Factors influencing time to return to sport following clavicular fractures in adolescent athletes.

BACKGROUND: There is a trend toward increased surgical treatment of displaced clavicle fractures in the adolescent population presumably because of extrapolation of adult-derived best practice guidelines. The purpose of this study was to compare return to sport between nonoperative and operative treatment of clavicle fractures in high school athletes. METHODS: A retrospective review of clavicle fractures sustained in scholastic athletes participating in school-sponsored athletics in the upstate South Carolina was performed from 2015 to 2019. Injury circumstances, demographics, radiographs, treatment, and return to sport data were documented for all patients. Radiographs were evaluated for fracture location, comminution, displacement, shortening, and angulation. Patients were followed until complete return to sport, and results were compared based on sport participation, injury mechanism, fracture morphology, treatment type, and time to return to sport. RESULTS: Forty-seven patients (44 were male; average age 15.6 years) were included who all returned to sport within the original or subsequent season. Thirty-six patients (73%) were managed conservatively (30 middle third fractures, 4 medial third fractures, 2 distal third fractures), whereas 11 were managed surgically (11 middle third fractures). Eighty-one percent of fractures occured in collision athletes (55% in football). There was no difference in time loss based on participating in collision vs. noncontact sports (P = .4). Conservatively managed fractures returned to sport faster (61 ± 38 days vs. 100 ± 49 days; P = .008) compared with surgically managed patients. Fracture displacement ≥100% (100 ± 51 days vs. 54 ± 27 days; P = .001), greater comminution (128 ± 50 days vs. 59 ± 31 days; P = .001), and angulation (86 ± 52 days vs. 54 ± 22 days; P = .001) all were statistically significant for slower return to sport. Athletes presenting with clavicular shortening <2 cm returned to sport within a similar time frame as athletes with ≥2 cm (P = 0.1). CONCLUSION: Our results show that adolescent athletes with clavicular fractures predictably return to athletics, including collision sports. Athletes conservatively managed returned 40% faster than those with surgery. However, this appears to be associated with the severity and complexity of fractures treated surgically. This study provides evidence to counsel adolescent athletes following clavicular fractures on return to sport expectations.

Traumatic Brachial Plexopathy in Athletes: Current Concepts for Diagnosis and Management of Stingers.

Traumatic upper trunk brachial plexopathy, also known as a stinger or burner, is the most common upper extremity neurologic injury among athletes and most commonly involves the upper trunk. Recent studies have shown the incidence of both acute and recurrent injuries to be higher in patients with certain anatomic changes in the cervical spine. In addition, despite modern awareness, tackling techniques, and protective equipment, some think the incidence to be slowly on the rise in contact athletes. The severity of neurologic injury varies widely but usually does not result in significant loss of playing time or permanent neurologic deficits if appropriate management is undertaken. Timely diagnosis allows implementation of means to minimize the risk of recurrent injury. It is important for treating physicians to understand the pathogenesis, evaluation, and acute and long-term management of stingers to improve recovery and minimize chronic sequela.

Unusual presentation of failed metal-on-metal total hip arthroplasty with features of neoplastic process.

Metal-on-metal (MoM) total hip arthroplasty (THA) is associated with increased incidence of failure from metallosis, adverse tissue reactions, and the formation of pseudotumors. This case highlights a 53-year-old female with an enlarging painful thigh mass 12 years status post MoM THA. Radiographs and advanced imaging revealed an atypical mass with cortical bone destruction and spiculation, concerning for periprosthetic malignancy. Open frozen section biopsy was performed before undergoing revision THA in a single episode of care. This case illustrates that massive pseudotumors can be locally aggressive causing significant femoral bone destruction and may mimic malignancy. It is important that orthopaedic surgeons, radiologists and pathologists understand the relative infrequency of periprosthetic malignancy in MoM THA to mitigate patient concerns, misdiagnosis, and allow for an evidence based discussion when treating massive pseudotumors.

Ankle fractures in the elderly: risks and management challenges.

Ankle fractures are the third most common osseous injury in the elderly, behind hip and distal radius fractures. While there is a rich history of clinical advancement in the timing, technique, perioperative management, and associated risks of hip fractures, similar evaluations are only more recently being undertaken for ankle fractures. Traditionally, elderly patients were treated more conservatively; however, nonoperative management has been found to be associated with increased mortality. As such, older and less healthy patients have become operative candidates. The benefits of geriatric/orthopedic inpatient comanagement that have been well elucidated in the hip fracture literature also seem to improve outcomes in elderly patients with ankle fractures. One of the orthopedist's roles is to recognize the complexities of osteoporotic bone fixation and optimize wound healing potential. Though the immediate cost of this surgical approach is inevitably higher, the ultimate cost of long-term care has been found to be substantially reduced. It is important to consider the mortality and morbidity benefits and cost reductions of operative intervention and proper inpatient care of geriatric ankle fractures when they present to the emergency department or the office.

Costs Associated With Geriatric Ankle Fractures.

INTRODUCTION: Ankle fractures are the third most common orthopaedic injury seen in the geriatric patient. Studies have identified mortality benefits with operative management, but treatment must be considered on a case-by-case basis. In the era of value-based analysis, a thorough of understanding of outcomes and costs of treatment is required. The purpose of this study was to analyze the inpatient and readmission costs associated with operative and nonoperative management of geriatric ankle fractures. METHODS: Patients were identified using diagnosis codes for ankle fractures from all 2008 Part A Medicare claims. Patients younger than 65 years and those who sustained an ankle fracture during the previous year were excluded. Operative patients were then identified by ICD-9 procedure codes. Other variables collected included age, comorbidities, and the incidence of hospital readmissions. Inpatient costs were determined using Medicare reimbursement data. RESULTS: A total of 19 648 patients with ankle fractures were identified. Of these, 15 193 (77.3%) underwent operative intervention. The mean cost for initial fracture admission was $5097.20 for nonoperative management compared with $8798.10 for operative management ( P < .05). The mean inpatient costs associated with readmission for nonoperative intervention was $5161.50 and for operative treatment, it was $5071.40 ( P > .05). The reimbursement for hospital readmissions for both groups combined for approximately $29.7 million. The total cost of initial treatment plus readmission for both treatment groups combined was approximately $185 million. DISCUSSION: The total expenditure estimate of $185 million in this study has likely increased given the steady growth of the geriatric population. Expenditures associated with these readmissions was approximately $30 million-nearly a sixth of total costs. Future work must focus on determining which patients will benefit from operative intervention and optimizing care to decrease readmissions and their associated cost in this growing cohort of patients. LEVELS OF EVIDENCE: Therapeutic, Level III: Retrospective study.