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.

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.

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.

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.

Patient-reported outcomes after operative versus nonoperative treatment of pediatric lateral humeral condyle fractures.

ABSTRACT: Lateral humeral condyle fractures in children are treated with several approaches, yet it is unclear which has the best treatment outcomes. We hypothesized that functional outcomes would be equivalent between treatment types, reduction approaches, and fixation types. Our purpose was to assess patient-reported outcomes and complications by treatment type (operative versus nonoperative), reduction approach (open versus percutaneous), and fixation type (cannulated screws versus Kirschner wires).We retrospectively reviewed data from acute lateral humeral condyle fractures treated at our level-1 pediatric trauma center from 2008 to 2017. Patients were included if they were 8 years or older and had completed clinical follow-up. Fractures were categorized by fracture severity as mild (<2-mm displacement), moderate (isolated, 2- to 5-mm displacement), or severe (isolated, >5-mm displacement or >2-mm displacement with concomitant elbow dislocation or other elbow fracture). We extracted data on patient age, sex, treatment type, reduction approach, fixation type, patient-reported outcomes (shortened Disabilities of the Arm, Shoulder, and Hand and Patient Reported Outcome Measurement Information System upper extremity), treatment complications, and follow-up duration. Patients in the operative versus nonoperative group and across fracture severity subgroups did not differ significantly by age, sex, or follow-up duration. Bivariate analysis was performed to determine whether outcomes differed by intervention. Alpha = 0.05.No differences were observed in patient-reported outcomes between operative versus nonoperative groups for the mild and severe fracture subgroups. No differences were observed between approach (open versus percutaneous) or instrumentation (cannulated screw versus Kirschner wire fixation) for any outcome measure within the operative group. Patients whose fractures were stabilized with screws versus wires had significantly higher rates of return to the operating room (94% versus 8.3%, P < .001). The overall complication rate for our cohort was low, with no differences by treatment type or fracture severity.In our cohort, patient-reported outcomes were similar across fracture severity categories, irrespective of treatment or fixation type. Patients who underwent internal fixation with cannulated screws experienced significantly higher rates of return to the operating room compared with those treated with Kirschner wires but otherwise had similar complication rates and patient-reported outcomes.Level of Evidence: 3.

Closed Reduction for the Treatment of Grade IV Supination-External Rotation Fracture of the Ankle Joint: A Retrospective Analysis.

OBJECTIVE: To investigate the curative effect of closed reduction and external fixation in the treatment of grade IV supination-external rotation fractures of the ankle joint. METHODS: Fifty-six patients treated with closed reduction and external fixation from February 2016 to March 2020 were included in this retrospective study, all with sprains. After receiving nerve block anesthesia, the patient underwent closed reduction under C-arm fluoroscopy, and the ankle joint was fixed in a dorsiflexion-inversion position with casting and splints after the end of the fracture met the reduction standard by fluoroscopy. One week and four weeks after the reduction treatment, oblique axial and coronal MR scans of the ankle joint were performed to determine the degree of injury and healing of the inferior tibiofibular syndesmosis; anteroposterior and lateral X-rays of the ankle joint (including the ankle acupoints) were regularly reviewed to observe the fracture alignment and healing. Combined with the images and physical examination, the patients were instructed to undergo ankle weight-bearing rehabilitation training when they met the clinical healing standard, and at the last follow-up, the Mazur ankle evaluation and grading system were used for evaluation. After the reduction, the images were evaluated according to the Leeds standard. The image healing of fracture was evaluated by callus growth criteria. RESULTS: The follow-up period of patients ranged from 11 to 58 months, with an average of 26.8 months. The clinical healing time was (8.51 ± 2.12) weeks. The excellent and good rating after reduction was 82.1%, and the excellent and good rating during clinical fracture healing was 73.2%, according to the Leeds imaging evaluation. According to the Mazur ankle evaluation and grading system, the excellent and good rating was 75.0%. Pairwise comparison of callus images at 4, 6 and 12 weeks showed statistically significant differences (P < 0.05), suggesting callus growth at different time periods. A total of 56 patients had anterior inferior tibial fibular ligament (AITFL) injuries (grade II-III), among which 11 patients had AITFL injuries combined with grade II injuries of the interosseous ligament (IOL) and 4 patients had AITFL injuries combined with grade III injuries of the IOL. CONCLUSIONS: Most of the patients with grade IV supination-external rotation fracture of the ankle joint had good prognosis after closed reduction and plaster combined with splint fixation. For patients with IOL injury who had poor prognosis, open reduction and internal fixation therapy is appropriate.

Complications of traditional bonesetting in contemporary fracture care in low- and middle-income countries: A systematic review.

OBJECTIVE: To provide an overview of the evidence on the prevalence and pattern of complications among patients treated by traditional bonesetting presenting for modern orthopaedic services in low- and middle-income countries (LMIC). METHODS: Systematic review following PRISMA guidelines. Articles were identified by searching PubMed, Embase, ScienceDirect, SCOPUS, and Web of Science using the keywords "fracture care", "traditional bonesetters" and "complications". Papers included for review were original articles set in an LMIC that directly reported the prevalence and pattern of musculoskeletal complications of traditional bonesetters' fracture treatment in LMIC settings. RESULTS: A total of 176 papers were screened for eligibility and 15 studies were finally included. Nine were prospective studies, six were retrospective studies. All were hospital-based, observational studies that investigated the outcomes of treatment of fractures by traditional bonesetters published between 1986 and 2018. In total, this review covers 1389 participants with 1470 complications of fracture treatment. CONCLUSION: Traditional bonesetting complications are associated with significant morbidity. However, traditional bonesetters have the potential to contribute positively to primary fracture care when they are trained.

Clinical efficacy of closed reduction and percutaneous parallel K-wire interlocking fixation of first metacarpal base fracture.

BACKGROUND: This study aimed to explore the clinical efficacy of treating a first metacarpal base fracture by closed reduction and percutaneous parallel K-wire interlocking fixation between the first and second metacarpals. METHODS: Twenty patients treated by the abovementioned modified technique (modified technique group) and ten patients treated by the traditional percutaneous K-wire fixation technique (traditional technique group) from October 2015 to November 2019 at our institution were retrospectively reviewed. The patients' average age was 38 years (range, 16-61 years). The mean follow-up period was 13 months (range, 10-18 months). At the final follow-up, the functional recovery of the injured hand was assessed and compared between the modified and traditional technique groups. In addition, the functional recovery of the injured hand was compared with that of the uninjured hand within the modified technique group. RESULTS: All patients recovered well, with no cases of infection or nonunion. Compared with the traditional technique group, the modified technique group had a shorter operative time, lower postoperative visual analogue scale pain score, better effective range of motion score of the first carpometacarpal joint (Kapandji score), and had almost no need for auxiliary plaster fixation, enabling functional exercise to be started earlier. Within the modified technique group, the mean hand grip strength, pinch strength, and Kapandji score on the injured side did not significantly differ to the values on the uninjured side in both the extra-articular and intra-articular fracture subgroups. While the abduction and flexion-extension arcs of the thumb on the injured hand were significantly smaller than those on the uninjured hand in both the extra-articular and intra-articular fracture subgroups, the patients felt clinically well with respect to daily activities and strength. CONCLUSION: The percutaneous parallel K-wire and interlocking fixation technique is simple, effective, and economical for first metacarpal base fractures.

Comparison of lateral entry and crossed entry pinning for pediatric supracondylar humeral fractures: a meta-analysis of randomized controlled trials.

BACKGROUND: Closed reduction and pinning entry fixation have been proposed as treatment strategies for displaced supracondylar humeral fractures (SCHFs) in children. However, controversy exists regarding the selection of the appropriate procedure. Hence, this meta-analysis was conducted to compare the effect of lateral and crossed pin fixation for pediatric SCHFs, providing a reference for clinical treatment. METHODS: Online databases were systematically searched for randomized controlled trials (RCTs) comparing lateral pinning entry and crossed pinning entry for children with SCHFs. The primary endpoints were iatrogenic ulnar nerve injuries, complications, and radiographic and functional outcomes. RESULTS: Our results showed that iatrogenic ulnar nerve injuries occurred more commonly in the crossed pinning entry group than in the lateral pinning entry group (RR = 4.41, 95% CI 1.97-9.86, P < 0.05). However, its risk between the crossed pinning with mini-open incisions group and the lateral pinning entry group was not significantly different (RR = 1.58, 95% CI 0.008-29.57, P = 0.76). The loss of reduction risk was higher in the lateral pinning entry group than in the crossed pinning entry group (RR = 0.66; 95% CI 0.49-0.89, P < 0.05). There were no significant differences in the carry angle, Baumann angle, Flynn scores, infections, and other complications between these two groups. CONCLUSIONS: The crossed pinning entry with mini-open incision technique reduced the loss of reduction risk, and the risk of iatrogenic ulnar nerve injury was lower than in the lateral pinning entry group. The crossed pinning entry with mini-open incision technique is an effective therapeutic strategy for managing displaced supracondylar humeral fractures in children.

Sagittal plane alignment affects the strength of pin fixation in supracondylar humerus fractures.

ABSTRACT: Closed reduction with percutaneous pin fixation is commonly used to treat pediatric supracondylar humerus fractures. Various pin configurations of varying biomechanical strength have been described. However, to our knowledge, no biomechanical study has focused on pin alignment in the sagittal plane. Our goal was to compare the stability of fixation using 3 different pin constructs: 3 lateral pins diverging in the coronal plane but parallel in the sagittal plane (3LDP), 3 lateral pins diverging in the coronal and sagittal planes (3LDD), and 2 crossed pins (1 medial and 1 lateral).Transverse fractures were made through the olecranon fossa of 48 synthetic humeri, which were then reduced and pinned in the 3LDP, 3LDD, and crossed-pin configurations (16 specimens per group) using 1.6-mm Kirschner wires. The sagittal plane pin spread was significantly greater in the 3LDD group than in the 3LDP group, whereas we found no difference in the coronal plane. Sagittal extension testing was performed from 0° to 20° at 1°/s for 10 cycles using a mechanical torque stand. The torque required to extend the distal fragment 20° from neutral was compared between groups using one-way analysis of variance with multiple comparison post-hoc analysis. P values ≤.05 were considered significant.The 3LDD configuration was more stable than the 3LDP and crossed-pin configurations. The mean torque required to displace the pinned fractures was 5.7 Nm in the 3LDD group versus 4.1 Nm in the 3LDP group and 3.7 Nm in the crossed-pin group (both, P < .01). We found no difference in stability between the 3LDP and crossed-pin groups (P = .45).In a synthetic biomechanical model of supracondylar humerus fracture, sagittal alignment influenced pin construct stability, and greater pin spread in the sagittal plane increased construct stability when using 3 lateral pins. The lateral pin configurations were superior in stability to the crossed-pin configuration.Level of Evidence: Level V.

A novel retractor-assisted closed reduction combined with percutaneous pinning fixation for the treatment of elderly distal radius fractures: a retrospective cohort study.

BACKGROUND: Percutaneous pinning fixation (PCP) has been used for the treatment of distal radius fractures for decades, especially in the elderly with fragile soft tissue. However, achieving and maintaining a sound anatomic reduction before PCP is difficult if we use the manipulative reduction method alone. Our study innovatively applied the Steinmann pin retractor for closed reduction combined with PCP, to provide a new protocol for the treatment of distal radius fractures. METHODS: From March 2017 to July 2018, 49 patients out of 57 that met the inclusion criteria but not the exclusion criteria were included in our retrospective cohort study. Sixteen patients were treated with Steinmann pin retractor-assisted closed reduction combined with PCP (S-PCP), and 19 patients were treated with the manipulative reduction combined with PCP (M-PCP), and 14 patients were treated with the manipulative reduction combined with cast splint (M-C). All these patients received a positive postoperative radiological and clinical evaluation. RESULTS: All the patients were followed up for a minimum of 2 years. The radiological parameters in each group improved significantly postoperative (posttreatment). In the S-PCP group, the values of radial height (postoperative, 13.33±1.74 mm; the first follow-up, 13.27±1.81mm; last follow-up, 13.16±1.76mm) and ulnar variance (postoperative, -0.10±1.29mm; the first follow-up, -0.05±1.27mm; last follow-up, -0.12±1.09mm) significantly improved as compared to the M-PCP and M-C groups. While the patients in the M-C group experienced significant re-displacement at the first and last follow-ups, in the S-PCP group, the range of wrist motion including extension (89.94±5.21%), radial deviation (90.69±6.01%), and supination (90.25±5.87%); ulnar deviation (89.81±5.82%) and QuickDASH score (2.70±3.64); and grip strength (92.50±5.59%), pronation (90.50±6.04%), and modified Mayo wrist score (90.94±4.17, the excellent rate reached up to 75%) also improved as compared to the M-PCP group, M-C group, or both groups at the last follow-up. CONCLUSION: S-PCP improves fracture reduction and wrist function and can serve as an effective method for A2(AO/OTA) and A3 type of distal radius fractures in the elderly with limited dorsal comminution, including intra-articular fractures with displacement less than 2mm.

Operative Fixation Versus Cast Immobilization: Tibial Shaft Fractures in Adolescents.

INTRODUCTION: Tibial shaft fractures are common injuries in the adolescent age group. Potential complications from the injury or treatment include infection, implant migration, neurovascular injury, compartment syndrome, malunion, or nonunion. METHODS: Published literature was reviewed to identify studies which describe the management options, complications, and outcome of tibial shaft fractures in adolescents. RESULTS: Acceptable alignment parameters for tibial shaft fractures have been defined. Operative indications include open fractures and other severe soft tissue injuries, vascular injury, compartment syndrome, ipsilateral femoral fractures, and polytrauma. Relative indications for operative treatment are patient/family preference or morbid obesity. Closed reduction and cast immobilization necessitates radiographic observation for loss of reduction over the first 3 weeks. Cast change/wedging or conversion to operative management may be required in 25% to 40%. Flexible nailing provides relative fracture stability while avoiding the proximal tibial physis, but the fracture will still benefit from postoperative immobilization. Rigid nailing provides greater fracture stability and allows early weight bearing but violates the proximal tibial physis. Plate and screw osteosynthesis provide stable anatomic reduction, but there are concerns with delayed union and wound complications related to the dissection. External fixation is an excellent strategy for tibia fractures associated with complex wounds but also requires observation for loss of reduction. DISCUSSION AND CONCLUSIONS: The majority of adolescent tibia shaft fractures can be successfully managed with closed reduction and cast immobilization. Unstable fractures that have failed cast treatment should be treated operatively. Flexible intramedullary nailing, rigid intramedullary nailing, plate and screw osteosynthesis, and external fixation are acceptable treatment options that may be considered for an individual patient depending upon the clinical scenario.

Anterior C2-3 fusion surgery alone for highly displaced Hangman's fracture with severe angulation of C2-3 of more than 30°.

BACKGROUND: Highly displaced Hangman's fracture is a very rare and extremely unstable fracture of the C2 axis. Combined anteroposterior or posterior long-segment fusion surgery is typically performed for the treatment of highly displaced Hangman's fracture. However, these kinds of surgeries increase the risk of complications, loss of motion, and hospital costs. OBJECTIVE: We sought to investigate the surgical outcomes of anterior C2-3 fusion surgery alone for highly displaced Hangman's fractures with severe angulation of C2-3 by more than 30° and discoligamentous injury. METHODS: A total of five patients (four men and one woman) were included in this study with a mean age of 40.4 years (range, 26-70 years). The mean follow-up period after surgery was 37.2 months (range, 12-96 months). The fracture characteristics, treatment methods, and outcomes were retrospectively analyzed. RESULTS: All five patients had type II Hangman's fractures (according to the Levine and Edwards classification scheme). None of the included patients had neurologic deficit or other spine injury but all patients had complete C2-3 discoligamentous injury. Before surgery, all patients successfully achieved closed reduction by skull traction, followed by C2-3 anterior decompression and fusion (ACDF) with plating. For interbody grafting, three patients received a polyetheretherketone (PEEK) cage filled with an autogenous cancellous iliac bone graft and two received autogenous tricortical iliac bone grafts. Severe angulation (39.2° vs. 3.0°, P < 0.001) and severe displacement (76.1% vs. 4.0%, P < 0.001) of C2-3 were both significantly corrected after surgery. All patients had achieved solid fusion at last follow-up. In terms of clinical outcomes, the mean neck pain visual analog scale score was significantly improved (8.6 points vs. 1.8 points, P < 0.001). The mean neck disability index value was also significantly improved (45.4 points vs. 13.0 points, P < 0.01). According to Odom's criteria, all patients achieved satisfactory outcomes. No major complications occurred. One patient complained of dysphagia, but recovered after three months with conservative treatment. CONCLUSIONS: Preoperative closed reduction and anterior C2-3 fusion surgery alone should be considered as a less-invasive and useful surgical option for highly displaced Hangman's fracture with severe angulation of C2-3, which is an extremely unstable fracture of the C2 axis.

Comparison of outcomes of ORIF versus bidirectional tractor and arthroscopically assisted CRIF in the treatment of lateral tibial plateau fractures: a retrospective cohort study.

BACKGROUND: Lateral tibial plateau fractures (TPFs) are often treated with conventional open reduction and internal fixation (ORIF) through standard anterolateral sub-meniscal arthrotomy. There has been increasing support for "bidirectional rapid redactor" device-assisted closed reduction and internal fixation (CRIF) for treating TPFs. The aim of the present study is to compare the clinical and radiological outcomes between CRIF and ORIF procedures. METHODS: We performed a retrospective cohort study of 55 lateral TPF patients (Schatzker types I-III) who accepted surgical treatment at our trauma level 1 center between January 2016 and January 2018. They were divided into the CRIF group (32 patients) and the ORIF group (23 patients) based upon the different surgical protocols. The patients' clinical outcome analysis was evaluated by using the Knee Society Score (KSS) and Rasmussen's clinical score. For radiological assessment, changes in tibial plateau width (TPW), articular depression depth (ADD), medial proximal tibial angle (MPTA), and posterior tibial slope angle (PTSA) were evaluated using radiographs and computed tomography (CT) scan. RESULTS: The CRIF group had a mean follow-up of 28.9 months, and the ORIF group had a mean follow-up of 30.7 months (p>0.05). Furthermore, there was no statistically significant difference in terms of age, gender, injury mechanism, follow-up time, time interval from injury to surgery, and Schatzker classification in the two groups. With respect to the clinical outcomes including the KSS score and Rasmussen's clinical score, there was also no significant difference (p>0.05). Nevertheless, the CRIF group had lower intra-operative blood loss, shorter hospitalization days, and better range of movement of the knee joint than the ORIF group (p<0.05). Furthermore, CRIF had better radiological results when compared to the ORIF group using Rasmussen's radiological score (p<0.05), although no significant difference was observed in TPW, ADD, MPTA, and PTSA between the two groups (p>0.05). CONCLUSION: The present study showed that CRIF could achieve comparable clinical outcomes and better radiological results for treating lateral TPFs as compared with conventional ORIF.

Achieve Closed Reduction of Irreducible, Unilateral Vertically Displaced Pelvic Ring Disruption with an Unlocking Closed Reduction Technique.

OBJECTIVE: To be able to treat irreducible unilateral vertically displaced pelvic ring disruption (UVDPRD) using closed reduction, we introduced a technique named Unlocking Closed Reduction Technique (UCRT) and evaluated its effectiveness with improved pelvic closed reduction system (PCRS). METHODS: A retrospective study was performed in our department. Between January 2014 and December 2017, 43 patients whose UVDPRD were not successfully reduced using transcondylar traction. Subsequently, they were treated with UCRT using improved PCRS. The study included 19 male and 24 female patients, with a mean age at the time of the operation of 46.2 years. During surgery, operation time and blood loss were recorded. Post-surgical reduction quality was evaluated using Matta scoring criteria and patient lower-extremity functional outcome was evaluated using Majeed functional scoring criteria. RESULTS: When used with improved PCRS, UCRT achieved pelvic reduction in all 43 cases of irreducible UVDPRD with postoperative pelvic reduction quality rated excellent and good for 42/43 (97.6%) patients according to the Matta scoring criteria (Matta Score < 10 mm). While no post-surgical complications emerged as the direct result of UCRT in this cohort of patients, 8/37 patients who were treated with subcutaneous supra-acetabular pedicle screw internal fixation (INFIX) for anterior ring fixation developed lateral femoral cutaneous nerve injury but recovered 6 months postoperatively. No revision surgery was performed on any of the recruited patients. All patients' lower-extremity functionality was rated excellent with an average Majeed function score of 94.3 during the last follow-up at an average of 41.6 months postoperatively. CONCLUSION: With excellent surgical and functional outcomes in patients with irreducible UVDPRD, improved PCRS-assisted UCRT proved to be a safe and effective method for the treatment of irreducible UVDPRD.

Ultrasound-directed reduction of distal radius fractures in adults: a systematic review.

OBJECTIVE: To conduct a systematic review of the clinical literature to determine whether ultrasound can be used to improve the reduction of distal radius fractures in adults in the ED. METHODOLOGY: A study protocol was registered on PROSPERO. EMBASE, PubMed/MEDLINE, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov of the US National Library of Medicine were searched for studies evaluating ultrasound-assisted distal radial fracture reductions in comparison with standard care. The primary outcome of interest was manipulation success rates, defined as the proportion of fracture manipulations resulting in acceptable anatomical alignment, with secondary outcome being subsequent surgical intervention rates in ultrasound and standard care group of patients. RESULTS: 248 were screened at title and abstract, and 10 studies were included for a narrative synthesis. The quality of this evidence is limited but suggests ultrasound is accurate in determining distal radius fracture reduction and may improve the quality of reduction compared with standard care. However, there is insufficient evidence to determine whether this affects the rate of subsequent surgical intervention or functional outcome. CONCLUSION: There is a lack of evidence that using ultrasound in the closed reduction of distal radius fractures benefits patients. Properly conducted randomised controlled trials with patient-orientated outcomes are crucial to investigate this technology.

Biomechanical analysis of the closed reduction internal fixation with cannulated screw of femoral neck fractures.

ABSTRACT: The influencing factors in closed reduction internal fixation with cannulated screw of femoral neck fractures have not been well investigated. This study evaluated these factors in patients with femoral neck fractures.Fifty-seven patients (36 males and 21 females) diagnosed with femoral neck fracture with the average age of 52.44 ±â€Š15.04 years who underwent closed reduction internal fixation with cannulated screw were included in this study. Data were collected through case report reviews, phone call follow-ups, and outpatient follow-ups to evaluate pre- and postoperative radiograph images. Statistical analysis was performed using Garden classification, binary and multinomial logistic regression analysis by including factors such as patient's age, gender, fracture type, time to fixation, reduction quality, functional recovery period, removal of cannulated screw, and preoperative traction. Logistic regression analysis revealed that age and reduction quality was statistically significant (P < .05) to clinical outcome and other factors were not statistically significant.The main factors affecting clinical outcomes were functional recovery and reduction quality. The biomechanical effects of fixation provide a good foundation for fracture healing. Patient's conditions should be carefully evaluated before selecting reduction procedures to reach an optimal surgical outcome.

Factores relacionados con el riesgo de reintervención en pacientes operados de reducción cerrada de fractura de huesos propios / Factors related to the risk of reoperation in patients operated on for closed reduction of nasal bone fractures

INTRODUCCIÓN Y OBJETIVO: La fractura de huesos nasales es la fractura facial más frecuente. En relación a la cirugía, la técnica habitualmente empleada ante ella es la reducción cerrada bajo anestesia local o general. Presentamos nuestra experiencia en pacientes intervenidos de fractura de huesos nasales y valoramos el riesgo de reintervención en relación al tipo de técnica anestésica empleada. MATERIAL Y MÉTODO: Recopilamos datos de manera retrospectiva de pacientes intervenidos de reducción cerrada de fractura nasal en nuestro centro entre diciembre de 2014 y junio de 2019. Estudiamos la variable cualitativa analizada (la reintervención) con el test exacto de Fisher y las variables cuantitativas analizadas (días desde el traumatismo hasta cirugía y grados de desviación nasal) con el test U de Mann-Whitney. RESULTADOS: Incluimos 128 pacientes (91 hombres y 37 mujeres). La causa de fractura más frecuente fue la agresión, seguida por el traumatismo por caída y los deportes. Las fracturas por agresión se produjeron con mayor frecuencia los sábados y domingos entre las 3 y las 5 horas de la madrugada. Las fracturas por caída los lunes y martes a la 1 del mediodía. En 99 casos la cirugía se llevó a cabo en las primeras 24 horas, y en 29 pasado ese tiempo. Con respecto a la técnica anestésica, 9 pacientes fueron intervenidos bajo anestesia local, 24 bajo sedación y 95 bajo anestesia general. Tres de los intervenidos con anestesia local y 4 con anestesia general precisaron reintervención por mal resultado tras la primera cirugía. Ninguno de los pacientes intervenidos con sedación fue reintervenido. CONCLUSIONES: En nuestra experiencia, la reducción de la fractura nasal bajo sedación tiene buenos resultados, por lo que consideramos que es una buena alternativa en los casos de fractura nasal quirúrgica para reducir los efectos adversos de la anestesia general

BACKGROUND AND OBJECTIVE: Nasal bone fracture is the most frequent facial fracture. In relation to surgery, the most frequently employed technique is closed reduction under local or under general anesthesia. We present our experience with patients who underwent nasal bone fracture surgery and the risk of reintervention in relation to the type of anesthetic technique used. METHODS: Data were collected retrospectively of patients who underwent closed reduction of nasal fracture in our center between December 2014 and June 2019. Qualitative variable analyzed (reintervention) were studied with Fisher's exact test and the quantitative variables analyzed (days from trauma to surgery and degrees of nasal deviation) with the Mann-Whitney U test. RESULTS: One hundred and twenty-eight patients (91 men and 37 women) were included in the study. The most frequent cause of fracture was aggression, followed by falls and sports. Aggression fractures occurred most frequently on Saturdays and Sundays between 3 and 5 a.m. Fall fractures occurred most frequently on Mondays and Tuesdays at 1 p.m. In 99 cases the surgery was performed in the first 24 hours, while in 29 cases it was performed after that time. Regarding the anesthetic technique, 9 patients were operated under local anesthesia, 24 under sedation and 95 under general anesthesia. Three of the patients operated with local anesthesia and 4 with general anesthesia required reoperation because of poor results after the first surgery. None of the patients operated with sedation were reoperated. CONCLUSIONS: In our experience, nasal fracture reduction under sedation has good results making it a good alternative in cases of surgical nasal fracture reducing the deleterious effects of general anesthesia

Pediatric Radial Neck Fractures: Which Ones Can Be Successfully Closed Reduced in the Emergency Department?

BACKGROUND: The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED). METHODS: A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories. RESULTS: CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED. CONCLUSIONS: Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED. LEVEL OF EVIDENCE: Level III-prognostic.