Education Improves Musculoskeletal Radiology Interpretation by Trainees in a Low-Resource Setting.

OBJECTIVE: The aims of this study were to assess baseline musculoskeletal radiology knowledge among Haitian orthopedists and to determine the impact of an adult and pediatric musculoskeletal radiology lecture series. DESIGN: Participants were given lectures reviewing normal and abnormal elbow radiographs and received assessments before and after the intervention. Bivariate and multivariate analyses were used to identify factors associated with baseline and postintervention scores. SETTING: This study was carried out as part of the 2018 Haitian Annual Assembly of Orthopaedic Trauma. This is an annual continuing medical educational conference in the capital city of Port-au-Prince open to all Haitian orthopedic surgeons and associated care providers, with a strong focus on resident training. PARTICIPANTS: Haitian orthopedic surgery residents and surgeons attending the 2018 Haitian Annual Assembly of Orthopaedic Trauma. RESULTS: Thirty-seven residents and faculty consented to participate in this study and 32 (86.5%) were male with a median age of 33 (interquartile rage: 30-35). On multivariate analysis controlling for the title (resident versus attending), total years of orthopedics (beginning of residency and beyond), and formal radiology teaching in medical school or residency, conference attendance in the past was significantly associated with higher preintervention assessment scores (odds ratio = 1.24, 95% confidence interval = 1.06-1.44, p = 0.010]. The mean total preintervention accuracy for correctly identification of pathology, if present, was 70% compared to 83% at the postassessment (p < 0.001). CONCLUSIONS: Overall, this study demonstrates that a brief lecture series at a continuing medical conference in Port-au-Prince, Haiti improved upper extremity radiographic interpretation based on pre and postassessments, and that prior conference attendance may be associated with higher baseline scores.

Associations between upper extremity injury patterns in side impact motor vehicle collisions with occupant and crash characteristics.

INTRODUCTION: Side impact motor vehicle collisions (MVC) represent a significant burden of mortality and morbidity caused by automotive injury within the United States. The objective of this study was to evaluate the relationship between upper extremity (UE) injury patterns and contact sources in side impact MVC with occupant and crash variables. METHODS: Crash Injury Research and Engineering Network data obtained from 1998 to 2012 were used to evaluate UE injuries in side impact crashes. First row drivers and passengers that were at least 16 years old with complete crash information were included. Side impact crashes were defined to have an area of deformation to the side of the vehicle and a principal direction of force between 60° and 120° or 240° and 300°. Injuries were stratified by type, anatomic location, and Abbreviated Injury Scale (AIS) severity. Occupant variables included age, sex, height, weight, body mass index, and Injury Severity Score. Vehicle and crash variables included in the analysis were change in vehicle velocity at the time of impact, maximum door intrusion, maximum B-pillar intrusion, seat track position, belt use, vehicle type, impact type, and injury source. Statistical analysis of the UE injury data included descriptive statistics, linear regression analyses with occupant variables, and logistic regression analyses with vehicle and crash variables. RESULTS: There were 903 UE injuries among 408 case occupants. The most common injury type was soft tissue injury (72.5%). The majority of fractures were proximal to and including the humerus (70.3%) with the clavicle being the most common fracture location (N = 89). AIS 2+ UE injuries were associated with a significantly higher mean occupant Injury Severity Score than AIS 1 UE injuries (p = 0.01). Contact with the door was the leading cause of UE injury (34.2%). The odds (OR [95% confidence interval], p-value) of an AIS 2+ UE injury due to contact with the B-pillar (5.3 [3.1, 9.1], <0.0001), door (1.9 [1.3, 2.7], 0.0006), and steering wheel/assembly (2.7 [1.1, 6.3], 0.03) were significantly higher than all other injury sources combined. Scapula fractures were significantly associated with rearward seat track positions (1.46 [1.04, 2.05], 0.03). CONCLUSIONS: This study provides insight into UE injury patterns in side impact MVC. The clavicle was the most common UE fracture location. Contact with the door resulted in the highest number of UE injuries and the B-pillar resulted in the most severe injuries. Additionally, exposure to greater B-pillar intrusion was associated with increased odds of scapula and clavicle fractures in side impacts.

Clinical Outcomes and Complications of the Surgical Implant Generation Network (SIGN) Intramedullary Nail: A Systematic Review and Meta-Analysis.

OBJECTIVES: This study is a systematic review and meta-analysis of the clinical outcomes and pooled complication rate of femoral, tibial, and humeral fracture fixation using SIGN nails. We aimed at comparing the pooled rate of adverse events based on the country of study origin, acute versus delayed fracture fixation, and length of follow-up. METHODS: We searched PubMed/MEDLINE/Cochrane databases from 2000 to 2016 for English language studies. There was substantial heterogeneity among included studies. Therefore, we used subgroup analysis of varying adverse events and removal of potential outlier studies based on the "remove one" sensitivity analysis to address the heterogeneity across studies. A funnel plot was drawn and inspected visually to assess publication bias. We reported pooled complication rates for each adverse event with 95% prediction interval. RESULTS: There were 14 studies with 47,169 cases across 58 different low- and middle-income countries. The average age was 33 ± 14 years, with 83% men and 17% women. Sixty percent of SIGN nails used in these 14 studies were used in femur fracture fixation, 38% in tibial shaft fractures, and the remaining 2% for humeral shaft fractures. Approximately 23% of patients had follow-up data recorded. All studies that measured clinical outcome indicated that >90% achieved full weight-bearing status, favorable range of motion (knee range of motion >90 degrees according to the SIGN database), and radiographic or clinical union depending on the specific variable(s) measured in each study. The overall complication rate was 5.2% (4.4%-6.4%). Malalignment (>5 degrees of angulation in any plane) was the most common complication (7.6%), followed by delayed/nonunion (6.9%), infection (5.9%), and hardware failure, (3.2%). CONCLUSIONS: Overall, the use of SIGN nails in fixing femoral, tibial, and humeral shaft fractures demonstrates good results with a high rate of return to full weight-bearing and radiographic/clinical union. The most common complications when using the SIGN nail are malalignment, delayed/nonunion, infection, and hardware failure. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk of mortality in individuals with low QRS voltage and free of cardiovascular disease.

The prognostic significance of low QRS voltage (LQRSV) in the electrocardiogram (ECG) of individuals free of cardiovascular disease (CVD) is unclear. We evaluated the association between LQRSV and all-cause mortality in 6,440 participants (53% women, mean age 60 years) from the Third National Health and Nutrition Examination Survey, a representative sample of the US population. Participants with history of CVD or major ECG abnormalities were excluded. LQRSV was automatically defined from standard 12-lead ECG as QRS complex amplitudes of <0.5 mV in all frontal leads and/or <1.0 mV in all precordial leads. Mortality data through 2006 were obtained from National Death Index records. LQRSV was detected in 1.4% (n = 89) of the participants. During a median follow-up of 13.8 years, 2,000 deaths occurred. The mortality rate in individuals with LQRSV was almost twice that in those without LQRSV (51.1 vs 23.5 events per 1,000 person-years, p <0.01). In a demographic-adjusted model, LQRSV was associated with 63% increased risk of mortality (hazard ratio 1.63, 95% confidence interval [1.21, 2.18]). The magnitude of this risk did not appreciably change after additional adjustment for body mass index, smoking status, systolic blood pressure, blood pressure medication use, dyslipidemia, diabetes, cancer, pulmonary disease, and ECG abnormalities (hazard ratio 1.61, 95% confidence interval [1.20, 2.16]) and was consistent across age, race, and sex subcategories. In conclusion, LQRSV is associated with an increased risk of mortality in individuals free of apparent CVD. More research is warranted to determine the mechanisms by which LQRSV is associated with increased risk of mortality in apparently healthy individuals.