Early Fracture Fixation Research Articles

Early external fixation of tibial plateau fractures is associated with an increased risk of compartment syndrome

IntroductionTibial plateau fractures are often associated with high-energy trauma necessitating external fixation as a means of temporization. There is evidence that pin placement and fracture distraction may result in transient increases in compartment pressures, and the optimal timing of external fixator placement is unknown. This study sought to determine the effect of early versus late external fixator placement on the risk of compartment syndrome after a tibial plateau fracture. MethodsThe Trauma Quality Improvement Program was retrospectively queried between 2015 and 2019 for adult patients with a tibial plateau fracture who underwent external fixator placement. Patients with concomitant tibial shaft and/or distal femur fractures, requiring lower extremity fasciotomy before external fixation, or external fixation >7 days after admission were excluded. The primary study outcome was inpatient compartment syndrome. Secondary outcomes were inpatient acute respiratory failure/unplanned intubation, surgical site infection, and venous thromboembolism (VTE). A time threshold of delayed external fixation was identified at which the odds of compartment syndrome no longer significantly decreased with increasing time using a Markov Chain Monte Carlo simulation of a restricted cubic spline model. The odds of each outcome were compared between patients who underwent early versus delayed external fixation on or after the time threshold, adjusting for potential confounding by patients, injury, and hospital characteristics. Significance was defined as p < 0.05. ResultsA threshold for delayed external fixation was identified at 28.8 h from admission. Of the 3,185 eligible patients, 2,656 (83.4 %) were classified as early external fixation and 529 (16.6 %) were classified as delayed external fixation. Delayed external fixation was associated with lower adjusted odds (aOR) of compartment syndrome (aOR: 0.31, 95 % Confidence Interval (CI): 0.13–0.74, p = 0.008) and higher aOR of acute respiratory failure/unplanned intubation (aOR: 2.13, 95 % CI: 1.13–4.0.2, p = 0.019), however no significant differences in adjusted odds of surgical site infection or VTE were observed. ConclusionPatients with tibial plateau fractures who underwent closed reduction and external fixation within 28.8 h of admission were associated with greater odds of compartment syndrome than those undergoing external fixation after this time threshold.

Clinical outcome of surgically treated displaced acetabular fractures with central dislocation using combined anterior and medial plating

&amp;lt;p&amp;gt;&amp;lt;strong&amp;gt;Aim &amp;lt;/strong&amp;gt;Acetabular fractures are complex articular fractures with a big challenge for orthopaedic surgeons. Surgically managed displaced fractures carry favorable outcomes, especially if the articular surface is reduced accurately. This study aims to assess the clinical outcomes of surgical-ly fixed displaced acetabular fractures with central dislocation using combined anterior and medial plating.&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Methods &amp;lt;/strong&amp;gt;We have retrospectively evaluated sixteen patients, who had surgically managed dis-placed acetabular fractures with central dislocation at our institute. All patients underwent open reduction and internal fixation using combined anterior and medial plating via the Kocher-Langenbeck, the ilioinguinal, or the Stoppa approach. The functional outcome was assessed using the Harris Hip score.&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Results &amp;lt;/strong&amp;gt;Our study includes sixteen patients (12 males, 4 females) with a mean age of 35 years (range: 15-53 years). The mean follow-up was 7.8 years (range: 5-13 years). Functional outcomes were good to excellent in 12 (80%) patients and fair in 3 (20%) patients. At the final follow-up, the solid union had been achieved in all fractures, the mean HHS was 88.84 &amp;amp;plusmn; 7.61.&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Conclusion &amp;lt;/strong&amp;gt;Early reduction and surgical fixation of dis-placed acetabular fractures with central dislocation using combined anterior and medial plates appear to have good clinical outcomes.&amp;lt;/p&amp;gt;

9 Early vs Late Definitive Fixation of Pelvic Ring Fractures in Polytraumatized Patients. a Systematic Review and Meta-Analysis

Abstract Aim The aim of this systematic review is to compare the short-term clinical outcomes between early (EDF) and late definitive fixation (LDF) in polytraumatized patients with pelvic ring fractures (PRF). Method The following databases: Embase, Medline and Cochrane Library were searched until June 2022. Studies comparing EDF and LDF for PRF in polytrauma patients defined as ISS &amp;gt;15 were included. The methodological quality of studies was assessed using the Newcastle Ottawa Scale. Results Out of 869 studies screened, 10 were included in the meta-analysis with a total of 2918 patients. The most common time point used to define EDF was within 24 hours of hospital admission and LDF (&amp;gt;24hr). The most common reasons for LDF were surgeon’s choice, availability of pelvic surgeon and transfer from other hospitals. Our meta-analysis revealed that EDF was associated with a reduced length of hospital stay (WMD=-3.52 days; 95% CI: [-5.43 to -1.62], p&amp;lt;0.0003) and lower incidence of ARDS (RR=0.48; 95% CI: [0.20 to 1.18], p=0.04). No significant association was found in mortality, length of ICU stays, multi-organ failure, sepsis and surgical site infection between EDF and LDF. Conclusions These findings suggest that early definitive fixation may be a safe and viable option with no increased risk of complications and mortality. However, the adequacy of resuscitation and the estimate of physiologic reserve should be balanced with the risks of operative fixation in all patients. Further prospective validation studies are warranted to test the predictive ability of the various proposed trauma care models and stratify patients for EDF.

Fat Embolism Syndrome: A Rare Case Report

Background: Fat embolism syndrome (FES) is a life-threatening complication in patients with orthopedic trauma, especially long bone fractures. The diagnosis of fat embolism is made by clinical features alone with no specific laboratory findings. FES has no specific treatment and requires supportive care, although it can be prevented by early fixation of bone fractures. Here, we report a case of FES in a patient with a right closed femoral fractrure severe comminutive, which was diagnosed initially by Gurd’s criteria and subsequently confirmed by typical appearances on Magnetic Resonance Imaging (MRI) of the brain. The most important for fat embolism syndrome management is divided two-fold: preventative and supportive. Patient: A 43-year-old male fell from a high-rise building approximately 3 days before admission. A deformity was observed on the right thigh and the patient felt intense pain. After a few hours, the patient became weak and experienced a loss of consciousness. He was diagnosed with Fat Embolism Syndrome (FES) by using Gurd’s criteria. The diagnosis was confirmed after excluding other diagnoses with similar clinical presentation.

Early vs Late Fixation of Extremity Fractures Among Adults With Traumatic Brain Injury

The optimal timing for fixation of extremity fractures after traumatic brain injury (TBI) remains controversial. To investigate whether patients who underwent extremity fixation within 24 hours of TBI experienced worse outcomes than those who had the procedure 24 hours or more after TBI. This cohort study used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Patients 16 years or older with TBI who underwent internal extremity fixation met inclusion criteria. To compare outcomes, patients who underwent the procedure within 24 hours were propensity score matched with those who underwent it 24 hours or later. Patients were treated from December 9, 2014, to December 17, 2017. Data analysis was conducted between August 1, 2022, and December 25, 2023. The primary outcome was an unfavorable functional status at 6 months (Glasgow Outcome Scale-Extended [GOSE] score ≤4). A total of 253 patients were included in this study. The median age was 41 (IQR, 27-57) years, and 184 patients (72.7%) were male. The median Injury Severity Score (ISS) was 41 (IQR, 27-49). Approximately half of the patients (122 [48.2%]) had a mild TBI while 120 (47.4%) had moderate to severe TBI. Seventy-four patients (29.2%) underwent an internal extremity fixation within 24 hours, while 179 (70.8%) had the procedure 24 hours or later. At 6 months, 86 patients (34.0%) had an unfavorable functional outcome. After propensity score matching, there were no statistically significant differences in unfavorable functional outcomes at 6 months (odds ratio [OR], 1.12 [95% CI, 0.51-1.99]; P = .77) in patients with TBI of any severity. Similar results were observed in patients with mild TBI (OR, 0.71 [95% CI, 0.22-2.29]; P = .56) and moderate to severe TBI (OR, 1.08 [95% CI, 0.32-3.70]; P = .90). The outcomes of extremity fracture fixation performed within 24 hours after TBI appear not to be worse than those of procedures performed 24 hours or later. This finding suggests that early fixation after TBI could be considered in patients with mild head injuries.

Damage-control orthopedics or early total care: What you need to know.

Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.

A novel degradable PCL/PLLA strapping band for internal fixation of fracture

Early fracture fixation is the critical factor in fracture healing. Common internal fracture implants are made of metallic materials, which often affects the imaging quality of CT and MRI. Most patients will choose secondary surgery to remove the internal fixation implants, which causes secondary damage to them. The development of new degradable internal fracture implants has attracted more and more attention from orthopedic surgeons and researchers. Based on these problems, we improved the various properties of medical grade polycaprolactone (PCL) by adding poly(L-lactide) (PLLA). We produced PCL/PLLA strapping bands with different mass ratios by injection molding. We compared the mechanical properties, degradation properties, cell biocompatibility, bone marrow mesenchymal stem cells (BMSCs) adhesion, proliferation, osteogenic differentiation and fracture fixation effect of these strapping bands. The results showed that the tensile strength and yield force of the strapping bands increased with the increase of the content of PLLA. The addition of PLLA could significantly improve the mechanical strength in the early stage and accelerate the degradation rate of the strapping band. PCL/PLLA (80/20) strapping band had no significant cytotoxicity toward rBMSCs and could promote osteogenic differentiation of rBMSCs. The strapping band could ensure femoral fracture healing of beagles in 3 months and didn’t cause damage to the surrounding tissues and main organs. This study will provide some new insights into the biodegradable products of PCL/PLLA blends for internal fixation of fracture.Graphical We produced novel degradable PCL/PLLA strapping bands with different mass ratios by injection molding. We tested the biological safety of the prepared internal fixation strapping bands for fracture, such as cell experiment in vitro and animal experiment, and studied the degradation behavior in vitro. The strapping bands could ensure femoral fracture healing of beagles. This study will provide some new insights into the biodegradable products of PCL/PLLA blends for internal fixation of fracture. A Immunofluorescence staining of rBMSCs (live cells: green; dead cells: red). B Young’s modulus change curve during strapping bands degradation. C The implantation process of strapping bands. D Micro-CT images of the beagle’s fracture recovery after the operation.

Simple parameters to identify patients treatable with early definitive fixation: A nationwide study

IntroductionEarly appropriate care (EAC) is widely accepted as a safe strategy to perform early definitive fracture fixation, and good clinical outcomes have been reported in selected, multiply injured patients, although the optimal candidate for early definitive fixation (EDF) has not been validated. The aim of this study was to identify simple clinical parameters to help select patients who could undergo EDF. MethodsPatients with extremity injuries who underwent open reduction and internal fixation were retrospectively identified, using data from the Japan Trauma Data Bank (JTDB). Age, vital signs on hospital presentation, and the injury severity score (ISS) were examined by transforming these variables to binary categories. Patients were divided into categories based on these variables, and in-hospital mortality was compared between patients treated with EDF (EDF group) and those treated without EDF (non-EDF group) in each category. ResultsOf the 12,735 patients who were eligible for the analyses, 3706 (29.1 %) were managed with EDF. In-hospital mortality was significantly higher in the EDF group than in the non-EDF group among patients with a low Glasgow Coma Scale (GCS) score (<13), low systolic blood pressure (sBP) (<90 mmHg), and ISS≥15, whereas in-hospital mortality was comparable between the EDF and non-EDF groups among patients with GCS scores ≥13, sBP ≥90 mmHg, and ISS <15. DiscussionIn this large nationwide database of trauma patients, EDF was performed without affecting mortality in patients with GCS scores ≥13 and sBP ≥90 mmHg on hospital presentation, as well as ISS <15. These parameters might be useful as screening tools to select the candidates who could be treated with EDF safely.

DAMAGE CONTROL IN ORTHOPEDICS

Introduction: DAMAGE CONTROL - in orthopedic surgery and traumatology, it is indicated for fresh fractures, especially for trauma with open bone fractures. In all these fresh fractures, hemodynamic instability of the body occurs. In these cases, a minimally invasive procedure is recommended, which initially aims to temporarily stabilize the fractures and control bleeding Material and methods: In our work, we will present the official literature that deals with the issue of damage control in orthopedics. Discussion: One of the leading causes of death in people under 40 is polytrauma. Fractures of the diaphysis of the tibia, femur, and pelvis are the most common fractures that are stabilized using external fixation. Bilateral fractures of the femoral diaphysis are associated with a poor prognosis in terms of mortality and fat embolism syndrome.Hemodynamically stable patients should always undergo definitive fracture fixation. Any prolonged intervention in hemodynamically unstable patients worsens the favorable outcome. Then the immune response can be triggered and increased, which is identified with the clinical condition “Second trauma”. Therefore, these patients should be immediately subjected to DAMAGE CONTROL with temporary stabilization and then delayed definitive fixation for a period of 5-10 days from damage control, i.e. in the second act. Orthopedic surgeons should be very careful and recognize the triangle of death - acidosis, hypothermia and coagulopathy, which are interconnected and eventually become irreversible and lead to death as the final outcome. Damage control surgery in orthopedics includes three stages: the first stage of treatment involves controlling bleeding, reducing contamination, and achieving temporary fracture fixation. The time in which all this is done should be as short as 1-2 hours. The second phase involves the stabilization of vital parameters in the ICU as well as the reanimation of the child with the prescription of the necessary therapy as well as blood replacement The aim: The aim of our work is to demonstrate the outcome and feasibility of damage control in orthopedic surgery for both adults and children with multiple limb injuries and polytraumatized patients Conclusion: Polytrauma is a condition of the body that requires immediate action and a special approach because the patient’s life is at risk in a high percentage. The principles used to manage patients with multiple injuries including head, lower leg. Early fracture fixation led to earlier mobilization of patients and thus And reduced the percentage of complications, wound infections as well as reducing treatment costs. DAMAGE CONTROL is not only used in traumatized adult patients. It is also necessary to do it in children’s patients.

Clearing of Polytrauma Patients for Early Definitive Fracture Fixation: A Systematic Literature Review

Abstract Background Early patient assessment is important for surgical decision making in severely injured patients. Moreover it is known that early fracture fixation is beneficial, such as those in stable condition or those who respond well to resuscitation. Aims The aim of this systematic review is to identify parameters that indicate risk factors for an unfavorable outcome and early complications. In addition, we aim to improve decision making and separate patients who would benefit from early versus staged definitive surgical fixation. Methods A systematic review was performed of peer-reviewed articles in English or German published between January 1, 2000, and May 15 2022 (PUBMED) according to PRISMA guidelines. The primary outcome was the pathophysiologic response to polytrauma, including coagulopathy, shock/hemorrhage, hypothermia, and soft tissue injury to determine the treatment strategy with the least number of complications. Articles that had used quantitative parameters to distinguish between stable and unstable patients were combined. Results The initial systematic search for MeSH criteria yielded 1550 publications deemed relevant to the following topics (coagulopathy (n = 37), hemorrhage/shock (n = 7), hypothermia (n = 11), soft tissue injury (n = 24)). Thresholds for stable, borderline, unstable, and in extremis conditions were defined according to the existing literature as follows: Coagulopathy; International Normalized Ratio (INR) and viscoelastic methods (VEM)/blood/shock; lactate, systolic blood pressure and hemoglobin, hypothermia; thresholds in degrees Celsius/soft tissue trauma: traumatic brain injury, thoracic and abdominal trauma, and musculoskeletal trauma. Conclusions In this systematic literature review, we summarize the publications by focusing on the different pathways that stimulate pathophysiologic cascades and distant organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients.

The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial

IntroductionMultiple rib fractures (≥ 3 displaced rib fractures and/or flail chest) are severe chest trauma with high morbidity and mortality. Rib fixation has become the first choice for multiple rib fracture treatment. However, the timing of surgical rib fixation is unclear.Materials and methodsThe present study explored whether early rib fracture fixation can improve the outcome of multiple rib fractures. The present research included patients who were hospitalized in three Jiangsu hospitals following diagnosis with multiple rib fractures. Patients received early rib fracture fixation (≤ 48 h) or delayed rib fracture fixation (> 48 h) utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures included hospital length of stay, intensive care unit (ICU) stay, mechanical ventilation, inflammatory cytokine levels, infection marker levels, infection, and mortality.ResultsA total of 403 individuals were classified into two groups, namely, the early group (n = 201) and the delayed group (n = 202). Patients belonging to the two groups had similar baseline clinical data, and there were no statistically significant differences between them. Early rib fracture fixation greatly decreased the length of stay in the ICU (4.63 days vs. 6.72 days, p < 0.001), overall hospital stay (10.15 days vs. 12.43 days, p < 0.001), ventilation days (3.67 days vs. 4.55 days, p < 0.001), and hospitalization cost (6900 USD vs. 7600 USD, p = 0.008). Early rib fracture fixation can decrease inflammatory cytokine levels and infection marker levels, prevent hyperinflammation and improve infection in patients with multiple rib fractures. The timing of rib fracture fixation does not influence the surgical procedure time, operative blood loss, 30-day all-cause mortality, or surgical site infection.ConclusionThe findings from the present research indicated that early rib fracture fixation (≤ 48 h) is a safe, rational, effective and economical strategy and worth clinical promotion.

Rib Plating Outcomes in Elderly Trauma Patients With Multiple Rib Fractures: A Community Hospital Experience.

Rib fractures in the elderly are one of the most common injuries in trauma patients admitted to the hospital, accounting for over 350,000 patients annually in the United States. Rib plating has been shown to be most beneficial among certain populations. Early surgical intervention is important to utilize approaches that limit the use of pain medications. This is a retrospective data analysis to determine the efficacy of rib plating in elderly trauma patients with rib fractures. A total of 253 patients were seen with rib fractures, 63% were male and 37% were female. The mean age is 64 ± 18.5years. Of these patients analyzed, 76% had an associated comorbid condition. A majority of patients (95%) presented to the emergency department (ED) with mild GCS range (13-15). Moderate GCS range (9-12) was 4%, and 3% of patients were with severe GCS (3-8.) The mean ISS was 10. The overall mortality rate was 4.5%. Patients were divided into 2 groups: group I consisted of patients who received open reduction and fixation of the fractured ribs, and group II was patients managed conservatively without surgery. Statistical analyses using Student's t-test and Chi-square test were performed. Institutional Review Board approval was obtained for this study. Rib plating in elderly trauma patients with multiple rib fractures has shown to be beneficial in terms of mortality. Furthermore, geriatric patients with comorbidities will benefit from early open reduction and fixation of rib fractures, though a larger study is needed to establish clearer criteria for rib plating.

Early internal fixation of open ankle malleolar fractures is not associated with increased complications: case control study

The timing of definitive fixation of open ankle malleolar fractures is still controversial. This study intended to evaluate the outcome of patients who were managed by immediate definitive fixation in comparison to delayed definitive fixation following open ankle malleolar fractures. This was an IRB approved retrospective case control study of 32 patients who were treated with open reduction and internal fixation (ORIF) for open ankle malleolar fractures at our Level I trauma center 2011-2018. Patients were divided into 2 groups; immediate ORIF group (within 24 hours) and delayed ORIF group (first stage included debridement and external fixator or splinting followed by second stage of delayed ORIF). Outcomes assessed were postoperative complications (wound healing, infection, nonunion). Logistic regression models were used to access the unadjusted and adjusted associations between post- operative complications and selected co factors. The immediate definitive fixation group included 22 patients while the delayed staged fixation group included 10 patients. Gustilo type II and III open fractures were associated with higher complications rate (p-value = 0.012) in both groups. Comparing the 2 groups, There was no increase in complication in the immediate fixation group compared to the delayed group. Complications following open ankle malleolar fractures are usually associated with Gustilo type II and III open fractures. Immediate definitive fixation after adequate debridement was not found to increase complication rate compared to staged management.

A comparison of early fixation of distal radius fractures versus late corrective osteotomy of distal radius malunion.

Fractures of the distal radius are common. Closed reduction and moulded casting is often the first line treatment. Malunion after casting is not uncommon and can lead to discussion on acute surgical fixation versus delayed corrective osteotomy if symptomatic. However, it is unclear if late surgery will provide similar outcomes as early intervention. We performed a single centre, age matched, case series comparison study, comparing outcomes of patients who had undergone early fixation (ORIF) versus those who had undergone late corrective osteotomy (CO) following distal radius fracture. Twenty-six patients were available for review, 13 in each group. Fracture patterns were similar. Reviewing CO versus ORIF; patients achieved a mean DASH; 22 versus 18 (P= 0.355), PRWE; 35 versus 26 (P= 0.237), and VAS 2 versus 2 (P= 0.490). Grip strength was significantly better in those who had undergone ORIF; 2% versus -22% (P ≤ 0.001). Range of motion was generally better with primary fixation but of doubtful clinical importance, reviewing CO versus ORIF; Flexion 46° versus 60° (P= 0.045), extension 55° versus 64° (P= 0.137), pronation 73° versus 85° (P= 0.078), supination 84° versus 84° (P= 0.747), flexion/extension arc 101 versus 124 (P= 0.017), ulnar/radial deviation arc 42° versus 59° (P= 0.01), pronation/supination arc 157° versus 168° (P= 0.118). Ulnar variance was significantly improved in the ORIF group; +0.5 mm versus +2 mm in the CO group (P= 0.023). Radial inclination, radial height and volar tilt were not significantly different between either group. Our findings suggest that patient measured outcome of corrective osteotomy is not inferior to early internal fixation. III (Case Series Comparison).

Standing oral surgery for the management of mandible and maxilla fractures in horses: a case series of 15 horses

Fractures of the mandible and maxilla are common in horses. The present study was conducted on fifteen horses referred for the management of mandible or maxilla fractures. Fixation methods were used to repair the fractures in these horses, including tension band and cerclage wires, dynamic compression plates, and lag screw fixation. All procedures were performed under chemical restraint and regional nerve block anesthesia in the standing position. According to the results, the long term follow-up of the horses was satisfactory, and no severe complications were observed. Jaw fractures are most successfully treated by early diagnosis and fracture fixation. The surgical management of most oral region injuries may be readily performed in the standing position, to avoid the risks associated with general anesthesia in horses.

Parkland Trauma Index of Mortality: Real-Time Predictive Model for Trauma Patients.

Vital signs and laboratory values are used to guide decisions to use damage control techniques in lieu of early definitive fracture fixation. Previous models attempted to predict mortality risk but have limited utility. There is a need for a dynamic model that captures evolving physiologic changes during a trauma patient's hospital course. The Parkland Trauma Index of Mortality (PTIM) is a machine learning algorithm that uses electronic medical record data to predict mortality within 48 hours during the first 3 days of hospitalization. It updates every hour, recalculating as physiology changes. The model was developed using 1935 trauma patient encounters from 2009 to 2014 and validated on 516 patient encounters from 2015 to 2016. Model performance was evaluated statistically. Data were collected retrospectively on its performance after 1 year of clinical use. In the validation data set, PTIM accurately predicted 52 of the sixty-three 12-hour time intervals within 48 hours of mortality, for sensitivity of 82.5% [95% confidence interval (CI), 73.1%-91.9%]. The specificity was 93.6% (95% CI, 92.5%-94.8%), and the positive predictive value (PPV) was 32.5% (95% CI, 25.2%-39.7%). PTIM predicted survival for 1608 time intervals and was incorrect only 11 times, yielding a negative predictive value of 99.3% (95% CI, 98.9%-99.7%). The area under the curve of the receiver operating characteristic curve was 0.94.During the first year of clinical use, when used in 776 patients, the last PTIM score accurately predicted 20 of the twenty-three 12-hour time intervals within 48 hours of mortality, for sensitivity of 86.9% (95% CI, 73%-100%). The specificity was 94.7% (95% CI, 93%-96%), and the positive predictive value was 33.3% (95% CI, 21.4%-45%). The model predicted survival for 716 time intervals and was incorrect 3 times, yielding a negative predictive value of 99.6% (95% CI, 99.1%-100%). The area under the curve of the receiver operating characteristic curve was 0.97. By adapting with the patient's physiologic response to trauma and relying on electronic medical record data alone, the PTIM overcomes many of the limitations of previous models. It may help inform decision-making for trauma patients early in their hospitalization. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Diaphyseal Femoral Fracture Fixation: Outcome of 108 Consecutive Fixations in a Tertiary Hospital

Background: femoral shaft fractures are common orthopaedic problems and usually result from high energy impact with increased risk of associated injuries. Though global trend is moving towards early and effective fixation of fractures using options that cause minimal disruption of the soft tissue envelope around the fracture site, the practice in countries with weak health systems may vary from standard as predicted by available resources and skill. Aim: we present the outcome of surgical fixation of 108 femoral shaft fractures within a three year period. Method: Patients who meet inclusion criteria were recruited into the study after consent was obtained. Data was analyzed using SPSS 17 for windows and results were presented in frequency tables. Graphs and charts. Result: Femoral shaft fractures represents 3.8% of the total number of patients with orthopaedic conditions within study centre at the period of the study. The mean age was 31.2± 14.7 years with a M:F ratio of 2.1:1. There were more closed fractures (97; 89.2%) than open fractures (11, 10.8%) with transverse fractures being the most common fracture pattern (50.5%, n=46/108). Most fractures were treated by open reduction and locked intramedullary nailing (78/108, 72.5%) with bone union rates of 75% and 96% at 12weeks and 18 weeks post intervention respectively. There was no statistically significant difference in the union rate between the interlocking group and the plating group at both 12 weeks and 18 weeks post intervention (p=0.24). Bone infection, non-union and mal-union rates were 1.8% (n=2/108). Conclusion: femoral diaphyseal fractures can be effectively fixed with open locked IM nailing with optimal options are not available.

Fixation of Multiple-Segmented Costosternal Cartilage Fracture in Flail Chest Injury: A Case Report

Early internal fixation of rib fractures in the setting of flail chest has proven benefits over traditional conservative treatment. This can decrease pneumonia, time on mechanical ventilation, length of stay in intensive care units, need for tracheostomy and increase in the pulmonary function test. However, there are few reports regarding on how to restore the costochondral junction, or costal cartilage in cases of anterior or anterolateral flail chest involving cartilage matrix of the ribs or costochondral joint. This case report describes a surgical technique to restore the costochondral junction with plate osteosynthesis and the results.

Fragility fractures of the pelvis in the older population.

Pelvic fractures are an increasingly common injury seen in the older population and represent a significant burden of morbidity and mortality in this age group, as well as a large financial burden on the health service. It is well established that early fixation of femoral neck and acetabular fractures improves outcomes and increases the chances of patients returning close to their premorbid functional baseline. However, fixation of fragility fractures of the pelvis is less well established in current practice. There has been recent development of novel stabilisation techniques for unstable pelvic fractures, designed to tackle the difficulties associated with fixation in poor bone quality, along with medical trials of parathyroid hormone analogue treatment. However, it is still current practice to manage nearly all fragility fractures of the pelvis conservatively. In this article, we consider whether the development of surgical stabilisation techniques for pelvic fragility fractures may have the potential to improve the well-described morbidity and mortality associated with them.

What are the risk factors for complications after combined injury of the pelvic ring and acetabulum?

Combined acetabular and pelvic ring injuries represent a unique subset of pelvic trauma and little is known regarding their complications and outcomes. We sought to further evaluate these injury patterns and quantify their outcomes. A retrospective review at a single level 1 trauma center was performed on all patients with operatively treated combined ring and acetabulum injuries during a seven-year period. Main outcome measurements include all-cause complication including residual neurologic deficit, deep infection, conversion to total hip arthroplasty, deep venous thrombosis and mortality. Seventy operatively treated combined ring and acetabulum patients with one-year follow-up were reviewed. The overall complication rate was 44%. Hip dislocation occurred in 40% of the cohort and was significantly associated with residual neurologic deficit and all-cause complication. Angiography with embolization was not associated with an increased rate of deep infection. Open acetabular approaches had a significantly higher complication rate compared to percutaneous procedures. Delay to definitive fixation greater than 36h trended toward but did not reach association with all complications. Combined injuries to the acetabulum and pelvic ring have high rates of complications. No individual fracture patterns were identified as risk factors, but hip dislocation was associated with an increased rate of complications. When possible, percutaneous reduction and fixation of acetabular fractures and early definitive fracture fixation lead to lower rates of complications. Use of angiography with embolization appears to be safe and does not increase the risk of infection or other complications.