The Efficacy of Sequential Intranasal Packing Removal in Overcorrected Nasal Bone Fracture: Evaluation With Computed Tomography.

BACKGROUND: Despite the evolution of new techniques to treat nasal bone fractures, closed reduction with appropriate palpation and inspection is one of the critical basic tools to treat nasal bone fractures properly. Despite its rarity, overcorrection after closed reduction of the nasal bone fracture could happen even with experienced surgeons. This study hypothesized that sequential packing removal is mandatory for optimal outcomes based on the preoperative and postoperative Computed Tomography scans in overcorrected cases. This is the first study to evaluate the efficacy of sequential nasal packing removal assessed by facial CT scans. METHODS: In this retrospective study, we evaluated the medical records and preoperative and postoperative facial Computed Tomography scans of 163 patients with nasal bone fractures treated with a closed reduction from May 2021 to December 2022. Preoperative and Postoperative CT scan was routinely used to assess the outcome. Merocels were used for intranasal packing. In overcorrected cases based on immediate postoperative CT scan, we routinely removed the intranasal packing on the overcorrected side first immediately. On postoperative day 3, we removed the remaining intranasal packing on the other side. We assessed additional postoperative CT scans on postoperative two to three weeks. RESULTS: With sequential packing removal starting on the day of surgery, all overcorrected cases were successfully corrected clinically and radiologically without noticeable complications. Two representative cases were presented. CONCLUSION: Sequential nasal packing removal provides significant benefits in overcorrected cases. An immediate postoperative CT scan is also vital to do this procedure. This strategy is advantageous if the fracture is significant and there is a substantial possibility of overcorrection.

Case report of a delayed iatrogenic Pipkin type III femoral head fracture-dislocation.

RATIONALE: Pipkin III femoral head fracture dislocation (FHFD) is rarely observed in clinical practice, and its outcome is alarming. A considerable proportion of Pipkin III fractures result from repeated or forceful closed reduction of an irreducible FHFD. Pipkin type III fractures pose a therapeutic challenge. Most patients underwent total hip arthroplasty. PATIENT CONCERNS: A 34-year-old man experienced high-energy trauma to the left hip from a terrible traffic accident. Radiography and computed tomography (CT) at the local hospital revealed a left posterior FHFD. Emergency close reduction of the hip was performed.48 hours later, the patient was transferred to our institution. New radiography and CT examinations demonstrated an iatrogenic femoral neck fracture (FNF) associated with FHFD. In addition, a right talar fracture was observed. DIAGNOSIS: Pipkin III fracture combined with contralateral talar fracture. INTERVENTIONS: Considering his Pipkin fracture classification (Pipkin Type-III) and the time to surgery after his injury (>48 hours), the patient underwent left total hip arthroplasty uneventfully, followed by below-ankle plaster cast immobilization for his right ankle. OUTCOMES: At the 6-month follow-up, the patient was able to walk pain-free, and plain radiographs were satisfactory, with no evidence of heterotopic ossification or osteonecrosis of the talus. LESSONS: Before emergency closed reduction, early recognition of the unique characteristics of an irreducible FHFD is essential to avoid iatrogenic femoral neck fracture.

Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures: A Population-Based Cohort Study.

STUDY OBJECTIVE: Temporary lower limb immobilization may be a risk for venous thromboembolism. The purpose of this study was to examine the 90-day incidence of venous thromboembolism among patients discharged from an emergency department (ED) with ankle fractures requiring temporary immobilization. Secondary objectives were to examine individual factors associated with venous thromboembolism in this population and to compare the risk of venous thromboembolism in patients with ankle fractures against a priori-selected control groups. METHODS: This was a retrospective cohort study using province-wide health datasets from Ontario, Canada. We included patients aged 16 years and older discharged from an ED between 2013 and 2018 with closed ankle fractures requiring temporary immobilization. We estimated 90-day incidence of venous thromboembolism after ankle fracture. A Cox proportional hazards model was used to evaluate risk factors associated with venous thromboembolism, censoring at 90 days or death. Patients with ankle fractures were then propensity score matched to 2 control groups: patients discharged with injuries not requiring lower limb immobilization (ie, finger wounds and wrist fractures) to compare relative hazard of venous thromboembolism. RESULTS: There were 86,081 eligible patients with ankle fractures. Incidence of venous thromboembolism within 90 days was 1.3%. Factors associated with venous thromboembolism were older age (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39), venous thromboembolism or superficial venous thrombosis history (HR: 5.18; 95% CI: 4.33 to 6.20), recent hospital admission (HR: 1.33; 95% CI: 1.05 to 1.68), recent nonankle fracture surgery (HR: 1.58; 95% CI: 1.30 to 1.93), and subsequent surgery for ankle fracture (HR: 1.80; 95% CI: 1.48 to 2.20). In the matched cohort, patients with ankle fractures had an increased hazard of venous thromboembolism compared to matched controls with finger wounds (HR: 6.31; 95% CI: 5.30 to 7.52) and wrist fractures (HR: 5.68; 95% CI: 4.71 to 6.85). CONCLUSION: The 90-day incidence of venous thromboembolism among patients discharged from the ED with ankle fractures requiring immobilization was 1.3%. These patients had a 5.7- to 6.3-fold increased hazard compared to matched controls. Certain patients immobilized for ankle fractures are at higher risk of venous thromboembolism, and this should be recognized by emergency physicians.

Comparison of lateral entry and crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis of randomized controlled trials.

BACKGROUND: Closed reduction and pinning entry fixation have been proposed as treatment strategies for displaced supracondylar humeral fractures (SCHFs) in children. However, controversy exists regarding the selection of the appropriate procedure. Hence, this meta-analysis was conducted to compare the effect of lateral and crossed pin fixation for pediatric SCHFs, providing a reference for clinical treatment. METHODS: Online databases were systematically searched for randomized controlled trials (RCTs) comparing lateral pinning entry and crossed pinning entry for children with SCHFs. The primary endpoints were iatrogenic ulnar nerve injuries, complications, and radiographic and functional outcomes. RESULTS: Our results showed that iatrogenic ulnar nerve injuries occurred more commonly in the crossed pinning entry group than in the lateral pinning entry group (RR = 4.41, 95% CI 1.97-9.86, P < 0.05). However, its risk between the crossed pinning with mini-open incisions group and the lateral pinning entry group was not significantly different (RR = 1.58, 95% CI 0.008-29.57, P = 0.76). The loss of reduction risk was higher in the lateral pinning entry group than in the crossed pinning entry group (RR = 0.66; 95% CI 0.49-0.89, P < 0.05). There were no significant differences in the carry angle, Baumann angle, Flynn scores, infections, and other complications between these two groups. CONCLUSIONS: The crossed pinning entry with mini-open incision technique reduced the loss of reduction risk, and the risk of iatrogenic ulnar nerve injury was lower than in the lateral pinning entry group. The crossed pinning entry with mini-open incision technique is an effective therapeutic strategy for managing displaced supracondylar humeral fractures in children.

Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

BACKGROUND: Nearly 1 in 5 American children are obese. The primary purpose of this study is to evaluate the relationship between childhood obesity and perioperative complications, patient-reported outcomes (PRO), and functional recovery after closed reduction and percutaneous pinning (CRPP) of type II and III supracondylar humerus fractures. METHODS: Retrospective review of patients treated operatively with CRPP of Wilkins modification of the Gartland classification type II and III supracondylar humerus fractures was performed over a 1-year timeframe (July 1, 2016 to July 1, 2017). One hundred forty-four patients under the age of 16 treated were identified. Obesity was defined as body mass index (BMI) at or above the 95th percentile for age. Obesity as a risk factor for poor outcomes was assessed. The primary outcome measure was postoperative PRO [quick-DASH, Patient Reported Outcomes Measurement Information System (PROMIS)-UE, PROMIS Global Health, and PROMIS Pain scores]. RESULTS: Mean age at surgery was 5.9 years (SD=2.1, 1.07 to 12.2) and mean age at final follow-up (3.3 y) was 8.8 (SD=2.14, 4 to 16). Mean patient BMI was 17.2 (SD=4.48, 12.4 to 56.2). Sixty-six patients were female (45.8%) and 78 patients were male (54.2%). In all, 31 of 144 patients (21.5%) met criteria for obesity. Obesity (95th percentile for BMI or above) was not associated with a higher rate of complications overall (χ2=1.29, P=0.256), range of motion loss (χ2=0.2, P=0.655) or requirement of postoperative physical therapy (χ2=0.17, P=0.678). Seventy-five patients were available and willing to participate in the outcomes score assessments. Mean follow-up for this cohort of 75 patients was 3.3 years (SD=0.31, 2.85 to 3.88). There were no differences in PROMIS pain, PROMIS upper extremity function, PROMIS general health, or quick-DASH scores when comparing obese with nonobese patients. CONCLUSIONS: Obesity is a growing concern in the United States and its effect on long-term outcomes after CRPP of supracondylar humerus fractures is unknown. The present study demonstrates no difference in complications or PRO among obese patients compared with nonobese patients. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Pediatric Radial Neck Fractures: Which Ones Can Be Successfully Closed Reduced in the Emergency Department?

BACKGROUND: The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED). METHODS: A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories. RESULTS: CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED. CONCLUSIONS: Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED. LEVEL OF EVIDENCE: Level III-prognostic.

Fracturas de húmero distal en pacientes mayores de 65 años: ¿cuál es la mejor opción terapéutica? / Distal humerus fractures in patients over 65 years: what is the best therapeutic option? / Fraturas do úmero distal em pacientes maiores de 65 anos: qual é a melhor opção terapêutica?

Introducción: Las fracturas del húmero distal corresponden al 2% de todas las fracturas. Son los pacientes más añosos, los que presentan mayor desafío terapéutico. Suelen presentarse con huesos osteoporóticos, lo que conlleva a producir fracturas con mayor conminución articular y metafisaria; así como también dificultar una fijación estable y rígida de las mismas, que permita una movilidad precoz. Estas características generan controversia a la hora de elegir el tratamiento adecuado. El objetivo de este estudio es revisar la bibliografía de la última década, acerca de cuál es la mejor opción terapéutica para las fracturas de húmero distal en pacientes añosos. Materiales y métodos: Se realizó una búsqueda sistematizada a través de los buscadores electrónicos PubMed y Timbó en agosto 2019. La búsqueda llego a un total de 475 artículos, de los cuales se seleccionaron 24 según criterios de inclusión y exclusión. Discusión: La mayoría de los estudios analizados son estudios de serie de casos retrospectivos. En los trabajos revisados, existen fracturas tanto extra como intra-articulares. Se analizaron los resultados de los distintos tratamientos realizados según parámetros clínicos, scores funcionales y complicaciones. Conclusiones: El tratamiento conservador es una opción válida para aquellos pacientes en los que el terreno no permita una intervención quirúrgica. Para las fracturas tipo extra-articulares y parcialmente articulares, la reducción abierta y fijación interna es el tratamiento de elección. Para las fracturas articulares completas, no hay diferencias significativas en cuanto a scores utilizados entre la reducción abierta y fijación interna con la artroplastia de codo. Faltan estudios prospectivos que comparen ambos tratamientos.

Introduction: Distal humerus fractures account for 2% of all fractures. It is the elderly patients who present the greatest therapeutic challenge. Osteoporotic bones, more common in this population, lead to the production of fractures with greater joint and metaphyseal comminution. As a result, stable and rigid fixation becomes more difficult, hindering early mobility. These characteristics generate controversy when choosing the appropriate treatment. The aim of this study is to review the literature of the last decade regarding the best therapeutic option for distal humerus fractures in elderly patients. Methods: A systematized search was performed through the electronic search engines PubMed and Timbó in august 2019. The search reached a total of 475 articles, of which 24 were selected according to inclusion and exclusion criteria. Discussion: Most of the studies analyzed are retrospective case series studies. In the articles reviewed, there are both extra and intra-articular fractures. The results of the different treatments performed were analyzed according to clinical parameters, functional scores and complications. Conclusions: Conservative treatment is a valid option for those patients where the terrain does not allow surgical intervention. For extra-articular and partial-articular fractures, open reduction and internal fixation is the treatment of choice. For complete articular fractures, there are no significant differences in scores used between open reduction and internal fixation and elbow replacement. There is a lack of prospective studies comparing both treatments.

Introdução: Fraturas do úmero distal correspondem a 2% de todas as fraturas. São os pacientes mais idosos os que apresentam maior desafio terapêutico. Geralmente apresentam-se com ossos osteoporóticos, o que implica produzir fraturas com maior cominuição articular e metafisária; assim como também dificultar uma fixação estável e rígida das mesmas, que permita uma mobilidade precoce. Estas características geram controvérsia na escolha do tratamento adequado. O objetivo deste estudo é rever a bibliografia da última década, sobre qual é a melhor opção terapêutica para fraturas de úmero distal em pacientes idosos. Materiais e métodos: Foi realizada uma pesquisa sistematizada através dos buscadores eletrônicos Pubmed e Timbó em agosto 2019. A pesquisa chegou a um total de 475 artigos, dos quais 24 foram selecionados segundo critérios de inclusão e exclusão. Discussão: A maioria dos estudos analisados são estudos de série de casos retrospectivos. Nos trabalhos revisados, existem fraturas tanto extra como intra-articulares. Foram analisados os resultados dos diferentes tratamentos realizados segundo parâmetros clínicos, scores funcionais e complicações. Conclusões: O tratamento conservador é uma opção válida para os pacientes em que o terreno não permita uma intervenção cirúrgica. Para fraturas tipo extra-articulares e parcialmente articulares, a redução aberta e fixação interna é o tratamento de escolha. Para fracturas articulares completas, não há diferenças significativas em termos de scores utilizados entre a redução aberta e a fixação interna com artroplastia do cotovelo. Faltam estudos prospectivos que comparem os dois tratamentos.

Haematoma block: a safe method for pre-surgical reduction of distal radius fractures.

BACKGROUND: The haematoma block (HB) has been successfully used to minimise pain prior to otherwise painful closed reduction manoeuvres for distal radius fractures. However, the invasive manner of the procedure, which technically produces an open fracture, still raises the question, whether HBs increase the risk of infection compared to conventional intravenous analgesia (IA). The purpose of this study was to assess complication rates and safety of the HB procedure for the closed reduction of surgically treated distal radius fractures. METHODS: We included 176 distal radius fractures in 170 patients in a retrospective mono-centric study, who underwent closed reduction and casting followed by definitive surgical care over a period of two years. Patients either received a HB or IA before closed reduction and were evaluated for minor and major complications over a follow-up period of four years. RESULTS: Overall, 42 distal radius fractures were treated with a HB (23.9%) and 134 with IA (76.1%) before closed reduction. There were a single major (2.3%) and eight minor (19%) complications observed in the HB group compared to two major (1.4%) and 24 minor (17.9%) complications in the IA group. No significant differences were identified between the two groups. Sex and type of fracture had no effect on complication rates, however, younger patients experienced higher complication rates in comparison to older ones (p = 0.035). CONCLUSION: According to our data, the apprehensions that clinicians may have of creating open fractures through HB procedures, are unnecessary and may be abandoned confidently.

Closed Vs. Open Reduction/Salter Innominate Osteotomy for Developmental Hip Dislocation After Age 18 Months: Comparative Survival at 45-Year Follow-up.

BACKGROUND: Despite widespread use of single-stage open reduction and pelvic osteotomy for treatment of developmental dysplasia of the hip (DDH) after walking age, this aggressive strategy remains controversial. We directly compared dislocated hips treated with closed reduction (CR) to those treated with open reduction and Salter innominate osteotomy (OR/IO) to estimate the relative hazard of total hip arthroplasty (THA) and the THA-free survival time. METHODS: In a series of patients 18 to 60 months of age, 45 patients (58 hips) underwent CR and 58 patients (78 hips) were treated with OR/IO and followed to a minimum 40 years post-reduction. Observations in the survival analysis were censored if no THA had occurred by 48 years. Multivariate Cox regression analysis was used to estimate the hazard of THA given treatment, age, and bilaterality. Complications and additional procedures were noted. RESULTS: At 48 years of follow-up, 29 (50%) of the hips survived after CR compared with 54 (69%) after OR/IO. At 45 years, the survival probability after OR/IO was 0.63 (95% confidence interval [CI] = 0.50 to 0.78) compared with 0.55 (95% CI = 0.43 to 0.72) after CR. The hazard ratio (HR) of THA was modeled as a function of treatment, age at reduction, and bilaterality. The effect of age and treatment on the outcome of hips in patients with unilateral involvement was minimal. However, age did significantly alter the relationship between treatment and outcome in bilateral cases. In the bilateral group, the predicted HR of THA was lower after CR in hips that were reduced at the age of 18 months (HR = 0.16, 95% CI = 0.04 to 0.64) but higher in those that were reduced at 36 months (HR = 4.23, 95% CI = 2.00 to 8.95). Additional procedures were indicated for 17% and 22% of hips after CR and OR/IO, respectively. CONCLUSIONS: Osteoarthritis and THA was more likely after CR than OR/IO, but the data do not indicate a difference in unadjusted hip-survival time. In patients with bilateral disease, an older age at reduction was associated with an increased hazard of THA after CR than after OR/IO. Both treatments provided substantial benefit relative to the natural history of DDH, but THA is the expected outcome in middle adulthood. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Doing Our Part to Conserve Resources: Determining Whether All Personal Protective Equipment Is Mandatory for Closed Reduction and Percutaneous Pinning of Supracondylar Humeral Fractures.

BACKGROUND: Closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures is one of the most common procedures performed in pediatric orthopaedics. The use of full, standard preparation and draping with standard personal protective equipment (PPE) may not be necessary during this procedure. This is of particular interest in the current climate as we face unprecedented PPE shortages due to the current COVID-19 pandemic. METHODS: This is a retrospective chart review of 1,270 patients treated with CRPP of a supracondylar humeral fracture at 2 metropolitan pediatric centers by 10 fellowship-trained pediatric orthopaedic surgeons. One surgeon in the group did not wear a mask when performing CRPP of supracondylar humeral fractures, and multiple surgeons in the group utilized a semisterile preparation technique (no sterile gown or drapes). Infectious outcomes were compared between 2 groups: full sterile preparation and semisterile preparation. We additionally analyzed a subgroup of patients who had semisterile preparation without surgeon mask use. Hospital cost data were used to estimate annual cost savings with the adoption of the semisterile technique. RESULTS: In this study, 1,270 patients who underwent CRPP of a supracondylar humeral fracture and met inclusion criteria were identified. There were 3 deep infections (0.24%). These infections all occurred in the group using full sterile preparation and surgical masks. No clinically relevant pin-track infections were noted. There were no known surgeon occupational exposures to bodily fluid. It is estimated that national adoption of this technique in the United States could save between 18,612 and 22,162 gowns and masks with costs savings of $3.7 million to $4.4 million annually. CONCLUSIONS: We currently face critical shortages of PPE due to the COVID-19 pandemic. Data from this large series suggest that a semisterile technique during CRPP of supracondylar humeral fractures is a safe practice. We anticipate that this could preserve approximately 20,000 gowns and masks in the United States over the next year. Physicians are encouraged to reevaluate their daily practice to identify safe opportunities for resource preservation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The management of acute fracture dislocations of proximal interphalangeal joints: a systematic review.

LEVEL OF EVIDENCE: III.

Effect of Surgery vs Functional Bracing on Functional Outcome Among Patients With Closed Displaced Humeral Shaft Fractures: The FISH Randomized Clinical Trial.

Importance: Humeral shaft fractures traditionally have been treated nonsurgically, but there has been a steady increase in the rate of surgery over the past 2 decades without high-quality evidence to justify the trend. Objective: To compare the effectiveness of surgical treatment with open reduction and internal plate fixation to nonsurgical treatment with functional bracing in the treatment of closed humeral shaft fractures. Design, Setting, and Participants: Randomized clinical trial conducted at 2 university hospital trauma centers in Finland, enrollment between November 2012 and January 2018 with a final follow-up of January 2019. A total of 82 adult patients with closed, unilateral, displaced humeral shaft fracture met criteria for inclusion. Patients were excluded if they had cognitive disabilities preventing them from following the protocol or had multimorbidity or multiple trauma. Interventions: Patients were randomly assigned to surgical treatment with open reduction and internal plate fixation (n = 38) or to nonsurgical treatment with functional bracing (n = 44). Main Outcome and Measure: The primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 12 months (range, 0 to 100 points, 0 denotes no disability and 100 extreme disability; minimal clinically important difference, 10 points). Results: Among 82 patients who were randomized (mean age, 48.9 years; 38 women [46%]; 44 men [54%]), 78 (95%) completed the trial. Thirteen (30%) of the patients assigned to functional bracing underwent surgery during the 12-month follow-up period to promote healing of the fracture. At 12 months, the mean DASH score was 8.9 (95% CI, 4.2 to 13.6) in the surgery group and 12.0 (95% CI, 7.7 to 16.4) in the bracing group (between-group difference, -3.1 points; 95% CI, -9.6 to 3.3; P = .34). Eleven patients (25%) allocated to functional bracing developed fracture nonunion. Three patients (8%) allocated to surgery developed a temporary radial nerve palsy. Conclusions and Relevance: Among patients with closed humeral shaft fracture, internal fixation surgery, compared with nonoperative functional bracing, did not significantly improve functional outcomes at 12 months. However, the substantial amount of treatment crossover from nonoperative to surgical treatment should be considered when interpreting the trial results. Trial Registration: ClinicalTrials.gov Identifier: NCT01719887.

Results of open reduction internal fixation versus percutaneous iliosacral screw fixation for unstable pelvic ring injuries: retrospective study of 36 patients.

INTRODUCTION: Surgical stabilization of posterior pelvic ring fractures can be achieved by closed reduction and percutaneous fixation (CRPF) or by open reduction and internal fixation (ORIF). The aim of the present study is to compare the clinical results of both methods. MATERIAL AND METHODS: Medical records of 36 patients consecutively operated for unstable pelvic ring injuries were retrospectively reviewed. We compared 22 patients treated with CRPF versus 14 patients stabilized by using ORIF between 2007 and 2017. The Majeed and Pohlemann scores were used to evaluate postoperative functional outcomes. Complications like blood loss, infection rate, Neurological injury, the operative time and the length of hospital stay were analyzed. RESULTS: The median Majeed pelvic score was 87 points for the CRPF technique compared with 69 points for the ORIF technique. The median Pohlemann score, operative time and length of hospitalization were similar between the two groups. The median blood loss for the CRPF technique was 300 ml compared to 500 ml for the ORIF technique. CRPF and ORIF procedure had each one neurological lesion. There was one case of infection in the ORIF group and none in the CRPF group. No measurements except for the blood loss have reached the significance threshold. CONCLUSION: The CRPF technique shows a clear decrease in blood loss. There was no statistically significant difference in the functional results, infection rate, neurological injury, operative time and hospital stay between both techniques.

Deterioration of initially accepted radiological alignment of conservatively treated AO type-C distal radius fractures: mid-term outcome.

BACKGROUND AND AIMS: It still remains controversial how often the once-accepted radiological alignment of an AO type-C distal radius fracture deteriorates after conservative treatment, and to what extent this deterioration is perhaps associated with patient-rated outcome measures (PROms). Thus, we aimed to evaluate this radiological deterioration and its association with mid-term functional follow-up. PATIENTS AND METHODS: We retrospectively reviewed 66 patients (mean age at fracture 53 years, SD 14.1, range 18-73, female 65%) with 68 C-type distal radius fractures at a mean of 6.7 years (SD 0.5 years, range 5.8-7.7 years) after primary closed reduction and cast immobilization. Radiographs of the wrists were taken and analysed for any radial shortening, dorsal tilt or step-off at the joint surface. Range of motion and grip strength were measured. In addition to the radiological result, primary outcome measures included Quick Disabilities of the Arm, Shoulder and Hand (QDash) and Patient-Rated Wrist Evaluation (PRWE). RESULTS: At mid-term follow-up, an acceptable anatomical radiological result was seen in only 22 wrists (32%). Deterioration of the once-achieved and accepted primary alignment was seen in a majority of cases (68%). Radial shortening of ≥ 2 mm was found in 34 wrists (51%, mean 4 mm, range 2-8 mm), with no association with QDash (12.8 vs. 5.5, p = 0.22) or PRWE (9.1 vs. 5.7, p = 0.40). Only four patients (6%) showed step-off at the joint surface (mean 1.1 mm, range 0.5-2 mm). Twenty-two wrists (32%) showed dorsal tilt of ≥ 10° (five with volar tilt of 15°-25°), with no effect on QDash or PRWE (14.7 vs. 6.5, p = 0.241 and 10.1 vs. 5.8, p = 0.226). Altogether, patients with dorsal tilt, step-off or shortening did not show significantly worse QDash (10.3 vs. 5.7, p = 0.213) or PRWE (8.1 vs. 5.1, p = 0.126) versus those with none. Twenty-nine (43%) of the patients had deficits in range of motion (ROM), either in extension (39%), flexion (43%), supination (16%) or pronation (4%), or combinations of these. Worse extension was associated with worse QDash (15.9 vs. 5.0, p = 0.037), flexion deficit with worse PRWE (11.5 vs. 4.4, p = 0.005) and supination deficit with both QDash (21.7 vs. 6.8, p = 0.025) and PRWE (18.9 vs. 5.2, p = 0.007). CONCLUSIONS: The initially accepted radiological alignment of AO type-C radius fractures deteriorated in a majority of cases during conservative treatment. However, this deterioration was fairly mild and showed no significant association with functional outcome. Restricted ROM showed some association with PROms. LEVEL OF EVIDENCE: IV.

Improving Quality in the Treatment of Pediatric Forearm Fractures: Minimizing the Need for Repeat Intervention With Long-arm Extension Casting.

PURPOSE: Repeat intervention for pediatric forearm fractures after closed manipulation is as high as 46% with flexed elbow (FE) long-arm casts. Casting with the elbow extended (EE) has been advocated as an alternative technique. We documented outcomes of patients treated with closed manipulation and casting with EE long-arm casts for displaced, diaphyseal both-bone forearm fractures. METHODS: We retrospectively reviewed charts for patients who had sedated manipulations and casting for closed, diaphyseal forearm fractures. Open fractures, immediate surgical intervention, metabolic bone disease, recurrent fractures, and Monteggia injuries were excluded. Closed manipulations were performed by orthopaedic residents assisted by cast technicians, with sedation provided by emergency department physicians. Radiographic angulation and displacement of the radius and ulna on immediate postreduction radiographs and all follow-up radiographs were recorded. Patients requiring repeat intervention were compared with those who did not by using the Mann-Whitney U and Fisher exact tests. RESULTS: Of 86 patients (7.2±2.8 y) available for analysis, 82 (95.3%) completed treatment after a single-sedated manipulation and placement of an EE long-arm cast. There were no malunions or nonunions. The average follow-up was 50 days. Four (4.7%) patients required repeat interventions (2 had surgery, 1 had a repeat sedated manipulation, and 1 had a nonsedated manipulation). There were no statistically significant differences in age, sex, laterality, fracture position in the diaphysis, or immediate postreduction angulation of the radius or ulna. A literature review showed average repeat intervention rates of 14.9% (range, 0% to 45.9%) for FE casts and 3.3% (range, 0% to 15%) for EE casts. CONCLUSIONS: There was a low rate of repeat interventions (4.7%) in patients with EE casts compared with historical rates for FE casts. Improving the quality of health care involves identifying and implementing practices that provide the best outcomes at the lowest costs. The use of EE long-arm casts following closed manipulation of pediatric forearm fractures may decrease the rate of repeat manipulation or surgery compared with conventional FE casts. LEVEL OF EVIDENCE: Level IV-case series.

Is a hip flip the right trick?

Clinical introductionA 68-year-old man, with known spasticity and a total left hip arthroplasty (THA) performed 6 years ago, was brought to our ED after falling down the stairs. Laying on the stretcher, his left leg was internally rotated and in hyperflexion. An X-ray of the left hip was performed. The diagnosis of posterior hip dislocation was made (figure 1). The patient received sedation and analgesia with 75 mg propofol and 9 mg esketamine intravenously, and a closed reduction procedure was attempted using manual flexion, adduction, traction and internal rotation. Unfortunately, the reduction failed.emermed;37/1/53/F1F1F1Figure 1The patient's X-ray. QUESTION: Why is closed reduction not effective in this case?The femoral head is located more cranially expected, due to material failure. The whole THA should be replaced.This is an anterior dislocation. The closed reduction procedure should be performed by using extension, abduction, traction and internal rotation.The femoral head is not reduced centrally in the acetabulum and the closed reduction procedure should be repeated more forcefully.A dual-mobility cup is used and the liner is not in place anymore. Revision surgery is required. For answer see page 2.

Can we predict failure of percutaneous fixation of femoral neck fractures?

PURPOSE: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns. METHODS: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test. RESULTS: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure. CONCLUSION: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.

The Utility of the Early Postoperative Follow-up and Radiographs After Operative Treatment of Supracondylar Humerus Fractures in Children.

BACKGROUND: Supracondylar humerus (SCH) fractures are common elbow injuries in pediatric patients. The American Academy of Orthopedic Surgeons published guidelines for the standard of care in the treatment of displaced SCH fractures, however, no recommendations for follow-up care were made. With the recent push to eliminate unnecessary radiographs and decrease health care costs, many are questioning postoperative protocols. The purpose of our study was to evaluate the utility of the 1-week follow-up appointment after closed reduction and percutaneous pinning (CRPP) of displaced SCH fractures. METHODS: A retrospective review performed at a single institution from 2014 to 2016 included patients under 14 years of age with a closed, displaced SCH fracture treated with CRPP. Exclusion criteria included patients without complete clinical or radiographic follow-up. Variables examined included time to initial follow-up, change in treatment plan after 1-week x-rays, complications, demographics, fracture type, pin number and configuration, reduction parameters, immobilization, time to pin removal, duration of casting, and clinical outcome. RESULTS: A total of 412 patients were divided into 2 groups based on time to initial follow-up. Overall, 368 had an initial follow-up at 7 to 10 days (group 1) and 44 at 21 to 28 days (group 2). There was no difference in age, sex, fracture type, pin configuration, or a number of pins between groups. Statistically significant findings included time to initial follow-up and days to pin removal (group 1 at 26.2 d vs. group 2 at 23.8 d), type of immobilization (group 1 with 5% circumferential casts and group 2 with 70%), and time to surgery (26.2 vs. 62.9 h, respectively). There was no significant difference in complication rates and only a 0.5% rate of change in management in group 1. CONCLUSIONS: Early postoperative follow-up and radiographs did not change the patient outcome and might be eliminated in children with displaced SCH fractures treated with CRPP. Given the current focus of on efficiency and cost-effective care, eliminating the 1-week postoperative appointment would improve appointment availability and decrease medical cost. LEVEL OF EVIDENCE: Level III-Therapeutic.

A Comparison of Complications and Union Rates in Intramedullary Nailing of Femoral Shaft Fractures Treated With Open Versus Closed Reduction.

Intramedullary rod fixation is a common technique for treatment of femoral shaft fractures, with both open and closed reduction techniques described. The purpose of this study was to assess union and complication rates among patients treated with open vs closed reduction and intramedullary nailing of closed femoral shaft fractures. A total of 107 patients undergoing intramedullary fixation of nonpathologic femoral shaft fractures (AO/OTA type 32) between January 2012 and June 2017 were retrospectively studied. Those undergoing open reduction prior to intramedullary nailing were compared with those undergoing closed reduction. The primary outcome analyzed was union rate. Secondary outcomes were time to union, complications necessitating return to the operating room, and operative times. Mean follow-up was 14 months in both groups (range, 6-48 months). Of the 107 patients, 34.6% (n=37) underwent open reduction and 65.4% (n=70) underwent closed reduction. Patients in the open reduction group had rates of union (89.1%, 33 of 37) similar to those of patients in the closed reduction group (92.9%, 65 of 70; P=.378). Patients in the open reduction group who had union did so in a mean of 6.2 months (range, 3-12 months) vs a mean of 5.4 months (range, 2-11 months) in the closed reduction group (P=.13). Six patients (16.2%) in the open reduction group and 6 patients (8.6%) in the closed reduction group had a postoperative complication requiring return to the operating room (P=.18). Open reduction and intramedullary nailing results in rates of union, time to union, and rates of significant complications similar to those of closed reduction and intramedullary nailing. [Orthopedics. 2020; 43(2): 103-107.].

Accuracy of Closed Reduction of Pediatric Supracondylar Humerus Fractures Is Training in Pediatric Orthopedic Surgery Necessary?

BACKGROUND: Supracondylar humerus fractures account for two thirds of all hospitalizations for elbow injuries in children. A prevailing assumption exists regarding whether treatment quality varies by surgeon training background. This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained pediatric orthopedists (PO) and non-pediatric orthopedists (adult traumatologists, AT) with regard specifically to ability to obtain and maintain an operative closed reduction. METHODS: We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed extension-type supracondylar humerus fractures. Inclusion criteria included skeletally immature patients with Gartland classification type II and III fractures. Eighty-five cases were included with 37 fractures treated by four fellowship trained adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthopedists at a tertiary referral center. Radiographs were analyzed for Baumann's angle and shaft-condylar angle, then statistical comparisons were performed to compare preoperative and postoperative measurements. RESULTS: There was no difference in age, gender, laterality, fracture classification, use of medial pins, or neurovascular injuries between PO and AT (p > 0.05). Change in Baumann's angle (p = 0.61) or shaft-condylar angle (p = 0.87) did not differ between PO and AT. There was no significant difference in operative and postoperative Baumann's angle (p = 0.18 and p = 0.59, respectively) and shaft-condylar angle measurements (p = 0.05 and p = 0.09, respectively) between PO and AT. There was no difference in loss of reduction between the two groups (p = 0.64). CONCLUSIONS: Radiographic analysis of supracondylar humerus fractures showed no significant difference in alignment or loss of reduction when treated by pediatric orthopedists compared to non-pediatric orthopedists. Though it seems that the trend is to send pediatric fracture care to tertiary referral centers it may not be necessary for simple fracture management.