Assessment of Splinting Quality: A Prospective Study Comparing Different Practitioners.

BACKGROUND: Splinting is routinely performed in the emergency department (ED), and follow-up visits of improperly placed splints are commonplace in orthopaedic clinics. As open reduction and internal fixation (ORIF) of fractures has become the preferred treatment for many injuries, orthopaedic surgeons and emergency physicians have received less instruction on splinting technique. Limited literature exists regarding error/complication rates of splint application. The purpose of this study is to determine: (1) Is there a difference in splinting complication rates between orthopaedic and non-orthopaedic services, and low versus high volume emergency room and urgent care centers? (2) What are the most common technical errors and complications in splint application? METHODS: Patients presenting to orthopaedic clinic with any extremity splint were enrolled in this IRB approved prospective study. Splint characteristics collected included: type of provider placing the splint, duration of wear, type of splint, and material used (i.e. plaster or fiberglass). Errors included inappropriate length, circumferential placement, and direct contact between the ACE bandage and the skin; while complications included swelling, blistering, ulceration, heat injury, and other issues on a case-by-case basis. RESULTS: 203 patients were enrolled in this study. 98 (48%) were splinted by the Orthopaedics service, 69 (34%) were splinted in the trauma hospital ED, and 36 (18%) were treated at an outside hospital. 123/203 (61%) had an error/ complication related to the splint. Error/complication rates for orthopaedics, the trauma hospital ED, and outside hospitals were 46% (45/98), 65% (45/69), and 92% (33/36) respectively. The most common errors were inappropriate length, present in 58/203 (29%) patients, and direct contact between the ACE bandage and skin, present in 50/203 (25%) patients. CONCLUSION: The appropriateness and complication rates of splints applied in the ED differ based on the type of provider and the institution. Outside hospitals were found to have the highest complication rates, while the lowest rates were associated with splints placed by Orthopaedics. These findings support the importance of education of proper splinting technique in non-trauma hospitals.Level of Evidence: III.

Cost Analysis of Hemiarthroplasty Versus Reverse Shoulder Arthroplasty for Fractures.

Complex proximal humerus fractures in older patients can be treated with hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA), with both providing good pain relief and function. This study compared the costs, complications, and outcomes of HA vs RSA after proximal humerus fracture in older patients. Patients 65 years or older who were admitted between January 2007 and August 2011 with a 3- or 4-part proximal humerus fracture and treated with HA or RSA were identified. Surgeries were performed at the same institution by 1 of 3 surgeons trained in trauma or shoulder surgery. Operating room costs, implant costs, total costs to the patient and hospital, and range of motion were compared. In the study group, 8 patients (7 women and 1 man; mean age, 77 years) received HA and 16 patients (13 women and 3 men; mean age, 77 years) received RSA. Hemiarthroplasty implant cost and operating room cost were $9140 and $8900 less than those of RSA, respectively (P<.001). The total cost to the patient was $33,480 for HA vs $57,000 for RSA (P<.001) with no difference in admission length, transfusion requirements, or final range of motion. In patients with complex proximal humerus fractures, RSA restored function similar to HA and resulted in better pain and outcome scores. However, RSA had a significantly higher cost to both the patient and the hospital compared with HA. Further investigation of postsurgical rehabilitation costs, skilled nursing needs, or revision surgery will elucidate whether there is long-term functional or financial benefits to RSA over HA. [Orthopedics. 2016; 39(4):230-234.].

Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care.

OBJECTIVES: The purpose was to define which clinical conditions warrant delay of definitive fixation for pelvis, femur, acetabulum, and spine fractures. A model was developed to predict the complications. DESIGN: Statistical modeling based on retrospective database. SETTING: Level 1 trauma center. PATIENTS: A total of 1443 adults with pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 851) fractures. INTERVENTION: All fractures were treated surgically. MAIN OUTCOME MEASUREMENTS: Univariate and multivariate analysis of variance assessed associations of parameters with complications. Logistic predictive models were developed with the incorporation of multiple fixed and random effect covariates. Odds ratios, F tests, and receiver operating characteristic curves were calculated. RESULTS: Twelve percent had pulmonary complications, with 8.2% overall developing pneumonia. The pH and base excess values were lower (P < 0.0001) and the rate of improvement was also slower (all Ps < 0.007), with pneumonia or any pulmonary complication. Similarly, lactate values were greater with pulmonary complications (all Ps < 0.02), and lactate was the most specific predictor of complications. Chest injury was the strongest independent predictor of pulmonary complication. Initial lactate was a stronger predictor of pneumonia (P = 0.0006) than initial pH (P = 0.047) or the rate of improvement of pH over the first 8 hours (P = 0.0007). An uncomplicated course was associated with the absence of chest injury (P < 0.0001) and definitive fixation within 24 (P = 0.007) or 48 hours (P = 0.005). Models were developed to predict probability of complications with various injury combinations using specific laboratory parameters measuring residual acidosis. CONCLUSIONS: Acidosis on presentation is associated with complications. Correction of pH within 8 hours to >7.25 was associated with fewer pulmonary complications. Presence and severity of chest injury, number of fractures, and timing of fixation are other significant variables to include in a predictive model and algorithm development for Early Appropriate Care. The goal is to minimize complications by definitive management of major skeletal injury once the patient has been adequately resuscitated.

Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course.

OBJECTIVES: We hypothesized that early definitive management (within 24 hours of injury) of mechanically unstable fractures of the pelvis, acetabulum, femur and spine would reduce complications and shorten length of stay. DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: 1005 skeletally mature patients with Injury Severity Score (ISS) ≥18 with pelvis (n = 259), acetabulum (n = 266), proximal or diaphyseal femur (n = 569), and/or thoracolumbar spine (n = 98) fractures. Chest (n = 447), abdomen (n = 328), and head (n = 155) injuries were present. INTERVENTION: Definitive surgery was within 24 hours in 572 patients and after 24 hours in 433. MAIN OUTCOME MEASUREMENTS: Complications related to the initial trauma episode included infections, sepsis, pneumonia, deep venous thrombosis, pulmonary embolism, acute respiratory distress syndrome (ARDS), organ failure, and death. RESULTS: Days in intensive care unit (ICU) and total hospital stay were lower with early fixation (5.1 ± 8.8 vs. 8.4 ± 11.1 ICU days (P = 0.006); 10.5 ± 9.8 versus 14.3 ± 11.4 total days (P = 0.001), after adjusting for ISS and age. Fewer complications (24.0% vs. 35.8%, P = 0.040), ARDS (1.7% vs. 5.3%, P = 0.048), pneumonia (8.6% vs. 15.2%, P = 0.070), and sepsis (1.7% vs. 5.3%, P = 0.054) occurred with early versus delayed fixation. Logistic regression was used to account for differences in age and ISS between the early and delayed groups. Adjustment for severity of chest injury was included when analyzing pulmonary complications including pneumonia and ARDS. CONCLUSIONS: Definitive fracture management within 24 hours resulted in shorter ICU and hospital stays and fewer complications and ARDS, after adjusting for age and associated injury types and severity. Surgical timing must be determined with consideration of the physiology of the patient and complexity of surgery. Parameters should be established within which it is safe to proceed with fixation. These data will serve as a baseline for comparison with prospective evaluation of such parameters in the future. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries.

BACKGROUND: Type and timing of treatment of femur fractures is controversial. Although reported as safe and effective in many reports, others have suggested that early definitive stabilization may cause complications, particularly in patients with chest and head injuries. Damage control orthopedics was proposed as an alternative in unstable patients. This study examines the effects of timing of fixation and investigates risk factors for complications. METHODS: Seven hundred fifty patients with femur fractures treated between 1999 and 2006 were reviewed. Skeletally mature patients with mean age 35.8 years and mean Injury Severity Score (ISS) 23.7 were included. Four hundred ninety-two patients had ISS ≥18. Early stabilization (n = 656) was defined as definitive treatment of the femur fracture within 24 hours of injury. RESULTS: Early definitive stabilization in patients with multiple injuries was associated with fewer complications than delayed stabilization (18.9% vs. 42.9%, p < 0.037) after adjusting for patient age and ISS. Early treatment was also associated with shorter hospital stay, intensive care unit stay, and ventilator days (p < 0.001). Severe (Abbreviated Injury Scale score ≥3) abdominal injury was associated with more complications than severe head (Glasgow Coma Scale score ≤8) and chest (Abbreviated Injury Scale score ≥3) injuries (44.2% vs. 40.9%, p = 0.68, and 34.4%, p = 0.024, respectively) and was an independent risk factor for complications (p < 0.0001). Chest injury was an independent risk factor for pulmonary complications (p < 0.001), but surgical delay in patients with chest injury was also associated with pulmonary complications (p = 0.04). More sepsis was noted patients with severe head injury (22.7% vs. 4.5%, p = 0.037) or severe chest injury (10.2% vs. 2.5%, p = 0.044) when treated on a delayed basis. More patients transferred from other hospitals were treated on a delayed basis (48.9% vs. 37.5%, p = 0.04). CONCLUSIONS: Early definitive stabilization is associated with acceptably low rates of complications and is safe in most patients with multiple injuries, including some with severe abdominal, chest, or head injuries with attention to resuscitation before surgery. More complications and longer hospital stay were noted with delayed fixation after adjusting for age and ISS. Chest injury was associated with pulmonary complications; however, the presence of severe abdominal injury was the greatest risk factor for complications. Expediting access to definitive care may reduce complications and expenses.

Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity.

BACKGROUND: Although the benefits of acute stabilization of long bone fractures are recognized, the role of early fixation of unstable pelvis and acetabular fractures is not well-defined. The purpose of this study was to review complications and hospital course of patients treated surgically for pelvis and acetabulum fractures. We hypothesized that early definitive fixation would reduce morbidity and decrease length of stay. METHODS: Six hundred forty-five patients were treated surgically at a level I trauma center for unstable fractures of the pelvic ring (n = 251), acetabulum (n = 359), or both (n = 40). Mean age was 40.5 years, and mean Injury Severity Score (ISS) was 25.6 (range 9-66). They were retrospectively reviewed to determine complications including acute respiratory distress syndrome (ARDS), pneumonia, deep vein thrombosis, pulmonary embolism, multiple organ failure (MOF), infections, and reperations. RESULTS: Definitive fixation was within 24 hours of injury in 233 patients (early, mean 13.4 hours) and >24 hours in 412 (late, mean 99.2 hours). Twenty-nine patients (12.4%) had complications after early fixation versus 81 (19.7%) after late, p = 0.006. Length of stay and intensive care unit days were 10.7 days versus 11.6 days (p = 0.26) and 8.1 days versus 9.9 days (p = 0.03) for early and late groups, respectively. With ISS >18 (n = 165 early [ISS 32.7]; n = 253 late [ISS 33.1]), early fixation resulted in fewer pulmonary complications (12.7% versus 25%, p = 0.0002), less ARDS (4.8% versus 12.6%, p = 0.019), and less MOF (1.8% versus 4.3%, p = 0.40). Rates of complications, pulmonary complications, deep vein thrombosis, and MOF were no different for patients with pelvis versus acetabulum fractures. In patients receiving ≥ 10U packed red blood cells (n = 41 early, n = 56 late) early fixation led to fewer pulmonary complications (24% versus 55%, p = 0.002), less ARDS (12% versus 25%, p = 0.09), and MOF (7.3% versus 14%, p = 0.23). Two hundred ten patients had some chest injury (32.6%). Chest injury with Abbreviated Injury Scores ≥ 3 was present in 46 (19.7%) of early and 78 (18.9%) of late patients (p = 0.44) and was associated with pulmonary complications in 26.1% versus 35.9%; ARDS in 15.2% versus 23.1%; and MOF in 6.5% versus 6.4%, respectively (all p > 0.20). However, chest injury with Abbreviated Injury Scores ≥ 3 was independently associated with more complications including ARDS (20.2% versus 3.3%, p < 0.0001), other pulmonary complications (32.3% versus 10.4%, p < 0.0001), and MOF (6.5% versus 1.2%, p = 0.0016), regardless of timing of fixation. CONCLUSIONS: Early fixation of unstable pelvis and acetabular fractures in multiply injured patients reduces morbidity and length of intensive care unit stay, which may decrease treatment costs. Further study to ascertain the effects of associated systemic injuries and the utility of physiologic and laboratory parameters during resuscitation may delineate recommendations for optimal surgical timing in specific patient groups.

Clavicular anatomy and the applicability of precontoured plates.

BACKGROUND: Plate fixation of clavicular fractures is technically difficult because of the complex anatomy of the bone, with an S-shaped curvature and a cephalad-to-caudad bow. The purpose of the present study was to characterize variations in clavicular anatomy and to determine the clinical applicability of an anatomic precontoured clavicular plate designed for fracture fixation. METHODS: One hundred pairs of clavicles were analyzed. The location and magnitude of the superior clavicular bow were determined with use of a digitizer and modeling software. Axial radiographs were made of each clavicle and the precontoured Acumed Locking Clavicle Plate, which is designed to be applied superiorly. With use of Adobe Photoshop technology, the plates were freely translated and rotated along each clavicle to determine the quality of fit and the location of the "best fit." RESULTS: The location of the maximum superior bow was lateral, with a mean distance of 37.2 +/- 18.4 mm from the acromial articulation and with a mean magnitude of 5.1 +/- 5.9 mm. There was no significant difference in the location or magnitude of the apex of the bow between specimens from male and female donors. The anatomic precontoured clavicular plate had the best fit in specimens from black male donors and the worst fit in specimens from white female donors, with a poor fit being seen in 38% (nineteen) of the fifty specimensfrom white female donors. The best location for superior plate application was along the medial aspect of the clavicle. CONCLUSIONS: The apex of the superior bow of the clavicle is typically located along the lateral aspect of the bone, whereas the medial aspect of the superior surface of the clavicle remains relatively flat, making it an ideal plating surface. The precontoured anatomic clavicular plate appears to fit the S-shaped curvature on the superior surface of the majority of clavicles in male patients but may not be as conforming in white female patients. While this plate fits in the medial three-fifths of the clavicle, it does not fit as well laterally.

Three-dimensional analysis of pelvic volume in an unstable pelvic fracture.

BACKGROUND: A model was developed to predict changes in pelvic volume associated with increasing pubic diastasis in unstable pelvic fractures. METHODS: Intact and postfracture pelvic volumes were calculated in 10 cadavers using computerized axial tomography (CT). The true pelvis was assumed to be either a sphere, a cylinder, or a hemi-elliptical sphere. Using the appropriate equations for calculating the volume of each of these shapes, pelvic volume was predicted and then compared with the measured values. RESULTS: The observed volume changes associated with increasing pubic diastasis were much smaller than previously reported. The mean difference between the measured and predicted volume was 20.0 +/- 9.9% for the sphere, 10.7 +/- 6.5% for the cylinder, and 4.5 +/- 5.9% for the hemi-elliptical sphere. The differences between these means were statistically significant (p < 0.001). CONCLUSIONS: This data suggests that the hemi-elliptical sphere best describes the geometric shape of the true pelvis and better predicts quantitative changes in pelvic volume relative to an increasing pubic diastasis as the radius has little effect on the change in volume. Due to the small changes in volume observed with increasing diastasis, factors other than the absolute change in volume must account for the clinically observed effects of emergent pelvic stabilization.

Concomitant fractures of the acetabulum and spine: a retrospective review of over 300 patients.

BACKGROUND: The incidence and spectrum of concomitant acetabulum and spine trauma has not been clearly defined. METHODS: We retrospectively reviewed 307 acetabulum fracture patients over 5 years, and evaluated this cohort for concomitant spine injuries. Patient and injury demographics, spine and neurologic injury and delay in diagnosis were examined. RESULTS: Complete data were available for 275 (90%) of the cohort, and 55 spine injuries (54 fractures and 1 traumatic disc herniation) were identified in 34 patients. Thus, the incidence of concomitant acetabulum and spine fractures was approximately 13% (34 of 275). Four percent of the patients sustained significant thoracolumbar fractures (burst, flexion-distraction, or dislocation). An average 8.6-day delay in diagnosis occurred in three spine fracture patients. One suffered progressive neurologic injury. CONCLUSIONS: It is essential that the traumatologists have a high index of suspicion for spine injury, particularly thoracolumbar injury in patients who sustain fractures of the acetabulum. We recommend early thoracolumbar computed tomography imaging in patients with fractures of the acetabulum if plain radiographs are not possible or inadequate.

Treatment of compartment syndrome: transverse fasciotomy as an adjunct to longitudinal dermatofasciotomy: an in vitro study.

OBJECTIVE: This study describes a previously unpublished technique for compartment release that combines adjunctive transverse fasciotomies with a limited longitudinal dermatofasciotomy and compares its efficacy with a standard extensile longitudinal dermatofasciotomy. DESIGN: Limited 10-cm longitudinal dermatofasciotomies were performed bilaterally on 14 cadaveric specimens (28 legs). Next, we performed transverse fasciotomies on 1 limb and performed extensions of the longitudinal incision on the contralateral limb. Subsequent changes in compartment pressures were recorded after each release. Two-tailed paired and unpaired Student t tests were performed for statistical analysis with significance set at P < 0.05. SETTING: Anatomy laboratory. RESULTS: After a 10-cm longitudinal dermatofasciotomy, the average compartment pressure was 17 +/- 7.1 mm Hg proximally and 15.5 +/- 7.4 mm Hg distally. With an extensile 16-cm longitudinal incision, a significant decrease in compartment pressure was seen both proximally (6.5 +/- 3.1 mm Hg) and distally (4.7 +/- 4.7 mm Hg). With adjunctive transverse fasciotomies, a significant reduction in compartment pressure also was observed proximally (6.9 +/- 6.1 mm Hg) and distally (6.1 +/- 5.4 mm Hg). There was no statistically significant difference in compartment pressures between an extensile 16-cm incision and 10-cm incision combined with transverse fasciotomies both proximally and distally (P = 0.84 and P = 0.5, respectively). CONCLUSIONS: A combined approach of transverse fasciotomies with a limited longitudinal dermatofasciotomy in this in vitro compartment syndrome study is as effective as a standard 16-cm longitudinal release in the anterior compartment of this cadaveric leg model.