10 respectively. Furthermore, the mean time to fracture union in our population was 47 days (approximately 7 weeks). There were only 2 post-operative surgical complications but no anaesthesia-related complications. Conclusions: Surgical fixation of distal radius fractures in appropriately selected patients in the superelderly population yields good functional outcomes.

[Plate osteosynthesis of the coronoid process of the ulna]

OBJECTIVE

The aim of surgical treatment is reconstruction of the coronoid process' bony anatomy.

INDICATIONS

Large shear fractures of the coronoid process (Regan-Morrey type II-III, O'Driscoll "tip" subtype 2 and "basal" subtype 1-2) and fractures of the anteromedial facet (O'Driscoll "anteromedial" subtype 1-3) can occur isolated or as part of the "terrible triad" injuries to the elbow. Due to the resulting instability of these injuries, surgical reconstruction is generally indicated.

CONTRAINDICATIONS

In case of major accompanying soft tissue injuries to the elbow or an elbow infection, primary operative treatment using anatomical plate osteosynthesis is contraindicated.

SURGICAL TECHNIQUE

Plate osteosynthesis of the coronoid process is performed through a medial approach (Hotchkiss or M. flexor carpi ulnaris split). After repositioning of the fracture fragments, a preformed anatomical plate can be fixed to the coronoid process.

POSTOPERATIVE MANAGEMENT

The arm is immobilized in an over-the-elbow cast until the wounds are dried. Afterwards, the elbow should preferably be treated functionally without varus or valgus stress.

RESULTS

Between January 2015 and July 2018, a total of 11 patients underwent osteosynthesis of the coronoid using anatomically preformed plate osteosynthesis. After a mean follow-up of 10.7 months, the mean Mayo Elbow Performance Score showed an excellent result with 78.89 points. The Quick Disabilities of Arm, Shoulder and Hand (Q-DASH) score showed a median of 18.64 points with a mean functional arc of 118°.

Latissimus muscle sparing approach to subscapular rib fracture plating

Surgical stabilization of fractured ribs has been shown to improve trauma related outcomes, however the procedure itself can be a source of morbidity. This report details two cases of latissimus dorsi muscle sparing sub-scapular multi-rib fracture plating. We combined several techniques to make this possible. The first technique was use of a vertical skin incision along the anterior border of the latissimus muscle. The second was the use of a mammary retractor to provide adequate and sustained retraction of the latissimus and scapula. The third was utilization of a right angle screwdriver to allow placement of the posterior screws. Sparing the latissimus muscle for sub-scapular fractures is possible but requires planning and extra equipment to perform. Minimizing rib fixation related morbidity makes it a more appealing treatment.

Surgical Fixation Using Screw-Rod Construct Instrumentation for Upper Cervical Instability in Pediatric Down Syndrome Patients

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To describe the indications and outcomes of cervical fixation using modern instrumentation in a case series of pediatric Down syndrome (DS) patients.

SUMMARY OF BACKGROUND DATA

Cervical instability is the major cervical spine concern in children with DS. Although fixation techniques have advanced over the past quarter-century, the outcome of fixation with modern instrumentation for upper cervical instability in DS patients has not been thoroughly investigated.

METHODS

We searched the orthopedic database at our institution for patients with a diagnosis of DS who had undergone a cervical spine fusion between 2006 and 2017. Patient demographics, diagnoses, surgical indications, surgical details, and complications were recorded. Preoperative imaging was reviewed to determine atlanto-dens intervals and spinal cord signal changes. Postoperative radiographs or CT scans were reviewed to determine union.

RESULTS

Twelve DS patients met our inclusion criteria. The mean age at surgery was 9.3 years (range 3.8-18.8 years). Patients with secondary causes of instability included 7 patients with os odontoideum and 1 patient with a pars fracture. Three patients (25%) were identified on asymptomatic screening, with none of these having cord signal changes on magnetic resonance imaging (MRI). Modern implants (screws, plates, cages) were used in every patient in our series. The mean number of levels fused was 1.9 (range 1-5). The overall complication rate was 41.7% (5/12). Four patients required repeat surgery for nonunion. All patients with adequate radiographic follow-up demonstrated union (11/11, 100%). One patient was lost to follow-up.

CONCLUSIONS

Fixation for cervical instability is a critical component of the management of DS. A minority of patients receiving surgery were identified through asymptomatic screening. There was a high complication risk associated with surgery in our study; however, the addition of rigid fixation has lessened the complication rate compared with previous studies.

LEVEL OF EVIDENCE

Level IV.

Injuries Around the Proximal Interphalangeal Joint

Proximal interphalangeal joint (PIPJ) injuries are common and challenging to treat, involving a spectrum of conditions ranging from isolated ligamentous injuries to severe fracture dislocations. The main goal of treatment is to achieve a congruent, stable joint, which is key to achieving early range of motion and a favorable outcome. Injuries that do not compromise the stability of the joint may be treated nonsurgically, whereas those that render the joint unstable may be managed with one of many surgical strategies available. This article focuses on the current practices of treatment of injuries around the PIPJ.

Outcomes after surgical treatment of acetabular fractures: a review

Acetabular fractures are fractures that extend into the hip joint and pose a challenge for orthopaedic trauma surgeons. The first known descriptions of surgical fixation of acetabular fractures were case reports in 1943. In 1964, Robert Judet, Jean Judet, and Émile Letournel published a landmark article describing a classification system and surgical approaches to treat acetabular fractures. These teachings had a significant effect on clinical outcomes after surgical fixation of acetabular fractures. In 1980, Letournel demonstrated 80% good-to-excellent results in 492 hips, and in 2012, Joel Matta demonstrated 79% survivorship in 816 patients follow surgical acetabular fixation. Both Letournel and Matta have definitively shown that anatomic reduction of the fracture is the most influential factor predictive of clinical outcome. The intent of this review is to summarize the salient factors affecting clinical outcomes after surgical treatment of acetabular fractures.

Percutaneous screw fixation of fractured neck of femur in a teenage girl with osteogenesis imperfecta. A case report

INTRODUCTION

Neck of femur fracture in osteogenesis imperfecta is rarely reported. The management is uncertain and always reported as difficult. Clinical outcomes are not well described.

CASE PRESENTATION

A teenage girl, who is known to have osteogenesis imperfecta, sustained neck of femur fracture in the presence of a previously inserted implant. She was treated by percutaneous screw fixation. In both immediate and long term follow up, our patient had satisfactory outcome and return to pre-fracture functional status.

DISCUSSION

Dealing with fragility fracture in small abnormal hips is challenging especially, in the presence of a retained implant in- situ. Intra-operative difficulty were encountered during positioning, reduction, and screw insertion attempt.

CONCLUSION

This rare case illustrates the anticipated difficulties in managing neck of femur fracture in osteogenesis imperfect patients. It also emphasize on the importance of surgical fixation to control pain and allow for healing in anatomically functional position.

Rib Fracture Fixation: Indications and Outcomes

Rib fractures are a frequently identified injury in the trauma population. Not only are multiple rib fractures painful, but they are associated with an increased risk of adverse outcomes. Pneumonia in particular can be devastating, especially to an elderly patient, but other complications such as prolonged ventilation and increased intensive care and hospital durations of stay have a negative impact on the patient. Computed tomography scan is the best modality to diagnosis rib fractures but the treatment of fractures is still evolving. Currently patient care involves a multidisciplinary approach that includes pain control, aggressive pulmonary therapy, and possibly surgical fixation.

Should lower limb fractures be treated surgically in patients with chronic spinal injuries? Experience in a reference centre

OBJECTIVE

To report the outcomes of surgical treatment of lower limb fractures in patients with chronic spinal cord injuries.

MATERIAL AND METHOD

A total of 37 lower limb fractures were treated from 2003 to 2010, of which 25 fractures were treated surgically and 12 orthopaedically.

RESULTS

Patients of the surgical group had better clinical results, range of motion, bone consolidation, and less pressure ulcers and radiological misalignment. No differences were detected between groups in terms of pain, hospital stay, and medical complications.

DISCUSSION

There is no currently consensus regarding the management of lower limb fractures in patients with chronic spinal cord injuries, but the trend has been conservative treatment due to the high rate of complications in surgical treatment.

CONCLUSIONS

Chronic spinal cord injuries patients with lower limb fractures who are treated surgically achieved a more reliable consolidation, practically a free range of motion, low rate of cutaneous complications, and pain associated with the fracture. This allows a quick return to the previous standard of living, and should be considered as an alternative to orthopaedic treatment in these patients.

Stabilisation of distal radius fractures: Lessons learned and future directions

Our understanding of the diagnosis and management of distal radius fractures has been a long developed over centuries. There has been a shift in treatment of these very common injuries from closed reduction and casting to internal fixation. The answer to the best method of treatment has yet to be found. Today, we have a multitude of treatment options available with varying degrees of evidence to support their use. This review helps to illustrate the lessons we have learned and future directions for treatment.

Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them

Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-out, nonunion, Z-effect/medial migration, periimplant failure and avascular necrosis. High quality surgical fixation is of outmost importance to avoid surgical complications. This article presents the aetiology, risk factors and incidence of perioperative and post-fracture fixation complications. Technical tips and tricks for a successful fixation as well as the contemporary evidence surrounding the augmentation of osteoporotic bone fixation in internal fixation of hip fractures are discussed.

Biomechanical comparison of bionic, screw and Endobutton fixation in the treatment of tibiofibular syndesmosis injuries

BACKGROUND

The two prevalent fixation methods in the treatment of syndesmosis injuries, the rigid screw fixation and flexible Endobutton fixation, are not without issues; thus, we have designed a novel bionic fixation method which combines the features of both rigid and flexible fixations. The aim of this study was to compare the biomechanical properties of the bionic fixation to the screw and Endobutton fixations.

METHODS

Six normal fresh-frozen legs from amputation surgery were used. After initial tests of intact syndesmosis, screw, bionic and Endobutton fixations were performed sequentially for each specimen. Axial loading as well as rotation torque were applied, in five different ankle positions: neutral position, dorsiflexion, plantar flexion, varus, and valgus. The displacement of the syndesmosis and the tibial strain were analysed using a biomechanical testing system.

RESULTS

Whether receiving axial loading or rotation torque, in most situations (neutral position, dorsiflexion, varus, plantar flexion with low loading, valgus with high loading, internal and external rotation), the bionic group and Endobutton group had comparable displacements, and there was no significant difference among the intact, bionic, and Endobutton groups; whereas the displacements of the screw group were smaller than any of the other three groups. Results of the tibial strain were similar with that of the displacement.

CONCLUSIONS

The bionic fixation at least equals the performance of Endobutton fixation; it also allows more physiologic movement of the syndesmosis when compared to the screw fixation and may serve as a viable option for the fixation of the tibiofibular syndesmosis.

Operative Treatment of Acute Scaphoid Fractures

Optimal treatment of acute scaphoid fractures is a necessary goal for many reasons. One is that the scaphoid is the most commonly fractured carpal bone. Another is that a missed diagnosis of an acute scaphoid fracture leads to the more challenging situation of a delayed union, non-union and risk for premature radiocarpal arthrosis. Because the scaphoid has an inherent risk for nonunion due to its the tenuous blood supply, timely diagnosis and appropriate treatment are considered critical to achieving acceptable results and to avoiding the consequences of failed union.

Multiligament knee injuries with associated tibial plateau fractures: A report of two cases

The management of a combination of fracture and multiligament knee injury (MKI) in traumatic knee injury remains controversial, and there are evolving treatment recommendations. Currently, there are no studies focusing on older adult patients with MKI’s in combination with tibia fractures. As a result, there is no well-established treatment algorithm for older adult patients with these complex injuries. We report two cases of MKI’s with concomitant fractures in patients fifty years of age or older. Both patients were treated surgically for their associated tibial plateau fractures, but were managed with conservative treatment of the multiligamentous knee injuries. We also provide a review of the literature and guidelines for older adult patients with these types of complex traumatic injuries. Early to mid term acceptable outcomes were achieved for both patients through surgical fixation of the tibial plateau fracture and conservative treatment of the ligament injuries. We propose a comprehensive treatment algorithm for management of these complex injuries.

The surgical stabilization of multiple rib fractures using titanium elastic nail in blunt chest trauma with acute respiratory failure

BACKGROUND

Blunt chest injuries are usually combined with multiple rib fractures and severe lung contusions. This can occasionally induce acute respiratory failure and prolong ventilations. In order to reduce the periods of ventilator dependency, we propose a less invasive method of fixing multiple rib fractures.

METHODS

Since October 2009, we have developed a new method to fix fractured ribs caused by blunt trauma. Rib fixations were performed using 2.0- or 2.5-mm intramedullary titanium elastic nails (TEN), with the help of video-assisted thoracoscopic surgery (VATS) and minimal thoracic incisions. All the patients' demographics and postoperative data were collected.

RESULTS

From January 2010 to December 2012, a total of 65 patients presenting with multiple rib fractures resulting in acute respiratory failure were included in the study. Twelve patients received the new surgical fixation. Rib fixations were performed at an average of 4 days after trauma. Patients were successfully weaned off ventilators after an average of 3 days. The average length of stay in the hospital and the intensive care unit (ICU) was shorter for the patients with fixation than for nonsurgical patients. All twelve patients returned to normal daily activities and work.

CONCLUSIONS

In the reconstruction of an injured chest wall, the VATS with TENs fixation in multiple rib fractures is feasible. This method is also effective in decreasing the length of the surgical wound. Because the structure of the chest cage is protected, the period of mechanical ventilation is shortened and the length of stay in the hospital and the ICU can be reduced.

Patient characteristics and risk of subsequent contralateral hip fracture after surgical management of first fracture

BACKGROUND

Sequential hip fractures are associated with increased morbidity and mortality. Understanding of risk factors is important for secondary prevention. Although hip fractures have a multifactorial aetiology related to falls, it is unknown whether fracture management approach influences the risk of sequential hip fractures.

OBJECTIVES

Our objective is to explore whether subsequent contralateral hip fractures are more common following femoral head replacement or salvage procedures for the treatment of hip fractures.

METHODS

Patients older than 50, admitted to a single regional trauma unit in Worcestershire between 2010 and 2012 were identified from the national database. 700 patients matched our inclusion criteria and case notes were reviewed. The male to female ratio was 1:3.3 and the mean age was 82.8 years (standard deviation: 8.9 years). Contralateral fractures were identified from admission X-rays. Risk factors were analysed based on patient demographics and data related to first hip fracture management.

RESULTS

Seventy-one patients presented with contralateral fractures, of which 19 had their first fracture during the data collection period, estimating a period prevalence of 10.1%, and incidence of 2.9%. Contralateral fracture rates were not significantly different between femoral head salvage and replacement procedures (P-value 0.683). Older institutionalised females with poorer mobility status were at greatest risk of contralateral hip fractures. Half (50.7%) of these occurred within 2 years of their first fracture.

CONCLUSION

No additional risk was seen in either fixation approaches. Risk factors identified were in keeping with existing literature, which can help to identify high-risk groups for targeted prevention strategies.

Surgical versus nonsurgical treatment of subaxial cervical pedicle fractures

BACKGROUND

Pedicle fractures in the cervical spine are common. They may occur in isolation or in combination with other concomitant fractures. Multiple classification systems have been introduced to provide a clinical framework when approaching these types of fractures; however, these systems do not provide guidelines for optimal treatment. Data regarding decision making are limited. Conservative treatment with orthoses may result in subluxation and instability requiring further treatment. Surgery may not be required in all instances because many of these injuries may heal without surgical intervention.

METHODS

All cases of cervical fractures treated at a single institution over a 5-year period were retrospectively reviewed. Cases with pedicle fractures were further evaluated, and 40 cases managed either with or without surgery were identified. Data on presenting history, neurologic examination, imaging findings, comorbidity, method of treatment, complication rate, and length of hospital stay were collected. Fractures were classified based on computed tomography scans. Data on associated injuries were also collected. Fusion rate and fracture displacement were assessed by plain radiographs and computed tomography scans at follow-up. Follow-up time points included 2, 6, and 12 weeks and 6 months after injury. Primary outcome was fracture healing regardless of modality in the absence of progressive deformity (i.e., listhesis, kyphosis) and need for further surgery.

RESULTS

Conservative therapy was administered to 26 patients, and 14 patients underwent surgery. There were no statistically significant differences between the 2 groups in terms of total levels injured (P = 0.9) or injury severity score (P = 0.5). Patients who presented with intact neurologic status were more likely to be treated conservatively (88% vs. 29%; P = 0.0004), whereas patients presenting with spinal cord injuries were more likely to undergo surgical fixation (35% vs. 0%; P = 0.0004). Length of hospital stay trended toward being significantly greater in patients who underwent surgery (10.6 days vs. 5.5 days; P = 0.07). According to our classification system, the most common fracture type was single line horizontal fracture occurring in 68% (27 of 40 cases). Vertical split pedicle fracture occurred in 28% (11 of 40 cases), and double line horizontal fracture occurred in 5% (2 of 40 cases). Posttreatment progressive listhesis was significantly higher in patients who were treated conservatively (31% vs. 0%; P = 0.03), especially when associated with comminuted lateral mass or subluxation or both.

CONCLUSIONS

This study describes and classifies unique cervical pedicle fractures and associated injuries. Our findings suggest that surgical treatment results in definitive stability for these injuries compared with conservative therapy, particularly for pedicle fractures associated with comminuted lateral mass or initially displaced fractures. However, nondisplaced vertical split pedicle fractures and isolated single line horizontal fractures may be treated nonsurgically without occurrence of further instability. A larger prospective study is required to confirm these findings.

Unstable odontoid fracture: surgical strategy in a 22-case series, and literature review

Surgical treatment of unstable odontoid fracture (type II OBAR or HTAL) has progressed, with a range of techniques, the specificities of which need to be known so as to determine their respective roles in the therapeutic arsenal now available. A retrospective study of 22 patients operated on in our center for odontoid fracture between 2005 and 2010 examined the operative techniques employed and analyzed results in the light of the literature, so as to construct an updated decision tree. Two populations could be distinguished: elderly victims of simple fall (mean age, 82.1 years), and younger victims of high-energy trauma (mean age, 42.6 years). Surgical techniques comprised: anterior odontoid screwing (n=14), transarticular C1-C2 screwing on the posterior Magerl (n=3) or anterior Vaccaro approach (n=1), Harms' posterior C1-C2 arthrodesis (n=3), and occipitocervical arthrodesis (n=3). The overall complications rate for the series was 28%, including one case of non-union, at a mean 11 months' follow-up. The risk/benefit ratio may be hard to assess in elderly patients. However, anterior screwing restores odontoid anatomy and is the technique of choice in first intention for reducible fracture. In second intention, transarticular C1-C2arthrodesis may be performed on an anterior or posterior approach, depending on local vertebral artery anatomy. Harms' posterior C1-C2 arthrodesis allows fixation of non-reduced fractures. Occipitocervical arthrodesis is a last resort, as the associated morbidity rate is higher.

Proximal femoral fractures: Principles of management and review of literature

The purpose of this study was to review the principles involved in the management of proximal femoral fractures as reported in the literature.

METHODS

A medical literature search in the MEDLINE (PubMed) and Cochrane database was undertaken to review strategies and principles in proximal femoral fracture treatment. Randomized control trials and meta analysis were given preference while case reports/small series were rejected.

RESULTS AND CONCLUSIONS

Early anatomical reduction and surgical fixation remains the best option to reduce the risk of complications like non-union and avascular necrosis in treating fracture neck femurs. Cancellous screws continue to be the preferred treatment for fixation of neck femur fractures in younger population until the benefit of using sliding hip screws is validated by large multicentric studies. In the geriatric age group, early prosthetic replacement brings down the mortality and morbidity associated with neck femur fractures. Sliding hip screw (DHS) is the best available option for stable inter trochanteric fractures. The use of intramedullary nails e.g. PFN is beneficial in treating inter trochanteric fractures with comminution and loss of lateral buttress. Intramedullary implants have been proven to have increased success rates in subtrochanteric fractures and should be preferred over extramedullary plate fixation systems.