Unstable Fracture Patterns Research Articles

New Persistent Opioid Use and Associated Risk Factors Following Treatment of Ankle Fractures.

The aim of this study was to define the rate of new persistent opioid use and risk factors for persistent opioid use after operative and nonoperative treatment of ankle fractures. Using a nationwide insurance claims database, Clinformatics DataMart Database, we identified opioid-naïve patients who underwent surgical treatment of unstable ankle fracture patterns between January 2009 and June 2016. Patients who underwent closed treatment of a distal fibula fracture served as a comparative group. We evaluated peritreatment and posttreatment opioid prescription fills. The primary outcome, new persistent opioid use, was defined as opioid prescription fulfillment between 91 and 180 days after the procedure. Logistic regression was used to evaluate the effect of patient factors, and the differences of the effect were tested using Wald statistics. The adjusted persistent use rates were calculated. A total of 13 088 patients underwent treatment of an ankle fracture and filled a peritreatment opioid prescription. When compared with closed treatment of a distal fibula fracture, only 2 surgical treatment subtypes demonstrated significantly increased rates of persistent use compared with the closed treatment group: open treatment of bimalleolar ankle fracture (adjusted odds ratio [aOR], 1.32; 95% CI, 1.10-1.58; P = .002) and open treatment of trimalleolar ankle fracture with fixation of posterior lip (aOR, 1.47; 95% CI, 1.04-2.07; P = .027). Rates were significantly increased (aOR, 1.56; 95% CI, 1.34-1.82; P < .001) among patients who received a total peritreatment opioid dose that was in the top 25th percentile of total oral morphine equivalents. Factors independently associated with new persistent opioid use included mental health disorders, comorbid conditions, tobacco use, and female sex. All ankle fracture treatment groups demonstrated high rates of new persistent opioid use, and persistent use was not directly linked to injury severity. Instead, we identified patient factors that demonstrated increased risk of persistent opioid use. Limiting the peritreatment opioid dose was the largest modifiable risk factor related to new persistent opioid use in this privately insured cohort. Level III, retrospective cohort study.

Implant Fracture Analysis of the TFNA Proximal Femoral Nail.

Mechanical failure of intramedullary nails is rare. This investigation was prompted by a series of cases of observed breakage of the recently introduced TFNA Proximal Femoral Nailing System (TFN [Trochanteric Fixation Nail]-Advanced; DePuy Synthes) in our region. Laboratory analysis and case data are presented, in contribution to post-market surveillance. Medical and imaging records from the 3 public tertiary orthopaedic trauma hospitals in Western Australia were reviewed. Relevant data of patients in whom breakage of the TFNA implant occurred between 2016 and 2018 were collected and analyzed. Laboratory review of retrieved implants was conducted at the Centre for Implant Technology and Retrieval Analysis (CITRA) in Western Australia. A total of 16 cases of TFNA implant breakage were recorded and analyzed. The predominant OTA/AO fracture classification was 31A3 (12 cases, 75%). The reduction quality was good in 10 cases, acceptable in 4 cases, and poor in 2 cases. The mean time to failure (and standard deviation) was 5.0 ± 2.2 months (range, 2.2 to 9.8 months). The treatment modality for the breakage was revision nailing in 11 cases, arthroplasty in 3, and nonoperative management in 2. All nails broke at the proximal screw aperture, with 1 nail additionally breaking at the distal aperture. Of 8 patients treated with a second TFNA implant for nail breakage, 3 (38%) returned with breakage of the revision implant. Laboratory analysis of the broken nails demonstrated a unique fracture pattern, with a stepped propagation pathway. This study represents the largest series, to our knowledge, of proximal femoral nail breakages in the published English literature and is the first that we are aware of to involve laboratory analysis of the TFNA implant. Changes to the nail design and/or alloy may have contributed to the observed cases of breakage, and this study will be followed by an evaluation of breakage rates in comparison with those of previous generations of nailing systems. We advise close clinical and radiographic surveillance of patients with unstable hip fracture patterns who undergo osteosynthesis with use of a TFNA implant. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Environment at the time of injury determines injury patterns in pelvic blast

The use of explosives by terrorists, or during armed conflict, remains a major global threat. Increasingly, these events occur in the civilian domain, and can potentially lead to injury and...

Pediatric tibia and femur fractures in patients weighing more than 50 kg (110lb): mini-review on current treatment options and outcome.

The main objective of this paper is to review the current literature on treatment of tibial and femur fractures in children and adolescents guided by body weight in patients weighing 50kg (110lb) or more. A secondary aim of this mini-review was to determine, as per literature review, whether weight > 50kg (110lb) is an identifiable factor associated with increased complication rate. A search of the PubMed/MEDLINE, EMBASE and Cochrane Database of Systematic Reviews databases from 1954 to September 2017 was performed to identify papers related to pediatric tibia and femur fractures in children weighing more than 50kg (110lb). Abstracts were screened, and relevant full-text articles were retrieved for further review. Reference sections of identified papers were also screened to identify further literature. All levels of evidence were included. Overall, seven full-text articles dealing with pediatric tibia or femur fractures in patients weighing more than 50kg (110lb), and one article reporting on both femur and tibia fractures in this patients' population, have been identified (n = 8 full-text article included). The articles reviewed a total of 679 children. In particular, 48/438 femur shaft fractures (mean weight: 51.7kg or 113.9lb) and 91/241 tibia fractures (mean weight: 53.3kg or 117.5lb) met the inclusion criteria. The overall rate of complications was 27.9%. In particular, the rate of complication was 51.7 and 29.6% in children with femur and tibia fracture weighing more than 50kg (110lb), respectively (p < 0.05). Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for displaced tibia and femur shaft fractures in children between six and 12-15years of age. Unstable fracture pattern, higher age and higher weight have been reported as potential risk factors associated with poor outcomes in children and adolescents treated with ESIN for displaced long bone fractures of the lower extremity, in particular femur shaft fractures. Despite these findings, data reporting exclusively on ESIN-treated long bone fractures in children weighing 50kg (110lb) or more remain scant.

Classifications in Brief: The Russell-Taylor Classification of Subtrochanteric Hip Fracture.

Classifications in Brief: The Russell-Taylor Classification of Subtrochanteric Hip Fracture.

Indications, Postoperative Management, and Advances in Ankle Fracture Fixation

Ankle fracture management continues to be an evolving process, particularly with regards to identifying unstable fracture patterns, improving fixation techniques, and optimizing postoperative management. The most accurate method to identify unstable ankle fractures based on preoperative imaging remains controversial and further prospective studies with functional outcomes and well-defined instability parameters are still needed. Several studies have investigated advanced fixation techniques, however, standard nonlocking, one-third tubular plates can still be used for the majority of fractures. Locking plates may provide a biomechanical advantage in patients with osteoporotic bone and intramedullary fibular nails may be beneficial in patients at risk for postoperative wound complications. With regards to postoperative management, the long-term benefit of early weight-bearing has yet to be proven and the need for venous thromboembolism prophylaxis remains without consensus and should be based on individual patient risk stratification. Level of Evidence: See Instructions for Authors for a complete description of levels of evidence.

Study to compare the results of osteosynthesis of unstable intertrochanteric femoral fractures in elderly osteoporotic patients versus coxafemoral bypass by cemented bipolar prosthesis

Introduction: Intertrochanteric fractures constitute about 45% of all hip fractures. Dynamic hip screw and plate (DHS) and Proximal femoral nail are commonly used for osteosynthesis. However, there are many studies which prefer hemiarthroplasty, i.e. coxafemoral bypass with cemented bipolar prosthesis as they claim that it allows early mobilization and decreases the complications of osteosynthesis. Hence, we decided to carry out this study. Material and methods: The present study was a retrospective review of all unstable or comminuted intertrochanteric fractures in elderly (above age 65 years) patients who were operated with osteosynthesis with DHS and plate and those with cemented hemiarthroplasty with bipolar prosthesis at MIMER Medical College, Talegaon (D) between January 2009 to December 2016. Data was collected from in-patient hospital files and out-patient department follow up. Unstable fracture patterns were included in the study. Patients in group one were operated with osteosynthesis by dynamic hip screw and plate while those in group two were operated with coxafemoral bypass surgery with cemented bipolar prosthesis. Patients were followed up in out-patient department after discharge, clinically and radiologically Results: There were 54 patients in group one (osteosynthesis with DHS plate) and 48 patients in group two (coxafemoral bypass with bipolar prosthesis). There were 21 males out of these in group one and 14 males in group two. In our study, we got less pressure sores and incidence of deep vein thrombosis in group of patients who underwent coxafemoral bypass with cemented bipolar prosthesis. Also need for blood transfusion was less than DHS group. Also hospital stay was significantly less. Operative time was, however, significantly more in bipolar group. However, there were not significant differences in implant or prosthesis related failure, pulmonary complications, dislocations or mortality in both groups. Bipolar cemented prosthesis group has better Harris Hip Score. Conclusion: Cemented bipolar prosthesis gives better results in unstable intertrochanteric femur fractures as compared to osteosynthesis

Treatment of forearm fractures in children and adolescents with titanium elastic nails (Tens): A prospective study

Paediatric forearm fractures are generally treated nonoperatively by close reduction and casting. Recently there has been trend on intramedullary nailing of diaphyseal forearm fractures for unstable fracture pattern to impove clinical outcomes. In our study we evaluated the rate of fracture union, functional outcome and complications in forearm fractures of children and adolescents treated with titanium elastic intramedullary nails. All cases achieved union within 16 weeks and excellent functional outcome after surgical management without significant complications. Intramedullary nailing with Titanium elastic nails is a feasible and effective method of treatment for unstable diaphyseal fractures of forearm in children and adolescents.

Fragility fractures of the pelvic ring

Improved diagnostics and ageing population have led to increasing rates of pelvic ring fragility fractures. This is a patient group that presents with significant co-morbidities, requiring wide range of resources, prolonged care, and significant financial burden. However, the literature lacks clear guidance on their diagnosis and management. Fragility fractures of the pelvis behave differently to the classical high-energy injuries in young adults, and hence, their management principles are also different. The management goal is to control pain and restore pre-injury mobility. Multidisciplinary input and early social care planning are vital. Most patients can be managed conservatively, but a selected group may require surgical fixation owing to failure to progress with conservative treatment. Early identification of those patients and unstable fracture patterns is the key to prevent progression to complex non-unions. Surgical fixation requires special considerations compared to young adult fractures. Stabilization of both anterior and posterior parts of the pelvic ring provides adequate biomechanical construct to allow full weight-bearing in this age group. This review aims to provide guidance on the assessment and management of those injuries.

Paediatric pelvic fractures: A review of 2 cohorts over 22 years

AimsThe aim of this retrospective review was to identify all children that presented to our institution with a pelvic or acetabular fracture and to compare these children to a previous cohort of paediatric pelvic fractures that we have reported. Patients53 children under the age of 16 were identified over a ten year period. MethodsWe reviewed our trauma database, hospital records and radiological imaging to determine the age, gender, fracture pattern, associated injuries and management of the pelvic fracture. ResultsThere were 32 boys and 21 girls. Mean age of the boys was 8.8 years and the girls 10.7 years. In seven children the pelvic fracture was an isolated injury and in the remaining 46 children, there were 113 additional injuries. 56% of the additional injuries was either a fracture/dislocation (37%) or a head injury (19%). Compared to our first cohort, we had a larger number of children in the second cohort. Age, sex distribution, mechanism of injury was similar in the two groups. In this current cohort, use of CT scan imaging was more frequent, there were more unstable pelvic fracture patterns identified, ISS scores were higher and mortality was lower. ConclusionWe have seen more children with more severe injuries, higher ISS scores but a lower mortality rate.

Hybrid blade and locking plate fixation for proximal humerus fractures: a comparative biomechanical analysis

BackgroundOpen reduction and internal fixation of proximal humerus fractures can be difficult to achieve adequate, complication free results due to osteopenia of the proximal humerus and unstable fracture patterns. This study aimed to compare the biomechanical properties of a novel hybrid fixed angle blade plate (Fx plate) with an established fixed angle locking plate (PHILOS plate).MethodsA two-part fracture was simulated in synthetic composite humeri by creating a transverse osteotomy and 10 mm fracture gap at the surgical neck. After treating the fractures with either an Fx plate or a PHILOS plate, humeral head was fixed and the shaft was displaced in a cantilever fashion. For elastic tests, loading was along the frontal and sagittal plane to achieve varus/valgus and extension/flexion, respectively. In plastic tests, loading was in a varus direction to determine the constructs’ resistance to varus collapse.ResultsIn elastic tests, both construct types had higher peak load and stiffness in extension/flexion than varus/valgus. Fx plate constructs were significantly stiffer than PHILOS constructs in varus/valgus (mean: 7.590/6.900 vs. 6.609/6.091 N/mm; p < 0.001 for both) but significantly less stiff in extension/flexion (8.770/9.541 vs. 9.533/9.997 N/mm; p < 0.001 for extension, p < 0.05 for flexion). In varus plastic tests, significantly higher peak loads were reported for Fx plate than PHILOS (134.391 vs. 115.531 N; p < 0.001).ConclusionsIn this fracture gap model, humeri implanted with a novel Fx plate provided higher varus/valgus stiffness but lower extension/flexion stiffness than a more traditional proximal humeral locking plate design (PHILOS).

Risk Factors Associated With Cephalomedullary Nail Cutout in the Treatment of Trochanteric Hip Fractures.

To evaluate the association of cephalomedullary nail cutout in trochanteric femur fractures with the presence of the following radiographic variables: lateral wall fracture, posteromedial fragment, angular malreduction, residual basicervical fracture gapping, screw placement, and tip-apex distance. Retrospective review. Academic medical center. A total of 362 patients were included in the study. The average age was 83 years and the majority was female. All sustained low-energy trochanteric femur fractures treated operatively with cephalomedullary nails. Minimum radiographic follow-up was 3 months, with an average of 11 (range 3-88) months. Cephalomedullary nailing with either a lag screw or helical blade. Cutout of the lag screw or helical blade. A total of 22 (6%) cutouts occurred. Univariate analysis showed significantly (P ≤ 0.01) more frequent cutout with fracture of the lateral wall, posteromedial fragment, residual gapping (>3 mm) at basicervical component, neck-shaft malreduction >5 degrees varus or 15 degrees valgus, and tip-apex distance >25 mm, and superior screw/blade positioning. There was no difference with unstable fracture pattern (P = 0.58) or fellowship training (P = 0.21). Multivariate regression analysis demonstrates that lateral wall fracture (Odds ratios [OR] = 8.0, 95% confidence interval [CI], 2.4-27.1), neck-shaft malreduction (OR = 4.3, CI, 1.3-14.7), and residual basicervical gapping (OR = 3.6, CI, 1.0-13.0) were associated with fixation cutout. Risk factors for cutout of trochanteric fractures in our study can be viewed as modifiable or nonmodifiable factors. Statistically significant factors included lateral wall fracture (nonmodifiable) as well as basicervical gapping and malreduction (modifiable). Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is trochanteric fixation nail a better implant in the management of intertrochanteric fracture in elderly compared to dynamic hip screw

Background: Intertrochanteric fractures are the most common fractures in elderly and have devastating sequence if not managed properly. The ultimate goal in the management of Intertrochanteric fracture is early mobilization of patients to prevent morbidity and mortality. Early mobilization primarily depends on the implant used & stability of the surgical construct. The purpose of this study is to compare the functional and radiological outcome of intertrochanteric fractures in elderly & osteoporotic patients managed with Dynamic Hip Screw (DHS) & Trochanteric Fixation Nail (TFN). Materials and Methods: The present study was carried out at Rajah Muthiah Medical College & Hospital from June 2016 to May 2017. 20 patients of age more than 60 years with intertrochanteric factures of femur were treated with Trochanteric Fixation nail (10 cases) and Dynamic Hip Screw (10 cases). Discussion: Individual cases were followed up for at least 24 weeks to one year and during each & every follow up visit clinical, radiological, functional outcomes were documented, analyzed, evaluated and compared. In our study of 10 patients, we had 8 patients (40%) with stable type of fracture pattern and 12 patients (60%) cases were of unstable fracture pattern. 5 patients underwent DHS and 3 patients underwent TFN in the stable category of 8.Whereas 5 patients underwent DHS and 7 patients underwent TFN in unstable Intertrochanteric fracture group of 12 patients. Results: The Average time taken for union was about 16 weeks (Range: 12 to 20 weeks) and full weight bearing correlated well with the time of fracture union. Conclusion: We conclude that the fracture pattern& experience of the surgeon are the primary determinants of implants choice & primary fixation of intertrochanteric fractures aid early rehabilitation and return back to activities of daily living.

Evidence based management of intracapsular neck of femur fractures.

Neck of femur fractures are occurring at an increased incidence. Functionally independent patients without cognitive impairment can expect reasonable life expectancy. This indicates the need for a durable surgical option that optimises the chance to return to pre-injury functional status, with minimal risk of complications and reoperation. Most fractures are displaced. Surgical options include internal fixation, hemiarthroplasty or total hip arthroplasty (THA). Evidence is conclusive that arthroplasty options outperform internal fixation in terms of function, quality of life and reoperation rates. In anyone other than young patients where head preserving surgery is required, arthroplasty is the standard of care. Hemiarthroplasty is the heavily favoured arthroplasty option for surgeons. However, in patients other than the extreme elderly, medically infirm, neurologically impaired, or with little or no ambulatory capacity, the evidence to support hemiarthroplasty is lacking. In functionally independent patients without cognitive impairment, THA should be considered the gold standard, producing better functional and quality of life outcomes, lower reoperation rates and better cost effectiveness, with no difference in complications or mortality. An increased risk of dislocation does exist. This may be reduced with modern surgical technique and implant options. Low amounts of research have been afforded to undisplaced fractures. For this fracture type, surgery is the standard of care. Despite a higher risk of reoperation, internal fixation is the preferred option for all age groups. Further study is required to identify the difference between internal fixation and THA, in particular, for unstable fracture patterns in elderly patients.

Comparative study between proximal femoral nail and dynamic hip screw with trochanteric stabilizing plate in unstable intertrochantric femur fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Unstable fractures accounts for approximately 50 to 60% of all intertrochanteric fractures. Failure rates of (DHS) dynamic hip screw for unstable fracture patterns are as high as 50%. Proximal femoral nail is technically more demanding surgery and also associated with complications like implant failure, femoral shaft fracture, improper reduction, screw cut-out and non-union. This study was done to compare the results of using Trochanteric stabilization plate in addition to dynamic hip screw versus proximal femoral nail which is considered as a better implant for unstable fractures.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;A prospective study was conducted comparing outcomes of proximal femoral nailing versus trochanteric stabilization plate with dynamic hip screw for 44 patients with unstable intertrochanteric fractures (22 each). Harris hip scoring system and Parker mobility score was used for evaluation&lt;/span&gt;.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;In our study, Average time of union in all 22 patients of PFN group was about 12 weeks while average time of union in all 22 patients of DHS with TSP group was about 14 weeks. The Harris hip score was 85.45 in DHS with TSP group while it was 84.72 in the PFN group (p=0.846). The Parker mobility score was 7.81 in the DHS with TSP group while it was 7.95 in the PFN group (p=0.728)&lt;/span&gt;&lt;span lang="EN-IN"&gt;. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Use of TSP with DHS can give good results in unstable IT fractures. Addition of TSP to DHS gives good lateral wall buttress which prevent excessive medialisation of shaft and gives comparable result to PFN.&lt;/span&gt;&lt;/p&gt;

Proximal Femoral Shortening After Cephalomedullary Nail Insertion for Intertrochanteric Fractures

To assess the incidence of proximal femoral shortening (PFS) and its effect on the patient outcomes when intertrochanteric fractures were treated with a cephalomedullary nail (CMN). Retrospective cohort study. Level II trauma center. Forty-eight consecutive patients with OTA/AO 31-A intertrochanteric fractures. All patients were treated with a Gamma3 CMN (Stryker, Kalamazoo, MI). PFS was assessed for abductor lever arm (x vector), femoral height (y vector), and overall shortening (z vector) on anteroposterior radiographs. Fixation success and retained ambulatory capacity were noted. Shortening of >5 mm of the x, y, and z vectors was evident in 18, 20, and 29 patients, respectively. Shortening of >10 mm of the x, y, and z vectors was measured in 5, 6, and 8 patients, respectively. Mean shortening of the x, y, and z vectors was 4.5, 5.5, and 7 mm, respectively. Greater PFS was found to be associated with fixation failure and inability to retain ambulatory capacity, independently (P ≤ 0.05 and P ≤ 0.025, respectively). Of note, an unstable fracture pattern was not found to be associated with greater PFS. PFS is a common phenomenon after CMN of intertrochanteric fractures with a Gamma CMN. In addition, greater PFS seems to be associated with fixation failure and inability to retain ambulatory capacity postoperatively. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The tip-apex distance in the X-Bolt dynamic plating system.

ObjectivesThe Sliding Hip Screw (SHS) is commonly used to treat trochanteric hip fractures. Fixation failure is a devastating complication requiring complex revision surgery. One mode of fixation failure is lag screw cut-out which is greatest in unstable fracture patterns and when the tip-apex distance of the lag screw is > 25 mm. The X-Bolt Dynamic Hip Plating System (X-Bolt Orthopaedics, Dublin, Ireland) is a new device which aims to reduce this risk of cut-out. However, some surgeons have reported difficulty minimising the tip-apex distance with subsequent concerns that this may lead to an increased risk of cut-out.Patients and MethodsWe measured the tip-apex distance from the intra-operative radiographs of 93 unstable trochanteric hip fractures enrolled in a randomised controlled trial (Warwick Hip Trauma Evaluation, WHiTE One trial). Participants were treated with either the sliding hip screw or the X-Bolt dynamic hip plating system. We also recorded the incidence of cut-out in both groups, at a median follow-up time of 17 months.ResultsThere was a significantly increased tip-apex distance with the use of the X-Bolt (mean difference 3.7mm (95% confidence interval 1.58 to 5.73); SHS mean 17.1 mm, X-Bolt mean 20.8; p = 0.001. However, this was not associated with an increased incidence of cut-out at a median follow-up time of 17 months, with three cut-outs (6%) in the SHS group and 0 (0%) in the X-Bolt group.ConclusionThe X-Bolt is a safe implant with no increased risk for cut-out. Concerns about minimising the tip-apex distance may be justified but do not appear to be clinically important.Cite this article: M. A. Fernandez, A. Aquilina, J. Achten, N. Parsons, M. L. Costa, X. L. Griffin. The tip-apex distance in the X-Bolt dynamic plating system. Bone Joint Res 2017;6:–207. DOI: 10.1302/2046-3758.64.BJR-2015-0016.R2.

Combat-related pelvic ring fractures in survivors

Background: Pelvic fractures have been associated with rates of mortality up to 20%, with open injuries approaching rates up to 50%. This study compares differences in patients with open and closed pelvic ring injuries sustained during combat. Methods: Retrospective review of 114 patients who sustained a pelvic ring fracture and were alive upon presentation to the United States. We collected demographics, associated injuries, transfusion requirements, and outcomes to include residual bowel or bladder dysfunction and ambulatory status. Results: There were 114 patients, 98% male, with 75 closed and 39 open injuries. Average age was 26.6 yr. An average of 8.1 and 28.1 units of red blood cells were transfused in closed and open injuries, respectively (P&lt;0.0001). Bilateral lower extremity amputations occurred in 11% of closed and 59% of open injuries (P&lt;0.0001). Unstable fracture patterns occurred in 39% of closed fractures compared to 51% in open fractures (P=0.233). The time to weight bearing was 93 and 126 days for closed and open injuries (P=0.039). At latest follow-up, abnormal bladder and bowel function both occurred in 10% of closed and, respectively, 39% and 33% of open injuries (P=0.006). The rate of ambulation was 94% for closed injuries and 89% for open injuries (P=0.439). Conclusions: In the largest report of combat-related pelvic fractures in surviving patients, the incidence of open fractures was 34%. Although there are significant differences in associated injuries, transfusion requirements and time to weight bearing, patients with open pelvic fractures are able to return to a similar level of ambulatory function as those with closed fractures.

Results and complications in elderly patients with acetabular fractures

Background: The frequency of acetabular fractures in elderly patients is rising over time. The group presents with underlying challenges including osteoporosis, medical comorbidities, and varying levels of baseline physical and cognitive function. The purposes of this study were to characterize such patients and to determine rates of complications and secondary operations. We propose to identify injury and treatment features associated with optimal recovery. Methods: One hundred and ninety-three patients over the age of 60 with acute acetabular fractures were retrospectively reviewed over 12 yr. Complications, mortality, and secondary operations were documented for 171 patients with complete records and mean 18.5 mo follow-up. Ninety-one were treated operatively. Results: Patients who underwent open reduction and internal fixation had a mean age of 73 yr (vs. 69 yr, P=0.0003) and mean Injury Severity Score of 28.4 (vs. 15.7, P=0.001), consistent with higher-energy injuries and unstable fracture patterns compared to patients treated nonoperatively. Twenty-two percent developed early complications, with a trend toward a higher rate in patients treated surgically (27% compared to 16%, P=0.057). After open reduction and internal fixation, posttraumatic arthrosis and conversion to total hip arthroplasty occurred in 18% and 14%, respectively, compared to 3.8% of patients who had nonoperative care (both P&lt;0.02). Mortality at 1 yr was 9.9% and at 5 yr was 29.5%, increasing with greater age. Conclusions: Additional research into efforts to expedite open reduction and internal fixation in stable patients with unstable fracture patterns may minimize complications by promoting mobility from bed. Further study to define patients better suited for nonoperative management is needed, as is investigation into the role of acute total hip arthroplasty or minimally invasive methods of reduction and fixation.

Bridge Plating Length-Unstable Pediatric Femoral Shaft Fractures

The treatment of pediatric diaphyseal femur fractures, particularly length-unstable fractures, continues to be an area of controversy in patients from age 6 to skeletal maturity. Submuscular bridge plating is an alternative that allows for stable internal fixation while minimizing soft tissue disruption. We describe a surgical technique that has simplified both implantation and removal. This technique provides a stable construct in comminuted and unstable fracture patterns allowing for early mobilization with minimal complications.