Clinical and radiological risk factors associated with the occurrence of acute compartment syndrome in tibial fractures: a systematic review of the literature.

Introduction: Acute compartment syndrome (ACS) is an orthopedic emergency that may lead to devastating sequelae. Diagnosis may be difficult. The aim of this systematic review is to identify clinical and radiological risk factors for ACS occurrence in tibial fractures. Methods: PubMed® database was searched in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Additional articles were found by a manual research of selected references and authors' known articles. Results: The identification process individualized 2758 via database and 30 via other methods. After screening and eligibility assessment, 29 articles were included. Age, gender, occupation, comorbidities, medications, habits, polytrauma, multiple injuries, mechanism, sports, site, open vs closed, contiguous lesion, classification, and pattern were found to be related to ACS occurrence. Conclusions: Younger age and male gender are strong independent risk factors in tibial plateau and shaft fractures. High-energy fractures, polytrauma, more proximal fractures and fractures with contiguous skeletal lesions are aggravating risk factors; higher AO/OTA and Schatzker classification types, increased displacement of the tibia relative to the femur, and increased tibial joint surface width are associated risk factors in tibial plateau fractures; higher AO Foundation/Orthopaedic Trauma Association classification types and subgroups and more proximal fractures within the diaphysis are associated risk factors in tibial shaft fracture. Open fractures do not prevent ACS occurrence. Increased fracture length is the only factor suggesting a higher risk of ACS in tibial pilon fractures. The presence of each independent predictor may have a cumulative effect increasing the risk of ACS occurrence.

High-energy blunt pelvic ring injury incidence and polytrauma caseload in a single level I trauma center during COVID-19 related pseudo-lockdown measures: a retrospective cohort study based on a prospective registry.

BACKGROUND: Pelvic ring injuries are potentially lethal lesions associated with polytrauma patients and need an efficient trauma team for their management. The purpose of this study was to evaluate the incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients in a single level I trauma center during the 2020 pseudo-lockdown period related to the Coronavirus pandemic, and to compare it with corresponding periods in 2014-2019 in order to better understand the need of organized and dedicated personnel and infrastructures. METHODS: This retrospective cohort study was based on data prospectively recorded into the institutional Severely Injured Patients' Registry. Data were obtained for each year period (January 1st to December 31st) and corresponding pseudo-lockdown period (March 16th to June 19th). High-energy blunt pelvic ring injuries inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) pelvic ring injury presence. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; (3) penetrating, blast, burn and electrical injuries, drownings; (4) patients living outside the defined institution's catchment area; and (5) any document attesting the patient's will to not participate in any study. Polytrauma patients inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) Injury Severity Score ≥ 16. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; and (3) any document attesting the patient's will to not participate in any study. Categorical variables were reported using proportions and continuous variables using medians and interquartile ranges. Because data were exhaustive for the authors' level I trauma center, no inferential statistics were computed. RESULTS: The incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients remained within range of previous years despite pseudo-lockdown measures. CONCLUSIONS: These observations bring better knowledge about pseudo-lockdown's impact on trauma and may help for future health strategy planning by pointing out the importance of maintaining the activity of level I trauma centers in terms of personnel and infrastructures.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

OBJECTIVE: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

Epidemiology of high-energy blunt pelvic ring injuries: A three-year retrospective case series in a level-I trauma center.

BACKGROUND: High-energy pelvic ring injuries (PRI) represent a heavy burden for institutions treating severely injured patients. Epidemiological data knowledge may help to provide them appropriate management. Only two epidemiologic studies about high-energy PRI were published during last decade. This study aimed to determine the gender-specific and global incidences of high-energy blunt AO/OTA type B or C PRI and their frequency among high-energy blunt trauma. It further reports the spectrum of these injuries and compares their characteristics and outcomes to high-energy blunt trauma without type B or C PRI. HYPOTHESIS: Type B or C PRI incidence isn't gender specific and approximates 5/100,000/year. PATIENTS AND METHODS: A prospective database of a level-I trauma center serving approximately 500,000 inhabitants was retrospectively queried for all high-energy trauma patients injured between 01.01.2014 and 12.31.2016. Inclusion criteria were: alive emergency department delivery; entire acute treatment at the authors' institution; age >16. Exclusion criteria were: penetrating, blast, burn and electrical injuries; drownings; low-energy trauma; patients living outside the institution's catchment area. Three authors performed PRI classifications. Clinical data were extracted from the database. RESULTS: We analyzed 434 patients. High-energy blunt type B or C PRI incidence was 3.8/100,000/year without gender disparity (p=0.6697). High-energy blunt trauma incidence was lower in women than in men (20.5 vs. 51.6/100,000/year, p<0.001). Type B or C PRI frequency during high-energy blunt trauma was higher in women than in men (17.6% vs. 7.9%, p=0.003). Type B or C PRI patients were more severely injured and needed more treatment resources than other high-energy blunt trauma patients but didn't present higher complication or death rates. DISCUSSION: The incidence of high-energy blunt type B or C PRI was comparable to previously published data. Women were less likely to sustain a high-energy blunt trauma, but when they sustained one, they were more likely to have a type B or C PRI. Despite higher injury severity score and resource requirements, complication and death rates weren't different between type B or C PRI patients and other high-energy blunt trauma patients. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

High-energy blunt pelvic ring injury: dataset of patients and injury characteristics from a severely injured patients' registry.

Since mid-2013, data on high-energy trauma patients admitted to the Emergency Department of the University Hospitals of Geneva, Switzerland, are prospectively recorded in a dedicated registry. This includes data on patients with high-energy blunt pelvic ring injuries (PRI), defined as closed fracture of the pelvic ring following falls from a height >1 m, road traffic accidents, sport, crush, farm and industrial injuries. The registry was screened for patients aged ≥16 years with high-energy blunt PRI admitted to the aforementioned academic level I trauma center between 2014.01.01 et 2019.12.31, to assess the outcome of the institutional PRI management protocol. Data on 195 patients were collected and analyzed for this purpose [1]. The dataset "patients' demographic and injury characteristics" provides the raw demographics and Abbreviated Injury Scale (AIS) of these 195 patients. These data can contribute to the knowledge of patients' demographics and injury characteristics of high-energy blunt PRI patients.

Management of high-energy blunt pelvic ring injuries: A retrospective cohort study evaluating an institutional protocol.

INTRODUCTION: High-energy blunt pelvic ring injuries with hemodynamic instability are complicated by a high mortality rate (up to 32%). There is no consensus on the best management strategy for these injuries. The aim of this study was to evaluate the high-energy blunt pelvic ring injury management protocol implemented in the authors' institution. PATIENTS AND METHODS: This retrospective cohort study was performed in an academic level I trauma center. The institutional protocol incorporates urgent pelvic mechanical stabilization of hemodynamically unstable patients not responding to a pelvic belt, fluids, and transfusions. If hemodynamic instability persists, angiography ± embolization is performed. Adult patients sustaining a high-energy blunt pelvic ring injury between 2014.01.01 and 2019.12.31 were included in the study. The primary outcome was mortality at 1, 2, 30 and 60 days. The secondary outcomes were the number of packed red blood cell units transfused during the first 24 h, intensive care unit stay, and total hospitalization length of stay. RESULTS: 192 high-energy blunt pelvic ring injury patients were analyzed. Of these, 71 (37%) were hemodynamically unstable, and 121 (63%) were stable. The overall in-hospital mortality of the hemodynamically unstable and stable groups was 20/71 (28.2%) and 4/121 (3.3%) respectively (p<0.001). Cumulative mortality rates for hemodynamically unstable patients were 15.5% at day 1, 16.9% at day 2, 26.8% at day 30 and 28.2% at day 60, and for hemodynamically stable patients, rates were 0% at day 1 and 2, 2.5% at day 30 and 3.3% at day 60. Unstable patients required a higher number of packed red blood cell units than stable patients during the first 24 h (5.1 vs. 0.1; p<0.001). Intensive care unit length of stay and total hospitalization duration was 11.25 and 37.4 days for unstable patients and 1.9 and 20.9 days for stable patients (p<0.001). CONCLUSIONS: For both hemodynamically unstable and stable patients, the institutional protocol showed favorable mortality rates when compared to available literature. Comparative studies are needed to determine the management strategies with the best clinical outcome and survival.

Acetabular Peri-Prosthetic Fractures-A Narrative Review.

Acetabular peri-prosthetic fractures are rare but their incidence is rising due to the increased prevalence of total hip arthroplasty, the increasing life expectancy and the growing functional demand of an ageing population, the incidence of primary total hip arthroplasty is increasing. They are either intra-operative or post-operative and have various aetiologies. Several factors such as implant stability, bone loss, remaining bone stock, fracture pattern, timing, age and co-morbidities of the patients must be considered for adequate treatment. To date, the literature on this subject has been sparse and no universally recognized treatment algorithm exists. Their rarity makes them a little-known entity and their surgical management represents a challenge for most orthopaedic surgeons. This review aims to present an update on epidemiology, the diagnostic work up, existing classification systems, surgical approaches and therapeutic options for acetabular peri-prosthetic fractures.

Association between open tibia fractures and acute compartment syndrome: A retrospective cohort study.

BACKGROUND: Studies on the association of open tibia fractures and acute compartment syndrome (ACS) show confusing results, with some papers highlighting a positive association, and others failing to do so. The aim of this study was to determine if an open tibia fracture is at increased risk of ACS occurrence, when compared to a closed fracture. HYPOTHESIS: Skin injury in the setting of an open tibia fracture does not prevent from ACS occurrence, because the energy transmitted to the limb during trauma may lead to soft tissue lesions, including skin lacerations and ACS. PATIENTS AND METHODS: In total, 711 consecutive adult patients (mean age 44.6 years; 65.8% males) sustaining 725 tibia fractures between 01.01.2005 and 31.12.2009 were included in this retrospective study. The outcome measure was ACS. The following variables were assessed: soft tissue condition, age, sex, low- vs. high-energy injury, type of fracture, associated contiguous skeletal injury. A logistic regression model was used and adjustment was performed for age and sex. RESULTS: ACS occurred in 10.4% of proximal intra-articular fractures, 10.4% of extra-articular fractures and 3.3% of distal intra-articular fractures, and in 8.7% of closed fractures, 7.8% of open Gustilo 1 fractures and 13.3% of open Gustilo 2 and 3 fractures. Open lesions were not associated with ACS when tibia fractures were considered as a whole. When stratifying by types of fractures, open Gustilo 2 and 3 lesions were associated with ACS in proximal intra-articular fractures (p=0.048). There was no association with closed or any type of open lesions for extra-articular fractures. There were not enough ACS cases among distal intra-articular fractures to draw conclusions. DISCUSSION: As ACS may occur with any type of open tibia fractures, clinicians should not be wrongly reassured by an open fracture, assuming that the wound would relieve the pressure inside the muscle compartments. There is a weak association between open Gustilo 2 and 3 lesions and ACS in proximal intra-articular fractures only. These findings are important for surgeons treating these injuries, especially by intubated, sedated or obtunded patients. LEVEL OF EVIDENCE: III; retrospective diagnostic study.

Osteosynthesis of non-displaced femoral neck fractures in the elderly population using the femoral neck system (FNS): short-term clinical and radiological outcomes.

BACKGROUND: Femoral neck fractures (FNF) are frequent in the elderly population, and surgical management is indicated in the vast majority of cases. Osteosynthesis is an alternative to arthroplasty for non-displaced FNF. Triple screw construct (TS) and the dynamic hip screw system (DHS) are considered gold standards for osteosynthesis. The newly available femoral neck system (FNS) currently lacks evidence as to whether it is a valid alternative to TS and DHS. The purpose of this study was to evaluate the short-term clinical and radiological outcomes after non-displaced (Garden I and II) FNF osteosynthesis using TS, DHS, and FNS. METHODS: All the patients of the author's institution aged ≥ 75 years with a non-displaced (Garden I and II) FNF eligible for osteosynthesis between November 2015 and December 2019 were included in this single-center retrospective non-randomized study. Patients were treated with either TS, DHS, or FNS depending on the surgeon's preference. Clinical data (age, gender, ASA score, duration of surgery, need for blood transfusion and number of packed red blood cells transfused, surgical site complications, length of stay, discharge location, postoperative medical complications and readmission within 30 days, and mortality within 3 months) were extracted from the patients' charts. The radiological analysis assessed the fracture classification, fracture impaction, and proximal femur shortening at 3 and 6 months using the institutional imaging software. RESULTS: Baseline characteristics in the TS (n = 32), DHS (n = 16), and FNS (n = 15) groups were similar with respect to age (mean 85 years), gender (female to male ratio 4:1), and ASA score. There were no significant differences across the groups for the need for blood transfusion, surgical site complications, length of stay, postoperative medical complications and readmission within 30 days, discharge location, and mortality within 3 months. The duration of surgery was significantly lower in the FNS group (43.3 vs 68.8 min; p < 0.001). The radiological assessment found similar impaction (5.2 mm ± 4.8) and shortening (8.6 mm ± 8.2) in all groups that did not seem to progress after 3 months. CONCLUSION: The FNS appears to be a valid alternative implant for FNF osteosynthesis and is associated with a shorter operative time than TS and DHS. Short-term clinical and radiological outcomes of FNS are similar to TS and DHS implants. Further long-term multicenter randomized studies are however necessary to confirm these first results.

Inter- and intraobserver reliability assessment of the 2018 AO/OTA classification for high-energy pelvic ring injuries: A retrospective study.

BACKGROUND: A fracture classification system should be a reliable and reproducible means of communication between different observers. It should be logical, comprehensible, and shouldn't contain an unmanageable number of categories. The aim of this study was to assess the intra- and interobserver agreement and reliability of the revised 2018 AO/OTA classification for high-energy pelvic ring injuries (PRI), at the level of the types, groups, subgroups and qualifications. HYPOTHESIS: Agreement and reliability of the revised 2018 AO/OTA classification for high-energy PRI are improved when compared to previous versions of the classification. PATIENTS AND METHODS: Plain radiographs and computed tomography images of a consecutive series of 86 adult patients admitted at a level I trauma center with a high-energy PRI between 01.01.2014 and 31.12.2016 were retrospectively analyzed. Three orthopedic surgeons independently classified these PRI using the 2018 AO/OTA and the Young and Burgess classifications. The senior surgeon analyzed all injuries twice, at 6 months interval, to determine intraobserver reliability. Classification agreement was assessed using percent agreement and classification reliability was assessed using kappa coefficients. RESULTS: For the intraobserver analysis, injury classifications with the 2018 AO/OTA classification were concordant in 88% of cases (type), 74% (group), 66% (subgroup) and 49% (qualification). Respective kappa coefficients were 0.79, 0.68, 0.62 and 0.47. Interobserver agreement declined from 77% (type) to 42% (group), 36% (subgroup) and 24% (qualification). Respective kappa coefficients were 0.72, 0.48, 0.48 and 0.37. Intraobserver (respectively interobserver) percent agreement with the Young and Burgess classification was 76% (50%) and kappa coefficient was 0.69 (0.51). DISCUSSION: The 2018 AO/OTA classification is a reliable tool for daily clinical use and for research purpose at the fracture type level but not at the group, subgroup and qualification levels. These results compare favorably with previously published data for older versions of the classification and may represent an improvement of the AO/OTA classification system in terms of reliability. LEVEL OF EVIDENCE: III; retrospective diagnostic study.

Incidence rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries: a retrospective cohort study.

BACKGROUND: The aim of this study was to determine the rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries (PRI). METHODS: This retrospective cohort study was conducted in a level I trauma center serving 500,000 inhabitants. A total of 127 consecutive patients with high-energy blunt PRI were included between January 1st, 2014 and December 31st, 2017. Every patient had a total body or thoraco-abdominal computed tomography scan including contrast enhanced arterial sequences. A board-certified radiologist reviewed all the vascular images and precisely described every intra-pelvic arterial lesion in terms of localization. Complete pelvic series (standard radiographs and fine cut computed tomography images) were reviewed by three board-certified orthopedic surgeons experienced in PRI management, and Young and Burgess and AO/OTA classifications were determined. Demographic, clinical, therapeutic and outcome data were extracted from the institutional severely injured patients' registry. RESULTS: Patients' mean age was 45.3 years and 58.3% were males. Fifteen (11.8%) had a total of 21 intra-pelvic arterial lesions: seven lesions of the obturator artery, four of the superior gluteal artery, three of the inferior gluteal artery, two of the vesical artery, and one of each of the following arteries: internal iliac, internal pudendal, fifth lumbar, lateral sacral, ilio-lumbar. These lesions occurred in 8.6% of lateral compression injuries, 33.3% of anteroposterior compression injuries and 23.5% of vertical shear and combined mechanism injuries (Young and Burgess classification, p = 0.003); and in 0% of type A injuries, 9.9% of type B injuries and 35% of type C injuries (AO/OTA classification, p = 0.001). Patients with an intra-pelvic arterial lesion were more likely to present with pre-hospital hemodynamic instability (p = 0.046) and to need packed red blood cells transfusion within the first 24 h (p = 0.023; they needed a mean of 7.53 units vs. 1.88, p = 0.0016); however, they did not have a worst outcome in terms of complications or mortality. CONCLUSIONS: This systematic study found an 11.8% rate of intra-pelvic arterial lesion related to high-energy blunt PRI. The obturator, superior gluteal and inferior gluteal arteries were most often injured. These findings are important for the aggressive management of high-energy blunt PRI.

The Intraseptal Course of the Superficial Peroneal Nerve: An Anatomic Study.

BACKGROUND: Anatomic and clinical studies show many variants of the superficial peroneal nerve (SPN) course and branching within the compartments and at the suprafascial layer. The anatomy of the transition zone from the compartment to the subcutaneous layer has been occasionally described in the literature, mainly in studies reporting the intraseptal SPN variant in 6.6% to 13.6% of patients affected by the SPN entrapment syndrome. Despite the little evidence available, the knowledge of the transition zone is relevant to avoid iatrogenic lesions to the SPN during fasciotomy, open approaches to the leg and ankle, and SPN decompression. Our anatomic study aimed to describe the SPN transition site and to evaluate the occurrence of a peroneal tunnel and of an intraseptal SPN variant. METHODS: According to the institutional ethics committee requirements, 15 fresh-frozen lower limbs were dissected to study the SPN course and its branching, focusing on the transition site to the suprafascial layer. RESULTS: The SPN was located in the anterior compartment in 2 cases and in the lateral in 13. An intraseptal tunnel was present in 10 legs (66%), at a mean distance of 10.67 cm from the lateral malleolus. Its mean length was 2.63 cm. The tunnel allowed the passage of the main SPN in 8 cases and of its branches in two. In the remaining 5 legs (33%), the SPN pierced a crural fascia window. CONCLUSION: In our sample a higher rate than expected of intraseptal SPN variants was found. CLINICAL RELEVANCE: The knowledge of the anatomy of the SPN course and intraseptal variant is relevant to avoid iatrogenic lesions during operative dissection. Further studies are needed to evaluate the effective prevalence of an intraseptal tunnel, independently from the SPN entrapment syndrome, and how to avoid associated iatrogenic complications.

Operatively treated ankle fractures in Switzerland, 2002-2012: epidemiology and associations between baseline characteristics and fracture types.

BACKGROUND: Ankle fractures are common, and their incidence has been increasing. Previous epidemiological studies have been conducted in the US, Scandinavia, and Scotland. Our objectives were to provide a current epidemiological overview of operatively treated ankle fractures and to evaluate the influence of age, sex, lifestyle factors, and comorbidities on fracture types. METHODS: We performed a population-based epidemiological study of all ankle fractures treated operatively in a 10- year period from 2002 to 2012. RESULTS: Two thousand forty-five ankle fractures were operated upon. Men and women differed significantly in age (median 41 vs. 57 years old), obesity (16% vs. 23%), diabetes (5% vs. 10%), smoking (45% vs. 24%), and accident type (daily activities 48% vs. 79%, transportation 24% vs. 9%, sports 21% vs. 8%) respectively. Overall, there were 2% Weber A, 77% Weber B, and 21% Weber C fractures; 54% were uni-, 25% bi-, and 21% trimalleolar; 7.5% of all fractures were open. Weber C fractures were much more frequent among men and with higher BMI (lowest vs. highest category: 14% vs. 32%), but slightly less frequent with older age and among current smokers. Trimalleolar fractures were twice as frequent in women and increased with age. CONCLUSION: Men and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture. Male sex and higher BMI were more frequently associated with Weber C fractures, whereas female sex and older age were associated with trimalleolar fracture. The risk for severe fracture increased linearly with the degree of obesity.

Fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures using a sliding hip screw system: can we trust a two-hole side plate construct? A review of the literature.

Trochanteric femur fractures are frequently fixed with a four-hole side plate sliding hip screw device, but in recent decades two-hole side plates have been used in an attempt to minimize operative time, surgical dissection, blood loss and post-operative pain.The aim of this review was to determine whether two-hole sliding hip screw constructs are an acceptable option for fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures.An electronic MEDLINE® database search was performed using PubMed®, and articles were included in this review if they were reporting historical, biomechanical, clinical or outcome data on trochanteric fracture fixation using a two-hole sliding hip screw device.A two-hole dynamic hip screw with a minimally invasive muscle-splitting approach is recommended for fixation of AO-OTA 31-A1 simple trochanteric fractures; this implant is biomechanically safe, and allows the use of a minimally invasive muscle-splitting approach which potentially provides better clinical outcome, such as decreased surgical trauma, shorter operative time, less blood loss, decreased analgesics use, and shorter incision length. As the majority of reviewed publications relate to the dynamic hip screw, it is not clear whether the above recommendations can be extended to any other sliding hip screw device.An intramedullary device is recommended for all other extra-capsular proximal femoral fractures. Cite this article: EFORT Open Rev 2020;5:118-125. DOI: 10.1302/2058-5241.5.190020.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures: a retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the association between epidemiological, clinical and radiographic factors of patients with tibial shaft fractures and the occurrence of acute compartment syndrome. METHODS: 270 consecutive adult patients sustaining 273 tibial shaft fractures between January 2005 and December 2009 were included in this retrospective cohort study. The outcome measure was acute compartment syndrome. Patient-related (age, sex), fracture-related (high- vs. low-energy injury, isolated trauma vs. polytrauma, closed vs. open fracture) and radiological parameters (AO/OTA classification, presence or absence of a noncontiguous tibial plateau or pilon fracture, distance from the centre of the tibial fracture to the talar dome, distance between tibial and fibular fracture if associated, and angulation, translation and over-riding of main tibial fragments) were evaluated regarding their potential association with acute compartment syndrome. Univariate analysis was performed and each covariate was adjusted for age and sex. Finally, a multivariable logistic regression model was built, and odds ratios and 95% confidence intervals were obtained. Statistical significance was defined as p < 0.05. RESULTS: Acute compartment syndrome developed in 31 (11.4%) cases. In the multivariable regression model, four covariates remained statistically significantly associated with acute compartment syndrome: polytrauma, closed fracture, associated tibial plateau or pilon fracture and distance from the centre of the tibial fracture to the talar dome ≥15 cm. CONCLUSIONS: One radiological parameter related to the occurrence of acute compartment syndrome has been highlighted in this study, namely a longer distance from the centre of the tibial fracture to the talar dome, meaning a more proximal fracture. This observation may be useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients). However, larger studies are mandatory to confirm and refine the prediction of acute compartment syndrome occurrence. Radiographic signs of significant displacement were not found to be correlated to acute compartment syndrome development. Finally, the higher rate of acute compartment syndrome occurring in tibial shaft fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries must raise the level of suspicion of any surgeon managing multiply injured patients.

A case report depicting patient's installation on the fracture table when an ankle spanning external fixator is already in place.

BACKGROUND: Fractures of the proximal and diaphyseal femur are frequently internally fixed using a fracture table. Moreover, some femoral neck fractures may be treated with total hip arthroplasty using a direct anterior approach and a traction table. Fracture and traction tables both use a boot tightly fitted to the patient's foot in order to: 1) obtain fracture reduction by traction and adequate rotation exerted on the slightly abducted or adducted extremity; or 2) adequately expose the hip joint using traction, rotation and extension to implant total hip arthroplasty components. In some instances, multiply injured patients may present with both a proximal or diaphyseal femur fracture and a diaphyseal or distal tibia or ankle fracture necessitating an ankle spanning external fixator on the same limb. Frequently, the tibia or ankle fracture has to be treated first, and standard use of the fracture or traction table may be thereafter difficult due to the external fixator construct preventing tight fitting of the boot to the patient's foot. CASE PRESENTATION: In order to address this situation, the authors describe a simple technique allowing rigid fixation of the limb with an ankle spanning external fixator to the traction or fracture table, providing accurate control of the position of the lower limb in all planes for adequate fracture reduction and fixation or total hip arthroplasty. The technique is exemplified with a clinical case. CONCLUSIONS: This technique allows an efficient way to: 1) timely stabilize diaphyseal or distal tibia or ankle fractures; and 2) subsequently use all the advantages of a fracture or traction table to adequately reduce and fix proximal or diaphyseal femur fractures, or optimally expose femoral neck fractures for total hip arthroplasty using a direct anterior approach.

False negative computed tomography scan due to pelvic binder in a patient with pelvic disruption: a case report and review of the literature.

BACKGROUND: Pelvic binders are routinely used in the prehospital setting for stabilization of pelvic injuries in patients with trauma. Emergency department trauma management relies on primary and secondary survey assessment and imaging, most often computed tomography, in hemodynamically stable patients. Maintaining the pelvic binder in situ allows stabilization of pelvic injuries during imaging but may hinder the visualization of some pelvic lesions. We report a very rare case of severe pelvic disruption with an absolutely normal computed tomography scan due to the effective placement of a pelvic binder. CASE PRESENTATION: We report the case of a 49-year-old Caucasian man referred to our Emergency Department after a high velocity motorcycle accident. Primary assessment revealed a left wrist deformation and pelvic pain, and a pelvic binder was applied by paramedics. A total body computed tomography scan was performed after arrival in our Emergency Department and did not reveal any pelvic injury. The pelvic binder was removed and because of persisting symphyseal pain, pelvic plain radiography was performed revealing a pelvic disruption with an opening of the pubic symphysis and of the left sacroiliac joint ("open book" type pelvic injury) requiring surgical stabilization. CONCLUSIONS: Pelvic binders may mask pelvic disruption in patients with trauma. Pelvic plain radiography should be repeated after pelvic binder removal in patients with high velocity trauma and pelvic symptoms or neurological alterations limiting the reliability of clinical examination.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial plateau fractures: a retrospective cohort study.

BACKGROUND: The aim of the study was to evaluate the relation between demographic, injury-related, clinical and radiological factors of patients with tibial plateau fractures and the development of acute compartment syndrome. METHODS: All consecutive adult patients with intra-articular tibial plateau fractures admitted in our urban academic medical centre between January 2005 and December 2009 were included in this retrospective cohort study. The main outcome measurement was the development of acute compartment syndrome. RESULTS: The charts of 265 patients (mean age 48.6 years) sustaining 269 intra-articular tibial plateau fractures were retrospectively reviewed. Acute compartment syndrome occurred in 28 fractures (10.4%). Four patients presented bilateral tibial plateau fractures; of them, 2 had unilateral, but none had bilateral acute compartment syndrome. Non-contiguous tibia fracture or knee dislocation and higher AO/OTA classification (type 41-C) were statistically significantly associated with the development of acute compartment syndrome in multivariable regression analysis, while younger age (<45 years), male sex, higher Schatzker grade (IV-V-VI), higher tibial widening ratio (≥1.05) and higher femoral displacement ratio (≥0.08) were significantly associated in the analysis adjusted for age and sex. CONCLUSIONS: Two parameters related to the occurrence of ACS in tibial plateau fractures were highlighted in this study: the presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification. They may be especially useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients), and should rise the suspicion level of the treating surgeon. In these cases, regular clinical examinations and/or intra-compartmental pressure measurements should be performed before and after surgery, even if acute compartment syndrome seemed unlikely during initial assessment. However, larger studies are mandatory to confirm and refine both factors in predicting the occurrence of acute compartment syndrome.

Primary hemiarthroplasty for treatment of unstable pertrochanteric femoral fractures (AO/OTA Type 31 A2.3) in elderly osteoporotic patients.

INTRODUCTION: The aim of this study was to prospectively analyze the role of primary hemiarthroplasty in unstable osteoporotic pertrochanteric fractures (AO/OTA Type 31 A2.3), with emphasis given to postoperative Functional Independent Measure (FIM) and Harris Hip Score (HHS). METHODS: Fifty-six consecutive patients (average age 78.25 ± 5.45), out of which 24 males (79.29 ± 4.99) and 32 females (77.47 ± 5.72), with unstable pertrochanteric femoral fractures, operated with primary hemiarthroplasty procedure from 2012 to 2014 were included in this prospective study with a follow-up of two years. Primary outcomes were FIM and HHS. Secondary outcomes included duration of surgery, estimated intraoperative blood loss, time to first postoperative full weight-bearing, time to walking ability with and without crutches, average hospital stay, postoperative complications, and mortality. RESULTS: The FIM score at 3 months was 85.9 ± 5.7. HHS at two years was excellent for 41 patients (73, 2%), good for eight (14.3%), fair for four (7.1%), and poor for three (5.4%). The mean duration of surgery was 62.6 min, estimated intraoperative blood loss 175.5 mL, time to first postoperative full weight-bearing 2.2 ± 0.4 days, ability to walk with crutches 6.3 ± 1.8 days and without crutches 44.2 ± 12.7 days, and the average hospital stay was 9.6 ± 2.7 days. CONCLUSION: This study highlighted good clinical postoperative outcome scores for primary hemiarthroplasty for the treatment of unstable pertrochanteric femoral fractures in elderly osteoporotic patients. This procedure seems to be secure and effective, and offers a good quality of life in terms of FIM and HHS.