Management Of Open Fractures Research Articles

Validation of minimally invasive articular cartilage sparing technique for olecranon osteotomy.

The authors present a cadaveric validation of a minimally invasive articular cartilage preserving olecranon osteotomy technique for use in the operative management of distal humeral fractures. Twenty-four elbows in six male and six female formaldehyde embalmed cadavers were dissected. With the cadaver placed in a lateral decubitus position, a posterior sub-periosteal dissection was performed to the medial and lateral aspects of the olecranon at the level of the joint and Mini Hohmann retractors were inserted into each side of the ulnohumeral joint. The medial (M) and the lateral (L) points where the retractors touch the articular surface were marked with a fine marker pen (Crown point) and a line drawn between the two points. The midpoint formed the apex of the chevron osteotomy. An osteotomy was performed and analysis of the osteotomy relative to the ulnar bare area (UBA) was undertaken. The distal boundary of the UBA can be reliably found at a distance of 4.8 ± 0.4 mm (females) and 5.4 ± 0.8 mm (males) distal to the Crown point using this technique. Identifying the Crown of the olecranon articular surface is a reliable and accurate technique which identifies the ulnar bare area reproducibly for the safe performance of a cartilage sparing, and minimally invasive, olecranon osteotomy for the surgical management of distal humeral fractures.

Factors Influencing Postoperative Inpatient Rehabilitation Requirement After Surgical Intervention for Isolated Hip Fracture: A Multicenter Study.

Hip fractures in the elderly, especially those discharged to a rehab facility, have historically been associated with poor outcomes. There has yet to be identified which patients have a higher likelihood of a rehab discharge after isolated hip fracture fixation. The purpose of this study was to identify factors that predispose patients to require short or long-term rehab after surgical intervention of traumatic, isolated hip fractures. Patients undergoing operative management of hip fractures (n = 71,849) from 2017 to 2019 at institutions that submitted data to a nationwide database were analyzed retrospectively. Various factors were compared between patients discharged to inpatient rehab (n = 56,178) versus home (n = 15,671). The rehab discharge group was significantly older and predominantly female. This cohort had a longer average hospital stay, higher incidence of diabetes, congestive heart failure, chronic renal failure, history of cerebrovascular accident, functionally dependent health status, hypertension, chronic obstructive pulmonary disease, dementia, baseline anticoagulation therapy, and history of myocardial infarction. DVT during hospitalization was encountered more often in patients discharged to rehab. Patients with femoral neck fractures and those undergoing total hip arthroplasty were more often discharged home. Patients with intertrochanteric hip fractures and those undergoing fracture fixation were more often discharged to rehab. Multiple risk factors associated with a significantly higher likelihood of a rehab discharge after isolated hip fracture surgery were identified. Early identification of these patients may provide an opportunity to optimize patients for home discharge and better outcomes. Level III, Case-Control Study.

External fixation followed by cast immobilization in the management of gustilo-anderson iiia and iiib open tibial fractures

External fixation followed by cast immobilization in the management of gustilo-anderson iiia and iiib open tibial fractures

Timing of debridement: When to do it, and who should perform it?

The timely and effective management of open fractures continues to be a challenge in modern orthopaedic practice. Lower limb high energy fractures with complex soft tissue injuries require multi-disciplinary care to achieve the best results. Despite an extensive published literature on open fractures, the timing of debridement and the most appropriate personnel to perform it continue to be a source of debate. National guidelines on the topic are few but they suggest immediate debridement for open fractures with highly contaminated wounds and debridement within 12 to 24 h is considered desirable for less contaminated wounds. There is actually limited evidence linking timing of debridement to infection risk but the largest studies recently published do indicate a link between delay to debridement and increasing infection risk. Most studies on management are based on a clinical model where the initial debridement and fixation are performed by an orthopaedic surgeon and if required delayed coverage and closure is subsequently carried out by a plastic surgeon. More recently, studies have proposed an alternative approach, with initial debridement and temporary fixation followed within 48 h with a further debridement, definitive fixation and flap cover with a combined orthoplastic team. Reported results have been favourable. This is a significant change in management and there are limited data at present to determine if this approach will improve results in the most complex open fractures.

Impact of the COVID-19 Pandemic on the Incidence, Etiology, Demographics, and Treatment of Craniomaxillofacial Trauma.

To compare the incidence, etiology, demographics, and treatment of craniomaxillofacial (CMF) trauma before, during, and after COVID-19. Retrospective cohort. Eighty-three health care organizations across the United States. The TriNetX Research Network identified 77,977,880 patients during 2017 to 2022. CMF fractures and soft tissue injuries during March to August of each year, aligning with the 2020 pandemic lockdown, were analyzed. In 2020, compared to immediately prepandemic in 2019, there were significant reductions of -17.5% in facial fractures and -19.0% in soft tissue injuries (P < .001). Conversely, in 2021, both injury types increased by +16.7% and +16.3%, respectively, compared to 2020 (P < .001). Changes in injury mechanisms in 2020 included significant decreases in athletic injuries (-57.6%), falls (-16.8%), assaults (-15.5%), motor vehicle collisions (-8.7%), and pedestrian accidents (-6.9%) (P < .01), while off-road vehicle (+48.4%), bicycle (+16.2%), and motorcycle (+8.9%) accidents increased (P < .01). The 10- to 14- and 5- to 9-year-old age groups experienced the most substantial reductions in facial fractures (-39.7% and -29.9%, respectively) and soft tissue injuries (-29.2% and -28.3%, respectively) in 2020 compared to 2019 (P < .001). Operative management of fractures and soft tissue injuries dropped by -20.3% and -12.4%, respectively, in 2020 versus 2019, and then rebounded with +15.8% and +14.6% increases in 2021 compared to 2020 (P < .001). In 2022, compared to prepandemic rates of 2019, there were fewer patients with facial fractures (-2.8%), soft tissue injuries (-4.5%), and operative repairs (-6.9% for fractures, -1.2% for soft tissue injuries) (P < .03). CMF trauma decreased in 2020, with subsequent years showing a rebound to levels slightly below those immediately prior to pandemic onset. Changes in etiology, demographics, and treatment highlight the complex dynamics of traumatic injuries during periods of societal disruption.

Weight-bearing timing after the operative management of ankle fractures: Single center audit and critical appraisal of literature

The postoperative weight-bearing policy following internal fixation of unstable ankle fractures varies greatly and is largely surgeon-dependent. While early weight-bearing is favoured for its superior functional and economic outcomes, late weight-bearing may be safer initially. However, consensus on the preferred treatment protocol is lacking. We audited practices at University Hospitals Leuven, Belgium, comparing them to existing literature to establish an updated protocol.In a retrospective study of 236 patients with unstable ankle fractures, we compared outcomes between early (EWB) and late weight-bearing (LWB) strategies, with or without braces and/or vacuum casts. Most patients followed a LWB protocol, while EWB was reserved for younger, lower BMI individuals. The difference in brace or vacuum cast usage was insignificant. All open fractures followed a LWB protocol. No disparities in union rates, complications, or length of stay were found between EWB and LWB. Surgical management cost €6,419 (6,921 US $) on average, with length of stay being the main cost driver. Total healthcare costs did not differ significantly between EWB and LWB. FRI was revealed in 6 cases, (1 [4%] vs. 5 [2.5%], EWB vs. LWB respectively, P=0.922)In conclusion, while no significant differences in outcomes were observed between EWB and LWB rehabilitation, differences in group characteristics may have influenced these findings. Despite limited EWB cases, it appears safe for younger patients with low BMI. Vacuum casts and braces aid in EWB. Reducing length of stay, rather than restricting orthotic use, may help control healthcare costs.

Erratum. Contemporary management of pediatric open skull fractures: a multicenter pediatric trauma center study.

Erratum. Contemporary management of pediatric open skull fractures: a multicenter pediatric trauma center study.

Orthoplastic Management of Lower Limb Traumas: A Retrospective Study on Polytraumas Versus Isolated Injuries.

Open fractures of the lower limb represent a common challenge for trauma centers. Even where national guidelines are available, these standards are frequently missing. Our study evaluates the influence of polytrauma on the adherence to the timing and management required in an orthoplastic approach. A retrospective review was performed on 36 patients affected by a Gustilo-Anderson grade IIIA, IIIB, or IIIC fracture of the lower limb between 2018 and 2022. Data related to patient management were analyzed: time to the first evaluation by a plastic surgeon, time to soft tissue coverage, time to definitive osteosynthesis, days in intensive care unit (ICU), days of hospitalization, and total cost of hospital stay. Patient satisfaction was evaluated through the administration of 2 questionnaires: the Enneking and the Foot Function Index (FFI). In 23 patients (63.9%), a soft tissue reconstruction was required. Of these, 13 were polytraumas (PT) (56.5%) and 10 were affected by an isolated lower limb fracture (ILLF) (43.5%). The median time to wound excision was 7.0 days (IQR, 0-16.0) in the PT group and 12.5 days (IQR, 1-41.0) in the ILLF group, whereas the mean time to soft tissue coverage was 15.0 days (IQR, 4.0-17.0) in the PT group and 38.0 days (IQR, 25.0-65.0) in the ILLF group. Mean time to definitive fixation was 33.0 days (IQR, 6.5-70.0) in the PT group and 16.5 days (IQR, 3.0-26.0) in the ILLF group. Statistically significant difference was reported on mean time to soft tissue coverage, whereas not relevant differences were reported on mean time to plastic surgeon involvement, first debridement, definitive fixation, days of hospitalization, costs, and Enneking and FFI score. This is the first study comparing the effectiveness of the orthoplastic approach between isolated lower limb fractures and polytraumas. According to our study, open lower limb fracture management is paradoxically more effective in polytraumas rather than in isolated injuries because a multidisciplinary approach is mandatory in severely injured and compromised patients.

Salvage of a comminuted proximal tibial polymicrobial infected non-union with antibiotic loaded bio-composite and intramedullary nailing: a case report

Background. Management of open proximal metaphyseal fractures poses a significant challenge and is fraught with complications. These injuries are severe, often accompanied by extensive soft tissue and vascular damage, leading to high risks of infection and long-term disability. Case presentation. A 72-year-old male was severely injured in a road traffic accident. Plain X-rays and CT angiogram identified a comminuted proximal tibial fracture with transection of the popliteal artery and vein. Initial emergency treatment included fasciotomies, external fixation, and vascular primary repair. On the 12th day of admission, the patient underwent open reduction and internal fixation (ORIF) with dual plate fixation using a two incision technique. A plastic surgeon performed skin grafting, harvested from the patient’s thigh, to allow closure of his fasciotomy wounds immediately following ORIF. Four weeks post-operatively, the patient developed a wound breakdown over the lateral fasciotomy site, exposing the metal plates with a small defect developing on the medial fasciotomy wound in tandem. The patient’s course was further complicated by persistent polymicrobial infections. Over 6 months of antibiotic regimes, operative intervention was ultimately required. All of the infected metal implants were removed, the non-union sites were aggressively debrided. The tibial canal was reamed to prepare for a tibial nailing. An antibiotic loaded bio-composite was then inserted through the non-union sites into the canal followed by an intramedullary nail. A blocking screw was used to address the procurvatum deformity in the sagittal plane. The patient currently shows signs of recovery, mobilizing over short distances, weight-bearing with assistive aids and with healing wounds and early signs of callus formation on recent CT scans and plain X-rays. Conclusions. The management of complex tibial fractures with vascular involvement demands an aggressive multidisciplinary approach and continuous adaptability in treatment plans to address the evolving challenges of such severe injuries. This case exemplifies the utility of injectable antibiotic-loaded bio-composites in a limb-salvage setting and their ability to provide high doses of local antibiotics to an infection site which, in conjunction with appropriate stable fixation and systemic antibiotics, can aid in eradicating and treating fracture-related infections.

A Scoping Review on the Management of Open Fractures in African Trauma and Orthopaedics Centres.

An open fracture is when the fractured part of a bone is exposed to the external environment by breaching the overlying soft tissue and skin.Open fractures often arise from high-energy injuries, and the risk of microbial contamination is high. There is a need to understand the management of open fractures in Africa by assessing the overall prevalence of open fractures, the mechanisms of injury, management approaches and outcomes. A literature search was conducted using PubMed, African Journal Online, and Google Scholar regarding open fracture management in Africa from inception till date. Thirty-nine (39) studies were included in this review. Road traffic accidents represented the majority of all mechanisms of open fractures, with the Tibia being the most affected bone. 320 cases were classified as Gustilo Anderson Type 1, with 487 classified as Type 2. Type 3 was divided into 3A (330), 3B (248), and 3C (34). Most studies recorded the immediate administration of intravenous antibiotics, but tetanus prophylaxis was only given in 13 studies, while initial debridement and washout were done in 35 studies. External fixators and Kirschner wires were most used for initial fixation. Follow-up for patients was between six weeks to 50 months. There were 645 cases of malunion, 83 cases of non-union, and 88 patients who had delayed union. There were 147 cases of wound infection and 119 cases of pin tract infections. Our findings emphasize the need for standardized protocols and robust emergency services to manage open fractures within Africa.

Orthoplastics Management of Open Lower Limb Fractures at a Major Trauma Centre: Audit of Adherence to BOAST4 Guidelines

IntroductionThe British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guide the optimal management of open lower limb fractures. Adherence of the newly established Orthoplastic service at the Major Trauma Centre covering the Southeast of England was audited in relation to these standards. Materials and methodsAudit standards were produced. Data were collected using hospital records and the Trauma Audit and Research Network database. All open lower limb fractures managed between August 2020-August 2022 were included. Data collected included patient and injury demographics, and information related to initial and definitive management. ResultsOverall, 133 patients were identified, 70 men and 63 women, with an average age of 58 years. Women had a higher average age (69 years) and ASA grade (71% ASA 3 or higher). Low-energy injuries occurred in 69% of women compared to 78% of high-energy injuries in men (p<0.001). Among them, 108 (81%) were debrided within 24 h. The average time to first debridement was 18.78 h, and 95 (75%) were definitively closed within 72 h, 76 with primary closure, 7 with split-thickness skin graft, 7 with local flap and 36 with free flap. Overall, the post-operative infection rate was 13% with 94% of these fractures definitively closed within 72 h. ConclusionMost open lower limb fractures occurred in older women with higher ASA grade, from low-energy mechanisms. Most injuries were definitively managed as per the BOAST guidelines, but further efforts are required to improve the adherence to initial debridement targets, including training, appropriate resource allocation and implementation of procedures and proformas to guide injury management and improve documentation.

Treatment of Diaphyseal Tibial Non-unions After Open Fracture: A Retrospective Observational Study on Characteristics and Outcomes

Abstract Purpose Non-union is a significant complication following open diaphyseal tibia fractures. Management can be complex and unpredictable. Several principles must be addressed often in combination to achieve union. The aim of this study is to report on the characteristics, management and eventual outcome of non-united open tibial fractures over a 12-year period from a level I trauma centre. Methods This is a retrospective observational study of all adults (age 18 years and older) presenting to a level 1 trauma centre with a diaphyseal tibia fracture. Non-union was diagnosed using the standard FDA definition of incomplete union by 9 months or no progress to union in the preceding 3 months. Injury and patient demographics in addition to all interventions and complications were recorded for each patient. Results Forty three cases of diaphyseal non-union were identified from 2008 to 2019. Only the presence of peripheral vascular disease demonstrated a statistically significant association with the development of non-union. In 44% of cases, more than one additional operation was required to achieve union. Successful union was achieved in 90% of cases with 74% of patients returning to full pre-injury function without complication. Conclusion Management of non-union is a complex problem which requires a multifaceted and bespoke approach. We have included an algorithm to help guide decision making based on our institutional experience. A satisfactory result is achievable in the majority of patients.

Management of Femoral and Tibial Shaft Fractures in Chronic Spinal Cord Injury Patients.

To compare outcomes and complications between non-operative and operative management of femur and tibia fractures in patients with paraplegia or quadriplegia from chronic spinal cord injury (SCI). Design: Retrospective cohort study. Three Level-1 Trauma centers. All adult patients with paraplegia or quadriplegia due to a chronic SCI with operative or nonoperative treatment of a femoral or tibial shaft fracture from 01/01/2009 through 12/31/2019 were included. Outcomes collected included range of motion, pain, return to baseline activity, extent of malunion and treatment complications (infection, pressure ulcers, nonunion, DVT/PE, stroke, amputation, death). Comparison between operative and nonoperative treatment were made for each outcome. Fifty-nine patients with acute lower extremity fracture in the setting of chronic SCI fulfilled inclusion criteria with a median age of 46 years in the operative group and 47 years in the non-operative group. Twelve patients (70.6%) in the nonoperative group were male with 32 (76.2%) male patients in the operative group. Forty-six patients (78%) presented as low energy trauma. Differences were seen between operative and non-operative management for pressure ulcers (19% vs 52.9%, p=0.009) and mean VAS pain score at first follow-up (1.19 vs 3.3, p=0.03). No difference was seen for rates of infection, nonunion, DVT/PE, stroke, amputation, death, return to baseline activity, and range of motion. Tibial and femoral shaft fractures commonly resulted from low energy mechanisms in patients with chronic SCI. Operative treatment seemed to decrease morbidity in these patients via lowered rates of pressure ulcers and decreased pain compared to non-operative management. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radiographic and Functional Outcome of Depressed Tibial Plateau Fractures Treated with Raft Plate with Bone Graft – A Prospective Study

Tibial plateau fractures are the fractures that involve the articular surface of the tibial condyles. The Schatzker and OA classifications are the most commonly used to classify these fractures. The Schatzker classification system is a widely recognized method used by orthopedic surgeons to categorize tibial plateau fractures into six distinct types. This classification helps in assessing the initial injury, planning the appropriate management strategy, and predicting the prognosis. Each type represents a different pattern of fracture, which can guide treatment decisions and expectations for recovery. These fractures typically result from the external(valgus) or internal(varus) forces on the knee with axial loading. In younger individuals, tibial plateau fractures are most commonly caused by road traffic accidents due to the high-energy impact. However, in elderly patients with osteopenic bone, even a simple fall can lead to these fractures because their bones are more fragile and susceptible to injury. The tibial plateau fractures are intra-articular fractures of the knee joint and are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. Surgery is the preferred modality of treatment for these fractures, along with bone void fillers to address bone defects caused by the injury. At present, there is no consensus on the optimal method of fixation or the void filling to treat such fractures. Techniques of operative management of tibial plateau fractures have become more successful in achieving and maintaining reduction of the fracture. Still, avoiding malalignment of the limb has been shown to be at least as important as articular congruity to long-term joint viability.

Operative Management of Atypical Femur Fractures.

https://ota.org/education/ota-online-resources/video-library-procedures-techniques/operative-management-atypical#/+/0/score,date_na_dt/desc/.

Functional Outcome Measures after Operative Management of Acetabular Fractures

Objective: This study evaluated the functional outcome of patients with acetabular injuries using the Majeed pelvic score. The specific objectives were to assess any differences in functional outcomes among patients treated early versus delayed surgery and those with or without concomitant injuries. Methodology: Patients from our institution, Baguio General Hospital and Medical Center, with acetabular injuries from January 2019 to December 2022, were investigated. Patients with acetabular fractures with or without other injuries were included. All available data sources were reviewed, such as charts from hospital records, patient census, and electronic medical records. Patients underwent physical therapy before discharge and were followed up. The patients’ outcomes after surgical intervention were assessed using Majeed's pelvic score Results: Thirteen patients were included in the study with follow-ups ranging from one to three years. A functional assessment using Majeed's pelvic score with a mean of 83 points (range 72–100). The majority had good functional outcomes. Conclusions: Early surgical intervention may have no advantage over delayed surgeries regarding functional outcomes. However, concomitant injuries and complications may contribute to a poor to fair functional outcome.

Management of Open Fractures of the Extremities and Pediatrics.

The modern management of open fractures was established after the foundational work of Gustilo and Anderson, but we continue to strive to determine the optimal treatment of open fractures to diminish the risk of infection. The ideal timing of antibiotics, presentation to the operating room, and timing of procedures such as flap coverage continue to be investigated with incremental changes recommended over the years. This article aims to provide the most recent review of the literature regarding the timing and management of both upper and lower extremity open fractures, pediatric open fractures, current topics of controversy, and the data supporting current treatment recommendations.

955 Is Non-Operative Management Equal to or Superior to Operative Management of Distal Radius Fractures for Patients Over 60?

955 Is Non-Operative Management Equal to or Superior to Operative Management of Distal Radius Fractures for Patients Over 60?

Superior versus anterior plating of midshaft clavicle fractures: 6 months follow up (union rates, risks, and complications: hardware irritation and need for removal)

Background Operative management of midshaft clavicle fractures is gaining popularity. The clavicle is a tubular bone with a flat lateral end. Open reduction and internal fixation could be achieved by the application of plates and screws either to the superior or anterior surface of the clavicle. However, there is no consensus in the literature to support one technique over the other. This study aims to compare the early functional and radiographic outcomes of anterior versus superior plating for the treatment of midshaft clavicle fractures. Patients and methods From March 2021 to November 2022, a prospective randomized clinical trial was conducted at our institute. We included all patients with isolated midshaft clavicle fractures. Thirty-six patients were randomized by the closed envelope technique, 18 were managed with superior plating (superior group), and the other 18 patients were managed using anterior plating (anterior group). All patients were followed up for 6 months. All patients were assessed clinically for union, range of motion, and functional scores. The secondary outcome measures included operative time, complications, hardware irritation, and the need for hardware removal or secondary procedure. Results The mean time to full union was 11.28 weeks in the anterior group and 11.72 weeks in the superior group. Mean constant shoulder score for the anterior group was 84.11 while for the superior group it was 82.67. No patients had skin and wound complications in the anterior group versus one patient in the superior group that got superficial infection successfully managed by repeated dressing and antibiotics. There was no statistically significant difference between superior and anterior plating regarding union, functional scores, return to ADLs, hardware problems, or complications. Conclusion Both superior and anterior plating of the clavicle fractures are safe treatment options for displaced midshaft clavicle fractures, and they lead to similar functional outcomes, functional scores, and complication rates. Moreover, the selection of the technique of plating depends on surgeon preferences.

Seasonal variation and preoperative risk factors for polymicrobial infection following open fracture

IntroductionDespite modern approaches to open fracture management, fracture-related infection (FRI) rates remain high. Recent studies demonstrated the seasonal and regional variation of causative organisms in FRI. This study aims to better understand the causative organisms and identify preoperative risk factors for the primary outcome of FRIs at a Level I trauma center. Materials and methodsThis retrospective cohort study examined all patients that underwent irrigation and debridement of an open fracture at a single Level I trauma center between 2007 and 2019. Exclusion criteria included gunshot wounds, hand injuries, and follow-up less than 3 months. Patients that developed FRI were compared by season, injury characteristics, patient demographics, initial management, and causative organisms. ResultsAmong 695 patients with open fractures, 78 patients (11.2 %) developed infection, of which eight were Gustilo-Anderson (GA) Type I, 16 were GA Type II, 25 were GA Type IIIA, 26 were GA Type IIIB, and three were GA Type IIIC. Gram-positive FRIs were most common (81.1 %), followed by 56.8 % polymicrobial, 54.1 % gram-negative, and 10.1 % culture-negative infections. More than half (55.1 %) of the infections were from open tibial fractures and occurred after a motorcycle (32.1 %) or motor vehicle collision (23.1 %). Patients were more likely to have high FRI rates in the summer (12.8 %, n = 29) and fall (15.8 %, n = 32) in comparison of spring (4.7 %, n = 7) and winter (8.5 %, n = 10) (p < 0.01). Staphylococcus infections were more common in fall and winter (73.8 %, n = 31) versus spring and summer (44.4 %, n = 16) (p = 0.01). Patients that were transferred from outside hospitals had significantly higher rates of polymicrobial infection when compared to those who arrived from the field (63.6 % vs 41.2 %, p = 0.03). No differences were observed in infection causative organisms based on GA type. ConclusionsTwo preoperative risk factors for polymicrobial infection following open fracture include inter-hospital transfers and warm/humid weather. Broadening antibiotic prophylaxis during spring/summer months or for transferred patients may enhance antibiotic coverage and reduce infections.