Fracture Grade Research Articles

Role of Survival Time and Injury Severity in Fatal Pulmonary Fat Embolism.

Pulmonary fat embolism (PFE) is frequent in blunt trauma and may occasionally lead to death. A correlation between fracture grade and severity and PFE grade has been described before, but no correlation between PFE and survival time, fat crushing extent, fat crush grade, or number of body regions with fractures could be noted in this small study. To further examine this, we decided to examine the aforementioned points in a far larger study group.Autopsy protocols of 188 nonresuscitated fatalities with blunt trauma and without right heart injury, which underwent whole body dissection, were retrospectively reviewed concerning the presence and the severity of PFE, injuries, survival time, age, sex, and the body mass index.The fracture grade, the fracture severity, and the number of the fractured regions correlated very well with the grade of PFE, but the crushed regions, crush grade, and crush severity did not. We observed a time correlation between survival time and PFE only in the sense that very rapid deaths were often PFE negative. High-grade PFE was observed most often in patients having died less than 6 hours after the incident, and PFE grades of 2 or more were occasionally noted even after 48 hours.

Rapid Magnetic Resonance Imaging Evaluation of Femoral Neck Stress Fractures in a U.S. Active Duty Military Population.

Timely diagnosis of femoral neck stress fractures is important to prevent fracture completion and displacement. We hypothesize that an abbreviated magnetic resonance imaging (MRI) hip examination can diagnose femoral neck stress fractures and that femoral neck stress fractures are common in U.S. military recruits. We retrospectively reviewed abbreviated hip MRI examinations performed on active duty patients from November 1, 2013, to August 5, 2014. Patients were referred by primary care providers on the basis of high clinical suspicion. Study variables included presence and grade of femoral neck stress fractures. 229 patients were evaluated with an abbreviated hip MRI. 43 patients (18.8%) were diagnosed with femoral neck stress fractures and 12 patients (5.2%) had bilateral femoral neck stress fractures. All femoral neck stress fractures were on the compressive side. Grading of stress fractures was as follows: 0 Grade I (0%), 8 Grade II (14.5%), 32 Grade III (58.2%), and 15 Grade IV (27.2%). An abbreviated MR hip examination can diagnose femoral neck stress fractures as well as additional pathologies that explain the patient's symptoms. Femoral neck stress fractures are common in U.S. military personnel.

Supracondylar fracture of humerus in children; presentation and outcome in a tertiary centre of Sri Lanka

Introduction: Supracondylar fracture is an important long bone fracture in children. It is of special concern due to the neurovascular injuries and malunion associated with it. Fracture sub-types, associated injuries and grades are important in decision making. The objectives were to assess epidemiology and closed manipulation impact on neurovascular outcomes. Methods: Consecutive patients were included in the study. Structured questionnaire was filled denoting demography, severity, subtypes and associated injuries. All patients underwent closed reduction and initial casting. Outcome was measured objectively to decide on need of open surgery. Results: There were 75 patients (male - 58%). Ninety two percent were extension-type while 48% and 21% were Gartland type 2 and 3, respectively. Neurological and vascular deficit was observed in 11% and 8% of patients, respectively. Major mechanisms of injury were direct fall (64%) and road traffic injuries (20%). Regression showed neurovascular deficit, need of open reduction and varus deformity was significantly higher with Grade 3 fracture (P Oxford elbow score was not different between Grade 2 and Grade 3. Eighty seven percent of Grade 2 and 68% of Grade 3 fractures were successfully reduced with closed manipulation. Conclusions: Vascular and neurological deficits were seen in 11%and 8% of patients but they were transient in most cases. Closed reduction alone has achieved good results in a majority. Further analysis is planned in future to compare these data with, closed reduction and percutaneous pinning.

The functional outcome and quality of life following open diaphyseal tibial fractures

Introduction: The clinical outcome of open tibia fracture been extensively studied in many institutions. However, the functional outcome and quality of life has not been widely studied. The aim of this study is to evaluate the functional outcome and quality of life for patients with open tibia fracture that were treated in Hospital Tengku Ampuan Afzan. Methods: Between 2009 and 2010, we treated 33 patients with open diaphyseal tibial fractures with a minimum period of one year follow up. There were 31 males and 2 females; the mean age of 29 years old (range: 10 to 60). Four patients sustained open fracture grade I, 13 grade II, 12 grade IIIA and 4 with grade IIIB. All patients who fulfill the inclusion criteria were called for interview in the clinic by the investigator. The outcome that were analyzed include health related quality of life (SF36) and Lower Extremity Functional Score (LEFS). Results: All except one fracture achieve union. One patient with grade IIIB open fracture developed infected non union. Quality of life is satisfactory in all domains. The functional outcome score was significantly reduced in grade IIIB (48.5) as compare to other grade (grade I 74.2, grade II 70.4, grade IIIA 74.1). Conclusions: The quality of life and the functional outcome worsened with increasing severity of fracture.

Treatment of acute proximal humeral fractures in children with modular external fixator

ObjectiveTo evaluate the follow-up of the fractures treated by external fixator. MethodsA total of 31 children aged 6–15 years with proximal humeral fractures Grade IV according to Neer–Horowitz classification were treated. The medium follow-up was 24 months. ResultsIn all cases, a good stability of the fracture and a quick healing process were obtained. The mean time of follow-up was 24 months. The external fixation was removed after 6 weeks (5–8 weeks) on average. Constant shoulder score was proposed to all patients and the average result was 97.5 (84–100). ConclusionsAdvantages of the external fixation are rapid mobilization of the joint, low invasiveness, a single surgery and the possibility to correct any secondary displacement. It is important to underline that the positioning of external fixator should be implanted by expert surgeons and that the patients must cooperate during the entire process up to the time of the removal of the fixator.

Suprapatellar Intramedullary Nail Technique Lowers Rate of Malalignment of Distal Tibia Fractures.

To report on the immediate postoperative alignment of distal tibia fractures (within 5 cm of the tibial plafond) treated with suprapatellar intramedullary nail (IMN) insertion compared with the infrapatellar technique. Primary outcomes include alignment on both the anteroposterior and lateral radiographic views. Retrospective cohort study. Two urban level I trauma centers. A total of 266 skeletally mature patients with a distal tibia fracture were treated with an IMN. One hundred thirty-two patients underwent this procedure through a suprapatellar technique. Intramedullary nail placement. Alignment. The 2 treatment groups were evenly matched with respect to age, gender, fracture grade, and the presence of open fracture. Within the suprapatellar group, the fibula was intact, fixed, and remained fractured in 6 (4.5%), 22 (16.7%), and 104 (78.8%) cases, respectively. The fibula was intact, repaired, and remained fractured in 9 (6.7%), 32 (23.9%), and 93 (69.4%) cases, respectively, in the infrapatellar group. There was no difference in the rate of fibular fixation between the groups (P = 0.2). Primary angular malalignment of ≥5 degrees occurred in 35 (26.1%) patients with infrapatellar IMN insertion and in 5 (3.8%) patients who underwent suprapatellar IMN insertion (P < 0.0001). This is the largest patient series directly comparing the suprapatellar with infrapatellar IMN insertion technique in the treatment of distal tibia fractures. In the treatment of distal tibia fractures, suprapatellar IMN technique results in a significantly lower rate of malalignment compared with the infrapatellar IMN technique. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical management of intercondylar fracture of distal humerus in adults by olecranon osteotomy

Intercondylar fracture of the distal humerus are uncommon injuries and present the most difficult challenge of the fracture of lower end of humerus. Restoration of the articular surface of distal humerus must be nearly perfect and sufficiently rigid to permit early mobilization of the elbow if the results is to be satisfactory. This is a prospective study of 20 cases of intercondylar fracture of distal humerus in adults admitted to hospital, between august 2011 to September 2013. Cases were taken according to inclusion and exclusion criteria i.e. with intercondylar fracture distal humerus above the age of 18 years and fit for surgery. Medically unfit and not willing for surgery were excluded from the study. Good results seen in 8 cases, fair results in 9 cases and poor results in 3 cases. There were 2(10%) cases each of superficial infection, implant failure, ulnar neuropathy and one (5%) case of non- union and they treated accordingly. Operative treatment with rigid anatomical internal fixation. Should be the line of treatment for all grades of riseborough radin internal fracture as it gives best chance to achieve good elbow function.

A prospective study of surgical management of distal end humerus fractures in adults

Introduction: Distal humerus fractures are uncommon injuries that account for fewer than 2% of all adult fractures. The aim of the study is to evaluate the functional outcome of the surgical management of distal humerus fractures in adults treated by various methods using the post-operative functional criteria by Riseborough and Radin and the Mayo Elbow Performance Index (MEPI). Materials and Method: A Prospective clinical study was conducted over a period of 4 years which included 93 patients in tertiary care centre. The patients were treated with primary open reduction and internal fixation using 3.5 mm reconstruction plates, 4 mm cannulated cancellous screws, bipillar plating using reconstruction plating, K-wires and Y plate or a combination of the above methods using a posterior approach. Results: The average age of the patients in our study was 42.91 years with a range of 18-72 years. In our series, according the Riseborough and Radin criteria, the results were Good in 55(59.13%) patients, Fair in 32(34.4%) and Poor in 6(6.45%) patients. According to MEPI, we had Excellent results in 20(21.5%), Good in 43(46.2%), Fair in 25(26.8%) and Poor in 5(5.37%) patients. Conclusion: Operative treatment with rigid anatomical internal fixation should be the first line of treatment for all grades of Riseborough Radin intercondylar fractures, more so in young adults as it gives best chance to achieve good elbow function. Vigorous, active physiotherapy is a must for good results. Stable fixation allows early, active and aggressive post-operative mobilization.

Femoral Neck Stress Fracture

Background: Limited research is available regarding return-to-running (RTR) time after femoral neck stress fractures. While studies have shown the prognostic value of image-based grading scales for stress fractures at other sites, few have included femoral neck stress fractures. Purpose: To determine if the grade of femoral neck stress fractures based on magnetic resonance imaging (MRI) characteristics correlates with RTR time. Study Design: Cohort study; Level of evidence, 3. Methods: This study included 24 patients (mean age, 32.9 years; range, 18-51 years) who were diagnosed with 27 femoral neck stress fractures by MRI from 2009 to 2015 at a single sports medicine clinic. All fractures were compression sided and were treated nonoperatively. Charts were reviewed for patient demographics and RTR time. Images were graded from 1 to 4 using the Arendt stress fracture severity scale. Statistical analysis was performed using survival analysis and Cox proportional hazard model to compare the RTR time between grades. Cox regression was repeated, adjusted for age, bone mineral density (BMD), and body mass index (BMI). Results: The mean (±standard error of the mean) RTR time in weeks for patients with fractures graded 1 to 4 was 7.4 ± 2.7 (range, 4-11), 13.8 ± 3.8 (range, 6-21), 14.7 ± 3.5 (range, 8.5-24), and 17.5 ± 3.4 (range, 10-32), respectively. Survival analysis indicated that there was a statistically significant effect of fracture grade on RTR time (P = .0065). The Cox model indicated a statistically significant difference in RTR time between grades 1 and 2 (P = .036), 1 and 3 (P = .014), and 1 and 4 (P = .002). The unadjusted hazard ratio was significant (P = .037). There were no statistically significant differences between the remaining grades (P = .82 for grades 2 and 3, P = .37 for grades 2 and 4, and P = .31 for grades 3 and 4). Age (P = .71) and BMD (P = .81) did not have an effect on RTR time. The hazard ratio remained significant (P = .05) after adjusting for age and BMD. BMI tended to have an effect on RTR time (P = .09). After adding BMI to the adjustment, the hazard ratio decreased in significance (P = .13), although sample size also decreased. Conclusion: Grade 2 to 4 femoral neck stress fractures require longer RTR time than do grade 1 injuries. Patients with lower BMI tend to require a longer RTR time.

Depression of the Thoracolumbar Posterior Vertebral Body on the Estimation of Cement Leakage in Vertebroplasty and Kyphoplasty Operations.

Background:The cross-section of thoracolumbar vertebral body is kidney-shaped with depressed posterior boundary. The anterior wall of the vertebral canal is separated from the posterior wall of the vertebral body on the lateral X-ray image. This study was designed to determine the sagittal distance between the anterior border of the vertebral canal and the posterior border of the vertebral body (DBCV) and to analyze the potential role of DBCV in the estimation of cement leakage during percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP).Methods:We retrospectively recruited 233 patients who had osteoporotic vertebral compression fractures and were treated with PVP or PKP. Computed tomography images of T11–L2 normal vertebrae were measured to obtain DBCV. The distance from cement to the posterior wall of the vertebral body (DCPW) of thoracolumbar vertebrae was measured from C-arm images. The selected vertebrae were divided into two groups according to DCPW, with the fracture levels, fracture grades and leakage rates of the two groups compared. A relative operating characteristic (ROC) curve was applied to determine whether the DCPW difference can be used to estimate the degree of cement leakage. The data were processed by statistical software SPSS version 21.0 using independent sample t-test and Chi-square tests.Results:The maximum DBCV was 6.40 mm and the average DBCV was 3.74 ± 0.95 mm. DBCV appeared to be longer in males than in females, but the difference was not statistically significant. The average DCPW of type-B leakage vertebrae (2.59 ± 1.20 mm) was shorter than that of other vertebrae (7.83 ± 2.38 mm, P < 0.001). The leakage rate of group DCPW ≤6.40 mm was lower than that of group DCPW >6.40 mm for type-C and type-S, but much higher for type-B. ROC curve revealed that DCPW only has a predictive value for type-B leakage (area under the curve: 0.98, 95% confidence interval: 0.95–0.99, P < 0.001), and when the cut-off value was 4.05 mm, the diagnostic sensitivity and the specificity were 94.87% and 93.02%, respectively.Conclusions:Depression of the thoracolumbar posterior vertebral body may be informative for the estimation of cement location on C-arm images. To reduce type-B leakage, DCPW should be made longer than DBCV on C-arm images for safety during PVP or PKP.

Seasonal variations in posttraumatic wound infections after open extremity fractures.

The vast majority of the orthopedic trauma literature has dealt with risk of infection as a function of time to debridement and severity of open fracture. The goal of this analysis was to determine if either the incidence or causative organism of posttraumatic infection varies with the season in which the open fracture occurred. No such study has been previously published. This is a retrospective chart review of all skeletally mature patients sustaining an open fracture of either the upper or the lower extremity long bones from 2007 to 2012. Charts were reviewed to extract information regarding date of injury, Gustilo-Anderson grade of open fracture, Injury Severity Score (ISS), time to surgical debridement, any posttraumatic wound infection (deep or superficial), and the causative organisms. Patients were placed into one of four groups based on the time of year: spring (March to May), summer (June to August), fall (September to November), and winter (December to February). Patients were excluded if they were skeletally immature, smokers, or also diagnosed with a condition that would increase risk of infection. Statistical analysis was performed to assess whether any observed differences were of significance. All four groups were similar with respect to Gustilo grade, ISS, and time to surgical debridement. A total of 1,128 open fractures were treated between 2007 and 2012. There were 58 total infections for an overall incidence of 4.3%. The incidence of infection based on season was 6.0% for spring, 4.9% for summer, 2.8% for fall, and 3.6% for winter (p < 0.05). The incidence of infection was 5.5% for spring and summer combined and 3.9% for winter and fall combined (p < 0.05). Gram-positive organisms were more prevalent in the spring and summer seasons (p < 0.05). Although gram-negative organisms were cultured more commonly in the fall and winter seasons (52%) compared with the spring and summer seasons (36%), they were evenly distributed with gram-positive organisms during the winter and fall. A seasonal variation exists regarding the incidence of infection and causative organisms for posttraumatic wound infection following open extremity fractures. The incidence of infection is significantly higher in the spring and summer months with a preponderance of gram-positive organisms. Patients with infection after injuries sustained in the fall and winter months are more likely to have a Gustilo Grade 3 injury and gram-negative bacteria as the causative organism. Epidemiologic study, level III.

Predictors of Compartment Syndrome After Tibial Fracture.

The aim of our study was to identify the risk factors associated with the development of acute compartment syndrome (ACS) after a fracture of the tibia. Retrospective cohort study. Orthopaedic trauma unit, university teaching hospital. From our trauma database, we identified all patients who sustained an acute tibial diaphyseal fracture over a 13-year period. A retrospective analysis of 1407 patients was performed to record and analyze the OTA fracture classification, open fracture grade according to Gustilo, soft tissue injury classification according to Tscherne, treatment, development of ACS, and other patient demographics including smoking, occupation, and socioeconomic deprivation. A diagnosis of ACS was made using clinical signs, compartment pressure monitoring, or a combination of the 2. One thousand three hundred eighty-eight patients were included with a mean age of 39 (12-98) years, and 957 (69%) were male. One hundred sixty patients (11.5%) were diagnosed with ACS. On initial analysis, age, male gender, blue-collar occupation, sporting injury, fracture classification, and treatment with intramedullary nails were predictive of ACS (all P < 0.05). Age was the strongest predictor of developing ACS (P < 0.001), with the highest prevalence between 12-19 years and 20-29 years. Occupation (P = 0.01) and implant type (P = 0.004) were the only factors that remained significant after adjusting for age. On further subanalysis, implant type was not predictive when stratified by Tscherne class (P = 0.11). We have documented the risk factors for the development of ACS after an acute tibial diaphyseal fracture, with youth the strongest predictor. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive plate osteosynthesis for proximal humeral fractures.

To report the outcome after minimally invasive plate osteosynthesis (MIPO) through the deltoid-splitting approach for proximal humeral fractures. 10 men and 30 women aged 37 to 88 years underwent MIPO through the deltoid-splitting approach using the Proximal Humerus Internal Locking System or the Locking Proximal Humerus Plate for 2-part (n=18), 3-part (n=20), and 4-part (n=2) proximal humeral fractures. The rehabilitation protocol was standardised. All 40 patients were followed up at 3 months, 34 (85%) at 6 months, 30 (75%) at one year, and 13 (33%) at 2 years. Two patients had malunion. No patient had avascular necrosis, infection, nerve palsy, or nonunion. The mean Constant score at one year and 2 years was 75 and 87.5, respectively. The Constant score at 6 months correlated to that at one year (r=0.926, p<0.0001) and at 2 years (r=0.874, p=0.0001). In younger patients, improvement in the range of motion was faster. The early plateau group (those with no further improvement after 6 months) and the late plateau group (those with no further improvement after one year) did not differ significantly in age, fracture grade, or hand dominance. MIPO for fixation of proximal humeral fractures using a locking plate is safe and effective in enabling an early return of shoulder function.

Quantitative evaluation of fracture development in Triassic Yanchang Formation, Ordos Basin, NW China

Abstract To uniformly evaluate the fracture development of the Triassic Yanchang Formation in Ordos Basin, a set of evaluation methods for fracture development degree is established by observation and account of fractures developed in the sandstone cores of the Yanchang Formation in the five blocks of Maling, Huaqing, Anbian, Wuqi and Yanhewan in the Shaanbei Slope. The methods include four aspects of qualitative and quantitative indices, i.e., fracture type, fracture strength, fracture grade and fracture assemblage, which are applicable to the fracture assorting, single well evaluation, block evaluation and belt evaluation, respectively. Quantitative evaluation plates of block fracture development degree have been built and applied to evaluate the fracture development degree of the five blocks. The Chang 7 1 Member in Maling block has high angle fractures of three grades (weak, moderate and strong) developed simultaneously and low angle fractures in moderate-strong development degree; the Chang 7 2 Member in Maling block has weakly to moderately developed high angle fractures and moderately to strongly developed low angle fractures; both the Chang 7 1 and Chang 7 2 members in Anbian block have strongly developed high angle fractures, but undeveloped low angle fractures; the Chang 6 3 Member in Huaqing block has undeveloped high angle fractures and moderately to strongly developed low angle fractures locally; the Chang 6 members in Wuqi block and Yanhewan block have undeveloped high angle fractures and low angle fractures.

Return of functional mobility after an open tibial fracture: a sensor-based longitudinal cohort study using the Hamlyn Mobility Score.

In this study we quantified and characterised the return of functional mobility following open tibial fracture using the Hamlyn Mobility Score. A total of 20 patients who had undergone reconstruction following this fracture were reviewed at three-month intervals for one year. An ear-worn movement sensor was used to assess their mobility and gait. The Hamlyn Mobility Score and its constituent kinematic features were calculated longitudinally, allowing analysis of mobility during recovery and between patients with varying grades of fracture. The mean score improved throughout the study period. Patients with more severe fractures recovered at a slower rate; those with a grade I Gustilo-Anderson fracture completing most of their recovery within three months, those with a grade II fracture within six months and those with a grade III fracture within nine months. Analysis of gait showed that the quality of walking continued to improve up to 12 months post-operatively, whereas the capacity to walk, as measured by the six-minute walking test, plateaued after six months. Late complications occurred in two patients, in whom the trajectory of recovery deviated by > 0.5 standard deviations below that of the remaining patients. This is the first objective, longitudinal assessment of functional recovery in patients with an open tibial fracture, providing some clarification of the differences in prognosis and recovery associated with different grades of fracture.

High‐temperature fracturing and subsequent grain‐size‐sensitive creep in lower crustal gabbros: Evidence for coseismic loading followed by creep during decaying stress in the lower crust?

AbstractThe mechanism of shear zone formation in lower crustal, relatively “dry” rocks is still poorly understood. We have studied the high‐temperature deformation of the Hasvik gabbro (northern Norway) which commences by fracturing. The 10–20 µm wide fractures show little displacement. The fine‐grained plagioclase and orthopyroxene in the fractures lack a crystallographic preferred orientation (CPO) or a systematic crystallographic orientation with respect to the host grains. Fractures grade into narrow shear zones, which are composed of fine (10–20 µm), equant grains of recrystallized plagioclase, amphibole, and pyroxene. Recrystallized plagioclase and pyroxene have compositions different from the magmatic grains, suggesting that they have formed by nucleation and growth. Based on conventional plagioclase‐amphibole thermobarometry, the shear zones have formed at temperatures and pressures of 700–750°C and 0.5–0.6 GPa. The observed primary minerals cut by fractures suggest high‐temperature fracturing in the absence of high pore pressures, which implies a high strength of the lower crustal gabbros and high stresses at fracturing. The shear zones are characterized by the lack of CPO and a small grain size, suggesting that the mechanism of deformation of the fine‐grained plagioclase and orthopyroxene has been grain boundary sliding accommodated by diffusive mass transfer. The amphibole grains have strong CPOs, which most likely result from oriented growth and/or rigid body rotations during deformation. The process that initiated the fracturing and subsequent viscous creep in the Hasvik gabbro may have resulted from a process of coseismic loading followed by creep during decaying stress in the lower crust.

New response in electrochemical impedance spectroscopy due to the presence of molybdenum on AB5-type alloys

During the present investigation, it was observed that the inclusion of molybdenum in LaNi3.6Co0.7Mn(0.4-x)Al0.3Mox AB5-type alloys produced new responses in the electrochemical impedance spectroscopy (EIS) when they are used as an anode active material for Ni-MH batteries. The aim of this work is to study, using electrochemical impedance spectroscopy, the influence of molybdenum, on the performance of the electrode. EIS spectra were adjusted in terms of a physicochemical model of the dynamic response of the system. X ray diffraction and hydrogen diffusion coefficient calculated from discharges curves supported EIS model outcomes.The replacement of manganese by molybdenum, in a 2% w/w concentration level (AB5M1), has a positive effect for applications as energy storage material. In this sense, this alloy exhibits the lowest value of charge transfer resistance obtained from the analysis of impedance spectra. Moreover, changes in the (i0. aa) parameter, that is, the exchange current density and active area, respectively display a maximum value. The larger grade of fracture observed in AB5M1 can be due to the higher material's fragility as a consequence of molybdenum incorporation. XRD analysis on the three alloys confirms this hypothesis as shown in the paper.

Ankle Fractures and Modality of Hospital Transport at a Single Level 1 Trauma Center: Does Transport by Helicopter or Ground Ambulance Influence the Incidence of Complications?

In an era of concern over the rising cost of health care, cost-effectiveness of auxiliary services merits careful evaluation. We compared costs and benefits of Helicopter Emergency Medical Service (HEMS) with Ground Emergency Medical Service (GEMS) in patients with an isolated ankle fracture. A medical record review was conducted for patients with an isolated ankle fracture who had been transported to a level 1 trauma center by either HEMS or GEMS from January 1, 2000 to December 31, 2010. We abstracted demographic data, fracture grade, complications, and transportation mode. Transportation costs were obtained by examining medical center financial records. A total of 303 patients was included in the analysis. Of 87 (28.71%) HEMS patients, 53 (60.92%) had sustained closed injuries and 34 (39.08%) had open injuries. Of the 216 (71.29%) GEMS patients, 156 (72.22%) had closed injuries and 60 (27.78%) had open injuries. No significant difference was seen between the groups regarding the percentage of patients with open fractures or the grade of the open fracture (p = .07). No significant difference in the rate of complications was found between the 2 groups (p = 18). The mean baseline cost to transport a patient via HEMS was $10,220 + a $108/mile surcharge, whereas the mean transport cost using GEMS was $976 per patient + $16/mile. Because the HEMS mode of emergency transport did not significantly improve patient outcomes, health systems should reconsider the use of HEMS for patients with isolated ankle fractures.

Plate fixation of extra-articular fractures of the proximal phalanx: do new implants cause less problems?

Limited range of finger motion is a frequent complication after plate fixation of phalangeal fractures. The purpose of this study was to evaluate the results of plate fixation of extra-articular fractures of the proximal phalanx using current low-profile mini-fragment-systems. From 2006 to 2012, 32 patients with 36 extra-articular fractures of the proximal phalanx of the triphalangeal fingers were treated with open reduction and plate fixation (ORPF) using 1.2 and 1.5mm mini-fragment systems. Patients presenting with open fractures grade 2 and 3 or relevant laceration of adjacent structures were excluded from the study. We retrospectively evaluated the rate of mal-union or non-union after ORPF, the need for revision surgery, for plate removal, and for tenolysis. Data were analyzed for further complications with regard to infections or complex regional pain syndrome (CRPS). No infections were noted. Five patients developed transient symptoms of CRPS. Six weeks postoperatively, total active finger motion (TAM) averaged 183°, and all 32 patients underwent formal hand therapy. At the latest follow-up or at the time of plate removal, respectively, the mean TAM improved to 213°. Extension lag of proximal interphalangeal joints was found in 67% of all fractured fingers. Secondary surgery was necessary in 14 of 32 patients (2 corrective osteotomies, 12 plate removals including 7 procedures explicitly because of reduced mobility). Despite of new implant designs significant problems persist. Adhesions of extensor tendons leading to limited range of finger motion are still the most frequent complications after ORPF of proximal phalangeal fractures, even in absence of significant soft-tissue damage. Therapeutic, Retrospective, Level IV.

Predebridement wound culture in open fractures does not predict postoperative wound infection: A pilot study.

Background:There is confusion in the current literature regarding the value of obtaining predebridement wound cultures in the management of open fractures with several studies reporting contrasting results. We undertook a pilot study to determine the initial bacterial flora of open fractures in our environment and determine the correlation between subsequent wound infection if any, and the initial bacterial flora.Materials and Methods:Initial/predebridement wound swabs were obtained for 32 patients with open fractures. Patients underwent a debridement of the open wound and preliminary stabilization of fracture in the operating room within 24 h. Postdebridement wound cultures were obtained at 48 h and repeated subsequently, if indicated, during the follow-up period. The antibiotic therapy was modified based on the culture reports.Results:Initial wound swab culture showed bacterial contamination in 18 patients (56%); 14 patients (44%) developed an infection in the immediate postoperative period or during follow-up. Age, gender, co-morbid medical condition, delay in presentation, and grade of open fracture were not found to be predictors of postoperative infection. No patient had an infection with the same organism, which was present in the initial culture.Conclusion:The findings of this study suggest that the initial flora are not the infecting organisms in the open fracture wounds, and predebridement wound cultures have no value in predicting postdebridement wound infection.