Fracture Grade Research Articles

Enhancing Interpretability of Vertebrae Fracture Grading using Human-interpretable Prototypes

Vertebral fracture grading classifies the severity of vertebral fractures, which is a challenging task in medical imaging and has recently attracted Deep Learning (DL) models. Only a few works attempted to make such models human-interpretable despite the need for transparency and trustworthiness in critical use cases like DL-assisted medical diagnosis. Moreover, such models either rely on post-hoc methods or additional annotations. In this work, we propose a novel interpretable-by-design method, ProtoVerse, to find relevant sub-parts of vertebral fractures (prototypes) that reliably explain the model’s decision in a human-understandable way. Specifically, we introduce a novel diversity-promoting loss to mitigate prototype repetitions in small datasets with intricate semantics. We have experimented with the VerSe’19 dataset and outperformed the existing prototype-based method. Further, our model provides superior interpretability against the post-hoc method. Importantly, expert radiologists validated the visual interpretability of our results, showing clinical applicability.

External fixation as definitive treatment or external fixation followed by early fixation in open fractures of the tibial shaft: A descriptive study

IntroductionTreatment options for open tibial shaft fractures include external fixation with or without early conversion to internal fixation. ObjectivesThe aim of this study was to describe 1) early conversion to internal fixation and definitive external fixation and 2) in case of conversion, to identify risk factors for complications. MethodsSeventy-two external fixations of open fractures of the tibial shaft (Gustilo classification, 7 fractures (9.7 %) grade I, 25 fractures (34.7 %) grade II, 40 fractures (55.6 %) grade III (31 grade IIIA and 9 grade IIIB)) were included in a continuous non-randomised study. Thirty-three fractures without infection signs were converted to internal fixation at a mean time of 40.5 +/-15 days (IF group). External fixation was maintened in the remaining 39 fractures (EF group). ResultsIn the “IF” group, the union rate was 69.7 % at 6.3 +/-3.6 months (3–16). All patients had complete union at 16 months, requiring 2.8 +/-0.8 reoperations. Fixation with external fixation only (“EF” group) showed a union rate of 51.3 % at 8.9 +/-4 (5–22) months and 96 % at 16 months after 3.7 +/-0.9 reoperations. Superficial infection (12.1 %; p = 0.011) and numerous surgeries (2.76; p = 0.004) were found to be risk factors for deep infection. Time to wound closure >7 days (p = 0.049), time to reoperation >28 days (p = 0.00), numerous surgeries (2.76; p = 0.004) and deep infection (6.1 %; p = 0.027) were found to be union failure factors. ConclusionEarly conversion of external fixation to internal fixation is an effective option to achieve bone union of open tibial fractures in selected patients.

Arthroscopically Assisted Technique in the Treatment of Ankle Fractures with Posterior Malleolus Fragment in Adults

Abstract Introduction: Ankle fractures constitute a challenging condition due to its high impact on the long term. Thus, advancements in management have been proposed to ensure the best possible outcome. Hence, we aimed to assess the role of arthroscopy in the treatment of ankle fractures that involve posterior malleolus fragments in adults. Patients and Methods: In a quasi-experimental, interventional, prospective, nonrandomized study, we included 16 adult patients with acute ankle fracture with posterior malleolus fragment. They underwent arthroscopically assisted technique for their fracture treatment. A standard systematic arthroscopic ankle examination, their fracture grade, and classification were assessed, and subsequent management was conducted. The patients were followed up for 6 months using the American Orthopedic Foot and Ankle Society (AOFAS) score and radiographic monitoring with standard X-ray. Results: The mean AOFAS score improved significantly after 6 months of follow-up (from 84.81 in the 3rd month to 92.81 in the 6th month). Ankle dorsiflexion angle and ankle plantar-flexion angle showed a gradual increase during follow-up, reaching 17.31° ± 3.25° and 45° ± 5°, respectively. Only two patients developed complications. Age, body mass index, and grade of the osteochondral lesion were negatively correlated statistically significantly with the AOFAS score. This proves the effective role of arthroscopically assisted technique in the treatment of ankle fractures with posterior malleolus fragment. Conclusion: Arthroscopically assisted technique in the treatment of ankle fractures with posterior malleolus fragment in adults resulted in good functional outcomes with less complications and it allows the assessment of associated intra-articular injuries. Further studies with longer follow-up periods are needed for the assessment of outcomes and complications for comparison.

Association of Timing With Postoperative Complications in the Management of Open Distal Radius Fractures

Background: This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. Methods: Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. Results: One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. Conclusion: Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. Level of Evidence: Level IV

Gartland classification concordance of supracondylar fractures among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

The modified Gartland classification is the most widely accepted grading method of supracondylar humeral fractures among orthopedic surgeons and is relevant to identifying fractures that may require surgery. To assess the interobserver reliability of the modified Gartland classification among pediatric radiologists, pediatric orthopedic surgeons, and pediatric emergency medicine physicians. Elbow radiographs for 100 children with supracondylar humeral fractures were retrospectively independently graded by two pediatric radiologists, two pediatric orthopedic surgeons, and two pediatric emergency medicine physicians using the modified Gartland classification. A third grader of the same subspecialty served as a tie-breaker as needed to reach consensus. Readers were blinded to one another and to the medical record. The modified Gartland grade documented in the medical record by the treating orthopedic provider was used as the reference standard. Interobserver agreement was assessed using kappa statistics. There was substantial interobserver agreement (kappa = 0.77 [95% CI, 0.69-0.85]) on consensus fracture grade between the three subspecialties. Similarly, when discriminating between Gartland type I and higher fracture grades, there was substantial interobserver agreement between specialties (kappa = 0.77 [95% CI, 0.66-0.89]). The grade assigned by pediatric radiologists differed from the reference standard on 15 occasions, pediatric emergency medicine differed on 19 occasions, and pediatric orthopedics differed on 9 occasions. The modified Gartland classification for supracondylar humeral fractures is reproducible among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

Male–female disparity in clinical features and significance of mild vertebral fractures in community-dwelling residents aged 50 and over

This investigation examined the clinical implications of mild vertebral fractures in older community-dwelling residents. Focusing on the locomotion health of older individuals, the earlier reported Obuse study enrolled 415 randomly sampled Japanese residents aged between 50 and 89 years, 411 of whom underwent X-ray evaluations for pre-existing vertebral fractures. A blinded assessment of vertebral fractures based on Genant’s criteria was conducted on the T5-L5 spine for rating on a severity scale. Grade 1 mild fractures were not linked to age in males, but increased with aging in females. Female participants had fewer Grade 1 and 2 fractures (P = 0.003 and 0.035, respectively) but more Grade 3 fractures (P = 0.013) than did males independently of age (Grade 1, 2, and 3: 25%, 16%, and 9% in females and 40%, 22%, and 6% in males, respectively). Weak negative correlations were observed between the number of fractures and bone mineral density in females for all fracture grades (Spearman’s rho: 0.23 to 0.36, P < 0.05). Our study showed that Grade 1 mild vertebral fractures in males lacked pathological significance, while in females they potentially indicated fragility fractures and were related to poor lumbopelvic alignment.

An overview of the performance of AI in fracture detection in lumbar and thoracic spine radiographs on a per vertebra basis

PurposeSubtle spinal compression fractures can easily be missed. AI may help in interpreting these images. We propose to test the performance of an FDA-approved algorithm for fracture detection in radiographs on a per vertebra basis, assessing performance based on grade of compression, presence of foreign material, severity of degenerative changes, and acuity of the fracture.MethodsThoracic and lumbar spine radiographs with inquiries for fracture were retrospectively collected and analyzed by the AI. The presence or absence of fracture was defined by the written report or cross-sectional imaging where available. Fractures were classified semi-quantitatively by the Genant classification, by acuity, by the presence of foreign material, and overall degree of degenerative change of the spine. The results of the AI were compared to the gold standard.ResultsA total of 512 exams were included, depicting 4114 vertebra with 495 fractures. Overall sensitivity was 63.2% for the lumbar spine, significantly higher than the thoracic spine with 50.6%. Specificity was 96.7 and 98.3% respectively. Sensitivity increased with fracture grade, without a significant difference between grade 2 and 3 compression fractures (lumbar spine: grade 1, 52.5%; grade 2, 72.3%; grade 3, 75.8%; thoracic spine: grade 1, 42.4%; grade 2, 60.0%; grade 3, 60.0%). The presence of foreign material and a high degree of degenerative changes reduced sensitivity.ConclusionOverall performance of the AI on a per vertebra basis was degraded in clinically relevant scenarios such as for low-grade compression fractures.

Influence of screw configuration on reduction and stabilization of simulated complete lateral condylar fracture in equine limbs.

To determine the influence of screw configuration on the reduction and stabilization of simulated complete lateral condylar fracture. Randomized experimental crossover study. A lateral condylar fracture was simulated in 18 cadaver limbs from nine horses. Each limb underwent repair with 4.5 mm diameter cortex screws, tightened to 4 Nm, in a linear and triangular configuration. Computed tomography (CT) of each repair was performed with the limbs in unloaded and loaded conditions. Fracture gaps were measured at the dorsal, palmar, and middle locations of the third metacarpal condyle. Fracture gap measurements were graded 0-4, based on voxels. Following descriptive analysis, a Bayesian network (BN) model was fitted to the data. The median fracture grade was 0 (range: 0-4) for unloaded linear repairs and 2 (0-4) for loaded linear repairs. The median fracture grade was 0 (0-3) for unloaded triangular repairs and 1 (0-3) for loaded triangular repairs. Bayesian network sensitivity analysis showed that the construct configuration reduced the uncertainty in the measured fracture outcome by 0.8%. Triangular screw configuration resulted in better fracture reduction and stability in comparison with linear screw configuration. However, the BN sensitivity analysis results showed that the effect of construct configuration on fracture outcome was weak. These findings indicate a low probability that triangular repair of lateral condylar fracture will result in improved outcomes, when compared with linear repair.

External Fixation as a Primary and Definitive Treatment for Complex Tibial Diaphyseal Fractures: An Underutilized and Efficacious Approach.

External fixation is one of the most often utilized treatment options for complicated tibial diaphyseal fractures (TDF). The purpose of this study was to assess the efficacy of unilateral external fixators as primary and definitive therapy for complex TDF in a resource-limited setting. A retrospective study between June 2016 and March 2021 included 110 subjects with TDF who were treated with an external fixator as definitive fixation in hospitals affiliated with Ibb University. The patient's demographic characteristics, complications, and outcomes were gathered and analyzed. Factors associated with pin site infection were also investigated. The mean age was 42.1 ± 10.1 years, with 92.7% being male. Rural residents accounted for 22.7%. Smoking and diabetes mellitus were present in 27.3% and 30.0%, respectively. General complications occurred in 12.0%, with pulmonary embolism being the most common at 4.5%. Orthopedic complications included pin-track infections in 27.3% (30) and osteomyelitis in 1.8% (2). Pin site infections required medical treatment in 21 cases and external fixator changes in five. Two cases each needed several debridements for osteomyelitis and soft tissue. Full union occurred in 79.1% (87) over 23.1 ± 3.2 weeks and final alignment in 97.3% (107) over 34.8 ± 4.8 weeks. Malunions occurred in 1.8% (2), and one case had hypertrophic nonunion. Factors like rural residency, smoking, diabetes, open fractures, worst fracture grade (Gustilo and Anderson type C), and general complications occurrence significantly correlated with pin site infection (all p-values < 0.05). A unilateral external fixator as a primary and definitive treatment is a viable, simple, and effective option for TDF with a high success rate even in a resource-limited setting. In this study, residents in rural areas, smoking, diabetes, open fracture, worst fracture grade, and general complication occurrence were associated with pin site infection occurrence.

The role of neutrophil to lymphocyte ratio with wound healing in open tibial fracture grade IIIA

Introduction: Open fractures of the tibia are challenging injuries to treat. The neutrophil-lymphocyte ratio (NLR) has been used to predict poor prognosis in various orthopedic conditions. This study aims to analyze the role of NLR in the wound healing of patients with open fractures. Methods: This is a retrospective study with data taken from all patients with grade IIIA open tibial fractures admitted to the hospital for treatment between January 2018 and June 2023. The initial NLR value and wound healing state were recapped after 6 weeks of follow-up. A statistical analysis between NLR values and wound healing state was done to measure the significance between variables. Results: There were 49 participants included in this study. Our current study found a significant difference between the mean NLR value of the healed and nonhealed wound (12.59±11.2 vs 10.46±7.9, P =0.015). The mean NLR in the healed group was significantly higher than in the nonhealed group. Calculating NLR involves dividing the absolute count of neutrophils by the total count of lymphocytes, which can be obtained through a complete blood count test. This ratio offers valuable insights into the balance between inflammatory and anti-inflammatory responses in the body. Conclusion: The NLR was significantly higher in the healed group than in the nonhealed group. Further research with higher-quality studies might be needed to prove its prognostic factor.

Immediate plate fixation of open tibial plafond fractures does not elevate risk of infection.

To determine if immediate plate fixation of open tibial plafond fractures has a negative effect on soft tissue complications and increases the risk of deep infection. This was a single-institution retrospective cohort study performed at level-1 trauma center. All patients with open OTA/AO 43C plafond fractures treated over 20-year period with follow-up until fracture union or development of deep infection. Ninety-nine of 333 identified patents met the inclusion criteria. The intervention was operative treatment of open tibial plafond fractures. The main outcome measurements were return to operating room for deep infection, nonunion, and below knee amputation. The overall rate of complications was 52%. Gender, body mass index, tobacco use, diabetes, ASA classification, time to OR from injury, wound location, and associated fibula fracture were not associated with deep infection. There was a significant difference in Gustilo-Anderson fracture grade among infected versus non-infected (P = 0.04). There was no significant difference in postoperative infection rates between patients treated with external fixation, external fixation and limited plate fixation, and plate fixation alone during initial surgery (P = 0.64). It is well established that open pilon fractures have a high incidence for postoperative infection and development of complications such as nonunion. As these injuries have poor clinical outcomes, any additional measures to prevent infection and soft tissue complications should be utilized. In appropriately selected cases, both immediate plate fixation and immediate limited plate fixation with external fixation at the time of I&D do not appear to elevate risk of deep infection. Therapeutic Level III.

Interpretable Severity Scoring of Pelvic Trauma Through Automated Fracture Detection and Bayesian Inference.

Pelvic ring disruptions result from blunt injury mechanisms and are potentially lethal mainly due to associated injuries and massive pelvic hemorrhage. The severity of pelvic fractures in trauma victims is frequently assessed by grading the fracture according to the Tile AO/OTA classification in whole-body Computed Tomography (CT) scans. Due to the high volume of whole-body CT scans generated in trauma centers, the overall information content of a single whole-body CT scan and low manual CT reading speed, an automatic approach to Tile classification would provide substantial value, e. g., to prioritize the reading sequence of the trauma radiologists or enable them to focus on other major injuries in multi-trauma patients. In such a high-stakes scenario, an automated method for Tile grading should ideally be transparent such that the symbolic information provided by the method follows the same logic a radiologist or orthopedic surgeon would use to determine the fracture grade. This paper introduces an automated yet interpretable pelvic trauma decision support system to assist radiologists in fracture detection and Tile grading. To achieve interpretability despite processing high-dimensional whole-body CT images, we design a neurosymbolic algorithm that operates similarly to human interpretation of CT scans. The algorithm first detects relevant pelvic fractures on CTs with high specificity using Faster-RCNN. To generate robust fracture detections and associated detection (un)certainties, we perform test-time augmentation of the CT scans to apply fracture detection several times in a self-ensembling approach. The fracture detections are interpreted using a structural causal model based on clinical best practices to infer an initial Tile grade. We apply a Bayesian causal model to recover likely co-occurring fractures that may have been rejected initially due to the highly specific operating point of the detector, resulting in an updated list of detected fractures and corresponding final Tile grade. Our method is transparent in that it provides fracture location and types, as well as information on important counterfactuals that would invalidate the system's recommendation. Our approach achieves an AUC of 0.89/0.74 for translational and rotational instability,which is comparable to radiologist performance. Despite being designed for human-machine teaming, our approach does not compromise on performance compared to previous black-box methods.

Improving vision transformer for medical image classification via token-wise perturbation

Transformer has achieved impressive successes for various computer vision tasks. However, most of existing studies require to pretrain the Transformer backbone on a large-scale labeled dataset (e.g., ImageNet) for achieving satisfactory performance, which is usually unavailable for medical images. Additionally, due to the gap between medical and natural images, the improvement generated by the ImageNet pretrained weights significantly degrades while transferring the weights to medical image processing tasks. In this paper, we propose Bootstrap Own Latent of Transformer (BOLT), a self-supervised learning (SSL) approach specifically for medical image classification with the Transformer backbone. Our BOLT consists of two networks, namely online and target branches, for self-supervised representation learning. Concretely, the online network is trained to predict the target network representation of the same patch embedding tokens with a different perturbation. To maximally excavate the impact of Transformer from limited medical data, we propose an auxiliary difficulty ranking task. The Transformer is enforced to identify which branch (i.e., online/target) is processing the more difficult perturbed tokens. Overall, the Transformer endeavours itself to distill the transformation-invariant features from the perturbed tokens to simultaneously achieve difficulty measurement and maintain the consistency of self-supervised representations. The proposed BOLT is evaluated on three medical image processing tasks, i.e., skin lesion classification, knee fatigue fracture grading and diabetic retinopathy grading. The experimental results validate the superiority of our BOLT for medical image classification, compared to ImageNet pretrained weights and state-of-the-art SSL approaches.

The Relationship of Age, Surgery Type, and Time to Surgery with Post-Operative Outcome of Open Tibial Fracture Grade III at RSUP Sanglah Denpasar in 2018-2020

Open tibial fracture is one of the most common lower extremity fractures in the world, especially in Denpasar City. Clinically, open tibial fracture grade III has higher risk of worse outcome, such as infection and bone healing complication than grades I and II, thus it should be evaluated further regarding risk factors affecting that occurrence. This research aims to know the relationship between several risk factors, those are age, surgery type, and time to surgery with postoperative outcomes in open tibial fractures grade III in terms of clinical, radiological, and functional based on Johner-Wruhs criteria. This research used cross-sectional method and used patients with open tibial fracture grade III who underwent surgery at RSUP Sanglah Denpasar in 2018-2020. Based on the data collection, there were 31 patients fulfilled the inclusion and exclusion criteria. The data collected were characteristics and postoperative outcome assessed using Johner-Wruhs criteria which consisted of 4 categories. From Kendall Tau correlation test, there was no significant relationship between age and outcome (p=0,215) and a significant relationship between time to surgery and outcome (p=0,021). Moreover, the results of Fisher’s Exact Test did not find significant relationship between surgery type and outcome (p=0,720). Based on the results, it can be concluded that time to surgery (debridement) has significant effect on postoperative outcome compared to age and surgery type. Time to debridement also has unidirectional relationship with outcome, which means the longer time to debridement, the worse outcome experienced by the patient.&#x0D; Keywords : open tibial fracture, surgery type, outcome, age, time to surgery

Reporting of paediatric osteoporotic vertebral fractures in Duchenne muscular dystrophy and potential impact on clinical management: the need for standardised and structured reporting

BackgroundIn boys with Duchenne muscular dystrophy (DMD), initiation of bisphosphonate is recommended upon identification of moderate or severe vertebral fractures, even if asymptomatic. Clear radiological reporting is important for consistency of clinical interpretation and management.ObjectivesTo audit radiology reports of spine imaging for vertebral fracture assessment in DMD, and assess potential impact on diagnosis and management.Materials and MethodsLateral thoracolumbar spine imaging (71 lateral spine radiographs and 13 lateral dual energy absorptiometry spine image) in 84 boys with DMD performed across two centres. Anonymised radiology reports by paediatric radiologists were circulated to two neuromuscular clinicians and two endocrinologists. Clinicians determined if there was vertebral fracture, no vertebral fracture, or unclear interpretation. Endocrinologists also determined if bisphosphonate was indicated. A single observer (a clinician with expertise in vertebral fracture assessment) performed vertebral fracture assessment in 37 images and re-reported using a structured format. Structured reports were re-circulated to the four clinicians to re-evaluate the degree of concordance in clinical diagnosis of vertebral fracture and treatment decisions with bisphosphonate.ResultsThe term “fracture” was used in 25/84 (30%) radiology reports and only in 8/43 (19%) with description of vertebral body abnormalities. Fracture grading was included in 7/43 (16%) radiology reports. Diagnostic concordance by the clinicians was noted in 36/84 (43%). Unclear interpretation was noted in 22% to 51% based on radiology reports. No unclear interpretation was noted with structured reports. Complete diagnostic (37/37, 100%) and treatment (37/37, 100%) concordance was noted with the structured reports, whereas complete diagnostic and treatment concordance was noted in only 16/37 (43%) and 17/37 (46%) of the radiology reports, respectively.ConclusionOnly a third of radiology reports of spine imaging in DMD explicitly used the terminology “fracture”. Grading was only noted in a small percentage. Variability in diagnostic interpretation by clinicians may lead to differing management plans. As identification of vertebral fracture is a trigger for treatment, developing reporting guidelines for paediatric vertebral fracture assessment will improve care. A structured template should be introduced for radiological reporting of paediatric vertebral fracture assessment.

IS MALNUTRITION CONTRIBUTING TO THE SEVERITY OF SUPRACONDYLAR FRACTURES IN CHILDREN? A RETROSPECTIVE REVIEW

The aims of this study was to determine the incidence of malnutrition in children with supracondylar fractures. It was hypothesised that the presence of malnutrition will increase the severity type of fractures.The study was a retrospective, cross-sectional study at a single institution. Children between 0 years and 12 years of age, who sustained documented supracondylar fracture treated surgically as a result of low velocity trauma were included in the study. Patients who sustained high velocity trauma, who had known bone disorders or had incomplete chart data, were excluded from the study Data was captured from children's’ notes who have been treated surgically for supracondylar fractures from casualty, theatre and the clinic notes. The nutritional status of children and fracture grade were identified and the two sets of data were compared against each other to try to identify a possible relation between fracture severity and malnutrition. Data was analysed in STATA and 5% level of significance was used to signify statistically significant associations.150 patients were identified and included in the study. The majority of patients reviewed were in the normal nutritional range according to their z-scores. The severity of the fracture was not only associated with a poorer nutritional status however children with high and low z-scores (over weight as well as undernourished children) had the more severe fracture patterns, while children with normal z-scores had a fracture patterns of varying severity.Children who were malnourished were more likely to sustain more severe fracture types. The results highlighted the need for all children to have a good nutritional status as this may play a role in preventing more complex fractures.

ISCSO-PTCN-BIGRU Prediction Model for Fracture Risk Grade of Gas-Containing Coal Fracture

A multi-strategy improved sand cat swarm algorithm with PTCN-BIGRU is proposed to solve the problem of predicting the risk level of gas-containing coal fracture. Combined with kernel entropy component analysis to downscale the gas-containing coal fracture risk level predictors, TCN is used for feature extraction by parallel convolution operation, and BiGRU is used to further obtain the contextual links of the features. A parameterized exponential linear unit based on the standard TCN is used to improve the linear unit and to enhance the generalization capability of the model. Combined with the sand cat swarm optimization algorithm to determine the optimal BIGRU network parameters, Singer chaos mapping, chaos decreasing factor, and adaptive t-distribution are used to improve the SCSO for optimal risk level prediction accuracy. The results show that the prediction accuracy of the ISCSO-PTCN-BiGRU model is 93.33%, which is better than other models, and it is proved that this paper can effectively improve the prediction accuracy of gas-containing coal fracture risk level. This research adds a theoretical support for the prevention of gas protrusion accidents and a guarantee for the safety of underground production in coal mines.

Management of open fractures: A narrative review

Open fractures are an emergency where the principal aim of the treatment is to maximise the restoration of limb function while preventing the dreaded consequences of infection and non-union. The decision-making process for open injuries is influenced by a variety of criteria, such as patient age, injury features, systemic response, activity level, comorbidities, and functional requirements. A collaborative orthoplastic approach to treating these injuries is essential for minimizing complications and need to be considered as a single specialty in early and long-term management. It has been shown that early prophylactic systemic antibiotics, wound irrigation, aggressive debridement of contaminated and devitalized tissue, and appropriate fracture fixation decreases the complications in all grades of open fractures. The advantages of Gram-negative antibiotics, the use of local antibiotics, intraoperative wound cultures, the "fix and flap" approach, and Negative Pressure Wound Therapy are few of the treatment options that are still controversial. The aim of this review is to provide a comprehensive review and practice guidelines regarding the management of open fractures.

Functional outcomes and quality of life at 1-year follow-up after an open tibia fracture in Malawi: a multicentre, prospective cohort study

Injuries are a major cause of disability globally and injury incidence is rapidly increasing, largely due to road traffic injuries in low-income and middle-income countries. Current estimates of the scale and consequences of disability from injury are largely based on modelling studies, with a scarcity of empirical evidence from severe injuries in low-income countries. We aimed to better understand the outcomes for individuals with open tibia fractures in Malawi. In this multicentre, prospective cohort study, adults (aged ≥18 years) with open tibia fractures were systematically recruited at six hospitals in Malawi (two tertiary hospitals and four district hospitals). Follow-up lasted at least 1 year, during which in-person follow-up reviews were done at 6 weeks, 3 months, 6 months, and 1 year post-injury. The primary outcome was function at 1 year post-injury, measured by the Short Musculoskeletal Functional Assessment (SMFA) score. Secondary outcomes included quality-adjusted life-years (QALYs; as determined via the European Quality of Life 5-Dimensions 3-Levels [EQ-5D-3L] survey) and fracture-related infection at 1 year post-injury. Multilevel regression models investigated associations between SMFA score, EQ-5D-3L, baseline factors, and orthopaedic management. Between Feb 12, 2021, and March 14, 2022, 287 participants were enrolled (median age 34 years [IQR 25-44]; 84% male). The most common mode of injury was road traffic injuries (194 [68%] of 287). Overall, 268 (93%) participants had debridement; of the 63 participants who were debrided in district hospitals, 47 (75%) had the procedure under local or no anaesthesia. Following substantial declines by 6 weeks after injury, function and quality of life had not recovered by 1 year post-injury for participants with Gustilo grade I-II fractures (posterior mean SMFA at 1 year: 10·5, 95% highest density interval [HDI]: 9·5-11·6; QALYs: 0·73, 95% HDI: 0·66-0·80) nor Gustilo grade III fractures (posterior mean SMFA at 1 year: 14·9, 95% HDI: 13·4-16·6; QALYs: 0·67, 95% HDI: 0·59-0·75). For all fracture grades, intramedullary nailing substantially improved function and quality of life at 1 year post-injury. Delayed definitive fixation after 5 days had 5-times greater odds of infection compared with early management within 2 days (adjusted odds ratio: 5·1, 95% CI 1·8-16·1; p=0·02). Adults with open tibia fractures in Malawi have poor function and quality of life in the 1 year following injury. Centralised orthopaedic surgical management, including early definitive fixation and intramedullary nailing for more severe injuries, might improve outcomes. Wellcome Trust. For the Chichewa translation of the abstract see Supplementary Materials section.

752 How Do We Manage Open Fractures in Emergency Department? – a Closed Loop Audit

Abstract Aim Patient with an open fracture is resuscitated mainly by the emergency physician prior to being referred to the relevant surgical specialties. Yet, there is lack of uniform guidance in managing open fractures. This audit aimed to evaluate the existing guidelines at the emergency department. Method A retrospective search was performed at the Tertiary trauma center. Four main parameters were evaluated 1.) the photo documentation. 2.) Antibiotic administration rate 3.) Tetanus prophylaxis utilisation. 4.) Systematic evaluation of neurovascular status pre and post splint. Results 41 patients (M: F, 63%:37%) were analysed. The most common open-fracture were lower-limb long bone (39%) and phalanx (39%) , followed by upper-limb long bone fracture (9.8%), head (7.3%), facial (2.4%) and pelvis (2.4%). Multiple fractures were seen in 20.9%. Multiple open fractures were only seen in 1 case. The average transfer time by ambulance to the hospital was 116 mins. 97.5% of open fractures received antibiotics: 13.3%, 60%, and 100% of patients received antibiotics respectively within 1hr, 3hr, and 6hr from the time of injury. 48.8% received tetanus prophylaxis, and only 4.87% have documented tetanus assessment. 100% has a neurovascular examination. 72% of open fractures required surgical intervention. The average time to the theatre was 16.7 hours. Conclusions Antibiotic administration within the first hour from the timing of the injury is not practical in real-life situations. Future work should focus on creating a universe open fracture grading system, beyond lower-limb fracture, to better inform clinicians of the prognosis of open fracture and help with risk stratification.