Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis after a Fracture.

BACKGROUND: Clinical guidelines recommend low-molecular-weight heparin for thromboprophylaxis in patients with fractures, but trials of its effectiveness as compared with aspirin are lacking. METHODS: In this pragmatic, multicenter, randomized, noninferiority trial, we enrolled patients 18 years of age or older who had a fracture of an extremity (anywhere from hip to midfoot or shoulder to wrist) that had been treated operatively or who had any pelvic or acetabular fracture. Patients were randomly assigned to receive low-molecular-weight heparin (enoxaparin) at a dose of 30 mg twice daily or aspirin at a dose of 81 mg twice daily while they were in the hospital. After hospital discharge, the patients continued to receive thromboprophylaxis according to the clinical protocols of each hospital. The primary outcome was death from any cause at 90 days. Secondary outcomes were nonfatal pulmonary embolism, deep-vein thrombosis, and bleeding complications. RESULTS: A total of 12,211 patients were randomly assigned to receive aspirin (6101 patients) or low-molecular-weight heparin (6110 patients). Patients had a mean (±SD) age of 44.6±17.8 years, 0.7% had a history of venous thromboembolism, and 2.5% had a history of cancer. Patients received a mean of 8.8±10.6 in-hospital thromboprophylaxis doses and were prescribed a median 21-day supply of thromboprophylaxis at discharge. Death occurred in 47 patients (0.78%) in the aspirin group and in 45 patients (0.73%) in the low-molecular-weight-heparin group (difference, 0.05 percentage points; 96.2% confidence interval, -0.27 to 0.38; P<0.001 for a noninferiority margin of 0.75 percentage points). Deep-vein thrombosis occurred in 2.51% of patients in the aspirin group and 1.71% in the low-molecular-weight-heparin group (difference, 0.80 percentage points; 95% CI, 0.28 to 1.31). The incidence of pulmonary embolism (1.49% in each group), bleeding complications, and other serious adverse events were similar in the two groups. CONCLUSIONS: In patients with extremity fractures that had been treated operatively or with any pelvic or acetabular fracture, thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin in preventing death and was associated with low incidences of deep-vein thrombosis and pulmonary embolism and low 90-day mortality. (Funded by the Patient-Centered Outcomes Research Institute; PREVENT CLOT ClinicalTrials.gov number, NCT02984384.).

Secondary Bony Defects after Soft Tissue Reconstruction in Limb-Threatening Lower Extremity Injuries: Does the Approach to Flap Elevation Matter?

BACKGROUND: Limb-threatening lower extremity injuries often require secondary bone grafting after soft tissue reconstruction. We hypothesized that there would be fewer wound complications when performing secondary bone grafting via a remote surgical approach rather than direct flap elevation. METHODS: A retrospective cohort study was performed at a single Level 1 trauma center comparing complications after secondary bone grafting in patients who had undergone previous soft tissue reconstruction after open tibia fractures between 2006 and 2020. Comparing bone grafting via a remote surgical incision versus direct flap elevation, we evaluated wound dehiscence requiring return to the operating room as the primary outcome. Secondary outcomes were deep infection and delayed amputation. RESULTS: We identified 129 patients (mean age: 40 years, 82% male) with 159 secondary bone grafting procedures. Secondary bone grafting was performed via a remote surgical approach in 54% (n = 86) and direct flap elevation in 46% (n = 73) of cases. Wound dehiscence requiring return to the operating room occurred in one patient in the flap elevation group (1%) and none of the patients in the remote surgical approach. The odds of deep wound infection (OR, 1.77; p = 0.31) or amputation (OR, 1.43; p = 0.73) did not significantly differ between surgical approaches. No significant differences were found in complications between the reconstructive surgeon elevating and re-insetting the flap and the orthopaedic trauma surgeon performing the flap elevation and re-inset. CONCLUSION: Direct flap elevation for secondary bone grafting after soft tissue reconstruction for open tibia fractures did not result in more complications than bone grafting via a remote surgical approach. These findings should reassure surgeons to allow other clinical factors to influence the surgical approach for bone grafting.

Quitline usage does not improve rates of smoking cessation in orthopaedic trauma patients unless combined with nicotine replacement therapy.

PURPOSE: The negative effects of smoking following traumatic orthopaedic injury can lead to serious complications and decreased quality of life. The widely available quitline could be easily implemented in the orthopaedic postoperative period to improve outcome, but the effectiveness of this intervention in this population is unknown. The goal of this study was to determine if active referral to a quitline would improve rates of smoking cessation in this population. METHODS: This is a secondary analysis of a randomized control trial assessing the effectiveness of an inpatient intervention with varying intensities to promote smoking cessation. Participants were actively referred to the quitline as part of their intervention. Participants were surveyed at 6 weeks, 3 months and 6 months following their injury for 7-day abstinence, chemically confirmed with exhaled carbon monoxide monitoring. RESULTS: Smoking quitline use alone does not independently improve 7-day abstinence. Quitline and nicotine use are synergistic (OR, 5.6 vs. 2.3 at 3 months in patients who used nicotine patch and quitline vs. patch; OR, 7.8 vs. 2.1 at 3 months in patients who used any NRT and quitline vs. NRT alone). CONCLUSIONS: NRT use improves smoking cessation rates in orthopaedic trauma patients. Although smoking quitline use might not independently improve cessation rates in orthopaedic trauma patients postoperatively, concomitant use of NRT with quitline improves quit rates over NRT alone. Patients referred to quitline should be encouraged to use NRT.

What Outcomes Are Most Important to Patients Following a Lower Extremity Limb-threatening Injury?

OBJECTIVE: To determine what outcomes are most important to patients after a limb-threatening injury, and if those preferences vary based on the patients' treatment (salvage vs amputation), health, demographics, or time since injury. BACKGROUND: The preferences that motivate the patients' choice of treatment following a limb-threatening injury are poorly understood. Discrete choice experiments (DCEs) are a robust survey methodology to quantify preferences. METHODS: Patients with a history of traumatic limb-threatening injury, January 2010 to December 2020, completed a survey with our DCE and the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. The DCE attributes included recovery time, function, appearance, cost, and time in hospital. We used conditional logit modeling to estimate the relative importance of each attribute on a scale of 0% to 100%, determine willingness to pay for improvements in the included attributes, and assess variation in preferences based on patient characteristics, including PROMIS score. RESULTS: A total of 150 patients completed the survey (104 limb salvage, 46 amputation; mean age, 48±16 years; 79% male). Regaining preinjury function [relative importance=41%; 95% confidence interval (CI), 37%-45%] and minimizing costs (24%; 95% CI, 21%-28%) were of greatest importance. Changes in appearance were least important (7%; 95% CI, 5%-9%). The hierarchy of preferences did not vary between those who had limb salvage or amputation, but patient age, physical and mental health, and income were associated with preference variation. CONCLUSIONS: Patients with limb-threatening injuries most valued gains in function and reduced out-of-pocket costs.

Do superficial infections increase the risk of deep infections in tibial plateau and plafond fractures?

PURPOSE: Open reduction internal fixation of tibial plateau and pilon fractures may be complicated by deep surgical site infection requiring operative debridement and antibiotic therapy. The management of superficial surgical site infection is controversial. We sought to determine whether superficial infection is associated with an increased risk of deep infection requiring surgical debridement after fixation of tibial plateau and pilon fractures. METHODS: This is a secondary analysis of data from the VANCO trial, which included 980 adult patients with a tibial plateau or pilon fracture at elevated risk of infection who underwent open reduction internal fixation with plates and screws with or without intrawound vancomycin powder. An association of superficial surgical site infection with deep surgical site infection requiring debridement surgery and antibiotics was explored after matching on risk factors for deep surgical site infection. RESULTS: Of the 980 patients, we observed 30 superficial infections (3.1%) and 76 deep infections (7.8%). Among patients who developed a superficial infection, the unadjusted incidence of developing a deep infection within 90 days was 12.8% (95% confidence interval [CI] 1.3-24.2%). However, after a 3:1 match on infection risk factors, the 90-day marginal probability of a deep surgical site infection after sustaining a superficial infection was 6.0% (95% CI - 6.5-18.5%, p = 0.35). CONCLUSION: Deep infection after superficial infection is uncommon following operative fixation of tibial plateau and pilon fractures. Increased risk of subsequent deep infection attributable to superficial infection was inconclusive in these data. LEVEL OF EVIDENCE: Prognostic Level II.

Dual-Energy CT and Cinematic Rendering to Improve Assessment of Pelvic Fracture Instability.

Background Grading of pelvic fracture instability is challenging in patients with pelvic binders. Dual-energy CT (DECT) and cinematic rendering can provide ancillary information regarding osteoligamentous integrity, but the utility of these tools remains unknown. Purpose To assess the added diagnostic value of DECT and cinematic rendering, with respect to single-energy CT (SECT), for discriminating any instability and translational instability in patients with pelvic binders. Materials and Methods In this retrospective analysis, consecutive adult patients (age ≥18 years) were stabilized with pelvic binders and scanned in dual-energy mode using a 128-section CT scanner at one level I trauma center between August 2016 and January 2019. Young-Burgess grading by orthopedists served as the reference standard. Two radiologists performed blinded consensus grading with the Young-Burgess system in three reading sessions (session 1, SECT; session 2, SECT plus DECT; session 3, SECT plus DECT and cinematic rendering). Lateral compression (LC) type 1 (LC-1) and anteroposterior compression (APC) type 1 (APC-1) injuries were considered stable; LC type 2 and APC type 2, rotationally unstable; and LC type 3, APC type 3, and vertical shear, translationally unstable. Diagnostic performance for any instability and translational instability was compared between reading sessions using the McNemar and DeLong tests. Radiologist agreement with the orthopedic reference standard was calculated with the weighted κ statistic. Results Fifty-four patients (mean age, 41 years ± 16 [SD]; 41 men) were analyzed. Diagnostic performance was greater with SECT plus DECT and cinematic rendering compared with SECT alone for any instability, with an area under the receiver operating characteristic curve (AUC) of 0.67 for SECT alone and 0.82 for SECT plus DECT and cinematic rendering (P = .04); for translational instability, the AUCs were 0.80 for SECT alone and 0.95 for SECT plus DECT and cinematic rendering (P = .01). For any instability, corresponding sensitivities were 61% (22 of 36 patients) for SECT alone and 86% (31 of 36 patients) for SECT plus DECT and cinematic rendering (P < .001). The corresponding specificities were 72% (13 of 18 patients) and 78% (14 of 18 patients), respectively (P > .99). Agreement (κ value) between radiologists and orthopedist reference standard improved from 0.44 to 0.76 for SECT versus the combination of SECT, DECT, and cinematic rendering. Conclusion Combined use of single-energy CT, dual-energy CT, and cinematic rendering improved instability assessment over that with single-energy CT alone. © RSNA, 2022 Online supplemental material is available for this article.

Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?

BACKGROUND: Gunshot injuries of the extremities are common in the United States, especially among people with nonfatal gunshot wounds. Controversy persists regarding the proper management for low-energy gunshot-induced fractures, likely stemming from varying reports on the likelihood of complications. There has yet to be published a study on a large cohort of patients with gunshot-induced tibia fractures on which to base our understanding of complications after this injury. QUESTIONS/PURPOSES: (1) What percentage of patients with low-energy gunshot-induced tibia fractures developed complications? (2) Was there an association between deep infection and fracture location, injury characteristics, debridement practices, or antibiotic use? METHODS: This was a multicenter retrospective study. Between January 2009 and December 2018, we saw 201 patients aged 16 years or older with a gunshot-induced fracture who underwent operative treatment; 2% (4 of 201) of those screened had inadequate clinical records, and 38% (76 of 201) of those screened had inadequate follow-up for inclusion. In all, 121 patients with more than 90 days of follow-up were included in the study. Nonunion was defined as a painful fracture with inadequate healing (fewer than three cortices of bridging bone) at 6 months after injury, resulting in revision surgery to achieve union. Deep infection was defined according to the confirmatory criteria of the Fracture-Related Infection Consensus Group. These results were assessed by a fellowship-trained orthopaedic trauma surgeon involved with the study. Complication proportions were tabulated. A Kaplan-Meier chart demonstrated presentations of deep infection by fracture location (proximal, shaft, or distal). Univariate statistics and multivariate Cox regression were used to examine the association between deep infection and fracture location, entry wound size, vascular injury, intravenous (IV) antibiotics in the emergency department (ED), deep and superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics, while adjusting for age, race/ethnicity, smoking status, and BMI. A power analysis for the result of deep infection demonstrated that we would have had to observe a hazard ratio of 4.28 or greater for shaft versus proximal locations to detect statistically significant results at 80% power and alpha = 0.05. RESULTS: The overall complication proportion was 49% (59 of 121), with proportions of 14% (17 of 121) for infection, 27% (33 of 121) for wound complications, 20% (24 of 121) for nonunion, 9% (11 of 121) for hardware breakage, and 26% (31 of 121) for revision surgery. A positive association was present between deep infection and deep debridement (HR 5.51 [95% confidence interval 1.12 to 27.9]; p = 0.04). With the numbers available, we found no association between deep infection and fracture location, entry wound size, vascular injury, IV antibiotics in the ED, superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics. CONCLUSION: In this multicenter study, we found a higher risk of complications in operative gunshot-induced tibia fractures than prior studies have reported. Infection, in particular, was much more common than expected based on prior studies. Consequently, surgeons might consider adopting the general management principles for nongunshot-induced open tibia fractures with gunshot-induced fractures, such as the use of IV antibiotics both initially and after surgery. Further research is needed to test and validate these approaches. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Immediate weight bearing as tolerated (WBAT) correlates with a decreased length of stay post intramedullary fixation for subtrochanteric fractures: a multicenter retrospective cohort study.

BACKGROUND: Subtrochanteric femur fractures associate with a relatively high complication rate and are traditionally treated operatively with a period of limited weight bearing. Transitioning from extramedullary to intramedullary implants, there are increasing biomechanical and clinical data to support early weight bearing. This multicenter retrospective study examines the effect of postoperative weight bearing as tolerated (WBAT) for subtrochanteric femur fractures. We hypothesize that WBAT will result in a decreased length of stay (LOS) without increasing the incidence of re-operation. METHODS: This study assesses total LOS and postoperative LOS after intramedullary fixation for subtrochanteric fractures between postoperative weight bearing protocols across 6 level I trauma centers (n = 441). Analysis techniques consisted of multivariable linear regression and nonparametric comparative tests. Additional subanalyses were performed, targeting mechanism of injury (MOI), Winquist-Hansen fracture comminution, 20-year age strata, and injury severity score (ISS). RESULTS: Total LOS was shorter in WBAT protocol within the overall sample (7.4 vs 9.7 days; p < 0.01). Rates of re-operation were similar between the two groups (10.6% vs 10.5%; p = 0.99). Stratified analysis identified patients between ages 41-80, WH comminution 2-3, high MOI, and ISS between 6-15 and 21-25 to demonstrate a significant reduction in LOS as a response to WBAT. CONCLUSION: An immediate postoperative weight bearing as tolerated protocol in patients with subtrochanteric fractures reduced length of hospital stay with no significant difference in reoperation and complication rates. If no contraindication exists, immediate weight bearing as tolerated should be considered for patients with subtrochanteric femur fractures treated with statically locked intramedullary nails. LEVEL OF EVIDENCE: Therapeutic Level III.

Musculoskeletal Trauma in Critically Injured Patients: Factors Leading to Delayed Operative Fixation and Multiple Organ Failure.

BACKGROUND: Musculoskeletal injuries are common following trauma and variables that are associated with late femur fracture fixation are important to perioperative management. Furthermore, the association of late fracture fixation and multiple organ failure (MOF) is not well defined. METHODS: We performed a retrospective cohort investigation from 2 academic trauma centers. INCLUSION CRITERIA: age 18-89 years, injury severity score (ISS) >15, femoral shaft fracture requiring operative fixation, and admission to the intensive care unit >2 days. Admission physiology variables and abbreviated injury scale (AIS) scores were obtained. Lactate was collected as a marker of shock and was described as admission lactate (LacAdm) and as 24-hour time-weighted lactate (LacTW24h), which reflects an area under the curve and is considered a marker for the overall depth of shock. The primary aim was to evaluate clinical variables associated with late femur fracture fixation (defined as ≥24 hours after admission). A multivariable logistic regression model tested variables associated with late fixation and is reported by odds ratio (OR) with 95% confidence interval (CI). The secondary aim evaluated the association between late fixation and MOF, defined by the Denver MOF score. The summation of scores (on a scale from 0 to 3) from the cardiac, pulmonary, hepatic, and renal systems was calculated and MOF was confirmed if the total daily sum of the worst scores from each organ system was >3. We assessed the association between late fixation and MOF using a Cox proportional hazards model adjusted for confounding variables by inverse probability weighting (a propensity score method). A P value <.05 was considered statistically significant. RESULTS: One hundred sixty of 279 (57.3%) patients received early fixation and 119 of 279 (42.7%) received late fixation. LacTW24h (OR = 1.66 per 1 mmol/L increase, 95% CI, 1.24-2.21; P < .001) and ISS (OR = 1.07 per 1-point increase, 95% CI, 1.03-1.10; P < .001) were associated with higher odds of late fixation. Late fixation was associated with a 3-fold increase in the odds of MOF (hazard ratio [HR] = 3.21, 95% CI, 1.48-7.00; P < .01). CONCLUSIONS: In a cohort of multisystem trauma patients with femur fractures, greater injury severity and depth of shock, as measured by LacTW24h, were associated with late operative fixation. Late fixation was also associated with MOF. Strategies to reduce the burden of MOF in this population require further investigation.

Transition From Acute to Chronic Pain in Lower Extremity Fracture Patients: A Pain Phenotyping Protocol.

BACKGROUND: Traumatic injury is a major source of chronic pain, particularly for individuals with traumatic fracture of the fibula and/or tibia (lower extremity fracture [LEFx]). Although several factors (e.g., older age, being female, high pain intensity at time of initial injury) have been identified as risk factors for chronic pain associated with LEFx. Comprehensive biopsychosical models to predict the odds of transitioning from acute to chronic pain after LEFx are needed to better understand the underlying processes, predict risk for chronic pain, and develop personalized therapies for individuals at higher risk for developing chronic pain. OBJECTIVE: The aim of the study was to outline the study design that will be used to examine the physiological, psychological, and genetic/genomic variables-models that predict the transition from acute to chronic pain after LEFx. METHOD: This prospective descriptive cohort study will enroll 240 participants with a fibula and/or tibia fracture and 40 controls with no LEFx. Data will be collected during an in-hospital baseline visit, five in-person clinic visits (6 weeks, 12 weeks, 24 weeks, 52 weeks, and 24 months), and seven online between-visit surveys (2 weeks, 4 weeks, 8 weeks, 10 weeks, 16 weeks, 20 weeks, and 18 months) from participants with LEFx and at concordant intervals from controls. Measures will consist of 19 questionnaires characterizing pain and psychological status, neurophysiological testing for peripheral sensory nerve function, and peripheral blood samples collections for RNA sequencing. Illumina standard protocols will be used to sequence RNA, and read counts will be used to measure gene expression. ANALYSIS: Direct-entry, multiple logistic regression will be used to produce odds ratios expressing the relative risk on each explanatory variable when controlling for other predictors/covariates in the model. CONCLUSION: This study is one of the first to longitudinally characterize the biopsychosocial variables associated with a clinically relevant problem of the transition from acute to chronic posttraumatic fracture pain in individuals with LEFx. Results from this study will be used to construct predictive risk models of physiological, psychological, and genetic/genomic variables associated with increased risk for transitioning from acute to chronic pain status after LEFx. This work will lead to a better understanding of the trajectory of pain and relevant variables over time; initiate a better understanding of variables associated with risk for transitioning from acute to chronic pain; and, in the future, could provide a foundation for the identification of novel therapeutic targets to improve the outcomes of individuals with LEFx.

A patient-centered composite endpoint weighting technique for orthopaedic trauma research.

BACKGROUND: This study aimed to address the current limitations of the use of composite endpoints in orthopaedic trauma research by quantifying the relative importance of clinical outcomes common to orthopaedic trauma patients and use those values to develop a patient-centered composite endpoint weighting technique. METHODS: A Best-Worst Scaling choice experiment was administered to 396 adult surgically-treated fracture patients. Respondents were presented with ten choice sets, each consisting of three out of ten plausible clinical outcomes. Hierarchical Bayesian modeling was used to determine the utilities associated with the outcomes. RESULTS: Death was the outcome of greatest importance (mean utility = - 8.91), followed by above knee amputation (- 7.66), below knee amputation (- 6.97), severe pain (- 5.90), deep surgical site infection (SSI) (- 5.69), bone healing complications (- 5.20), and moderate pain (- 4.59). Mild pain (- 3.30) and superficial SSI (- 3.29), on the other hand, were the outcomes of least importance to respondents. CONCLUSION: This study revealed that patients' relative importance towards clinical outcomes followed a logical gradient, with distinct and quantifiable preferences for each possible component outcome. These findings were incorporated into a novel composite endpoint weighting technique.

Change in Pain Score after Administration of Analgesics for Lower Extremity Fracture Pain during Hospitalization.

BACKGROUND: Effective acute pain management following injury is critical to improve short-and long-term patient outcomes. Analgesics can effectively reduce pain intensity, yet half of injury patients report moderate to severe pain during hospitalization. PURPOSE: The primary aim of this study was to identify the analgesic, different analgesic combinations, or analgesic and adjuvant analgesic combination that generated the largest percent change from pre- to post-analgesic pain score. DESIGN: This was a descriptive retrospective cohort study of 129 adults admitted with lower extremity fractures to a trauma center. METHODS: Name, dose, and frequency of analgesics and adjuvant analgesics administered from admission to discharge were collected from medical records. Percent change was calculated from pain scores documented on the 0-10 numeric rating scale. RESULTS: The analgesic with largest percent change from pre- to post-administration pain score was hydromorphone 2 mg IV (53%) for the emergency department and morphine 4 mg IV (54%) for the in-patient unit. All analgesics administered in the emergency department and ∼50% administered on the in-patient unit produced a minimal (15%) decrease in pain score. CONCLUSIONS: This study revealed that few analgesics administered in the emergency department and the in-patient unit to patients with lower extremity fractures provide adequate pain relief. In the emergency department, all analgesics administered resulted in at least minimal improvement of pain. On the in-patient unit 13 analgesic doses resulted at least minimal improvement in pain while nine doses did not even reach 20% change in pain. Findings from this study can be used guide the treatment of fracture pain in the hospital.

The Current Treatment of Hip Fractures: Can a Consensus Be Reached?

There is a significant global burden of disease associated with the management of hip fractures. Despite numerous studies that are focused on the treatment of patients with proximal femur fractures, the management of these injuries remains controversial. Clinicians should become familiar with the current evidence regarding the management of these common injuries and understand the key issues and controversies because they will have important implications given the large-scale effect of hip fractures internationally.

CT Prediction Model for Major Arterial Injury after Blunt Pelvic Ring Disruption.

Purpose To develop and test a computed tomography (CT)-based predictive model for major arterial injury after blunt pelvic ring disruptions that incorporates semiautomated pelvic hematoma volume quantification. Materials and Methods A multivariable logistic regression model was developed in patients with blunt pelvic ring disruptions who underwent arterial phase abdominopelvic CT before angiography from 2008 to 2013. Arterial injury at angiography requiring transarterial embolization (TAE) served as the outcome. Areas under the receiver operating characteristic (ROC) curve (AUCs) for the model and for two trauma radiologists were compared in a validation cohort of 36 patients from 2013 to 2015 by using the Hanley-McNeil method. Hematoma volume cutoffs for predicting the need for TAE and probability cutoffs for the secondary outcome of mortality not resulting from closed head injuries were determined by using ROC analysis. Correlation between hematoma volume and transfusion was assessed by using the Pearson coefficient. Results Independent predictor variables included hematoma volume, intravenous contrast material extravasation, atherosclerosis, rotational instability, and obturator ring fracture. In the validation cohort, the model (AUC, 0.78) had similar performance to reviewers (AUC, 0.69-0.72; P = .40-.80). A hematoma volume cutoff of 433 mL had a positive predictive value of 87%-100% for predicting major arterial injury requiring TAE. Hematoma volumes correlated with units of packed red blood cells transfused (r = 0.34-0.57; P = .0002-.0003). Predicted probabilities of 0.64 or less had a negative predictive value of 100% for excluding mortality not resulting from closed head injuries. Conclusion A logistic regression model incorporating semiautomated hematoma volume segmentation produced objective probability estimates of major arterial injury. Hematoma volumes correlated with 48-hour transfusion requirement, and low predicted probabilities excluded mortality from causes other than closed head injury. © RSNA, 2018 Online supplemental material is available for this article.

Quantitative MDCT assessment of binder effects after pelvic ring disruptions using segmented pelvic haematoma volumes and multiplanar caliper measurements.

OBJECTIVE: To assess effects of pelvic binders for different instability grades using quantitative multidetector computed tomography (MDCT) parameters including segmented pelvic haematoma volumes and multiplanar caliper measurements. METHODS: CT examinations of 49 patients with binders and 49 controls performed from January 2008-June 2016, and matched 1:1 for Tile instability grade and Pennal/Young-Burgess force vector, were compared for differences in pubic symphysis and sacroiliac displacement using caliper measurements in three orthogonal planes. Pelvic haematoma volumes (ml) were derived using semi-automated seeded region-growing segmentation. Median caliper measurements and volumes were compared using the Mann-Whitney U test, and correlations assessed with Pearson's correlation coefficient. Relevant caliper measurement cutoffs were established using ROC analysis. RESULTS: Rotationally unstable (Tile B) patients with binders showed significant decreases in sacroiliac diastasis (2.7 mm vs. 4.5 mm; p=0.003) and haematoma volumes (135 ml vs. 295 ml; p=0.008). Globally unstable (Tile C) binder patients showed decreased sacroiliac diastasis (4.7 mm vs. 6.4 mm, p=0.04), without significant difference in haematoma volumes (284 ml vs. 234 ml, p=0.34). Four Tile C patients with binders demonstrated over-reduction resulting in pubic body over-ride. CONCLUSION: Rotationally unstable patients with binders have significantly less sacroiliac diastasis versus controls, corresponding with significantly lower haematoma volumes. KEY POINTS: • Haematoma segmentation and multiplanar caliper measurements provide new insights into binder effects. • Binder reduction corresponds with decreased pelvic haematoma volume in rotationally unstable injuries. • Discrimination between rotational and global instability is important for management. • Several caliper measurement cut-offs discriminate between rotationally and globally unstable injuries. • Pubic symphysis over-ride is suggestive of binder over-reduction in globally unstable injuries.

Acute Pain Characteristics in Patients with and without Chronic Pain following Lower Extremity Injury.

Many patients with injuries to lower extremities report chronic pain. High pain intensity at time of admission for injury is a risk factor for chronic pain, but it is not clear whether specific acute pain patterns following injury influence the development of chronic pain. To examine the relationship between the pain trajectory, the mean pain score, and the frequency of pain documentation during the immediate hospitalization following injury, with the report of chronic pain. This was a descriptive, retrospective cohort study of adults admitted with lower extremity fractures to an academic urban trauma center. Participants, 6-45 months postinjury, rated their current pain, worst pain, and average pain over the last 3 months. Pain scores from hospitalization associated with the injury were obtained through a retrospective chart review. The pain trajectory, mean pain score, and frequency of pain documentation was compared between patients with and without chronic pain. A total of 129 patients were enrolled in this study and 78% reported chronic pain at the site of injury. The mean pain score (5.1 vs. 4.2) and first pain score (5.6 vs. 3.4) were higher for patients with chronic pain compared to patients with no chronic pain. Consistent with other studies, high pain intensity at time of injury was associated with chronic pain. The findings contribute valuable information about acute pain characteristics associated with chronic pain and provide insight into the importance of early and adequate acute pain treatment.

Does Surgical Stabilization of Lateral Compression-type Pelvic Ring Fractures Decrease Patients' Pain, Reduce Narcotic Use, and Improve Mobilization?

BACKGROUND: Debate remains over the role of surgical treatment in minimally displaced lateral compression (Young-Burgess, LC, OTA 61-B1/B2) pelvic ring injuries. Lateral compression type 1 (LC1) injuries are defined by an impaction fracture at the sacrum; type 2 (LC2) are defined by a fracture that extends through the posterior iliac wing at the level of the sacroiliac joint. Some believe that operative stabilization of these fractures limits pain and eases mobilization, but to our knowledge there are few controlled studies on the topic. QUESTIONS/PURPOSES: (1) Does operative stabilization of LC1 and LC2 pelvic fractures decrease patients' narcotic use and lower their visual analog scale pain scores? (2) Does stabilization allow patients to mobilize earlier with physical therapy? METHODS: This retrospective study of LC1 and LC2 fractures evaluated patients treated definitively at one institution from 2007 to 2013. All patients treated surgically, all nonoperative LC2, and all nonoperative LC1 fractures with complete sacral injury were included. In general, LC1 or LC2 fractures with greater than 10 mm of displacement and/or sagittal/axial plane deformity on static radiographs were treated surgically. One hundred fifty-eight patients in the LC1 group (107 [of 697 screened] nonoperative, 51 surgical) and 123 patients in the LC2 group (78 nonoperative, 45 surgical) met inclusion criteria. The surgical and nonoperative groups were matched for fracture type. To account for differences between patients treated surgically and nonoperatively, we used propensity modeling techniques incorporating treatment predictors. Propensity scores demonstrated good overlap and were used as part of multiple variable regression models to account for selection bias between the surgically treated and nonoperative groups. Patient-reported pain scores and narcotic administration were tallied in 24-hour increments during the first 24 hours of hospitalization, at 48 hours after intervention, and in the 24 hours before discharge. Time from intervention to mobilization out of bed was recorded; intervention was defined as the date of definitive surgical intervention or the day the surgeon determined the patient would be treated without surgery. RESULTS: There was no difference in the narcotics distributed to any of the groups with the exception that the patients with surgically treated LC2 fractures used, on average (mean [95% confidence interval]) 40.2 (-72.9 to -7.6) mg morphine less at the 48-hour mark (p = 0.016). In general, there were no differences between the groups' pain scores. The surgically treated patients with LC1 fractures mobilized 1.7 (-3.3 to -0.01) days earlier (p = 0.034) than their nonoperative counterparts. There was no difference in the LC2 cohort in terms of time to mobilization between those treated with and without surgery. CONCLUSIONS: There were few differences in pain scores and morphine use between the surgical and nonoperative groups, and the differences observed likely were not clinically important. We found no evidence that surgical stabilization of certain LC1 and LC2 pelvic fractures improves patients' pain, decreases their narcotic use, and improves time to mobilization. A randomized trial of patients with similar fractures and similar degrees initial displacement would help remove some of the confounders present in this study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables.

BACKGROUND: Accurate prediction of tibial nonunions has eluded researchers. Reliably predicting tibial nonunions at the time of fixation could change management strategies and stimulate further research. QUESTIONS/PURPOSES: We asked (1) whether data from medical records, fracture characteristics, and radiographs obtained at the time of fixation would identify features predictive of tibial fracture nonunion; and (2) whether this information could be used to create a model to assess the chance of nonunion at the time of intramedullary (IM) nail fixation of the tibia. METHODS: We retrospectively reviewed all tibial shaft fractures treated at our center from 2007 to 2014. We conducted a literature review and collected data on 35 factors theorized to contribute to delayed bone healing. Patients were followed to fracture healing or surgery for nonunion. Patients with planned prophylactic nonunion surgery were excluded because their nonunions were anticipated and our focus was on unanticipated nonunions. Our cohort consisted of 382 patients treated with IM nails for tibial shaft fractures (nonunion, 56; healed, 326). Bivariate and multivariate regression techniques and stepwise modeling approaches examined the relationship between variables available at definitive fixation. Factors were included in our model if they were identified as having a modest to large effect size (odds ratio > 2) at the p < 0.05 level. RESULTS: A multiple variable logistic regression model was developed, including seven factors (p < 0.05; odds ratio > 2.0). With these factors, we created the Nonunion Risk Determination (NURD) score. The NURD score assigns 5 points for flaps, 4 points for compartment syndrome, 3 points for chronic condition(s), 2 points for open fractures, 1 point for male gender, and 1 point per grade of American Society of Anesthesiologists Physical Status and percent cortical contact. One point each is subtracted for spiral fractures and for low-energy injuries, which were found to be predictive of union. A NURD score of 0 to 5 had a 2% chance of nonunion; 6 to 8, 22%; 9 to 11, 42%; and > 12, 61%. CONCLUSIONS: The proposed nonunion prediction model (NURDS) seems to have potential to allow clinicians to better determine which patients have a higher risk of nonunion. Future work should be directed at prospectively validating and enhancing this model. LEVEL OF EVIDENCE: Level III, diagnostic study.