Do All Fractures Need Surgery?

Common fractures managed by orthopaedic surgeons include ankle fractures, proximal humerus fractures in patients older than 60 years, humeral shaft fractures, and distal radius fractures. Recent trends indicate that surgical management is the best option for most fractures. However, there is limited evidence regarding whether most of these fractures need surgery, or whether there is a subset that could be managed without surgery, with no change in outcomes, or even possibly having improved results with lower complication rates with nonsurgical care.

Plunging Dangerously: A Quantitative Assessment of Drilling the Clavicle.

Bicortical drilling of the clavicle is associated with risk of iatrogenic damage from plunging given the close proximity of neurovascular structures. This study determined plunge depth during superior-to-inferior clavicle drilling using a standard drill vs drill-sensing technology. Two orthopedic surgeons drilled 10 holes in a fresh cadaveric clavicle with drill-sensing technology in freehand mode (functions as standard orthopedic drill) and another 10 holes with drill-sensing technology in bicortical mode (drill motor stops when the second cortex is breached and depth is measured in real time). The drill-measured depths were compared with computed tomography-measured depths. Distances to the neurovascular structures were also measured. The surgeons' plunge depths were compared using an independent t test. With freehand (standard) drilling, the mean plunge depth was 8.8 mm. For surgeon 1, the range was 5.6 to 15.8 mm (mean, 10.9 mm). For surgeon 2, the range was 3.3 to 11.0 mm (mean, 6.4 mm). The surgeons' plunge depths were significantly different. In bicortical mode, the drill motor stopped when the second cortex was penetrated. Drill-measured depths were verified by computed tomography scan, with a mean difference of 0.8 mm. Mean distances from the clavicle to the neurovascular structures were 15.5 mm for the subclavian vein, 18.0 mm for the subclavian artery, and 8.0 mm for the brachial plexus. Plunge depths differed between surgeons. However, both surgeons' plunge depths were greater than distances to the neurovascular structures, indicating a risk of injury due to plunging. Although a nonspinning drill bit may still cause soft tissue damage, drill-sensing technology may decrease the risk of penetrating soft tissue structures due to plunging. [Orthopedics. 2021;44(1):e36-e42.].

Examination of fluoroscopy monitor as a source of indirect bacterial contamination in orthopaedic surgery.

BACKGROUND: Surgical site infection is a well-documented complication of surgery. While contact with fomites represents a recognised source of contamination, electrostatic charge can cause contamination without surface contact as shown in previous studies evaluating operating room equipment. In cases requiring fluoroscopy, an intraoperative X-ray method, it is common for a surgeon to point to the associated monitor, particularly when teaching. This close proximity without direct contact poses a theoretical risk of contamination due to potential electrostatic forces. AIM/OBJECTIVE: To assess whether a gloved finger could be contaminated by a fluoroscopy monitor without direct contact. METHODS: Using a laser-guided level, a sterile, gloved finger was traversed side-to-side, top-to-bottom, across a fluoroscopy monitor used during surgery at distances of 1 cm, 2 cm, 4 cm and 8 cm. Two negative controls and a positive control were collected for comparison. Specimens were inoculated onto agar plates and incubated for 48 h at 37 °C. Following incubation, samples were analysed for growth and the number of colonies was recorded. This was repeated during 10 randomly selected operative cases using fluoroscopy for a total of 70 samples. RESULTS: No bacterial growth was identified as a result of inoculation on any of the 70 experimental or control specimens. DISCUSSION: We conclude that the practice of pointing to a fluoroscopy monitor for educational or other purposes is unlikely to increase the risk of glove contamination.

Bone density of first and second segments of normal and dysmorphic sacra.

BACKGROUND: Iliosacral screw fixation is safe and effective but can be complicated by loss of fixation, particularly in patients with osteopenic bone. Sacral morphology dictates where iliosacral screws may be placed when stabilizing pelvic ring injuries. In dysmorphic sacra, the safe osseous corridor of the upper sacral segment (S1) is smaller and lacks a transsacral corridor, increasing the need for fixation in the second sacral segment (S2). Previous evidence suggests that S2 is less dense than S1. The aim of this cross-sectional study is to further evaluate bone mineral density (BMD) of the S1 and S2 iliosacral osseous pathways through morphology stratification into normal and dysmorphic sacra. MATERIALS AND METHODS: Pelvic computed tomography scans of 50 consecutive trauma patients, aged 18 to 50 years, from a level 1 trauma center were analyzed prospectively. Five radiographic features (upper sacral segment not recessed in the pelvis, mammillary bodies, acute alar slope, residual S1 disk, and misshapen sacral foramen) were used to identify dysmorphic characteristics, and sacra with four or five features were classified as dysmorphic. Hounsfield unit values were used to estimate the regional BMD of S1 and S2. Student's t-test was utilized to compare the mean values at each segment, with statistical significance being set at p < 0.05. No change in clinical management occurred as a result of inclusion in this study. RESULTS: A statistical difference in BMD was appreciated between S1 and S2 in both normal and dysmorphic sacra (p < 0.0001), with 28.4% lower density in S2 than S1. Further, S1 in dysmorphic sacra tended to be 4% less dense than S1 in normal sacra (p = 0.047). No difference in density was appreciated at S2 based on morphology. CONCLUSIONS: Our results would indicate that, based on BMD alone, fixation should be maximized in S1 prior to fixation in S2. In cases where S2 fixation is required, we recommend that transsacral fixation should be strongly considered if possible to bypass the S2 body and achieve fixation in the cortical bone of the ilium and sacrum. LEVEL OF EVIDENCE: Level III.

Bilateral Isolated Fractures of the Sustentaculum Tali: A Case Report.

CASE: This article presents a case of bilateral isolated fractures of the sustentaculum tali. Subtle radiographic findings of sustentaculum fractures on routine foot and ankle series are often difficult to detect, which can result in a delayed diagnosis. Early diagnosis and timely operative management allowed for a good short-term outcome. CONCLUSIONS: We emphasize the importance of a thorough physical examination in all high-energy trauma patients and an awareness of less common injury patterns that are subtle on radiographs and may require further workup. When clinical suspicion exists, we recommend the use of computed tomography scans for evaluation.

Achieving Anatomic Acetabular Fracture Reduction-When is the Best Time to Operate?

OBJECTIVES: We hypothesize that earlier operative intervention for acetabular fractures improves the probability of achieving an anatomic reduction. DESIGN: Retrospective review. SETTING: Academic level I trauma center. PATIENTS/PARTICIPANTS: Six hundred fifty acetabular fractures treated through open reduction and internal fixation (ORIF) between September 2001 and February 2014. INTERVENTION: Acetabular fracture ORIF. MAIN OUTCOME MEASUREMENTS: Reduction quality was assessed through postoperative radiographs. Displacement of ≤1 mm was considered an anatomic reduction, 2-3 mm imperfect, and >3 mm poor. RESULTS: Anatomic reductions were observed in 85% (n = 553) of cases, imperfect reductions in 11% (n = 74) of cases, and poor reductions in 4% (n = 23) of cases. Patients with anatomic reductions had significantly shorter times from injury to ORIF [odds ratio (OR) interval] (median, 3 d) when compared with either imperfect (median, 4.5 days, P = 0.02) or poor reductions (median, 7 days, P < 0.001) reductions. The OR interval of imperfect reductions was also significantly shorter than that of poor reductions (P = 0.02). Logistic regression analysis demonstrated that OR interval had an effect of -0.12, meaning that the log odds of anatomic reduction decreases by 0.12 with each day from injury to ORIF. CONCLUSION: The interval from injury to operative fixation of acetabular fractures affects reduction quality. Earlier intervention improves the probability of achieving an anatomic reduction; therefore, ORIF should be performed as early as possible, provided the patient is optimized for surgery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.