Reduction Attempts Research Articles

Intra-Articular Lidocaine versus Procedural Sedation for Shoulder Dislocation Reduction: A Randomized Trial.

Two common ways of providing anesthesia for shoulder dislocation reductions in the emergency department (ED) are intra-articular lidocaine (IAL) injections and procedural sedation (PS). We sought to compare PS with propofol or etomidate to IAL for shoulder dislocation reductions in the ED. This was an open-label, randomized controlled trial of patients aged 18-70 years with anterior shoulder dislocations who presented to a single ED. We randomized patients to either PS or IAL for their shoulder dislocation reduction. The primary outcome measure was ED length of stay (LOS). Secondarily, we assessed patient satisfaction and the number of attempts required for successful reduction. We identified 60 patients who met the criteria for enrollment, and were able to enroll 43. We randomized 23 patients to IAL and 20 to PS. In the IAL group, the mean ED LOS was 133 min as compared to 124 min for the PS group (difference 9 min [95% confidence interval (CI)-22-41], P = 0.54). Patients in the IAL group required an average of 1.9 reduction attempts as compared to 1.2 in the PS group (difference of 0.7 [95% CI 0.2-1.2]). The mean patient satisfaction scores were similar at 9.7 and 9.8 for the IAL and PS groups, respectively. This study lacked a sufficient sample size to detect small differences but found no statistically significant difference in mean ED LOS or patient satisfaction for patients who received IAL as compared to PS. Patients in the PS group required fewer attempts for successful reduction.

GCT-18. Endoscopic third ventriculostomy (ETV) and tumor biopsy are not associated with relapse rate or patterns in primary central nervous system (CNS) germ cell tumor (GCT)

Abstract BACKGROUND: ETV and tumor biopsy are central to the surgical management of children with primary CNS GCT. An ETV creates a communication between the intraventricular compartment and the subarachnoid spaces and decompartmentalizes the ventricular system. “Tumor spill” or shedding may result from surgical interventions, such as biopsy. ETV with simultaneous biopsy may impart a greater tendency for dissemination and possible distant relapse. This is a concern in CNS GCT given the attempts of irradiation field and dose reduction following chemotherapy. METHODS: We performed a retrospective review of the prospective database for the Children’s Oncology Group (COG) ACNS1123 study. Possible associations were explored among ETV, endoscopic biopsy, and combined ETV+biopsy with relapse, distant relapse, progression free survival (PFS), and time to distant relapse. RESULTS: Among 244 eligible patients, 97 ETV+/-biopsies were performed, and 30 relapses occurred. There were no associations among ETV and/or biopsy with relapse (Cochran-Mantel-Haenszel [CMH] test, with histology (germinoma vs. nongerminomatous germ cell tumor (NGGCT)) as stratification variable: ETV: p=0.3167, biopsy: p=0.3375, combined: p=0.3066), distant relapse (CMH test, ETV: p=0.4631, ETV+biopsy: p=0.6795), PFS (log-rank test, ETV: NGGCT p=0.1632, germinoma p=0.9288; biopsy: NGGCT p=0.1682, germinoma p=0.9701; ETV+Biopsy: NGGCT p=0.1306, germinoma p=0.7758), or time to distant relapse with death/local relapse as competing risk (Gray’s test, ETV: NGGCT p=0.5694, germinoma p=0.2327; biopsy: NGGCT p=0.3505, germinoma p=0.5747; ETV+Biopsy: NGGCT p=0.3988, germinoma p=0.6839). CONCLUSIONS: Based on a secondary analysis of prospective data from the ACNS1123 trial, ETV and biopsy did not impart a greater likelihood of relapse in children with primary CNS GCT treated with combined chemotherapy and irradiation. However, three tract recurrences did occur (all germinoma), suggesting that they may affect pattern of relapse. Current and future prospective trials should continue to explore associations among these variables and relapse, including patterns of relapse.

A Comparative Study on Closed Reduction vs. Open Reduction Techniques in the Surgical Treatment of Rotated Lateral Condyle Fractures of the Distal Humerus in Children.

ObjectiveThe best approach between closed reduction and open reduction in the treatment of total displaced and rotated LCFs is still being debated. This study aimed to comparatively evaluate the clinical outcomes and complications of closed reduction vs. open reduction in the treatment of displaced and rotated lateral condyle fractures in children.MethodsWe retrospectively evaluated 46 children who underwent surgical treatment for totally displaced and rotated lateral condyle fractures. Thirty-one children underwent open reduction and percutaneous pinning (ORPP). Ten children underwent closed reduction and percutaneous pinning (CRPP). Five children were changed to ORPP procedures because of the failure of closed reduction attempts. Clinical outcomes and complications in the groups were compared.ResultsAmong three groups, no significant differences were found in demographic variables, and no differences were detected in the incidence of postoperative complications and clinical parameters. The ORPP group had the shortest surgical duration of the three groups (p < 0.005). Patients in CRPP group had faster fracture healing than the patients who underwent open reduction procedures. However, the success of CRPP seemed to be dependent on the earlier surgical intervention.ConclusionORPP is still the first-line treatment for the totally displaced and rotated lateral condyle fractures because of its direct visualization of the joint surface and easy-to-accomplish characteristics. In addition, CRPP may be a feasible option for the treatment of this type of fractures because of it is less invasive and potentially minimizes complications. However, the technical difficulties of CRPP must be taken into account.

A Rare Closed Reduction of Posterolateral Dislocation with Medial Collateral Ligament (MCL) Injury : A Case Report

Introduction: Irreducible posterolateral dislocation of the knee is a rare condition. Due to limited reports available, it is a common dilemma whether closed reduction should be attempted at all or an open surgery is the only method. “Dimple Sign'' can be found in the presence of injured medial structure, including the medial collateral ligament rupture (MCL), failure to recognize this sign may lead to repeated attempts of close manual reduction where could lead to secondary soft tissue injuries. Case Report : In this study we present a 50 years old male with successful attempt of closed reduction in posterolateral knee dislocation combined with tendon repair for the MCL rupture. Conclusion: This study may add more perspective and be beneficial for similar cases where prompt open surgery is not possible and closed reduction is considered.

Location of Initial Closed Reduction Attempt Significantly Increases Cost and Length of Stay in Total Hip Arthroplasty.

BackgroundProsthetic hip dislocation remains one of the most frequent complications following total hip replacement. Dislocations are predominantly managed by a closed reduction in the emergency department (ED) or the operating room (OR). This study aimed to evaluate how the location of an initial closed reduction attempt impacts a patient's course of care including length of stay (LOS) and cost of care.Material and methodsA retrospective chart review was performed on all patients presenting to a single ED with a unilateral prosthetic hip dislocation from 2009 to 2019. A total of 108 patients were identified. Data collected included patient demographics, ED/hospital course, and hospital charges.ResultsSeventy-four patients (69%) had initial reduction attempted in the ED (65/74, 88% were successful), while 34 patients (31%) went directly to OR (100% successful with closed reduction). Failed closed reduction in ED or direct to OR resulted in a greater LOS and rate of placement to a skilled nursing facility following discharge. Median hospital charges for successful ED reduction were $6,837, while failed ED closed reduction or direct to OR resulted in median charges of $27,317 and $20,481, respectively.ConclusionMany patients successfully underwent closed reduction in the ED, and there was no difference in complications, independent of where the reduction was first performed. Patients undergoing reduction in the OR had greater LOS and cost of care, independent of whether a reduction attempt was performed and failed in the ED, than those successfully reduced in the ED.

Proximal humeral fracture-dislocations: which patterns can be reduced in the emergency department?

Shoulder fracture-dislocations can represent a challenging management scenario in the emergency department (ED) because of concern for the presence of occult fractures that may displace during a reduction attempt. The alternative, a closed reduction attempt in the operating room, has the benefit of full paralysis but requires additional resource utilization. There is limited guidance in the literature about the risks of an initial reduction attempt in the ED as a function of fracture pattern to help guide physicians with this decision. This was a retrospective case review of adult patients with shoulder dislocations and fracture-dislocations seen in the ED at a level 1 trauma center over a 10-year period. Imaging and medical records were reviewed to evaluate whether the reduction attempt was successful, unsuccessful without worsening, or unsuccessful with worsening alignment of any fractures, as well as the ultimate clinical outcome. We identified 165 patients with fracture-dislocations and 484 patients with simple dislocations during the same period. Of the patients with fracture-dislocations, 103 had greater tuberosity fractures, 12 had nondisplaced surgical neck fractures, and 50 had displaced surgical neck fractures. None of the patients with simple dislocations had displacement during an ED reduction attempt, including 100 patients aged >65 years. Of the 103 patients with greater tuberosity fracture-dislocations, only 1 had displacement of a humeral shaft fracture during ED reduction. Displacement occurred in 6 of 8 patients with nondisplaced neck fractures who underwent an initial ED reduction attempt vs. 1 of 4 patients who underwent the initial reduction attempt in the operating room. ED reduction was attempted in 25 of the 50 displaced humeral neck fracture-dislocations and was successful in 10 of these (40%). For patients with greater tuberosity fracture-dislocations, there is a low rate of displacement with a reduction attempt in the ED, but an ED reduction attempt in nondisplaced neck fractures is not recommended because of the high rate of displacement. For displaced neck fractures, closed reduction can be successful in select patients. Finally, these data confirm prior reports that closed reduction of simple shoulder dislocations in patients aged >65 years is safe in the ED.

Ultrasound-guided interscalene block versus intravenous analgesia and sedation for reduction of first anterior shoulder dislocation

PurposeThis study aims to compare the efficacy of ultrasound-guided interscalene block (US-ISB) with that of intravenous analgesia and sedation (IVAS) in reducing first shoulder dislocation. Material and methodsA prospective study was performed in 66 patients with first anterior shoulder dislocation in emergency department. The patients were divided into a US-ISB (n = 32) group and an IVAS (IVAS n = 34) group. The procedure time (anesthesia, reduction, and hospital times), pain score (before, during, and after reduction), reduction attempts, complications, and patient satisfaction were recorded and compared between the two groups. ResultsThe anesthesia time (P < 0.01) and reduction time (P < 0.01) were shorter and the hospital time (P < 0.01) was longer in the IVAS group than in the US-ISB group. No significant differences in preoperative (P = 0.18) and postoperative (P = 0.27) pain scores were found between the two groups, but the intraoperative score of the US-ISB group was significantly higher than that of the IVAS group. More reduction attempts (P < 0.01) were recorded in the US-ISB group than that in the IVAS group. Complications (P < 0.01) such as nausea, vomiting, headache, and hypoxia occurred more frequently in the IVAS group than in the US-ISB group. No significant difference in patient satisfaction was observed between two groups (P = 0.96). ConclusionCompared with IVAS group, US-ISB group reduces the time to discharge and achieves lesser complication. The pain score and reduction attempt are lower in the IVAS group than in the US-ISB group.

Effect of a workplace mobile phone-based instant messaging intervention on smoking cessation: a cluster-randomized controlled trial.

To test the effectiveness of intractive, instant messaging chat-based mobile phone support versus text-based mobile phone support integrated with brief interventions on self-reported smoking abstinence in workplaces. A two-arm parallel cluster-randomized controlled trial with follow-up to 12 months. Seventy-five companies in Hong Kong, China. Daily cigarette adult smokers (92.0% male, 90.9% not ready to quit within the next 30 days) from 75 companies (clusters). Participants were cluster-randomized to receive text-based support (TBS, n = 375; 38 clusters) or chat-based support (CBS, n = 304; 37 clusters). TBS participants received automated and fix-scheduled text messages on cessation advice and support. CBS participants received fix-scheduled text messages and additional real-time psychosocial and cessation support via instant messaging services (e.g. WhatsApp) by counsellors. Both groups received a 1-hour health talk at baseline and brief telephone counselling at 1week and 1, 3, 6 and 12 months. The primary outcome was self-reported 7-day point-prevalence abstinence at 6months post-treatment initiation. Secondary outcomes included 7-day point-prevalence abstinence at 12 months, repeated 7-day point-prevalence abstinence, smoking reduction, quit attempts and intervention engagement, defined as having read text messages and/or engaged in conversation with counsellors. By intention-to-treat assuming that dropouts were smoking, self-reported abstinence was not significantly different between the CBS and TBS groups at 6months [18.8 versus 21.6%, risk ratio (RR) = 0.87, 95% confidence interval (CI) = 0.61, 1.23, retention = 71.3%] and 12 months (21.4 versus 24.0%, RR = 0.90, 95% CI = 0.66, 1.21, retention = 70.8%). The repeated 7-day point-prevalence abstinence, smoking reduction and quit attempts were similar between the groups. The participants who were engaged in the text- and/or chat-based interventions had greater abstinence (adjusted RR = 2.91, 95% CI = 1.87, 4.52) at 6months compared with unengaged participants. Compared with a text messaging mobile phone intervention, a chat-based instant messaging mobile phone intervention did not improve smoking abstinence over 12 months in workplaces. Engagement in text-based or chat-based interventions was associated with higher quit rates compared with non-engagement.

English

BACKGROUND Colles fracture is the most common wrist fracture in adults, predominantly affecting elderly women. Our study intends to reinforce the role of ultrasonography assisted reduction of Colles fractures as a suitable alternative to blind manipulation, as it can verify the adequacy of reduction in a single sitting in real time, and avoid multiple reduction sessions. METHODS 20 adult patients diagnosed with Colles fracture were enrolled in this case control study. Patients were divided into two groups of 10 each, study and control groups. The sample size was limited due to the Covid-19 pandemic of 2020. Study group was subjected to ultrasonography assisted reduction. Control group was subjected to blind manipulation and reduction. RESULTS Baseline characteristics between two groups were similar. The rate of repeat reduction was reduced in the ultrasound group (20 % VS 40 %; P =.329). The post reduction radiographic indices were similar between the two groups, although the ultrasound group had improved volar tilt (mean, 2.80 VS 1.60; P =.394). The operative rate was reduced in the ultrasound groups (10 % VS 30 %; P =.263). These results, though similar to existing studies into the topic, were not statistically significant, probably due to low sample size. CONCLUSIONS Despite the inability of our study to arrive at statistically significant results, we have positive findings for the parameters of volar tilt, number of multiple reduction attempts and number of cases proceeding to surgery. These findings are in line with other studies that were successful in establishing statistical significance for the above parameters. In view of this, a recommendation can be made to prefer ultrasonography assisted reduction over blind manipulation in initial management of Colles fractures, where the facility is available. KEY WORDS Colles Fractures, Ultrasonography, Blind Manipulation, Reduction, Volar Tilt, Operative Rate

Investigation of determinism-related issues in the Sobol′ low-discrepancy sequence for producing sound global sensitivity analysis indices

A computationally efficient and robust sampling scheme can support a sensitivity analysis of models to discover their behaviour through Quasi Monte Carlo approximation. This is especially useful for complex models, as often occur in environmental domains when model runtime can be prohibitive. The Sobol' sequence is one of the most used quasi-random low-discrepancy sequences as it can explore the parameter space significantly more evenly than pseudo-random sequences. The built-in determinism of the Sobol' sequence assists in achieving this attractive property. However, the Sobol' sequence tends to deteriorate in the sense that the estimated errors are distributed inconsistently across model parameters as the dimensions of a model increase. By testing multiple Sobol' sequence implementations, it is clear that the deterministic nature of the Sobol' sequence occasionally introduces relatively large errors in sensitivity indices produced by well-known global sensitivity analysis methods, and that the errors do not diminish by averaging through multiple replications. Problematic sensitivity indices may mistakenly guide modellers to make type I and II errors in trying to identify sensitive parameters, and this will potentially impact model reduction attempts based on these sensitivity measurements. This work investigates the cause of the Sobol' sequence's determinism-related issues.

Complex Dorsal Metacarpophalangeal Dislocation of Index Finger- A case report

Complex posterior metacarpophalangeal dislocations of the long fingers are rare, typically caused by entrapment of the volar plate within the joint space. They require surgical reduction to release the soft tissues interposed between the metacarpal head and the proximal phalanx. but there is an operative risk of digital nerve injury because of intricate displacement of the normal anatomy. We report the case of a 30-year-old patient who presented to the emergency department at the second day after his trauma with a complex posterior metacarpophalangeal dislocation of the right index finger. After failure of the closed reduction attempt, the dislocation was reduced surgically by an volar approach. The neurovascular bundle has been identified and carefully removed. The volar plate has been reduced, resulting in reduction of the dislocation. The volar plate has been completely repaired. At six weeks, all the range of motion of the MCP and other joints of the index finger had been found. At the last follow-up, the joint was still stable. Different techniques are described in the literature for the reduction of the complex posterior dislocations of long fingers, but the volar approach remains the best for palmar plate reduction and its full repair, which may decrease the risk of late instability.

Moderators of changes in smoking, drinking and quitting behaviour associated with the first COVID-19 lockdown in England.

AimTo estimate changes in smoking, drinking and quitting behaviour from before to during the first COVID‐19 lockdown in England, and whether changes differed by age, sex or social grade.DesignRepresentative cross‐sectional surveys of adults, collected monthly between August 2018 and July 2020.SettingEngland.ParticipantsA total of 36 980 adults (≥ 18 years).MeasurementsIndependent variables were survey month (pre‐lockdown: August–February versus lockdown months: April–July) and year (pandemic: 2019/20 versus comparator: 2018/19). Smoking outcomes were smoking prevalence, cessation, quit attempts, quit success and use of evidence‐based or remote cessation support. Drinking outcomes were high‐risk drinking prevalence, alcohol reduction attempts and use of evidence‐based or remote support. Moderators were age, sex and occupational social grade (ABC1 = more advantaged/C2DE = less advantaged).FindingsRelative to changes during the same time period in 2018/19, lockdown was associated with significant increases in smoking prevalence [+24.7% in 2019/20 versus 0.0% in 2018/19, adjusted odds ratio (aOR) = 1.35, 95% confidence interval (CI) = 1.12–1.63] and quit attempts (+39.9 versus –22.2%, aOR = 2.48, 95% CI = 1.76–3.50) among 18–34‐year‐olds, but not older groups. Increases in cessation (+156.4 versus –12.5%, aOR = 3.08, 95% CI = 1.86–5.09) and the success rate of quit attempts (+99.2 versus +0.8%, aOR = 2.29, 95% CI = 1.31–3.98) were also observed, and did not differ significantly by age, sex or social grade. Lockdown was associated with a significant increase in high‐risk drinking prevalence among all socio‐demographic groups (+39.5 versus –7.8%, aOR = 1.80, 95% CI = 1.64–1.98), with particularly high increases among women (aOR = 2.17, 95% CI = 1.87–2.53) and social grades C2DE (aOR = 2.34, 95% CI = 2.00–2.74). Alcohol reduction attempts increased significantly among high‐risk drinkers from social grades ABC1 (aOR = 2.31, 95% CI = 1.78–3.00) but not C2DE (aOR = 1.25, 95% CI = 0.83–1.88). There were few significant changes in use of support for smoking cessation or alcohol reduction, although samples were small.ConclusionsIn England, the first COVID‐19 lockdown was associated with increased smoking prevalence among younger adults and increased high‐risk drinking prevalence among all adults. Smoking cessation activity also increased: more younger smokers made quit attempts during lockdown and more smokers quit successfully. Socio‐economic disparities in drinking behaviour were evident: high‐risk drinking increased by more among women and those from less advantaged social grades (C2DE), but the rate of reduction attempts increased only among the more advantaged social grades (ABC1).

The Role of Embodied Carbon Databases in the Accuracy of Life Cycle Assessment (LCA) Calculations for the Embodied Carbon of Buildings

Studies conducted by major national and international scientific bodies have indisputably concluded that the increase in anthropogenic greenhouse gas emissions (GHG) since the mid-20th century has led to irreversible changes in the climate. Data has shown that the contribution of the building sector accounts for 39% of these emissions. Reducing GHG emissions associated with the construction phase of buildings, or embodied carbon (EC), will prevent GHG emissions from entering the atmosphere earlier, reducing the negative impacts. However, to achieve any meaningful reduction, there is a need for consistency and accuracy in the calculations. The accuracy of these calculations is primarily tied to the accuracy of embodied carbon factors (ECF) used in the calculations, values determining the environmental impact of a product or procedure per unit weight. The emissions of any product can be calculated by performing a Life Cycle Assessment (LCA). While the requirements for carrying out an LCA have been standardised in ISO14044, the lack of a definitive national ECF database in the UK means that EC calculations can vary drastically based on the chosen database. An LCA has been carried out on a standard Lidl supermarket design within the A1–A3 boundary. For the calculation, the ECFs were sourced from two different databases, using the GHG conversion factor data published in 2020 by the UK Department of Energy &amp; Climate Change and data published in 2019 by the Inventory of Carbon and Energy (ICE). The latter is currently accepted as the most consistent database for carbon factors in the UK. This study showed that using a more detailed database compared to using a more general database could result in a 35.2% reduction of embodied carbon, while using more detailed data from a single database can reduce it by a further 5.5%. It is necessary to establish the most accurate baseline for embodied carbon so that any carbon reduction attempts can be as effective as possible.

Clinical presentation and management of childhood intussusception in South Africa

PurposeWe assessed management and outcomes for intussusception at nine academic hospitals in South Africa.MethodsPatients ≤ 3 years presenting with intussusception between September 2013 and December 2017 were prospectively enrolled at all sites. Additionally, patients presenting between July 2012 and August 2013 were retrospectively enrolled at one site. Demographics, clinical information, diagnostic modality, reduction methods, surgical intervention and outcomes were reviewed.ResultsFour hundred seventy-six patients were enrolled, [54% males, median age 6.5 months (IQR 2.6–32.6)]. Vomiting (92%), bloody stool (91%), abdominal mass (57%), fever (32%) and a rectal mass (29%) represented advanced disease: median symptom duration was 3 days (IQR 1–4).Initial reduction attempts included pneumatic reduction (66%) and upfront surgery (32%). The overall non-surgical reduction rate was 28% and enema perforation rate was 4%. Surgery occurred in 334 (70%), 68 (20%) patients had perforated bowel, bowel resection was required in 61%.Complications included recurrence (2%) and nosocomial sepsis (4%). Length of stay (LOS) was significantly longer in patients who developed complications. Six patients died—a mortality rate of 1%. There was a significant difference in reduction rates, upfront surgery, bowel resection, LOS and mortality between centres with shorter symptom duration compared longer symptom duration.ConclusionDelayed presentation was common and associated with low success for enema reduction, higher operative rates, higher rates of bowel resection and increased LOS. Improved primary health-care worker education and streamlining referral pathways might facilitate timely management.

The use of real-time sonography-assisted fracture reduction in children with displaced forearm fractures.

Pediatric forearm and wrist fractures are common; furthermore, some are displaced and require manipulation and reduction. The procedure is commonly performed without real-time image guidance and evaluated radiographically after reduction and casting, leading to multiple reduction attempts and malalignment. Although fluoroscopy can provide real-time assessment of fracture alignment during the procedure, it is not readily available in many emergency departments (EDs) and involves radiation exposure. Ultrasonography is an alternative real-time imaging modality that is inexpensive and readily available. The purpose of this study was to determine whether the use of real-time bedside sonography during closed reduction of distal and middle third forearm fractures can decrease the number of reduction attempts and reduce the number of patients requiring surgery. We compared the results of a conventional blind manipulation, fracture reduction, and casting to fracture reduction under real-time ultrasonographic guidance, in patients treated in our ED between 2014 and 2016. Overall, 458 patients with distal or middle third fractures were included. Of these reductions, 289 were performed without real-time imaging (group 1) and 169 under real-time ultrasound guidance (group 2). In group 1, 10% of patients required re-reduction, and 5% of patients needed surgery. In group 2, only one patient (0.6%) required re-reduction and 1% of patients required surgery due to fracture instability. In conclusion, the current study shows that real-time ultrasound-guided forearm fracture reduction is an effective and inexpensive method for correction of displaced forearm and wrist fractures in children, which does not involve any radiation exposure.

Does the size of Thurston-Holland fragment have an effect on premature physeal closure occurrence in type 2 distal tibia epiphyseal fractures?

The purpose of this study was to investigate the possible effect of Thurston-Holland fragment (THF) size on the development of premature physeal closure (PPC) in distal tibia type 2 epiphyseal injuries. Fifty-eight fractures in 57 patients with a minimum follow-up period of 12 months were included. For statistical analysis, sex and age of the patient, number of reduction attempts, percentage of THF base relative to physis length on anteroposterior or lateral radiograph, maximal initial and postreduction displacement amount, presence of accompanying fibula fracture and trauma mechanism were evaluated. PPC was observed in 12 fractures (20.7%). An increased amount of initial displacement, increased number of reduction attempts and passing the physis with three Kirschner wires were determined as statistically significant factors for PPC occurrence (P = 0.011, 0.011 and 0.005, respectively). The THF percentage was not found to be an important factor for the occurrence of PPC. In males, THF size was less than 50% more frequently than that in females (P = 0.013). THF size had no significant effect on PPC occurrence after distal tibial epiphyseal fractures.

Accuracy of point-of-care ultrasound for determining the adequacy of pediatric forearm fracture reductions

The objective of the present study was to the determine the accuracy of point-of-care ultrasound (POCUS) in assessing closed reduction (CR) of pediatric forearm fractures in a pediatric emergency setting. After determination of the need for CR using X-ray images by an orthopedic consultant, POCUS examinations were performed just before and after the reduction attempt. The transducer was positioned longitudinally over the dorsal, volar, and lateral surfaces of the radius and ulna to view the fracture site. The presence of angulation, displacement, or bayonetting of the fracture fragments was recorded. The adequacy of realignment according to the POCUS and the orthopedic consultant's final determination were recorded. Sixty-two patients were enrolled in the study and 96 bones were evaluated. The sensitivity and specificity of POCUS for adequacy of CR were 95.8% [95% confidence interval (CI): 88.3-99.1)] and 95.8% (95% CI: 78.8-99.8), the positive predictive value was 98.5% (95% CI: 91.0-99.7), and the negative predictive value was 88.4% (95% CI: 71.6-95.8). The corresponding positive and negative likelihood ratios were 23 (3.37-156.77) and 0.04 (0.01-0.12). There was high agreement between POCUS and X-ray images for predicting adequacy of CR [κ: 0.892 (±0.053)]. There was also a significant correlation between POCUS and X-ray measurements of angulation and displacement performed before and after CR, respectively (p < 0.001). Our study has reported the successful use of POCUS for the management of pediatric forearm fractures in a pediatric emergency department. Point-of-care ultrasound can minimize radiation exposure and appears to be an alternative and accurate tool for reduction attempts.

Arthroscopy in Distal Radius Fractures: Indications and When to Do It.

Wrist arthroscopy in the setting of distal radius fractures allows for direct visualization of the articular surface and treatment of associated soft tissue injuries. Arthroscopic techniques may be used to fine tune reductions with residual articular step-off or gap after an initial reduction attempt and are critical for addressing free articular fragments and die-punch lesions. Surgeon training, experience, and comfort with wrist arthroscopy remains a barrier to widespread adoption of this technique. Level I studies are needed to investigate whether improved articular reduction leads to meaningful clinical differences.

Radiofrequency Identification Track for Tray Optimization: An Instrument Utilization Pilot Study in Surgical Oncology

Surgical instrument tray reduction attempts to minimize intraoperative inefficiency and processing costs. Previous reduction methods relied on trained observers manually recording instrument use (i.e. human ethnography), and surgeon and/or staff recall, which are imprecise and inherently limited. We aimed to determine the feasibility of radiofrequency identification (RFID)-based intraoperative instrument tracking as an effective means of instrument reduction. Instrument trays were tagged with unique RFID tags. A RFID reader tracked instruments passing near RFID antennas during 15 breast operations performed by a single surgeon; ethnography was performed concurrently. Instruments without recorded use were eliminated, and 10 additional cases were performed utilizing the reduced tray. Logistic regression was used to estimate odds of instrument use across cases. Cohen's Kappa estimated agreement between RFID and ethnography. Over 15 cases, 37 unique instruments were used (median 23 instruments/case). A mean 0.64 (median=0, range=0-3) new instruments were added per case; odds of instrument use did not change between cases (OR=1.02, 95%CI 1.00-1.05). Over 15 cases, all instruments marked as used by ethnography were recorded by RFID tracking; 7 RFID-tracked instruments were never recorded by ethnography. Tray size was reduced 40%. None of the 25 eliminated instruments were required in 10 subsequent cases. Cohen's Kappa comparing RFID data and ethnography over all cases was 0.82 (95%CI 0.79-0.86), indicating near perfect agreement between methodologies. Intraoperative RFID instrument tracking is a feasible, data-driven method for surgical tray reduction. Overall, RFID tracking represents a scalable, systematic, and efficient method of optimizing instrument supply across procedures.

Physeal Fractures of Distal Tibia: A Systematic Review and Meta-analysis.

Fractures involving the distal tibia growth plate are common in children. Injury or treatment that damages the growth plate may result in progressive angular deformity or leg length discrepancy. There is no consensus on treatment and follow-up of these injuries. This study aims to describe which factors increase the risk of premature physeal closure (PPC). A systematic review and meta-analysis were performed. Altogether 395 articles were reviewed, and ultimately 12 of them were found eligible, comprising 1997 patients. The most usual type of fracture was Salter-Harris (SH) II (n=855, 49%) followed by SH III (n=296, 17%) and SH I (n=261, 15%). The risk of PPC according to number of reduction attempts, method of treatment, and residual displacement was the primary outcome. The total rate of PPC was 13% (n=245). The PPC rate varied from 0.2% to 42% across the studies. Patients with SH IV fractures were most likely to develop PPC (20%), followed by those with SH II (12%) (P<0.05) and repeated (>2) reduction maneuvers were associated with a higher risk of PPC (pooled odds ratio, 8.5; 95% confidence interval, 6.3-12.17; P<0.05). Open reduction was associated with a lower risk of PPC when analyzing only displaced fractures (odds ratio, 0.63; 95% confidence interval, 0.38-0.91; P<0.05). This meta-analysis implies that residual displacement after reduction is the most significant factor in predicting PPC. It seems that open reduction might reduce the PPC rate among patients with dislocated fractures. In addition, there is some evidence that a higher number of reduction attempts correlates positively with the risk of PPC.