Orthopaedic Trauma Surgeons Research Articles

Femoral locking plate failure salvaged with hexapod circular external fixation: a report of two cases.

Femoral non-unions are difficult to treat even for the experienced orthopaedic trauma surgeon. If the non-union follows failure of modern stable internal fixation, the complexity of the management is further increased. We report two cases of stiff hypertrophic femoral non-unions after failed locking plate fixation that were successfully treated with a new hexapod circular external fixator. In addition to providing the necessary stability for functional rehabilitation and union, the hexapod circular fixator software allows gradual correction of deformities in order to restore the normal mechanical alignment of the limb.

Supply and Demand Analysis of the Orthopaedic Trauma Surgeon Workforce in the United States.

To investigate recent trends in the orthopaedic trauma workforce and to assess whether supply of orthopaedic trauma surgeons (OTS) matches the demand for their skills. Supply estimated using Orthopaedic Trauma Association (OTA) membership and American Academy of Orthopaedic Surgeons census data. The annual number of operative pelvic and acetabular fractures reported by American College of Surgeons verified trauma centers in the National Trauma Data Bank (NTDB) was used as a surrogate of demand. Because surrogates were used, the annual rate of change in OTA membership versus rate of change in operative injuries per NTDB center was compared. From 2002 to 2012, reported operative pelvic and acetabular injuries increased by an average of 21.0% per year. The number of reporting trauma centers increased by 27.2% per year. The number of OTA members increased each year except in 2009, with mean annual increase of 9.8%. The mean number of orthopaedic surgeons per NTDB center increased from 7.98 to 8.58, an average of 1.5% per year. The annual number of operative pelvic and acetabular fractures per NTDB center decreased from 27.1 in 2002 to 19.03 in 2012, down 2.0% per year. In the United States, from 2002 to 2012, the number of OTS trended upward, whereas operative pelvic and acetabular cases per reporting NTDB center declined. These trends suggest a net loss of such cases per OTS over this period.

Metaphyseal Distal Tibia Fractures

The purpose of this study was to compare clinical and functional outcomes of patients with distal tibia fractures treated with minimally invasive plating (MIPO) or intramedullary nailing (IMN). Cohort study. Level II regional trauma center. Overall, 86 patients with metaphyseal distal fractures (within 5 cm of joint) with simple or no articular involvement treated by a single, fellowship trained, orthopedic trauma surgeon from 2002 to 2013. Intramedullary nailing or minimally invasive plate osteosynthesis. Clinical and radiographic results were evaluated at a minimum of 1-year follow-up. Limb-specific outcomes (American Orthopedic Foot and Ankle Surgeons' ankle-hindfoot instrument) and whole-person measures [Short Form 36 (SF-36) instrument] were assessed at the final follow-up. We studied 86 patients with distal tibia fractures treated with MIPO (43 patients) and IMN (43 patients). Thirty-seven patients in the MIPO group and 27 in the IMN group met inclusion criteria. All patients ultimately healed, with the average time to union of 23 weeks in both the groups. Complications were similar between the 2 groups (MIPO vs. IMN, respectively), including nonunion (8% vs. 7%), malalignment (3.6% vs. 3%), wound complications (3.6% vs. 3%), and infection (0% vs. 3.6%). The need for secondary procedures for the removal of implants was 25.9% in the IMN group (distal locking screws only in 6/7) versus 8.3% in the MIPO group (P = 0.05). Additionally, the American Orthopedic Foot and Ankle Surgeons and all SF-36 version 2 domain scores were quantitatively higher for the IMN group, although only Role Emotional reached a level of statistical superiority between the groups. Similar clinical results and marginally enhanced functional outcomes were seen when treating nonarticular or minimally articular metaphyseal distal tibia fractures with IMN compared with MIPO. However, patients treated with IMN required more frequent secondary surgeries for the removal of painful distal locking screws. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Development of a Universally Accepted Sacral Fracture Classification: A Survey of AOSpine and AOTrauma Members

Introduction Sacral fractures are complex injuries that pose diagnostic and technical challenges for surgeons. While multiple classifications have been proposed, there is not a comprehensive, universally accepted classification. The AOSpine Trauma Knowledge Forum partnered with orthopaedic traumatologists from AOTrauma to develop a straightforward, hierarchical classification system for sacral fractures. While the classification was developed via a consensus process of clinical experts, the authors solicited input from the global community to ensure that the proposed classification could achieve global acceptance. Material and Methods Prior to finalizing the new AOSpine Sacral Injury Classification System, a survey was sent to all members of AOSpine and AOTrauma. The survey included the preliminary sacral classification as well as questions asking for their input on key parts of the classification. Along with demographic information, the following four questions were asked: (1) Since type B injuries in the new AOSpine sacral classification refer only to vertical fracture patterns and exclude injuries with a transverse component, do you agree that there is an increase in the risk of neurologic injury as the B subtype increase: B1—an injury medial to the foramen; B2—an injury lateral to the foramen and B3 an injury through the foramen. (2) Do you think the hierarchical nature of the sacral classification is appropriate with: A = transverse; B = Unilateral vertical fracture; C = Any fracture that leads to spinopelvic instability. (3) Do you think the integrity of the L5/S1 facet is adequately considered in this classification system? (4) Do you think C0 (a non-displaced sacral U fracture that may be seen in low energy insufficiency fractures) is a clinically relevant entity that deserves its own spot in the classification? Results A total of 596 surgeons from all six AO regions of the world responded to the survey. 70.9% of respondents were orthopaedic trauma surgeons, 18.5% were orthopaedic spine surgeons and 4.7% were neurosurgeons. Overall 78.1% of respondents agreed that the B subtypes were correctly ordered for an increase in the risk of a neurologic injury. 86.1% of respondents felt that the hierarchical nature of the classification was appropriate. 82.9% of respondents felt that the L5/S1 facet was adequately considered in the classification, and 84.1% of surgeons felt that C0 is clinically relevant entity that deserves its own spot in the classification. When surgeons were stratified as either a trauma surgeon or a spine surgeon (orthopaedic or neurosurgeon), significantly more spine surgeons than trauma surgeons agreed with the organization of B type injuries (84.7% versus 75.4%, respectively, p = 0.03); however, still more than 3 in 4 trauma surgeons agreed with the organization of B type injuries. No other significant difference was identified by specialty. Additionally, no significant difference (p > 0.39) was found when respondents were grouped by years in practice (0–10 years, 11–20 years and >20 years). Conclusion While validation studies are ongoing for the new AOSpine sacral fracture classification, the classification is designed such that worldwide acceptance from both spine surgeons and trauma surgeons may be possible.

Current Opinions on Fracture Follow-up: A Survey of OTA Members Regarding Standards of Care and Implications for Clinical Research.

To determine current practice standards among Orthopaedic Trauma Association surgeons for postoperative fracture follow-up and to investigate the implications of these standards on clinical research. Survey. Web-based survey. One hundred eighty-four orthopaedic trauma surgeons. A web-based questionnaire was distributed to Orthopaedic Trauma Association members to identify standard postoperative radiographic and clinical follow-up duration. Assuming uneventful, complete fracture healing at 3 months, data were collected for 3 generic fracture types (diaphyseal, extra-articular metaphyseal, and intra-articular) and 3 specific fractures (femoral shaft, intertrochanteric, and tibial plateau). Suggested follow-up for clinical research was also investigated. For extra-articular fractures, standard radiographic and clinical follow-up were considered to be 6 months or less by greater than 70% of respondents. For intra-articular fractures, standard radiographic and clinical follow-up was considered to be 6 months or less by greater than 39% of respondents. The most common responses for radiographic follow-up were 3 months for extra-articular fractures (33%) and 12 months for intra-articular fractures (34%). The most common responses for clinical follow-up were 6 months for extra-articular fractures (37%) and 12 months for intra-articular fractures (35%). The majority (55%) indicated that follow-up to clinical and radiographic healing or the establishment of a nonunion should be the minimum follow-up for clinical fracture studies and 66% recommended follow-up to at least 1 year for functional outcome studies. Most surgeons follow-up patients with lower extremity extra-articular fractures (with uneventful healing) radiographically for 3-6 months and clinically for 6 months and slightly longer for intra-articular fractures. Many surgeons cease radiographic and clinical follow-up by 6 months. Therefore, retrospective fracture healing studies can only reasonably expect follow-up for 6 months. Publication requirements for longer follow-up of fracture-related studies would likely eliminated retrospective studies from consideration. Most surgeons support obtaining at least 1-year follow-up for clinical studies that include functional outcome. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Classification and treatment of distal radius fractures: a survey among orthopaedic trauma surgeons and residents

PurposeClassification, the definition of an acceptable reduction and indications for surgery in distal radius fracture management are still subject of debate. The purpose of this study was to characterise current distal radius fracture management in Europe.MethodsDuring the European Congress of Trauma and Emergency Surgery (ECTES) 2015 a 20-question multiple-choice survey was conducted among the attending surgeons and residents of the hand and wrist session. Consensus was defined as more than 50 % identical answers (moderate consensus 50–75 % and high consensus more than 75 %).ResultsA total of 46 surgeons and residents participated in the survey. High consensus was found among both surgeons and residents for defining the AO/OTA classification as the preferred classification system. For the definition of an acceptable reduction, a moderate to high consensus could be determined. Overall, high consensus was found for non-operative treatment instead of operative treatment in dislocated extra- and intra-articular distal radius fractures with an acceptable closed reduction, regardless of age. We found high (surgeons) and moderate (residents) consensus on the statement that an intra-articular gap or step-off ≥2 mm, in patients younger than 65 years, is an absolute indication for ORIF. The same applied for ORIF in dislocated fractures without an acceptable closed reduction in patients younger than 75 years of age.ConclusionCurrent distal radius fracture management in Europe is characterised by a moderate to high consensus on the majority of aspects of fracture management.

Prevalence of musculoskeletal disorders among orthopedic trauma surgeons: an OTA survey

Occupational injuries and hazards have gained increased attention in the surgical community in general and in the orthopedic literature specifically. The aim of this study was to assess prevalence and characteristics of musculoskeletal disorders among orthopedic trauma surgeons and the impact of these injuries on the surgeons' practices. We sent a modified version of the physical discomfort survey to surgeon members of the Orthopaedic Trauma Association (OTA) via email. Data were collected and descriptive statistics were analyzed. A total of 86 surgeons completed the survey during the period of data collection; 84.9% were men, more than half were 45 years or older and 40.6% were in practice for 10 years or more. More than 66% of respondents reported a musculoskeletal disorder that was related to work; the most common was low back pain (29.3%). The number of body regions involved and disorders diagnosed was associated with increasing age and number of years in practice (p = 0.033). Time off work owing to these disorders was associated with working in a private setting (p = 0.045) and working in more than 1 institute (p = 0.009). To our knowledge, our study is the first to report a high percentage of orthopedic trauma surgeons sustaining occupational injuries some time in their careers. The high cost of management and rehabilitation of these injuries in addition to the related number of missed work days indicate the need for increased awareness and implementation of preventive measures.

The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures

PurposeTo determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes. MethodsSkeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts. ResultsThirty two subjects were successfully recruited (32/42 or 76%). Average age was 45±22 with average study follow up being 47±29 months. Average outcome scores were DASH 12±16, SST 10±2.7, SF-12 PCS 50±7.9, and SF-12 MCS 54±8.8. Healed sagittal plane deformity averaged 8±5.7° [range 0−18], and 15±7.9° [range 2−27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p>0.05). Patients with at least 20° (n=7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2±18.7 vs 11.7±16.1; p=0.83]; [SST (10.3±2 vs 10.0±2.9; p=0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p<0.05 for all). ConclusionResidual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.

Publication Productivity of Early-Career Orthopedic Trauma Surgeons

The goals of this study were to: (1) define the publication productivity of early-career orthopedic trauma surgeons over time; (2) compare the early-career publication productivity of recent orthopedic trauma fellowship graduates vs their more senior colleagues; and (3) determine the proportion of fellowship graduates who meet the Orthopaedic Trauma Association (OTA) publication criteria for active membership early in their careers. Orthopedic trauma fellowship graduates from 1982 to 2007 were analyzed. A literature search was performed for each fellow's publications for the 6-year period beginning the year of fellowship graduation. Publication productivity was compared between early and recent groups of graduates, 1987 to 1991 and 2003 to 2007, respectively. Fulfillment of OTA publication criteria was determined. Seventy-nine percent of graduates contributed to 1 or more publications. The recent group produced more total publications per graduate (4.06 vs 3.29, P=.01) and more coauthor publications (2.60 vs 2.04, P=.019) than the early group. The number of first-author publications did not differ between groups (1.46 vs 1.25, P=.26). A greater percentage of the recent group met current OTA publication criteria compared with the early group (51% vs 35%, P=.04). The findings showed that recent orthopedic trauma graduates had increased publication productivity compared with their more senior colleagues, although a proportion had not qualified for active OTA membership 6 years into their career. Overall, these data are encouraging and suggest that young orthopedic trauma surgeons remain committed to sustaining a high level of academic excellence.

Technical errors and complications in orthopaedic trauma surgery.

IntroductionAdverse events and associated morbidity and subsequent costs receive increasing attention in clinical practice and research. As opposed to complications, errors are not described or analysed in literature on fracture surgery. The aim of this study was to provide a description of errors and complications in relation to fracture surgery, as well as the circumstances in which they occur, for example urgency, type of surgeon, and type of fracture.MethodsAll errors and complications were recorded prospectively in our hospital’s complication registry, which forms an integral part of the electronic medical patient file. All recorded errors and complications in the complication registry linked to fracture surgery between 1 January, 2000 and 31 December, 2010 were analysed.ResultsDuring the study period 4310 osteosynthesis procedures were performed. In 78 (1.8 %) procedures an error in osteosynthesis was registered. The number of procedures in which an error occurred was significantly lower (OR = 0.53; p = 0.007) when an orthopaedic trauma surgeon was part of the operating team. Of all 3758 patients who were admitted to the surgical ward for osteosynthesis, 745 (19.8 %) had one or more postoperative complications registered. There was no significant difference in the number of postoperative complications after osteosynthesis procedures in which an orthopaedic trauma surgeon was present or absent (16.7 vs. 19.1 %; p = 0.088; OR 0.85).DiscussionIn the present study the true error rate after osteosynthesis may have been higher than the rate found. Errors that had no significant consequence may be especially susceptible to underreporting.ConclusionThe present study suggests that an osteosynthesis procedure performed by or actively assisted by an orthopaedic trauma surgeon decreases the probability of an error in osteosynthesis. Apart from errors in osteosynthesis, the involvement of an orthopaedic trauma surgeon did not lead to a significant reduction in the number of postoperative complications.

Professional Demands and Job Satisfaction in Orthopaedic Trauma: An OTA Member Survey.

The goal of this study was to examine the factors that affect career satisfaction in orthopaedic traumatologists. We hypothesize that the level of stress and career satisfaction in orthopaedic traumatology would be affected by increased number of call nights and work hours. A 30-question survey was emailed to members of the OTA. The survey evaluated 5 critical areas: training/experience, practice characteristics, demands, stress management strategies, and satisfaction. After approval by the OTA research committee, all active and associate US members of the OTA were contacted. The survey was open to the OTA members from July through November of 2012. Of 1031 members of the OTA, 263 members responded for an overall response rate of 25.5%. Most respondents were fellowship-trained (218, 82.9%) and predominantly young (<5 years in practice, 34.4%) or established surgeons (>15 years in practice, 28.5%). Most surgeons were married (229, 87.1%) and have not been divorced (226, 85.9%). Career satisfaction was statistically improved by belonging to larger practice (P = 0.016), decreased by work for more hours per week (P = 0.001), and improved by taking more call (P = 0.014). Career satisfaction among orthopaedic trauma surgeons was extremely high. Our results indicate that young surgeons may improve their job satisfaction and potentially prolong their career by limiting the numbers of hours worked, taking a consistent number of calls and joining a larger group. Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Sexual Function Is Impaired After Common Orthopaedic Nonpelvic Trauma.

The purpose of this study was to investigate the prevalence and longitudinal improvement of patient reported sexual dysfunction after 5 common nonpelvic orthopaedic traumatic conditions. Retrospective analysis of prospectively collected data. Academic Medical Center. The functional status of 1324 patients with acute proximal humerus fractures (n = 104), acute distal radius fractures (n = 396), acute tibial plateau fractures (n = 118), acute ankle fractures (n = 434), and chronic long bone fracture nonunions (n = 272) was prospectively assessed at baseline, 3, 6, and 12 months of posttreatment. Patient reported sexual dysfunction, acquired from validated functional outcomes surveys, was compared with overall patient reported functional outcome for each follow-up visit. Men and women were analyzed separately. Sexual dysfunction at the 3-month follow-up was reported in 31% of proximal humerus fracture patients, 32% of distal radius fracture patients, 47% of tibial plateau patients, 11% of ankle fracture patients, and 42% of long bone nonunions. By 1-year follow-up, greater than 80% of patients with all fracture types reported mild or no sexual dysfunction. Women reported a significantly higher degree of sexual dysfunction than men at 6 months (P = 0.003) and 12 months of follow-up (P = 0.031). After treatment of acute and chronic orthopaedic trauma conditions, a considerable number of patients experience sexual dysfunction, with women reporting more dysfunction than men. The results of this study should allow orthopaedic trauma surgeons to counsel patients regarding expectations of sexual function after traumatic orthopaedic conditions. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The callus fracture sign: a radiological predictor of progression to hypertrophic non-union in diaphyseal tibial fractures.

We report a radiological sign which predicts progression to hypertrophic non-union for fractures of the tibial diaphysis. Radiographs of 46 tibial fractures were reviewed independently by four orthopaedic trauma surgeons and two musculoskeletal radiologists. Patients were identified from a database of tibial fractures managed with Ilizarov frame fixation. There were 23 fractures that progressed to non-union requiring further surgery. The controls were 23 fractures that had united without need for further surgery at 1-year follow-up. Radiographs selected were the first images taken following frame removal. All radiographs were anonymised and randomized prior to review. Presence of the callus fracture sign was identified in 16 radiographs of the fractures that progressed to non-union, and 7 of the united fracture group. Sensitivity is 69.6 %. Specificity is 91.4 %. Positive and negative predictive values are 88.9 and 75.0 %, respectively. These results compare favourably with computerised tomography for predicting non-union. Intra- and inter-observer reliability was good (κ = 0.68), and moderate (κ = 0.57), respectively. The callus fracture sign is a useful radiological predictor of progression to non-union and may represent insufficient mechanical stability at the fracture site.

Ultrasound-assisted external fixation: a technique for austere environments

IntroductionUltrasound-assisted external fixation of long bones has the potential to enhance extremity damage control surgery in locations without fluoroscopy, such as forward surgical elements, the intensive care unit, and spacecraft....

Getting Started in Orthopaedic Trauma Research.

Incorporating research into practice as an orthopaedic trauma surgeon can be very fulfilling. There are challenges when getting started whether in a university or other practice setting. Understanding the various components of the research process is important before beginning and thereafter. This article reviews some of the issues that may be encountered and strategies to help.

Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture?

Controversy regarding heterotopic ossification (HO) prophylaxis exists after Kocher-Langenbeck for treatment of acetabular fracture. Prophylaxis options include antiinflammatory oral medications, single-dose radiation therapy, and débridement of gluteus minimus muscle. Prior literature has suggested single-dose radiation therapy as the best prophylaxis to prevent HO formation. However, recent reports have emerged of radiation-induced sarcoma after radiotherapy for HO prophylaxis, which has led many surgeons to reconsider the risks and benefits of single-dose radiation therapy. We set out to determine if radiotherapy, in addition to standard débridement of gluteus minimus muscle, affected postoperative HO formation after a Kocher-Langenbeck approach for acetabular fracture. (1) After the Kocher-Langenbeck approach and gluteus minimus débridement, is single-dose radiotherapy associated with a decreased risk of HO? (2) Does addition of single-dose radiotherapy prolong length of stay after a Kocher-Langenbeck approach and gluteus minimus débridement as compared with patients without radiotherapy? After institutional review board approval, all adult patients treated for acetabular fracture by a single surgeon with a Kocher-Langenbeck approach between August 2011 and October 2014 were identified (n = 60). Débridement of gluteus minimus muscle caudal to the superior gluteal bundle was standard in all patients. Radiotherapy was given with a single dose of 700 cGy within 72 hours of surgery from August 2011 until April 2013. Patients treated subsequently did not receive radiotherapy. Patients treated with indomethacin (n = 1) and with fewer than 10 weeks followup were excluded (n = 12) because several studies suggest that most HO that develops is visible by that point in time. Our study group totaled 46 patients with 24 in the radiotherapy and débridement group and 22 in the débridement group. Charts were reviewed to determine length of stay. Attending orthopaedic trauma surgeons who were blinded to the patient's treatment group graded all followup radiographs according to the Brooker system, and Classes III and IV HO were considered clinically important Fisher's exact test was used to analyze clinically significant differences HO between the two groups. Length of stay was compared using a t-test. Single-dose radiotherapy is associated with a decreased risk of clinically important (Brooker III-IV) HO after a Kocher-Langenbeck approach and gluteus minimus débridement (radiotherapy: one of 24 [4%], no radiotherapy: seven of 22 [32%], relative risk: 0.131 [95% confidence interval {CI}, 0.018-0.981], p = 0.020). Addition of single-dose radiotherapy did not result in increased length of stay (radiotherapy: 12 ± 7.0 days; no radiotherapy: 11 ± 7.2 days; mean difference: 1.0 [95% CI, -3.2 to 5.2] days, p = 0.635). Single-dose radiation in combination with gluteus minimus débridement decreases the risk of clinically important HO compared with gluteus minimus débridement alone after a Kocher-Langenbeck approach for acetabular fracture. No differences in length of stay were seen. Surgeons who chose not to use radiotherapy as a result of concern for future sarcoma may see higher rates of clinically significant HO after a Kocher-Langenbeck approach for acetabular fracture fixation. Level III, therapeutic study.

Venous Thromboembolism Prophylaxis in Orthopaedic Trauma Patients: A Survey of OTA Member Practice Patterns and OTA Expert Panel Recommendations.

First, to provide the readership with a summation of the current practice patterns of North American orthopaedic surgeons for venous thromboembolism prophylaxis after musculoskeletal trauma. Second, to establish a set of guidelines and recommendations based on the most current and best available evidence for venous thromboembolism (VTE) prophylaxis after musculoskeletal trauma. A 24 item questionnaire titled "OTA VTE Prophylaxis Survey" was sent to active members of the Orthopaedic Trauma Association. PubMed and OVID/MEDLINE were used to search the current published literature regarding VTE prophylaxis in trauma patients using the following search terms: deep venous thrombosis, DVT, pulmonary embolism, PE, venous thromboembolism, VTE, prophylaxis, trauma, fracture, pneumatic compression device, PCD, sequential compression device, SCD, screening, ultrasound, duplex, ultrasonography, DUS, venography, magnetic resonance venography, MRV, inferior vena cava, IVC, filter, and IVCF. Each recommendation was graded using articles that were considered by the subcommittee as "the best available evidence" using the grading system adopted and endorsed by the American Academy of Orthopedic Surgeons' Evidenced Based Quality and Value committee. Overall, 185 of 1545 members completed the online survey. The range and variety of prophylaxis and screening methods used among orthopaedic trauma surgeons in North America is large, with a number of agents or methods for which no literature exists to support their use in musculoskeletal trauma. A set of recommendations and guidelines were constructed based on the results of the literature analysis and graded according to guidelines mentioned above. Due to the wide variability in practice patterns, poor scientific support for various therapeutic regimens and important medical-legal implications highlighted by the survey, a standardized set of guidelines and recommendations for VTE prophylaxis after musculoskeletal trauma will be critical in helping to improve patient care and minimize surgeons' exposure to potentially litigious activity. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Radiographic Measurement of Rotational Deformity in Pelvic Fractures: A Novel Method With Validity and Reliability Testing.

Measuring pelvic ring displacement on plain radiographs has focused on gap and translational displacements with little discussion of rotational displacement, likely because of measurement difficulties. Our hypothesis is that rotational displacement can be accurately measured on computer-reconstructed radiographs (CRRs) with good validity and reliability. A Sawbones model was used to simulate common pelvic ring fracture patterns. CT scans were obtained and converted to CRRs simulating standard views. A technique of measuring axial rotation on the inlet view and sagittal rotation on the inlet/outlet views was developed. The novel rotational assessment techniques were then used by 8 senior orthopaedic residents and 3 fellowship-trained orthopaedic trauma surgeons on the CRR of each model. These measurements were then assessed for interobserver reliability and validity. Validity was tested by comparing the values obtained by the observers to the actual displacement as measured on CT scans. Newly described techniques for axial and sagittal rotational measurements showed excellent reliability with average confidence intervals of 1.8° and 3.4°, respectively. There was good validity of the technique, with the majority of the "true" measurements falling within the 95% confidence interval of the observer measurements. A new radiographic technique for measuring axial and sagittal rotational deformities shows excellent interobserver reliability and good validity. This technique offers a low-cost and low-radiation examination to assess this deformity, which is readily available in most clinical settings. This measurement system can be used in future clinical studies to assess the clinical implications of residual rotational displacement.

Polytrauma.

Since prehistoric times, physicians have been called upon to treat polytrauma patients. However, the demand for treatment has increased dramatically in the last 40 years, as the incidence of high velocity trauma has risen, and following the introduction of the concept of damage control. In developed countries, political decisions impacting on road safety (by measures such as motorway construction programmes and safety-oriented legislation) and on safety in the workplace have reduced the number of polytrauma deaths occurring each year. In consequence, the three main variables currently responsible for the successful outcome of many patients are rapid attention/transport from the accident site to specialised facilities, accurate diagnosis and prompt treatment. With respect to the first of these variables, medicalised transport is of the utmost importance, together with effective emergency reception at the hospital. Acute modern diagnostic tools, such as very early blood tests, contrast CT-scanning and the abdominal ultrasound protocol Echo-FAST (echo-focused abdominal sonography for trauma), together with resuscitation techniques, in particular surgical management to stop bleeding, have enabled the successful recovery of many patients who would otherwise have died. In fact, the latter positive development is associated with the increasing occurrence of certain complications such as systemic inflammatory syndrome and multiorgan failure. The infusion of fluid is based on the use of colloids, erythrocyte concentrate and plasma transfusion, and these are vital resources, but the overriding goal remains that of avoiding further blood loss. Orthopaedic trauma surgeons are aware that pelvic ring fractures must be treated immediately. In this respect, the ring must be closed to its normal diameter and long bone fractures addressed by immobilising the lower extremities, preferably with external fixation, as the first step to prevent major bleeding. This approach has been termed damage control orthopaedics, and the concept has recently been extended to the early treatment of spinal injuries. Many combinations of lesions in polytrauma patients may be encountered, and the situation is highly complex. Accordingly, the above observations provide only a general introduction. Both general and specific lesions of polytrauma patients – adult, children and elderly – are discussed in this issue of The Open Orthopaedic Journal.

Guesstimation of posterior malleolar fractures on lateral plain radiographs

BackgroundAccurate assessment of articular involvement of the posterior malleolar fracture fragments in ankle fractures is essential, as this is the leading argument for internal fixation. The purpose of this study is to assess diagnostic accuracy of measurements on plain lateral radiographs. MethodsQuantification of three-dimensional computed tomography (Q-3D-CT) was used as a reference standard for true articular involvement (mm2) of posterior malleolar fractures. One-hundred Orthopaedic Trauma surgeons were willing to review 31 trimalleolar ankle fractures to estimate size of posterior malleolus and answer: (1) what is the involved articular surface of the posterior malleolar fracture as a percentage of the tibial plafond? and (2) would you fix the posterior malleolus? ResultsThe average posterior malleolar fragment involved 13.5% (SD 10.8) of the tibial plafond articular surface, as quantified using Q-3D-CT. The average involvement of articular surface of the posterior malleolar fragment, as estimated by 100 observers on plain radiographs was 24.4% (SD 10.0). The factor 1.8 overestimation of articular involvement was statistically significant (p<0.001). Diagnostic accuracy of measurements on plain lateral radiographs was 22%. Interobserver agreement (ICC) was 0.61. Agreement on operative fixation, showed an ICC of 0.54 (Haraguchi type I=0.76, Haraguchi type II=0.40, Haraguchi type III=0.25). ConclusionsDiagnostic accuracy of measurements on plain lateral radiographs to assess articular involvement of posterior malleolar fractures is poor. There is a tendency to misjudge posteromedial involvement (Haraguchi type II).