Lower Extremity Fractures Research Articles

Epidemiology of Lower Leg Fractures at a Colorado Ski Resort

Category: Trauma; Ankle; Sports Introduction/Purpose: Lower extremity fractures are relatively common among winter sports participants. The purpose of this study is to evaluate the demographics, injury mechanisms and environmental features among patients evaluated for lower leg fractures at a high-volume Colorado ski resort during five consecutive ski seasons. Methods: We conducted a retrospective descriptive analysis of patients with lower leg fractures at the Denver Health Winter Park Medical Center during the 2012/13 to 2016/17 ski seasons. We included all fractures below the knee (excluding tibial plateau and isolated fibular head fractures) sustained by skiing or snowboarding. Chart review was performed on the patient cohort, confirming diagnosis and evaluating factors associated with these fractures. Results: There were 346 lower leg, ankle, and/or foot fractures (5.4% of all clinic visits) during the study period. The average age was 33.1 years (range 4-74) with the majority being male (60.7%) and mainly as a result of skiing (84.7%). The majority of fractures were sustained among skiers and snowboarders who self-identified as beginner or intermediate skill level (64.8%), and on easy (green) or intermediate (blue) runs (64.9%). The most common fractures sustained were complete tibia-fibula fractures (30.9%) and lateral malleolus fractures (27.5%). More than half (57.0%) of complete tibia-fibula fractures were classified and boot top (mid- shaft just above the ski boot) fractures. The most common type of lateral malleolus fractures was Danis-Weber B (72.0%) with only 5.4% being Weber C fractures. Foot fractures were rare with only 12 total cases (3.5%). Conclusion: Skiers are much more likely to sustain lower leg fractures compared to snowboarders. Men were much more likely than women to sustain lower leg fractures. Most fractures occurred in mild or moderately difficult ski runs relative to advanced runs. Fractures appear to be more common with advancing age. Complete tibia-fibula fractures were the most common fractures sustained in all riders with lateral malleolus fractures being the second most common. Foot fractures are very rare in this population. Given the frequency of these injuries, additional education around prevention may be warranted.

Comparative Risk Stratification for Prediction of Early Postoperative Morbidity and Mortality after Open Fixation of Periarticular Lower Extremity Fractures

Category: Trauma; Ankle; Hindfoot Introduction/Purpose: The standardized identification of patients who are at higher risk of early postoperative adverse events has implications for quality improvement, preoperative medical optimization, and cost reduction through bundled payments. The purpose of the present study was to develop points-based risk stratification systems for predicting 30-day adverse events (AEs) and mortality after open fixation of periarticular hip, knee, and ankle fractures. Methods: Query of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database yielded 65,529 patients who underwent periarticular hip, knee, and ankle fracture repair from 2010-2019. We collected patient demographics and preoperative risk factors. To generate our risk stratification systems, 60% of patients were randomly designated as the development cohort and analyzed with multivariable regression plus bootstrap modeling to identify independent risk factors for early AE and mortality. A nomogram analysis was then conducted to assign scores for each risk factor and generate two points-based risk stratification systems, for AE and mortality. To validate our models, the systems were applied to the remaining 40% of patients (the validation cohort) and tested for predictive ability. Results: In total, 13,212 patients (20.2%) experienced any AE and 3,613 patients (5.5%) mortality within 30 days of fracture fixation. Patients were assigned points for each of the following in both risk stratification systems: fracture type (+4 hip, +2 knee, +0 ankle), male gender (+1), age (>=80 years +5, 60-79 years +3, 40-59 years +2), functionally dependent (+2), anemia (+2 for AE, +1 for mortality), pulmonary disease (+3 for AE, +1 for mortality), congestive heart failure (+3 for AE, +2 for mortality), and end- stage renal disease (+3 for AE, +1 for mortality). Corticosteroid use (+1), hypertension (+1), and insulin-dependent diabetes (+2) were additional predictors for only AEs. The AE and mortality models had maximum scores of 27 and 17 points, and Harrell C statistics of 0.66 and 0.75, respectively. The estimated risk of developing early AE ranged from 3.4-79.5% and mortality from 0.08- 54.4%. Conclusion: Fracture type, male gender, age >=40 years, corticosteroid use, functional dependence, anemia, hypertension, insulin-dependent diabetes, pulmonary disease, congestive heart failure, and end-stage renal disease can be used in the prediction of early AE or mortality following open fixation of periarticular lower extremity fractures, with a marked disparity in estimated risks depending on the number of risk factors possessed by a patient.

Race, Gender, and Primary Language Were Not Associated With Changes in Opioid Prescribing in Children: Results From a Single Institution, 2010 to 2020.

Patients should be prescribed medication based on their medical condition, without prejudice because of their race, gender, or primary language. However, previous research has shown that men are prescribed more medication than women, patients who are White are prescribed more medications than patients who are non-White, and English-speaking people are prescribed more medications than non-English-speaking patients. However, it is unclear whether these differences also occur in pediatric orthopaedic populations. We asked: (1) Was the amount of opiates prescribed at discharge associated with patient age, gender, race, or primary language? (2) Did the amount of opiates prescribed to patients at discharge change from 2010 to 2020? In a single center, between January 2010 and December 2019, we treated 331 patients younger than 18 years surgically for upper and lower long-bone extremity fractures. Patients were considered eligible if they had a nonpathologic fracture. Femur fractures were not included. Based on these criteria, all patients were eligible. The mean age was 12 ± 4 years. The mean weight was 57 ± 33 kg. Among these patients, 76% (253 of 331) were boys and 24% (78 of 331) were girls. From the hospital discharge records, we recorded the amount of opiates prescribed at the time of discharge as measured by morphine milligram equivalents (MMEs). We examined the association of age, gender, race, primary language, weight, and year of treatment using this measurement. We determined a patient's race retrospectively by information given by their parents at time of admission. We did not attempt to contact patients to obtain more nuanced information about their racial background. These data were obtained from the electronic health record. The Wilcoxon rank sum test, t-test, or chi-square test was used to assess associations depending on the distribution of variables, as appropriate. Because opioids as measured in MMEs is zero-inflated, a two-part model analysis was used to adjust for confounding variables. One component of the model was for the probability of having any opiate prescription and another was for the mean number of opioids received. Findings were considered statistically significant if p values were < 0.05. In total, 57% (189 of 331) of children were prescribed opiates at discharge after surgery for long-bone fractures. Opiate MMEs increased with patient age (r = 0.38; p < 0.01). Boys and girls showed no difference in the amounts of pain medication (adjusted odds ratio [OR] 1.38 [95% confidence interval (CI) 0.80 to 2.39]; p = 0.71; adjusted opioid difference: 0.35 MME [95% CI -51.7 to 52.4]; p = 0.99), nor were there differences between patients who were White and those who were non-White (adjusted OR 0.78 [95% CI 0.49 to 1.23]; p = 0.28; adjusted opioid difference: 21.5 MME [95% CI -19.3 to 62.4]; p = 0.30), or between patients for whom English was there primary language and those for whom English was not their primary language (adjusted OR 1.16 [95% CI 0.52 to 2.57]; p = 0.71; adjusted opioid difference: 22.7 MME [95% CI -55.7 to 101.3]; p = 0.57) when adjusted for age and weight. There was no change in opioid prescription amounts from 2010 to 2020 after adjusting for changes in patient age across years (Spearman r = -0.08; p = 0.16). Fairness in opioid prescribing based on race, gender, or primary language is possible. Additional research is needed to determine what factors in our institution led to this result. We suggest that prescribers should apply consistent protocols based on factors such as weight or injury type rather than making individual decisions for each patient. This will lead to fairer opioid prescribing to patients from different race and gender groups. Level III, therapeutic study.

The COVID-19 Pandemic: Effects on Pediatric Fracture Patterns in the Emergency Department and Subspecialty Follow-up Care.

Purpose:The COVID-19 pandemic affected pediatric fracture injury patterns and volume. There is a paucity of research evaluating this trend throughout the pandemic and also follow-up to orthopaedic subspecialty care after emergency fracture management.Methods:This retrospective cohort study reviewed patients 2 to 18 years of age presenting for fracture care to an urban pediatric emergency department. We assessed patient demographics, clinical care, and follow-up to surgical subspecialist. Time periods investigated included March 30 to September 4, 2020 (pandemic), March 30 to September 4, 2019, and March 30 to September 4, 2018 (prepandemic). Subanalysis within the pandemic was during the “stay-at-home order” verses the phased re-opening of the state. Descriptive statistical analysis, Pearson’s χ2 or Fisher exact tests, and Mann-Whitney U tests were performed.Results:In this population, fractures overall declined by 40% (n=211) during the pandemic compared with 2019 (n=349) and 28% compared with 2018 (n=292). Lower extremity fractures accounted for a greater percentage of injuries during the pandemic compared with prepandemic. Time to surgical subspecialty follow-up was shortest during the 2020 pandemic peak at 9 days and was significantly longer during phased reopening (phase 1: 18 d, P=0.001; phase 2: 14 d, P=0.005). These patterns were also consistent for days to repeat imaging.Conclusions:We found differences in fracture prevalence, mechanisms, and follow-up care during the pandemic. Time to subspecialty follow-up care was longer during pandemic phased reopening despite overall fewer fractures. Plans to absorb postponed visits and efficiently engage redeployed staff may be necessary to address difficulties in follow-up orthopaedic management during public health crises.Level of Evidence:Level II.

Epidemiology of ballistic fractures in the United States: A 20-year analysis of the Firearm Injury Surveillance Study

IntroductionBallistic (i.e., gunshot-induced) fractures present unique treatment challenges and can be associated with high rates of complications and considerable morbidity. Large-scale epidemiologic data on these types of fractures are scarce. There is concern that gun-related violence may be on the rise, potentially increasing the burden of ballistic orthopaedic trauma, but there are few contemporary studies on the topic. The aim of this study, therefore, was to investigate the incidence and demographics of patients with ballistic fractures in the United States (US) over the last 20 years. Materials and MethodsThis descriptive epidemiology study retrospectively analyzed the Firearm Injury Surveillance Study to identify cases of ballistic fractures in the US from 2000 to 2019. Overall and annual numbers of fractures and fracture incidence rates (IRs), patient demographics, incident characteristics, and temporal trends were analyzed. Patients of all ages were included. Ballistic fractures were grouped by anatomic location for comparisons (non-spine axial, spine, upper extremity, lower extremity). ResultsAn estimated N = 240,555 patients (n = 8,322 unweighted cases) sustained ballistic fractures over the 20-year study period for an overall IR of 39.2 per 1,000,000 person-years at-risk (PYR). Overall, lower extremity fractures accounted for the largest percentage of cases (45.9%; IR=18.8 PYR), followed by upper extremity fractures (32.8%; IR=13.4 PYR), non-spine axial fractures (16.1%; IR=6.6 PYR), and spine fractures (5.2%; IR=2.1 PYR). Diaphyseal femur fractures were the most common ballistic fractures overall. Nearly three-fourths (71.2%) of all cases occurred in males in the second through fourth decades. The most common injury intent was assault (71.8%) and a majority of patients (71.2%) required hospital admission. Accounting for population growth yielded a significantly increasing incidence of all ballistic fractures over the study period from 15.7 PYR in 2000 to 96.8 PYR in 2019 (average annual percent change=10.3, p < 0.00001). ConclusionThese data suggest that the nationwide burden of ballistic fractures in the US has increased significantly in the last two decades. Ballistic fractures are associated with significant morbidity and societal cost, and increasing injury rates highlight the need for future research aimed at better understanding the ideal treatment of these types of fractures and their outcomes.

"It's Not Just a Plaster Cast, My Leg Is in It!": Patient Experiences: A Qualitative Study.

Plaster casts have been used in the treatment of fractures since 1850, and they play an important role in the healing of extremity injuries and operative repairs. Despite the high incidence of fractures and the widespread use of plaster casts in patients with fractures, the quality of counseling in patients with plaster casts has been neglected. There are few studies on the quality of this patient advisement and the nonmedical experiences of patients with plaster casts. We believe that understanding the feelings, thoughts, and experiences of patients who have had plaster casts will contribute to holistic patient care and will guide the planning of such care. The aim of this study was to describe some of the nonmedical experiences of being in a plaster cast and to illustrate these difficulties through patient quotes. This qualitative research study used a qualitative, descriptive approach guided by phenomenology to explore and describe the subjective experiences of patients with plaster casts. Participants consisted of 10 patients with lower extremity fractures, all of whom had been in a plaster cast for at least 6 weeks. Data were collected through in-depth individual interviews using semistructured questionnaires. The content analysis method was used to analyze the data. COREQ (Consolidated Criteria for Reporting Qualitative Research) was used in structuring and reporting the study. Six themes that described the experiences of patients with a plaster cast were determined in the study. These themes were the basic physiological and functional concern, self-image challenges, social roles, dependence/independence, emotions, and the experience of being in a plaster cast. We determined that many aspects of the lives of patients had been affected by being in a plaster cast and that they had experienced not only physiological issues but also psychological, social, emotional, and aesthetic issues. In addition, all the participants stated that they sought solutions to these issues by requesting support from a person or persons around them. Understanding the experiences of individuals with a plaster cast will contribute to the holistic healthcare of individuals who suffer fractures, allowing it to be more patient-centered. This understanding will also support the planning and implementation of patient-centered counseling and education.

Incidence of Traumatic Sciatic Nerve Injury in Association with Acetabular Fracture: A Retrospective Observational Single-Center Study.

PurposeTraumatic sciatic nerve injury is one of the most serious consequences of acetabular fracture. However, reports on this type of injury are rare. In this study, we investigated the demographics of acetabular fracture with traumatic sciatic nerve injury, the clinical characteristics of patients with these injuries, and potential risk factors.Patients and MethodsWe retrospectively reviewed patients diagnosed to have acetabular fracture at our trauma center between January 2014 and June 2021. Data on patient demographics, characteristics of the acetabular fracture, whether or not sciatic nerve injury occurred, types of sciatic nerve injury, and risk factors were analyzed.ResultsA total of 195 patients met the diagnostic criteria for acetabular fractures. The average Injury Severity Score was 25.9 and the average Abbreviated Injury Scale score was 12.4. Road traffic accidents and falls from height were the main causes. Chest injuries and lower extremity fractures were the most common associated injuries. Posterior wall fractures were the most common fracture type. After exclusion of spinal cord and iatrogenic sciatic nerve injuries, 18 patients with acetabular fractures had traumatic sciatic nerve injury. Four of the 19 sides with traumatic sciatic nerve injury involved the common peroneal nerve division and 15 involved both the common peroneal and tibial nerve divisions. Logistic regression analysis identified a higher AIS score, posterior column fracture, and posterior hip dislocation to be predictors of traumatic sciatic nerve injury.ConclusionAcetabular fractures were mostly high-energy injuries. Posterior wall fractures were the most common acetabular fracture types. Most patients sustained injury to the sciatic nerve as well as injury to the common peroneal and tibial nerve divisions. A higher AIS score, posterior column fracture, and posterior hip dislocation were predictors of acetabular fracture combined with traumatic sciatic nerve injury.

How Can Negative Pressure Wound Therapy Pay for Itself?-Reducing Complications Is Important.

Orthopaedic trauma demonstrates a relatively high rate of surgical site infections (SSI) as compared with other surgical specialties. SSIs provide significant clinical challenges and create significant health care costs. Incisional negative pressure wound therapy (iNPWT) has reduced the risk of SSI in orthopaedic surgery and other surgical specialties. The purpose of this study is to investigate potential cost savings with the use of iNPWT (3M Prevena Therapy, 3M, St. Paul, MN) in high-risk orthopaedic trauma patients with closed OTA/AO 41C and 43C fractures. This is a retrospective cohort study performed at a single, level-1 trauma center using data from a lower extremity fracture registry. Using the results from the registry and baseline infection rates derived from the literature, a health economic model was developed to evaluate the potential cost savings. A total of 79 patients included in the registry underwent open reduction and internal fixation of OTA/AO 41C and 43C fractures. A total of 10.1% developed a SSI. For those who received iNPWT, the rate of SSI was 7.4%. A health economic model suggests that the use of iNPWT may reduce the costs per patient by approximately $1381 to $4436 per patient. This health economic assessment and model suggests that judicious use of iNPWT may reduce health care costs in patients undergoing open reduction and internal fixation of OTA/AO 41C and 43C fractures. Economic Level IV.

Return to play and performance in the National Basketball Association after undergoing operative or nonoperative treatment for foot fracture

BackgroundThe incidence of distal lower extremity fractures in National Basketball Association (NBA) athletes continues to increase. There is a paucity of data regarding return-to-play (RTP) rates and performance after sustaining foot fractures in these athletes. The purpose of this study is to quantify RTP rates and performance in NBA players after sustaining a foot fracture. MethodsSixty-two NBA athletes suffered foot fractures between 2005 and 2021 according to publicly accessible online data. Each athlete was matched to a control player based on age at start of career, age at index injury year, body mass index (BMI), and position played. Performance statistics from 3 seasons prior and 3 seasons following the index injury season were recorded. ResultsWe found that players who suffered foot fracture injuries are expected to make a full recovery and reach their previous level of performance within three years. 100% of players treated nonoperatively returned to play; meanwhile only 90% of players who were treated operatively returned to play. This difference is statistically significant. ConclusionNBA athletes have a high RTP rate after sustaining a foot fracture. Players may experience an initial decrease in playing time and performance when returning to play, however, these variables were found to return to baseline over time. After three seasons, player statistics returned to baseline in mostly every category, including player efficiency rating (PER). We found that players are expected to make a full recovery and return to their previous level of performance, regardless of whether they were treated operatively or not. Players treated nonoperatively returned to play at a rate of 100% meanwhile those treated operatively returned at a rate of 90%. Therefore, it is our recommendation that players opt for nonoperative treatment when possible.

Clostridium difficile colitis portends poor outcomes in lower extremity orthopaedic trauma surgery

IntroductionClostridium difficile is the most common cause of healthcare-associated infectious diarrhea and colitis, and carries the potential for high morbidity, particularly in frail patient populations. The purpose of this study was to utilize a large nationally representative database in order to report 1.) the incidence of CDC in patients with operative lower extremity fractures, 2.) risk factors for the development of CDC, 3.) the association of CDC with length of stay (LOS), readmission, and 30-day mortality rates. MethodsThe ACS-NSQIP (2015–2019) was queried for patients who underwent surgical fixation of lower extremity fractures. A backward elimination multivariate regression model was used to identify risk factors for CDC. Chi squared and multivariate regression that controlled for preoperative variables and comorbidities were used to compare outcomes in patients with and without CDC. Results95,532 patients were included, 681 (0.71%) of whom developed CDC. Risk factors for CDC were advanced age, ASA class ≥ 3, smoking, dialysis, anemia, hypoalbuminemia, preoperative SIRS, preoperative wound infections, preoperative sepsis, and the use of spinal anesthesia or MAC/IV sedation. Patients with CDC had significantly increased 30-day mortality rates (10.6% vs 4.4%; OR 1.80, 95% CI 1.41–2.31), readmission (34.2% vs 7.5%; OR 5.13, 95% CI 4.36–6.05, and length of stay (7.5 days vs 5.3 days) compared to patients without CDC. ConclusionThe incidence of CDC in lower extremity orthopedic trauma patients was 0.71%. An occurrence of CDC was associated with approximately a 2.5 times increase in 30-day mortality, five times the readmission rate, and a longer hospital stay compared to patients without CDC. Mitigating the spread of c. diff through improved antibiotic stewardship and prompt treatment of CDC is paramount to decreasing the burden this infection imposes on orthopedic trauma patients and the healthcare system.

Psychosocial Predictors of Chronic Pain 12Months After Surgical Fixation for Lower Extremity Fracture: A Prospective Study.

Pain is a common outcome after lower extremity fracture (LEF) requiring surgical fixation. Although psychosocial characteristics have meaningful associations with adverse outcomes, no studies have evaluated how psychosocial characteristics throughout recovery are associated with pain outcomes. The primary purpose of this study was to determine whether psychosocial characteristics are early risk factors for pain outcomes in patients following LEF who have no history of chronic pain. Participants, 122 patients with a LEF, consented to this single-center, prospective cohort study. Measurements of depression, pain self-efficacy, pain catastrophizing, and fear of movement were completed at 1week, 6weeks, 3months, 6months, and 12months after LEF. Chronic pain development and pain intensity were assessed at 12months. Univariate analyses assessing the difference between means and corresponding effect sizes were evaluated between those individuals with and without chronic pain at 12months. Separate logistic and linear regression models using psychosocial scores at each time point were used to determine the association with the development of chronic pain and pain intensity, respectively. Of 114 patients (93.4%) who completed the study, 51 (45%) reported chronic pain at 12months. In the univariate analysis, all psychosocial variables at 6weeks, 3months, 6months, and 12months were significantly different between those with and those without chronic pain at 12months (Cohen d range = 0.84 to 1.65). In the multivariate regression models, all psychosocial variables at 6weeks, 3months, and 6months were associated with chronic pain development (odds ratio range = 1.04 to 1.22) and pain intensity (β range = .05 to .14) at 12months. Psychosocial scores as early as 6weeks after surgery are associated with pain outcomes 12months after LEF. Physical therapists should consider adding psychosocial screening throughout recovery after LEF to identify patients at increased risk for long-term pain outcomes.

Sleep Should Be Focused on When Analyzing Physical Activity in Hospitalized Older Adults after Trunk and Lower Extremity Fractures-A Pilot Study.

Although the importance of resting in bed for hospitalized older adults is known, current methods of interpreting physical activity (PA) recommend the use of a broad definition of sedentary behavior (SB) that includes 0–1.5 metabolic equivalents (METs) of sleep (SL) and sitting. We investigated the characteristics of PA by conducting a cross-sectional study of 25 older adults with trunk and lower extremity fractures. The intensity of their PA was interpreted as SL (0–0.9 METs), SB (1–1.5 METs), low-intensity PA (LIPA: 1.6–2.9 METs), and moderate-to-vigorous PA (MVPA: >3.0 METs). We calculated the correlation coefficients to clarify the relationship between each PA intensity level. Our analyses revealed that the PA time (min/day) was accounted for by SB (53.5%), SL (23.2%), LIPA (22.8%), and MVPA (0.5%). We observed negative correlations between SL and SB (r = −0.837) and between SL and LIPA (r = −0.705), and positive correlations between SB and LIPA (r = 0.346) and between LIPA and MVPA (r = 0.429). SL and SB were also found to have different trends in relation to physical function. These results indicate that SL and SB are trade-offs for PA during the day. Separate interpretations of the SL and SB of older hospitalized adults are thus recommended.

Costs and 30-day readmission after lower limb fractures from motorcycle crashes in Queensland, Australia: A linked data analysis

BackgroundLower limb trauma is the most common injury sustained in motorcycle crashes. There are limited data describing this cohort in Australia and limited international data establishing costs due to lower limb trauma following motorcycle crashes. MethodsThis retrospective cohort study utilised administrative hospitalisation data from Queensland, Australia from 2011–2017. Eligible participants included those admitted with a principal diagnosis coded as lower extremity or pelvic fracture following a motorcycle crash (defined as the index admission). Multiply injured motorcyclists where the lower limb injury was not coded as the primary diagnosis (i.e. principal diagnosis was rather coded as head injury, internal organ injures etc.) were not included in the study. Hospitalisation data were also linked to clinical costing data. Logistic regression was used to determine risk factors for 30-day readmission. Costing data were compared between those readmitted and those who weren't, using bootstrapped t-tests and ANVOA. ResultsA total of 3342 patients met eligibility, with the most common lower limb fracture being tibia/fibula fractures (40.8%). 212 participants (6.3%) were readmitted within 30-days of discharge. The following were found to predict readmission: male sex (OR 1.84, 95% CI 1.01–1.94); chronic anaemia (OR 2.19, 95% CI 1.41–3.39); current/ex-smoker (OR 1.60, 95% CI 1.21–2.12); emergency admission (OR 2.77, 95% CI 1.35–5.70) and tibia/fibula fracture type (OR 1.46, 95% CI 1.10-1.94). The most common reasons for readmission were related to ongoing fracture care, infection or post-operative complications. The average hospitalisation cost for the index admission was AU$29,044 (95% CI $27,235-$30,853) with significant differences seen between fracture types. The total hospitalisation cost of readmissions was almost AU$2 million over the study period, with an average cost of $10,977 (95% CI $9,131- $13,059). ConclusionsUnplanned readmissions occur in 6.3% of lower limb fractures sustained in motorcycle crashes. Independent predictors of readmission within 30 days of discharge included male sex, chronic anaemia, smoking status, fracture type and emergency admission. Index admission and readmission hospitalisation costs are substantial and should prompt health services to invest in ways to reduce readmission.

Fatal blunt chest trauma: an evaluation of rib fracture patterns and age

The following study was undertaken to determine if any specific occupant characteristics, crash factors, or associated injuries identified at autopsy could predict the occurrence or number of fractured ribs in adults. Data were accrued from the Traffic Accident Reporting System (TARS) and coronial autopsy reports from Forensic Science SA, Adelaide, South Australia, from January 2000 to December 2020. A total of 1475 motor vehicle fatalities were recorded in TARS between January 2000 and December 2020, and 1082 coronial autopsy reports were identified that corresponded to TARS fatal crash data. After applying exclusion criteria involving missing data, 874 cases were included in the analysis. Of the 874 cases, 685 cases had one or more rib fractures. The leading cause of death for those with rib fractures was multiple trauma (54%), followed by head injury (17%) and chest injuries (10%). The strongest predictor of one or more rib fractures was increasing age (p < 0.001). Other factors found in the regression to be predictive of the number of rib fractures were the presence of a variety of other injuries including thoracic spinal fracture, lower right extremity fracture, splenic injury, liver injury, pelvic fracture, aortic injury, lung laceration, and hemothorax. Age is most likely associated with increasing rib fractures due to reduced tolerance to chest deflection with greater injuries occurring at lower magnitudes of impact. The association of other injuries with rib fractures may be a marker of higher impact severity crashes.

Effect of Silver Nanoparticles With Thermoplastic Polyurethane on Postoperative Rehabilitation of Diabetic Patients With Open Fracture of Lower Extremities.

ObjectiveThis retrospective study aims to explore the effect of silver nanoparticles with thermoplastic polyurethane (TPU/NS) on the rehabilitation of diabetic patients with open fracture of lower extremities.MethodsDiabetic patients (n = 98) with open fracture of lower extremities treated in our hospital were analyzed retrospectively from June 2015 to December 2021. TPU/NS nanocomposites were prepared for postoperative treatment of diabetic patients with open fracture of lower extremities. First, the cultured Staphylococcus aureus and Escherichia coli were used to test the antibacterial effect of TPU/NS dressing in vitro. After using TPU/NS dressing (observation group) and traditional dressing (control group), the inflammatory reaction, clinical treatment, functional rehabilitation, and adverse reactions in patients were compared.ResultsTPU/NS dressing effectively inhibited the growth of bacteria with a minimum inhibitory concentration of 2 μg/mL. The usage of TPU/NS dressing reduced the inflammatory reaction by reducing positive rate of bacteria after the dressing on the seventh day postoperatively. Besides, the times of dressing, stopping time of wound exudation, wound healing time, length of hospital stay, and VAS score in the observation group were lower than those in the control group; the incidence of adverse reactions after treatment was lower in the observation group as compared with the control group (17.07% vs. 35.09%). Meanwhile, the functional rehabilitation and life quality of patients in the observation group were better TPU/NS dressing treatment.ConclusionTPU/NS dressing has the function of promoting the postoperative recovery of patients by inhibiting the bacterial infection of the wound, thus improving the limb function and life quality. As a result, there was a tremendous potential to apply the constructed TPU/NS membrane to diabetic patients with open fractures, especially those with soft tissue injury.

Impact of establishing a level-1 trauma center for lower extremity trauma: a 4-year experience

PurposeA multidisciplinary approach is essential for trauma patients’ treatment, particularly for cases with open lower extremity fractures, which are considered major traumas requiring a comprehensive approach. Recently, the social demand for severe-trauma centers has increased. This study analyzed the clinical impact of establishing a trauma center for the treatment of open lower extremity fractures.MethodsA retrospective chart review was conducted for trauma patients admitted to our hospital. Patients were classified into two groups: before (January 2014–December 2015, 178 patients) and after establishment of a Level-1 trauma center (January 2017–December 2018, 125 patients). We included patients with open fracture below the knee level and Gustilo type II/III, but excluded those with life-threatening trauma that affected the treatment choice.ResultsTotal 273 patient were included in this study, initial infection was significantly more common and external fixator application significantly less in post-center establishment group. The time to emergency operation decreased significantly from 13.89 ± 17.48 to 11.65 ± 19.33 h post-center setup. By multivariate analysis, the decreased primary amputation and increased limb salvage was attributed to establishment of the trauma center.ConclusionWith the establishment of the Level-1 trauma center, limbs of patients with open lower extremity fractures could be salvaged, and the need for primary amputation was decreased. Early control of initial open wound infection and minimizing external fixator use allowed early soft tissue reconstruction. The existence of the center ensured a shorter interval to emergency operation and facilitated interdepartmental cooperation, which promoted active limb salvage and contributed to patients’ quality of life.

Patients value their own pain over braking safety when deciding when to return to driving: a discrete choice experiment on lower extremity injuries.

To quantify patient preferences towards time to return to driving relative to compromised reaction time and potential complication risks. Cross-sectional discrete choice experiment. Academic trauma center. Ninety-six adult patients with an operative lower extremity fracture from December 2019 through December 2020. None. Patient completed a discrete choice experiment survey consisting of 12 hypothetical return to driving scenarios with varied attributes: time to return to driving (range: 1 to 6 months), risk of implant failure (range: 1% to 12%), pain upon driving return (range: none to severe), and driving safety measured by braking distance (range: 0 to 40 feet at 60 mph). The relative importance of each attribute is reported on a scale of 0% to 100%. Patients most valued a reduced pain level when resuming driving (62%), followed by the risk of implant failure (17%), time to return to driving (13%), and braking safety (8%). Patients were indifferent to returning to driving at 1 month (median utility: 28, interquartile range [IQR] -31 to 80) or 2 months (median utility: 59, IQR: 41 to 91) postinjury. Patients with lower extremity injuries demonstrated a willingness to forego earlier return to driving if it might mean a decrease in their pain level. Patients are least concerned about their driving safety, instead placing higher value on their own pain level and chance of implant failure. The findings of this study are the first to rigorously quantify patient preferences toward a return to driving and heterogeneity in patient preferences. V.

Comparative risk stratification for prediction of early postoperative morbidity and mortality after open fixation of periarticular lower extremity fractures

IntroductionThe identification of patients at higher risk of early postoperative adverse events has implications for quality improvement, preoperative medical optimization, and cost reduction through bundled payments. The purpose of the present study was to develop points-based risk stratification systems for predicting 30-day adverse events (AEs) and mortality after open fixation of periarticular hip, knee, and ankle fractures. MethodsQuery of the NSQIP database yielded 65,529 patients who underwent periarticular lower extremity repair from 2010 to 2019. To generate our risk stratification systems, 60% of patients were randomly analyzed with multivariable regression plus bootstrap modeling to identify independent risk factors for early AE or mortality. A nomogram analysis was then conducted to assign scores for each risk factor. To validate our models, the systems were tested for predictive ability using the remaining 40% of patients. ResultsIn total, 13,212 patients (20.2%) experienced any AE and 3613 patients (5.5%) mortality within 30 days of fracture fixation. Patients were assigned points for the following in both risk stratification systems: fracture type, male gender, age, functional dependence, anemia, pulmonary disease, congestive heart failure, and end-stage renal disease. Corticosteroid use, hypertension, and insulin-dependent diabetes were additional predictors for only AEs. The AE and mortality models had maximum scores of 27 and 17 points, and Harrell C statistics of 0.66 and 0.75, respectively. The estimated risk of developing early AE ranged from 3.4 to 79.5% and mortality from 0.08 to 54.4%. ConclusionFracture type and preoperative characteristics can be used in the prediction of early AE or mortality following open fixation of periarticular lower extremity fractures, with a marked disparity in estimated risks depending on the number of risk factors possessed by a patient. Level of EvidenceTherapeutic IV.

A comparative study between bone transport technique using Ilizarov/LRS fixator and induced membrane (Masquelet) technique in management of bone defects in the long bones of lower limb.

In earlier times due to difficulty in managing segmental long bone defects, amputation was the preferred treatment. Nonunion with bone loss of long bones is a challenging problem, requiring serious attention. Post-traumatic segmental bone defects can have severe long-term ill impact on patient's lives. Reconstruction is more difficult and functional outcome is usually less satisfactory compared to bony outcome. Distraction osteogenesis and induced membrane technique are the techniques that can be used. To find out and compare clinical, radiological, and functional outcome of bone transport technique and induced membrane technique in management of bone defects in the long bones of lower limb. A comparative study was conducted on 24 patients (22 males and 2 females) of lower extremity fractures with bone defect more than 3 cm. Patients were divided into two groups according to the method of reconstruction used, that is, either bone transport technique in 12 patients (group A) or masquelet in the other 12 patients (group B). The mean age of the patients was 44 years in group A and was 38 years in group B. Regular follow-up was done with a mean period of follow up of 18.35 ± 5.58 months in group A and 18.25 ± 3.95 months in group B. In group A (bone transport), 67% showed union, 25% showed union with bone graft and 8% showed delayed union. In group B (masquelet), 75% showed union and 25% showed delayed union. bone transport technique showed excellent results in 58.3% and good in 41.7% while Masquelet technique showed excellent result in 50% and good in 50%. For an orthopaedic surgeon, long bones defects with a substantial loss of bone volume are one of the most challenging bone defects encountered in clinical practice. Induced membrane technique and bone transport both offer successful options for filling of bone defects. Both techniques have its own pros and cons and provide varied option for healing. In our study, both methods have comparable results statistically although induced membrane technique required soft tissue reconstructive procedures.

Epidemiology of Traumatic Orthopedic Injuries: A Cross-Sectional Survey from Northern Tehran, Iran

Background: Trauma is a leading cause of death and morbidity in developing countries. Previous research has revealed that epidemiological features of fractures may change from one study to the next. National Trauma Registry of Iran (NTRI) was launched in 2015, but it did not include any centers in northern Tehran, Iran. This study aimed to evaluate the epidemiology of fractures in the only Level 1 Trauma Center in that area.&#x0D; Methods: This retrospective cross-sectional study was performed on all patients with the primary diagnosis of orthopedic injury, from July to October 2019, who referred to the emergency department of Shohada Tajrish Hospital, Tehran. The patients’ files and operation notes were reviewed for demographics, medical history, physical examination, referral time, mechanism of injury, hospital stay, level of education, and intensive care unit (ICU) hospitalization.&#x0D; Results: 398 patients with orthopedic trauma were referred to the hospital with a mean age of 40.85 ± 21.03 years. 317 patients (79.65%) were men. The peak referral time was between 12 AM and 12 PM. A road traffic accident was the main cause of orthopedic trauma (39.4%). The mean days of hospital stay were 6.29 ± 5.36 days. The waiting time for surgery and days of hospital stay were related to the fracture site (high in lower extremity fractures) and older age.&#x0D; Conclusion: Trauma in northern Tehran is primarily caused by motor vehicle accidents and falls, respectively. Patients with older age and lower extremity fractures need more time of hospitalization.