Systems issues limiting acute fracture care delivery at a tertiary care hospital in Northern Tanzania.

Introduction: sub-Saharan Africa experiences a significant musculoskeletal trauma burden. Among patients who receive surgical treatment, there have been no reports as to how often surgical care is determined to be "adequate" or, if "inadequate", then what hospital and orthopaedic specialty-specific systems limitations might be prohibitive. Methods: data from patients presenting to the orthopaedic trauma service at a tertiary care center in sub-Saharan Africa were prospectively collected over a 6-week period and then retrospectively reviewed to determine whether the surgical treatment was "adequate" (or otherwise, "inadequate") according to the principle of restoring length, alignment, and rotation. Exclusion criteria included insufficient clinical information; isolated spinal injury; infection; cases involving only removal of hardware; soft-tissue procedures; tumor cases; and medical (non-surgical) conditions. Results: 112 cases were included for analysis. Surgery was indicated in 106 of 112 cases (94.6%), and of those, surgery was performed in 62 cases (58.4%). Among patients who underwent surgery with available post-operative imaging (n=56), surgical treatment was "inadequate" in 24 cases (42.9%). The most common reasons treatment was deemed "inadequate" included unavailability of appropriate implants (n=16), unavailability of intraoperative fluoroscopy (n=10) and incomplete intraoperative evaluation of injury (n=5). Conclusion: several systems limitations prevent the delivery of adequate surgical treatment in patients with acute orthopaedic traumatic injuries, including lack of intraoperative fluoroscopy and lack of implant availability. This study will serve as a useful baseline for ongoing efforts seeking to improve orthopaedic specialty resource availability and facilitate more effective fracture care in this region.

Itm2a expression marks periosteal skeletal stem cells that contribute to bone fracture healing.

The periosteum contains skeletal stem/progenitor cells that contribute to bone fracture healing. However, the in vivo identity of periosteal skeletal stem cells (P-SSCs) remains unclear, and membrane protein markers of P-SSCs that facilitate tissue engineering are needed. Here, we identified integral membrane protein 2A (Itm2a) enriched in SSCs using single-cell transcriptomics. Itm2a+ P-SSCs displayed clonal multipotency and self-renewal and sat at the apex of their differentiation hierarchy. Lineage-tracing experiments showed that Itm2a selectively labeled the periosteum and that Itm2a+ cells were preferentially located in the outer fibrous layer of the periosteum. The Itm2a+ cells rarely expressed CD34 or Osx, but expressed periosteal markers such as Ctsk, CD51, PDGFRA, Sca1, and Gli1. Itm2a+ P-SSCs contributed to osteoblasts, chondrocytes, and marrow stromal cells upon injury. Genetic lineage tracing using dual recombinases showed that Itm2a and Prrx1 lineage cells generated spatially separated subsets of chondrocytes and osteoblasts during fracture healing. Bone morphogenetic protein 2 (Bmp2) deficiency or ablation of Itm2a+ P-SSCs resulted in defects in fracture healing. ITM2A+ P-SSCs were also present in the human periosteum. Thus, our study identified a membrane protein marker that labels P-SSCs, providing an attractive target for drug and cellular therapy for skeletal disorders.

Musculoskeletal Issues in Children and Adolescents: Common Childhood Musculoskeletal Injuries.

Active children and adolescents have unique risk factors for musculoskeletal injuries compared with adults. Physes and developing bones are at higher risk of injury than tendons and ligaments. Children's bone remodeling is robust, allowing most clavicle fractures and torus fractures of the forearm to be managed conservatively. Radial head subluxation is managed with reduction. Apophyseal injuries are traction or overuse injuries that typically can be managed nonoperatively. Osteochondritis dissecans and other osteochondroses require frequent monitoring and occasionally surgical intervention.

Intraoperative pneumatic tourniquet application reduces soft-tissue microcirculation, but without affecting wound healing in calcaneal fractures.

BACKGROUND: Wound healing complications are a major challenge following the extended lateral approach in calcaneal fractures. Soft-tissue microcirculation plays an important role via the delivery of oxygen, nutrients, and the regulation of a local milieu. The aim of this clinical study was to examine the effect of intraoperative pneumatic tourniquet application on skin and subcutaneous microcirculation, and its impact on wound healing progression. METHODS: Patients with calcaneal fractures were randomly assigned to two groups defined by a surgery conducted either with use or without use of a tourniquet. Blood flow (BF [AU]), tissue oxygen saturation (SO2[%]) and the relative amount of haemoglobin (rHb[AU]) were intraoperatively measured at two depths (2 and 8 mm) non-invasively by spectrophotometry (Micro-Lightguide O2C®, LEA Medizintechnik, Giessen, Germany). Time points were before and after inflation of the pneumatic tourniquet and also at the end of surgery before deflation. A linear mixed model (LMM) was fitted for statistical analysis. RESULTS: Thirty-four patients (3 women and 31 men) with 37 calcaneal fractures were included. In 22 of them, the surgery was conducted with a tourniquet and in the other 15 without its use. A significant decrease of microcirculation, characterized by decreases in blood flow (p = 0.011) and tissue oxygenation (p = 0.023) was measured in 8 mm depth after inflating the tourniquet. However, these changes did not influence the time of postoperative wound healing. CONCLUSION: The use of a pneumatic tourniquet reduces deep microcirculation without affecting postoperative wound healing. Trial registration The study was registered in www. CLINICALTRIALS: gov (NCT01264146).

Analysis of Punch Injuries: Clinical Characteristics, Management and Outcomes.

PURPOSE OF THE STUDY: The aim of this study is to describe injury patterns, characteristics, treatment modalities and functional outcomes after punching related injuries. MATERIAL AND METHODS: Retrospective data of cases admitted to emergency department following punch injury between January 1, 2012, and December 31, 2022. was collected. Patient's demographic data, the dominant and injured upper extremity side, punched object, a time of patient admission were recorded. Smoking habit and blood ethanol level were documented. Trauma mechanism, diagnosis (1: dermabrasions: skin, 2: lacerations: neurovascular structures or tendons and 3: osseous pathologies), treatment modalities were analyzed. Outcomes were assessed using the DASH questionnaire (Disabilities of the Arm, Shoulder, and Hand) at the last follow-up. RESULTS: A total of 1052 patients (male=968 (92%), female=84 (8%)) with mean age 24.6 ± 7.2 included this study. Six hundred and twenty-one (59%) patients punched a solid object and 675 (64%) had osseous pathology. The most commonly fractured bone, injured tendon, injured nerve, and injured artery were 5th metacarpal, extensor digitorum communis (EDC), ulnar nerve, and ulnar artery, respectively. The majority of the patients, (73%) were smokers while 15% of the patients had high level of blood ethanol concentration on admission (82±12.3 mg/100 ml). A comparison between smokers and non-smokers did not reveal any significant differences (p=0.425) in terms of diagnosis whereas 74% of alcoholic patients admitted with lacerations which was statistically significant (p=0.023). Injuries of 321 (30.5%) patients required surgery in the operating room, while 711(67.5 %) patients received interventions in the emergency room setting. The average DASH score differed between subgroups, with significantly higher scores in patients with laceration type injuries (7.2 SD), indicating more disability (p=0.001) DISCUSSION. The study reveales a high prevalence of hand injuries among individuals aged 18 to 40, with the dominant hand being most affected, primarily due to physical violence and self-harming behaviors. Primary contributing factors to this pattern are the escalated incidents of physical violence and self-harming behaviors arising from an inability to manage anger impulses. Punching solid objects, especially during late afternoon and evening periods often associated with alcohol use, was a common cause, resulting in metacarpal fractures being the most reported injury. Multiple tendon and nerve injuries were frequent, highlighting the severity and complexity of these traumas, often necessitating surgical intervention. CONCLUSIONS: These findings highlight the several key aspects, including demographic characteristics of the patient population, common causes and types of injuries observed, and the association between alcohol use as well as the specific injury profiles. Satisfactory results can be achieved with both conservative and surgical treatment for punch injuries. KEY WORDS: punching, fisting, boxing injuries, laceration, blood ethanol level.

Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review.

BACKGROUND: The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures. METHODS: This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach. RESULTS: A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2). CONCLUSION: A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room. LEVEL OF EVIDENCE: Systematic Review/Meta-Analysis; Level IV.

Challenging biases in delivery mode decisions for women with pelvic fracture history: a call for evidence-based practices and patient-centered care.

Pelvic fractures significantly impact young individuals, with a prevalence of 20 per 100,000, leading to long-term complications such as chronic pain and genitourinary dysfunction. Notably, women with a history of pelvic fractures face increased cesarean section (C-sections) rates during childbirth. This editorial investigates the factors contributing to higher C-section rates in these women, including provider assumptions about delivery complications and systemic hospital biases. Despite these trends, evidence suggests that vaginal delivery can be successful, especially when considering factors like pelvic displacement and the timing of delivery post-fracture. We advocate for education programs to challenge provider biases, transparent patient communication, and evidence-based practices prioritizing patient-centered care. Addressing these issues can enhance maternal and fetal outcomes, supporting women in making informed decisions about their delivery options.

Combination of bacteriophages and vancomycin in a co-delivery hydrogel for localized treatment of fracture-related infections.

Fracture-related infections (FRIs), particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA), are challenging to treat. This study designed and evaluated a hydrogel loaded with a cocktail of bacteriophages and vancomycin (1.2 mg/mL). The co-delivery hydrogel showed 99.72% reduction in MRSA biofilm in vitro. The hydrogel released 54% of phages and 82% of vancomycin within 72 h and maintained activity for eight days, in vivo the co-delivery hydrogel with systemic antibiotic significantly reduced bacterial load by 0.99 log10 CFU compared to controls, with active phages detected in tissues at euthanasia (2 × 103 PFU/mL). No phage resistance was detected in the phage treatment groups, and serum neutralization resulted in only a 20% reduction in phage count. In this work, we show that a phage-antibiotic co-delivery system via CMC hydrogel is a promising adjunct to systemic antibiotic therapy for MRSA-induced FRI, highlighting its potential for localized, sustained delivery and improved treatment outcomes.

Evaluation of treatment planning discrepancies: CT versus plain radiographic findings in patients with foot and ankle trauma.

This study aimed to compare the findings of plain radiography and computed tomography (CT) of foot and ankle in patients submitted to the emergency department with high-energy foot and ankle trauma, to demonstrate if missing fractures on plain radiographs will significantly alter the treatment plan considered for each patient based on the findings of each imaging modality. We retrospectively observed standard radiological foot and ankle x-rays and CT scans in patients who presented to our center from April 2019 to June 2020 with a history of foot and ankle trauma with either loss of consciousness, a history of high-energy trauma, or clinical presentation disproportionate to plain radiographic findings. We investigated the number of fractures of each bone detected on plain radiographs and CT scans and the treatments based on each modality's findings in patients admitted to our center. Sixty-five out of 163 (39.87%) included in our study had at least one missed fracture on plain radiography that was detected on CT. Thirty-one (19%) patients had normal radiography despite actually having fractures. In 38 (23.31%) patients CT changed the treatment plan decided by our surgeons (P < 0.001). The two imaging modalities had a moderate agreement for detecting foot and ankle fractures overall (κ = 0.432). The failure to detect fractures in patients with high-energy trauma can significantly impact treatment effectiveness. Integrating CT scans into the diagnostic process can lead to changes in treatment planning and ultimately improve patient outcomes. LEVEL OF CLINICAL EVIDENCE: IV.

Management of zone 2 fifth metatarsal fractures varies based on treating specialty.

Aims: This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures. Methods: This was a retrospective cohort study of patients with acute zone 2 fifth metatarsal fractures who presented to a single large, urban, academic medical centre between December 2012 and April 2022. Zone 2 was the region of the fifth metatarsal base bordered by the fourth and fifth metatarsal articulation on the oblique radiograph. The proportion of patients allowed to bear weight as tolerated immediately after injury was compared between patients treated by orthopaedic surgeons and podiatrists. The effects of unrestricted weightbearing and foot and/or ankle immobilization on clinical healing were assessed. A total of 487 patients with zone 2 fractures were included (mean age 53.5 years (SD 16.9), mean BMI 27.2 kg/m2 (SD 6.0)) with a mean follow-up duration of 2.57 years (SD 2.64). Results: Overall, 281 patients (57.7%) were treated by orthopaedic surgeons, and 206 patients (42.3%) by podiatrists. When controlling for age, sex, and time between symptom onset and presentation, the likelihood of undergoing operative treatment was significantly greater when treated by a podiatrist (odds ratio (OR) 2.9 (95% CI 1.2 to 8.2); p = 0.029). A greater proportion of patients treated by orthopaedic surgeons were allowed to immediately bear weight on the injured foot (70.9% (178/251) vs 47.3% (71/150); p < 0.001). Patients treated by podiatrists were immobilized for significantly longer (mean 8.4 weeks (SD 5.7) vs 6.8 weeks (SD 4.3); p = 0.002) and experienced a significantly longer mean time to clinical healing (12.1 (SD 10.6) vs 9.0 weeks (SD 7.3), p = 0.003). Conclusion: Although there was considerable heterogeneity among zone 2 fracture management, orthopaedic surgeons were less likely to treat patients operatively and more likely to allow early full weightbearing compared to podiatrists.

Nonoperative Management of Both Column Acetabular Fracture and Protrusio Acetabuli in a Pregnant Patient: A Case Report.

CASE: We present a case of a 39-year-old woman at 23 weeks gestation who sustained traumatic both-column acetabular fracture and protrusio acetabuli, managed with initial traction and delayed total hip arthroplasty (THA) until after cesarean section delivery. CONCLUSION: Initial skeletal traction with subsequent delayed THA may be a viable treatment option in select pregnant female patients who sustain both-column acetabular fractures. Interdisciplinary collaboration is necessary to optimize maternal-fetal health and provide patient education of procedural risk to enable informed decision making.

[Treatment of clavicle fracture: Interpretation of the 2023 American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines].

Clavicle fracture is a common orthopedic injury, accounting for approximately 2.6%-4% of all adult skeletal fractures. In 2023, the American Academy of Orthopaedic Surgeons (AAOS) developed evidence-based treatment guidelines for clavicle fractures, which include 4 recommendations and 10 options. This article, based on a thorough review of the guidelines, discusses the clinical treatment of clavicle fractures, aiming to share advancements and the latest diagnostic and therapeutic considerations with orthopedic colleagues to enhance treatment outcomes.

Non-operative management of metacarpal II-IV fractures: A retrospective study from a tertiary hand unit.

Metacarpal fractures produce significant hand disability, and non-operative management of these fractures can produce satisfactory functional outcomes with few complications. However, most studies assessing non-operative outcomes of metacarpal fractures revolves around metacarpals I and V, which possess different anatomy. Therefore, further investigation into outcomes after non-operative treatment of metacarpals II-IV is required to inform management decisions and allow modification of the rehabilitation protocols to specific fracture patterns. All records for 76 non-operative patients presenting with fractures of metacarpals II-IV to our tertiary centre in the year 2019 were retrospectively reviewed. Patients were treated with thermoplastic splinting or fibreglass casting with a rehabilitative exercise programme. Range of motion (ROM) of the Metacarpophalangeal (MCPJ), Proximal Interphalangeal (PIPJ), and Distal Interphalangeal joints (DIPJ), return to work time, and complications were assessed at 12 weeks post-treatment. Mean return to work time was 5.4 weeks, and patients did not report any serious adverse events; the main complication reported was tenderness on palpation (20%). The MCPJ exhibited the poorest ROM (9° flexion reduction relative to the healthy hand). Metacarpal II fractures were associated with significantly worse MCPJ flexion than metacarpal III (p = 0.022) and metacarpal IV (p = 0.049) fractures. Fractures of the metacarpal base were associated with superior MCPJ flexion (p = 0.004) but longer return to work time (p = 0.042) than head fractures. Spiral fractures were associated with shorter return to work time (p = 0.043) and superior ROM results (p = 0.041). In conclusion, outcomes of the non-operative treatment of metacarpal II-IV fractures are highly dependent on the location and pattern of the fracture, and this should be considered during clinical decision making.

Clinical management and innovation in fracture non-union.

INTRODUCTION: With the introduction and continuous improvement in operative fracture fixation, even the most severe bone fractures can be treated with a high rate of successful healing. However, healing complications can occur and when healing fails over prolonged time, the outcome is termed a fracture non-union. Non-union is generally believed to develop due to inadequate fixation, underlying host-related factors, or infection. Despite the advancements in fracture fixation and infection management, there is still a clear need for earlier diagnosis, improved prediction of healing outcomes and innovation in the treatment of non-union. AREAS COVERED: This review provides a detailed description of non-union from a clinical perspective, including the state of the art in diagnosis, treatment, and currently available biomaterials and orthobiologics.Subsequently, recent translational development from the biological, mechanical, and infection research fields are presented, including the latest in smart implants, osteoinductive materials, and in silico modeling. EXPERT OPINION: The first challenge for future innovations is to refine and to identify new clinical factors for the proper definition, diagnosis, and treatment of non-union. However, integration of in vitro, in vivo, and in silico research will enable a comprehensive understanding of non-union causes and correlations, leading to the development of more effective treatments.

Epidemiology and Management of Pediatric Fractures in Malawi.

BACKGROUND: Pediatric fractures are common in Malawi, and surgical care, when needed, remains inaccessible to many. Understanding which children in Malawi receive surgery or nonsurgical treatment would help set priorities for trauma system development. METHODS: We used multivariate logistic regression to evaluate associations between surgical treatment and age, sex, school enrollment, injury mechanism, fracture type, open fracture, referral status, hospital of presentation, delayed presentation (≥2 days), healthcare provider, and inpatient vs outpatient treatment. RESULTS: From 2016 to 2020, 10,400 pediatric fractures were recorded in the Malawi Fracture Registry. Fractures were most commonly of the wrist (26%), forearm (17%), and elbow (14%). Surgical fixation was performed on 4.0% of patients, and 24 (13.0%) open fractures were treated nonsurgically, without débridement or fixation. Fractures of the proximal and diaphyseal humerus (odds ratio [OR], 3.72; 95% confidence interval [CI], 2.36 to 5.87), knee (OR, 3.16; 95% CI, 1.68 to 5.95), and ankle (OR, 2.63; 95% CI, 1.49 to 4.63) had highest odds of surgery. Odds of surgical treatment were lower for children referred from another facility (OR, 0.62; 95% CI, 0.49 to 0.77). CONCLUSIONS: Most Malawian children with fractures are treated nonsurgically, including many who may benefit from surgery. There is a need to increase surgical capacity, optimize referral patterns, and standardize fracture management in Malawi.

Sports Endocrinology.

Sports endocrinology holds a unique importance in understanding and optimizing an active and healthy lifestyle. Active patients with diabetes will need to consider modifying medications, especially insulin. The use of the dual energy x-ray absorptiometry and Fracture Risk Assessment Tool scores is important as both initiate and monitor bone health treatment. Menstrual disorders and energy imbalances are some special concerns when treating female athletes, calling for a multidisciplinary treatment team. Performance agents are popular and have made their way into recreational sports.

[Lisfranc injuries]. / Verletzungen des Lisfranc-Gelenks.

Lisfranc injuries are rare but severe injuries of the foot. They range from ligament sprain to complex fracture dislocations. Etiologically, a distinction is made between indirect and direct force and between high-energy and low-energy trauma. Inadequate diagnostics (injuries overlooked or misinterpreted) can lead to painful posttraumatic osteoarthritis, chronic instability and deformity of the foot. A fracture, malalignment and unclear findings in conventional radiological diagnostics necessitate computed tomography imaging including 3D reconstruction. Lisfranc injuries are often associated with accompanying pathologies of the foot that also need to be addressed. Only stable non-displaced fractures can be treated conservatively. Depending on the injury pattern, surgical treatment is performed percutaneously, minimally invasive or open. The prognosis following Lisfranc injury is determined by the severity of damage and the quality of reconstruction.