Sling and Forget It? A Systematic Review of Operative versus Non-Operative Outcomes for Scapula Fractures.

BACKGROUND: The majority of scapula fractures have historically been treated non-operatively. The current literature describing patient outcomes following scapula fractures is limited. Our objective was to determine differences in outcomes between operatively and non-operatively treated scapular fractures. The goal of our study was to provide an updated and comprehensive systematic review for scapula body, neck, and glenoid fractures focusing on several outcomes including union rate, return to work, pain, shoulder active range of motion, strength, functional scores, and any recorded complications. METHODS: The PRISMA methodology was followed for this systematic review. Articles were obtained from the PubMed/Medline database using the following search terms: scapula body OR scapula neck OR intra-articular glenoid AND fracture. Additional articles were obtained by searching the bibliographies of included references. Studies were included if they contained clinical data on one or more of our study objectives and contained participants with a scapular body, neck, and/or glenoid fracture who were at least 16 years old. A total of 35 papers, with 822 total cases were included. Studies chosen were assessed for level of evidence and reviewed for data pertaining to the current study objectives. All cases of scapula fractures found throughout the literature were analyzed for outcome data. Outcomes studied included union rate, return to work, pain, shoulder active range of motion, strength, functional scores, and recorded complications. RESULTS: The overwhelming majority of scapula fractures go on to union. The majority of patients will eventually return to work. Persistent post-injury pain is unfortunately common. Shoulder range of motion and strength are decreased when compared to the contralateral shoulder. Non-operative glenoid fractures have the lowest reported functional scores. Malunion, need for additional surgeries, and post-traumatic arthritis were the most common complications. CONCLUSION: When treating scapula fractures, orthopedic surgeons must consider the specific fracture pattern, as well as patient specific goals. Risks and benefits of both operative and non-operative management should be discussed with the patient including the exceptionally low non-union rate regardless of treatment option and that persistent pain following injury is unfortunately common.

The major league baseball pitch clock: First year analysis of pitcher injuries.

Introduction: Recently, star pitchers in Major League Baseball (MLB) have faced devastating elbow injuries, causing some to question whether implementation of the MLB pitch clock during the 2023 season has led to a higher rate of elbow injuries among pitchers. This study aims to determine if implementation of the MLB pitch clock in the 2023 MLB season affected the injury rate in pitchers. Methods: Injury data was collected for the 2021, 2022, and 2023 MLB seasons using the fangraphs.com injury database. Incidence rate ratio was calculated to compare the injury rate for the 2023 season to the 2021 and 2022 seasons. A z-test for proportions was used to determine significance levels. Results: The 2023 season showed a decrease in the rate of the total number of injuries when compared to the 2021 (P = 0.01) and 2022 (P = 0.02) seasons. There was no statistical difference in the rate of Tommy John Surgery, Flexor Tendon Injuries, or other cause elbow injuries. Conclusion: Following implementation of the MLB pitch clock during the 2023 season, the total number of injuries decreased, but there was no change in the rate of elbow injuries in pitchers compared with the 2021 and 2022 MLB seasons. Future studies are needed to determine if the pitch clock has a longitudinal effect on injuries.

Complications of Hip Hemiarthroplasty.

Hip hemiarthroplasty is a commonly performed orthopedic surgery, used to treat proximal femur fractures in the elderly population. Although hip hemiarthroplasty is frequently successful in addressing these injuries, complications can occur. Commonly seen complications include dislocation, periprosthetic fracture, acetabular erosion, and leg-length inequality. Less frequently seen complications include neurovascular injury and capsular interposition. This article presents a comprehensive review of the complications associated with the management of hip hemiarthroplasty. [Orthopedics. 2023;46(4):e199-e209.].

Surgical Treatment for Avulsion Fractures of the Anterolateral Ligament Associated with Periarticular Fractures of the Knee.

The existence and anatomy of the anterolateral ligament (ALL) of the knee are a somewhat controversial topic in orthopaedic surgery. The fixation of the avulsion fracture of the ALL (Segond fracture), associated with periarticular knee fractures, is rarely given much consideration while the major fracture fragments are reconstructed. This study aims to confirm the existence of ALL and evaluate the clinical outcomes of surgical management for avulsion fractures, involving its insertion, when associated with periarticular knee fractures. Twenty-three patients (16 males and 7 females) with avulsion fractures of the ALL associated with periarticular knee fractures were fixed with a spider plate, cannulated screw, or suture anchor. Eight patients were diagnosed with distal femoral fracture, 10 with tibial plateau fracture, and 5 with tibial eminence avulsion fracture. All patients underwent X-rays at follow-up. Clinical and functional outcomes were assessed with the pivot-shift test, objective and subjective International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. The ALL was found and identified as a distinct ligamentous structure in all patients. Prior to Segond repair, patients had significantly more instability, as determined by pivot-shift test, than seen postoperatively (p < 0.0001). At final follow-up, the mean subjective IKDC score was 83.2 ± 10.3. Fourteen patients were graded A, 6 were graded B, and 3 was graded C on the IKDC objective score. The mean Lysholm score was 85.4 ± 12.2. The mean Tegner score was 7.5 ± 1.2. This study confirmed that the ALL is a distinct structure in the anterolateral portion of the knee. The fixation of the avulsion fracture of the ALL associated with periarticular knee fractures can be an effective procedure without specific complications. Long-term and comparative follow-up studies are necessary to confirm the effects.

Platelet-Rich Plasma and Stem Cell Injections in the Treatment of Arthritis of the Knee.

Platelet-rich plasma (PRP) and stem cell (SC) injections have become increasingly common in the treatment of knee arthritis. This systematic review was performed to answer the following questions: (1) What effects does intraarticular PRP injection have in the setting of knee arthritis? (2) What effects does intra-articular SC injection have in the setting of knee arthritis? (3) What adverse events have been reported in the literature from PRP injections for knee arthritis? (4) What adverse events have been reported in the literature from SC injections for knee arthritis? [Orthopedics. 2021;44(6):376-383.].

Do Early Weight-Bearing and Range of Motion Affect Outcomes in Operatively Treated Ankle Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVES: This systematic review was performed to answer the following questions: (1) Does early weight-bearing (WB) after ankle fracture (AF) open reduction internal fixation (ORIF) affect outcomes? (2) Does early WB after AF ORIF cause an increase in complications? (3) Does early ankle motion after AF ORIF affect outcomes? and (4) Does early ankle motion after AF ORIF cause an increase in complications? DATA SOURCES: Articles from 1970 to 2020 were found using the PubMed database. STUDY SELECTION: Level I studies of adult patients with operatively treated ankle fractures were selected. A total of 1130 cases across 20 studies fit the participant criteria. DATA EXTRACTION: Studies were reviewed for data pertaining to the current study questions. DATA SYNTHESIS: The meta-analysis used logistic regression and standardized mean difference. RESULTS: Based on the current literature, early WB in operative ankle fractures with stable fixation showed no difference in outcomes when compared with delayed WB protocols. Early WB after ORIF did not significantly increase complications. Early ankle motion after AF ORIF did not have significant standardized mean differences between range of motion and immobilization outcomes. Early range of motion before wound healing may lead to an increase in complications [pooled odds ratio: 3.11, 95% confidence interval (CI): 1.64-5.90] but did not show an increase in infection. CONCLUSIONS: The authors recommend that early WB at 2 weeks postoperatively can be safely considered for ankle fractures when stable fixation has been obtained. Early ankle motion before wound healing is not recommended due to increased wound complications, without improvement in long-term results. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Effect of a Dynamic Fixation Construct on Syndesmosis Reduction: A Cadaveric Study.

OBJECTIVES: To explore what effect a dynamic fixation construct would have on the final reduction of the syndesmosis. METHODS: Syndesmotic ligaments were sectioned in 10 cadaveric specimens. The syndesmosis was intentionally malreduced with a clamp, and the distance from the anterior edge of the fibula to the anterior incisura of the tibia was measured to quantify the sagittal syndesmotic displacement (SSD). A 3.5-mm quadricortical screw was then placed, the clamp was removed, and the SSD measured. The clamp was then replaced, and a suture-button construct (Knotless Tightrope; Arthrex Inc, Naples, FL) was then placed through the bone tunnel, the clamp was again removed, and the SSD was measured. RESULTS: In all cases, the fibula reduced to within 1 mm of its native anatomical position with the dynamic construct. The static screw construct, however, maintained an identical SSD measurement as the clamped malreduction. The dynamic suture-button construct reliably improved the SSD (P < 0.0001). CONCLUSIONS: Our study demonstrates that dynamic fixation constructs can help restore anatomical alignment in the case of syndesmotic malreduction. The size difference between the suture diameter and drill hole effectively allows the fibula to be pulled and seated into the tibial incisura fibularis. These findings should not be viewed as a justification to ignore the syndesmotic reduction; however, they do validate an important benefit of dynamic fixation that has been found in the recent clinical literature. LEVEL OF EVIDENCE: Therapeutic Level III.

Sternoclavicular Joint Dislocation: A Systematic Review and Meta-analysis.

OBJECTIVES: This meta-analysis was performed to answer the following questions: (1) What is the expected outcome of sternoclavicular (SC) dislocations left untreated? (2) What are the indications for closed reduction of SC dislocations? (3) What are the indications for open reduction of SC dislocations? and (4) Does the evidence support the need for a cardiothoracic surgeon to be available for the open reduction of a SC dislocation? DATA SOURCES: Articles were obtained from the database EBSCOhost and supplemented by hand searching of bibliographies of included references. A search using the following terms: SC joint AND (dislocation OR injuries OR vascular injury OR cardiovascular surgeon) of the English-language literature from 1970 to 2018 on the topic of SC joint dislocations was performed. STUDY SELECTION: Studies were included if they contained clinical data on one or more of our study objectives. Articles were included if they contained participants presenting with an acute (<3 week old) SC joint dislocation who were 16 years of age or above. A total of 92 cases fit this participant criteria. DATA EXTRACTION: Studies chosen based on the inclusion and exclusion criteria were assessed for level of evidence and were then carefully reviewed for data pertaining to the current study questions. Data from individual articles were recorded in a spreadsheet program and grouped appropriately. DATA SYNTHESIS: Individual cases of acute SC joint dislocations reported in the literature were noted by the authors. The cases were organized into a spreadsheet, which allowed for the calculation of total patients treated and with what treatment option. Complications that followed treatment were also noted, allowing for a quantitative analysis of patient outcome. CONCLUSIONS: Based on the current body of literature, closed reduction should be attempted in the acute setting and open treatment performed in cases of failed closed reduction in posterior SC dislocations. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biomechanics of the Injured Fibula Following Plate Fixation of a Concomitant Tibia Fracture To Fix or Not to Fix?

BACKGROUND: The mechanical role of supplemental fibula fixation in both bone lower leg fractures is not well defined. The benefit of fibula plate fixation in this context is controversial. The purpose of this study was to ascertain the mechanical contributions of the fibula under three conditions (intact, fractured, or plated fibula) following standard tibia locked plating. METHODS: A laboratory fracture model was created with 10 cadaveric legs (5 matched pairs) with no known history of lower extremity trauma or other musculoskeletal conditions. A both bone lower leg fracture was simulated by performing distal osteotomies, 3 to 5 cm above the tibia plafond, leaving a bony defect to simulate an unstable fracture (AOTrauma OTA classification 43-A3). Coronal and sagittal gauge-pins were placed above and below the fracture sites to measure relative displacement across three planes of motion. Axial and torsional loads were applied to the leg under the following conditions: tibia intact and fibula intact (control 1), tibia fracture and fibula intact, tibia fracture and fibula fracture (control 2), and the three conditions of primary interest: tibia plated and fibula intact, tibia plated and fibula fracture (osteotomy), and tibia plated and fibula plated. The load applied for level 1 was 75 N of axial compression and 0.3 Nm of torque, and the load for level 2 was 175 N of axial compression and 1.3 Nm of torque. RESULTS: There were significant differences in motion across the fracture site of the injured leg when the tibia was not plated compared with an intact and plated tibia, p < 0.05. However, when the tibia was plated, there were no significant differences in fracture motion when the fibula was left either intact, osteotomized, or underwent supplemental plate fixation, p > 0.05. This was true regardless of the loads applied. CONCLUSION: The mechanical stability of supplemental fibula fixation in a both bone lower leg fracture model was not significantly improved from standalone distal tibia fixation in this laboratory model. The clinical effects of these findings are yet to be demonstrated.

Efficacy of Arthroscopic Teaching Methods: A Prospective Randomized Controlled Study.

Arthroscopic education research recently has been focused on the use of skills labs to facilitate resident education and objective measure development to gauge technical skill. This study evaluates the effectiveness of three different teaching methods. Medical students were randomized into three groups. The first group received only classroom-based lecture. The second group received the same lecture and 28 minutes of lab-based hands-off arthroscopy instruction using a cadaver and arthroscopy setup. The final group received the same lecture and 7 minutes of hands-on arthroscopy instruction in the lab on a cadaver knee. The arthroscopic knee exam that followed simulated a diagnostic knee exam and subjects were measured on task completion and by the number of look downs. The number of look downs and the number of tasks completed did not achieve statistical significance between groups. Posttest survey results revealed that the hands-on group placed significantly more value on their educational experience as compared with the other two groups. (Journal of Surgical Orthopaedic Advances.

Open and contaminated pediatric pelvic ring injury case report: Fixation without metal.

INTRODUCTION: Pelvic fractures are relatively uncommon in children, accounting for 0.3-7.5% of all pediatric injuries (Gänsslen et al., 2013; Ismail et al., 1996; Peltier, 1965; Galano et al., 2005; Spiguel et al., 2006). This case report describes a pediatric open pelvic injury caused by a crush mechanism between a car and guardrail. CASE: A 13year old male presented with an open APC 3 pelvic injury after being pinned between a car and guardrail. His definitive treatment included bilateral SI screw placement, as well as a less invasive method for anterior pelvic ring disruption (Internal Brace suture anchor dynamic fixation). DISCUSSION/CONCLUSION: A less invasive method for the anterior pelvic ring was used to avoid additional dissection due to extensive soft tissue loss, and to decrease hardware burden, which lessens the chance of complications such as infection. Suture fixation of the pubic symphysis provided stable fixation to allow healing in the current case of open pelvic fracture.

The incidence of deep vein thrombosis and pulmonary embolism after fracture of the tibia: An analysis of the National Trauma Databank.

Controversy exists regarding the routine use of chemical prophylaxis in isolated lower extremity fractures. The incidence of VTE in specific fracture locations in the lower extremity is largely unknown, and represents key information necessary to determine the need for prophylaxis. A large cross-sectional study using the National Trauma Databank was performed evaluating for the incidence and risk factors of VTE in isolated tibia fractures. The overall incidence of DVT and PE are extremely low in cases of isolated tibia fractures, which brings into doubt a role for routine use of chemical prophylaxis for these fractures.

Examination Under Anesthesia for Posterior Wall Acetabular Fracture A Survey of the OTA Membership.

OBJECTIVES: The purpose of this survey was to learn more about the indications, criteria, and methods surgeons use for performing examination under anesthesia (EUA) for "intermediate" sized posterior wall acetabular fractures (those involving 20% to 40% of the posterior wall) and to find what criteria are used to determine hip instability. METHODS: An 18 question survey was posted on the Ortho- paedic Trauma Association's website and was used to gather anonymous data from orthopaedic surgeons regarding their approach to the intermediate sized posterior wall fracture. RESULTS: Considerable variability existed among re- sponses to many of the questions asked. Based on the an - swers given to the survey, a consensus of 75% or more of respondents was found for the following: 1. Supine position for the examination (100%); 2. "Live" fluoroscopy is used during the examination (97%); 3. The AP and obturator oblique are the x-rays most frequently used (81% and 76%, respectively); 4. The hip is placed in flexion and adduction during the exam (100% and 84%, respectively); 5. Axial load is applied during the examination (90%); Finally, 6. instabil - ity is defined as subluxation on exam by most respondents (98%), and any perceived visible subluxation is what defines instability (88%). CONCLUSION: Most surgeons agreed with the following: 1. Supine is the position of choice for the examination; 2. "Live" fluoroscopy is used during the examination; 3. The AP and obturator oblique are the x-rays most frequently used; 4. The hip is placed in flexion and adduction during the exam; 5. Axial load is applied during the examination; and 6. Instability is defined as subluxation on exam.

Muscle Viability Revisited: Are We Removing Normal Muscle? A Critical Evaluation of Dogmatic Debridement.

PURPOSE: Determination of muscle viability during debridement is a subjective process with significant consequences. Evaluating muscle color, consistency, contractility, and capacity to bleed (the 4 Cs) was established by a study performed half a century ago. This work reinvestigates the utility of the 4 Cs using current histopathologic techniques. METHODS: After institutional review board approval, 36 biopsies were prospectively collected at a level-1 trauma center from 20 patients undergoing a debridement for open fracture (81%), compartment syndrome (11%), infection (5%), or crush injury (3%). Surgeons graded the biopsies using the 4 Cs, and provided their overall impression as healthy, borderline, or dead. Blinded pathological analysis was performed on each specimen. A correlation between the 4 Cs and surgeon impression with histopathological diagnosis was sought through a univariate statistical analysis. RESULTS: The surgeon's impression was dead muscle in 25 specimens, borderline in 10, and healthy in 1. Pathological analysis of the 35 specimens considered as dead or borderline muscle by the surgeon demonstrated normal muscle or mild interstitial inflammation in 21 specimens (60%). Color (P = 0.07), consistency (P = 0.12), contractility (P = 0.51), capacity to bleed (P = 0.07), and surgeon impression (P = 0.50) were unable to predict histologic appearance. CONCLUSIONS: Neither the 4 Cs nor the surgeon's impression correlate with histological findings regarding muscle viability. In 72% of specimens, the treating surgeon's gross assessment differed from the histopathologic appearance. Although the fate of the debrided muscle remains unclear if left in situ, these results raise questions regarding current practices, including the possibility that surgeons are debriding potentially viable muscle. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Fractures Due to Gunshot Wounds: Do Retained Bullet Fragments Affect Union?

BACKGROUND: Many types of projectiles, including modern hollow point bullets, fragment into smaller pieces upon impact, particularly when striking bone. This study was performed to examine the effect on time to union with retained bullet material near a fracture site in cases of gunshot injury. METHODS: All gunshot injuries operatively treated with internal fixation at a Level 1 Trauma Center between March 2008 and August 2011 were retrospectively reviewed. Retained bullet load near the fracture site was calculated based on percentage of material retained compared to the cortical diameter of the involved bone. Analyses were performed to assess the effect of the lead-cortical ratio and amount of comminution on time to fracture union. RESULTS: Thirty-two patients (34 fractures) met the inclusion criteria, with an equal number of comminuted (17) and non-comminuted fractures (17). Seventeen of 34 fractures (50%) united within 4 months, 16/34 (47%) developed a delayed union, and 1/34 (3%) developed a nonunion requiring revision surgery. Sixteen of 17 fractures (94%) that united by 4 months had a cumulative amount of bullet fragmentation retained near the fracture site of less than 20% of the cortical diameter. Nine out of 10 fractures (90%) with retained fragments near the fracture site was equal to or exceeding 20% of the cortical diameter had delayed or nonunion. Fracture comminution had no effect on time to union. CONCLUSIONS: The quantity of retained bullet material near the fracture site was more predictive of the rate of fracture union than was comminution. Fractures with bullet fragmentation equal to or exceeding 20% of the cortical width demonstrated a significantly higher rate of delayed union/nonunion compared to those fractures with less retained bullet material, which may indicate a local cytotoxic effect from lead on bone healing. These findings may influence decisions on timing of secondary surgeries. LEVEL OF EVIDENCE: Level III.

Medial malleolus screws: out in one view and out.

Cartilage damage or mechanical blocking from screw penetration into intra-articular cartilage can reduce the chances of successful outcomes during medial malleolus fixation. There have been diverging opinions among surgeons concerning the reliability of radiographic assessment of fracture fixation and malleolus screw positioning. Therefore, this radiographic study examines the location of medial malleolus lag screws relative to the ankle mortise articular surface. In three Sawbones models, Kirschner wires were overdrilled with a 4.0-mm cannulated cortical screw simulating screws that would be intra- and extra-articular when performing open reduction and internal fixation of a medial malleolar fracture. Under fluoroscopy, images were evaluated to determine whether known intra-articular screws appeared extra-articular in any radiographic view. No image from models with known intra-articular penetration appeared extra-articular in any view or under "live" fluoroscopy. At 20° internal rotation, a screw with a known extra-articular position appeared to be within the cartilage. Intra-operative fluoroscopy is necessary to ensure proper extra-articular placement of screws. If a screw is pictured extra-articular in any radiograph, then it can be assumed that the screw is indeed out of the joint.

Intramedullary nailing of subtrochanteric fractures--does malreduction matter?

INTRODUCTION: Subtrochanteric femur fractures remain challenging injuries to treat. Historically, varus malreduction has been linked to the development of nonunion; however, there is a paucity of literature evaluating the impact of sagittal plane malreduction. The purpose of this study was to evaluate the influence of coronal and sagittal plane malreductions on time to union of subtrochanteric femur fractures treated with an intramedullary device. METHODS: A retrospective study was performed of all sub-trochanteric fractures (AO/OTA type 32) treated at a single institution. Inclusion criteria consisted of: 1. 18 or more years of age, and 2. fracture stabilization using an intramedullary device. All patients included were followed to union or revision surgery. Radiographic evidence of healing was defined as bridging callus on three of four cortices on AP and lateral views. Delayed union was defined as lack of radiographic healing by 4 months postoperatively and nonunion as lack of healing by 6 months. The definition of malreduction was coronal or sagittal plane deformity greater than 10° at the fracture site. RESULTS: Thirty-five patients met inclusion criteria; 20 men and 15 women with an average age of 55 years (range 19 to 100 years). Mean clinical follow up was 7 months (range 3 to 18 months). Thirty-four of 35 fractures (97%) healed without need for additional surgery. Twenty-one of the 35 fractures (60%) healed within 4 months of surgery. Thirteen fractures (37%) had delayed union, and 1 (2.9%) developed nonunion requiring reoperation. Seven of 35 fractures (20.0%) had a malreduction of greater than 10°, defined as varus (2 fractures), flexion (4 fractures), or both (1 fracture). Of the seven fractures with a malreduction, all (100%) developed a delayed (6) or nonunion (1). Of the 28 fractures without malreduction, 21 (75%) healed within 4 months, 7 (25%) had a delayed union, and none had a nonunion. The presence of a malreduction greater than 10° in any plane resulted in a significantly higher rate of delayed or nonunion (p = 0.0005). CONCLUSION: For patients with subtrochanteric fractures treated with an intramedullary device, malreduction in any plane of greater than 10° resulted in a significantly increased rate of delayed or nonunion or both.

Minimally displaced clavicle fracture after high-energy injury: are they likely to displace?

BACKGROUND: Nondisplaced or minimally displaced clavicle fractures are often considered to be benign injuries. These fractures in the trauma patient population, however, may deserve closer follow-up than their low-energy counterparts. We sought to determine the initial assessment performed on these patients and the rate of subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture. METHODS: We retrospectively reviewed the cases of trauma alert patients who sustained a midshaft clavicle fracture (AO/OTA type 15-B) with less than 100% displacement treated at a single level 1 trauma centre between 2005 and 2010. We compared fracture displacement on initial supine chest radiographs and follow-up radiographs. Orthopedic consultation and the type of imaging studies obtained were also recorded. RESULTS: Ninety-five patients with clavicle fractures met the inclusion criteria. On follow-up, 57 (60.0%) had displacement of 100% or more of the shaft width. Most patients (63.2%) in our study had an orthopedic consultation during their hospital admission, and 27.4% had clavicle radiographs taken on the day of admission. CONCLUSION: Clavicle fractures in patients with a high-energy mechanism of injury are prone to fracture displacement, even when initial supine chest radiographs show nondisplacement. We recommend clavicle films as part of the initial evaluation for all patients with clavicle fractures and early follow-up within the first 2 weeks of injury.

CONTEXTE: Les fractures de la clavicule accompagnées d'un déplacement minime voire nul sont souvent considérées comme des blessures mineures. Toutefois, ces fractures méritent probablement un suivi plus étroit chez le patient polytraumatisé que chez le patient dont la blessure résulte d'un impact à faible énergie. Nous avons voulu analyser l'évaluation initiale de ces patients et le degré de déplacement subséquent des fractures chez les victimes d'un traumatisme à forte énergie dont la première radiographie du thorax en position couchée a initialement révélé une fracture de la clavicule présentant un bon alignement. MÉTHODES: Nous avons passé en revue de façon rétrospective les dossiers de patients polytraumatisés ayant fait l'objet d'une alerte, atteints d'une fracture de la clavicule (type 15-B selon la classification AO/OTA) accompagnée d'un déplacement inférieur à 100 % et traités dans un seul centre de traumatologie de niveau 1 entre 2005 et 2010. Nous avons comparé le déplacement des fractures entre les radiographies thoraciques initiales en position couchée et les radiographies de suivi. Les consultations en orthopédie et les types d'épreuves d'imagerie ont aussi été consignés. RÉSULTATS: Quatre-vingt-quinze patients atteints d'une fracture de la clavicule répondaient aux critères d'inclusion. Au moment du suivi, 57 (60 %) présentaient un déplacement de 100 % ou plus du corps de la clavicule. La plupart des patients (63 %) de notre étude ont eu une consultation en orthopédie au cours de leur hospitalisation et 27 % avaient subi une radiographie de la clavicule le jour de leur admission. CONCLUSION: Les fractures de la clavicule chez des patients victimes d'un traumatisme à forte énergie sont sujettes au déplacement, et ce, même si les radiographies thoraciques initiales en position couchée ne montrent aucun déplacement. Nous recommandons la prise de clichés de la clavicule dans le cadre de l'évaluation initiale de tous les patients victimes d'une fracture de la clavicule et un suivi rapproché dans les 2 premières semaines suivant la fracture.

Caesarean section rates following pelvic fracture: a systematic review.

BACKGROUND: Following pelvic fracture in females of childbearing age, the question of whether or not natural pregnancy and childbirth can occur is often asked by both patients and clinicians. The following is a systematic review of the literature examining caesarean section rate in patients with prior pelvic fracture. METHODS: An extensive search of the English-language literature was performed to include all articles describing pregnancy outcomes in women with prior pelvic fracture. The primary outcomes analyzed were vaginal delivery and caesarean section. Secondary outcomes investigated included the rate of new caesarean section, indications for caesarean section, and caesarean section rates with operative versus nonoperative treatment of the pelvic fracture. RESULTS: Eight articles assessing 148 patients who underwent childbirth after pelvic fracture were eligible for inclusion. Among the 148 patients who underwent childbirth after pelvic fracture, 79 (53%) delivered vaginally and 69 (47%) underwent caesarean section. When patients who had already undergone a caesarean section prior to their pelvic fracture were excluded, 137 patients remained. Among these 137 patients, 79 (58%) delivered vaginally and 58 (42%) had caesarean section performed. Indications for caesarean section were sporadically listed but in some series did include patient or obstetrician preference as a result of prior pelvic fracture. Prior pelvic fixation had no demonstrable effect on pregnancy outcomes (p>0.05). CONCLUSIONS: Patients with prior pelvic fracture undergo caesarean section at a rate greater than those without prior pelvic fracture. The cause for this is not entirely understood but seems to be related at least in part to patient and obstetrician bias rather than solely due to the pelvic fracture and cephalopelvic disproportion.

Retained bullet removal in civilian pelvis and extremity gunshot injuries: a systematic review.

BACKGROUND: Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances. QUESTIONS/PURPOSES: We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments? METHODS: A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE(®) and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included. RESULTS: No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal. CONCLUSIONS: The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.