Case Series Evaluating the Operative and Nonoperative Treatment of Scapular Fractures.

The injury parameters and patient characteristics that affect function after scapular fracture are poorly defined. We performed a retrospective review of 594 adult patients with a minimum 12-month follow-up after scapular fracture. Functional outcomes were prospectively assessed using the American Shoulder and Elbow Surgeons (ASES) survey in 153 patients after a mean of 62 months of follow-up. The population was 78% male, and 88% had injuries caused by a high-energy event. Only 4.6% had injuries isolated to the scapula. All fractures healed primarily and the mean ASES score was 79.3, indicating minimal functional impairment. However, 7 patients (4.6%) reported severe functional deficits. Fifteen patients (9.8%) underwent open reduction and internal fixation. These patients had a better mean ASES score than those who were treated nonoperatively (92.1 vs 77.9, P = .03). When fracture types were analyzed individually, there was an advantage to surgery in fractures involving the glenoid (96.0 vs 75.7, P < .05). Concomitant chest wall injury or the presence of adjacent fractures did not affect functional outcomes. Smokers had a worse mean score (73.3 vs 84.5, P = .01), as did patients with a history of alcohol abuse (70.3 vs 83.9, P < .05). In conclusion, mean ASES scores indicated good function overall. Patients with a history of tobacco use or alcohol abuse had worse outcome scores.

A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis?

BACKGROUND: Osteonecrosis and posttraumatic arthritis are common after talar neck fracture. We hypothesized that delay of definitive fixation would not increase the rate of osteonecrosis, but that the amount of initial fracture displacement, including subtalar and/or tibiotalar dislocations, would be predictive. We investigated the possibility of dividing the Hawkins type-II classification into subluxated (type-IIA) and dislocated (type-IIB) subtalar joint subtypes. METHODS: The cases of eighty patients with eighty-one talar neck and/or body fractures who had a mean age of 36.7 years were reviewed. The fractures included two Hawkins type-I, forty-four type-II (twenty-one type-IIA and twenty-three type-IIB), thirty-two type-III, and three type-IV fractures. Open fractures occurred in twenty-four patients (30%). RESULTS: One deep infection, two nonunions, and two malunions occurred. After a mean of thirty months of follow-up, sixteen of sixty-five fractures developed osteonecrosis, but 44% of them revascularized without collapse. Osteonecrosis never occurred in fractures without subtalar dislocation (Hawkins type I and IIA), but 25% of Hawkins type-IIB patterns developed osteonecrosis (p = 0.03), and 41% of Hawkins type-III fractures developed osteonecrosis (p = 0.004). Osteonecrosis occurred after 30% of open fractures versus 21% of closed fractures (p = 0.55). Forty-six fractures were treated with urgent open reduction and internal fixation (ORIF) at a mean of 10.1 hours, primarily for open fractures or irreducible dislocations. With the numbers studied, the timing of reduction was not related to the development of osteonecrosis. Thirty-five patients had delayed ORIF (mean, 10.6 days), including ten with Hawkins type-IIB and ten with Hawkins type-III fractures initially reduced by closed methods, and one (5%) of the twenty developed osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01). CONCLUSIONS: Following talar neck fracture, osteonecrosis of the talar body is associated with the amount of the initial fracture displacement, and separating Hawkins type-II fractures into those without (type IIA) and those with (type-IIB) subtalar dislocation helps to predict the development of osteonecrosis as in this series. It never occurred when the subtalar joint was not dislocated. When it does develop, osteonecrosis often revascularizes without talar dome collapse. Delaying reduction and definitive internal fixation does not increase the risk of developing osteonecrosis.

Treatment and complications in orthopaedic trauma patients with symptomatic pulmonary embolism.

OBJECTIVES: The purpose of this study is to characterize the presentation, size, treatment, and complications of pulmonary embolism (PE) in a large series of orthopaedic trauma patients who developed PE after injury. METHODS: We reviewed the records of orthopaedic trauma patients who developed a PE within 6 months of injury at 9 trauma centers and 2 tertiary care facilities. RESULTS: There were 312 patients, 186 men and 126 women, average age 58 years. Average body mass index was 29.6, and average Injury Severity Score was 18. Seventeen percent received anticoagulation before injury, and 5% had a history of PE. After injury, 87% were placed on prophylactic anticoagulation and 68% with low-molecular weight heparin. Fifty-three percent of patients exhibited shortness of breath or chest pain. Average heart rate and O2 saturation before PE diagnosis were 110 and 94%, respectively. Thirty-nine percent had abnormal arterial blood gas, and 30% had abnormal electrocardiogram findings. Eighty-nine percent had computed tomography pulmonary angiography for diagnosis. Most clots were segmental (63%), followed by subsegmental (21%), lobar (9%), and central (7%). The most common treatment was unfractionated heparin and Coumadin (25%). Complications of anticoagulation were common: 10% had bleeding at the surgical site. Other complications of anticoagulation included gastrointestinal bleed, anemia, wound complications, death, and compartment syndrome. PE recurred in 1% of patients. Four percent died of PE within 6 months. CONCLUSIONS: This is the first large data set to evaluate the course of PE in an orthopaedic trauma population. The complications of anticoagulation are significant and were as common in patients with lower risk clots as those with higher risk clots.