A retrospective analysis of functional and radiographic outcomes of humeral shaft fractures treated operatively versus nonoperatively.

Background: To determine differences in functional outcomes, return to work, and complications, in operatively vs. nonoperatively treated diaphyseal humeral shaft fractures. Methods: 150 patients who presented to our center with a diaphyseal humeral shaft fracture (Orthopedic Trauma Association type 12) treated by open reduction internal fixation or closed reduction with bracing were retrospectively reviewed. Data collected included patient demographics, injury information, surgical details, and employment data. Clinical, radiographic, and patient-reported functional outcomes were recorded at routine standard-of-care follow-ups. Complications were recorded. Outcomes were analyzed using standard statistical methods and compared. Results: 150 patients with a mean 24.4 months of follow-up (12 to 60 months) were included for analysis. 83 (55.3%) patients were treated with nonoperative care in a functional brace. The rest were treated surgically. The mean time to healing did not differ between the cohorts (P > .05). Patients treated operatively recovered faster with regards to functional elbow range of motion by 6 weeks (P = .039), were more likely to be back at work by 8 weeks after injury (P = .001), and demonstrated earlier mean time to return-to-daily activities (P = .005). Incidence of nonunion was higher in the nonoperative cohort (10.84% vs. 0%, P = .031). Three (4.5%) patients in the operative group developed iatrogenic, postoperative nerve palsy. Two patients in the operative group (4%) had a superficial surgical site infection. Conclusion: More patients treated surgically had functional range of motion by 6 weeks. Functional gains should be weighed by the patient and surgeon against risk of surgery, nonunion, nerve injury, and infection when considering various treatment options to better accommodate patients' needs.

The nonsalvageable tibia: amputation and prosthetics.

Mangled extremities are a challenging problem for the orthopaedic surgeon. The decision for salvage versus amputation is multifactorial. Several work groups have attempted to create scoring systems to guide treatment, but each case must be regarded individually. As surgical technique and prosthetics continue to improve, amputations should be seen as a viable reconstructive option, rather than failure. This article reviews scoring systems for the mangled extremity, outcomes on salvage versus amputation, amputation surgical technique, and prosthetic options.

Damage-control orthopedics or early total care: What you need to know.

ABSTRACT: Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.

Hands-free Femoral Traction Using the Bookwalter Retractor System During Anterior Approaches to the Acetabulum.

SUMMARY: Displaced acetabular fractures with medial and cranial displacement of the femoral head commonly require an anterior approach for reduction and stabilization. Restoration of the femoral head to its native position under the reduced acetabular dome is a primary goal of surgery. We present a surgical technique for applying traction to the proximal femur using the Bookwalter retractor system during the repair of acetabular fractures when using an anterior approach. By placing traction in line with the femoral neck, the femoral head is moved to a more anatomical position allowing acetabular fracture fragments to be reduced unimpeded and the femoral head may be used as a reconstructive template. We review a case series of 116 patients treated using this technique and report the short- and long-term radiographic and clinical results of treatment.

Clinical and Radiographic Comparison of Splinting Constructs for Distal Radius Fractures: An Effort to Free the Elbow.

OBJECTIVES: To compare short-term functional outcomes, reduction loss, and rates of surgery for distal radius fractures initially immobilized with a traditional sugar-tong splint versus clamshell splint freeing the elbow. DESIGN: Prospective randomized trial. SETTING: Level 1 trauma center. PATIENTS: Eighty-nine consecutive patients sustaining distal radius fractures were enrolled between 2018 and 2020. Short-term first follow-up (1-2 weeks) radiographic parameters and 6 weeks for functional questionnaires were established to assess initial outcomes. MAIN OUTCOME MEASURES: The main outcome measures were reduction loss based on radiographic criteria, rate of surgery, and short-term patient functional outcome using the Disabilities of the Arm, Shoulder, and Hand (DASH) score. RESULTS: There were no differences noted in DASH scores ( P -value = 0.8) or loss of reduction ( P -value = 0.69), and splint type was not correlated with likelihood to have surgery ( P = 0.22). A binomial regression model demonstrated splint type was not a significant predictor variable of loss of fracture reduction in the regression model. CONCLUSIONS: These results suggest both sugar-tong splint and clamshell splint construct are acceptable options in the acute management of distal radius fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Preoperative and Intraoperative Considerations Using Intramedullary Nails for the Treatment of Tibial Shaft Fractures Below Total Knee Arthroplasty.

SUMMARY: Periprosthetic tibial shaft fractures below total knee arthroplasty (TKA) are relatively rare, with an incidence of approximately 1%. However, as the rates of arthroplasty increase, orthopaedic surgeons are likely to see a corresponding increase in these types of fractures. Native tibial shaft fractures are routinely treated with either nails or plates, and the success of intramedullary nailing of tibial shaft fractures has been well described in the literature. In this article, we seek to describe a case series of tibial shaft fractures in patients with ipsilateral TKA treated with infrapatellar intramedullary nailing. We will focus on preoperative considerations including templating and measurement of the anterior cortical implant distance on the lateral radiograph to ensure space for safe nail passage. We will also discuss intraoperative technical tricks, including Kirschner wire insertion for sounding the start point, utilization of the curved awl, use of hand reamers, and rotation of the nail to bypass the implant. Using meticulous preoperative planning and technical intraoperative tricks, patients with tibial shaft fractures below TKA may be successfully treated with intramedullary nailing.

Extra-articular Unstable Iliac Fractures: Associated Injuries, Fixation Strategies, and Outcomes.

OBJECTIVE: To characterize the associated injuries, fixation constructs, and outcomes of extra-articular unstable iliac fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS: Thirty-three extra-articular unstable iliac fractures treated over a 20-year period. INTERVENTION: Percutaneous or open fixation of iliac fractures at the pelvic brim AND/OR iliac crest. MAIN OUTCOME MEASURES: Incidence of union, fixation failure, and angiography at the time of injury. RESULTS: Twenty-five patients were treated operatively with appropriate follow-up. Four patients had fixation failure with displacement, all in the group with only brim OR crest fixation (4/8 patients, 50% rate). In patients with both crest AND brim fixation (n = 17), there were no cases of implant failure or late displacement. In displaced fractures (n = 22), 4 patients (18%) required embolization by interventional radiology. In all 4 cases, the superior gluteal artery was embolized. In patients with both crest AND brim fixation, all went on to uneventful union with an average Visual Analog Scale (VAS) pain score of 0.9 (range, 0-5) at final follow-up. CONCLUSIONS: Extra-articular unstable iliac fractures are high-energy injuries that demonstrate a high rate of union when both pelvic brim AND iliac crest fixation is used. Approximately 1 in 5 patients with a displaced iliac fracture presented with a superior gluteal artery disruption requiring embolization. Pelvic brim OR iliac crest fixation used in isolation was associated with a fixation failure rate of 50%, supporting previous biomechanical work. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Repair of Humeral Shaft Nonunion With Plate and Screw Fixation and Iliac Crest Bone Graft.

SUMMARY: A 58-year-old woman with a proximal 1/3 humeral shaft nonunion presented 2 years after initial injury. We present a technique for nonunion repair, including nonunion site preparation, direct compression of the fracture site using plate osteosynthesis, and iliac crest bone graft harvest and utilization. The purpose of this video is to review humeral shaft nonunion literature and describe our management technique.

Sternoclavicular Joint Reconstruction for Medial Clavicle Fracture Nonunion.

SUMMARY: Operative management of sternoclavicular fracture-dislocations is recommended in the setting of symptomatic nonunion. Treatment options include open reduction internal fixation, fragment excision, and ligamentous reconstruction. We present a 29-year-old man with a medial clavicle fracture nonunion that previously failed open reduction internal fixation and was treated with sternoclavicular joint reconstruction using tendon allograft.

Distal Humerus Fractures Evolution of Management.

Distal humerus fractures are a challenging problem that has vexed many orthopedic surgeons through the years. This article reviews the historical management of distal humerus fractures from nonoperative treatment to prolonged traction with ice tongs to the advent of AO technique and beyond. Current controversies, including plate orientation, ulnar nerve management, and the role of arthroplasty, are reviewed. Based on the best available evidence, parallel plating has been shown to be biomechanically superior, but no differences have been found in clinical outcomes, and the surgeon should let the fracture pattern dictate plate placement. The evidence surrounding ulnar nerve management is controversial, but a systematic review has shown no benefits to routine transposition. Finally, total elbow arthroplasty is an excellent option in geriatric fractures with osteoporotic bone and should be considered in these cases. Ultimately, distal humerus fractures, especially in the geriatric population, remain a difficult problem, but with meticulous technique and stable restitution of the bony columns and tie arch, good outcomes can be obtained.