Progressive displacement of clavicular fractures in the early postinjury period.

BACKGROUND: Historically, minimally to moderately displaced clavicular fractures have been managed nonoperatively. However, there is no clear evidence on whether clavicular fractures can progressively displace following injury and whether such displacement might influence decisions for surgery. METHODS: We retrospectively reviewed data on 56 patients who received operative treatment for clavicular fractures at our institution from February 2002 to February 2007 and identified those patients who were initially managed nonoperatively based on radiographic evaluation (<2 cm displacement) and then subsequently went on to meet operative indications (≥2 cm displacement) as a result of progressive displacement. Standardized radiographic measurements for horizontal shortening (medial-lateral displacement) and vertical translation (cephalad-caudad displacement) were developed and used. RESULTS: Fifteen patients with clavicle fractures initially displaced less than 2 cm and treated nonoperatively underwent later surgery because of progressive displacement (14 diaphyseal and 1 lateral). Radiographs performed during the injury workup and at a mean of 14.8 days postinjury demonstrated that progressive deformity had taken place. Ten of 15 patients (67%) displayed progressive horizontal shortening. Average change in horizontal shortening between that of the injury radiographs and the repeat radiographs in this group was 14.3 mm (5.9-29 mm). Thirteen of 15 patients (87%) displayed progressive vertical translation. Eight of 15 patients (53%) displayed both progressive horizontal shortening and vertical translation. CONCLUSION: We have demonstrated that a significant proportion of clavicle fractures (27% of our operative cases over a 5-year period) are minimally displaced at presentation, but are unstable and demonstrate progressive deformity during the first few weeks after injury. Because of this experience, we recommend close monitoring of nonoperatively managed clavicular fractures in the early postinjury period. A prudent policy is to obtain serial radiographic evaluation for 3 weeks, even for initially, minimally displaced clavicle fractures.

Obesity and its relationship with pelvic and lower-extremity orthopedic trauma.

Obesity has been increasing steadily in the US population over the past 50 years. In trauma patients, obesity is associated with higher morbidity and mortality. There are reported increases in the incidence of cardiovascular, pulmonary, venous thromboembolic, and infectious complications in obese trauma patients. Obese patients who sustain high-energy traumatic injuries often sustain orthopedic injuries to the pelvis or lower extremities. Obese orthopedic trauma patients may be at higher risk for nerve injuries secondary to positioning, intraoperative complications, loss of reduction after surgery, increased intraoperative estimated blood loss, and increased operative times. Orthopedic surgeons must be aware of these results when treating these fractures in obese trauma patients.

Progressive displacement of scapula fractures.

BACKGROUND: Historically, minimally to moderately displaced extra-articular scapula fractures have been managed conservatively. It is possible that operative criteria could be met for a given patient if progressive displacement were to occur. We hypothesize that certain displaced scapula fractures progressively displace in early postinjury period. METHODS: A consecutive series of 49 patients with operatively managed extra-articular scapula fractures was evaluated to identify patients initially managed nonoperatively and later operatively because of progressive displacement. Three examiners then independently analyzed radiographs to measure the displacement between injury films and the films used to determine operative indications. A standard method for radiographic measurement of deformity was developed and was used to determine the degree of deformity at injury and at follow-up time when operative care was decided. RESULTS: Eight patients met inclusion criteria. All sustained a specific extra-articular transverse fracture pattern Arbeitsgemeinschaft für Osteosynthefragen/Orthopaedic Trauma Association (AO/OTA) Type A3, Ada-Miller Type IIC). Mean time interval between injury and repeat radiographs was 11.3 (range, 9-15) days. All patients displayed progressive displacement in at least one of the four measured parameters (medial/lateral displacement, angulation, translation, and glenopolar angle), according to the three independent examiners. Predominantly "good" inter- and intraobserver scores were achieved. CONCLUSIONS: Certain extra-articular scapula fractures may displace in postinjury period. We recommend close monitoring of conservatively treated fractures to screen for progressive displacement.