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Background: Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures., Methods: This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups., Discussion: If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella. Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284.

Background: Trauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors. Use of direct oral anticoagusants (DOACs) for VTE prophylaxis is effective in elective orthopedic surgery, but currently not approved for trauma patients. The primary objective of this study was to compare the effectiveness and safety of thromboprophylaxis of DOACs with low-molecular-weight heparin (LMWH) in trauma patients sustaining LEF., Materials and Methods: We included adult trauma patients admitted to trauma quality improvement program participating trauma centers (between 2013 and 2016), who sustained LEF and were started on DOACs or LMWH for thromboprophylaxis after admission. Propensity score matching was performed to compare symptomatic VTE and bleeding control interventions between the groups., Results: Of 1,009,922 patients in trauma quality improvement program, 167,640 met inclusion criteria (165,009 received LMWH and 2631 received DOACs). After propensity score matching, 2280 predominantly elderly (median age: 67 y) isolated femur fracture patients (median ISS: 10) were included in each group (4560 patients in total). Symptomatic VTE occurred in 1.4% of patients in both matched groups (P = 0.992). Bleeding control interventions occurred less often in the DOAC group, albeit statistically insignificant (5.8% versus 6.0%, P = 0.772)., Conclusions: This study found similar rates of VTE and bleeding control measures for thromboprophylaxis with DOACs or LMWH in matched trauma patients with LEF. Further prospective research is warranted to consolidate the safety of DOAC thromboprophylaxis in trauma patients with LEF. Favorable oral administration and likely increased adherence could benefit this high-risk population., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws. Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties. The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones. Although designed for the proximal humerus, the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity. This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest related to this manuscript., (Copyright © 2020 Chinese Medical Association. Production and hosting by Elsevier B.V. All rights reserved.)

The purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) after chemoprophylaxis in patients with pelvic and lower-extremity fractures, and to identify risk factors for VTEs in this subgroup of patients. To detect VTE, multi-detector computed tomography (CT) angiography was performed. Of 363 patients assessed, the incidence of symptomatic VTE was 12.4% (45 patients), and the incidence of symptomatic PE was 5.2% (19 patients). For the risk-factor analysis, a higher Charlson comorbidity index (p = 0.037), and a history of external fixator application (p = 0.007) were associated with increased VTE risk. Among patients who had VTE, male sex (p = 0.017), and above-the-knee fractures (p = 0.035) were associated with increased pulmonary embolism (PE) risk. In conclusions, the incidence of VTE in post-traumatic patients is not low after chemoprophylaxis. Risk factors for VTE and PE are different among patients with pelvic and lower-extremity fractures.

Aims: The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb., Patients and Methods: An economic evaluation was conducted from the perspective of the United Kingdom NHS and Personal Social Services, based on evidence from the 460 participants in the Wound Management of Open Lower Limb Fractures (WOLLF) trial. Economic outcomes were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Bivariate regression of costs (given in £, 2014 to 2015 prices) and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained associated with NPWT dressings. Sensitivity and subgroup analyses were undertaken to assess the impacts of uncertainty and heterogeneity, respectively, surrounding aspects of the economic evaluation., Results: The base case analysis produced an incremental cost-effectiveness ratio of £267 910 per QALY gained, reflecting higher costs on average (£678; 95% confidence interval (CI) -£1082 to £2438) and only marginally higher QALYS (0.002; 95% CI -0.054 to 0.059) in the NPWT group. The probability that NPWT is cost-effective in this patient population did not exceed 27% regardless of the value of the cost-effectiveness threshold. This result remained robust to several sensitivity and subgroup analyses., Conclusion: This trial-based economic evaluation suggests that NPWT is unlikely to be a cost-effective strategy for improving outcomes in adult patients with severe open fractures of the lower limb. Cite this article: Bone Joint J 2019;101-B:1392-1401.

Objectives: Treatment of open fractures is complex and patients may require muscle and skin grafts. The aim of this study was to gain a greater understanding of patient experience of recovery from open fracture of the lower limb 2-4 years postinjury., Design: A phenomenological approach was used to guide the design of the study. Interviews took place between October 2016 and April 2017 in the participants' own homes or via telephone., Setting: England, UK., Participants: A purposive sample of 25 patients were interviewed with an age range of 26-80 years (median 51), 19 were male and six female, and time since injury was 24-49 months (median 35 months)., Results: The findings identified a focus on struggling to recover as participants created a new way of living, balancing moving forward with accepting how they are, while being uncertain of the future and experiencing cycles of progress and setbacks. This was expressed through three themes: (i) 'being disempowered' with the emotional impact of dependency and uncertainty, (ii) 'being changed' and living with being fragile and being unable to move freely and (iii) 'being myself' with a loss of self, feeling and looking different, alongside recreation of self in which they integrated the past, present and future to find meaningful ways of being themselves., Conclusion: This study identified the long-term disruption caused by serious injury, the hidden work of integration that is required in order to move forward and maximise potential for recovery. Supportive strategies that help people to self-manage their everyday emotional and physical experience of recovery from injury are required. Research should focus on developing and testing effective interventions that provide support and self-management within a holistic rehabilitation plan., Trial Registration Number: Current Controlled Trials ISRCTN33756652; Post-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Introduction: The present retrospective study investigated the localization, cause, treatment and healing of long bone fractures in cattle. Over a period of ten years, medical records of 194 cattle of all ages with a long bone fracture, presented at the Clinic for Ruminants with Ambulatory and Herd Health Services at LMU Munich, were evaluated. The majority of patients (n = 131, 67.5%) were younger than two weeks of age. Of these, 118 calves sustained the fracture on the day of birth (60.8%). An obstetrical assistance was found in 57.4% (n = 58) of birth-related cases as a fracture cause. The femur was most frequently affected in calves aged up to two weeks (n = 35; 26.7%). The second most frequent fractures occurred in the metacarpus (n = 31; 22.9%) in this age group, followed by metatarsus (n = 28; 21.4%) and tibia (n = 27; 20.6%). Fractures of the antebrachium (n = 9; 6.9%) and the humerus were rare (n = 1; 0.8%). A total of 194 patients were diagnosed with 50 femur fractures (25.8%), 53 metacarpal fractures (27.3%), 43 metatarsal fractures (22.2%), 30 tibial fractures (15.5%), 11 antebrachial fractures (5.7%) and 7 humeral fractures (3.6%). Of the 194 animals, 78 (40.2%) had to be euthanized, 42 of them (53.8%) without treatment. In 150 patients, treatment was initiated, of which 110 patients (73.3%) were dismissed healthy from the clinic. Among the conservative treatment methods were stall rest, casts, casts combined with a U-shaped metal rail (walking casts) and the Thomas splint. Surgical therapy (internal fixation with plates or screws, transfixation pin casts) was used to treat 65 animals (33.5%). While 86.9% (74 out of 85) of the conservatively treated animals left the clinic alive, it were only 58.1% (36 out of 65) animals after surgical treatment. In the newborn calves, colostrum supply had a significant effect on the success of the treatment. If the gamma-glutamyl transferase concentration was below 200 IU/L in the calves aged under 4 days, the healing rate was significantly different from the cure rate of sufficiently immunized patients (26.9% (7 out of 26) vs. 65.3% (47 out of 72), P = 0.001).

Introduction: Malnutrition, as indicated by hypoalbuminemia, is known to have detrimental effects on outcomes after arthroplasty, geriatric hip fractures, and multiple general surgeries. Hypoalbuminemia has been examined in the critically ill but has largely been ignored in the orthopaedic trauma literature. We hypothesized that admission albumin levels would correlate with postoperative course in the nongeriatric lower extremity trauma patient., Methods: Patients with lower extremity (including pelvis and acetabulum) fracture who underwent operative intervention were collected from the ACS-NSQIP database. Patients younger than 65 years were included. Patient demographic data, complications, length of stay, reoperation rate, and readmission rate were collected, and patient modified frailty index scores were calculated. Poisson regression with robust error variance was then conducted, controlling for potential confounders., Results: Five thousand six hundred seventy-three patients with albumin available were identified, and 29.6% had hypoalbuminemia. Hypoalbuminemic patients had higher rates of postoperative complications [9.3% vs. 2.6%; relative risk (RR) 1.63] including increased rates of: mortality (3.2% vs. 0.4%; RR 4.86, 95% confidence interval 2.66-8.87), sepsis (1.5% vs. 0.5%, RR 2.35), and reintubation (2.3% vs. 0.4%; RR 3.84). Reoperation (5.5% vs. 2.6%, RR 1.74) and readmission (11.4% vs. 4.1%; RR 2.53) rates were also higher in patients with low albumin., Conclusion: Hypoalbuminemia is a powerful predictor of acute postoperative course and mortality after surgical fixation in nongeriatric, lower extremity orthopaedic trauma patients. Admission albumin should be a routine part of the orthopaedic trauma workup. Further study into the utility of supplementation is warranted, as this may represent a modifiable risk factor., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The aim of the present review is to assess the effectiveness of ultrasound (US) in the detection of upper and lower limb bone fractures in adults compared to a diagnostic gold standard available in secondary and tertiary care centres (e.g. radiography, CT scan or MRI)., Methods: The review followed PRISMA guidelines and used a database-specific search strategy with Medline, EMBASE and The Cochrane Library plus secondary sources (see supplementary material for completed PRISMA checklist). Diagnostic performance of ultrasound was assessed with a qualitative synthesis and a meta-analysis of two data subgroups., Results: Twenty-six studies were included (n = 2360; fracture prevalence =5.3 % to 75.0%); data were organised into anatomical subgroups, two of which were subjected to meta-analysis. Sensitivity and specificity ranged from 42.11 - 100% and 65.0 - 100%, with the highest diagnostic accuracy in fractures of the foot and ankle. The pooled sensitivity and specificity of US was 0.93 and 0.92 for upper limb fractures (I 2  = 54.7 % ; 66.3%), and 0.83 and 0.93 for lower limb fractures (I 2  = 90.1 % ; 83.5%)., Conclusion: Ultrasonography demonstrates good diagnostic accuracy in the detection of upper and lower limb bone fractures in adults, especially in fractures of the foot and ankle. This is supported by pooled analysis of upper and lower limb fracture subgroups. Further research in larger populations is necessary to validate and strengthen the quality of the available evidence prior to recommending US as a first-line imaging modality for prehospital use., Trial Registration: The protocol is registered with the PROSPERO International register of systematic reviews: ID =  CRD42017053640 .

Objective: The objective was to develop a disability-based metric for motor vehicle crash (MVC) upper and lower extremity injuries and compare functional outcomes between children and adults. Methods: Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 3 extremity injuries (22 unique injuries). Pediatric (7-18 years), young adult (19-45 years), middle-aged (46-65 years), and older adult (66+ years) MVC occupants with an FIM score and at least one of the 22 extremity injuries were included. DR was calculated for each injury as the proportion of occupants who were disabled of those sustaining the injury. A maximum AIS-adjusted disability risk (DR MAIS ) was also calculated for each injury, excluding occupants with AIS 4+ co-injuries. Results: Locomotion impairment was the most frequent disability type across all ages. DR and DR MAIS of the extremity injuries ranged from 0.06 to 1.00 (6%-100% disability risk). Disability risk increased with age, with DR MAIS increasing from 25.9% ± 8.6% (mean ± SD) in pediatric subjects to 30.4% ± 6.3% in young adults, 39.5% ± 6.6% in middle-aged adults, and 60.5 ± 13.3% in older adults. DR MAIS for upper extremity fractures differed significantly between age groups, with higher disability in older adults, followed by middle-aged adults. DR MAIS for pelvis, hip, shaft, knee, and other lower extremity fractures differed significantly between age groups, with older adult DR MAIS being significantly higher for each fracture type. DR MAIS for hip and lower extremity shaft fractures was also significantly higher in middle-aged occupants compared to pediatric and young adult occupants. The maximum AIS-adjusted mortality risk (MR MAIS , proportion of fatalities among occupants sustaining an MAIS 3 injury) was not correlated with DR MAIS for extremity injuries in pediatric, young adult, middle-aged, and older adult occupants (all R 2 < 0.01). Disability associated with each extremity injury was higher than mortality risk. Conclusions: Older adults had significantly greater disability for MVC extremity injuries. Lower disability rates in children may stem from their increased physiological capacity for bone healing and relative lack of bone disease. The disability metrics developed can supplement AIS and other severity-based metrics by accounting for the age-specific functional implications of MVC extremity injuries.

Background and purpose - Teriparatide accelerates fracture healing in animals and probably in man. Abaloparatide is a new drug with similar although not identical effects on the teriparatide receptor. Given at 4 times the teriparatide dose in a human osteoporosis trial, abaloparatide increased bone density more than teriparatide, and both reduced fracture risk. We investigated in mice whether abaloparatide stimulates fracture healing, and if it does so with the suggested dose effect relation (4:1). Patients and methods - In a validated mouse model for metaphyseal healing (burr hole with screw pull-out), 96 mice were randomly allocated to 11 groups: control (saline), teriparatide or abaloparatide, where teriparatide and abaloparatide were given at 5 different doses each. In a femoral shaft osteotomy model, 24 mice were randomly allocated to 3 groups: control (saline), teriparatide (15 µg/kg) or abaloparatide (60 µg/kg). Each treatment was given daily via subcutaneous injections. Results were evaluated by mechanical testing and microCT. Results - In the metaphyseal model, a dose-dependent increase in screw pull-out force could be seen. In a linear regression analysis (r = 0.78) each increase in ln(dose) by 1 (regardless of drug type) was associated with an increase in pull-out force by 1.50 N (SE 0.18) (p < 0.001). Changing drug from teriparatide to abaloparatide increased the force by 1.41 N (SE 0.60; p = 0.02). In the diaphyseal model, the callus density was 23% (SD 10), 38% (SD 10), and 47% (SD 2) for control, for teriparatide and abaloparatide respectively. Both drugs were significantly different from controls (p = 0.001 and p = 0.008), but not from each other. Interpretation - Both drugs improve fracture healing, but in these mouse models, the potency per µg of abaloparatide seems only 2.5 times that of teriparatide, rather than the 4:1 relation chosen in the clinical abaloparatide-teriparatide comparison trial.

Purpose: Infectious complications following lower extremity fracture surgery are a major concern and account for a substantial socio-economic burden to society. The aim of this pilot study was to investigate the feasibility of a new portable single-use negative pressure wound therapy device in patients undergoing major foot ankle surgery., Methods: Patients undergoing major foot ankle fracture surgery at a single level 1 trauma centre were eligible for this prospective case series. Patient characteristics were collected, as were fracture and surgical characteristics. Primary outcome was surgical site infection within 30 days as classified by the criteria from the Centers for Disease Control and Prevention. Patients in the prospective cohort were case-matched with a historical cohort from the same institution., Results: Sixty patients were included. In seven patients, the NPWT failed and treatment was ceased. Mean age was 44 years and 85% was ASA 1; 43% of the patients were actively smoking. Indications for surgery were midfoot, calcaneal, talar, and ankle fractures. In 53 patients, four (7.5%) surgical site infections occurred, two superficial (3.3%) and two (3.3%) deep infections. For 47 patients, a match was available. The incidence of surgical site infection did not statistically significantly differ between the prospective cohort and retrospective matched cohort (4.3 versus 14.9%, p = 0.29, respectively). This was also the case when looking at superficial and deep surgical site infections separately (0 versus 8.5%, p = 0.08, and 4.3 versus 6.4%, respectively)., Conclusion: We have observed surgical site infections in 7.5% of the patients with the use of prophylactic negative pressure wound therapy. The incidence of surgical site infections was not statistically significantly lower compared to a matched historical cohort.

Introduction We aimed to identify population demographics of motorcyclists and pillion passengers with isolated open lower-limb fractures, to ascertain the impact of the revised 2009 British Orthopaedic Association/British Association of Plastic Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4), in terms of time to skeletal stabilisation and soft-tissue coverage, and to observe any impact on patient movement. Methods Retrospective cohort data was collected by the Trauma Audit and Research Network (TARN). A longitudinal analysis was performed between two timeframes in England (pre-and post-BOAST 4 revision): 2007-2009 and 2010-2014. Results A total of 1564 motorcyclists and 64 pillion passengers were identified. Of these, 93% (1521/1628) were male. The median age for males was 30.5 years and 36.7 years for females. There was a statistically significant difference in the number of patients who underwent skeletal stabilisation (49% vs 65%, P < 0.0001), the time from injury to skeletal stabilisation (7.33 hours vs 14.3 hours, P < 0.0001) and the proportion receiving soft-tissue coverage (26% vs 43%, P < 0.0001). There was no difference in the time from injury to soft-tissue coverage (62.3 hours vs 63.7 hours, P = 0.726). The number of patients taken directly to a major trauma centre (or its equivalent) increased between the two timeframes (12.5% vs, 41%, P < 0.001). Conclusions Since the 2009 BOAST 4 revision, there has been no difference in the time taken from injury to soft-tissue coverage but the time from injury to skeletal stabilisation is longer. There has also been an increase in patient movement to centres offering joint orthopaedic and plastic care.

Purpose: Patients with fractures of the pelvis and/or lower extremities are at a high risk of developing postoperative venous thromboembolism (VTE). The purpose of this study was to determine whether the thrombin-antithrombin III complex (TAT) tests could be used for postoperative screening of VTE in patients with lower limb or pelvic fractures., Methods: We enrolled 133 patients who underwent surgical treatment for fracture of the pelvis or lower extremities. TAT and D-dimer levels were compared in patients with and without VTE. Receiver operating characteristic (ROC) curve analysis was done and the appropriate TAT and D-dimer cutoff levels were determined for VTE screening., Results: VTE was diagnosed in 41 patients (30.8%). Patients with VTE had significantly higher levels of TAT and D-dimer on postoperative days 1, 3, and 7 than those without VTE, respectively. ROC curve analysis suggested that TAT test at postoperative day 7 had the highest accuracy for predicting postoperative VTE. With the optimal cutoff TAT level of 3.0 ng/mL, sensitivity and specificity were 93.3% and 70.1%, respectively. With the optimal cutoff D-dimer level of 7.4 µg/mL, sensitivity and specificity were 93.3% and 57.0%, respectively., Conclusion: TAT levels measured at postoperative day 7 could be the most useful parameter for screening postoperative VTE. TAT can be used as a screening tool for screening postoperative VTE in patients with lower limb and pelvic fractures.

Unlabelled: In this cross-sectional study the psychometric properties are examined of the adapted Dutch translation of the Short Musculoskeletal Function Assessment (SMFA) questionnaire in severely injured patients (ISS>15)., Patients and Methods: Patients (N=173) completed the SMFA, the World Health Organization Quality of Life assessment instrument-BREF (WHOQOL-BREF), the Dutch Impact of Event Scale (IES), the Hospital Anxiety and Depression Scale (HADS) and the Cognitive Failure Questionnaire (CFQ). The Abbreviated Injury Score and the Injury Severity Score were established to determine the injured body area and the severity of the injuries. Exploratory factor analysis (method: PAF) was performed. Correlations were calculated between our SMFA factors and scores on the WHOQOL-BREF, IES, HADS and CFQ. The SMFA scores of the factors Upper extremity dysfunction and Lower extremity dysfunction were compared between subgroups of patients with and without injuries in respectively the upper extremities and the lower extremities. For responsiveness analysis, data were compared with the baseline SMFA measurement of a reference group., Results: A three-factor structure was found: Lower extremity dysfunction, Upper extremity dysfunction, and Emotion. Strong correlations between the SMFA and the other questionnaires were found. Patients with injury of the lower extremities had significantly higher scores on the factor Lower extremity dysfunction than patients without injury of the lower extremities (p=0.017). In none of the factors, a significant difference in mean scores was found between patients with and without injury of the upper extremities. Severely injured patients had significantly higher SMFA scores than the reference group (p<0.001)., Conclusion: The adapted Dutch translation of the SMFA showed good psychometric properties in severely injured patients. It appeared to be useful to get a general overview of patients' Health Status as well as patients' Health Related Quality Of Life., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Bone stress injuries (BSIs) are common running injuries and may occur at a rate of 20% annually. Both biological and biomechanical risk factors contribute to BSI. Evaluation of a runner with suspected BSI includes completing an appropriate history and physical examination. MRI grading classification for BSI has been proposed and may guide return to play. Management includes activity modification, optimizing nutrition, and addressing risk factors, including the female athlete triad. BSI prevention strategies include screening for risk factors during preparticipation evaluations, optimizing nutrition (including adequate caloric intake, calcium, and vitamin D), and promoting ball sports during childhood and adolescence., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Millions of dollars are lost each year to the US military in medical discharges from injuries sustained in the initial training of recruits. Most medical discharges in recruits are related to musculoskeletal overuse injuries, including stress fractures. Any strategies that can reduce injury rates are also likely to reduce rates of medical discharge. This study evaluated the Army Physical Readiness Training (PRT) program which was established to provide a method of physical fitness training that would reduce the number of preventable injuries. We conducted a retrospective study to evaluate the number of lower extremity stress fractures that were diagnosed in the 6 months prior to and 6 months following the implementation of the PRT program. Electronic medical records were queried for specific diagnoses of stress fractures to the pelvis, femoral neck, femoral shaft, tibia, fibula, tarsals and metatarsals. The observed number of diagnoses in each time period were compared using the χ² method. Decrease was shown not only in the overall occurrence of stress fractures, but specifically in the occurrence of stress fractures of the femoral neck, femoral shaft, and tarsals. Our study was able to show a correlation between the PRT program and a decrease in the observed occurrence of lower extremity stress fractures.

Background: Background: Gender disparities in pediatric fracture events has been well-documented however, less is known about racial disparities. The aim of this study is to investigate the epidemiology of pediatric bone fractures in a Hispanic population., Methods: This is a retrospective cross-sectional analysis of patient’s records from a Pediatric Orthopeadic outpatient clinic in the Southwest region of Puerto Rico during a 1-year span (August 2014 – August 2015). Differences in sex, BMI, health insurance coverage, parental educational level and employment status, mechanism of fracture, fracture site, and seasonality were investigated among three age classes (pre-school children, school children and adolescents)., Results: The sample consited of 243 subjects (0-21 y/o) sustaining a fracture of any extremity within the study period. Boys were at a higher risk of having a fracture event and as age increased, the male/female ratio also increased. The mean BMI was 18.0 kg/m2, with the highest in the school children age group (20.3 kg/m2). Slighlty more than half of the subjects (55.7%) benefitted from public health insurance coverage. The typical father was a laborer with a high school diploma, while the mother had a high school diploma but was unemployed There was a tendency for the children to suffer a bone fracture while at school (49.4%), followed by fractures at home (34.6%). In both the pre-school and school children groups, the upper extremity was more frequently involved (66.7% and 63.9%, respectively) in fracture events. Finally, there was very little variation in the seasonality of fracture events., Conclusion: This study provided valuable epidemiological information about pediatric bone fractures within a Hispanic population. It may contribute to the development and implementation of educational and preventive strategies appropriate to age and sex-differences.

As long as radiography remains cheap and provides value in patient care, it will continue to be widely used as a front-line imaging technique. There are limitations to what a radiograph can depict, however. It is imperative to understand the limitations of radiography to avoid pitfalls owing to the overlap of numerous osseous structures. This article reminds the reader of the association between certain radiographic abnormalities and the anatomic relevance in the patient. Although interpretive errors occur in fast-paced, high-volume emergency settings, meticulous attention to changes in the cortex and medullary bone may help to keep errors to a minimum., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Obese patients are highly prevalent in the pediatric orthopaedic surgeon's practice and obesity is an increasing issue in the United States. Increased body mass index (BMI) has been associated with increased complications in pediatric orthopaedic patients, but no study has looked specifically at external fixation. The purpose of this study was to determine whether obesity is a risk factor for increased complications in lower-extremity procedures requiring external fixation., Methods: A retrospective chart review was conducted of pediatric patients who underwent external fixation as definitive operative treatment for any condition at a tertiary care hospital over a 15-year period. Patients were grouped into normal weight, overweight, and obese based on Centers for Disease Control definitions. All orthopaedic complications were recorded., Results: A total of 208 patients with a mean age of 11.2 years were identified. Ninety-four children were obese at the 95th percentile BMI or higher, 22 were overweight and 93 were normal weight. External fixation was applied to the tibia in 82 cases, to the femur in 77 and to both in 49. Mean duration of fixation was 160 days (range, 31 to 570 d) and patients were followed for a mean of 3.9 years (range, 1.0 to 12.0 y). There was no statistically significant difference in the rate of complications between the 3 groups (P=0.61). In the obese group complications occurred in 68.1% versus 66.7% in the overweight group and 61.3% in normal weight., Conclusions: In the setting of external fixator use for lower-extremity pathology in pediatric patients, there is no association between an increase in complications and obesity as defined by BMI. Complication rates are high when external fixation is utilized for the lower extremity, however, patients and families should not be counseled that increased BMI will add to the burden of orthopaedic complications in this situation., Level of Evidence: Level II-prognostic.

Study Design: Systematic review., Objectives: To systematically review the descriptors used to define running-related musculoskeletal injury and to analyze the implications of different definitions on the results of studies., Background: Studies have developed their own definitions of running-related musculoskeletal injuries based on different criteria. This may affect the rates of injury, which can be overestimated or underestimated due to the lack of a standard definition., Methods: Searches were conducted in the Embase, PubMed, CINAHL, SPORTDiscus, LILACS, and SciELO databases, without limits on date of publication and language. Only articles that reported a definition of running-related injury were included. The definitions were classified according to 3 domains and subcategories: (1) presence of physical complaint (symptom, body system involved, region), (2) interruption of training or competition (primary sports involved, extent of injury, extent of limitation, interruption, period of injury), and (3) need for medical assistance. Spearman rank correlation was performed to evaluate the correlation between the completeness of definitions and the rates of injury reported in the studies., Results: A total of 48 articles were included. Most studies described more than half of the subcategories, but with no standardization between the terms used within each category, showing that there is no consensus for a definition. The injury rates ranged between 3% and 85%, and tended to increase with less specific definitions., Conclusion: The descriptors commonly used by researchers to define a running-related injury vary between studies and may affect the rates of injuries. The lack of a standardized definition hinders comparison between studies and rates of injuries.

Purpose: This prospective study examined the psychometric properties of the adapted Dutch translation of the Short Musculoskeletal Function Assessment (SMFA) questionnaire in patients with isolated unilateral lower fracture (LEF) or upper extremity fracture (UEF)., Methods: Patients (N = 458) completed the SMFA, WHOQOL-BREF, and the RAND-36 at time of diagnosis (i.e. pre-injury status), 1, and 2 weeks post-fracture. Principal axis factoring was performed, and Cronbach's alpha coefficients (α) and intra-class correlation coefficients (ICC) were calculated. Furthermore, Pearson's product-moment correlations (r), paired t tests, and standardized response means (SRM) were calculated., Results: A three-factor structure was found: Lower extremity dysfunction, Upper extremity dysfunction, and Daily life consequences. This structure was different for patients with LEF versus UEF. ICCs ranged from .68 to .90, and α varied from .81 to .95. The correlations between the SMFA and, respectively, the RAND-36 and WHOQOL-BREF were small to large depending on the SMFA factor combined with fracture location. Responsiveness was confirmed (p < .0001; SRM ranging from .28 to 1.71)., Conclusions: The SMFA has good psychometric properties in patients with fractures. Patients with UEF and LEF could not be regarded as a homogenous group. The development of separate SMFA modules should be considered.

Partial weight bearing is often prescribed for patients with orthopedic injuries. Patients’ ability to accurately reproduce partial weight bearing orders is variable, and its impact on clinical outcomes is unknown. This observational study measured patients’ ability to reproduce partial weight bearing orders, factors influencing this, patients’ and physiotherapists’ ability to gauge partial weight bearing accuracy, and the effect of partial weight bearing accuracy on long-term clinical outcomes. Fifty-one orthopedic inpatients prescribed partial weight bearing were included. All received standard medical/nursing/physiotherapy care. Physiotherapists instructed patients in partial weight bearing using the hand-under-foot, bathroom scales, and/or verbal methods of instruction. Weight bearing was measured on up to 3 occasions during hospitalization using a force-sensitive insole. Factors that had the potential to influence partial weight bearing accuracy were recorded. Patients and their physiotherapists rated their perception of partial weight bearing accuracy. Three-month clinical follow-up data were retrieved from medical records. The majority of patients (72% or more) exceeded their target load, with mean peak weight bearing as high as 19.3 kg over target load (285% of target load). Weight bearing significantly increased over the 3 measurement occasions (P<.001) and was significantly associated with greater body weight (P=.04). Patients and physiotherapists were unable to accurately gauge partial weight bearing accuracy. The incidence of clinically important complications at 3 months was 9% and not significantly associated with partial weight bearing accuracy during hospitalization (P≥.45). Patients are unable to accurately reproduce partial weight bearing orders when trained with the hand-under-foot, bathroom scales, or verbal methods of instruction.

Background: Presentation of own experiences, observations and results of treatment of patients with stress fractures treated in the Department of Paediatric Orthopaedics. The authors present an algorithm of diagnosing and treatment of stress fractures., Material and Methods: Over the period 1998 - 2010, 38 patients were hospitalised (40 fractures) with the final diagnosis of stress fracture. Personal patients' data, case histories and management preceding the diagnosis of the disease, diagnostic and therapeutic methods, as well as the results of treatment were collected on the basis of medical documentation. Standard diagnostic procedure consisted of: clinical and radiological examination, laboratory tests as well as computed tomography (CT). In 11 cases, the procedure included also scintigraphy and in two children MRI scan was performed., Results: Complete healing of fractures was finally achieved in all patients, Conclusions: In case of suspected stress fracture, it is necessary to perform a series of radiograms, which should present the picture of bone rebuilding and incorporation of the periosteal callus. If plain radiograph is inconclusive we should consider MRI , CT or scintigraphy scan. The results of laboratory tests should not show any abnormalities. In case of confirmed stress fracture nonweight-bearing of the affected extremity is recommended as well as introducing of close clinical-radiological monitoring. The results of MRI examination should be interpreted very cautiously, be cause it can be misleading. The observation strategy (“wait and see”) should be implemented. However, the lack of the regression of pain sensation, bone rebuilding features and incorporation of periosteal callus or the appearance of visible bone destruction (lysis) should raise questions and present an indication for taking biopsy of the laesion.

Rotationplasty is a reconstructive, limb-sparing option for management of lower extremity bone deficiency. This technique involves an intercalary resection, followed by 180° rotation of the distal limb to allow the ankle to function as a knee joint when it is fitted with a modified below-knee prosthesis. Gait analysis and functional outcome studies have reported favorable results with rotationplasty compared with those of above-knee amputation. Moreover, patient satisfaction with rotationplasty is higher than with other limb salvage procedures. The primary drawback of this procedure is patient acceptance of the limb's appearance.

A method for the qualitative assessment of certain characteristics of the bullet trajectory in the case of a gunshot wound to an extremity is proposed to be used for the mathematical simulation of the mechanism of formation of such injuries.

Background: Deleterious effects of lower limb immobilization in adults have been well described and suggest that altered muscle strength was not fully recoverable after rehabilitation. In this study, we hypothesized that the same significant differences in strength and power performances between the injured and noninjured leg are foreseeable 18 months after a lower limb fracture in teenagers, and between injured adolescents and healthy controls., Methods: The effects of cast immobilization on the strength and power performance were evaluated 18 months after a lower limb fracture in 39 injured teenagers who were paired with healthy controls. Strength and power performance were assessed during a single-leg vertical jump test using a force platform., Results: At 18 months, strength performance in injured teenagers was similar in both lower limbs. A significant difference was found between injured and noninjured legs for maximal muscular power measurement. However, the limb symmetry index was superior to 85% for maximal muscular power, which should be considered as normal. Limb asymmetries greater than 15% for muscular strength and power were more frequent in injured teenagers than in noninjured children and adolescents, but the difference was statistically significant only for the mean muscle power (P=0.0003)., Conclusions: These findings show that the recovery of muscular strength and power is foreseeable after a lower limb fracture in the pediatric population, even if a greater percentage of injured teenagers was found to have limb asymmetries greater than 15% for mean muscular power 18 months after trauma compared with the healthy controls., Level of Evidence: Level III, case-control study.

Objective: The purposes of this study were (a) to evaluate the distribution by primary payer (public vs. private) of U.S. pediatric patients aged 5-18 years who were hospitalized with a sports-related lower extremity fracture and (b) to discern the adjusted mean hospital length of stay and mean charge per day by payer type., Methods: Children who were aged 5 to 18 years and had diagnoses of lower extremity fracture and sports-related injury in the 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database were included. Lower extremity fractures are defined as International Classification of Diseases, 9th Revision, Clinical Modification codes 820-829 under Section "Injury and Poisoning (800-999)," while sports-related external cause of injury codes (E-codes) are E886.0, E917.0, and E917.5. Differences in hospital length of stay and cost per day by payer type were assessed via adjusted least square mean analysis., Results: The adjusted mean hospital length of stay was 20% higher for patients with a public payer (2.50 days) versus a private payer (2.08 days). The adjusted mean charge per day differed about 10% by payer type (public, US$7,900; private, US$8,794)., Conclusions: Further research is required to identify factors that are associated with different length of stay and mean charge per day by payer type, and explore whether observed differences in hospital length of stay are the result of private payers enhancing patient care, thereby discharging patients in a more efficient manner.

Stress reactions and stress fractures in the lower extremities occur frequently in military and athletic populations. As the clinical symptoms of stress fracture may mimic other less severe musculoskeletal injuries, the diagnosis of stress fracture can often be delayed. The following article reviews the characteristics, advantages and disadvantages of the various imaging tools available to detect stress fracture of the lower limbs in order to clarify their utility when diagnosing this condition. Plain radiography, the primary imaging tool for diagnosing suspected stress injuries, may not detect stress fracture injury until fracture healing is well underway. In some cases of suspected stress fracture, this delay in diagnosis can lead to catastrophic fracture and surgical intervention. Bone scintigraphy has long been recommended for the diagnosis of stress fracture, claiming that skeletal scintigraphy is 100% sensitive for the detection of stress fracture. However, there is a potential for a false negative examination and findings might be nonspecific as tumours or infections may mimic stress injury. In addition, bone scintigraphy involves ionizing radiation and it should not be used whenever there is an alternative. Computed tomography (CT) provides exquisitely fine osseous detail, but should be reserved only for specific indications because it also involves ionizing radiation. Magnetic resonance (MR) imaging, which is noninvasive, has no ionizing radiation, is more rapidly performed than bone scintigraphy, and should be the method of choice for stress fracture diagnosis whenever it is available. However, using MR imaging demands an experienced diagnostician in order to decrease reported false-positive injuries. The ultrasonography technique, which is being used increasingly in the evaluation of the musculoskeletal system has recently been shown to have some potential in the diagnosis of stress fracture; however, currently the imaging modalities are insufficient. The peripheral quantitative CT (pQCT) device, which has been developed to specifically assess skeletal status of the extremities, provides data on bone geometry, strength and density. However, the pQCT needs further evaluation prior to being considered for use in diagnosis stress changes in bone. This article reviews the utility of each of the imaging modalities currently available to detect stress fracture injuries of the lower extremities, as well as other utilization factors, which include exposure to ionizing radiation, the ability to detect early- and late-stage reactions in the bone and surrounding soft tissues, and the ability to differentiate between different types of bone lesions.

The intramedullary nail or rod is commonly used for long-bone fracture fixation and has become the standard treatment of most long-bone diaphyseal and selected metaphyseal fractures. To best understand use of the intramedullary nail, a general knowledge of nail biomechanics and biology is helpful. These implants are introduced into the bone remote to the fracture site and share compressive, bending, and torsional loads with the surrounding osseous structures. Intramedullary nails function as internal splints that allow for secondary fracture healing. Like other metallic fracture fixation implants, a nail is subject to fatigue and can eventually break if bone healing does not occur. Intrinsic characteristics that affect nail biomechanics include its material properties, cross-sectional shape, anterior bow, and diameter. Extrinsic factors, such as reaming of the medullary canal, fracture stability (comminution), and the use and location of locking bolts also affect fixation biomechanics. Although reaming and the insertion of intramedullary nails can have early deleterious effects on endosteal and cortical blood flow, canal reaming appears to have several positive effects on the fracture site, such as increasing extraosseous circulation, which is important for bone healing.