Early Surgical Fixation Research Articles

Delayed fixation of distal radial fractures beyond three weeks after initial failed closed reduction increases the odds of reoperation.

We aimed to compare reoperations following distal radial fractures (DRFs) managed with early fixation versus delayed fixation following initial closed reduction (CR). We used administrative databases in Ontario, Canada, to identify DRF patients aged 18 years or older from 2003 to 2016. We used procedural and fee codes within 30 days to determine which patients underwent early fixation (≤ seven days) or delayed fixation following CR. We grouped patients in the delayed group by their time to definitive fixation (eight to 14 days, 15 to 21 days, and 22 to 30 days). We used intervention and diagnostic codes to identify reoperations within two years. We used multivariable regression to compare the association between early versus delayed fixation and reoperation for all patients and stratified by age (18 to 60 years and > 60 years). We identified 14,960 DRF patients, 8,339 (55.7%) of whom underwent early surgical fixation (mean 2.9 days (SD 1.8)). In contrast, 4,042 patients (27.0%) underwent delayed fixation between eight and 14 days (mean 10.2 days (SD 2.2)), 1,892 (12.7%) between 14 and 21 days (mean 17.5 days (SD 1.9)) and 687 (4.6%) > 21 days (mean 24.8 days (SD 2.4)) post-fracture. Patients who underwent delayed fixation > 21 days post-fracture had a higher odds of reoperation (odds ratio (OR) 1.33 (95% CI 1.11 to 1.79) vs early fixation). This worsened for patients aged > 60 years (OR 1.69 (95% CI 1.11 to 2.79)). We found no difference in the odds of reoperation for patients who underwent delayed fixation within eight to 14 or 15 to 21 days post-fracture (vs early fixation). These data suggest that DRF patients with fractures with unacceptable reduction following CR should be managed within three weeks to avoid detrimental outcomes. Prospective studies are required to confirm these findings.

Our Experience with Surgical Treatment of Scaphoid Fractures with Headless Compression Screw

BACKGROUND: Fractures of the scaphoid bone are quite common, and they come with their own set of challenges due to the specific shape of the fractures and the delicate blood supply to the scaphoid bone. Failing to diagnose and treat acute scaphoid fractures promptly can result in failure of the bone to heal and subsequent development of wrist arthritis. Advances in diagnosis, surgery, and implant materials have led to a growing inclination towards early surgical fixation, even for non-displaced scaphoid fractures that could potentially be treated without surgery. AIM: The study's goal was to assess the effectiveness of headless compression screws for treating acute scaphoid fractures and, in two cases, nonunion following previous conservative therapy. METHODS: Between January 2022 and March 2024 ten patients with scaphoid fractures were surgically treated at the University Clinic of Traumatology Skopje, within twelve months follow-up. All of them were male with mean age of 27,3 years. All were diagnosed with X-rays and CT scans. Six of the fractures were on the right hand and four on the left. RESULTS: All the patients were surgically treated with open reduction and internal fixation with headless compression screw. Volar approach was used in 9 cases and dorsal approach in only one of them. Six of the patients were surgically treated within 4-14 days after injury and four of them were surgically treated due to non union after previous conservative treatment, two of them after three and two of them after seven months of injury. All fractures united after a mean time of 9,5 weeks, without secondary displacement. Throughout the follow-up period, there were no incidences of developing osteoarthritis of the wrist. CONCLUSIONS: It is crucial to understand that achieving a positive result is not guaranteed for every patient and relies on selecting the right patients and fractures. However, our study shows favorable results in sooner surgical treatment with the headless compression screw, rather than delayed treatment of scaphoid fractures. Surgical treatment with headless compression screw showed both functional and radiographic results. While it is beneficial for the screw to be positioned in the subchondral area, it is important to be cautious to avoid cortical penetration, as this will require the screw to be removed later.

A Short-Term Study of 18 Cases of Distal Femur Fractures Managed By Locking Compression Plate [Lcp] Using A Less Invasive Skeletal Stabilisation System [LISS

Distal femur fractures have traditionally been the most challenging to treat. Restoring full motion and function to the knee may be challenging due to these fractures' proximity to the knee joint. Regardless of the treatment method, comminution, damage of soft tissue, fracture extension into the knee joint, and related injury to the quadriceps mechanism frequently concludes in suboptimal outcomes. The early surgical fixation notion, increased implant availability, early postoperative knee joint immobilization, and a better understanding of damage patterns have all significantly improved the patient's functional result. Our study focuses on distal femur fractures managed by LCP [locking compression plate] using a less invasive skeletal stabilization system [LISS]. This is a retrospective research of 18 cases of distal femur fractures in adults who had LCP treatment with the LISS. The operation at Saveetha Medical College and Hospital in Chennai runs from January 2021 to January 2022. All types of intercondylar and supracondylar fractures are included. Children's fractures and pathological fractures were not included. Age distribution, side of injury, sex distribution, anatomy of injury, mechanism of injury, damage grading, subtype of fracture, concomitant injuries, and open fractures were the parameters used to assess the cases. AP and lateral views of the X-ray were taken. A thorough preoperative workup was completed. Every case was scheduled for surgery as soon as feasible. External fixators were used in the initial treatment of complicated cases. Patients underwent locking compression plate (LCP) fixation with the LISS. Radiological examination immediately following surgery, four weeks, six weeks, eight weeks, twelve weeks, four months, and every six months for a maximum of one year.The age range of the patients was 21 to 70 years, with a mean age of 30 years. A maximum incidence of fractures was noted in individuals aged 40 to 60. Males accounted for the majority of the 18 cases, with a female-to-male ratio of 3:5. Our series was predominantly right-sided. The most frequent cause of injury has been traffic accidents. Throughout the research period, no patients were lost to follow-up. Of the eighteen cases, the majority involved distal femur fractures, with intercondylar extension accounting for a higher number of cases, and isolated supracondylar fractures following. A head injury was present in one case, and acetabular fracture in another, a Boxer’s fracturein a third case, and 2 open fractures (1 compound grade III A, the other compound grade II). The fractures took an average of 13.3 weeks to heal. It required an average of 15.3 weeks longer in cases of compound fractures. Less than six degrees of malalignment (varus, valgus) were present. Every patient exhibited optimal articular alignment.Excellent outcomes were obtained with the LISS, which combines appropriate physiotherapy with an LCP (angle stable build). In principle, an LCP implant is the best option for fractured and osteoporotic bones. In summary, the use of LCPs in the LISS appears to yield superior outcomes when managing distal femur fractures.

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

Acetabular fractures are complex articular fractures with a big challenge for orthopaedic surgeons. Surgically managed displaced fractures carry favourable outcomes, especially if the articular surface is reduced accurately. This study aims to assess the clinical outcomes of surgically fixed displaced acetabular fractures with central dislocation using combined anterior and medial plating. We have retrospectively evaluated sixteen patients, who had surgically managed displaced 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. 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 ± 7.61. Early reduction and surgical fixation of displaced acetabular fractures with central dislocation using combined anterior and medial plates appear to have good clinical outcomes.

Comparison of Twin Screw Derotation Type Versus Single Helical Blade Type Cephalomedullary Nail in the Management of Unstable Intertrochanteric Fractures.

The intertrochanteric fracture is a frequently occurring fracture, often attributed to osteoporosis in older populations. Recently, there has been a proposal to perform early surgical fixation on elderly patients to facilitate early rehabilitation. This approach has been shown to have a beneficial effect in lowering comorbidities. The study aims to compare the efficacy of the twin screw derotation type cephalomedullary nail with that of the single helical blade type cephalomedullary nail in the management of unstable intertrochanteric fractures. The research sample included patients from the orthopedic outpatient and emergency departments of Adesh Medical College and Hospital,Ambala Cantt, India, who were scheduled for surgery for unstable intertrochanteric femur fractures. The patients were categorized into two groups according to the kind of implant they were given: either a twin screw derotation cephalomedullary nail or a single helical blade cephalomedullary nail. The functional result was evaluated by comparing the modified Harris hip score (HHS). Patients with unstable intertrochanteric fractures, including reverse oblique fractures and fractures with posteromedial comminution, as well as patients who provided consent, were included in this study. Thirteen individuals received treatment with proximal femoral nail antirotation (PFNA2), whereas 19 individuals received treatment with proximal femoral nail (PFN). The mean age in the PFNA2 group was 69.51, whereas the mean age in the PFN group was 70.804. There were three patients in the PFNA2 group and five patients in the PFN group who had a tip apex distance of more than 25 mm. According to the Cleveland index, nine patients in the PFNA2 group and eight patients in the PFN group had an implant location that was not optimum. Four patients in the PFNA2 group and seven patients in the PFN group had a neck shaft angle difference of more than 10° between their undamaged and operated sides. The mean HHS was 74.55 for the PFNA2 group and 69.88 for the PFN group. The PFNA2 group exhibited four problems, whereas the PFN group had five issues. The study found that both implants offer similar functional outcomes, with adherence to specific radiological parameters optimizing results. While both face similar challenges with osteoporosis, there was no notable distinction between them. Notably, the PFNA2 group showed superior outcomes in perioperative morbidity.

The rate of nonunion in the MRI-detected occult scaphoid fracture.

There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion. A total of 1,989 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 256 patients (12.9%) were diagnosed with a previously occult scaphoid fracture. Of the patients with scaphoid fractures, six underwent early surgical fixation (2.3%) and there was a total of 16 cases of delayed or nonunion (6.3%) in the remaining 250 patients treated with cast immobilization. Of the nine nonunions (3.5%), seven underwent surgery (2.7%), one opted for non-surgical treatment, and one failed to attend follow-up. Of the seven delayed unions (2.7%), one (0.4%) was treated with surgery at two months, one (0.4%) did not attend further follow-up, and the remaining five fractures (1.9%) healed after further cast immobilization. All fractures treated with surgery had united at follow-up. There was one complication of surgery (prominent screw requiring removal). MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion of scaphoid fractures diagnosed only after MRI seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. This study adds weight to the evidence base supporting the use of early MRI for these patients.

A Study on Outcome of Conservative Management of Shaft Humerus Fracture: A Case Report.

Conservative or surgical treatment options are available for humeral shaft fractures. To pinpoint individuals who would benefit from early surgical fixation, fracture characteristics were examined. In conservative treatment, the "U" slab prevents displacement, and overriding is corrected by gravity while the patient continues to move about. Rotation is prohibited for 14 days by holding the arm immobile to the chest with the elbow flexed. The preferred course of treatment for fractures of the humeral shaft at all levels is the hanging cast. This study was conducted at Eras Lucknow Medical College and Hospital. Forty patients with Humerus shaft fractures (HSF) who met the inclusion criteria and presented in casualty or outpatient department participated in the study. This prospective cross-sectional study was of 24 months duration. Descriptive statistical analysis was performed to calculate the mean with corresponding standard deviations (s.d.). Test of proportion was used to find the standard normal deviate (Z) to compare the difference. The ratio of male and female (Male: Female) was 3:1. Test of proportion showed that the proportion of males (75.0%) was significantly higher than that of females (25.0%) (Z = 7.07; P < 0.001). Thus, in this study, the males were at higher risk of having fracture shaft of humerus than females. Right-sided fractures (57.5%) were significantly higher than left-sided fractures (42.5%) (Z = 2.12; P = 0.034). About 72.5% of the patients were with disabilities of the arm, shoulder, and hand (DASH) score between 14 and 16 which was significantly higher than other DASH scores (Z = 3.30; P < 0.0001). Our observation regarding this study is that conservative management of HSF can be opted as the most effective way of treatment, and any complications due to any untoward event during the operative treatment should be limited.

USG Guided Lumbosacral Plexus Block for Surgery for Fracture Hip in High-Risk Patients– A Retrospective Case Series

Background 1.6 million patients worldwide are victims of hip fracture. The incidence is expected to rise with ageing of world’s population. Elderly patients with hip fracture pose a medical challenge for the anesthesiologist and are often associated with high incidence of morbidity and mortality. Early surgical fixation of fractured joint is necessary to reduce associated morbidity. Advanced age and delayed surgical correction and medical history are independent factors determining 1 year mortality after hip fixation which is 23.9% in these patients. Objective: In this case series where we share our experience of fracture femur fixation performed under USG guided combined lumbosacral block for 19 patients of ASA 3/4 physical status. Method: Hip fracture fixation was performed under USG guided and neurostimulation technique Lumbar plexus and Para-sacral sciatic nerve block with 20 ml and 15 ml of 0.3% Ropivacaine respectively. All patients were shifted to ICU for further care. Conclusion: USG guided Lumbosacral plexus block for surgeries around the hip joint can be used as a sole anesthetic in high-risk patients. Detailed preoperative evaluation and optimization, vigilant patient selection, counselling, monitoring, providing optimum drug dosage are key for success. Keywords: Lumbosacral plexus block, Hip fracture, USG-guided

Comparative study of functional and radiological outcomes of the usage of two devices, derotation type cephalomedullary nail and the helical blade type in unstable intertrochanteric fractures in the geriatric population at a tertiary-level center

Background: Intertrochanteric fracture is a common osteoporotic fracture among elderly populations in an aging society. Early surgical fixation on these aging patients has been proposed recently for early rehabilitation and has had a positive impact on reducing comorbidities. For unstable fractures, intramedullary implants generally present biomechanical advantages over their extramedullary counterparts. Methods: The study was a 2 years prospective comparative study from 1st December 2020 to 1st December 2022 conducted in the department of orthopaedics, Rajendra institute of medical sciences, Ranchi, Jharkhand, India. Total number of patients were 50, PFN done in 25 cases and PFN-A2 in another 25 cases. Results: Mean age is 64.4 years in PFN group as compared to 67.3 years in PFN-A2 group. PFN-A2 was done in 84% male while PFN in only 76 % male and in both groups right side was mostly affected. Average surgery time, amount of blood loss, average number of C-arm shoot was more in PFN group. Conclusions: In this study of 50 patients, 25 treated by PFN and 25 by PFN-A2, it was concluded that PFN-A2 was a better construct to treat patients of older age group having osteoporosis because here reaming was not done and helical blade was inserted by hammering which caused compaction of bones in head and neck region.

Emergency Sternotomy for Innominate Injury During Percutaneous Tracheostomy: An Argument for Early Surgical Fixation

Rib fractures account for 85% of blunt thoracic trauma and are associated with up to 33% morbidity and 25% mortality. Age, number of rib fractures, and flail segment are associated with poorer outcomes, longer duration of mechanical ventilation and hospital length of stay. Current management standards include locoregional analgesia, supportive ventilation, and physiotherapy. Surgical rib fixation has been shown to reduce morbidity, mortality, duration of mechanical ventilation, rates of tracheostomy, and length of stay in flail rib fractures. Whilst surgical fixation is becoming more popular, patient selection consensus and evidence in multiple and multi-segmental rib fractures is lacking. We present a case of conservatively managed rib fractures resulting in unplanned emergency sternotomy, and advocates for early surgical rib fixation to reduce risks of extended ventilation, tracheostomy, and their inherent complications.

SURGICAL RIB FRACTURE FIXATION IN THE NORTH OF SCOTLAND: EARLY OPERATIVE INTERVENTION IMPROVES OUTCOMES

This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or non-operative management at our center over a six-year time period.Retrospective analysis was performed to identify all patients with complex rib fractures at our center from May 2016 to September 2022. Outcome measures included mechanical ventilation, tracheostomy, pneumonia, and mortality at one year.388 patients with complex rib fractures were identified. 37 (10%) patients fulfilled criteria for surgical management and underwent rib fracture fixation; 351 patients were managed non-operatively with anaesthetic block or analgesia alone. The fixation group had a significantly higher proportion of patients with flail chest (30 (81%) vs 94 (27%), p&lt;0.001) and were significantly more likely to require ICU admission (30 (81%) vs. 16 (5%), p&lt;0.001) than the non-operative group. At one year follow-up, no significant differences were seen for mortality between these groups (1 (3%) vs. 27 (7%), p=0.276).Of the surgical management group, those that underwent fixation &lt;72 hours post injury were significantly less likely to develop pneumonia than those who were delayed &gt;72 hours (2 (18%) vs 15 (58%), p=0.038), with downward trends noted for ICU length of stay (6 vs 10 days, p=0.140) and duration of mechanical ventilation (5 vs 8 days, p=0.177); no significant differences were seen for tracheostomy (3 vs. 5, p=0.588) or mortality (0 vs 1, p=0.856).Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Early surgical fixation led to reduced rates of pneumonia and may improve other outcome measures.

Determining the Key Predictive Factors for Non-Union in Fifth Metatarsal Fractures: A Machine Learning-Based Study

Category: Midfoot/Forefoot; Trauma; Other Introduction/Purpose: Metatarsal fractures account for over 35% of all foot fractures, and of these 68% specifically involve the fifth metatarsal [1],[2]. Subgroups of fractures affecting the fifth metatarsal base may be at higher risk of nonunion and therefore benefit from early surgical fixation, but traditional predictive models focus on the location of the fracture and little else. In this study, we aimed to determine predictive factors associated with non-union of fifth metatarsal fractures to assist surgeons and patients, alike, in identifying those at higher risk of nonunion. Methods: A retrospective machine learning-based analysis of 1,000 patients, &gt;=18 y/o, diagnosed with a fifth metatarsal fracture at three tertiary medical centers was conducted. The fifth metatarsal base fracture was confirmed radiographically. We gathered imaging and narrative data including demographics (age, height, weight, BMI, gender, race, smoking habits, activity level), medications, chronic conditions, and fracture status (fracture zone, displacement, treatment method, healing status, and healing time). Non-union was described as failing to heal within 180 days of initial injury [3]. A machine learning analysis together with Pearson's correlation test and T-test were utilized where applicable. Five imputation methods were used to fill in missing datapoints. P&lt;0.05 was considered statistically significant. Results: Overall, this cohort of patients demonstrated a non-union rate of 22.4%. When divided by fracture zone, Zone 2 fractures results in a statistically significant increased rate of delayed union (17.2%) and non-union (8.6%), when compared to Zone 1 (10.8% and 5.8%, respectively) and Zone 3 (9.7%, 2.3%). Analysis of correlation between demographics data and union rates found no correlation with age, gender, race, or BMI. Our machine learning algorithm outcomes showed a significant correlation between nonunion and seven chronic diseases: diabetes, thyroid disease, hypertension, gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS) obstructive sleep apnea (OSA), and glaucoma. In terms of medications, significant correlation with nonunion was demonstrated with the use of levothyroxine, lisinopril, aspirin, steroids, and acetaminophen. Conclusion: Zone 2 fifth metatarsal base fractures have a significantly higher rate of nonunion as compared to other zones. Comorbid conditions including diabetes, thyroid disease, OSA, and glaucoma as well as medications, may also play a role, though their mechanism or correlative precipitants are yet to be determined. Although our results demonstrated correlation, causality can only be assessed using studies with limited confounding factors, such as clinical trials. Our outcomes suggest that physicians should pay attention not only to the location of the fracture, but also past medical history and medication use when making treatment decisions and discussing prognosis with patients.

Retrospective study of consecutive rib fracture patients treated by open reduction internal fixation in a single major trauma centre, UK.

IntroductionRib fractures are a common presentation in both patients presenting with high impact poly-trauma and as a result of low energy falls in the elderly. This injury can lead to various complications including prolonged hospital admission, pneumonia, need for ventilation and in admission to intensive care unit. There is much controversy around the management of this injury in the literature, with favourable outcomes for patients treated non-operatively as well as surgically. MethodsWe collated a database for all rib fracture fixations between 2014 and 2019 that took place at the major trauma centre in Liverpool. The decision to undergo surgical fixation was after discussion with multidisciplinary team at trauma meeting. Following British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs), these injuries should ideally be operated on within 48 h. ResultsOverall, a total of 220 patients were included in the study (143 male and 77 female). 142 (64%) patients were operated on within 48 h of admission. A total of 101 (45%) patients required admission to ITU. Those in the early surgical fixation group had a statistically significant decrease in their hospital length of stay (12.8 days compared to 15.5 days, p=<0.001). Mean length of ITU stay was shorter in the early surgical group with no statistical significance (p = 0.1). Those patients that required mechanical ventilation in turn stayed in hospital for a longer period compared to those who did not (p=<0.001). There is no statistical difference in survival between the 2 patient groups (p = 0.3). DiscussionTo our knowledge, this is the largest data set published in the rib fracture fixation cohort. Our results agree with previous studies which have demonstrated that those who undergo ORIF tend require fewer days of hospital stay, less ventilatory support and overall have better outcomes in terms of pain when compared to those treated non-operatively. Our study adds that patients who receive treatment within 48-hours as per BOAST guidelines have better outcomes, specifically reducing hospital length of stay by nearly 4 days (p = 0.014). ConclusionEarly surgical fixation of rib fractures leads to significantly favoured outcomes.

A rare paediatric 'floating elbow'; a supracondylar fracture with an ipsilateral Monteggia fracture: A case report.

Introduction and importanceA paediatric floating elbow involves fractures of the supracondylar region of the humerus with ipsilateral fracture of the forearm bones. A floating elbow is very uncommon with an incidence of 3 to 13% of all supracondylar fractures. A concomitant supracondylar and Monteggia fracture is extremely rare with only six cases reported in the literature.Case presentationWe present the unusual case of an eight-year-old girl with a concomitant ipsilateral supracondylar humerus fracture and open Monteggia fracture. Physical examination showed a neurovascularly intact limb. Surgical management was carried out in the form of closed and open reduction, percutaneous pinning using Kirschner (K) wires and Titanium Elastic Nails (TENs), and wound washout and debridement of the open lesion.The patient developed pin site infection six weeks post operation and subsequently underwent surgery for removal of pins. She was later followed up with normal radiographic and physical examination findings.Clinical discussionThe complexity of these fractures can lead to debilitating complications if proper management is not initiated. It is imperative that neurovascular and motor function be assessed in great detail and early surgical fixation be carried out in order to prevent these complications.ConclusionA paediatric floating elbow is a rare surgical emergency. Although no guidelines for the management of these fractures exist, we recommend surgical management in a step-by-step approach be used over conservative management. We also stress the importance of regular follow up to address any post operative complications that may arise such as the one in our case.

Literature review on the management of simultaneous bilateral extracapsular hip fractures in the elderly

Currently, there is a wide awareness of the high degree of functional impairment and morbimortality associated with hip fractures in the elderly, and efforts are being made to improve outcomes. As age rises, physiological reserves decline, and more severe complications occur. Simultaneous bilateral extracapsular hip fractures in the setting of low-energy trauma in the elderly are rare but deserve special attention with treatment strategies that are in between those for unilateral hip fractures and elderly patients with multiple injuries. Adequate initial assessment, a multidisciplinary approach to trauma care, and the integration of medical and orthopaedic surgical attention are paramount. Furthermore, there is a need for early single-stage surgical fixation in medically stable patients and optimization of patients who are unfit. Despite some variations from unilateral cases, the main objective remains to achieve painless hips and stable fixation for early mobilization with the lowest morbidity and mortality rates. General anesthesia for intramedullary nailing using short nonreamed nails for stable fracture patterns and minimal reaming when long nails are used may be regarded as the best option. Physicians should be cautious of the higher risk of complications such as blood loss, fat embolism syndrome, and adult respiratory distress syndrome. Orthogeriatric management and multidisciplinary teams may also improve outcomes, as demonstrated for unilateral hip fractures. Secondary prevention of fractures is promoted through the prescription of antiosteoporotic treatment, nutritional assessment, and skills training. This literature review aims to help optimize the management of patients with simultaneous bilateral extracapsular hip fractures, outlining the differential concerns with respect to unilateral cases.

Shamrock Lumbar Plexus Block for Hip Hemiarthroplasty in a High Risk Elderly Patient with Hip Fracture.

Hip fractures in the geriatric population are associated with high morbidity and mortality rate. Early surgical fixation is of major importance, as it is one of the factors that contribute to patient optimization. However, these patients usually present a high burden of comorbidities, including aortic stenosis that could affect their treatment. Despite major advances in anesthetic and surgical techniques, severe aortic stenosis remains an independent, important risk factor for patients undergoing anesthesia for noncardiac surgery. In these patients, general and/or neuraxial anesthesia should be avoided; peripheral nerve blockade is a viable option. This article presents a 96-year-old hip fracture patient with severe aortic stenosis and aspiration pneumonia that successfully underwent hip hemiarthroplasty under peripheral nerve blockade as sole anesthesia.

Evaluation of Elbow Range of Motion Following Delayed Surgical Fixation of Pediatric Supracondylar Humerus Fractures: A Prospective Study

Introduction: To achieve excellent functional outcome in Pediatric Supracondylar fractures, early surgical fixation is recommended. Unfortunately, there are still some cases which have delayed presentation to the medical health care, leading to delay in appropriate management required for a good functional outcome. We studied the functional outcome, in terms of range of motion following fixation of type III supracondylar fracture of humerus in children presenting 10 days after initial injury. Materials &amp; Methods: This was a prospective study conducted at The Children Hospital and Institute of Child Health, Lahore between February 1st, 2020 and July 30th 2021. Following approval from the Institutional Ethical committee, 44 pediatric patients presenting to the Emergency and outpatient department with initial trauma to affected elbow more than 10 days old with Supracondylar Fracture of Humerus extension type III were admitted and Open Surgical Fixation with K-wires was performed and Half Cast above elbow was applied for 3 weeks. Goniometer was used to measure range of motion of the effected elbow following the removal of half cast on the day of removal of cast, at 1 week, 2 weeks, and then at 2 weekly intervals until 90 % of Range of motion of the contralateral normal elbow was achieved. Results: The mean delay in presentation was 13.20 ± 2.66 days. None of the patients had close manipulation attempted. Mean Hospital stay was 40.20 ± 1.46 hours. It took a mean of 35.25±2.79 and 49.43± 1.21 days to achieve 90% range of motion in extension and flexion (p-value ≤ 0.001). On average extension was achieved earlier than flexion range of motion. Conclusion: Our study showed good functional outcome in terms of elbow flexion and extension in patients managed after delayed presentation of supracondylar humerus fracture but taking longer time to achieve 90% ROM of the normal elbow. Despite delayed presentation being common in our population, it is not associated with increased peri and post-op complications. Because the ROM improves over time, prolonged follow up is all that is required in such patients. Key words: Delayed fixation, Pediatric, Supracondylar Fracture

LUNG HERNIATION: A RARE RESULT OF CPR

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lung herniation as a result of cardiopulmonary resuscitation (CPR) is a rare condition whereby the pleura-covered lung parenchyma protrudes through a defect in the chest wall. CASE PRESENTATION: A 70-year-old male with a history of end stage renal disease on dialysis and heart failure presented to the hospital with three weeks of progressive dyspnea and diagnosed with pulmonary edema. He was started on hemodialysis for volume removal. On hospital day four, the patient developed cardiac arrest, and was found to be in hemorrhagic shock, with massive hemorrhage from his dialysis fistula. The patient underwent high quality chest compressions while receiving standard advanced cardiac life support and a massive transfusion protocol. After return of spontaneous circulation and control of the bleeding, a right chest mass was palpated. Imaging demonstrated multiple consecutive right anterior rib and costochondral junction fractures resulting in flail chest and a large anterior herniation of the lung with an associated moderate hemothorax. A thoracostomy tube was offered as was surgical fixation; however, the patient's family decided to pursue comfort measures. DISCUSSION: Lung herniation is an extremely rare entity first described in association with CPR in 1986. Since then, there have been only seven cases of lung herniation after CPR reported in the literature. Furthermore, an occurrence with chondrosternal disruption is even more uncommon, such as our patient with flail chest. When providing high-quality chest compressions, traumatic injuries to the sternum and ribs is often unavoidable and rate of injury does not vary based on medical training of compressor nor patient factors such as age and gender. However, certain comorbidities place patients at increased risk for traumatic lung herniation including COPD and obesity. Chest tube drainage of associated hemothorax may result in spontaneous reduction of the herniated lung. Otherwise, early surgical fixation should be pursued as it is associated with low morbidity and excellent prognosis. There is no consensus on management with concurrent flail chest. Clinicians should include lung herniation in the differential of a patient with recent chest trauma from CPR, when confronted with worsening respiratory symptoms or worsening ventilatory mechanics, as intervention is necessary. CONCLUSIONS: Lung herniation is a rare phenomenon that may be the result of high-quality CPR, especially in patients with the aforementioned risk factors. We believe the incidence of this thoracic pathology will increase as the at-risk population continues to rise thus emphasizing the importance of clinician recognition of this condition as early surgical fixation may provide a definitive treatment. REFERENCE #1: Batra AK. Lung herniation after CPR. Crit Care Med. 1986;14(6):595-6. doi: 10.1097/00003246-198606000-00022. PMID: 3709206. REFERENCE #2: Deliliga, A., Chatzinikolaou, F., Koutsoukis, D. et al. Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases. BMC Emerg Med 19, 23 (2019). https://doi.org/10.1186/s12873-019-0234-5 REFERENCE #3: Allen GS, Fischer RP. Traumatic lung herniation. Annal Thoracic Surg. 1997;63(5):1455–6. doi: 10.1016/s0003-4975(97)00109-4. DISCLOSURES: No relevant relationships by Andrew Deitchman, source=Web Response No relevant relationships by Jesse Liou, source=Web Response No relevant relationships by John Nawrocki, source=Web Response

Stress Fractures of the Foot and Ankle

Stress fractures are relatively unique to the athletic population with up to 98.5% of all stress fractures occurring in the athletic population. However, stress fractures are a rare entity even in the athletic population, yet they can have a high morbidity. Stress fractures are the result of repeated submaximal loads without adequate recovery time or inadequate biologic repair. Multiple factors contribute to the etiology of these injuries including type and frequency of activity, shoe wear, playing surface, vascular supply, osseous anatomy and alignment, and endocrine abnormalities. Most stress fractures of the foot and ankle can successfully be treated nonoperatively with nonweightbearing for 4-6 weeks with provisions for early range of motion and progressive return to weightbearing in a fracture boot. Base of the fifth metatarsal, navicular and medial malleolus stress fractures have a higher risk of displacement, malunion, nonunion or delayed union and should be considered for early surgical fixation in the athlete to limit time away from play and ensure timely healing. Adjuvants to treatment including vitamin D and calcium supplementation, daily bone stimulator, and biweekly shockwave therapy should be used liberally in the athletic population if feasible. Early diagnosis and treatment can decrease the time away from activity, thus a high index of suspicion is critical in this population. Advanced diagnostic imaging should be used liberally in athletes to identify these injuries early. The following chapter will discuss the etiology, epidemiology, presentation, and management of specific stress fractures of the foot and ankle as they pertain to the athlete.

Cost-effectiveness of surgery versus cast immobilization for adults with a bicortical fracture of the scaphoid waist

The aim of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was to determine the optimal treatment for adults with a bicortical undisplaced or minimally displaced fracture of the waist of the scaphoid, comparing early surgical fixation with initial cast immobilization, with immediate fixation being offered to patients with nonunion. A cost-effectiveness analysis was conducted to assess the relative merits of these forms of treatment. The differences in costs to the healthcare system and quality-adjusted life years (QALYs) of the patients over the one-year follow-up of the trial in the two treatment arms were estimated using regression analysis. Our base case analysis found that patients randomized to early surgical fixation had statistically significantly higher mean costs to the NHS of £1,295 more than for the cast immobilization arm (p < 0.001), primarily due to the cost of surgery. They also had a marginally better quality of life, over the period, of 0.0158 QALYs; however, this was not statistically significant (p = 0.379). The mean combined cost per additional QALY was £81,962, well above the accepted threshold for cost-effectiveness used in the UK and internationally. The probability of early surgery being cost-effective in this setting was only 5.6%. Consistent with the clinical findings of SWIFFT, these results indicate that initial cast immobilization of minimally displaced scaphoid fractures, with immediate fixation only offered to patients with nonunion, is the optimal form of treatment, resulting in comparable outcomes with less cost to the healthcare system. Cite this article: Bone Joint J2021;103-B(7):1277-1283.