Manipulation Of Fractures Research Articles

Alternatives to Sedation for Painful Procedures

Conscious sedation is used frequently to perform procedures that may be undertaken with or without minimal sedation. Fracture manipulation can be performed with minimal discomfort in the awake patient using various techniques-for example, intravenous regional anesthesia, nerve blocks, and hematoma blocks. These have been used for many years and are very safe. They may require some specific equipment (eg, automatic tourniquet) to perform the anesthesia but patients have the same results and are able to go home much quicker because sedation is not used.Use of topical anesthesia for both intact skin and wounds has been used over many years. Its use now should be standard. Nerve blocks can also be used to anesthetize specific areas which may be difficult to use topical anesthesia (eg, lip, hand, etc) or are painful because of injection directly into the wound. These may include infraorbital nerve blocks for lip lacerations, ulna or median nerve blocks for hand injuries, and so on. Other novel approaches to topical anesthesia have seen the use of iontophoresis (again requires specific expensive equipment), jet injection of lidocaine, or "freeze sprays." Each has its own advantages and disadvantages.Femoral nerve block is a useful intervention for analgesia in patients with femoral fractures and can obviate the need for parenteral analgesia and allows excellent analgesia particularly during x-ray examination.Thus, it is important to remember that there are alternatives to conscious sedation which gives good analgesia during the procedure and allows the patient to be discharged sooner.

A Comprehensive Analysis With Minimum 1-Year Follow-up of Vertically Unstable Transforaminal Sacral Fractures Treated With Triangular Osteosynthesis

To analyze the radiographic, clinical, and functional results of triangular osteosynthesis constructs for the treatment of vertically unstable comminuted transforaminal sacral fractures. Level I trauma center. During a 3-year period (July 1, 2003 to June 30, 2006), 58 patients with vertically unstable pelvic injuries were treated with triangular osteosynthesis fixation by a single surgeon at a single institution. Patients were followed-up prospectively as a single cohort, with institutional review board approval. Inclusion criteria for this study were skeletally mature patients with a vertically unstable pelvic ring injury associated with a comminuted transforaminal sacral fracture. Minimum follow-up, both clinically and radiographically, was 1 year. Computed tomography scan was performed on all patients at 6 months to assess healing of the fracture. If the fracture healed, the fixation was removed. Functional outcome was assessed using the Short Form 36, version 2, and short version of Musculoskeletal Functional Assessment questionnaires at 6 months (before fixation removal) and 12 months. Forty of 58 patients with an average age of 39 years were available for a minimum of 1-year follow-up. Wound complications requiring surgical debridement occurred in 5 patients (13%), all of whom had severe soft tissue wounds with internal degloving. Two patients required removal of infected fixation. Iatrogenic L5 nerve injury occurred in 5 patients (13%). Ten patients (25%) had a delayed union on computed tomography scans, and 3 patients had a nonunion as a result of residual fracture gap and incomplete reduction. Six patients (15%) were found to have pronounced tilting of the L5 vertebral body (scoliosis) and distraction of the L5/S1 facet joint ipsilateral to the fixation. This did not correct with removal of the fixation. Failure of the triangular osteosynthesis construct resulting in malunion occurred in 2 patients (5%). All but 2 patients (95%) complained of painful and prominent implants. Functional outcome scoring showed that patients continued to function below the population mean at 1 year but continued to improve, particularly with function and daily activity. Ninety-seven percent of patients returned to some form of work or schooling. Triangular osteosynthesis fixation is a reliable form of fixation that allows early full weight-bearing at 6 weeks while preventing loss of reduction in comminuted vertical shear transforaminal sacral fractures. For this study group, operative reduction was maintained until healing in 95% of patients. However, the 1-year follow-up shows a substantial rate of potential technical problems and complications. Of primary concern were the asymmetric L5 tilting with L5-S1 facet joint distraction and the need for a second surgery in all patients to remove painful fixation. Iatrogenic nerve injury occurred in 5 patients (13%) and is thought to arise secondary to fracture manipulation and reduction. We recommend selective use of this technique for comminuted transforaminal sacral fractures in situations only where reliable iliosacral or trans-sacral screw fixation is not obtainable.

Iatrogenic Radial Nerve Palsy After Operative Management of Humeral Shaft Fractures

It is generally agreed that a period of observation is appropriate for primary radial nerve palsy associated with humeral shaft fractures. There is no consensus, however, with regard to secondary radial nerve palsy, particularly when it is iatrogenic. Most texts state that surgical exploration is indicated for nerve palsy that occurs after fracture manipulation, but our experience suggests that it is not necessary for radial nerve palsy developing after operative management of humeral shaft fractures. A total of 707 humerus shaft fractures were treated operatively at our two hospitals over a 10-year period. Of these, 30 patients sustained iatrogenic radial nerve palsy. Another 16 cases were referred to us with adequate documentation from other institutions. No recognized intraoperative injuries to the radial nerve were recorded in any case. Of the 46 patients, 21 were female and 25 were male. The median age was 40 years (range, 19-75 years). A total of 39 patients had been treated with dynamic compression plates, 3 with a rigid interlocking intramedullary nail, and 4 with Ender nails. All fractures were diaphyseal, at the middle or distal third level. At the discretion of the surgeon, five cases were surgically explored. In all five cases the radial nerve was in continuity and no macroscopic lesions were noted. All cases eventually recovered grade 4 of 5 muscle strength or better. The median time to the beginning of clinical recovery was 16 weeks (range, 5-30 weeks). The timing and pattern of radial nerve recovery in this situation was similar to that seen in primary radial nerve palsy. There appears to be no advantage to early exploration of the radial nerve. In the absence of obviously misplaced instrumentation or fracture displacement, we treat it like a primary palsy and recommend observation for a minimum of 4 months before exploration.

Bier'S Block for Emergency Department Management of Distal Radius Fractures

Background Distal radius fractures commonly present to emergency departments (ED). Optimum treatment methods remain unclear and individual hospital practices differ. Objectives To ascertain the number and success rate of manipulation under intravenous regional anaesthesia (IVRA) of distal radius fractures, and to determine the re-manipulation rate. Methods Retrospective observational study of patients undergoing manipulation of distal radius fracture under IVRA in the ED from January 2003 to January 2004. The resuscitation room procedure log, hospital computer records, ED records and theatre records were examined for each patient. Results A total of 84 manipulations were performed. Complete information was available for 74 procedures (73 patients). Manipulation was successful in 73.5% with only 19 out of 73 patients requiring operation. All patients were manipulated under IVRA with middle grade or consultant supervision; and 52 (71.2%) patients were managed entirely as outpatients. Conclusion Our policy of manipulating displaced distal radius fractures under IVRA in the ED has a high success rate and allows the majority of patients to be managed as outpatients. This policy may lead to cost savings from a health service financing perspective.

Paediatric distal radial fracture manipulation: multicentre analysis of process times

Background:Children with simple radial fractures requiring manipulation are conventionally admitted for manipulation under general anaesthesia. On the assumption that children (and their parents) wish to spend as little time in...

Comparing the Effectiveness of Modified Forearm and Conventional Minidose Intravenous Regional Anesthesia for Reduction of Distal Forearm Fractures in Children

Minidose intravenous regional anesthesia (IVRA) and modified forearm IVRA have been used for closed reduction of forearm fractures and for hand surgery in children. Children (5-17 years old) with forearm fractures presenting to a pediatric emergency department were enrolled in a randomized controlled trial to test if modified forearm and minidose IVRA together would provide improved analgesia with reduced risk of anesthetic toxicity compared with conventional minidose IVRA. Pain was assessed using a visual analog scale (FACES) and an objective pain scale (OPS) score at baseline and at critical times. Spearman rank correlation and repeated-measures analysis of variance were used to compare interobserver pain measures and detect differences between the groups over time. Among the 62 patients in the study, no significant differences were observed between groups in objective measures of blood pressure, oxygen saturation, and heart rate at baseline, 5 minutes after IVRA, during surgical reduction, and 15 minutes after reduction. Nurses reported patients experienced a reduction in pain of 2.5 (SD, 3.1) on FACES and 2.3 (SD, 3.1) on OPS at 5 minutes after sedation (P < 0.001 for both). From time of reduction to 15 minutes after the procedure, FACES score declined 1.7 (SD, 3.4) (P = 0.001), and OPS declined 2.1 (SD, 3.6) (P = 0.002). No significant differences were found between experimental arms. The modified forearm minidose IVRA procedure is an acceptable alternative for the relief of pain that usually accompanies the manipulation and reduction of forearm fractures but does not appear to provide additional pain relief compared with conventional minidose IVRA. Level I, therapeutic study.

Demographic and Financial Implications of Pediatric Emergency Department Fracture Manipulation

The demographic features, work relative value units (WRVUs), and financial implications of pediatric emergency department (ED) manipulative fracture treatment are presented. The aims of this study are to quantify these parameters and gauge their impact on lifestyle and reimbursement. All ED fracture reductions performed by orthopaedic residents in a children's hospital for fiscal year 2004 were grouped by month, day, time, anatomical location, and payer mix. Work relative value units and reimbursement were assigned for each fracture, contrasting the use of global current procedural terminology manipulation facture codes to the actual use of global current procedural terminology nonmanipulation codes first generated when the child presented to the senior staff office. Three hundred seventy-five fractures were manipulated in the ED. Eighty-one manipulations were done on Saturday and 61 on Sunday compared with an average of 47 for the other 5 days. Nineteen percent of manipulations were performed between 7 AM and 6 PM, 37% between 6 and 11 PM, and 44% between 11 PM and 7 AM. Sixty-nine percent of the children had private insurance, 29% had Medicaid, and 2% had no medical coverage. Potentially 2358 WRVUs could have been recorded had senior staff been present for the reduction in the ED compared with the actual total of 1168 WRVUs recorded in the office a few days later. Using a proxy model of 100% Western Pennsylvania Medicare coverage for these fractures, $179,754 of reimbursement was available with manipulation included compared with $106,010 without manipulation. For our actual payer mix, manipulation would have contributed a 37% increase to fracture care margin for these 375 fractures but would have only provided a 2.5% increase to overall pediatric orthopaedic revenue production for fiscal year 2004. The component of reimbursement resulting from manipulation contributed significantly to fracture care margin for those fractures requiring manipulation but did not have a significant impact on overall pediatric orthopaedic revenue production. The added senior staff work effort required to gain the manipulation reimbursement component of fracture care in the ED is substantial considering the small contribution to overall revenue. Alternative mechanisms of compensation should be devised if the goal is to offer financial incentive to senior staff for their availability for all fracture manipulations in the ED.

Use of the mini C-arm for wrist fractures--establishing a diagnostic reference level

The establishment of diagnostic reference levels (DRLs) for all typical radiological examinations became mandatory following the implementation of the Ionising Radiations (Medical Exposure) Regulations Act 2000. At present, there are no national dosage guidelines in the UK regarding use of fluoroscopy in orthopaedic trauma. The increasing popularity of the mini C-arm image intensifier amongst surgeons has led to concerns regarding use of ionizing radiation by personnel who have not been trained in radiation protection. It is therefore essential to have formal protocols for use of the mini C-arm to comply with the law and to maintain safe clinical practice. It is attempted to provide dose data for wrist fracture manipulations that may be used as a basis for setting a DRL for this procedure. Screening times were recorded for 80 wrist manipulations in a fracture clinic setting using a mini C-arm image intensifier. A DRL was set using the third quartile value for screening time. The median screening time for wrist fractures was 20 s with a range from 1 to 177 s. The third quartile value for screening time was 34 s. This value can be used as a provisional DRL for wrist fracture manipulations. The DRL is a quantitative guide for the optimisation of radiological protection. IR(ME)R 2000 states that if it is consistently exceeded by an individual operator or a piece of equipment, investigation and remedial action must be taken. We recommend that trauma units establish their own local DRLs for common procedures as made mandatory by legislation.

Changes in nasal aesthetics following nasal bone manipulation

Nasal bone fractures are the commonest type of bony facial injury causing aesthetic deformity. The aim of this study was to identify the effect of nasal trauma and fracture manipulation on the aesthetic proportions of the nose, by comparing pre- and post-treatment nasal aesthetics. Thirty-two patients (26 men and 6 women) underwent aesthetic assessment prior to treatment of the injury by closed nasal manipulation, 7 to 10 days after the initial injury. Standard facial aesthetic photographic assessments were performed prior to and following manipulation. Assessment involved measurement of standard nasal aesthetic parameters. In the nasal trauma cohort, the main anomalies in nasal aesthetics were nasal deviation and differences in the nasal aesthetic profile. Nasal fracture manipulation successfully reduced deviation from an average of 35 degrees pre-manipulation to an average of 9 degrees post-manipulation.

Facial Fractures in Kajang Hospital, Malaysia: A 5-Year Review

The objective of this study was to determine the demographic data as well as other relevant data pertaining to the management of patients with maxillofacial injury in a Malaysian government regional hospital. Medical records of 313 patients who sustained maxillofacial injury treated in Kajang Hospital, Selangor, Malaysia over a 5-year period (1998-2002) were collected. Data regarding age, gender and race, etiology of injury, site of injury, other associated injuries and treatment undertaken were analyzed. Two hundred and forty-nine male (79.6%) and 64 female patients (20.4%) were treated for maxillofacial trauma. The patients' age range from 1 to 67 years old, with a median age of 23 years old. A high number of Malays (60.1%) sustained maxillofacial injury, followed by Indians (16%), Chinese (13.4%) and other races (10.5%). Road traffic accident was the main etiology for maxillofacial injury with 230 cases (73.5%), followed by fall (16.6%), assault (5.4%), industrial accident (2.6%), sports injuries (0.6%) and others (1.3%). Mandibular fractures were the most common, occurring in 83.1% of the cases while the midfacial fractures accounted for 16.9%. Majority of patients were treated with closed reduction and intermaxillary fixation (88.1%) and 11.9% underwent open reduction and internal fixation. Road traffic accident involving motorcyclists was the main cause of maxillofacial trauma in Malaysia. The most common facial fracture was the mandibular fracture. Non-surgical manipulation of fracture was the most common treatment carried out in this hospital.

Gap index: a good predictor of failure of plaster cast in distal third radius fractures

The aim of this study was to assess the usefulness of the cast index and an indigenously developed gap index as measures of poor moulding of plaster. Twenty cases of re-manipulation of distal third radius fractures in children excluding growth plate injuries were compared with a control of 80 patients. A significant difference (<0.001) was observed in the cast index and the gap index of both the groups. The gap index was more sensitive than the cast index in predicting failure. At a level of cast index of more than 0.8 the relative risk of failure is 6.8 as compared with 35 when the sum of the gap index is more than 0.15. The gap index is a better predictor of failure than the cast index. A quick assessment of these indices is a good practice before accepting any plaster following a manipulation of distal radial fractures.

Gap index—A good predictor of failure of plaster cast in distal forearm fractures

The aim of this study was to assess the usefulness of Cast index and an indigenously developed Gap index as measures of poor moulding of plaster. 20 cases of re-manipulation of distal third forearm fractures excluding growth plate injuries were compared with a control of 80 patients. 5 patients in the control group had an axial deviation of more than 10 degrees but were not remanipulated and therefore were included in the failure group. The gap index and the cast index of the two groups was compared as predictors of failure of conservative treatment. The groups were similar in terms of demography and post reduction alignment. There was a significant difference ( 0.8) in predicting failure of plaster was 48% while that of the sum of Gap index (>0.15) in AP & Lat view was 88%. Gap index was found to be more accurate (84%) than Cast index (78%) in predicting failure. The gap index is a better predictor of failure than the cast index. A quick assessment of these indices, especially by the less experienced surgeons, is a good practice before accepting any plaster following a manipulation of distal radial fractures. It would not only save the patient a second anaesthesia but also complications of a more extensive second procedure and of course hospital resources.

Comparison of forearm and conventional bier's blocks for manipulation and reduction of distal radius fractures

Forearm-based Bier's block has been advocated as a useful anaesthesic technique in hand surgery. However, there is limited data comparing forearm blocks with the conventional Bier's block. We conducted a randomised controlled trial (n=30) comparing the two techniques of anaesthesia for manipulation and reduction of closed distal radius fractures in an emergency room setting. Pain scores measured using the Visual Analogue Scale during the procedure were used as the primary outcome assessment. There was no significant difference in pain scores between the forearm and conventional Bier's block (mean VAS 18.4 SD 22.10 versus 33.7 SD 29.6). No major complications were observed in either group. The forearm-based Bier block is an effective alternative to the conventional block.

Axillary Block for Analgesia During Manipulation of Forearm Fractures in the Pediatric Emergency Department A Prospective Randomized Comparative Trial

Our objective was to compare procedural distress during manipulation of forearm fractures in children receiving either axillary (brachial plexus) block regional anesthesia (20 children) or deep sedation with ketamine and midazolam (21 children). This was a prospective randomized unmasked controlled comparative trial conducted in an urban children's hospital emergency department. The 2 groups were similar in age (older than 8 years), fracture types, initial pain scores, narcotic analgesia received, and midazolam doses before fracture manipulation. The primary outcome measure was procedural distress during manipulation as measured with the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The mean CHEOPS score was 6.4 +/- 2.8 in the group with axillary block and 7.5 +/- 1.6 in those receiving deep sedation; the difference between the CHEOPS scores in the 2 groups was not statistically significant (P = 0.126, 95% CI: 2.5, 0.3). Axillary block was used successfully in 18 (90%) of the 20 children. No patient in either group experienced any adverse events.

Cost-effectiveness Analysis of Sedation and Analgesia Regimens During Fracture Manipulation in the Pediatric Emergency Department

To conduct a cost-effectiveness analysis, from a hospital's perspective, of 4 procedural sedation and analgesia (PSA) regimens to facilitate forearm fracture manipulation in the pediatric emergency department (ED): deep sedation with ketamine/midazolam (K/M) administration, propofol/fentanyl administration, fentanyl/midazolam (F/M) administration, and axillary block. We constructed a decision analytic model using relevant probabilities from published studies of pediatric patients who underwent fracture manipulation in the EDs. Total costs were calculated by assessing ED resource utilization associated with uncomplicated PSA and with PSA complicated by adverse events. Costs of consumable equipment were considered to be fixed. Total sedation time, personnel time, and drug costs were considered variable. We assumed that all PSA regimens provided effective relief from procedural distress. Failure rates for axillary block were estimated based on reports in the literature. When patients experienced emesis, recovery agitation, respiratory depression, lidocaine toxicity, or regional block failure, we assumed that the patients would require 1 additional hour of ED stay. Sensitivity analyses of all key variables in the model were performed to identify those that may result in a change in the preferred option. Monte Carlo simulations were performed to assess model robustness. Under baseline assumptions, the propofol/fentanyl regimen was the most cost-effective choice (expected cost, 84.06 US dollars), followed by axillary block (88.18 US dollars), K/M (105.32 US dollars), and F/M (159.79 US dollars), respectively. Varying the fixed and variable costs by 50% to 200% of their baseline values did not alter the ranking. When ketamine and propofol were administered without adjunctive midazolam and fentanyl, respectively, propofol remained the optimum choice. With total PSA time as the outcome measure, the incremental cost-effectiveness ratios were 8.1 US dollars and 24.9 US dollars per hour of ED time saved, for propofol/fentanyl versus axillary block and for axillary block versus K/M, respectively. Among PSA regimens during forearm fracture manipulation in the pediatric ED, propofol/fentanyl is the most cost-effective regimen followed by axillary block, K/M, and F/M.

Awareness

Intraoperative awareness has been reported to occur in 0.8-5.0% of paediatric patients undergoing anaesthesia and, therefore, seems to be more common than in adults (incidence 0.1-0.2%). In adult patients, the consequences of intraoperative awareness are well known and can be severe, in children, however, they have not yet been adequately studied. The causes for intraoperative awareness can be divided into three broad categories: First, no or only a light anaesthetic is given on purpose, second, an insufficient dose of an anaesthetic is given inadvertently, third, there is equipment malfunction or the anaesthesiologist makes an error. Unfortunately, especially in young children, painful interventions are still performed without adequate analgesia, e.g. awake intubation or fracture manipulation under midazolam sedation alone. The key issue is, however, that pharmacokinetics and pharmacodynamics change enormously from the 500 g preterm baby to the adolescent patient. Adequate dosing is much more difficult in paediatric patients compared to standard adult surgical patients. Solid knowledge of the pharmacokinetic and pharmacodynamic characteristics of commonly used drugs in different paediatric age groups, as well as aiming for perfection in daily care will help to reduce the incidence of awareness. Methods for monitoring the depth of hypnosis, e.g. the bispectral index, will be used increasingly, at least in children above 1 year of age. In addition to clinical parameters, they will hopefully help to further reduce the incidence of intraoperative awareness.

Closed Fracture Manipulation – Improving Charnley's Three Point Fixation Technique

TECHNIQUE Sir John Charnley1 describes a method of three point fixation when applying a moulded plaster. The fracture is reduced and a plaster cast is applied. The plaster is moulded to apply pressure at the site of the fracture and proximal/distal to the fracture (Fig. 1). Determining the exact site of the fracture can be difficult once the cast is applied. Moulding at a site away from the fracture can result in subsequent fracture displacement. Sir John Charnley did not have the advantage of image intensification. The fracture is reduced and plaster applied. A metal pointer (e.g. a pair of scissors) is placed beside the limb and moved to the site of fracture by using the image intensifier as a guide (Fig. 2). The plaster cast is moulded and final radiograph images are obtained (Fig. 3).

Technical Notes and Tips: Closed Fracture Manipulation – Improving Charnley's Three Point Fixation Technique

Technical Notes and Tips: Closed Fracture Manipulation – Improving Charnley's Three Point Fixation Technique

A Cost-Effective External Splint Device For Nasal Fractures And Rhinoplasty: A Technical Note

Following manipulation of nasal bone fractures or osteotomies, some form of external nasal splinting is often needed. Although various types of splints include plaster of Paris, thermoplastic splints and padded metal splints are available in the market, they are cumbersome or costly. In this paper, we describe a simple, inexpensive but an effective method of splinting with a detailed step-by-step explanation of their use. We believe that this technique can be adapted for widespread use, but has a major application in developing countries where its cost-effectiveness combined with its effectiveness makes it an ideal method for nasal splinting.

THE CLASSIC: Penicillin: Its Practical Application in Orthopaedic Surgery and Fractures

THE CLASSIC: Penicillin: Its Practical Application in Orthopaedic Surgery and Fractures