Provisional reduction plating in the treatment of ankle fractures: a technical trick.

Reduction plating is a concept used to provisionally maintain reduction in the treatment of various fractures throughout the body. It is often used in challenging fracture patterns where the use of reduction clamps hinders placement of the definitive fixation construct. In this article, we present a technique for fixation of ankle fractures, in which a mini-fragment plate is used to keep provision reduction of the fracture, while the definitive plate is applied. This technique is particularly useful when using a posterolateral one-third tubular plate as your definitive construct. This study provides Level V evidence.

Associated Injuries in Skeletally Immature Children with Pelvic Fractures.

BACKGROUND: Pediatric pelvic fractures are rare injuries resulting from high-energy mechanisms that warrant an extensive work-up for associated injuries. OBJECTIVES: We performed a retrospective study to review concomitant injuries in children who suffered a pelvic fracture and have an open triradiate cartilage. METHODS: Using a database, pediatric pelvic fractures presenting to the authors' institution were extracted. Radiographs and computed tomography scans were reviewed, ensuring that triradiate cartilages were not fused and the pelvic injuries were classified using the Modified Torode Classification. Epidemiologic data extracted included Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and Abbreviated Injury Score (AIS). RESULTS: Sixty patients met the inclusion criteria, and their average age was 8.3 years (range 2-14 years). There were no mortalities. The most common mechanism of injury was a vehicle striking a pedestrian. There were no significant correlations between GCS, ISS, and AIS. All 60 children (100%) suffered extremity injuries. Nineteen patients required surgical orthopedic intervention, and 6 required operative stabilization of the pelvis. Patients who were struck by a motor vehicle were more likely to have multiple pelvic fractures (p < 0.05). Patients with multiple pelvic fractures were more likely to require orthopaedic surgical intervention and require a blood transfusion (p < 0.05). Patients who had type III-B or IV fractures were more likely to require a transfusion than patients with III-A fracture (p < 0.05). CONCLUSIONS: Patients sustaining fractures to an immature pelvis are likely to have additional injuries, which may be fatal or disabling if not diagnosed in a timely manner.

Impact of specialty and level of training on CT measurement of femoral version: an interobserver agreement analysis.

BACKGROUND: To determine the interobserver agreement on femoral version measurements between an orthopedic attending, orthopedic senior and junior residents, and an attending radiologist. MATERIALS AND METHODS: Postoperative computed tomography (CT) scanograms of 267 patients who underwent femoral intramedullary (IM) nailing with corresponding radiology attending reads for femoral version were collected and de-identified. Femoral version measurements performed by a trauma fellowship-trained attending orthopedic surgeon (ORTHO), a senior orthopedic resident (PGY4), a junior orthopedic resident (PGY1), and a musculoskeletal fellowship-trained attending radiologist (RADS) were compared via Pearson's interclass correlation coefficient to assess interobserver level of agreement. RESULTS: Version measurements provided by the two attending physicians exhibited the highest level of agreement (r = 0.661, p < 0.01). The orthopedic attending and the senior resident had the next highest level of agreement (r = 0.543, p < 0.01). The first-year orthopedic resident had the weakest agreement across the board: with the orthopedic attending, the radiology attending, and the senior resident. CONCLUSION: Regardless of specialty, experience and higher levels of training produce stronger agreement when measuring femoral version. Residents in training, especially those who are junior, produce weak agreement when compared to their senior colleagues. LEVEL OF EVIDENCE: Level III, diagnostic study.

Perioperative Impact of Early Limited Surgical Intervention to Treat Pilon Fractures.

BACKGROUND: The operative treatment of pilon fractures is classically treated with a staged protocol with ankle spanning external fixator, followed by definitive open reduction and internal fixation in order to decrease risk of soft tissue complications and infection. However, treatment of pilon fractures with patrial tibial fixation in addition to ankle spanning external fixation at the time of index procedure may facilitate final fixation while avoiding complications that were associated with acute definitive fixation. METHODS: Retrospective cohort series of 113 patients treated for pilon fractures from September 2012 to November 2018 at a single level 1 trauma center. Charts were reviewed to compare patients who underwent traditional management with a staged protocol and those who had a limited tibial reduction and fixation (LTRF) during the index procedure. The main outcome measurement was time to definitive fixation. RESULTS: Twenty-six percent of patients (29 of 113) had limited tibial reduction and fixation (LTRF) during index surgery. Mean time between index procedure and definitive ORIF was 4.75 days less for LTRF cohort compared to standard stage cohort (10.86 ± 7.44 vs. 15.61 ± 8.59 days, P = .009). The index procedure took on average 51 minutes longer in the LTRF cohort (P < .001), yet definitive procedure operative time was decreased by an average of 98 minutes (P < .001), and overall (index plus definitive) operative duration was shortened by an average of 50 minutes (P = .044). There was no difference in rate of infection between LTRF (3.1%) and traditional treatment (2.5%) (P = .86) or reduction quality (P = .270). There were no nonunions in either treatment group. CONCLUSION: Patients who had LTRF had quicker time to definitive ORIF and decreased operative time for definitive ORIF. There was no difference in infection rate, reduction quality, or nonunion rate between groups. LEVEL OF EVIDENCE: Level IV, Retrospective Cohort Study.

Distal Humerus Traction Radiographs: Is the Interobserver and Intraobserver Reliability Comparable With Computed Tomography?

OBJECTIVES: To compare the interobserver and intraobserver reliability of traction radiographs with 2-dimensional computed tomography (2D CT) in distal humerus fracture classification and characterization. DESIGN: Randomized controlled radiographic review of retrospectively collected data. SETTING: Academic Level 1 trauma center. PATIENTS/PARTICIPANTS: Skeletally mature patients with intra-articular distal humerus fractures with both traction radiographs and CT scans were reviewed by 11 orthopaedists from different subspecialties and training levels. INTERVENTION: The intervention involved traction radiographs and 2D CT. MAIN OUTCOME MEASUREMENTS: The main outcome measurements included interobserver and intraobserver reliability of fracture classification by the OTA/AO and Jupiter-Mehne and determination of key fracture characteristics. RESULTS: For the OTA/AO and Jupiter-Mehne classifications, we found a moderate intraobserver agreement with both 2D CT and traction radiographs (κ = 0.70-0.75). When compared with traction radiographs, 2D CT improved the interobserver reliability of the OTA/AO classification from fair to moderate (κ = 0.3 to κ = 0.42) and the identification of a coronal fracture from slight to fair (κ = 0.2 to κ = 0.34), which was more pronounced in a subgroup analysis of less-experienced surgeons. When compared with 2D CT, traction radiographs improved the intraobserver reliability of detecting stable affected articular fragments from fair to substantial (κ = 0.4 to κ = 0.67). CONCLUSIONS: Traction radiographs provide similar diagnostic characteristics as 2D CT in distal humerus fractures. For less-experienced surgeons, 2D CT may improve the identification of coronal fracture lines and articular comminution.

Brevibacteria tibial osteomyelitis.

Brevibacteria are Gram-positive rods found in human skin flora and dairy products. Although generally not considered human pathogens, case reports have implicated Brevibacterium species as rare causes of bacteremia, endocarditis, peritonitis, and osteomyelitis. We report a case of Brevibacterium tibial osteomyelitis in an immunocompetent individual with implanted hardware and highlight the challenge of identifying the organism and recognizing it as a potential pathogen.

Orthopaedic trauma during COVID-19: Is patient care compromised during a pandemic?

BACKGROUND: The Coronavirus disease-2019 (COVID-19) placed unprecedented pressure on the healthcare system. Many institutions implemented a government-mandated restructured set of safety and administrative protocols to treat urgent orthopaedic trauma patients. The objective of this study was to compare two cohorts of patients, a COVID group and non-COVID control group, and to evaluate the effectiveness of safety measures outlined in the Rutgers Orthopaedic Trauma Patient Safety Protocol (ROTPSP). Secondary outcomes were to elucidate risk factors for complications associated with fractures and COVID-19. METHODS: Patients treated for orthopaedic traumatic injuries were retrospectively identified between March and May 2020, and compared to a series of patients from the same time period in 2018. Main outcome measures included surgical site infections (SSI), length of stay (LOS), post-operative LOS (poLOS), presentation to OR time (PORT), and length of surgery. RESULTS: After review, 349 patients (201 non-COVID, 148 COVID) undergoing 426 surgeries were included. Average LOS (11.91 days vs. 9.27 days, p = 0.04), poLOS (9.68 days vs. 7.39 days, p = 0.03), and PORT (30.56 vs. 25.59 h, p < 0.01) was significantly shorter in the COVID cohort. There were less SSI in the COVID group (5) compared to the non-COVID group (14) (p = 0.03). Overall complications were significantly lower in the COVID group. Patients receiving Cepheid tests had significantly shorter LOS and poLOS compared to patients receiving the RNA and DiaSorin tests (p < 0.01 and p < 0.01, respectively). The Cepheid test carried the best benefit-to-cost ratio, 0.10, p < 0.05. CONCLUSION: The restructuring of care protocols caused by COVID-19 did not negatively impact perioperative complication rates, PORT or LOS. Cepheid COVID test type administered upon admission plays an integral role in a patient's hospital course by reducing both length of stay and hospital costs. This information demonstrates we can continue to treat orthopaedic trauma patients safely during the COVID-19 pandemic by utilizing strict safety protocols.

Patella fracture fixation with a non-locked anterior plating technique: A biomechanical study.

OBJECTIVES: The purpose of this study was to compare the biomechanical attributes of patella fracture fixation with either anterior plating utilizing two parallel, longitudinal 2.0 mm plates technique versus a cannulated screw tension band technique. METHODS: Five matched pairs (ten specimens) of fresh frozen cadavers were utilized. A transverse patella fracture (OTA 34C1.1) was fixed using either two 4.0 mm cannulated screw anterior tension band (CATB) or with two 2.0 mm stainless steel non-locking plates along the anterior cortex secured with 2.4 mm cortical screws traversing the fracture site. Specimens underwent 1000 cycles of simulated active knee range of motion before load to failure destructive testing. RESULTS: During cyclic loading there were no failures in the plate fixation group, and 2 out of 5 specimens catastrophically failed in the CATB group (p = 0.22). Average fracture displacement at the end of fatigue testing was 0.96 mm in the plate fixation group and 2.72 mm in the CATB group (p = 0.18). The specimens that withstood cyclic testing underwent a destructive load. Mean load to failure for the plate fixation specimens was 1286 N, which was not significantly different from the CATB group mean of 1175 N (p = 0.48). The mechanism of failure in the plate fixation cohort was uniformly via a secondary vertical patella fracture around the plates in all five specimens. In the CATB group, the mechanism of failure was via wire elongation and backing out of the screws. CONCLUSIONS: Patella fixation with anterior plating technique statistically performed equivalent to cannulated screw anterior tension band in ultimate load to failure strength and fatigue endurance under cyclical loading. No failures were observed cyclic simulated active range of motion in the anterior plate group. There was a trend towards improved fatigue endurance in the plate fixation group, however this did not reach statistical significance. We believe plate fixation technique represents a low-profile implant option for treatment of transverse patella fractures, which may allow for early active range of motion, and these data support biomechanical equivalency to standard of care.

External Fixator-Assisted Reduction of Distal Femur Fractures: A Technical Trick.

SUMMARY: Restoration of anatomical alignment while preserving the soft-tissue envelope around the fracture site remains a challenge during distal femur fracture fixation. Although the lateral distal femoral locking plate allows surgeons to achieve adequate bony stability, their application has been associated with malalignment leading to inferior outcomes. We propose a biologically friendly, percutaneous technique that sequentially reduces and aligns distal femur fractures with an anterior external fixator before definitive fixation with a lateral distal femoral locking plate.

Operative Versus Nonoperative Outcomes of Middle-Third Clavicle Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVES: Middle third clavicle fractures have long been managed conservatively with immobilization. Some patients, especially those with completely displaced or shortened clavicle fractures are now thought to have increased risk of nonunion or symptomatic malunion. The authors performed a meta-analysis to study the incidence of nonunion and symptomatic malunion and test the hypothesis that surgical fixation of these fractures significantly lowers the risk of these complications. METHODS: A search was performed in the PubMed, Embase, and Cochrane Library databases for randomized clinical trials and quasi-experimental trials that compare outcomes of operative and nonoperative management for clavicle fractures that are fully (100%) displaced or have greater than 2 cm of shortening. Pooled patient data were used to construct forest plots for the meta-analysis. RESULTS: Eleven studies including 497 patients who were treated and 457 patients treated conservatively were analyzed. Patients managed operatively had significantly lower relative risk of developing nonunion [0.17 (95% confidence interval 0.08-0.33)] and symptomatic malunion [0.13 (95% confidence interval 0.05-0.37)]. Plate fixation significantly reduced the risk of nonunion, but intramedullary nail fixation did not. There was no difference in Constant-Murley or DASH scores between the 2 treatment groups or in the rate of secondary operative procedures. CONCLUSIONS: Patients who undergo operative fixation of displaced middle-third clavicle fractures have a lower incidence of nonunion and symptomatic malunion. The clinical significance of this effect is uncertain, as functional scores were similar in both groups. Further research into the risk factors for nonunion and symptomatic malunion will be necessary to determine which patients benefit from operative fixation. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

A Machine Learning Algorithm to Predict the Probability of (Occult) Posterior Malleolar Fractures Associated With Tibial Shaft Fractures to Guide "Malleolus First" Fixation.

OBJECTIVES: To develop an accurate machine learning (ML) predictive model incorporating patient, fracture, and trauma characteristics to identify individual patients at risk of an (occult) PMF. METHODS: Databases of 2 studies including patients with TSFs from 2 Level 1 trauma centers were combined for analysis. Using ten-fold cross-validation, 4 supervised ML algorithms were trained in recognizing patterns associated with PMFs: (1) Bayes point machine; (2) support vector machine; (3) neural network; and (4) boosted decision tree. Performance of each ML algorithm was evaluated and compared based on (1) C-statistic; (2) calibration slope and intercept; and (3) Brier score. The best-performing ML algorithm was incorporated into an online open-access prediction tool. RESULTS: Total data set included 263 patients, of which 28% had a PMF. Training of the Bayes point machine resulted in the best-performing prediction model reflected by good C-statistic, calibration slope, calibration intercept, and Brier score of 0.89, 1.02, -0.06, and 0.106, respectively. This prediction model was deployed as an open-access online prediction tool. CONCLUSION: A ML-based prediction model accurately predicted the probability of a (occult) PMF in patients with a TSF based on patient- and fracture-specific characteristics. This prediction model can guide surgeons in their diagnostic workup and preoperative planning. Further research is required to externally validate the model before implementation in clinical practice. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of the Computed Tomographic Scan in the Diagnosis of Acetabular Fracture in the Immature Pelvis.

OBJECTIVES: We present a series of skeletally immature patients sustaining acetabular fractures. We hypothesized that if the secondary ossification centers of the acetabulum are not completely ossified, fractures often will not be identified on plain radiography. Our objective was to determine the efficacy of diagnostic plain radiography in these patients. DESIGN: Retrospective case series. SETTING: Urban, level-I trauma center. PATIENTS/PARTICIPANTS: Skeletally immature patients with acetabular fractures following blunt force trauma. INTERVENTION: We obtained a dedicated axial computed tomographic (CT) scan of the pelvis with sequential sections of 2.5-mm thickness. MAIN OUTCOME MEASURES: The accuracy of plain radiography as compared with CT in diagnosing acetabular fractures in skeletally immature patients. RESULTS: Fourteen patients with 16 fractures of the acetabulum were identified by CT scan; however, 69% (11 of 16) were not visible on plain radiography. Radiographs were less likely to identify acetabular fractures compared with pelvic ring fractures [31% (5/16) vs. 92% (11/12); odds ratio, 0.04; 95% confidence interval, 0.01-0.37; P = 0.001]. Patients younger than 12 years were less likely to have acetabular fractures identified on plain radiography [9% (1/11) vs. 80% (4/5); odds ratio, 0.03; 95% confidence interval 0.01-0.59; P = 0.013]. The mean age of patients whose acetabular fractures were not identified on plain radiography was less than those whose fractures were identified on plain radiography (7.6 ± 2.9 vs. 12.8 ± 1.6; P = 0.004). Acetabular fractures visible on plain radiography were more likely to require operative stabilization [60% (3/5) vs. 0% (0/11); P = 0.004]. CONCLUSIONS: In skeletally immature patients with suspected injury to the pelvis, particularly in patients younger than 12 years, diagnostic evaluation using plain radiographs alone may lead to missed injuries. If an acetabular fracture is identified, patients should be followed closely both clinically and radiographically to ensure early identification of any developing posttraumatic deformity. LEVEL OF EVIDENCE: Level IV; Diagnostic-Investigating a diagnostic test.

Physiologic widening of the medial clear space: What's normal?

BACKGROUND: Literature has validated the use of stress radiographs for evaluation of ankle stability. However, to our knowledge no study has reported the amount of physiological widening that occurs with manual external rotation stress test in uninjured ankles. The purpose of this study was to assess the amount of medial clear space widening that occurs with a manual external rotation stress test in uninjured ankles. METHODS: A cohort of adult patients undergoing operative fixation of unstable ankle fractures were prospectively enrolled to have their contralateral ankle undergo manual external rotation stress examination. Fluoroscopic images of the unaffected ankle were performed in the OR. A non-stressed mortise view and manual external rotation stress view were obtained with a standardized marker to correct for magnification differences. The images were de-identified, presented in a randomized order and reviewers who were blinded. Each reviewer measured the medial clear space. RESULTS: Thirty fluoroscopic images on fifteen patients were obtained. The mean medial clear space on the non-stressed mortise view was 3.1 mm (SD-0.69; Range 1.9 to 4.2, 95% CI [2.75, 3.45]) versus a mean of 3.2 mm (SD-0.71; Range 2.0 to 4.7, 95% CI [2.94, 3.66]) in the stressed mortise view group. Inter-rater reliability was excellent between all observers for medial clear space (ICC-0.88; CI [0.78, 0.94]). CONCLUSIONS: Our results support the previous literature and allow us to advocate for ankle fractures with >5 mm medial clear space after external rotational stress to be considered unstable. Additionally, ankles with a medial clear space between 4 and 5 mm, instability should be considered only if lateral shift is > 2 mm on stress examination. Our data shows that no physiologically healthy ankles widened beyond these established cut-offs before or after the manual external rotation stress.

Propionibacterium acnes Infection of the Shoulder After a Manipulation Under Anesthesia for Stiffness Status Post Open Reduction and Internal Fixation Proximal Humerus: A Case Report.

INTRODUCTION: Propionibacterium acnes infection has been more frequently recognized as an important cause of post-operative shoulder infection. Infection by this organism is more frequently seen after total shoulder arthroplasty but can also be seen after an open reduction and internal fixation (ORIF) of the proximal humerus. We present a patient with P. acnes infection of the shoulder that only became apparent after he underwent a manipulation under anesthesia for stiffness of the shoulder after an ORIF. CASE REPORT: Our patient was a 64-year-old male who sustained a proximal humerus fracture after a motorcycle collision and underwent an ORIF of the proximal humerus with plate fixation. Postoperatively, the patient had stiffness of the shoulder so he underwent a manipulation under anesthesia of the shoulder. On post-operative day 5, the patient developed an erythematous area over the incision. This area opened up and began to drain by post-operative day 10. The patient underwent an irrigation and debridement of the shoulder with partial removal of hardware. He was also started on antibiotics and clinically cleared his infection. CONCLUSION: Infection by P. acnes can be difficult to diagnose and may present with shoulder stiffness as the only initial symptom. This case is unique as there have not been any documented cases of a latent P. acnes infection presenting after a manipulation under anesthesia of the shoulder. There must be a high clinical suspicion for P. acnes infection in any patient presenting with post-operative stiffness.

Concomitant Proximal and Distal Tibiofibular Joint Dislocation Associated With a Tibial Shaft Fracture.

An association exists between tibial shaft fractures and ankle injuries. In addition, although uncommon, an association between tibial shaft fractures and proximal tibiofibular dislocations has also been established. A review of the previous literature resulted in one case report of a complete proximal and distal tibiofibular joint dislocation without fracture of the tibia or fibula. Here, we discuss a case of a complete proximal and distal tibiofibular syndesmotic complex dislocation associated with a tibial shaft fracture. To the best of our knowledge, this is the first report of this injury pattern associated with a tibial shaft fracture.

The Incidence of Posterior Malleolar Involvement in Distal Spiral Tibia Fractures: Is it Higher than We Think?

OBJECTIVES: To investigate the incidence of concomitant posterior malleolar fractures (PMFs) in operative, distal-third, spiral tibia fractures. DESIGN: Prospective protocol with retrospective review of data. SETTING: Single, Level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred ninety-three consecutive, skeletally mature patients with operatively treated fractures of the distal-third, tibial shaft and metaphysis. Pilon fractures were excluded. INTERVENTION: Computed tomography (CT) scans were obtained in all distal-third, spiral fractures of the tibia to determine fracture morphology and presence of a PMF. MAIN OUTCOME MEASUREMENTS: The incidence of concurrent PMFs in operative spiral fractures of the distal tibia. RESULTS: Twenty-six distal-third, spiral fractures were identified with an ipsilateral PMF diagnosed in 92.3% of cases (24 cases). PMFs were over 25 times more likely to occur in distal-third, spiral fractures when compared with other distal-third fracture patterns (relative risk = 25.7, 95% confidence interval, 11.6-56.8). PMFs were treated with supplemental fixation in 23/24 (95.8%) cases. CONCLUSIONS: There is a high incidence of concomitant, ipsilateral fractures of the posterior malleolus in patients presenting with operative distal-third, spiral fractures of the tibia. A preoperative ankle computed tomography should be strongly considered in all cases with this specific fracture morphology. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management and Outcome of Transepiphyseal Femoral Neck Fracture-Dislocation with a Transverse Posterior Wall Acetabular Fracture: A Case Report.

CASE: We present the case of a 10-year-old girl who sustained a transepiphyseal femoral neck fracture with posterior dislocation of the femoral epiphysis and an associated transverse posterior wall acetabular fracture, leading to complete separation of the capital femoral epiphysis. She underwent urgent operative intervention; she was followed for 13 years and achieved an excellent outcome. CONCLUSION: Pediatric hip fracture-dislocations are complex injuries that should be managed by a competent pelvic reconstructive surgeon in a well-resuscitated patient. If a quality reduction is obtained in a timely manner, the patient has the best chance of achieving a favorable long-term outcome.

Evaluation of the Content and Accessibility of Web Sites for Accredited Orthopaedic Trauma Surgery Fellowships.

BACKGROUND: Orthopaedic trauma fellowship applicants use online-based resources when researching information on potential U.S. fellowship programs. The 2 primary sources for identifying programs are the Orthopaedic Trauma Association (OTA) database and the San Francisco Match (SF Match) database. Previous studies in other orthopaedic subspecialty areas have demonstrated considerable discrepancies among fellowship programs. The purpose of this study was to analyze content and availability of information on orthopaedic trauma surgery fellowship web sites. METHODS: The online databases of the OTA and SF Match were reviewed to determine the availability of embedded program links or external links for the included programs. Thereafter, a Google search was performed for each program individually by typing the program's name, followed by the term "orthopaedic trauma fellowship." All identified fellowship web sites were analyzed for accessibility and content. Web sites were evaluated for comprehensiveness in mentioning key components of the orthopaedic trauma surgery curriculum. By consensus, we refined the final list of variables utilizing the methodology of previous studies on the topic. RESULTS: We identified 54 OTA-accredited fellowship programs, offering 87 positions. The majority (94%) of programs had web sites accessible through a Google search. Of the 51 web sites found, all (100%) described their program. Most commonly, hospital affiliation (88%), operative experiences (76%), and rotation overview (65%) were listed, and, least commonly, interview dates (6%), selection criteria (16%), on-call requirements (20%), and fellow evaluation criteria (20%) were listed. Programs with ≥2 fellows provided more information with regard to education content (p = 0.0001) and recruitment content (p = 0.013). Programs with Accreditation Council for Graduate Medical Education (ACGME) accreditation status also provided greater information with regard to education content (odds ratio, 4.0; p = 0.0001). Otherwise, no differences were seen by region, residency affiliation, medical school affiliation, or hospital affiliation. CONCLUSIONS: The SF Match and OTA databases provide few direct links to fellowship web sites. Individual program web sites do not effectively and completely convey information about the programs. The Internet is an underused resource for fellow recruitment. The lack of information on these sites allows for future opportunity to optimize this resource.

Safe Zone Quantification of the Third Sacral Segment in Normal and Dysmorphic Sacra.

OBJECTIVE: To quantify the osseous anatomy of the dysmorphic third sacral segment and assess its ability to accommodate internal fixation. DESIGN: Retrospective chart review of a trauma database. SETTING: University Level 1 Trauma Center. PATIENTS: Fifty-nine patients over the age of 18 with computed tomography scans of the pelvis separated into 2 groups: a group with normal pelvic anatomy and a group with sacral dysmorphism. MAIN OUTCOME MEASUREMENTS: The sacral osseous area was measured on computed tomography scans in the axial, coronal, and sagittal planes in normal and dysmorphic pelves. These measurements were used to determine the possibility of accommodating a transiliac transsacral screw in the third sacral segment. RESULTS: In the normal group, the S3 coronal transverse width averaged 7.71 mm and the S3 axial transverse width averaged 7.12 mm. The mean S3 cross-sectional area of the normal group was 55.8 mm. The dysmorphic group was found to have a mean S3 coronal transverse width of 9.49 mm, an average S3 axial transverse width of 9.14 mm, and an S3 cross-sectional area of 77.9 mm. CONCLUSIONS: The third sacral segment of dysmorphic sacra has a larger osseous pathway available to safely accommodate a transiliac transsacral screw when compared with normal sacra. The S3 segment of dysmorphic sacra can serve as an additional site for screw placement when treating unstable posterior pelvic ring fractures.

Measuring the attitudes and impact of the eighty-hour workweek rules on orthopaedic surgery residents.

BACKGROUND: The literature on graduate medical education contains anecdotal reports of some effects of the new eighty-hour workweek on the attitudes and performance of residents. However, there are relatively few studies detailing the attitudes of large numbers of residents in a particular surgical specialty toward the new requirements. METHODS: Between July and November 2004, a survey created by the Academic Advocacy Committee of the American Academy of Orthopaedic Surgeons was distributed by mail, fax, and e-mail to a total of 4207 orthopaedic residents at the postgraduate year-1 through year-6 levels of training. The survey responses were tabulated electronically, and the results were recorded. RESULTS: The survey response rate was 13.2% (554 residents). Sixty-eight percent (337) of the 495 respondents whose postgraduate-year level was known were at the postgraduate year-4 level or higher. Attitudes concerning the duty rules were mixed. Twenty-three percent of the 554 respondents thought that eighty hours constituted an appropriate number of duty hours per week; 41% believed that eighty hours were too many, and 34% thought that eighty hours were not sufficient. Thirty-three percent of the respondents had worked greater than eighty hours during at least a single one-week period since the new rules were implemented; this occurred more commonly among the postgraduate year-3 and more junior residents. Orthopaedic trauma residents had the most difficulty adhering to the new duty-hour restrictions. Eighty-two percent of the respondents indicated that their residency programs have been forced to make changes to their call schedules or to hire ancillary staff to address the rules. The use of physician assistants, night-float systems, and so-called home-call assignments were the most common strategies used to achieve compliance. CONCLUSION: Resident attitudes toward the work rules are mixed. The rules have forced residency programs to restructure. Junior residents have more favorable attitudes toward the new standards than do senior residents. Self-reporting of duty hours is the most common method of monitoring in orthopaedic training programs. Such systems allow ample opportunity for inaccuracies in the measurement of hours worked. Although residents report an improved quality of life as a result of these new rules, the attitude that the quality of training is diminished persists.