Postreduction Imaging Research Articles

Evaluating the utility of post-reduction imaging for simple hip joint dislocations: Is computed tomography always necessary?

IntroductionFollowing closed reduction of hip dislocations, computed tomography (CT) is considered standard of care to identify occult fractures or intra-articular loose bodies that may be missed on X-ray. The purpose of this study was to evaluate the sensitivity of post-reduction X-rays and the usefulness of subsequent post-reduction CT imaging. MethodsAll patients presenting to our hospital system for traumatic hip dislocations from 2013 to 2022 were retrospectively reviewed. Participants were included if they had a simple dislocation of a native hip, underwent closed reduction, and received post-reduction X-ray and CT imaging. A sensitivity analysis was performed for the detection of associated fractures and intraarticular loose bodies by post-reduction X-ray, using CT as a reference standard. ResultsThirty-five subjects with a mean age of 26 years were included. Post-reduction CT revealed 6 fractures and 3 loose bodies, whereas post-reduction X-ray identified 3/6 (50%) fractures and 3/3 (100%) loose bodies. Four cases received operative management, all of which were identified by X-ray. Post-reduction X-ray had a sensitivity of 67% for identifying pathology that was subsequently found on CT, and a sensitivity of 100% for identifying pathology requiring surgery. Of the 13 cases with pre-reduction CT scans, none had new findings identified on post-reduction CT. ConclusionsPost-reduction X-rays are effective in the evaluation of acute pathology associated with closed reduction of traumatic hip dislocations, especially for cases requiring operative management. Our findings suggest that if a fracture or loose body was not identified on post-reduction X-ray, a post-reduction CT added no value in surgical decision-making and was not necessary.

Winter sports injuries to the elbow joint

Elbow injuries occur quite often when practicing winter sports. Due to the high sports dynamics and risk of fall the elbow joint is prone to injuries. Hereby, the most common injury is the dislocation of the elbow. Isolated ligamentous instabilities can usually be treated non-operatively when the joint is centered on post-reduction imaging. In the case of persistent symptomatic instability, secondary ligament reconstruction surgery is associated with reliable and good results. Most fractures of the elbow involve the radial head in terms of postero-lateral rotation instability, whereas distal humerus and olecranon fractures are more likely to occur in high-energy or direct trauma. Indication for surgical treatment is given according to common guidelines, including involvement of the joint line, fragment dislocation and instability with risk of secondary fracture dislocation. Minimally invasive techniques for the radial head as well as anatomic preformed locking plate systems seem to have reached a wide acceptance.

EP.FRI.34 Audit of management of shoulder dislocations against BOA Traumatic anterior shoulder instability Guidelines

Abstract Background Traumatic anterior shoulder dislocation is associated with a high risk of shoulder instability, reduced functional outcome, and recurrence. We conducted an audit to assess the direct management, review in fracture clinic, and definitive imaging of patients with anterior shoulder instability in Southport and Formby Hospital. Aim To identify compliance with the 2015 BOA Traumatic anterior shoulder instability guidelines. Method Identified all patients from 01/01/2019 to 31/12/2019 who had shoulder dislocation coded for their diagnosis. We used imaging, scanned notes, and clinic letters where available to identify the clinical information. We excluded patients with a false diagnosis code, and those with non-local post codes from the analysis. Results We identified 67 patients who had an anterior dislocation. 88% of patients had x-rays in both AP and Lateral. We identified that 8.9% of patients had pre-reduction x-rays in AP only, 11.9% had no pre-reduction x-rays, and 1.5 % had no post reduction imaging. 79% of patients were seen in clinic within 6 weeks but only 40.3% were seen by a shoulder specialist and only 43.3% had appropriate imaging. 16.4% of patients were not given fracture clinic follow up. Conclusion Although most patients were managed acutely according to the guidelines, the follow up and subsequent investigations of these patients can be improved. One method we suggest is renaming fracture clinic days from consultant names to sub-specialty clinic names. In addition, a dedicated session to review the guideline with senior orthopedic surgeons cold improve the compliance as well.

94 Audit of Management of Shoulder Dislocations Against BOA Traumatic Anterior Shoulder Instability Guidelines

Abstract Background Traumatic anterior shoulder dislocation is associated with a high risk of shoulder instability, reduced functional outcome, and recurrence. We conducted an audit to assess the direct management, review in fracture clinic, and definitive imaging of patients with anterior shoulder instability in Southport and Formby Hospital. Aim To identify compliance with the 2015 BOA Traumatic anterior shoulder instability guidelines. Method Identified all patients from 01/01/2019 to 31/12/2019 who had shoulder dislocation coded for their diagnosis. We used imaging, scanned notes, and clinic letters where available to identify the clinical information. We excluded patients with a false diagnosis code, and those with non-local post codes from the analysis. Results We identified 67 patients who had an anterior dislocation. 88% of patients had x-rays in both AP and Lateral. We identified that 8.9% of patients had pre-reduction x-rays in AP only, 11.9% had no pre-reduction x-rays, and 1.5 % had no post reduction imaging. 79% of patients were seen in clinic within 6 weeks but only 40.3% were seen by a shoulder specialist and only 43.3% had appropriate imaging. 16.4% of patients were not given fracture clinic follow up. Conclusions Although most patients were managed acutely according to the guidelines, the follow up and subsequent investigations of these patients can be improved. One method we suggest is renaming fracture clinic days from consultant names to sub-specialty clinic names. In addition, a dedicated session to review the guideline with senior orthopedic surgeons cold improve the compliance as well.

325 The Role of Point of Care Ultrasound in the Diagnosis and Management of Shoulder Dislocation

Interest in the use point-of-care ultrasound (POCUS) for diagnosis and reduction confirmation in shoulder dislocations is continually emerging. There is hesitance though because of the potential to miss humerus fractures with or without an associated shoulder dislocation. The objective of this study was to evaluate the use of POCUS in the diagnosis and management of individuals with shoulder pain where there is a clinical suspicion for shoulder dislocation and/or proximal humeral fractures. This was a retrospective chart review conducted at an academic level I trauma center with an emergency medicine (EM) residency and 64, 000 annual visits. All patients who underwent a shoulder POCUS between the dates of 07/01/2016 and 2/28/2021 were included. Data was collected from both QPath (point of care ultrasound workflow manager) and EPIC (electronic medical record software). The majority of the ultrasounds were performed by resident physicians, who had been formally trained in shoulder and musculoskeletal POCUS. Results of the shoulder ultrasounds, as documented by the performing physician, were compared against pre- and post-reduction x-rays if there was a dislocation, and against solitary x-ray if no dislocation. Emergency department (ED) patient care timelines were reviewed to determine time to pre-reduction x-ray, post-reduction x-ray, initial ultrasound and reduction ultrasound. Statistical analysis was performed to calculate sensitivity, specificity, positive predictive and negative predictive values. In total, 85 shoulder ultrasounds were performed, with 38 being on dislocated shoulders. Shoulder ultrasound showed a 97% sensitivity, 100% specificity, 100% positive predictive value, and 98% negative predictive value when evaluating for shoulder dislocation and successful post reduction. Overall, shoulder ultrasound displayed a 92% sensitivity and 100% specificity in all pathology compared with x-ray. All 8 humerus fractures seen on x-ray were identified on ultrasound. Ultrasound visualized 2 cases of bursitis, 5 cases of effusions, and 1 torn pectoral muscle not seen on x-ray. Of the 85 cases, 22 cases had missed diagnosis on ultrasound compared to x-ray with 16 Hill-Sachs lesions, 2 Bankart lesions, 2 clavicle fractures, 1 Acromioclavicular (AC) separation and 1 shoulder dislocation. Time to first x-ray and ultrasound averaged 75 and 92 minutes but was not statistically significant (p=0.15). There was a statistically significant difference in time to post reduction radiograph and ultrasound (169 vs 138 minutes, p<0.0001) Shoulder ultrasound is highly sensitive and specific in evaluating for shoulder dislocation and missed no proximal humerus fractures. Although, it may be limited in identifying other injuries such as Hill-Sachs lesions, Bankart lesions, clavicle fractures, and AC separations. In cases of shoulder dislocations, ultrasound demonstrated a statistically significant decrease in time to post reduction imaging compared to plain radiographs. This may help decease ED length of stay and improve throughput with minimal risk of missing significant injury.

197 Acute Management of Traumatic Anterior Shoulder Dislocations During COVID-19: Are We Meeting Published National Standards for Treatment During the Pandemic?

BackgroundBESS/BOA Patient Care Pathways provide national guidelines for acute management of traumatic anterior shoulder dislocations with respect to emergency reduction and clinic follow-up. COVID-19 posed challenges in terms of analgesia choice for reductions and altered follow-up arrangements. This study aimed to assess variance from the care pathway.MethodWe performed a retrospective case note analysis of all emergency presentations with acute traumatic anterior shoulder dislocations at the MTC in Bristol from 01/04/2019-31/05/2019 to the same period in 2020 to analyse the effects of COVID-19 on management of these injuries.ResultsWe identified 32 patients in 2019, and 24 in 2020. Entonox usage fell, in favour of Penthrox. Use of conscious sedation (requiring full PPE) remained around 20%. Pre- and post-reduction imaging was near 100% throughout. Referral to follow-up was 88% in 2019 but 38% in 2020. Those assessed in clinic during COVID-19, fewer were mobilised early or referred to outpatient physiotherapy compared to 2019.ConclusionsAcute management of anterior shoulder dislocations during COVID-19 was challenged by choice of suitable analgesia that limits AGPs, and limiting access to ’face-to-face’ follow-up. A key concern was a significant decrease in patient follow-up, thus limiting the access to optimal aftercare such as physiotherapy and further imaging.

Nuances of Radiographic Assessment of Distal Radius Fractures to Avoid Missed Fragments.

Distal radius fractures, like many articular and periarticular fractures, can make it difficult to determine the true number, location, and orientation of fracture fragments. This article should help the reader work through imaging interpretation starting from the initial, often displaced radiographs to postreduction imaging and determination if further 3-dimensional imaging is necessary.

Fluoroscopy as Definitive Postreduction Imaging of Pediatric Wrist and Forearm Fractures Is Safe and Saves Time

Recent studies indicate that formal postreduction radiographs may be unnecessary for closed, isolated pediatric wrist, and forearm when mini C-arm fluoroscopy is used for reduction. Our institution changed the Emergency Department (ED) management protocol to reflect this by allowing orthopaedic providers to determine if fluoroscopy was acceptable to assess fracture reduction. We hypothesized that using fluoroscopy as definitive postreduction imaging would decrease total encounter time, without an increase in the rate of rereduction or surgery. Patients with closed, isolated distal radius/distal ulna (DR/DU) or both bone forearm (BBFA) fractures that required sedation and reduction under mini C-arm fluoroscopy at our Level 1 pediatric ED were reviewed for 6 months both before and after this policy change. Before, all patients had formal postreduction radiographs; after, the decision was left to the orthopaedic physician. Timestamp data were collected, as was the need for rereduction or surgery. In addition to descriptive statistics, between-group differences were analyzed with the Student t test, χ test, and multivariable regression as appropriate. A total of 243 patients (119 before, 124 after) had 165 DR/DU and 78 BBFA fractures. Demographic data were similar before and after. After protocol implementation, univariable analysis (Student t test) showed that sedation times were longer, while total ED time and the time from sedation beginning to discharge were similar. The proportion of patients requiring rereduction or surgery were similar.After multivariable regression, "fluoroscopy as definitive imaging" was the only independent determinant of the time intervals compared with using conventional radiography. Sedation was an average of 13.8 minutes longer (P<0.001), while the interval from sedation beginning to discharge was 15.8 minutes shorter (P=0.007), and total ED time was 33.0 minutes shorter (P=0.018). Fluoroscopy as definitive imaging was not a predictor of surgery (odds ratio=0.63, P=0.520), although having a BBFA increased the likelihood (odds ratio=4.50, P=0.008). Implementing a protocol in which the provider could use mini C-arm fluoroscopy for definitive postreduction imaging did not result in increased rates remanipulation or need for surgery. Regression analysis further demonstrated time savings associated with foregoing conventional radiographs. Level III-therapeutic.

Using Fluoroscopy for Definitive Post-Reduction Imaging of Wrist and Forearm Fractures Saves Time and Is Safe

Purpose Recent studies have indicated that formal post-reduction films may be unnecessary after manipulation for closed, isolated pediatric wrist and forearm fractures when mini C-arm fluoroscopy is used for reduction. Our institution changed the Emergency Department (ED) management protocol in 2017 to reflect this. We hypothesized that using fluoroscopy as definitive post-reduction imaging would decrease total encounter time and cost, without an increase in the rate of re-reduction or surgery. Methods A retrospective chart review was performed for all patients with isolated, closed wrist or forearm fractures that required …

Using Fluoroscopy for Definitive Post-Reduction Imaging of Wrist and Forearm Fractures Saves Time and Is Safe

Using Fluoroscopy for Definitive Post-Reduction Imaging of Wrist and Forearm Fractures Saves Time and Is Safe

Outcomes After Open Reduction With Internal Fixation of Mandible Fractures.

Mandible fractures contribute substantially to morbidity after blunt trauma. Controversy exists surrounding the appropriate timing of surgical intervention and benefit from routine postreduction imaging. The authors retrospectively reviewed 146 patients who sustained traumatic mandible fractures at a level 2 trauma center over a 5-year period, between January 2012 and December 2016. The authors excluded all patients who did not undergo surgery, underwent operative closed reduction only, sustained other significant maxillofacial injuries, penetrating mechanisms, and other major injuries based on injury severity scores (ISS) over 15. There were 51 patients meeting inclusion criteria. The authors reviewed admission face computed tomography (CT) scans and Panorex x-rays. Patients were divided into early (<72 hours) and late (>72 hours) open reduction with internal fixation (ORIF) groups. The authors reviewed demographics, mechanism of injury, postreduction imaging, and ISS. All statistical analyses were performed using Stata 15. There were 39 males (76%) and 12 females (24%) in the authors' study, with a mean age of 32 years. Twenty-eight patients (55%) underwent early ORIF and 23 patients (45%) underwent late ORIF, with no mortalities. There was no statistically significant difference in ISS between the 2 groups (P = 0.081). Preoperative face CT scans were performed in 49 patients (96%) and Panorex in 2 patients (4%). Eight patients (16%) had both modalities, with CT face identifying fractures in 5 patients not seen on Panorex, resulting in a change in operative approach. Postreduction imaging was obtained in 33 patients (65%), of whom 26 were Panorex X-rays. These demonstrated adequate reduction in 31 patients (94%) and did not change management in any instance. Complications occurred in 19 patients (37%), of whom there were 11 with uncontrolled pain after 1 week, 6 abscesses, 5 nonunions/malunions, 2 hardware extrusions, and 1 incisional dehiscence. A positive urine drug screen predicted uncontrolled pain (P < 0.05). There was no statistically significant difference in complications between the 2 groups. The authors' data suggest that CT scans of the face are superior to panoramic radiographs in traumatic mandible fracture evaluation, with no apparent benefit from routine postreduction imaging in detecting complications. Open reduction with internal fixation remains an effective treatment with favorable outcomes, and operative delays > 72 hours do not appear to increase complication rates.

Utility of Post‐reduction Radiographic Analysis of Mandible Fractures

Objectives: Recognize that immediate post-reduction films: 1) Have a significant associated cost; 2) Do not alter management. Methods: A retrospective review of the medical record was performed on patients with mandible fractures operated on by the otolaryngology-head and neck surgery service between November 1, 2010, and November 30, 2012, at a level 1 county hospital. The post-operative imaging modalities were determined as well as if any changes in care were initiated by that image. Those patients who did have repeat imaging were evaluated to determine what led to the second image and what action was taken. Results: Fifty-seven patients met inclusion criteria. Fifty-five patients (96.5%) had a post-reduction image with 45 (79.0%) having a computed tomography (CT; $1,965) and 10 (17.5%) having a Panorex ($282). No immediate intervention was performed. Eleven patients (19.3%) had a second post-operative image with 4 (36.4%) receiving at least 1 panorex and 8 (72.7%) receiving at least one CT. Of these 11 patients, 8 (72.7%) underwent an intervention based on the imaging. Analysis showed imaging significantly affected the management of the second group of 11 but did not affect the first group of 55 (p=0.0000). Conclusions: In this study, 96.5% of patients received postoperative imaging at a cost of $91,245 with no change in management. This supports the conclusion that routine post-reduction imaging does not alter the immediate clinical course and should be reserved for those patients who have a postoperative clinical finding or complaint.

Paramedic-Performed Digital Nerve Block To Facilitate Field Reduction Of A Dislocated Finger

ABSTRACTThis short report describes the use of digital nerve block by a paramedic to facilitate the reduction of a dislocated finger in the prehospital setting. The finger was successfully reduced at the scene without requiring administration of parenteral opioids. The patient was reluctant to visit an emergency department, but was able to be referred to a local primary care practice for postreduction imaging and further care. Paramedic-performed local and regional anesthesia has not been previously described in the emergency medicine or emergency medical services literature. With appropriate training, prehospital digital nerve blocks may be a feasible option to supplement existing paramedic analgesic options.

Intraosseous Median Nerve Entrapment Following Pediatric Posterior Elbow Dislocation

Intra-articular entrapment of the median nerve following reduction of a pediatric posterior elbow dislocation is a rare complication but has been reported in the literature.This article describes a case of a 7-year-old girl who sustained a posterior elbow dislocation associated with a medial epicondyle fracture and the subsequent intraosseous entrapment of her median nerve. The entrapment is believed to have resulted from new bone formation over the nerve that went unrecognized for nearly 2 years following injury. Routine imaging studies failed to detect the entrapment prior to exploratory surgery. Intra-articular entrapment of the median nerve must be suspected following pediatric elbow dislocation when concentric reduction fails, postreduction images demonstrate joint widening, or the patient has persistent clinical symptoms. This case demonstrates the potential for delay in diagnosis of the cause for neurological impairment following a relatively common injury in the pediatric population.Objective intraoperative findings and intraoperative micropathology aided in limiting the amount of nerve resected to nonviable portions. Our case demonstrates the potential use of a cable nerve graft to bridge segmental defects in peripheral nerves.

Assessment of the Adequacy of Closed Reduction in Fractures of the Zygomatic Arch Using "C"-Arm Image Intensifier

Major problems in closed reduction of isolated, minimally displaced, and depressed zygomatic arch fractures are blind nature of the technique, reliability on digital palpation, reduction click, and step deformity between fragments. The purpose of this study was to objectively confirm the adequacy of closed reduction intraoperatively and the usefulness of the "C"-arm image intensifier. A total of 12 patients with 1- to 8-day-old unilateral isolated and depressed zygomatic arch fracture underwent closed reduction under "C"-arm image intensifier. Of these patients, 9 were men and 3 were women, with age ranging from 18 to 32 years. Intraoperative prereduction and postreduction images were obtained using the "C"-arm image intensifier. Criteria for adequate reduction were the following: intrafragmentary gap less than 0.5 mm, no overriding of fragments, no depression of fragments, and no step deformity. After being clinically satisfied about the reduction, images on "C"-arm showed no intrafragmentary gap. In 3 patients, there were residual overriding and minimal rotation around the anteroposterior axis of the posterior fragment. In 1 patient, rotation and step deformity remained. In this patient, additional stabilization was provided. The "C"-arm image intensifier shows some poorly reduced or unstable isolated depressed zygomatic arch fractures that remain unidentified even after careful palpation. Thus, it plays a recognizable role to avoid the trouble of second intervention.

Abstract P6-03-02: Breast Reduction Mammoplasty and Incidence of Occult Carcinoma. A 10 Year Experience

Abstract Background: The aim of this study was to report the incidence of cancer in reduction mammoplasty specimens and suggest alternative pragmatic cost-effective way of identifying and treating patients with carcinoma. Methods: All patients who underwent breast reduction surgery at Northern General Hospital over a 10-year period were identified from a prospective database. The histopathology reports and case records of all patients with significant abnormalities were analysed. All breast reduction specimens were sliced at 1 cm intervals and examined macroscopically. At least 3 blocks per breast were examined microscopically in addition to sampling of any grossly abnormal tissue. Results: Between October 1999 and April 2010, 1,588 patients underwent reduction mammoplasty. The median age of patients was 38 years (range 16-75 years). Indications for surgery were macromastia in 1,194 (75.2%), congenital asymmetry in 182 (11.5%) and contralateral symmetry procedure post breast cancer surgery in 178 (11.2%). 9 specimens showed atypical hyperplasia (0.57%). 5 cancers were detected (0.31%). 4 of the 5 patients had normal mammograms 1-3 years before the reduction operation (not done in 1). Of these cancers, 4 were invasive (3 invasive lobular, 1 invasive ductal) (0.25%) (mean invasive tumour size 9 mm (SD 7.4)) and 1 was DCIS (4mm) (0.06%). A lump was felt macroscopically by the pathologist in 2 of the 4 patients with invasive cancer. The median age of patients with invasive cancer was 56 years (range 47-68 years). Patient found to have DCIS did not undergo further surgery while those with invasive disease underwent mastectomy (3) and axillary nodal staging (4). None of the patients with benign/normal post-reduction breast imaging had residual breast cancer on histology. Conclusion: The incidence of occult carcinoma in reduction mammoplasty specimens is less than 0.5%. Pre-operative mammogram is not useful as 4 of the 5 patients with cancer had a normal mammogram 1-3 years before surgery and invasive lobular cancers are often not detected on mammogram. Mastectomy may be avoided in patients with no residual breast disease on post-reduction imaging. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-03-02.

Can portable bedside fluoroscopy replace standard, postreduction radiographs in the management of pediatric fractures?

To determine the accuracy of portable bedside fluoroscopy in documenting postreduction fracture alignment in the pediatric emergency department (ED). Prospective trial in an urban pediatric ED. Convenience sample of 80 pediatric patients requiring ED reduction of isolated long bone fractures. Patients who underwent closed fracture reduction using portable fluoroscopic guidance (FluoroScan) in the ED were enrolled in the study. Postreduction images were obtained using both bedside fluoroscopy and conventional radiographs. A pediatric orthopedic subspecialist, blinded to clinical outcome, reviewed the fluoroscopic and radiographic images for adequacy of alignment and rated the utility of conventional radiography for fracture management. The patients were 2.5 to 16 years of age (mean 8.3). Distal radial and radioulnar fractures comprised 96% (76/80) of cases. Sixty-three percent of the fractures were displaced, and the mean angulation of the primary fracture site was 24 degrees . Fluoroscopy was found to be 100% sensitive (75/75 cases) and 100% specific (5/5 cases) in predicting postreduction fracture position when compared to conventional radiographs. Intra-rater observer agreement on the necessity of conventional postreduction radiographs was 0.92 (95% CI 0.82-1.00) using the kappa coefficient. In no case did postreduction radiographs alter acute fracture management. Bedside fluoroscopy with printed fluoroscopic images are highly reliable in evaluating fracture reduction and can replace conventional radiography in documenting adequate distal forearm fracture reduction when there is no intraarticular involvement.