Geriatric proximal femur fracture updates.

Proximal femur fractures in the aging population present a variety of challenges. Physiologically, patients incurring this fracture are typically frail, with significant medical comorbidities, yet require early surgical treatment to restore mobility to prevent deterioration. Socioeconomically, the occurrence of a fragility fracture may be the beginning of the loss of independence, and the burdens of rehabilitation and support are borne by the individual patient and health care systems.

Current practices in the management of closed femoral shaft fractures in children: A nationwide survey among Dutch orthopaedic surgeons.

Background: There remains a lack of high-quality evidence on the treatment of pediatric femur shaft fractures. Therefore, treatment choices may still be based on personal preference of treating surgeons. To gain insight in considerations regarding treatment options, we conducted a survey among Dutch trauma and orthopedic surgeons. Methods: This survey was conducted in 2020, regarding treatment considerations for closed femoral shaft fractures in children in different age and weight groups. Results: One hundred forty-two surgeons were included in the analysis. 31% of participating surgeons considers surgical fixation in children of 2-4 years old, compared to 83% in children of 4-6 years old. In terms of weight, 30% considers surgery in children of 10-15 kg, compared to 77% considering surgery in children weighing 15-20 kg. While most surgeons find traction and spica cast suitable options for children younger than 4 years, a minority also considers these treatment modalities for children older than 4 (traction: 81% versus 19%, spica cast 63% versus 29% respectively). 33% of surgeons considers ESIN under 4 years of age, compared to 88% in children older than 4. Conclusion: An age of 4 years and a weight of 15 kg seem to be cut off points regarding preference of non-surgical versus surgical treatment of closed femoral shaft fractures. There is a wide range of ages and sizes for which treatment options are still being considered, sometimes differing from the national guideline. This questions guideline adherence, which may be due to a lack of available high-quality evidence.

Pelvic ring injuries: recent advances in diagnosis and treatment.

Pelvic ring injuries typically occur from high-energy trauma and are often associated with multisystem injuries. Prompt diagnosis of pelvic ring injuries is essential, and timely initial management is critical in the early resuscitation of polytraumatized patients. Definitive management of pelvic ring injuries continues to be a topic of much debate in the trauma community. Recent studies continue to inform our understanding of static and dynamic pelvic ring stability. Furthermore, literature investigating radiographic and clinical outcomes after nonoperative and operative management will help guide trauma surgeons select the most appropriate treatment of patients with these injuries.

Managing periprosthetic fractures: perspectives on periprosthetic pelvic fractures.

Periacetabular periprosthetic fractures are rare but potentially disastrous for the longevity of the adjacent implants, leading to multiple revision surgeries. It is of paramount importance to identify and treat intraoperative fractures, which will lead to satisfactory results. Postoperative fractures may be managed operatively or nonoperatively depending on the patient's pain and function, the fracture pattern, and the stability of the acetabular component.

The prevalence of non-accidental trauma among children with polytrauma: A nationwide level-I trauma centre study.

OBJECTIVE: We aimed to investigate the prevalence and characteristics of non-accidental trauma (NAT) in children with polytrauma treated at level-I trauma centres (TC). SUMMARY OF BACKGROUND: Data 6-10% Of children who present at the emergency department with injuries, sustain polytrauma. Polytrauma may result from either accidental (AT) or NAT, i.e. inflicted or neglect. The prevalence of NAT among children with polytrauma is currently unclear. METHODS: This is a retrospective study that included children (0-18 years) with an Injury Severity Score >15, who presented at one of the 11 Level-I trauma centers (TC) in the Netherlands between January 1, 2010 and January 1, 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect-team. Cases in which conclusions were unavailable and there was no clear accidental cause of injuries were reviewed by an expert panel. RESULTS: The study included 1623 children, 1452 (89%) were classified as AT, 171 (11%) as NAT; 39 (2,4%) inflicted and 132 (8,1%) neglect. Of pre-school aged children (<5 years) 41% sustained NAT (OR26.73, 95%CI 17.70-40.35), 35/342 (10%) inflicted and 104/342 (31%) neglect. Admission due to 'cardiopulmonary arrest' was the result of inflicted trauma (30% vs 0%,p < 0.001). NAT had a higher mortality rate (16% vs 10%, p = 0.006). Indicators of NAT were: (near-)drowning (OR10.74, 95%CI 5.94-19.41), burn (OR8.62, 95%CI 4.08-18.19) and fall from height (OR2.18, 95%CI 1.56-3.02). CONCLUSIONS: NAT was the cause of polytrauma in 11% of children in our nationwide level-I TC study; 41% of these polytrauma were the result of NAT experienced by preschool-aged children. Our data show the importance of awareness for NAT.

Prevalence of inflicted and neglectful femur shaft fractures in young children in national level I trauma centers.

BACKGROUND: The prevalence of inflicted femur fractures in young children varies (1.5-35.2%), but these data are based on small retrospective studies with high heterogeneity. Age and mobility of the child seem to be indicators of inflicted trauma. OBJECTIVE: This study describes other factors associated with inflicted and neglectful trauma that can be used to distinguish inflicted and neglectful from accidental femur fractures. MATERIALS AND METHODS: This retrospective study included children (0-6 years) who presented with an isolated femur fracture at 1 of the 11 level I trauma centers in the Netherlands between January 2010 and January 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect teams or the court. Cases in which conclusions were unavailable and there was no clear accidental cause were reviewed by an expert panel. RESULTS: The study included 328 children; 295 (89.9%) cases were classified as accidental trauma. Inflicted trauma was found in 14 (4.3%), while 19 (5.8%) were cases of neglect. Indicators of inflicted trauma were age 0-5 months (29%, positive likelihood ratio [LR +] 8.35), 6-12 months (18%, LR + 5.98) and 18-23 months (14%, LR + 3.74). Indicators of neglect were age 6-11 months (18%, LR + 4.41) and age 18-23 months (8%, LR + 1.65). There was no difference in fracture morphology among groups. CONCLUSION: It is unlikely that an isolated femur fracture in ambulatory children age > 24 months is caused by inflicted trauma/neglect. Caution is advised in children younger than 24 months because that age is the main factor associated with inflicted trauma/neglect and inflicted femur fractures.

Treatment of closed femoral shaft fractures in children aged 2-10 years: a systematic review and meta-analysis.

OBJECTIVE: To review current literature on treatment of closed femoral shaft fractures in children of 2-10 years old, with subgroup analysis of children aged 2-6 years, comparing intramedullary nailing (IMN) to conservative treatment modalities. METHODS: We included clinical trials and observational studies that compared traction and subsequent casting (TSC), spica casting and IMN for treatment of femur shaft fractures in children of 2-10 years of age. Subgroup analysis of children aged 2-6 years was performed. RESULTS: Compared to treatment with immediate spica casting, IMN led to significantly less coronal angulation (mean difference (MD): 2.03 degrees, confidence interval (CI) 1.15-2.90), less sagittal angulation (MD: 1.59 degrees, CI 0.82-2.35) and lower rates of LLD (Risk difference (RD): 0.07, CI 0.03-0.11). In terms of rehabilitation, IMN leaded to shorter time until walking with aids (MD: 31.53 days, CI 16.02-47.03), shorter time until independent ambulation (MD: 26.59 days, CI 22.07, 31.11) and shorter time until full weight bearing (MD: 27.05 days, CI 6.11, 47,99). Compared to TSC, IMN led to a lower rate of malunion (RD: 0.31, CI 0.05-0.56), shorter hospital stays (MD: 12.48 days, CI 11.57, 13.39), time until walking with aids (MD: 54.55, CI 40.05-69.04) and full weight bearing (MD: 27.05 days [6.11, 47,99]). CONCLUSION: Although a lack of quality evidence, this systematic review showed a clear tendency to treatment with elastic intramedullary nails of femoral shaft fractures in children of 2-10 years of age.

High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands.

PURPOSE: Between 0.1-3% of injured children who present at a hospital emergency department ultimately die as a result of their injuries. These events are typically reported as unnatural causes of death and may result from either accidental or non-accidental trauma (NAT). Examples of the latter include trauma that is inflicted directly or resulting from neglect. Although consultation with a forensic physician is mandatory for all deceased children, the prevalence of fatal inflicted trauma or neglect among children is currently unclear. METHODS: This is a retrospective study that included children (0-18 years) who presented and died at one of the 11 Level I trauma centers in the Netherlands between January 1, 2014, and January 1, 2019. Outcomes were classified based on the conclusions of the Child Abuse and Neglect team or those of forensic pathologists and/or the court in cases referred for legally mandated autopsies. Cases in which conclusions were unavailable and there was no clear accidental cause of death were reviewed by an expert panel. RESULTS: The study included 175 cases of childhood death. Seventeen (9.7%) of these children died due to inflicted trauma (9.7%), 18 (10.3%) due to neglect, and 140 (80%) due to accidents. Preschool children (< 5 years old) were significantly more likely to present with injuries due to inflicted trauma and neglect compared to older children (44% versus 6%, p < 0.001, odds ratio [OR] 5.80, 95% confidence interval [CI] 2.66-12.65). Drowning accounted for 14 of the 18 (78%) pediatric deaths due to neglect, representing 8% of the total cases. Postmortem radiological studies and autopsies were performed on 37 (21%) of all cases of childhood death. CONCLUSION: One of every five pediatric deaths in our nationwide Level I trauma center study was attributed to NAT; 44% of these deaths were the result of trauma experienced by preschool-aged children. A remarkable number of fatal drownings were due to neglect. Postmortem radiological studies and autopsies were performed in only one-fifth of all deceased children. The limited use of postmortem investigations may have resulted in missed cases of NAT, which will result in an overall underestimation of fatal NAT experienced by children.

[Compartment syndrome of the forearm in a child]. / Compartimentsyndroom van de onderarm bij een jongere.

BACKGROUND: Compartment syndrome is a rare but serious entity with various causes. Timely diagnosis and treatment are essential. CASE DESCRIPTION: We present a case of a 14-year-old boy with a crush injury of the forearm including a fracture of the radius and ulna. In addition, a traction injury of the brachial plexus was present. Despite the absence of pain, a fasciotomy was performed because of excessive swelling of the forearm with obvious bulging of the muscles intra-operatively. CONCLUSION: Compartment syndrome can develop at several places in the body, including the forearm. Disproportional pain is the most relevant symptom which can however be absent due to concurrent neurological injury. Surgical exploration is always warranted in case of a clinical suspicion of compartment syndrome to prevent severe complications.

Operative Treatment of Pediatric Pelvic and Acetabulum Fractures.

Pediatric pelvic fractures are rare and differ from adults in etiology, fracture type, and associated injuries. They are observed in multitrauma patients, with severe associated injuries. Treatment of these children in specialized hospitals is likely to provide the best outcome because of the rarity of these fractures. Only a small percentage of the fractures, particularly the displaced ones, need operative treatment with the aim to restore the anatomy of the pelvic ring. In a significant proportion of the operated patients, morbidity and mortality were not linked to the pelvic fractures but to the other associated injuries. Long-term prognosis depends on restoring pelvic symmetry. Nondisplaced fractures of the acetabulum or fractures with minimal displacement with a relatively low roof-arc angle or crush injuries of the triradiate physis are managed nonoperatively. In young patients where continuation of growth is expected, fixation that does not cross the physis anatomically could be used. In some very young children, plate removal may be indicated to allow for continued growth of the acetabulum. One of the major complications in this patient cohort is acetabular dysplasia.

The HIPPO Trial, a Randomized Double-blind Trial Comparing Self-gripping Parietex Progrip Mesh and Sutured Parietex Mesh in Lichtenstein Hernioplasty: A Long-term Follow-up Study.

OBJECTIVE: To evaluate the effect of a self-gripping mesh (Progrip) on the incidence of chronic postoperative inguinal pain (CPIP) and recurrence rate after Lichtenstein hernioplasty. BACKGROUND: Chronic pain is the most common complication of inguinal hernioplasty. One of the causes may be the use of sutures to secure the mesh. METHODS: Adult male patients undergoing Lichtenstein hernioplasty for a primary unilateral inguinal hernia were randomized to a self-gripping polyester mesh or a sutured polyester mesh. Follow-up took place after 2 weeks, 3, 12, and 24 months. Pain and quality of life were assessed using the Verbal Rating Scale, Visual Analog Scale, and Short Form 36. CPIP was defined as moderate pain lasting at least 3 months postoperatively. RESULTS: There were 165 patients in the Progrip mesh group and 166 patients in the sutured mesh group. The incidence of CPIP was 7.3% at 3 months declining to 4.6% at 24 months and did not differ between both groups. Pain and quality of life scores were significantly improved after 2 years. Hernia recurrence rate after 24 months was 2.4% for the Progrip mesh and 1.8% for the sutured mesh (P = 0.213). The mean duration of surgery was significant shorter with the Progrip mesh (44 vs 53 minutes, P < 0.001). CONCLUSIONS: The self-gripping Progrip mesh does not reduce CPIP rates. Outcomes of the Progrip mesh are comparable to the Lichtenstein technique with the additional advantage of a reduced operation time. NCT01830452.

Isolated fractures of the teardrop of the acetabulum.

INTRODUCTION: Fractures of the teardrop are very rare. We would like to present two patients with a fracture of the teardrop. The teardrop is a radiological entity, also known as the U figure. It can be seen on the antero-posterior as well as on the obturator oblique radiographs of the pelvis. It is one of the six fundamental radiographic reference lines corresponding to anatomical landmarks, which Letournel introduced for the evaluation of acetabular fractures. Injuries of the hip joint may include pure hip dislocations, dislocations with fracture of the femoral head, dislocations with fracture of the acetabulum, or both. The position of the femoral head in relation to the acetabulum and the vector of the force at the time of impact determine the type of injury produced. Dislocation of the hip can be classified as posterior, anterior, obturator, or central. Anterior dislocations of the hip are uncommon and constitute 10-15% of traumatic hip dislocations. Anterior dislocations are classified according to the position assumed by the femoral head: pubic, obturator, or perineal. In obturator dislocations, the femoral head can cause a fracture of the infero-medial margin of the acetabulum-the teardrop. METHODS: Two patients are presented with a fracture of the teardrop. Both had a different type of trauma mechanism. The first patient had an obturator hip dislocation combined with a fracture of the teardrop and a fracture of the femoral head. In this case, the intra-articular fragments had to be removed. The second patient had an isolated fracture of the infero-medial margin of the acetabulum probably due to an anterior subluxation and spontaneous relocation of the femoral head. This fracture was treated non-operatively. RESULTS: At 12 and 24 months post-operatively, functional outcome scores were normal, with a normal range of motion and a pain-free hip joint. At 24 months, the radiographs of both patients showed a normal containment of the femoral head inside the joint, no narrowing of the joint space, and no signs of posttraumatic arthritis. CONCLUSIONS AND SIGNIFICANCE: An isolated fracture of the teardrop is very rare. The typical injury mechanism consists in an anterior subluxation or luxation of the femoral head needing hip reduction on an emergency basis. The fracture of the teardrop itself can be treated non-operatively with a perfect functional result, because the infero-medial localization of the fracture does not impair the containment or congruity of the hip joint. In case of a painful or displaced fragment of the teardrop interfering with hip joint mobility, fragment removal may be indicated. In case of an associated supero-lateral femoral head fracture, the fragment can either be internally fixed or debrided depending on its size and fragmentation.

Pediatric supracondylar humerus fractures: the anterior approach.

OBJECTIVES: To evaluate the efficiency of the anterior approach for displaced supracondylar pediatric humeral fractures. DESIGN: A retrospective analysis. SETTING: Clinical and outpatient clinic care. PATIENTS: The anterior approach group consisted of twenty-six patients. The historical group consisted of thirty-two patients. All had a completely displaced extension-type supracondylar humerus fracture (Gartland Type III). All were operated within six hours of admission. All patients were contacted; twenty-five of the twenty-six and twenty-nine of the thirty-two patients were re-examined at the outpatient clinic. The other patients were contacted by telephone. INTERVENTION: All fractures in the anterior approach group were operated through a ventral approach: An incision was made in the cubital fossa of only the skin and subcutaneous tissue, and reduction was performed with the thumb and index finger. The fractures in the historical group were approached through a lateral or a combined lateral and medial approach. For each case in both groups fixation was done with crossed percutaneous K-wires followed by plaster of Paris splinting for two weeks. Radiographic and clinical results were evaluated in follow-up examinations. MAIN OUTCOME MEASUREMENTS: Functional and anatomic measurements were obtained at follow-up. RESULTS: In both groups no compartment syndrome or Volkmann's ischemic contracture was seen. Two in the anterior approach group and one in the historical group had an associated brachial artery injury. Early postoperative fracture displacement occurred in one of the twenty-six anteriorly approached and in four of the thirty-two historical group patients. One of the four patients in the historical group with early displacement had no cosmetic or functional loss during follow-up examinations. One patient in the anterior approach group and two patients in the historical group had a rotational deformity, one of whom also suffered a functional loss. The only other functional losses were found in two patients in the anteriorly approached group and in three patients in the historical group. CONCLUSIONS: The results of this study show that the anterior approach is safe, simple, and easy to perform. The anterior approach has good and excellent results by Flynn's criteria in 84 percent versus 75 percent in the control group (p = 0.56).

Clinical trials of the T-fluted (Ash Advantage) peritoneal dialysis catheter.

The Ash Advantage is a T-shaped peritoneal catheter with a single transabdominal tube joining to a tube lying against the parietal peritoneum. Segments with long flutes (grooves) serve as fluid ports rather than 1-mm diameter holes. The folded catheter is placed through the expandable Y-TEC Quill positioned peritoneoscopically, similar to the procedure for a conventional Tenckhoff catheter. In a clinical study, we placed 18 Ash Advantage ("Advantage") catheters, 8 in patients with prior hydraulic or infectious complications of Tenckhoff catheters and 10 in patients initiating peritoneal dialysis. Mean follow-up has been 8.4 months. Outflow rate for the Advantage catheters is uniformly higher than for Tenckhoff catheters at 220 +/- 100 mL/min for the first 5 minutes and 145 +/- 72 mL/min for the next 5 minutes, with outflow completed in 6 to 15 minutes. Variation of outflow volumes for similar exchanges in the same patient is +/- 3% to 5%, much less than with Tenckhoff catheters. Four catheters failed after placement, each for a different reason including outflow failure because of preexisting intraperitoneal adhesions, preexisting peritonitis failing to clear, tubing kink during placement, and catheter break after a freak accident. Life-table analysis of the production version of the catheter in study patients and 12 additional unselected patients indicates a 90% survival at 12 months. In long-term use, the fixed position of the cuffs of this catheter may avoid catheter extrusion, pericatheter hernias, and pericatheter leaks. Multiple fluted ports appear to diminish omental attachment. The catheter may be a useful alternative to conventional Tenckhoff catheters in patients at high risk of catheter failure or in standard peritoneal dialysis patients.