The principles and practice of open fracture care, 2018.

The principles of open fracture management are to manage the overall injury and specifically prevent primary contamination becoming frank infection. The surgical management of these complex injuries includes debridement & lavage of the open wound with combined bony and soft tissue reconstruction. Good results depend on early high quality definitive surgery usually with early stable internal fixation and associated soft tissue repair. While all elements of the surgical principles are very important and depend on each other for overall success the most critical element appears to be achieving very early healthy soft tissue cover. As the injuries become more complex this involves progressively more complex soft tissue reconstruction and may even requiring urgent free tissue transfer requiring close co-operative care between orthopaedic and plastic surgeons. Data suggests that the best results are obtained when the whole surgical reconstruction is completed within 48-72 h.

Emergency management of high-energy pelvic trauma.

A fractured pelvis can be a significant cause of patient morbidity and mortality. Injuries to the pelvis that result from high-energy trauma can be devastating, and patients often have other associated injuries. This article reviews the pathophysiology of pelvic fractures and how to classify and manage them in the emergency setting in order to improve patient outcomes.

The direct posterior gluteal muscle splitting approach for posterior access to acetabular fractures: Surgical technique and case series.

We present a minimally invasive direct posterior, gluteal muscle splitting approach (PMS) as an alternative to the traditional Kocher-Langenbeck (KL) approach for posterior access to acetabular fractures. We believe it offers significant advantages and provides improved access while maximizing the range of fracture patterns that can be addressed through a posterior approach. One hundred and eighty-four consecutive patients treated with this approach by the senior author (RMS) between 2001 and 2018 were reviewed. The most common individual fracture pattern addressed was a posterior wall (66/36%) but more complex combination fracture types were the dominant group (106/58%), and included transverse with posterior wall, posterior wall / posterior column, and T types. A radiographically congruent reduction was consistently obtained at surgery, without any operative sciatic nerve palsies and a comparable heterotopic bone formation rate to previous reports. We have reviewed all 120 patients who were followed beyond 6 months and noted the hip replacement conversion rates to be different with each fracture type. The rate was highest with Transverse/ posterior wall injuries (36%), 16% of the posterior wall injuries were converted, a history of dislocation was not specifically associated with conversion. We believe this approach improves the posterior access to the acetabulum, but this study also confirms the poor prognosis of specific groups of higher energy multi-fragmentary, posterior acetabular injuries and suggests the need for a classification system that better predicts the prognosis for the hip joint. LEVEL OF EVIDENCE: 4.

Effect of surgeon training, fracture, and patient variables on calcaneal fracture management.

BACKGROUND: There appears to be a general lack of consensus in treating calcaneus fractures. Many different patient-based variables such as smoking, diabetes, or occupation, may influence treatment decisions possibly more so than the nature of the injury itself. Indications for operative versus nonoperative treatment are often unclear. The goals of this study were to determine if lack of consensus exists, determine which factors most influence orthopaedic surgeons in choosing operative versus nonoperative treatment and determine if there are differences in treatment based on fellowship training and exposure to these injuries. MATERIALS AND METHODS: Practicing orthopaedic surgeons of various backgrounds and training were administered an electronic survey. The survey consisted of clinical vignettes and questions regarding fellowship training, demographics and exposure to calcaneus fractures. Orthopaedic surgeons were asked to weigh the importance of patient-based variables in determining operative versus nonoperative treatment. RESULTS: For patients with an uncomplicated medical history, there was a general consensus on treatment as guided by the Sanders classification. For those with a complex medical history, there was less consensus on management despite fracture pattern. Foot & ankle fellowship-trained surgeons (F&AT) ranked calcaneal deformity as more important than trauma fellowship-trained surgeons (NFT), and ranked peripheral vascular disease (PVD)/diabetes mellitus (DM) more important than did both trauma fellowship-trained surgeons (TFT) and NFT surgeons. There was no significant difference in choosing operative versus nonoperative treatment for surgeons treating more calcaneus fractures (more than four per month) versus those who treated fewer (less than one a month). CONCLUSION: There was general agreement among surgeons regarding the most important variables for determining management of calcaneus fractures. How this information is utilized varies according to practitioner and leads to varying consensus. There was generalized consensus regarding management in cases of anatomic deformity at either end of the spectrum of severity and non-complex medical histories. When additional confounders were added, the agreement between surgeons declined.

Two cases of acute anterolateral compartment syndrome following inversion ankle injuries.

INTRODUCTION: Compartment syndrome is a limb threatening, and sometimes life-threatening medical condition. It usually occurs in high energy lower extremity injuries, commonly in the younger patient with classic signs and symptoms. Pain out of proportion to exam is one of the key elements in diagnosis. A high vigilance for signs and symptoms of this condition should be present on most physicians' radars who treat emergency conditions, as this case report demonstrates, the mechanism and story are not always classic. PRESENTATION OF CASES: Two cases of young, healthy adults who underwent fasciotomy for compartment release for compartment syndrome isolated to the anterolateral compartment, but who did not sustain a high energy trauma, but rather a twisting ankle injury. CONCLUSION: Compartment syndrome can occur in young, healthy, active patients with a lower energy twisting injury and without fracture. A high level of suspicion on the clinicians' part will prevent adverse outcomes to the patient.

"Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic.

BACKGROUND: With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. METHODS: We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. RESULTS: Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. CONCLUSIONS: Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lymphoscintigraphy does not enhance sentinel node identification or alter management of patients with early breast cancer.

UNLABELLED: Lymphoscintigraphy (LS) is often performed before sentinel lymph node dissection (SLND) for breast cancer. The purpose of this study was to determine whether routine LS enhances rate of identification of sentinel nodes (SN), and if findings on LS alter either the SLND procedure or the subsequent patient management. METHODS: LS using technetium-99m sulfur colloid (99mTc) was performed in 136 consecutive patients undergoing SLND for invasive breast cancer. Three equal aliquots of 99mTc were injected peritumorally, and LS images were obtained at 60 to 120 min after 99mTc injection. Data were collected on the success of LS to visualize SN. Information regarding body mass index (BMI), biopsy type (core vs excisional), tumor location (medial vs lateral), and SN positivity were recorded and comparison was made with success of operative SN identification. In all SLND cases, 1% lymphazurin blue dye was used in addition to the 99mTc. RESULTS: LS failed to identify an SN in 9 of 136 cases (6.6%). Failed mappings did not correlate with biopsy type, tumor location, or SN positivity. There was a positive correlation between increased BMI and failed LS (p = <0.001). Failed LS did not predict operative SLND failure, as an SN was identified in 100% of cases (136/136), including the 9 with a failed LS. In 67% (6/9) of the failed LS, the SN was both hot and blue at operation. Internal mammary (IM) drainage was observed in 4% (6/136) of LS. Positive SN were found in 26% (35/136) of patients. Findings on LS did not affect adjuvant treatment decisions in any patient. CONCLUSIONS: There was a correlation between failed LS and BMI, but no correlation with biopsy type or tumor location. Drainage to extraaxillary sites was rare. LS findings did not enhance success of intraoperative identification of SN or alter the postoperative management of patients with early stage breast cancer.

Is Closed Reduction and Percutaneous Fixation of Unstable Posterior Ring Injuries as Accurate as Open Reduction and Internal Fixation?

OBJECTIVES: The objective of this retrospective review was to determine whether a closed reduction technique for unstable pelvic ring injuries is as accurate as an open technique. DESIGN: Retrospective review. SETTING: Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS: We reviewed the records of 113 patients who had unilateral unstable pelvic ring injuries (Bucholz type 3, OTA type 61-C1) treated with closed reduction and percutaneous fixation (CRPF) or open reduction with internal fixation (ORIF). INTERVENTION: Sixty patients were treated at one institution with open reduction and percutaneous iliosacral screw fixation. This involved prone positioning and a gluteus maximus sparing approach for direct visualization and reduction of the fracture. A second cohort of 53 patients was treated at a separate institution with closed reduction and percutaneous iliosacral screw fixation. This involved supine positioning and skeletal traction. MAIN OUTCOME MEASURES: Preoperative and postoperative plain radiographs of the pelvis were reviewed and standardized measurements were made to compare quality of reduction. RESULTS: We were able to measure displacement within 0.1 mm. Overall reduction quality was slightly better for the CRPF group. The largest average difference in postoperative displacement was seen at the iliac wing height on anteroposterior pelvis radiographs with 6.3 mm (range 0-19.6) in the ORIF group versus 1.9 mm (range 0-4.7) in the CRPF group. CONCLUSIONS: The closed reduction technique described here is as effective as the ORIF technique in obtaining reduction of unstable pelvic ring injuries (Bucholz type 3, OTA type 61-C1). LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.