Closed reduction of glenohumeral dislocations with associated tuberosity fracture in the emergency department is safe.

AIM: A fracture of the tuberosity is associated with 16% of glenohumeral dislocations. Extension of the fracture into the humeral neck can occur during closed manipulation, leading some to suggest that all such injures should be managed under general anaesthesia in the operating theatre. The purpose of this study was to establish the safety of reduction of glenohumeral dislocations with tuberosity fractures in the emergency department (ED). PATIENTS AND METHODS: We reviewed 188 consecutive glenohumeral dislocations with associated tuberosity fractures identified from a prospective orthopaedic trauma database. Patient demographics, injury details, emergency department management and complications were recorded. The method of reduction, sedation, grade of clinician and outcome were documented. RESULTS: The mean age was 61 years (range 18-96 years) with 79 males and 109 females. The majority of injuries (146, 78%) occurred after a fall from standing height. Closed reduction under sedation in the ED was successful in 162 (86%) cases. Of the remainder, 22 (11%) failed closed reduction under sedation and subsequently went to theatre and 6 (3%) were deemed not suitable for ED manipulation. At presentation 35 (19%) patients had a nerve injury, of which 29 (90%) resolved spontaneously. Two iatrogenic fractures occurred during close manipulation, one in the ED and the other in the operating theatre. Therefore, the risk of iatrogenic propagation of the fracture into the proximal humerus neck was 0.5% if the reduction was performed in the ED, and 1% over-all. More than two attempted reductions predicted a failed ED reduction (P = 0.001). CONCLUSION: Closed reduction of glenohumeral dislocations with associated tuberosity fractures in the ED is safe, with a rate of iatrogenic fracture of 1%. These injuries should be managed by those with appropriate experience only after two adequate radiographic views. In cases where there is ambiguity over the integrity of the humeral neck, reduction should be delayed until multiplanar CT imaging has been obtained.

Percutaneous reduction and fixation of low energy Lisfranc injuries results in better outcome compared to open reduction and internal fixation: Results from a matched case-control study with minimum 12 months follow up.

BACKGROUND: Percutaneous fixation of Lisfranc injuries is potentially less invasive to traditional open techniques but evidence of any clinical benefit is lacking. The aim of this study is to compare the clinical outcomes of percutaneous reduction and internal fixation (PRIF) of low energy Lisfranc injuries with a matched, control group of patients treated with ORIF. METHODS: Over a seven-year period (2012-2019), 16 consecutive patients with a low energy Lisfranc injury (Myerson B2-type) were treated with PRIF. Patient demographics, injury mechanism and radiological outcomes were recorded within a prospectively maintained database at the institution. This study sample was matched for age, sex and mechanism of injury to a control group of 16 patients with similar low energy Lisfranc injuries (Myerson B2-type) treated with ORIF. Clinical outcome was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ). RESULTS: At a mean follow up of 43 months (95% CI 35.6 - 50.4), both the AOFAS and MOXFQ scores were significantly higher in the PRIF group compared to the control ORIF group (AOFAS 89.1vs 76.4, p=0.03; MOXFQ 10.0 vs 27.6, p=0.03). There were no immediate postoperative complications in either group. There was no radiological evidence of midfoot osteoarthritis in the PRIF group, three patients in the ORIF group developed midfoot osteoarthritis (p=0.2). CONCLUSIONS: PRIF of low energy Lisfranc injures is a safe, minimally invasive technique and is associated with better mid-term clinical outcomes compared to ORIF.

Biomechanical Comparison of Intramedullary Fibular Nail Versus Plate and Screw Fixation.

BACKGROUND: Clinical evidence has shown that percutaneous ankle fracture fixation using an intramedullary fibular nail results in good outcomes at 1 year and reduces postoperative wound complications in patients with vulnerable soft tissues. Confirmatory biomechanical evidence of its strength when used to secure a supination external rotation (SER) IV (AO/OTA 44B-type) fracture, compared with traditional plates and screws, is currently lacking. METHODS: Twenty cadaveric lower limbs (10 cadavers) had a SER IV injury surgically created. One leg was randomly allocated to fixation with a fibular nail and the other a lag screw and neutralization plate. A mechanical testing apparatus subjected all lower limbs to an axially loaded supination external rotation force to failure. RESULTS: Superior ultimate torque to failure was demonstrated with a trend toward increased energy absorption in the nail group ( P = .28 and .07, respectively). No difference was demonstrated in angle at failure. All specimens in the plate group lost reduction at the bone-metal interface as a result of screw pullout. In contrast, all specimens in the nail group failed because of disruption of the lateral ligaments. CONCLUSIONS: This study demonstrated greater torque to failure and better maintenance of the fibular construct for the intramedullary fibular nail compared to standard plating. CLINICAL RELEVANCE: These results suggest that the previously documented clinical benefits of the fibular nail are complemented by biomechanical properties that compare favorably to standard techniques.