Fracture Side Research Articles

INFLUENCE ISCHEMIA-REPERFUSION ON THE MORPHOLOGICAL CHANGES LARGE JOINTS OF THE LOWER EXTREMITIES UNDER COMBINED ABDOMINO-SKELETAL INJURY

To study the effect of limb reperfusion in a model of combined abdominal-skeletal trauma and massive blood loss on histological changes of the knee joints. The experiment used 40 adult white male Wistar rats weighing 190-220 g, which were on a standard diet of vivarium. The experimental animals who modeled closed abdominal trauma, skeletal trauma, massive external blood loss, and ischemia-reperfusion of the lower extremities. The studies were performed 21 days after trauma modeling. All trauma experiments were performed under thiopental sodium (40 mg·kg-1 mass). The closed femoral bone fracture was modeled by applying a single metered blow to a specially designed thigh device. Closed trauma to the abdominal organs was modeled by applying two metered blows to the abdominal cavity with a specially designed device. Massive external blood loss was modeled by blood flow from 20 to 22 % of circulating blood volume from the femoral vessels on the opposite side of the femur fracture. Lower limb ischemia­reperfusion was simulated by imposing hemostatic plaits on the proximal portions of the lower legs of the test animals for two hours. In the preparations of the tissues of the hip and knee joint tissue reactive changes characteristic of inflammatory processes was found: pronounced changes in the hyaline cartilage of the metepiphyseal plate of the joints, edema of the connective tissue, disruption of the ordered arrangement of the insert plates of the compact part of the bone, significant vascular disorders in the form of arteries, edema of the adventitious sheath of vessels was noted. Thus, it was determined that combined trauma combined with ischemia reperfusion of the lower extremities in the later periods after the traumatic period can cause reactive changes in the large joints of the lower extremities.

On the Strength of Hair across Species

Summary The hair of mammals varies in diameter across species from ∼60 μm in humans to over ∼400 μm in giraffes and elephants. Here, we establish that the tensile strength of hair generally decreases with increasing diameter. Although there is a commonality in the morphology of the hair in such differing species as they all possess a cortex surrounded by cuticles, there are also significant differences in the hierarchical structure that contribute to the observed differences in strength. In this work, the internal structure of the hair from different species is examined, with some unique peculiarities in javelina and capybara hair uncovered. The dimensional dependence of hair strength is compared using Weibull predictions. The good correlation of the strength of hair using such Weibull analysis suggests that the failure strength is dictated by the probability distribution of flaws within the cortex.

THE USE OF CAD/CAM TECHNOLOGY IN SURGICAL TREATMENT OF CONDYLAR HEAD FRACTURE


 
 
 Management of the condylar head fractures is still one of the most controversial issues of the maxillofacial surgery. The aim of the present study was to increase the accuracy and quality of the surgical treatment of condylar head fracture with the use of navigation sur- gical guide and patient specific reinforcement two-component plate and individualized fixator with the use of CAD/CAM technology. In study was included 8 patient with 10 condylar head fractured. In 5 cases was used navigation guides, in 4 cases (the biomechanical unfavorable) was used the patient specific two-component plate and only in one case we used individualized patient specific plate. A CT scan was done immediately after the operation. The reduction of the fragments and the location of the screws, plate and fixator were checked on the same view in the preoperative and postoperative pictures on the computer. The relation between the screw and the cortical bones was clearly shown on CT, and the sizes of the bicortical screws were suitable with no injury to the articular cartilage or surrounding tissue. The three-dimensional objects showed that the screw was in the designated position and the condyle had been replaced and fixed in the normal position. The height of the ramus on the fractured side was restored imme- diately postoperatively. The malocclusion was corrected and the passive mouth opening of each patient was never less than 3 cm. One patients had transient paralysis of the temporal branch of the facial nerve postoperatively, which gradually recovered within a 2 month. Postoperative clinical examination showed good occlusion and mouth opening of at least 3 cm in all patients after 3 months without pain. All patients regained normal mandibular movements and had short and invisible scars at 6 months’ follow-up. Given the small number of patients, this issue needs further study in randomized prospective studies involving more patients and evaluating long-term postoperative outcomes.
 
 

Concomitant injuries in maxillofacial fractures from head and neck division of surgery department at Dr. Sutomo General Hospital, Surabaya, Indonesia in 2015-2016 period

Introduction: Maxillofacial fractures were caused most by traffic accidents. This study aims to know about concomitant trauma in maxillofacial fractures.Method: Observational descriptive study to evaluate maxillofacial fracture patients in Head and Neck Division of Surgery Department, Dr Sutomo Hospital between 2015 – 2016.Result: Distribution of maxillofacial fracture patients in 2015 - 2016 based on sex, data on male patients was 77.52%. In 2015 male compared to female 70.5%, increased in 2016 male compared to female 83.82%. The side of fracture found midface fracture 48%, lower face 30.2% and combination mid and lower face 21.7%. Data on maxillofacial trauma with concomitant trauma were 46.5%. Concomitant injury in 2015 was 36.06% and in 2016 as many as 55.88% where there was an increase in cases of concomitant trauma. In 2015 there were 63.63% of the accompanying brain injuries, while in 2016 there were 42.1% brain injuries, where the trauma outside the brain injury also increased.Conclusion: Incidence of concomitant injuries in maxillofacial fractures is 46,5 %, and head injury found 50 % in concomitant injuries. The cause of traffic accidents were motorcycles.Â

Suprapatellar versus infrapatellar approaches in the treatment of tibia intramedullary nailing: a retrospective cohort study

BackgroundTibial shaft fractures are routinely managed with intramedullary nailing (IMN). An increasingly accepted technique is the suprapatellar (SP) approach. The purpose of this study was to compare the clinical and functional outcomes of knee joint after tibia IMN through an suprapatellar (SP) or traditional infrapatellar (IP) approach.MethodsRetrospective analysis was performed in patients with tibial shaft fractures that were treated with IMN through a SP or IP approach between 01/01/2014 and 31/12/2016. The clinical and functional outcomes of the knee were assessed with the Hospital for Special Surgery (HSS) Knee Score. Secondary outcomes included the operation time and intraoperative blood loss.ResultsA total of 50 patients/fractures (26 IP and 24 SP) with a minimum follow-up of 15 months were evaluated. All fractures were OTA 42. No significant differences were found between the two groups in age, gender, side of fractures, operation time, intra-operative blood loss, and follow-up time. No significant difference was seen in HSS score (P = 0.62) between them. Sub analysis of all the HSS components scores revealed no significant differences between pain (P = 0.57), the stand and walk (P = 0.54), the need for walking stick (P = 0.60) and extension lag (P = 0.60). The other HSS components showed full scores (IP 10 vs. SP 10) in both approaches, including muscle force, flexion deformity and stability components. The range of motion (ROM) component score was superior in the IP group (P = 0.04) suggesting a higher ROM.ConclusionsBoth SP and IP approach results in equivalent overall HSS knee scores. However, for the HSS component, the IP approach was superior to SP approach regarding the ROM.

Investigation of pelvic symmetry using CAD software.

Severe pelvic fractures often prove difficult for surgeons as they require patient-specific surgical treatment plans and customized equipment. Developing virtual patient-specific 3D pelvis models would ease the surgical planning process and enable development of custom fixation plates. This paper aims to examine pelvic symmetry to conclude whether the contralateral side may be used as a reference model for the fractured side of the pelvis. Fourteen subjects with intact pelvises were involved in this study. CT scans of the pelvises were converted to 3D models and the right sides of the pelvises were reflected and aligned with the left sides. A deviation analysis was then performed for each set of models and results showed that the average root mean square (RMS) of values was 1.14 ± 0.26 mm and the average percentage of points below a deviation threshold of ± 2 mm was 91.9 ± 5.55%. The deviation color maps (DCMs) showed that the largest deviations were on the non-articular surfaces. The volume and surface area of each model were also examined and showed no significant differences between left and right sides. These results indicate that the pelvis displays bilateral symmetry and this concept can be used to develop fully intact patient-specific 3D pelvis models for fracture reconstruction using the unfractured contralateral side. Graphical Abstract.

Risk factors for pneumonia following rib fractures

IntroductionPneumonia is a known complication following rib fractures. This study was undertaken to identify clinical and demographic factors associated with the development of pneumonia among trauma patients with rib fractures. MethodsThis retrospective study examined trauma patients with one or more rib fractures, who were admitted for inpatient management during the time period 2012 through 2017. Variables studied included age, gender, injury severity score (ISS), mechanism of injury, smoking status, alcohol use, administration of influenza and pneumococcal vaccine, number and side of rib fracture(s), pulmonary contusion, pneumothorax, flail chest, spirometer use, blood transfusion, and intravenous fluid administration. ResultsAmong 78 cases and 74 controls (matched for age and ISS), patients who developed pneumonia were more likely to be male, have higher number of rib fractures, alcohol consumption of 1–5 drinks per day, and a higher initial volume of intravenous fluids during first 24 h. Patients with pneumonia were more likely to be treated with incentive spirometry. There were no difference in age, ISS, smoking status, side of rib fractures, pulmonary contusion, pneumothorax, flail chest, influenza vaccination, pneumonia vaccination, or mechanism of injury between the two groups. ConclusionRisk factors for the development of pneumonia following rib fractures include male gender, higher number of rib fractures, alcohol consumption, and higher rates of intravenous fluid administration during the initial 24 h following trauma.

The relationship between the status and position of third molars and the presence of mandibular angle and condylar fractures.

The aim of this study was to assess the relationship between the status and position of third molars, and the presence of mandibular angle and/or condylar fractures, in a group of patients treated for mandibular fractures, thus hoping to contribute to the knowledge of potential predictors of these fractures. A retrospective study was designated to include all the patients who were diagnosed and treated with open reduction and internal fixation for isolated mandibular angle fractures or isolated mandibular condylar fractures between 1st of January 2012 and 31st of December 2018. The following data were collected for each included patient: gender, age, etiology, site and side of the fracture, and presence and eruption state of third molars in the fracture side. Seventy patients were diagnosed with a condylar fracture, 48 with an angle fracture. No statistically significant difference was observed as for etiology and gender distribution between angle fracture and condyle fracture patients (p > 0.05). Angle fractures were statistically associated with the presence of third molars, whereas condylar fractures with the absence of third molars (p < 0.000005). The presence of completely erupted 3Ms was associated with condylar fractures (p < 0.05), and partially impacted 3Ms were associated with angle fractures (p < 0.0005). Mandibular angle fractures and third molar presence are associated in patients who present with mandibular fractures, especially if the third molar is incompletely erupted. This information should be kept in consideration as for the diagnosis and management of patients with mandibular fractures.

Correlation between Post-Operation Center-Trochanteric Distance (CTD) and Tip Apex Distance (TAD) changes in Intertrochanteric Fractures Treated by Dynamic Hip Screw

Background: One of the most common injuries and an important cause of mortality and morbidity in the elderly is intertrochanteric fracture. The dynamic hip screw (DHS) is one of the best procedures for fixation of these fractures; however, using DHS is accompanied by failure risk. Objectives: Therefore, with the purpose of reducing failure risk, this study aimed to evaluate the correlation between post-operation CTD and TAD, NSA changes in patients with intertrochanteric fractures. Methods: In this case series study, patients with intertrochanteric fracture treated with DHS between September 2015 and January 2016 were included. The exclusion criteria were pathologic fracture, multiple fractures, greater trochanter fracture, soft-tissue issues, A3OTA type, patients who missed the follow-up period, history of previous hip fracture or dislocation, and TAD>25mm. Ultimately, 24 patients were included in this study. Two surgeons reviewed the anteroposterior (AP) and lateral (Lat) radiographs. The measures of TAD, CTD, and NSA after six-months of follow-up were assessed. In addition, variables such as demographic data, fracture side, duration of operation, blood loss volume, weight bearing day, and Harris hip score (HHS) were analyzed. The relationship between post-operation CTD and TAD, NSA changes after six months of follow-up was analyzed. All data was analyzed using SPSS 20 software (SPSS, IBM Inc., USA). The significance level for all tests was considered to be 0.05. Results: This study evaluated 24 patients. The mean age of the patients was 69.9 ± 12.00 years, and 15 (62.5%) of them were male. No significant correlations were seen in the collected data, especially CTD and NSA changes after six-months of follow-up (p>0.05). Maximum and minimum TAD values after surgery were 25.6 and 11.0, respectively. Maximum and minimum TAD values at the six-month follow-up were 34.9 and 11.0, respectively. Mean TAD was constant at 19.8±5.3 in postoperative and follow-up measurements. This shows that patients experienced increases in TAD and others experienced decreases in TAD within the six months of follow-up. Conclusion: The results showed that despite the abnormal CTD after surgery, the risk of TAD changes increased. Generally, TAD is a well-established radiographic measurement for predicting the risk of cut-out. CTD and TAD can be used together or separately to predict the risk of DHS screw cut-out in patients with intertrochanteric fractures in future studies.

Icariin promotes early and late stages of fracture healing in rats.

This study aims to evaluate the effects of locally applied icariin on bone fracture healing in femur fractured rat model. The study included 64 male Sprague-Dawley rats (mean age 6 months; weighing, 280-490 g) in eight main study groups. Fracture healing process and level were evaluated with radiography, histopathology and dual energy X-ray absorptiometry to investigate the effects of local administration of icariin at varying doses, which is an exogenous osteo-inductive substance. Activities of superoxide dismutase (SOD) and glutathione peroxidase (GPx) were measured in the peripheral blood in addition to glutathione (GSH) and myeloperoxidase (MPO) levels to investigate the effects of icariin on the oxidant-antioxidant systems. Radiological bone mineral density measurements and histopathological findings revealed that icariin improved all these parameters in the two healing periods tested. Superoxide dismutase activity decreased in association with local icariin application to the fractured side whereas GPx and GSH increased and MPO remained unchanged. Icariin increased the GPx and GSH levels which are responsible from scavenging hydroxyl radical and hydrogen peroxide. Locally administered icariin to the fracture accelerated bone healing by reducing the oxidative stress.

Comparison of the efficacy of non-operative and surgical treatment of distal clavicle fractures in older children

Objective To compare the clinical efficacy of non-operative and surgical treatment of distal clavicle fractures in older children. Methods From January 2011 to March 2018, 41 older children with distal clavicle fractures were treated. Among them, 24 cases underwent non-operative treatment, shoulder abduction brace fixation for 4 to 6 weeks (non-operation group); while 17 cases underwent surgical treatment, open reduction and Kirschner wire internal fixation of the fractures on the affected side, and shoulder abduction brace fixation for 4 to 6 weeks (operation group). The fracture healing time, Constant-Murley shoulder function score and complication rate of the two groups were compared and analyzed. Results All the 41 cases were follow-up for 3 to 17 months, with an average of 8.4 months. There was no significant difference in gender, age and fracture side between the two groups, so two groups were comparable. All the incisions in the operation group achieved primary healing. X-ray examination showed that there was continuous callus formation at the fracture end and Kirschner wire was removed. The fracture healing time was (44.3±6.7) days. No early complications such as infection occurred. In the non-operation group, X-ray examination showed bone healing at the fracture end. The healing time was (41.7±7.6) days. At the last follow-up, there were no complications such as malunion of fracture, premature epiphyseal closure and obvious shoulder dysfunction in both groups. Constant-Murley shoulder joint function score: non-operative group was (97.7±4.7) points, while operation group was (96.5±3.7) points. There was no significant difference between the two groups (P=0.32). Conclusion Non-operative treatment of the distal clavicle fractures in older children has the same effect as surgical treatment. However, non-operative treatment has the advantages of less trauma, low cost and no need of secondary surgical removal of internal fixation. Key words: Clavicle; Fractures,bone; Child

Comminuted intra articular fracture of distal radius: Outcome of Management with closed reduction and percutaneous pinning.

Objectives: To determine the outcome and various complications in the management of comminuted intra articular fractures of distal radius in adults treated with closed reduction associated with Percutaneous Pinning. Study Design: Observational study. Setting: Department of Orthopaedic PUMHS, Nawabshah. Period: January 2017 to December 2018. Material and Methods: 45 consecutive cases of closed comminuted intra articular fractures of distal radius matching the inclusion criteria, all patients were adult aged between 23 – 38 years having Gartland and Werly type II and III fractures of 6 to 7 days duration. After initial resuscitation, thorough clinical examination done and all base line laboratory investigations and x-rays were obtained. The demographic and clinical data was recorded on a proforma. The patients were informed about the study and surgery and a written consent was taken and all of the patients were gone for closed reduction with percutaneous K – wiring. Functional outcome like union, healing and any complication were assessed. Patients were also checked for the range of movements. After 6 weeks, the K – wires and cast were removed and the procedure of physiotherapy started. After six weeks all the patients were advised for follow up at an interval of 3 months and 6 months. The data collected was statistically analysed and the results were tabulated. Results: 45 cases of closed intra articular fractures of distal radius were assessed, out of these 20 cases have Gartland type II and 25 cases have Gartland type III fractures. The age of patient was ranged between 23 – 38 years (mean 34+ 4.63), majority (55.6%) of patients were male. The left side of fractures were present in 66.3% of cases. All the patients checked for complications and that were seen in only 07 cases consisting of pin tract infection, reduced grip strength and finger stiffness. At the end of study period the range of movements in different directed were checked and evaluation was done according to modified Demerit scoring system. Conclusion: Closed reduction of distal radius with percutaneous pinning in comminuted intra articular fractures gives promising excellent results, it is a simple and minimal procedure providing anatomic reduction, fixation of fracture and maintenance of reduction with an suitable technique of immobilization.

Frequency of Mandibular 3rd Molar Presence and Position on Risk of Mandibular Angle Fracture

Objective of study was to determine the frequency of mandibular third molar presence and position in mandibular angle fractures. Study Design: Cross Sectional Study Setting: This study was carried out in department of dentistry, Nishtar institute of dentistry, Multan. Duration of Study : This study was conducted from 1 st July 2016 to 31 st January 2017. Methadology : Study was started after taking informed consent from the patients and approval of ethical committee. Fracture side was diagnosed by history and examination. Status of mandibular third molar (erupted, un-erupted and impacted) on the side of fracture was evaluated through clinical and radio-graphical examination. Data was collected for basic demographics (Age, Sex and side of fracture).Patients from both gender with age range of 25-40 years having mandibular angle fracture of any side of < one month duration were included in this study. Patients with history of extraction of mandibular third molar and those with history of fracture from gunshot injury were excluded from the study.Data was collected for mandibular third molar presence and position and noted in especially designed proforma. Results: A total of 158 patients of both gender with mandibular angle fracture of any side were included . Age range in this study was from 25 to 40 years with mean age of 32.689 ± 3.28 years, mean height 1.612 ± 0.04 meters, mean BMI 23.929 ± 2.08 Kg/m 2 and mean duration of fracture was 11.354 ± 6.08 days. Majority of the patients (55.7%) belongs to 25-33 years age groups. While males were 90.5% as compare to females 9.5%. UnErupted Mandibular third molar was seen in 12.7% patients, Erupted 44.3% and Impacted was 43%. Conclusion: Conclusion of this study is that the absence of an impacted third molar decrease the prevalence of mandibular angle fractures. Keywords: Mandibular angle fractures, Mandibular third molar, Frequency. DOI : 10.7176/JMPB/60-07 Publication date :October 31 st 2019

Efficacy of intravenous tranexamic acid in reducing perioperative blood loss in patients undergoing hemiarthroplasty

Introduction: Femoral neck fractures are frequent injuries in a trauma centre and have a high incidence in the general population. Hip fracture surgeries are associated with substantial blood loss, exposing patients to postoperative anaemia. The severity of anaemia is related directly to post-operative functional recovery of the patients, which is related to long-term mortality. Blood transfusion related adverse effects also can directly influence the recovery. Tranexamic acid is a simple and inexpensive synthetic antifibrinolytic agent, which prevents the degradation of fibrin and delays the breakdown of haemostasis clots. Aim of this study is to assess the efficacy of intra-venous administration of Tranexamic acid in patients undergoing hemiarthroplasty with regards to blood loss at perioperative period. Materials and Methods: A prospective randomised control study was done in a tertiary care hospital in southern part of India during the period of January 2016 to June 2017. 40 consecutive fracture neck of femur patients were randomised into two group, each group consist of 20 patient, Group 1 patients received placebo of 50 ml of normal saline administered intravenously 10 minutes before starting the surgery. Group 2 patients received Tranexamic acid -1500Mg diluted in 50ml Normal Saline administered intravenously 10 minutes before the surgery. Intraoperative blood loss was assessed by collecting the number of fully soaked mopping pads, fully soaked gauze pieces and quantity of irrigation fluid form suction bottle after subtracting the amount of normal saline used for wash. Post operatively all patients were assessed by evaluating the haemoglobin, Packed cell volume values from patients and blood collected in the negative suction drain of day 1 and day 2. The study group and control group parameters were analysed and compared. Results: 45 patients were enrolled in our study and 5 patients were excluded from the study due to not giving consent for study. Demographic date like age, gender, side of fracture, type of fracture type of prosthesis were not influenced our study. Requirement of intra operative blood transfusion were significantly reduced in study group in comparison with control group which was statistically significant (p=0.027). In study group only 3 patient received blood transfusion, whereas control group 11 patents were received. Conclusion: In our study, there was significant reduction in the amount of blood loss in tranexamic acid administered group when compared to the placebo group. Tranexamic acid was cost effective and safer when compared to blood components. Tranexamic acid should be considered for routine use in Hemiarthroplasty surgery to decrease blood loss.

Comparison of Baumgaertner and Chang reduction quality criteria for the assessment of trochanteric fractures.

ObjectivesDifferent criteria for assessing the reduction quality of trochanteric fractures have been reported. The Baumgaertner reduction quality criteria (BRQC) are relatively common and the Chang reduction quality criteria (CRQC) are relatively new. The objectives of the current study were to compare the reliability of the BRQC and CRQC in predicting mechanical complications and to investigate the clinical implications of the CRQC.MethodsA total of 168 patients were assessed in a retrospective observational study. Clinical information including age, sex, fracture side, American Society of Anesthesiologists (ASA) classification, tip-apex distance (TAD), fracture classification, reduction quality, blade position, BRQC, CRQC, bone quality, and the occurrence of mechanical complications were used in the statistical analysis.ResultsA total of 127 patients were included in the full analysis, and mechanical complications were observed in 26 patients. The TAD, blade position, BRQC and CRQC were significantly associated with mechanical complications in the univariate analysis. Only the TAD (p = 0.025) and the CRQC (p < 0.001) showed significant results in the multivariate analysis. In the comparison of the receiver operating characteristic curves, the CRQC also performed better than the BRQC.ConclusionThe CRQC are reliable in predicting mechanical complications and are more reliable than the BRQC. Future studies could use the CRQC to assess fracture reduction quality. Intraoperatively, the surgeon should refer to the CRQC to achieve good reduction in trochanteric fractures.Cite this article: Bone Joint Res 2019;8:502–508.

How Does Perioperative Ketorolac Affect Opioid Consumption and Pain Management After Ankle Fracture Surgery?

The investigation of nonnarcotic drug regimens for postoperative pain management is important in addressing the opioid epidemic. NSAIDs can be a powerful adjunct in managing postoperative pain, but the possibility of delayed bone healing is a major concern for orthopaedic surgeons. Our recent retrospective study on ketorolac administration demonstrated that the NSAID is not associated with an increased risk of delayed union or nonunion after ankle fracture surgery. To determine whether postoperative ketorolac (1) reduces opioid consumption, (2) improves VAS pain control, and (3) affects fracture healing after open reduction and internal fixation of ankle fractures. Between August 2016 and December 2017, 128 patients undergoing open reduction and internal fixation of an acute ankle fracture were randomized before surgery via simple randomization to treatment with or without ketorolac. No patients changed treatment regimen groups or opted out of randomization. All other aspects of perioperative care were treated identically. A once-daily survey was distributed via email on postoperative Days 1 to 7. Unblinded participants were asked to report their daily opioid consumption, pain level, and sleep interference using the VAS, and pain frequency using a five-point Likert scale, and side effects with the VAS. For VAS pain, > 20 mm/100 mm on the VAS scale was required to be considered "improved." In all, 83% (106 of 128) patients completed all seven postoperative surveys with 14 in the control group and eight in the ketorolac group lost to follow-up. Fifty-six patients were administered ketorolac with opioid medication (treatment group) and 50 were administered opioids alone (control group). Participants were comprised of 42% men (44), and 58% women (62); mean age was 48 years. The treating surgeon assessed clinical healing based on the patient's ability to ambulate comfortably at 12 weeks postoperatively. Radiographic healing was assessed by two fellowship-trained orthopaedic foot and ankle surgeons blinded to the patient's name and time since surgery. The surgeons evaluated randomized standard ankle series (anteroposterior, mortise, and lateral) radiographs for resolution of each fracture line to determine fracture union, with delayed union being defined as fracture lines present on radiographs taken at 12-week postoperative visits. Intention-to-treat analysis was performed. Patients in the treatment group consumed a mean of 14 opioid pills, which was less than the mean of 19.3 opioids pills consumed by patients in the control group (p = 0.037). Patients with ketorolac had lower median VAS scores for pain (p < 0.035) postoperatively on postoperative Days 1 and 2 than did control patients. By contrast, patient-reported pain scores and scores for sleep did not convincingly show a benefit to the use of ketorolac. For patients whose ankle fractures healed at 12 weeks, there was no difference between the groups in terms of clinical healing (p = 0.575) and radiographic healing (p = 0.961). In this randomized study, adding ketorolac to the postoperative drug regimen decreased the use of opioid medication after open reduction and internal fixation of ankle fractures in the early postoperative period, and there were mixed, small effects on pain reduction. This NSAID is a valuable tool in helping patients manage postoperative pain with less use of narcotic analgesia. However, our study was underpowered to determine the true safety of this drug in terms of fracture healing and side effects and these questions warrant higher-powered randomized study investigation. Level I, therapeutic study.

Early effectiveness of mini-Swashbuckler approach for distal femoral type C fractures

To explore the early effectiveness and advantages of mini-Swashbuckler approach in treatment of distal femoral type C fractures by comparing with Swashbuckler approach. A retrospective analysis was made on 43 patients with distal femoral type C fractures between January 2014 and June 2018. Twenty-two patients were treated with open reduction via mini-Swashbuckler approach and internal fixation with less invasive stabilization system (LISS) plate in modified group; and 21 patients were treated with open reduction via Swashbuckler approach and internal fixation with LISS plate in traditional group. There was no significant difference in age, gender, cause of trauma, fracture classification, fracture side, interval between injury and operation, and complications between the two groups ( P>0.05). The operation time, intraoperative blood loss, intraoperative fluoroscopy times, hospitalization time, fracture healing time, Hospital for Special Surgery (HSS) scores of the knee, and postoperative complications were recorded and compared between the two groups. The operation successfully completed in both groups. The operation time of the modified group was significantly longer than that of the traditional group, the fluoroscopy times was increased and the blood loss was reduced, the differences were significant ( P<0.05). There was no significant difference in hospitalization time between the two groups ( t=0.277, P=0.783). All patients in the two groups were followed up 6-8 months, with an average of 7.2 months. Fractures healed in both groups, there was no significant difference in healing time between the two groups ( t=0.861, P=0.394). The HSS scores of the modified group were 82.91±2.88 and 89.28±3.63 at 3 and 6 months after operation, respectively, which were superior to those of the traditional group (74.62±3.64) and (81.48±4.55) ( t=8.306, P=0.000; t=6.231, P=0.000). There was 1 case of incision infection, 1 case of deep vein thrombosis, and 2 cases of knee flexion and extension dysfunction in traditional group, and 1 case of deep vein thrombosis, 1 case of varus deformity, and 1 case of internal fixation loosening in modified group. There was no significant difference in the incidences of complications between the two groups ( P>0.05). Compared with Swashbuckler approach, mini-Swashbuckler approach has limited visual field exposure, which leads to prolonged operation time and increased fluoroscopy times, but the risks of complications do not increase. Because of its small soft tissue injury and less blood loss, it is conducive to the recovery of knee joint function after operation.

Flat chest projection in the detection and visualization of rib fractures: A cross-sectional study comparing curved and multiplanar reformation of computed tomography images in different reader groups

BackgroundRib fractures are common and potentially life-threatening. Fast and correct detection as well as comprehensive visual overview of rib fractures are of clinical and forensic importance. This study compared two computed tomography (CT) reformation methods, curved planar reformation (CPR) with conventional multiplanar reformation (MPR), regarding detection of rib fractures in different readers. MethodsTwelve postmortem CT datasets were retrospectively assessed for rib fractures using CPR and MPR. After defining the gold-standard regarding side, level, localization, and quantity of fractures, four reader groups per two readers consisting of radiologists, trauma surgeons, forensic pathologists, and laypersons, were evaluated for sensitivity, proportion of false positives, time to fracture detection, and subjective preference. ResultsOverall sensitivity for fracture detection did not vary significantly between both methods. However, it was significantly higher in trauma surgeons and laypersons when reading CPR compared to MPR (70.7% vs. 62.0%, p=0.038 and 33.7% vs. 22.1%, p=0.003 respectively). It was significantly lower in radiologists (63.8% vs. 76.8%, p=0.001). Forensic pathologists performed similarly with both methods (53.6% vs. 56.5%, p=0.549). All non-radiologists preferred the use of CPR (75%). All readers found CPR to provide better visual overview (100%). ConclusionCPR may increase rib fracture detection rates of non-radiologists (i.e. trauma surgeons and laypersons) and provides a better visual overview. However, radiologists achieve higher fracture detection rates when allowed to work with the software tools they are more experienced with. The overall sensitivity was improvable and better visualization methods are warranted in order to avoid misdiagnosis and medicolegal errors regarding rib fracture detection.

Clinical and radiological outcomes of conservative treatment for unilateral sagittal split fractures of C1 lateral mass

ObjectiveThe aim of this study was to assess the effect of transverse atlantal ligament (TAL) integrity on clinical and radiological outcomes in patients with unilateral sagittal split fracture (USSF) of the C1 lateral mass (LM). MethodsTwenty-six consecutive patients (16 men and 10 women; mean age: 52 years (range: 32–69)) with C1 LM USSF were included in this study. Sixteen were TAL injury group (nine of type I injuries and seven of type II injuries according to Dickman's classification) and ten were TAL intact group. All cases were conservatively treated with a rigid brace for TAL intact or by halo-vest stabilization for TAL injury for three months. The mean follow-up was 16 months (range, 12–47 months). The results were compared with radiological assessment of fracture healing, LM displacement and Neck visual analog scale. ResultsAt the last follow-up, for TAL intact group, total LM displacement (LMD), unilateral LMD of fracture side, atlanto-dental interval, basion-dental interval, clivus canal angle, and atlanto-occipital joint axis angle were maintained compared to initial presentation. However, for TAL injury group, all radiological parameters were worsened. The worsening of radiological parameters was more severe in type I injury than type II injury except for total LMD and unilateral LMD. Neck visual analog scale significantly decreased and patient's satisfaction was higher in TAL intact group compared to TAL injury group. ConclusionConservative treatment for USSF of C1 LM with TAL injury failed to achieve healing of the fracture, which resulted in lateral displacement of C1 LM. This caused coronal and sagittal malalignment of occipitocervical junction, resulting in unsatisfactory clinical outcomes. Our results suggest that early surgical stabilization should be considered in USSF of C1 LM with TAL injury, especially type I injury. However, conservative treatment may be sufficient for a USSF of the C1 LM with TAL intact. Level of EvidenceLevel III, Therapeutic Study.

Radiologic criteria to predict injury of the transverse atlantal ligament in unilateral sagittal split fractures of the C1 lateral mass.

Unilateral sagittal split fracture (USSF) of the C1 lateral mass (LM) has been recently recognized as a rare variant of C1 atlas fracture. To date, there has been no study to investigate whether radiologic criteria can be applied to determine the presence or absence of transverse atlantal ligament (TAL) injury in USSF of the C1 LM.Twenty six consecutive cases of USSF of the C1 LM were included in this study. According to Dickman classification, 16 cases were TAL injury, and 10 cases were TAL intact. Radiologic parameters were measured and compared between the 2 groups.Total LM displacement (LMD) of the 2 sides (5.9 ± 2.0 mm vs 1.2 ± 2.0 mm), unilateral LMD of the fracture side (4.3 ± 1.2 mm vs 1.0 ± 1.1 mm), atlanto-dental interval (ADI) (2.0 ± 0.9 mm vs 1.5 ± 0.4 mm), and fracture gap (6.9 ± 2.7 mm vs 2.1 ± 1.1 mm) were statistically higher in the TAL injury group than the TAL intact group. However, basion-dental interval, clivus canal angle, and atlanto-occipital joint axis angle were not different between the 2 groups. Total LMD and unilateral LMD positively correlated with ADI and fracture gap. The incidence of fracture gap larger than 7 mm was statistically higher in the TAL injury group than the TAL intact group (81% vs 30%).In conclusion, total LMD > 5.9 mm or unilateral LMD > 4.3 mm suggests the presence of TAL injury in USSF of the C1 LM. The possibility of diagnostic error for TAL injury can be further reduced in USSF of the C1 LM by considering the fracture gap larger than 7 mm.