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The purpose of this study was to critically evaluate the efficacy of single screw and washer fixation in comparison with other methods for securing olecranon osteotomies. The hypothesis is that screw and washer fixation is a safe and effective means of olecranon osteotomy fixation with fusion and complication rates similar to other methods of fixation.Retrospective review.Two Level I Urban Trauma Centers.Patients were treated within the last 20 years and received 1 of 4 types of fixation (screw and washer alone, screw and washer augmented with tension band, tension band alone, or plate and screws) after osteotomy.Open reduction and internal fixation of OTA/AO 13B/C distal humerus fractures with an olecranon osteotomy.The primary outcome measure was the presence of osteotomy union. Secondary outcome measures were olecranon nonunion, loss of articular reduction, and removal of hardware. Logistic regression was used to determine the associations between method of osteotomy fixation and removal of hardware or nonunion rates. Comorbidities were stratified using the Charlson comorbidity index.One hundred sixty patients met the inclusion criteria. Thirty-nine patients underwent screw fixation alone, 47 had tension band fixation, 16 had plate fixation, and 58 had tension band and screw fixation. Screw fixation demonstrated equal or better rates of union, maintenance of reduction, absence of infection, and implant removal compared with alternative fixation techniques. Higher Charlson scores were associated with higher rates of nonunion.Screw and washer fixation is a safe and effective means of securing an olecranon osteotomy. Charlson comorbidity score is one factor that may influence the development of nonunion after osteotomy.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

SUMMARY: The Fracture Improvement with Teriparatide (Fix-IT) study randomized 13 women with an atypical femur fracture to immediate vs delayed teriparatide therapy; all were followed for 12 months. Results suggested a trend for superior healing and lesser bone mineral density declines in the immediate vs delayed group with no differences in adverse events. PURPOSE: Little clinical data are available on the use of teriparatide for the treatment of bisphosphonate-associated atypical femur fractures (AFF). The goal of the Fix-IT study was to determine if immediate therapy with teriparatide was superior for fracture healing after an AFF compared to a 6-month delay in teriparatide therapy. METHODS: This randomized pilot clinical trial included 13 women with an AFF who were randomized to immediate teriparatide vs a delay of 6 months. All were followed for 12 months on teriparatide. The primary outcomes included individual and composite measures of radiologic bone healing (scored 1 point [no healing] to 4 points [complete healing]) at 6 and 12 months. Secondary outcomes included bone mineral density of the unfractured contralateral hip, spine, 1/3 distal radius, and adverse events. RESULTS: We found there was a trend for superior healing with the composite score (12.6 vs 11.2 at 6 months and 15.4 vs 13.2 at 12 months), and lesser bone mineral density declines at the 1/3 distal radius (12-month change − 1.9 vs − 6.1%) in the immediate vs the delayed group. There were no differences in adverse events. There was one implant failure in the delayed group. CONCLUSIONS: There is a preliminary signal for greater improvements with immediate teriparatide therapy vs delayed therapy. However, because an AFF is a rare event, and only a small number of patients were included, the results must be interpreted with caution.

Background: mu-opioid receptor ( OPRM1) and catechol-O-methyltransferase ( COMT) contribute to the neurotransmission pathway of pain. COMT affects mu receptor expression and density in the brain. The aim of this study was to explore the OPRM1 and COMT interaction effects on postoperative pain and opioid consumption. Methods: This cross-sectional exploratory study used genotype and clinical data from 153 postoperative patients. Using multiple regression analyses, four single-nucleotide polymorphisms of COMT (rs6269, rs4633, rs4818, and rs4680), their haplotypes, and diplotypes were considered for their interactions with A118G of OPRM1 regarding postoperative pain and opioid consumption. Results: For opioid consumption, significant interactions were found between OPRM1 A118G and COMT rs4680 ( p = .037) and between OPRM1 and COMT rs4633 ( p = .037). Patients having Met158Met of COMT rs4680 and AG/GG of OPRM1 or TT of COMT rs4633 and AG/GG of OPRM1 consumed the largest amount of opioid compared to those having other combinations. For postoperative pain, a significant interaction was found between OPRM1 and the low pain sensitivity (LPS; GCGG) haplotype of COMT ( p = .017). For patients with no copies of the LPS haplotype, AA of OPRM1 A118G was significantly associated with higher pain scores compared to the variant AG/GG. However, the opposite direction was observed for patients with at least one copy of the LPS haplotype. Conclusions: The interaction of OPRM1 with COMT may contribute to variability in postoperative pain and opioid consumption. Additional larger studies are needed to confirm findings.

Previous studies have associated mu-opioid receptor ( OPRM1) genotype with pain and analgesia responses in postoperative and patient populations. This study investigates the role of catechol-O-methyltransferase ( COMT) and OPRM1 genotypes in acute postoperative pain scores, opioid use, and opioid-induced sedation after surgical procedures for orthopedic trauma in an otherwise healthy patient population. Verbal pain/sedation scores, opioid use, and physiologic responses in the immediate postoperative period were examined for association with genetic variants in Caucasians genotyped for OPRM1 single nucleotide polymorphisms (SNPs) A118G and C17T and COMT SNPs. The OPRM1 A118G genotype was associated with patients’ postoperative Numerical Pain scale (NPS) ratings at 15 min in the postanesthesia care unit (PACU) ( p = .01) and patients' sedation scores at 15 min in the PACU ( p = .02). COMT genotype (rs4818) was associated with opioid consumption in the first 45 min in the PACU ( p = .04). NPS ratings at 45 min were also higher in the group of patients with A/A genotype of rs4680 than in patients with the other two genotypes at this SNP ( p = .03). Our haplotype trend analysis identified a COMT haplotype “GCGG” significantly associated with NPS at 15 min ( p = .0013), amount of opioids consumed in the first 45 min ( p = .0024), and heart rate at 45 min in the PACU ( p = .017). The results indicate that genetic variations in COMT contribute to the acute postoperative pain and analgesia responses and physiologic responses in this group of otherwise healthy postoperative orthopedic trauma patients.

Background: An increased rate of complications has been clearly shown in diabetic patients undergoing operative treatment for displaced ankle fractures. To date, no studies have specifically looked at the complication rates following the operative management of pilon fractures in this difficult patient population. We performed a retrospective review to determine the rates of complications in diabetic patients undergoing operative fixation of tibial pilon fractures compared with a control group of patients without diabetes. M aterials and Methods: The trauma registry was utilized to identify all patients who underwent primary treatment for a tibial pilon fracture between January 2005 and June of 2007 at a single Level 1 trauma center. A minimum of 6-month followup was required for inclusion. A chart and radiographic review was completed to identify the complications seen in each patient population. Specifically, we looked at the rate of infection (superficial and deep), the rate of nonunion or delayed union, and the rate of surgical wound complications. Results: A total of 14 fractures in 13 diabetic patients, and 69 fractures in 68 non-diabetic patients met inclusion criteria. In the diabetic patient group, the average age was 48 years, the average BMI was 35, and 36% of the fractures were open. In the non-diabetic group, the average age was 47 years, the average BMI was 29, and 35% of the fractures were open. Only the difference in BMI was statistically significant. The infection rate was 71% for diabetic patients (43% deep infection), and 19% for non-diabetic patients (9% deep infection) [ p < 0.001, odds ratio 10.719 (95% confidence interval 2.914 to 39.798)]. Overall, the rate of non-union/delayed union was 43% in the diabetic group versus 16% in the non-diabetic group [ p = 0.02, odds ratio 3.955 (95% confidence interval 1.145 to 13.656)]. The rate of surgical wound complications was 7% in both the non-diabetic and diabetic patient groups. Conclusion: The management of tibial pilon fractures in diabetic patients is difficult, with a high rate of complications compared to non-diabetic patients. These results mirror those previously reported for ankle fractures in diabetic patients. Level of Evidence: IV, Retrospective Case Series

Von den externen Hilfen zur Forderung der Frakturheilung scheint sich niedrigintensiver gepulster Ultraschall als sicheres, kosteneffektives und verlassliches Verfahren zu erweisen. Verschiedene experimentelle Studien haben sowohl mit In-vivo- als auch mit In-vitro-Arbeiten zur Aufklarung moglicher Wirkungsmechanismen des Ultraschalls beigetragen. Daruber hinaus existiert eine Reihe prospektiver, randomisierter, doppelblinder, placebokontrollierter Studien, die die klinische Wirksamkeit niedrigintensiven, gepulsten Ultraschalls belegen. In diesem Artikel werden diese Studien zusammengefasst.

Current methods of fracture care use various adjuncts aimed at decreasing time to fracture union and improving fracture union rates. Among the most commonly used modalities, low-intensity pulsed ultrasound is emerging as a safe, cost-effective and reliable treatment for both fresh fractures and fracture nonunions. Both in vivo and in vitro basic science studies have helped to elucidate potential mechanisms of ultrasound action and a number of prospective, randomised, double-blind, placebo-controlled trials exist demonstrating the clinical efficacy of low-intensity pulsed ultrasound. This article will review the evidence for the use of low-intensity pulsed ultrasound in fracture care.

The treatment of tibial plafond fractures is challenging and often is complicated by the compromise of the anterior ankle soft-tissue envelope and a high degree of fracture comminution. Many of these injuries are nonreconstructable and posttraumatic osteoarthritis of the tibiotalar joint is unavoidable. These patients may benefit from a salvage procedure using a posterior blade plate fusion of the tibiotalar joint. This procedure avoids the compromised anterior ankle soft-tissue envelope and allows simultaneous reconstruction of the metaphyseal defect as well as fusion of the tibiotalar joint. Indications include the acute treatment of severely comminuted tibial plafond fractures that appear nonreconstructable, management of posttraumatic tibiotalar osteoarthritis that is associated with significant compromise of the anterior ankle soft tissue envelope, and salvage of distal metaphyseal nonunions or delayed unions that are associated with posttraumatic tibiotalar osteoarthritis. We suggest posterior blade plate fusion as a standard procedure for these patient populations. Further clinical trials are required to investigate the clinical long-term outcomes in these patients.

UNLABELLED Sacroiliac joint dysfunction is believed to be a significant source of low back and posterior pelvic pain. METHODS To assess the clinical presentation, diagnostic testing, and treatment options for sacroiliac joint dysfunction, a systematic literature review was performed using MEDLINE. RESULTS Presently, there are no widely accepted guidelines in the literature for the diagnosis and treatment of sacroiliac instability. Establishing management guidelines for this disorder has been complicated by the large spectrum of different etiologic factors, the variability of patient history and clinical symptoms, limited availability of objective testing, and incomplete understanding of the biomechanics of the sacroiliac joint. CONCLUSIONS A reliable examination technique to identify the sacroiliac joint as a source of low back pain seems to be pain relief following a radiologically guided injection of a local anaesthetic into the sacroiliac joint. Most patients respond to non-operative treatment. Patients who do not respond to non-operative treatment should be considered for operative sacroiliac joint stabilization.

To evaluate whether FIM instrument motor outcomes differ between hip fracture survivors undergoing rehabilitation in inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs).Inception cohort with follow-up to 12 weeks after hospital discharge.University-affiliated tertiary care hospital, IRFs, and SNFs.All hip fracture patients prospectively admitted between March 1, 2002, and June 30, 2003, were eligible if they were 60 years or older and had surgical stabilization of the fracture.Posthip fracture rehabilitation delivered at either IRFs or SNFs.FIM motor score obtained postoperatively and at 2 and 12 weeks posthospital discharge.IRF patients stayed an average of 12.8 days, whereas SNF patients averaged 36.2 days. Rehabilitation participation scores were obtained during therapy sessions and did not differ between groups. A repeated-measures analysis of covariance found a significant group by time interaction (F 2,68 =23.75, P.001), which indicates that patients in an IRF had significantly higher FIM motor scores than those in an SNF across time. Logistic regression showed that IRF subjects were more likely to reach 95% of their prefracture FIM motor by week 12 than were SNF patients. A significantly higher percentage of IRF patients were discharged home after rehabilitation compared with SNF patients.IRF patients had superior 12-week functional outcomes, as measured by the FIM motor score, compared with those treated in an SNF. The improved outcomes occurred during a significantly shorter rehabilitation length of stay and remained even when statistically controlling for baseline differences between groups. These data suggest that hip fracture survivors should not be excluded from receiving inpatient rehabilitation services. Randomized clinical trials are needed to understand more fully differences between rehabilitation treatment settings.

Background: Exchange reamed nailing of the tibia is a common procedure in the treatment of an aseptic tibial nonunion. However, reports in the literature supporting this technique are limited. Methods: Forty patients with a tibial nonunion after initial unreamed intramedullary nailing were retrospectively assessed after an exchange reamed nailing. The main outcome measurements included radiographic and clinical union as well as time from exchange reamed nailing to union. Results: Thirty-eight patients achieved union of their fracture (95%). The average time from exchange nailing to union was 29 ± 21 weeks. Complications included one deep vein thrombosis (2.5%) and two hardware failures (5%). Conclusion: Exchange reamed nailing for nonunions of the tibia results in a high union rate and is associated with a low complication rate. This technique is recommended as a standard procedure for aseptic tibial nonunions after initial unreamed intramedullary nailing.

Total hip arthroplasty is a prevalent orthopedic intervention in the United States. Massive postoperative hematomas are a rare albeit serious complication of the procedure. Sequelae of these hematomas can include lower extremity paralysis from compression of the sciatic nerve. A 66-year-old woman taking aspirin and clopidogrel for coronary stents presented with a complete foot drop, paresthesias, and lower extremity pain 10 days after a total hip arthroplasty. The patient was initially seen by a neurology service at another hospital and thought to have lateral recess stenosis. At the authors' center, magnetic resonance imaging of the lumbar spine failed to show lateral recess stenosis. Urgent pelvic computed tomography showed a large hematoma and raised suspicion of sciatic nerve compression. Hip magnetic resonance imaging showed a right gluteal hematoma compressing the sciatic nerve. The patient was then taken to the operating room for the clot to be evacuated and was later referred for rehabilitation. Massive hematomas after total hip arthroplasty are an important consideration in the differential diagnosis of nontraumatic acute foot drop. Prompt diagnosis may correlate with improved neurological outcome and help reduce overall morbidity. [ Orthopedics. 2016; 39(2):e374–e376.]

SummaryThe approach to pelvic fractures has undergone substantial change throughout the years. Considerable controversy exists concerning this fracture in terms of hemorrhage etiologies, treatment options, complications, and outcomes. External fixation became popular when conservative treatment was

Background: The validity of the Functional Capacity Index (FCI) is evaluated by examining its distributional characteristics, its correlation with other well-known measures of outcome and its ability to discriminate among persons with injuries of varying type and severity. Methods: A telephone survey which included the FCI and the SF-36 was administered 1 year post-injury to 1240 blunt trauma patients discharged from 12 trauma centers. A subsample of 656 patients also completed the Sickness Impact Profile (SIP) by mail. Results: FCI scores correlated well with the physical health subscores of the SIP and SF-36. They also correlated well with self-reported change in health status and return to work. The FCI, when compared to either the SF-36 or the SIP, however, appears to discriminate better among patients according to the presence and severity of head trauma. Conclusions: While further testing of the FCI is needed, it holds promise as a preference based measure for assessing the physical impact of trauma.

The Ilizarov method has gained popularity in the management of osteomyelitis. In this chapter we describe close and open techniques for the treatment of osteomyelitis with llizarov frame. Also, the use of Ilizarov frame has been highly successful in limb salvage when infected nonunion was combined with soft-tissue defect. Presently, it is the only comprehensive approach that can simultaneously address infection, nonunion, length discrepancy, and soft-tissue defect.

Background: The treatment of highly comminuted tibial pilon fractures is controversial. The aim of this study was to determine the effectiveness and outcomes of primary arthrodesis following highly comminuted tibial plafond fractures. Methods: A database search was performed to identify all patients who underwent blade plate arthrodesis at our institution over a sixteen-year period. Inclusion criteria included patients with an Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association type-C2 or type-C3 pilon fracture that was deemed to be non-reconstructable by the treating surgeon. Outcomes were measured using the Short-Form 36-Item Health Survey, time to independent walking, time to consolidation of the arthrodesis, and wound-healing complications. Results: A total of twenty patients were included in this study, and seventeen patients (85%) were available for follow-up at a minimum of two years after their surgery. Wound infections or wound dehiscence did not occur in this series. All patients were walking without crutches or a walker at their latest follow-up. One patient developed an aseptic nonunion and healed successfully after revision surgery. Conclusions: Blade plate ankle fusion using a posterior approach is a reliable method for the treatment of a small subset of patients with severely comminuted, non-reconstructable pilon fractures. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The study reviewed in this article evaluated a group of patients who underwent surgical therapy for calcaneal fractures at a Level I trauma center. One group of patients was treated after outpatient referral to the center, whereas the other group was admitted to, and underwent surgery at, the center. This study attempted to determine which patient risk factors or injury characteristics might lead to an increased rate of wound-healing complications. Bohler's angle is a classic radiographic method of determining the severity of calcaneal injury in this group of patients. The question posed by the authors of this study was: Does a drastic correction in Bohler's angle lead to an increased incidence of wound-healing complications? The authors do not recommend undercorrection of Bohler's angle but urge avoidance of overcorrection and stress the importance of early surgical fixation after lateral skin wrinkling is found.

Patients with ankle arthritis and deformity can experience severe pain and functional disability. Those patients who do not respond to nonoperative treatment modalities are candidates for ankle arthrodesis, provided pathologic changes in the subtalar region can be ruled out. Several techniques are available for performing the procedure; the most successful combine an open approach with compression and internal fixation. The foot must be positioned with regard to overall limb alignment and in the optimal position for function. A nonunion rate as high as 40% has been reported. Osteonecrosis of the talus and smoking are known risk factors for nonunion. When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain.

The calcaneus is the most commonly fractured tarsal bone. The degree of intraarticular involvement is assessed byusing both plain radiographs and computed tomography scans. Patient swelling is reduced as soon as possible after the injury by the use of a bulky dressing and a plaster splint or an external compression pump. A lateral approach is used to expose the fracture with the creation of an osteocutaneous flap. Articular surfaces are reduced initially followed by reestablishment of normal heel height and width. The fracture fragments are temporarily held in place with Kirshner wires. Subarticular screws are used for initial reduction and support of the posterior and middle facets. The lateral wall is stabilized to the body of the calcaneus with a lateral plate and screws. A double–layered closure technique is used to prevent wound dehiscence. Solid fixation allows for early postoperative range of motion.

This retrospective study investigated outcomes of wound healing in a series of 63 consecutive patients with 64 fractures of the calcaneus who underwent open reduction and internal fixation done by two surgeons experienced in this fracture during a 3-year period. Thirty-nine patients were managed preoperatively as outpatient referrals before surgery. Twenty-four patients were admitted directly to the trauma service and were managed as inpatients preoperatively. Minimum patient follow-up was 6 months, with an average follow-up of 18 months. A trend correlating the time between injury and operative intervention with the incidence of complications in wounds was noted; the incidence rose in patients who underwent surgery5 days after their injury. Two-layered closures had a lower incidence of dehiscence compared to single-layered tension-relieving sutures. Patients with a higher body-mass index (BMI) (kg/ m2) took longer to heal their wounds. Strong trends were noted to link BMI and severity of fractures. In the outpatient group, a history of active smoking preoperatively correlated with increased time to wound healing. In 43 patients, there were no wound-healing complications. In 21 feet, there were varying degrees of wound dehiscence. Average wound healing took 47 days. Risk factors for complications in the wound after calcaneal open reduction and internal fixation include single layered closure, high BMI, extended time between injury and surgery, and smoking. Age, type of immobilization, medical illness (including diabetes), type of bone graft, or use of a Hemovac did not influence wound healing.

This review describes surgical techniques used to treat some common pelvic ring disruptions including the indications for fixation, as well as operative techniques. Fracture patterns discussed include symphaseal injuries, sacral-iliac joint fractures and dislocations, crescent fractures, sacral fractures, and fractures involving the iliac wing. Additionally, postoperative management and complications are reviewed.

Objectives To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. Design Retrospective review. Setting Two level one trauma centres. Patients Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. Intervention Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). Main outcome measurements Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Results Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p = 0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p p = 0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p = 0.333). Conclusions A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. Level of evidence Level III.

Fractures of the tibial plateau present a treatment challenge and are susceptible to both prolonged operative times and high postoperative infection rates. For those fractures treated with open plating, we sought to identify the relationship between surgical site infection and prolonged operative time as well as to identify other surgical risk factors.We performed a retrospective controlled analysis of 309 consecutive unicondylar and bicondylar tibial plateau fractures treated with open plate osteosynthesis at our institution's level I trauma centre during a recent 5-year period. We recorded operative times, injury characteristics, surgical treatment, and need for operative debridement due to infection. Operative times of infected cases were compared to uncomplicated surgical cases. Multivariable logistic regression analysis was performed to identify independent risk factors for postoperative infection.Mean operative time in the infection group was 2.8h vs. 2.2h in the non-infected group (p=0.005). 15 fractures (4.9%) underwent four compartment fasciotomies as part of their treatment, with a significantly higher infection rate than those not undergoing fasciotomy (26.7% vs. 6.8%, p=0.01). Open fracture grade was also significantly related to infection rate (closed fractures: 5.3%, grade 1: 14.3%, grade 2: 40%, grade 3: 50%, p0.0001). In the bicolumnar fracture group, use of dual-incision medial and lateral plating as compared to single incision lateral locked plating had statistically similar infection rates (13.9% vs. 8.7%, p=0.36). Multivariable logistic regression analysis of the entire study group identified longer operative times (OR 1.78, p=0.013) and open fractures (OR 7.02, p0.001) as independent predictors of surgical site infection.Operative times approaching 3h and open fractures are related to an increased overall risk for surgical site infection after open plating of the tibial plateau. Dual incision approaches with bicolumnar plating do not appear to expose the patient to increased risk compared to single incision approaches.

The CYP2D6 gene encodes for an enzyme that is involved in the metabolism of more than 25% of all medications, including many opioids and antiemetics. It may contribute to the risk of postoperative nausea and vomiting (PONV), a common surgical complication. However, little research has been conducted in this area. The purpose of this study was to explore the association of CYP2D6 genotypes with PONV in adult surgical trauma patients. Data from 112 patients (28% female) with single extremity fractures, aged 18–70 years, were analyzed. PONV was defined as present if patients reported nausea, were observed vomiting, or received medication for PONV. Saliva samples collected for DNA extraction and Taqman® allele discrimination and quantitative real time polymerase chain reaction (qRT-PCR) were used to collect genotype data that were then used to assign CYP2D6 phenotype classification. The incidence of PONV was 38% in the postanesthesia care unit and increased to 50% when assessed at 48 hr. CYP2D6 classification results were 7 (6%) poor metabolizers, 34 (30%) intermediate metabolizers, and 71 (63%) extensive metabolizers. No ultrarapid metabolizers were identified. Patients who were classified as poor metabolizers had less PONV and higher pain scores. Gender and history of PONV, but not smoking, were also significant risk factors. Findings suggest variability in CYP2D6 impacts susceptibility to PONV.

The management of hemodynamically unstable patients with displaced pelvic ring fractures and associated abdominal, thoracic, or head injuries is controversial. We studied 312 consecutive trauma patients with pelvic fractures admitted from July 1, 1989 through June 30, 1993: thirty-six of these patients were in shock (SBPor = 90 mm Hg) and were treated by a protocol including volume resuscitation, and treatment of the associated injuries, without use of acute external fixation. Evaluation of the pelvic fractures revealed 39% to be rotationally unstable; 61% were both rotationally and vertically unstable. The mean injury Severity Score was 27 +/- 12, the average Glasgow Coma Scale score was 12 +/- 5, and the Abbreviated Injury Scale (AIS) scores stratified for the abdomen and the thorax were 1.9 +/- 1.7 and 1.6 +/- 1.8, respectively. Eighteen patients required thoracotomy, laparotomy, or both. The total blood requirement in the initial 24 hours postinjury was 4.0 +/- 4 Units. Deaths of four patients (11%) were a function of associated injuries and comorbid factors, not the result of uncontrolled pelvic hemorrhage. The data suggest that aggressive resuscitation of these patients and treatment of extrapelvic injuries in conjunction with early or delayed ORIF, without application of acute external fixation, resulted in a low overall mortality rate.

Operative fixation of foot and ankle trauma can be challenging. Often times, the soft tissue envelope can have extensive damage as a result of the fracture. In these cases, percutaneous fixation may be used. Percutaneous fixation can benefit both soft tissue and osseous healing when used correctly. Many techniques have been described in the literature that may help to preserve blood supply, minimize soft tissue dissection, and restore a functional limb. This article reviews general guidelines for fracture and soft tissue management, osseous healing of fractures, and how certain techniques influence fracture healing. It also illustrates certain techniques for specific fracture reduction.

An unstable pelvic ring fracture requires surgical stabilization. The anterior ilioinguinal approach to the sacroilliac (SI) joint is recommended for a vertically, posteriorly, or laterally displaced hemipelvis because it allows for a direct visualization and it affords for an anatomic reduction of the SI joint. Other indications for use of the anterior approach include the need for fixation of associated acetabular, iliac wing, or symphyseal fractures. This technique is not applicable for fractures of the sacrum because of the proximity to the L5 nerve root. Biomechanical data supports the use of anterior plating for rigid osseous stabilization of the SI joint. Other techniques of internal fixation include transiliac screws, posterior tension band plate, and sacral bars. These methods place important neurologic and vascular structures at risk. Further, a posterior approach has inherent difficulty in reducing a SI disruption and may cause a higher incidence of skin necrosis. This article describes the advantages and the technique of anterior stabilization of the SI joint in the management of an unstable pelvic ring fracture.

Scapulothoracic dissociation is an infrequent injury with potentially devastating outcomes. Knowledge of this injury is based on small patient series and case reports. The aim of this article is to review the evaluation, management and functional outcomes following scapulothoracic dissociation. Often caused by high traction forces applied to the shoulder girdle, there is a complete loss of the scapulothoracic articulation with lateral scapular displacement and intact skin. This is frequently associated with muscular, ligamentous and osseous injuries to the shoulder girdle, vascular injuries to the subclavian, or axillary, vessels and brachial plexus lesions. In the acute setting, the timely diagnosis of the associated neurovascular injuries is crucial. Severe neurovascular and soft tissue compromise often requires an early above-elbow amputation. Further, complete brachial plexus avulsions are associated with a limited potential for functional recovery.

Treatment of atrophic nonunions is a challenge to orthopaedic surgeons. Growth factors potentially are valuable factors for improvement of tissue healing. The use of growth factors, however, is limited by their short half-lives. Gene therapy has the potential to improve the treatment. This study aimed to establish and validate an atrophic nonunion model in a rabbit for the use of a percutaneous in vivo gene therapy protocol. An atrophic tibial nonunion was established in 24 New Zealand White rabbits. Radiologic and histologic followup was for 64 weeks. The rabbit tibias showed no radiologic or histologic signs of healing. In addition, an adenoviral vector carrying a marker gene was injected percutaneously into the nonunion site in 12 rabbits. Expression of the marker gene was assessed for as many as 4 weeks. The percutaneous gene delivery resulted in transgene expression in the nonunion site for as many as 4 weeks. The described model reliably leads to an atrophic tibial nonunion in rabbits. Adenoviral percutaneous gene delivery into the nonunion site is feasible and leads to transgene expression locally for at least 1 month. This study provides investigators with a reliable and reproducible model of an atrophic nonunion.

During a 6-year period, 177 patients with a displaced sacral fracture were treated at our level-one trauma centre. At the initial presentation, 13 patients demonstrated a neurological deficit as a result of their sacral fracture. Six patients underwent surgical decompression, and seven patients were managed without surgical decompression. All patients were re-assessed at an average follow-up of 27.1 (range 12–84) months using the modified SOFCOT Index and the SF-36. Patients undergoing surgical decompression had a significantly better neurological improvement as measured by the modified SOFCOT Index (p=0.014). Moreover, patients undergoing surgical decompression had a significantly better physical function than the patients that were managed without surgical decompression, as measured by the SF-36 (p=0.044). We therefore believe that patients undergoing surgical decompression achieve better neurological improvement and better functional results.

BackgroundInternal snapping hip is an underdiagnosed cause of hip pain that sidelines many recreational and competitive athletes. It originates from a taut iliopsoas tendon that snaps across bony prominences when the hip is extended from a flexed position. When nonoperative treatment methods fail, fractional tendon-lengthening procedures may be used.HypothesisSurgical tendon lengthening through a true ilioinguinal approach, which has not been previously reported, will achieve good results in patients with internal snapping hip.Study DesignRetrospective cohort study.MethodsIn 30 patients with symptoms in their anterior hip, internal snapping hip was diagnosed by history and physical examination. All patients were initially treated nonoperatively; 19 (63%) improved and did not require further intervention. Eleven patients (12 hips) whose symptoms were recalcitrant to physical therapy were offered the surgical option of iliopsoas tendon lengthening. The procedure was performed via an ilioinguinal intrapelvic approach. Patients were followed up for an average of 3 years.ResultsAll 11 surgically treated patients (100%) had complete postoperative mitigation of their snapping hip. Nine (82%) reported excellent pain relief. Moreover, nine patients thought that they had greatly benefited from the tendon lengthening and would repeat the surgery.ConclusionAlthough nonoperative measures are usually successful in the treatment of internal snapping hip, surgical tendon lengthening is a viable approach in cases refractory to nonoperative therapy.

There is a paucity of large cohort studies that address outcomes after acute orthopaedic trauma. The regional trauma registry is a powerful tool to study trends of large populations over long periods of time. We used such a regional trauma registry to review retrospectively a large subset of orthopaedic trauma patients over a long period of time and to evaluate the relationship between initial presentation, hospital course, hospital charges, and outcomes as a function of age. A retrospective review of 130,506 level I and II trauma admissions with acute orthopaedic injuries over 10 years (1985–1995) was conducted. Aggregate data were analyzed among five age groups. Descriptive analyses were conducted for mechanism of injury, mortality, time to death, injury type, injury severity score (ISS), Glasgow Coma Scale (GCS) on presentation, length of stay (LOS), discharge destination, and hospital charges. Forty-six percent of the patients were in the 18–35-year-old age group; however, 21% of all patients were older than 65 years of age at the time of injury. There were no differences in GCS or ISS on admission. Injury types were similar across all age groups, mostly extremity fractures. Younger patients were much more likely to be injured in a motor vehicle accident (MVA), whereas older patients were injured in a fall. Penetrating trauma was seen almost exclusively in the young. LOS in the hospital was longer in the elderly; however, LOS in the intensive care units were similar across all age groups. Time to death from initial presentation differed across age groups. Elderly patients who eventually died were much more likely to survive more than 24 h in the hospital as compared with young patients. Hospital charges per hospitalization increased with age, although the total charges to the youngest age group were higher due to the group's high volume. Younger American trauma patients with acute orthopaedic injuries are much more likely than their older counterparts to sustain penetrating trauma and pass the socioeconomic burden to society by way of large opportunity costs, lack of insurance, and high rates of recidivism. Elderly patients fared as well as younger patients after acute orthopaedic trauma, although their hospital stays were longer and resulted in increased hospital charges. The excessive costs of trauma, $100 billion and more than 150,000 deaths annually, necessitate study of general population trends. Indirect costs, including rehabilitation costs and opportunity costs, as well as direct costs, are incurred during the post-trauma hospitalization. Attention must focus on prevention of penetrating injuries in the young and falls in the elderly to reduce morbidity, mortality, and the costs of trauma.

Medical records and radiographs of 52 patients were studied after inclusion/exclusion criteria were met. The anatomical location of proximal femoral fractures that involved the femoral neck were examined after the primary fracture planes were drawn onto templates of the proximal femur. The AO classification is comprehensive and widely accepted. It has not been used in this injury combination in a large series of patients. Therefore, we classified each fracture by the AO method and then the AO classes were tabulated and analysed. Only three patterns of proximal femoral fractures appeared. The inferior aspect of the fracture line clustered in the inferomedial aspect of the femoral neck above an intact lesser trochanter in each separate pattern: 55 per cent were AO B2.1 (basilar); 35 per cent AO B2.3 (intracapsular); and 10 per cent AO A1.2 (pertrochanteric) fractures). Eleven fractures (21 per cent) were not detected initially. None of these were A1.2, eight were B2.1 and three were B2.3. Despite many proximal femoral fracture types reported in the literature only three fracture patterns were noted in this large study group. A new finding of clustering of these fractures in the inferomedial femoral neck was noted. AO class B2.1 fractures were the most common fractures missed at initial presentation and were the most common type seen.

The purpose of this multiple-subject case report is to describe the physical impairments, disabilities, and handicaps of patients with multiple traumas and pelvic-ring fractures after management with open reduction internal fixation. Nineteen men and 12 women, with a mean age of 38+/-16 years (chi+/-SD), were interviewed and examined at least 1 year (chi+/-14.5 months) after sustaining multiple traumas, including an unstable pelvic-ring fracture that was repaired by open reduction internal fixation. Disabilities and handicaps were assessed using the Oswestry Low Back Pain Questionnaire and the Sickness Impact Profile (SIP). Assessments of physical performance consisted of lift capacity, the amount of forward bending, and gait. A descriptive analysis by age and pelvic fracture classification is reported. Theor = 50-year-old group had the best physical testing scores, except for the lifting test. The50-year-old group had the lowest scores. Subjects with B1-class "open-book" pelvic fractures had a tendency to score higher in individual SIP categories. The average SIP scores of 9.34+/-7.47 for the total SIP score, 7.79+/-6.93 for the physical dimension, and 8.24+/-9.61 for the psychosocial dimension represent mild disability. The mean Oswestry score of 13.26%+/-15.41% also represents mild disability. Some subjects demonstrated impairments, disabilities, and handicaps 1 year postoperatively, but for the most part the subjects recovered almost all lost function. The data and clinical management information can be used as a basis of comparison for treatment and research with these types of patients.

We describe a case of unilateral entrapment of the ureter in the sacroiliac joint of a patient who sustained blunt abdominal trauma resulting in fractures of the public rami and sacroiliac joint and multiple bladder perforations. The entrapment was discovered intraoperatively and released by external traction and reduction of the pelvic fractures. No ureteric damage was observed, and reimplantation was not necessary. The importance of evaluating the upper tracts for potential injury in patients with fractures of the bony pelvis and concomitant bladder rupture is emphasized.

An unstable pelvic ring fracture represents a severe injury and is associated with high morbidity and mortality. Little data are available assessing the long-term functional limitations, including disability, in a patient with an unstable pelvic ring fracture. The purpose of this study was to describe the impairment and functional outcome (disability) for patients with unstable pelvic ring fractures managed with open reduction and internal fixation (ORIF). Disability was measured at a minimum of 1 year postinjury using the Sickness Impact Profile (SIP), a measure of the health-related quality of life as perceived by the patient. Of the 230 consecutive patients with a pelvic ring fracture, 54 had unstable fractures requiring ORIF; 48 patients were available at a 1 year follow-up. The follow-up roentgenograms confirmed an osseous union and an anatomic alignment of the pelvis. Thirty-seven (77%) of the patients had mild disability (total SIP10); 11 (23%) of the patients had moderate disability (SIP10) at 1 year. Of the patients who were employed preinjury, 76% were employed 1 year postinjury; 62% had returned to full time work and 14% had returned with job modification. Of the 7 patients who had been in school, 6 had returned full time and 1 student returned part time. Mean SIP scores for subcategories were: physical health = 6.8 +/- 9.4, psychosocial health = 7.4 +/- 12.7, work = 17.6 +/- 25.5, home management = 8.3 +/- 13.0, ambulation = 10.7 +/- 13.7, and mobility = 5.3 +/- 13.0. Despite the magnitude of the bony injuries, the majority of patients with unstable pelvic ring fractures managed with ORIF had mild disability 1 year postinjury; the majority of the patients had returned to work.

OBJECTIVE Open reduction and internal fixation of unstable posterior pelvic ring injury provides better bony stability and less long term morbidity than nonoperative treatment. However, open reduction and internal fixation of the posterior pelvis may involve substantial intraoperative blood loss, reported infection rates of 6 to 25%, and wound complications in 25%. Our hypothesis was that percutaneous cannulated iliosacral screws placed by fluoroscopic control would provide early, rapid, definitive stabilization with minimal blood loss, infection, and wound complications. DESIGN A retrospective medical record and radiographic study. MATERIALS, METHODS, MEASUREMENTS AND MAIN RESULTS: Twenty consecutive patients with an unstable posterior pelvic ring injury treated by percutaneous fixation (41 screws) under fluoroscopic guidance were reviewed. Average patient age was 34 years, trauma score was 14.4 +/- 3.3, and Injury Severity Score was 22.9 +/- 10.6. Mechanisms were motor vehicle collisions (11), falls (3), crush injury (3), and pedestrian/auto (3). Pelvic injuries were classified as Tile B (5) or Tile C (15). Associated injuries were present in 80%. Seventy-five percent of patients underwent pelvic fixation less than 72 hours after injury with closed percutaneous screw placement achieved in 60%, assisted by open reduction in 25% or aided by anterior external fixation in 15%. Mean operative time was 52 minutes for patients requiring percutaneous screws only (7 of 20 patients, 35%), whereas average blood loss was 233 mL for all cases (including open anterior and posterior procedures). No loss of fixation or wound complications occurred during 9.6 months follow-up. CONCLUSIONS Percutaneous iliosacral screw fixation for unstable posterior pelvic disruption provided early fixation with minimal operative time, minimal blood loss, and wound-related morbidity.

Thirty-one patients with unstable displaced pelvic or acetabular fractures were admitted and underwent an open reduction and internal fixation of their fracture. All patients were studied prospectively for the incidence of proximal deep vein thrombosis (DVT) utilizing venous duplex ultrasound. Duplex scans were repeated at 1 week postoperatively in all patients. Additional scans were performed when clinically indicated. A total of 61 scans were completed. DVT developed in three patients (approximately 10%). Two of the three positive scans were noted only on postoperative examination. The third scan was positive on the preoperative phase. Duplex ultrasound was easily applied and well tolerated by the multiply injured patient.