Appropriateness of patients transferred with orthopedic injuries: experience of a level I trauma center.

BACKGROUND: Trauma patients are frequently transferred to a higher level of care for specialized orthopedic care. Many of these transfers are not necessary and waste valuable resources. The purpose of this study was to quantify our own experience and to assess the appropriateness of orthopedic transfers to a level I trauma center emergency department. METHODS: A retrospective review of orthopedic emergency department transfers to a level I trauma center was performed. Data collected included time of transfer, injury severity score (ISS), age, gender, race, orthopedic coverage at transfer institution, and insurance status. Two orthopedic trauma surgeons graded the appropriateness of transfer. A weighted logistic regression model was used to compare dependent and independent variables. RESULTS: A total of 324 patient transfers were reviewed; 65 (20.1%) of them were graded as inappropriate. There was no statistically significant relationship between appropriateness of transfer and age, availability of orthopedic coverage, night/weekend transfer, or insurance status. Regression analysis showed that only ISS (OR 1.130, p = .008) and "polytrauma" (OR 25.39, p < .0001) designation were associated with increased odds ratio of appropriate transfer. The kappa coefficient for inter-rater reliability between the two raters was 0.505 (95% CI, 0.388-0.623) reflecting moderate agreement. CONCLUSION: Inappropriate transfers create a significant medical burden to our health care system using valuable resources. Our study found similar results of inappropriate transfers compared to previous studies. However, we did not find a relationship between insurance status or nights/weekends and transfer appropriateness.

Fixation for metacarpal neck fracture: a biomechanical study.

BACKGROUND: There is no robust evidence of the best operative treatment for displaced unstable metacarpal neck fractures. Numerous constructs are used in the fixation of metacarpal neck fractures. Currently, two common methods are dorsal locking plate and K-wire fixation. A new metacarpal sled fixation system for metacarpal neck fracture was designed to provide fracture stability but limit dissection and avoid exposed hardware. The purpose of this study was to compare the biomechanical integrity of the metacarpal sled versus standard locking plate fixation and retrograde K-wire fixation in a simulated porcine metacarpal fracture model. METHODS: Transverse metacarpal neck fractures were created in 30 porcine second metacarpals. The specimens were randomly fixed with locking plates, metacarpal sleds, or retrograde K-wires. Constructs were then loaded to failure in three-point bending. Stiffness and peak load were measured from the load-to-failure deflection curve. Data were analyzed via ANOVA, followed by Tukey-Kramer's post hoc pairwise comparison. RESULTS: The K-wire group had the highest initial stiffness followed by the sled group and then the plate group. Statistical difference was only found between K-wires and plate. Peak load for the K-wire group was lowest, followed by sled, and then by plate. A statistically significant difference was observed between the peak loads of the K-wires and plate, as well as the sled and plate. However, a difference in peak load was not detected between the K-wires and sled. CONCLUSIONS: For transverse metacarpal neck fractures, a metacarpal sled construct provides similar fixation to K-wires with limited dissection and without exposed hardware or the potential for soft tissue tethering. The new low profile construct using a minimally invasive technique would be suitable for unstable metacarpal neck fractures.