Asymptomatic macrocephaly: to scan or not to scan.

BACKGROUND: Macrocephaly is a common finding in infants and is often idiopathic or familial. In the absence of clinical signs and symptoms, it can be difficult to determine when concern for underlying pathology is justified. OBJECTIVES: The objectives of this study were to determine the utility of screening head ultrasound (US) in asymptomatic infants with macrocephaly and to identify clinical factors associated with significant US findings. MATERIALS AND METHODS: A 20-year retrospective review was performed of infants undergoing head US for macrocephaly or rapidly increasing head circumference. Data collected included age, gender, head circumference at birth and at the time of US, specialty of the ordering physician, US findings, computed tomography (CT) or magnetic resonance imaging (MRI) findings, and clinical course including interventions. RESULTS: Four hundred and forty infants met inclusion criteria. Two hundred and eighty studies (64%) were found to be normal, 137 (31%) had incidental findings, 17 (3.8%) had indeterminate but potentially significant findings, and 6 (1.4%) had significant findings. Twenty of the 23 infants with indeterminate or significant findings had subsequent CT or MRI. This confirmed significant findings in eight infants (1.8%): three subdural hematomas, two intracranial tumors, two aqueductal stenoses, and one middle fossa cyst. Five of the eight infants required surgical procedures. The only statistically significant association found with having a significant finding on head US was head circumference at birth. CONCLUSION: Ultrasound is a useful initial study to evaluate infantile macrocephaly, identifying several treatable causes in our study and, when negative, effectively excluding significant pathology.

Three-Dimensional Mapping of Scapular Body, Neck, and Glenoid Fractures.

OBJECTIVES: The purpose of this study was to report patterns of scapular fractures and define them with a contemporary methodology. METHODS: . DESIGN: Retrospective study, 2015-2021. SETTING: Single, academic, Level 1 trauma center. PATIENT SELECTION CRITERIA: Consecutive patients ≥18 years, presenting with unilateral scapula fracture, with thin-slice (≤0.5-mm) bilateral computed tomography (CT) scans of the entirety of both the injured and uninjured scapulae. OUTCOME MEASURES AND COMPARISONS: Thin-slice (0.5-mm) CT scans of injured and normal scapulae were obtained to create three-dimensional (3D) virtual models. 3D modeling software (Stryker Orthopedics Modeling and Analytics, Stryker Trauma GmbH, Kiel, Germany aka SOMA) was used to create a 3D map of fracture location and frequency. Fracture zones were delineated using anatomic landmarks to characterize fracture patterns. RESULTS: Eighty-seven patients were identified with 75 (86%) extra-articular and 12 (14%) intra-articular fractures. The dominant fracture pattern emanated from the superior lateral border (zone E) to an area inferior to the spinomedial angle (zone B) and was present in 80% of extra-articular fractures. A second-most common fracture line propagated from the primary (most-common) line toward the inferior medial scapular border with a frequency of 36%. Bare zones (with 1 or no fractures present) were identified in 4 unique areas. Furthermore, intra-articular fractures were found to be heterogenous. CONCLUSIONS: The 3D fracture map created in this study confirmed that extra-articular scapular fractures occur in certain patterns with a relatively high frequency. Results provide greater insight into scapular fracture locations and may help to study prognosis of injury and improve treatment strategy including operative approaches and surgical tactics.

Rib Fracture Map in High-Energy Injuries.

OBJECTIVES: To use a novel rib unfurling technology to investigate the locations of multiple rib fractures occurring from high-energy trauma to discern if there are reproducible rib fracture patterns. METHODS: Patients between the ages of 18 and 48 years presenting to a Level 1 academic trauma center with ≥2 rib fractures after a high-energy mechanism of injury between 2017 and 2019 were identified. Curved planar reformatting of CT scans was used to create two-dimensional unfurled rib images by flattening out the view of the ribs from a CT scan. Rib fractures were placed on a template map using a standardized measurement method, and subsequent frequency and heat maps were created. RESULTS: Among 100 consecutive patients, 534 fractures on 454 ribs were identified. The most common high-energy mechanism of injury was motor vehicle accidents (41%). Flail chest occurred in 8% of patients. The mean number of ribs fractured per patient was 4.54 ± 3.14 and included a mean of 5.34 ± 4.38 total fractures. Among all fractures, 50.9% were located on ribs 4 through 7. The most common fracture location was located in the lateral or anterolateral zone of the rib cage. CONCLUSIONS: Patients with multiple rib fractures from high-energy trauma have rib fractures with locations of common occurrence. An understanding of location and frequency of rib fractures can help inform surgical approaches, prognosis, indications, classifications, and implant design in the management of a complex population of patients with chest wall injury after trauma. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mapping of Pelvic Ring Injuries From High-Energy Trauma Using Unfolded CT Image Technology.

OBJECTIVES: High-energy pelvic ring injuries are associated with significant morbidity and mortality, elevating the importance of injury pattern identification. The purpose of this study was to use a novel 3D computed tomography (CT) unfolding process to both evaluate high-energy pelvic ring injures and to produce injury frequency maps based on injury patterns. METHODS: Patients 18-65 years of age presenting to a level 1 trauma center with pelvic ring injuries between 2016 and 2020 were identified. Of the 482 patients reviewed, 355 were excluded primarily due to having a low energy mechanism, inadequate radiographs, or an isolated fracture. Unfolded pelvic CT images were created using syngo.via CT Bone Reading software. Pelvic ring injury frequency maps were created using the unfolded pelvic CT images and a previously described mapping technique. RESULTS: One hundred twenty-seven patients analyzed had a mean age of 32.7 years. The most common mechanisms of injury (MOI) were motor vehicle collision (30.7%) and fall from height (23.6%). The breakdown of pelvic ring injuries included LC1 = 44.1%, LC2 = 7.1%, LC3 = 14.2%, APC1 = 2.4%, APC2 = 15.0%, APC3 = 5.5%, and VS = 11.8%, with OTA/AO-61B = 74.0% and OTA/AO-61C = 26.0%. Pelvic ring mapping revealed that articular and bony injuries varied markedly between the different types of pelvic ring disruptions, both in type and location. CONCLUSIONS: Pelvic ring injury frequency maps created from unfolded CT images reflect consistent injury patterns providing distinctive information based on force vector mechanisms. Unfolded CT images allow for a novel way to visualize pelvic ring injuries which yield greater comprehension of failure patterns with implications for treatment.

An overview of 3D printing and the orthopaedic application of patient-specific models in malunion surgery.

As the emerging technology of three-dimensional (3D) printing impacts several facets of medicine, innovative techniques and applications are increasingly being incorporated into clinical workflows. Specifically, 3D printing technology has allowed for the individualization of patient care through the creation of printed surgical guides, patient-specific anatomical models, and simulation practice models. In this paper, we review the broad applications of 3D printing in orthopaedic surgery. The purpose of this paper is to help orthopaedic trauma surgeons understand 3D printing's emerging influence on the delivery of care as well as how to directly apply this technology to their practice. We aim to illustrate these principles through a specific example of a patient who presented for malunion surgery. A 3D printed model of a very complex traumatic scapula malunion was used to not only pre-surgically plan the reconstruction, but to also facilitate provider and patient education. This paper highlights the benefits of 3D printing and how trauma surgeons are uniquely positioned to apply this technology to improve patient care.

Outcomes After Operative Reconstruction of Symptomatic Rib Nonunions.

OBJECTIVE: To assess the outcomes of patients after rib nonunion reconstruction. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Between January 2007 and August 2019, 25 consecutive patients with 51 nonunions with disabling pain or chronic instability were treated for nonunited rib fractures. INTERVENTION: Rib nonunion reconstructions performed using plate and screw fixation, recannalizing the medullary canal and augmented with autogenous iliac crest bone graft. MAIN OUTCOME MEASUREMENTS: Patient demographics, mechanism of injury, number of rib nonunions, and postoperative radiographs were assessed. Satisfaction, patient-reported complications, return to occupation and activity, and general health measures were captured using patient questionnaires. RESULTS: In 25 patients, 51 painful rib nonunions were surgically treated. The average length from injury to surgical rib reconstruction was 25.1 months (range = 3-118 months; median = 12 months). Follow-up was obtained in 18 of 25 patients (72%) with a mean of 46.1 months (range = 13-139 months). All ribs achieved radiographic union at an average of 12.3 weeks (range = 8-24 weeks) after surgery. Sixteen of 18 patients (89%) reported satisfaction with surgery and 15 patients (83%) reported mild to no pain at final follow-up. Five patients had complications that all resolved after subsequent treatment. CONCLUSIONS: Successful treatment of symptomatic rib nonunion is possible using rib plates in conjunction with bone grafting and has high union rates, satisfactory results, and limited complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

In Situ Reconstruction of a Painful Sternal Z-Deformity Nonunion in a Severely Osteoporotic and Kyphotic Patient: A Case Report.

CASE: An osteoporotic and kyphotic 72-year-old woman presented with sternal pain, severe chest instability, and shortness of breath secondary to a traumatic sternal nonunion resulting from an unhealed sternal fracture sustained in a motor vehicle accident several months earlier. One-year functional and radiographic outcomes are presented with complete resolution of symptoms. CONCLUSION: Consideration for treatment with multiplanar, contourable, locked plating, augmented by autogenous graft, is warranted in the setting of sternal deformity and nonunion, particularly in the setting of osteoporosis and other sagittal plane deformity.

Structures Endangered During Minimally Invasive Plate Osteosynthesis of the Upper Extremity.

Minimally invasive plate osteosynthesis is a surgical technique that is becoming increasingly common because radiographic images and implant technologies advance in capabilities. It is imperative for surgeons to enhance their understanding of the surgical anatomy related to new approaches for fracture fixation. While performing minimally invasive plate osteosynthesis, there is a danger of injuring structures in the common percutaneous and submuscular pathways. We describe the critical anatomical structures in these pathways and tips for injury avoidance when operating on the clavicle, scapula, humerus, and wrist.

Mapping of common rib fracture patterns and the subscapular flail chest associated with operative scapula fractures.

BACKGROUND: Rib fractures occur in approximately 10% of trauma patients and are associated with more than 50% of patients with scapula fractures. This study investigates the location and patterns of rib fractures and flail chest occurring in patients with operatively treated scapula fractures. Novel frequency mapping techniques of rib fracture patterns in patients who also injure the closely associated scapula can yield insight into surgical approaches and fixation strategies for complex, multiple injuries patients. We hypothesize that rib fractures have locations of common occurrence when presenting with concomitant scapula fracture that requires operative treatment. METHODS: Patients with one or more rib fractures and a chest computed tomography scan between 2004 and 2018 were identified from a registry of patients having operatively treated scapula fractures. Unfurled rib images were created using Syngo-CT Bone Reading software (Siemens Inc., Munich, Germany). Rib fracture and flail segment locations were marked and measured for standardized placement on a two-dimensional chest wall template. Location and frequency were then used to create a gradient heat map. RESULTS: A total of 1,062 fractures on 686 ribs were identified in 86 operatively treated scapula fracture patients. The mean ± SD number of ribs fractured per patient was 8.0 ± 4.1 and included a mean ± SD of 12.3 ± 7.2 total fractures. Rib fractures ipsilateral to the scapula fracture occurred in 96.5% of patients. The most common fracture and flail segment location was ipsilateral and subscapular; 51.4% of rib fractures and 95.7% of flail segments involved ribs 3 to 6. CONCLUSION: Patients indicated for operative treatment of scapula fractures have a substantial number of rib fractures that tend to most commonly occur posteriorly on the rib cage. There is a pattern of subscapular rib fractures and flail chest adjacent to the thick bony borders of the scapula. This study enables clinicians to better evaluate and diagnose scapular fracture patients with concomitant rib fractures. LEVEL OF EVIDENCE: Diagnostic test, level IV.

Ten Days to Implementation of 3D-Printed Masks for a Level-I Orthopaedic Trauma Practice During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has substantially impacted the global supply chain of personal protective equipment (PPE) for hospitals. At the time of our project, local and national recommendations for PPE were based on supply rather than provider or patient safety, and we intended to give providers a better option than scarves and cloth masks. Our objective was to utilize in-house 3D-printing capabilities to make 3D-printed face masks for our orthopaedic trauma providers that use filters that were verified to be nearly equivalent to the filtration material that is found in N95 masks. To meet this goal, we used open-source face-mask design files from the National Institutes of Health with use of an Ultimaker S3 desktop printer. We printed 50 reusable face masks with replaceable filter inserts and distributed them to physicians, physician assistants, and residents in a midwestern level-I trauma center. Our work highlights the innovative solutions that are being explored on a local level to confront the nationwide PPE shortage in the United States.