Result Of High-energy Mechanisms Research Articles

Early Definitive Fixation of Talus Fractures Is Safe: A Retrospective Review

Background Talus fractures are often result of high energy mechanisms and can lead to devastating complications. Treatment is often operative; however, the appropriate timing of this has been debated. The purpose of this study is to determine the efficacy and safety of the early treatment of talus fractures. Methods Patients aged 18 years or older who underwent definitive operative stabilization of their talus fracture at a single urban level 1 trauma center were retrospectively reviewed. Patients were split into 2 groups based on their time to definitive fixation: ≤ or >24 hours. Pertinent demographic, surgical, and follow-up data were collected and analyzed. Results A total of 108 fractures were treated with 65 in the ≤24 hours fixation group and 43 in the >24 hours fixation group. Fractures involving the talar neck were the most commonly treated fracture pattern followed by the body and the head. There was no difference between the 2 groups in length to full weight bearing, union, or time to union. Open fracture was found to be the only significant risk factor for nonunion in both groups. There was no significant difference in infection or arthrodesis rates between the 2 groups. Conclusion Definitive treatment of talus fractures within 24 hours from presentation is both safe and effective with equal outcomes and without increased complications when compared with those injuries that undergo delayed or staged definitive fixation. Level of Evidence: Level III

Talonavicular Dislocations: A Bad Actor Made Worse Without Sufficient Fixation

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: The talonavicular joint (TNJ) is critical to midfoot architecture, and traumatic disruptions of this joint threaten the midfoot arch. We sought to better elucidate injuries to the TNJ and understand if transient methods of stabilization after TN dislocations (TNDs), such as closed/open reduction with or without percutaneous pinning resulted in different radiographic and clinical outcomes when compared to more permanent methods such as bridge plating or primary arthrodesis of the TNJ. Methods: We retrospectively identified skeletally mature patients from one tertiary level 1 trauma center treated for midfoot injuries between 2002-2022. Patients with isolated or concomitant TNDs were included. Demographics, treatment, radiographic outcomes, and patient reported outcomes (PROs) were recorded. Patients who underwent temporary fixation methods (closed/open reduction and trans-articular pinning with k-wire removal at 6-8 weeks) were compared to those with permanent fixation (bridge plating or primary arthrodesis). Primary outcome was reoperation, including fusions and amputations. Secondary outcomes were radiographic arch measurements (Meary’s angle [MA], calcaneal inclination angle [CIA]) and PROMIS measures of physical function, pain interference, and anxiety. Sixty-two patients and 66 feet were included (Table 1). Average follow up was 2 years. Results: TNDs manifested as both pure dislocations (18) and in conjunction with associated injuries: chopart dislocations (5), talar head/body fractures (23), navicular fractures (35), and subtalar dislocations (25). Twelve were a part of Hawkins IV talar neck fracture dislocations (18%). Forty-two patients were treated with temporary fixation (64%). Injuries treated with transient fixation had higher mean change in MA from immediately postop to final follow-up (-7.9° v -1.1°, p=0.006). They also exhibited significantly different MA and CIA values at final follow-up (7.8° v -1.4°; 17.3° v 21.3°, p< 0.03). Nearly two thirds required reoperation; 32% underwent fusion and 7% required amputation. Fixation method had no significant association with PROMIS scores, but those with temporary fixation methods trended toward lower final PF scores (34.9 v 41.1, p=0.11). Conclusion: TNDs are generally the result of high energy mechanisms, often occurring in combination with other significant mid/hindfoot injuries. Reduction and fixation method of these injuries should be carefully considered to avoid potential ramifications of loss of normal arch and midfoot sag.

Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius.

Background Ipsilateral fractures of the distal radius and scaphoid are rare, with few reports describing mechanisms of injury, fracture patterns, and treatment approaches. Purpose This article describes the clinical and radiographic features of ipsilateral distal radius and scaphoid fractures occurring simultaneously. Materials and Methods Electronic databases from 2007 to 2017 at a single Level 1 trauma center were reviewed for patients with concurrent fractures of the distal radius and scaphoid. Patient demographics, injury mechanism, scaphoid and distal radius fracture pattern, treatment approach, and radiographic healing were studied. Results Twenty-three patients were identified. Nineteen of the 23 (83%) were males, and 19 of 23 (83%) of the injury mechanisms were considered high energy. Twenty-two of the 23 (96%) scaphoid fractures were nondisplaced, all treated with screw fixation. Most distal radius fractures were displaced and comminuted, 17 of 23 (74%) were intra-articular. All distal radius fractures were treated surgically with internal and/or external fixation. Three patients were lost to follow-up. Average follow-up of the remaining 20 was to 19.8 weeks. Nineteen of the 20 (95%) scaphoids healed, one scaphoid went on to nonunion with avascular necrosis. All 20 radius fractures healed, 16 of 20 (80%) in anatomic alignment. Conclusion Ipsilateral fractures of the distal radius and scaphoid are rare and are usually result of high-energy mechanisms. The scaphoid fracture is usually a nondisplaced fracture at the waist. The distal radius fracture pattern varies but most are displaced and comminuted. The union rate of the scaphoid is high, even if subjected to radiocarpal distraction required for distal radius management. Level of Evidence Therapeutic level IV study.

Open Calcaneus Fractures and Associated Injuries

Open calcaneus fractures are usually the result of high-energy mechanisms and are associated with other orthopedic and whole body system injures. Understanding the difference between open versus closed fractures is essential for the provider, and they must be vigilant for the associated injuries that present with this condition. We performed a retrospective medical record review of 62 patients (64 calcaneus fractures) with open calcaneus fractures from January 2003 to January 2013 presenting at a level 1 trauma center. Sex, age, laterality, mechanism of injury, wound appearance, initial management, and associated injures were recorded. The most common mechanisms were motor vehicle accidents (35 [56.4%]) and falls from >6 ft (15 [24.1%]). Four (6.4%) patients had a posterior tibial artery transection. Eight (12.9%) patients had a femoral shaft fracture, 14 (22.5%) an ipsilateral ankle fracture, 16 (25.8%) a metatarsal fracture, and 11 (17.7%) had associated midfoot fractures. Of the midfoot fractures, 12 (19.3%) patients had a talus fracture and 5 (8.0%) a cuboid fracture. Spinal fractures were present in 9 (14.5%) of the patients, with lumbar fractures occurring in 6 (9.6%) patients. Fifteen (24.1%) patients had associated upper extremity fractures. Thirteen (20.9%) patients had an associated pulmonary injury, including 8 pneumothoraces. Ten (16.1%) patients had a closed head injury and 6 (9.6%) had an abdominal injury. Fifteen (23.4%) patients were treated with percutaneous wire fixation and 7 (10.9%) with open reduction internal fixation. A total of 44 (68.7%) fractures were treated without internal fixation. Overall, 5 (8.0%) patients with an open calcaneus fracture eventually underwent a below-the-knee amputation. Open calcaneus fractures are severe, high-energy injuries with the potential for considerable morbidity to the patient, given the high rate of concomitant orthopedic and whole body system injuries. Type III open injuries have an increased risk of requiring subsequent amputation. The management of these injuries should include intravenous antibiotics, tetanus prophylaxis, and urgent debridement and irrigation.

Functional outcomes of operative fixation of clavicle fractures in patients with floating shoulder girdle injuries.

BackgroundDouble disruptions of the superior suspensory shoulder complex, commonly referred to as ‘floating shoulder’ injuries, are ipsilateral midshaft clavicular and scapular neck/body fractures with a loss of bony attachment of the glenoid. The treatment of ‘floating shoulder’ injuries has been debated controversially for many years. The purpose of this study was to demonstrate the clinical and functional outcomes of patients with ‘floating shoulder’ injuries who underwent operative fixation of the clavicle fracture only.Materials and methodsBetween 2002 and 2010, 32 consecutive floating shoulder injuries were identified in skeletally mature patients at a level I trauma center and followed in a single private practice. Thirteen patients met the inclusion and exclusion criteria for this retrospective study with a minimum 12-month follow-up. Clavicle and scapular fractures were identified by Current Procedural Technology codes and classified based on Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen criteria. ‘Floating shoulder’ injuries were surgically managed with only clavicular reduction and fixation utilizing modern plating techniques. Nonunion, malunion, implant removal, range of motion, need for secondary surgery, pain according to the visual analog scale (VAS), and return to work were measured.ResultsAll injuries were the result of high-energy mechanisms. Fracture union of the clavicle was seen after initial surgical fixation in the majority of patients (12; 92.3 %). Final pain was reported as minimal (11 cases; 1–3 VAS), moderate (1 case; 4–6 VAS), and high (1 case; 7–10 VAS) at last follow-up. Excellent range of motion (180° forward flexion and abduction) was observed in the majority of patients (8; 61.5 %). The Herscovici score was 12.9 (range 10–15) at 3 months. Unplanned surgeries included two clavicular implant removals and one nonunion revision. None of the patients required reconstruction for scapula malunion after nonoperative management. Twelve patients returned to previous work without restrictions.Conclusions‘Floating shoulder’ injuries with only clavicular fixation return to function despite persistent scapular deformity and some residual pain.Level of evidence Level IV.

Spinopelvic Fixation in Complex Sacral Fractures.

Vertically unstable and complex bilateral sacral fractures are a result of high-energy mechanisms that are often associated with other injuries1-19. Vertically unstable sacral fractures result in the separation of the hemipelvis from the lumbar spine, whereas complex bilateral fractures result in a complete dissociation of the appendicular and axial skeleton. Recently, the surgical treatment algorithm for these fractures has changed, with an increasing number of surgeons advocating for the use of spinopelvic fixation or triangular osteosynthesis, a combination of spinopelvic fixation along with sacroiliac or transsacral screw fixation, to increase the stability of the construct and to allow for early weight-bearing with decreased concern for secondary displacement1-19. ### Osseous and Ligamentous Anatomy The sacrum is a rhomboid-shaped bone consisting of five fused segments that is the lowest functional section of the spinal column and acts as the keystone of the pelvic ring20. When force enters the sacrum, it propagates laterally across the sacroiliac joints into the pelvis. Because of the shape of the sacrum and the orientation of the sacroiliac joints, axial forces stabilize the sacroiliac articulation in the pelvic outlet plane; however, in the pelvic inlet plane, the osseous configuration lacks inherent stability. The interosseous ligaments and posterior sacroiliac ligaments provide the majority of the intrinsic stability. Comparatively, the sacrospinous and sacrotuberous ligaments provide the extrinsic stability21. The osseous architecture of the sacrum can be …

Combined acetabulum and pelvic ring injuries.

Combined fractures of the acetabulum and pelvic ring are more common than previously believed, with an incidence as high as 15.7%. Recent series that include combined injuries indicate that the incidence of lateral compression and anteroposterior compression pelvic ring injuries is similar and that transverse and both-column acetabular fractures are the most common acetabular fracture patterns. Combined injuries most often are the result of high-energy mechanisms, and, compared with patients who present with isolated pelvic or acetabular injury, patients with combined injury typically have higher injury severity scores, higher transfusion requirements, and lower systolic blood pressure, with reported mortality rates of 1.5% to 13%. Treatment requires a multidisciplinary approach. The first priority is resuscitation following the Advanced Trauma Life Support protocols. Once the patient is stable, acetabular fractures and pelvic ring injuries should be assessed individually, and the most appropriate treatment for each should be outlined. These treatments should then be integrated to develop the most appropriate overall treatment strategy. Although outcomes data are available for isolated acetabulum and pelvic ring disruptions, no such data currently exist for combined injuries.

Intracranial injuries after accidental head trauma in children under 3 years of age

Summary Aim A retrospective study of common points found between the circumstances of occurrence and the presence of intracranial injuries in accidental head trauma for children under 3 years of age. Methodology All these children hospitalized at Angers University Hospital between 2002 and 2010 recovering from head trauma reported as accidental, having undergone a cerebral CT-scan were included. Conditions of occurrence were classified according to their mechanism. Cutaneous signs and fundus results were sought in medical files. Brain scans were reinterpreted according to a pre-determined grid. Results Thirty-four files were included. The occurrence mechanism was high energy in 20 cases, including six domestic accidents. Cutaneous signs were only observed in 17 files. The intracranial injuries identified comprised 16 parenchymal contusions of which eight with subdural hematomas, two isolated subdural hematomas, six epidural hematomas, and two subarachnoid hemorrhages. Subdural hematomas and complex bone fractures were always the result of high-energy mechanisms even when the accidents were domestic, while epidural hematomas could occur when accidents were low-energy. Conclusion Subdural hematomas are always the result of high-energy mechanisms, as are complex fractures. This concept is important when a variation exists between a traumatic mechanism reported as apparently benign and severe injuries. Effects on soft tissue are insufficiently described where they show evidence of a direct shock. These items highlight the importance of comparing the anamnestic record with clinical and radiological items, and to include expert appraisals from forensic examiners in order to prevent a failure to recognize a suspected abusive situation.

Rationale and Treatment of Multiple-Ligament Injured Knees: The Seattle Perspective

The senior author (CJW) is the primary surgeon for the management of multiple-ligament knee injuries at Harborview Medical Center and the University of Washington. These injuries are usually the result of high-energy mechanisms, and the patients often have multiple other injuries and difficult social situations. The workup of these patients is very important and involves coordination of multiple services, including the orthopedic traumatologists, general surgeons, and vascular specialists. Surgical management revolves around a few basic principles including early motion of the knee, early surgical reconstruction if possible, and reconstruction of the central pivot as well as the medial and lateral structures during a single procedure. The detailed steps of the workup and surgical management are detailed in this article. We also discuss surgical consideration as related to concomitant injuries and our rehabilitation protocol.