Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomised controlled trial

PURPOSE

The role of topical vancomycin in fracture-related infection (FRI) is debatable. Very few studies have reported their efficacy in open and high-risk extremity fractures. This study aimed to assess topical vancomycin's role in reducing FRI in closed fractures undergoing open surgical intervention with an implant.

METHODS

This prospective randomized cohort study was carried out between February 2021 to January 2022. Patients with isolated closed fractures, who were planned for open reduction and internal fixation within 2 weeks from the time of injury were included for this study. The data collected included age, gender, socioeconomic status, mechanism of injury, diagnosis, Tscherne classification, and time interval to take up for surgery. Patients were randomized into the intervention and control groups using the block randomization technique. The control group received only systemic antibiotic prophylaxis, whereas the intervention group received topical application of vancomycin powder in the surgical wound alongside systemic antibiotic prophylaxis. The primary outcome measure was the incidence of FRI among these individuals. Clinical and radiological findings and culture reports (in cases with infection) were recorded during the post-operative period and at 6 weeks of follow-up. All relevant statistical calculations were done using STATA statistical/data analysis-parallel edition version 16.0 (StataCorp LLC). The quantitative variables like age and duration of the surgery were assessed for normalcy by Shapiro-Wilk W test. An independent samples t-test with equal variances was applied to the age data. Fisher's exact test was used for the analysis of the primary outcome measure (presence of FRI following surgery), and "Risk of FRI" and "Risk difference" between the 2 groups was calculated. The strength of the association between qualitative variables was assessed using the Fisher's exact and Chi-square tests, respectively.

RESULTS

There were 88 patients included in this study. No statistical significance was found about FRI between both groups (p = 0.494). At 6 weeks following surgery, no incidence of infection was observed in the intervention group. Two infections (4.5%) were found in the control group, with positive cultures reported in one of them but none in the treatment group. Radiologically, 15.9% of patients in the control group showed lysis around the implant compared to 2.3% in the intervention group. Impaired fracture healing was observed in 22.7% of patients in the intervention group compared to 15.9% in the control group.

CONCLUSION

Applying topical vancomycin in closed fractures undergoing open reduction and internal fixation does not significantly reduce the incidence of FRI until the end of 6 weeks following surgery.

Surgical Treatment for Isolated Closed Multi-metatarsal Fractures: At Least 2-Year Outcomes in 79 Feet

Multimetatarsal fractures are a particular type possibly associated with worse functional outcomes. Existing studies are scarce, fragmented, and lack control for confounders. This study aimed to explore the functional prognosis of isolated closed extra-articular multimetatarsal fractures and the different outcomes between the plate-screw and K-wire fixation. This retrospective study included 79 patients who underwent surgery for isolated closed extra-articular multimetatarsal fractures from May 2017 to December 2020. We recorded baseline characteristics. The primary outcome measure was Visual Analogue Scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) score, and Foot and Ankle Outcome Score (FAOS). Exploratory correlation analysis of the variables with VAS, AOFAS score, and FAOS was performed. The differences between the plate-screw group (n = 58) and K-wire group (n = 21) were compared. Seventy-nine patients (79 feet) were included with a follow-up of (47.3 ± 12.7) months (range, 26-70). Full weight bearing time was (11.7±5.3) weeks. VAS was (1.4±1.8) points, AOFAS score was (86.4±13.3) points, and FAOS was (79.0±11.1) points. Complications were observed in 17 cases (21.5%). According to exploratory correlation analysis, VAS was weakly associated with fixation method and gender, AOFAS was weakly associated with fixation method, FAOS was weakly associated with trauma mechanism. When the plate-screw group (n = 58) was compared with the K-wire group (n = 21), we found the former was superior to the latter in terms of full weight bearing time, VAS, AOFAS score, and malunion rate (all p < .05). FAOS was nonsignificant (p = .056). Operative treatment of isolated closed extra-articular multimetatarsal fractures showed good mid-term results. Plate-screw fixation was associated with faster rehabilitation as well as a lower malunion rate. The mid-term follow-up results showed patients with plate-screw fixation had better VAS and AOFAS scores.

Primary total talus arthroplasty for Hawkins type IV talar neck fracture dislocation

A woman in her 40s was involved in a motor vehicle collision and sustained a closed Hawkins type IV talar neck fracture dislocation. The injury was treated with reduction, percutaneous pinning and spanning external fixation, followed by definitive treatment with total talus arthroplasty (TTA) 2 months following injury. This is a unique example of definitive management for a severe talar neck fracture dislocation with arthroplasty in the subacute setting. TTA is perhaps a primary option for these injuries at high risk for avascular necrosis, non-union, malunion and post-traumatic arthritis.

MRI in suspected chest wall fractures: diagnostic value in work-related chest blunt trauma

OBJECTIVE

To describe and analyze MRI findings in suspected early fractures of the chest (ribs and sternum) and assess if this technique can add value in occupational medicine.

MATERIALS AND METHODS

In this retrospective study, we reviewed 112 consecutive patients with work-related mild closed chest trauma who underwent early thoracic MRI, when there was not a clear fracture on radiograph or when the symptoms were intense and not explained by radiographic findings. MRI was evaluated by two experienced radiologists independently. The number and location of fractures and extraosseous findings were recorded. A multivariate analysis was performed to correlate the fracture characteristics and time to RTW (return-to-work). Interobserver agreement and image quality were assessed.

RESULTS

100 patients (82 men, mean age 46 years, range 22-64 years) were included. MRI revealed thoracic wall injuries in 88%: rib and/or sternal fractures in 86% and muscle contusion in the remaining patients. Most patients had multiple ribs fractured, mostly at the chondrocostal junction (n=38). The interobserver agreement was excellent, with minor discrepancies in the total number of ribs fractured. The mean time to return-to-work was 41 days, with statistically significant correlation with the number of fractures. Time to return-to-work increased in displaced fractures, sternal fractures, extraosseous complications, and with age.

CONCLUSION

Early MRI after work-related chest trauma identifies the source of pain in most patients, mainly radiographically occult rib fractures. In some cases, MRI may also provide prognostic information about return-to-work.

CURRENT CONCEPTS IN THE MANAGEMENT OF BOXER'S FRACTURE

Fractures of the metacarpal particularly the 5th metacarpal is quite common among all hand fractures and has a high incidence in male adult population. Proper management of these fractures plays a key role in rehabilitation and early return to work thus reducing the economic burden. Treatment of these injuries depends on the type of injury: whether it is a closed/open fracture, degree of angulation at the fracture site and also mal-rotation and shortening of the finger. Non-operative management is suitable for fractures which are closed, non-displaced and without angulation or rotation. Open fractures, fractures with angulation and/or mal-rotation and fractures with neuro-vascular injury are more suitable for operative management. The acceptable angulation for conservative management for most studies is 70 degrees. Buddy strapping with a Futura splint provides good functional results. In fractures requiring operative intervention, K-wire fixation is a minimally invasive method of fixation, which in most cases has good functional results. Plate and screw fixation, however, is preferred for cases with significant comminution or multiple metacarpal fractures.

Plating Versus Intramedullary Nailing of OTA/AO 43C1 and C2 Intra-articular Distal Tibia Fractures: A Propensity Score and Multivariate Analysis

OBJECTIVE

To compare rates of reduction loss, nonunion, and infection in intra-articular distal tibia fractures (IADTF) treated with limited open reduction internal fixation and intramedullary nailing (IMN) as compared to open reduction internal fixation with plate and screws (plate fixation [PF]).

METHODS

DESIGN

Retrospective review.

SETTING

Level-I academic trauma center.

PATIENT SELECTION CRITERIA

Patients age ≥ 18 with OTA/AO 43C1 and C2 IADTF treated with IMN or PF between 2013-2021.

OUTCOME MEASURES AND COMPARISONS

Loss of reduction, surgical site infection (SSI), nonunion, and patient-reported outcomes (PROs) were compared for IMN versus PF treatments.

RESULTS

One hundred ten patients met the inclusion criteria (IMN 33 and PF 77). There was no loss of reduction found. Seventeen nonunions (15% overall; IMN 4/33 and PF 13/77) and 13 SSIs (12% overall; IMN 2/33 and PF11/77) were identified. Despite several risk factors being identified for nonunion and SSI in bivariate analysis, only open fracture remained significant as a risk factor for both nonunion (odds ratio 0.09 for closed fracture, 95% confidence interval, 0.02-0.56, P = 0.009) and SSI (odds ratio 0.07 for closed fracture, 95% confidence interval, 0.06-0.26, P = 0.012) in the multivariate model. Propensity scoring based on presurgical variables was significantly different between patients who received IMN versus PF ( P = 0.03); however, logistic regression incorporating the propensity score revealed no significant association with nonunion and SSI. Adjusting for the propensity score, there remained no association comparing IMN versus PF with nonunion and SSI ( P = 0.54 and P = 0.17, respectively). There was also no difference in PROs between IMN and PF (physical function: P = 0.25 and pain interference: P = 0.21).

CONCLUSIONS

Overall nonunion and SSI prevalence was 15% and 12%, respectively, in operatively treated OTA/AO 43C1 and C2 IADTF. An open fracture was a significant risk factor for nonunion and SSI. Metaphyseal fixation through IMN or PF did not affect loss of reduction, nonunion, SSI, or PROs.

LEVEL OF EVIDENCE

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

Physeal Bar Formation After Pediatric Medial Malleolus Fractures

Pediatric medial malleolus fractures are commonly Salter-Harris (SH) type III or IV fractures of the distal tibia and are associated with a risk of physeal bar formation and subsequent growth disturbance. The purpose of this study was to determine the incidence of physeal bar formation following pediatric medial malleolus fracture and evaluate for patient and fracture characteristics predictive of physeal bar formation. Seventy-eight consecutive pediatric patients during a 6-year period who had either an isolated medial malleolar or a bimalleolar ankle fracture were retrospectively reviewed. Forty-one of 78 patients had greater than 3 months of radiographic follow-up and comprised the study population. Medical records were reviewed for demographic information, mechanism of injury, treatment, and need for further surgery. Radiographs were reviewed to assess for initial fracture displacement, adequacy of fracture reduction, SH type, percentage of the physeal disruption from the fracture, and physeal bar formation. Twenty-two of 41 patients (53.7%) developed a physeal bar. The mean time to diagnosis of physeal bar was 4.9 months (range, 1.6-11.8 months). Twenty-seven percent (6 of 22) of bars were diagnosed at greater than 6 months from injury. Adequacy of reduction was predictive of physeal bar formation, although all patients were reduced to within 2 mm. The mean residual displacement of patients with a bar was 1.2 mm compared with 0.8 mm for those without a bar (P=.03). Because the bar formation rate is greater than 50% on radiographs, routine radiographic assessment of all pediatric medial malleolar fractures should continue for at least 12 months after injury. [Orthopedics. 2024;47(1):e33-e37.].

Development, Validation and Characterization of a Novel Portable Closed Fracture Device

BACKGROUND/AIM

As one of the common clinical diseases, fractures have many causes, mechanisms, healing and influencing factors; especially fracture healing is a long-term and complex process. Animal fracture models can simulate the various states of human fractures, and on this basis, the prevention, mechanism, and treatment of fractures can be studied to further guide clinical practice.

MATERIALS AND METHODS

Here, we developed a novel and portable device to create a closed fracture model in mice. We then compared this novel closed fracture model with the traditional open model in multiple dimensions to evaluate the modelling process of establishment and healing. The two models were evaluated by imaging, immunostaining, and behavioral tests, which fully demonstrated the stability, universality and operability of the modified fracture model in mice.

RESULTS

Surgical quality assessment revealed that the closed fracture model had a shorter operation time and smaller wound than the open model. X-ray and micro-CT results showed no differences between the two models in the evaluation of radiographic and morphological changes during fracture healing. Histological examination revealed the process of the typical intrachondral osteogenic pathway after fracture. Moreover, animal gait analysis indicated reduced postoperative pain in the closed group compared to the open group.

CONCLUSION

This study provides a constructive strategy for a closed fracture model in mice and demonstrates the effectiveness and feasibility of the closed fracture model in studying the typical intrachondral osteogenic pathway of fractures from multiple dimensions.

Retro-Antegrade Technique in the Management of Severely Angulated Fourth and Fifth Metacarpal Neck Fractures: A Case Series

Background: This study introduces a novel method for the management of closed metacarpal neck fractures. Kirschner wires (K-wire) are introduced in a retrograde and the wires withdrawn through skin proximally at the base of the metacarpal. The fracture is reduced using traction and the reduction is maintained by antegrade advancement of the K-wires. The aim of this study is to report the outcomes of this technique. Methods: A total of 36 patients with severely angulated closed metacarpal neck fractures underwent reduction and fixation using this novel method from January 2017 to December 2020 in centres in Ireland and Saudi Arabia. We performed a retrospective review of these patients' clinical data examining their outcomes. Results: Six months postoperatively, all fractures demonstrated bony union and correction of angulation. All patients exhibited excellent range of motion (ROM) with no significant impairment of hand function. Conclusions: The method detailed here is a simple, minimally invasive and reliable technique that has not previously been described. It is suitable for use in the management of closed metacarpal neck fractures of the fourth and fifth metacarpal, with dorsal angulation greater than 60°. Level of Evidence: Level IV (Therapeutic).

Trends in and Factors Associated With Surgical Management for Closed Clavicle Fractures

INTRODUCTION

Clavicle fractures are common and have historically been managed nonsurgically. Over time, there are increasing surgical considerations for such injuries. Nonetheless, trends over the past decade are not well characterized.

METHODS

Adult patients presenting for first diagnosis of clavicle fractures were identified from the 2010 to 2020 PearlDiver M151 database. Patients were defined to have undergone surgical management if they received clavicular open reduction and internal fixation within 90 days after fracture diagnosis. Patient age, sex, Elixhauser Comorbidity Index (ECI), geographic region, insurance coverage, fracture anatomic location, and polytraumatic diagnoses were extracted. Factors independently associated with surgical management versus nonsurgical management were assessed with multivariable analysis.

RESULTS

Overall, 50,980 patients with clavicle fractures were identified of whom 6,193 (12.1%) were managed surgically. This proportion increased significantly over the study period (7.4% in 2015 to 13.9% in 2020, P < 0.001). Independent predictors of surgical management included fracture diagnosis in 2020 (versus 2015, odds ratio [OR] 2.36), anatomic location (relative to lateral end, shaft OR 1.84 and sternal OR 3.35), and Midwest region of service (OR 1.26, relative to South) (P < 0.001 for all).

DISCUSSION

A small but increasing minority of patients with clavicle fractures are managed surgically. Clinical factors and nonclinical factors were associated with surgical management.

Open tibial plateau fractures: Infection rate and functional outcomes

INTRODUCTION

Open tibial plateau fractures are complex injuries that require specialized management to prevent complications. The objective of this study was to compare the infection risk and functional outcomes between open and closed tibial plateau fractures.

MATERIALS AND METHODS

In this multicenter cohort study the propensity score matching was used to pair participants according to age, sex, and Schatzker classification. 190 patients were followed for 1 year postoperatively. The Fracture-Related Infection (FRI) Consensus Group criteria was used to diagnose infection. Knee functionality was measured using the Oxford Knee Score scale (OKS).

RESULTS

The proportion of open fractures was 5.1%, and the overall incidence rate of FRI was 8% with 14% of them represented by open fractures and 4% for closed fractures (p = 0.014). Open fractures were found to be a risk factor associated with FRI, with a 5.48 times higher probability of FRI than closed fractures (odds ratio 5.41, 95% confidence interval [CI] 1.55-18.85). Among the study population, 50% had satisfactory functional outcomes of the knee (median OKS 45, IQR = 3). The median OKS was 44 (IQR = 11) in open fractures and 46 (IQR = 7) in closed ones (p = 0.03). Multivariate analysis showed that the OKS was 3 points lower for open fractures (95% CI -5.530--0.478) than closed ones, and the score was 9.7 points lower for FRI.

CONCLUSION

Open TPF is a risk factor that increases the probability of fracture related infections. Functional outcomes were excellent for both open and closed TPF, with a slight difference numerical that was under the minimal clinical difference (MCID). The presence of FRI significantly decreases the functional outcome.

[Clinical analysis of posterior axillary approach internal fixation for IdebergⅠa andⅡglenoid fractures]

OBJECTIVE

To investigate the efficacy of posterior axillary approach internal fixation for Ideberg Ⅰa andⅡ glenoid fractures.

METHODS

From December 2018 to September 2021, 9 patients with lower part of glenoid fractures were treated by posterior axillary approach, including 3 males and 6 females, aged from 50 to 78 years old. All the fractures were closed fractures. According to Ideberg type of scapular glenoid fracture was type Ⅰa in 6 cases and type Ⅱ in 3 cases. AP and lateral X-ray films of scapula were taken at 6, 12 weeks and 6 and 12 months postoperatively. Constant-Murley and disabilities of the arm shoulder and hand (DASH), and other complications were recorded at the latest follow-up.

RESULTS

Nine patients were followed up, ranged from 6 to 15 months. And bone healing was achieved in all 9 patients at the final follow-up, the healing time 3 to 6 months, Constant-Murley score at the final follow-up ranged from 55 to 96, and DASH score ranged from 3.33 to 33.33. Both of them were better than preoperative.

CONCLUSION

The posterior axillary approach internal fixation for Ideberg Ⅰa and Ideberg Ⅱ Glenoid fractures scapular fracture is satisfactory and worthy of clinical application.

The value of radiomics-based CT combined with machine learning in the diagnosis of occult vertebral fractures

PURPOSE

To develop and evaluate the performance of radiomics-based computed tomography (CT) combined with machine learning algorithms in detecting occult vertebral fractures (OVFs).

MATERIALS AND METHODS

128 vertebrae including 64 with OVF confirmed by magnetic resonance imaging and 64 corresponding control vertebrae from 57 patients who underwent chest/abdominal CT scans, were included. The CT radiomics features on mid-axial and mid-sagittal plane of each vertebra were extracted. The fractured and normal vertebrae were randomly divided into training set and validation set at a ratio of 8:2. Pearson correlation analyses and least absolute shrinkage and selection operator were used for selecting sagittal and axial features, respectively. Three machine-learning algorithms were used to construct the radiomics models based on the residual features. Receiver operating characteristic (ROC) analysis was used to verify the performance of model.

RESULTS

For mid-axial CT imaging, 6 radiomics parameters were obtained and used for building the models. The logistic regression (LR) algorithm showed the best performance with area under the ROC curves (AUC) of training and validation sets of 0.682 and 0.775. For mid-sagittal CT imaging, 5 parameters were selected, and LR algorithms showed the best performance with AUC of training and validation sets of 0.832 and 0.882. The LR model based on sagittal CT yielded the best performance, with an accuracy of 0.846, sensitivity of 0.846, and specificity of 0.846.

CONCLUSION

Machine learning based on CT radiomics features allows for the detection of OVFs, especially the LR model based on the radiomics of sagittal imaging, which indicates it is promising to further combine with deep learning to achieve automatic recognition of OVFs to reduce the associated secondary injury.

Radiologic blind spots in hip and pelvic radiographs

PURPOSE

The purpose of our study was to identify the locations at which hip and pelvic fractures are commonly missed on radiographs.

METHODS

A retrospective study was performed at four non-Level 1 trauma center emergency departments. IRB approval was obtained. All emergency department hip or pelvic radiographs with subsequent CT performed within 48 h were identified from 2017 to 2022. Reports for each radiograph and CT were scored for the presence or the absence of fracture in the following locations: ilium, sacrum, superior pubic ramus, inferior pubic ramus, pubis, acetabulum, subcapital femoral, femoral neck, greater trochanter, lesser trochanter, intertrochanteric, and subtrochanteric. The CT report was used as the gold standard. The false-negative radiography cases were reviewed on a PACS workstation to determine whether the case had an "unexpected miss" of a fracture, a subtle fracture, radiographically occult fracture, or exam was limited by artifact. The percentage of missed fractures at each location was calculated.

RESULTS

Nine hundred seventy-five radiography cases with subsequent CT were identified. One hundred forty-six cases did not meet entry criteria; therefore, 829 cases were analyzed further. Seventy-four percent of patients were female with age of 74 ± 16 (mean ± standard deviation) years (range 1-103). Three hundred fifty-two cases had at least one fracture, and many cases had multiple fractures. There were 68 false-negative cases. The most commonly missed fractures by percentage were pubis, ilium, and greater trochanter. The most common unexpectedly missed fractures were greater trochanter and femoral subcapital.

CONCLUSION

A careful systematic evaluation of hip and pelvic radiographs, with particular attention to the pubis, ilium, greater trochanter, and subcapital region, may improve radiographic fracture detection and decrease delays in diagnosis.

Quantitative evaluation of bone marrow characteristics in occult and subtle rib fractures by spectral CT

PURPOSE

The present study aimed to determine whether the water content change in the medullary cavity of occult rib fractures by spectral computed tomography (CT).

METHODS

The material decomposition (MD) images were reconstructed using the water-hydroxyapatite basis material pairs from spectral CT. The water contents of the medullary cavity in subtle or occult rib fractures and the symmetrical sites of the contralateral ribs were measured, and their difference was calculated. The absolute value of the water content difference was compared to patients without trauma. An independent samples t-test was adopted to compare the consistency of the water content in the medullary cavity of the normal ribs. Intergroup and pairwise comparisons were applied to the difference in water content among the subtle/occult fractures and normal ribs, followed by receiver operating characteristic curve calculations. p < 0.05 was considered to have a statistically significant difference.

RESULTS

A total of 100 subtle fractures, 47 occult fractures, and 96 pairs of normal ribs were included in this study. The water content of the medullary cavity in the subtle and occult fractures was both higher than that in their symmetrical sites with the difference value of 31.06 ± 15.03 mg/cm3 and 27.83 ± 11.40 mg/cm3, respectively. These difference values between the subtle and occult fractures were not statistically significant (p = 0.497). For the normal ribs, the bilateral water contents were not statistically different (p > 0.05) with a difference value of 8.05 ± 6.13 mg/cm3. The increased water content of fractured ribs was higher than that of normal ribs (p < 0.001). According to the classification based on whether the ribs were fractured, the area under the curve was 0.94.

CONCLUSIONS

The water content measured on MD images in spectral CT in the medullary cavity increased as a response to subtle/occult rib fractures.

Risk Factors for Failure of Closed Forearm Fracture Reduction in the Pediatric Emergency Department

OBJECTIVES

This study aimed to explore risk factors for failure of forearm fracture closed reduction in the pediatric emergency department (ED) and to suggest indications for initial surgery.

METHODS

This retrospective cohort study included all patients aged 0 to 18 years who presented to our pediatric ED with an extraarticular forearm fracture treated with closed reduction between May 2017 and April 2021. We explored risk factors for procedural failure, defined as a need for surgical intervention within 6 weeks of the closed reduction attempt.

RESULTS

Of 375 patients (median age 8.1 years, 294 [78.2%] boys), 44 (11.7%) patients sustained a reduction failure, of whom 42 (95.5%) had both radius and ulna fractures. Of the 259 patients with fractures of both bones, the following parameters were independent predictors for reduction failure: refracture (adjusted odds ratio [aOR] 17.6, P < 0.001), open fracture (aOR 10.1, P = 0.007), midshaft fracture (aOR 2.6, P = 0.004), radial translation rate 37% and higher in either plane (aOR 5.1, P = 0.004), and age of 10 years and older (aOR 2.9, P = 0.01).

CONCLUSIONS

Most pediatric forearm fractures can be successfully managed by closed reduction in the ED. Two-bone fractures had the strongest association with reduction failure. Refracture, open fracture, midshaft location, initial radius bone translation of 37% and higher (and not initial angulation), and patient age of 10 years and older are independent risk factors for reduction failure in two-bone fractures. We propose a risk score for reduction failure that can serve as a decision-making tool.

Effects of repeated intravenous doses of tranexamic acid on closed tibial fracture healing: Experimental study based on the rat model

OBJECTIVE

The aim of this study was to assess the effects of tranexamic acid on fracture healing in the rat tibia closed fracture model.

METHODS

Sixty-four male Sprague-Dawley rats were included in this study, where closed fracture and intramedullary nailing were performed on their right tibial diaphyses. They were divided into 2 main groups, the experimental group, which was given weekly tranexamic acid injections, and the control group, which received no additional treatment. Eight rats from each group were sacrificed and evaluated for fracture healing at the first experimental group and control group, second experimental group and control group, third experimental group and control group, and fourth experimental group and control group weeks. Fracture healing was radiologically assessed according to the "Spencer Index" and "Lane and Sandhu Scoring System," and histologically evaluated according to the scoring system devised by Huo et al. Results: According to the Spencer Index, the mean union score was statistically significantly higher in the E3 group than in the third con- trol group (P = .014). Furthermore, the mean union score was statistically significantly higher in the fourth experimental group compared to the fourth control group (P=.047). According to the Lane and Sandhu Scoring System, only the mean union scores of the E3-4 groups were statistically significantly higher than the mean union scores of the C3-4 groups (P=.048). There was no histological difference between groups in terms of union, according to the criteria defined by Huo et al (P > .05).

CONCLUSION

This study showed us that repeated intravenous administrations of tranexamic acid had no negative effect on fracture heal- ing in the rat tibia fracture model. Although tranexamic acid demonstrated better radiological healing in the late period, it had no effect on histological union.

A risk prediction model for postoperative recovery of closed calcaneal fracture: a retrospective study

OBJECTIVE

To explore the risk factors for postoperative recovery of closed calcaneal fracture and develop a prediction model.

METHODS

We retrospectively enrolled patients with closed calcaneal fracture from January 1, 2017 to December 31, 2020. Patients treated from 2017 to 2019 were selected as a training cohort and those in 2020 as a validation cohort. The outcome variable was the postoperative recovery evaluated by the Creighton-Nebraska calcaneal fracture scoring system. Multivariate logistic regression analysis was used to screen the risk factors of postoperative recovery. A risk prediction model was constructed in the training cohort and the corresponding nomogram was drawn. The model was validated internally using bootstrapping and externally by calculating the performance in the validation cohort.

RESULTS

A total of 659 patients with closed calcaneal fracture met the inclusion and exclusion criteria, which were divided into the training cohort (n = 509) and the validation cohort (n = 150). 540 cases (81.9%) patients recovered well after calcaneal fracture surgery. According to multivariate logistic regression analysis, female (OR = 2.525, 95% CI 1.283-4.969), > 60 years (OR = 6.644, 95% CI 1.243-35.522), surgery within 8-14 days after fracture (OR = 2.172, 95% CI 1.259-3.745), postoperative infection (OR = 4.613, 95% CI 1.382-15.393), and weight-bearing time longer than 3 months after surgery (4-6 months, OR = 2.885, 95% CI 1.696-4.907; 7-12 months, OR = 3.030, 95% CI 1.212-7.578; > 12 months, OR = 15.589, 95% CI 3.244-74.912) were independent risk factors for postoperative recovery of calcaneal fractures. The C-indices were 0.750(95% CI 0.692-0.808) in the training cohort and 0.688(95% CI 0.571-0.804) in the external validation cohort, and the C-index of internal validation was 0.715. The Hosmer-Lemeshow test showed good fitting of the model (all P > 0.05), which was consistent with the results of the calibration plots. Decision Curve Analysis indicated that the clinical effectiveness was the best when the threshold probability was between 0.10 and 0.45.

CONCLUSIONS

Patients with female, > 60 years, surgery within 8-14 days after fracture, postoperative infection, and weight-bearing time longer than 3 months after surgery are more likely to have poor postoperative recovery. The risk prediction of fracture patients through this model might be translated into clinical guidance and application. Trial registration This study was registered on the Chinese Clinical Trial Registry (Registration number: ChiCTR-EPR-15005878).

Management of Hardware-Exposed Soft Tissue Defects Using Dermal Substitutes and Negative Pressure Wound Therapy

INTRODUCTION

Reconstruction of complex injuries of the extremities with full-thickness wounds is a challenging but important task. If primary closure is not feasible, more complex procedures are required, such as split-thickness skin graft or flap surgery. Recently, several studies have shown good results when combined with negative pressure wound therapy (NPWT) and artificial dermal replacement therapy after extensive surgical debridement and NPWT administration for severe complex wounds accompanied by tendon or bone exposure. However, flap surgery remains the only treatment for wounds in which the hardware is exposed after fracture fixation. Therefore, in this study, we attempted to prove the usefulness of the combined treatment using artificial dermal substitutes (MatriDerm) and NPWT by focusing on hardware-exposed wounds, which have not been studied before.

METHODS

From 2019 to 2021, we treated with our wound management procedure 14 patients with hardware-exposing wounds after internal fixation using plates, out of 48 patients with full-thickness posttraumatic skin defect. Before skin grafting, after surgical debridement and thorough washouts, MatriDerm was placed and NPWT was applied over it. This staged approach aimed at conditioning even the most complex wounds so that closure with MatriDerm-augmented skin grafting would become possible in a one-step approach.

RESULTS

We stratified the duration of treatment and number of replacements in NPWT according to the type of injury. Cases with open fractures required significantly longer NPWT than those with closed fractures (P = 0.01); however, there was no significant difference between the Gustilo-Anderson classification within open fractures (P > 0.05). Patients with open fractures underwent a mean of 6.6 changes while those with closed fractures underwent 2.5 (P = 0.002) until the final wound closure with MatriDerm-augmented skin grafting was performed. There was no significant difference in the treatment period based on the location and size of the wound, and there was no significant difference in the number of NPWT replacements. Skin grafting was successful in all 14 patients.

CONCLUSIONS

This study revealed that NPWT and artificial dermis-augmented skin grafting after combined treatment with NPWT and artificial dermis were sufficiently useful for hardware-exposed wounds, where flap surgery has been considered the only treatment to date.

Presentation and Referral Patterns in Pediatric Closed Hand Fractures

BACKGROUND

Although pediatric hand fractures are common and generally have good outcomes, they remain a considerable source of anxiety for non-hand surgeons, who are less familiar with these injuries. We hypothesized that this anxiety may manifest as inefficiency in referral patterns.

METHODS

The records of pediatric patients with isolated, closed hand fractures without concurrent trauma seen at our institution by a hand surgeon between January 2017 and December 2018 were retrospectively reviewed.

RESULTS

There were 454 patients included; 62.1% were men, and the mean age was 9.6 years at initial encounter. Most patients (89.6%) were treated nonoperatively and incurred few complications (0.5%). Roughly half of all cases (n = 262) initially presented to an outside provider. Of these, 24.0% (n = 64 of 262) were evaluated by 2+ providers before a hand surgeon. Most commonly, these patients were referred from an outside emergency department (ED) to our ED before hand surgeon evaluation (n = 45 of 64). Forty-seven patients required surgery; however, none were performed urgently. Although a greater proportion of 7- to 11-year-old patients saw 2+ providers prior to a hand surgeon (P = .007), fewer required surgery (P < .001).

CONCLUSIONS

Pediatric closed hand fractures are mainly treated nonoperatively and nonemergently with generally excellent outcomes. Our data suggest that many patients continue to be referred through the ED or multiple EDs/providers for treatment. These inefficient referral patterns demonstrate the need for better education for ED and primary care providers, as well as better communication between these providers and local pediatric hand surgeons. Advancements in these areas are likely to improve efficiency of care and decrease costs.

Immunohistochemical Analysis of CCN2 in Experimental Fracture Healing Models

Skeletal fractures are most common large-organ traumatic injuries that impact the functions and esthetic outcomes and quality of life. Unfortunately, infection during the fracture healing process and inadequate blood supply to the bone impede reduced ability to produce cartilage and effective bone callus formation, leading to nonunion or delayed union fracture. Therefore, studying the mechanism of fracture healing is an important task in solving the problem of fracture healing failure. Animal models of bone fracture healing are important tools to investigate the pathogenesis and develop treatment strategies. This protocol introduces researchers to a bone repair model utilizing the ribs of rats and the immunohistological expression of cellular communication network factor/connective tissue growth factor (CTGF/CCN2) during the fracture healing processes.

Salter-Harris Type III Fracture of the Distal Phalanx: A Rare Juxtaphyseal Variant

Juxtaphyseal fractures of the distal phalanges of upper extremity digits are most commonly of the Salter-Harris II variety and occur most commonly in the thumb. The diagnosis of this injury is essential as it may present as an open fracture with a nailbed injury ("Seymour fracture"). However, an intra-articular, epiphyseal fracture may also occur and mimic a mallet deformity or Seymour fracture. Prompt diagnosis is essential to rule out an open fracture and obtain anatomical alignment and stability to attempt to reduce complications such as physeal arrest. Here, we present a patient with a displaced Salter-Harris type III fracture of his thumb distal phalanx and review his management and early-term outcome. We present this case to bring attention to this rare and unique injury, review the available literature, and discuss management and outcomes.

Variant Salter-Harris Type III Distal Ulna "T" Fracture in the Setting of Galeazzi Equivalent Wrist Injury: A Case Report

CASE

An 11-year-old Caucasian boy presented to the emergency department with a displaced, closed, Galeazzi equivalent (GE) left wrist fracture sustained after a fall. Closed reduction was deemed unsatisfactory because of persistent displacement of the distal ulna epiphysis. An open reduction of the distal ulna and percutaneous fracture pinning was performed. At 1 year, the patient reported return to his preinjury baseline. No evidence of subsequent pathologic growth was detected on follow-up imaging.

CONCLUSION

Open anatomic reduction of the distal ulna epiphysis and percutaneous fracture pinning may improve patient outcomes and limit progressive wrist deformity when treating GE wrist injuries.

Radial Nerve Paralysis in Diaphyseal Fractures of the Humerus

One of the most common complications associated with a diaphyseal humeral fracture is the development of a radial nerve injury. We conducted a study to analyze the degree of recovery and prognostic factors associated with radial nerve palsy in patients with diaphyseal humerus fractures. We retrospectively analyzed 28 patients who presented to the Hospital La Fe, Valencia, Spain, with a diaphyseal humerus fracture associated with radial nerve injury between 2010 and 2020. A total of 14.3% (n = 4) of the patients in our cohort had open fractures and 85.7% (n = 24) had closed fractures. There were no statistically significant differences between the type of treatment and the type of fracture (p = .13). There were also no significant differences between the type of treatment and recovery time (p = .42). There was a statistically significant difference (p = .04) in the mean recovery time for patients with preoperative radial nerve injuries (11.9 months) compared with patients who sustained a radial nerve injury secondary to surgical repair of the fracture (8.6 months). The difference in recovery time between patients with open and closed fractures was not statistically significant (p = .3). Results of the study showed that the type of fracture (i.e., open or closed) did not affect radial nerve palsy recovery time. Patients who sustain radial nerve injuries secondary to a surgical repair have a shorter recovery time than patients who sustain primary radial nerve injuries.

Management and Outcomes of Clinical Scaphoid Fractures in Children

Background: Acute wrist trauma with clinical suspicion of a scaphoid fracture, but normal radiographs, is known as a clinical scaphoid fracture. Standard treatment involves immobilization and repeat radiographs in 10 to 14 days. When repeat radiographs are normal but a scaphoid fracture is still clinically suspected, the optimal management in children is unknown. This study retrospectively assessed the management and outcomes of pediatric patients diagnosed with clinical scaphoid fractures. Methods: A retrospective study was performed of all patients over a 2-year period treated for a clinical scaphoid fracture at a tertiary pediatric center. Patients were included if they had clinical signs of a scaphoid fracture and 2 negative x-rays 7 to 14 days apart postinjury. Results: Ninety-one patients with a mean age of 13.2 years (range: 7.8-17.7) were included. Sixteen patients (17.6%) underwent computed tomography (CT) or magnetic resonance imaging (MRI) at a mean time of 10.2 weeks postinjury. Five patients (5.5%) were diagnosed with a scaphoid fracture by x-ray or CT at an average of 4.5 weeks postinjury (range: 3-6). Six patients were diagnosed with other wrist fractures at a mean time postinjury of 3.1 (range: 3-6.5) weeks. Out of 195 total radiographs, the surgeon and radiologist disagreed on 59 (30.2%) images. No patients underwent surgery. Conclusions: Management of clinical scaphoid fractures at our institution was relatively uniform: nearly all patients were immobilized and less than 20% received advanced imaging. Our findings suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and lack of advanced imaging, providing an avenue for future prospective studies.

Postoperative Reduction Quality May Be the Most Important Factor That Causes Worse Functional Outcomes in Open and Closed Pelvic Fractures

Background

Data on the functional outcomes of patients with open pelvic fractures after osteosynthesis are limited, and whether open fracture is a risk factor for worse outcomes, as compared with closed fracture, remains unclear. This study aimed to compare the functional outcomes of patients with open and closed pelvic fractures and evaluate potential factors that might affect outcomes.

Methods

Overall, 19 consecutive patients with open pelvic fractures and 78 patients with closed pelvic fractures between January 2014 and June 2018 were retrospectively reviewed. All fractures were surgically treated, with a minimal follow-up period of three years. Patients’ demographic profile, associated injuries, management protocol, quality of reduction, and outcomes were recorded and analyzed.

Results

Patients with open pelvic fractures had higher new injury severity score, higher incidence of diverting colostomy, and longer length of stay. Both radiological and functional evaluations revealed no significant differences between the two groups at 1-year and 3-year evaluations. Multiple logistic regression analysis identified poor radiological outcomes (using Lefaivre criteria) and longer length of stay as risk factors for worse short-term functional outcomes. At 3-year evaluation, fair-to-poor radiological outcomes (using Matta/Tornetta and Lefaivre criteria) and the presence of diverting colostomy were potential risk factors.

Conclusions

Compared with closed pelvic fracture, open pelvic fracture was not an indicator of worse functional outcomes. Functional outcomes may be comparable between patients with open and closed pelvic fractures at different time points within three years postoperatively. Achieving anatomical reduction in a fracture is crucial, because it might affect patient satisfaction.

Fractures Presumed to Be Low Risk for Abuse in Young Mobile Children: Association With Concomitant Suspicious Injuries

OBJECTIVES

To evaluate the likelihood of abuse for various fractures, we aimed to compare the prevalence of concomitant suspicious injuries (CSIs) in subjects with fractures presumed to be low risk for abuse to those with non-low-risk fractures (aim 1) and to evaluate the prevalence of low-risk and non-low-risk fractures identified on skeletal survey (SS) (aim 2).

METHODS

Subjects included toddlers 9 to 23 months of age presenting to a children's hospital system with a fracture and having an SS completed (aim 1) as well as those who had an SS completed for any concern for abuse (aim 2). For aim 1, we performed a 5-year retrospective case-control study. Low-risk fractures were defined as extremity buckle, clavicle, supracondylar, or toddler's fractures. Controls included moderate- and high-risk fracture groups. Groups were compared for the prevalence of CSIs. For aim 2, we described the frequencies of all fracture types identified by SS completed for any concern for abuse over the same period.

RESULTS

For aim 1, there were 58 low-risk, 92 moderate-risk, and 8 high-risk fractures. The rates of CSIs were not significantly different between low- and moderate-risk fractures (odds ratio, 0.9; 95% confidence interval, 0.4-2.5), whereas half of high-risk fractures had CSIs. Forty-five subjects had an occult fracture on SS completed for any abuse concern. All low-risk fractures were identified by SS, most commonly buckle fractures (22.2% of cases).

CONCLUSIONS

Fractures presumed to be low risk for abuse in young, mobile children require consideration of abuse as a cause.

Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition

OBJECTIVES

To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated.

METHODS

Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage.

RESULTS

Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%).

CONCLUSIONS

About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.

[Behavior of patients with tibial pilon fractures treated by external fixation]

INTRODUCTION

Tibial pylon fractures are difficult to manage injuries due to their anatomical situation, mechanism of production, and damage to the surrounding soft tissue. Surgical treatment is the most widely used, including external fixation that can be used temporarily or permanently.

OBJECTIVE

To evaluate the use of external fixation in patients with tibial pylon fractures.

MATERIAL AND METHODS

A pre-experimental study with a level of evidence II, recommendation grade B, was carried out in 34 patients with tibial pylon fracture, treated from January 2014 to February 2020. From the statistical point of view, the distribution of absolute and relative frequencies was used for qualitative variables and for quantitative variables, the Student's t test.

RESULTS

The general average age was 45.8 years, the male sex predominated with a ratio of 1.4 to 1 and the closed-open fractures 1.8 to 1. Type A fractures predominated according to the classification of the AO group. In relation to open fractures, 3A types predominated. Significance between a before and after was detected when applying the Olreud C and Molander H scales, from the American Ankle and Foot Society, and the Ankle Scoring System. The complications of the surgical procedure were minimal.

CONCLUSIONS

External fixation in patients with tibial pylon fractures is an effective method that can be used immediately and definitively in patients with both open and closed fractures with few complications.

Modern treatment of tibial shaft fractures: Is there a role today for closed treatment?

PURPOSE

The decision to attempt closed treatment on tibial shaft fractures can be challenging. At our institution, we attempt treatment of nearly all closed, isolated tibial shaft fractures. The purpose of this study was to report the results of 10 years of experience to develop a tool to identify patients for whom non-operative treatment of tibial shaft fractures may be a viable option METHOD: This was a retrospective review of patients with tibial shaft fracture seen at a level 1 trauma center over 10 years. Patients with closed, isolated injuries underwent sedation, closed reduction, long-leg casting, and outpatient follow-up. Patients were converted to surgery for inability to obtain or maintain acceptable alignment or patient intolerance. Radiographic characteristics and patient demographics were extracted. Logistic regression analysis was used to develop a model to predict which patient and injury characteristics determined success of nonoperative treatment.

RESULTS

334 patients were identified with isolated, closed tibial shaft fractures, who were reduced and treated in a long leg cast. 234 patients (70%) converted to surgical treatment due to inability to maintain alignment, patient intolerance, and nonunion. In a regression model, coronal/sagittal translation, sagittal angulation, fracture morphology, and smoking status were shown to be significant predictors of success of nonoperative treatment (p < 0.05). We developed a Tibial Operative Outcome Likelihood (TOOL) score designed to help predict success or failure of closed treatment. The TOOL score can be used to identify a subsegment of patients with injuries amenable to closed treatment (38% of injuries) with a nonoperative success rate over 60%.

CONCLUSION

Non-operative treatment of tibial shaft fractures is feasible, although there is a relatively high conversion rate to operative treatment. However, it is possible to use injury characteristics to identify a cohort of patients with a higher chance of success with closed treatment, which is potentially useful in a resource-constrained setting or for patients who wish to avoid surgery.

LEVEL OF EVIDENCE

Prognostic Level 3.

Occult periprosthetic fractures of the acetabulum in THA using an elliptic cup design have no adverse impact on outcome

Occult periprosthetic fractures have been defined as a fracture only visible on postoperative CT scans but not on postoperative plain radiography after an uneventful surgery without intraoperative fracture. The fracture rate for hemispherical and peripheral self-locking cups has been described as 8.4%. We retrospectively analyzed postoperative CT scans after primary THA to clear the question whether such occult periprosthetic fractures of the acetabulum require particular treatment strategy. Between 2014 and 2018 we identified 115 CT scans of 114 patients after primary cementless THA with elliptical cups using a direct anterior approach. The CT scans were obtained as part of other investigations. Localization of the fracture, patients demographics, clinical (WOMAC, Harris Hip Score) and radiological outcome were analyzed. Fracture and non-Fracture group were compared with regard to demographics and short-term outcome after 1 year. Four occult fractures (3.5%) were identified. Three fractures involved the posterior wall. All patients had an uneventful routine postoperative rehabilitation. Patients with occult fractures showed similar post- operative HHS and WOMAC scores at 3 (HHS p = 0.576, WOMAC p = 0.128) and 12 (HHS p = 0.479, WOMAC p = 0.588) months. There were no cup loosening nor radiolucent lines at latest follow-up (mean FU 22 months, range 12-34 months). Clinical and radiological short-term outcome was not impaired by the occurrence of an occult periprosthetic fracture of the acetabulum. The incidental detection of an occult periprosthetic fracture of the acetabulum does not seem to oblige the surgeon to adapt the postoperative regime.

A novel autologous bone graft substitute comprised of rhBMP6 blood coagulum as carrier tested in a randomized and controlled Phase I trial in patients with distal radial fractures

Bone morphogenetic proteins (BMPs) are known to induce new bone formation in vivo but treating trabecular bone defects with a BMP based therapeutic remains controversial. Here, we evaluated the safety and efficacy of a novel Autologous Bone Graft Substitute (ABGS) comprised of recombinant human BMP6 (rhBMP6) dispersed within an autologous blood coagulum (ABC) as a physiological natural carrier in patients with a closed distal radial fracture (DRF). We enrolled 32 patients in a randomized, standard of care (SoC) and placebo (PBO) controlled, double-blinded Phase I First in Human (FiH) clinical trial. ABGS was prepared from peripheral blood as 250 μg rhBMP6/mL ABC or PBO (1 mL ABC containing excipients only) and was administered dorsally via a syringe injection into the fracture site following closed fracture fixation with 3 Kirschner wires. Patients carried an immobilization for 5 weeks and were followed-up for 0 to 26 weeks by clinical examination, safety, serial radiographic analyses and CT. During the 13 weeks follow-up and at 26 weeks post study there were no serious adverse reactions recorded. The results showed that there were no detectable anti-rhBMP6 antibodies in the blood of any of the 32 patients at 13- and 26-weeks following treatment. Pharmacokinetic analyses of plasma from patients treated with ABGS showed no detectable rhBMP6 at any time point within the first 24 h following administration. The CT image and radiographic analyses score from patients treated with AGBS showed significantly accelerated bone healing as compared to PBO and SoC at 5 and 9 weeks (with high effect sizes and P = 0.027), while at week 13 all patients had similar healing outcomes. In conclusion, we show that intraosseous administration of ABGS (250 μg rhBMP6/mL ABC) into the distal radial fracture site demonstrated a good tolerability with no serious adverse reactions as well as early accelerated trabecular bone healing as compared to control PBO and SoC patients.

CDllb+ targeted depletion of macrophages negatively affects bone fracture healing

Inflammation is an important part of the fracture repair process which requires osteogenic cells to interact with innate immune cells such as macrophages. All murine macrophages express the F4/80 cell surface marker but they may be further subdivided into two main phenotypes: M1 (proinflammatory) or M2 (anti-inflammatory) based on surface marker expression and function. Macrophages polarize between these two main classes in response to inflammation while differentially regulating the healing process. Studies have shown that F4/80+ cell ablation impairs fracture healing, however, the distinct phenotypes that participate in the early healing process is unclear. We hypothesized that the M1 subtype is essential for the early steps of fracture healing and their depletion would impair fracture repair. To test this hypothesis, M1 (F4/80+/MHCII+/CD86+/CDllb+) macrophages were depleted using a saporin conjugated Mac-1 antibody (Mac1SAP) in vitro using primary macrophages and in vivo using a mouse femur fracture model. Primary macrophages isolated from mice femoral bone marrow were either left undifferentiated (+PBS), differentiated into M1 macrophages (+LPS), or differentiated to M2 macrophages (+IL-4), and then treated with either vehicle or 10 pM Mac1SAP. Samples were collected at day 2 and 5 post Mac1SAP treatment. Macrophage subtypes were identified by flow cytometry and cytokine secretion profiles were quantified using xMAP. For the in vivo model, mice were treated with Mac1SAP 24 h prior to fracture. Femur bone marrow samples were collected and analyzed by flow cytometry, xMAP, immunohistochemistry, MicroCT, and histology. The results demonstrated that Mac1SAP significantly depleted M1 macrophages both in vivo and in vitro. Mac1SAP treatment altered expression of 75% of cytokines in vitro and 30% of cytokines in vivo including IL-6, TNF-a, and IP-10. In both the in vitro and in vivo models, the M1 subtype correlated highly with cytokines G-CSF, IL-1α, IL-6, IL-10, LIX, KC, MCP-1, IP-10, MIP1α, MIP1β, RANTES, IL-9, IL-2 and TNFα. M1 depletion was also found to reduced callus properties at day 14 via microCT analysis. Overall, the data suggests that depletion of M1 macrophages by Mac1SAP treatment alters the cytokine expression profiles during early bone repair which ultimately impairs bone healing.

[CT imaging features and misdiagnosis analysis of occult anterior calcaneal process fracture]

OBJECTIVE

To explore CT imaging features and reason for missed diagnosis of clinical practice of occult anterior calcaneal process fracture.

METHODS

From July 2013 to November 2018, the clinical data of 13 patients with occult an anterior calcaneal process fracture were retrospectively analyzed, including 2 males and 11 females, aged from 22 to 54 years old. Classification of fracture, displacement of fracture, direction of fracture line, size of fracture, with or without tarsal coalition, other fractures and misdiagnosis, the time from injury to diagnosis, condition of treatment and fracture healing were observed according to case history, data of X-ray and CT.

RESULTS

Thirteen patients were diagnosed as occult anterior calcaneal process fracture after CT examination. According to Degan classification, 9 patients were type I, 4 patients were typeII; 4 patients were occurred displacement, and 9 patients did not occurred displacement. On the horizontally CT, fracture line of 12 patients showed transverse, 1 patient oblique, and the size of fracture ranged from 0.40 to 1.72 cm; while on the sagittal view, fracture line of 12 patients showed vertical, 1 patient oblique, and the size of fracture ranged from 0.10 to 0.59 cm. No patients combined with talocalcaneal and scaphoid bridge. Six patients were simple anterior calcaneal process fracture, 7 patients combined with other fractures. Eight patients were misdiagnosed. The time from injury to diagnose ranged from 0 to 21 days. Nine patients with type Iwere performed conservative treatment, 6 patients healed well and 3 patients with fracture line less than 1 cm on horizontally view occurred fracture nonunion. Four patients with type II did not perform operation, and fracture were not union, regardless of fracture size.

CONCLUSIONS

Occult anterior calcaneal process fracture have high rate of missed diagnosis in clinical practice. CT imaging features of fracture showed that most fracture line were transverse on CT horizontal plane while vertical on CT sagittal plane, as well as small side of fragment on CT sagittal plane with differernt sizes of fragment on CT horizontal plane; type Ifracture with fragment less than 1 cm on CT horizontal plane and type II both have high rate of nonunion while treated with conservative treatment.

[Closed reduction combined with Taylor three-dimensional space stent fixation for supracondylar femoral fracture in children]

OBJECTIVE

To explore the effectiveness and safety of closed reduction combined with Taylor three-dimensional space stent fixation in treatment of supracondylar femoral fractures in children.

METHODS

Between July 2008 and July 2016, 20 patients with supracondylar femoral fractures were treated with closed reduction combined with Taylor three-dimensional space stent fixation. There were 14 males and 6 females, with an average age of 10.3 years (range, 6-14 years). The cause of injury was traffic accident in 5 cases, falling from high place in 6 cases, and falling in 9 cases. All fractures were closed fractures. Among them, 12 cases were flexion type and 8 cases were straight type. According to AO classification, 12 cases were rated as type A1 and 8 cases as type A2. The fractures were over 0.5-5.0 cm (mean, 2.5 cm) of the epiphysis line. The time from injury to surgery was 2-8 days (mean, 3.5 days). Postoperative knee joint function was evaluated based on the Kolment evaluation criteria.

RESULTS

All children were followed up 6-24 months (mean, 18.1 months). There was no complication such as nail infection, vascular nerve injury, external fixation looseing, fracture displacement, or re-fracture. All fractures healed and the fracture healing time was 4-6 weeks with an average of 4.5 weeks. The stent removal time was 8-12 weeks (mean, 9.5 weeks). The gait and knee function recovered, and there was no abnormality of the epiphysis. At last follow-up, the knee joint function were excellent in 18 cases and good in 2 cases according to the Kolment evaluation criteria, and the excellent and good rate was 100%.

CONCLUSION

Closed reduction combined with Taylor three-dimensional space stent fixation is an effective treatment for the children with supracondylar femoral fractures, with small trauma and rapid recovery. It can avoid damaging the tarsal plate, be high fracture healing rate, and promote the recovery of limb function.

Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines

BACKGROUND

Evidence-based medicine is the application of research findings to inform individual clinical decisions. There is a tension-both philosophical and practical-between the average result from a population study and the circumstances and needs of an individual patient. This personal account of "evidence-based" trauma care illustrates and explores this tension.

THE CASE

The author, a keen athlete, describes her experience of a high-impact cycle accident that led to limb fractures (which were diagnosed and treated according to evidence-based guidelines) and also an occult injury to the cervical spine (which was not diagnosed at the time). Some evidence-based guidelines are reviewed and applied to the case. The clinical record described the cycle accident as a "fall." Initial assessment directed the clinicians' gaze to the obvious injuries, whose treatment was straightforward. On admission, the patient (aged 55 years at the time) was offered "falls prevention" via a guideline-based checklist. Several months later, neurological sequelae indicated possible damage to the cervical spine. But the NICE Guideline recommending cervical spine imaging in cases of high-impact trauma had not been considered-perhaps because the clinical narrative had been prematurely assigned to the script of "older person with fall." Furthermore, the author, who was (appropriately) treated with neurosurgery, was surprised at the response of clinical colleagues, based on application of an irrelevant section of a guideline, that her cervical discectomy was "nonevidence based." Nonsteroidal anti-inflammatory drugs for postoperative pain were indicated in this patient even though they were not recommended for the average patient.

CONCLUSION

As Sir John Grimley Evans' warned, we should avoid using evidence-based guidelines in the manner of the fabled drunkard who searched under the lamp post for his key because that was where the light was, even though he knew he had lost his key somewhere else.

[Effectiveness analysis of surgical treatment of Schatzker type tibial plateau fractures]

Objective

To introduce a surgical protocol based on the location and orientation of the apex of the medial condylar fracture line for the treatment of Schatzker type Ⅳ tibial plateau fractures and report the preliminary effectiveness.

Methods

The clinical data of 18 patients with Schatzker type Ⅳ tibial plateau fractures underwent open reduction and internal fixation between March 2012 and April 2016 were retrospectively analysed. There were 6 males and 12 females, aged 36-74 years (mean, 45 years). The causes of injury included traffic accident in 2 cases, falling in 14 cases, bruise injury in 1 case, and crush injury of heavy object in 1 case. All cases were fresh closed fractures, without injury of nerves and blood vessels. According to sub type of Wahlquist tibial plateau type Ⅳ fracture classification, there were 1 case of type A, 5 cases of type B, and 12 cases of type C. The interval of injury and operation was 6-16 days (mean, 9.5 days). The location of the apex of the medial condylar fracture line was determined the surgical approach. After operation, reduction of tibial plateau fractures was evaluated by the DeCoster score evaluation criteria. The knee joint function was assessed by short Musculoskeletal Function Assessment (SMFA) score and Hospital for Special Surgery (HSS) score.

Results

The incisions all healed by first intension after operation without surgery related complications. All the patients obtained satisfactory exposure and reduction during operation. According to DeCoster score evaluation criteria, the results were excellent in 13 cases and fair in 5 cases. All the patients were followed up 12-30 months (mean, 18 months). X-ray films showed that all fractures healed at 10-16 weeks (mean, 12 weeks) after operation. There was no plate displacement, screw loosening, and other complications occurred during follow-up. At last follow-up, the SMFA score was 15-48 (mean, 28.5). The HSS score was 52-94 (mean, 81.1), and the results were excellent in 10 cases, good in 5 cases, fair in 2 cases, and poor in 1 case with an excellent and good rate of 83.3%; the main clinical manifestation was severe traumatic osteoarthritis symptom in 1 case with the fair result.

Conclusion

The surgical program should be developed based on the location and orientation of the apex of the medial condylar fracture line. Open reduction and internal fixation for treating Schatzker type Ⅳ fractures can achieve satisfactory effectiveness.

[Posterolateral minimal incision, poking reduction, and simple internal fixation in treatment of collapsed fractures of posterolateral tibial plateau]

Objective

To explore the effectiveness of limited incision, poking reduction, and simple internal fixation in the treatment of collapsed fractures of the posterolateral tibial plateau.

Methods

Between October 2010 and January 2016, 16 patients with collapsed fractures of the posterolateral tibial plateau underwent posterolateral incision, poking reduction, and simple internal fixation. There were 10 males and 6 females with the age of 22-63 years (mean, 43.5 years). The injury was caused by falling in 5 cases, traffic accident in 7 cases, and falling from height in 4 cases. All cases had closed fractures. The left knee was involved in 9 cases and the right knee in 7 cases. The injury-to-admission time was 2 hours to 3 days (mean, 10 hours). X-ray films showed that the articular surface collapsing was more than 2 mm. According to Schatzker criteria, 6 cases were rated as type II and 10 cases as type III. Twelve cases had fracture of fibular head. The incision length, operation time, intraoperative blood loss, and incision healing were recorded; fracture healing was observed, and tibial plateau angle and posterior slope angle were measured on X-ray films; loss of articular surface reduction was observed by CT scan; and American Hospital for Special Surgery (HSS) score was used to evaluate the knee joint function.

Results

The incision length was 7-10 cm (mean, 8.6 cm); operation time was 35-55 minutes (mean, 46 minutes); intraoperative blood loss was 10-35 mL (mean, 28 mL). Primary healing of incision was obtained. Skin pain occurred in 1 case at 2 months because Kirschner wire retracted. Fifteen cases were followed up 8-21 months (mean, 13.5 months). The fracture healing time was from 3 to 6 months (mean, 4.8 months). There was no significant difference in tibial plateau angle and posterior slope angle between at immediate after operation and at last follow-up ( t=-1.500, P=0.156; t=-1.781, P=0.097). The anatomic reduction rate of articular surface was 93.8% (15/16) at immediate after operation. At last follow-up, the recollapse height of articular surface was 0.1-1.2 mm (mean, 0.36 mm). According to the HSS score system, the results were excellent in 12 cases, good in 2 cases, and fair in 1 case, and the excellent and good rate was 93.3%.

Conclusion

The limited incision by posterolateral approach, poking reduction, and simple internal fixation have the advantages of small injury, full exposure, and easy operation in the treatment of simple posterolateral tibial plateau fractures; bone graft support and simple internal fixation can prevent recollapse of the articular surface and achieve satisfactory knee function.

Close Intramedullary Interlocking Nailing Versus Locking Compression Plating In the Treatment of Closed Fracture Shaft of the Tibia

Fracture of tibial shaft is the commonest site of long bone fractures due to its superficial location involving young or middle-age people. Proper management is an important issue regarding the future effective movements. In this study patients were grouped in closed Intra medullary interlocking nailing and locking compression plating. Post-operative follow up at 2 weeks, 6 weeks, 12 weeks and 3 months thereafter up to 6 months were done. Each of the patients was evaluated clinically and radiologically by tucker criteria of Tuker et al. Patients were assessed for pain on full weight bearing and kneeling, shortening and range of motion of knee and ankle joints. Radiological assessment for union of fracture, alignment of fracture and angulations and position of nail and screws and infection were observed during follow up. A total number of 32 patients were selected but only 27 patients were available for follow up for a period of 6 months. They were grouped into Group A, consisting of 15 patients who took the treatment in the form of closed intramedullary interlocking nailing and Group B, consisting of 12 patients those underwent ORIF with locking compression plating. In both of the groups Motor Vehicle Accident was the main mechanism of trauma. Fracture involving the middle 3rd of the tibia is common in both the groups. During post-operative follow up, four patients in Group A complained anterior knee pain, one patient in Group B had superficial infection, most of the patients had no restriction of movement in the ankle and knee joints and a single patient in Group B showed 1.5cm shortening of the lower limb. Period of hospital stay and fracture union time were less in Group A, which was statistically significant. Both groups showed excellent result with minimum complications. So this study permits to conclude that close IM interlocking nailing and open reduction and internal fixation by locking compression plating is equally effective for the management of close fracture shaft of the tibia.

How to perform first aid

RATIONALE AND KEY POINTS: This article aims to help nurses to perform first aid in a safe, effective and patient-centred manner. First aid comprises a series of simple, potentially life-saving steps that an individual can perform with minimal equipment. Although it is not a legal requirement to respond to an emergency situation outside of work, nurses have a professional duty to respond and provide care within the limits of their competency. First aid is the provision of immediate medical assistance to an ill or injured person until definitive medical treatment can be accessed. First aid can save lives and it is essential that nurses understand the basic principles. REFLECTIVE ACTIVITY: Clinical skills articles can help update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: 1. Your skill in performing first aid and any areas where you may need to extend your knowledge. 2. How reading this article will change your practice. Subscribers can upload their reflective accounts at: rcni.com/portfolio .

[PRELIMINARY APPLICATION OF VIRTUAL PREOPERATIVE RECONSTRUCTION PLANNING IN Pilon FRACTURES]

OBJECTIVE

To investigate the application value of three-dimensional reconstruction and virtual preoperative planning for Pilon fractures.

METHODS

Between July 2010 and June 2014, 16 patients with closed Pilon fracture were treated, including 12 males and 4 females with an average age of 36.5 years (range, 22-53 years) and a mean disease duration of 10.2 days (range, 6-14 days). According to AO/Orthopaedic Trauma Association (AO/OTA) typing, 2 cases were rated as 43.B2 type, 3 cases as 43.B3 type, 3 cases as 43.C1 type, 2 cases as 43.C2 type, and 6 cases as 43.C3 type. The preoperative CT data from 16 patients were imported into Mimics10.01 software to establish the detailed fracture three-dimensional digital models. Virtual operation of fracture reduction and implanting internal fixation was performed on the models, and the optional surgical planning was made. Based on the virtual preoperative planning, operations were performed.

RESULTS

Established detailed three-dimensional Pilon fracture digital models could perfectly reflect the fracture characteristics, could be observed at any direction, and aided for fracture classification accurately. Virtual fracture operations of reduction, internal fixation and other could be performed to simulate the clinical operation, which could assist the surgeon better preoperative planning in achieving visual presentation and improving the communication. The operation time was 70-130 minutes (mean, 87.8 minutes); intraoperative blood loss volume was 30-150 mL (mean, 71.9 mL). The wounds healed by first intension in all patients. The mean follow-up time was 11.6 months (range, 8-18 months). Postoperative radiological results at 3 groups showed good anatomic reduction according to the Burwell-Charnley criteria, and the fracture healing time was 3-6 months (mean, 3.7 months). There was no complication of internal fixation loosening or breakage during follow-up. The American Orthopedic Foot and Ankle Society (AOFAS) score was 71-100 (mean, 92.3); the results were excellent in 10 cases, good in 5 cases, and fair in 1 case, with an excellent and good rate of 93.8% at last follow-up. No loss of fracture reduction was observed on the X-ray film.

CONCLUSION

The clinical feasibility of virtual reconstruction preoperative planning is good in the treatment of Pilon fractures, which helps surgeons better understanding Pilon fracure and making the surgical planning.

[Ilizarov TECHNOLOGY COMBINED WITH TARSAL V-SHAPE OSTEOTOMY FOR TREATMENT OF TRAUMATIC CLUBFOOT]

OBJECTIVE

To discuss the effectiveness of Ilizarov technology combined with tarsal V-shape osteotomy for the treatment of traumatic clubfoot.

METHODS

Between August 2011 and August 2014, 14 patients with traumatic clubfoot were treated. There were 10 males and 4 females, aged 13 to 61 years (mean, 31 years). of 14 cases, 11 had open fractures of the tibia and ankle and 3 had closed fracture of the ankle joint. The interval from trauma to operation was 7-78 months (mean, 36 months). The plantar flexion of the ankle was 44-89° (mean, 57°). After invasive foot soft tissue release and tarsal V-shape osteotomy, the Ilizaroy external fixator with elastic stretching rod was used. At 5-12 weeks after operation, the neutra pos ofthe ankle joint was restored. Then the neutral position of the ankle joint was maintained for 8 to 12 weeks. After removal of external fixator, protective walking brace was used for 8 to 12 weeks.

RESULTS

Infection occurred in 9 cases, and was cured after symptomatic treatment. The patients were followed up 10-36 months (mean, 15 months). After treatment, 14 patients had normal appearance of the ankle joint, and X-ray films showed normal structure of the ankle. The ankle dorsal extension was 10° in 9 patients, who had normal walking function; it was 5° in 4 patients, who could walk; in 1 case of neutral position, the foot had no function of up and down stairs. One case had pain during correction because of poor tolerance, and delay traction was given, the function was recovered to normal after active rehabilitation training. According to the International Clubfoot Study Group (ICFSG) score standard, the results were excellent in 9 cases, good in 4 cases, and fair in 1 case; the excellent and good rate was 92.9% at last follow-up.

CONCLUSION

Ilizarov external fixation combined with V-shape osteotomy is effective for the treatment of traumatic clubfoot, with the advantages of less trauma, reliable fixation, satisfactory correction of the deformity, and good function recovery of the ankle.

[EFFECTIVENESS OF LOCKING COMPRESS PLATE FOR TREATMENT OF ASEPTIC DIAPHYSEAL HUMERAL NONUNIONS]

OBJECTIVE

To evaluate the effectiveness of locking compress plate (LCP) for the treatment of aseptic diaphyseal humeral nonunions.

METHODS

Between January 2006 and January 2012, 23 patients with aseptic diaphyseal humeral nonuninons were treated with LCP and autologous iliac crest bone graft, and the clinical data were retrospectively analyzed. There were 15 males and 8 females with the average age of 42.5 years (range, 28-60 years). The fracture located at left side in 11 cases and right side in 12 cases. The mechanism of the injury was traffic accident in 15 patients, and falling from height in 8 patients. Fracture was treated by internal fixation in 20 cases and external fixation in 3 cases. And 6 patients had open fractures and other 17 had close fractures. Based on the Weber-Cech classification, 6 cases were rated as atrophic nonunions, and 17 cases as hypertrophic nonuninons. Shoulder function was evaluated by Constant-Murley score and elbow function was evaluated by Mayo score.

RESULTS

After operation, 2 patients had transient radial nerve symptoms of numbness and 1 patient had superficial infection. Primary healing of incision was obtained in the other patients. All patients were followed up 22.22 months on average (range, 16-30 months). Normal range of motion of the shoulder was found in 11 cases; and limited movements of abduction, elevation, and posterior extension were observed in 12 cases. And osseous union was observed clinically and radiographically in all patients. The average union time was 16.95 weeks (range, 12-24 weeks). The average Constant-Murley score was 81.87 (range, 50-98); and shoulder function was excellent in 14 cases, good in 6, and fair in 3. And the average Mayo score was 87.78 (range, 70-96); and the result was excellent in 14 cases, good in 7, and fair in 2.

CONCLUSION

Aseptic diaphyseal humeral nonunions can be successfully treated with LCP, coupled with the use of autologous iliac crest bone graft.

[TREATMENT OF POSTEROLATERAL TIBIAL PLATEAU COLLAPSED AND SPLITED FRACTURES BY POSTEROMEDIAL AND ANTEROLATERAL APPROACHES]

OBJECTIVE

To explore the effectiveness of posteromedial and anterolateral approaches in the treatment of posterolateral tibial plateau collapsed and splited fractures.

METHODS

Nineteen consecutive patients with posterolateral tibial plateau collapsed and splited fractures were treated between August 2010 and August 2013, and the clinical data were retrospectively analyzed. There were 13 males and 6 females, with an average age of 36.9 years (range, 25-75 years). All cases had closed fractures, involving 8 left sides and 11 right sides. Fractures involved posterior column according to the three-column classification based on CT scans; according to the Schatzker classification, all fractures were type II; according to the AO/Association for the Study of Internal Fixation classification (AO/OTA), all fractures were type 41-B3.1.2. The interval between injury and operation was 7-14 days (mean, 9 days). The reduction of collapsed fractures and implantation of artificial bone allograft were supported by T-shaped distal radius plate via the posteromedial approach. The splited fractures was fixed by less invasive stabilization system (LISS) plate via the anterolateral approach.

RESULTS

The mean operation time was 69.0 minutes (range, 50-105 minutes). All incisions healed by first intention without neurovascular complications or wound infection. All patients were followed up 14-20 months (mean, 18.2 months). X-ray and CT examinations showed that collapsed tibial plateau and joint surface were completely corrected; bony union was obtained at 12 weeks on average (range, 10-16 weeks). No secondary collapsed fracture and knee varus or valgus occurred. The results were excellent in 12 cases, good in 5 cases, and fair in 2 cases with an excellent and good rate of 89.5% according to the Rasmussen's scoring system for knee function.

CONCLUSION

The posteromedial approach combined with anterolateral approach for posterolateral tibial plateau fractures can fully expose the posterolateral aspects of the tibial plateau, and thus collapsed and splited fractures can be treated at the same time, which will lead to less operative time and good outcomes in the treatment of posterolateral tibial plateau collapsed and splited fractures.

[EFFECTIVENESS COMPARISON OF DIFFERENT OPERATIVE METHODS IN TREATMENT OF CLOSED FRACTURE OF TIBIAL SHAFT]

OBJECTIVE

To explore the effectiveness of three different operative methods in the treatment of closed fracture of the tibial shaft.

METHODS

Between January 2012 and May 2014, 94 patients with closed fracture of the tibial shaft were treated, and the clinical data were retrospectively analyzed. Fracture was fixed with locking plate (external fixation) in 25 cases (group A), with intramedullary nail in 34 cases (group B), and with minimally invasive locking plate in 35 cases (group C). There was no significant difference in gender, age, reasons of injury, fracture types, and time from injury to operation among groups (P>0.05). The operation time, intraoperative blood loss, fluoroscopy frequency during operation, fracture union time, and complications were recorded. The effectiveness was evaluated according to Johner-Wruhs criteria.

RESULTS

The operation time and fluoroscopy frequency during operation in groups A and C were significantly less than those in group B (P<0.05), but there was no significant difference between groups A and C (P>0.05). The intraoperative blood loss in groups A and C was significantly less than that in group B (P<0.05), and the blood loss in group A was significantly less than that in group C (P<0.05). All patients were followed up 15.61 months on average (range, 12-41 months). There was no significant difference in fracture union time among 3 groups (F=1.712, P=0.186). The excellent and good rates of groups A, B, and C were 92.00%, 88.24%, and 91.43% respectively according to Johner-Wruhs criteria at 12 months after operation, showing no significant difference (X2=0.301, P=0.860). At 12 months after operation, the complication incidences of groups A (12.00%, 3/25), and C (15.55%, 5/35) were significantly lower than that of group B (44.12%, 15/34) (P<0.017), but no significant difference was found between groups A and C (P>0.017).

CONCLUSION

Using locking plate as external fixation and minimally invasive locking plate internal fixation are better than intramedullary nail fixation in treating closed fracture of tibial shaft because of less injury and lower complication incidence, and locking plate as external fixation is better than minimally invasive locking plate internal fixation because of less injury.

[Electromagnetic navigation interlocking intramedullary nail technology for treatment of femoral shaft fractures]

OBJECTIVE

To explore the value of electromagnetic navigation interlocking intramedullary nail in the treatment of femoral shaft fracture.

METHODS

Between July 2012 and October 2013, 53 cases of femoral shaft fracture were treated. There were 40 males and 13 females, aged 16-52 years (mean, 38.3 years). The causes of injury were traffic accident in 28 cases, falling from height in 11 cases, falling in 7 cases, crush injury in 4 cases, and other in 3 cases. Of 53 cases, there were 3 cases of open fracture (Gustilo I degree) and 50 cases of closed fracture. Fracture was located in the proximal femur in 17 cases, middle femur in 29 cases, and distal femur in 7 cases. According to Winquist classification, 7 cases were rated as type I, 8 cases as type II, 22 cases as type III, and 16 cases as type IV; according to AO classification, 18 cases were rated as type 32-A, 28 cases as type 32-B, and 7 cases as type 32-C. The time from injury to operation was 3-11 days (mean, 5 days). Distal interlocking intramedullary nail was implanted using electromagnetic navigation.

RESULTS

The distal locking nail operation with interlocking intramedullary nail was successfully completed under electromagnetic navigation; the one-time success rate of distal locking nail operation reached 100%; and the locking nail time was 5.0-9.5 minutes (mean, 7.0 minutes). Healing of incision by first intention was obtained after operation, and no complication of skin necrosis, infection, and sinus tract occurred. Fifty-three cases were all followed up 5-12 months (mean, 9 months). One case had hip pain and weaken middle gluteal muscle strength, and the symptoms disappeared after removing the nail. During the follow-up period, no broken nails, nail exit, infection, or re-fracture occurred. All fractures achieved clinical healing, and the healing time was 8-22 weeks (mean, 14.5 weeks). In 49 patients followed up 8 months, the Lysholm score was excellent in 44 cases, good in 4 cases, and acceptable in 1 case, with an excellent and good rate of 98%.

CONCLUSION

Electromagnetic navigation system is safe and reliable, with the advantages of high positioning accuracy, short operation time, and no radiation, the clinical application of the system for distal locking nail operation can obtain excellent short-term effectiveness.