Treatment and outcome in combined scapula and rib fractures: a retrospective study.

PURPOSE: The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment strategies. METHODS: All adult (≥ 18 years) patients with concurrent ipsilateral scapula and rib fractures admitted to the study hospital between 1st January 2010 and 31st June 2021 were retrospectively reviewed. RESULTS: A total of 223 patients were admitted with concurrent ipsilateral rib and scapula fractures. A total of 160 patients (72%) were treated conservatively, 63 patients (28%) operatively. Among operatively treated patients, 32 (51%) underwent rib fixation (RF) only, 24 (38%) underwent scapula fixation (SF) only, and seven patients (11%) underwent combined fixation of scapula and ribs (SRF). In general, more severely injured patients were treated with more extensive surgery. RF patients had a median hospital length of stay of 16 days, the SF patients 11 days and SRF patients 18 days. There were no significant differences in complications (pneumonia, recurrent pneumothorax and revision surgery) between groups. CONCLUSION: Injury severity resulted in different treatment modalities. As a result, different patient characteristics between treatment groups were observed, which makes direct comparison between treatment modalities impossible. All treatment modalities seem feasible; however, the additional value of both rib and scapula fixation has yet to be proven in large multicentre studies.

Does plate position influence the outcome in midshaft clavicular fractures? A multicenter analysis.

PURPOSE: To date, it remains unclear whether superior or anterior plating is the best option for treating midshaft clavicular fractures. The aim of this study was to compare both techniques with regard to the incidence of implant removal due to implant irritation, risk of complications, time to union, and function. METHODS: In this retrospective cohort study, all midshaft clavicular fractures treated operatively between 2017 and 2020 in two hospitals in Switzerland were analyzed. The participating hospitals differed with regard to their standard practice; one offered superior plating only, while the other predominantly employed an anterior plate. The primary outcome was the incidence of implant removal for irritation. Secondary outcomes were time to union, complications, re-interventions, and range of motion during the follow-up period of at least 6 months. RESULTS: In total, 168 patients were included in the study of which 81 (48%) received anterior plating and 87 (52%) superior plating. The overall mean age was 45 years (SD 16). There was no significant difference between anterior and superior plating with regard to implant removal (58.5% versus 57.1%, p = 0.887), infection (5.7% versus 1.8%, p = 0.071), and time to union (median 48 weeks versus 52 weeks, p = 0.643). Data on range of motion were available in 71 patients. There was no significant difference in anteflexion (median 180 degrees anterior versus 180 degrees superior) and abduction (median 180 degrees anterior versus 180 degrees superior) between the two groups. CONCLUSION: This retrospective cohort study did not find sufficient evidence to recommend one implant position over the other for midshaft clavicular fractures with regard to removal due to irritation. Time to union was similar and Infections were equally rare in both groups. Notably, a considerable number of patients in both groups had their implants removed due to irritation. Larger prospective studies are needed to determine how much plate position contributes to the occurrence of irritation and whether other patient or implant-related factors might play a role. Until this is clarified, implant position should be based on surgeons preference and experience.

Routine 6-Week Outpatient Radiography and Visit in Patients with Conservatively Treated Multiple Rib Fractures: Valuable or a Waste of Resources?

Background: This study investigated the incidence and clinical consequences of abnormal radiological and clinical findings during routinely performed 6-week outpatient visits in patients treated conservatively for multiple (3 or more) rib fractures. Methods: A retrospective analysis was conducted among patients with multiple rib fractures treated conservatively between 2018 and 2021 (Opvent database). The primary outcome was the incidence of abnormalities on chest X-ray (CXR) and their clinical consequences, which were categorized as requiring intervention or additional clinical/radiological examination. The secondary focus was the incidence of deviation from standard treatment in response to the findings (clinical or radiological) at the routine 6-week outpatient visit. Results: In total, 364 patients were included, of whom 246 had a 6-week visit with CXR. The median age was 57 years (interquartile range, 46-70 years) and the median Injury Severity Score was 17 (interquartile range, 13-22). Forty-six abnormalities (18.7%) were found on CXR. These abnormalities resulted in additional outpatient visits in 4 patients (1.5%) and in chest drain insertion in 2 (0.8%). Only 2 patients (0.8%) with an abnormality on CXR presented without symptoms. None of the 118 patients who had visits without CXR experienced problems. Conclusion: Routine 6-week outpatient visits for patients with conservatively treated multiple rib fractures infrequently revealed abnormalities requiring treatment modifications. It may be questioned whether the 6-week outpatient visit is even necessary. Instead, a more targeted approach could be adopted, providing follow-up to high-risk or high-demand patients only, or offering guidance on recognizing warning signs and providing aftercare through a smartphone application.

Low profile dual plating for mid-shaft clavicle fractures: a meta-analysis and systematic review of observational studies.

INTRODUCTION: Low profile dual plate fixation using two mini fragment plates (< 2.7 mm thickness) is a relatively new technique and alternative to single plating for treating midshaft clavicle fractures. To date, no meta-analysis has been performed comparing these two techniques. Therefore, a systematic review and meta-analysis of observational studies and randomized clinical trials was performed comparing single plating to low profile dual plating for midshaft clavicle fractures. METHODS: PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies comparing both treatments. Effect estimates were pooled across studies using random effects models. The primary outcome is overall complication rate and re-intervention rate. Secondary outcomes include healing, operation duration and functional scores. RESULTS: Low profile dual plating has favourable outcomes regarding overall complication rate (8.1% vs. 22.5%, OR 0.3, 95% CI 0.2-0.7, I2 = 16%, p = 0.007) and re-intervention rate (6.1% vs. 16.1%, OR 0.3, 95% CI 0.1-0.9, I2 = 25%, p = 0.02). The largest contributing factor behind these differences was the high incidence of implant related complaints in the single plating group (4.7% vs. 11.6%, OR 0.4, 95% CI 0.2-0.9, I2 = 0%, p = 0.02). The use of low profile dual plating does not have a detrimental effect on healing with union being attained in 99% compared to 97.4% in the single plating group (OR 1.8, 95% CI 0.3-10.7, I = 0%, p = 0.5). Data on operating time and functional results is limited. CONCLUSION: This meta-analysis shows that dual plating low profile plates for midshaft clavicle fractures is a safe procedure attaining the same union rates seen in patients treated with single plating. In addition, it seems to have a lower overall complication and re-intervention rate, mostly driven by the lower incidence of implant related complaints. Low profile dual plating, however, is a fairly new technique and should be further explored in respect to more differentiated endpoints to test whether these first findings are valid. LEVEL OF EVIDENCE: III.

The value of fibular fixation in patients with stabilized distal tibia fractures.

PURPOSE: There is currently no consensus regarding the need for fixation of concomitant fibula fractures in patients with surgically treated distal tibia fracture. Although studies have shown it to be beneficial for fractures involving the syndesmosis, it remains unclear for suprasyndesmotic fractures. This study evaluates what effect the fixation of such suprasyndesmotic fibula fractures had on patients who underwent fixation of distal tibia fractures. METHODS: This retrospective cohort study included all consecutive adult patients who received surgical treatment for an extra-articular or simple intraarticular distal tibia fracture between 2012 and 2020 and had a concomitant fibula fracture proximal to the syndesmosis. Two groups were formed depending on whether the fibula was stabilized. The need for revision surgery, the occurrence of complications, fracture healing, rotational and angular malalignment were evaluated for both groups. RESULTS: This study included 120 patients, of which 40 (33.3%) had operative treatment of the fibula fracture. Of those with stabilized fibula fractures, 28 (70%) were treated with a plate and 12 (30%) with a titanium elastic nail. The group of patients with surgically treated fibula fractures had significantly more angular malalignments (10% vs 1.2%, p = 0.042), while there was no difference regarding rotational malalignment or fracture healing. Further, infections of the fibular surgical site occurred in 15% of surgically treated patients leading to significantly more revision surgeries in this group (40% vs 20%, p = 0.03). All infections occurred when a plate was used. CONCLUSION: This study was unable to show any benefit from stabilizing concomitant, suprasyndesmotic fibula fractures in surgically treated distal tibia fractures. On the contrary, infection, revision surgery and angular malalignment were more frequent when the fibula was fixed. Therefore, such concomitant fibula fractures should not routinely be fixed and if stabilization is deemed necessary, the implant should be chosen carefully.

Temporary external fixation versus direct ORIF in complete displaced intra-articular radius fractures: a prospective comparative study.

PURPOSE: In complex distal radius fractures (DRF), both direct osteosynthesis (one-stage approach) and temporary external fixation as a bridge to definitive osteosynthesis (two-stage approach) are used. Studies directly comparing these two management options are lacking. This study aims to compare the two procedures with regard to complications, and radiological and functional outcomes. MATERIAL: This prospective observational study included all patients presenting with AO OTA C2 or C3 DRF (1) between January 2011 and January 2018. All patients were categorised into two groups according to received treatment: patients who underwent direct definitive osteosynthesis (Group One Stage) and patients who received an external fixator followed by definitive fixation (Group Two Stage). Primary outcome was the Patient-Rated Wrist Evaluation score (PRWE) measured at 1 year follow-up. Secondary outcomes included complications, range of motion (ROM), and radiologic parameters (ulnar variance, radial inclination and volar tilt). RESULTS: A total of 187 patients were included in Group One Stage with a mean age of 55.6 years (SD 17.2), of which 67 had a C2 and 120 a C3 fracture. Group Two Stage consisted of 66 patients with a mean age of 53.7 years (SD 20.4 years), of which 6 patients having a C2 and 60 a C3 fracture. There was no significant difference in complications and median PRWE between Group One Stage (12.0, IQR 2.0-20.0) and Group Two Stage (12.2, IQR 5.5-23.4) (p = 0.189), even after correction for differences in baseline characteristics. The ROM and radiologic parameters did not show any significant differences as well. CONCLUSION: No differences were found in clinical, functional, and radiological outcome between one- and two-staged surgical techniques. It may be concluded that a two-stage approach is a viable and safe alternative.

Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies.

PURPOSE: This meta-analysis compares open reduction and internal fixation with a plate (ORIF) versus nailing for humeral shaft fractures with regard to union, complications, general quality of life and shoulder/elbow function. METHODS: PubMed/Medline/Embase/CENTRAL/CINAHL was searched for observational studies and randomised clinical trials (RCT). Effect estimates were pooled across studies using random effects models. Results were presented as weighted odds ratio (OR) or risk difference (RD) with corresponding 95% confidence interval (95% CI). Subgroup analysis was performed stratified for study design (RCTs and observational studies). RESULTS: Eighteen observational studies (4906 patients) and ten RCT's (525 patients) were included. The pooled effect estimates of observational studies were similar to those obtained from RCT's. More patients treated with nailing required re-intervention (RD 2%; OR 2.0, 95% CI 1.0-3.8) with shoulder impingement being the most predominant indication (17%). Temporary radial nerve palsy secondary to operation occurred less frequently in the nailing group (RD 2%; OR 0.4, 95% CI 0.3-0.6). Notably, all but one of the radial nerve palsies resolved spontaneously in each groups. Nailing leads to a faster time to union (mean difference - 1.9 weeks, 95% CI - 2.9 to - 0.9), lower infection rate (RD 2%; OR 0.5, 95% CI 0.3-0.7) and shorter operation duration (mean difference - 26 min, 95% CI - 37 to - 14). No differences were found regarding non-union, general quality of life, functional shoulder scores, and total upper extremity scores. CONCLUSION: Nailing carries a lower risk of infection, postoperative radial nerve palsy, has a shorter operation duration and possibly a shorter time to union. Shoulder impingement requiring re-intervention, however, is an inherent disadvantage of nail fixation. Notably, absolute differences are small and almost all patients with radial nerve palsy recovered spontaneously. Satisfactory results can be achieved with both treatment modalities.

Improving the protocol for whole-body CT scans in trauma patients.

PURPOSE: While whole-body computed tomography is an established diagnostic method for the work up of polytraumatized patients, the protocols used differ between trauma centers. This study aimed to compare scan duration and estimated radiation of two protocols. Secondary aim was to assess if using the revised CT protocol reduced the number of additional images of the upper extremities. METHODS: Two groups of consecutive trauma patients, which both received a whole-body CT, were analyzed. Patients, who received a three-phased CT during which their arms needed to be repositioned from their side to above the head, were assigned to group A. Those, who received a CT with their arms placed on a pillow ventral to the abdomen throughout the entire scan were assigned to group B. Estimated radiation dose, scan duration, number of upper limb injuries and number of additional images of the upper limbs within 24 h after initial CT were assessed. RESULTS: Group A consisted of 182 patients, group B of 218. The scan duration was 3 min shorter (p < 0.001) and the estimated radiation dose lower (15.0 vs 22.9 mSv, p < 0.001) in group B. There was no difference in the number of upper limb injuries detected or the number of upper limb additional images required within 24 h. CONCLUSION: Using a whole-body CT scan protocol in which the arms remain on a pillow ventral to the torso instead of one which requires a repositioning of the arms, both scan duration and estimated radiation dose can be reduced. Despite the arms being within the scanned area in the revised protocol, the number of additional imaging of the upper extremities could not be reduced.

Conventional and laparoscopic reversal of the Hartmann procedure: a review of literature.

PURPOSE: The aim of this study was to provide a systematic overview on both laparoscopic and conventional Hartmann reversal. Furthermore, the Hartmann procedure is reevaluated in the light of new emerging alternatives. METHODS: Medline, Ovid, EMBASE, and Cochrane database were searched for studies reporting on outcomes after Hartmann reversal. RESULTS: Thirty-five studies were included in this review of which 30 were retrospective. A total of 6,249 patients with a mean age of 60 years underwent Hartmann reversal. Two thirds of patients were classified as American Society of Anesthesiologists (ASA) I-II. The mean reversal rate after a Hartmann procedure was 44%, and mean time interval between Hartmann procedure and Hartmann reversal was 7.5 months. The most frequent reported reasons for renouncing Hartmann reversal were high ASA classification and patients' refusal. The overall morbidity rate ranged from 3% to 50% (mean 16.3%) and mortality rate from 0% to 7.1% (mean 1%). Patients treated laparoscopically had a shorter hospital stay (6.9 vs. 10.7 days) and appeared to have lower mean morbidity rates compared to conventional surgery (12.2% vs. 20.3%). CONCLUSION: Hartmann reversal carries a high risk on perioperative morbidity and mortality. The mean reversal rate is considerably low (44%). Laparoscopic reversal compares favorably to conventional; however, high level evidence is needed to determine whether it is superior.