Morphology of the Posterior Malleolar Fracture Associated With a Spiral Distal Tibia Fracture.

OBJECTIVE: To define the pathoanatomy of the posterior malleolus fracture associated with a spiral distal tibia fracture to guide clamp and implant placement when treating these common injuries. DESIGN: Retrospective cohort. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: One hundred twenty-two spiral infraisthmal tibia fractures identified from a cohort of 922 tibia fractures undergoing intramedullary nailing over a 7-year period. MAIN OUTCOME MEASUREMENTS: We collected instances of intra-articular extension seen on preoperative, intraoperative, or postoperative imaging. For patients with a posterior malleolus fracture and computed tomography imaging, we used an axial image 2-3 mm above the articular surface to create a fracture map. RESULTS: Intra-articular extension was present in 84 patients (68.9%), with posterior malleolus fractures occurring most commonly (n = 59, 48.4%). Other fractures included plafond fractures (n = 8), medial malleolus fractures (n = 7), anterior-inferior tibiofibular ligament avulsions (n = 5), and other anterior fractures (n = 5). Forty-one of 44 (93%) posterior malleolus fractures with cross-sectional imaging were Haraguchi type I (posterolateral-oblique type) with an average angle of 24 degrees off the bimalleolar axis. The remaining 3 were type II (transverse-medial extension type) fractures. Posterior malleolus fractures were visible 61% of the time on preoperative radiographs. DISCUSSION: Posterior malleolus fractures occur in approximately half of spiral distal tibia fractures and are consistently posterolateral in their morphology. This study can be used to enhance evaluation of the posterior malleolus intraoperatively (eg, ∼25 degrees external rotation view), and if the typical variant of posterior malleolus is identified, clamps and lag screws might be applied accordingly.

Characterization of pediatric golf cart injuries to guide injury prevention efforts.

BACKGROUND: Golf cart injuries represent an increasing source of morbidity and mortality in the United States. Characterization of the circumstances of these injuries can inform injury prevention efforts. METHODS: This study retrospectively reviews a prospective trauma registry at a level-one pediatric trauma center for golf cart-related injuries in patients under 18years of age admitted to the hospital between 2008 and 2016. RESULTS: The 40 identified crashes were associated with 82 hospital days, 17 ICU days, and more than $1 million in hospital charges over the study period. The median hospital stay was 1.5days, and the median hospital charge was $20,489. Severe injuries with an Injury Severity Score of >15 were identified in 25% of patients, and moderate injuries with scores between nine and 15 were identified in an additional 30%. The most common injures were head and neck (60%) and external injuries to the body surface (52.5%). Only a single child was wearing a seatbelt, and the vast majority was not using any safety equipment. Children as young as nine years old were driving golf carts, and child drivers were associated with the cart overturning (p=0.007). CONCLUSIONS: Golf cart crashes were a source of substantial morbidity at a level-one trauma center. Increased safety measures, such as higher hip restraints, seatbelts, and front-wheel breaks could substantially increase the safety of golf carts. Increased regulation of driving age as well as driver education may also reduce these injuries.

Increased minimum vein diameter on preoperative mapping with duplex ultrasound is associated with arteriovenous fistula maturation and secondary patency.

OBJECTIVE: Autogenous arteriovenous hemodialysis accesses (arteriovenous fistulas [AVFs]) are preferred for chronic hemodialysis access. Preoperative vein mapping by duplex ultrasound is recommended before AVF creation, but there are few data correlating vein diameter with postoperative outcomes. Also, vein diameter has not been included in prior predictive models of fistula maturation. This study aims to test whether preoperative vein diameter is associated with failure of AVF maturation and long-term (secondary) patency. METHODS: We performed a retrospective analysis of clinical variables of patients undergoing brachiobasilic or brachiocephalic AVF creation. Kaplan-Meier and multivariate Cox regression models tested whether preoperative minimum vein diameter (MVD) and clinical covariates were associated with failure of AVF maturation and secondary patency. RESULTS: The sample included 158 adults (54 ± 14 years; 45% male; 61% white; 56% diabetes; body mass index, 32 ± 8; MVD, 3.4 ± 1.1 mm; follow-up, 12 ± 9 months [range, <1-40 months]). Increased MVD was associated with decreased risk of AVF failure. More than one third of AVFs with MVD <2.7 mm failed to mature within 6 months. Multivariate models that adjusted for age, diabetes, race, gender, body mass index, and preoperative dialysis status demonstrated that increased MVD was associated with decreased risk of failure of maturation and better long-term patency overall (P = .005 and P = .001, respectively). CONCLUSIONS: Patients with a larger MVD on preoperative vein mapping are at lower risk for failure of fistula maturation and have increased long-term AVF patency. MVD is the only clinical or demographic factor associated with both AVF maturation and long-term patency. MVD is an important preoperative indicator of fistula success in assessment of potential AVF sites. Future predictive models of fistula maturation and patency should include MVD.

Health literacy of living kidney donors and kidney transplant recipients.

BACKGROUND: Health literacy (HL) may be a mediator for known socioeconomic and racial disparities in living kidney donation. METHODS: We evaluated the associations of patient and demographic characteristics with HL in living kidney donors (LD), living donor kidney transplant recipients (LDR), and deceased donor recipients (DDR) in a single-center retrospective review of patients undergoing kidney donation or transplantation from September 2010 to July 2012. HL and demographic data were collected. HL was assessed via the Short Literacy Survey (SLS) comprising three self-reported screening questions scored using the five-point Likert scale (low, moderate, high). Chi-square and logistic regression were used to test factors associated with lower HL. RESULTS: The sample included 360 adults (105 LD, 103 LDR, and 152 DDR; 46±14 years; 70% white; 56% male; 14±3 years of education). HL scores were skewed (49% high, 41% moderate, and 10% low). The distribution of HL categories differed significantly among groups (P=0.019). After controlling for age, race, sex, education, and a race-education interaction term, DDR was more likely to have moderate or low HL than LDR (OR, 1.911; 95% CI, 1.096-3.332; P=0.022). CONCLUSION: Overall, living donors had high HL. The distribution of low, moderate, and high HL differed significantly between LD, DDR, and LDR. DDR had a higher likelihood of having low HL than LDR. Screening kidney transplant candidates and donors for lower HL may identify barriers to living donation. Future interventions addressing HL may be important to increase living donation and reduce disparities.