Management of Pain Associated with Fractures.

PURPOSE OF REVIEW: The purpose is to review current literature on pain management strategies from initial presentation to postoperative care on common fracture types. RECENT FINDINGS: - Hip fractures benefit from use of multimodal pain control for early mobility and decreased narcotic requirement. - Distal radius fracture pain during reduction can be managed with hematoma block. Postoperatively, a soft dressing is adequate, and use of a compression glove may improve pain control and edema. - Ankle fractures can be reduced with hematoma block, though use of procedural sedation may reduce reduction attempts for fracture dislocations. - Long bone fracture pain management is trending toward multimodal pain control. Though there is no high-quality evidence, concern that regional anesthesia may mask compartment syndrome has limited its use in high-risk fractures. - The effect of NSAIDs on bone healing has not been conclusively demonstrated. The literature is still inconclusive regarding superiority of either spinal or general anesthesia during operative treatment. Fracture pain control is complex and multifactorial, requiring nuanced clinical judgment in the face of mixed clinical findings.

Second physician review of radiographs after wrist and ankle reductions offers limited utility to clinical management.

PURPOSE: The purpose of this study is to determine the clinical utility of second-physician review of radiographs obtained after reduction of distal radius and ankle fractures. METHODS: Fifty consecutive ankle and distal radius fractures requiring reduction were reviewed. The time from post-reduction radiograph to second-physician interpretation was obtained. The second-physicians' interpretation was evaluated for clinically influential information. Patients requiring a repeat reduction were identified, and the timing of the repeat reduction radiograph was compared with the timing of the second-physician interpretation of the initial post-reduction radiograph. RESULTS: The mean time of second-physician interpretation for post reduction ankle radiographs was 6 h and 47 min (range 4 min to 43 h and 3 min). Eleven of 50 (22%) interpretations of post reduction ankle radiographs commented on acceptability of reduction. The mean time of second-physician interpretation for post reduction distal radius radiographs was 5 h and 34 min (range 8 min to 22 h and 59 min). Seven of 50 (14%) interpretations of post reduction distal radius radiographs commented on acceptability of reduction. Three distal radius (6%) and 8 ankle fractures (16%) required repeat reduction. Repeat reductions were completed in 10/11 cases (91%) before the second-physician review of the initial post reduction radiograph was obtained. In only 1 case of repeat reduction was the second-physician review of the post reduction radiograph available before repeat reduction was attempted. CONCLUSION: The timing and quality of second-physician review of post-reduction radiographs offers little utility to the clinical management of ankle and distal radius fractures.

Suprapatellar Tibial Nailing: Future or Fad?

Over the last hundred years, there have been significant advancements in the way the Orthopaedic community treats tibial fractures. More recently, the focus of Orthopaedic trauma surgeons has been comparing the different techniques of insertion for tibial nails, specifically suprapatellar (SPTN) versus infrapatellar. The existing literature is convincing that there does not appear to be any clinically significant differences between suprapatellar and infrapatellar tibial nailing, with some apparent benefits of SPTN. Based on the current body of literature and our personal experience with SPTN, we believe the suprapatellar tibial nail will become the future for most tibial nailing procedures, regardless of fracture pattern. We have seen evidence of improved alignment in both proximal and distal fracture patterns, decreased radiation exposure and operative time, relaxation of the deforming forces, ease of imaging, and static positioning of the leg, which would be helpful for the unassisted surgeon, as well as no difference in anterior knee pain or articular damage within the knee between the two techniques.

Conceptualizing Biological Aging and Frailty in Orthopaedics: A Framework for Clinical Practice.

➤: Biological aging can best be conceptualized clinically as a combination of 3 components: frailty, comorbidity, and disability. ➤: Despite advancements in the understanding of senescence, chronological age remains the best estimate of biological age. However, a useful exercise for practitioners is to look beyond chronological age in clinical and surgical decision-making. ➤: A chronologically aging person does not age biologically at the same rate. ➤: The best way to understand frailty is to consider it as a physical phenotype. ➤: Physical optimization should parallel medical optimization before elective surgery. ➤: The poorer the host (both in terms of bone quality and propensity for healing), the more robust the implant construct must be to minimize reliance on host biology.

Improving outcomes after hip fracture at a safety net hospital with a standardised hip fracture protocol.

INTRODUCTION: standardised protocols for the care of geriatric hip fractures demonstrate improved patient outcomes with decreased cost. The purpose of this study is to evaluate outcomes of a standardised hip fracture protocol at an urban safety-net hospital. METHODS: All trauma patients presenting to our urban safety-net hospital are included in a trauma database and inpatient outcomes recorded. A hip fracture protocol was introduced at our institution in 2015, which depended on admission to a monitored setting due to the absence of a geriatric co-management service. The database was queried to identify patients surgically treated for a geriatric hip fracture in the 3 years prior to protocol implementation (2012-2014) and patients treated in the 3 years following protocol implementation (2016-2018). Demographics, time to surgery, inpatient complications, and length of stay were compared between groups. RESULTS: A total of 633 patients treated operatively for isolated hip fractures were identified, 262 patients in the 2012-2014 pre-protocol cohort, and 371 patients in the 2016-2018 protocol cohort. Following implementation of a hip fracture protocol the number of patients admitted to a surgical service increased from 198 (76%) to 348 (94%, p < 0.005) with the number of patients being admitted to a monitored setting increasing from 40 (15%) to 83 (22%, p = 0.026). The time to surgery was reduced to 2.75 days (p = 0.054). The complication rate fell from 23% to 4% (p < 0.0005). Length of stay was significantly reduced from 13.2 days to 12 days (p = 0.045). CONCLUSIONS: A hip fracture protocol including admission to a monitored setting can be effectively implemented at an urban safety-net hospital where geriatric co-management is not available. This resulted in a decrease in complications and length of stay. Additional interventions are required to decrease average time to surgery below 36 hours.