Treatment Of Long Bone Fractures Research Articles

Surgical methods of treatment for tibial diaphyseal fractures

Background. Bone fractures are a public health concern. In recent years, there has been an upward trend in body weight of people of all age groups. Obesity has long been thought to help protect against fractures, but recent studies have shown that for every 5 cm increase in waist circumference, the risk of any fracture is 3 % higher. The purpose: according to the meta-analysis of modern medical literature, to determine the main directions of surgical treatment for long bone fractures, their advantages, and disadvantages, including in overweight patients, the features of diaphyseal fracture fixation in overweight patients. Materials and methods. A meta-analysis of special literature from scientific databases was conducted: Cochrane Library, Scopus, National Library of Medicine — National Institutes of Health, ReLAB-HS Rehabilitation Resources Repository. One hundred and thirty articles were analyzed, from them 31 were selected, which, in our opinion, reflect the purpose of the study. Results. All methods of surgical fixation of fractures have their advantages and disadvantages. The frequency of nonunions caused by intramedullary fixation of the femoral shaft can reach 10 %, and varus/valgus and rotational deformities and shortening can also be observed. But the use of locking screws prevents the occurrence of most complications. When fixing the fractures with plates, the main complications are related to superficial and deep infections, which were more often observed in overweight patients. The analysis demonstrated that in overweight and obese patients, the main complicating factor is not the method for fixing the fracture zone, but factors related to the health of the patient himself. So, despite the fact that the results of treatment of fractures in patients with normal weight and obesity did not have a statistically significant difference, an increase in cardiovascular complications, exacerbation of chronic respiratory diseases was observed. Moreover, it is the presence of concomitant diseases that often makes surgical intervention impossible. Conclusions. There is a large amount of research on surgical methods of fixing tibial diaphyseal fractures, but data on the choice of fixation method in overweight and obese patients as a separate approach were not found. There are data on complicating factors of excess weight in the treatment of fractures and surgical interventions. Systematic studies related specifically to the algorithm for choosing the method of fracture fixation and complications have also not been found.

Challenges in the Surgical Orthopedic Treatment of Long Bone Fracture in a Rare Case of Pycnodysostosis

Pycnodysostosis is a rare autosomal recessive disorder caused by an inactivating mutation in cathepsin K (CTSK) and characterized by dysmorphic facial features, a short stature, acro-osteolysis, osteosclerosis with increased bone fragility, and delayed closure of cranial sutures. Although the satisfying healing potential, many issues exist in managing fractures in pycnodysostosis patients. In this paper, we report the challenges faced in managing a fracture of the femoral shaft in a 14-year-old boy coming from a low-income family. The patient was administered to the Paediatric Surgical Emergency Department of the Children's Hospital in Rabat for the management of a closed fracture of the left femur. Despite being of small stature with dysmorphic facial features, a prominent forehead, and brachydactyly, he never had a medical consultation before. The patient then underwent a surgical reduction. We attempted titanium elastic nail fixation, but metaphyseal drilling was not feasible due to the high bone density, and the narrow medullary canal eliminated this option. Therefore we opted for the palate fixation. Sclerotic bone made drilling extremely difficult. The postoperative fracture was successfully healed.

Intramedullary Nailing with an Absorbable Antibiotic Carrier (INaac): A Simple Technique Using Standard Implants

Introduction: Intramedullary nailing has revolutionized the treatment of long bone fractures and non-unions. However, there is rightly concern about the use of nails when there is established infection or when the risk of subsequent infection is high. Recently, this concern has been partly addressed by the introduction of intramedullary nails combined with an antibacterial coating. Various methods have been reported with some success but also with some drawbacks. Methods: This paper reports a simple technique for coating an intramedullary nail with an absorbable antibiotic carrier. The carrier is injected directly into the reamed medullary canal, coating the nail during nail passage and delivering high levels of antibiotics at the nail-bone interface. Results: This technique was found to be easy to apply. It allowed use of standard fracture implants without the need for downsizing of the nail diameter. There is no need for nail removal or exchange after initial treatment of the infection. Conclusion: This simple technique combines the benefits of a bioabsorbable antibiotic carrier with standard fracture nails to prevent or treat long bone infections. It avoids the problems of PMMA coated nails or the need for specialist implants.

Treatment of long bone fractures in children by elastic stable intramedullary nailing: Outcome and challenges in a unit with restricted technical platform.

Elastic stable intramedullary nailing (ESIN), developed by the Nancy school in France, is the gold standard for surgical treatment of long bone fractures in children. In Africa, few works have been devoted specifically to this technique. This study aimed to describe the outcome and to present the challenges with this technique in the treatment of long bone fractures in children. This was a prospective and descriptive study over 4 years including patients aged 0-15 years old operated using ESIN. Sixty-two patients underwent ESIN, of whom 44 patients (70.96%) were for femur fractures, nine patients (14.52%) for tibia and fibula fractures and nine patients (14.52%) for humerus fractures. The majority of the patients treated with ESIN were children older than 6 years. Nine patients (14.51%) and 13 patients (20.98%) underwent ESIN following polytrauma and multiple fractures, respectively. Seven patients (11.29%) were operated on through-closed ESIN method. The unavailability of image intensifier (38.71%) and the presence of bone callus (40.32%) were the major reasons for using the open ESIN method. Thirty-three patients (53.23%) had minor or major complications. The majority of patients had satisfactory therapeutic outcomes. ESIN gives good results, even when the fracture site is approached.

Solid locked intramedullary nailing for expeditious return of bone-setting-induced abnormal fracture union victims to work in South-western Nigeria

Wage earning in low- and middle-income countries (LMICs) is predominantly through physical labour. Consequently, limb-related disabilities caused by abnormal fracture unions (AFUs) preclude gainful employment and perpetuate the cycle of poverty. Many AFUs result from traditional bone-setting (TBS), a pervasive treatment for long bone fractures in LMICs. The objective of this study was to accentuate the expediency of solid locked intramedullary nail in the early restoration of victims of TBS-induced abnormal fracture unions (AFUs) to their pre-injury functioning, including work. One hundred AFUs in 98 patients treated with a solid locked intramedullary nail in our center over a period of 7 years were prospectively studied. We found the mean age to be 47.97 years. Males constituted 63.9% of the patients’ population. Atrophic non-union accounted for 54.1% of the AFUs. The mean fracture-surgery interval was 21.30 months. By the 12th post-operative week, more than 75% of the fractures had achieved knee flexion/shoulder abduction beyond 90°, were able to squat and smile (or do shoulder abduction-external rotation), and were able to bear weight fully. The study demonstrated the expediency of solid locked nail in salvaging TBS-induced abnormal fracture unions in a way that permitted early return to pre-injury daily activities and work, thereby reducing fracture-associated poverty.

STIFFNESS PARAMETERS OF VARIOUS MODIFICATIONS OF RING FIXATOR

Relevance. To date, there is no final solution to the theoretical and practical issues of the problem of external fixation in the treatment of long bone fractures.
 Objective. To determine the rational methods of completing ring retainer (RF) in the treatment of nonunions of the shin bones after fractures of long bones on the basis of clinical and experimental substantiation of the choice, taking into account the peculiarities of the assembly of the apparatus and the implementation of the connection "apparatus-fragments of non-union".
 Materials and methods. In the experimental part, Sawbones® synthetic composite bone was used. The rigidity of fixation of bone fragments of the RF of the wire-rod type was studied. We tested and compared 5 different options for fixation of bone fragments in RF. The samples were tested in 4 modes: compression along the axis of the bone; compression on the head of the bone; twisting; bending. The strength and deformation characteristics of the materials were determined with a maximum force of up to 5 kN using the TIRATEST-2151 universal testing machine. They chose the most optimal configuration of the RF. Then, in the clinical part, the clinical effectiveness of the optimal structures was evaluated based on the analysis of their use in 12 patients with non-union of the shin bones.
 Results. Optimal structures have been determined from the point of view of integral rigidity of the structure. The greatest rigidity was the RF system No. 3, in which 3 spokes are used: 2 of them are held at an angle, 1 - in the plane of the ring. In the case of an increase in the number of spokes, the stiffness of the system increased. When tested in compression along the axis of the bone, the stiffness of System No. 3 is 6.5% greater than that of System No. 2 and 12.5 % greater than System No. 1, in which only 2 spokes are used. Fixing the spokes at an angle to the plane of the ring also increases the rigidity of the system. When tested in compression along the axis of the bone, the stiffness of System No. 3 is 6.5 % greater than that of System No. 2. The stiffening rib affects the stiffness of the entire system. But the bend became the most sensitive. Flexural stiffness decreased by 23 % and compression by 8.5 %. Debris removal during bending increased by 1.5-1.8 times.
 Conclusion. The best indicators of fixation rigidity have options for the arrangement of spokes with a cross not only in the frontal, but also in the sagittal planes. The stability of the fixation of the rod is significantly increased by mounting the "stiffness triangle". The obtained clinical data indicate the promising application of improved ring fixators.

Three-dimensional printable metamaterial intramedullary nails with tunable strain for the treatment of long bone fractures

Novel metamaterial unit cells with tunable strain were incorporated into titanium intramedullary (IM) nails to overcome problems of dense metallic implants. Three-dimensional (3D) models of cylindrical, pillar, and reference metamaterials were tuned and analyzed for structural authentication. Further, one solid IM nail (S0) and four different cylindrical metamaterial cell IM nails with gap sizes of 0.15 mm, 0.30 mm, 0.45 mm, and 0.60 mm were used to achieve 5% (S1), 10% (S2), 15% (S3), and 20% (S4) strain, respectively, in a 3-mm fracture, to investigate the healing outcomes. The bending stiffness (callus quality) in the S2 metamaterial IM nail increased by 22% between the 7th and 16th iterations, whereas for the S0, S1, S3, and S4 IM nails, the increases were 5.6%, 8.1%, 12.4%, and 9.0%, respectively. The S2 IM nail exhibited the best healing and bending stiffness; however, the S0 IM nail exhibited the worst results. This unique design was customized for different fracture gap sizes according to patient-specific needs.

Therapeutic Efficacy and Safety of Osteoinductive Factors and Cellular Therapies for Long Bone Fractures and Non-Unions: A Meta-Analysis and Systematic Review.

Background: Long bone fractures display significant non-union rates, but the exact biological mechanisms implicated in this devastating complication remain unclear. The combination of osteogenetic and angiogenetic factors at the fracture site is an essential prerequisite for successful bone regeneration. The aim of this study is to investigate the results of the clinical implantation of growth factors for intraoperative enhancement of osteogenesis for the treatment of long bone fractures and non-unions. Methods: A systematic literature review search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the PubMed and Web of Science databases from the date of inception of each database through to 10 January 2022. Specific inclusion and exclusion criteria were applied in order to identify relevant studies reporting on the treatment of upper and lower limb long bone non-unions treated with osteoinductive or cellular factors. Results: Overall, 18 studies met the inclusion criteria and examined the effectiveness of the application of Bone Morphogenetic Proteins-2 and -7 (BMPs), platelet rich plasma (PRP) and mesenchymal stem cells (MSCs). Despite the existence of limitations in the studies analysed (containing mixed groups of open and close fractures, different types of fractures, variability of treatment protocols, different selection criteria and follow-up periods amongst others), their overall effectiveness was found significantly increased in patients who received them compared with the controls (I2 = 60%, 95% CI = 1.59 [0.99–2.54], Z =1.93, p = 0.05). Conclusion: Administration of BMP-2 and -7, PRP and MSCs were considered effective and safe methods in fracture treatment, increasing bone consolidation, reducing time to repair and being linked to satisfactory postoperative functional scores.

Wnt10b-overexpressing umbilical cord mesenchymal stem cells promote fracture healing via accelerated cartilage callus to bone remodeling

ABSTRACT The aim of this study was to investigate whether HUCMSCsWnt10b could promote long bone fracture healing. Commercially-available HUCMSCsEmp (human umbilical cord mesenchymal stem cells transfected with empty vector) in hydrogel, HUCMSCsWnt10b in hydrogel and HUCMSCsWnt10b with the Wnt signaling pathway inhibitor IWR-1 were transplanted into the fracture site in a rat model of femoral fracture. We found that transplantation of HUCMSCsWnt10b significantly accelerated bone healing in a rat model of femoral fracture. Meanwhile, three-point bending test proved that the mechanical properties of the bone at the fracture site in the HUCMSCWnt10b treatment group were significantly better than those of the other treatment groups. To understand the cellular mechanism, we explored the viability of periosteal stem cells (PSCs), as they contribute the greatest number of osteoblast lineage cells to the callus. In line with in vivo data, we found that conditioned medium from HUCMSCsWnt10b enhanced the migration and osteogenic differentiation of PSCs. Furthermore, conditioned medium from HUCMSCsWnt10b also induced endothelial cells to form capillary-like structures in a tube formation assay, which was blocked by SU5416, an angiogenesis inhibitor, suggesting that enhanced vessel formation and growth also contribute to accelerated hard callus formation. In summary, our study demonstrates that HUCMSCsWnt10b promote fracture healing via accelerated hard callus formation, possibly due to enhanced osteogenic differentiation of PSCs and vessel growth. Therefore, HUCMSCsWnt10b may be a promising treatment for long bone fractures.

Otojen kemik iliği enjeksiyonunun uzun kemik kaynamamış kırıklarına etkisi

Purpose: The impact on bone union of injecting bone marrow from the anterior iliac crest was examined in patients with non-unions. 
 Materials and Methods: The present study was prepared following a retrospective study on non-union patients who applied to our clinics who accepted bone marrow injection and were followed up and monitored after the procedure. A total of 14 bones from 13 patients with long bone diaphysis and metaphysis non-union were included in the study from among patients who applied during the dates of November 2016 – December 2019. Bone marrow aspiration from the anterior iliac crest was conducted on the patients under anesthesia which was injected to the fracture line under local anesthesia and fluoroscopy. All patients were monitored on a monthly basis with front-rear and side radiography. The injection operation was conducted three times on seven patients and 2 times on a total of seven non-unions in 6 patients. 
 Results: A total of 11 unions took place in 14 patients. A union could not be attained in three fractures. The gap was over 2 mm in fractures without union. Fracture union ratio was obtained as 79 %. The mean injection number applied on the patients was 2.5. A statistically significant correlation could not be identified between the fixation method and non-union type and union. 
 Conclusion: Bone marrow injection is a cheap, effective, easy to use and safe surgical method for the treatment of long bone fractures with non-union.

Evaluation of a novel semicircular locking external fixator for treating fractures of long bones: Biomechanical comparison with a circular external fixator

PurposeThis study aimed to investigate the biomechanical properties of a novel semicircular locking external fixator with locking screw mechanism, shape of trapezoidal corrugations, half- ring designed for greater stability. Materials and methodsThe novel external fixator had a half-ring with the shape of trapezoidal corrugations and locking screws fixing the bone at different angles in all three planes (sagittal, axial, and coronal). The biomechanical properties of the semicircular locking external fixator (group 1) were compared with those of a standard Ilizarov-type circular external fixator (group 2) (TST, İstanbul, Turkey) in an experimental study design. Five frames were used in each group. Standard PE 1000 (polyethylene) rod models (n = 10) simulating the tibia bone model were used. Both systems were compared biomechanically by applying axial and torsional loads simultaneously. ResultTwo samples in group 2 were damaged before the test ended during axial loading. All of the samples in group 1 completed the tests without damage after 150,000 cycles. The axial stiffness of the semicircular locking external fixator was found to be significantly higher than that of the Ilizarov-type circular external fixator (p < 0.05). No statistically significant difference was found between the two fixators in torsional loading. The application time of semicircular locking external fixator was significantly shorter than Ilizarov-type circular external fixator (p < 0.05). ConclusionThe novel semicircular locking external fixator was biomechanically stronger than the Ilizarov-type external fixator for treating fractures of long bones. It can be used as a permanent external fixator for the definitive treatment of long bone fractures with soft tissue damage in terms of stability and application time.

The experience of use the bioactive coated intramedullary flexible nailiing in treatment of long bone fracture

The study concerns a new method of treatment of bone fractures of upper and lower limbs based on osteogenesis stimulation by intramedullary implants with bioactive organic hydroxyapatite (HA). The method decreases consolidation period of diaphyseal fractures to 2-4 times. A technology of osteosynthesis and bone formation dynamics at the fracture zone and around the implant is described.

Contrast-Enhanced Ultrasound: A Viable Diagnostic Tool in Predicting Treatment Failure after Non-union Revision Surgery for Upper- and Lower-Limb Non-unions

Non-unions remain a major complication in the treatment of long-bone fractures and affect quality of life considerably. Both early detection and treatment of non-unions are essential to secure subsequent fracture union. Sufficient vascularization plays a key role in the healing process. The aim of this prospective study was to quantify the microperfusion within non-unions by means of contrast-enhanced ultrasound (CEUS) as early as 12 wk after non-union surgery and to examine the prognostic capability of CEUS in predicting treatment failure. Among 112 patients who had undergone non-union surgery, consolidation within 36 mo was achieved in 89 patients (“responders”), whereas 23 patients showed persistent non-unions (“non-responders”) and required further surgery. CEUS quantification parameters such as peak enhancement, wash-in area under the curve and wash-in perfusion index revealed significantly higher perfusion levels in “responders” compared with “non-responders” (p < 0.05). Receiver operator characteristic curve analysis revealed that persistent fracture non-unions could be predicted with a sensitivity/specificity of 88.7%/72.2% in lower-limb non-unions and a sensitivity/specificity of 66.7%/100.0% in upper-limb non-unions. CEUS is a suitable diagnostic tool in predicting treatment failure as early as 12 wk after non-union surgery and should be integrated into the clinical routine when deciding on revision surgery at an early stage.

The advent of elastic stable intramedullary nailing for the treatment of long bone fractures in skeletally immature patients

Introduction Management of pediatric long bones fractures is a complex and rapidly evolving field. Traditionally, casting and conservative techniques played a key-role in the management of fractures in skeletally immature patients. However, the surgical approach has evolved steadily over the past four decades or so and increasing evidence has been published supporting the advantages of fixation techniques over conservative methods. The purpose of this narrative review is to outline how innovations in orthopedic surgery have changed the rationale of treating long bones fractures in children and adolescents with focus on surgical techniques, particularly elastic stable intramedullary nailing (ESIN). Material and methods We aimed to describe the main trends in pediatric long bones fractures management and to identify its specificities and difficulties as well as the best standard of care. Results The introduction of ESIN has profoundly influenced the management of pediatric upper and lower extremity fractures. Overall, in comparison to conservative techniques, advantages of ESIN include minimally invasiveness, short hospital stay, primary bone union, early mobilization and progressive weight bearing, and good outcome with low complication rate. Moreover, the flexible nail can be used as a closed reduction tool itself. Conclusions Irrespective of the technique performed, the key-concepts remain 1) the proper understanding of the injury to treat; 2) the identification the main characteristics of the patient; 3) the pros and cons of each technique; and 4) the potential complications.

Numerical modeling of implant surgery and rehabilitation of humerus bone fractures for the elderly patients

Background: Implantation is becoming more widespread in such areas of modern medicine as orthopedics and traumatology. Due to the lack of an adequate substitute for natural bone, combined approaches are used. For older patients, the problem is exacerbated by a decrease in bone mineral density. When choosing a scheme for the surgical treatment of long bone fractures, preference is given to simple and maximally sparing approaches. In this regard, the main task of osteosynthesis is to provide optimal mechanical channels not only for the fracture healing process, but also to restore full functional capabilities in the future. The paper considers the urgent task of optimizing and increasing the efficiency of planning rehabilitation measures, including taking into account the individual characteristics of a particular patient, and the results are of fundamental and applied importance. Objectives: development of physical and mathematical models for modeling the stress-strain state of the elements of the musculoskeletal system to optimize the planning of bone surgeries when installing implants. Materials and methods. For the analysis, both specific clinical results and modern methods of computer modeling and processing of results were used. The advantage of physical and mathematical models based on the used finite element method is the possibility of optimizing the design of prostheses and reducing the problems caused by osteopenia. Results: To illustrate the proposed approach, a specific example of the treatment of a comminuted fracture of the humerus in an elderly patient is considered. To describe the physicomechanical properties of bone tissue, sets of standard data on the main characteristics of tissues and materials of implants such as elastic modulus and Poisson's ratio were used. As the bone grows together, simultaneously with a decrease in stresses, the difference between the stress on the entire structure and the stress on the bone decreases. This indicates that the bone begins to take on an increasingly significant relative part of the load, which should have a positive effect on its bone mineral density. Conclusions: The advantages of modeling using the finite element method and by non-invasive modeling of the work of the patient's musculoskeletal system with various variants of prostheses (implants) and the choice of the most optimal one are shown. It was found that the use of the Von Mises stress-strain state as a criterion for assessing the stress-strain state of the system gives effective assessments of the reliability of the structure and its elements.

OUR EXPERIENCE IN USING THE UKRNDITO POLIFUNCTIONAL APPARATUS IN THE TREATMENT OF LONG BONE FRACTURES

Among diaphyseal long bones fractures - fractures of the femur and tibia are the most common. Femoral fractures range from 10.4 to 23.9% of all long bone fractures and from 13 to 36.3% of tibial injuries. The problem of treatment of these injuries is due to the large number of unsuccessful treatment results, as evidenced by the high percentage of disability (up to 20-30%). The purpose of the study is to publish the experience of using multifunctional devices UKRNDITO in the treatment of long bone fractures. The fixed device belongs to unilateral external multifunctional fixators on the basis of sticks and was used in 17 cases of open injuries, 20 - closed fractures of long bones and in 3 cases of osteomyelitis processes. Analysis of clinical cases of patients’ treatment with fractures long bones using these devices showed that these operations are accompanied by minimal blood loss and trauma, significantly reduce the duration of surgery, allow for early functional load and ensure mobility of joints adjacent to fractures, reduce the length of hospital stay, are «comfortable» for patients.

Nailing of long bone fractures in precarious situations: focus on the Surgical Implant Generation Network (SIGN) nail

Le développement économique des pays à faibles revenus a pour corollaire une augmentation considérable des véhicules motorisés, et en particulier des motocyclettes. Les accidents de la circulation augmentent ainsi que les fractures qui y sont associées. Le traitement des fractures des os longs repose dans la majorité des cas sur l´enclouage centro-médullaire verrouillé, procédé rarement disponible en situation sanitaire dégradée. Pour apporter à ces pays un traitement optimal, le clou SIGN (Surgical Implant Generation Network) a été développé en 1999 par Lewis Zirkle. Il est actuellement utilisé gratuitement dans 53 pays. En contrepartie une base de données internationale doit être remplie afin de l´évaluer et de le faire évoluer. A la lumière de nos expériences en Haïti et au Burundi et d´une revue de la littérature, nous décrivons ici ses particularités conceptuelles et techniques, dont l´implantation dans les pays francophones reste limitée.

A new technology using a customized 3D printed fixator to assist fracture reduction and fixation: Technical note.

Poor reduction can lead to complications such as deformity and delayed fracture healing. We introduce a 3D printed external fixator technology that can assist in fracture reduction and fixation. A fractured long bone was first fixed by a temporary external fixator and then scanned with computed tomography. Three-dimensional reconstruction of the contour and bone fragments of the affected limb was performed using Mimics software, and the fracture reduction was simulated. Subsequently, data were imported into SolidWorks software for customized external fixator design and 3D printing. Through the precise assembly of the 3D printed external fixator and external fixation pins, automatic fracture reduction. The patient's fractures were well reduced, firmly fixed, and the postoperative fractures healed well with no complications. The technique we introduce not only assists in fracture reduction for temporary external fixation but can also be used as a definitive treatment for long bone fractures.

Language Barriers and Timely Analgesia for Long Bone Fractures in a Pediatric Emergency Department.

IntroductionLong bone fractures are common painful conditions often managed in the pediatric emergency department (PED). Delay to providing effective pediatric pain management is multifactorial. There is limited information regarding how the issue of language spoken impacts the provision of adequate and timely institution of analgesia. We sought to determine whether there is a difference between English-speaking and non-English speaking patients with respect to time to pain management for long bone fractures in a multi-ethnic urban PED.MethodsWe conducted a retrospective cohort study of consecutive cases over 29 months of children <18 years old who presented to the PED with a first-time long bone fracture. A correlation of multiple clinical variables with timeliness to providing analgesia as a primary outcome was determined. We performed regression analysis to eliminate confounding and to determine the magnitude of each variable’s effect on the outcome.ResultsWe analyzed a total of 753 patient cases (power 0.95). Regression analysis showed that the variable of English vs non-English language spoken was the most significant predictor of timeliness to pain management (p < 0.001). There was a significant difference in median time to triage measurement of pain score (1 minute vs 4 minutes for English vs non-English speakers [p < 0.001]); median time to initial analgesia (4 minutes vs 13 minutes for English vs non-English speakers (p < 0.001]); and median time to opioid analgesia (32 minutes vs 115 minutes for English vs non-English speakers (p < 0.001]), respectively. All measurements of time were from the creation of a patient’s electronic health record. Just 30% of all patients received an opioid analgesic for treatment of long bone fractures, including only 37% with moderate triage pain scores.ConclusionDelay to receiving analgesic medications in pediatric patients with long bone fractures can be augmented by language barriers. Time to providing analgesia for long bone fractures is significantly delayed in non-English speaking families, contributing to disproportionate care in the PED. Furthermore, use of opioid analgesia for fractures in children remains poor.

The history of intramedullary nailing.

To summarize the evolution of intramedullary nailing, highlight important milestones, introduce the atmosphere of the era concerning the first uses and development of intramedullary nailing, and present the status of nailing in modern international orthopaedics and traumatology. A thorough literature search was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize the literature on the history and evolution of intramedullary nailing. The first use of an intramedullary device was attested in ancient Egypt; however, the first use of intramedullary nailing was reported in 1524 in Mexico, and the first medical journals reported on intramedullary nailing around the mid-1800s. The evolutions of intramedullary nailing including approach, material, cross-section and shape, and reaming technique occurred in the twentieth century. During the 1960s, intramedullary nailing was abandoned in favour of plate and screws osteosynthesis; however, in the 1970s, 1980s, and 1990s, a surge of novelties including flexible reaming, interlocking, and use of image intensification and titanium nails led to the advent of the second-generation intramedullary nailing. Today, intramedullary nailing has become the standard treatment of long bone fractures with low infection rates, small scars, excellent stabilization of the fractures, and immediate mobilization of the patients. Intramedullary nailing has revolutionized the treatment of long bone fractures. However, with numerous nail designs, a lot of information on their efficacy is lacking. Considerably more work will need to be done to determine the optimal nail specifications.