Specific Fracture Patterns Research Articles

Omega plate for the treatment of acetabular fractures involving the quadrilateral plate.

This retrospective study aimed to assess the outcome of a modified Stoppa approach using an anatomically precontoured plate for the treatment of acetabular fractures. In total, 30 patients (mean age 50.3 years; 25 men and 5 women) with acetabular fractures were treated between January 1, 2018 and December 31, 2019. In all 30 cases, fracture reduction was performed through a modified Stoppa approach and fixed with the omega plate. In specific fracture patterns, additional approaches were needed (lateral window in 4 cases and posterior Kocher-Langenbeck approach in 7 cases). Patients were assessed for restoration of the hip joint congruency, complications, and overall fracture reduction. Quality of reduction was categorized based on Matta's radiological principles and to assess functional outcome the Merle d'Aubigné-Postel and Harris hip score was used. The average anesthesia time was 253.6 min, the mean intraoperative blood lost was 266.6 ml and the mean intraoperative fluoroscopy dose was 3.21 mGy. According to Matta criteria for reduction quality, anatomical reduction was recorded in 22 cases, imperfect reduction in 6 cases and 2 cases had poor reduction. The average follow-up was 22.5 months. Malunion, loss of reduction or implant loosening were not recorded. Late complications included one case of avascular necrosis of the femoral head and post-traumatic arthritis changes in 5 cases. At the final follow-up, a mean Merle d'Aubigné-Postel score of 13.26±4.46 and a mean Harris score of 86.03±13.37 were recorded. The possibility of an anatomically precontoured plate with subsequent lower operative time combined with stable fixation of the primary acetabular fracture fragments and the quadrilateral plate makes the omega plate a viable option for treating acetabular fractures with a very low complication rate and good to excellent results in 89% of the cases.

Current Management of Femoral Neck Fractures (Literature Review)

Summary. Femoral neck fractures are a commonly encountered injury in orthopedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. The use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help choosing appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in their management.

Load to Failure of the Ankle Joint Complex After Fusion of the Subtalar and Talonavicular Joints: A Cadaveric Study

Recent literature has proposed that restriction of joints in the rearfoot secondary to coalitions may lead to increased risk for severe ankle fracture after trauma. There is a paucity of literature regarding the rigidity of the ankle joint after arthrodesis of the subtalar and talonavicular joints. In this study, load-to-failure testing of cadaveric ankle joints with and without fusion of the subtalar and talonavicular joints was performed to determine if clinically relevant fracture patterns could be reproduced. Of the 3 fixation patterns studied, combined subtalar and talonavicular joint fusion resulted in a measurable increase in joint stiffness; however, this was not statistically significant. Clinical and radiographic examination postloading revealed that all tested ankle joints sustained a dislocation type injury rather than a specific bone fracture pattern. It was determined that a pure low-speed bending and compression model does not produce clinically relevant fracture patterns, and that higher energy mechanisms are required.

Plate Fixation of Distal Radius Fractures: What Type of Plate to Use and When?

There are several options for plate fixation of distal radius fractures. Volar plating has broad applicability and consistent outcomes, and thus is the most commonly used plate type. Dorsal plates are advantageous for specific fracture patterns, and can provide direct fracture reduction and buttressing, but may be prominent and can cause tendon irritation. Bridge plates offer an alternative to external fixation while avoiding the complications with prominent hardware, because they span highly comminuted fractures and can be used for immediate weight bearing; however, they require plate removal. Choice of plate fixation should depend on fracture type, patient factors, and surgeon experience.

Inferior Outcome after Unstable Trochanteric Fracture Patterns Compared to Stable Fractures in the Elderly

Background: Various risk factors affecting outcome of elderly patients after proximal femur fracture have been identified. The present study aims to evaluate the impact of the fracture pattern in trochanteric fractures on postoperative mobility and complications. Methods: Ninety-two patients with a mean age of 84 years were included. According to the revised AO/OTA classification, fractures were divided into stable (AO 31A1) and unstable (AO 31A2/3) patterns. A follow-up examination was performed 12 months after cephalomedullary fixation to assess outcome parameters for mobility/activities of daily living (Parker Mobility Score (PMS)/Barthel Index (BI)) and complications (increase in requirement of care, hospital readmission, mortality rate). Results: At follow-up, patients with unstable trochanteric fracture patterns presented with lower PMS and BI compared to stable fractures (p < 0.05). Further, higher requirement of care and higher readmission rates compared to stable patterns were observed. Conclusion: Unstable trochanteric fractures presented inferior outcome compared to simple fracture patterns. This might be explained by the increasing surgical trauma in unstable fractures as well as by the mechanical impact of the lesser trochanter, which provides medial femoral support and is of functional relevance. Subsequent studies should assess if treatment strategies adapted to the specific fracture pattern (refixation of lesser trochanter) influence outcome in unstable trochanteric fractures.

Fracture-Hit Detection Using LF-DAS Signals Measured during Multifracture Propagation in Unconventional Reservoirs

SummaryLow-frequency distributed acoustic sensing (LF-DAS) data are a powerful attribute to detect fracture hits and characterize fracture geometry during multistage hydraulic fracturing treatments in unconventional reservoirs. The DAS data in low-frequency bands linearly correlate with strain and strain rate induced by dynamic fracture propagation. Due to the complexity of multiple-fracture propagation in unconventional reservoirs, the measured signals from different wells exhibit various characteristics. Mechanisms causing the differences are not well understood, which makes the interpretation of real LF-DAS data and detection of fracture hits very challenging. Hence, it is necessary to relate the observed strain/strain-rate signatures to specific fracture patterns based on the physical model of rock deformation during fracture propagation and to quantitatively characterize signatures surrounding fracture hits. In this study, we have applied our in-house fracture propagation model to simulate simultaneous multiple-fracture propagation as well as fracture-induced strain and strain-rate responses along an offset monitor well. Then a general guideline for fracture-hit detection is proposed based on quantitative analysis of strain/strain-rate responses during multiple-fracture propagation. Finally, a set of field examples are presented to demonstrate the potential of LF-DAS data on hydraulic fracturing monitoring.During multiple-fracture propagation, a “heart-shaped” zone with positive strain rates may be identified for each fracture before the fracture hit. Immediately after the fracture encounters the monitor well, part of the fiber within the fracture path keeps being extended, while the fiber sections off the path become compressed. Three 1D features along the channel (location) axis are designed to detect fracture hits. The features are maximum strain rate, the summation of strain rates, and summation of strain-rate amplitudes. Channels with fracture hits usually exhibit significant peak values of the three features. However, the characteristic signatures can be less detectable when the gauge length is close to the cluster spacing. Connections between fracture-hit locations and cluster perforations clearly reflect the fracture propagation direction. The field examples illustrate the complexity of real LF-DAS signals and demonstrate the adequacy of the proposed guideline for fracture-hit detection with multicluster completion. The fractures propagate nearly perpendicular to the horizontal wellbore in this unconventional shale formation. In addition, four to five fractures out of eight perforation clusters can propagate 396.24 m (1,300 ft) and hit the monitor well, and the “heel-biased” fracture pattern is observed (fractures that do not hit the monitor well are usually close to the toe side). Fracturing fluid leaking off into the previous stage can also be diagnosed, which could negatively affect the completion efficiency.

Usefulness of prophylactic antibiotics in preventing infection after internal fixation of closed hand fractures

Prophylactic antibiotics (PA) have been shown to be ineffective in reducing the incidence of surgical site infection (SSI) in clean wounds associated with elective surgery of the hand. Routine administration of PA for internal fixation of hand fractures is a subject that has been scarcely studied. We hypothesized that PA do not reduce SSI incidence in fixation of closed hand fractures. We did a retrospective comparative study in patients who underwent open or closed reduction and internal fixation of a hand and carpus fracture. Patient demographics, past medical history, fracture characteristics and the type of internal fixation used were extracted from our electronic archives. Follow-up period lasted for 1 year, during which any form of clinically evident SSI, such as pus formation, wound dehiscence and positive bacterial culture was documented. A total of 107 patients met the inclusion criteria, 63 in the control group and 44 in the test group. The overall infection rate was 6.5%. All infections (3 in the control group and 4 in the test group) were pin-tract infections that resolved completely after pin extraction. Our study did not find significant differences between groups (P = 0.442). No specific fracture pattern was associated with increased total infection rate (p = 0.898). In this study, we found no support for routine administration of PA prior to internal fixation of closed fractures of the hand and carpus. PA should still be administered in selected patients, such as those with decreased immunity or open fractures. Further large-scale research is needed to establish proper guidelines, to reduce the adverse effects of antibiotic treatment.

Buckled, bent or broken? A guide to paediatric forearm fractures.

The radius and ulna are the most commonly fractured long bones in the school-aged population, accounting for 40% of all fractures. Management of individual fractures depends on the fracture pattern and age of the child. The aim of this article is to provide an overview of the management concepts for specific fracture patterns and support general practitioners to confidently manage these fractures and refer to orthopaedic services when required. Orthopaedic advice and/or referral are recommended for unstable fracture types (greenstick and complete fractures), particularly in older children where remodelling potential is minimal. Early referral for growth plate injuries and suspected Monteggia and Galeazzi injuries is warranted to minimise long term complications.

Interfacility Transfers for Isolated Craniomaxillofacial Trauma: Perspectives of the Facial Trauma Surgeon.

Secondary overtriage is a burden to the medical system. Unnecessary transfers overload trauma centers, occupy emergency transfer resources, and delay definitive patient care. Craniomaxillofacial (CMF) trauma, especially in isolation, is a frequent culprit. The aim of this study is to assess the perspectives of facial trauma surgeons regarding the interfacility transfer of patients with isolated CMF trauma. A 31-item survey was developed using Likert-type scale and open-ended response systems. Internal consistency testing among facial trauma surgeons yielded a Cronbach's α calculation of .75. The survey was distributed anonymously to the American Society of Maxillofacial Surgeons, the North American Division of AO Craniomaxillofacial, and the American Academy of Facial Plastic and Reconstructive Surgery. Statistical significance in response plurality was determined by nonoverlapping 99.9% confidence intervals (P < .001). Sum totals were reported as means with standard deviations and z scores with P values of less than .05 considered significant. The survey yielded 196 responses. Seventy-seven percent of respondents did not believe that most isolated CMF transfers required emergency surgery and roughly half (49%) thought that most emergency transfers were unnecessary. Fifty-four percent of respondents agreed that most patients transferred could have been referred for outpatient management and 87% thought that transfer guidelines could help decrease unnecessary transfers. Twenty-seven percent of respondents had no pre-transfer communication with the referring facility. Perspectives on the transfer of specific fracture patterns and their presentations were also collected. Most facial trauma surgeons in this study believe that emergent transfer for isolated CMF trauma is frequently unnecessary. Such injuries rarely require emergent surgery and can frequently be managed in the outpatient setting without activating emergency transfer services. The fracture-specific data collected are a representation of the national, multidisciplinary opinion of facial trauma surgeons and correlate with previously published data on which specific types of facial fractures are most often transferred unnecessarily. The results of this study can serve as the foundation for interfacility transfer guidelines, which may provide a valuable resource in triaging transfers and decreasing associated health-care costs.

Functional outcome of supracondylar humerus fracture in children with the use of pin configuration as per Bahk classification

IntroductionA variety of fracture patterns are seen in supracondylar humerus fractures in children and these are well described by Bahk et al. Currently followed treatment protocol doesn’t recognize these common fracture patterns and pin placement is done at the discretion of the treating surgeon. The aim of the study is to evaluate the usefulness of Bahk classification system in deciding the pin configuration for the specific fracture patterns and thereby assess the functional outcome in the management of supracondylar fractures in children. MethodThe study was done on 100 children of 2–12 years of age from February 2019 to January 2020. After closed reduction under general anesthesia, fractures were classified and pin configuration was decided according to Bahk classification. In the follow-up, patients were assessed for clinicoradiological outcomes based on Modified Flynn’s criteria, Baumann angle, and anterior humeral line. ResultsIn our study Typical transverse and low sagittal fracture were the most common fracture patterns. In the final follow up as per Flynn’s criteria, 93% of the patients showed excellent results. Mean Baumann’s angle was not significantly different from the uninjured side and anterior humeral line passed through anterior or middle third of the capitulum in 95% patients. ConclusionUsing pin configuration suitable to fracture pattern as per Bahk classification improves functional outcome in supracondylar humerus fractures in children and minimizes complications.

Outcome and complications of distal tibia fractures treated with intramedullary nails versus minimally invasive plate osteosynthesis and the role of fibula fixation.

Distal tibia fractures have been managed conservatively as well surgically. A large number of implants have been used for surgical management of these fractures. No treatment method or implant has been proven to be superior to others. In this prospective comparative study, the complications and outcome of distal tibia fractures managed with intramedullary nails and minimally invasive plate osteosynthesis has been compared. Further, the role of fibula fixation in these fractures has been evaluated. One hundred and fifty-four patients of distal tibia fractures with concomitant fibula fractures were randomized into 4 treatment groups based on predetermined inclusion criteria. Functional outcome in these groups was compared based on AOFAS score at 1year. Intra-operative, post-operative parameters as well as radiological alignment, complications and the need for reoperation were also compared in these groups. The functional outcome in all four treatment groups was similar. The duration of surgery and radiation exposure was higher with minimally invasive plate osteosynthesis. There was no improvement in outcome with plating of fibula. However, fixation of fibula improved the rotational alignment in distal tibia fractures. Although there is no difference in outcome of distal tibia fractures with either nailing or minimally invasive plating, nailing is recommended for closed displaced extraarticular fractures. Fixation of fibula should not be done routinely but should be reserved only for a few specific fracture patterns.

Do 3-D Printed Handheld Models Improve Surgeon Reliability for Recognition of Intraarticular Distal Radius Fracture Characteristics?

For fracture care, radiographs and two-dimensional (2-D) and three-dimensional (3-D) CT are primarily used for preoperative planning and postoperative evaluation. Intraarticular distal radius fractures are technically challenging to treat, and meticulous preoperative planning is paramount to improve the patient's outcome. Three-dimensionally printed handheld models might improve the surgeon's interpretation of specific fracture characteristics and patterns preoperatively and could therefore be clinically valuable; however, the additional value of 3-D printed handheld models for fractures of the distal radius, a high-volume and commonly complex fracture due to its intraarticular configuration, has yet to be determined. (1) Does the reliability of assessing specific fracture characteristics that guide surgical decision-making for distal radius fractures improve with 3-D printed handheld models? (2) Does surgeon agreement on the overall fracture classification improve with 3-D printed handheld models? (3) Does the surgeon's confidence improve when assessing the overall fracture configuration with an additional 3-D model? We consecutively included 20 intraarticular distal radius fractures treated at a Level 1 trauma center between May 2018 and November 2018. Ten surgeons evaluated the presence or absence of specific fracture characteristics (volar rim fracture, die punch, volar lunate facet, dorsal comminution, step-off > 2 mm, and gap > 2 mm), fracture classification according to the AO/Orthopaedic Trauma Association (OTA) classification scheme, and their confidence in assessing the overall fracture according to the classification scheme, rated on a scale from 0 to 10 (0 = not at all confident to 10 = very confident). Of 10 participants regularly treating distal radius fractures, seven were orthopaedic trauma surgeons and three upper limb surgeons with experience levels ranging from 1 to 25 years after completion of residency training. Fractures were assessed twice, with 1 month between each assessment. Initially, fractures were assessed using radiographs and 2-D and 3-D CT images (conventional assessment); the second time, the evaluation was based on radiographs and 2-D and 3-D CT images with an additional 3-D handheld model (3-D printed handheld model assessment). On both occasions, fracture characteristics were evaluated upon a surgeon's own interpretation, without specific instruction before assessment. We provided a sheet demonstrating the AO/OTA classification scheme before evaluation on each session. Multi-rater Fleiss's kappa was used to determine intersurgeon reliability for assessing fracture characteristics and classification. Confidence regarding assessment of the overall fracture classification was assessed using a paired t-test. We found that 3-D printed models of intraarticular distal radius fractures led to no change in kappa values for the reliability of all characteristics: volar rim (conventional kappa 0.19 [95% CI 0.06 to 0.32], kappa for 3-D handheld model 0.23 [95% CI 0.11 to 0.36], difference of kappas 0.04 [95% CI -0.14 to 0.22]; p = 0.66), die punch (conventional kappa 0.38 [95% CI 0.15 to 0.61], kappa for 3-D handheld model 0.50 [95% CI 0.23 to 0.78], difference of kappas 0.12 [95% CI -0.23 to 0.47]; p = 0.52), volar lunate facet (conventional kappa 0.31 [95% CI 0.14 to 0.49], kappa for 3-D handheld model 0.48 [95% CI 0.23 to 0.72], difference of kappas 0.17 [95% CI -0.12 to 0.46]; p = 0.26), dorsal comminution (conventional kappa 0.36 [95% CI 0.13 to 0.58], kappa for 3-D handheld model 0.31 [95% CI 0.11 to 0.51], difference of kappas -0.05 [95% CI -0.34 to 0.24]; p = 0.74), step-off > 2 mm (conventional kappa 0.55 [95% CI 0.29 to 0.82], kappa for 3-D handheld model 0.58 [95% CI 0.31 to 0.85], difference of kappas 0.03 [95% CI -0.34 to 0.40]; p = 0.87), gap > 2 mm (conventional kappa 0.59 [95% CI 0.39 to 0.79], kappa for 3-D handheld model 0.69 [95% CI 0.50 to 0.89], difference of kappas 0.10 [95% CI -0.17 to 0.37]; p = 0.48). Although there appeared to be categorical improvement in kappa values for some fracture characteristics, overlapping CIs indicated no change. Fracture classification did not improve (conventional diagnostics: kappa 0.27 [95% CI 0.14 to 0.39], conventional diagnostics with an additional 3-D handheld model: kappa 0.25 [95% CI 0.15 to 0.35], difference of kappas: -0.02 [95% CI -0.18 to 0.14]; p = 0.81). There was no improvement in self-assessed confidence in terms of assessment of overall fracture configuration when a 3-D model was added to the evaluation process (conventional diagnostics 7.8 [SD 0.79 {95% CI 7.2 to 8.3}], 3-D handheld model 8.5 [SD 0.71 {95% CI 8.0 to 9.0}], difference of score: 0.7 [95% CI -1.69 to 0.16], p = 0.09). Intersurgeon reliability for evaluating the characteristics of and classifying intraarticular distal radius fractures did not improve with an additional 3-D model. Further studies should evaluate the added value of 3-D printed handheld models for teaching surgical residents and medical trainees to define the future role of 3-D printing in caring for fractures of the distal radius. Level II, diagnostic study.

Radiographic Evaluation of the Consolidation of Humerus Surgical Neck Fractures Treated With Percutaneous Fixation.

Objective To evaluate radiographically the postoperative results of patients with fracture of the proximal humerus in two parts of the surgical neck treated with threaded percutaneous fixation. Methods We evaluated the radiographic results of percutaneous fixation with threaded pins on the treatment of proximal humerus fractures in our service. Preoperative and postoperative images of 42 patients were evaluated, evaluating radiographs until 8 weeks postoperatively. We considered on evaluation the fracture deviation on preoperative images, the loss of reduction and no consolidation. Results Our consolidation rate was 90.4%, with loss of reduction in 16.6% of the cases and no consolidation rates in just 4 operated cases. We observed a predominance of a specific fracture pattern in the cases with loss of reduction. Conclusion The present study allows us to consider the percutaneous fixation technique with threaded pins as an alternative in our therapeutic arsenal for the proximal humerus fracture of the surgical neck. Contraindications are considered for low fracture trait on the metaphysis and with medial/lateral cortical impairment.

Evaluation of Complications After Open Reduction and Internal Fixation of Mandibular Condylar Base and Neck Fractures Using Trapezoidal Plates

The purpose of the study was to evaluate the different fracture pattern of patients being treated with trapezoidal plate fixation of condylar base and neck fractures using the AOCMF Classification System to determine specific fracture pattern that are associated with failure of trapezoidal plate fixation. Ten patients with mandibular condylar base and neck fractures underwent internal fixation using trapezoidal plates. Fractures of the condylar process were classified according to the AOCMF Classification System using computed tomography data. The fracture pattern was compared to complications according to hardware failure such as plate or screw loosening and plate fracture. Plate and screw loosening of trapezoidal plates for fixation of condylar base and neck fractures was associated with fracture location in the neck region and major fragment displacement with contact loss between the proximal and distal fragment of the fracture. Further investigations such as finite-element analysis of different plating systems for fixation of condylar neck fractures are necessary to establish the optimal fixation technique for condylar neck fractures.

POSTERO-MEDIAL TIBIAL PLATEAU (MOORE’S TYPE) FRACTURE AND THE IMPORTANCE OF COMPUTER TOMOGRAPHY IN DIAGNOSIS: A CASE REPORT

Moore type I posteromedial split fracturedislocation of proximal tibia are relatively uncommon. It is a specific fracture pattern that is not well described by the AO (41B2.2/B3.2) or Schatzker (IV) classification system because these systems do not differentiate when the medial fragment is primarily posterior and associated with a dislocation as the Moore system does. 1The additional use of computed tomography scans in the assessment of tibial plateau fracture may improve surgeon’s agreement that lead to the final decision and optimization of treatment. 2Galla and Lobenhoffer described a direct posteromedial approach for managing Moore type I tibial plateau fracture1.Report:A 48 years old malay gentlemen was alleged motor-vehicle accident, sustained closed fracture tibial plateau of right knee. Initially patient was diagnosed with right tibial fracture schatzker IV based on right knee anterior-posterior and lateral view xray. But CT scan had done, show the proximal tibial fracture transversing medial aspect with coronal spliting. Patient was treated with posteromedial locking compression plate with Lobenhoffer approach. Intraoperatively, diagnosis was confirmed with Hohl & Moore classification type I, there is coronal split fracture extending to posteromedially. The importance of computerised tomography scans when dealing with intra-articular fracture of tibial plateau may improve regarding localisation of fracture lines, depression zone, comminution, and the surgical treatment plan. 2Alexander et al. reported after addition of computerised tomography scans significantly improved to “good” in all classification. The features of Moore’s type I fracture which is coronal split fracture dominantly posterior column, coronal view from CT scans is more useful compare than sagital view. Galla and Lobenhoffer have introduce a direct postero-medial approach that minimizes soft tissue injury while allowing excellent fracture visualization, reduction, and fixations. 1This technique protect the neurovascular bundle and requires only suboeriosteal elevation of the popliteus to obtain full exposure. Furthermore, because of the protecting posterior soft tissues, skin closure and wound healing are reliable.Conclusion:Moore’s type I fracture managed with postero-medial approach has better post operative outcome, improved reliability and shows good reproducibility when classified with computerised tomography scans.

Tibial plateau fractures are associated with a long-term increased risk of mortality: a matched cohort study of 7950 patients.

Disregarding proximal femoral fractures, the current literature includes only limited information regarding mortality following lower extremity fractures. Information regarding risk of mortality related to specific fracture patterns is essential when planning treatment modalities. The primary aim of this study was to report the long-term cumulative survival rate in patients with a tibial plateau fracture compared to an age- and gender-matched reference population. Patients who sustained a tibial plateau fracture in Denmark between 1996 and 2000 were included in the study. Survival status was monitored until 2015. We compared the mortality rate with a tenfold reference population matched on age and gender without a prior tibial plateau fracture. The study was based on register data from the Danish National Patient Register. The study included 7950 patients sustaining 8065 tibial plateau fractures. The cohort had a mean follow-up period of 13.9years. Patients with a tibial plateau fracture had a 1.52 (95% CI 1.46-1.58) times higher hazard ratio (HR) of death compared to the age- and gender-matched reference population. The 30-day, 6-month and 1-year mortality rates were 1.2%, 3.3% and 4.9%, respectively. Patients with a proximal tibial plateau fracture have a higher cumulative risk of death during the mean 13.9-year observational period compared to an age- and gender-matched reference population.

Does surgical approach affect sagittal plane alignment and pilon fracture outcomes?

PurposeSagittal plane alignment beyond articular reduction and its effect on clinical outcomes has not been emphasized. Surgical approach may influence a surgeon's ability to correct the sagittal plane alignment. The purpose of our study was to evaluate how surgical approach impacts anterior distal tibial angle (ADTA) and lateral talar station (LTS). Our hypothesis was that the anterolateral (AL) approach would improve the sagittal plane parameters due to the primary plate placement. Patients and methodsA retrospective review was performed on patients who underwent operative management for pilon fractures at 2 ACS Level 1 Academic Trauma Centers. Clinical data points including demographics, comorbidities, AO/OTA classification, surgical approach, and complications were recorded. Quality of reduction was measured using the ADTA, lateral distal tibia angle (LDTA), and lateral talar station (LTS) from radiographs. Results580 pilon fractures met inclusion criteria. When compared to the AL approach, the modified anteromedial (AM) approach had decreased rates of local wound care, and unplanned reoperations. The AM approach had increased rates of superficial infection, deep infection, non-union, and amputations. There was no difference in ADTA, LDTA, or LTS between the AM and AL approach (P = 0.49, P = 0.41, P = 0.85). There was a difference in LTS with tobacco users (P = 0.02). ConclusionsThe sagittal plane alignment does not appear to be affected by the surgical approach. Therefore, the surgical approach to pilon fractures should be based on the fracture pattern and the patient's soft tissue envelope. This study shows that the AM is a relatively safe and effective approach to complex fractures and the surgeon should consider the specific fracture pattern and patient soft tissue envelope when choosing the specific approach.

Functional outcome following fixation of distal tibial fracture (Extra articular) with locking compression plate (LCP) using the minimally invasive percutaneous osteosynthesis (MIPO) technique

Background: Distal tibia is more superficial, with minimal soft tissue coverage and poor blood supply, hence operative treatment can lead to complications, making it a challenging surgery. The aim is to see the results of the distal tibial fracture fixation with LCP using MIPO technique.Methodology: Twenty consecutive patients with type AO 43A distal tibia fractures were prospectively included into the study during the period of march 2018 to march 2019 with a follow-up of minimum one year. Fourteen male and six female patients with a mean age of 47 years were reviewed. Patients of Bidar institute of medical sciences with closed extra articular distal tibial fractures who fulfill the inclusion & exclusion criteria were taken in to study after obtaining informed written consent. History, Clinical examination and details of investigations were recorded in the study Performa. Minimally Invasive Percutaneous Plate Osteosynthesis was carried out depending on requirement for specific fracture pattern. These cases were reviewed periodically at 6, 12, 24 weeks and regularly both clinically and radiologically for bony union. Clinical outcome and Radiological criteria (RUST SCORE) regarding fracture union and complications was evaluated and documented. Functional outcome was measured by lower extremity functional score (LEFS).Results: Mean time to union was 6.5 months (range 4–16 months). Sixteen fractures healed with good functional outcome. Two patient had delayed union. One patient had nonunion which was treated with iliac crest bone grafting that ultimately healed with good functional outcome. One patient developed superficial infection that was treated with appropriate antibiotics and the fracture united eventually.Discussion: The MIPO technique for pilon A type fractures is proven ti be more effective over the conventional methods. Early mobilization with no risk of secondary displacement helps to prevent stiffness of the ankle joint and good wound healing.

Patterns of serial rib fractures after blunt chest trauma: An analysis of 380 cases

Rib fractures represent the most common bone fracture, occurring in 10–20% of all blunt trauma patients and leading to concomitant injuries of the inner organs in severe cases. The purpose of this study was to identify specific serial rib fracture patterns after blunt chest trauma. 380 serial rib fracture cases were investigated. Fractures were assigned to five different locations within the transverse plane. Rib level, fracture type, and dislocation grades were recorded and related to the cause of accident. In total, 3735 rib fractures were identified (9.8 per patient). 54% of the rib fractures were detected on the left thorax. Rib fracture distribution exhibited a hotspot at rib levels 4 to 7 in the lateral and posterolateral segments. On average, most rib fractures occurred in crush/burying injuries (15.8, n = 13) and pedestrian accidents (12.8, n = 13), least in car/truck accidents (8.9, n = 75). In the car/truck accident group, 47% of all rib fractures were in the lateral segment, in case of frontal collision (n = 24) even 60%. Fall injuries (n = 141) entailed mostly posterolateral rib fractures (35%). In case of falls >3 m (n = 45), 48% more rib fractures were detected on the left thorax. In cardiopulmonary resuscitation related serial rib fractures (n = 33), 70% of all rib fractures were located anterolaterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all rib fractures were dislocated (15% ≥ rib width). Serial rib fractures showed distinct fracture patterns depending on the cause of accident. When developing a serial rib fracture classification system, data regarding patterns, fracture types, dislocation grades, and associated fractures should be included.

Fat embolism syndrome: Case study of a Clinical conundrum

The effect of recent advances in critical care and the emphasis on current practice in early diagnosis in patient with fat embolism syndrome by conducting 2 year review of experiences at our trauma centre.18 patients with clinically apparent fat embolism syndrome were identified. The diagnosis of FES was made by clinical criteria including hypoxia (18 patients 100%), mental status changes (13 patients 72%), high temperature (13 patients 72%), tachycardia (18 patients 100%), thrombocytopenia (10 patients 55%).10 patients (55%) had multiple long bone fractures and 8 patients (45%) had single long bone fractures. 6 patients (33%) had open fractures remaining 12 patients (67%) had closed fractures. Manage the patients for early operative fixation was emphasized. There were 7 deaths with mortality of 39%. Conclusion: The fat embolism syndrome remains a diagnosis of exclusion and is based on clinical criteria. Clinically apparent FES is unusual but may be masked by associated injuries in more Severely injured patients. No association could be identified between FES and a specific fracture pattern or location. While FES seems to have a direct effect on survival, the management of FES remains primarily supportive and early operative stabilization should be done to reduce the mortality and morbidity.