Midshaft humeral fracture - Operative or nonoperative treatment?

HISTORY: A 49yo male is involved in a fall while skiing. He was brought off the ski hill and was found to have suffered a closed fracture of the left midshaft humerus. Distal neurovascular exam was normal. He is otherwise unhurt (Figs. 1 and 2). PAST MEDICAL HISTORY: previous history of back surgery for a disc problem when he was 35yo. Has been told that he has high blood pressure but does nothing for this. He is Right hand dominant. SOCIAL HISTORY: married with one child and works as an equipment operator for a crane company; he is a social drinker and smokes 1pack per day for 30 years. Has a history of using some recreational drugs but none for 10 years.

Surgical versus conservative treatment of greater trochanteric fractures with occult intertrochanteric fractures: Retrospective cohort study.

BACKGROUND: Greater trochanter (GT) fractures are rare and frequently associated with occult intertrochanteric (IT) fractures. No consensus has been reached regarding whether surgical or conservative treatment is preferred for such fractures. The purpose of this study was to evaluate the clinical outcomes of surgical versus conservative treatment for coexistent GT and occult IT fractures. MATERIALS AND METHODS: Between January 2006 and December 2021, we enrolled patients who were diagnosed with GT fracture on radiography or CT and underwent MRI to reveal occult IT fracture. Eligible patients were divided into two treatment groups: surgical and conservative treatment. The characteristics and outcomes of the patients were compared between the two groups. RESULTS: Fifty patients were included in this study. There were 29 patients (3 male, 26 female; mean age: 84.45 ± 10.68 years) in the surgical treatment group and 21 patients (3 male, 18 female; mean age: 83.33 ± 9.34 years) in the conservative group, respectively. The demographic and clinical characteristics of the two groups were comparable, including sex, age, body mass index (BMI), percentage of extension into the IT area, days from injury to diagnosis, and activities of daily living (ADL) before injury. All 50 patients healed without displaced fractures, regardless of the percentage of extension into the IT area. There were no significant differences in the modified functional ambulation category scores between the two groups at one week, one month, and three months following the start of the treatment intervention (P = 0.653, 0.923, and 0.577, respectively). The length of hospital stay was 48.4 ± 5.97 days in the surgical treatment group and 50.6 ± 7.55 days in the conservative treatment group (P = 0.422). There was no significant difference in one-year mortality between surgical and conservative treatments (P = 0.219). CONCLUSIONS: There were no significant differences in any outcome between the surgical and nonsurgical treatment groups. The results of the study suggested that coexistent GT and occult IT fractures may be managed conservatively without developing complete fractures, regardless of extension into the IT area.

The utility of air on computed tomography scans in the assessment of type 1 open fractures.

PURPOSE: The presence of air on computed tomography (CT) scans has been demonstrated to accurately diagnose occult traumatic arthrotomies. The purpose of this study was to determine if the presence of air on CT scans also has diagnostic utility for type 1 open fractures. METHODS: A retrospective review at a level 1 trauma center identified twenty-eight patients with Gustilo-Anderson Type 1 open fractures and preoperative CT scans. These patients were matched 2:1 with 56 closed fractures who also had CT scans. CT scans were reviewed to determine the presence of suprafascial and subfascial air. RESULTS: Air near the fracture site on CT scan was more common in open fractures then closed fractures (21 (75%) vs. 9 (16%) patients, proportional difference: 59% (37-75%), p < 0.0001). In the open fracture group, 18 (64.2%) patients had both supra- and subfascial air, 2 (7.1%) patients had isolated subfascial air, and 1 (3.5%) patient had isolated suprafascial air. In the closed fracture group, 3 (5.3%) patients had supra- and subfascial air, 4 (7.1%) had isolated subfascial air, and 2 (3.5%) had isolated suprafascial air. The sensitivity and specificity of air on CT for identifying a type 1 open fracture was 75 and 84%, respectively. CONCLUSIONS: This study found that the presence of air on CT scan was more likely in type 1 open versus closed fractures; however, the sensitivity or specificity was too low to be used reliably to identify occult open fractures in isolation. LEVEL OF EVIDENCE: Diagnostic Level III.

Effect of Local Antibiotic Prophylaxis on Postoperative Deep Infection in Fracture Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVES: Despite the use of systemic antibiotic prophylaxis, postoperative infection after fracture surgery remains an issue. The purpose of this systematic review and meta-analysis was to evaluate the effect of locally applied antibiotics on deep infection in fracture surgery in both the open and closed fractures. DATA SOURCES: A comprehensive search of MEDLINE, Embase, and PubMed was performed from the date of inception to April 15, 2021, and included studies in all languages. STUDY SELECTION: Cohort studies were eligible if they investigated the effect on the infection rate of local antibiotic prophylaxis on deep infection after fracture surgery. DATA EXTRACTION: This study was conducted according to the Cochrane Handbook for Systematic Reviews and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials and the Methodological Index for Nonrandomized Studies tool where applicable. DATA SYNTHESIS: An inverse variance random-effects model was the primary analysis model because of the anticipated diversity in the evaluated populations. Univariate models were used when a single outcome was of interest. CONCLUSIONS: The risk of deep infection was significantly reduced when local antibiotics were applied compared with the control group receiving systemic prophylaxis only. This beneficial effect was observed in open fractures but failed to reach statistical significance in closed fractures. This meta-analysis suggests that there may be a significant risk reduction in deep infection rate after fracture surgery when local antibiotics are added to standard systemic prophylaxis, particularly in open fractures. Further high-powered Level I studies are needed to support these findings. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment Order and Risk of Surgical Site Infection in Patients Undergoing Concurrent Operative Fixation of Closed and Open Fractures.

This study aimed to characterize postoperative infection rate among patients undergoing definitive fixation of both open and closed fractures during the same surgery. Outcomes between patients with open fractures (OF) treated first were compared to those with closed fractures (CF) treated first. We identified 303 adult patients with multiple (≥ 2) pelvis and extremity fractures who presented to our Level 1 Trauma hospital in 2017. Forty patients with at least one open and one closed fracture treated with operative fixation during the same surgery were included in analysis. Eight surgical site infections (SSI) developed in seven patients. There was no significant difference between treatment order groups (OF = 4 patients (5 fractures), CF = 3 patients (3 fractures); p > 0.99). This is the first study comparing different chronologies of operative fixation in coexisting open and closed fractures. Our study shows that the choice of treatment order does not influence SSI risk. (Journal of Surgical Orthopaedic Advances 31(3):181-186, 2022).

"You're O.K. Anesthesia": Closed Reduction of Displaced Pediatric Forearm and Wrist Fractures in the Office Without Anesthesia.

BACKGROUND: Angulated wrist and forearm fractures are among the most common pediatric fractures, and they often require closed reduction with anesthesia. There are several issues associated with pediatric anesthesia including the low but non-zero risk of significant complications, increased physician and staff time and effort, and increased cost. Despite these issues, there have not been any studies to prove that using anesthesia results in better outcomes or higher caregiver satisfaction in comparison to performing closed reductions without anesthesia. The purpose of this study was to evaluate the quality of closed reductions of angulated pediatric wrist and forearm fractures and to determine caregiver satisfaction with an anesthesia-free reduction technique. METHODS: This study included 54 pediatric patients with closed, angulated fractures of the radius or combined radial and ulnar shafts. All closed reductions were performed by a single pediatric fellowship-trained orthopaedic surgeon in the office setting without any anesthesia. Radiographs were obtained to assess the quality of the reduction. At the first follow-up visit, caregivers were asked about their interim use of pain medications. Caregivers were later surveyed about patient use of analgesics and their satisfaction with an anesthesia-free reduction technique. RESULTS: The average age of the 54 patients in this study was 9 years (1.8 to 16.8 y). Thirty-three fractures were combined radial and ulnar forearm shaft fractures, 18 were distal radius fractures, and 3 were radial shaft fractures. ≤10 degrees of residual angulation was achieved in 98% of patients. Nine percent (5/54) of the patients used ibuprofen or acetaminophen for pain control. Seventy eight percent (42/54) of the caregivers responded to the telephone and email surveys. All responding caregivers stated that the patients returned to full function and had satisfactory outcomes. Ninety eight percent (41/42) of the caregivers stated they would choose the same anesthesia-free reduction technique again. CONCLUSIONS: Closed reduction of angulated pediatric wrist and forearm fractures in the office without anesthesia can achieve satisfactory reductions and high caregiver satisfaction while eliminating the risks and complications associated with pediatric anesthesia. LEVEL OF EVIDENCE: Level IV Case series.

Microbiology of surgical site infection in closed upper limb fractures: Data from a prospective trauma registry.

The current study aims to determine the rate of surgical site infection, causal microorganism, and antibiotic sensitivity pattern in operated upper limb closed fractures at the Aga Khan University Hospital, Karachi. Cases presenting between June 2015 to October 2019, were selected from a single-centre, longitudinal, prospective orthopaedic trauma registry. Infection rate, causal microorganism, and antibiotic sensitivity pattern were determined up to six months after surgery. From among a total of 376 closed fractures, 12 encountered surgical site infection with some having late onset, giving an infection rate of 3% which is 1% higher than the international benchmark. Microorganism culture was performed on 5 (42%) patients out of which 2 (40%) were positive. Frequently used prophylactic antibiotics were first generation Cephalosporin and Co-amoxiclav in 9 (75%) patients, but all other patients required other antibiotic categories. Five patients required implant removal with antibiotic coverage. K-wire insertion required prolonged antibiotic treatment. Most of the cultures were negative in spite of the presence of infection.

Outcomes After Operative Treatment of Pediatric Monteggia Fracture-Dislocations: Comparison Between Open and Closed Injuries.

BACKGROUND: Open pediatric Monteggia fracture-dislocations are a relatively uncommon injury pattern, with limited numbers reported in previous series. Open fracture-dislocations frequently represent more severe injury patterns with potential for contamination. We aim to determine differences in long-term clinical and functional outcomes in the operative management of closed versus open pediatric Monteggia fracture-dislocations. METHODS: A retrospective review of operatively treated pediatric Monteggia fracture-dislocations was performed. Closed versus open injuries were compared in both clinical outcomes, as well as patient-reported outcomes through Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. RESULTS: Of 30 operatively treated injuries, 12/30 (40%) were open fracture-dislocations. Patients were followed clinically for an average of 15.65 months in open injuries and an average of 4.61 months in closed injuries. A trend toward increased time to union was observed, however, significance was not achieved; open injuries averaged 8.0 versus 5.8 weeks for closed injuries ( P =0.07). Two patients (11%) in the closed fracture group experienced postoperative complications; both were minor. Five patients (42%) in the open fracture-dislocation group experienced a total of 6 postoperative complications; 5 of the 6 complications were major. QuickDASH scores were obtained at an average of 5 years postoperatively; mean QuickDASH scores were higher in the open fracture group, 13.1, compared with the closed fracture group, 5.9 ( P =0.038). Increased QuickDASH scores were independently associated with presence of postoperative complications. QuickDASH score could be expected to increase by 12.5 points in those with major complications ( P =0.044). CONCLUSION: We present the largest single cohort of pediatric open Monteggia fracture-dislocation injuries to date. These injuries are predictive of poorer outcomes including trend toward increased time to union, increased risk of major complication, and can independently predict worse long-term patient-reported functional outcomes. LEVEL OF EVIDENCE: Level III-these data represent a retrospective comparative study of clinical and functional outcomes.

Open versus closed pilon fractures: Comparison of management, outcomes, and complications.

BACKGROUND: Despite the low incidence of pilon fractures amongst lower limb injuries, their high impact nature presents difficulties in surgical management and recovery. The high complication rate and long recovery times presents a challenge for surgeons and patients. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in outcomes and complications between open and closed pilon fractures, and between patients treated by open reduction internal fixation (ORIF) or fine wire fixator (FWF) for open and closed fracture subgroups. METHODS: This retrospective study was conducted at a major trauma centre including 135 patients over a 6-year period. Primary outcome was AOFAS score at 3, 6, and 12-months post-injury. Secondary outcomes included time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, and complications during the follow-up time. AO/OTA classification was used (43A: n = 23, 43B: n = 30, 43C: n = 82). Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807). RESULTS: Higher AOFAS scores were seen in ORIF groups of both open and closed fractures, compared to FWF groups. The difference was not statistically significant apart from 12-month AOFAS score of 43C open fractures (p = 0.003) and in 43B closed fractures 3 and 6 months post-injury (p<0.001 and p<0.001, respectively). The majority of ORIF subgroups, open and closed fractures, also had shorter time to PWB, FWB, time to union, and follow-up. Statistically significant differences were seen in the following cases: ORIF-treated 43B closed fracture subgroup had shorter time to PWB and FWB (p<0.001 and p = 0.017, respectively), ORIF-treated 43C closed fractures had shorter time to union (p = 0.005). Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (24%), superficial infection (21%). All occurred more frequently in FWF-treated patients. CONCLUSION: Most ORIF-treated subgroups in either open or closed pilon fractures showed better primary and secondary outcomes than FWF-treated subgroups, yet few were statistically significant. Overall, our use of a two-staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.

Clinical Application Study of Minimally Invasive Double-Reverse Traction in Complex Tibial Plateau Fractures.

The aim of this study was to evaluate the clinical application of double-reverse traction for minimally invasive reduction of complex tibial plateau fractures. A retrospective analysis was performed to identify all patients admitted to the Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, from March 2017 to December 2019 with Schatzker type VI tibial plateau fractures. 12 patients were identified (7 men and 5 women) with an average age of 46.15 ± 13 (39-58) years old. All patients were treated with double-reverse traction and closed reduction. After the fracture was reduced, the bone plate was fixed by percutaneous minimally invasive implantation. Outcomes assessed in this study include operation time and intraoperative blood loss. Imaging was performed during the postoperative follow-up, and functional recovery was evaluated at the final follow-up according to the Hospital for Special Surgery (HSS) score and the International Knee Joint Literature Committee (IKDC) functional score. Patients were followed up for 12.54 ± 1.5 (8-15) months. The average operation time was 63.63 ± 21 (35-120) minutes, and the average intraoperative blood loss was 105.45 ± 21 (60-200) mL. The Rasmussen imaging score was either excellent or good in all cases. The knee joint HSS score was 86.15 ± 6 (79-90) points, and the IKDC score was 80.01 ± 11 (75-90) points. No complications, such as wound infection, incision disunion, loosening of internal fixation, and internal fixation failure, occurred. In the treatment of Schatzker VI type complex tibial plateau fracture, the dual-reverse traction minimally invasive technique has the advantages of safety and effectiveness, less soft tissue injury, and allowing early joint movement, which is worthy of clinical promotion.

Does intraoperative periprosthetic occult fracture of the acetabulum affect clinical outcomes after primary total hip arthroplasty?

INTRODUCTION: The frequency of intraoperative periprosthetic occult fracture of the acetabulum (IPOA) in primary total hip arthroplasty (THA) is relatively high. However, the effect of this fracture on clinical outcome and survival of primary THA remains unknown. This study aimed to determine the impact of IPOA on the outcomes of primary THA during a minimum follow-up of 5 years. MATERIALS AND METHODS: This retrospective case-control study compared the outcomes of primary THA with or without IPOA during a minimum 5-year follow-up. Thirty-eight patients who underwent primary THA with IPOA (O group) were matched to 76 patients without IPOA (C group) between 2004 and 2013 based on age, sex, body mass index, primary diseases, cup diameter, cup design, and additional dome screw. Both groups underwent the same rehabilitation programs after surgery. We evaluated the Japanese Orthopaedic Association clinical outcomes score; postoperative complications, such as nerve injury, dislocation, heterotopic ossification, iliopsoas impingement, or infection; and radiographic outcomes. Additionally, we performed Kaplan-Meier survival analysis with cup aseptic loosening, cup failure revision, and all-cause revision as the endpoints. RESULTS: There were no significant differences in the pre- and postoperative clinical scores, postoperative complication rates, and cup sagittal rotation between the two groups. Radiographic evaluations showed no aggravation of cases to overt fractures. Bone ingrowth was observed in all cases, and none of the acetabular cups had a progressive radiolucent line ≥ 2 mm in all the 3 acetabular zones. Ten-year survival rates for cup aseptic loosening and cup failure revision were 100% in both groups; those for all-cause revision were 97.4% (92.0-100%) and 100% in the O and C groups, respectively (p = 0.157). CONCLUSIONS: Primary THA with IPOA provides favorable mid- to long-term outcomes. On IPOA diagnosis, although radiographic follow-up is necessary, additional treatments or rehabilitation programs are not required. Furthermore, postoperative computed tomography images for the detection of IPOA may be unnecessary.

Closed reduction and locked intramedullary nailing of diaphyseal long bone fractures without intra-operative imaging and fracture table.

PURPOSE: Early closed reduction and locked intramedullary (IM) nailing has become the standard treatment for diaphyseal long bone fractures in high income countries. The low and middle income countries (LMICs) are still lagging behind in transiting from open surgical reduction and non-operative modalities to closed reduction due to lack of requisite equipment. However, some surgeons in LMICs are beginning to achieve closed reduction even without the equipment. METHODS: A prospective descriptive study was done on a total of 251 fresh diaphyseal fractures of the humerus, femur and tibia fixed with a locked nail over a 5½-year period. The fractures were grouped into those that had open reduction, closed reduction or reduction with a finger. RESULTS: Closed reduction was done for 135 (53.8%) fractures belonging to 123 patients. The mean and range of the patients' ages were 41.33 and 13-81 years, respectively. Males constituted 69.9% and mostly (48%) sustained fractures in motorcycle accident. There was a significant negative association between closed reduction and fracture-to-surgery interval (p < 0.001). Closed reduction also had positive associations with: (i) humerus and tibia fractures (p < 0.001), (ii) middle, distal and segmental fractures (p = 0.025), (iii) retrograde approach to femur fracture nailing (p < 0.001), and (iv) wedge or multifragmentary type femur fractures (p = 0.005). CONCLUSION: With constant practice, it is possible to achieve closed reduction of many fresh diaphyseal long bone fractures in spite of the limitations imposed on surgeons in LMICs by poor health systems and grossly inadequate fracture care facilities.

Outcomes of closed interlocking intramedullary nailing of the tibia without fluoroscopy in resource-limited settings: experience from two hospitals in Cameroon.

INTRODUCTION: closed static interlocking nailing with c-arm guidance is the standard procedure for the treatment of closed diaphyseal leg fractures. It is still very difficult to carry out such procedures in a low-income setting because of few or absent image intensifiers (c-arm) despite the necessity. The aim of this study was to describe the outcomes of patients with tibial fractures treated with closed interlocking intramedullary nails without c-arm guidance in a Cameroonian population. METHODS: this was a prospective study including adult patients treated for tibial fractures without a c-arm in two regional hospitals. RESULTS: finally, 22 patients were included. The mean age was 34 ± 12.6 years with a male predominance (16 males and 6 females). Ninety percent of the fracture lines were simple or with a wedge fragment grade 42A or 42B respectively according to the AO classification. The mean surgery time was 1 hour 26 ± 34 minutes. The various aspects evaluated were the nail entry point which was good in 19 (86.4%) cases; proper nail driving which was considered good in 15 (68%) cases; the distal locking which was missed in 6 (27.3%) cases. Bone consolidation was obtained in an average of 4 ± 1.2 months in all 22 cases. CONCLUSION: in resource constraints settings where c-arm are not always available, closed interlocked nail of tibia without c-arm guidance still gives overall good results. Nevertheless, there is a need to improve equipment in sub-Saharan African hospitals to make trauma surgery with c-arm a gold standard as currently recommended.

Saphenous Nerve Entrapment Neuropathy After Closed Tibial Fracture: A Case Report.

CASE: A 43-year-old man who underwent intramedullary nailing for a closed tibial fracture developed saphenous nerve entrapment neuropathy. He developed severe medial leg pain, which was worse on walking or standing, 2 years postoperatively. Surgical neurolysis resulted in complete pain relief and functional recovery of the limb without recurrence of symptoms. CONCLUSION: Clinicians should consider several etiologies in the diagnostic evaluation of a patient with chronic pain after limb trauma. If a patient complains of lower extremity pain after intramedullary fixation of closed fractures of the tibial shaft, the possibility of saphenous nerve entrapment neuropathy should be considered.

Risk factors for refracture of the femoral shaft in children after removal of external fixation.

BACKGROUND: External fixation is the primary treatment option in children for femoral shaft fractures, such as open femoral or multiple fractures. One complication is refracture, which is the biggest limitation of fixation devices. This study aims to investigate the risk factors associated with refracture after the removal of external fixation devices and decrease the frequency of refracture. MATERIALS AND METHODS: Retrospectively reviewed clinical data of 165 patients treated at our hospital for fresh femoral shaft fractures with external fixation between May 2009 and February 2018 were included in this study. Patients with pathological fractures, fractures of the femoral neck, fractures that were fixed using plates or elastic stable intramedullary nailing, and old fractures, as well as those who underwent postoperative femoral surgery were excluded. Potential risk factors included: patient age, gender, and weight, fracture sides, open or closed fracture, fracture sites, reduction methods, operation time, perioperative bleeding, number and diameter of the screws, and immobilization time. These factors were identified by univariate and logistic regression analyses. RESULTS: Femoral shaft refracture developed in 24 patients. Univariate analysis revealed that refracture was not statistically significantly associated with any of the above factors, except AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) classification type 32-D/4.2 and L2/L3 ratio (L2, length of femur fixed by the two screws farthest from the fracture line; L3, the total length from the greater trochanter to the distal end of femur; P < 0.001 and P = 0.0141, respectively). Multivariate analysis showed that PCCF classification type 32-D/4.2 and L2/L3 ratio were also independent risk factors for femoral refracture. CONCLUSIONS: Femoral shaft refracture is relatively common in children treated with external fixation. Because of the limited number of cases in this study, we cautiously concluded that the PCCF classification type 32-D/4.2 and L2/L3 ratio were independent risk factors for femoral shaft refracture in these patients. LEVEL OF EVIDENCE: IV.

Generation of Closed Transverse Fractures in Small Animals.

The most common procedure that has been developed for use in rats and mice to model fracture healing is described. The nature of the regenerative processes that may be assessed and the types of research questions that may be addressed with this model are briefly outlined. The detailed surgical protocol to generate closed simple transverse fractures is presented and general considerations when setting up an experiment using this model are described.

Usefulness of prophylactic antibiotics in preventing infection after internal fixation of closed hand fractures.

Prophylactic antibiotics (PA) have been shown to be ineffective in reducing the incidence of surgical site infection (SSI) in clean wounds associated with elective surgery of the hand. Routine administration of PA for internal fixation of hand fractures is a subject that has been scarcely studied. We hypothesized that PA do not reduce SSI incidence in fixation of closed hand fractures. We did a retrospective comparative study in patients who underwent open or closed reduction and internal fixation of a hand and carpus fracture. Patient demographics, past medical history, fracture characteristics and the type of internal fixation used were extracted from our electronic archives. Follow-up period lasted for 1 year, during which any form of clinically evident SSI, such as pus formation, wound dehiscence and positive bacterial culture was documented. A total of 107 patients met the inclusion criteria, 63 in the control group and 44 in the test group. The overall infection rate was 6.5%. All infections (3 in the control group and 4 in the test group) were pin-tract infections that resolved completely after pin extraction. Our study did not find significant differences between groups (P = 0.442). No specific fracture pattern was associated with increased total infection rate (p = 0.898). In this study, we found no support for routine administration of PA prior to internal fixation of closed fractures of the hand and carpus. PA should still be administered in selected patients, such as those with decreased immunity or open fractures. Further large-scale research is needed to establish proper guidelines, to reduce the adverse effects of antibiotic treatment.