Interlocking intramedullary nail for forearm diaphyseal fractures in adults-A systematic review and meta-analysis of outcomes and complications.

PURPOSE: The purpose of this systematic review is to examine the outcomes, complications, and potential advantages of using anatomical interlocking intramedullary nails (IMN) in the treatment of radius and ulnar shaft diaphyseal fractures in adults. METHODS: Medline, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched between January 2000 and January 2023. Studies meeting criteria were observational or randomized controlled trials evaluating outcomes in IMN for adult diaphyseal forearm fractures. Standardized data extraction was performed and a quality assessment tool was used to evaluate individual study methodology. Descriptive statistics for interventions, functional outcomes, and complications were reported. Meta-analysis was performed for patient-reported outcome measures and operative time. RESULTS: A total of 29 studies involving 1268 patients were included with 764 (60%) undergoing IMN, 21% open reduction and internal fixation (ORIF), and 9% hybrid fixation. There was no significant difference between groups in DASH and Grace-Eversmann scores. Operative time was significantly shorter in IMN compared with ORIF. The DASH scores were: 13.1 ± 6.04 for IMN, 10.17 ± 3.98 for ORIF, and 15.5 ± 0.63 in hybrids. Mean operative time was 65.3 ± 28.7 in ORIF and 50.8 ± 17.7 in IMN. Complication rates were 16.7% in the IMN group, 14.9% in ORIF, and 6.3% in hybrid constructs. There were 11 cases of extensor pollicis rupture in the IMN group. Average IMN pronation and supination were 78.3° ± 7.9° and 73° ± 5.0°, respectively. Average ORIF pronation and supination was 82.15° ± 1.9° and 79.7° ± 4.5°, respectively. CONCLUSIONS: Similar functional outcomes and complication rates along with shorter operative times can be achieved with IMN compared with ORIF. The use of IMN is promising, however, higher quality evidence is required to assess appropriate indications, subtle differences in range of motion, implant-related complications, and cost-effectiveness. Trail Registration PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42022362353).

A homozygous SP7/OSX mutation causes osteogenesis and dentinogenesis imperfecta with craniofacial anomalies.

Osteogenesis imperfecta (OI) is a heterogeneous spectrum of hereditary genetic disorders that cause bone fragility, through various quantitative and qualitative defects of type 1 collagen, a triple helix composed of two α1 and one α2 chains encoded by COL1A1 and COL1A2, respectively. The main extra-skeletal manifestations of OI include blue sclerae, opalescent teeth, and hearing impairment. Moreover, multiple genes involved in osteoblast maturation and type 1 collagen biosynthesis are now known to cause recessive forms of OI. In this study a multiplex consanguineous family of two affected males with OI was recruited for genetic screening. To determine the causative, pathogenic variant(s), genomic DNA from two affected family members were analyzed using whole exome sequencing, autozygosity mapping, and then validated with Sanger sequencing. The analysis led to the mapping of a homozygous variant previously reported in SP7/OSX, a gene encoding for Osterix, a transcription factor that activates a repertoire of genes involved in osteoblast and osteocyte differentiation and function. The identified variant (c.946C > T; p.Arg316Cys) in exon 2 of SP7/OSX results in a pathogenic amino acid change in two affected male siblings and develops OI, dentinogenesis imperfecta, and craniofacial anomaly. On the basis of the findings of the present study, SP7/OSX:c. 946C > T is a rare homozygous variant causing OI with extra-skeletal features in inbred Arab populations.

Splint versus no splint after ankle fracture fixation; Results from the multi-centre post-operative ankle splint trial (PAST).

BACKGROUND: There is considerable variation in the rehabilitation of ankle fractures. Ankle fractures treated surgically are often immobilized or splinted in the early post-operative period, despite the lack of robust evidence supporting this intervention. Thus, this randomized controlled trial aims to investigate the anecdote that splinting reduces pain and oedema. METHODS: A prospective multi-centre randomized controlled trial was performed in three trauma centres. Eligible patients were over 18 years of age that have sustained an isolated unilateral ankle fracture requiring surgical intervention. Patients were randomized to two groups receiving either; a plaster of Paris posterior back-slab or compressive bandage dressing. The post-operative rehabilitation protocol was standardized across both groups. Baseline demographics and fracture characteristics and classifications were analysed. Primary outcomes included; oedema measured by the figure-of-eight-20 technique and pain at multiple time points. Secondary outcomes included; the American Orthopaedic Foot and Ankle Society (AOFAS) score, satisfaction, unplanned emergency room (ER) visits and complications. RESULTS: A total of 104 comparable participants were included; 54 in the non-splint group and 50 in the splint group. There was no significance difference in ankle oedema, ankle oedema compared to contralateral ankle and pain scores between the two groups (P = 0.56, P = 0.25, P = 0.39 respectively). Patient satisfaction was higher in the early postoperative period in the non-splint group (P = 0.016). The AOFAS score was not significantly different across any time point (P = 0.534). In the splint group, there was a 46% rate of splint-related complaints and complications. Unplanned ER visits occurred in 46% of the splint group and 7.4% of the non-splint group (P < 0.001). There were 2 wound infections, 1 non-union and 1 deep vein thrombosis in the splint group. There was 1 wound infection and 1 deep vein thrombosis in the no-splint group (P = 0.481) CONCLUSION: The routine use of a splint does not add any perceivable benefit to the postoperative course of an ankle fracture fixation, particularly in the reduction of oedema and postoperative pain. Another key finding is that the absence of a splint does not appear to result in higher complication rates, instead leads to higher unplanned ER visits and lower early satisfaction rates.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

OBJECTIVE: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

A custom-made weight-drop impactor to produce consistent spinal cord injury outcomes in a rat model.

Objective: The main objective of this study is to design a custom-made weight-drop impactor device to produce a consistent spinal cord contusion model in rats in order to examine the efficacy of potential therapies for post-traumatic spinal cord injuries (SCIs). Methods: Adult female Sprague-Dawley rats (n = 24, 11 weeks old) were randomly divided equally into two groups: sham and injured. The consistent injury pattern was produced by a 10 g stainless steel rod dropped from a height of 30 mm to cause (0.75 mm) intended displacement to the dorsal surface of spinal cord. The neurological functional outcomes were assessed at different time intervals using the following standardized neurobehavioral tests: Basso, Beattie, and Bresnahan (BBB) scores, BBB open-field locomotion test, Louisville Swim Scale (LSS), and CatWalk gait analysis system. Results: Hind limb functional parameters between the two groups using BBB scores and LSS were significantly different (p < 0.05). There were significant differences (p < 0.05) between the SCI group and the sham group for the hind limb functional parameters using the CatWalk gait analysis. Conclusion: We developed an inexpensive custom-made SCI device that yields a precise adjustment of the height and displacement of the impact relative to the spinal cord surface.

Posterior Hip Dislocation in Association With Anterior Column Acetabular Fracture, Femoral Head Fracture, and Sciatic Nerve Injury: A Case Report.

CASE: Posterior hip dislocations are classically associated with posterior acetabular wall fractures. We report the case of a 29-year-old man presented after a motorcycle accident with an unusual combination of injuries that included posterior hip dislocation, anterior column acetabulum fracture, femoral head fracture, and sciatic nerve injury. At the final follow-up, excellent outcomes were obtained with complete recovery of the sciatic nerve injury. CONCLUSION: A favorable outcome may be achieved in young patients who sustain this unusual compilation of ipsilateral anterior acetabulum fracture, posterior hip dislocation, femoral head fracture, and sciatic nerve injury with meticulous preoperative surgical planning and tailored patient management.

Pain, Pattern and Polytrauma - Predictors of Sexual Dysfunction in Pelvic Fractures: A Retrospective Multicenter Analysis.

Objectives: In the local and cultural setting of high trauma rates and a reserved outlook on sexual function, this study examines the incidence and underlying factors of sexual dysfunction (SD) following pelvic fractures. Methods: A Multi-center retrospective cohort analysis performed in two general hospitals and one tertiary orthopedic center with collection between 2017 and 2019. Consecutive patients with pelvic fractures between January 2017 and February 2019 were followed up at 18-24 months to screen for new-onset SD using the International Index of Erectile Function-5 (IIEF-5) and Female-Sexual-Function-Index-6 (FSFI-6). Additional variables include age, sex, Young-Burgess classification, urogenital injury, injury severity score, persisting pain, sacroiliac disruption, intervention and if sexual health was discussed or patient referred for sexual healthcare. Results: One-hundred and sixty-five patients (n = 165) were included, (83%) male, (16%) female with a mean age of 35.1 years (Range 18-55). Fracture patterns included lateral compression (LC) (51.5%), anteroposterior compression (APC) (27.7%), and vertical shear (VS) (20.6%). The urogenital injury occurred in 10.3%. The mean IIEF-5 and FSFI-6 scores were 20.8 and 24.7 in males and females, respectively. A total of 40 males (29%) scored below the 21 cut-off scores for SD, while only one female (3.7%) scored below the corresponding score of 19. Of all participants reporting sexual dysfunction, 56% discussed sexual health with their providers, while 46% of these patients were referred for further management. Significant predictive factors for SD using a multivariate logistic regression model include increasing age (OR-1.093, p = 0.006), APC III (OR 88.887, p = 0.006), VS (OR-15.607, p = 0.020), persisting pain (OR 3.600, p = 0.021) and increasing injury severity score (OR 1.184, p <0.001). Conclusion: SD is common among pelvic fractures, and risk factors include APC or VS type fractures, increasing age, increasing injury severity score, and persisting pain. Providers should ensure patients are screened for SD and referred appropriately as patients may not willingly disclose underlying symptoms.

A computed tomography (CT) based morphometric study of superior pubic ramus anatomy among Arabs to determine safe intramedullary pubic rami screw insertion.

PURPOSE: To assess the morphometric variables of the superior pubic ramus in an Arab/ Middle Eastern population to establish a safe pubic screw fixation technique. METHODS: Cross-sectional retrospective analysis of computed tomography (CT) pelvic images. Morphometric data were extracted including; on pubic ramus length, insertion angles, potential danger zones and ramus diameters. The correlation between pubic rami diameter and patient demographics was also analyzed. RESULTS: A total of 231 participants were included (45% female). The mean pubic ramus length was 104 mm in females and 127 mm in males. The narrowest canal diameters at the para-symphyseal area were; 7.35 mm (males) and 4.75 mm (females). The mediolateral insertion angle was 49.4° in females and 41.8° in males. The cephalic-caudal angle was 49.9° in males and 42.1° in females. The mean distance from the lateral ilium entry point to the joint articular surface was 23.5 mm in males and 19.9 mm in females. The symphysis pubis to tubercle exit point was higher in females than males (24.2 mm vs 16.6 mm, respectively). There was a significant positive correlation between age and pubic ramus diameters in all age groups. CONCLUSION: The results from this study suggest that percutaneous pubic rami screw fixation using the standard 6.5 or 7.3 mm cannulated screw system may potentially be unsafe in female Arab patients. This subset of patients may require alternative non-cannulated screws (3.5-4.5 mm) or plate options. Further, female patients may have a higher risk of acetabular joint penetration, while males have a potentially higher risk of pudendal nerve injury.

Circumferential periosteal block versus hematoma block for the reduction of distal radius and ulna fractures: a randomized controlled trial.

PURPOSE: To assess the analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB). METHODS: This study was a prospective single-center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on the severity of pain was analyzed in multivariate regression. Finally, complications and end outcomes were compared across both techniques. RESULTS: Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p = < 0.0001). There were no significant differences between groups at baseline (P = 0.55) and injection (P = 0.40) stages. CONCLUSION: The CPB provides a superior analgesic effect over the conventional HB with no documented complications in either technique. LEVEL OF EVIDENCE: Therapeutic Level II.

Comparison of pain and extent of anesthesia in digital blocks for isolated finger lacerations: A randomized controlled trial.

OBJECTIVES: Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block (SV) technique. Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anesthetized regions. METHODS: This is a single-center prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anesthesia along with the anesthesia onset time. RESULTS: A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5.00] vs. 3.00 [2.00, 4.00], respectively, P = 0.006). However, anesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anesthesia was more predictable in the dorsal block compared to the volar block. CONCLUSION: The single-injection volar subcutaneous blocks are less painful with a similar anesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anesthesia of the region.

The Importance of Scar Cosmesis across the Surgical Specialties: Factors, Perceptions, and Predispositions.

Existing disparities in the perception of scars between patients and practitioners can translate into undesirable physical and psychological outcomes. An understanding of the determinants of surgeons' perceptions on the importance of scar cosmesis is a first step toward bridging this gap. Methods: In an online survey, surgeons were asked about the extent to which various patient and technical factors affect the importance of scar cosmesis. Additional data were obtained on surgeon characteristics, including their specialty, gender, years of experience, and work sector to investigate potential relationships. Results: A total of 303 responses were obtained from surgeons across six specialties. Based on the survey, the importance of scar cosmesis was rated highest among plastic surgeons and obstetricians and gynecologists, and lowest among orthopedic and vascular surgeons. Compared with surgeons in private practice, publicly employed surgeons' rating of the importance of cosmesis was lower. The patient's request for a cosmetic outcome was the most highly rated factor. Regarding the influence of patient demographics on surgeons' attitudes, scar cosmesis in young and female patients was favored in comparison with older and male patients. Factors that reduced the importance of cosmesis were emergency and late-night surgeries followed by lengthy procedures, large incisions, and busy operative lists. Conclusions: These initial findings highlight a need to investigate means of fostering a more holistic, impartial approach toward scar cosmesis, as well as addressing potential workplace barriers that may prevent surgeons from seeking a more cosmetic result. Greater alignment between the priorities of surgeons and patients may manifest in objective and subjective improvements in patient's scars and well-being.

Traumatic orthopedic consultations in COVID-19 inpatients - A cross sectional analysis of results and a review of lessons in tele-orthopedics.

INTRODUCTION: COVID-19 has led to intricate global challenges, among these, the impact on emergency and elective orthopedic services. Patients with COVID-19 often complain of musculoskeletal symptoms. The subsequent orthopedic consultations require careful assessment of possible inpatient trauma and to rule out any injuries that require active management. METHODS: A retrospective cross-sectional analysis involving 13,580 admitted patients in a national quarantine center between March 2020 and April 2021. All patients with orthopedic consultations were included in the study, and were assessed by orthopedic surgeons in person. Patients were further evaluated for age, sex, presence of trauma, cause for consultation, diagnosis and management. RESULTS: Seventy-five orthopedic consultations were included, 44% females and 56% males. Of the 75 consultations, 29 (38%) were related to a history of inpatient trauma. Of the 29 cases, 11 sustained fractures of the distal radius, proximal humerus, femoral neck, clavicle and ankle. Four of which were treated operatively. DISCUSSION AND CONCLUSION: Inpatient orthopedic consultations must be assessed carefully to avoid misdiagnoses. Elderly or frail patients are more likely to both; sustain trauma and fractures. Potential limitations of tele-orthopedics may be apparent here, especially in the presence of technological incompetence and high likelihood of fractures.

A torque induced iatrogenic fracture of the humeral shaft in proximal humeral fracture plating - A case report and biomechanical perspectives.

INTRODUCTION: Proximal humerus fractures are common amongst the elderly and osteoporotic cohorts. Common treatment methods include proximal locking plates. In this case, we describe an iatrogenic fracture of the proximal humeral shaft during screw insertion under power. Similar cases have not been described previously in open reduction and internal fixation of a proximal humerus fracture. Further, we focus particularly on precautionary measures that aim to avoid such complications that may lead to considerable morbidity. CASE PRESENTATION: We describe a case of a 65 year old osteoporotic female who underwent open reduction internal fixation of a proximal humerus fracture complicated by an unusual iatrogenic humeral fracture at the level of insertion of the distal screw, likely secondary to inserting the proximal locking screws under power. CONCLUSION: In this case, we explore the possible factors leading to the fracture and precautionary measures to avoid them. The rate of iatrogenic intraoperative fractures are likely underreported and have not been described in open reduction and internal fixation of an existing fracture. The underlying factors that may predispose to such complications have not been previously described in similar cases. This case serves as a warning of an unanticipated complication and describes the potential biomechanical factors involved.