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Tibial shaft fractures are the most common long bone injury and are often treated surgically in an attempt to minimize complications. Although treatment options for tibial shaft fractures vary based on factors including open injury, severity of fracture, and soft tissue status, intramedullary nailing in adults has emerged as the preferred definitive option for stabilization. Therefore, the primary purposes of this review and cadaveric study were to evaluate the entry points for reamed tibial nails and the risks, benefits, and advantages of each approach. Due to concerns of violating the joint capsule and the generalized applicability to everyday practice of the extra-articular lateral parapatellar semi-extended technique, the secondary goal of this manuscript was to evaluate whether an intramedullary tibial nail can be consistently placed extra-articularly using the lateral parapatellar technique described by Kubiak et al. and generalizability to surgeons of varying experience.

External fixation is often used for temporary stabilization of the tibia in several clinical scenarios. Conventional placement of external fixation pins may impede instrumentation with intramedullary nailing, thus requiring pin removal, loss of reduction, and increased operative time during definite fixation. In this article, we describe a strategic pin placement routinely used at our institution in which we create a medially based inverted triangular construct that allows for pins to remain in place during definitive fixation.

During a pandemic, it is paramount to understand volume changes in Level I trauma so that with appropriate planning and reallocation of resources, these facilities can maintain and even improve life-saving capabilities. Evaluating nonaccidental and accidental trauma can highlight potential areas of improvement in societal behavior and hospital preparedness. These critical questions were proposed to better understand how healthcare leaders might adjust surgeon and team coverage of trauma services as well as prepare from a system standpoint what resources will be needed during a pandemic or similar crisis to maintain services.(1) How did the total observed number of trauma activations, defined as patients who meet mechanism of injury requirements which trigger the notification and aggregation of the trauma team upon entering the emergency department, change during a pandemic and stay-at-home order? (2) How did the proportion of major mechanisms of traumatic injury change during this time period? (3) How did the proportion and absolute numbers of accidental versus nonaccidental traumatic injury in children and adults change during this time period?This was a retrospective study of trauma activations at a Level I trauma center in New Orleans, LA, USA, using trauma registry data of all patients presenting to the trauma center from 2017 to 2020. The number of trauma activations during a government mandated coronavirus 2019 (COVID-19) stay-at-home order (from March 20, 2020 to May 14, 2020) was compared with the expected number of activations for the same time period from 2017 to 2019, called "predicted period". The expected number (predicted period) was assumed based on the linear trend of trauma activations seen in the prior 3 years (2017 to 2019) for the same date range (March 20, 2020 to May 14, 2020). To define the total number of traumatic injuries, account for proportion changes, and evaluate fluctuation in accidental verses nonaccidental trauma, variables including type of traumatic injury (blunt, penetrating, and thermal), and mechanism of injury (gunshot wound, fall, knife wound, motor vehicle collision, assault, burns) were collected for each patient.There were fewer total trauma activations during the stay-at-home period than during the predicted period (372 versus 532 [95% CI 77 to 122]; p = 0.016). The proportion of penetrating trauma among total activations was greater during the stay-at-home period than during the predicted period (35% [129 of 372] versus 26% [141 of 532]; p = 0.01), while the proportion of blunt trauma was lower during the stay-at-home period than during the predicted period (63 % [236 of 372] versus 71% [376 of 532]; p = 0.02). The proportion of gunshot wounds in relation to total activations was greater during the stay-at-home period than expected (26% [97 of 372] versus 18% [96 of 532]; p = 0.004). There were fewer motor vehicle collisions in relation to total activations during the stay-at-home period than expected (42% [156 of 372] versus 49% [263 of 532]; p = 0.03). Among total trauma activations, the stay-at-home period had a lower proportion of accidental injuries than the predicted period (55% [203 of 372] versus 61% [326 of 532]; p = 0.05), and there was a greater proportion of nonaccidental injuries than the predicted period (37% [137 of 372] versus 27% [143 of 532]; p0.001). In adults, the stay-at-home period had a greater proportion of nonaccidental injuries than the predicted period (38% [123 of 328] versus 26% [123 of 466]; p0.001). There was no difference between the stay-at-home period and predicted period in nonaccidental and accidental injuries among children.Data from the trauma registry at our region's only Level I trauma center indicate that a stay-at-home order during the COVID-19 pandemic was associated with a 70% reduction in the number of traumatic injuries, and the types of injuries shifted from more accidental blunt trauma to more nonaccidental penetrating trauma. Non-accidental trauma, including gunshot wounds, increased during this period, which suggest community awareness, crisis de-escalation strategies, and programs need to be created to address violence in the community. Understanding these changes allows for adjustments in staffing schedules. Surgeons and trauma teams could allow for longer shifts between changeover, decreasing viral exposure because the volume of work would be lower. Understanding the shift in injury could also lead to a change in specialists covering call. With the often limited availability of orthopaedic trauma-trained surgeons who can perform life-saving pelvis and acetabular surgery, this data may be used to mitigate exposure of these surgeons during pandemic situations.Level III, therapeutic study.

Objectives: To define the maximal sagittal cross sectional dimensions of the S1 vertebral body and quantify the area available for safe placement of transverse sacroiliac (SI) screws. Methods: A laboratory investigation was performed using twelve fresh, frozen, non-preserved cadaveric pelvic specimens (six males, six females). The sacrum was dissected and removed from each pelvis. After the gross height and widths were measured, the sacra were split in the midsagittal plane and the dimensions of the first sacral segment were recorded. Then, starting from the center, the vertebral bodies were sequentially reamed in a medial to lateral direction in increasing one millimeter increments until a cortical breech occurred in the narrowest portion of the ala at the first sacral neural foramina. Using the diameter of the largest reamer, the cross-sectional area of space available for a transverse sacroiliac screw in the S1 body was calculated. Results: The cross-sectional area of space in the sagittal plane, corresponding to a transverse sacroiliac screw trajectory, of the first sacral vertebral body averaged 204 mm2 (range, 153 mm2 to 226 mm2 ), corresponding to a mean maximum reamer diameter of 16.1 mm (SD 1.08). The male and female sacra did not differ significantly with respect to overall size (mean height, 15.6 cm, SD 1.02; mean width 10.7 cm; SD 0.75) and the dimensions of the S1 body (mean height 28.41 mm, SD 2.23, mean depth 27.17 mm, SD 3.69). Conclusions: Our results improve upon our understanding of the surgical anatomic parameters of the upper sacral segment with respect to placement of transverse sacroiliac screw(s) by quantifying the cross-sectional area in the sagittal plane.

We describe a case of a morbidly obese Jehovah's Witness who sustained a popliteal artery and vein transection after a spontaneous knee dislocation. Following surgical repair, the patient fatally deteriorated, while blood products had to be withheld according to the patient's preoperative request.

Acute or chronic infection in the presence of nonunited fracture or chronic nonunion often necessitates staged surgical treatment. Treatment typically involves removal of hardware, débridement of infected tissue, use of local antibiotic delivery, and a long-term course of intravenous antibiotics. Several methods of local antibiotic delivery using antibiotic-impregnated polymethylmethacrylate (PMMA) have been commonly used, including commercial or hand-fashioned PMMA beads, antibiotic spacers, and antibiotic PMMA-coated guide rods. While these methods address the problem of infection, they do little to address fracture stability. In this report we describe a simple method for fashioning an antibiotic cement-coated interlocking intramedullary nail to treat an infected tibia fracture. This technique capitalizes on local delivery of antibiotics through use of antibiotic cement with the added benefit of improving fracture stability and fixation with an interlocking nail to achieve bony union.

Musculoskeletal injuries in the pediatric population are unique and require a thorough evaluation by a trained specialist. Unlike adults, many of the injuries may be treated closed due to the amazing growth and remodeling potential of children. Special consideration should be taken in treating certain fracture patterns to prevent the long-term consequences of growth deformities and protect children from child abuse. It is the goal of this article to outline common orthopedic injuries in the pediatric population to facilitate proper care in the multidisciplinary evaluation and treatment of children.