Hand Fractures Research Articles

Intramedullary Screw Fixation of Metacarpal and Phalangeal Fractures.

Metacarpal and phalangeal fractures are the second and third most common hand and wrist fractures seen in the emergency department. There are a multitude of operative fixation methods for metacarpal and phalangeal fractures, including closed reduction percutaneous pinning, open reduction internal fixation, external fixation, and intramedullary screw fixation. Although intramedullary fixation is a relatively new surgical technique, it is gaining in popularity as it allows patients to resume range of motion early in the postoperative period with excellent clinical outcomes.

A commentary on 'Radiographic views for hand fractures - call for three-view national UK guidelines - a quality improvement study'.

A commentary on 'Radiographic views for hand fractures - call for three-view national UK guidelines - a quality improvement study'.

Rate of Complications after Hip Fractures Caused by Prolonged Time-to-Surgery Depends on the Patient's Individual Type of Fracture and Its Treatment.

Hip fractures are common injuries in the elderly and are usually treated with timely surgery. While severe postoperative complications are reported for up to 10% of patients, many studies identified predictive factors for the occurrence of complications postoperatively. A controversially discussed factor is "time-to-surgery". The aim of the study was to examine if time-to-surgery was associated with the occurrence of complications and if the complication rate differed between the patient individual fracture types of intracapsular on the one hand and extracapsular hip fractures on the other hand. We hypothesized that time-to-surgery had less impact on complications in intracapsular hip fractures compared to extracapsular ones, and therefore, guidelines should pay attention to the patient individual case scenario. All patients who were admitted to the Department of Trauma and Orthopaedic Surgery of an academic teaching hospital for hip fracture surgery (n = 650) over a five-year period were included in the study. After the application of the exclusion criteria, such as periprosthetic or pathologic fractures, cases needed immediate surgical treatment, and after outlier adjustment, 629 cases remained in the study. Hip fractures were classified into intracapsular fractures (treated by hip arthroplasty) and extracapsular fractures (treated by intramedullary nailing osteosynthesis). The occurrence of severe complications in patients treated within 24 h was compared with patients treated later than 24 h after injury. For statistical evaluation, a multivariate logistic regression analysis was performed to investigate the impact of time-to-surgery interval on the occurrence of complications. Patients with an extracapsular fracture, which was treated with intramedullary nailing (44.5%), rarely suffered a serious complication when surgery was performed within 24 h after injury. However, when the interval of the time-to-surgery was longer than 24 h, the complication rate increased significantly (8.63% vs. 25.0%, p = 0.002). In contrast to this finding in patients with intracapsular fractures (55.5%), which were treated with cemented arthroplasty, complication rates did not depend on the 24 h interval (26.17% vs. 20.83%, p = 0.567). The occurrence of complications after surgical treatment of hip fractures is associated with the time interval between injury and surgery. A 24 h time interval between injury and surgical procedure seems to play a major role only in extracapsular fractures treated with osteosynthesis but not in intracapsular fractures treated with arthroplasty. Therefore, guidelines should take notice of the patient individual case scenario and, in particular, the individual hip fracture type.

Preventable hand injuries: A national audit

Little is known of the scale of avoidable injuries presenting to medical services on a national level in the UK. This study aimed to assess the type and incidence of preventable wrist and hand injuries (as defined by the core research team) at a national level in the UK. 28 UK hospitals undertook a service evaluation of all hand trauma cases presenting to their units over a 2 week period in early 2021 identifying demographical and aetiological information about injuries sustained. 1909 patients were included (184 children) with a median age of 40 (IQR 25-59) years. The commonest five types of injury were fractures of the wrist; single phalangeal or metacarpal fractures; fingertip injuries; and infection, with the most common mechanisms being mechanical falls and manual labour. This is the first extensive survey of preventable hand injuries in the UK, identifying a need for further work into prevention to reduce healthcare burden and cost. 50% of injuries presenting to hand surgeons are preventable, with the most common injuries being single fractures of the wrist, phalanx and metacarpal. Few preventable injuries were related to alcohol or narcotic intoxication. Further research is needed to identify how to initiate injury prevention measures for hand injuries, particularly focussed towards hand fracture prevention.

Regional Anesthesia for Wrist Fractures and Dislocations: Are We Really Blocking Opioid Prescribing?

The aim of this study was to evaluate the impact of regional anesthesia for the treatment of wrist fractures or dislocation on opioid prescription-filling patterns. Patients undergoing surgery for hand and wrist fractures or dislocations from 2010 to 2018 were identified by using a national insurance claims database. Patients were stratified by procedures conducted with and without regional anesthesia. Preoperative opioids were defined by a filled opioid prescription within 1 month prior to surgery, postoperative within 1 month following the surgery, and prolonged postoperative 3 to 6 months following surgery. Patients' demographic data, comorbidities, additional medications, 30-day emergency department (ED) visits, and hospital readmissions were analyzed. A total of 24 598 patients treated with and 115 199 patients treated without a regional nerve block for wrist fractures and dislocations were identified. Regional anesthesia was associated with greater postoperative opioid prescription but fewer prolonged postoperative prescriptions. There was an increased odds of all-cause 30-day ED visits but a decreased odds of 30-day hospital readmissions when patients received a regional nerve block prior to surgery. In this study, receiving regional anesthesia prior to surgical intervention for wrist fractures or dislocations was associated with increased filling of postoperative opioid prescriptions, but not prolonged postoperative opioid prescriptions. Additional investigation is needed to identify and implement nonnarcotic multimodal analgesia regimens that may help decrease usage of narcotic medications surrounding these procedures. Level III, retrospective cohort study.

Biomechanical study of the fixation ability of the dorsal and volar locking plate for transverse metacarpal neck fractures.

Metacarpal neck fracture is one of the most common types of hand fractures; the literature suggests that applying a bone plate on the dorsal side provides higher fixation strength than that provided by other fixation methods. However, bone plate fixation on the dorsal side may result in postoperative tendon adhesion. So far, no studies have investigated the fixation of metacarpal neck fractures on the volar side by using a bone plate. The objective of this study was to investigate the differences in the fixation results between bone plate fixation on the dorsal side and bone plate fixation on the volar side of the metacarpal in the case of a metacarpal neck fracture. A saw blade was used to create a transverse metacarpal neck fracture on 14 artificial metacarpal bone specimens. The specimens were divided into 2 groups depending on the fixation method: a volar locking plate (VLP) group and a dorsal locking plate (DLP) group. All specimens were subjected to a cantilever bending test on a material testing system, and a force-displacement curve was used to measure the yield force and stiffness, which served as an indicator of the fixation ability of the 2 fracture fixation methods. For the experimental results, the Mann-Whitney U test was used to compare the fixation abilities of the 2 fixation methods. In terms of yield force, the DLP group (266.9 ± 68.3 N) scored significantly higher than the VLP group (32.6 ± 2.7 N) (P < .05); expressed in terms of median, the DLP group scored 8.2 times higher than the VLP group. Similarly, in terms of stiffness, the DLP group (69.0 ± 13.4 N/mm, median ± interquartile range) scored significantly higher than the VLP group (12.9 ± 1.4 N/mm) (P < .05); expressed in terms of median, the DLP group scored 5.3 times higher than the VLP group. The fixation strength of volar bone plates is only about one-third of that of dorsal bone plates.

Characteristics of carpal tunnel syndrome in patients with cervical radiculopathy: A cross-sectional study.

Cervical radiculopathy (CR) is a group of signs and symptoms caused by cervical root dysfunction. Patients with this condition may also have carpal tunnel syndrome (CTS), which is caused by compression of the median nerve in the carpal tunnel. This coexistent condition is referred to as double crush syndrome (DCS) which is explained by proximal disruption in axoplasmic flow that may result in nerve dysfunction. Yet, the accuracy of this hypothesis remains controversial. Patients with confirmed CR according to electromyography were included in this retrospective study. However, we omitted patients with overt diabetic neuropathy, prior spinal or hand surgery and/or fractures, and rheumatoid arthritis. Patients underwent electrodiagnostic studies, and the results were used to determine CTS severity. We used Pearson's χ 2 test to assess the correlation between the severity of CTS and CR. Descriptive analysis was used to report patient characteristics and the prevalence of CTS in CR patients. We included 291 participants, 59% of whom were women. Although insignificant, DCS was observed more in women (n = 110) compared to men (n = 71). However, we found that patients with DCS (54.81 ± 13.3) were older than non-DCS patients (43.71 ± 12.94) which was statistically significant (p < 0.05). There was statistically no correlation between the severity of CR and CTS, ipsilaterlly (p > 0.05). In total, CTS was observed in 62.2% (n = 181) patients. In summary, we found a relatively high prevalence of DCS in the present study. In patients with and without DCS, gender did not seem to play a role but the growing age seemed to contribute to DCS. The severity of CTS was not related to CR severity at any cervical level, which negates a causal relation between the pre-existing CR and newly diagnosed CTS.

Single or double Kirschner wire fixation: which provides better outcomes for pediatric proximal phalanx base fractures?

The most common hand fracture in children is seen at the base of the proximal phalanx. This study aims to compare clinical outcomes of single versus double Kirschner wire pinning for pediatric proximal phalanx base fractures. The retrospective study enrolled patients who underwent closed K-wire pinning for proximal phalanx base fractures from January 2016 to February 2022. We divided patients into two groups based on the number of K-wire inserted (single versus double). Demographics, removal of implant, complication rate were analyzed. Patients were asked to answer the Michigan Hand Outcomes Questionnaire (MHQ) by telephone. Data including fracture type, diaphyseal axis-metacarpal head angle (DHA) and Total Active Flexion Scale (TAFS) were analyzed. This study included 37 pediatric patients with proximal phalanx base fractures, treated with either single (n = 10) or double K-wire (n = 27) fixation. The mean operation time was significantly shorter for the single K-wire group. No significant differences were observed in complication rates, TAFS, implant removal times, MHQ, or pre- and post-operative DHA between the two groups. The single K-wire technique demonstrates similar effectiveness to the double K-wire technique in treating pediatric proximal phalanx base fractures, with the added benefit of shorter operation time. Therefore, the choice between using one or two K-wires should be determined based on the surgeon's proficiency and preference.

Comparison of Joshi's external stabilization system and Kirschner wire fixation technique for extra-articular metacarpal fractures

Hand fractures, especially metacarpals and phalanges, account for 15% of emergency department admissions. Metacarpal fractures can be treated using various algorithms. Hand fractures have been treated with K wire fixation, micro plates, and external fixator application devices. A successful functional outcome requires surgical intervention with good fixation principles and a rigid system that allows early mobilization. JESS is a simple, lightweight fixation that can be used with splints or converted to dynamic mobilization units. In open fractures, JESS rigidly fixes bones. Compress, neutralize, or distract a fracture fragment to aggressively treat bone and soft tissue injuries. Moving the proximal and distal joints instantly reduces edema, capsular fibrosis, joint stiffness, and muscle atrophy. Kirschner wires are the easiest, cheapest, and most versatile hand injury treatment. They can be percutaneously introduced. It allows early movements without surgical stress This study compares intramedullary Kirschner wires and Joshi’s external fixator device for unstable extra-articular metacarpal fractures.

1008 Impact of COVID-19 Vaccination-Based Triaging on Recovery of Services for Plastic Surgery Hand Trauma in a Plastic Surgery Tertiary Referral Centre

Abstract Aim Evaluate the impact vaccination-based-triaging on recovery of operative services. Method Data was collected retrospectively on 120 patients who underwent surgical management for closed hand fractures, nerve injuries, and tendon injuries. Forty were in the pre-covid group (Jan-Mar 2019), 40 in the post-covid pre-vaccine group (Jan-Mar 2022), and 40 in the post-covid post-vaccine group (Jul-Sep 2022). Outcome measures:Average number of days between decision to operate and operation (operative delay)Adherence to operative timing requirements, as set by the British Society for Surgery of the Hand (BSSH) Results In the post-covid post-vaccine group, operative delay was shorter than in the post-covid pre-vaccine group for hand fractures (3.6 vs 3.9) nerve injuries (3.8 vs 2.5), and tendon injuries (2.1 vs 2.2). Overall, the difference was not statistically significant (3.3 vs 2.7, p = 0.2526). BSSH operative timing requirements were met in a higher proportion of patients for hand fractures (93% vs 85%), nerve repairs (100% vs 87%), tendon repairs (89% vs 85%) and overall (89% vs 85%). In the pre-covid group, operative delay was shorter than both post-covid groups for hand fractures (2.5), nerve injuries (1.8), and tendon injuries (1.4). Overall, the difference was statistically significant compared to the post-covid pre-vaccine (1.9 vs 3.3, p = 0.0024) and pre-covid post-vaccine groups (2.7 vs 1.9, p = 0.0238). Overall, BSSH operative timing requirements were met for a higher proportion of patients than both pre-covid groups (100% vs 89%). Conclusions Plastic surgery hand trauma services have not yet fully recovered. Further interventions are required to aid recovery to pre-pandemic standards.

1030 Impact of COVID-19 on Operative Timing for Plastic Surgery Hand Trauma in a Plastic Surgery Tertiary Referral Centre

Abstract Aim To evaluate the impact of COVID-19 on operative timing for hand trauma in a plastic surgery tertiary referral centre. Method Data was collected retrospectively on 80 patients who underwent surgical management for closed hand fractures, digital nerve injuries, and tendon injuries. Forty patients were in the pre-covid group (Jan-Mar 2019) and 40 in the post-covid group (Jan-Mar 2022). Outcome measures:Mean number of days between decision to operate and operation (operative delay time)Adherence to the operative timing requirements, as set by the British Society for Surgery of the Hand (BSSH) Results There was a statistically significant difference in operative delay time between the pre-covid group and the post-covid pre-vaccine group for hand fractures (2.5 vs 3.9, P = 0.0503), tendon injuries (1.4 vs 2.2, p = 0.016), and overall (1.9 vs 3.3, p = 0.0024). There was no significant difference between the 2 groups for nerve injuries (3.8 vs 1.8, p = 0.3062). In the post-covid group, BSSH operative timing requirements were met for a lower proportion of patients than the pre-covid group for hand fracture fixations (85% vs 100%), nerve repairs (87% vs 100%) tendon repairs (85% vs 100%). Overall, there was a statistically significant difference between the 2 groups (85% vs 100%, p = 0.0214). Operative delays were documented as being related to COVID-19 in 100% of patients who did not meet BSSH operative timing requirements. Conclusions COVID-19 has had a significant impact on operative timing for plastic surgery hand trauma. Further studies are needed to evaluate the usefulness of various interventions in the recovery of services following the COVID-19 global pandemic.

Antegrade Intramedullary Pinning versus Retrograde Intramedullary Pinning versus Transverse k-Wires Fixation of Neck of 5th Metacarpal Fracture: A Systematic Review

Background The 5th metacarpal fractures accounts for 40% of all hand fractures. Neck fractures are the commonest, as it is the weakest point in metacarpals, and accounts for about 10% of all hand fractures. Improper management of hand fractures has negative economic effect due to disabilities that occur to hands of workers, athletes and housewives. Objective To do a systematic review on literature that compares between using the antegrade verses retrograde intra-medullary k-wires and transverse pinning techniques in treatment of fifth metacarpal's neck fracture (boxer's fracture) regarding union, functional outcome and complications. Patients and Methods Recent clinical trials or cluster trials, prospective and retrospective comparative cohort studies. Search results will be uploaded to systematic review management software and manually screened for eligibility to be included. PRISMA flowchart will be introduced on the search results and the inclusion/exclusion criteria. Results Application of inclusion and exclusion criteria to study abstracts yielded 8 articles. The full-text articles for these 100 studies were then reviewed and subjected to our inclusion criteria. A total of 8 articles were eligible for final systematic review. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2022. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Conclusion Despite the limitations of this review, we found some evidence that the IM technique could have advantages over the use of transverse pinning in the treatment for the fifth metacarpal neck fractures. The quantitative analyses indicated probable better efficacy of IM particularly in relation to VAS, TAM, active ROM of the fifth ray and residual angulation. Our results can fit into the context of current practice where many hand surgeons consider the IM technique as their preferred method to treat neck fractures of the fifth metacarpal.

FTP8.11 Impact of COVID-19 on operative timing for plastic surgery hand trauma in a plastic surgery tertiary referral centre

Abstract Aim To evaluate the impact of COVID-19 on operative timing for hand trauma in a plastic surgery tertiary referral centre. Methods Data was collected retrospectively on 80 patients who underwent surgical management for closed hand fractures, digital nerve injuries, and tendon injuries. Forty patients were in the pre-covid group (Jan-Mar 2019) and 40 in the post-covid group (Jan-Mar 2022). Outcome measures: Results There was a statistically significant difference in operative delay time between the pre-covid group and the post-covid pre-vaccine group for hand fractures (2.5 vs 3.9, P=0.0503), tendon injuries (1.4 vs 2.2, p=0.016), and overall (1.9 vs 3.3, p=0.0024). There was no significant difference between the 2 groups for nerve injuries (3.8 vs 1.8, p=0.3062). In the post-covid group, BSSH operative timing requirements were met for a lower proportion of patients than the pre-covid group for hand fracture fixations (85% vs 100%), nerve repairs (87% vs 100%) tendon repairs (85% vs 100%). Overall, there was a statistically significant difference between the 2 groups (85% vs 100%, p=0.0214) Operative delays were documented as being related to COVID-19 in 100% of patients who did not meet BSSH operative timing requirements. Conclusion COVID-19 has had a significant impact on operative timing for plastic surgery hand trauma. Further studies are needed to evaluate the usefulness of various interventions in the recovery of services following the COVID-19 global pandemic.

FTP8.10 Impact of COVID-19 vaccination-based triaging on recovery of services for Plastic Surgery Hand Trauma in a Plastic Surgery Tertiary Referral Centre

Abstract Aim Evaluate the impact vaccination-based-triaging on recovery of operative services. Method Data was collected retrospectively on 120 patients who underwent surgical management for closed hand fractures, nerve injuries, and tendon injuries. Forty were in the pre-covid group (Jan-Mar 2019), 40 in the post-covid pre-vaccine group (Jan-Mar 2022), and 40 in the post-covid post-vaccine group (Jul-Sep 2022). Outcome measures: Results In the post-covid post-vaccine group, operative delay was shorter than in the post-covid pre-vaccine group for hand fractures (3.6 vs 3.9) nerve injuries (3.8 vs 2.5), and tendon injuries (2.1 vs 2.2). Overall, the difference was not statistically significant (3.3 vs 2.7, p=0.2526). BSSH operative timing requirements were met in a higher proportion of patients for hand fractures (93% vs 85%), nerve repairs (100% vs 87%), tendon repairs (89% vs 85%) and overall (89% vs 85%). In the pre-covid group, operative delay was shorter than both post-covid groups for hand fractures (2.5), nerve injuries (1.8), and tendon injuries (1.4). Overall, the difference was statistically significant compared to the post-covid pre-vaccine (1.9 vs 3.3, p=0.0024) and pre-covid post-vaccine groups (2.7 vs 1.9, p=0.0238). Overall, BSSH operative timing requirements were met for a higher proportion of patients than both pre-covid groups (100% vs 89%) Conclusions Plastic surgery hand trauma services have not yet fully recovered. Further interventions are required to aid recovery to pre-pandemic standards.

Diagnostic Accuracy and Confidence in Management of Forearm and Hand Fractures Among Foundation Doctors in the Accident and Emergency Department: Survey Study.

Accurate interpretation of radiographs is crucial for junior doctors in the accident and emergency (A&E) department (the emergency medicine department). However, it remains a significant challenge and a leading cause of diagnostic errors. This study aimed to evaluate the accuracy and confidence of foundation doctors (doctors within their first 2 years of qualifying) in correctly interpreting and managing forearm and hand fractures on plain radiographs. A total of 42 foundation doctors with less than 2 years of experience and no prior emergency medicine training who worked in a large district general hospital participated in a web-based questionnaire. The questionnaire consisted of 3 case studies: distal radius fracture, scaphoid fracture, and a normal radiograph. Respondents were required to identify the presence or absence of a fracture, determine the fracture location, suggest appropriate management, and rate their confidence on a Likert scale. Overall, 48% (61/126) of respondents accurately identified the presence and location of fractures. The correct management option was chosen by 64% (81/126) of respondents. The median diagnostic confidence score was 4 of 10, with a mean diagnostic certainty of 4.4 of 10. Notably, respondents exhibited a significantly lower confidence score for the normal radiograph compared to the distal radius fracture radiograph (P=.01). This study reveals diagnostic uncertainty among foundation doctors in interpreting plain radiographs, with a notable inclination toward overdiagnosing fractures. The findings emphasize the need for close supervision and senior support to mitigate diagnostic errors. Further training and educational interventions are warranted to improve the accuracy and confidence of junior doctors in radiographic interpretation. This study has several limitations, including a small sample size and reliance on self-reported data. The findings may not be generalizable to other health care settings or specialties. Future research should aim for larger, more diverse samples and explore the impact of specific educational interventions on diagnostic accuracy and confidence.

The Calgary Kids’ Hand Rule: External Validation of a Prediction Model to Triage Pediatric Hand Fractures

Background: The Calgary Kids’ Hand Rule (CKHR) is a clinical prediction rule intended to guide referral decisions for pediatric hand fractures presenting to the emergency department, identifying “complex” fractures that require surgical referral and optimizing care through better matching of patients’ needs to provider expertise. The objective of this study was to externally validate the CKHR in two different tertiary pediatric hospitals in Canada. Methods: We partnered with British Columbia Children's Hospital (BCCH) and the Children's Hospital of Eastern Ontario (CHEO) to externally validate the CKHR using data from retrospective cohorts of pediatric hand fractures (via electronic medical record and x-ray review). Model performance was evaluated at each site using sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and the C-statistic. Results: A total of 954 hand fractures were included in the analysis (524 at BCCH and 430 at CHEO. At BCCH, the CKHR had a sensitivity of 91.1% (133 predicted complex out of 146 total complex fractures), specificity of 71.4% (269 predicted simple out of 377 total simple fractures), and C-statistic of .81, 95% CI [0.78-0.84]. At CHEO, the CKHR had a sensitivity of 98.3%, specificity of 30.2%, and C-statistic of .64, 95% CI [0.61-0.67]. Conclusion: The CKHR performed well at two different tertiary care centres with high sensitivity, supporting its ability to facilitate hand fracture triage in other populations without further modification. This work should be followed by rigorous implementation analysis to determine its impact on patient care.

Open fractures of the hand: a new classification based on risk score to predict infection requiring re-debridement.

We developed a classification for open hand fractures based on risk score to predict the risk of infection requiring re-debridement. A total of 846 retrospectively included patients underwent multivariable analysis with backward elimination to derive the predictive risk score from independent predictors. The incidence of infection requiring re-debridement was 4%. Independent predictors include diabetes mellitus or immunocompromised condition, injuries from a bite, fractures with comminution/bone loss, neurovascular injuries and inadequate soft tissue coverage. The area under the receiver operating characteristic curve of the prediction score was 0.79. The new classification system for open hand fractures divides patients into three groups: low-risk open fractures (Type I, score <1); moderate-risk open fractures (Type II, score 1 to 2.5); and high-risk open fractures (Type III, score >2.5), based on the risk of infection requiring re-debridement. Re-debridement and delayed primary closure are suggested for type III open fractures.Level of evidence: III.

Radiographic views for hand fractures - call for three view national uk guidelines - a quality improvement study.

A three-view radiographic examination (comprising of antero-posterior, oblique and lateral views) is crucial for the accurate assessment and subsequent decision making in hand fracture management. The superiority of a three-view examination, compared to only two-views, has been demonstrated by multiple studies, citing increased diagnostic accuracy and reduced rates of misdiagnosis. As such, the American College of Radiology (ACR) now recommend a standard three-view examination for finger and hand injuries, despite this no formal guidance exists in the United Kingdom. Out of the 235 patients referred to our tertiary hand trauma unit with a confirmed hand fracture, less than half (45%) had three-view radiographic examination performed. Less than two-thirds (57%) of metacarpal fractures had three-views available at assessment in our unit, with the lateral radiograph most commonly lacking (38%). Less than a third (30%) of phalangeal fractures had all three-views, with the oblique view most commonly absent (64% of cases). Reviewed radiology protocols from six local hospitals were inconsistent; all recommended three-views for suspected metacarpal fractures, but only two for suspected phalangeal injuries. Despite the superiority of a three-view examination and no additional cost of a third view, over half of the patients in this study lacked a three-view radiographic series. We would like to call for national published guidance advocating the use of three-view radiographic series in all patients with a high hand fracture suspicion (as defined by the presence of swelling, bruising and/ or deformity) to reduce variability in local radiology hand fracture protocols and increase availability of three-view radiographs in the primary, secondary and tertiary setting.

Pediatric Hand and Wrist Fractures in Osteogenesis Imperfecta: An Analysis of Incidence, Patient-specific Risk Factors, and Fracture-specific Characteristics.

Children with osteogenesis imperfecta (OI) frequently present with fractures; however, hand and wrist fractures (HWFs), those distal to the radial and ulnar diaphysis, are seldom observed. Yet, HWFs remain among the most common fractures in children with non-OI. The objective of this study was to identify the incidence of OI HWFs. Secondary objectives aimed at identifying patient-specific risk factors for HWFs in OI and comparing clinical courses to non-OI HWFs. A retrospective cohort study was conducted. Database query by ICD-10 codes identified 18 patients with OI HWF, 451 patients with OI without HWFs, and 26,183 patients with non-OI HWF. Power analysis estimated appropriate sample sizes and random sampling was utilized to collect patients. Patient demographics, OI-specific variables, fracture morphology, and fracture clinical courses were recorded. Data were analyzed for patient-specific and fracture-specific factors affecting OI HWF incidence. Of patients with OI, 3.8% (18/469) sustained HWFs. Patients with OI HWF were significantly older than patients with OI without HWFs ( P = 0.002) with no differences in height, weight, ethnicity, sex, or ambulatory status. Compared with non-OI HWFs, patients with OI HWF were significantly shorter ( P < 0.001), weighed less ( P = 0.002), and were less likely to be ambulatory ( P < 0.001). OI HWFs were more commonly on the side of hand dominance ( P < 0.001) with transverse patterns ( P = 0.001). OI HWFs were less frequent in the thumb ( P = 0.048) and trended towards significance in the metacarpals ( P = 0.054). All OI HWFs were treated nonoperatively with similar union rates and refracture rates to non-OI HWFs. Multivariate regression showed that older patient age (odds ratio: 1.079, 95% CI: 1.005,1.159, P = 0.037) and OI type I (odds ratio: 5.535, 95% CI: 1.069, 26.795, P = 0.041) were significant prognosticators for HWFs in patients with OI. OI HWFs are uncommon (3.8%, 18/469) but specific HWF morphologies and locations are more common in patients with OI; however, these are not pathognomonic. Older patients with mild penetrance of type I OI are at the highest risk for HWFs. OI HWFs do well when managed nonoperatively with noninferior clinical courses compared with non-OI HWFs. Level III.

ATV-Related Trauma in the Pediatric Population.

All-terrain vehicles (ATVs) are prevalent in Appalachia and cause significant morbidity and mortality in the pediatric population. This study investigated the injury types and severity in pediatric patients over a 15-year period. A retrospective chart review was performed on pediatric ATV-related traumas presenting to our institution from 2005 to 2020. Patients were divided into 3 age groups (0-7, 8-12, and 13-17y) to evaluate differences in accident demographics, hospitalization, Glasgow Coma Scale, Injury Severity Score, substance use, characterization of orthopaedic and nonorthopaedic injuries, and procedures performed. Inclusion criteria were met by 802 patients. Males represented 71.7% (n=575) and females 28.3% (n=227); the mean age was 12.4 years. The majority (88.5%, n=710) of patients admitted following their accident had a mean stay length of 3.3 days. Of admissions, intensive care unit admission was required by 23.8%, n=191 (mean stay 4.0d). There were 7 fatalities. The vast majority of accidents occurred between May and September (79.2%, n=635). In patients with documented helmet status, 45% (n=271) were helmeted. Roughly half of all patients (n=393) sustained a fracture (excluding fractures to the head), 370 sustained an injury to the head/face, 129 sustained intra-abdominal/intra-thoracic injuries, and 29 sustained injuries to all 3 systems. The most common fractures involved the forearm (n=98), femur (n=65), and spine (n=59). The most common open fractures were the tibia (n=12), humerus (n=8), and forearm (n=8). The oldest group was more likely than the middle or younger groups to sustain spine ( P <0.0001), pelvis ( P =0.0001), hand ( P =0.0089), and foot ( P =0.0487) fractures. Ethanol testing was positive in 5.0% (n=25) of the oldest group and cannabinoids were present in 6.8% (n=34). The youngest group was significantly more likely to sustain a fracture of the humerus than the middle or older groups ( P <0.0001). Orthopaedic surgical management was required in 24.4% (n=196) of patients. Pediatric ATV accidents present a significant source of morbidity and mortality. Further intervention is necessary to minimize pediatric ATV injuries. Level IV-Retrospective Case Series.