Heterotopic ossification (HO) is a frequent complication after surgical management of distal humerus fractures. This study aimed to identify factors associated with HO formation following fixation of AO/OTA type C distal humerus fractures, with particular attention to the potential influence of the olecranon osteotomy approach. We retrospectively analyzed 57 patients who underwent open reduction and internal fixation for intra-articular distal humerus fractures (AO/OTA 13C1-C3) between 2015 and 2024. Patients treated with either olecranon osteotomy or paratricipital approaches were included. Demographic, clinical, and radiological data were collected, and HO was graded using the Hastings and Graham classification at six months postoperatively. Statistical analyses were conducted to identify independent risk factors for HO. HO was observed in 31 patients (54.4%). HO was significantly associated with the surgical delay of ≥ 6 days (OR = 4.94; p = 0.005), and AO/OTA type C3 fractures (31.6%) (OR = 5.11; p = 0.008). The use of olecranon osteotomy (31.6%) initially appeared to increase the risk of heterotopic ossification (OR = 4.13; p = 0.020) in univariate analysis; however, this significance diminished after adjustment for confounding factors in the multivariate analysis (OR = 2.97; p = 0.123). Age, surgical duration, intraoperative blood loss, and trauma energy did not show significant association with HO. The incidence of higher-grade HO (≥ 2) (67.7%) was also more frequent in patients with these risk factors. Olecranon osteotomy, delayed surgery, and AO/OTA type C3 fracture patterns are independent risk factors for HO development following distal humerus fracture surgery. Surgeons should consider early intervention and triceps-sparing approaches to minimize HO risk, particularly in complex fractures. Not applicable. This study is a retrospective study with ethics committee approval.

Radial head fractures (RHF) plate fixation has been associated with chronic pain and stiffness. This study aimed to evaluate if the new generation of anatomic low-profile locking-plates (ALPLP) allows to obtain satisfactory results lowering the complication rate and the need for reintervention. Fifty-seven patients treated with ALPLP for RHF were analyzed: 24 were Mason II fractures and 33 were Mason III fractures. Post-operative and follow-up radiographs, range of motion and clinical scores (MEPS, DASH and ASES-e) were evaluated. Complications and reinterventions were recorded. The statistical analysis was performed using the ANOVA with post-hoc Tukey and Chi-squared test. The mean follow-up was 5 years. The mean ROM was 9°-140° in extension-flexion and 81°-81° in pronation-supination; the mean MEPS, DASH and ASES-E were 98, 3 and 93.9, respectively. Eight patients underwent reinterventions during follow-up, two patients developed asymptomatic nonunions. Significant differences were observed between Mason II and Mason III patients as for flexion and between patients who underwent "in situ" or "on table" reconstruction in terms of MEPS. Degenerative changes appeared to be significantly more frequent in RHF with involvement of the articular surface with respect to isolated neck RHF. The main indications for osteosynthesis with ALPLP were a Mason II fracture with sinking of the head-neck junction and a multifragmentary Mason III fracture without radial neck comminution; with these indications, ALPLP provide satisfactory results in most cases, allowing to preserve the radial head in 96.5% of cases. The anatomical reduction of fracture, the sub-equatorial positioning of the plate in the "safe zone", the reconstruction of the annular ligament without excessive tension and the early rehabilitation are the four main factors that affect results.

Nasal bone fractures are the most common type of facial bone fracture. Closed reduction is the standard treatment and is typically followed by intranasal packing. Conventional materials such as Vaseline or Furacin roll gauze and Merocel are widely used, but biodegradable synthetic polyurethane foam (SPF, Nasopore) has recently gained popularity as it does not require removal. This study focused on postoperative pain primarily caused by mucosal injury, and investigated whether polyvinylpyrrolidone (PVP), a mucosal protective agent, could reduce pain when applied to SPF packing. A retrospective review was conducted of 117 patients who underwent closed reduction for nasal bone fractures at the authors' hospital between March 2019 and February 2022. Sixty patients received PVP-soaked SPF, while 57 patients received SPF alone. Postoperative pain was assessed by comparing the mean frequency of daily analgesic administrations during hospitalization. Of the 117 patients, 57 were included in the SPF group (group A) and 60 in the PVP-SPF group (group B). The mean frequency of analgesic administration until postoperative day 2 was 0.68 in group A and 0.50 in group B, demonstrating a significantly lower analgesic requirement in the PVP-SPF group (P = 0.013). Following closed reduction of nasal bone fractures, intranasal packing serves to stabilize the fracture site, achieve hemostasis, and protect the nasal mucosa. As pain is predominantly derived from mucosal injury rather than osseous movement, the use of PVP-soaked SPF may effectively reduce postoperative discomfort and improve patient satisfaction. These findings suggest that PVP-soaked SPF represents a valuable option for postoperative nasal packing.

Femoral head fractures resulting from hip dislocations are rare injuries resulting from high-velocity trauma. Garrett Pipkin, in 1957, classified these fractures into four types. All varieties are associated with hip dislocations, which are attended to as emergencies. Few cases of isolated femoral head fractures without hip dislocation have been published in the literature; we describe one such atypical variant. A 38-year-old male presented with a history of pain and swelling in his right knee following a traffic accident. After 48 hours of bed rest on ambulating, the patient had mild right hip discomfort, but hip examination was essentially normal. Radiology was repeated with plain radiographs and non-contrast computed tomography (NCCT), followed by contrast-enhanced magnetic resonance imaging (MRI) pelvis with bilateral hips. He had a fracture of the head of the femur and acetabular lip with concentric joint. Without hip dislocation, this was an unusual presentation of Pipkin Type IV fracture of the femoral head & posterior acetabular lip. It was managed with open reduction and lag screw fixation of supra-foveal femoral head fracture approaching through the acetabular bony rim avulsion, which was later fixed with lag screw and spring plates. The patient recovered well. This was an unusual presentation of Pipkin type IV fracture without hip dislocation and can be missed due to a subtle presentation, not yet described in the literature. A high degree of suspicion and advanced radiology helped in the appropriate management of the case.

Finite element analysis. To investigate the biomechanical response of posterior short-segment fixation with or without intermediate screws at the index vertebra in osteoporotic thoracolumbar burst fractures using finite element analysis. Spinal fixation in elderly patients with osteoporotic vertebral fractures is challenging because osteoporosis weakens the screw-bone interface, leading to screw loosening and loss of fracture reduction. Short segment fixation with intermediate screws has been proposed to reduce kyphosis recurrence and implant failure in unstable thoracolumbar fractures. However, the mechanisms by which intermediate screws enhance fixation strength in osteoporotic spines remain unclear. Six finite element models of T12 burst fractures were developed to simulate short-segment stabilization under normal or osteoporotic bone conditions, with/without augmentation screws at the fractured vertebra. Spinal stiffness, implant stresses, and axial displacement/micromotion of the bony defect were measured and compared under mechanical loading. Osteoporotic models exhibited a greater range of motion (ROM) than normal bone. All six-screw constructs reduced ROM across all motions compared with traditional four-screw models. Osteoporotic fracture models gained greater benefit from intermediate screw augmentation at the fracture vertebra, which also lowered axial displacement/micromotion. In six-screw models, rod stress increased while pedicle screw stress decreased. Intermediate screws at fractured vertebrae produced similar changes in stress distribution across all fixation models, regardless of bone quality. Our findings may facilitate implant selection for osteoporotic burst fractures, supporting the use of more rigid fixation sixscrew constructs to reduce the risk of mechanical failure and postoperative re-collapse.

Impact of surgical timing on perioperative outcomes after open reduction and internal fixation of periprosthetic proximal femoral fractures.

Clinical study on arthroscopic reduction and internal fixation for malunion and nonunion talus fractures classified as type II by Zwipp.

The aim of this study was to evaluate the biomechanical efficiency of different Schanz screw positions for indirect reduction of distal femur fractures using finite element analysis. A three-dimensional finite element model of a comminuted distal femur fracture was constructed, incorporating relevant anatomical structures including ligaments, menisci, and the gastrocnemius muscle. A 30 N posterior force simulated gastrocnemius-induced deformity, followed by a 15 N horizontal traction force applied through Schanz screws inserted at six positions (hole 1 to 6) on a standard distal femur locking plate. Residual displacement and reduction ratios were measured to assess reduction efficiency. The model successfully replicated the characteristic posterior displacement (~15 mm) caused by gastrocnemius contraction. Among the six pin positions, hole 6 (most anterior and distal position) achieved the greatest reduction (12.90 mm) with an 86.83% correction ratio, while hole 4 (most posterior and distal position) performed the worst (26.88%). More anterior and distal pin locations provided superior reduction outcomes due to improved mechanical advantage and alignment with the deforming force vector. Schanz screw placement significantly influences the effectiveness of traction-assisted reduction in distal femur fractures. Hole position 6 yielded the most optimal biomechanical performance and may serve as a practical reference for optimizing intraoperative pin placement, potentially improving surgical efficiency and outcomes.

Resuscitative transesophageal echocardiography (TEE) is an effective tool for managing perioperative cardiac arrest in non-cardiac surgery. We present a case of a patient, who suffered hemodynamic collapse following induction of general anesthesia for open reduction and internal fixation of a traumatic pelvic fracture. Resuscitative TEE helped make a diagnosis of acute massive pulmonary embolism leading to emergent surgical pulmonary embolectomy. Resuscitative TEE also helped guide CPR and central venous access. Our case highlights the utility of resuscitative TEE during management of intraoperative cardiac arrest.

An Improved Path Planning Algorithm for Precise Fracture Reduction of an Orthopedic Robot

Study Design: A retrospective study. Objective: This study mostly focuses on addressing malocclusion related to the fractures and outcome after doing open reduction and internal fixation. Methods: Our retrospective study included 43 patients diagnosed with unilateral and bilateral Le-fort fractures who went open reduction and internal fixation. Demographic data, causes of trauma, accompanying facial bone fractures, treatment methods, and complications were analyzed. Fisher’s exact test was employed to assess the association between fractures and malocclusion. Results: During follow up days 10 patients complains of sensory, 4 patients complain of derranged occlusion, 3 patients complain of facial deformation and 2 patients complains of sensitivity of teeth. Condylar fractures showed a statistically significant association with occlusal disorders (P = 0.044). Surgeon variability did not significantly impact occlusal outcomes (P = 0.25). Conclusions: Management of facial bones requires a thorough understanding of surgical principles, anatomy, occlusions and consideration of concomitant fractures. Fracture reduction is gained based on occlusion is crucial for successful outcomes, and in some old cases additional Le Fort I osteotomy may be considered. Occlusion is key factor in management of any facial bones, mostly mandibular and maxillary factures.

Atrophic jaws are frequently seen in edentulous patients due to early tooth loss, leading to progressive alveolar bone resorption, bone fragility, and increased susceptibility to fractures, even with low-energy trauma. Surgical management of these fractures presents additional challenges, such as reduced bone density, fragment instability, reduced blood flow, and lack of natural occlusal support. With advances in implant-supported rehabilitation, new perspectives have emerged, but risks remain, especially in areas with severe resorption. Iatrogenic fractures can occur during implant placement due to reduced bone thickness. Fracture reduction and adaptation of reconstruction plates are also limited by atrophic anatomy, compromising the stability of osteosynthesis. This paper reports the case of a 55-year-old patient with an iatrogenic fracture in the atrophic mandible after an attempt at dental implant placement. The treatment involved 3-dimensional virtual planning, biomodel printing, and prior adaptation of a reconstruction plate. The use of digital planning contributed to greater predictability, precision, and reduced surgical time. During the postoperative period, the patient developed an infection in the fistula region, which was successfully treated with antimicrobial photodynamic therapy (aPDT) with methylene blue, demonstrating efficacy in controlling the infection and accelerating healing. It is concluded that the management of atrophic mandibles remains challenging, requiring therapeutic individualization, and the use of digital technology through virtual surgical planning and 3-dimensional prototyping has proven to be an important tool in mandibular fracture surgery, although limitations persist regarding the accuracy of condylar positioning in edentulous patients.

Aim: The study aimed to compare the outcomes of closed reduction and splinting performed by emergency physicians and orthopedic surgeons in cases of both-bone forearm fractures. Materials and Methods: This retrospective study included pediatric patients with both-bone forearm fractures. Surgical intervention, hospitalization, and discharge outcomes following closed reduction performed by emergency and orthopedic physicians were evaluated. Results: A total of 91 patients were included, with a mean age of 9.97 ± 3.58 years, of whom 72.5% were male. Statistically significant differences were observed in surgical intervention rates (p=0.006) and hospitalization rates (p=0.001) between emergency physicians and orthopedic surgeons, while discharge outcomes showed no significant difference (p=0.590). Conclusion: The comparable discharge rates between emergency physicians and orthopedic surgeons emphasize the value of emergency physicians' role in closed reduction. Emergency physicians can achieve high-quality reductions in pediatric both-bone forearm fractures with full functional recovery.

Background: Mandibular condylar fractures constitute nearly one-third of all mandibular fractures and, if inadequately treated, may result in significant functional and anatomical sequelae. While closed reduction has traditionally been preferred, open reduction and internal fixation (ORIF) through the retromandibular transparotid approach (RMA) provides direct visualization, stable fixation, and anatomical accuracy. Aims and Objectives: This study aimed to evaluate the effectiveness, safety, and post-operative outcomes of the RMA in the management of condylar and subcondylar fractures. Materials and Methods: A prospective clinical observational study was conducted in the Department of Oral and Maxillofacial Surgery, Bharatpur Hospital. Twelve patients with condylar neck or subcondylar fractures underwent ORIF through the RMA. Clinical and radiographic data were analyzed for operative access, duration, mouth opening, occlusion, facial nerve function, scarring, and complications. Results: The patients (10 males and two females; mean age was 36.3 years, range 21–56 years) showed excellent functional recovery. The mean post-operative interincisal opening improved to 28.6±4.8 mm (P=0.001). All patients achieved satisfactory occlusion intraoperatively; one patient developed a minor occlusal discrepancy, which was corrected with selective intermaxillary fixation. No cases of transient or permanent facial nerve weakness, wound dehiscence, infection, salivary fistula, or sialocele were observed. Scars were esthetically acceptable, with no patients reporting visible marks during follow-up. Conclusion: The RMA provides excellent access and visualization for anatomical reduction and rigid fixation of condylar fractures. It ensures favorable functional and esthetic outcomes with minimal complications, establishing it as a safe and reliable technique for managing condylar and subcondylar fractures.

Fractures of the calcaneus and talus are among the most complex injuries of the hind foot, requiring precise anatomical orientation to select the optimal surgical approach, achieve accurate fracture reduction, and ensure stable fixation. This study aimed to synthesize contemporary anatomical, topographic, and clinical data that inform surgical decision-making in the treatment of calcaneal and talar fractures, with a focus on minimizing postoperative complications. An information-analytical approach was employed, incorporating a systematic review of scientific literature, morphological and clinical analyses, and statistical evaluation of complication rates and correlations between fracture localization and the topography of vascular and neural structures. High-risk zones identified during surgical interventions include areas of the calcaneus containing nutrient foramina transmitting the medial and lateral calcaneal arteries, branches of the posterior tibial and fibular arteries, and the tarsal sinus. The study also highlights the influence of ligamentous and tendinous structures on fragment displacement and implant selection. Preoperative consideration of anatomical and biomechanical parameters was shown to reduce the risk of avascular necrosis, post-traumatic arthrosis, and neurological injury. The findings emphasize that detailed knowledge of hindfoot surgical anatomy is essential for successful osteosynthesis and improved functional outcomes.

Open tibial shaft fractures (OTSFs) pose significant therapeutic challenges due to high-energy trauma, extensive soft tissue damage, and contamination risks, complicating fracture stabilization and increasing infection rates. Conventional freehand closed reduction often requires multiple attempts, exacerbating soft tissue injury and radiation exposure. To address these limitations, this study evaluates a double reverse traction-assisted technique, hypothesizing that it could improve reduction accuracy and reduce complications in OTSFs managed with hexapod external fixators (HEFs). This retrospective cohort study analyzed the records of 55 hospitalized patients with AO/OTA type 42-A or 42-B OTSFs treated with HEF between March 2020 and March 2023. Double reverse traction-assisted closed reduction was performed on 28 patients (DRTA group), while traditional freehand closed reduction was performed on 27 patients (Freehand group). We documented fracture reduction time, fluoroscopy time, external fixation time, radiographic results, electronic prescription count, and complications. Final clinical outcomes were assessed using the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria at a mean follow-up of 15.3 months. Statistical analysis was performed using independent samples t-tests or the chi-square test. DRTA group demonstrated significantly shorter fracture reduction time (12.13 ± 2.12 vs. 17.14 ± 3.43 min; p < 0.001) and fluoroscopy time (8.12 ± 1.78 vs. 13.75 ± 2.62; p < 0.001) compared to the Freehand group. External fixation time showed no significant difference (p > 0.05). DRTA group exhibited superior radiographic alignment, with significantly reduced residual translation and angulation on AP/lateral views (all p < 0.05). The electronic prescription count for postoperative correction was significantly lower in the DRTA group (0.9 ± 0.7 vs. 1.4 ± 1.0; p < 0.05). The complication rate was lower in the DRTA group (32.1%) than in the Freehand group (48.1%), but this difference was not statistically significant (p > 0.05). ASAMI scores were similar between both groups (p > 0.05). ASAMI bone and functional scores were similar between groups. In this retrospective study, both reduction techniques achieved favorable therapeutic outcomes. However, the double reverse traction-assisted technique was associated with greater efficiency in fracture reduction, more accurate radiographic alignment, and a nonsignificant trend toward lower complications compared to traditional freehand reduction. These results indicate that the double reverse traction-assisted technique is a feasible and promising alternative, but its definitive advantages need to be confirmed by larger, prospective, randomized controlled trials.

Procedural care in pediatric emergency departments (PEDs) frequently involves painful and anxiety-provoking interventions such as fracture reductions and laceration repairs. These experiences can result in significant psychological impacts, including long-term anxiety and posttraumatic stress. To systematically map existing pediatric procedural experience measures in PEDs, focusing on pain, anxiety, and satisfaction associated with both pharmacological and nonpharmacological interventions. A comprehensive search was conducted across the MEDLINE, Embase, and Web of Science databases from inception to August 28, 2024. Additional references were identified through citation searching. All forms of primary research assessing pediatric procedural experiences, including both pharmacological and nonpharmacological interventions in emergency or urgent care settings, were eligible. Conference abstracts were included if sufficient data were available. Data were extracted using a custom extraction form. A narrative synthesis was performed, comparing demographic characteristics, interventions, and outcome measures. A total of 143 studies were included, with 82.5% focusing on pharmacological interventions and 14.7% on nonpharmacological strategies. Under half (45.1%) of reported outcomes included child self-reports. Satisfaction measures were predominantly caregiver-focused, and qualitative methods were employed in just 3.5% of studies. This review highlights the need for standardized frameworks integrating pain, anxiety, and satisfaction measures while prioritizing child perspectives. Current approaches often overlook emotional and psychological dimensions, relying on clinician- or caregiver-focused assessments and quantitative measures. Future research should prioritize the development of multidimensional, child-reported experience frameworks that integrate pain, anxiety, and satisfaction to guide more emotionally supportive and trauma-informed pediatric procedural care.

Background: High-frequency ultrasonography (US) is increasingly used to guide closed reduction in nasal bone fractures, but near-field resolution over the curved nasal dorsum depends critically on the acoustic coupling medium. We aimed to determine whether a semi-solid standoff gel pad (PAD) provides superior image contrast and signal stability compared with a liquid gel barrier (LGB) during intraoperative nasal bone fracture sonography. Methods: In this prospective, single-center, within-subject crossover study, 30 adults with isolated nasal bone fractures underwent intraoperative high-frequency US of the nasal dorsum under two coupling conditions differing only by the medium used: a 7 mm hydrogel standoff pad (PAD) and a custom-made 7 mm liquid gel barrier (LGB). All scans were acquired on the same platform using fixed B-mode presets (10 MHz, 4.0 cm depth, single focal zone at the cortex). Rectangular regions of interest (ROIs) were placed on the cortical interface (bone ROI) and adjacent soft tissue (soft-tissue ROI) at matched depth. For each subject and condition, contrast-to-noise ratio (CNR) and two signal-to-noise ratios (SNR_bone, SNR_soft) were derived from ROI gray-level statistics and compared using paired t-tests. Results: The PAD yielded a significantly higher CNR at the cortical interface compared to the LGB (3.46 ± 0.17 vs. 2.50 ± 0.19; mean paired difference 0.96, 95% CI 0.88-1.04; p < 0.0001). SNR_bone was also higher with PAD (4.31 ± 0.35 vs. 3.63 ± 0.34; difference 0.68, 95% CI 0.52-0.83; p < 0.0001). Using the soft-tissue ROI as the noise reference (SNR_soft), PAD again outperformed LGB (7.64 ± 0.73 vs. 6.68 ± 0.78; difference 0.96, 95% CI 0.59-1.33; p = 0.000012). Conclusions: Compared with a liquid gel barrier of similar thickness, a semi-solid standoff gel pad provides higher near-field CNR and SNR at the nasal cortical interface under standardized intraoperative conditions. These quantitative differences support the use of a gel pad as a practical coupling medium for real-time ultrasound guidance during closed reduction in nasal bone fractures, although the impact on clinical outcomes remains to be determined.

To explore clinical efficacy of ultrasound-guided manual reduction combined with external fixation with small splints of fir bark in treating O'Brien typeⅡand Ⅲ radial neck fractures in children. A retrospective analysis was conducted on clinical data of 21 children with type O'BrienⅡand Ⅲ radial neck fractures admitted from June 2023 to December 2024, including 11 boys and 10 girls; aged from 4 to 12 years old with an average of (8.43±1.60) years old;12 patients with O'Brien typeⅡand 9 patients with type Ⅲ. All treatments were carried out using ultrasound-guided manual reduction. Ultrasound examination was conducted again to check the quality of fracture reduction after reduction was completed. After the treatment, external fixation with small splints of fir bark was performed. The success rate of manual reduction and the incidence of complications during the process of manual reduction were observed. Postoperative images and post-operative functions were evaluated using Metaizeau standard. All the children were followed up, and the duration ranged from 3 to 12 months. Closed reduction was successful in 19 children, while 2 children had difficulty in reduction and were transferred to surgical treatment. No related complications such as neurovascular injury occurred. Closed reduction was successful in 19 patients. Postoperative X-ray films showed good alignment and alignment of fractures, and the fracture healing time ranged from 4 to 7 weeks. Metaizeau criteria at 3 months after treatment, 17 patients were excellent and 2 good. In the later functional evaluation, all 19 patients were rated as excellent, and no obvious elbow joint dysfunction or residual pain occurred. Ultrasound-guided manual reduction could effectively increase success rate of manual reduction for O'Brien typeⅡand Ⅲ radial neck fractures in children, and reduce radiation and adverse outcomes.

Emergency medicine (EM) physicians must be competent in managing distal radius fractures, yet training gaps exist. This study evaluated academic EM physician proficiency in managing a simulated distal radius fracture and the impact of a simulation-based mastery learning (SBML) intervention. We conducted a pretest-posttest study of board-certified or board-eligible EM physicians at a university-based training hospital between August and December 2023. Four trained facilitators assessed participants on distal radius fracture management using a task trainer and a 41-item checklist with a minimum passing standard (MPS) of 37/41 (90.2%). The SBML intervention included baseline assessment, individualized feedback, deliberate practice, and reassessment. Fifty-one physicians participated in the pretest, with a median score of 32/41 (78.0%) and 10 (19.6%) achieving the MPS initially. Of the 20 participants who completed the posttest, 19 (95%) achieved the MPS after SBML intervention. The intervention resulted in a significant mean score improvement of 8.4 points (95% confidence interval: 6.92-9.78; P < 0.01). Only performing a distal radius fracture reduction in the past year significantly predicted higher pretest performance (3.3 points higher, P = 0.04). Participant comfort with all aspects of distal radius fracture management significantly improved after SBML. Academic EM physicians demonstrated performance gaps in distal radius fracture management that were effectively addressed by SBML. Few clinical experience metrics predicted performance, suggesting a need for targeted educational interventions to maintain skills in this important procedural area.