Case Report: A Rare Case Of Bilateral Tibial Plafond Fracture In A Young Soldier.

Introduction: Tibial pilon fractures, involving the weight-bearing surface of the distal tibia,present a formidable challenge for orthopedic surgeons due to their complex nature and the delicate soft tissue envelope surrounding the ankle joint.Early approaches to pilon fracturesoften resulted in poor outcomes, but modern principles of internal fixation and anatomicalreconstruction have significantly improved patient prognosis. Despite advancements in surgicaltechniques and implants, achieving anatomical reduction of the articular surface remains asignificant hurdle. Case Report: This article presents a case report of a 27-year-old male soldier who sustained bilateral tibial pilon fractures following a fall from height. The patient underwent surgical intervention with differing approaches due to the complexity of the fractures. A combination of minimally invasive plate osteosynthesis (MIPPO) and external fixation was employed to address the fractures. The patient was followed up for 06 months post-op. Conclusion: The importance of respecting the soft tissue envelope in surgical planning and timing, as well as the role of advanced imaging techniques such as CT scanning in preoperative assessment is crucial to achieving a successful outcome.While tibial pilon fractures remain complex injuries, advancements in surgical management have led to improved outcomes. However, ongoing research and innovation are necessary to address the multifaceted challenges associated with these fractures and optimize patient care.

A Unique "Galeazzi-Like" Fracture through a Vacated External-Fixator Pin Track: A Case Report.

Introduction: Galeazzi fractures are fractures of the radial shaft accompanied by distal radioulnar joint (DRUJ) instability. They usually occur due to a mechanical fall or direct trauma to the wrist or forearm. Management of this serious injury varies from non-operative treatment with closed reduction and splinting to operative fixation using an external fixator (ex-fix) or open reduction internal fixation with plate and screws. Case Report: We present a 76-year-old female who presented with a right distal radius fracture after a ground-level fall. Due to fracture displacement after initial conservative management, she was placed in an external fixator for stabilization. After removal of the ex-fix, she sustained a midshaft radius fracture with DRUJ malalignment, consistent with a "Galeazzi-like" fracture. Conclusion: "Galeazzi-like" fractures with associated DRUJ malalignment can occur from previous external fixator pin sites and are adequately treated with standard operative fixation.

Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review.

Introduction: External fixation devices are commonly used in orthopaedic surgery to manage a range of pathologies. In this patient population, there is currently no consensus on optimal rehabilitation techniques. There exists a large variation in practice, with a limited understanding of how these affect treatment outcomes. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review was conducted of Allied and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PEDro, and COCHRANE databases, grey literature sources and forward and backward searching of included articles. Studies were selected following rigorous screening with predefined inclusion criteria. Data quality was assessed using validated appraisal tools. Articles were synthesised by rehabilitation type and descriptive analysis was subsequently performed. Results: From 1,156 articles identified, 18 were eligible for inclusion. The overall quality was low, with clinical commentaries and case studies being the most common study type. Studies were synthesised by rehabilitation type, the most common themes being gait re-education, strengthening, therapy-assisted, active exercises and weight-bearing exercises. Conclusion: There is a lack of high-quality evidence to support meaningful recommendations and guide rehabilitation practices for this patient cohort. Further research for patients being treated in external fixation, especially related to the potential effects of physical rehabilitation on bone healing, return of strength, mobility and independent function is likely to have transferability within wider orthopaedic populations. Clinical significance: This systematic review is unable to provide clinical recommendations due to the poor quality of the available literature. However, it is hoped this paper will provide a foundation for further research to improve rehabilitation for patients being treated with external fixation. How to cite this article: Pawson JR, Church D, Fletcher J, et al. Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review. Strategies Trauma Limb Reconstr 2024;19(1):45-55.

Outcomes of open pelvic fractures: A case series.

Introduction: Albeit rare, open pelvic fractures are life threatening injuries associated with significant morbidity and mortality. Due to their rarity, there is paucity of data and literature on best management practices. An open pelvic fracture is one where there is a connection between the fracture site and either the skin, rectum, vagina, or genitourinary system. They commonly affect young individuals involved in high energy injuries. During resuscitation, prompt recognition and control of sepsis and stabilization of unstable fractures should precede definitive management. Materials and methods: We conducted a retrospective study of prospectively collected data between 2012 and 2022 for patients managed in two teaching hospitals in Kenya. All patients were followed up for at least 6 months. The Faringer classification was used to classify the soft tissue wounds and the Young and Burgess classification was used to classify the pelvic fractures. We investigated their functional outcomes using their ability to ambulate independently and the Merle d' Aubigne-Postel score. Results: Eight patients with an average age of 31 years were included. All were referrals. Three (37.5 %) developed sepsis but resolved. Four (50 %) needed a diverting stoma, which included 2 of the 3 patients who had developed sepsis. 5(62.5 %) needed an external fixator as part of definitive management. There were no mortalities. All achieved full independent ambulation; and all our patients achieved an average Merle d' Aubigne-Postel score of 17. Conclusion: Our study demonstrates that early sepsis control, appropriate fracture fixation and a multidisciplinary approach can yield satisfactory functional outcomes.

The role of anterior supra-acetabular external fixator as definitive treatment for anterior ring fixation in unstable pelvic fractures.

PURPOSE: Management of anterior ring injuries is still a matter of discussion, and there are only few studies reporting anterior external fixator as definitive treatment for unstable pelvic injuries. This study aimed to describe the clinical and radiological outcomes of a consecutive series of mechanically unstable pelvic injuries that were treated with definitive anterior supra-acetabular external fixator for the anterior ring, and to identify risk factors for failure. METHODS: We included a consecutive series of patients with unstable pelvic ring fractures who underwent anterior supra-acetabular external fixation for definitive treatment, between January 2012 and January 2020. All demographics, associated injuries and procedures, injury mechanism, and complications were analysed. Pelvic fracture was classified based on Orthopaedic Trauma Association/Tile AO (OTA/AO) and Young-Burgess classifications. Complications associated with the external fixator were revised. All patients were functionally evaluated at final follow-up and asked to report their clinical outcomes using the Majeed score. RESULTS: A total of 47 patients were included, of which 25 were females. The median age was 44 years (interquartile range 23-59). Median follow-up duration was 14 months (interquartile range 6-31). The most frequent aetiology was motor vehicle accident (35), followed by fall from height (8). All fractures required posterior pelvic ring fixation. The median time during which patients had external fixation in situ was 11 weeks (interquartile range 9-13). All patients achieved healing of pelvic fracture at median time of 10 weeks (interquartile range 8-12). At final follow-up, the median displacement of the anterior pelvis was 6 mm (interquartile range 0-11). Superficial infection was the most common complication (n = 7). No washout procedures were needed. No major complication was reported. No patient required reoperation for anterior ring fracture. The median Majeed score was 88 points (range 60-95; interquartile range 80-90) at final follow-up. CONCLUSION: Our findings suggest that the use of supra-acetabular external fixator is safe and effective for definitive treatment of the anterior ring in unstable pelvic fractures. It is a method with high proportion of excellent results, regardless of the type of fracture. The rate of complications is low, and it does not compromise functional results.

Case Report: Virtual Reality Analgesia in an Opioid Sparing Orthopedic Outpatient Clinic Setting: A Case Study.

Immersive virtual reality is proving effective as a non-pharmacologic analgesic for a growing number of painful medical procedures. External fixator surgical pins provide adjunctive stability to a broken pelvic bone until the bones heal back together, then pins are removed. The purpose of the present case study was to measure for the first time, whether immersive virtual reality could be used to help reduce pain and anxiety during the orthopedic process of removing external fixator pins from a conscious patient in the orthopedic outpatient clinic, and whether it is feasible to use VR in this context. Using a within-subject within wound care design with treatment order randomized, the patient had his first ex-fix pin unscrewed and removed from his healing pelvic bone while he wore a VR helmet and explored an immersive snowy 3D computer generated world, adjunctive VR. He then had his second pin removed during no VR, standard of care pain medications. The patient reported having 43% less pain intensity, 67% less time spent thinking about pain, and 43% lower anxiety during VR vs. during No VR. In addition, the patient reported that his satisfaction with pain management was improved with the use of VR. Conducting simple orthopedic procedures using oral pain pills in an outpatient setting instead of anesthesia in the operating room greatly reduces the amount of opioids used, lowers medical costs and reduces rare but real risks of expensive complications from anesthesia including oversedation, death, and post-surgical dementia. These preliminary results suggest that immersive VR merits more attention as a potentially viable adjunctive non-pharmacologic form of treatment for acute pain and anxiety during medical procedures in the orthopedic outpatient clinic. Recent multi-billion dollar investments into R and D and mass production have made inexpensive immersive virtual reality products commercially available and cost effective for medical applications. We speculate that in the future, patients may be more willing to have minor surgery procedures in the outpatient clinic, with much lower opioid doses, while fully awake, if offered adjunctive virtual reality as a non-pharmacologic analgesic during the procedure. Additional research and development is recommended.

External fixation of unstable pelvic fractures: a systematic review and meta-analysis.

BACKGROUND: Unstable pelvic fractures are typically caused by high-impact trauma. Early stabilization is required to prevent further neurological or visceral injury, haemorrhage, reduce pain, infection and long-term deformity and disability. The aim was to review the optimal external fixation techniques and management for unstable pelvic fractures. METHODS: A total of 28 studies were identified from the initial database search. Seventeen studies met our inclusion criteria - eight prospective cohorts, four retrospective cohorts and five in vitro studies. This equated to 539 patients and 38 cadaveric (in vitro) models. RESULTS: Type B and double vertical fractures have less re-displacement (43.7% and 68.2% <5 mm, respectively) than Type C fractures (55.7% >15 mm) regardless of pin placement. Greater than 50% experience a complication with the most common being pin site infection (36%) and a trend towards increased infection with increasing pins was seen. Most can be managed with antibiotics alone (93%). A minimum time of 6-8 weeks in frame was required for definitive management of all fractures. CONCLUSION: This review supports the use of supra-acetabular pins over iliac crest pins to decrease re-displacement, the least number of pins for the shortest amount of time and the largest size pin where possible. Type B fractures will generally have a better outcome than Type C fractures. Definitive management in a frame should be at least 8 weeks. Further studies directly comparing iliac crest and supra-acetabular pin placement are recommended.

Improvised External Fixation-a Modification.

A modification is presented to a commonly used type of improvised external fixator for hand fractures. Our modified fixator is easy to apply and allows fracture manipulation in three dimensions after application, before the cement sets.