Analgesic Techniques for Managing Orthopedic Injuries: A Review for the Emergency Clinician.

BACKGROUND: Orthopedic injuries are commonly managed in the emergency department (ED) setting. Fractures and dislocations may require reduction for proper management. There are a variety of analgesic and sedative strategies to provide patient comfort during reduction. OBJECTIVE: This narrative review evaluates hematoma block, intra-articular injection, intravenous regional analgesia (IVRA) (also known as the Bier block), and periosteal block for orthopedic analgesia in the ED setting. DISCUSSION: Analgesia is an essential component of management of orthopedic injuries, particularly when reduction is necessary. Options in the ED setting include hematoma blocks, intra-articular injections, IVRA, and periosteal blocks, which provide adequate analgesia without procedural sedation or opioid administration. When used in isolation, these analgesic techniques decrease complications from sedation and the need for other medications, such as opioids, while decreasing ED length of stay. Emergency clinicians can also use these techniques as analgesic adjuncts. However, training in these techniques is recommended prior to routine use, particularly with IVRA. CONCLUSIONS: Knowledge of analgesic techniques for orthopedic procedures can assist clinicians in optimizing patient care.

Chiropractic Manipulation Causing Anterior-Posterior Compression Type Pelvic Ring Injury: A Case Report.

CASE: We present a case of an anteroposterior compression (APC) type pelvic ring injury that occurred after chiropractic manipulation in a patient with a history of quadriplegia. Emergent surgical stabilization was undertaken, and he had an excellent outcome with no complications at 3.5-year follow-up. CONCLUSION: APC type pelvic ring injuries usually occur to high-energy mechanisms. We describe a case of a patient with quadriplegia and osteopenia that suffered a pelvic ring injury because of a unique mechanism. Practitioners performing pelvic manipulation should be aware of this type of injury in at-risk patients.

A Case Report of U-Type Sacral Fracture After Chiropractic Adjustment.

CASE: A U-type sacral fracture, or spinopelvic dissociation, resulting from chiropractic manipulation has not been described in the medical literature. This report presents the case of a 74-year-old male patient who sustained a U-type sacral fracture after drop-table chiropractic manipulation. CONCLUSION: Our case demonstrates that chiropractic manipulative therapy involving the commonly used drop-table can cause severe injury. The patient's course was complicated by a delay in diagnosis and a prolonged hospital stay. Orthopaedic surgeons should have a high degree of suspicion for spinopelvic dissociation in the setting of bilateral sacral fractures. One year after injury, with conservative management, the patient returned to baseline function with mild residual neuropathy.

Cost Analysis of Intramedullary Screw versus Plate Osteosynthesis for Phalangeal and Metacarpal Fractures: An Observational Study.

Background: To compare the observed healthcare and societal costs of intramedullary screw (IMS) and plate fixation of extra-articular metacarpal and phalangeal fractures in a contemporary Australian context. Methods: A retrospective analysis, based on previously published data, was performed utilising information from Australian public and private hospitals, the Medicare Benefits Schedule (MBS) and the Australian Bureau of Statistics. Results: Plate fixation demonstrated longer surgical lengths (32 minutes, compared to 25 minutes), greater hardware costs (AUD 1,088 vs. AUD 355), more extended follow-up requirements (6.3 months, compared to 5 months) and higher rates of subsequent hardware removal (24% compared to 4.6%), resulting in an increased healthcare expenditure of AUD 1,519.41 in the public system, and AUD 1,698.59 in the private sector. Wage losses were estimated at AUD 15,515.78 when the fracture cohort is fixed by a plate, and AUD 13,542.43 when using an IMS - a differential of AUD 1,973.35. Conclusions: There is a substantial saving to both the health system and the patient when using IMS fixation over dorsal plating for the fixation of extra-articular metacarpal and phalangeal fractures. Level of Evidence: Level III (Cost Utility).

Surgical management of clavicle fractures in Australia: an analysis of Australian Medicare Benefits Schedule database from 2001 to 2020.

BACKGROUND: There is no consensus on the optimal management of clavicle fractures, with advocates of both operative and non-operative management. The objective of this study is to assess the trends in the management of clavicle fractures in Australia over the past two decades. METHODS: The incidence of surgical fixation of clavicle fractures from 2001 to 2020 was analysed using the Australian Medicare Benefits Schedule database, reflective of operations performed on privately insured patients, thus excluding public patients and compensable cases. An offset term was utilized with data from the Australian Bureau of Statistics to account for population changes over the study period. RESULTS: A total of 17 089 procedures for the management of clavicle fractures were performed from 2001 to 2020. The incidence of operative intervention increased from 1.87 per 100 000 in 2001 to a peak of 6.63 per 100 000 in 2016. An overall increase was seen in males (310%) and females (347%) over the study period, as well as across all age groups. A greater proportion of operative interventions was performed on males (n = 14 075, 82%) than females (n = 3014, 18%, P < 0.001). The greatest increase in intervention was noted in those aged 65 or older (14% increase per year, 95% CI 11%-17%, P < 0.05). In 2020, the incidence of operative intervention decreased to a level last seen in 2013. CONCLUSIONS: The incidence of operative interventions for clavicle fractures has increased in Australia over the 20-year study period. This increase is in keeping with recent evidence suggesting several advantages when displaced mid-shaft clavicle fractures are operatively managed.

Treatment of Multiple Finger Laceration Caused by Green Onion Cutting Machines in South Korea.

Background: Finger injuries caused by green onion cutting machines in Korean kitchens have unique characteristics of an incomplete amputation in which multiple parallel soft tissues and blood vessels are injured in the same form. In this study, we aimed to describe unique finger injuries and to report the treatment outcomes and experiences of performing possible soft tissue reconstructions. Methods: This case series study included 65 patients (82 fingers) from December 2011 to December 2015. The mean age was 50.5 years. We retrospectively classified the presence of fractures and the degree of damage in patients. The injured area involvement level was categorised as distal, middle or proximal. The direction was categorised as sagittal, coronal, oblique or transverse. The treatment results were compared according to the amputation direction and injury area. Results: Of the 65 patients, 35 had a partial finger necrosis and needed additional surgeries. Finger reconstructions were performed through stump revision or local or free flap use. The survival rate was significantly lower in patients with fractures. As for the injury area, distal involvement led to 17 out of 57 patients displaying necrosis and all 5 patients showing the same in proximal involvement. Conclusions: Unique finger injuries caused by green onion cutting machines can easily be treated with simple sutures. Then prognosis is affected by the extent of injury and the presence of fractures. Reconstruction is necessary for finger necrosis owing to extensive blood vessel damage and limitations when making this selection. Level of Evidence: Level IV (Therapeutic).

Augmented osteosynthesis in fragility fracture.

Due to poor bone quality and complexity, some fractures are difficult to treat, with high risk of failure. Moreover, general health is often poor in elderly patients with multiple comorbidity and poor compliance, necessitating perfect first-line management to avoid re-operation. The armamentarium comprises specific internal fixation implants and also complementary methods such as autologous, homologous or heterologous bone graft or bone substitutes with varying mechanical and biological characteristics. Associating these options is what is mean by "augmented fixation". The present review of augmented osteosynthesis addresses the following questions: What are the characteristics of fragility fractures? Fragility fracture is caused by low-energy trauma on bone with poor structural quality and low mineral density. Treatment aims to enable early mobilization and weight-bearing while avoiding mechanical failure of fixation. Prolonged bedrest, loss of mobility and surgical revision are aggravating and sometimes fatal factors in these fragile patients. What are the biological techniques of fixation augmentation in fragility fracture? Autologous or homologous bone graft are the most widely used biological augmentation techniques. They fill spaces and promote osteoconduction and consolidation. Some bone-like phosphocalcic structures are opening up promising lines of research. What are the non-biological techniques of fixation augmentation in fragility fracture? Hydroxyapatite, phosphocalcic cement and acrylic cement are the most widely used synthetic materials. Biological and mechanical effects are variable according to composition, requiring specific implementation. What are the mechanical techniques of fixation augmentation in fragility fracture? There is at present no consensus as to the augmentation techniques to be applied in fragility fracture. Cerclage or complementary plating, or external fixation associated to internal fixation are possibilities. However, the literature consists only of small series reporting surgical techniques specific to a given surgeon or team. When and how should osteosynthesis for fragility fracture be augmented? The choice of augmentation depends on fracture location, comminution, available material and local experience. The more severe the fracture, the more complex the fixation. The approach needs to be adapted to the preoperative planning and the associated mechanical means (plate, complementary cerclage) and prosthetic replacement should be considered in certain joint fractures or fractures close to load-bearing surfaces. LEVEL OF EVIDENCE: V; expert opinion.

A retrospective analysis of the definitive management of open talus fractures at a major trauma centre, comparing ORIF to FUSION: cohort study and audit of BOAST 4 guidelines.

PURPOSE: Open talus fractures are notoriously difficult to manage, and they are commonly associated with a high level of complications including non-union, avascular necrosis and infection. Currently, the management of such injuries is based upon BOAST 4 guidelines although there is no suggested definitive management, and thus, definitive management is based upon surgeon preference. The key principles of open talus fracture management which do not vary between surgeons are early debridement, orthoplastic wound care, anatomic reduction and definitive fixation whenever possible. However, there is much debate over whether the talus should be preserved or removed after open talus fracture/dislocation and proceeded to tibiocalcaneal fusion. METHODS: A review of electronic hospital records for open talus fractures from 2014 to 2021 returned fourteen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, and five cases were definitively managed with FUSION, while the others were managed with alternative methods. We collected patient's age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines. The average follow-up of the cohort was 4 years and one month. EQ-5D-5L and FAAM-ADL/Sports score was used as a patient reported outcome measure. Data were analysed using the software PRISM. RESULTS: Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group. CONCLUSION: FUSION is typically used as second line to ORIF or failed ORIF. However, there is a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate and quality of life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients.

Individualized herbal prescriptions for delayed union: A case series.

Background Bone fractures are important clinical events for both patients and professionals. Active treatment options are limited for delayed unions and for nonunions; surgery is common but not entirely risk-free. This report describes three cases of delayed union successfully treated with herbal decoction. Participants Three patients had trapezoid and 3rd metacarpal bone fractures, 2nd, and 5th metatarsal bone fractures, respectively. All three patients were diagnosed with delayed union by an independent orthopedic surgeon based on computed tomography (CT) scan/radiographic imaging and fracture duration without a healing process. Patients took herbal decoction, Jeopgol-tang, with individually added herbs based on symptom manifestations, twice daily for 56, 85 and 91 days with no additional interventions except for a splint that they had been wearing since fracture diagnosis. Outcomes Improvement of delayed union was evaluated using radiographic imaging or CT during treatment with Jeopgol-tang. Results After taking herbal medicine, callus and bony bridging were confirmed on follow-up imagings and the patients described their experience with pain reduction at an interview after recovery. Conclusions This case series suggests that the herbal decoction Jeopgol-tang warrants further investigation to establish its role as a complementary and integrative medicine treatment option for delayed unions.

Effects of fixation of clavicle fracture using wide-awake local anesthesia no tourniquet (WALANT) technique on intra-operative bleeding volume, surgical duration, and post-operatively visual analog scale (VAS); A case series study.

Clavicle fractures are common fractures with a rate of 2-5 percent among fractures. Mid-shaft fractures of the clavicle are more common than the other sites of the clavicle. Traditionally, surgical fixation of clavicle fractures has been performed under General Anesthesia (GA). The purpose of this study was to assess the effects of WALANT on intraoperative bleeding, pain control during and after surgery, postoperative complications and patients' function. In the current study, 30 patients with clavicle fractures were surgically fixed using the WALANT technique. The obtained results showed that it could be an effective technique for pain control during the operation and also early postoperative period. Moreover, the WALANT technique could be considered safe in patients who are at risk for GA because of medical comorbidities, cervical spine injuries, or other factors that make intubation difficult.

Clinical analysis of the acromial height-measuring device combined with new-type clavicular hook plate and standard clavicular hook plate in the treatment of Neer type II distal clavicle fractures.

BACKGROUND: Distal clavicular fracture is a shoulder joint injury that is common in clinical settings and is generally surgically treated using the clavicular hook plate technique with a confirmed curative effect. However, symptoms, such as shoulder abduction limitation, shoulder discomfort, and postoperative joint pain, may occur in some patients. To overcome these problems, after a previous study we developed an acromial height-measuring device and a new type of clavicular hook plate. This study aimed to investigate whether an acromial height-measuring device combined with an improved new-type clavicular hook plate can better reduce the incidence of complications and improve postoperative function. To provide patients with better treatment effects, an acromion gauge and clavicular hook plate are used. METHODS: A retrospective analysis was performed on 81 patients with distal clavicular fractures admitted to our hospital. They were divided into experimental and control groups according to different plates, and the Constant-Murley score, visual analogue scale score, incidence of acromion osteolysis, and incidence of subacromial impingement syndrome were compared. RESULTS: Compared with the standard clavicular hook plate, the acromial height-measuring device combined with the new-type clavicular hook plate in the treatment of distal clavicle fractures has a lower incidence of subacromial impingement syndrome with better postoperative functional recovery and quality of life. CONCLUSIONS: We considered the acromial height-measuring device combined with the new clavicular hook plate to be a safe and promising alternative to distal clavicular fractures.

Fix and replace: Simultaneous fracture fixation and hip replacement for acetabular fractures in older patients.

INTRODUCTION: Displaced acetabular fractures in the elderly present significant treatment challenges. The 'fix and replace' concept involves open reduction and internal fixation of the acetabulum, providing bony stability to accept the press-fit of an acetabular cup, with a cemented femoral stem. This allows early mobilisation and the advantages this confers. This study of 57 patients treated with fix and replace describes our technique, outcomes, and survival analysis. METHODS: A retrospective review of 57 'fix and replace' procedures in patients aged over 60 was performed. Data was collected on mechanism, fracture type, demographics, time to surgery, comorbidity index, complications, EQ-5D and Oxford hip scores (OHS). Radiographs were reviewed for fracture healing, implant loosening, cup migration, and heterotopic ossification. RESULTS: 57 patients aged 60 to 95 had fix and replace surgery. The median ASA score was 3. The mean Charlson Index was 4.8. 45 patients had a low-energy fall, 6 had a road traffic accident, 3 fell off a bicycle, and 1 mechanism was unclear. The fracture patterns were anterior column posterior hemitransverse (67%), associated both columns (9%), posterior column (9%), posterior column and posterior wall (9%), and transverse (2%). The mean time to surgery was 8.4 days (0-14). 26 out of 57 (46%) received a blood transfusion. Mean length of stay was 17.6 days (7-86). The mean follow-up was 35.5 months. 4 dislocations were treated with closed reduction, whilst 1 required excision arthroplasty. 2 infections resolved with debridement, antibiotics, and implant retention (DAIR), whilst 1 required a two-stage revision. 1 acetabular component had migrated requiring revision. The median pre-injury OHS was 44 (26-48) compared to 37.3 (28-48) at 1 year. There were no deaths at 30-days, whilst at 1 year 7 patients had died. Kaplan Meier survival analysis showed mean survival was 1984.5 days. Implant survival was 90% at 1 year. CONCLUSION: While fix and replace is conceptually attractive, this medically complex patient group requires considerable support peri­ and post-operatively. Further studies are required to provide clinicians with more information to decide on how best to provide a holistic management strategy for such injuries in this frail patient cohort.

Temporal trends in the management of metacarpal and phalangeal fractures in the 21st century: an analysis of Australian population-based data.

BACKGROUND: Fractures of the hand, specifically the metacarpals and phalanges, are a common injury. Whilst many of these fractures can be treated non-operatively, a number of advances have led to the increase in popularity of surgical intervention. The aim of this study was to assess and describe trends in management of phalangeal and metacarpal fractures in Australia over the last two decades. METHODS: A review was conducted of the Medicare Benefits Scheme (MBS), specifically querying the item numbers pertaining to the management of metacarpal and phalanx fractures. Data was recorded as the incidence per 100 000 patients. RESULTS: Overall, there was a statistically significant decrease in the incidence of closed reduction of metacarpal and phalanx fractures, with a converse statistically significant increase in open reduction internal fixation. CONCLUSION: This study demonstrates that over the last 20 years, there has been a decrease in closed reduction of intra- and extra-articular phalangeal and metacarpal fractures, with a converse but smaller increase in open reduction and fixation. These trends are likely multi-factorial in aetiology, and should be monitored to guide resource allocation and health provision in the future.

Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation: A Randomized Controlled Trial.

BACKGROUND: Postoperative complications and substantial loss of physical function are common after musculoskeletal trauma. We conducted a prospective randomized controlled trial to assess the impact of conditionally essential amino acid (CEAA) supplementation on complications and skeletal muscle mass in adults after operative fixation of acute fractures. METHODS: Adults who sustained pelvic and extremity fractures that were indicated for operative fixation at a level-I trauma center were enrolled. The subjects were stratified based on injury characteristics (open fractures and/or polytrauma, fragility fractures, isolated injuries) and randomized to standard nutrition (control group) or oral CEAA supplementation twice daily for 2 weeks. Body composition (fat-free mass [FFM]) was measured at baseline and at 6 and 12 weeks postoperatively. Complications were prospectively collected. An intention-to-treat analysis was performed. The relative risk (RR) of complications for the control group relative to the CEAA group was determined, and linear mixed-effects models were used to model the relationship between CEAA supplementation and changes in FFM. RESULTS: Four hundred subjects (control group: 200; CEAA group: 200) were enrolled. The CEAA group had significantly lower overall complications than the control group (30.5% vs. 43.8%; adjusted RR = 0.71; 95% confidence interval [CI] = 0.55 to 0.92; p = 0.008). The FFM decreased significantly at 6 weeks in the control subjects (-0.9 kg, p = 0.0205), whereas the FFM was maintained at 6 weeks in the CEAA subjects (-0.33 kg, p = 0.3606). This difference in FFM was not seen at subsequent time points. CONCLUSIONS: Our results indicate that CEAA supplementation has a protective effect against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures. Given the potential benefits of this inexpensive, low-risk intervention, multicenter prospective studies in focused trauma populations are warranted. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Long-term patient reported sexual and urological dysfunction in males after operatively treated pelvic ring injuries Do generic outcome measures identify genitourinary health problems?

BACKGROUND: A consecutive series of 177 male patients, with high energy pelvic ring injuries, were treated operatively in our institution. The purpose of this study was to evaluate long-term sexual and urological dysfunction in these patients using validated disease specific patient reported outcome measures (PROMs), and identify if sexual and urological dysfunction is detectable from generic outcome scores used in the assessment of pelvic ring injury at a minimum of 10 years follow-up (range 10-22). METHODS: Surviving patients were contacted to complete validated PROMs to examine genitourinary and global functional outcome. Fifty-two male participants, had a mean age of 44-years-old (range,16-69) and ISS of 17 at time of injury. Mean duration follow-up of 15 years. The primary outcome measures were the Sexual Health Inventory for Men (SHIM) and the Modular Questionnaire for Male Lower Urinary Tract Symptoms (MLUTS). Secondary outcomes were the EQ-5D and Short Form 36. Responses were tested for correlation between generic and disease-specific PROMs and analyzed for association with genitourinary injury and age as risk factors of poor outcome. RESULTS: Genitourinary injuries occurred in 7 patients (13%), and ten patients (19%) had documented neurological dysfunction following injury. Satisfactory general functional outcome was reported with EQ-5D-3L VAS score of 71. However, 80% report some level of sexual dysfunction with 37% reporting it as severe. MLUTS mean symptom score was 9 (range, 0 - 26) and bothersomeness score was 21 (range, 0-90). There was poor correlation between urological and sexual dysfunction scores and between the disease specific and generic scores. CONCLUSION: In operatively treated pelvic ring injuries, validated disease specific PROMs, (SHIM and MLUTs) identified a significant impact to both sexual and urological patient health, with 37% reporting severe sexual dysfunction. Longstanding sexual and/or urological dysfunction can be a source of significant psychological impact that this study has shown is not identifiable using generic PROMs; EQ-5D-3L and SF-36. To gain a holistic understanding of the functional outcome of patients following a pelvic injury, urological and sexual dysfunction must not be overlooked.

WALANT technique versus locoregional anesthesia in the surgical management of metacarpal and phalangeal fractures: Lessons from the Covid-19 crisis.

Wide Awake Local Anesthesia No Tourniquet (WALANT) is an anesthetic method which uses a local injection of anesthetic and epinephrine, avoiding use of a tourniquet. During the COVID-19 pandemic, human and logistic resources had to be reorganized, and WALANT ensured resilience in our department to maintain access to surgical care. The objective of the present study was to compare hand function recovery 3 months after surgery for unstable metacarpal or phalangeal fracture under regional anesthesia versus WALANT. From November 2020 to May 2021, 36 patients presenting a metacarpal or phalangeal fracture requiring surgical treatment were included in a single-center study in a university hospital center. Nineteen patients underwent surgery under locoregional anesthesia with tourniquet, and 17 under WALANT. The main endpoint was functional recovery at 3 months on QuickDASH score. Need for complementary anesthesia, surgery duration, analgesic consumption, reintervention rate, and patient satisfaction were also assessed. There was no significant difference between groups in functional recovery at 3 months or on the secondary endpoints. In the COVID-19 context, WALANT proved to be a safe and effective method in hand fracture surgery, ensuring access to surgical care. It should be included in surgical training to optimize day-to-day surgical care and face future crises.

A retrospective study about functional outcome and quality of life after surgical fixation of insufficiency pelvic ring injuries.

BACKGROUND: Fragility fractures without significant trauma of the pelvic ring in older patients were often treated conservatively. An alternative treatment is surgery involving percutaneous screw fixation to stabilize the posterior pelvic ring. This surgical treatment enables patients to be mobilized quickly and complications associated with bedrest and temporary immobility are reduced. However, the functional outcome following surgery and quality of life of the patients have not yet been investigated. Here, we present a comprehensive study addressing the long-term well-being and the quality of life of patients with fragility pelvic ring fractures after surgical treatment. METHODS: Between 2011-2019, 215 geriatric patients with pelvic ring fractures were surgically treated at the university hospital in Göttingen (Germany). Of these, 94 patients had fragility fractures for which complete sets of computer tomography (CT) and radiological images were available. Fractures were classified according to Tile and according to the FFP classification of Rommens and Hofmann. The functional outcome of surgical treatment was evaluated using the Majeed pelvic score and the Short Form Health Survey-36 (SF-36). RESULTS: Thirty five tile type C and 48 type B classified patients were included in the study. After surgery eighty-three patients scored in average 85.92 points (± 23.39) of a maximum of 100 points using the Majeed score questionnaire and a mean of 1.60 points on the numerical rating scale ranging between 0 and 10 points where 0 points refers to "no pain" and 10 means "strongest pain". Also, the SF-36 survey shows that surgical treatment positively effects patients with respect to their general health status and by restoring vitality, reducing bodily pain and an increase of their general mental health. CONCLUSIONS: Patients who received a percutaneous screw fixation of fragility fractures of the posterior pelvic ring reported an overall positive outcome concerning their long-term well-being. In particular, older patients appear to benefit from surgical treatment. TRIAL REGISTRATION: Functional outcome and quality of life after surgical treatment of fragility fractures of the posterior pelvic ring, DRKS00024768. Registered 8th March 2021 - Retrospectively registered. Trial registration number DRKS00024768 .

The history of orthopaedic surgery in India: from antiquity to present.

Indian orthopedists have a legacy dating back more than 4000 years. Starting with the Harappan civilization, ancient orthopaedic surgeons reduced fractures and conducted therapeutic trepanations. Since then, Indian physicians have pioneered many of the orthopaedic techniques still used today - including the use of prosthetics, fracture tables, and rehabilitative physical therapy. Today, orthopaedic surgeons coexist with traditional Indian bonesetters. Although bonesetting practices can have complication rates as high as 40%, bonesetters still handle a majority of fractures in India and are often culturally preferred. Importantly though, bonesetters are often the only expedient option available in both rural and urban settings.