Relationship Between Perioperative Regional Anesthesia and the Risk of Missing Acute Compartment Syndrome Following Tibia Fractures.

BACKGROUND: The aim of this study was to determine the incidence of missed compartment syndrome in tibia fractures treated with and without regional anesthesia. METHODS: A retrospective chart review was performed of patients with operative tibial shaft or plateau fractures at a single level-one trauma hospital between January 2015 and April 2022 with a minimum of 3-month follow-up. Patients under 18 years of age, an ipsilateral knee dislocation, known neurologic injury at presentation, or prophylactic fasciotomy were excluded. We defined missed acute compartment syndrome (ACS) as a postinjury motor deficit still present at the 3-month postoperative appointment. For patients that received a peripheral nerve block, we recorded whether a continuous perineural catheter or one-time single-shot injection was performed, and the number of nerves blocked. Incidence rates for ACS were calculated with exact binomial 95% confidence intervals (CIs). Morphine milligram equivalents (MMEs) consumed 24 hours after surgery, use of nerve block, nerve block timing, and type of block were compared using Mann-Whitney and Kruskal-Wallis nonparametric tests. Statistical significance was defined as P < .05. RESULTS: The incidence of compartment syndrome diagnosed and treated during index hospitalization was 2.2% (17/791, 95% CI, 1.3%-3.4%). The incidence of missed ACS was 0.9% (7/791, 95% CI, 0.4%-1.8%). The incidence of missed ACS was not different between those who received nerve block 0.7% (4/610, 95% CI, 0.2%-1.7%), and those who did not (1.7% (3/176, 95% CI, 0.4%-4.8%) P = .19). Within patients receiving a nerve block, all patients with missed ACS (n = 4) received a perineural catheter. Similar missed ACS rates were observed between tibial shaft and plateau fractures. Patients receiving a nerve block had lower MME compared to those who did not receive a nerve block (P < .001). CONCLUSIONS: The results do not provide evidence that perioperative regional anesthesia increases the incidence of missed ACS in patients with operative tibial shaft or plateau injuries. but does decrease postoperative opioid requirements.

Orthopaedic fracture surgery in polytraumatized patients while on extracorporeal membrane oxygenation (ECMO): A report of two cases.

Extracorporeal membrane oxygenation (ECMO) has become a salvage therapy for patients with severe acute respiratory distress syndrome (ARDS). The management of orthopaedic trauma in ECMO-supported patients with ARDS remains an evolving area of interest. Orthopaedic injuries are often temporized with external fixators, skeletal traction, or splints due to hemodynamic instability as well as concerns of exacerbating underlying pulmonary injury. However, patients requiring ECMO support do not rely on their pulmonary system for oxygenation, the need for delayed fixation may not apply. However, patients utilizing ECMO therapy can have external cardiac and pulmonary support depending on their cannulation strategy, bypassing the need for delayed fixation. We present a case series of two polytrauma patients with ARDS who underwent surgical management of pelvic ring and femoral shaft fractures while receiving ECMO support. Both patients underwent surgical management without complication and were able to be weaned from ECMO and ventilator support postoperatively. These cases highlight the potential benefits to orthopaedic fixation and underscore the need for further clinical research.

Is the Presence of a Psychiatric Disorder Associated With More Aggressive Management of Compartment Syndrome?

OBJECTIVE: To determine whether pre-existing psychiatric disorder is associated with potentially unnecessary fasciotomy. DESIGN: Retrospective cohort study. SETTING: Academic Level-1 trauma center. PATIENTS: All the patients with orthopaedic trauma undergoing leg fasciotomy at an academic Level I trauma center from 2006 to 2020. INTERVENTION: Pre-existing diagnosis of psychiatric disorder. MAIN OUTCOME MEASUREMENTS: Early primary wound closure and delayed primary wound closure. RESULTS: In total, 116 patients were included. Twenty-seven patients (23%) had a pre-existing diagnosis of psychiatric disorder with 13 having anxiety, 14 depression, 5 bipolar disorder, and 2 ADHD. Several patients had multiple diagnoses. Fifty-one patients (44%) had early primary closure (EPC), and 65 patients (56%) had delayed primary closure. Of patients with a psychiatric disorder, 52% received EPC compared with 42% of patients without a disorder, P = 0.38. This lack of a strong association did not seem to vary across specific psychiatric conditions. After adjusting for sex, age, injury type, and substance abuse, there was still no significant association between a psychiatric disorder and EPC with an odds ratio of 1.08 (95% CI, 0.43-2.75). CONCLUSIONS: Among patients with orthopaedic trauma undergoing emergent fasciotomy for acute compartment syndrome, a psychiatric disorder was not associated with a significantly increased rate of possibly unnecessary fasciotomy. Given the potential for a psychiatric condition to complicate the diagnosis of acute compartment syndrome, this data is somewhat reassuring; however, there remains a need for continued vigilance in treating patients with psychiatric conditions and research in this area. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minimally Invasive Plate Osteosynthesis Posterior Approach to Distal Humeral Shaft Fractures-A Surgical Technique.

Comminuted extraarticular metaphyseal and diaphyseal fractures of the distal humerus frequently require operative fixation through a posterior approach. Most of the previously described approaches to the posterior humerus are dependent on large and extensile approaches. This video demonstrates open reduction and internal fixation of a comminuted metaphyseal distal humerus fracture through a minimally invasive posterior approach.

Predicting symptoms of post-traumatic stress among patients undergoing orthopedic surgery on the basis of routinely collected cardiovascular data.

The present study examined whether in-hospital assessments of heart rate and blood pressure predicted symptoms of post-traumatic stress (PTS) in 110 patients undergoing total knee replacement surgery. After controlling for conceptually relevant factors, in-hospital cardiovascular functioning predicted symptoms of PTS three months following surgery. Specifically, lower pre-surgical and post-surgical systolic and diastolic blood pressure predicted more symptoms of avoidance and PTS (total). In contrast, higher heart rate prior to and shortly following surgery predicted marginally more intrusive thoughts. The present findings suggest that routinely collected medical data may provide a means to identify patients at risk for problematic outcomes following surgery.