Global experience of orthopaedic trauma surgeons facing COVID-19: a survey highlighting the global orthopaedic response.

BACKGROUND: The COVID-19 (SARS-CoV-2) pandemic has significantly affected all aspects of healthcare, including orthopaedics. Due to the unique challenges presented by COVID-19 as well as the distinct timeframes that it will surge in different geographies, much can be learned from the experiences of orthopaedic professionals in many global settings. The goal of this project is to characterize the preparations, strategies, lessons, and personal experiences of orthopaedic trauma surgeons and departments across the world in combating COVID-19. In doing so, we will shed light on current practices and challenges, which may help us manage the current pandemic in addition to preparing for future global pandemics that may arise. METHODS: A 20-item questionnaire was sent out to 150 orthopaedic trauma surgeons representing 42 countries who were identified based on professional relationships and/or prior involvement in international meetings either led or participated by the senior author. RESULTS: The questionnaire was completed by 63 orthopaedic trauma surgeons representing 28 countries and 14 US states. The results of this study show that orthopaedic trauma departments across the world have been greatly impacted by COVID-19 with 91% of participating hospitals currently having a reduced case load compared with pre-COVID-19 and only 17% of respondents currently performing elective orthopaedic surgery. Furthermore, 30% of orthopaedic departments have deployed orthopaedic personnel to non-orthopaedic floors in order to help mitigate the increased patient load and 86% of respondents noted at least some shortage of PPE. Lastly 73% of participating orthopedic departments including those in LMICs, have incorporated telemedicine into their practice with a majority stating that it would most likely become a permanent change to their practice post-COVID-19. CONCLUSION: To our knowledge, this is the largest data set characterizing global COVID-19 situations and responses of orthopaedic trauma practices around the world. There is much to be learned from each of the participants' responses in order to persevere during the current pandemic, as well as to prepare for future pandemics as it relates specifically to orthopaedic trauma practices.

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.

Effectiveness of an Orthopaedic Trauma Research Fellowship to Produce Successfully Matching Residents.

OBJECTIVE: Orthopaedics is becoming increasingly competitive. Approximately 25% of applicants to orthopaedic surgery go unmatched each year. The mean US Medical Licensing Examination step scores and average publication numbers have increased markedly in recent years. Reapplicants have a match rate of <60%. This study describes the results of an orthopaedic trauma research fellowship and its effectiveness in obtaining a successful orthopaedic match. METHODS: A 1 to 2-year research fellowship was established at a level 1 academic trauma center. Prefellowship and fellowship metrics of 11 fellows were recorded, including undergraduate and medical schools; step-1 + step-2 scores; Alpha Omega Alpha appointment; and publication, podium, poster, and chapter accomplishments. RESULTS: The average step-1 score of the fellows was 218 (range, 192 to 252) and 232 (range, 212 to 254) for step-2. Seven of 11 fellows were reapplicants. Prefellowship, the average number of journal publications was 1, one podium, two posters, and zero textbook chapters. During fellowship, the average publications was 5, five podiums, six posters, and 1.5 textbook chapters. Ten of 11 fellows successfully matched into an orthopaedic residency, with six of seven being reapplicants. CONCLUSIONS: Six of 7 reapplying fellows (86%) successfully matched highlighting the effectiveness of this fellowship. Research fellowships should be considered as an excellent choice for applicants who may be less than ideal candidates or reapplicants.

Exposing the Care Conundrum of Low-Energy Pelvic Ring Fractures in Older Adults: A Review of 322 Patients.

Introduction: A care conundrum for low-energy pelvic ring fracture patients in which they face financial burden after not qualifying for an inpatient stay of 3 days or more has been noted in the literature. The purpose of this study was to identify factors that lead to inpatient length of stay (IP LOS) ≥3 days in older adults with nonoperative pelvic ring fragility fractures and to highlight the challenging financial decision-making of those with IP LOS <3 days in the context of the Medicare 3-day rule. Methods: This was a retrospective review of 322 patients aged ≥65 presenting from March 2016 and February 2019 to either of 2 emergency departments (EDs) after a ground-level fall resulting in a pelvic ring fracture. Patient demographic, IP LOS, and mortality data were extracted. Case management notes were analyzed to summarize financial decision-making for patients with IP LOS <3 days. Multivariate logistic regression analysis was conducted to identify factors that predicted IP LOS ≥3 days and mortality. Results: IP LOS ≥3 days was associated with presentation to level I hospital (OR .30 [.19, 0.50]) and being single (OR 2.50 [1.10, 5.68]). 70.3% required a post-acute skilled nursing facility (SNF) stay. Of patients with LOS <3 days, 25.0% were financially responsible for their SNF stay, while 7.9% elected home care due to financial reasons. Overall 30-day, 90-day, and 1-year mortality were 2.5%, 8.1%, and 20.8%, respectively. For patients with LOS <3 days, returning to assisted living compared to discharging to a SNF increased 90-day mortality risk (HR 8.529, P = .0451). Having Medicare trended towards increased 90-day mortality risk compared to commercial insurance (HR 4.556, P = .0544). Conclusion: The current system is failing older adult patients who sustain nonoperative low-energy pelvic ring fractures in terms of financial coverage of necessary post-acute treatment. This care conundrum has yet to be solved.

Management of scapular fractures.

With the exception of displaced articular glenoid fractures, management of scapular fractures has largely consisted of benign neglect, with an emphasis on motion as allowed by the patient's pain. Better understanding of this injury has resulted in greater acceptance of surgical management of highly displaced variants. However, little agreement exists on indications for surgery, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures. Scapular fractures are the result of high-energy mechanisms of injury, and they often occur in conjunction with other traumatic injuries. In addition to performing meticulous physical and neurologic examination, the surgeon should obtain plain radiographs, including AP shoulder, axillary, and scapular Y views. Three-dimensional CT is used to determine accurate measurements in surgical candidates. Surgical approach, technique, and timing are individualized based on fracture type and other patient-related factors.

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.

Hip fracture care during the COVID-19 pandemic: retrospective cohort and literature review.

OBJECTIVES: The goal of this study was to investigate whether the COVID-19 pandemic has affected hip fracture care at a Level I Trauma hospital. The secondary goal was to summarize the published hip fracture reports during the pandemic. DESIGN: A retrospective cohort study. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: Eighty-six operatively treated hip fracture patients age ≥65 years, occurring from January 17 to July 2, 2020. INTERVENTION IF ANY: N/A. MAIN OUTCOME MEASUREMENTS: We defined 3 phases of healthcare system response: pre-COVID-19 (period A), acute phase (period B), and subacute phase (period C). The primary outcome was 30-day mortality. Clinical outcomes including time to surgery (TTS) and length of stay (LOS) were extracted from the electronic medical record. RESULTS: Twenty-seven patients from Period A, 27 patients from Period B, and 32 patients from Period C were included. The 30-day mortality was not statistically different. The mean TTS was 20.0 +/- 14.3 hours and was the longest in Period C (22.1 +/- 9.8 hours), but the difference was not statistically significant. The mean LOS was 113.0 +/- 66.2 hours and was longest in Period B (120.9 +/- 100.6 hours). However, the difference was not statistically significant. CONCLUSIONS: The 30-day mortality, TTS, and LOS were not statistically different across multiple phases of pandemic at a level 1 trauma center. Our results suggest that we successfully adapted new protocol changes and continued to provide evidence-based care for hip fracture patients. Our results were comparable with that of other authors around the world.

Creative bracing: A descriptive overview of an alternative technique for non-operative fracture management of frail older adults.

As the world population ages, a higher proportion of older and frailer patients will sustain fragility fractures. Considering their depleted physiologic reserve and potentially different goals of care at their stage in life, these patients; especially those enrolled in hospice care, with profound dementia, or at end-of-life care; may not benefit from traditional surgical methods of fracture care. Non-operative treatment using standard immobilization or casting techniques in older and frailer patients can still render them susceptible to complications and adverse events. Here we describe our alternative non-operative treatment method of creative bracing to address the needs of this specific population. Creative bracing can be done with simple supplies available in almost all healthcare settings. Through patient-specific pre-treatment assessment, a creative brace tailored to the patient's risk factors and goals of care can be designed to provide sufficient fracture immobilization and comfort. Creative bracing is a low-cost, low-technical demand modality for non-operative treatment of some fragility fractures. Its benefit can be appreciated to greatest effect in the frailest patients for whom standard, surgical treatment does not represent best care.

Hip Fracture Care in Parkinson Disease: A Retrospective Analysis of 1,239 Patients.

Introduction: Compared to other patients, Parkinson disease (PD) patients may experience suboptimal outcomes after hip fracture. The purpose of this study was to describe and compare characteristics and outcomes of hip fracture patients with PD to those without PD. Methods: This retrospective cohort study included all patients admitted for hip fracture within a large healthcare system between July 1, 2017 and June 30, 2019. Demographics, injury characteristics, Charlson Comorbidity Index (CCI), treatment characteristics, and outcomes including complications, readmissions, and mortality were extracted. Patients with PD were compared to those without PD. Chi-square tests, two-sample t-tests, and Fisher exact tests were conducted to identify group differences. Results: A total of 1239 patients were included (4.0% PD and 96.0% non-PD). PD patients were mostly male (59.2%) compared to mostly female non-PD patients 69.4%, P < .001). PD patients on average had a higher CCI (2.3 vs 1.7, P = .040) and more frequently had dementia (42.9% vs 26.7%, P = .013). No PD patients were discharged home without additional assistance compared to 8.1% of patients without PD. More PD patients were discharged to a skilled nursing facility (SNF) than non-PD patients (65.3% vs 48.2%, P = .021). Only 22.4% of PD patients were previously prescribed osteoporosis medication, and only 16.3% were referred for osteoporosis follow-up after fracture. In-house complications, readmissions, and mortality up to 1 year were comparable between groups (P>.191). Conclusions: Outcomes between PD patients and non-PD patients were mostly equivalent, but more PD patients required discharge to a higher-level care environment compared to non-PD patients. Although PD seems to be a risk factor for hip fracture regardless of age and sex, most patients had not undergone proper screening or preventative treatment for osteoporosis. These results emphasize the need for early bone health evaluation, multidisciplinary collaboration, and care coordination in preventing and treating hip fractures in PD.

Capturing patient-reported outcomes: paper versus electronic survey administration.

Objective: To compare the capture rates and costs of paper patient-reported outcomes (pPRO) administered in-clinic and electronic PROs (ePRO) collected through emails and texts. Design: Retrospective review. Setting: Level 1 trauma center. Patients/Participants: The pPRO program enrolled 2164 patients for postsurgical follow-up in 4 fracture types: ankle, distal radius, proximal humerus, and implant removal from 2012 to 2017. The ePRO program enrolled 3096 patients in 13 fracture types from 2018 to 2020. Among the patients enrolled in the ePRO program, 1296 patients were matched to the 4 original fracture types and time points. Main Outcome Measures: PRO capture rates in 4 fracture types by matched time point and estimated cost of each program per enrolled patient. Results: At first follow-up, pPRO provided a higher capture rate than ePRO for 3 of 4 fracture types except for implant removal (P < 0.05). However, at 6-month and 1-year follow-ups, ePRO demonstrated statistically significant higher capture rates when compared with pPRO for all applicable modules (P < 0.05). The average cost for the pPRO program was $171 per patient versus $56 per patient in the ePRO program. Patients were 1.19 times more likely to complete ePRO compared with pPRO (P = 0.007) after controlling for age, sex, fracture type, and time point. Conclusion: The electronic PRO service has improved long-term capture rates compared with paper PROs, while minimizing cost. A combined program that includes both in-clinic and out of clinic effort may be the ideal model for collection of PROs. Level of Evidence: Level 3.

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.

Outcomes of COVID-19 Negative Hip Fracture Patients During the Acute and Subacute Pandemic.

OBJECTIVES: To better elucidate how the COVID-19 pandemic has affected the operatively treated geriatric hip fracture population and how the health care system adapted to pandemic dictated procedures. DESIGN: Retrospective cohort study. SETTING: A community hospital. PARTICIPANTS: Individuals ≥65 years of age presented with a proximal femoral fracture from a low-energy mechanism undergoing operative treatment from January 17, 2020 to July 2, 2020 (N = 125). MEASUREMENTS: We defined 3 phases of healthcare system response: pre-COVID-19, acute phase, and subacute phase. Thirty-day mortality, time to operating room (OR), length of stay, time to start physical therapy, perioperative complications, delirium rate, hospice admission rate, discharge dispositions, readmission rate, and the reason of surgery delay were assessed. RESULTS: The number of hip fractures has remained constant during the pandemic. The 30-day mortality rate, time to OR, and length of stay were higher in the pandemic compared to the pre-pandemic. Those who had a longer wait time to OR (≥ 24 hours) had more complications and increased 30-day mortality rates. Some of the surgery delays were related to OR unavailability as a consequence of the COVID-19 pandemic. Surgery was delayed in 3 patients who were on direct oral anticoagulants (DOACs) in pandemic but none for pre-pandemic period. CONCLUSION: This is the first study to compare the effect of the acute and subacute phases of the pandemic on uninfected hip fracture patients. In the age of COVID-19, to provide the best care for the vulnerable geriatric orthopedic populations, the healthcare system must adopt new protocols. We should still aim to promote prompt surgical care when indicated. It is important to ensure adequate resource availability, such as OR time and staff so that hip fracture patients may continue to receive rapid access to surgery. A multidisciplinary approach remains the key to the management of fragility hip fracture patients during the pandemic.

Fracture Risk Assessment: An Update.

➤: Our ability to accurately identify high fracture risk in individuals has improved as the volume of clinical data has expanded and fracture risk assessment tools have been developed. ➤: Given its accessibility, affordability, and low radiation exposure, dual x-ray absorptiometry (DXA) remains the standard for osteoporosis screening and monitoring response to treatment. ➤: The trabecular bone score (TBS) is a DXA software add-on that uses lumbar spine DXA imaging to produce an output that correlates with bone microarchitecture. It has been identified as an independent fracture risk factor and may prove useful in further stratifying fracture risk among those with a bone mineral density (BMD) in the osteopenic range (-1.0 to -2.4 standard deviations), in those with low-energy fractures but normal or only mildly low BMD, or in those with conditions known to impair bone microarchitecture. ➤: Fracture risk assessment tools, including the Fracture Risk Assessment Tool (FRAX), Garvan fracture risk calculator, and QFracture, evaluate the impact of multiple clinical factors on fracture risk, even in the absence of BMD data. Each produces an absolute fracture risk output over a defined interval of time. When used appropriately, these enhance our ability to identify high-risk patients and allow us to differentiate fracture risk among patients who present with similar BMDs. ➤: For challenging clinical cases, a combined approach is likely to improve accuracy in the identification of high-risk patients who would benefit from the available osteoporosis therapies.

Global orthopaedic trauma surgeons highlight telenomics during the COVID-19 era: A case for advancing telemedicine in orthopaedics.

The Coronavirus (COVID-19) pandemic sparked rapid widespread adoption of telemedicine throughout specialties, including orthopaedics. A succession of factors, starting with payers, followed by provider adoption, and reciprocated by patient approval, created newly accepted telehealth practices that have moved from trial to norm in a short time span. Orthopaedic surgeons believe telehealth will endure as a permanent change to their practice beyond the COVID-19 era, however, many permanent changes must take place by payers, providers, and patients to sustain telehealth into the future. The goal of this paper is to highlight the indelibility of telemedicine adoption in orthopaedic practices globally, characterize the chain of events that led to its large-scale adoption, and catalyze discussion around actionable next steps to sustain its benefits.

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.

Low-Energy Pelvic Ring Fractures: A Care Conundrum.

INTRODUCTION: A need exists for improved care pathways for patients experiencing low-energy pelvic ring fractures. A review of the current literature was performed to understand the typical patient care and post-acute rehabilitation pathway within the US healthcare system. We also sought to summarize reported clinical outcomes worldwide. Significance: Low-energy pelvic ring fracture patients usually do not qualify for inpatient admission, yet they often require post-acute rehabilitative care. The Center for Medicare and Medicaid Services' (CMS) 3-day rule is a barrier to obtaining financial coverage of this rehabilitative care. RESULTS: Direct admission of some patients to post-acute care facilities has shown promise with decreased cost, improved patient outcomes, and increased patient satisfaction. Secondary fracture prevention programs may also improve outcomes for this patient population. CONCLUSIONS: Post-acute care innovation and secondary fracture prevention should be prioritized in the low-energy pelvic fragility fracture patient population. To demonstrate the effect and feasibility of these improved care pathways, further studies are necessary.

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.

Minimizing Nonessential Follow-up for Hip Fracture Patients.

INTRODUCTION: Hip fractures pose a significant burden to patients and care providers. The optimal protocol for postoperative care across all surgically treated hip fracture patients is unknown. The purpose of this study was to investigate the effect that routine follow-up had on changing the clinical course. METHODS: This was a retrospective review of all low-energy hip fractures (ie, femoral neck fractures, pertrochanteric hip fractures, and subtrochanteric fractures) treated surgically from January 2018 through December 2019. Charts were reviewed for demographic information; the procedure performed; the number of postoperative follow-up visits each patient had with the orthopaedic surgery team; the number of sets of postoperative radiographic images obtained; and postoperative complications. RESULTS: Eight hundred eleven patients with 835 hip fractures were included in the study. The overall number of patient visits was 1,788, and the number of radiograph sets was 1,537. The median number of follow-up visits was two visits/fracture (interquartile range: 1 to 3 visits, maximum = 9 visits), with the median follow-up length of 54 days (interquartile range: 33 to 97 days) with the treating orthopaedic surgeons. Sixty-two (7.6%) patients had 81 (4.5%) postoperative visits and 26 (1.7%) sets of images that led to treatment changes. Among them, 48 (77.4%) patients had concerns that were initiated by the patients and/or care provider. Fourteen standard patient visits led to treatment changes that were not initiated as concerns by the patient and/or care provider. DISCUSSION: Most clinic visits and radiographs did not lead to a change in the care plan. We recommend that emphasis be placed on comprehensive orthogeriatric care of these patients, and we believe that these data provide the impetus to work toward improving the care pathways for elderly patients with hip fractures.