Combining robotics and 3D printing facilitates closed reduction of humeral shaft fractures using a minimally invasive plate as a reduction template: A proof-of-concept study.

BACKGROUND: Minimally invasive percutaneous plate osteosynthesis for humeral shaft fractures (HSFs) has limitations due to malreduction and radiation exposure. To address these limitations, we integrated robotics and 3D printing by incorporating plates as reduction templates. METHOD: The innovative technology facilitated closed reduction of HSFs in the operating theatre using 18 models with cortical marking holes. The dataset of the precontoured plate was imported into 3D planning software for virtual fixation and screw path planning. The models were divided into half to simulate transverse fractures. During the operation, the software generated drilling trajectories for robot navigation, and precise plate installation achieved automatic fracture reduction. RESULTS: The evaluation results of reduction accuracy revealed variations in length, apposition, alignment, and rotation that meet the criteria for anatomic reduction. High interoperator reliabilities were observed for all parameters. CONCLUSIONS: The proposed technology achieved anatomic reduction in simulated bones.

Eliminating rote postoperative radiographs for surgically managed pediatric supracondylar humerus fractures.

BACKGROUND: Use of postoperative radiographs after surgical management of supracondylar humerus (SCH) fractures is often based on rote practice rather than evidence. The purpose of this study was to determine the frequency with which 3-week postoperative radiographs at the time of pin removal altered management plans in pediatric SCH fractures that were intraoperatively stable after closed reduction and percutaneous pinning (CRPP). METHODS: We prospectively recruited pediatric patients with SCH fractures managed by CRPP at our institution from June 2020 until June 2022, and reviewed retrospective data on pediatric SCH fractures managed surgically at our institution between April 2008 and March 2015. Patients were assessed for post-CRPP fracture alignment and stability. For prospective patients, we asked clinicians to document their management decision at the 3-week follow-up visit before evaluating the postoperative radiographs. Our primary outcome was change in management because of radiographic findings. RESULTS: Overall, 1066 patients in the retrospective data and 446 prospectively recruited patients met the inclusion criteria. In the prospective group, radiographic findings altered management for 2 patients (0.4%). One patient had slow callus formation and 1 patient was identified as having cubitus varus. Altered management included prolonged immobilization or additional radiographic follow-up. Radiographic findings altered management in 0 (0%) of 175 type II fractures, in 2 (0.9%) of 221 type III fractures, and in 0 (0%) of 44 type IV fractures. We obtained similar findings from retrospective data. CONCLUSION: Rote use of 3-week postoperative radiographs after surgical management of SCH fractures that are intraoperatively stable has minimal utility. Eliminating rote postoperative radiographs for SCH fractures can decrease the time and financial burdens on families and health care systems without affecting patient outcomes.

Refraining from closed reduction of displaced distal radius fractures in the emergency department-in short: the RECORDED trial.

BACKGROUND: With roughly 45,000 adult patients each year, distal radius fractures are one of the most common fractures in the emergency department. Approximately 60% of all these fractures are displaced and require surgery. The current guidelines advise to perform closed reduction of these fractures awaiting surgery, as it may lead to post-reduction pain relief and release tension of the surrounding neurovascular structures. Recent studies have shown that successful reduction does not warrant conservative treatment, while patients find it painful or even traumatizing. The aim of this study is to determine whether closed reduction can be safely abandoned in these patients. METHODS: In this multicenter randomized clinical trial, we will randomize between closed reduction followed by plaster casting and only plaster casting. Patients aged 18 to 75 years, presenting at the emergency department with a displaced distal radial fracture and requiring surgery according to the attending surgeon, are eligible for inclusion. Primary outcome is pain assessed with daily VAS scores from the visit to the emergency department until surgery. Secondary outcomes are function assessed by PRWHE, length of stay at the emergency department, length of surgery, return to work, patient satisfaction, and complications. A total of 134 patients will be included in this study with follow-up of 1 year. DISCUSSION: If our study shows that patients who did not receive closed reduction experience no significant drawbacks, we might be able to reorganize the initial care for distal radial fractures in the emergency department. If surgery is warranted, the patient can be sent home with a plaster cast to await the call for admission, decreasing the time spend in the emergency room drastically. TRIAL REGISTRATION: This trial was registered on January 27, 2023.

The midterm psychological effect of cast removal procedures in children.

OBJECTIVES: This study aimed to compare the course of anxiety change in children who used headphones during cast removal with controls in midterm follow-up. PATIENTS AND METHODS: Sixty-six patients who underwent forearm fracture treatment with closed reduction and long arm casting between June 2021 and March 2023 were retrospectively reviewed. Patients were divided into two groups based on the use of headphones (n=27; 21 males, 6 females; mean age: 8.0±1.8 years; range, 6 to 12 years) or not (n=39; 27 males, 12 females; mean age: 8.9±1.8 years; range, 6 to 12 years) during cast removal with an oscillating saw. Primary outcome measures included preprocedure, postprocedure, and six-month anxiety assessments with the State-Trait Anxiety Inventory. RESULTS: There was an acute increase in the mean state anxiety scores after the procedure, which returned to below baseline at the six-month follow-up in the headphone (31.4±8.3, 33.3±8.7, and 25.1±4.1, respectively) and control groups (34.9±11.1, 37.4±9.5, and 27.3±5.3, respectively). The mean trait anxiety scores before the procedure, after the procedure, and at six months remained similar in the headphone (33.6±3.0, 34.6±3.2, and 32.4±2.8; p>0.05) and control groups (34.1±2.7, 33.7±3.0, and 33.7±3.0, p>0.05). CONCLUSION: This study suggests that the acute anxiety during cast removal did not create anxiety sequelae in the sixth month regardless of headphone use.

Dual Joystick Technique for Reduction of Torsional Profile in Pediatric Supracondylar Humerus Fracture With Delayed Presentation.

BACKGROUND: Reduction of some modified Gartland type III and IV supracondylar humerus fractures can pose difficulties, especially if they present late to the hospital. Various techniques of reduction have been tried for reducing the supracondylar humerus fracture for sagittal and coronal plane correction. This retrospective study assesses the dual joystick technique's possible effectiveness in achieving an anatomical reduction of the supracondylar humerus fracture. METHODS: Patients with modified Gartland's type III and IV supracondylar humerus fractures who underwent closed reduction and percutaneous pinning using the dual joystick technique at our trauma center between January 2020 and January 2022 were the subject of a retrospective review. Forty-six patients treated by the above technique who met the inclusion criteria were analyzed at the end of the final follow-up. RESULTS: The mean age of the children was 7.9+/- 2.25 years, with a male predominance at 32:14. The Right upper limb was more involved compared to the left side. The mean injury to hospital presentation was 2.67+/- 1.28 days, and the mean surgical duration was 24.57+/- 13.76 minutes. The average pin spread ratio at the fracture site was 35.17+/- 3.04%. Baumann angle at the final follow-up was 74.83+/- 2.56 degrees. The mean lateral rotation percentage was 2.8+/- 1.3%. 39 patients had excellent cosmetic outcomes, and 42 had excellent functional outcomes, whereas 7 and 4 patients had good cosmetic and functional outcomes, respectively, according to Flynn criteria. CONCLUSIONS: In modified Gartland type III and IV fractures with late presentation where reduction is challenging, this technique is shown to be convenient and easily reproducible and helps accomplish near anatomical reduction with reduced lateral rotation percentage and results in excellent to good outcomes.

Positive buttress reduction in femoral neck fractures: a literature review.

BACKGROUND: Femoral neck fractures (FNFs) in young adults are usually caused by high-energy trauma, and their treatment remains a challenging issue for orthopedic surgeons. The quality of reduction is considered an important factor in improving the poor prognosis of patients with FNFs. In recent years, positive buttress closed reduction technique has received widespread attention in the treatment of FNFs. This comprehensive literature review is designed to encapsulate the impacts of both non-anatomic and anatomic reduction on the biomechanical stability, clinical outcomes, and postoperative complications in the management of FNFs, conjecture the efficacy of positively braced reduction techniques and provide a thorough summarization of the clinical outcomes. METHODS: In this literature review, we have examined all clinical and biomechanical studies related to the treatment of FNFs using non-anatomical reduction or positive and negative buttress reduction. PubMed, Web of Science, Google Scholar and Embase Library databases were searched systematically for studies published before September 1, 2023. Published literature on fracture reduction techniques for treating FNFs was reviewed. In addition, we evaluated the included literature using the MINORs tool. RESULTS: Although the "arch bridge" structure formed by the positive buttress reduction technique improved the support to the cortical bone and provided a more stable biomechanical structure, no significant differences were noted in the clinical efficacy and incidence of postoperative complications between the positive buttress reduction and anatomical reduction. CONCLUSION: Positive buttress reduction is an effective treatment method for young patients with FNFs. When facing difficult-to-reduce FNF, positive buttress reduction should be considered first, followed by anatomical reduction. However, negative buttress reduction should be avoided.

Comparison of closed percutaneous screw reduction versus open reduction and internal fixation in the treatment of frontal sinus fractures: A retrospective study.

The aim of this study was to compare closed percutaneous screw reduction to traditional open reduction-internal fixation (OR-IF) for the treatment of anterior table fractures. Both groups were evaluated in terms of operative variables, complications, and treatment success. Of 32 patients included, 19 patients underwent OR-IF, while 13 underwent percutaneous screw reduction. The median operative time, length of hospital stays, and treatment cost of the OR-IF group were 100 min (range 60-130), 4 days (range 3-9), and $727 (range $642-$1291), respectively. The same variables for the closed reduction group were 30 min (range 20-40), 2 days (range 1-2), and $303 (range $252-$349), respectively. The closed reduction group exhibited a shorter operative time (p< 0.001), reduced length of hospital stays (p< 0.001), lower treatment cost (p< 0.001), and a lower complication rate (p = 0.025) compared to the OR-IF group. Late-term outcomes in both groups showed no visible contour changes or step deformities. In conclusion, the percutaneous screw reduction technique is a safe and effective option with minimal morbidity in the treatment of frontal sinus anterior table fractures. Therefore, traditional OR-IF should be reserved for fractures that are not suitable for reduction using minimally invasive techniques.

Does Preoperative Manual Reduction (Omoto Technique) Affect Surgical Outcomes for Calcaneal Fractures? A Multicenter (TRON Group) Retrospective Study.

The Omoto technique is a well-known method that is commonly used for noninvasive manual repair of calcaneal fractures. However, there have been no detailed studies on its clinical outcomes in preoperative closed reduction for surgical cases. This multicenter retrospective study aimed to compare the clinical and radiographic outcomes of calcaneal fractures treated with and without the preoperative Omoto technique, assessing its effectiveness. We extracted 335 patients with calcaneal fracture who underwent surgery between 2015 and 2020 from our multicenter database, named TRON. We evaluated the clinical outcomes using the American Orthopedic Foot and Ankle Society (AOFAS) score, the Böhler angle (BA) for radiographic analysis, and noted any complications. We divided the patients into those managed with the Omoto technique (group O) and those managed without the Omoto technique (group N). Patients were matched by age, sex, and fracture type, resulting in 43 patients per group. The use of the Omoto technique at the time of injury significantly improved the Böhler angle (BA). Furthermore, there were no significant differences in AOFAS, postoperative complications, or BA values at the final follow-up. In conclusion, our study demonstrates that the Omoto technique, when used preoperatively for calcaneal fractures, does not negatively impact the outcomes of subsequent surgical treatments. For patients who prefer to avoid surgery, the Omoto technique can be an effective initial intervention. Additionally, our findings suggest that the Omoto technique may facilitate less invasive surgical options in certain cases.

Closed Reduction for the Treatment of Traumatic Thoracolumbar Spondylolisthesis.

OBJECTIVE: Thoracolumbar traumatic spondylolisthesis is a relatively rare phenomenon and has poor prognosis due to serious spinal cord or cauda equina injuries. In such cases, closed reduction is a method for restoring the vertebral sequence and may play an important role in the treatment process, although whether it is actually feasible for patients with this condition requires further investigation. The present study included 9 patients with serious thoracolumbar traumatic spondylolisthesis to determine the advantages of closed reduction over total reduction through open surgery. METHODS: Data from 9 patients (cases 1-9), diagnosed with severe thoracolumbar traumatic spondylolisthesis between June 2012 and August 2023, were retrospectively reviewed. Five patients were treated with closed reduction in an emergency department and subsequently underwent delayed internal fixation surgery at least 48 hours after the injury, and 4 with similar serious injuries underwent emergency surgery. The incidence of complications and recovery of the spinal cord or cauda equina were compared between groups. RESULTS: There were no significant differences in demographic characteristics or adverse events between the 2 groups. The reduction group had a shorter surgical duration and less blood loss than the surgery group. Although patients in the surgery group may have experienced more pain, there were no significant differences between the groups in Oswestry Disability Index or Japanese Orthopaedic Association scores. Thus, regardless of whether closed reduction was chosen, patients experienced a similar quality of life for a relatively prolonged period. CONCLUSIONS: Closed reduction may be feasible for serious thoracolumbar traumatic spondylolisthesis, although the safety of this method requires further research.

Pediatric Type I Open Both Bone Forearm Fractures: Predicting Failure of Nonoperative Management.

BACKGROUND: In recent years, nonoperative treatment of pediatric type I open both bone forearm fractures (OBBFFs) with bedside irrigation, antibiotics, closed reduction, and casting has yielded low infection rates. However, risk factors for failure of type I OBBFF closed reduction have not been well described. Our purpose was to describe management of patients with type I OBBFFs at our institution and determine what factors are associated with failure of closed reduction in this population. METHODS: This was a review of patients between 5 and 15 years of age who received initial nonoperative management for type I OBBFFs at one institution between 2015 and 2021. Primary outcome was success or failure of nonoperative management (defined as progression to surgical management). Secondary outcomes included infections, compartment syndromes, and neuropraxias. Other variables of interest were demographic information, prereduction and postreduction translation and angulation of the radius and ulna, cast index, and antibiotic administration. RESULTS: Sixty-one patients (67.7% male) with 62 type I OBBFFs were included in this study. Following initial nonoperative management, 55 injuries (88.7%) were successfully treated in casts, while the remaining 7 (11.3%) required surgical intervention following loss of acceptable reduction in cast. Median cast index (0.84, IQR 0.8 to 0.9 vs. 0.75, IQR 0.7-0.8, P =0.020) and postreduction radius translation on anteroposterior films (32.0%, IQR 17.0% to 40.0% vs. 5.0%, IQR 0.0% to 26.0%, P =0.020) were higher among those who failed nonoperative management. Multivariable logistic regression models identified increased odds of failure for every SD (0.7) increase in cast index (OR 3.78, P =0.023, 95% CI: 1.4-14.3) and 25% increase in postreduction radius translation on anteroposterior films (OR 7.39, P =0.044, 95% CI 1.2-70.4). No infections or compartment syndromes and 2 transient ulnar neuropraxias occurred. CONCLUSIONS: Closed reduction of type I OBBFFs was successful in 88.7% of cases. There were no infections after nonoperative management. Increases in cast index of 0.7 and postreduction radius translation on anteroposterior radiographs of 25% were associated with increased likelihood of failure, thus requiring surgery; age was not. LEVEL OF EVIDENCE: Level IV-retrospective comparative study.

The 'Shish-Kebab technique' in intra-articular fractures of the hamate body and concomitant 4th metacarpal base fracture.

PURPOSE: Hamate fractures are infrequent and often overlooked wrist injuries. Our objective is to present the Shish-Kebab method, a surgical approach utilized in the treatment of intra-articular Hamate body fractures occurring concurrently with fourth metacarpal base fractures and dislocations. METHODS: This study was conducted at a single-center using a prospective design. It included patients aged 16-65 with Kim Type IIB fractures affecting the dominant side. Patients with the same features of fracture and carpometacarpal (CMC) instability findings were divided into two groups according to the success of the closed reduction procedure. In the conservative group (8 patients), all fractures and instability findings were successfully resolved with closed reduction and a short arm plaster cast. The surgical group (8 patients), comprising those requiring open reduction and internal fixation, underwent the application of the 'shish kebab' method. RESULTS: At the 6th and 12th week follow-ups, no significant differences were observed between the groups concerning pVAS and QuickDash scores. However, upon examining the QuickDash scores, a statistically significant difference emerged between the 6th and 12th weeks within both the conservative (p = 0.017) and surgical (p = 0.012) groups in the intragroup analysis. Grip strength, measured as 83.78% of the contralateral side in the surgical group and 79.51% in the conservative group, did not exhibit a statistically significant difference (p = 0.462). CONCLUSION: In the management of Hamate body intra-articular fractures and accompanying fourth metacarpal base fracture dislocations, good clinical results can be achieved with the 'Shish-Kebab' method in cases where closed reduction is unsuccessful.

Radiologic, clinical, and functional evaluation of children with displaced T-condylar fractures treated by closed reduction and percutaneous fixation using the Mayo Elbow Performance Score.

PURPOSE: T-condylar (T-C) fractures of the distal humerus are rare in children. There is no accepted treatment for such an injury, and there is a lack of reports evaluating the outcome of T-C fractures treated by closed reduction and percutaneous fixation. The aim of this study was to evaluate the feasibility of closed reduction and percutaneous K-wire and screw (CRPKS) fixation in patients with type II and III T-C fractures according to the Toniolo-Wilkins classification modified by Canavese et al. (TWC classification). METHODS: The clinical data of 12 consecutive patients (8 males, 4 females) who were younger than 14 years of age and who had a T-C fracture that was managed by CRPKS were retrospectively evaluated. Fractures were classified according to the TWC classification. The baseline information of the patients, carrying angle (CA) and Mayo Elbow Performance Score (MEPS) were used to evaluate clinical and functional outcomes; related complications were recorded. Statistical analysis was performed. RESULTS: The mean age at the time of injury was 11.6 ± 1.8 years (range, 8-14). The time from injury to surgical treatment was 1.5 ± 1.0 days (range, 0-3), and the mean follow-up duration was 33.7 ± 12.3 months (range, 18-61). Surgery lasted 45.7 ± 7.6 min on average (range, 35-58). All fractures healed in 4.9 ± 1.0 weeks on average (range, 4-7). At the last follow-up visit, the CA was 12.6° ± 5.8° on the injured side and 13.8° ± 1.8° on the uninjured side (p=0.432). The MEPS was 100 (95, 100) on the injured side and 100 (100, 100) on the uninjured side (p=0.194). Three complications were recorded. CONCLUSION: Good functional and radiological outcomes can be expected in pediatric patients with type II and III T-C fractures treated by CRPKS. The technique is relatively simple to perform and has a lower rate of complications.

Satisfacción estética y funcional tras reducción cerrada de fracturas nasales: implementación de la escala NOSE / Aesthetic and functional satisfaction after closed reduction of nasal fractures: implementation of the NOSE scale

Introducción y objetivo: La fractura nasal es la lesión facial más común y más del 50 % de todas las fracturas faciales en adultos. Debido a que en muchas ocasiones no es diagnosticada y tratada oportunamente, puede generar diferentes grados de limitación funcional y resultados estéticos indeseables. Pocos estudios evalúan la satisfacción de los pacientes tratados con técnica cerrada de reducción de fractura nasal. Nuestro objetivo es valorar la satisfacción funcional y estética posterior a reducción cerrada de fractura de huesos nasales en un hospital de Colombia, mediante la escala de evaluación de síntomas de obstrucción nasal (NOSE, por sus siglas en inglés - nasal obstruction symptom evaluation) y la escala estética subjetiva. Material y método: Estudio observacional analítico prospectivo de pacientes con fractura nasal llevados a reducción cerrada en el Hospital Universitario de Santander, Colombia. Se registraron las puntuaciones de las escalas NOSE y estética subjetiva, antes y 2 meses después de la cirugía. Resultados: Evaluamos 55 pacientes, 90.9% hombres. La mediana de edad fue de 31 años (RIC 24-48). El contexto de lesión principal fue violencia física (40%), seguido de accidente de tránsito (32.7%). Tras el procedimiento, los pacientes presentaron mejoría de obstrucción nasal medida con la escala NOSE (p<0.001); antes de la cirugía el 89% presentaba obstrucción nasal moderada-severa, posteriormente descendió a 14.5%. La escala NOSE mostró fabilidad por consistencia interna con alfa de Cronbach de 0.8317. Tras la cirugía hubo aumento de la satisfacción respecto al aspecto nasal (p<0.001). Conclusiones: En nuestro estudio, el cuestionario NOSE permitió cuantificar la mejora de síntomas de obstrucción nasal en pacientes con reducción cerrada por fractura de huesos nasales. Observamos mejoría de síntomas obstructivos nasales y aumento de satisfacción estética.Nivel de evidencia científica 4c Terapéutico.(AU)

Background and objective: Nasal fracture is the most common facial injury, accounting for more than 50% of all facial fractures in adults. Because it is often not diagnosed and treated promptly, it can generate different degrees of functional limitation and undesirable aesthetic results. Few studies evaluate the satisfaction of patients treated with the closed nasal fracture reduction technique. Our objective is to evaluate functional and aesthetic satisfaction after closed reduction of a nasal bone fracture in a hospital in Colombia, using the nasal obstruction symptom evaluation (NOSE) and subjective aesthetic scales. Methods: Prospective analytical observational study of patients with nasal fractures undergoing closed reduction at the University Hospital of Santander, Colombia. The scores of the NOSE scales and subjective aesthetics were recorded, before and 2 months after surgery. Results: We evaluated 55 patients, 90.9% men. Median age 31 years (IQR 24-48). The main injury context was physical violence (40%), followed by traffic accident (32.7%). After the procedure, the patients presented improvement in nasal obstruction measured with the NOSE scale (p<0.001); before surgery, 89% had moderate-severe nasal obstruction, later it decreased to 14.5%. The NOSE scale showed reliability due to internal consistency with Cronbach's alpha of 0.8317. After surgery, there was an increase in satisfaction regarding the nasal appearance (p<0.001). Conclusions: The NOSE questionnaire allows us to quantify the improvement of nasal obstruction symptoms in patients with closed reduction due to nasal bone fracture. Improvement of nasal obstructive symptoms and increased aesthetic satisfaction was observed.Level of evidence 4c Terapeutic.(AU)

Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial.

Aims: There is no level I evidence dealing with the optimal period of immobilization for patients with a displaced distal radial fracture following closed reduction. A shorter period might lead to a better functional outcome due to less stiffness and pain. The aim of this study was to investigate whether this period could be safely reduced from six to four weeks. Methods: This multicentre randomized controlled trial (RCT) included adult patients with a displaced distal radial fracture, who were randomized to be treated with immobilization in a cast for four or six weeks following closed reduction. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score after follow-up at one year. Secondary outcomes were the abbreviated version of the Disability of Arm, Shoulder and Hand (QuickDASH) score after one year, the functional outcome at six weeks, 12 weeks, and six months, range of motion (ROM), the level of pain after removal of the cast, and complications. Results: A total of 100 patients (15 male, 85 female) were randomized, with 49 being treated with four weeks of immobilization in a cast. A total of 93 completed follow-up. The mean PRWE score after one year was 6.9 (SD 8.3) in the four-week group compared with 11.6 (SD 14.3) in the six-week group. However, this difference of -4.7 (95% confidence interval -9.29 to 0.14) was not clinically relevant as the minimal clinically important difference of 11.5 was not reached. There was no significant difference in the ROM, radiological outcome, level of pain, or complications. Conclusion: In adult patients with a displaced and adequately reduced distal radial fracture, immobilization in a cast for four weeks is safe, and the results are similar to those after a period of immobilization of six weeks.

Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures: A Population-Based Cohort Study.

STUDY OBJECTIVE: Temporary lower limb immobilization may be a risk for venous thromboembolism. The purpose of this study was to examine the 90-day incidence of venous thromboembolism among patients discharged from an emergency department (ED) with ankle fractures requiring temporary immobilization. Secondary objectives were to examine individual factors associated with venous thromboembolism in this population and to compare the risk of venous thromboembolism in patients with ankle fractures against a priori-selected control groups. METHODS: This was a retrospective cohort study using province-wide health datasets from Ontario, Canada. We included patients aged 16 years and older discharged from an ED between 2013 and 2018 with closed ankle fractures requiring temporary immobilization. We estimated 90-day incidence of venous thromboembolism after ankle fracture. A Cox proportional hazards model was used to evaluate risk factors associated with venous thromboembolism, censoring at 90 days or death. Patients with ankle fractures were then propensity score matched to 2 control groups: patients discharged with injuries not requiring lower limb immobilization (ie, finger wounds and wrist fractures) to compare relative hazard of venous thromboembolism. RESULTS: There were 86,081 eligible patients with ankle fractures. Incidence of venous thromboembolism within 90 days was 1.3%. Factors associated with venous thromboembolism were older age (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39), venous thromboembolism or superficial venous thrombosis history (HR: 5.18; 95% CI: 4.33 to 6.20), recent hospital admission (HR: 1.33; 95% CI: 1.05 to 1.68), recent nonankle fracture surgery (HR: 1.58; 95% CI: 1.30 to 1.93), and subsequent surgery for ankle fracture (HR: 1.80; 95% CI: 1.48 to 2.20). In the matched cohort, patients with ankle fractures had an increased hazard of venous thromboembolism compared to matched controls with finger wounds (HR: 6.31; 95% CI: 5.30 to 7.52) and wrist fractures (HR: 5.68; 95% CI: 4.71 to 6.85). CONCLUSION: The 90-day incidence of venous thromboembolism among patients discharged from the ED with ankle fractures requiring immobilization was 1.3%. These patients had a 5.7- to 6.3-fold increased hazard compared to matched controls. Certain patients immobilized for ankle fractures are at higher risk of venous thromboembolism, and this should be recognized by emergency physicians.

The use of real-time sonography-assisted fracture reduction in children with displaced forearm fractures.

Pediatric forearm and wrist fractures are common; furthermore, some are displaced and require manipulation and reduction. The procedure is commonly performed without real-time image guidance and evaluated radiographically after reduction and casting, leading to multiple reduction attempts and malalignment. Although fluoroscopy can provide real-time assessment of fracture alignment during the procedure, it is not readily available in many emergency departments (EDs) and involves radiation exposure. Ultrasonography is an alternative real-time imaging modality that is inexpensive and readily available. The purpose of this study was to determine whether the use of real-time bedside sonography during closed reduction of distal and middle third forearm fractures can decrease the number of reduction attempts and reduce the number of patients requiring surgery. We compared the results of a conventional blind manipulation, fracture reduction, and casting to fracture reduction under real-time ultrasonographic guidance, in patients treated in our ED between 2014 and 2016. Overall, 458 patients with distal or middle third fractures were included. Of these reductions, 289 were performed without real-time imaging (group 1) and 169 under real-time ultrasound guidance (group 2). In group 1, 10% of patients required re-reduction, and 5% of patients needed surgery. In group 2, only one patient (0.6%) required re-reduction and 1% of patients required surgery due to fracture instability. In conclusion, the current study shows that real-time ultrasound-guided forearm fracture reduction is an effective and inexpensive method for correction of displaced forearm and wrist fractures in children, which does not involve any radiation exposure.