Extremity Fractures In Patients Research Articles

From Bench to Bedside: Our Patients Want to Move, So Why Are We Slowing Them Down?

Both TKA and THA, which were once managed with inpatient admission of days to more than one week, have been safely transitioned to outpatient or overnight procedures [9]. This is but one example of the benefits of accelerated rehabilitation. Compelling evidence exists that early motion is less restrictive and generally leads to the same or often better outcomes following elbow injuries and surgery [13], Achilles’ tendon ruptures treated either operatively or nonoperatively [1, 2], and proximal humerus fractures [5]. The obvious retort or rebuttal is that early motion may lead to complications, implying that we, as surgeons, would rather treat (or more commonly ignore and write off to a natural sequelae) a stiff, healed injury than a reinjury or treatment complication. But is it really true that early motion leads to increased complications? The answer seems simply to be “no.” While this is not an all-encompassing review article, there are many (many) studies demonstrating that early motion is beneficial, whereas I did not find any recent articles suggesting that early motion was harmful or associated with inferior outcomes. The same can be said for early, permissive weightbearing on many fractures. Early weightbearing appears to be safe, resulting in no increase in complications such as loss of fixation or articular collapse, and yield equivalent or better patient-reported outcomes for everything from ankle fractures [11], to tibial plateau fractures [3], to geriatric hip fractures [7, 8]. Taking a closer look at the latter case of hip fractures, patients older than 65 years of age generally have worse mobility scores in the setting of (attempted) weightbearing restrictions [8], worse outcomes (including mortality) without early mobilization and weightbearing [7], and are unable to follow weightbearing restrictions even when they are imposed or recommended [4, 8]. All of this raises the question: If our patients want to move and are better for it, why are we so slow to adapt and let them? There is evidence suggesting that is exactly what we are doing for both motion and weightbearing. One survey study noted that nearly 40% of low-volume surgeons (and over 20% of high-volume surgeons) still delayed weightbearing after ACL reconstruction, with very similar proportions for delays in permitting full ROM [6]. Another survey of 702 surgeons from both the Orthopaedic Trauma Association and American Orthopaedic Foot & Ankle Society reported wide ranges in time to full weightbearing following ankle fractures [12]. And Ottesen et al. [7] reported that at least 25% of patients with hip fractures were placed on restricted weightbearing status after surgery. I am not at all criticizing the flood of recent studies seeking to demonstrate the equivalence or benefit of early mobilization and/or weightbearing. Rather, I would argue that we need more of them. The ankle fracture survey cited above concluded that there was “reluctance of many practicing surgeons to adopt some of the more aggressive mobilization protocols,” but conceded “there is very little objective guidance for what is most appropriate” [12], although the latter situation has since improved [11]. And one systematic review of pelvic fractures concluded: “A review of postoperative weightbearing regimens reveals a nonexistent scientific evidence base from which to make recommendations” [10]. Still, we can infer a lot from recently published studies and at the very least adapt our own clinical practices to match the existing evidence. Next, (as I am fond of explaining to my patients) making a patient “permissive weightbearing” or “weightbearing as tolerated” does not mean those patients will be able to immediately tolerate full weightbearing. On the contrary, there is evidence that patients will auto-regulate and adapt their weightbearing to match their injury and healing, such as patients with more severe tibial plateau fractures taking longer to achieve full weightbearing than their less severe counterparts [3]. But discrepancies such as this should make us more, not less, comfortable letting our patients attempt do more, sooner. Finally, there are certainly injuries, such as articular, osteoporotic lower extremity fractures in patients with diabetes or neuropathic joints of the ankle and hindfoot, for which surgeons are understandably hesitant to be too aggressive and for which (surprise!) there is to my knowledge no evidence in favor of immediate mobilization and unrestricted weightbearing. And then there are injuries, such as pelvic fractures, for which there is, indeed, a dearth of evidence to guide as and requiring further study. So it seems like we need more research to guide us and help us migrate away from the AO’s “magical 10 to 12 week” timeline for healing, as my colleague Robert O’Toole MD sarcastically likes to call it. But for many injuries, orthopaedic procedures, and fractures, we need to heed the evidence that already exists. Our patients want to move and we have demonstrated that they are better for it when they do. Let’s move with them.

Outpatient lower extremity fracture surgery: should we be concerned?

With rising healthcare costs and insurance push against non-emergent hospital admission, lower extremity fracture treatment is shifting toward outpatient procedures over inpatient hospitalizations. This study compares outcomes for fractures treated as inpatient versus outpatient. We conducted a retrospective review of lower extremity fracture patients. We collected demographics, injury information, hospital course, and complication data. Length of stay was categorized as "inpatient" and "outpatient" based a 24-h hospital stay cutoff. Data analysis included differences between cohorts with regards to readmissions and complications. We identified 229 patients who met inclusion criteria. Inpatient versus outpatient status was predictive of in-hospital complications; however, inpatient versus outpatient status did not predict 1-year readmission. Outpatient surgery is safe and effective. As the population increases and ages, low-risk surgeries should be considered for outpatient rather than inpatient stays to lower costs, save resources, and reduce complications.

The Incidence and Location of Deep Vein Thrombosis in Lower Extremity Fracture Patients Receiving Sequential Chemical Prophylaxis.

To investigate the incidence and location of deep vein thrombosis (DVT) in patients with lower extremity fractures receiving pharmacological thromboprophylaxis with LMWH followed by rivaroxaban. All patients aged ≥18 years with lower extremity fractures were included in the study. Duplex ultrasonography (DUS) was performed in the lower extremities before and after surgery for DVT evaluation. According to the location, the DVT was divided into proximal, distal, and mixed thromboses. According to fracture location, patients were classified as having fractures proximal, around, and distal to the knee. All patients received sequential chemical prophylaxis. A total of 404 patients with a mean age of 44.2 ± 13.8 years were included. The incidence of DVT postoperatively was higher than that preoperatively and at 1 month postoperatively. Patients with fractures proximal and around the knee had higher DVT incidences detected on DUS postoperatively and at 1 month postoperatively. Most DVTs were located in the distal vein. DVT incidence and severity were the highest immediately after surgery. DVT incidence in fractures around and proximal to the knee increased after surgery and at 1 month postoperatively. Although with chemical thromboprophylaxis, distal DVT was the most variable during the early stage.

Nomogram for Predicting Deep Venous Thrombosis in Lower Extremity Fractures.

Deep venous thrombosis (DVT) is a common complication in patients with lower extremity fractures, causing delays in recovery short-term and possible impacts on quality of life long-term. Early prediction and prevention of thrombosis can effectively reduce patient pain while improving outcomes. Although research on the risk factors for thrombosis is prevalent, there is a stark lack of clinical predictive models for DVT occurrence specifically in patients with lower limb fractures. In this study, we aim to propose a new thrombus prediction model for lower extremity fracture patients. Data from 3300 patients with lower limb fractures were collected from Wuhan Union Hospital and Hebei Third Hospital, China. Patients who met our inclusion criteria were divided into a thrombosis and a nonthrombosis group. A multivariate logistic regression analysis was carried out to identify predictors with obvious effects, and the corresponding formulas were used to establish the model. Model performance was evaluated using a discrimination and correction curve. 2662 patients were included in the regression analysis, with 1666 in the thrombosis group and 996 in the nonthrombosis group. Predictive factors included age, Body Mass Index (BMI), fracture-fixation types, energy of impact at the time of injury, blood transfusion during hospitalization, and use of anticoagulant drugs. The discriminative ability of the model was verified using the C-statistic (0.676). For the convenience of clinical use, a score table and nomogram were compiled. Data from two centers were used to establish a novel thrombus prediction model specific for patients with lower limb fractures, with verified predictive ability.

Surgical outcome of upper extremity fractures in patients with Parkinson\u2019s disease

Patients with Idiopathic Parkinson’s Disease (PD) have an increased risk for fractures. Currently, many studies have reported inferior outcomes in PD patients after orthopedic procedures. However, there are very few studies assessing the outcome of upper extremity fractures (UEF) in PD patients. In this study, we reviewed 40 patients with PD that received surgical intervention for an UEF. We retrospectively reviewed patients with PD that received surgical fixation for an UEF at a tertiary trauma center. The primary objective was to determine the treatment failure rate after surgical fixation. The secondary outcomes include mode of failure, time to treatment failure, length of hospital stay, readmission rate, reoperation rate, and postoperative complications. A total of 40 patients with PD (42 fractures) underwent surgery. The most common fracture type was radius fracture (n = 19), followed by humerus fracture (n = 15), metacarpal/phalangeal fracture (n = 5), clavicle fracture (n = 2) and olecranon fracture (n = 1). The overall treatment failure rate was 40.5% (n = 17). The time to treatment failure was 1.24 ± 3.1 months and length of hospital stay was 6 ± 3.9 days, the readmission rate within 30 days was 14% (n = 6), and reoperation rate was 14% (n = 6). The complication rate was 16.6% (n = 7) and patients with humeral fractures appeared to have the longest hospital stays (6.6 days) and increased complication rates (13%, n = 2). Patients with PD have high treatment failure rates despite surgical fixation of an UEF. These patients often have a frail status with multiple comorbidities which may complicate their postoperative course.Level of evidence level 4 case series.

Tourniquet use for extremity fractures has no adverse effect on number of ventilator days for patients who are treated with reamed femoral or tibial shaft nails

IntroductionConcern exists regarding the pulmonary effects of using tourniquets for secondary extremity fractures in patients also undergoing intramedullary nail (IMN) fixation of femoral or tibial shaft fractures. Our hypothesis was that tourniquet use would be associated with increased ventilator days. MethodsAt a Level I trauma center, we conducted a retrospective review of 1966 patients with 2018 fractures (1070 femoral shaft and 948 tibial shaft) treated with IMN from December 2006 to September 2014. Medical record review and bivariate and multiple variable regression analyses were conducted, and the main outcome measurement was number of ventilator days. ResultsNo statistically significant negative association was found between use of a tourniquet and number of ventilator days in the femoral or tibial fracture group. Use of tourniquets in the upper extremities showed a statistically significant decrease in amount of ventilator days in the femoral group (−2.2 days, p = 0.003) but no association in the tibial group (1.1 days, p = 0.36). Use of tourniquets concurrently in both upper and lower extremities of both femoral and tibial groups also had a protective effect (−6.8 days, p < 0.001 and −2.3 days, p = 0.009, respectively). Stratified and sensitivity analyses (to account for effects of mortality and missing data) showed consistently similar results. ConclusionTourniquet use for secondary extremity fractures, in patients also undergoing IMN fixation for femoral or tibial shaft fractures, was not associated with an increased number of ventilator days. A potential protective effect of tourniquet use was shown in patients with upper extremity fractures and in those with both upper and lower extremity fractures. Level of evidenceTherapeutic Level III (Retrospective cohort study).

Transition From Acute to Chronic Pain in Lower Extremity Fracture Patients: A Pain Phenotyping Protocol.

Traumatic injury is a major source of chronic pain, particularly for individuals with traumatic fracture of the fibula and/or tibia (lower extremity fracture [LEFx]). Although several factors (e.g., older age, being female, high pain intensity at time of initial injury) have been identified as risk factors for chronic pain associated with LEFx. Comprehensive biopsychosical models to predict the odds of transitioning from acute to chronic pain after LEFx are needed to better understand the underlying processes, predict risk for chronic pain, and develop personalized therapies for individuals at higher risk for developing chronic pain. The aim of the study was to outline the study design that will be used to examine the physiological, psychological, and genetic/genomic variables-models that predict the transition from acute to chronic pain after LEFx. This prospective descriptive cohort study will enroll 240 participants with a fibula and/or tibia fracture and 40 controls with no LEFx. Data will be collected during an in-hospital baseline visit, five in-person clinic visits (6 weeks, 12 weeks, 24 weeks, 52 weeks, and 24 months), and seven online between-visit surveys (2 weeks, 4 weeks, 8 weeks, 10 weeks, 16 weeks, 20 weeks, and 18 months) from participants with LEFx and at concordant intervals from controls. Measures will consist of 19 questionnaires characterizing pain and psychological status, neurophysiological testing for peripheral sensory nerve function, and peripheral blood samples collections for RNA sequencing. Illumina standard protocols will be used to sequence RNA, and read counts will be used to measure gene expression. Direct-entry, multiple logistic regression will be used to produce odds ratios expressing the relative risk on each explanatory variable when controlling for other predictors/covariates in the model. This study is one of the first to longitudinally characterize the biopsychosocial variables associated with a clinically relevant problem of the transition from acute to chronic posttraumatic fracture pain in individuals with LEFx. Results from this study will be used to construct predictive risk models of physiological, psychological, and genetic/genomic variables associated with increased risk for transitioning from acute to chronic pain status after LEFx. This work will lead to a better understanding of the trajectory of pain and relevant variables over time; initiate a better understanding of variables associated with risk for transitioning from acute to chronic pain; and, in the future, could provide a foundation for the identification of novel therapeutic targets to improve the outcomes of individuals with LEFx.

Extremity fractures in patients presenting with traumatic spinal fractures and spinal cord injury

Clinical features of extremity fractures (EFs) in patients presenting with traumatic spinal fractures (TSFs) and spinal cord injury (SCI) have not been investigated. To investigate the clinical features and risk factors for EFs in patients presenting with TSFs and SCI.Data from 1392 patients presenting with TSFs and SCI in our hospitals between 2001 and 2010 were retrospectively reviewed, among which 165 patients (129 males and 36 females, 37.5 ± 10.6 years old) presented with EFs. The clinical features of EFs have been investigated.The frequencies of upper limb fractures were significantly higher in the motor vehicle collisions (MVCs) group than in the high-fall group (P = .012) and the struck-by-object group (P = .002). The frequencies of lower limb fractures were significantly higher in the struck-by-object group (P = .019) and the high-fall group (P = .011) than the MVCs group. Univariate logistic regression analysis show that being in the 19 to 39 age group (P = .001), having a lumbar spinal fracture (P < .001) and experiencing a high fall (P < .001) were risk factors for EFs. Multivariate logistic regression analysis showed that we should focus on the factors that having a lumbar spinal fracture and experiencing a high fall.High fall and MVCs were the most common aetiologies for EFs. Having a lumbar spinal fracture and experiencing a high fall were significant risk factors for EFs. We should make early diagnoses and initiate timely treatment according to different patterns of extremity fractures in patients with TSFs and SCI.

Valuing the Recovery Priorities of Orthopaedic Trauma Patients After Injury: Evidence From a Discrete Choice Experiment Within 6 Weeks of Injury.

To determine the recovery priorities of extremity fracture patients during the subacute phase and the patient factors associated with variation in recovery priorities. Discrete choice experiment. Academic trauma center. One hundred ninety-eight patients with a fracture to the appendicular skeleton. Patients with severe traumatic brain injuries, spinal cord injuries, and non-English-speaking patients were excluded. The relative importance of clinical recovery, work-related recovery, and obtaining disability benefits after injury. In the subacute period, clinical recovery was the main priority for fracture patients (mean: 62%, SD: 5.3). Work-related recovery (mean: 27%, SD: 3.9) and the receipt of other disability benefits (mean: 11%, SD: 6.4) were each of significantly less importance. Heterogeneity was observed across these estimates based on the physical demands of preinjury employment, preinjury physical health, preinjury work status, health insurance type, and the severity of the fracture. Clinical recovery was of paramount importance for fracture patients during the subacute recovery phase. However, patients also valued resuming work and access to disability benefits. Understanding a patient's recovery priorities early in the clinical care pathway will enable the development of multidisciplinary care plans that are responsive to these priorities and, hence, deliver value-based health care. Level V. See Instructions for Authors for a complete description of levels of evidence.

Interfacility Transfer Is a Risk Factor for Venous Thromboembolism in Lower Extremity Fracture Patients.

To compare the incidence of venous thromboembolism (VTE) among patients with pelvic and/or lower extremity fractures directly admitted to our institution versus those transferred from an outside hospital for definitive management. Retrospective cohort. Tertiary care orthopaedic hospital. Six hundred ninety patients who received definitive care for a lower extremity fracture at our institution between 2010 and 2017. Interfacility transfer for definitive management of pelvic or lower extremity fracture. VTE incidence and time to surgery. The interfacility transfer (TR) group comprised 126 patients, and the direct admission (DA) group comprised 564 patients. TR patients had a significantly higher incidence of VTE compared with the DA group: 9.5% versus 0.7%, respectively (P < 0.001). Time to surgery was also longer in the TR group compared with the DA group: 3.05 ± 3.00 days versus 2.16 ± 2.42 days, respectively (P = 0.005). Demographics for TR and DA did not significantly differ with regard to age, sex, length of stay, or American Society of Anesthesiologist score. In the TR group, no complete and explicit documentation regarding thromboprophylaxis administration while at the outside facility was found. Patients undergoing interfacility transfer for definitive management of pelvic and lower extremity fractures are at a significantly increased risk of the development of VTE. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical implications of fracture-associated vascular damage in extremity and pelvic trauma

BackgroundVascular damage in polytrauma patients is associated with high mortality and morbidity. Therefore, specific clinical implications of vascular damage with fractures in major trauma patients are reassessed.MethodsThis comprehensive nine-year retrospective single center cohort study analyzed demography, laboratory, treatment and outcome data from 3689 patients, 64 patients with fracture-associated vascular injuries were identified and were compared to a control group.Results: Vascular damage occurred in 7% of patients with upper and lower limb and pelvic fractures admitted to the trauma room. Overall survival was 80% in pelvic fracture and 97% in extremity fracture patients and comparable to non-vascular trauma patients. Additional arterial damage required substantial fluid administration and was visible as significantly anemia and disturbed coagulation tests upon admission. Open procedures were done in over 80% of peripheral extremity vascular damage. Endovascular procedures were predominant (87%) in pelvic injury.ConclusionVascular damage is associated with high mortality rates especially in combination with pelvic fractures. Initial anemia, disturbed coagulation tests and the need for extensive pre-clinical fluid substitution were observed in the cohort with vascular damage. Therefore, fast diagnosis and early interventional and surgical procedures are necessary to optimize patient-specific outcome.

Disparities in follow-up care for ballistic and non-ballistic long bone lower extremity fractures

ObjectivesTo describe differences in follow-up compliance and emergency department (ED) visits between ballistic and non-ballistic operative lower extremity fracture patients. DesignRetrospective study. SettingUrban level 1 trauma center. Patients/ParticipantsPatients age ≥18 years with ≥1 tibia or femur fractures treated with ORIF or intramedullary nailing (IMN) between September 1, 2013 and August 31, 2015. Main Outcome MeasureA compliance fraction calculated as ([number of attended follow-up visits] / [number of attended follow-up visits + number of missed follow-up visits]) and ED visits in the post-operative period. Results612 patients were studied. Patients with ballistic lower extremity fractures had a younger mean age (30.8 years v. 41.6 years; p < 0.0001); a shorter length of stay (5.00 days v. 8.00 days; p < 0.0001); and were more likely to be male (92.6% v. 68%; p < 0.0001) and African-American (90.1% v. 63.1%; p < 0.0001) when compared to non-ballistic long bone injuries. Increased follow-up compliance (defined as a compliance fraction ≥0.75) was associated with having a non-ballistic fracture (OR 1.73, 1.13–2.64; p = 0.01), not having an ED visit (OR 2.08, 1.30–3.33; p = 0.002), and being female (OR 1.82, 1.27–2.61; p = 0.001). Increased ED utilization (≥ 1 ED visit) was associated with ballistic mechanism (OR 1.95, 1.20–3.16; p = 0.006), a low follow-up compliance fraction (OR 2.08, 1.30–3.33; p = 0.0019), homelessness (OR 3.91, 1.53–9.98; p = 0.006), and African-American race (OR 2.26, 1.26–4.05; p = 0.05). Scheduling a specific follow-up visit on the discharge summary did not predict higher compliance (OR 1.51, 0.98–2.33; p = 0.06). Conversely, the lack of a specific follow-up visit scheduled on the discharge summary did not predict ED utilization (OR 0.63, 0.34–1.17; p = 0.14). ConclusionThe results of this study demonstrate that increased utilization of the ED was associated with ballistic fractures, homelessness, decreased clinic compliance, and African American race. Furthermore, patients with non-ballistic injuries, women, and those without any ED visit were more likely to have higher outpatient clinic compliance.

Dipeptidyl peptidase-4 inhibitor use is associated with decreased risk of fracture in patients with type 2 diabetes: a population-based cohort study.

The aim of this study was to investigate the putative link between dipeptidyl peptidase-4 inhibitor (DPP-4i) use and the risk of fracture in patients with type 2 diabetes. This propensity-score-matched population-based cohort study was performed between 2009 and 2013 on patients with type 2 diabetes who were stable metformin users. A total of 3996 patients with type 2 diabetes used DPP-4i as a second-line antidiabetic drug. The same number of matched non-DPP-4i users were followed up until fracture occurrence, health insurance policy termination, or the end of 2013. The incidence rates of overall and cause-specific fractures were estimated based on the Poisson assumption. A multiple Cox proportional hazard model was used to estimate the covariate-adjusted hazard ratio (HR) and 95% confidence interval (CI) to determine the association between DPP-4i use and overall and cause-specific fractures stratified by age and sex. Over a maximum follow-up period of 5 years, 340 DPP-4i users and 419 non-DPP-4i users were newly diagnosed with fractures, yielding incidence rates of 28.03 and 32.04 per 1000 people per year, respectively. The Cox proportional hazard model revealed that DPP-4i use significantly reduced the risk of all-cause fractures and upper extremity fractures, with adjusted HRs of 0.86 (95% CI: 0.74-0.99) and 0.75 (95% CI: 0.59-0.95), respectively. The aforementioned associations of DDP-4i use with fracture were sustained across sex and age stratifications. The results of this study supported the premise that DPP-4i usage is associated with a reduced risk of all-cause fractures and upper extremity fractures in patients with type 2 diabetes.

Long-term Use of Inhaled Corticosteroids in COPD and the Risk of Fracture

It is uncertain whether long-term use of inhaled corticosteroids (ICSs), widely used to treat COPD, increases the risk of fracture, particularly in women, in view of the postmenopausal risks. We assessed whether long-term ICS use in patients with COPD increases the risk of hip or upper extremity fractures, and examined sex-related differences. The Quebec health-care databases were used to form a cohort of patients with COPD over 1990 to 2005, followed until 2007 for the first hip or upper extremity fracture. In a nested case-control analysis, each case of fracture was matched with 20 control subjects on age, sex, and follow-up time. The adjusted rate ratio (RR) of fracture with ICS use, by duration and dose, was estimated using conditional logistic regression, with an interaction term to compare the risk in men and women. In the cohort of 240,110 subjects, 19,396 sustained a fracture during a mean 5.3years (rate, 15.2 per 1,000 per year). Any use of ICSs was not associated with an increased rate of fracture (RR, 1.00; 95%CI, 0.97-1.03). The fracture rate was increased with > 4 years of ICS use at daily doses≥ 1,000 μg in fluticasone equivalents (RR, 1.10; 95%CI, 1.02-1.19). This risk increase did not differ between men and women. Long-term ICS use at high doses is associated with a modest increase in the risk of hip and upper extremity fractures in patients with COPD. This dose-duration risk increase does not appear to be higher for women.

Lower extremity fractures in patients with spinal cord injury characteristics, outcome and risk factors for non-unions

Context: Sublesional osteoporosis is an important sequel after spinal cord injury (SCI) resulting in a high incidence of fractures and impaired osseous healing due to altered bone metabolism. The following study aims to identify demographic characteristics and outcome of patients with SCI with lower extremity fractures.Design: Retrospective observational study.Setting: Level-I cross-regional trauma center.Participants: All patients with SCI suffering from osteoporotic/pathologic fractures during an 11-year-period (01/2003–12/2013) at the Center for Spinal Cord Injuries (Trauma Center Murnau) were analyzed via a chart review.Outcome measures: Demographics, surgical and radiologic outcome as well as complication rate were assessed with a special emphasis on union rates and independent risk factors for non-unions.Results: We identified 132 patients (105 males) who fulfilled the inclusion criteria. Most of them were paraplegic (n=101) and showed motor complete syndromes (n=119). Supracondylar femur fractures were the most prevalent in this study (n=47). We observed a non-union rate of 15.9% (n=21). The development of pseudarthrosis was associated with the time interval since the initial SCI (P < 0.010), delayed in-patient submission (P < 0.038), fracture classification (P < 0.002) and the localization of the fracture (P < 0.0001). The overall complication rate was 16.7%. All dislocated subtrochanteric femur fractures (Garden III and IV) (n=10) developed a non-union, regardless of their management (conservative or surgical). The following independent predictors for non-unions were identified: fracture localization (P < 0.0002), fracture classification (P < 0.056), and fracture management (P < 0.036).Conclusions: Even though modern techniques allow surgical interventions in bones with reduced mineral density, non-unions remain a common complication in patients with SCI. Risk factors for non-unions of lower extremity fractures are identified.

When Surgical Resources are Severely Constrained, Who Receives Care? Determinants of Access to Orthopaedic Trauma Surgery in Uganda.

In low- and middle-income countries, the volume of traumatic injuries requiring orthopaedic intervention routinely exceeds the capacity of available surgical resources. The objective of this study was to identify predictors of surgical care for lower extremity fracture patients at a high-demand, resource-limited public hospital in Uganda. Skeletally mature patients admitted with the intention of definitive surgical treatment of an isolated tibia or femur fractures to the national referral hospital in Uganda were recruited to participate in this study. Demographic, socioeconomic, and clinical data were collected through participant interviews at the time of injury and 6months post-injury. Social capital (use of social networks to gain access to surgery), financial leveraging, and ethnicity were also included as variables in this analysis. A probit estimation model was used to identify independent and interactive predictors of surgical treatment. Of the 64 patients included in the final analysis, the majority of participants were male (83%), with a mean age of 40.6, and were injured in a motor vehicle accident (77%). Due to resource constraints, only 58% of participants received surgical care. The use of social capital and femur fractures were identified as significant predictors of receiving surgical treatment, with social capital emerging as the strongest predictor of access to surgery (p<0.05). Limited infrastructure, trained personnel, and surgical supplies rations access to surgical care. In this environment, participants with advantageous social connections were able to self-advocate for surgery where demand for these services greatly exceeded available resources.

Clinical analysis of lower extremity fractures in patients with complete paralysis after spinal cord injury

Clinical analysis of lower extremity fractures in patients with complete paralysis after spinal cord injury

Increased mortality after lower extremity fractures in patients

Background and purpose — The association between mortality and lower extremity fractures (other than hip fractures in older individuals) is unclear. We therefore investigated mortality in adults of all ages after lower extremity fractures that required inpatient care.Patients and methods — Diagnosis code (ICD10), procedure code (NOMESCO), and 7 additional characteristics of patients admitted to the trauma ward at Central Finland Hospital were collected between 2002 and 2008 (n = 3,567). Patients were followed up until the end of 2012. Mortality rates were calculated for patients with all types of lower extremity fractures using data from the population at risk.Results — During the study, 2,081 women and 1,486 men sustained a lower extremity fracture. By the end of follow-up (mean duration 5 years), 42% of the women and 32% of the men had died. For all lower extremity fractures, the standardized mortality ratio (SMR) was 1.9 (95% CI: 1.8–2.0) for women and 2.6 (CI: 2.4–2.9) for men. In patients aged ≥65 years, mortality was increased and of similar magnitude after fractures of the hip, femoral diaphysis, and knee (distal femur, patella, and proximal tibia). In patients aged <65 years, mortality was increased after fractures at all sites. The SMR after fractures at different sites ranged between 2.1 (CI: 1.4–3.2) (ankle) and 6.7 (CI: 5.0–9.0) (hip) in patients aged <65 years and between 0.6 (CI: 0.30–1.1) (leg) and 2.2 (CI: 2.0–2.3) (hip) in patients aged ≥65 years.Interpretation — The post-fracture SMR of patients aged <65 years was at least double that of older patients. Furthermore, the higher mortality observed after proximal fractures of the lower extremity was greater in younger patients. The reasons behind these findings remain unclear.

Treatment of Bilateral Proximal Humeral Fracture in Patients with Parkinson’s Disease: A Case Report

There are only a few reports about upper extremity fractures in patients with Parkinson’s disease (PD). This is a case report of a PD patient with severe tremors who had proximal humeral fracture. We performed surgery for the left side and conservative treatment for the right side. The patient was a 73-year-old woman who had been diagnosed with PD 10 years prior to presentation. Open reduction internal fixation was conducted for the left proximal humeral fracture. 7 months after the left shoulder fracture, she fell resulting in a right proximal humeral fracture for which she underwent conservative treatment. Although bone union was obtained bilaterally, anterior subluxation occurred in the operated side 9 months postoperative. Screw remove was performed because perforation of the screw was observed in the humeral head and was causing pain. Currently, restriction in range of motion and subluxation may be seen on the side that received conservative treatment, although pain is absent and patient satisfaction is high. On the operated side, there is a marked restriction in range of motion, subluxation, and pain. Our experience revealed that conservative treatment was effective for proximal humeral fractures and that optimal bone union might be obtained even in patients with suboptimal PD control.

Medico-surgical management of lower extremity fractures in patients with spinal cord injury: Assessment and advice based on a 10-year retrospective study carried out in a university hospital

To evaluate the management of lower extremity fractures in patients with spinal cord injury in a referent university center. Retrospective monocentric study carried out in patients with spinal cord injury cared for lower extremity fractures at a University Hospital of Nantes. In 10 years, 57 fracture events responsible for 61 fractures in 41 patients were managed. Average patient age was 50 years old (22–83), 73.3% of patients were AIS A. The median time to onset of the 1st fracture was 14.2years. The most common sites were distal femur (27.9%), distal (21.3%) and proximal tibia (16.4%). Fracture mechanism was wheelchair fall in 50% of cases. Surgery was carried out for 65.6% of the fractures. At least one medico-surgical complication occurred after 25% of surgical treatments and 57.1% of orthopedic treatments. Forty-two percent of the fracture events were followed by hospitalization. Douze patients had dual-energy X-ray absorptiometry performed at the lumbar spine and femoral necks. The average bone mineral density was 0.566 g/cm 2 at the right femoral neck (T-score: −3.3; Z-score: −2.6), 0.574 g/cm 2 at the left one (T-score: −3.4; Z-score: −2.8) and 1.07 g/cm 2 at the lumbar spine (T-score: −0.38; Z-score: −0.21). Onze patients were treated with bisphosphonate. Lower extremity fractures occur close to the knee for low traumas. Surgery seems to provide fewer complications. For sub-lesional bone loss screening, a low bone mineral density is predictive of fractures. The best site of measurement is the distal femur because of reliability and reproducibility. The measurement on the lumbar spine is not recommended. Bisphosphonates have never shown efficacy for the reduction of the number of fractures but allow an increase of bone mineral density.