Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres.

PURPOSE: This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres. METHODS: A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes. RESULTS: Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome. CONCLUSION: These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Predictors of 30-day mortality, unplanned related readmission and reoperation among isolated closed femoral shaft fractures.

Background: Isolated, closed, femoral shaft fractures are dangerous injuries that commonly occur in the setting of high energy trauma or among older patients with significant comorbidities. Despite their prevalence, relatively little data exists connecting patient independent risk factors to the time to 30-day mortality, unplanned reoperations and unplanned readmissions in these fractures. Methods: Using National Surgical Quality Improvement Program (NSQIP) database, isolated close femoral shaft fractures were identified using ICD-10 codes. Patient demographics, perioperative course and adverse events were identified. Categorical and binary variables were analyzed among procedure cohorts using Chi2 analysis. Univariate and multivariate analysis were conducted to identify independent risk factors associated with primary outcomes. Results: Between 2010 and 2019, 1346 closed isolated femoral shaft fracture patients with a mean age of 66.7 were identified, of whom 30.6% and 69.4% were male and female, respectively. Surgical procedures included: 915 (68.0%) intramedullary nail (IMN); 428 (31.8%) open reduction internal fixation (ORIF); and 3 (0.2%) external fixator (Ex-fix). Patients who underwent ORIF reported 3.19 (OR: 3.19; CI: 1.45-7.03; p = 0.004) and 2.12 (OR: 2.12; CI: 1.10-4.09; p = 0.024) increased odds of mortality and unplanned related readmission compared to patients who received IMN. Transfusion, DVT, and PE rates were 34.2%, 1.4%, and 1.1%, respectively. Furthermore, 50% of mortality cases occurred within 6 days of surgery. Patients requiring reintubation reported 61.8 (OR: 61.8; CI: 15.7-242.40; p < 0.001) increased odds of mortality compared to patients not requiring reintubation. Conclusion: Patients with femoral shaft fractures who require reintubation have increased odds of mortality than those successfully extubated. In addition to precautions prior to extubation, patients with femoral shaft fractures should also be carefully monitored for the development of DVT or PE, and they should be definitively fixed with IMN whenever possible.

Risk factors for failure of a single surgical debridement in adults with acute septic arthritis.

BACKGROUND: Acute septic arthritis in a native joint may require more than one surgical debridement to eradicate the infection. Our objectives were to determine the prevalence of failure of a single surgical debridement for acute septic arthritis, to identify risk factors for failure of a single debridement, and to develop a prognostic probability algorithm to predict failure of a single surgical debridement for acute septic arthritis in adults. METHODS: We collected initial laboratory and medical comorbidity data of 128 adults (132 native joints) with acute septic arthritis who underwent at least one surgical debridement at our institution between 2000 and 2011. Univariate and logistic regression analyses were used to identify potential risk factors for failure of a single surgical debridement. Stepwise variable selection was used to develop a prediction model and identify probabilities of failure of a single surgical debridement. RESULTS: Of the 128 patients (132 affected joints) who underwent surgical debridement for acute septic arthritis, forty-nine (38%) of the patients (fifty joints) experienced failure of a single debridement and required at least two debridements (range, two to four debridements). Staphylococcus aureus was the most common bacterial isolate (in sixty, or 45%, of the 132 joints). Logistic regression analysis identified five independent clinical predictors for failure of a single surgical debridement: a history of inflammatory arthropathy (odds ratio [OR], 7.3; 95% confidence interval [CI], 2.4 to 22.6; p < 0.001), the involvement of a large joint (knee, shoulder, or hip) (OR, 7.0; 95% CI, 1.2 to 37.5; p = 0.02), a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L (OR, 4.7; 95% CI, 1.8 to 17.7; p = 0.002), S. aureus as the bacterial isolate (OR, 4.6; 95% CI, 1.8 to 11.9; p = 0.002), and a history of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; p = 0.04). CONCLUSIONS: Most (62%) of the septic joints were managed effectively with a single surgical debridement. Adults with a history of inflammatory arthropathy, involvement of a large joint, a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L, an infection with S. aureus, or a history of diabetes had a higher risk of failure of a single surgical debridement for acute septic arthritis and requiring additional surgical debridement(s).

Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment.

The Schatzker classification system for tibial plateau fractures is widely used by orthopedic surgeons to assess the initial injury, plan management, and predict prognosis. Many investigators have found that surgical plans based on plain radiographic findings were modified after preoperative computed tomography (CT) or magnetic resonance (MR) imaging. The Schatzker classification divides tibial plateau fractures into six types: lateral plateau fracture without depression (type I), lateral plateau fracture with depression (type II), compression fracture of the lateral (type IIIA) or central (type IIIB) plateau, medial plateau fracture (type IV), bicondylar plateau fracture (type V), and plateau fracture with diaphyseal discontinuity (type VI). Management of type I, II, and III fractures centers on evaluating and repairing the articular cartilage. The fracture-dislocation mechanism of type IV fractures increases the likelihood of injury to the peroneal nerve or popliteal vessels. In type V and VI fractures, the location of soft-tissue injury dictates the surgical approach and the degree of soft-tissue swelling dictates the timing of definitive surgery and the need for provisional stabilization with an external fixator. CT and MR imaging are more accurate than plain radiography for Schatzker classification of tibial plateau fractures, and use of cross-sectional imaging can improve surgical planning.