Posterior malleolar involvement can drastically affect patient outcomes. Literature has supported the use of preoperative Computed Tomography (CT) to assess posterior malleolar fracture morphology. ...The purpose of this study is to determine whether preoperative CT is associated with significant improvement in surgical time, postoperative complications, reoperation rates in trimalleolar ankle fractures. Surgeons were also asked to complete survey regarding use of CT scans to gauge utility preoperatively.BackgroundPosterior malleolar involvement can drastically affect patient outcomes. Literature has supported the use of preoperative Computed Tomography (CT) to assess posterior malleolar fracture morphology. The purpose of this study is to determine whether preoperative CT is associated with significant improvement in surgical time, postoperative complications, reoperation rates in trimalleolar ankle fractures. Surgeons were also asked to complete survey regarding use of CT scans to gauge utility preoperatively.Adult patients with trimalleolar ankle fractures who underwent operative fixation between 2018-2020 were retrospectively reviewed. Primary outcomes included surgical time, postoperative complications, and reoperations. Secondary outcome was presence of posterior malleolar fixation. 15 surgeons who performed ankle ORIF were surveyed to gain information regarding why or why not preoperative CT scan was obtained.MethodsAdult patients with trimalleolar ankle fractures who underwent operative fixation between 2018-2020 were retrospectively reviewed. Primary outcomes included surgical time, postoperative complications, and reoperations. Secondary outcome was presence of posterior malleolar fixation. 15 surgeons who performed ankle ORIF were surveyed to gain information regarding why or why not preoperative CT scan was obtained.288 patients with trimalleolar ankle fractures were included, 94 had preoperative CT scans (32.6%). No significant differences found in patient age, gender, BMI, smoking status between the groups that did and did not have preoperative CT scan. No significant differences were observed in AO/OTA classification between groups. Average surgical time was significantly higher in group that received a preoperative CT (114 without CT vs. 145 with CT, p<0.05). Complications (10.3% no CT vs 7.4% with CT, p=0.55) and reoperations (6.7% without CT vs. 7.4% with CT, p=0.16) not significantly different between groups. No significant difference was observed in rate of posterior malleolus fixation between groups (43.8% without CT vs 39.4% with CT; p=0.52). Of surveyed surgeons, 87% reported they don't routinely obtain preoperative CT scan for trimalleolar ankle fractures. Most common reasons for preoperative scans were deciding on approach/positioning, assessing for impaction, determining the size of the posterior malleolus.Results288 patients with trimalleolar ankle fractures were included, 94 had preoperative CT scans (32.6%). No significant differences found in patient age, gender, BMI, smoking status between the groups that did and did not have preoperative CT scan. No significant differences were observed in AO/OTA classification between groups. Average surgical time was significantly higher in group that received a preoperative CT (114 without CT vs. 145 with CT, p<0.05). Complications (10.3% no CT vs 7.4% with CT, p=0.55) and reoperations (6.7% without CT vs. 7.4% with CT, p=0.16) not significantly different between groups. No significant difference was observed in rate of posterior malleolus fixation between groups (43.8% without CT vs 39.4% with CT; p=0.52). Of surveyed surgeons, 87% reported they don't routinely obtain preoperative CT scan for trimalleolar ankle fractures. Most common reasons for preoperative scans were deciding on approach/positioning, assessing for impaction, determining the size of the posterior malleolus.Although preoperative CT scans are obtained in one third of patients with operative trimalleolar ankle fractures, we did not find an improvement in surgical time, complications, and reoperation. Level of Evidence: III.ConclusionAlthough preoperative CT scans are obtained in one third of patients with operative trimalleolar ankle fractures, we did not find an improvement in surgical time, complications, and reoperation. Level of Evidence: III.
Background: Trauma team activation (TTA) criteria trigger early mobilization of resources for the sickest trauma patients. Patients with moderately depressed Glasgow Coma Scale (GCS) scores who do ...not trigger the highest level activation are at risk for adverse outcomes, potentially from delayed time to intervention. The study objective was to define the impact of time to first head CT on outcomes among blunt trauma patients with moderately depressed GCS scores. Methods: Patients from the Trauma Quality Improvement Program (TQIP) databank (2013-2016) with a GCS score of 9-12 in the emergency department (ED) were included. Transfers, penetrating mechanisms, death < 24h, Abbreviated Injury Scale (AIS) score = 6 in any body region, and patients with severe associated injuries were excluded. Study groups were defined by time to first head CT after ED arrival: immediate (< 1h) v. delayed (1-6h). Primary outcomes were time to neurosurgical intervention and time to ED discharge. Results: After exclusions, 4997 patients were identified. Of these, 79% (n = 3954) underwent immediate head CT and 21% (n = 1043) had delayed head CT. Median GCS score was 11 10-12 in both groups and there was no difference in median head AIS score (4 3-4 v. 4 3-4, p = 0.586). Time to craniotomy and intracranial pressure (ICP) monitor insertion were longer in the delayed group (4.2h 3.0-7.6 v. 3.1h 2.1-8.7, p = 0.001; and 5.7h 3.8-13.0 v. 4.4h 2.6-12.0, p = 0.008), as was time in the ED (4.3h 2.7-6.5 v. 2.1h 1.2-3.7, p < 0.001). There was no difference in need for craniotomy (11% v. 10%, p = 0.287), need for ICP monitor (12% v. 12%, p = 0.899), or mortality (11% v. 9%, p = 0.160). On multivariate analysis, age > 65 years (odds ratio OR 2.813, p < 0.001), systolic blood pressure < 90 mm Hg (OR 2.934, p < 0.001), ED intubation (OR 1.486, p = 0.001), and head AIS scores of 4 (OR 1.884, p < 0.001) and 5 (OR 6.729, p < 0.001) were independently associated with death. Conclusion: Immediate head CT for blunt trauma patients with moderately depressed GCS scores decreases time to intervention and reduces ED time. A protocol to shorten time to head CT may be beneficial for both patients and hospitals.
A 35-year-old right hand dominant male sustained a high energy closed right distal radius fracture with associated generalized paresthesias. Following closed reduction, the patient was found to have ...an atypical low ulnar nerve palsy upon outpatient follow-up. After continued symptoms and an equivocal wrist MRI the patient underwent surgical exploration. Intraoperatively, the ulnar nerve as well as the ring and small finger flexor digitorum superficialis tendons were found to be translocated around the ulnar head. The nerve and tendons were reduced, the median nerve was decompressed, and the fracture was addressed with volar plating. Post-operatively, the patient continued to have sensory deficits and stiffness of the ring and small fingers. After one year, he reported substantial improvements as demonstrated by full sensation (4.0 mm two-point discrimination) and fixed flexion contractures at the proximal and distal interphalangeal joints of the small finger. The patient returned to work without functional limitations. This case highlights a unique case of ulnar nerve and flexor tendon entrapment following a distal radius fracture. History, physical examination, and a high index of clinical suspicion is essential for proper management of this rare injury. Level of Evidence: V.
Orthopaedic surgeons debate the timing of and necessity for surgical intervention when treating displaced midshaft clavicle fractures (MCFs). This systematic review evaluates the available literature ...regarding functional outcomes, complication rates, nonunion, and reoperation rates between patients undergoing early versus delayed surgical management of MCFs.
Search strategies were applied in PubMed (Medline), CINAHL (EBSCO), Embase (Elsevier), Sport Discus (EBSCO), and Cochrane Central Register of Controlled Trials (Wiley). Following an initial screening and full-text review, demographic and study outcome data was extracted for comparison between the early fixation and delayed fixation studies.
Twenty-one studies were identified for inclusion. This resulted in 1158 patients in the early group and 44 in the delayed. Demographics were similar between groups except for a higher percentage of males in the early group (81.6% vs. 61.4%) and longer time to surgery in the delayed group (4.6 days vs. 14.5 months). Disability of the arm, shoulder, and hand scores (3.6 vs. 13.0) and Constant-Murley scores (94.0 vs. 86.0) were better in the early group. Percentages of initial surgeries resulting in complication (33.8% vs. 63.6%), nonunion (1.2% vs. 11.4%), and nonroutine reoperation (15.8% vs. 34.1%) were higher in the delayed group.
Outcomes of nonunion, reoperation, complications, DASH scores, and CM scores favor early surgery over delayed surgery for MCFs. However, given the small cohort of delayed patients who still achieved moderate outcomes, we recommend a shared decision-making style for treatment recommendations regarding individual patients with MCFs.
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Fragility femoral neck fractures are traditionally seen in elderly patients after a low-energy fall. In contrast, displaced femoral neck fractures in young patients are usually associated with ...high-energy mechanisms such as a fall from height or high-speed motor vehicle collisions. However, patients under the age of 45 with fragility femoral neck fractures represent a unique population, and one that is not well-described. This study aims to describe this population and their current workup.
A single institution retrospective chart review of patients who underwent open reduction internal fixation or percutaneous pinning of femoral neck fractures from 2010-2020 was conducted. Inclusion criteria were patients 16-45 years old and femoral neck fractures with a low-energy mechanism of injury (MOI). Exclusion criteria were high-energy fractures, pathologic fractures, and stress fractures. Patient demographics, MOI, past medical history, imaging studies, treatment plan, lab values, DEXA results, and surgical outcomes were recorded.
The average age in our cohort was 33 ± 8.5 y/o. 44% (12/27) were male. Vitamin D level was obtained in 78% (21/27) patients and 71% (15/21) those patients were found to be abnormally low. A DEXA scan was obtained in 48% (13/27) of patients and abnormal bone density was found in 90% (9/10) of available results. 41% (11/27) patients received a bone health consultation.
A significant portion of femoral neck fractures in young patients were fragility fractures. Many of these patients did not receive bone health workup and their underlying health condition remained untreated. Our study highlighted a missed opportunity of treatment for this unique and poorly understood population.
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Treatment of distal femur fractures have reported high fracture healing complications in several studies. The development of far cortical locking (FCL) technology results in improved fracture healing ...outcomes. There are biomechanical and animal studies demonstrating that the locked plating incorporating FCL screws provides a more flexible form of fixation compared to traditional locking plates (LP). Clinical studies have shown that the commercially available Zimmer Motionloc system with FCL screws provide good results in distal femur fractures and periporsthetic distal femur fractures. FCL constructs may help resolve fracture healing problems in the future. However, there is not enough available clinical evidence to conclusively indicate whether clinical healing rates are improved with FCL screw constructs compared to traditional LP's. Therefore, further prospective study designs are needed to compare FCL to LP constructs and to investigate the role of interfragmentary motion on callus formation. Level of Evidence: V.
Despite the increased frequency of cephalomedullary fixation for unstable intertrochanteric hip fractures, failure with screw cut-out and varus collapse remains a significant failure mode. Proper ...positioning of implants into the femoral neck and head directly influences the stability of fracture fixation. Visualization of the femoral neck and head can be challenging and failure to do so may lead to poor results; Obstacles include patient positioning, body habitus, and implant application tools. We present the "Winquist View," an oblique fluoroscopic projection that shows the femoral neck in profile, aligns the implant and cephalic component, and assists in implant placement.
With the patient in the lateral position, the legs are scissored when possible. Following standard reduction techniques, the Winquist view is used to check reduction prior to surgical draping. Intraoperatively, we rely on a perfect image to place implants in the ideal portion of the femoral neck, with a trajectory that achieves the center-center or center-low position of the femoral neck. This is achieved by incorporating the anterior-posterior, lateral, and Winquist view.
We present 3 patients who underwent fixation with a cephalomedullary nail for intertrochanteric hip fractures. The Winquist view facilitated excellent visualization and positioning in all cases. All postoperative courses were uneventful, without failures or complications.
While standard intraoperative imaging may be adequate in many cases, the Winquist view facilitates optimal implant positioning and fracture reduction. With lateral imaging, implant insertion guides may obscure visualization of the femoral neck during which Winquist view is the most helpful.
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Intra-articular fractures represent a challenging group of injuries that can occur in many different locations. In addition to restoring the mechanical alignment and stability of the extremity, ...accurate reduction of the articular surface is a primary goal for the treatment of peri-articular fractures. A variety of methods have been deployed to assist in the visualization and subsequent reduction of the articular surface, each with a unique set of pros and cons. The ability to visualize the articular reduction must be balanced against the soft tissue trauma required for extensile exposures. Arthroscopic assisted reduction has gained popularity for the treatment of a variety of articular injuries. Recently, needle based arthroscopy has been developed, predominantly as an outpatient tool for the diagnosis of intra-articular pathology. We present an initial experience with and technical tricks for the use of a needle based arthroscopic camera in the treatment of lower extremity peri-articular fractures.
A retrospective review of all cases where needle arthroscopy was used as a reduction adjunct in lower extremity peri-articular fractures at a single, academic, level one trauma center was performed.
Five patients with six injuries were treated with open reduction internal fixation with adjunctive needle based arthroscopy. Early experience and tips and tricks for successful utilization of this technique are presented.
Needle based arthroscopy may represent a valuable adjunct in the treatment of peri-articular fractures and warrants further investigation.
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Locking plate technology was developed approximately 25-years-ago and has been successfully used since. Newer designs and material properties have been used to modify the original design, but these ...changes have yet to be correlated to improved patient outcomes. The purpose of this study was to evaluate the outcomes of first-generation locking plate (FGLP) and screw systems at our institution over an 18 year period.
Between 2001 to 2018, 76 patients with 82 proximal tibia and distal femur fractures (both acute fracture and nonunions) who were treated with a first-generation titanium, uniaxial locking plate with unicortical screws (FGLP), also known as a LISS plate (Synthes Paoli Pa), were identified and compared to 198 patients with 203 similar fracture patterns treated with 2nd and 3rd generation locking plates, or Later Generation Locking Plates (LGLP). Inclusion criteria was a minimum of 1-year follow-up. At latest follow-up, outcomes were assessed using radiographic analysis, Short Musculoskeletal Functional Assessment (SMFA), VAS pain scores, and knee ROM. All descriptive statistics were calculated using IBM SPSS (Armonk, NY).
A total of 76 patients with 82 fractures had a mean 4-year follow-up available for analysis. There were 76 patients with 82 fractures fixed with a First-generation locking plate. The mean age at time of injury for all patients was 59.2 and 61.0% were female. Mean time to union for fractures about the knee fixed with FGLP was by 5.3 months for acute fractures and 6.1 months for nonunions. At final follow-up, the mean standardized SMFA for all patients was 19.9, mean knee range of motion was 1.6°-111.9°, and mean VAS pain score was 2.7. When compared to a group of similar patients with similar fractures and nonunions treated with LGLPs there were no differences in outcomes assessed.
Longer-term outcomes of first-generation locking plates (FGLP) demonstrate that this construct provides for a high rate of union and low incidence of complications, as well as good clinical and functional results.
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