Open hand fractures: a prospective analysis of functional outcomes and risk factors for infection after initial management in the emergency department.

PURPOSE: Open hand fractures are common orthopaedic injuries, historically managed with early debridement in the operating room. Recent studies suggest immediate operative treatment may not be necessary but have been limited by poor follow-up and lack of functional outcomes. This study sought to prospectively evaluate these injuries treated initially in the emergency department (ED), without immediate operative intervention, to determine long-term infectious and functional outcomes using the Michigan Hand Outcomes Questionnaire (MHQ). METHODS: Adult patients with open hand fractures managed initially in the ED at a Level-I trauma center were considered for inclusion (2012-2016). Follow-up and MHQ administration occurred at 6 weeks, 12 weeks, 6 months, and 1 year. Logistic regression and Kruskal-Wallis testing were used for analysis. RESULTS: Eighty-one patients (110 fractures) were included. Most had Gustilo Type III injuries (65%). Injury mechanisms most commonly included saw/cut (40%) and crush (28%). Nearly half of all patients (46%) had additional injuries involving a nailbed or tendon. Fifteen percent of patients had surgery within 30 days. The average follow-up was 8.9 months, with 68% of patients completing at least 12 months. Eleven patients (14%) developed an infection, of which 4 (5%) required surgery. Subsequent surgery and laceration size were associated with increased odds of infection, and at one-year, functional outcomes were not significantly different regardless of fracture classification, injury mechanism, or surgery. CONCLUSIONS: Initial ED management of open hand fractures results in reasonable infection rates compared to similar literature and functional recovery demonstrated by MHQ score improvements over time.

Radiographic evaluation of partial articular radial head fractures: assessment of reliability.

BACKGROUND: Historically, treatment of partial articular radial head fractures has hinged on radiographic assessment and application of the Mason classification. The inter- and intra-rater reliability of radiographic assessment and classification of radial head fractures may be lower than previously reported. We hypothesized that radiographic assessment leads to an underestimation of the number of fragments, percentage of articular surface involved, and displacement in millimeters. METHODS: We performed a retrospective review of all Mason II radial head fractures treated at our institution. Four independent observers performed radiographic assessment of the cohort. An independent observer performed these measurements on high-resolution computed tomography (CT) imaging, the reference standard. Radiographic assessments were then correlated with the CT findings using Pearson's correlation coefficient and Kappa statistic, where indicated. RESULTS: Fifty-nine Mason II radial head fractures were reviewed. These results were not impressive, with all comparisons showing a Kappa statistic less than 0.5 (ie, weak agreement). Intra-rater reliability was similar: displacement (measured by Pearson's correlation coefficient) was 0.58, percent articular involvement was 0.74, and the number of fragments (measured by the Kappa statistic) was 0.28. Fracture displacement was generally underestimated on radiographic measurements when compared to CT scan. Nearly half (45%) of all cases demonstrated inaccurate fragment number assessment when compared to the reference standard. CONCLUSION: Radiographs show poor inter- and intra-observer reliability for determining radial head fracture morphology. Assessment of the number of fragments was particularly inaccurate. High-resolution CT should be considered for patients with Mason II radial head fractures, especially in cases of poorly visualized fracture characteristics or borderline amounts of displacement, in an effort to appropriately indicate patients for the variety of treatment options available today.

Differential effects of neonatal handling on early life infection-induced alterations in cognition in adulthood.

We have previously demonstrated that bacterial infection (Escherichia coli) in neonatal rats is associated with impaired memory in a fear-conditioning task in adulthood. This impairment, however, is only observed if a peripheral immune challenge (lipopolysaccharide; LPS) is administered around the time of learning. We used a brief separation/handling paradigm to determine if the adult memory impairment associated with neonatal-infection could be prevented. Naturally occurring variations in maternal care promote striking variations in offspring cognitive development, and handling paradigms are used to manipulate the quality and quantity of maternal care. Rats were injected on post natal (P) day 4 with E. coli or PBS, and half from each group were handled for 15 min/day from P4 to 20. All rats were then tested in adulthood. Neonatal handling of rats infected as neonates prevented the increase in microglial cell marker reactivity within the hippocampus, and the exaggerated brain IL-1beta production to LPS normally produced by the infection. Thus, these neural processes were now comparable to levels of non-infected PBS controls. Furthermore, handling completely prevented LPS-induced memory impairment in a context-fear task in adult rats infected as neonates. Finally, neonatal handling dramatically improved spatial learning and memory and decreased anxiety in rats treated early with PBS, but had no beneficial effect on these measures in rats infected as neonates. Taken together, these data suggest that maternal care may profoundly influence neuroinflammatory processes in adulthood, and that infection may also prevent maternal care influences on cognition later in life.