Should a low starting point be abandoned for cannulated screw fixation of femoral neck fractures?

A validated femoral neck fracture model stabilized with three inverted cannulated screws was used to consider different intraoperative scenarios when the inferior screw hole is inadvertently started too inferiorly. These scenarios were to: (1) abandon the misplaced inferior screw hole and restart this hole more proximally, or (2) accept the mispositioned placement of the inferior screw and insert the remaining superior screws parallel or convergent to the inferior screw. Utilizing the second option and accepting the errant hole was associated with the greatest interfragmentary motion and stresses in the bone and hardware. In contrast, the first option created an improved mechanical environment for healing.

Safe transport of spica casted infants: Reducing the risk of traumatic injury in side impact collisions.

BACKGROUND: There is limited data on transporting small children in hip spica casts used to treat pediatric femur fractures. Specific challenges include the fixed position of the body in the casted position and the increased size of the child due to cast thickness. Additionally, children less than 2 years old are recommended to be rear facing during transportation. This traveling position requires seats that are specifically designed to accommodate the small size of the child as well as accommodate the rear facing position. While seats able to accommodate casted children are available, it is unclear if they provide adequate protection in side impact collisions for rear facing spica casted infants. Therefore, the aim of this study was to evaluate traumatic injury metrics in a side impact collision model where a spica casted infant crash dummy was restrained in currently available car seats. METHODS: Two seats designed for spica casted children (R82 Quokka, Merritt Wallenberg) and two traditional car seats (Britax Emblem, Graco Sequel) able to accommodate a casted one-year-old crash test dummy were identified. Side impact collision testing was performed with the dummy positioned in the rear facing position and injury metrics recorded. RESULTS: Testing identified contact between the dummy's head and the door panel for a specialty spica car seat without protective side-wings for the head. All other seats contained side wings and prevented door-head contact. CONCLUSIONS: Casted children should be transported in a seat able to accommodate the cast and safely restrain them. Our results demonstrate the importance of side wing protection in any seat used to transport these children as side bolsters may help decrease the potential for head contact with the door and lower the risk of severe head injury.

Crash Performance of Rear-facing Restraints With a Fracture Type Spica Casted 1-Year-Old Dummy.

BACKGROUND: Motor vehicle crashes represent a significant cause of mortality and morbidity for young children. Safely restraining a child is typically more complicated for special cases such as children treated with a hip spica cast. In the current study, hip spica casts typical for treatment of a femoral fracture were applied to a crash dummy representing the size and weight of a 1-year-old child. This spica casted dummy was used to study the performance of 4 rear-facing car seats in a series of simulated frontal impacts. METHODS: The restrained, rear-facing dummy was subjected to a frontal crash test at 30 mph (48 kph) per federal guidelines. Two of the tested car seats were specifically designed for transporting children with hip spica casts, while the other 2 were conventional seats capable of accommodating the cast. All seats were installed per the manufacturer's instructions. As a control, tests were performed without a cast using the conventional/standard seats. RESULTS: The lowest overall loading of the dummy's head, neck, and chest occurred during tests with the standard seats. While it was easier to seat the casted child in the spica-specific seats, these designs led to greater loading on the dummy's body. In a spica-specific seat, the chest acceleration values exceeded the federal limit in a test where the seat was installed in a reclined orientation that was within the manufacturer's described positioning. CONCLUSIONS: Spica-specific seats more easily accommodate the cast, but conventional seats can provide similar levels of protection in a crash. As cast and seat designs continue to evolve, hospitals might consider having a range of seats available for patient use. It is important to help caregivers make informed decisions on how and when to transport children with hip spica casts.

Pre-bending a dynamic compression plate significantly alters strain distribution near the fracture plane in the mid-shaft femur.

This study evaluated the effect of pre-bending dynamic compression plates on fracture site compression. Recommendations of 1 to 2 mm of pre-bend have been proposed, but there does not appear to be experimental data to confirm the optimal pre-bend magnitude. Dynamic compression plating was performed on the lateral convex surface of 18 femoral analogs to fixate a simulated mid-shaft fracture. Plates with 0 mm (flat plate), 1 mm, and 2 mm of pre-bend were evaluated for their production of compression by determining the strain magnitudes for 10 equal-sized zones across the anterior cortex at the osteotomy site using digital imaging correlation. The 0 and 1 mm plates produced significantly more compression at the near cortex (p = 0.001 and p = 0.003, respectively) than the 2 mm plate. However, the 0 and 1 mm plates also created visible diastasis at the far cortex, while the 2 mm plate exhibited compression across all zones. The strain magnitudes for the 0 mm (R2 = 0.62) and 1 mm (R2 = 0.86) plates linearly and significantly decreased from the region adjacent to the plate until a region 50%-60% across the analog diameter. In contrast, the 2 mm plate exhibited uniform strains across the osteotomy site. This study demonstrates that pre-bending a dynamic compression plate 2 mm prior to fixation on a convex lateral femur provides the most compression at the far cortex. It also produces more uniform compression across the fracture when compared to 0 and 1 mm of pre-bend.

Surgical Fixation of Sacral Fractures in the Elderly Population: Are There Predictors of Outcome? An Analysis of Return to Ambulation and Residential Living Status.

INTRODUCTION: Recent literature suggests that surgical fixation of elderly sacral fractures may reduce time to mobilization and ultimately self-sufficiency. However, it is unclear if predictors of success exist in this subpopulation. The objective of this study was to characterize relative change in ambulation and residential living statuses (pre-injury vs. post-surgery) of elderly patients who received surgical fixation of sacral fractures, as well as determine whether or not demographics and injury characteristics influence these findings. METHODS: Fifty-four elderly patients (≥60 years old) receiving percutaneous screw fixation of sacral fractures were retrospectively reviewed. All fractures were traumatic in nature; insufficiency fractures were excluded. Patient and surgical demographic data, as well as 1-year mortality status, was reported. Primary study endpoints included relative change in patient ambulation and residential living statuses (pre-injury to post-surgery). Statistical analyses were performed to assess relative change in ambulation/living status from pre-injury to post-surgery and to determine if predictors of outcome existed. RESULTS: Of the 54 patients who met inclusion criteria, 4 expired prior to discharge, 2 expired post-discharge, and 4 were lost to follow-up. Of those patients discharged, 95.7% regained some form of ambulation at last follow-up (mean: 22.4 ± 18.9 weeks). Of patients living independent pre-injury, 94.9% would eventually return to independent home living. Neither time-to-surgery, concomitant orthopaedic injury, Charlson Comorbidity Index, or injury mechanism were predictors of final ambulation or residential status (p ≥ 0.07). Mortality at 1-year was 11.1%. DISCUSSION: Operative fixation supported a high rate of return to pre-injury ambulation and residential living status. However, there did not appear to be measures predictive of final functional status. Further efforts with larger, prospective cohorts are warranted.

Open Reduction Internal Fixation of a Medial Epicondyle Avulsion Fracture With Incarcerated Fragment.

PURPOSE: The purpose of this video is to present a technique for open reduction and internal fixation of a displaced unstable medial epicondyle avulsion fracture. METHOD: A 13-year-old boy presented 2 days after injury at our institution after sustaining a medial epicondyle avulsion fracture with incarcerated fragment and posterolateral dislocation of the elbow after a fall off a fence. He described paresthesia in the ulnar nerve distribution and demonstrated slight weakness to intrinsic hand strength on examination. He was urgently reduced under sedation in the emergency department using the Roberts maneuver, a technique consisting of a valgus stress with forearm supination with finger and wrist extension that uses muscle forces to extract the fragment. Successful reduction of the ulna-humeral joint and extraction of the incarcerated medial epicondyle was demonstrated on CT. The patient was then taken in a nonurgent fashion to the operating room for open reduction and internal fixation of the displaced medial epicondyle fracture. Intraoperative examination after fixation demonstrated a congruent and stable elbow. A long-arm cast was then applied. RESULTS: The video is 7-minute, 38-second duration in time and 461 MB in size. CONCLUSIONS: Although fixation of medial epicondyle avulsion fractures may be controversial, there are some indications for ORIF including incarcerated epicondylar fragment, suspected entrapment and dysfunction of the ulnar nerve, marked instability of the elbow, and open fracture. Presented in this video is a safe technique for ORIF of the displaced and unstable medial epicondyle avulsion fracture.

Mycobacterium bovis infection of total hip arthroplasty after intravesicular bacille Calmette-Guérin therapy.

Bacille Calmette-Guérin (BCG) is a live, attenuated strain of Mycobacterium bovis. Intravesicular BCG therapy is the most effective treatment for superficial bladder cancer. The most common complication of this treatment is cystitis; there is a wide range of other complications. The English-language literature includes reports of 3 total hip arthroplasty infections and 1 total knee arthroplasty infection with M bovis after BCG therapy. These secondary infections may present either acutely during the therapy, months, or even years later. In this article, we report the case of a patient who presented with a painful right hip 6 years after successful total hip arthroplasty and 3 years after treatment for bladder cancer. Left total hip arthroplasty was performed 2 years after right hip arthroplasty. Surgeons examining a painful joint arthroplasty should be particularly suspicious of infection if the patient has a history of BCG therapy.