Effect of Computerized Tomography on Assessment and Surgical Planning for Olecranon Fractures.

OBJECTIVES: (1) Determine effects of computed tomography (CT) on reproducibility of olecranon fracture classification. (2) Determine effects of CT utilization on interobserver agreement regarding management of olecranon fractures. (3) Evaluate factors associated with articular impaction. METHODS: Seven surgeons retrospectively evaluated radiographs of 46 olecranon fractures. Each fracture was classified according to Colton, Mayo, Orthopaedic Trauma Association/AO Foundation (OTA/AO) systems. Observers determined whether articular impaction was present and provided treatment plans. This was repeated at minimum 6 weeks with addition of CT. Descriptive and comparative statistics were performed and intraclass correlation coefficients (ICCs) were calculated. RESULTS: Interrater agreement was near-perfect for all classifications using radiographs (ICC 0.91, 0.93, 0.89 for Colton, Mayo, OTA/AO) and did not substantially change with CT (ICC 0.91, 0.91, 0.93). Agreement was moderate regarding articular impaction using radiographs (ICC 0.44); this improved significantly with CT (ICC 0.82). Articular impaction was significantly associated with OTA/AO classification, with high prevalence of impaction in OTA/AO 2U1B1e ( P < 0.03). Agreement was substantial for chosen fixation construct using radiographs (ICC 0.71); this improved with CT (ICC 0.79). Utilization of CT changed fixation plans in 25% of cases. Agreement regarding need for void filler was fair using radiographs (ICC 0.37); this notably improved with CT (ICC 0.64). CONCLUSIONS: Utilization of CT for evaluating olecranon fractures led to significant improvements in interobserver agreement for presence of articular impaction. Impaction was significantly associated with fracture pattern, but not with patient-related factors. Addition of CT improved agreement regarding fixation construct and led to notable improvement in agreement regarding need for void filler.

Small residual fracture gaps delay time to union in length stable femur fractures treated with intrameduallary fixation.

OBJECTIVES: The purpose of this study was to investigate whether residual fracture gapping and translation at time of intramedullary nail (IMN) fixation for diaphyseal femur fractures were associated with delayed healing or nonunion. DESIGN: Retrospective cohort study SETTING: Level 1 trauma hospital, quaternary referral center PATIENTS/PARTICIPANTS/INTERVENTION: Length stable Winquist type 1 and 2 diaphyseal femur fractures treated with IMN at a single Level I trauma center were retrospectively reviewed. MAIN OUTCOME MEASURE: The largest fracture gap and translation were evaluated on immediate anteroposterior (AP) and lateral postoperative radiographs. Radiographic healing was assessed using Radiographic Union Score in Femur (RUSF) scores at each follow-up. Radiographic union was defined as a RUSF score ≥8 and consolidation of at least 3 cortices. ANOVA and student's t-tests were used to evaluate the influence of fracture gap parameters on time to union (TTU) and nonunion rate. Patients were stratified to measured average gap and translation distances <1mm, 1-3mm and >3mm for portions of the analysis. RESULTS: Sixty-six patients who underwent IMN with adequate follow-up were identified. A total of 93.9% of patients achieved union at an average of 2.8 months. Fractures with average AP/lateral gaps of <1mm, 1-2.9 mm, and >3mm had an average TTU of 70.1, 91.7, and 111.9 days respectively; fractures with larger residual gap sizes had a significantly longer TTU (p=0.009). Fractures with an average gap of 1-2.9mm and >3 mm had a significantly higher nonunion rate (1.5% and 4.5% respectively) compared to 0% nonunion in the <1 mm group (p=0.003). CONCLUSION: Residual gapping following intramedullary fixation of length stable diaphyseal femur fractures is associated with a significant increase in likelihood of nonunion. SUMMARY: Residual displacement of length stable femoral shaft fractures following intramedullary nailing can have a significantly negative impact on fracture healing. An average 3 mm AP/lateral residual fracture gap or a total of 6 mm of the AP + lateral fracture gap appeared to be a critical gap size with increased rates of nonunion and time to union. Therefore, we suggest minimizing the sum of the residual AP and lateral fracture gap to less than a total of 6 mm.

A Comparison of the Prevalence of, Demographics of, and Effects on Outcomes of Bilateral Versus Unilateral Femoral Shaft Fractures: A Retrospective Cohort Analysis From the National Trauma Data Bank.

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.

Medialized Trochanteric Entry Nailing Is a Safe and Effective Method for High-Energy Subtrochanteric Femur Fracture Treatment.

Fixation of subtrochanteric femur fractures using intramedullary nails can provide high rates of osseous union. However, a lateral starting point or a medial trajectory can result in varus alignment, typically seen with trochanteric entry nails. Even with piriformis nails, medial comminution can result in secondary malalignment and varus. Varus can predictably result in nonunion and need for repeat operations. Medialized trochanteric entry nailing has been reported previously as a method to prevent varus alignment in low-energy, atypical subtrochanteric femur fractures in association with bisphosphonate use. We present a surgical technique using a medialized trochanteric nail entry point to provide proper alignment and avoidance of varus malreduction in 24 patients with a subtrochanteric femur fracture after a high-energy traumatic event.

The pivot fracture: an unusual tibial plateau fracture found in association with acute ACL injury.

Tibial plateau fractures are common fractures which are often associated with concurrent soft tissue injury and for which accurate preoperative diagnosis is important for development of an appropriate treatment plan and outcome prediction. Here, we present an extreme manifestation of the pivot shift phenomenon with an unusual tibial plateau fracture with flipped component not described by any existing tibial plateau fracture classification system and never reported previously in conjunction with an anterior cruciate ligament injury. We describe the utilization of advanced imaging not typically utilized in the management of tibial plateau fractures in combination with clinical suspicion to diagnose the associated soft tissue injuries and develop an appropriate management plan.

In-Hospital Morbidity and Mortality With Delays in Femoral Shaft Fracture Fixation.

OBJECTIVES: To investigate trends in the timing of femur fracture fixation in trauma centers in the United States, identify predictors for delayed treatment, and analyze the association of timing of fixation with in-hospital morbidity and mortality using data from the National Trauma Data Bank. METHODS: Patients with femoral shaft fractures treated from 2007 to 2015 were identified from the National Trauma Data Bank and grouped by timing of femur fixation: <24, 24-48 hours, and >48 hours after hospital presentation. The primary outcome measure was in-hospital postoperative mortality rate. Secondary outcomes included complication rates, hospital length of stay (LOS), days spent in the intensive care unit LOS (ICU LOS), and days on a ventilator. RESULTS: Among the 108,825 unilateral femoral shaft fractures identified, 74.2% was fixed within 24 hours, 16.5% between 24 and 48 hours, and 9.4% >48 hours. The mortality rate was 1.6% overall for the group. When fixation was delayed >48 hours, patients were at risk of significantly higher mortality rate [odds ratio (OR) 3.60; 95% confidence interval (CI), 3.13-4.14], longer LOS (OR 2.14; CI 2.06-2.22), longer intensive care unit LOS (OR 3.92; CI 3.66-4.20), more days on a ventilator (OR 5.38; CI 4.89-5.91), and more postoperative complications (OR 2.05; CI 1.94-2.17; P < 0.0001). CONCLUSIONS: Our study confirms that delayed fixation of femoral shaft fractures is associated with increased patient morbidity and mortality. Patients who underwent fixation >48 hours after presentation were at the greatest risk of increased morbidity and mortality. Although some patients require optimization/resuscitation before fracture fixation, efforts should be made to expedite operative fixation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximal Tibia Skeletal Traction: Technique and Indications.

SUMMARY: Skeletal traction is a fundamental tool for the orthopaedic surgeon caring for patients with traumatic pelvic and lower-extremity orthopaedic injuries. Skeletal traction has proven to be an effective initial means of stabilization in patients with these injuries. Traction may be used for both temporary and definitive treatment in a variety of orthopaedic injuries. With the appropriate knowledge of regional anatomy, skeletal traction pins can be placed safely and with a low rate of complications. Several methods for placing skeletal traction have been described, and it is critical for orthopaedic surgeons to be proficient not only in their application but also understanding of the appropriate indications for use. Here we present a case example of a patient with a right femur fracture and discuss the technique and indications for placement of proximal tibia skeletal traction.

Surgical Wound Complications After Percutaneous Posterior Pelvic Ring Fixation in Patients Who Undergo Pelvic Arterial Embolization.

OBJECTIVE: To report on the incidence of surgical wound complications after percutaneous posterior pelvic ring fixation in patients who have also undergone pelvic arterial embolization (PAE) and determine whether the risks outweigh the benefits. DESIGN: Retrospective cohort study. SETTING: Academic level 1 trauma center. PATIENTS: Two hundred one consecutive patients who underwent percutaneous posterior pelvic fixation at our institution were included in this study. Of these, 27 patients underwent pelvic arterial embolization. INTERVENTION: Percutaneous posterior pelvic fixation and pelvic arterial embolization. MAIN OUTCOME MEASUREMENTS: Charts were reviewed for posterior percutaneous surgical wound complications including infection, dehiscence, seroma, tissue necrosis, and return to OR for debridement in all patients. RESULTS: Of the 27 patients who received PAE, none developed posterior surgical wound complications. Of those who did not receive PAE, there was one posterior surgical wound complication documented. There were no cases of wound infection in either group. CONCLUSION: Pelvic arterial embolization can be a valuable intervention in treating hemodynamically unstable patients with pelvic ring injuries. Although even selective pelvic arterial embolization is not entirely benign, there seems to be minimal risk of wound complications when percutaneous posterior pelvic ring fixation is performed. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Kocher-Langenbeck Approach for Posterior Wall Acetabular Fractures.

Adequate surgical exposure is necessary for anatomical reduction and fixation of posterior wall acetabular fractures. This video demonstrates the Kocher-Langenbeck approach to the posterior acetabulum, as well as operative indications, surgical reduction and fixation techniques, and outcomes for posterior wall acetabular fractures.

Medialized Trochanteric Starting Point and Focused Lateral Endosteal Beak Reaming to Optimize Success of Intramedullary Nailing in Atypical Femur Fractures: A Technical Trick and Case Series.

Optimal intramedullary treatment of atypical femur fractures associated with bisphosphonate use requires avoidance of postoperative malreduction, particularly varus. This can be difficult to achieve, given the fracture location, errors with nail entry point, endosteal beaking, and underlying patient osteology, all of which can contribute to postoperative varus and predispose the patient to treatment failure. We present a surgical technique and clinical series of 10 patients emphasizing a medialized trochanteric nail entry point and preferential lateral endosteal reaming to secure a biologically and biomechanically favorable reduction and fixation.

Ninety-Five Degree Angled Blade Plate Fixation of High-Energy Unstable Proximal Femur Fractures Results in High Rates of Union and Minimal Complications.

OBJECTIVES: To describe the surgical technique and clinical outcomes of high-energy proximal femur fractures treated with a 95-degree angled blade plate. DESIGN: Retrospective case series. SETTING: Single academic Level I trauma center. PATIENT/PARTICIPANTS: Forty-five consecutive patients from March 2012 to April 2017 who sustained a high-energy, unstable proximal femur fracture including (OTA/AO 31-A1, 31-A2, 31-A3, 31-B3, 32-A1a, and 32-C3i). INTERVENTION: Open reduction internal fixation with a 95-degree angled blade plate used in conjunction with an articulated tensioning device. MAIN OUTCOME MEASUREMENTS: Nonunion, malunion, secondary operations, and postoperative infection. RESULTS: Twenty six patients were available for follow-up. The mean age was 43.8 (range 22-86) years, and 81% (21/26) were men. The most common fracture pattern was OTA/AO 31-A3.3. Two fractures were open. The articulated tensioner was used in 100% of cases. Average clinical follow-up was 19.2 (range 7-40) months. Twenty-four of 26 patients (92%) achieved osseous union after the index procedure. One patient underwent nonunion repair, and 2 patients had the blade plate removed as it was symptomatic laterally. No other secondary procedures were performed, and no instances of implant failure were seen. No patients had evidence of a superficial or deep infection. CONCLUSIONS: We found that high-energy proximal femur fractures treated with a 95-degree condylar blade plate and articulated tensioning device had a high rate of union with minimal postoperative complications. Although intramedullary nailing of these fractures remains a preferred treatment modality, the angled blade plate with articulated tensioning device is an excellent option to restore anatomical alignment and obtain bony union in certain highly comminuted fracture patterns. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Proximal Humerus Fracture Open Reduction Internal Fixation with Concomitant Ipsilateral Shoulder Girdle Injuries: a Case Control Study.

BACKGROUND: Proximal humerus fractures treated in the face of ipsilateral injuries to the shoulder girdle may be predisposed to worse clinical outcomes. QUESTIONS/PURPOSES: The purpose of this investigation was to examine outcomes of proximal humerus fractures treated with open reduction internal fixation (ORIF) using an endosteal augment in the presence of a concomitant shoulder girdle injury in comparison to isolated proximal humerus fractures treated with ORIF and endosteal augment. METHODS: A prospective database was used to identify proximal humerus fractures with ipsilateral shoulder girdle injuries (glenohumeral and acromioclavicular dislocation, fractures of the acromion, clavicle, scapula, or humeral diaphysis). These were compared to isolated proximal humerus fractures treated in the same fashion (ORIF with endosteal augment). Minimum of 1 year follow-up was required for inclusion. Outcomes assessed included range of motion (ROM), development of avascular necrosis (AVN), hardware-related complications, reoperation, and subjective outcome assessments including the Disabilities of Arm Shoulder and Hand questionnaire (DASH), Constant score, UCLA rating scale, and the Short Form-36 (SF-36). RESULTS: Fifteen ipsilateral injuries were seen in 14 patients. Seventy-seven isolated proximal humerus fractures were available for comparison. The ipsilateral injury group had significantly worse forward flexion (141 vs 156°, p = 0.02), external rotation (56 vs 64°, p = 0.03), higher rates of avascular necrosis (4 of 14, 28.6% vs 1 of 77, 1.3%, p = 0.002), and inferior SF-36 physical health scores (48.5 vs 63.5; p = .04). Despite these differences, no significant differences were seen with hardware-related complications or DASH, Constant score, or UCLA rating scale results. No patients required secondary reconstructive procedures. CONCLUSION: Despite a statistically higher rate of AVN and decreased ROM, patient-based outcomes of proximal humerus fractures with ipsilateral shoulder injuries approached those seen in isolated proximal humerus fractures. This suggests that these injuries can achieve similarly good clinical results provided any associated shoulder pathology is identified and treated appropriately.

Dislocation is a risk factor for poor outcome after supination external rotation type ankle fractures.

INTRODUCTION: Ankle fractures are one of the most common fractures requiring surgical treatment. Ankle fracture-dislocations are significant injuries to the osseous and soft tissue envelope, but studies focused on the effect of dislocation on radiographic and functional outcomes are lacking. The objective of this study was to evaluate the effect of dislocations on postoperative outcomes in SER IV ankle fracture patients. MATERIALS AND METHODS: From 2004 through 2010, all operative SER IV ankle fractures treated by a single surgeon were enrolled in a prospective database. SER IV ankle fractures were separated into two groups based on clinical or radiographic evidence of dislocation. The primary and secondary functional outcomes measures were the Foot and Ankle Outcome Score (FAOS) and ankle and subtalar range of motion (ROM) with a minimum of 1-year follow-up, respectively. RESULTS: 108 patients with SER IV ankle fractures were identified, with 73 in the non-dislocation group (68%) and 35 patients in the dislocation group (32%). Patient demographics and co-morbidities were similar between the two groups. The incidence of open fractures and the application of an external fixator were significantly higher in the dislocation group (p = 0.037 and p = 0.003, respectively). The dislocation group showed a significant decrease in the accuracy of articular reduction (p = 0.003). At a mean follow-up of 21 months, ankle fracture-dislocation patients had increased pain (p = 0.005) and decreased activities of daily living (p = 0.014) on FAOS outcome measures and significantly worse ankle and subtalar ROM. CONCLUSIONS: The results of this study suggest that concurrent dislocation at time of ankle fracture is associated with worse radiographic and functional outcomes, but not an increase in superficial or deep infection. The results from this study may be helpful in counseling patients regarding expected clinical outcomes after ankle fracture-dislocation and in the surgical management of this complex injury.

Extensor Mechanism Injuries of the Knee: Demographic Characteristics and Comorbidities from a Review of 726 Patient Records.

BACKGROUND: The purpose of our study was to describe and compare extensor mechanism injuries with regard to age, sex, body mass index (BMI), and comorbidities. METHODS: We identified patients who had undergone surgical management of an extensor mechanism injury at two institutions between 1986 and 2012. Data analyzed included age at the time of surgery, sex, height, weight, and the presence of medical comorbidities. Patients with chronic disruption of the quadriceps or patellar tendon, those undergoing revision surgery, or those with injuries in the setting of total knee arthroplasty were excluded. RESULTS: Seven hundred and twenty-six patients were included. There were 427 (58.8%) patellar fractures, 210 (28.9%) quadriceps tendon ruptures, and eighty-nine (12.3%) patellar tendon ruptures. Sixty-seven percent of the patellar fractures occurred in females, while 91% of the quadriceps and 95.5% of the patellar tendon ruptures occurred in males (p < 0.001). Age distribution was significantly different among the groups: the mean patient age (and standard deviation) was 61.0 ± 13.1 years (range, twenty to ninety-two years) for quadriceps tendon rupture, 56.3 ± 17.4 years (range, sixteen to ninety-one years) for patellar fracture, and 39.5 ± 12.2 years (range, eighteen to seventy-two years) for patellar tendon rupture. Patellar fractures showed a bimodal distribution with regard to both age and sex: the median age of females was sixty-two years (range, sixteen to ninety-one years), and the median age of males was forty-seven years (range, sixteen to ninety-one years) (p < 0.001). BMI varied significantly among the cohorts: a mean of 25.0 ± 5.2 kg/m2 for patellar fracture, 28.7 ± 4.97 kg/m2 for patellar tendon rupture, and 30.0 ± 6.05 kg/m2 for quadriceps tendon rupture (p < 0.001). Ninety-six percent of the females with a quadriceps or patellar tendon injury had an underlying medical comorbidity compared with 68% of the males (p = 0.008). Of the patients with underlying comorbidities, 61% of the females had comorbidities that were considered to be risk factors for tendinopathy compared with 34% of the males (p = 0.008). CONCLUSIONS: Females with an extensor mechanism injury are more likely to sustain a patellar fracture compared with males. Younger males are more likely to sustain a patellar fracture or patellar tendon rupture; however, we found that 43% of the patellar tendon ruptures were in patients over the age of forty. Medical comorbidities were common with tendon ruptures, and we found that they were significantly more common in females than in males. CLINICAL RELEVANCE: Surgeons treating female patients with a tendinous extensor mechanism disruption should have a low threshold to initiate a medical work-up in search of a possible undiagnosed medical comorbidity.

Elective removal of implants after open reduction and internal fixation of Tibial Plateau fractures improves clinical outcomes.

INTRODUCTION: Tibial plateau fractures are common injuries often treated with open reduction and internal fixation. We have noted improved patient satisfaction following implant removal for these patients. The purpose of this study was to assess the effect of removal of surgical implants after union on patient reported outcomes. MATERIALS AND METHODS: All patients at our Level 1 Trauma Center undergoing open reduction an internal fixation by the senior surgeon are offered enrollment into a prospective registry and have clinical outcomes recorded at follow-up [Knee Outcomes Survey (KOS), Lower Extremity Functional Scale (LEFS), Short Form-36 Physical and Mental Component Summary (SF-36 PCS, SF-36 MCS), and Visual analog pain scale (VAS)]. Routinely, removal of surgical implants is offered after fracture union resulting in two cohorts: those who had undergone elective removal of surgical implants and those who had not. Outcome scores were compared before and after implant removal as well as between the two study populations at final follow-up. RESULTS: Seventy-five patients were identified as having 12 month outcome scores: 36 (48%) had retained implants; 39 (52%) had implants removed. KOS and LEFS outcomes improved significantly after implant removal (p < 0.05). Clinical outcomes (KOS, SF-36 PCS) were also significantly better in patients who had implants removed compared to those that did not at final follow-up (p < 0.05). There was no statistical difference seen in VAS pain scores. CONCLUSIONS: The results of this study indicate that patients who have elective removal of their surgical implants after open reduction and internal fixation of a tibial plateau fracture have improved clinical outcomes after removal and also demonstrate significantly better outcomes than those who have retained implants at final follow-up. Patients who are unhappy with their clinical result should be counseled that removal of the implant may improve function, but may not improve pain.

Anatomic Fixation of Supination External Rotation Type IV Equivalent Ankle Fractures.

OBJECTIVES: To compare radiographic and clinical outcomes of supination external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B2.1) treated with transsyndesmotic screw fixation with those treated with deltoid and posterior inferior tibiofibular ligament (PITFL) repair. DESIGN: Case series and single-surgeon retrospective analysis of a prospective database. SETTING: Academic level I trauma center. PATIENTS: Forty-five SER IV E ankle fractures fulfilled all inclusion/exclusion criteria with at least 12 months of radiographic follow-up. INTERVENTION: Deltoid and PITFL repair in addition to lateral malleolus fixation compared with transsyndesmotic screw fixation. MAIN OUTCOME MEASUREMENTS: Syndesmotic reduction compared with contralateral extremity on a postoperative computed tomography scan and maintenance of reduction based on final postoperative radiographs [medial clear space (MCS) and tibiofibular clear space (TCS)]. RESULTS: There was no significant difference in mean postoperative TCS, MCS, or change in TCS or MCS between the cohorts. The anatomic treatment group had significantly better postoperative syndesmotic reduction compared with the transsyndesmotic cohort (7.4% vs. 33.3%; P = 0.02). Fourteen patients in the transsyndesmotic screw cohort underwent removal compared with 3 patients in the anatomic cohort who required secondary procedures. The transsyndesmotic screw cohort had statistically significant better mean dorsiflexion of ankle (mean 20 vs. 17 degrees; P = 0.02). CONCLUSIONS: This comparison of treatment strategies for SER IV E ankle fractures has shown an improvement in immediate postoperative syndesmotic reduction and the elimination of reoperation for removal of transsyndesmotic screws in patients treated with PITFL repair. Previous research has shown a good correlation between functional outcomes and syndesmotic reduction; however, further investigation into the functional outcomes of these patients is necessary to determine the future clinical impact of this anatomic fixation strategy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Axillary View Typically Does Not Contribute to Decision Making in Care for Proximal Humeral Fractures.

BACKGROUND: Convention dictates that an axillary view be obtained when evaluating proximal humerus fractures (PHF). However, the axillary view is frequently omitted because of pain and technical considerations. Furthermore, its diagnostic utility is unclear in this setting. QUESTIONS/PURPOSES: The purpose of this study was to (1) determine the rate of obtaining an adequate axillary X-ray and complete shoulder series at a level I trauma center, (2) understand the cost of ordering and attempting an axillary radiograph, and (3) determine if axillary radiographs influence the management of PHF. PATIENTS AND METHODS: PHF treated between 2009 and 2011 that were ordered for an AP, scapular Y, and axillary view was identified. The types of radiographs actually obtained were recorded. The cost of obtaining three views and a single view of the shoulder with X-ray was determined. Lastly, three surgeons reviewed 42 PHF, both with and without an axillary view (AV), and treatment recommendations were compared. RESULTS: 30% of PHF in this series had an adequate axillary view, and 14% received a complete trauma series. No factors could be identified that were associated with successfully obtaining an axillary view. Reviewers demonstrated substantial intraobserver reliability (κ = 0.759-0.808) regarding treatment recommendations for PHF with and without the axillary view. The addition of the AV had minimal influence on treatment recommendations. CONCLUSION: Considering that the axillary view for PHF is painful, labor-intensive, costly, and does not appear to provide additional diagnostic value, orthopedic surgeons can consider foregoing the use of the axillary view when evaluating and treating PHF, particularly if other advanced imaging is utilized.

Standard perioperative imaging modalities are unreliable in assessing articular congruity of ankle fractures.

OBJECTIVES: To determine the sensitivity, specificity, and interobserver and intraobserver reliabilities of intraoperative fluoroscopy and postoperative plain radiographs (XR) in the assessment of articular congruency after open reduction and internal fixation (ORIF) of ankle fractures involving the tibial plafond. DESIGN: Retrospective cohort. SETTING: Academic level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred five patients treated surgically for rotational ankle fractures. INTERVENTION: ORIF. MAIN OUTCOME MEASUREMENTS: Sensitivity, specificity, and interobserver and intraobserver reliabilities of fluoroscopy and plain radiographs when compared with computed tomography imaging. RESULTS: The sensitivities of fluoroscopy and XR were 21% and 36%, respectively. Specificities were 95% (fluoroscopy) and 89% (XR). Fluoroscopy interobserver reliability was κ = 0.15, and mean intraobserver reliability was κ = 0.32. XR interobserver and mean intraobserver reliabilities were κ = 0.30 and κ = 0.59. CONCLUSIONS: Although results show acceptable specificity, the reliability and sensitivity of both intraoperative fluoroscopy and postoperative XR in the assessment of ankle articular congruency are low. This calls into question available literature correlating clinical results with articular reduction. During ORIF of an intra-articular ankle fracture, surgeons should be highly critical of fluoroscopic imaging that seems adequately reduced and direct visualization of the articular surface should be used as a reduction aid if possible. Furthermore, in the postoperative period, axial imaging may be warranted in patients who have poor clinical outcomes despite apparent anatomic articular reduction to evaluate for occult joint incongruence.