Fractures In Population Research Articles

Short-term morbidity factors associated with length of hospital stay (LOS): Development and validation of a Hip Fracture specific postoperative morbidity survey (HF-POMS)

BackgroundWe aimed to describe and quantify postoperative complications in the older hip fracture population, develop and validate a hip fracture postoperative morbidity survey tool (HF–POMS). MethodsA prospective clinical observation study of patients (≥ 70 years) admitted for emergency hip fracture surgery, was conducted across three English National Health Service hospitals. Outcome data items were developed from the Postoperative Morbidity Survey (POMS), Cardiac-POMS, hip fracture postoperative literature and orthogeriatric clinical team input. Postoperative outcome data were collected on days 1, 3, 5, 8 and 15; 341 patients participated. ResultsA 12-domain HF-POMS tool was developed with acceptable construct validity on all HF–POMS days. Patients with high perioperative risk scores as measured by the NHFS and ASA grade were more prone to develop HF–POMS defined morbidities. High morbidity rates occurred in the following domains; renal, ambulation assistance, pain and infectious. Presence of any morbidity on postoperative days 8 and 15 was associated with subsequent length of stay of 3.08 days (95% CI 0.90–5.26, p = 0.005) and 15.81 days (95% CI 13.35–18.27, p = 0.001) respectively. Observed average length of stay was 16.9 days. HF–POMS is a reliable and valid tool for measuring early postoperative complications in hip fracture patients. Additional domains are necessary to account for all morbidity aspects in this patient population compared to the original POMS. ConclusionMany patients remained in hospital for non-medical reasons. HF-POMS may be a useful tool to assist in discharge planning and randomised control trial outcome definitions.

Validation of the Nottingham Hip Fracture Score (NHFS) to predict 30-day mortality in patients with an intracapsular hip fracture

BackgroundThe Nottingham Hip Fracture Score (NHFS) was developed to predict 30-day mortality following a fracture of the hip. While the NHFS has been validated in three hip fracture populations within Great Britain, these studies make no distinction between the type of fracture and surgery. Literature ‘however’ shows an increased risk for mortality after a hemi-arthroplasty following an intra-capsular hip fracture. To verify whether the mortality after an intra-capsular hip fracture is higher compared to the predicted mortality score according to the NHFS, a validation of the NHFS in patients with a hemi-arthroplasty after an intra-capsular hip fracture was performed. MethodsThe NHFS was calculated for consecutive patients presenting with an intra-capsular fracture of the hip in two level II trauma teaching hospitals between 1 January 2011 and 1 May 2016. The observed 30-day mortality was compared with that predicted by the NHFS using several validation statistics. ResultsA total of 901 patients were included in the present study. Mean age in the patients was 83 years (SD 8) and 623 (68%) of the patients were female. Almost 60% of the patients had an ASA-score (American Society of Anaesthesiologists [ASA]) of≥3 and overall 30-day mortality was 9.5% (n=86). The median NHFS was 5, and there was no significant change in median NHFS over the past 5 years. The mortality rate in the studied population of hemi-arthroplasty patients was significantly higher than mortality rates predicted by the NHFS (p=0.022, Pearson's Chi-squared test). ConclusionsFindings suggest that for a patient with a hemi-arthroplasty following an intra-capsular hip fracture, there could be an underestimation for the 30-day mortality rate following the NHFS prediction model. Level of evidencePrognostic Level III, retrospective cohort study.

Frequency of Cervical Spine Injuries in Pediatric Craniomaxillofacial Trauma

In pediatric patients with craniomaxillofacial (CMF) trauma, evaluation for cervical spine injury (CSI) is critical, but there are no studies investigating CSI in this unique population. The aim of this study was to measure the frequency of CSI in the pediatric CMF fracture population. A retrospective cohort study of all pediatric patients who presented to the Johns Hopkins Hospital Emergency Department (Baltimore, MD) with CMF fractures were examined for concurrent CSIs. Patient charts were reviewed for mechanism of injury, type and level of CSI, type and location of CMF fracture patterns, and overall outcome. Data were analyzed for correlation and statistical relevance. A total of 2,966 pediatric patients (1,897 boys [64.0%]; age range, 0 to 15yr; average age, 7±4.73yr) were identified from 1990 to 2010 to have CMF fractures. Of these patients, only 5 children were found to have concomitant CSIs (frequency, 0.169%). The frequency of CSI in patients with CMF fracture and deciduous, mixed, and permanent dentition was 0, 0.307, and 0.441%, respectively. Of the 5 identified cases, 4 had concomitant middle-third facial skeletal fracture, 4 had concomitant upper-third cranial skeletal fracture, and 2 had concomitant lower-third cranial skeletal fracture. CSIs in pediatric patients with CMF fracture are rare (frequency, 0.169%); this is considerably lower than the reported ranges in adults (3.69 to 24%). No child with deciduous dentition was found to have a CSI. The lack of CSI in deciduous patients with CMF fracture could be explained by the anatomic differences between pediatric and adult cervical spines and supports conservative imaging for children in this age group (level of evidence, III).

Nail Plate Combination Technique for Native and Periprosthetic Distal Femur Fractures.

In the elderly, low-energy distal femur fractures (native or periprosthetic) can be devastating injuries, carrying high rates of morbidity and mortality, comparable with the hip fracture population. Poor, osteoporotic bone quality facilitates fracture in a vulnerable anatomical region, and as a result, operative fixation can be challenging. With goals of early mobilization to reduce subsequent complication risk, using the nail plate combination technique can offer stable, balanced fixation allowing for immediate weight bearing and early mobilization. We outline the rationale, technical steps, and early clinical outcomes after nail plate combination in the treatment of osteoporotic distal femur (native or periprosthetic) fractures.

Low-Energy Pelvic Ring Fractures in the Elderly Population: Expected Outcomes and Associated Mortality Rates.

BackgroundThe aim of the study was to uncover mortality risk utilizing a retrospective review at a level I trauma center in addition to demographic factors.MethodsPatients aged 65 and older with low-energy closed pelvic ring fractures treated non-operatively from 2007 to 2017 were queried from the level I trauma center database. Mortality rate and associated risks were calculated.ResultsThe average age of all the patients included in this study who sustained a low-energy pelvic fracture was 83.1 years (± 7.5; 66 - 97). The mean length of stay was 4.6 days (± 4.4; 0 - 37). The mean number of comorbidities was 2.2. The 1-year mortality rate was 23%. The relative risk (RR) of 1-year mortality for low-energy pelvic fractures for ages 65+ did not statistically differ compared to the US population in 2016 (6.6%) (RR: 1.0; 95% CI). The 2+ comorbidities showed a statistical significance in the pelvic fracture population with a P value of 0.037. Race, sex, discharge disposition and length of stay did not reach statistical significance (P > 0.05).ConclusionLow-energy pelvic injuries do not appear to increase rate of mortality compared to the US population. Fracture pattern, race, sex, discharge disposition and length of stay do not seem to have an effect on mortality. Elderly patients with an average age of 84.5 years and more than two comorbidities had higher rates of mortality; however, these patients were likely to sustain earlier mortality regardless of low-energy pelvic fracture.

Subsequent Fracture Prevention in Patients 50 Years and Older With Fragility Fractures: A Quality Improvement Initiative.

Because of osteoporosis, patients older than 50 years with fragility fractures are at risk of further fractures. We developed a quality improvement initiative based on an evidence-based Fracture Liaison Service (FLS) model of care to help prevent subsequent fractures. Previous to the implemented FLS model, less than 13% of patients with fragility fractures were assessed for osteoporosis at our institution. We created a registry tool to identify patients with fractures who were older than 50 years. Our interventions focused on identifying, contacting, and educating patients; and coordinating screening tests and an outpatient follow-up visit with an endocrinologist. Identification of patients older than 50 years with fragility fractures increased from 0% to 74.5%, with implementation of the fracture registry. Of those identified, 33.9% were screened and had a follow-up visit. The fragility fracture population older than 50 years is at risk of subsequent fractures and should be identified, contacted, educated, screened, and assessed for osteoporosis to prevent subsequent fractures.

Nutrition in Hip Fracture Units: Contemporary Practices in Preoperative Supplementation.

Introduction:Patients with hip fractures pose a significant burden on health services. Malnutrition, frailty, and cognitive impairment are common, and key to addressing the needs of this vulnerable patient group is nutrition optimization, including reduction in arbitrary nil by mouth (NBM) perioperative regimens. In order to understand current practices, we characterize preoperative nutrition in a regional hip fracture population.Methods:Prospective data were submitted to the National Hip Fracture Database by 6 hospitals in the north east of England over a 6-month period. Patients were stratified by preoperative nutritional intake, frailty, and cognitive function.Results:In all, 24.2% (n = 205) patients received no oral intake at all preoperatively; 15.3% of NBM patients were at risk of malnutrition; and 6.9% were malnourished at the time of assessment. Median time to surgery for NBM patients was 16.75 hours, and 6.34% of patients were fasted with no intake for >36 hours. In all, 6.5% (n = 44) of patients with an Abbreviated Mental Test Score (AMTS) of 8 or above were deemed to be at risk of malnutrition at admission, compared to 11.3% (n = 50) of patients with an AMTS of 7 or below. The NBM patients had similar mean Rockwood (4.97) and AMTS (6.51) scores to patients given oral nutrition.Conclusion:We have demonstrated contemporary preoperative nutritional practices in the management of over 800 hip fracture patients. Contrary to perception, nutrition practices vary little when stratified for age, cognition frailty, or comorbid burden. We have identified widespread prolonged NBM fasting and undersupplementation in patients sustaining hip fracture across a region. This work suggests a need to focus less on patient factors and more on systematic practices.

Assessment of Nutrition and Supplementation in Patients With Hip Fractures.

Introduction:Malnutrition is common in older people, is known to interact with frailty, and is a risk factor for wound complications and poor functional outcomes postoperatively. Sustaining a hip fracture is a significant life event, often resulting in a decline in mobility and functional ability. A poor nutritional state may further impede recovery and rehabilitation, so strategies to improve perioperative nutrition are of considerable importance. We provide a review of nutritional supplement practices in this vulnerable and growing population.Method:Systematic review of preoperative oral nutritional supplementation (ONS) in hip fracture patients.Results:We identified 12 articles pertaining to this important area of perioperative care. The findings suggest postoperative ONS can improve postoperative outcomes in hip fracture patients, especially in terms of increasing total serum protein, improving nutritional status to near-optimum levels, and decreasing postoperative complications.Discussion:There is an absence of evidence specific to preoperative ONS in patients admitted following hip fracture. Literature relating to other populations is encouraging but is yet to be robustly studied. It is unclear whether these results are generalizable to the frailer hip fracture population. There is a need for studies clearly defining outcome measurement and complication assessment pertaining to preoperative ONS. The potential benefit is considerable, and this review will provide a means to inform the construction of meaningful trials in preoperative ONS of patients sustaining hip fracture.Conclusion:Oral nutritional supplementation in hip fracture patients may decrease postoperative complications while increasing elderly patient’s nutritional state to a near-optimum level. This is extrapolated from postoperative literature, however with a clear gap in research pertaining specifically to preoperative care. The need for well-constructed studies focused on the impact and assessment of early ONS in this population is transparent.

Trunk Muscle Composition 2 Months After Hip Fracture: Findings From the Baltimore Hip Studies

ObjectiveTo determine if hip fracture patients would have smaller cross-sectional area (CSA) and lower radiological attenuation (suggesting greater fat infiltration) in all trunk muscles as compared to older adults without hip fractures. DesignCross-sectional analysis of computed tomography (CT) scans. SettingClinical imaging facility. ParticipantsForty-one white participants (19 men, 22 women) from the Baltimore Hip Studies seventh cohort at 2 months postfracture were compared to 693 white participants (424 men, 269 women) from the Health, Aging and Body Composition (Health ABC) study at the year 6 visit (N=734). InterventionNot applicable. Main Outcome MeasuresTrunk muscle CSA and attenuation values were obtained from a single 10-mm, axial CT scan completed at the L4-L5 disc space in each participant. ResultsThe hip fracture cohort had significantly smaller CSA for all trunk muscles (range: 12.1%-38% smaller) compared to the Health ABC cohort (P<.01), with the exception of the rectus abdominus muscle in men (P=.12). But, hip fracture patients, particularly female patients, had higher attenuation levels (lower intramuscular fat) in all trunk muscles (P<.0001). ConclusionsFindings are consistent with atrophy of the trunk muscles in the hip fracture population without a high level of intramuscular fat. Future work should evaluate the role of trunk muscle composition in the functional recovery of older adults after hip fracture.

Large variations in the practice patterns of surgical antiseptic preparation solutions in patients with open and closed extremity fractures: a cross-sectional survey

BackgroundSurgically-managed fractures, particularly open fractures, are associated with high rates of surgical site infections (SSIs). To reduce the risk of an SSI, orthopaedic surgeons routinely clean open fracture wounds in the emergency department (ED) and then apply a bandage to the open wound. Prior to the surgical incision, it is standard practice to prepare the fracture region with an antiseptic skin solution as an additional SSI prevention strategy. Multiple antiseptic solutions are available.ObjectivesTo explore the variation in practice patterns among orthopaedic surgeons regarding antiseptic solution use in the ED and antiseptic preparatory techniques for fracture surgery.MethodsWe developed a 27-item survey and surveyed members of several orthopaedic associations.ResultsTwo hundred and-ten surveys were completed. 71.0% of respondents irrigate the open wound and skin in the ED, primarily with saline alone (59.7%) or iodine-based solutions (32.9%). 90.5% of responders indicated that they dress the open wound in the ED, with 41.0% applying a saline-soaked bandage and 33.7% applying an iodine-soaked dressing (33.7%). In their surgical preparation of open fractures, 41.0% of respondents used an iodine-based solution, 26.7% used a chlorhexidine gluconate (CHG)-based solution, and 31.4% used a combination of the two. In closed fractures, 43.8% of respondents used a CHG-based solution, 28.1% used an iodine-based solution, and 27.1% used a combination. Despite theoretical concerns about the use of alcohol in open wounds, 51.4% used alcohol-based solutions or alcohol alone during skin preparation of open fractures.ConclusionsA lack of consensus exists regarding use of antiseptic surgical preparation solutions for fractures. High-quality clinical research is needed to assess the effectiveness of different surgical antiseptic preparation solutions on patient outcomes in fracture populations.

The prevalence of temporal bone fractures is high in horses with severe temporohyoid osteoarthropathy.

Temporohyoid osteoarthropathy is a well-recognized cause of equine neurologic disease. Temporal bone fractures associated with temporohyoid osteoarthropathy have been recognized with CT, however, little information is available regarding these fractures. The aims of this retrospective analytical study were to assess the prevalence of these fractures and to describe the specific configurations and associated imaging and clinical features. Fracture of the temporal bone was identified with CT in 16 of 39 included horses. All fractures were unilateral, minimally displaced and extended through the temporal bone in a rostrodorsal to caudoventral orientation. Two fracture configurations were identified: in nine cases, the fracture extended the full width of the petrous pyramid into the cranial vault and in seven cases, the fracture only extended through the lateral part of the petrous temporal bone, not involving the cranial vault. Fusion of the temporohyoid joint was present in 13 of the 16 fracture cases. Quarter Horses were over-represented in the fractured population (14/16). All horses with fractures had ipsilateral neurologic deficits. Patient outcomes were not significantly different between temporohyoid osteoarthropathy horses with and without temporal bone fractures (P=0.68). However, six of the nine patients with cranial vault involvement did not return to their previous use. Findings support previous studies indicating that temporal bones should be carefully assessed for concurrent fractures when temporohyoid osteoarthropathy is identified in CT images, especially when there is fusion of the temporohyoid joint. An improved awareness of specific fracture configurations will help with detection of these fractures.

Characterization of the natural fracture system of the Eagle Ford Formation (Val Verde County, Texas)

The Eagle Ford Formation has attracted considerable industry attention as a self-sourced unconventional shale reservoir. The productive interval in the Eagle Ford Formation is the transgressive systems tract, which contains parasequences whose lithologic content varies upward with increasing proportions of limestones. Optimum success in both exploration and production depends on the adequate characterization of fracture systems as a function of lithology. The outcrops present along US Highway 90 in Val Verde and Terrell Counties, Texas, provide considerable insight into the regional natural fracture system of the Eagle Ford Formation. Fracture-orientation analysis reveals two sets of conjugate hybrid shear fractures and two sets of regional fractures. Abutting relationships suggest that hybrid shear fractures formed first, followed by the thoroughgoing northeast-striking fracture set, and finally by a northwest-striking set, which tends to be confined to individual mechanical units. The orientation of these fractures suggests that they formed during post-Laramide stress relaxation and progressive exhumation. Spacing-frequency distribution analysis of the fracture population reveals a mature hypersaturated fracture system that likely formed at depth by overburden load and/or fluid pressure near maximum burial. Our results indicate that the Eagle Ford Formation displays a well-developed fracture network regionally distributed in the Val Verde Basin, and likely present in the productive Eagle Ford play. These observations provide evidence for pathways and vertical connectivity for potential fluid pathways throughout the Eagle Ford Formation.

Biomimetic matrices for rapidly forming mineralized bone tissue based on stem cell-mediated osteogenesis

Bone regeneration, following fracture, relies on autologous and allogenic bone grafts. However, majority of fracture population consists of older individuals with poor quality bone associated with loss and/or modification of matrix proteins critical for bone formation and mineralization. Allografts suffer from same limitations and carry the risk of delayed healing, infection, immune rejection and eventual fracture. In this work, we apply a synergistic biomimetic strategy to develop matrices that rapidly form bone tissue - a critical aspect of fracture healing of weight bearing bones. Collagen matrices, enhanced with two selected key matrix proteins, osteocalcin (OC) and/or osteopontin (OPN), increased the rate and quantity of synthesized bone matrix by increasing mesenchymal stem/stromal cell (MSC) proliferation, accelerating osteogenic differentiation, enhancing angiogenesis and showing a sustained bone formation response from MSC obtained from a variety of human tissue sources (marrow, fat and umbilical cord). In vivo assessment of OC/OPN mineralized scaffolds in a critical sized-defect rabbit long-bone model did not reveal any foreign body reaction while bone tissue was being formed. We demonstrate a new biomimetic strategy to rapidly form mineralized bone tissue and secure a sustained bone formation response by MSC from multiple sources, thus facilitating faster patient recovery and treatment of non-union fractures in aging and diseased population. Acellular biomimetic matrices elicit bone regeneration response from MSC, obtained from multiple tissue sources, and can be used in variety of scaffolds and made widely available.

Quality of life in older adults following a hip fracture: an empirical comparison of the ICECAP-O and the EQ-5D-3\xa0L instruments

BackgroundThe purpose of this study was to empirically compare the performance of two generic preference based quality of life instruments, EQ-5D-3 L (with a health and physical function focus) and ICECAP-O (with a wellbeing and capability focus), in a population of older Australians following hip fracture.MethodsOlder adults or their family member proxies (in cases of severe cognitive impairment) following surgery to repair a fractured hip were invited to take part in this cross sectional study. Inclusion criteria included an age of 60 years or older, confirmed falls-related hip fracture and those receiving current palliative care or consented to other research studies were excluded. 87 participants completed the ICECAP-O and EQ-5D-3 L instruments between one and three weeks post-surgery.ResultsFor the hip fracture population, the mean ICECAP-O score was 0.639 (SD 0.206, n = 82) and the mean EQ-5D-3 L utility score was 0.545 (SD 0.251, n = 87). There was a statistically significant positive correlation between the ICECAP-O and EQ-5D-3 L scores (r = 0.529, p = < 0.001).ConclusionsStudy findings indicate significant impairments in quality of life post hip fracture. In multiple regression analyses, age and health-related QoL (measured by the EQ-5D) were significant determinants of ICECAP-O scores, while proxy respondent status, age, and capability-related QoL (measured by the ICECAP-O) were significant determinants of EQ-5D scores. Approaches to measuring and valuing quality of life in this sample, should consider the target domains of the intervention in their choice of instrument. Studies aiming to measure the impact of interventions targeting broader domains of wellbeing and QoL should consider including a broader measure of QoL in conjunction with a HRQoL measure.

Elastic Properties of Fractured Rock Masses With Frictional Properties and Power Law Fracture Size Distributions

AbstractWe derive the relationships that link the general elastic properties of rock masses to the geometrical properties of fracture networks, with a special emphasis to the case of frictional crack surfaces. We extend the well‐known elastic solutions for free‐slipping cracks to fractures whose plane resistance is defined by an elastic fracture (shear) stiffness ks and a stick‐slip Coulomb threshold. A complete set of analytical solutions have been derived for (i) the shear displacement in the fracture plane for stresses below the slip threshold and above, (ii) the partitioning between the resistances of the fracture plane on the one hand and of the elastic matrix on the other hand, and (iii) the stress conditions to trigger slip. All the expressions have been checked with numerical simulations. The Young's modulus and Poisson's ratio were also derived for a population of fractures. They are controlled both by the total fracture surface for fractures larger than the stiffness length lS (defined by ks and the intact matrix elastic properties) and by the percolation parameter of smaller fractures. These results were applied to power law fracture size distributions, which are likely relevant to geological cases. We show that if the fracture size exponent is in the range −3 to −4, which corresponds to a wide range of geological fracture networks, the elastic properties of the bulk rock are almost exclusively controlled by ks and the stiffness length, meaning that the fractures of size lS play a major role in the definition of the elastic properties.

Position-by-position cooling paths within the Toki granite, central Japan: Constraints and the relation with fracture population in a pluton

Understanding the locational differences of time-temperature (t-T) paths within the granite contributes to clarifying the detailed formation history, especially the thermal evolution, of the entire pluton after the incipient intrusion of the granitic magma into the shallow crust. The position-by-position t-T paths of fifteen samples of the Toki granitic pluton, central Japan, are reconstructed from thermochronological data, including zircon U–Pb, biotite K–Ar, zircon fission-track (ZFT), and apatite fission-track (AFT) ages, FT length characterization, and FT inverse calculation. In case of sample No. 1, the t-T path consists of zircon U–Pb ages (74.0 ± 1.1 Ma and 72.6 ± 1.7 Ma), a biotite K–Ar age (73.0 ± 1.8 Ma), a ZFT age (57.2 ± 2.3 Ma), an AFT age (41.5 ± 2.7 Ma), and the FT inverse calculation. The t-T paths show position-specific characteristics that reflect the history of the pluton after the incipient intrusion of the granitic magma into the shallow crust. Shallow parts of the western and northeastern margins of the pluton show rapid cooling from the intrusion stage to the ZFT partial annealing zone (PAZ), and thus represent position-specific characteristics in relation to crustal assimilation in the intrusion/emplacement processes. The cooling behavior around the condition of AFT PAZ was interpreted as a reflection of regional tectonic exhumation of the pluton. This study also presents useful knowledge to evaluate fracture populations in a granitic pluton. The relationship between the position-specific t-T path and fracture frequency (fracture number per unit interval) provides a criterion for evaluating the fracture population of the granitic pluton, called ‘thermochronological evaluation’, which is a key insight to investigating fluid flow and mass transfer in the rock mass. The t-T path shows whether cooling was slow or rapid from thermal conditions of solidification/crystallization to the biotite K–Ar closure temperature; parts of the pluton that cooled slowly correspond to parts with high frequencies of fractures, and vice versa. The absolute value for duration between the zircon U–Pb age evaluated from the oscillatory-zoned area (OZ age) and biotite K–Ar age shows high correlation with fracture frequency (R2 = 0.89), and thus gives a quantitative indicator for evaluating fracture frequency; longer duration accompanies higher frequency. A combination of thermochronological evaluation, the local cooling indicator, and the lithofacies effect can be applied as potential diagnostic tools for detailed evaluation of the fracture population.

The focused abdominal sonography for trauma examination can reliably identify patients with significant intra-abdominal hemorrhage in life-threatening pelvic fractures.

The focused abdominal sonography for trauma (FAST) examination has been reported to be unreliable in pelvic fracture patients. Additionally, given the advent of new therapeutic interventions, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), rapid identification of intra-abdominal hemorrhage compared with Zone III hemorrhage may guide different therapeutic strategies. We hypothesized that FAST is reliable for detecting clinically significant intra-abdominal hemorrhage in the face of complex pelvic fractures. Our pelvic fracture database of all hemodynamically unstable patients requiring intervention from January 1, 2005, to July 1, 2015, was reviewed. The FAST examination was compared with operative and computed tomography (CT) scan findings. Confirmatory evaluation for FAST(-) patients was considered positive if therapeutic intervention was required. During the study period, 81 patients in refractory shock with FAST imaging in our emergency department (ED) underwent pelvic packing. Mean age was 45 ± 2 years and Injury Severity Score was 50 ± 1.5. The FAST examination was negative in 53 patients; 52 patients did not require operative intervention for abdominal bleeding while one patient required splenectomy. The FAST examination was positive in 28 patients; 26 had findings confirmed by CT or laparotomy while two patients did not have intra-abdominal hemorrhage on further evaluation. The sensitivity and specificity for FAST in this population was 96% and 96%, respectively, positive predictive value was 93%, and negative predictive value was 98%. The false-negative and -positive rates for FAST were 2% and 7%. Focused abdominal sonography for trauma examination reliably identifies clinically significant hemoperitoneum in life-threatening, pelvic fracture related hemorrhage. The incidence of a false-negative FAST in this unstable pelvic fracture population was 2%. FAST results may be used when determining the role of REBOA in these multisystem trauma patients and requires further study. REBOA placement should be considered in hemodynamically unstable pelvic fracture patients who are FAST(-), while laparotomy should be used in FAST(+) patients. Therapeutic, level IV.

Defining the width of the normal tibial plateau relative to the distal femur: Critical normative data for identifying pathologic widening in tibial plateau fractures.

Tibial plateau widening in the setting of fracture is an indication for surgical treatment, and restoring width is an important goal of surgery. In order to identify and correct pathological widening, the width of the normal tibial plateau must first be defined. The aim of this study was to establish normative data for the width of the tibial plateau relative to the distal femur to enable surgeons to identify and correct pathological widening in the setting of tibial plateau fracture. Fifty-one uninjured anteroposterior (AP) knee radiographs and 11 XR and CT scans of lateral tibial plateau fractures were retrospectively reviewed. The distances measured included maximal distal femoral width, femoral articular width, tibial articular width, and lateral plateau widening. On average, lateral plateau widening was +0.02±2.03mm, indicating that the most lateral aspect of the tibial plateau is collinear with the most lateral aspect of the lateral epicondyle of the femur. In the fracture population, average widening was 7.13±3.59mm on XR and 6.57±3.34mm on CT, with an absolute difference between XR and CT of 1.19±0.66mm. In conclusion, this study is the first to define the radiographic anatomy of the proximal tibia quantitatively. In the setting of tibial plateau fracture, residual widening of 2.1mm could be within normal variation. However, the authors consider widening >2.1mm pathological. These values can be used for assessing pathological widening of tibial plateau fractures. Clin. Anat. 31:688-692, 2018. © 2018 Wiley Periodicals, Inc.

Radiation Exposure During Operative Fixation of Pediatric Supracondylar Humerus Fractures: Is Lead Shielding Necessary?

Factors that impact radiation exposure during operative fixation of pediatric supracondylar humerus (SCH) fractures have been investigated; however, no studies have measured the equivalent dose at the patient's radiosensitive organs. Our hypothesis was that intraoperative fluoroscopy exposes pediatric patients to a significant radiation load and lead shielding of radiosensitive organs is important. The goal of the study was to quantify the patient's radiation exposure during the procedure by measuring the radiation load at the thyroid and gonads. A prospective quality improvement project of radiation exposure during percutaneous fixation of isolated SCH fractures was performed over a 4-week period. The c-arm image intensifier was used as the operating table and radiation dosimeters were positioned over the thyroid and gonadal lead shields. Fluoroscopy times were recorded, doses were calculated, and the dosimeters were analyzed. To assure that the prospective cohort was representative of a larger population of SCH fractures, demographics and fluoroscopy time of the prospective cohort were compared with a 12-month retrospective cohort in which dosimetry was not performed. Prospective cohort-18 patients with type 2 (8) and type 3 (10) fractures were prospectively studied with intraoperative measurement of thyroid and gonadal radiation equivalent doses. Mean age was 4.9 years (1.9 to 9.5 y) and mean weight was 21.4 kg (13.1 to 33.5 kg). Mean fluoroscopy time was 65.0 seconds (25.3 to 168.4 s), and absorbed skin dose at the elbow was 0.47 mGy (0.18 to 1.21 mGy). The radiation dosimeters overlying the thyroid and gonads measured minimal radiation indicating equivalent doses of <0.01 mSv for all patients in the prospective cohort.Retrospective cohort-163 patients with type 2 (60) and type 3 (103) fractures were retrospectively studied. The mean age was 5.5 years (0.02 to 13.7 y) and weight was 21.6 kg (2.0 to 71.9 kg). Mean fluoroscopy time was 74.1 seconds (10.2 to 288.9 s), and absorbed skin dose at the elbow was 0.53 mGy (0.07 to 2.07 mGy).There were no statistically significant differences between the cohorts. The smaller prospective cohort had fluoroscopy times and radiation doses that were not statistically different from the larger retrospective cohort, suggesting that the dosimeter measurements are representative of intraoperative radiation exposure during fixation of pediatric SCH fractures. The equivalent dose to the thyroid and gonads was minimal and approximates daily background radiation. Shielding of radiosensitive organs is appropriate when practical to minimize cumulative lifetime radiation exposure, particularly in smaller patients and when longer fluoroscopy times are anticipated. Level 2.

Opioid Use Disorders Are Associated With Perioperative Morbidity and Mortality in the Hip Fracture Population.

To determine whether opioid use disorders (OUDs) are associated with adverse perioperative outcomes in patients undergoing surgical fixation for proximal femur fractures. The National Hospital Discharge Survey was queried to identify patients surgically treated for proximal femur fractures between 1990 and 2007. Patients were grouped into those with a diagnosis of OUD, nonopioid drug use disorder, or neither. Demographic information and comorbidities were included in univariable and multivariable analyses to identify independent risk factors for perioperative outcomes. A total of 8154 patients with a diagnosis of drug use disorder and 4704 patients with a diagnosis of OUD were identified from a cohort of 4,732,165 surgically treated proximal femur fractures. Patients with OUD were significantly younger (46 vs. 79), and a significantly smaller proportion of them had medical comorbidities (21.9% vs. 60.2%) when compared with the no drug misuse cohort. Patients with OUD had significantly more medical complications (51.1% vs. 26.8%), mechanical complications (3% vs. 0.3%), and adverse events (55% vs. 39.7%) when compared with the no drug misuse group. OUD had higher odds for leaving against medical advice [odds ratio (OR) 12.868, range 10.7771-15.375], for any adverse event (OR 4.107, range 3.869-4.360), and for mortality (OR 1.744, range 1.250-2.433) when compared with nondrug misusers. Despite being younger and with significantly less medical comorbidities, patients with OUD have higher odds for adverse events, leaving against medical advice, and mortality after surgical treatment of a hip fracture. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.