High-energy Injuries Research Articles

Percutaneous Treatment With Bridge Plate and Extra-articular Screws in Low-Energy and High-Energy Lisfranc Injuries

Although there is no consensus regarding surgical treatment of unstable sprains and fractures dislocations of the Lisfranc complex, both anatomic reduction, proper alignment and adequate stabilization of the tarsometatarsal columns are essential when looking for good results. With the advent of minimally invasive surgery, and bearing in mind that the percentages of complications and sequelae despite the good results in reduction quality are still important, we aim to show the clinical and radiographic results over 1-year follow-up obtained by indirect reduction and percutaneous fixation with bridge plate and extra-articular screws in a series of patients with low-energy and high-energy Lisfranc lesions. Eleven patients were operated upon diagnosed with acute tarsometatarsal joint injuries, which showed unstable sprains and/or fracture dislocation with partial articular fracture and a minimum of 1-year follow up. The average age was 30.7 years. The results of the postoperative tomographic controls were as follows: residual joint step average of 0.2 mm, 0.45, and 0 mm in first cuneiform-base of first metatarsal, second cuneiform-base of second metatarsal and third cuneiform-base of third metatarsal, respectively. Anatomical reduction was obtained in the majority of our patients with very good functional results in the evaluated period. Although this is an ongoing investigation, we believe that this method could be taken into account in properly selected patients, even in high-energy injuries. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Upper Thoracic Spine Fractures Outcomes and Complications in King Abdul-Aziz Medical City, Riyadh

Introduction: Upper thoracic spine fractures (T1-T6) are not uncommon. They are often high-energy injuries complicated by multiple life-threatening comorbidities. There is a controversial discussion in the literature regarding the treatment choices. Thoracic pedicle screw fixation has replaced all other fixation techniques for its success rate and safety. Despite the number of studies discussing upper thoracic spine fractures, data on literature reporting postoperative complications are deficient. The aim of the study was to assess, in a series of patients, the impact of traumatic upper thoracic fractures on sagittal alignment, the incidence of possible complications, and the effect of associated injuries.
 Methodology: This retrospective chart review study included all adult cases diagnosed as traumatic upper thoracic spine fractures in KAMC in Riyadh. Data were obtained from the computerized database. The information reviewed included fracture characteristics, associated injuries, pre- and postoperative neurological status and sagittal alignment, follow-up duration, and the presence of complications.
 Result: A total of 19 patients were included in the study. Of them, 17 (89.5%) were injured secondary to a motor vehicle accident. There were three patients with a fixation level crossing the CT junction, more blood loss and procedure time was noticed with these cases. There was a notable improvement in upper thoracic kyphosis by 9º when measuring pre- and postop fracture Cobb's angle. The mean preop angle was 28.98 and the mean postop was 20.76. Of all the 19 cases involved in the study, 3 patients had developed surgical site infection as a complication. No other complication was reviewed.
 Conclusion: It is well-known in the literature that the correction of kyphosis and the absence of residual deformity postoperatively are indicators of the success and safety of the procedure used. Our findings correspond to the literature discussion that the current practice in managing traumatic upper thoracic spine fracture in KAMC in Riyadh is relatively safe and effective. Yet, further studies are needed to elaborate more on the relationship between the presence of other injuries and patients’ factors and postoperative outcomes.

The Hoffa Fracture: Review

The Hoffa fracture is an extremely rare injury of one or two condyles of the femur in the frontal plane, more often associated with injury to other structures of the knee joint area. The main cause of the Hoffa fracture is considered to be a high-energy injury (road accident in 80.5% of cases). The isolated Hoffa fracture accounts for 0.65% of all femoral fractures. To date, there is no consensus on surgical approach or optimal technique of internal fixation for the frontal fracture of the femoral condyles. There is also a large percentage of mistakes in the X-ray diagnosis of this pathology. The existing classifications have not found wide application in clinical practice, being difficult and inapplicable for solving the issue of treatment tactics and preoperative planning. The aim of the study is to present modern views on the diagnosis, principles and techniques of surgical treatment of patients with the Hoffa fractures based on the analysis of the literature. Based on the analyzed literature, conclusions are drawn about the need for careful collection of injury anamnesis, increased surgeon caution in the presence of this injury clinical picture and the simultaneous absence of pathology on standard knee joint X-rays, the need to perform an additional examination in the form of lateral (non-standard) projections of the knee joint X-rays, CT or MRI. During preoperative planning, preference should be given to minimally invasive technologies, including arthroscopically-associated methods of treatment.

Diagnostic Performance of the Caprini Risk Assessment Model Combined With D-Dimer for Preoperative Deep Vein Thrombosis in Patients With Thoracolumbar Fractures Caused by High-Energy Injuries

To assess the validity of the Caprini risk assessment model (RAM) in risk stratification for deep vein thrombosis (DVT) and to investigate the diagnostic value of Caprini score combined with D-dimer in predicting DVT. This study involved 429 patients with thoracolumbar fractures caused by high-energy injuries between October 2016 and November 2019. All patients were treated surgically and had a mean age of 45.3 ± 11.4 years. Patients were risk-stratified using the 2013 Caprini RAM. Mechanical and chemical prophylaxis were used for DVT. Duplex ultrasound of both lower extremities was performed before surgery. Of the 429 patients, 62 (14.45%) developed DVT. The incidence of preoperative DVT was correlated with Caprini score according to risk stratification(χ2= 117.4, P < 0.001). Based on the original Caprini RAM, all the patients scored in the highest risk category (score ≥5). Further substratification showed that the majority (277 of 429, 64.57%) of the patients were in the Caprini score range 7-8 and the risk of preoperative DVT was significantly higher among patients with Caprini score >10. The area under the receiver operating characteristic curve of Caprini score and D-dimer was 0.816 and 0.769 when Caprini score >8 or D-dimer >1.81mg/L was considered the criterion of predicting the risk of DVT. When combining the 2 variables, the area under the ROC curve can increase to 0.846. The Caprini RAM is an effective and reliable DVT risk stratification tool in patients with thoracolumbar fractures caused by high-energy injuries. Caprini score >8 or D-dimer >1.81 mg/L may predict the occurrence of preoperative DVT and the Caprini score combined with D-dimer exhibit better diagnostic performance.

Endovascular Repair of Thoracic Aorta Injury: 17 Years of Single-Center Experience.

BackgroundTraumatic thoracic aortic transection is one of the most severe complications of high-energy injuries, but patients rarely receive treatment, and it is fatal in the vast majority of cases. Due to the complexity of surgical revision for transection, endovascular repair with stent graft implantation is the preferred approach.Material/MethodsWe retrospectively analyzed the short-term and long-term treatment results for 31 patients (29 men, 2 women) treated at the Interventional Radiology Department, University Hospital Ostrava, for the isthmus part of a descending thoracic aorta injury between 2004 and 2020.ResultsThe median patient age was 48 years (interquartile range [IQR]: 28–63 years). The most common causes of injury were traffic accidents and falls or jumps, with the trauma location at the Ishimaru zones 2 to 4 of the aortic isthmus. Aortic stent grafts were successfully implanted in all patients; 13% of patients had complications and 10% died due to the trauma severity. The median procedure duration was 30 min (IQR: 25–43 min) and the median hospital stay was 29 days (IQR: 28–63 days).ConclusionsAortic stent graft implantation appears to be a safe and effective method for dealing with thoracic aorta injury, with a low complication rate and high patient survival. The endovascular approach is the method of choice for treating this severe disease, and a multidisciplinary approach for emergency medical treatment with a comprehensive trauma protocol is essential.

The impact of BMI on morbidity and mortality after femoral fractures.

PurposeFemur fractures are the result of high energy injury and are associated with life-threatening complications. Therefore, we studied how body mass index (BMI) contributes to complications after femoral fractures.MethodsUsing the 2016 American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) database, we stratified 41,362 patients into groups based on their BMI: Normal Weight (NW), Overweight (OW), Obese (OB), Severely Obese (SO), and Morbidly Obese (MO). We compared each BMI group to the NW cohort for differences in demographic factors, comorbidities, complications, and mechanism of injury.ResultsOB, SO, and MO patients sustained higher rates of traumatic injury from high energy mechanisms, such as motor vehicle trauma, in comparison to NW patients, who sustained more injuries from falls (p < 0.05). Correspondingly, obese patients were more likely than NW patients to sustain shaft and distal end fractures (p < 0.05). At hospital admission, obese patients presented with more comorbidities, such as bleeding disorders, congestive heart failure, diabetes mellitus, and hypertension (p < 0.05). Despite these individual findings, patients with OB, SO, and MO BMI, as opposed to NW BMI, were independently associated with a higher probability of developing at least one post-trauma complication. More specifically, MO patients were associated with a 45% higher odds of developing a complication (p < 0.05).ConclusionIrrespective of presenting with more comorbidities and sustaining high energy injuries, OB, SO, and MO patients were independently associated with having a higher risk of developing complications following a femoral fracture. Overall, better clinical outcomes are observed among patients with no underlying conditions and normal BMI.

Open tibia/fibula in the elderly: A retrospective cohort study

The incidence of open tibia/fibula fractures in the elderly is increasing, but current national guidelines focus on the aggressive treatment of high-energy injuries in younger patients. There is conflicting evidence regarding whether older age affects treatment provision and outcomes in open fractures. The aim of this study was to determine if elderly patients are sustaining a different injury to younger patients and how their treatment and outcomes differ. This may have implications for future guidelines and verify their application in the elderly.In this retrospective single centre cohort study (December 2015–July 2018), we compared the injury characteristics, operative management and outcomes of elderly (≥65 years) and younger (18–65 years) patients with open tibia/fibula fractures. An extended cohort examined free flap reconstruction.In total, 157 patients were included. High-energy injuries were commoner in younger patients (88% vs 37%; p<0.001). Most were Gustilo-Anderson IIIb in both age groups. Elderly patients waited longer until debridement (21:19 vs 19:00 h) and had longer inpatient stays (23 vs 15 days). There was no difference in time to antibiotics, operative approach or post-operative complications.Despite the low-energy nature of elderly patients’ injuries, the severity of soft tissue insult was equivalent to younger patients with high-energy injuries. Our data suggest that age and co-morbidities should not prohibit lower limb reconstruction. The current application of generic guidelines appears suitable in the elderly, particularly in the acute management. We suggest current management pathways and targets be reviewed to reflect the greater need for peri-operative optimisation and rehabilitation in elderly patients.

Complications of surgical reconstruction of multiligament injuries of the knee joint: diagnosis, prevention and treatment.

The main complications of surgical reconstruction of multiligament injuries of the knee joint are residual or recurrent instability, arthrofibrosis, popliteal artery injury, common peroneal nerve injury, compartment syndrome, fluid extravasation, symptomatic heterotopic ossification, wound problems and infection, deep venous thrombosis, and revision surgery.Careful surgical planning and execution of the primary surgical reconstruction of multiligament injuries of the knee joint can minimize the risk of the aforementioned complications.Careful postoperative follow-up is required to detect complications. Early recognition and prompt treatment are of paramount importance.To obtain good results in the revision surgery of failed multiligamentary knee reconstructions, it is crucial to perform a thorough and exhaustive evaluation to detect all the causes of failure.Addressing all associated injuries during revision surgery will lead to the best possible subjective and objective results, although functional outcomes are often modest.However, advanced age and high-energy injuries have been associated with the poorest functional outcomes after revision surgery of failed multiligament injuries of the knee joint. Cite this article: EFORT Open Rev 2021;6:973-981. DOI: 10.1302/2058-5241.6.210057

Watercraft propellers as a mechanism of orthopaedic injuries: injury patterns, management, and complications.

Recreational watercraft use is popular across the United States, and there is a high rate of injury associated with the use and misuse of these vehicles. Watercraft propeller injuries represent a particularly devastating mechanism of injury. We aim to describe and analyze the range of orthopaedic injuries sustained from a watercraft propeller with a particular focus on the mechanism, injury pattern, management, and complications associated with these unique, high-energy injuries. A retrospective review of 42 patients who sustained injuries from watercraft propeller that presented to a level 1 trauma center was performed. Data collected included patient demographics, mechanism of injury, surgical management, antibiotic use, and complications. Forty-two patients sustained 96 fractures. Ninety-one fractures (94.8%) were open and 5(5.2%) were closed. Twenty (20.8%) were of the upper extremity, 70(72.9%) were of the lower extremity, and 6(6.3%) were of the pelvic ring. The majority of open fractures were Gustilo-Anderson Type IIIA or greater (54, 59.3%). There were 9 total infections affecting 8 of 96 fracture sites (cumulative risk of 8.3%), and other complications included stiffness (3), heterotopic ossification (1), non-union (1), flap failure (1), DVT (2), PE (1), and systemic infection (1) for a total of 19 complications. Watercraft propellers often result in devastating injuries with high rates of morbidity. The high rate of open fractures and neurovascular injury, necessity for multiple surgeries, and extended length of hospital stay show the need for continued awareness about boat safety and the danger of propellers.

What Are the Functional Outcomes and Pain Scores after Medial Clavicle Fracture Treatment?

Medial clavicle fractures are uncommon, occurring in older and multiply injured patients. The management of these fractures and the factors that predispose toward poor outcomes are controversial. Furthermore, the functional outcomes of treatment are not well characterized or correlated with fracture patterns. (1) To determine minimum 1-year functional outcomes using QuickDASH scores and pain scores after medial clavicle fractures and (2) to identify factors associated with these outcome variables. In an institutional review board-approved, retrospective study, we identified adult patients with medial clavicle fractures at two tertiary care referral centers in a single metropolitan area in the United States from January 2010 to March 2019. Our initial query identified 1950 patients with clavicle fractures, from which 74 adult patients with medial clavicle fractures and at least 1 year of follow-up were identified. We attempted to contact these eligible patients by telephone for functional outcomes and pain scores. Twenty-six patients were deceased according to the most recent Social Security Death Index data and public obituaries, three declined participation, and 14 could not be reached, leaving 42% of the total (31 of 74) and 65% (31 of 48) of living patients included in the analysis. Demographic characteristics, fracture characteristics, and clinical and radiographic union as assessed by plain radiography and CT were collected through record review. Twenty-nine patients were treated nonoperatively and two patients underwent open reduction internal fixation. Sixty-eight percent (21 of 31) of the included patients also had radiographic follow-up at least 6 weeks postoperatively; two patients had persistent nonunion at a mean of 5 ± 3 years after injury. Our primary response variable was the QuickDASH score at a minimum of 1 year (median [range] 5 years [2 to 10]). Our secondary response variable was the pain score on a 10-point Likert scale. A bivariate analysis was performed to identify factors associated with these response variables. The following explanatory variables were studied: age, gender, race, dominant hand injury, employment status, manual labor occupation, primary health insurance, social deprivation, BMI, diabetes mellitus, smoking status, American Society of Anesthesiologists physical status classification, Charlson Comorbidity Index, nonisolated injury, high-energy mechanism of injury, nondisplaced fracture, fracture comminution, superior-inferior fracture displacement, medial-lateral fracture shortening, and surgical treatment of the medial clavicle fracture. The mean QuickDASH score was 12 ± 15, and the mean pain score was 1 ± 1 at a mean of 5 ± 3 years after injury. The mortality rate of the cohort was 15% (11 of 74) at 1 year, 22% (16 of 74) at 3 years, and 34% (25 of 74) at 5 years after injury. With the numbers available, no factors were associated with the QuickDASH score or pain score, but it is likely we were underpowered to detect potentially important differences. Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. This likely reflects both the frailty of a predominantly older patient population and the fact that these often are high-energy injuries. The outcome measures in our cohort were not associated with fracture displacement, shortening, or comminution; however, our sample size was underpowered on these points, and so these findings should be considered preliminary. Further studies are needed to determine the subset of patients with this injury who would benefit from surgical intervention. Level IV, therapeutic study.

Management of Panfacial Trauma: Sequencing and Pitfalls.

Panfacial trauma refers to high-energy mechanism injuries involving two or more areas of the craniofacial skeleton, the frontal bone, the midface, and the occlusal unit. These can be distracting injuries in an unstable patient and, as in any trauma, Advanced Trauma Life Support (ATLS) protocols should be followed. The airway should be secured, bleeding controlled, and sequential examinations should take place to avoid overlooking injuries. When indicated, neurosurgery and ophthalmology should be consulted as preservation of brain, vision, and hearing function should be prioritized. Once the patient is stabilized, reconstruction aims to reduce panfacial fractures, restore the horizontal and vertical facial buttresses, and resuspend the soft tissue to avoid the appearance of premature aging. Lost or comminuted bone can be replaced with bone grafts, although adequate reduction should be ensured prior to any grafting. Operative sequencing can be performed from top-down and outside-in or from bottom-up and inside-out depending on patient presentation. All protocols can successfully manage panfacial injuries, and the emphasis should be placed on a systematic approach that works from known areas to unknown areas.

Functional outcomes and quality of life after surgical treatment of spinopelvic dissociation: a case series with one-year follow-up

BackgroundSpinopelvic dissociation is a transverse sacral fracture in conjunction with a vertical fracture of the sacrum on both sides, which causes the dissociation of the upper sacrum and spine from the pelvis. The most common causes of these fractures are high energy injuries such as falls from height or motor vehicle accidents. Spinopelvic dissociation is rare and heterogenous with severe associated injuries. The aim of this study was to assess the injury characteristics, changes in the quality of life and functional outcomes in the 1-year period after spinopelvic dissociation.Materials and methodsDuring the period of 4 years (January 2016 and January 2020), 17 patients with spinopelvic dissociation were admitted to our centre and included in this single-centre prospective cohort study. One patient died during the admission; therefore 16 patients were enrolled in the analysis. Patients were followed-up for 12 months. The quality of life changes were evaluated via the SF-36 questionnaire, and the functional outcomes were evaluated using the Majeed pelvic score. Patients completed their questionnaires twice: firstly during hospitalization (regarding their pre-traumatic condition); and once again 1 year after their injury (regarding their current condition).ResultsThe mean age of the patients was 40.2 ± 17.7 years. Mean Majeed, PCS and MCS scores of SF-36 before the injury were 95.81 ± 9.50, 55.87 ± 8.89, and 43.76 ± 12.45, respectively. Mean Majeed, PCS and MCS scores 1 year after the injury were 71.13 ± 20.98, 43.45 ± 9.64, and 43.41 ± 7.56. During the period of 1 year after the injury, Majeed and PCS results reduced statistically significantly (P = 0.001 and P = 0.003, respectively), while MCS results remained similar (P = 0.501).ConclusionsAccording to the data of our study, for patients with spinopelvic dissociation functional outcomes are significantly reduced and only one-third of the patients achieved pre-traumatic functional outcomes 1 year after the injury.

Current concepts on the morphology of popliteus tendon and its clinical implications.

In this review we described the anatomy and biomechanics of popliteus muscle and its tendon. Furthermore, we combined the anatomy with clinics and discussed a wide spectrum of disorders regarding the popliteus and its musculotendinous complex. There are three main anatomical regions of the popliteus musculotendinous complex: the proximal origin, the mid-portion, the distal part on the tibia. The unique localisation and various origins of the tendon, connected with structures such as fibular head, Wrisberg, Humphrey and posterior cruciate ligament, lateral meniscus, medial collateral ligament, give an implication to diagnosis and treatment. Popliteus dysfunction is often overlooked, that is the reason why diagnosis and treatment of its injuries is mostly insufficient. Repetitive or acute direct varus forces, when the tibia is in external rotation, and knee hyperextension or flexion with forced external rotation of the tibia, are the main mechanisms of trauma. Popliteus injuries mainly affect the athletic population and lead to severe activity limitations. Chronic disorders of the popliteus tendon, less known, are often described as tendinopathy and are frequently seen in runners. Their symptoms can mimic the lateral meniscal tears. On the other hand, high-energy traumatic injuries of the popliteus tendon often accompany complex, multi ligamentous injuries seen in competitive sports. We also presented the implication of popliteus tendon in knee arthroplasty, due to its particular exposition to iatrogenic trauma during surgery. The issues such as proper tibial component location and well-designed cut systems are crucial to avoid the popliteus impingement and preserve its structure.

Bilateral suprascapular notches are asymmetrically shaped in a third of the Asian population.

The side-to-side differences within an individual's suprascapular notch (SSN) and the clinical characteristics of an ossified superior transverse scapular ligament are unclear. Therefore, the morphological asymmetry of the SSN was investigated, and the factors associated with the ossification of the superior transverse scapular ligament were analyzed. Two hundred and seventy-six computed tomography images were retrospectively analyzed, which included those of both scapulae of Asian patients (mean age, 62.1 ± 19.1years; males, 197) with high-energy injuries or respiratory diseases. Variations in the SSN were classified into six types based on Rengachary's classification using reconstructed three-dimensional computed tomography. The group with a type VI SSN (completely ossified superior transverse scapular ligament) in at least one scapula was compared with the other group for age, sex, and chronic comorbidities. Among 276 patients, 95 (34.4%) had asymmetric SSNs and 15 (5.4%) had type VI SSNs. There were no significant differences in age, sex, or comorbidities between both the groups. However, on comparing age groups, the prevalence of type VI SSN was higher in patients aged > 70years than in those aged < 70years. Fifteen patients had type VI SSNs, which were unilateral in 10 patients. Asymmetric SSNs were observed in a third of the Asian patients. There were variations in SSNs between individuals and also within an individual. In the cases with suprascapular nerve paralysis, the difference in SSN morphology compared to a healthy side should be considered. III.

Percutaneous Arthroscopic Assisted Fixation of a Tibial Plafond Impaction Fracture Fixation: Surgical Technique and Case Report

Tibial plafond fractures are high energy injuries caused by axial loading. Despite evolving equipment and surgical techniques, the prognosis remains relatively poor for individuals who sustain this type of injury, with reduced functional outcomes and early posttraumatic osteoarthritis. We present a case of a tibial plafond fracture treated percutaneously with arthroscopic assisted reduction, bone grafting and fixation, without the requirement for an external fixator, and with a successful outcome at 1-year follow up. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

Obliteration and Contouring of Comminuted Anterior Wall Frontal Sinus Fracture Using Pericranial Flaps.

Summary:One of the common postoperative complications of comminuted fractures of frontal sinus are contour deformity, hardware extrusion, adherence and/or palpability, and skin thinning. We are presenting our novel technique with pericranial flaps to decrease these complications. The study was performed from January 2019 to January 2020, on 40 cases of comminuted fractures of anterior wall of frontal sinus, 28 men and 12 women, with an average age of 41 years. Injury resulted from motor vehicle crashes (n = 25), motorcycle crashes (n = 11), and falling from heights (n = 4). Our novel technique involves the use of two anteriorly based pericranial flaps; one flap is used for obliteration of the frontal sinus and the other is used to overlay the hardware used to restore forehead contouring and to eliminate the possibility of early extrusion or late plates or mesh palpability. Two patients had postoperative minimal disruption of forehead lacerations healed with secondary intention and minimal scarring. Excellent patient compliance without any complaint of mesh palpability. No adherence occurred and no skin thinning. This technique (two anteriorly based pericranial flaps) may be more reliable to obliterate the frontal sinus also overlaying the hardware used to improve forehead contour and decrease the incidence of mesh palpability and skin adherence than using hardware without flap coverage.

Three-Dimensional Modeling of the Structural Microenvironment in Post-Traumatic War Wounds

BACKGROUND:The development of post-traumatic heterotopic ossification (HO) is a common, undesirable sequela in patients with high-energy (war-related) extremity injuries. While inflammatory and osteoinductive signaling pathways are known to be involved in the development and progression of post-traumatic HO, features of the structural microenvironment within which the ectopic bone begins to form remain poorly understood. Thus, increasing our knowledge of molecular and structural changes within the healing wound may help elucidate the pathogenesis of post-traumatic HO and aid in the development of specific treatment and/or prevention strategies.METHODS:In this study, we performed high-resolution microscopy and biochemical analysis of tissues obtained from traumatic war wounds to characterize changes in the structural microenvironment. In addition, using an electrospinning approach, we modeled this microenvironment to reconstitute a three-dimensional type I collagen scaffold with non-woven, randomly oriented nanofibers where we evaluated the performance of primary mesenchymal progenitor cells.RESULTS:We found that traumatic war wounds are characterized by a disorganized, densely fibrotic collagen I matrix that influences progenitor cells adhesion, proliferation and osteogenic differentiation potential.CONCLUSION:Altogether, these results suggest that the structural microenvironment present in traumatic war wounds has the potential to contribute to the development of post-traumatic HO. Our findings may support novel treatment strategies directed towards modifying the structural microenvironment after traumatic injury.

The horizontal shear fracture of the pelvis

PurposeVarious classification systems describe fractures of the acetabulum and pelvis separately. Horizontal shear fractures involve the pelvic ring and both acetabula and have not been previously described. The aim of this study is to describe the horizontal shear fracture of the pelvis.MethodsAt a level 1 trauma centre over 10 years from December 2008 to December 2018, 1242 patients had pelvic and acetabular fractures. Six patients had horizontal shear fractures, comprising 0.5% of all pelvic and acetabular fractures. Demographic, clinical and radiological data was collected. Clinical outcomes were pain and mobility level, sciatic nerve symptoms, further acetabular or pelvic surgery, or total hip arthroplasty. Radiological outcomes included fracture displacement, implant migration, femoral head osteonecrosis, and post-traumatic arthritis. Outcomes were assessed at a minimum 12 month follow-up.ResultsThe median patient age was 35 years. Five of six shear fractures were due to motorcycle crashes. No mortalities occurred. At follow-up, three patients reported pain, two patients had difficulty mobilising associated with traumatic sciatic nerve injury, and one patient underwent total hip arthroplasty for femoral head osteonecrosis. No fracture displacement or implant migration occurred. The Matta arthritis grade was excellent or good in all except one hip. Median follow-up time was 1.8 (range 1.1–7.8) years.ConclusionThe horizontal shear fracture of the pelvis is a high-energy injury characterised by separation of the anterior and posterior pelvic ring through the acetabula. Good outcomes can be achieved with open reduction and internal fixation of displaced fractures.

Circumferential Pelvic Antishock Sheeting.

Pelvic ring fractures range from low-energy falls in the elderly to high-energy mechanisms in young patients. These injuries can be a significant cause of morbidity and mortality and are frequently associated with additional injuries. Hemorrhage and resultant hemodynamic instability are often associated with high-energy injuries and require prompt management. Circumferential pelvic antishock sheeting is an effective and readily available tool for reducing pelvic volume at the accident scene or in the emergency department, while still allowing access to the abdomen and lower extremities for ongoing resuscitation. This article, and the associated instructional video, reviews the indications and proper technique for placing a pelvic sheet.