Fracture Subtypes Research Articles

Biological activity is not suppressed in mid-shaft stress fracture of the bowed femoral shaft unlike in "typical" atypical subtrochanteric femoral fracture: A proposed theory of atypical femoral fracture subtypes.

We have investigated mid-shaft stress fractures of the bowed femoral shaft (SBFs), well before the first report of an association between suppression of bone turnover and atypical femoral fractures (AFFs). Although all cases of SBF meet the criteria for AFF, SBFs can also occur in patients with no exposure to bone turnover suppression-related drugs (e.g., bisphosphonates). Using bone morphometry and biomechanical analyses, we devised a theory of AFF subtypes, dividing AFFs into fragility SBFs in the mid-shaft and "typical" subtrochanteric AFFs caused by suppressed bone turnover. The aim of this multicenter prospective study was to provide evidence for this novel concept in terms of biological activity. The study was conducted at 12 hospitals in Japan from 2015 through 2019. Thirty-seven elderly women with AFF were included and classified according to location of the fracture into a mid-shaft AFF group (n=18) and a subtrochanteric AFF group (n=19). Patient demographics and clinical characteristics were investigated to compare the two groups. The main focus was on histological analysis of the fracture site, and bone metabolism markers were evaluated to specifically estimate biological activity. All patients in the subtrochanteric AFF group had a history of long-term (>3years) exposure to specific drugs that have been reported to cause AFF, but 5 of the 18 patients in the mid-shaft AFF group had no history of exposure to such drugs. Femoral bowing was significantly greater in the mid-shaft AFF group (p<0.001). In the histological analysis, active bone remodeling or endochondral ossification was observed in the mid-shaft AFF group, whereas no fracture repair-related biological activity was observed in the majority of patients in the subtrochanteric AFF group. Levels of tartrate-resistant acid phosphatase-5b and undercaroxylated osteocalcin were significantly lower in the subtrochanteric AFF group (p<0.05). The possibility of our devised AFF subtype theory was demonstrated. Biological activity tends not to be suppressed in mid-shaft SBFs unlike in "typical" subtrochanteric AFFs involving bone turnover suppression. Although validation of the proposed theory in other populations is needed, we suggest that the pathology and treatment of AFFs be reconsidered based on its subtype.

Sex-based differences in pediatric supracondylar humerus fractures.

Supracondylar humerus (SCH) fractures are reported to be approximately twice as common among boys as among girls. Little is known about sex-associated differences in fracture patterns and complications. We compared the incidence of pediatric SCH fractures, injury mechanism (high-energy or low-energy), fracture subtypes, associated neurologic injuries, and treatment types by patient sex.We reviewed 1231 pediatric SCH fractures treated at 1 center from 2008 to 2017, analyzing sex distributions overall and by year and fracture subtype. We noted patient demographic characteristics, injury mechanisms, neurologic injuries, and treatments (nonoperative or operative). Binomial 2-tailed, chi-squared, and Student's t tests were used for analysis. Multiple logistic regression was performed to assess associations between sex, age, and injury mechanism. Alpha = 0.05.We found no significant difference in the distribution of girls (52%) vs boys (48%) in our sample compared with a binomial distribution (P = .11). Annual percentages of fractures occurring in girls ranged from 46% to 63%, and sex distribution did not change significantly over time. The mean (± standard deviation) age at injury was significantly younger for girls (5.5 ± 2.5 years) than for boys (6.1 ± 2.5 years) (P < .001). High-energy injury mechanism was associated with older age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03–1.06) but not male sex (OR, 1.04; 95% CI, 0.98–1.1). The overall incidence of neurologic injury was 9.5% but boys did not have greater odds of sustaining neurologic injury (OR, 1.03; 95% CI, 1.0–1.1). We found no sex-associated differences in the distribution of Gartland fracture subtypes (P = .13) or treatment type (P = .39).Compared with boys, girls sustain SCH fractures at a younger age. SCH fractures were distributed equally among girls and boys in our sample. Patient sex was not associated with fracture subtype, injury mechanism, neurologic injury, or operative treatment. These findings challenge the perception that SCH fracture is more common in boys than girls.Level III, retrospective study.

Association of abductor hip muscle atrophy with fall-related proximal femur fractures in the elderly

ObjectiveThe purpose of this study was to evaluate an association between fall-related intertrochanteric or femoral neck fractures and gluteus medius and minimus atrophy, furthermore, to find a correlation of whether any difference between femoral neck or intertrochanteric fracture and degree of muscle atrophy Materials and MethodsA retrospective review of 230 patients with intertrochanteric or femoral neck fracture, aged > 65 years, and 60 age- matched controls was performed. We assessed gluteus medius and minimus atrophy and calculated the cross-sectional area (CSA) and ratio of lean muscle to adipose infiltration (M/A ratio) for each muscle. ResultsThe atrophy scores for the g.medius and g.minimus muscles on the fractured side were significantly higher than scores on the healthy side and scores in the control group. The atrophy scores for the g.medius on the healthy side were not significantly different from scores in the control group. The atrophy scores for g.medius were significantly different between the fractured side and the healthy side for all ages, the atrophy scores for g.minimus was significantly different in the patients aged over 75. There was no significant difference in the following parameters between the fractured side and healthy side of the patients aged 65 - 75 years; the atrophy score, CSA and M/A ratio. The patients have a lower CSA and M/A ratio on the fractured side than on the healthy side and lower CSA and M/A ratio than in the control group. However, there were no significant differences in the M/A ratio between the healthy side and the control group. CSA was not significantly different between the fractured side and healthy side in the male patients and in the patients with lower BMI (<30). There was no significant difference in the atrophy scores between subjects with intertrochanteric versus femoral neck fractures, the CSAs of the g.medius and g.minimus were significantly different between the intertrochanteric fracture and femoral neck fracture groups. ConclusionsThe fractured sides showed greater g.medius and g.minimus muscle atrophy, which may be a predictor of fall-related hip fractures in the elderly. Gluteal muscle volume may be associated with proximal femur fracture subtype.

Description and Reliability of the AOSpine Sacral Classification System.

Background:Several classification systems exist for sacral fractures; however, these systems are primarily descriptive, are not uniformly used, have not been validated, and have not been associated with a treatment algorithm or prognosis. The goal of the present study was to demonstrate the reliability of the AOSpine Sacral Classification System among a group of international spine and trauma surgeons.Methods:A total of 38 sacral fractures were reviewed independently by 18 surgeons selected from an expert panel of AOSpine and AOTrauma members. Each case was graded by each surgeon on 2 separate occasions, 4 weeks apart. Intrarater reproducibility and interrater agreement were analyzed with use of the kappa statistic (κ) for fracture severity (i.e., A, B, and C) and fracture subtype (e.g., A1, A2, and A3).Results:Seventeen reviewers were included in the final analysis, and a total of 1,292 assessments were performed (646 assessments performed twice). Overall intrarater reproducibility was excellent (κ = 0.83) for fracture severity and substantial (κ = 0.71) for all fracture subtypes. When comparing fracture severity, overall interrater agreement was substantial (κ = 0.75), with the highest agreement for type-A fractures (κ = 0.95) and the lowest for type-C fractures (κ = 0.70). Overall interrater agreement was moderate (κ = 0.58) when comparing fracture subtype, with the highest agreement seen for A2 subtypes (κ = 0.81) and the lowest for A1 subtypes (κ = 0.20).Conclusions:To our knowledge, the present study is the first to describe the reliability of the AOSpine Sacral Classification System among a worldwide group of expert spine and trauma surgeons, with substantial to excellent intrarater reproducibility and moderate to substantial interrater agreement for the majority of fracture subtypes. These results suggest that this classification system can be reliably applied to sacral injuries, providing an important step toward standardization of treatment.

Open pronation abduction ankle fractures associated with increased complications and patient BMI

IntroductionPronation abduction (PA) ankle fractures are often associated with a medial tension failure wound. Though this injury pattern was defined based on the mechanism of injury, there is a paucity of literature evaluating risk factors for understanding which patients will sustain an open PA fracture. Furthermore, how patients with these types of fractures perform relative to other open ankle fractures has not been established. We hypothesized that open PA fractures are associated with obesity and increased number of reoperations. MethodsAll patients at a single level one trauma center who received operative treatment for an ankle fracture between February 2012 to January 2019 were retrospectively identified using Current Procedural Terminology (CPT) codes. Patients with open PA ankle fractures were identified. Demographic data, body mass index, medical comorbidities, time to surgery, and reoperations were compared between open PA ankle fractures and other open ankle fracture subtypes. ResultsThere were 22 open PA ankle fractures and 35 other open ankle fracture subtypes. The open PA fracture group had a significantly higher median and average BMI and percentage of patients with obesity. There was no difference in number of patients requiring reoperation between the two groups. When reoperation was required, patients with open PA ankle fractures were found to undergo significantly more reoperations and were significantly more likely to require arthrodesis or below knee amputation. ConclusionsOpen PA ankle fractures are more often associated with obesity (BMI > 30 kg/m2) than are other open ankle fractures caused by a different mechanism. When reoperation does occur, patients with open PA ankle fractures require more reoperations and are more likely to require arthrodesis or below knee amputation that patients with other open ankle fracture subtypes. Early identification of those patients or injuries at increased risk of complications can help ensure optimal outcomes.

The Reverse Oblique Supracondylar Humerus Fracture: Description of a Novel Fracture Pattern.

Sagittal profile descriptions of supracondylar humerus fractures are limited. We describe a reverse oblique (RO) pattern in which the distal fragment has a prominent anterior spike that is displaced posterior to the proximal fragment. This pattern presents a challenge during closed manipulation utilizing traditional reduction maneuvers. The purpose of this study is to compare the clinical and radiographic characteristics of the RO and non-RO patterns of supracondylar humerus fractures. We hypothesized that the RO pattern would be associated with greater soft tissue trauma. Retrospective evaluation of operative supracondylar humerus fractures treated at a tertiary pediatric hospital from 2014 to 2016. Patients were categorized into RO and non-RO groups for analysis. Associated neurovascular injuries were compared between groups. Two hundred ninety-nine consecutive patients were reviewed. The RO fracture pattern was seen in 12 patients. All displaced RO fractures were able to be closed reduced with a modification to the traditional reduction sequence. Overall cohort rates of preoperative soft tissue injury included antecubital ecchymosis 16.8%, nerve palsies 15%, and vascular compromise 6.4%. Compared with non-RO fractures, the RO fracture group had significantly higher rates of anterior interosseous nerve (AIN) palsies (P=0.013), antecubital ecchymosis (P=0.018), and compartment syndrome (P=0.043). When comparing RO with non-RO type II fractures, there were no differences in soft tissue injury (P=0.439). Compared with non-RO type III fractures, RO type III fractures had higher rates of AIN injury (P=0.047), antecubital ecchymosis (P=0.007), and overall soft tissue injury (P=0.009). This study introduces a previously undescribed supracondylar humerus fracture subtype: the RO fracture. We found increased rates of soft tissue compromise including antecubital ecchymosis and AIN palsy in this fracture type. Further, traditional reduction methods proved to be ineffectual for this fracture pattern. We utilized a simple modification that allowed for closed reduction and percutaneous pinning of displaced RO fractures. Level III-prognostic.

Orbital Fractures and Associated Ocular Injuries in Operation Iraqi Freedom and Operation Enduring Freedom Referred to a Tertiary Care Military Hospital and the Effect on Final Visual Acuity.

To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity. Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%). Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.Orbital fractures occur commonly during combat trauma and a significant number are legally blind despite appropriate treatment.

Patients with ankylosing spondylitis suffering from AO Type B3 traumatic thoracolumbar fractures are associated with increased frailty and morbidity when compared with patients with diffuse idiopathic skeletal hyperostosis

AO Type B3 hyperextension thoracolumbar fractures are the commonest fracture subtype in ankylosing spinal disorders. Although often considered together in spinal fractures, ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are distinct spondyloarthropathies with different pathophysiology. Few studies have compared the two entities in the setting of traumatic thoracolumbar fractures. The authors compare demographic metrics, injury profile, clinical and radiographical outcomes between patients with AS and DISH in patients suffering from AO Type B3 traumatic thoracolumbar fractures. From January 2008 to December 2018, a retrospective analysis of consecutive surgically-managed patients with AO Type B3 fractures was performed. Demographic metrics, co-morbidity [Charlson-comorbidity index, modified frailty index (mFI), etc.], injury profile (level of injury, mechanism of injury, etc.), clinical (postoperative complication, etc.) and radiographical variables were collected. Differences between patients with AS and DISH were compared. Fourteen patients were identified. All patients had AS (n=6) or DISH (n=8). The mean age was 72.8±10.2 years and 78.6% of patients were neurologically intact at presentation. Medical and/or surgical complications occurred in 10 of 14 (71.4%) patients. As compared to patients with DISH, patients with AS were more likely to have low falls as the injury mechanism [odds ratio (OR): 35.0, P=0.026], have higher mFI (OR: 30.6, P=0.015), and experience a higher number of postoperative complications per patient (AS: 1.8/patient vs. DISH: 0.5/patient, P=0.024). In the setting of AO Type B3 fractures, patients with AS are more frail and have higher in-hospital morbidity compared to patients with DISH. Despite both pathologies being ankylosing in nature, further studies are required to fully understand the clinical differences between the two entities to enable clinicians to apply a more targeted and nuanced approach in managing fractures in ankylosing spinal disorders.

Long-Term Outcomes after Colton Type I and II Fractures of the Olecranon

Background: It is unclear if the outcomes differ in different subtypes of olecranon fractures. Objective: Evaluate the outcomes of different Colton types of olecranon fractures, and if outcomes differ in dominant and non-dominant arms and in men and women. Methods: We evaluated primary journals and radiographs in 40 men and 55 women with isolated olecranon fractures and classified fractures according to Colton. Mean 19 years after fracture event, we re-examined subjective, clinical and radiographic outcomes in the former patients, using the uninjured arms as controls. Results: 89% of patients with Colton type I fractures reported at follow-up no subjective differences between the elbows, 84% with type II oblique/transverse fractures and 84% with type II comminuted fractures (p=0.91). The uninjured to former fractured arm differences in elbow range of motion and strength were no different in the 3 fracture types, the proportions of individuals with radiographic elbow degenerative changes were greater in type II than in type I factures (p&lt;0.001), and there were no differences between the proportions of individuals with reduced joint space in the 3 groups (p=0.40). The outcomes were no different if the fractures had occurred in the dominant or non-dominant arms (p=0.43), or in men or women (p=0.43). Conclusion: There were no different outcomes after Colton type I, type II oblique/transverse or type II comminuted fractures, no different outcomes between fractures in dominant or non-dominant arms and no different outcomes in men and women.

A Prospective Patient Reported Outcomes (PRO) Study Assessing Outcomes of Surgically Managed Ankle Fractures

Category:AnkleIntroduction/Purpose:Ankle fractures are a common cause of functional mobility that have seen a dramatic rise incidence over the past decade1. The purpose of this study was to compare the outcomes and prognosis of various fracture sub-types by utilizing two validated patient reported outcome measures: the PROMIS Physical Function and Pain Interference Computer Adaptive Tests (CATs) for patients at a major tertiary facility and level I trauma center.Methods:12-month post-operative PROMIS Physical Function and Pain Interference CATs were collected for 125 ankle fracture patients presenting between 2014 and 2017. Patients were initially stratified by ankle fracture sub-type after examining pre- operative X-rays and further refined by the presence or absence of concomitant deltoid injury or posterior malleolar fracture.Patients defined as members of vulnerable populations and patients presenting more than 2 weeks from time of injury/with prior acute ipsilateral fracture were excluded. The distribution of PROMIS physical function and pain interference T-scores were assessed via a Shapiro-Wilk test and a one-way ANOVA was used for further evaluation. If significant differences were found between groups, pair-wise comparisons were tested via Dwass, Steel, Critchlow-Fligner multiple comparison analysis.Results:Fracture types and corresponding n-value in this study: (44) isolated lateral malleolar, (12) isolated medial malleolar, (12) bimalleolar, (44) trimalleolar, (6) isolated syndesmotic injury, and (8) isolated posterior malleolar fractures. Mean values for the PROMIS physical function and pain interference domains for each fracture sub-type were calculated and compared to reference population mean T-scores of 50 (SD = 10): isolated lateral malleolar (PF:50/PI:51), isolated medial malleolar (PF:52/PI:49), bimalleolar (PF:48/PI:50), trimalleoar (PF:47/PI:51), isolated posterior malleolar (PF:53/PI:44), and isolated syndesmotic injury (PF:60/PI:46). The Shapiro-Wilk test indicated a non-normal distribution for the post-operative PROMIS physical function T-scores across all fracture patients (p-value = 0.0421). Pair-wise comparisons were done to compare relative prognosis between fracture sub-types but failed to yield statistically significant differences in physical function or pain domains.Conclusion:Surgical intervention is effective in returning patients to normal levels of physical function and pain interference across all sub-types according to post-op T-scores. Although our analysis indicated a significant difference when comparing across all fracture sub-types, none of the pairwise sub-type comparisons showed statistical significance. Analyses of fracture sub-types determined trimalleolar injuries report the poorest outcomes for both PROMIS domains while the isolated syndesmotic and posterior malleolar groups reported the best outcomes. Further investigation with a larger sample size for each group is needed to delineate whether a significant difference exists for PROMIS physical function and pain interference scores.

The case for the future role of evidence-based medicine in the management of cervical spine injuries, with or without fractures.

The authors believe that the standardized and systematic study of immobilization techniques, diagnostic modalities, medical and surgical treatment strategies, and ultimately outcomes and outcome measurement after cervical spinal trauma and cervical spinal fracture injuries, if performed using well-designed medical evidence-based comparative investigations with meaningful follow-up, has both merit and the remarkable potential to identify optimal strategies for assessment, characterization, and clinical management. However, they recognize that there is inherent difficulty in attempting to apply evidence-based medicine (EBM) to identify ideal treatment strategies for individual cervical fracture injuries. First, there is almost no medical evidence reported in the literature for the management of specific isolated cervical fracture subtypes; specific treatment strategies for specific fracture injuries have not been routinely studied in a rigorous, comparative way. One of the vulnerabilities of an evidenced-based scientific review in spinal cord injury (SCI) is the lack of studies in comparative populations and scientific evidence on a given topic or fracture pattern providing level II evidence or higher. Second, many modest fracture injuries are not associated with vascular or neural injury or spinal instability. The application of the science of EBM to the care of patients with traumatic cervical spine injuries and SCIs is invaluable and necessary. The dedicated multispecialty author groups involved in the production and publication of the two iterations of evidence-based guidelines on the management of acute cervical spine and spinal cord injuries have provided strategic guidance in the care of patients with SCIs. This dedicated service to the specialty has been carried out to provide neurosurgical colleagues with a qualitative review of the evidence supporting various aspects of care of these patients. It is important to state and essential to understand that the science of EBM and its rigorous application is important to medicine and to the specialty of neurosurgery. It should be embraced and used to drive and shape investigations of the management and treatment strategies offered patients. It should not be abandoned because it is not convenient or it does not support popular practice bias or patterns. It is the authors' view that the science of EBM is essential and necessary and, furthermore, that it has great potential as clinician scientists treat and study the many variations and complexities of patients who sustain acute cervical spine fracture injuries.

Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model.

Background:Tibial spine fractures, although relatively rare, account for a substantial proportion of pediatric knee injuries with effusions and can have significant complications. Meyers and McKeever type II fractures are displaced anteriorly with an intact posterior hinge. Whether this subtype of pediatric tibial spine fracture should be treated operatively or nonoperatively remains controversial. Surgical delay is associated with an increased risk of arthrofibrosis; thus, prompt treatment decision making is imperative.Purpose:To assess for variability among pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures.Study Design:Cross-sectional study.Methods:A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management choice. A convenience sample of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including physis-blinded radiographs displaying displaced fractures and a description of the patient’s sex, age, mechanism of injury, and predominant sport. Surgeons were asked whether they would treat the fracture operatively or nonoperatively. A mixed-effects model was then used to determine the patient attributes most likely to influence the surgeon’s decision, as well as surgeon training background, years in practice, and risk-taking behavior.Results:The majority of respondents selected operative treatment for 85% of the presented cases. The degree of fracture displacement was the only attribute significantly associated with treatment choice (P < .001). Surgeons were 28% more likely to treat the fracture operatively with each additional millimeter of displacement of fracture fragment. Over 64% of surgeons chose to treat operatively when the fracture fragment was displaced by ≥3.5 mm. Significant variation in surgeon’s propensity for operative treatment of this fracture was observed (P = .01). Surgeon training, years in practice, and risk-taking scores were not associated with the respondent’s preference for surgical treatment.Conclusion:There was substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate was based on the degree of fracture displacement. Identifying current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies for controversial type II tibial spine fractures.

Olecranon Osteotomy Approach for Complex AO-13C Fractures of Distal Humerus: A Prospective Analysis of 24 Cases.

Introduction: Olecranon osteotomy is well described approach for complex intra-articular distal humeral fractures. In this study, we investigated the usefulness and complications of olecranon osteotomy approach for such fractures. We hypothesise that outcome is comparable in young adults and middle age group and also functional outcome is independent of fracture subtype following surgical fixation.Materials and Methods: Between December 2012 and September 2015, twenty-four adult patients (male: 15, female: 9) having mean age of 41.4 years with closed intra-articular fracture (AO-13C) were surgically managed using olecranon osteotomy approach and were followed-up for a mean of 28.5 months (range: 22-35 months). Functional outcome was measured using Mayo Elbow Performance Score (MEPS) and complications were observed. Statistical analysis was done using Student t-test and Kruskal Wallis test.Results: All fractures united by the end of three months. Mean elbow flexion achieved was 123°, mean extension lag was 9° and mean active arc of motion was 114°. Mean MEPS was 87 (excellent: 8, good: 14, fair: 1 and poor: 1). Post-operative transient ulnar nerve palsy was noted in two cases, heterotopic ossification (HO) was in one case, infection in two cases, implant prominence in five and elbow stiffness in three cases. Motion arc was higher in young adults and MEPS was comparable in both age group. Functional outcome was also dependent on fracture subtype. Conclusion: The olecranon osteotomy approach for distal humerus fractures had good functional outcome with fewer complications. Joint congruity and fixation could easily be assessed intraoperatively.

Association of scapholunate dissociation and two-part articular fractures of the distal radius.

Scapholunate dissociation may occur in association with distal radial fractures and is easily missed at initial presentation. The aim of this study was to examine variances in the scapholunate distance with respect to subtypes of two-part partial articular distal radial fractures. Axial computed tomography (CT) scans of acute two-part intra-articular radial fractures were assessed retrospectively from 80 patients and compared to 20 controls. From each scan, two images were analysed to identify the scaphoid, lunate and articular fracture line in the distal radius for fracture type categorization. The images were overlaid on a standardized distal radius template and the scapholunate distance measured. Significant increase in the scapholunate distance was noted in fracture subtypes: radial styloid oblique; dorsal ulnar column; sagittal ulnar column; and volar coronal. We conclude that these findings support the need for a higher index of suspicion for scapholunate dissociation in these distal radial fracture subtypes. Level of evidence: III.

The Impact of Fractures on Survival in Multiple Myeloma: Results from a Population-Based Study

IntroductionMultiple myeloma (MM) causes lytic bone lesions, osteopenia, and fractures, which increase the morbidity of MM patients. Results from small previous studies have indicated that fractures in MM have a negative effect on survival.AimsThe aim of the study was to evaluate the impact of fractures on survival in MM patients diagnosed in Sweden in the years 1990-2013. Furthermore, to analyze the effect of bone fractures at MM diagnosis on subsequent survival.MethodsPatients diagnosed with MM in 1990-2013 were identified from the Swedish Cancer Registry. Information on date of birth, diagnosis, and death were collected from the Registry of Total Population. Information on all fractures were retrieved from the Swedish Patient Registry. Cox regression model was used with fractures as time-dependent variables. The effect of fractures on survival was assessed for any fracture or a subtype of fracture (a specific bone fracture or ICD-coded pathologic fracture). Either first fracture or the first subtype of fracture was used in the analysis. The effect of a fracture at MM diagnosis (within 30 days before or 30 days after MM diagnosis) on survival was also estimated using a Cox regression model. All models were adjusted for age, sex, time of diagnosis, and previous fractures.ResultsA total of 14,008 patients were diagnosed with MM in the study period. A total of 4,141 (29.6%) patients developed a fracture including fractures that occurred within a year before MM diagnosis and thereafter. Hereof 2,893 (20.7%) patients developed a fracture after MM diagnosis. The risk of death was significantly increased for patients that developed a fracture after the time of MM diagnosis with a hazard ratio (HR) of 2.00 (95% confidence interval (CI) 1.91-2.10) for all fractures combined. The risk of death was significantly increased for patients that developed all subtypes of fractures after MM diagnosis except ankle fractures. The risk of death was significantly increased for patients that developed pathologic fractures (HR=2.17; 95% CI 2.03-2.32), vertebral fractures (HR=1.73; 95% CI 1.61-1.87), hip fractures (HR=1.99; 95% CI 1.82-2.18), femoral fractures (HR=2.62; 95% CI 2.32-2.98), humerus fractures (HR=2.57; 95% CI 2.32-2.86), forearm fractures (HR=1.24; 95% CI 1.05-1.46), and rib fractures (HR=1.52; 95% CI 1.31-1.77), but not for ankle fractures (HR 1.07; 95% CI 0.79-1.44). A total of 942 (6.7%) of all MM patients were diagnosed with a fracture within 30 days before or 30 days after MM diagnosis. The patients with a fracture at diagnosis were at a significantly increased risk of death compared to those without (HR 1.31; 95% CI 1.21-1.41; Figure)ConclusionsOur large population-based study, including over 14,000 patients diagnosed with MM in Sweden in the years 1990-2013, showed that MM patients that developed a fracture after the time of diagnosis were at twofold increased risk of dying compared to MM patients without a fracture. Furthermore, MM patients with a fracture at diagnosis had a 30% higher risk of dying compared to patients without a fracture. Our results indicate that fractures in MM reflect a more advanced disease at diagnosis and stress the importance of managing MM bone disease in all MM patients. [Display omitted] DisclosuresLandgren:Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Merck: Membership on an entity's Board of Directors or advisory committees; Karyopharm: Consultancy; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy; Celgene: Consultancy, Research Funding; Amgen: Consultancy, Research Funding.

Complications with the clavicle hook plate after fixation of Neer type II clavicle fractures.

There is no consensus on the optimal surgical procedure for treating Neer type-2 distal clavicle fractures. Hook plates provide better stability than other fixation methods for small fragments but have been related to multiple complications. Retrospective study on patients operated for Neer type-2 fractures using a hook plate. At the time of the study, we performed functional (UCLA and Constant scales) and radiographic (coracoclavicular distance CCD) evaluation and ultrasound assessments of the condition of the rotator cuff. Twenty-four patients were included in the study, with a mean age of 43years (18-81) and a mean follow-up of 40.4months (22-67). All the fractures healed, except one. The plate was removed at a mean of fivemonths (3-13). The Constant score was 85.7 and the UCLA score was 32. The mean increase in CCD at final follow-up was 9.6% ± 7.2% (range 1.9-54.3%) compared with the uninjured side. Nine patients showed acromioclavicular arthrosis (only one case was symptomatic), and 12% showed subacromial osteolysis. No acromion fractures were recorded. The implant failed in three cases due to medial movement of the material, and we found one peri-plate fracture. The use of hook plates in this particular type of fracture provides high consolidation rates and good functional outcomes, irrespective of the fracture subtype. However, it is essential to select the correct length and depth of the hook to prevent complications such as medial movement of the implant. Ultrasound assessment showed that rotator cuff injury is not a common complication if the implant is removed as soon as the fracture has consolidated.

New Persistent Opioid Use Following Operative Treatment of Ankle Fractures Compared to Nonoperatively Treated Fractures

Category: Trauma Introduction/Purpose: Chronic opioid use is a major public health concern in the United States. Orthopaedic surgeons prescribe 8% of narcotics in the U.S. while only comprising 2.5% of U.S. physicians. Understanding that neither the amount nor duration of opioid prescription correlates with patient satisfaction, orthopaedic surgeons have a unique opportunity to play a prominent role in the solution. In order to address and mitigate this epidemic, it is important to first understand rates of new persistent opioid use following specific orthopaedic procedures and to identify patient-specific risk factors. Methods: Using a widely accepted insurance claims database, we identified patients who underwent surgical treatment of common ankle fractures patterns (bimalleolar, trimalleolar, and isolated distal fibula) between January 2008 and December 2016. None had an opioid prescription filled in the period of 12 months to 15 days prior to treatment (defined as “opioid naïve”). Opioid naïve patients who underwent closed treatment of a distal fibula fracture served as a comparative group. We evaluated peri-treatment and post-treatment opioid prescription fulfillment. The primary outcome, new persistent opioid use, was defined as opioid prescription fulfillment between 91 and 180 days after the procedure. Logistic regression was used to evaluate the effect of patient factors, including surgery type, age, gender, median household income, mental health and pain disorders on the likelihood of new persistent use. Results: There was no significant difference in new persistent opioid use rates overall following surgical treatment of ankle fractures (8.4%) compared to closed fibula fracture treatment (7.4%), and all treatment groups demonstrated high rates of new persistent use. Two surgically treated fracture subtypes, treatment of bimalleolar ankle fractures and treatment of trimalleolar ankle fractures with fixation of posterior lip, demonstrated significantly higher new persistent opioid use rates (Figure). Rates were significantly increased among patients who received an opioid dose prescribed in the peri-treatment period that was in the top 25th percentile of total oral morphine equivalents. Patient-specific factors which were associated with new persistent opioid use included certain mental health disorders, comorbid conditions, arthritis, tobacco use, female gender, and household income greater than $100,000. Conclusion: Chronic opioid use, even in opioid naïve patients, is a major problem following orthopaedic procedures. To decrease the rate of chronic opioid use, it is important to first understand and define the rate of persistent use following these procedures. The overall new persistent opioid use following surgical fixation of ankle fractures was similar to the rate of persistent use in patients who underwent closed treatment of a fibula fracture. Understanding these high persistent use rates and the risk factors that may play a role in this problem provides a foundation upon which to address this sometimes lethal public health problem.

Validity and responsiveness of the Nottingham clavicle score in clavicle shaft fractures treated with titanium elastic nailing

BackgroundThe Nottingham Clavicle Score (NCS) has been recently described for functional outcome assessment after injuries to clavicle and the Acromioclavicular joint. However; validity and responsiveness are context specific psychometric terms and the NCS has not been previously described in surgically treated clavicle shaft fractures. Aim of the present study was to investigate validity and responsiveness of the NCS in clavicle fractures treated with titanium flexible nailing. MethodsThis prospective study was undertaken on consecutively operated clavicle shaft fractures treated with titanium elastic nail from November 2013 to August 2016. Functional assessment using NCS was done at two and six months postoperatively. Construct validity was also evaluated by formulating the null hypothesis that there would be no difference in NCS at six months after open and closed reduction and in 15B1 and 15B2 fracture sub-types. The above two hypotheses were formulated based on previous studies that used Constant score and DASH score. Pre-specified hypothesis and results in accordance with the hypotheses suggest satisfactory construct validity. Responsiveness was evaluated using standardized response mean (SRM) and Effect size (ES). ES and SRM values ≥0.80 suggest satisfactory responsiveness. The proportion of patients having the least possible score of 0 points (floor effect) and the highest possible score of 100 points (ceiling effect) was evaluated at two and six months postoperatively. Floor and ceiling effect of <15% suggests satisfactory internal validity. ResultsThirty six consecutively operated patients were included in the study. The NCS at two months and six months was 69.6 ± 9.6 and 87.2 ± 7.1 respectively. The NCS at six months after fixation was 88.7 ± 4.8 in closed reduction cohort and 84.7 ± 9.4 in the open reduction cohort and this difference was not significant (p = 0.1). The NCS at six months after fixation was 85.3 ± 8.3 in 15B1 clavicular fractures and 89.7 ± 4.0 in 15B2 clavicular shaft fractures and this difference was also not significant (p = 0.07). All results pertaining to construct validity were in accordance with our hypothesis thereby suggesting that NCS demonstrates satisfactory construct validity. The ES and SRM were 1.8 and 2.6 respectively. NCS showed no ceiling (0%) or floor effect (0%) at two and six months postoperatively thereby suggesting adequate internal validity of the NCS. ConclusionNCS has satisfactory construct validity, internal validity and responsiveness in surgically treated clavicle shaft fractures with titanium elastic nailing.

Reverse Oblique Supracondylar Humerus Fracture and its Reduction Technique in Children: Report of 3 Cases.

Introduction: Supracondylar humerus fractures are commonly classified based on fracture displacement, utilizing the Gartland classification. To our knowledge, there are no reports in the literature describing the fracture pattern presented in this report. We present three cases of Gartland Type III supracondylar humerus fractures with reverse obliquity in the sagittal plane and describe the implications of this finding in guiding prognosis and reduction techniques. Case Report: In this fracture subtype, the fracture plane traverses the humerus from the anterior …

Reliability and Agreement of Different Spine Fracture Classification Systems: An Independent Intraobserver and Interobserver Study

Currently, no spinal classification system has achieved universal acceptance. Therefore, it is important to choose a reliable classification within clinical practice. The objective of this study was to determine and compare the intraobserver and interobserver agreement of the Load Sharing Classification (LSC), the Thoracolumbar Injury Classification System (TLICS), and the AOSpine Thoracolumbar Spine Injury Classification System. In this web-based intraobserver and interobserver study (www.spine.hostei.com), plain radiographs and computed tomographic scans of traumatic thoracolumbar fractures (T12-L2) were evaluated. By use of a questionnaire, fractures were classified according to the LSC, the TLICS, and the AOSpine classification. Data were analyzed with SPSS (Version 21, 76 Chicago, Illinois, USA). Intraobserver and interobserver agreement was determined by the Cohen κ. Statistical significance was defined as P < 0.05. Data from 91 patients were classified twice by 7 board-certified spine surgeons. The intraobserver and interobserver reliability considering the LSC total score was noted as fair (intraobserver/interobserver reliability: κ= 0.26/0.22). Considering the resulting TLICS total score, a moderate intraobserver agreement (κ= 0.41) was noted, whereas the interobserver results presented only fair reliability (κ= 0.23). In contrast to the LSC and the TLICS, the AOSpine classification showed substantial agreement considering the fracture type (A;B;C) (intraobserver/interobserver reliability: κ= 0.71/0.61) and moderate agreement considering the fracture subtype (e.g., A0;A1;…;B1;…) (intraobserver/interobserver reliability: κ= 0.57/0.48). In conclusion, the reliability of the AOSpine fracture classification is superior to the TLICS and the LSC. Therefore, this classification system could best be applied within clinical practice.