A notable percentage of people that die by suicide have had a medical visit within a few months of their death. In a survey-based experiment, we evaluated: 1) whether there are any surgeon, setting, ...or patient factors associated with surgeon rating of mental health care opportunities, and 2) if there are any surgeon, setting, or patient factors associated with likelihood of mental health referrals.
One hundred and twenty-four upper extremity surgeons of the Science of Variation Group viewed five scenarios of a person with one orthopedic condition. The following aspects of the scenarios were independently randomized: Social worker or psychologist available, office workload, socioeconomic status, gender, age, mental health factors, mental health clues, and diagnosis.
Accounting for potential confounders, surgeon likelihood of discussing mental health was associated with cancer, disadvantaged socioeconomic status, mental health factors other than being shy, prior suicide attempt, history of physical or emotional abuse, isolation, and when the office is not busy. Factors independently associated with higher likelihood of referring a patient for mental health care included cancer, disadvantaged socioeconomic status, mental health cues, mental health risk factors, and a social worker or psychologist available in the office.
Using random elements in fictitious scenarios we documented that specialist surgeons are aware of and attuned to mental health care opportunities, are motivated to discuss notable cues, and will make mental health referrals, in part influenced by convenience.
•People often present to musculoskeletal specialists with diminished mental health.•Specialist surgeons are aware of and attuned to mental health care opportunities.•Surgeons are motivated to discuss notable cues and make mental health referrals.•Likelihood of referral is associated with mental health professional availability.
BACKGROUND:Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares ...patient complexity to the logistic effects of our institutionʼs hip fracture care pathway.
METHODS:A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016.
RESULTS:LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications.
DISCUSSION:Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program.
LEVEL OF EVIDENCE:III
OBJECTIVES:To measure time to flap coverage after open tibia fractures and assess whether delays are associated with inpatient complications.
DESIGN:Retrospective cohort study.
SETTING:One forty ...level I and II trauma centers in Canada and the United States.
PATIENTS/PARTICIPANTS:Adult patients (≥16 years) undergoing surgery for (1) an open tibia (including ankle) fracture and (2) a soft-tissue flap during their index admission between January 1, 2012, and December 31, 2015, were eligible for inclusion.
EXPOSURE:Time from hospital arrival to definitive flap coverage (in days).
MAIN OUTCOME MEASUREMENTS:The primary outcome was a composite of the following complications occurring during the index admission(1) deep infection, (2) osteomyelitis, and/or (3) amputation. The primary analysis compared complications between early and delayed coverage groups (≤7 and >7 days, respectively) after matching on propensity scores. We also used logistic regression with time to flap coverage as a continuous variable to examine the impact of the duration of delay on complications.
RESULTS:There were 672 patients at 140 centers included. Of these, 412 (61.3%) had delayed coverage (>7 days). Delayed coverage was associated with a significant increase in complications during the index admission after matching (16.7% vs. 6.2%, P < 0.001, number needed to harm = 10). Each additional week of delay was associated with an approximate 40% increased adjusted risk of complications (adjusted odds ratio 1.44, 95% confidence interval 1.13–1.82, for each week coverage was delayed, P = 0.003).
CONCLUSION:This is the first multicenter study of flap coverage for tibia fractures in North America. Complications rose significantly when flap coverage was delayed beyond 7 days, consistent with current guideline recommendations. Because the majority of patients did not have coverage within this timeframe, initiatives are required to improve care for patients with these injuries.
LEVEL OF EVIDENCE:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Management of tibia fractures by internal fixation, particularly intramedullary nails, has become the standard for diaphyseal fractures. However, for metaphyseal fractures or those at the ...metaphyseal-diaphyseal junction, choice of fixation device and technique is controversial. For distal tibia fractures, nailing and plating techniques may be used, the primary goal of each being to achieve acceptable alignment with minimal complications. Different techniques for reduction of these fractures are available and can be applied with either fixation device. Overall outcomes appear to be nearly equivalent, with minor differences in complications. Proximal tibia fractures can be fixed using nailing, which is associated with deformity of the proximal short segment. A newer technique—suprapatellar nailing—may minimize these problems, and use of this method has been increasing in trauma centers. However, most of the data are still largely based on case series.
Objectives:
To document the prevalence of, and the effect on outcomes, operatively treated bilateral femur fractures treated using contemporary treatments.
Design:
A retrospective cohort using data ...from the National Trauma Data Bank.
Participants:
In total, 119,213 patients in the National Trauma Data Bank between the years 2007 and 2015 who had operatively treated femoral shaft fractures.
Main Outcome Measurements:
Complication rates, hospital length of stay (LOS), days in the intensive care unit (ICU LOS), days on a ventilator, and mortality rates.
Results:
Patients with bilateral femur fractures had increased overall complications (0.74 vs. 0.50,
P
< 0.0001), a longer LOS (14.3 vs. 9.2,
P
< 0.0001), an increased ICU LOS (5.3 vs. 2.4,
P
< 0.0001), and more days on a ventilator (3.1 vs. 1.3,
P
< 0.0001), when compared with unilateral fractures. Bilateral femoral shaft fractures were independently associated with worse outcomes in all primary domains when adjusted by Injury Severity Score (
P
< 0.0001), apart from mortality rates. Age-adjusted bilateral injuries were independently associated with worse outcomes in all primary domains (
P
< 0.0001) except for the overall complication rate. A delay in fracture fixation beyond 24 hours was associated with increased mortality (
P
< 0.0001) and worse outcomes for all other primary measures (
P
< 0.0001 to
P
= 0.0278) for all patients.
Conclusions:
Bilateral femoral shaft fractures are an independent marker for increased hospital and ICU LOS, number of days on a ventilator, and increased complication rates, when compared with unilateral injuries and adjusted for age and Injury Severity Score. Timely definitive fixation, in a physiologically appropriate patient, is critical because a delay is associated with worse inpatient outcome measures and higher mortality rates.
Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Computed tomography angiogram (CTA) is frequently utilized to detect vascular injuries even without examination findings indicating a vascular injury. We had the following hypotheses: (1) a CTA for ...lower extremity fractures with no clinical signs of a vascular injury is not indicated, and (2) fracture location and pattern would correlate with the risk of a vascular injury.
A retrospective review was conducted on patients who had an acute lower extremity fracture(s) and a CTA. Their charts were reviewed for multiple factors including the presence or absence of hard or soft signs of a vascular injury, soft tissue status, and fracture location/pattern. Every CTA radiology report was reviewed and any vascular intervention or amputation resulting from a vascular injury was recorded. Statistical analysis was performed.
Of the 275 CTAs of fractured extremities reviewed, 80 (29%) had a positive CTA finding and 16 (6%) required treatment. A total of 109 (40%) of the extremities had no hard or soft signs; all had normal CTAs. Having at least one hard or soft sign was a significant risk factor for having a positive CTA. An open fracture, isolated proximal third fibula fracture, distal and shaft tibia fractures, and the presence of multiple fractures in one extremity were also associated with an increased risk for having a positive CTA.
We found no evidence to support the routine use of CTAs to evaluate lower extremity fractures unless at least one hard or soft sign is present. The presence of an open fracture, distal tibia or tibial shaft fractures, multiple fractures in one extremity, and/or an isolated proximal third fibula fracture increases the risk of having a finding consistent with a vascular injury on a CTA. Only 6% of the cases required treatment, and all of them had diminished or absent distal pulses on presentation.
Diagnostic test, level III.
External fixation of tibial fractures Tejwani, Nirmal; Polonet, David; Wolinsky, Philip R
Journal of the American Academy of Orthopaedic Surgeons,
02/2015, Volume:
23, Issue:
2
Journal Article
Peer reviewed
Open access
External fixation for definitive or initial management of tibial fractures has a long history, with pin-to-bar external fixation being the standard of care for definitive management of tibial ...fractures. However, the use of this method lessened because of the increased popularity of intramedullary nailing and drawbacks associated with external fixation. This method is still commonly in use in the military environment and can be used for temporary stabilization of tibial fractures, especially in the setting of periarticular injuries. These fixators also may be useful for salvage of open and/or infected fractures that are unsuitable for internal fixation.
Achieving and maintaining reduction in patients with a diaphyseal femur fracture may be difficult; therefore, thorough preoperative planning is required. To fully prepare for successful surgical ...management of diaphyseal femur fractures, surgeons must consider appropriate patient positioning and necessary tools, including surgical tables, traction devices, and instruments. Principles of acceptable reduction rely on the restoration of length, alignment, and rotation. Reduction of diaphyseal femur fractures should be attained in the least invasive manner, via percutaneous reduction techniques, if possible, to preserve fracture biology and promote successful fracture healing. Intraoperative assessment of reduction often requires imaging studies of the contralateral extremity as a reference. Intraoperative assessment for associated femoral neck fractures and postoperative clinical examination of the hip and knee are imperative to the successful management of diaphyseal femur fractures. Other reference modalities and clinical examinations are required in patients with bilateral diaphyseal femur fractures.
INTRODUCTION:Antibiotics have been shown to be an essential component in the treatment of open extremity fractures. The American College of Surgeons’ Trauma Quality Improvement Program, based on a ...committee of physician leaders including orthopedic trauma surgeons, publishes best-practice guidelines for the management of open fractures. Accordingly, it established the tracking of antibiotic timing as a metric with a plan to use that metric prior to trauma center site reviews. Our hypothesis was that this physician-led effort at the national level would provide the necessary incentive to effect change within our institution.
METHODS:A retrospective review of all patients treated at our institution for open extremity fractures was performed over three time periods separated by two quality initiatives. The first initiative was an institution-driven effort to increase awareness and educate specific departments about the importance of prompt antibiotic administration. The second initiative was the tracking of antibiotic order and administration times with quarterly audits following newly published guidelines.
RESULTS:Neither antibiotic order placement within one hour nor administration within one hour improved following our first institution-specific initiative. Both outcome measures significantly improved following the second quality initiative, as did median times from arrival to antibiotic order and administration.
CONCLUSION:Metrics developed and measured by a physician-led national organization led to practice changes at our hospital. Tracking of antibiotic timing for open fracture treatment was more effective than institutional education of healthcare providers alone. This study suggests that nationally published guidelines, developed and measured by physician leaders, will be found to be relevant by other physicians and can be a powerful tool to drive change.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
PDF
