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Background and Purpose:  Hand fractures are commonly presented in emergency departments, yet diagnostic errors persist, leading to potential complications. The use of artificial intelligence (AI) in fracture detection has shown promise, but research focusing on hand metacarpal and phalangeal fractures remains limited. We aimed to train and evaluate a convolutional neural network (CNN) model to diagnose metacarpal and phalangeal fractures using plain radiographs according to the AO/OTA classification system and custom classifiers., Methods:  A retrospective analysis of 7,515 examinations comprising 27,965 images was conducted, with datasets divided into training, validation, and test datasets. A CNN architecture was based on ResNet and implemented using PyTorch, with the integration of data augmentation techniques., Results:  The CNN model achieved a mean weighted AUC of 0.84 for hand fractures, with 86% sensitivity and 76% specificity. The model performed best in diagnosing transverse metacarpal fractures, AUC = 0.91, 100% sensitivity, 87% specificity, and tuft phalangeal fractures, AUC = 0.97, 100% sensitivity, 96% specificity. Performance was lower for complex patterns like oblique phalangeal fractures, AUC = 0.76., Conclusion:  Our study demonstrated that a CNN model can effectively diagnose and classify metacarpal and phalangeal fractures using plain radiographs, achieving a mean weighted AUC of 0.84. 7 categories were deemed as acceptable, 9 categories as excellent, and 3 categories as outstanding. Our findings indicate that a CNN model may be used in the classification of hand fractures.

Introduction: The optimal management strategy for unstable distal clavicular fractures remains controversial. Recent studies on plate techniques have reported good-to-excellent outcomes with no serious complications. The questions are that: (1) Does the use of wire augmentation with locking plate in distal part (distal wire augmentation) reduce radiographic loss of reduction (RLOR) and get earlier bony union in distal clavicular fractures? (2) Which fixation methods are associated with a higher incidence of acromioclavicular (AC) joints arthritis or subluxation? We collected and analyzed clinical studies on different plate fixation methods for unstable fractures to identify the best surgical modality., Methods: This retrospective case-control study included 101 patients with Neer types IIB and V unstable distal clavicle fractures treated using plate techniques. The patients were divided into four groups according to the surgical procedure: hook plate (HP group) (n = 13), lateral locking plate alone (LP group) (n = 41), locking plate with coracoclavicular (CC) ligament suture repair (LPC group) (n = 26), and locking plate with distal wire augmentation (LPA group) without CC repair (n = 21). The clinical outcomes of shoulder function were the mean Constant score and the University of California-Los Angeles (UCLA) shoulder scale. The bony union time, loss of CC distance reduction, and AC joint condition were used to evaluate the radiographic results. One-way ANOVA, Kruskal-Wallis test, and chi-square test were performed to compare differences between groups. Multiple p-value comparison corrections were calculated using the Bonferroni method., Results: There were no significant differences in the mean Constant and UCLA scores among the groups after 1 year of follow-up. All fractures healed. The LPA and HP groups achieved earlier bone union (LPA 8.4 weeks, HP 8.9 weeks, LP 12.6 weeks, and LPC 13.4 weeks, P = 0.000); however, the HP group had the highest complication rate and required bone removal (LPA 4.0%, HP 23.1%, LP 0.0%, LPC 0.0%, P = 0.003). A low rate of RLOR was observed in the LPA group (LPA 9.5%, HP 23.1%, LP 22.0%, LPC 30.8%, P = 0.362). The incidence of AC joint subluxation was higher in the Neer type V group and was unrelated to surgical methods., Conclusions: Hook plate and locking plate with distal wire augmentation in distal clavicle fractures result in an earlier time to bone union when compared with CC suture repair or non-CC suture repair techniques. However, HP may have the higher complication rate and require subsequent implant removal. The incorporation of distal wire augmentation appears to be beneficial in maintaining fracture reduction. In the future, larger prospective studies are needed to confirm these findings., Level of Evidence: Level III, therapeutic study., Competing Interests: Declarations. Ethical approval: This retrospective chart review was approved by the Institutional Review Board of Chang Gung Medical Foundation (IRB number:202301001B0). Informed consent: The IRB approves the waiver of the participants’ consent. Conflict of interests: The authors declared that they did not receive any honoraria or consultancy fees in writing this manuscript. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Conservative treatment of clavicle fractures has the disadvantage of substantial pain and discomfort, whereas internal fixation of these fractures has a high rate of non-union. External fixation is an alternative method permitting early mobilization without disrupting the surrounding soft tissue envelope. These are extremely beneficial in young, athletic and highly functional patients as well as in patients with comminuted fractures. This was a retrospective study of 17 consecutive patients with clavicle fractures. Thirteen of them were young, athletic patients while the remaining four were not highly active patients, but had a comminuted fracture. Mobilization of the shoulder started shortly after the operation and the external fixator was removed when radiological and clinical evidences of fracture union were present. Patients were reviewed up to 1 year postoperatively. Fracture union and functional activity were assessed clinically, radiologically, and with the aid of the VAS and DASH scores. In 16 patients fracture union was achieved 8 weeks postoperatively, while in one patient union was observed at 10 weeks. The mean VAS score was 4 at 2 weeks postoperatively, while by 6 weeks all patients had full range of shoulder motion. The mean DASH score 6 months postoperatively was 8 points. There were no postoperative infections or non-union. In 2 patients with comminuted fractures there was a minor displacement. External fixation is an easier to apply and less invasive method of surgical stabilization relative to internal fixation. Furthermore, it permits early mobilization and guarantees union of the fracture.

Background: Acetabular fractures are among the most challenging orthopaedic fractures, and a high total hip arthroplasty (THA) conversion rate has been reported in older patients with acetabular fractures. Bone quality is a poor prognostic factor after acetabular fracture fixation and has been assessed using computed tomography (CT). However, the relationship between Hounsfield unit (HU) values measured using CT and early acetabular fracture outcomes remains unknown. This study aimed to elucidate the effect of HUs on early acetabular fracture outcomes., Methods: 50 consecutive patients who underwent open reduction and internal fixation for acetabular fractures were included. The mean follow-up duration was 24 months. 27 hips had elementary fractures and 23 had associated fractures. The reduction quality assessed using CT was as follows: anatomical, 13 hips; imperfect, 10 hips; and poor, 27 hips. Secondary hip osteoarthritis was observed in 5 patients (10%), and the surgery was converted to THA in 1 patient (2%). The HU values of the fifth vertebral body and the unaffected side of the femoral head were measured. The fracture type, radiological secondary hip osteoarthritis, conversion to THA, and postoperative displacement gap were recorded., Results: The unaffected femoral head HU values in elementary fractures (250.5 ± 50.5) were significantly higher than those in associated fractures (221.5 ± 48) ( p   <  0.047). The HU values of the fifth vertebral body and the unaffected femoral head were significantly correlated with the postoperative residual displacement gap and were significantly lower in those with secondary osteoarthritis than in those without it. The cut-off value for predicting early osteoarthritic change after an acetabular fracture was approximately 180., Conclusions: The HU values were correlated with the fracture type, postoperative displacement gap, and early osteoarthritic change after acetabular fractures and are clinically useful prognostic factors for early acetabular fracture outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: This study aimed to determine whether outpatient upper extremity fracture surgery was associated with increased postoperative emergency department (ED) visits and identify related risk factors., Design: Retrospective cohort., Setting: This multicenter study was conducted within a single academic institution, encompassing two Level 1, two Level 2, and one Level 3 trauma centers., Patient Selection Criteria: All patients >18 years of age who underwent upper extremity fracture surgery from 2015 to 2021 were included., Outcome Measures and Comparisons: Risk factors for postoperative ED visit that were investigated included age, sex, tobacco use, alcohol abuse, psychiatric diagnosis, Elixhauser comorbidity score, race, location of upper extremity fracture, surgical setting (inpatient vs. outpatient), upper extremity block, surgical specialty, and Area Deprivation Index. Variables with a P < 0.1 in bivariate analysis were included in a multivariable logistic regression to determine factors associated with a postoperative ED visit at 30 and 90 days., Results: A total of 6315 patients with an average age of 51 ± 19 years were identified of whom 52% were women and 65% had outpatient surgery. Postoperatively, 188 patients (3.0%) presented to the ED within 30 days and 304 (4.8%) presented within 90 days. Thirty-seven percent of ED visits were directly related to the procedure, most commonly for pain (20%), cast issues (4.3%), and swelling (3.9%). At 30 days postoperatively, 2.8% of patients who underwent surgery in an outpatient setting and 3.4% of those who underwent inpatient surgery returned to the ED, with these rates increased to 4.4% and 5.6%, respectively, by 90 days. In multivariable analysis, outpatient surgery (odds ratio [OR]: 1.5, P = 0.030), tobacco use (OR: 2.1, P < 0.001), higher Elixhauser comorbidity scores (OR: 1.2, P < 0.001), non-White race (OR: 1.9, P < 0.001), elbow fractures (OR: 1.8, P = 0.016), and hand fractures (OR: 1.6, P = 0.046) were associated with 30-day ED visits., Conclusions: Outpatient surgery was associated with increased rate of 30-day ED visits. Patients who smoke, had increased number of comorbidities, or were non-White presented to the ED more frequently., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The wide-awake local anesthesia no tourniquet (WALANT) technique, which is based on the local infiltration of lidocaine and epinephrine, is widely used in hand and wrist surgery. However, few studies have been conducted on the cost-benefit analysis of phalanx fracture surgery using the WALANT technique. This study aimed to investigate the clinical condition, as well as the time spent for anesthesia and operation. We also performed an economic analysis to compare general anesthesia, local anesthesia with a tourniquet, and the WALANT technique for plate fixation of phalanx fractures., Methods: This retrospective study included all patients with single phalanx fractures who underwent open reduction internal fixation with plating between January 2015 and December 2019. Patients were divided into three groups according to the anesthesia method: general anesthesia with a tourniquet (GA group), local anesthesia with a tourniquet (LA group), and the WALANT technique (WALANT group). Data, including demographics, anesthesia and surgical time, postoperative pain score, and vomiting ratio, were collected and analyzed., Results: A total of 62 patients were included in this study. Of the 62 patients, 15 were included in the GA group, 32 in the LA group, and 15 in the WALANT group. No complications were reported during surgery or follow-up in any group. The GA group exhibited a significantly longer anesthesia time than the other two groups, with an average of 32.4 minutes. However, no significant difference in surgical time was observed among the three groups. The WALANT group exhibited a significantly lower postoperative day 1 pain score than the other two groups. The additional cost of general anesthesia was approximately 350 US dollars (USD), accounting for approximately one-third to one-fourth of the total expenses for phalanx surgery., Conclusion: Open reduction with plate fixation of phalanx fractures using the WALANT technique or local anesthesia was cost-effective compared with general anesthesia. Patients who underwent phalanx fracture surgery using the WALANT technique experienced less pain on the first postoperative day because of the adequate tumescent technique and not using a tourniquet during surgery., Competing Interests: Conflicts of interest: The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article., (Copyright © 2024, the Chinese Medical Association.)

Purpose: To assess the rate of heterotopic ossification (HO) following acetabular surgery with a standardized protocol via the Kocher-Langenbeck. Secondarily, to evaluate patient characteristics, injury variables, and perioperative data among patients with HO and no HO., Methods: This was a retrospective case series from an academic Level I trauma center. Included patients had displaced acetabular fractures treated via Kocher-Langenbeck approach with debridement of (1) gluteus minimus muscle (GMM) from the posterior wall and column up to the superior gluteal neurovascular bundle, (2) unhealthy appearing piriformis muscle without fascial disruption, and (3) superior and inferior gemelli in the location of implant placement. Those with posterior hip dislocations and gluteus medius injury received prophylactic indomethacin., Results: Fifty-seven patients met inclusion criteria. Thirteen patients (22.8%) developed HO, and 44 patients (77.2%) had no evidence of HO. Ten (17%) patients developed mild HO (Brooker classification (BC) I/II), 3 (5%) developed moderate HO (BC III), and no patients developed severe HO (BC IV). There were no differences in the prevalence of elementary versus associated acetabular fracture patterns or individual fracture patterns among cohorts. Patients with HO had longer times to surgical intervention (5.3 ± 5.1 days vs. 2.4 ± 1.6 days, p = 0.002) and length of intensive care unit (ICU) stay (6.7 ± 12.2 days vs. 1.5 ± 3.3 days, p = 0.013) compared with the no HO cohort. There was no difference in rates of HO prophylaxis use and subsequent HO among cohorts., Conclusion: This study describes a standardized protocol developed by the senior author that resulted in low rates of HO following acetabular fixation via the Kocher-Langenbeck approach. Patients with HO had a significantly longer time to surgical intervention and length of ICU level of care., Level of Evidence: Therapeutic Level IV. See Instructions for Authors of a complete description of levels of evidence., Competing Interests: Declarations. Conflicts of interest: The authors report no potential conflicts of interest regarding this work., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: This retrospective cohort study aims to compare short-term complication rates between patients receiving open reduction and internal fixation (ORIF) for associated versus elementary acetabular fractures, with a secondary objective of identifying independent risk factors for adverse outcomes., Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using current procedural terminology (CPT) codes to identify patients that underwent ORIF for associated acetabular (CPT 27228) or elementary acetabular fractures (CPT 27226, 27227) from 2010 to 2021. Propensity score matching was employed to account for baseline differences and the short-term complication rates were compared between the cohorts., Results: We identified 1,330 patients who underwent ORIF for an acetabular fracture between 2010 and 2021, including 868 patients with elementary fractures and 462 with associated fractures. After matching, there were 462 patients in each cohort. The matched associated acetabular fracture group experienced higher rates of any adverse event (AAE, p = 0.029), transfusion (p = 0.010), and reoperation (p = 0.049). Increased age, increased operative time, higher body mass index (BMI), and prolonged hospital length of stay (LOS) augmented the risk of any complication., Conclusion: The findings of this study identify areas of greater risk of postoperative complications after ORIF in individuals with associated versus elementary acetabular fractures. Discussion of these heightened risks is critical to appropriate patient care. Understanding these risks plays an important role in the clinical decision-making process and may identify areas to monitor patients postoperatively., Competing Interests: Declarations. Conflicts of interest: There are no conflicts of interest, competing interests, or funding to report for any of the authors of this study., (© 2024. The Author(s).)

Background: Bone fractures remain a significant global public health issue despite preventive measures, leading to substantial health and economic consequences. Effective treatment options are difficult to access in most sub-Saharan African countries, leading to reliance on unqualified practitioners and resulting in serious complications that worsen poverty. In Nigeria, the main challenge is the need for out-of-pocket payment for healthcare, which is the primary method of health financing. However, anecdotal evidence suggests that some patients find it easier to finance their fracture care than others. This study aimed to identify the factors that predict difficult fracture-care financing among patients treated operatively for long-bone fractures (LBFs) in southwestern Nigeria., Methods: The study collected socio-demographic and clinical data on 690 consecutive adult patients with LBFs treated with SIGN nails between July 2014 and June 2024 at a mission teaching hospital in southwestern Nigeria. A literature review and preliminary interviews were conducted with patients, caregivers, and hospital staff to understand potential risk factors for difficult fracture-care financing. The patients were divided into two cohorts - easy fracture-care financing (EF) and difficult fracture-care financing (DF) - based on their promptness in paying the in-patient care bills. Potential risk factors for DF identified in the initial univariate analysis were entered as covariates into a binary logistic regression to determine the significant predictors of DF., Results: The mean age of the patients was 45.1 years (SD = 17.52). The DF cohort comprised 321 (46.5%) patients. Significant predictors of DF included younger age (p = 0.018), male gender (p = 0.002), lack of formal education or low level of education (p < 0.001), residence in the hospital city (p < 0.001), absence of health insurance (p = 0.013), lack of extended family support (p < 0.001), previous traditional bone setting treatment (p = 0.005), concomitant injury (p = 0.017), and a post-operative hospital stay longer than one week (p = 0.036)., Conclusions: The findings suggest that improving people's socioeconomic status through job creation, women's empowerment, reduction of gender inequality, higher education, comprehensive health insurance coverage, and stronger family bonds, as well as preventive strategies to reduce the occurrence and severity of injuries, can improve fracture-care financing in low-resource settings., Competing Interests: Declarations. Ethics approval and consent to participate: The Research Ethics Committee of Bowen University Teaching Hospital approved the study protocols. The procedures used in this study adhere to the principles of the Declaration of Helsinki. All participants provided informed consent to be included in the study. Informed consent to participate was obtained from the legal guardians of participants without formal education or illiterates. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Ballistic talus fractures are difficult to treat and there is a paucity of literature regarding the subject. The goal of the current study is to outline our experience and epidemiological findings from a single center with a large case series of ballistic talus fractures., Materials and Methods: Institutional Review Board approval was obtained for a retrospective review of skeletally mature patients with ballistic talus fractures from August 2019 to June 2023. Fracture morphology of the talus, the presence of displacement, and the talar declination angle (TDA) were all characterized. Demographic variables were obtained. All complications were recorded., Results: 21 tali were included in this cohort (average age = 26, SD = 9.5). 11 (52%) talus fractures were displaced at initial injury and 17 (81%) had additional fractures of the ipsilateral foot and ankle. 29% (6/21) of tali were treated operatively with fixation: 2 talar body, 2 talar neck, and 2 talar head. TDA improved in patients treated operatively (21.8° pre-operatively, 19.6° post-operatively) but not in those treated non-operatively (24.5° pre-operatively, 25.5° at final follow-up). The overall complication rate was 29% (6/21) including 2 minor complications (superficial wound dehiscence) and 4 major complications: 3 patients with early signs of avascular necrosis (AVN)/collapse and 1 infected non-union. Although we had 3 patients with signs of AVN, one of which was converted to an ankle fusion, all patients were sucessfully treated with limb salvage., Conclusions: The current study offers a unique and previously unreported cohort of gunshot related talar fractures. Our deep infection rate of 4.8% was similar to other studies of closed talus fractures. We found an improvement in the average TDA for the operatively treated fractures, which may represent improvements in fracture reduction with operative fixation. Further studies with longer follow-up are necessary improve our limited understanding of these injuries and to enhance treatment., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Paediatric fractures are common but can be easily missed on radiography leading to potentially serious implications including long-term pain, disability and missed opportunities for safeguarding in cases of inflicted injury. Artificial intelligence (AI) tools to assist fracture detection in adult patients exist, although their efficacy in children is less well known. This study aims to evaluate whether a commercially available AI tool (certified for paediatric use) improves healthcare professionals (HCPs) detection of fractures, and how this may impact patient care in a retrospective simulated study design., Methods and Analysis: Using a multicentric dataset of 500 paediatric radiographs across four body parts, the diagnostic performance of HCPs will be evaluated across two stages-first without, followed by with the assistance of an AI tool (BoneView, Gleamer) after an interval 4-week washout period. The dataset will contain a mixture of normal and abnormal cases. HCPs will be recruited across radiology, orthopaedics and emergency medicine. We will aim for 40 readers, with ~14 in each subspecialty, half being experienced consultants. For each radiograph HCPs will evaluate presence of a fracture, their confidence level and a suitable simulated management plan. Diagnostic accuracy will be judged against a consensus interpretation by an expert panel of two paediatric radiologists (ground truth). Multilevel logistic modelling techniques will analyse and report diagnostic accuracy outcome measures for fracture detection. Descriptive statistics will evaluate changes in simulated patient management., Ethics and Dissemination: This study was granted approval by National Health Service Health Research Authority and Health and Care Research Wales (REC Reference: 22/PR/0334). IRAS Project ID is 274 278. Funding has been provided by the National Institute for Heath and Care Research (NIHR) (Grant ID: NIHR-301322). Findings from this study will be disseminated through peer-reviewed publications, conferences and non-peer-reviewed media and social media outlets., Trial Registration Number: ISRCTN12921105., Competing Interests: Competing interests: NW reports the following competing interests: consultancy fees from InHealth Reporting, SM Radiology; speaker honoraria fees from AstraZeneca and travel grant award from Qure.ai Technologies. All other authors (SS, CP, EAllan, DL, EAshworth, K-WY, JB, SH, DR, SA, AN, KT and OJA) deny any competing interest statements., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Dorsiflexion weakness, or footdrop, is a well-described sequela of high-energy acetabular and pelvic trauma, but little data exists describing the factors related to neurologic recovery and the timeline therein. An improved understanding of these factors would facilitate prognostication, patient education, and treatment decision-making. The aim of this study was to compare neurologic recovery between acetabular and pelvic fractures, delineate factors associated with recovery, and determine the expected timeline of recovery., Methods: A retrospective chart review was conducted at a level 1 tertiary referral center from 2000 to 2021 using CPT codes and keyword search functions to identify adult patients with neurologic injury in the setting of operative acetabular and/or pelvic ring trauma. Patients were included if they had documented, graded weakness not clearly explained by a concomitant injury (extremity or spine) following a pelvic/acetabular injury. Patients were followed to a minimum of 6 months follow-up or to neurologic recovery. Primary outcomes were the presence of motor recovery and time to initial and maximum recovery. The contributions of injury type and initial neurologic status were analyzed using logistic regression for impact on neurologic recovery., Results: We identified 121 patients with neurologic injury and resultant footdrop in the setting of an operative pelvic ring or acetabular fracture. From this cohort, 58 patients (47.9 %) demonstrated some degree of neurologic recovery in follow-up. There was no difference in recovery when comparing injury type (pelvis vs. acetabulum). Any motor function (including flicker) at time of initial evaluation was predictive of recovery (OR 6.18, [2.00 - 19.14]; p = 0.002). Initial neurologic function also correlated with more rapid recovery in comparison to patients with initial absent neurologic function both in time to initial recovery (56 days vs 107 days; p = 0.016) and time to maximum recovery (153 days vs 241 days; p = 0.027)., Conclusions: These results highlight the relatively poor prognosis for neurologic recovery in operative pelvic and acetabular injuries. Any initial neurologic function is predictive of likelihood of neurologic recovery and correlates with a more expedient neurologic recovery. Ultimately, this enables providers to better educate patients and facilitates decisions regarding further intervention., Competing Interests: Declaration of competing interest Colby C. Wollenman:none Cade Morris: none Ridge Maxson: none Claudia Davidson: none Jacquelyn S. Pennings: 3Spine – personal fees Steamboat Orthopaedics – personal fees Steamboat Orthopaedics – personal fees Phillip M. Mitchell: none The relationship, financial and otherwise, between Jacquelyn Pennings and the listed entities does not represent a conflict of interest regarding the subject matter of the paper entitled Recovery after Neurologic Injury in Operative Acetabular and Pelvic Fractures: Defining the Natural History of Foot Drop. As such, there are no other conflicts of interest which would impact the subject matter of this article in any way., (Copyright © 2024. Published by Elsevier Ltd.)

Introduction: Bicycle accidents account for the majority of traffic-related accidents in Sweden. Despite the widespread everyday use of bicycles, little is known about the fracture panorama resulting from bicycle accidents. This study analysed the fracture patterns of bicycle accidents in Sweden in regard to fracture type, sex, age, and type of bicycle., Material and Methods: We retrieved data from the Swedish Fracture Register on all fractures caused by bicycle accidents between 2015 and 2022. The study population was comprised of both children and adults who had sustained one or more fractures in a bicycle accident as registered in the Swedish Fracture Register., Results: We included 33,384 fractures (25,960 in adults and 7424 in children) in 30,815 patients, with a dominance of fractures in men. The mean age at fracture was 41.6 years (SD 23). The majority of fractures (62.7 %, n = 20,932) were sustained via a low energy mechanism. Overall, the most commonly fractured body parts were the forearm (35.2 %, n = 11,747), the hand (15.6 %, n = 5,196) and the clavicle (13.7 %, n = 4,558). In children, fractures of the forearm (56.8 %, n = 4,215) clearly dominated, followed by the hand (11.7 %, n = 868), and the humerus (11.0 %, n = 816). In adults, the top 3 fracture locations were the forearm (29.0 %, n = 7,532), the hand (16.7 %, n = 4,328), and the clavicle (15.7 %, n = 4,086). Mountain bikes and road bikes showed a fracture panorama that was very similar with a predominance of fractures to the clavicle. Fractures were more common during the warm season., Conclusion: The main finding is that bicyclists predominantly sustained fractures of the upper limb via low energy mechanisms. The fracture panorama differed by age, sex, and type of bicycle., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Hypothesis/purpose: Mountain biking (MTB) is a quickly growing sport, with fractures being the most common injury among MTB athletes. Currently, there is a lack of analysis of MTB fractures based on emergency department (ED) data obtained on a national scale. It was hypothesized that the total number of fractures presenting to United States (US) EDs increased significantly over the last decade, and adult male riders experienced higher rates of fracture and fracture-related hospitalization than other demographics., Methods: All data was extracted from the National Electronic Injury Surveillance System (NEISS), a public database representing approximately 100 US EDs. NEISS was queried for all MTB-related fractures from January 1st, 2013-December 31, 2022., Results: NEISS returned a national estimate (NE) of 35,260 MTB fractures visiting EDs between 2013 and 2022. Fracture injuries increased significantly over the study period, including a 247 % increase from 2019 to 2020. The mechanism of injury most likely resulting in fracture was being thrown from the bike (39.6 %, NE:5,436). The upper extremity was the most commonly fractured body region (32.8 %, NE:11,574), and trunk fractures had the highest rate of hospitalization (44.2 %, NE:3705). Males accounted for the majority of fractures (87.9 %, NE:30,996), and were more likely to be hospitalized than females (22.2 %>17.4 %). Adults (age≥40) were more likely to sustain a fracture (48.8 %) and be hospitalized because of it (25.8 %) than other age groups. Adults were also most likely to fracture their trunk (33.9 %)., Conclusion: MTB fractures increased significantly from 2013 to 2022, possibly due to the gaining popularity of MTB since COVID-19. The upper extremity was the most frequently fractured body region, and being thrown from the bike was the mechanism most likely to result in a fracture. Adult male riders are at a high risk for trunk fractures, demonstrating the importance of protective equipment such as chest and torso protectors for these athletes., Level of Evidence: III., Competing Interests: Declaration of competing interest none, (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Children with cerebral palsy (CP) have a high risk of fracture; yet, little is known about their post-fracture health outcomes. A fracture is an unplanned event in contrast to surgeries or procedures where there is a pre-operative period to optimize body composition and health and planned post-operative follow-up care. Fractures may be associated with significant outcomes due to the unplannable nature and reactionary care. The objective of this study was to determine if fractures were associated with an increased rate of short-term adverse health outcomes among children with CP, and if these associations were dependent on age., Methods: This retrospective cohort study used commercial claims from 01/01/2001-12/31/2018. The primary cohort was children 2-18 years old with CP and an incident fracture (CP + Fx). Comparison cohorts were propensity score matched 1:1 to CP + Fx on demographic and health-related indicators: CP without fractures (CPw/oFx); without CP with (w/oCP + Fx) or without (w/oCPw/oFx) a fracture. The incidence rate (IR) and IR ratios (IRR) of 30-day and 31-90-day pneumonia and 90-day emergency department (ED) visit were estimated. Cox regression tested for effect modification by age and sex., Results: The CP + Fx cohort (n = 1670) had higher IRs of 30-day pneumonia (IRR range, 1.53-4.54) and 90-day ED visit (IRR range, 1.45-2.37) (all P < 0.05), and higher IRs of 31-90-day pneumonia but this did not reach statistical significance (IRR, 1.41 to 2.32, all P > 0.05). Notably, there was evidence of effect modification by age. The rate of 30-day pneumonia became more problematic for CP + Fx with older age relative to comparison cohorts and for 90-day ED visit compared to CPw/oFx. The rate of 90-day ED visit for CP + Fx was more problematic at younger ages compared to w/oCP + Fx., Conclusions: Fractures among children with CP were associated with an increased rate of short-term pneumonia and ED visit, which was more problematic with older age., Competing Interests: Declaration of competing interest All authors declare there is no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The authors believe that the L5-S1 facet joint injury in the setting of pelvic fractures is underappreciated by orthopedic traumatologists. The purpose of this study was to draw attention to the L5/S1 facet joint in the setting of pelvic ring injuries., Methods: This was a retrospective comparative study of all patients greater than or equal to 18 years of age with an acute pelvic ring injury (AO/OTA 62 B to C) presenting to a single level I trauma center. The primary objective was to determine demographic and injury characteristics associated with L5-S1 facet joint injuries in patients with pelvic ring injuries. The secondary objective was to determine the proportion of L5-S1 facet joint injuries that were missed on initial radiographic workup., Results: There were 476 patients included in the analysis, 53 (11.1%) of whom had an L5-S1 facet joint injury. Patients with an L5-S1 injury were more likely to be younger (44.1 vs. 53.2 years, p = 0.001) and experience a high energy mechanism of injury (95.0% vs. 78.0%, p = 0.002). Certain injury patterns were associated with L5-S1 facet joint injuries: any sacral fracture (96.2% vs. 73.8%, p < 0.001), Denis zone 2 fractures (43.4% vs. 20.1%, p  < 0.001), Denis zone 3 fractures (34.0% vs. 4.7%, p  < 0.001), bilateral displaced sacral fractures (18.9% vs. 3.5%, p  < 0.001), and L5 transverse process fractures (64.2% vs. 18.0%, p < 0.001). Only 16.0% of radiology reports identified an L5-S1 injury., Conclusions: Orthopedic traumatologists should scrutinize imaging for L5-S1 facet joint injuries in the presence of pelvic ring injuries, especially in patients with certain sacral fracture patterns., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery., Methods: Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management., Results: From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures., Conclusion: There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: The operative treatment of mid-shaft clavicle fractures shows benefit in union rates, return to work, and lower pain scores relative to non-operative treatment. We sought to determine if the surgical treatment of isolated mid-shaft clavicle fractures would result in fewer opioids prescribed as compared to those managed non-operatively., Methods: All mid-shaft clavicle fractures treated at a Level 1 trauma center were identified from 2012 to 2016. Demographics, fracture characteristics, surgical complications/outcomes, non-operative outcomes, and all narcotics prescribed for 6 months post-injury were collected. Narcotic prescriptions, in morphine equivalents (ME), were obtained through the state prescription drug monitoring program (PDMP)., Results: One hundred and ten operative and 48 non-operative patients were included. Age, gender, previous alcohol, tobacco or drug use, and final range of motion were similar between groups. Pre-treatment fracture shortening (1.8 cm vs. 0.7 cm, p < 0.001) and displacement (150% vs. 70%, p < 0.001) were greater in the operative group. Total ME's (604 vs. 187, p < 0.001) and post-operative ME's (420 vs. 187, p < 0.001) were greater for the operative group. In either group, no other variable influenced ME's prescribed., Conclusion: Clavicles treated operatively receive substantially more opiates than those treated non-operatively, despite data suggesting that operative treatment makes clavicle fractures less painful. The total amount of narcotic analgesics obtained by operatively treated patients was over three times that obtained by non-operatively managed patients, which equates to 55 5 mg oxycodone pills or 85 5 mg hydrocodone pills per patient. While there may certainly be advantages to the operative treatment of clavicle fractures, they must be weighed against the risks of a significant increase in opiate prescribing and potential consumption., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Osteogenesis imperfecta (OI) is the most common inherited form of bone fragility and includes a heterogeneous group of genetic disorders that most commonly result from defects associated with type I collagen. Although genetic analyses have been developed, nationwide research on the incidence and associated fractures in OI is lacking. This study aimed to investigate the patterns of OI prevalence, incidence, fracture rate, etc. in South Korea using National Health Insurance Service (NHIS) claims data. We found 1596 patients newly diagnosed with OI between March 2002 and February 2020. We evaluated the incidence, prevalence, and history of fractures, fracture site, prescription of anti-osteoporosis drugs, etc. To compare medical costs, fracture rates, and scoliosis rates, we created a control group comprising patients without OI using 1:1 propensity score matching. The prevalence of OI increased slightly each year, with an annual incidence of 20.20 per 100,000 live births. Mean fracture frequency in OI patients was 17 (2-32) times per patient and the most frequent fracture site was the lower leg. A total of 21.4% patients were prescribed anti-osteoporosis drugs, and the most popular drug was pamidronate. After 1:1 propensity score matching, in terms of scoliosis, OI patients had a 3.91 times higher prevalence of scoliosis than in healthy patients which was statistically significant. The sum of medical care expenses for patients with OI was 3.5 times higher than that for patients without OI. We identified nationwide trends in OI occurrence, fractures, and medication use. This study also highlighted the real-world data of scoliosis and medical costs compared to the control group., Competing Interests: Declarations. Competing Interests: Sin Hyung Park, Ho Yoon, Siyeong Yoon, MS3, Jaiwoo Chung, Jae-hyun Kim, and Soonchul Lee have no conflicts of interest to declare. Ethical Approval: The study design was approved by the Ethics Review Board of Bundang CHA Hospital (No. 2021-11-006). Consent to Participate: The requirement for informed consent was waived. Consent for Publication: All the authors hereby consent to publication of this work., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Neer type V distal clavicle fractures are considered the most unstable fracture type and are characterized by the disruption of continuity between the coracoclavicular (C-C) ligaments and proximal or distal bone fragments. However, owing to the rarity of such fractures, there is currently no universally accepted surgical procedure for their treatment. Recently, the scorpion plate, an anatomical, non-locking, pre-contoured plate with two grasping arms to fix the distal or inferior clavicular fragments, was introduced. This study aimed to investigate the postoperative functional and radiological outcomes of osteosynthesis using only scorpion plates in Neer type V fractures., Methods: We retrospectively identified 23 patients who underwent scorpion plate fixation for Neer type V fractures at two general hospitals. All patients underwent only plate fixation without C-C ligament augmentation. Subsequently, we investigated their postoperative functional outcomes, complication rates, and modified C-C distance ratio at 1 year., Results: The mean postoperative Constant score was 96 ± 5, with all cases achieving bone union. Complications within 1 year postoperatively included plate loosening in one patient (4.3%) and plate irritation in two patients (8.7%). Additionally, the modified C-C distance ratio averaged 114 ± 15%., Conclusions: This study offers novel insights into the management of Neer type V distal clavicle fractures. Our findings indicate that osteosynthesis using only scorpion plates can lead to satisfactory functional outcomes with minimal complications., Competing Interests: Declarations Consent for publication Not applicable. Competing interests The authors declare no competing interests. Ethical approval and consent to participate This study was approved by the Ashikaga Red Cross Hospital Independent Ethics Committee (No. 2023-28) and National Hospital Organization Tokyo Medical Center Independent Ethics Committee (No. R19-037). This retrospective study adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all patients using an opt-out notification on our hospital’s bulletin board and website. Competing interests The authors declare that they have no competing interests. Clinical trial number Not applicable., (© 2024. The Author(s).)

Background: Total elbow arthroplasty (TEA) is a mainstay treatment for elbow arthropathy and elbow fracture that can relieve pain and restore functional motion. The purpose of this study was to determine the role of surgical indication in the incidence of short-term adverse events and risk factors influencing complications in TEA to treat arthropathy compared to TEA for fracture. Matched cohorts were created to better isolate the impact of the surgical indication., Methods: The study identified patients within the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database that underwent TEA to treat arthropathy or fracture from 2010 to 2020. Matched cohorts were created to analyze the incidence of 30 day adverse events and risk factors for complications., Results: The study included 599 patients for analysis. The overall incidence of any adverse event was 9.7%. In matched cohorts of 218 patients, the fracture group experienced a higher incidence of overall adverse events (13.8% vs. 6.0% in the arthropathy group, p = 0.009) and postoperative transfusions (9.6% vs. 1.8% in the arthropathy group, p < 0.001). Logistic regression revealed an increased risk of any adverse event in the combined matched cohort with longer operative times (OR = 1.007, CI: 1.002-1.012, p = 0.006) and those undergoing fracture treatment (OR = 2.447, CI: 1.047-5.717, p = 0.039). Outpatient status was associated with a lower risk of adverse events in the combined matched cohort (OR = 0.207, CI: 0.058-0.739, p = 0.015)., Conclusions: Even when controlling for comorbidities, patients undergoing TEA for fracture have a greater likelihood of short-term complications, particularly requiring a blood transfusion. Treatment of a fracture and increased operative time were risk factors for all patients, while outpatient status was protective., Level of Evidence: III., Competing Interests: Declarations Ethics approval and consent to participate Not applicable due to the de-identified nature of the ACS NSQIP database. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Tile and Young-Burgess classification systems have been widely used to classify pelvic ring injuries in clinical settings; however, these two systems are rarely mentioned in the literature despite their reproducibility and practical application. The purpose of this study was to assess the interobserver and intraobserver reliability of the Tile and Young-Burgess classification of pelvic ring injuries. Eight hundred seven patients with pelvic fractures who presented to two I-level trauma centres between January 2016 and June 2020 were recruited for this study. The anteroposterior, inlet, and outlet of the pelvis were observed on radiographic images, and CT scans were performed on each patient. The anteroposterior, inlet, and outlet of the pelvis were radiographed at each visit, and CT scans were performed. Four observers were recruited to classify the injury type according to the Young-Burgess and Tile classification systems. Interobserver and intraobserver reliability (kappa coefficient, κ) were applied to assess the reproducibility of the two classification systems. A total of 174 patients (21.56%) could not be classified with the Young-Burgess classification, and all patients could be classified according to the Tile system. The mean κ value of the interobserver reliability was 0.558 (range, 0.444 to 0.653) for the Tile classification, indicating moderate agreement, whereas the mean κ value was 0.637 (range, 0.560 to 0.713), indicating substantial agreement, when the Young-Burgess classification was used. The mean κ value for intraobserver reliability was 0.597 (range, 0.567 to 0.653) for the Tile classification and 0.776 (range, 0.748 to 0.803) for the Young-Burgess classification. More pelvic ring injuries could be classified with the Tile classification than could be classified with the Young-Burgess classification. However, the reproducibility of the Young-Burgess classification was greater than that of the Tile classification., (© 2024. The Author(s).)

Background: Midshaft clavicle fractures are often subject to increased complications when treated nonoperatively, so surgical treatment with open reduction and internal fixation (ORIF) is a favored alternative. Despite safer outcomes, adverse events such as surgical site infections may still persist, particularly in the presence of certain patient characteristics. The objective of this study was to determine risk factors for and the frequency of adverse events following ORIF for clavicle fractures., Methods: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database from 2012 to 2021 identified patients undergoing isolated ORIF for clavicle fractures. Patient demographics and 30-day complications were collected. Bivariate analyses with a student's t-test or chi-square test were used to identify possible predictor variables for either AAE or SSI, and demographic metrics with P < 0.2 were included in a multivariable regression model. Multivariable analyses identified significant independent patient risk factors for any adverse event (AAE) or SSI within 30-days of surgery. Adjusted odds ratios were reported for each variable included in the model. Statistical significance was set a prior at P < 0.05., Results: The 6,753 selected patients who underwent ORIF for clavicle fractures between 2012 and 2021 were 38.1 ± 15.3 years of age, BMI 26.2 ± 4.9 kg m -12 , and 77.3 % male. Of this cohort, 88.4 % received treatment on an outpatient basis. Postoperative adverse events were experienced by 128 (1.9 %) patients within 30 days of surgery, and SSI were prevalent in 0.77 % of patients, followed by wound dehiscence in 0.12 % of patients. After controlling for patient demographics and comorbidities, notable risk factors for adverse events included current smoking status (OR=2.036; P < 0.001) and patient age (OR=1.025; P < 0.001). Outpatient status (OR=0.528; P = 0.004) was protective., Conclusion: The present study noted significantly increased risk of postoperative adverse events in older patients, as well as patients who smoke. Outpatient setting was significantly protective for adverse events. These findings help to provide further clinical context to guide surgical decision making and inform surgeons on current risks and outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Appropriate selection of surgical approach for associated fractures of the acetabulum that involves both columns is still elusive. Therefore, present study aimed to assess the quality of life of complex acetabulum fracture managed with combined anterior and posterior approach (dual approach) as well as the association of postoperative reduction and patient reported outcomes., Material and Methods: This retrospective study was performed on 42 associated acetabular fracture patients with involvement of both columns, who were treated with a dual approach including combined anterior modified ilio-inguinal approach in combination with posterior Kocher-Langenbeck (K-L) approach in a single anaesthetic session having minimum two years follow-up. Postoperative reduction and radiological outcomes were assessed using Matta criteria. Functional outcome was assessed by a score system developed by Merle d'Aubigné-Postel. Patient-reported outcomes were assessed using the 36-Item Short Form Survey (SF-36)., Results: The mean age of participants was 47.9 ± 11.95 years and mean follow-up period was 2.8 ± 0.49 years. Anatomical reduction was achieved in 32 (76.19%) cases in postoperative period. 8 (19.04%) cases had congruent and 2 (4.76%) had incongruent reduction. Radiological and functional outcome was excellent/good n  = 35 (83.33%) cases. Patient-reported outcome on domains physical function and role physical showed a significant improvement between 6 to 24 months period ( p  < 0.001)., Conclusions: The dual approach for complex acetabulum fracture with mid-term follow-up showed good to excellent radiological and functional outcomes. A significant improvement in patient-reported outcomes on Physical function and Role physical domains of SF-36 was also seen over the follow-up period., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: To identify the most relevant factors with respect to the management of fracture-related infection (FRI) and to develop a comprehensive FRI classification that guides decision-making and allows scientific comparison., Method: An international group of FRI experts determined the preconditions, purpose, primary factors for inclusion, format and detailed description of the elements of an FRI classification through a consensus driven process., Results: Three major elements were identified and grouped together in the FRI Classification: Fracture (F), Related patient factors (R) and Impairment of soft tissues (I). Each element was divided into five levels of complexity. Fractures can be healed (F1) or unhealed (F2-5). Patients may be fully healthy (R1) or have 4 levels of compromise, with and without end-organ damage (R2-5). Soft tissue condition ranges from well vascularized and easily closed (I1) to major skin defects requiring free flaps (I4). In all three elements, the fifth level (F5, R5 or I5) describes a patient who has an unreconstructible bone, soft tissue envelope or is not fit for surgery., Conclusion: The FRI classification, which is based on the three major elements Fracture (F), Related patient factors (R) and Impairment of soft tissues (I) is intended to guide decision-making and improve the quality of scientific reporting for FRIs in the future. The proposed classification is based on expert opinion and therefore an essential next step is clinical validation, in order to realize the ultimate goal of improving outcomes in the management of FRI., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Objectives: Side-by-side (SXS) and all-terrain vehicles (ATVs) are different off-road vehicles (ORVs) but often categorized together in the literature. We hypothesized pediatric upper extremity (UE) fracture patterns and injury severity scores (ISS) differ between ORV types., Methods: The authors' home-state trauma repository identified 157 pediatric patients aged 0 to 17 years with UE fractures after ORV accidents during 2011-2021. ORV injuries, fracture type, and procedures were identified using International Classification of Diseases, 9th Revision and 10th Revision coding followed by manual chart review or phone calls. We identified specific ORV type, driver/passenger status, and restraint use to compare differences between fracture characteristics, number of surgeries, and ISS. Groups were compared for differences at P < 0.05 significance., Results: Among 157 ORV injuries, 75 resulted from ATVs (48%), 50 SXSs (32%), and 32 from all other vehicles (20%). Average age was 12 years, and 49% (n = 77) required surgery. SXS injuries had significantly higher open fracture rates (42%, n = 21) compared with ATVs (7%, n = 5) and all other ORV types (16%, n = 5; P < 0.0001). Seventy percent of fractures (n = 35) sustained after SXS accidents required surgery compared with 41% (n = 31) for ATVs and 34% (n = 11) for all other ORV types ( P < 0.001). SXS drivers had 71% left-sided injuries, whereas 85% passengers had right-sided injuries ( P < 0.0001). Patients younger than 13 years (n = 73) had significantly higher surgery rates (59%) compared with 40% for those 13 years and older (n = 84; P = 0.02). There were no significant differences in mean ± SD ISS between ATV (8 ± 6), SXS (8 ± 6), and other vehicles (7 ± 4; P = 0.34)., Conclusions: UE fractures caused by SXS were more likely to be open and require surgery compared with ATVs and other ORVs. SXS drivers were more likely to sustain left-sided injuries, whereas passengers had significantly higher right-sided injuries. Patients younger than 13 years were more likely to require surgery compared with teenagers., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The purpose of this study was to compare the ICU length of stay (LOS), overall hospital LOS, in-hospital complications, and mortality rate between trauma ICU patients with orthopedic injuries versus those without., Methods: This was a retrospective cohort study in which the trauma registry of a single level 1 trauma center was queried over a 6-year period for patients admitted to the ICU during hospitalization. Patients were stratified based on the presence/absence of an orthopedic fracture. Negative binomial regression was used to evaluate the effect of orthopedic injury on overall hospital and ICU LOS while controlling for confounding factors. Secondary outcomes included group differences with respect to in-hospital complications, mortality, and discharge disposition., Results: A total of 1,785 trauma patients were admitted to the ICU and included. Among all trauma ICU patients, 61.1 % (n = 1,091) had no associated orthopedic injuries whereas 38.9 % (n = 694) had at least one. Patients with orthopedic injuries had higher odds of being severely injured (ISS ≥ 16: OR [CI] =1.47 [1.2-1.8]; p < 0.001) despite presenting with a higher level of consciousness than those without orthopedic injuries (mean GCS: 13.3 ± 3.5 vs 12.5 ± 4.1, p < 0.001). Multivariable models demonstrated having an orthopedic injury did not moderate ICU LOS (IRR [CI] = 0.93 [0.9-1.0]; p = 0.110) but did contribute significantly to increasing hospital LOS (IRR [CI] = 1.23 [1.1-1.3]; p < 0.001). There was no evidence to suggest that orthopedic injury increases the risk of in-hospital complication or in-hospital mortality. Orthopedically injured trauma ICU patients were less likely to be discharged home than those without orthopedic injuries., Conclusions: Trauma ICU patients with an associated orthopedic injury have significantly longer hospital stays compared to those without an orthopedic injury, despite no evidence to suggest that the orthopedic injury affects the duration of ICU stay or in-hospital complications., Level of Evidence: III, Retrospective cohort study., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: Emergency department (ED) visits because of pediatric fractures are not only burdensome for patients and their families but also result in an increased healthcare expenditure. Almost half of all children experience at least one fracture by the age of 15. Many fractures occur in playgrounds, with monkey bars and other climbing apparatuses noted as frequent mechanisms of injury. Our purpose was to identify the pattern of injury and the population sustaining monkey bar-associated fractures., Methods: We queried the National Electronic Injury Surveillance System database for all monkey bar-associated injuries in patients aged 0 to 18 years from January 1, 2009, to December 31, 2019. We described demographic data, patient disposition from the ED, fracture pattern, and injury setting using unweighted and weighted estimates. Weighted results that more closely reflect national estimates were calculated., Results: During the study period, 30,920 (862,595 weighted) monkey bar-associated injuries presented to EDs; 16,410 (53.1%) (weighted injuries: 408,722 [47.4%]) were fracture injuries. The average age of kids sustaining fractures was 6.5 years, with most injuries (66.4%) occurring in kids between 6 and 12 years. A higher percentage of male patients presented to the ED with fractures compared with female patients (53% versus 47%). Upper extremity fractures were most common, 382,672 (94%) with forearm fractures constituting the majority (156,691 [38%]). Most children were treated and released (354,323 [87%]), with only 35,227 children (9%) being admitted for treatment. Places of recreation/sports were the most common setting of fractures (148,039 [36%]), followed by schools (159,784 [39%]). A notable association was observed between year and ethnicity and between month period and injury setting., Conclusion: Monkey bar-associated injuries are a major cause of upper extremity fractures in children, with most injuries occurring in recreational areas or schools. Young elementary school children are at the highest risk of injury. ED visits because of monkey bar-associated fractures have increased over the study period, and these injuries continue to be a major cause of fractures in children. Additional measures should be installed to decrease these preventable fractures among children, with schools as a potential starting point., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: Basketball-related fractures involving the lower extremities frequently present to emergency departments (ED) in the United States (US). This study aimed to identify the primary mechanisms, distribution, and trends of these injuries., Hypothesis: We hypothesize that (1) lower extremity fracture frequency will decrease from 2013 to 2022, (2) the ankle will be the most common fracture site, and (3) noncontact twisting will be the most common injury mechanism., Study Design: Descriptive epidemiological., Level of Evidence: Level 3., Methods: The National Electronic Injury Surveillance System (NEISS) was queried for lower extremity fractures from basketball presenting to US EDs from January 1, 2013 to December 31, 2022. Patient demographics, injury location, and disposition were recorded. The injury mechanism was characterized using the provided narrative. National estimates (NEs) were calculated using the NEISS statistical sample weight. Injury trends were evaluated by linear regression., Results: There were 6259 cases (NE: 185,836) of basketball-related lower extremity fractures. Linear regression analysis of annual trends demonstrated a significant decrease in lower extremity fractures over the study period (2013-2022: P = 0.01; R 2 = 0.64). The most common injury mechanism was a noncontact twisting motion (NE: 49,897, 26.9%) followed by jumping (NE: 39,613, 21.3%). The ankle was the most common fracture site (NE: 69,936, 37.6%) followed by the foot (NE: 49,229, 26.49%). While ankle and foot fractures decreased significantly ( P < 0.05), fractures of the lower leg, knee, toe, and upper leg showed no significant trends ( P = 0.09, 0.75, 0.07, and 0.85, respectively)., Conclusion: Basketball-related lower extremity fractures decreased from 2013 to 2022, with the ankle being the most common fracture site and most fractures arising from a noncontact twist. Increasing utilization of outpatient clinics may have contributed to the decline, particularly for ankle and foot fractures. The prevalence of ankle fractures and twisting-related injuries reinforces the importance of protective footwear and targeted strengthening protocols., Competing Interests: The following authors report potential conflicts of interest: R.L.P has received educational support from Gotham Surgical Solutions and Devices. J.D.K. has received educational support from Paladin Technology Solutions and hospitality from Baxter Healthcare. D.P.T. has received educational support from Gotham Surgical Solutions and Devices and Arthrex.

Objectives: To evaluate the orthopaedic management, associated injuries, and outcomes in patients treated for low-velocity ballistic pelvic fractures., Design: Retrospective chart review., Setting: Single, urban, Level I trauma center., Patient Selection Criteria: Patients 15 years or older treated for low-velocity ballistic pelvic (OTA/AO 61 and 62) fractures from May 2018 to August 2021., Outcome Measures and Comparisons: Primary study measures included pelvic fracture location, concomitant associated injuries, surgical interventions, and antibiotic treatment. Postinjury sequelae evaluated include infection, neurologic deficit, and need for orthopaedic removal of foreign body. Risk factors of postinjury sequelae were investigated., Results: A total of 156 patients with ballistic pelvic fractures were included. The cohort consisted of 135 (86.5%) male patients with a mean age of 29.8 years. One hundred ten (70.5%) patients sustained 2 or more gunshot wounds. Ninety-eight (62.8%) patients underwent an exploratory laparotomy with 79 (50.6%) having a confirmed concomitant intestinal injury. Additional associated injuries included nerve injury (13.5%), vascular injury requiring repair or embolization (10.9%), and bladder injury (10.3%). Nine (5.7%) patients underwent orthopaedic operative management-five (3.2%) patients for operative fixation and 4 (2.5%) patients for removal of intra-articular foreign bodies. Diabetes (odds ratio [OR]: 33.1, P = 0.025), neurologic deficit on presentation (OR: 525.2, P < 0.001), vascular injury requiring repair or embolization (OR: 8.7, P = 0.033), and orthopaedic pelvic fixation (OR: 163.5, P = 0.004) were positively associated with the defined postinjury sequelae at 30 and 90 days of follow-up. There was not a statistically significant association between infection and retained foreign body (OR: 3.95 [95% CI 0.3-58.7, P = 0.318]) or bowel contamination (OR: 6.91 [95% CI 0.4-58.7, P = 0.178])., Conclusions: Ballistic fractures of the pelvis and acetabulum rarely required operative fixation (3.2%) or irrigation and debridement. Neither retained foreign body nor presumed bowel contamination of pelvic fractures had a statistically significant association with infection, which further supports conservative management of these injuries. Patients with diabetes, neurologic deficit on presentation, vascular injury necessitating intervention, and orthopaedic fixation of pelvic fracture are associated with increased risk of postinjury sequelae., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Declaration of competing interest None.

Background: Intrapelvic hemorrhage following pelvic fractures, including pelvic ring and acetabular fractures, originates from the venous system and the fracture. Arterial injury often causes significant bleeding and hemodynamic instability. The superior gluteal artery (SGA) is a frequently injured artery in patients with pelvic fractures. This study investigated the incidence and pattern of SGA injuries associated with pelvic fractures., Methods: We retrospectively reviewed the medical records of patients with pelvic fractures who visited our institution between January 2016 and April 2022. Patients who underwent angiography for suspected arterial injury and SGA embolization were identified. Furthermore, the demographics and patterns of pelvic fractures were evaluated., Results: In total, 2042 patients with pelvic fractures visited our trauma emergency department and 498 patients (24.4%) underwent embolization for arterial injuries. Of these, 30 patients (1.5% of the total and 6.0% of the patients who underwent procedures) received embolization therapy of the main trunk of the SGA. The mean age of patients was 51.2 (23-85 years), and the injury mechanisms were all high-energy injuries. There were 19 pelvic ring injuries, eight acetabular fractures, and three combined injuries. Acetabular fractures involved mostly both columns. The three combined injuries were lateral compression involving both columns, vertical shear involving both columns, and lateral compression with T-type fractures. Twelve (40.0%) occurred through the sciatic notch of different patterns., Conclusions: SGA injury occurred in 1.5% of all pelvic fractures and was identified in 6% of patients receiving embolization. SGA injury occurs through various injury mechanisms and fracture patterns, even in the absence of a fracture in the sciatic notch. However, no conclusions could be drawn in this study on the association between SGA injuries, injury mechanisms, and fracture patterns. Since the prediction of SGA injury by fracture pattern is limited, angiography should be performed regardless of fracture pattern when an injury is suspected., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Fracture-related infections are significant postoperative complications that carry substantial patient burden and additional healthcare costs. Despite their impact on outcome, early diagnosis of these infections remains challenging due to current available tests lacking acceptable diagnostic parameters. This review compiles existing information on blood-based biomarkers that have been evaluated as early diagnostic tools and highlights the challenges in their reliability. To begin to overcome these challenges new avenues of biomarker discovery utilizing "omics" technologies and novel analytical methods are being investigated in recent years. It appears that, despite their complexity, these newer approaches may be the future in biomarker discovery for fracture-related infection diagnosis., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Roman M. Natoli and Sarah Malek have patent METHODS FOR DETECTING FRACTURE-RELATED INFECTION (FRI) pending to The Trustees of Indiana University. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Pelvic fractures can be life-threatening for elderly individuals with diminished bone strength. Frailty is associated with fracture outcomes, but its impact on pelvic fracture recovery remains unexplored. The aim of this study was to investigate the association between frailty and short-term outcomes in older adults hospitalized for low-energy pelvic fractures., Methods: Data from the Nationwide Inpatient Sample (NIS) covering the years 2005 to 2018 were reviewed. Inclusion criteria were age ≥ 60 years admitted for a low-energy pelvic fracture. Patients were categorized into frail and non-frail groups using the 11-factor modified Frailty Index (mFI-11). Association between frailty and in-hospital outcomes were determined by univariate and multivariable regression analyses., Results: A total of 24,688 patients with pelvic fractures were included. The mean patient age was 80.6 ± 0.1 years, and 35 % were classified as frail. After adjustments, frailty was significantly associated with unfavorable discharge (adjusted odds ratio [aOR] = 1.07, 95 % confidence interval [CI]: 1.00-1.15, p = 0.038), prolonged hospitalization (aOR = 1.51, 95 % CI: 1.41-1.62, p < 0.001), complications (aOR = 1.42, 95 % CI:1.34-1.50, p < 0.001), and acute kidney injury (aOR = 1.68, 95 % CI: 1.56-1.82, p < 0.001). Stratified analyses based on age and fracture type showed frailty was consistently associated with adverse outcomes., Conclusions: Persons ≥60 years old with mFI-11 assessed frailty and a low-energy pelvic fracture are at higher risk of adverse in-hospital outcomes than non-frail patients. Additional research is needed to disclose the prognostic impact of clinical frailty on long-term functional outcomes and quality of life after discharge., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Posttraumatic osteoarthritis is a common indication for total knee arthroplasty (TKA). The purpose of this study was to evaluate the association between a history of patella fracture and postoperative complication rates after TKA., Methods: Patients diagnosed with a patella fracture before undergoing TKA were identified from a large national database and matched to a control cohort using propensity scoring. Rates of medical complications occurring within 90 days of TKA and surgery-related complications occurring within 1 year of TKA were compared using odds ratios. Healthcare utilization outcomes including 90-day emergency department (ED) presentation, hospital readmission, and total cost were also compared., Results: Compared with a propensity-matched control cohort, TKA patients with a history of patella fracture had a lower incidence of pulmonary embolism (OR 0.74, P = 0.0442) and higher incidences of periprosthetic joint infection (OR 1.68, P < 0.0001), revision surgery (OR 1.84, P < 0.0001), dislocation (OR 1.61, P = 0.026), lysis of adhesions (OR 2.21, P = 0.0082), and wound disruption (OR 1.52, P < 0.0001). A history of patella fracture was also associated with an increased rate of ED presentation (OR 1.08, P = 0.0454) and increased total cost ($14,359 vs. $12,786, P = 0.0003)., Conclusion: A history of patella fracture is associated with early surgery-related complications after TKA including periprosthetic joint infection, revision surgery, dislocation, lysis of adhesions, and wound disruption. Healthcare utilization is increased among these patients with higher rates of ED presentation and increased total cost. These findings allow for more accurate risk stratification and counseling of patients., Level of Evidence: III, Retrospective review., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Conventional radiography (CR) is primarily utilized for fracture diagnosis. Artificial intelligence (AI) for CR is a rapidly growing field aimed at enhancing efficiency and increasing diagnostic accuracy. However, the diagnostic performance of commercially available AI fracture detection solutions (CAAI-FDS) for CR in various anatomical regions, their synergy with human assessment, as well as the influence of industry funding on reported accuracy are unknown. Peer-reviewed diagnostic test accuracy (DTA) studies were identified through a systematic review on Pubmed and Embase. Diagnostic performance measures were extracted especially for different subgroups such as product, type of rater (stand-alone AI, human unaided, human aided), funding, and anatomical region. Pooled measures were obtained with a bivariate random effects model. The impact of rater was evaluated with comparative meta-analysis. Seventeen DTA studies of seven CAAI-FDS analyzing 38,978 x-rays with 8,150 fractures were included. Stand-alone AI studies (n = 15) evaluated five CAAI-FDS; four with good sensitivities (> 90%) and moderate specificities (80-90%) and one with very poor sensitivity (< 60%) and excellent specificity (> 95%). Pooled sensitivities were good to excellent, and specificities were moderate to good in all anatomical regions (n = 7) apart from ribs (n = 4; poor sensitivity / moderate specificity) and spine (n = 4; excellent sensitivity / poor specificity). Funded studies (n = 4) had higher sensitivity (+ 5%) and lower specificity (-4%) than non-funded studies (n = 11). Sensitivity did not differ significantly between stand-alone AI and human AI aided ratings (p = 0.316) but specificity was significantly higher the latter group (p < 0.001). Sensitivity was significant lower in human unaided compared to human AI aided respectively stand-alone AI ratings (both p ≤ 0.001); specificity was higher in human unaided ratings compared to stand-alone AI (p < 0.001) and showed no significant differences AI aided ratings (p = 0.316). The study demonstrates good diagnostic accuracy across most CAAI-FDS and anatomical regions, with the highest performance achieved when used in conjunction with human assessment. Diagnostic accuracy appears lower for spine and rib fractures. The impact of industry funding on reported performance is small., (© 2024. The Author(s).)

Pelvic ring fractures may present with relevant mechanical and haemodynamic instability. Classifications of the bony or ligamentous injuries of the pelvic ring are well established. The most common classifications used analyse the injury mechanisms and the resulting instability of the pelvic ring structure. Fracture classifications should be simple and easy to use, comprehensive, and radiographically and anatomically based, resulting in a hierarchical alphanumeric order of types and subtypes and thereby allow adequate treatment decisions based on a high degree of inter- and intraobserver reliability. In 2018 a new AO/OTA pelvic ring fracture and dislocation classification was published that combined the most commonly used "historical" classification schemes, e.g. the Tile/AO classification and the classification according to Young and Burgess. Compared with these older classifications, several relevant changes were integrated in the 2018 edition. The changes between the AO/OTA 1996/2007 and 2018 classifications were analysed in detail. Overall, several problems were identified regarding the type-B pelvic ring injury classification. These changes may result in difficulties in classifying pelvic ring injuries and thereby prevent relevant comparisons between former and future clinical studies on pelvic injuries.Level of Evidence: V., (© 2024. The Author(s).)

Objectives: Individuals with pelvic and acetabular fractures are at high risk of venous thromboembolism (VTE). The purpose of this study was to determine whether serum markers for thrombophilia and rapid thromboelastography (r-TEG) values correlate with increased VTE risk among patients with pelvic and acetabular fractures., Methods: ., Design: Prospective observational study., Setting: Two urban academic level 1 trauma centers., Patient Selection Criteria: Adult patients with isolated pelvis and/or acetabulum fractures (OTA/AO 61 and 62) treated surgically placed on a standardized VTE chemoprophylaxis regimen with enoxaparin over a 5-year period were included., Outcome Measures and Comparisons: Serum r-TEG, coagulation laboratory values, and markers for heritable thrombophilia were drawn postoperatively and after completion of a 6-week course of enoxaparin. The primary outcome was VTE event (either deep venous thrombosis or pulmonary embolism) diagnosed using a Duplex ultrasound, chest computed tomography angiogram, or lung ventilation-perfusion ordered based on clinical suspicion of a VTE event. Laboratory markers and values were then compared between patients who went on to have a VTE event and those who did not and patients with and without markers of thrombophilia., Results: One hundred thirty-three adult patients with isolated operative pelvic and/or acetabular fractures were enrolled in this study. The average age of patients at time of injury was 48.3 years (range 18-91). Sixty-seven percent of patients in the study were (n = 90) males. Sixty-three percent of patients (n = 84) completed both clinical and laboratory follow-up. Forty-one percent of patients (n = 54) had 1 or more markers of heritable thrombophilia. Twelve percent (n = 10) of patients who completed follow-up were diagnosed with VTE. Age, sex, and smoking status were not associated with VTE. Patients who developed VTE had a higher body mass index (P = 0.04). Having more than 1 marker of heritable thrombophilia (P = 0.004) and an r-TEG mean amplitude greater than 72 mm postoperatively was positively associated with VTE (P = 0.02)., Conclusions: Among patients treated surgically for isolated pelvic and acetabular fractures who received enoxaparin prophylaxis, the presence of more than 1 marker of heritable thrombophilia or r-TEG mean amplitude value greater than 72 mm postoperatively was associated with an increased risk of VTE., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: In low- and middle-income countries such as Haiti, musculoskeletal injuries are the leading cause of morbidity and mortality. Untreated injuries can contribute to decreased mobility, leading to disability and reduced productivity for individuals. The accessibility of timely fracture care poses a substantial challenge in Haiti, where socioeconomic instability and recent surges in gang violence exacerbate an already strained healthcare infrastructure. This manuscript delves into the intricate barriers to sustainable fracture care in Haiti, shedding light on the sociopolitical landscape and clinical challenges that influence the delivery of orthopedic services., Ethical Discussion: The ethical considerations in providing fracture care in Haiti are multifaceted, including classic medical principles, self-preservation in the face of violence, issues of justice in resource and service allocation, and concerns of nonmaleficence in the context of international volunteers. These ethical dilemmas arise from the complex interplay of limited resources, the dangers posed by the current sociopolitical climate, and the involvement of international aid in a vulnerable healthcare system., Conclusion: To address the clinical and ethical conflicts of providing fracture care in Haiti, solutions include education and training of Haitian orthopedic surgeons, capacity building of healthcare facilities, and establishing ethical standards for international volunteers. This comprehensive approach is vital for advancing sustainable fracture care in Haiti and other resource-limited settings., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Purpose: The authors experienced several cases of extra-articular calcaneal fracture accompanied by joint depression involving the entire posterior facet without joint involvement. This type of fracture and its characteristics and treatment outcomes have not been previously reported. The study was performed to analyze the characteristics of extra-articular calcaneal fractures of the joint depression type and their postoperative clinical and radiographic results and complications., Methods: Between February 2013 and March 2021, 23 extra-articular calcaneal fractures of the joint depression type were consecutively treated by a single surgeon. Relationships between fracture characteristics and patient demographics were assessed. Clinical results were quantified using visual analog scale, American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and Foot Function Index, radiographic results were evaluated using Böhler's angles, and calcaneal widths were determined using calcaneal axial and lateral radiographs obtained preoperatively and at last follow-up., Results: Twenty (87%) of the 23 cases occurred in women, and the mean age of all patients was 65.8 years (43-90). The three men were older than 65. Five (21.7%) patients had osteopenia, and 12 (52.2%) had osteoporosis. Bone mineral density testing could not be performed in the other six patients. Clinical and radiographic results were significantly improved after surgery., Conclusion: Extra-articular calcaneal fractures of the joint depression type are much more common in women and occur at an older age than calcaneal fractures commonly occur. These fractures are also more common in patients with a low bone mineral density., Level of Evidence: Level IV., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Objectives: To evaluate the risk of developing a new mental disorder diagnosis within 2 years of lower extremity fracture., Design: Retrospective cohort study., Setting: National insurance claims database., Patient Selection Criteria: Patients between 18 and 65 years with lower extremity, pelvis, and acetabular fractures without prior mental disorders as defined using International Classification of Diseases, 9th and 10th revision diagnosis codes were included. Mental disorders evaluated included alcohol use disorder, generalized anxiety disorder, bipolar disorder, major depressive disorder, drug use disorder, panic disorder, posttraumatic stress disorder, and suicide attempt., Outcome Measures and Comparisons: The individual lower extremity fracture cohorts were matched 1:4 with nonfracture controls. The specific groups of interest were pelvis fractures, acetabulum fractures, proximal femur fractures, femoral shaft fractures, distal femur fractures, patella fractures, tibia plateau fractures, tibia shaft fractures, ankle fractures, pilon fractures, calcaneus fractures, and Lisfranc fractures. Rates of mental disorders after primary lower extremity fractures within 2 years were compared using multivariable logistic regression., Results: Overall, the 263,988 patient-fracture group was 57.2% female with an average age of 46.6 years. Compared with controls with no fracture, patients who sustained pelvis, acetabulum, proximal femur, femoral shaft, distal femur, patella, tibia plateau, tibia shaft, pilon, calcaneus, or Lisfranc fracture had a statistically significantly increased risk of being diagnosed with a queried mental disorder within 2 years of fracture. When comparing all fracture patients by location, those suffering from fractures proximal to the knee joint, including pelvis fractures [OR: 1.51, 95% confidence interval (CI): 1.39-1.64] and proximal femur fractures [odds ratio (OR): 1.36, 95% CI: 1.26-1.47], demonstrated greater risk of developing any of the queried mental disorders compared with fractures distal to the knee, including ankle fractures (OR: 0.99, 95% CI: 0.95-1.03) and pilon fractures (OR: 1.05, 95% CI: 0.81-1.36). When comparing specific fracture patients with patients without fracture by mental disorder, patients demonstrated an increased risk of suicide attempt following fracture of the pelvis, acetabulum, femoral shaft, distal femur, and calcaneus, as well as patients sustaining a Lisfranc fracture., Conclusions: There is an increased risk of being diagnosed with a new mental disorder following lower extremity trauma in patients without prior mental disorder diagnosis compared with matched individuals without a lower extremity fracture. Among the fractures studied, those that were more proximal, such as pelvis and proximal femur fractures, carried greater risk compared with more distal fracture sites, including ankle and pilon fractures. Patients who experienced certain lower extremity fractures had a significantly higher rate of suicide attempt compared with patients without fracture. Physicians should consider increased mental health screening and potential referral for mental health evaluation for patients following lower extremity trauma., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: W.F. Sherman is a paid consultant for Stryker. K.C. Vemulapalli is a paid consultant for Skeletal Dynamics, Johnson & Johnson, and Smith & Nephew. All remaining authors have no conflicts of interest to declare., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To determine union and displacement metrics following percutaneous screw fixation (antegrade or retrograde) of superior pubic rami fractures., Methods: This is a retrospective cohort study from a single level 1 trauma center. Skeletally mature patients with at least one superior pubic ramus fracture present as part of a lateral compression-type pelvic ring injury were included., Results: Eighty-five (85) patients with 95 superior pubic rami fractures met the study's inclusion criteria. LC1, LC2, and LC3 injuries occurred in 76.5%, 15.3%, and 8.2% of patients, respectively. The majority of patients underwent concurrent posterior pelvic ring fixation (94.1%). Superior ramus screw placement occurred predominantly via retrograde technique (81.1%) with cannulated screws of size 6.5 mm or larger (93.7%). Of the 95 eligible fractures, 90 (94.7%) achieved union at a mean of 14.0 weeks (7-40 weeks). Of these united fractures, 69 (76.7%) healed with no measurable displacement, while the remaining 23.3% healed with residual mean displacement of 3.9 mm (range: 0.5-9.0 mm). Multivariable analysis demonstrated a positive association between age (p = 0.04) and initial displacement (p = 0.04) on the final degree of residual displacement at union. A Kaplan-Meier survival analysis identified increased age to be significantly related to increased time to union (X 2 (2) = 21.034, p < 0.001)., Conclusions: Union rates following percutaneous screw fixation of superior pubic rami fractures associated with lateral compression-type pelvic ring injuries approach 95%. Though minimal in an absolute sense, increasing age and a greater degree of initial displacement may influence the final degree of residual displacement at union., Level of Evidence: IV., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined., (© 2024. The Author(s).)

Introduction: Quadrilateral plate (QLP) is a relatively thin bony structure located below the pelvic brim proximal to the hip joint, so management of its fractures is challenging., Objectives: Evaluation of the functional and radiological outcomes of internal fixation of quadrilateral plate acetabular fractures; comparison of two methods of fracture fixation., Patients and Methods: A prospective multicentric study including 30 patients who underwent open reduction and internal fixation of QLP fractures through modified Stoppa approach. Patients were divided into two groups according to the method of fixation (anatomical QLP plate vs suprapectineal and infrapectineal plates). Post-operative quality of reduction was evaluated using Matta score. Radiographical assessment according Matta's grading criteria and clinical outcome assessment using the Harris Hip Score (HHS) were repeated at follow-up and at one year to assess displacement., Results: Mean age of patients was 34.9 ± 12.1 years. After one year follow-up, clinically mean HHS was 88. ± 5.74. Radiologically post-operative reduction quality was anatomical in 21 (70%) patients, satisfactory in eight (26.7%) patients and unsatisfactory in one (3.3%) patient. Matta's grading at the last follow-up was excellent in 21 (70%) patients, good in six (20%), fair in two (6.7%) patients and poor in one (3.3%) patient. No significant difference was recorded between the two groups in terms of radiographical and clinical results and rate of complications., Conclusion: Accurate reduction of quadrilateral plate fracture with secure fixation through modified Stoppa approach provides good and reproducible outcomes with few complications regardless the type of the implant., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: While decreased time to fixation in femur fractures improves mortality, it remains unclear if the same relationship exists for pelvic fractures. The National Trauma Data Bank (NTDB) is a data repository for trauma hospitals in the United States (injury characteristics, perioperative data, procedures, 30-day complications), and we used this to investigate early, significant complications after pelvic-ring injuries., Methods: The NTDB (2015-2016) was queried to capture operative pelvic ring injuries in adult patients with injury severity score (ISS) ≥ 15. Complications included medical and surgical complications, as well as 30-day mortality. Multivariable logistic regression was used to investigate the association between days to procedure and complications after adjusting for demographic characteristics and comorbidities., Results: 2325 patients met inclusion criteria. 532 (23.0%) sustained complications, and 72 (3.2%) died within the first 30 days. The most common complications were deep vein thrombosis (DVT) (5.7%), acute kidney injury (AKI) (4.6%), and unplanned intensive care unit (ICU) admission (4.4%). In a multivariate analysis, days to procedure was independently significantly associated with complications, with an adjusted odds ratio (95% confidence interval) of 1.06 (1.03-1.09, P < 0.001), best interpreted as a 6% increase in the odds of complication or death for each additional day., Conclusion: Time to pelvic fixation is a significant and modifiable risk factor for major complications and death. This suggests we should prioritize time to pelvic fixation on trauma patients to minimize mortality and major complications., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Patient-reported minimal clinically important differences (MCID) provide a standard to compare clinical outcomes. The purpose of this study was to calculate the MCID of PROMIS Physical Function (PF), Pain Interference (PI), Anxiety (AX), and Depression (DEP) scores in patients with pelvis and/or acetabular fractures., Methods: All patients with operatively treated pelvic and/or acetabular fractures were identified. Patients were categorized as either only pelvis and/or acetabular fractures (PA) or polytrauma (PT). PROMIS PF, PI, AX, and DEP scores were evaluated at 3-month, 6-month, and 12-month intervals. Distribution-based MCID and anchor-based MCID were calculated for the overall cohort, PA, and PT groups., Results: The overall distribution-based MCIDs were PF (5.19), PI (3.97), AX (4.33), and DEP (4.41). The overall anchor-based MCIDs were PF (7.18), PI (8.03), AX (5.85), DEP (5.00). The percentage of patients achieving MCID for AX was 39.8-54% at 3 months and 32.7-56% at 12 months. The percentage of patients achieving MCID for DEP was 35.7-39.3% at 3 months and 32.1-35.7% at 12 months. The PT group had worse PROMIS PF scores than the PA group at all time points [post-operative, 3-month, 6-month, and 12-month scores, (28.3 (6.3) vs. 26.8 (6.8) P = 0.016), (38.1 (9.2) vs. 35.0 (8.7) P = 0.037), (42.8 (8.2) vs. 39 (9.6) P = 0.015), (46.2 (9.7) vs. 41.2 (9.7) P = 0.011)]., Conclusion: An overall MCID for PROMIS PF was 5.19-7.18, PROMIS PI 3.97-8.03, PROMIS AX of 4.33-5.85, and PROMIS DEP of 4.41-5.00. The PT group had worse PROMIS PF at all time points. The percentage of patients achieving MCID for AX and DEP plateaued at 3 months post-operatively., Level of Evidence: Level IV., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Incomplete sacroiliac joint injuries are often associated with external rotation and extension deformities on the injured hemipelvis. To appropriately correct this deformity, an oblique reduction force from caudal to cranial and lateral to medial is helpful. These injuries are often associated with traumatic disruption of the pubic symphysis. However, in injuries without traumatic disruption to the pubic symphysis, a two-pin oblique anterior external fixator can be used to obtain and maintain reduction of the sacroiliac joint, while percutaneous fixation is subsequently placed. Through a small case series and three specific patient examples, we demonstrate that the oblique anterior external fixator frame is a simple and effective strategy with the reduction and stabilization process of these multiplanar hemipelvis deformities., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Reduction of AO/OTA 61-B2.3 (APC2) pelvic fractures is challenging in the setting of anterior ring comminution. The anterior ring is visually much simpler to evaluate for flexion or extension hemipelvis deformity than the posterior ring, except in the setting of comminution, necessitating some other visual reference to judge hemipelvis reduction. We sought to test whether pelvic inlet and outlet fluoroscopy of the contours of the sacroiliac joint could be used in isolation to judge hemipelvis flexion or extension., Methods: Symphyseal and anterior SIJ ligaments were cut (6 cadaveric pelvis). The symphysis was held malreduced to produce one centimeter flexion and extension deformity: 1 cm was selected to mimic a maximum clinical scenario. The SIJ was assessed using inlet and outlet fluoroscopy. The scaled width of the SIJ was assessed at the joint apertures and midjoint on both inlet and outlet views. Joint widths in flexion and extension were compared against joint widths measured on the reduced SIJ using paired t-tests., Results: There was no statistical difference in the superior (p = 0.227, 0.675), middle (p = 0.203, 0.693), and inferior (p = 0.232, 0.961) SIJ widths between hemipelvis flexion or extension models against reduced SIJ on outlet views. There was no statistical difference in the anterior (p = 0.731, 0.662), middle (p = 0.257, 0.655), and posterior (p = 0.657, 0.363) SIJ widths between flexion or extension models against reduced SIJ on inlet views., Conclusion: Inspection of SIJ width on inlet and outlet fluoroscopy cannot detect up to one centimeter of hemipelvis flexion or extension malreduction in the setting of AO/OTA 61-B2.3 (APC2) pelvic fractures with complex anterior injuries., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: The sustentaculum tali is a biomechanically important stabilizer of the hindfoot and contributes to articular congruency of the subtalar joint. Sustentaculum injury associated with a talus fracture has been described infrequently and treatment of this combined injury varies. The purpose of this study was to describe and evaluate the outcomes of the combined talus and sustentaculum fracture., Methods: Retrospective chart and radiographic review was performed on all talus fractures (n = 436) requiring operative fixation over a 21-year period at a single Level-1 trauma center. All talus fractures with sustentaculum fractures were included. Statistical analysis was performed using Chi-squared and Fishers exact tests where appropriate., Results: Sustentaculum fractures occurred in 6.2 % (n = 27) of patients with talus fractures. Average follow-up was 14 months; 18.5 % were open fractures, 88.8 % were from high-energy mechanisms, and 44.4 % were polytraumas. Diagnosis of the sustentaculum fracture was missed on presenting radiographs in 69.2 % (n = 18). The most common associated talus fracture was a talar neck fracture (40.7 %) and the majority (73.7 %) were Hawkins II. Overall, 40.7 % (n = 11) of the sustentaculum fractures were treated with independent fixation and 7.4 % (n = 2) were treated with acute subtalar arthrodesis. Subtalar post-traumatic osteoarthritis (PTOA) at final follow-up was seen in 23.1 % of combined injuries. Independent sustentaculum fixation did not influence the rate of PTOA or re-operation (p = 0.92, p = 0.91, respectively)., Conclusion: Talar fractures have an associated sustentaculum fracture in approximately 6 % of cases, especially with Hawkins II fracture-dislocations. Over two-thirds of the associated sustentaculum fractures were missed on presenting radiographs, reiterating the need for heightened awareness and consideration of advanced imaging for all talus fractures. The rate of PTOA following these combined injuries at mean follow-up of 24 months does not exceed established rates after isolated talus fractures. Further research is required to determine the optimal management of the sustentaculum in these combined injuries., Level of Evidence: IV., Competing Interests: Declaration of competing interest No author received any direct funding from any agencies in the public, commercial, or not-for-profit sectors specifically for this work. DLR receives reimbursement as an educator for AO Trauma North America and has stock ownership in Purgo Scientific. TFH receives grant funding through the U.S. Department of Defense, consulting fees from DePuy Synthes and Globus, has stock ownership in Orthogrid, SMV Holdings, NT nPhase, Imagen, and has leadership roles on the Orthopedic Trauma Association Board of Directors. JMH receives grant funding through the Arthritis Foundation, consulting fees from Stryker, Orthogrid, Osteocentric, Newclip Technics, is a participant on NIAMS Safety Officer for PA-20-206 advisory board, and has leadership roles for Orthopedic Trauma Association, Western Orthopedic Association, and AO Foundation. For the remaining authors, none were declared., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: Acetabular fracture shape is determined by the direction of force applied. We perceive an anecdotally observed connection between pre-existing autofused sacroiliac joints (aSIJ) and high anterior column (HAC) injuries. The purpose of this study was to compare variations in acetabular fracture patterns sustained in patients with and without pre-injury sacroiliac (SI) joint autofusion., Methods: All adult patients receiving unilateral acetabular fixation (level 1 academic trauma; 2008-2018) were reviewed. Injury radiographs and CT scans were reviewed for fracture patterns and pre-existing aSIJ. Fracture types were subgrouped presence of HAC injury (includes anterior column (AC), anterior column posterior hemitransverse (ACPHT), or associated both column (ABC))., Analysis: Logistic regression determined the association between aSIJ and HAC., Results: A total of 371 patients received unilateral acetabular fixation (2008-2018); 61 (16%) demonstrated CT evidence of idiopathic aSIJ. These patients were older (64.1 vs. 47.4, p < 0.01), more likely to be male (95% vs. 71%, p < 0.01), less likely to be smokers (19.0% vs. 44.8%, p < 0.01), and were injured from lower energy mechanisms (21.3% vs. 8.4%, p = 0.01). The most common patterns with autofusion were ACPHT (n = 13, 21%) and ABC (n = 25, 41%). Autofusion was associated with greater odds of patterns involving a high anterior column injury (ABC, ACPHT, or isolated anterior column; OR = 4.97, p < 0.01). After adjusting for age, mechanism, and body mass index, the connection between autofusion and high anterior column injuries remained significant (OR = 2.60, p = 0.01)., Conclusions: SI joint autofusion appears to change mode of failure in acetabular injuries; a more rigid posterior ring may precipitate a high anterior column injury., Level of Evidence: Prognostic level III., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)