Postoperative Chest X-Rays After Open Reduction Internal Fixation of Clavicle Fractures May Not Be Cost-Effective or Necessary.

OBJECTIVES: To assess the use of chest x-rays after open-reduction internal fixation of clavicle fractures. Particularly in detection of acute postoperative pneumothorax and cost-effectiveness of obtaining routine chest x-rays postoperatively. DESIGN: A retrospective cohort study. SETTING: Level I trauma center. PATIENTS: Two hundred thirty-six patients who underwent ORIF from 2013 to 2020 between the ages of 12 and 93. INTERVENTION: Chest x-ray performed postoperatively. MAIN OUTCOME MEASUREMENT: Presence of acute postoperative pneumothorax. RESULTS: Of the 236 patients who underwent surgery, 189 (80%) patients received a CXR postoperatively and 7 (3%) patients experienced respiratory symptoms. All patients who had respiratory symptoms received a postoperative CXR. Those who did not receive a CXR postoperatively did not experience any respiratory complications. Two patients in the cohort had a postoperative pneumothorax, which was present preoperatively and unchanged in size postoperatively. Both of these patients were managed with general anesthesia and endotracheal intubation for surgery. The most common finding on CXR postoperatively was atelectasis. The cost of a portable CXR can be upward of $594 when including technology, personnel fees, and radiologic interpretation. CONCLUSION: Postoperative chest x-rays after clavicle open reduction and internal fixation did not detect any acute postoperative pneumothorax in asymptomatic patients. It is not cost-effective to routinely get chest x-rays in patients after open-reduction internal fixation of clavicle fractures. In our study, of the 189 chest x-rays performed, only 7 patients experienced postoperative respiratory symptoms. Our health care system as a total could have saved upward of $108,108 in total for these patients because they may have been considered nonreimbursable by an insurance provider. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association.

Objectives: Fracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established. Methods: Clinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations. Results: A total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use. Conclusions: In patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.

Short cephalomedullary nail toggle: a closer examination.

OBJECTIVES: In patients with wide femoral canals, an undersized short nail may not provide adequate stability, leading to toggling of the nail around the distal interlocking screw and subsequent loss of reduction. The purpose of this study was to identify risk factors associated with nail toggle and to examine whether increased nail toggle is associated with increased varus collapse. DESIGN: Retrospective cohort study. SETTING: Level 1 and level 3 trauma center. PATIENTS/PARTICIPANTS: Seventy-one patients with intertrochanteric femur fractures treated with short cephalomedullary nails (CMN) from October 2013 to December 2017. INTERVENTION: Short CMN. MAIN OUTCOME MEASUREMENTS: Nail toggle and varus collapse were measured on intraoperative and final follow-up radiographs. Risk factors for nail toggle including demographics, fracture classification, quality of reduction, Dorr type, nail/canal diameter ratio, lag screw engaging the lateral cortex, and tip-apex distance (TAD) were recorded. RESULTS: On multivariate regression analysis, shorter TAD (P = .005) and smaller nail/canal ratio (P < .001) were associated with increased nail toggle. Seven patients (10%) sustained nail toggle >4 degrees. They had a smaller nail/canal ratio (0.54 vs 0.74, P < .001), more commonly Dorr C (57% vs 14%, P = .025), lower incidence of lag screw engaging the lateral cortex (29% vs 73%, P = .026), shorter TAD (13.4 mm vs 18.5 mm, P = .042), and greater varus collapse (6.2 degrees vs 1.3 degrees, P < .001) compared to patients with nail toggle < 4 degrees. CONCLUSIONS: Lower percentage nail fill of the canal and shorter TAD are risk factors for increased nail toggle in short CMNs. Increased nail toggle is associated with increased varus collapse.Level of evidence: Therapeutic Level III.

Circumferential Pelvic Antishock Sheeting.

Pelvic ring fractures range from low-energy falls in the elderly to high-energy mechanisms in young patients. These injuries can be a significant cause of morbidity and mortality and are frequently associated with additional injuries. Hemorrhage and resultant hemodynamic instability are often associated with high-energy injuries and require prompt management. Circumferential pelvic antishock sheeting is an effective and readily available tool for reducing pelvic volume at the accident scene or in the emergency department, while still allowing access to the abdomen and lower extremities for ongoing resuscitation. This article, and the associated instructional video, reviews the indications and proper technique for placing a pelvic sheet.

Cost-Effectiveness of Operative Versus Nonoperative Treatment of Displaced Midshaft Clavicle Fractures: A Decision Analysis.

BACKGROUND: While previous studies have shown higher union rates and a quicker return to work with operative treatment of substantially displaced clavicle fractures, there is disagreement whether operative treatment results in improved clinical outcomes. Patients who undergo operative treatment sometimes require additional surgery for implant removal. Nonoperative treatment may fail so that delayed surgical intervention is ultimately required. The duration for which the clinical benefits of operative treatment remain superior to those of nonoperative treatment has not been well established in the literature. Considering these uncertainties, surgeons are faced with a difficult decision regarding whether operative treatment of a midshaft clavicle fracture will be cost-effective. The purpose of this study was to identify the most cost-effective strategy by considering these uncertain parameters with use of decision-analysis techniques. METHODS: An expected-value decision tree was built to estimate the quality-adjusted life years (QALYs) and costs for operative and nonoperative treatment of substantially displaced midshaft clavicle fractures. Values for parameters in the decision model were derived from the literature. Medical costs were obtained from the Medicare database. A Markov model was used to calculate the QALYs for the duration of life expectancy. The decision model was used to analyze the duration for which the clinical results of operative treatment were superior to those of nonoperative treatment during the first 5 years after the operation and during a lifetime. Sensitivity analysis was performed to determine which parameters have the most influence on cost-effectiveness. RESULTS: Operative treatment was more cost-effective than nonoperative treatment in 54% and 68% of the Monte Carlo trials in the 5-year and lifetime analyses, respectively. The cost per QALY with operative management was <$38,000 and <$8,000 in the 5-year and lifetime analyses, respectively. This is below the willingness-to-pay threshold of $50,000 per QALY. For operative treatment to remain cost-effective, its clinical benefits must persist for at least 3 years. CONCLUSIONS: Operative treatment is more cost-effective than nonoperative treatment for substantially displaced midshaft clavicle fractures. The clinical benefits derived with operative treatment must persist for at least 3 years for operative treatment to remain cost-effective. This research should not be used to conclude that all clavicle fractures should be treated surgically. It is best that such a decision is made through a patient-surgeon shared decision-making process. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.