Non-operative treatment of atlanto-occipital incongruity following high energy trauma: a case report.

Background: Traumatic occipitocervical dislocations (OCDs) are rare and potentially devastating injuries, and delayed diagnosis and management is a well-known risk factor for poor outcomes in high energy trauma. Early surgical stabilization has been shown to improve outcomes and neurologic recovery in these patients. We present a case of incongruent atlanto-occipital (O-C1) joints found on post-operative computed tomography (CT) imaging following C1-C2 fusion. This patient was treated non-operatively in a cervical collar (C-collar) after traction testing revealed no dynamic instability. Case Description: A 19-year-old male with history of obesity was involved in a high-speed motor vehicle collision (MVC). On arrival, he had elevated troponins but otherwise normal laboratory workup and electrocardiogram (EKG). He remained hypotensive throughout his initial presentation. A reliable neurologic exam could not be obtained due to the patient's intubated and sedated status, however, bulbocavernosus reflex was intact, reflexes were normal and the patient did not demonstrate evidence of spinal or neurogenic shock. CT of the full spine revealed distraction of the C1-C2 articulation without associated fracture, and without clear disruption or distraction of the O-C1 joint. He was taken to the operating room for C1-C2 posterior instrumentation and fusion. Post-operative cervical spine CT revealed further distraction and subluxation of the occipitocervical junction bilaterally, with condyle to C1 interval (CCI) of 4-mm bilaterally, a basion-dens interval (BDI) of 10 mm, and a Power's Ratio of 1.1. The patient was brought back urgently to the operating room for traction testing to rule out OCD. There was no distraction noted on dynamic traction testing, and the patient was treated non-operatively in a C-collar. At 12 weeks post-injury, the patient experienced no neck pain, and flexion/extension radiographs showed no evidence of subluxation or distraction at the O-C1 joints. Conclusions: Incongruity of the O-C1 joint may not be synonymous with instability as previously thought, and in cases of O-C1 incongruity with stable traction testing, non-operative treatment with external immobilization can be considered as a viable treatment option even in the polytraumatized patient.

Single-Incision Fasciotomy Decreases Infection Risk Compared with Dual-Incision Fasciotomy in Treatment of Tibial Plateau Fractures With Acute Compartment Syndrome.

OBJECTIVES: Comparison of surgical site infection (SSI) rates in tibial plateau fractures with acute compartment syndrome treated with single-incision (SI) versus dual-incision (DI) fasciotomies. DESIGN: Retrospective cohort study. SETTING: Two, Level-1, academic, trauma centers. PATIENTS: Between January 2001 and December 2021, one-hundred ninety patients with a diagnosis of tibial plateau fracture and acute compartment syndrome met inclusion criteria (SI: n = 127, DI: n = 63) with a minimum of 3-month follow-up after definitive fixation. INTERVENTION: Emergent 4-compartment fasciotomy, using either SI or DI technique, and eventual plate and screw fixation of the tibial plateau. OUTCOMES: The primary outcome was SSI requiring surgical debridement. Secondary outcomes included nonunion, days to closure, method of skin closure, and time to SSI. RESULTS: Both groups were similar in demographic variables and fracture characteristics (all P > 0.05). The overall infection rate was 25.8% (49 of 190), but the SI fasciotomy patients had significantly fewer SSIs compared with the DI fasciotomy patients [SI 18.1% vs. DI 41.3%; P < 0.001; OR 2.28, (confidence interval, 1.42-3.66)]. Patients with a dual (medial and lateral) surgical approach and DI fasciotomies developed an SSI in 60% (15 of 25) of cases compared with 21.3% (13 of 61) of cases in the SI group ( P < 0.001). The nonunion rate was similar between the 2 groups (SI 8.3% vs. DI 10.3%; P = 0.78). The SI fasciotomy group required fewer debridement's ( P = 0.04) until closure, but there was no difference in days until closure (SI 5.5 vs. DI 6.6; P = 0.09). There were zero cases of incomplete compartment release requiring return to the operating room. CONCLUSIONS: Patients with DI fasciotomies were more than twice as likely to develop an SSI compared with SI patients despite similar fracture and demographic characteristics between the groups. Orthopaedic surgeons should consider prioritizing SI fasciotomies in this setting. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Staged Protocol for Treatment of High-Energy Tongue-Type Calcaneus Fractures: Surgical Technique and Case Series.

SUMMARY: Displaced tongue-type calcaneus fractures are frequently associated with severe soft tissue injuries, and urgent relief of the displaced tongue fragment on the posterior soft tissues is essential to preventing soft tissue complications. If there is a complex articular injury, the soft tissue envelope often needs time for swelling to resolve to allow for a safe open anatomic reduction because premature open reduction internal fixation is often associated with increased complications. We have found that in high-energy tongue-type calcaneus fractures with complex articular injuries, a staged protocol consisting of initial percutaneous reduction and fixation with later definitive reconstruction is soft tissue friendly, allows early restoration of calcaneal morphology, and affords extensile approaches for eventual reconstruction. The purpose of this study was to describe our protocol of staged treatment of high-energy tongue-type calcaneus fractures, along with postoperative surgical outcomes, in a case series of 53 patients.Our series of patients had a high rate of intra-articular injury with marked initial displacement (mean Bohler angle -8.4 ± 20.8 degrees). They were treated initially with percutaneous reduction and fixation at median 1 day postinjury (interquartile range [IQR] 0-1) and definitively at median 16 days postinjury (IQR 10-33). In this series, 2 of 53 (3.8%) patients developed a deep wound infection.In high-energy tongue-type calcaneus fractures at risk for soft tissue compromise or with a significantly displaced tongue fragment without initial soft tissue compromise, we found that staged management represents a feasible management strategy to mitigate risk of soft tissue complications and therefore helps facilitate safe definitive open treatment.

Conversion of External Fixator to Intramedullary Nail in Tibial fractures.

INTRODUCTION: Conversion of provisional external fixation to intramedullary nail (IMN) in femur fractures has been reported to be safe within 14 days of initial surgery. However, there is no current literature guiding this practice in tibial fractures. The purpose of this study was to identify the time period when conversion of external fixation to nail in tibial fractures is safe. METHODS: After obtaining IRB approval, tibial fractures (OTA 41A, 42, 43A) that received provisional ex-fix and were converted to IMN from 2009 to 2019 were retrospectively reviewed. Skeletally mature patients with minimum 6 months of follow-up were included. The primary outcome was deep infection. External fixation days were categorized as less than 7, 8 to 14, and 15+ days. Risk ratios of infection were estimated using generalized linear regression with a Poisson distribution. A separate regression model evaluated risk factors for infection using both the external fixation and non-external fixation tibial cohorts. RESULTS: Twenty-eight patients (32%) were treated for deep infection. The infection rate for closed fractures was 28% (11 of 39 patients) and for open fractures was 35% (17 of 49 patients) ( P = 0.56). Examining both tibial cohorts, external fixation (odds ratio [OR] = 2.39, P = 0.017), open fracture (OR = 3.13, P = 0.002), and compartment syndrome (OR = 2.58, P = 0.01) were all associated with infection in regression modeling. Median external fixation days for patients with deep infection was 8 days (Inter-quartile range, 3 to 18 days) as compared with 4 days (IQR, 2 to 9 days) in patients without infection ( P = 0.06). While controlling for open fractures, the 8- to 14-day group had RR = 1.81 ( P = 0.2), and the 15+-day group had RR = 2.67 ( P = 0.003) as compared with the <7-day group. DISCUSSION: Infection rates of tibial fracture patients treated with external fixation and converted to IMN were high. Surgeons should strongly consider the necessity of external fixation for these fractures. Earlier conversion of external fixation to definitive fixation reduced infection rates. LEVEL OF EVIDENCE: Level IV-case series.

Posteromedial Talar Body Fracture: Case Discussion and Surgical Technique.

SUMMARY: Posteromedial talar body fractures are a rare form of talus fracture that involves the tibiotalar and subtalar joints. In cases of displaced injuries, open reduction and internal fixation is typically recommended to minimize the risk of instability and post-traumatic osteoarthritis. This video presents a case of a posteromedial talar body fracture and highlights the technique for operative fixation through a posteromedial approach. Multiple methods to obtain reduction are discussed, and considerations with implant placement are described. The indications for surgical intervention are reviewed, and published outcomes following operative and nonoperative management of these injuries are presented.

A Student-Led National Conference on Leadership: Broadening the Medical Student Role.

This article was migrated. The article was marked as recommended. Students have traditionally held a singular role in medical education - the learner. This narrow view neglects students unique perspective and ability to shape the future of medical education. In recognizing the need for deliberate leadership skill development and networking opportunities for medical student leaders, the American Medical Association (AMA) supported the first AMA Accelerating Change in Medical Education Student-Led Conference on Leadership in Medical Education. A planning committee of 19 students from seven medical schools collaborated to develop this conference, which took place on August 4-5, 2017 at the University of Michigan, Ann Arbor. The primary goal of the conference was for students to learn about leadership skills, connect with other student leaders, feel empowered to lead change, and continue to lead from their roles as students. Attendees participated in a variety of workshops and presentations focused on developing practical leadership skills. In addition, students formed multi-institutional teams to participate on in the MedEd Impact Challenge, attempting to address issues in medical education such as leadership curriculum development, wellness, and culture change. Post-conference surveys showed an overwhelming majority of students connected with other student leaders, shared ideas, developed collaborations, and felt empowered to enact change. Looking forward, we believe that similar student-led conferences focused on broadening the medical student role would provide avenues for positive change in medical education.