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To determine if the use of a narrower elastic tourniquet compared to a standard pneumatic tourniquet reduces operative blood loss in the operative fixation of humeral shaft fractures.This retrospective cohort study was performed at a level I trauma center and included 134 patients, aged 18 to 90 years, with a humeral shaft fracture treated with open reduction internal fixation (ORIF) from January 2007 through June 2018. The primary variable of interest was the application of a HemaClear™ elastic tourniquet versus a standard pneumatic tourniquet during the fixation of a humeral shaft fracture. The primary outcome was estimated blood loss (EBL) during the humerus ORIF surgery as recorded in the operative record. The secondary outcomes were total tourniquet time and operative time. The primary purpose of the study was to compare the above outcomes between the two tourniquet types.Estimated blood loss was 42% lower (95% CI: 11% to 73%, p0.01) in the elastic tourniquet group when compared to the standard pneumatic tourniquet group. The use of the elastic tourniquet was also associated with a 67% increase (95% CI: 35% to 100%, p0.01) in tourniquet time compared to the standard pneumatic tourniquet. No difference in the total operative time between the two groups (difference, -3%; 95% CI: -21 to 14, p = 0.72) was observed.Elastic tourniquet use was associated with 42% less blood loss in the fixation of humeral shaft fractures compared to use of a traditional pneumatic tourniquet, although this may be of unclear clinical importance given the relatively low estimated blood loss in this cohort. The potential benefit of reduced blood loss associated with the narrower elastic tourniquet is likely caused by the increased tourniquet time, without a change in overall operative time.

Background Limb-threatening lower extremity injuries often require secondary bone grafting after soft tissue reconstruction. We hypothesized that there would be fewer wound complications when performing secondary bone grafting via a remote surgical approach rather than direct flap elevation. Methods A retrospective cohort study was performed at a single Level 1 trauma center comparing complications after secondary bone grafting in patients who had undergone previous soft tissue reconstruction after open tibia fractures between 2006 and 2020. Comparing bone grafting via a remote surgical incision versus direct flap elevation, we evaluated wound dehiscence requiring return to the operating room as the primary outcome. Secondary outcomes were deep infection and delayed amputation. Results We identified 129 patients (mean age: 40 years, 82% male) with 159 secondary bone grafting procedures. Secondary bone grafting was performed via a remote surgical approach in 54% (n = 86) and direct flap elevation in 46% (n = 73) of cases. Wound dehiscence requiring return to the operating room occurred in one patient in the flap elevation group (1%) and none of the patients in the remote surgical approach. The odds of deep wound infection (OR, 1.77; p = 0.31) or amputation (OR, 1.43; p = 0.73) did not significantly differ between surgical approaches. No significant differences were found in complications between the reconstructive surgeon elevating and re-insetting the flap and the orthopaedic trauma surgeon performing the flap elevation and re-inset. Conclusion Direct flap elevation for secondary bone grafting after soft tissue reconstruction for open tibia fractures did not result in more complications than bone grafting via a remote surgical approach. These findings should reassure surgeons to allow other clinical factors to influence the surgical approach for bone grafting.

Objectives To determine the effect of intramedullary screw-based fixation on early postoperative complications after olecranon fractures. We hypothesized that intramedullary screw-based fixation results in decreased need for reoperation compared to plate and screw and tension band-based fixation. Design: Retrospective cohort. Setting 2 academic level-1 trauma centers.Patients / Participants: 556 patients treated with a tension band, plate and screw, or intramedullary-based construct for an olecranon fracture over a 10-year period. Intervention: Open reduction and internal fixation. Main outcome measurement Unplanned reoperation. Demographic, injury type and severity, supplemental fixation, and length of follow up data were viewed as potential confounders and analyzed as such. Results We identified 556 relevant patients. 199 patients were treated with an intramedullary screw-based construct, 229 with a plate and screw-based construct, and 128 with a tension band-based construct. We observed significant differences in the age, fracture type, percentage of open fractures, use of supplemental fixation, and treating institution between the treatment groups. 95 patients (17.1%) had an unplanned reoperation. When we adjusted for confounders, intramedullary screw-based fixation reduced the odds of an unplanned reoperation by 54% compared to plate and screw-based treatment. In the adjusted analysis, we did not observe a difference between plate and screw-based treatment and tension band-based fixation. Conclusions Intramedullary screw-based fixation of olecranon fractures results in decreased need for early reoperation compared with more common olecranon fixation strategies. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: Laser-assisted Indocyanine Green Angiography (LA-ICGA) is a novel method for objectively quantifying soft tissue perfusion. The primary aim of this study was to determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. DESIGN: Prospective cohort study SETTING: Academic trauma centre PATIENTS: Eight pilon fracture patients and 19 tibial plateau fracture patients that underwent open reduction internal fixation MAIN OUTCOME MEASUREMENTS: Skin perfusion (fluorescence units) as measured by LA-ICGA RESULTS: Six patients were classified as Tscherne grade 0, nine as grade 1, ten as grade 2, and two as grade 3. Perfusion decreased by 14 fu (95% CI: −21, −6, p

Scapulothoracic dissociation, particularly in combination with open fractures of the shoulder girdle, can be associated with significant soft tissue injury and present challenges with coverage and fixation. A single case of an open scapulothoracic dissociation was reviewed. Case presentation, clinical course and initial outcomes are discussed. A 22-year-old patient presented with an open left segmental clavicle fracture, sternoclavicular dislocation and scapulothoracic dissociation after being ejected in a motor vehicle collision. The shoulder girdle was initially stabilized with trans-clavicular trans-manubrial plating followed by staged pedicled rotational rectus abdominis flap. Follow-up at 1 month revealed well healed wounds and 90 degrees of forward flexion. Patients with open fractures and scapulothoracic dissociation can present multiple challenges when considering fixation and soft tissue coverage. A viable option in these patients is a pedicled rotational rectus abdominis flap when more typical coverage options are precluded from associated injuries.

Introduction Rehabilitation of trauma patients is facilitated by surgical stabilization permitting weight bearing (WB) of the fractured extremity. Both-bone forearm fracture (BBFx) plate osteosynthesis is an accepted technique with high union and low complication rates; yet, postoperative WB protocols have not been adequately investigated. There exists concern for increased complications in plated BBFx fractures for patients prescribed immediate WB. We hypothesized that immediate WB of surgically treated BBFxs results in acceptable rates of complications. Methods Patients presenting to a Level-1 trauma center from 2007 to 2016 with a BBFx were identified retrospectively. Patients were skeletally mature, surgically treated with prescribed immediate WB protocol, and followed for 6 months or to fracture union. Collected data included demographics, fracture characteristics, associated injuries, and WB protocols for all extremities. Complications recorded included nonunion, hardware failure, and infection. Standard statistical comparisons were used to evaluate the risk of complication in polytrauma patients with modified lower extremity WB protocols (polytrauma group) and patients with no lower extremity WB restrictions (isolated group). Results Two hundred thirteen patients were included with 75 (35%) females and 138 (65%) males. Mean age was 40 years and mean follow-up was 46 weeks. There were 142 (67%) patients in the poly-trauma and 71 (33%) patients in the isolated groups. In the poly-trauma group 21 (10%) patients had bilateral lower extremity WB restrictions. There were 11 (6%) complications noted: 2 non-unions, 4 hardware failures, and 5 infections. Demographics did not vary between the two groups. There was no difference in complications in the isolated (5.7%) versus poly-trauma groups (5.0%) (P = 0.75). Conclusion Immediate WB rehabilitation after BBFx plate osteosynthesis seems to be safe and associated with low nonunion and complication rates. Our results demonstrate that polytrauma patients using ambulatory aids for lower extremity injuries can immediately WB without increased risk compared with isolated BBFx patients.

Background: Radial head fractures are often associated with poor outcomes. Both open reduction and internal fixation (ORIF) and radial head arthroplasty (RHA) might be considered in operative cases. This study aimed to compare long-term patient-reported functional outcomes among patients with operatively treated radial head fractures. Methods: A cross sectional study conducted at a Level I trauma center was used to identify patients with a radial head fracture who underwent ORIF or RHA between 2006 and 2018, and agreed to complete a survey in 2020. The primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Results: Seventy-six patients participated in the study. No significant differences in outcomes were observed between groups. QuickDASH scores were similar for both groups (ORIF: mean = 15.7, SD = 18.4; RHA: mean = 22.8, SD = 18.6; mean difference = 0.2 [-9.0 to 9.3], P = .97). Nineteen (37%) ORIF patients and 12 (48%) RHA patients reported a need for pain medication (adjusted odds ratio [OR] = 0.8 [0.3-2.4], P = .70). Thirteen (25%) ORIF patients and 6 (24%) RHA patients required additional surgery (adjusted OR = 1.7 [0.5-6.2], P = .39). A subgroup analysis of multi-fragmentary fractures revealed similar findings. Conclusion: Patient-reported outcomes, which included a subgroup analysis of multi-fragmentary fractures, were similar between ORIF and RHA groups at an average of 7.5 years from surgery. Reconstructing the radial head might not result in worse outcomes than RHA when both options are employed according to the best judgment of the operating surgeon.

To determine what outcomes are most important to patients after a limb-threatening injury, and if those preferences vary based on the patients' treatment (salvage vs amputation), health, demographics, or time since injury.The preferences that motivate the patients' choice of treatment following a limb-threatening injury are poorly understood. Discrete choice experiments (DCEs) are a robust survey methodology to quantify preferences.Patients with a history of traumatic limb-threatening injury, January 2010 to December 2020, completed a survey with our DCE and the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. The DCE attributes included recovery time, function, appearance, cost, and time in hospital. We used conditional logit modeling to estimate the relative importance of each attribute on a scale of 0% to 100%, determine willingness to pay for improvements in the included attributes, and assess variation in preferences based on patient characteristics, including PROMIS score.A total of 150 patients completed the survey (104 limb salvage, 46 amputation; mean age, 48±16 years; 79% male). Regaining preinjury function [relative importance=41%; 95% confidence interval (CI), 37%-45%] and minimizing costs (24%; 95% CI, 21%-28%) were of greatest importance. Changes in appearance were least important (7%; 95% CI, 5%-9%). The hierarchy of preferences did not vary between those who had limb salvage or amputation, but patient age, physical and mental health, and income were associated with preference variation.Patients with limb-threatening injuries most valued gains in function and reduced out-of-pocket costs.

Introduction Studies have shown a link between patients' preoperative expectations and their postoperative satisfaction. However, limited studies exist concerning patient factors associated with higher preoperative expectations in the hand surgery population. This study analyzed preoperative expectation scores of patients undergoing hand surgery and aimed to determine associated patient characteristics. Materials and Methods A total of 418 elective hand surgery patients aged 15 years and older enrolled in a prospectively collected orthopaedic registry from June 2015 to December 2018 were analyzed. Patients were administered preoperative questionnaires including six Patient-Reported Outcome Measurement Information System domains and other activity and pain scales. Expectation scores were measured using the six domains of the Musculoskeletal Outcomes Data Evaluation and Management System expectations questionnaire. Bivariate and multivariable analyses were conducted to identify independent predictors of higher expectations. Results Overall, patients had high expectations (≥ 80.0) of their hand surgery. Higher mean expectation scores were seen with females, college graduates, better baseline health status, and fewer prior hand surgeries (p Conclusion In sum, more educated patients with less pain at baseline and better baseline health status have higher expectations of their hand surgery. Hand surgeons can use these results to help focus their preoperative counseling and expectation management.

Background: The objectives of this study were to determine the baseline patient characteristics associated with preoperative opioid use and to establish whether preoperative opioid use is associated with baseline patient-reported outcome measures in patients undergoing common hand surgeries. Methods: Patients undergoing common hand surgeries from 2015 to 2018 were retrospectively reviewed from a prospective orthopedic registry at a single academic institution. Medical records were reviewed to determine whether patients were opioid users versus nonusers. On enrollment in the registry, patients completed 6 Patient-Reported Outcomes Measurement Information System (PROMIS) domains (Physical Function, Pain Interference, Fatigue, Social Satisfaction, Anxiety, and Depression), the Brief Michigan Hand Questionnaire (BMHQ), a surgical expectations questionnaire, and Numeric Pain Scale (NPS). Statistical analysis included multivariable regression to determine whether preoperative opioid use was associated with patient characteristics and preoperative scores on patient-reported outcome measures. Results: After controlling for covariates, an analysis of 353 patients (opioid users, n = 122; nonusers, n = 231) showed that preoperative opioid use was associated with higher American Society of Anesthesiologists class (odds ratio [OR], 2.88), current smoking (OR, 1.91), and lower body mass index (OR, 0.95). Preoperative opioid use was also associated with significantly worse baseline PROMIS scores across 6 domains, lower BMHQ scores, and NPS hand scores. Conclusions: Preoperative opioid use is common in hand surgery patients with a rate of 35%. Preoperative opioid use is associated with multiple baseline patient characteristics and is predictive of worse baseline scores on patient-reported outcome measures. Future studies should determine whether such associations persist in the postoperative setting between opioid users and nonusers.

The mangled limb is a life-altering event for the patient, often resulting in permanent disability and represents a daunting challenge for both the patient and surgeon. The chaotic and disorganized collection of injured tissue can nonetheless be salvaged routinely, incorporating a systematic approach. This approach is outlined in this chapter, along with a brief overview of the steps that will be covered in more detail throughout the text.

ObjectiveOccupational therapy is often prescribed after the acute treatment of upper extremity fractures. However, high out-of-pocket expenses and logistical constraints can reduce access to formal therapy services. We aimed to quantify preferences of patients with upper extremity fracture for attending occupational therapy, when considering possible differences in clinical outcomes.DesignDiscrete choice experiment.SettingLevel 1 trauma centre in Baltimore, Maryland, USA.Participants134 adult patients with upper extremity fractures.Primary outcome measuresThe scenarios were described with five attributes: cost, duration of therapy session, location of therapy, final range of motion and pain. We report the relative importance of each attribute as a proportion of total importance, and the willingness to pay for benefits of the therapy services.ResultsOf the 134 study participants, the mean age was 47 years and 53% were men. Cost (32%) and range of motion (29%) were the attributes of greatest relative importance. Pain (17%), duration of therapy (13%) and location of therapy (8%) were of lesser importance. Patients were willing to pay $85 more per therapy session for a 40% improvement in their range of motion. Patients were willing to pay $43 more per therapy session to improve from severe pain to mild pain. Patients were indifferent to whether the therapy treatment was home-based or in a clinical environment.ConclusionsWhen deciding on an upper extremity fracture therapy programme, out-of-pocket costs are a paramount consideration of patients. Improvements in range of motion are of greater importance than residual pain, the duration of therapy sessions and the location of service provision. Patients with upper extremity fracture should be prescribed occupational therapy services that align with these patients’ preferences.

Summary:. Dupuytren’s disease is a benign fibroproliferative disorder resulting in progressive contraction of palmar and digital fascia. Diseased fascia of the hand condenses into tensile cords, manifesting in various anatomical combinations. The spiral cord variant is especially troublesome, as the cord travels under the digital neurovascular bundle and places it at risk during surgical resection. In severe cases, limited fasciectomy is required to release contracture and restore finger extension. Here, we present the case of a 79-year-old right-handed man with a history of severe Dupuytren’s disease of both hands, who was found to have ulnar and radial spiral cords in his right ring finger. Diseased tissue was removed en bloc, restoring extension and function. To our knowledge, this is the first case of a digit with two spiral cords affecting both neurovascular bundles. It is important to be aware of the anatomical variations possible in Dupuytren’s disease to avoid iatrogenic injury.

OBJECTIVES Access to fractures of the distal humeral capitellum, trochlea, and lateral condyle is difficult through traditional approaches due to limited anterior articular exposure for direct reduction and fixation. The purpose of this study is to evaluate the relative articular exposure of a surgical dislocation (SD) approach to the distal humerus compared with olecranon osteotomy (OO). METHODS Eight paired elbows from 4 cadavers underwent either SD or OO approach. Methylene blue staining demarcated visualized articular surface before disarticulation of the elbows. The main outcome measures were average visualized total distal humeral articular surface and anterior and posterior surface, and capitellar surface relative to the total surfaces was compared for each surgical approach using unpaired parametric t-tests. RESULTS Intraclass correlation between raters was 0.995. The median exposed articular surface for SD and OO approaches was 90.0% and 62.8%, respectively. The overall exposure was significantly greater for the dislocation technique (P = 0.0003). With respect to specific regions of the distal humeral articular surface, SD allowed significantly greater visualization of the anterior surface (95.9% vs. 48.9%, P < 0.0001) and capitellum (100% vs. 40.4%, P < 0.0001). CONCLUSION The surgical elbow dislocation approach to the distal humerus permits near total exposure of the anterior articular surface and the entire capitellum. Our data support this approach for anterior articular fractures of the distal humerus, to include those fractures that extend to the medial surface of the trochlea.

Purpose We evaluated a cohort of patients who developed vasopressor-induced limb ischemia and the management options to prevent progression or minimize morbidity of digital necrosis. Methods We reviewed all current literature on pressor-induced limb ischemia and report options for the management of patients requiring vasopressors who developed limb ischemia. We then retrospectively reviewed presentation, treatment, and short-term outcomes for patients at our tertiary referral academic medical center that developed this complication. Finally, we recommend guidelines for the tiered management of these complex patients. Results Thirty-six patients were included. Twenty-six patients (72%) required resuscitation with more than one vasopressor. Vasopressors were initiated for septic-shock (52.7%), cardiogenic-shock (16.7%), hypovolemic-shock (13.9%), acute transplant rejection (13.9%), and neurogenic-shock (2.8%). According to the tiered management recommendations, patients were managed with phase 1 care (19%), phase 2 care (8.3%), phase 3 care (50%) or phase 4 care (5.6%). The patient expired in the acute setting in 13.9% of cases. Conclusion Life-saving vasopressors risk digital ischemia and necrosis. Early recognition, reporting, and treatment of this complication are important in minimizing morbidity. Using a tiered approach helps organize the healthcare team's management of this iatrogenic complication while respecting the treatment paradigm of “life over limb,” and may be safely performed with acceptable outcomes.

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique ( P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.

Copyright © 2018 by the American Society of Plastic Surgeons. Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. Results: Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm2 was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room. Conclusion: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.

Multiple factors are associated with mortality in necrotizing soft tissue infection, such as organ dysfunction and underlying medical comorbidities, but are not often modifiable. Operative interventions are an attractive modifiable variable in modern management of extremity necrotizing soft tissue infection, but the influence of amputation and advanced wound management techniques on mortality is unknown.A single-institution review was performed of extremity necrotizing soft tissue infection . Admission demographics, organ dysfunction, and operative interventions were investigated. The primary outcome was mortality. Advanced wound management techniques were considered flap creation or use of a dermal matrix substitute for coverage of neurovascular structures, tendon, or bone.Overall, 124 patients with extremity necrotizing soft tissue infection were included, with 112 of 124 (90.3%) patients living and 12 of 124 (9.7%) patients dying. Patients who lived had a lower Sequential Organ Failure Assessment score (1.00 [interquartile range, 5] vs 10.50 [interquartile range, 11], P.001), but no difference in use of amputation (11.6% vs 25.0%, P = .19) or advanced wound management techniques (12.5% vs 0%, P = 0.36), respectively. Indications for amputation in the 16 patients who underwent amputation included nonsalvageable limb in 13 of 16 (81.3%), medical comorbidity in 2 of 16 (12.5%), and a nonsalvageable limb and medical comorbidity in 1 of 16 (6.3%) patients. In multivariate analysis, only the Sequential Organ Failure Assessment score remained associated with mortality (odds ratio 1.315, 95% confidence interval 1.146-1.509, P.001) CONCLUSION: Use of amputation or advanced wound management techniques was not associated with mortality in patients with extremity necrotizing soft tissue infection. At centers able to provide the critical care support, aggressive use of limb salvage may not affect mortality.

OBJECTIVES To examine the relationship between the magnitude of soft-tissue defect and the risk of free-flap and limb-salvage complications/failures. DESIGN Retrospective cohort. SETTING Level I Trauma Center. PATIENTS One hundred twelve patients with free tissue transfers between January 2009 and June 2015. INTERVENTION A standardized approach using a consistent team of 2 orthopaedic microvascular surgeons was used for each free-flap reconstruction. MAIN OUTCOME MEASURE Soft tissue defect size, total or partial flap failure, and unplanned reoperations. RESULTS Of 112 free-flap reconstructions, 57 complications occurred in 43-cases (38%) including 5 total flap failures (4.5%), 7 partial flap failures (6%), and 8 early (7%) and 38 delayed complications (33%). There was a significant correlation between the large defect size (≥200 cm) and partial/total flap failure (n = 80, P = 0.023). There was also a significant correlation between large soft tissue defect size and any complication that is, total or partial failure and early or delayed unplanned return to the operating room (n = 80, P = 0.002). Of the flaps used, multivariate analysis revealed that latissimus flaps had higher odds for failure. CONCLUSIONS Soft-tissue defect size ≥200 cm can be associated with a higher rate of total or partial flap failure and any complication in acute trauma setting, which may be due to a larger zone of injury, a higher level of difficulty in achieving complete debridement, and a more complex microvascular dissection. Current and future efforts will need to continue to focus on risk stratification for limb salvage efforts because an accurate assessment of risk is important to the patient, health care provider, and the health care system in general. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this article is to explore the changes over the last 10 years related to limb salvage for even the most complex cases of limb trauma and describe a thoughtful approach to the mangled extremity. CT angiography has replaced formal angiography around the country with promising results for evaluating the vascular network of a limb. While concepts in skeletal fixation and vascular reconstruction have remained generally unchanged, advances in nerve grafting and conduit use will guide future directions for limb salvage and improve functional outcomes for patients. The surgeon should consider the analogies of home building and limb salvage when planning their reconstructive steps: image review as blueprints, debridement as foundation excavation, skeletal fixation as the foundation and framework, plumbing and electric as vessel and nerve repair, and soft tissue coverage as the roof above the reconstruction.

The authors aimed to characterize surgical and functional outcomes of open fractures of the distal radius in patients younger than 65 years. At their level I trauma center, the authors conducted a retrospective review of 92 patients (age range, 16–64 years) who had 94 open fractures of the distal radius (average follow-up, 30 months; range, 3–95 months). Sixty-four fractures received definitive treatment at the time of initial débridement; 30 received definitive fixation and soft tissue coverage after staged débridement. Primary surgical outcome was development of deep surgical site infection requiring repeat surgical débridement; secondary surgical outcome was surgical complications requiring reoperation. Functional outcome was assessed by wrist range of motion. Overall infection rate was 15% (14 of 94 fractures). Seven (11%) of 64 fractures in the immediate definitive fixation group developed infection compared with 7 (23%) of 30 fractures in the staged treatment group ( P =.13). Twenty-one (33%) of 64 fractures in the immediate definitive fixation group required reoperation compared with 15 (50%) of 30 in the staged treatment group ( P =.11). Deep surgical site infections and surgical complications associated with open fractures of the distal radius are driven by soft tissue injury. [ Orthopedics . 2019; 42(4):219–225.]

Soft tissue wounds overlying the dorsum of the foot and ankle are difficult to treat, and historically have been treated with free tissue transfer. Advances in surgical technique have expanded the use of pedicle perforator flaps to avoid free tissue transfer in certain situations. The authors describe a technique for using an extensor digitorum brevis flap to provide soft tissue coverage for wounds of the ankle and foot. In the senior authors' experience, the use of this flap has achieved wound coverage in 100% of patients with smaller wounds (≤45 cm) of the ankle.

Non-gadolinium-enhanced magnetic resonance angiography (nMRA) is a noninvasive, contrast-free imaging modality used for visualizing pedal arterial anatomy. We report application of the nMRA technique for detailed arterial imaging in a patient with dorsalis pedis aneurysm. Compared with digital subtraction angiography, we demonstrate that nMRA provides sufficient arterial detail needed to develop a complex operative plan before vascular intervention without risk of contrast agent or ionizing radiation exposure.

OBJECTIVE To assess whether "center-center" position is ideal starting point for minimum fracture displacement when placing an intramedullary (IM) screw in the ulna. METHODS Thirty-six arms (average age, 82 years) underwent a posterior approach to the olecranon and were randomized into 3 groups: center-center (center in sagittal plane, center in coronal plane), posterior-lateral (posterior in sagittal plane, lateral in coronal plane), and posterior-medial (posterior in sagittal plane, medial in coronal plane). Groups were matched into 18 pairs, and fixation was performed with an IM screw. Primary outcome measure was articular surface displacement on the olecranon. Measurements were compared across each combination of locations using the Kruskal-Wallis rank sums test, and a sign test determined whether each location differed from anatomic reduction. RESULTS Articular step-off measurements were significantly different between center-center (0.6 mm) and posterior-medial (2.1 mm) groups (P = 0.01) and approached significance with posterior-lateral versus posterior-medial (0.9 mm) locations (P = 0.07). No significant difference was found comparing center-center with posterior-lateral locations (P = 0.7). The articular surface (P = 0.04), posterior cortex (P = 0.02), and medial cortex (P = 0.001) measurements for the posterior-medial starting point were all worse compared with anatomic reduction. CONCLUSIONS Malreduction of a simulated olecranon fracture was most significant when the starting point for the IM screw was malpositioned medially. A central or laterally based starting point was more forgiving. Avoiding a medially based starting point is crucial for achieving benefits of fixation with an IM screw and reduces the chance of malreduction after fixation.

BACKGROUND: Motorcycle crashes (MCCs) constitute a disproportionately high number of road accidents that result in mortality and injury, compared with other motor vehicle collisions. Distribution and characteristics of upper extremity injuries sustained by motorcyclists and their implications are not well established. We sought to determine the epidemiology of upper extremity injuries in motorcyclists and the independent effects of the injuries on mortality and need for rehabilitative services. METHODS: All motorcyclist admissions at our Level I trauma center from 2006 through 2010 were retrospectively reviewed. We identified and categorized all upper extremity injuries. Demographic data, in-hospital mortality, disposition to a rehabilitation facility, and other potential confounding covariates were recorded. Propensity score-adjusted logistic regression models quantified the effects of upper limb injuries on mortality and transfer to rehabilitation facilities. RESULTS: Thirty-five percent (759 of 2,151 patients) involved in MCCs sustained upper extremity injury. Shoulder girdle injuries were most common (n = 433), followed by forearm fractures (n = 272). Mortality rate was 4% (87 of 2,151 patients) for all MCC admissions. Propensity score-adjusted logistic regression models showed that injuries distal to the humerus had an independent odds ratio for mortality of 0.41 (95% confidence interval, 0.21-0.8). Odds of requiring rehabilitation after discharge were 1.82 times (95% confidence interval, 1.47-2.26) higher when any upper extremity injury was sustained. CONCLUSION: Upper extremity injuries are common in MCCs. Distal injuries are associated with lower mortality rates possibly because of a "crumple zone effect" of distal upper extremities sparing the head and neck region from direct impact in head-first injuries. MCC patients with upper extremity injuries are more likely to require rehabilitation services. LEVEL OF EVIDENCE: Epidemiologic study, level III. Language: en

Evaluate whether mortality after discharge is elevated in geriatric fracture patients whose lower extremity weight-bearing is restricted.Retrospective cohort study SETTING: Urban Level 1 trauma center PATIENTS/PARTICIPANTS: 1746 patients65 years of age INTERVENTION: Post-operative lower extremity weight-bearing status MAIN OUTCOME MEASURE: Mortality, as determined by the Social Security Death Index RESULTS: Univariate analysis demonstrated that patients who were weight-bearing as tolerated on bilateral lower extremities (BLE) had significantly higher 5-year mortality compared to patients with restricted weight-bearing on one lower extremity and restricted weight-bearing on BLE (30%, 21% and 22% respectively, p 0.001). Cox regression analysis controlling for variables including age, Charlson Comorbidity Index, Injury Severity Scale, combined UE/LE injury, injury mechanism (high vs low), sex, BMI and GCS demonstrated that, in comparison to patients who were weight bearing as tolerated on BLE, restricted weight-bearing on one lower extremity had a hazard ratio (HR) of 0.97 (95% confidence interval 0.78 to 1.20, p = 0.76) and restricted weight-bearing in BLE had a HR of 0.91 (95% confidence interval 0.60 to 1.36, p = 0.73).In geriatric patients, prescribed weight-bearing status did not have a statistically significant association with mortality after discharge, when controlling for age, sex, body mass index, medical comorbidities, Injury Severity Scale (ISS), mechanism of injury, nonoperative treatment and admission GCS. This remained true in when the analysis was restricted to operative injuries only.

Objective The purpose of this retrospective case series was to examine the AO Foundation and Orthopaedic Trauma Association (AO/OTA) 13-C3 distal humeral fractures treated with open reduction–internal fixation (ORIF) in patients older than 70 years. Methods During an 8-year period, 21 patients older than 70 years with AO/OTA 13-C3 distal humeral fractures were treated with ORIF performed by 2 senior upper extremity traumatologists. There were 16 patients with >1 year of follow-up, with a mean age of 78 (70-84) years. Results At a mean follow-up of 4 years (1-8 years), all 16 patients demonstrated radiographic signs of bone union. Three patients underwent reoperations, including irrigation and debridement for postoperative infections (n = 2) and removal of implant for symptomatic olecranon intramedullary screw (n = 1). The mean postoperative total arc of ulnohumeral motion was 97° (80°-145°), including a mean flexion of 117° (106°-126°) and flexion contracture of 20° (14°-26°). The mean pronation was 69° (55°-85°), and supination was 78° (74°-9°0). The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 19 (standard deviation, 6.9; confidence interval, 15.4-22.8), and the mean Mayo Elbow Performance Score was 91 (standard deviation, 8.2; confidence interval, 86-95). Conclusions ORIF remains a reliable option for treatment of AO/OTA 13-C3 distal humeral fractures in elderly patients. Excellent clinical outcomes can be achieved with preservation of motion and arm function through anatomic reduction, rigid internal fixation, and early mobilization.

Background: Medial epicondyle fractures in pediatric patients might be associated with an occult elbow dislocation and neurovascular damage. Methods: A single case of a medial epicondyle fracture presenting with brachial artery transection was reviewed. Presentation, clinical course, and early outcome are reported. Results: A 14-year-old patient presenting with an apparently isolated medial epicondyle fracture was found to have examination and diagnostic test findings consistent with brachial artery transection. His injury was explored and repaired acutely, resulting in acute return of perfusion. Final follow-up revealed 0° to 130° of flexion-extension arc of motion and full pronation and supination with normal sensory and motor function of the hand. Conclusions: Pediatric medial epicondyle fractures should alert the clinician to the possibility of an occult dislocation of the elbow, and a full neurovascular assessment should be performed. Early recognition and repair of a vascular injury associated with this fracture can lead to a good outcome.

Purpose The purposes of this study were to identify the relative frequency of Monteggia fracture patterns and to investigate the required frequency of open reduction of the proximal radiocapitellar joint. Methods We identified 121 Monteggia fractures at a Level I trauma center from 1996 to 2015 and included 119 in this study. These fractures were identified using a database search for the appropriate International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes as well as individual surgeons' logs. Two fellowship-trained hand surgeons reviewed the identified patients' x-rays and operative notes. Each fracture was classified using Bado's original description, excluding transolecranon and Monteggia variants. Results Bado I lesion represented 68% (81 of 119) of Monteggia fractures. Annular ligament incarceration preventing radial head reduction occurred in approximately 17% (14 of 81) of this Bado type. Revision fixation of the ulna was not necessary (none of 119 cases) and functional range of motion (average arc, 117°) was recovered in most patients. The reoperation rate of 20% (23 of 119) was related to the severity of the presenting injury and hardware prominence. Conclusions Most radial head dislocations associated with Monteggia fractures occur anteriorly and will reduce with anatomic plating of the ulna. In cases where the radial head fails to reduce, entrapment of the annular ligament can be expected and open reduction is required. Revision fixation of the ulna to achieve reduction of the radial head is uncommon in our experience. Type of study/level of evidence Prognostic IV.

Background Humeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate. Methods We conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation. Results Thirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage ( p > .05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate ( p > .05). The need for flap coverage was significantly associated with failed salvage of the extremity ( p = .02). Conclusions Salvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries. Type of study/level of evidence Therapeutic III.

Introduction and aim There is a paucity of literature regarding outcomes of open fractures of the distal radius. No study has detailed this injury or treatment strategy in the geriatric population. The purpose of this study was to determine the safety of immediate open reduction and internal fixation of geriatric open fractures of the distal radius. Methods A total of 21 geriatric patients with open fractures of the distal radius treated with a single definitive procedure were identified from a prospectively collected database. We reviewed patient demographics, injury characteristics and treatment specifics. Our primary outcome was surgical-site infection defined by need for antibiotics or repeat surgery. Our secondary outcome was need for other re-operation. Patients were contacted and functional scores obtained. Results Patients were followed up for an average of 26 months. One deep infection and one nonunion occurred, and they required repeat surgery. Four minor operative complications occurred, including stiffness requiring manipulation and prominent fixation devices requiring removal. Patients maintained an average wrist flexion–extension arc of 89° and pronation–supination arc of 137°. The average QuickDASH (shortened disabilities of the arm, shoulder and hand questionnaire) score was 17.4, indicating minimal disability of the upper extremity. Conclusions Immediate open reduction and internal fixation of geriatric open fractures of the distal radius yields adequate functional results with low risk of major complications.

F ractures of the clavicle and acromioclavicular (AC) separations are common injuries in adults and have fairly good individual prognoses. Isolated clavicular fractures account for 2.6--4% of all adult fractures and 35% of shoulder girdle injuries. Treatment options vary depending on the type and location of the fracture and the patient characteristics. The widely accepted dogma has been that most clavicular fractures can be treated nonoperatively, are associated with low nonunion rates, and achieve excellent functional recovery. Recent studies suggest that widely displaced or comminuted fractures resulting from high-energy trauma have a propensity for adverse outcomes with nonoperative treatment and that early operative fixation might lead to improved function and patient satisfaction. AC joint injuries also are common, often resulting from a direct superior blow to the shoulder. These injuries are most commonly classified according to the Rockwood system, with Types I through III usually being the result of lower energy, sports, or fall-related mechanisms. Higher grade Types IV and V AC dislocations cause complete disruption of the stabilizing AC and coracoclavicular (CC) ligaments and displacement of the distal clavicle through the deltotrapezius fascia. Operative fixation of these injuries currently is standard practice. Combined AC separation and clavicular fracture in the same shoulder is rare and has been reported in only a few patients. It is thought that this entity is the result of high-energy trauma to the shoulder with poor outcomes if treated nonoperatively. Various surgical techniques to treat this type of floating clavicle injury have been described in the literature, with no consensus on the best approach to stabilize this injury. We herein present a patient with combined AC separation and clavicular fracture treated with dual plating of the clavicle and AC joint, using a clavicular hook plate in addition to a conventional limited contact dynamic compression plate. Informed consent was obtained from the patient for publication.

Objectives Although most clavicular fractures are amenable to nonoperative management, metadiaphyseal fractures are considerably more complex, with rates of suboptimal healing as high as 75% when treated nonoperatively. The poor results are ascribed to the deforming forces on the distal clavicle from the surrounding muscles and the weight of the arm. It recently has been noted that some operative fixations of these fractures are also failing when a standard superiorly placed plate is used. We hypothesized that anterior plating, when compared with superior plating, improves the strength and durability of the construct by redirecting the axis of the major deforming force across rather than in line with the screws of the construct. Methods Six pairs of fresh-frozen human cadaveric clavicles with the scapula attached by the coracoclavicular ligaments were osteotomized just medial to the ligaments and plated with a standard 3.5-mm limited-contact dynamic compression plate. Specimens were potted and mounted on a materials testing system machine, preserving the anatomic relationship of the clavicle and scapula. They were then loaded through the coracoclavicular ligaments to mimic the weight of the arm pulling inferiorly. Each specimen was loaded with 375 N at 1 Hz for 2000 cycles. Sequential loading was then applied at 25-N intervals until failure. Statistical analysis was performed using a Wilcoxon signed-rank test. Results The superiorly plated specimens failed after fewer cycles and with lower force than the anteriorly plated specimens. The median number of cycles to failure was 2082 for anterior plated specimens and 50 for superiorly plated (P = 0.028). The median load to failure was 587.5 N in the anterior group and 375 N in the superior group (P = 0.035). The median stiffness was 46.13 N/mm for anterior and 40.45 N/mm for superior (P = 0.375) plates. Conclusions Anteriorly plated distal third clavicular fractures have superior strength and durability compared with fractures plated superiorly when using a physician-contoured, 3.5-mm, limited-contact, dynamic compression plate in this cadaver model.

Background: Our center evaluates all distal radial fractures with traction radiographs before splinting. Although investigations of various imaging modalities to evaluate distal radial fractures have been presented in the literature, to our knowledge the use of traction radiographs has not been well described. We hypothesized that the addition of traction radiographs to standard radiographs increases interobserver and intraobserver reliability for injury descriptions, affects the choice of treatment plan, and decreases the perceived need for computed tomography. Methods: Radiographs for fifty consecutive eligible patients with distal radial fractures that were treated at a level-1 trauma center were used to create two image sets for each patient. Set 1 included injury and splint radiographs, and Set 2 included the images from Set 1 plus traction radiographs. The image sets were stripped of all demographic data and were presented in random order to seven fellowship-trained orthopaedic surgeons. The surgeons independently reviewed each of the 100 image sets and answered ten questions regarding the description and treatment of the injury. Analyses were conducted with kappa statistics to evaluate interobserver reliability. Intraobserver variability was assessed with the McNemar test after adjusting for clustering. Results: Traction radiographs improved interobserver reliability for four of ten questions. With regard to intraobserver variability, responses to two questions were significantly changed. With the addition of traction radiographs, the observation of intra-articular fragments requiring reduction increased from 38.3% to 53.1% (p < 0.05) and the perceived need to order computed tomography for further evaluation decreased from 21.7% to 5.1% (p < 0.001). No other changes reached significance. Conclusion: The addition of traction radiographs appeared to affect surgeons’ interobserver reliability in the evaluation of distal radial fractures. In addition, traction radiographs changed the rate of detection of intra-articular fragments requiring reduction and the perceived need for computed tomography. These data indicate that traction radiographs may provide some of the same information as computed tomographic scans at a lower cost and argue for additional research comparing computed tomographic scans and traction radiographs of the distal part of the radius.

To determine whether a single-incision extensile approach to the distal radius used for open reduction internal fixation and a concomitant radial sided carpal tunnel (CT) release safely and effectively decompresses the carpal tunnel.Five pairs of cadaveric forearms were mounted to a tabletop with a cable pulley system attached to the long finger. Each paired specimen was randomized to volar plating via either the flexor carpi radialis approach (control group) or the extensile volar exposure (combined flexor carpi radialis and radial-sided carpal tunnel release). Before and after the respective exposure and plating, increased CT pressures were created with 2.27, 4.54, and 6.81 kg of distraction. We used a paired t-test to compare the change in CT pressure at each level of distraction before and after intervention for the 2 groups, with significance set at p/= .05. A dissection of each exposure was performed with attention given to the radial aspect of the transverse carpal ligament (TCL) and any possible iatrogenic injuries.Carpal tunnel pressure increased with increasing distraction. We noted a statistically significant reduction in CT pressure after the extensile exposure and plating with 4.54 (p = .023) and 6.81 (p.001) kg of distraction, respectively. No significant reduction in mean CT pressure for the control group specimens occurred at any level of distraction force. The average length of the radial TCL was 22 mm (range, 18-31 mm); the average distance between the recurrent motor branch and distal TCL was 11 mm (range, 8-15 mm). No iatrogenic tendon or nerve injury occurred with the extensile volar exposure.Carpal tunnel pressure is safely reduced and the distal radius is adequately exposed for fixation with the extensile volar approach.

Background The goal of the current cadaver study was to compare two low-profile constructs for olecranon osteotomy repair: an intramedullary screw and tension band and a new olecranon nail. Methods Ten cadaveric elbow pairs were harvested. One of each pair was then randomly assigned to be tested either with a 6.5-mm intramedullary screw and tension band or with the olecranon nail. Using a testing apparatus to simulate an early postoperative motion protocol, the repairs were cyclically loaded. The maximal osteotomy gap observed during loading was recorded. A paired t-test was used for statistical anaylsis. Results The mean peak gap for the osteotomies repaired with the nail was 0.31 mm versus 0.75 mm for the screw. This difference was not statistically significant ( p = 0.158). Conclusion The data obtained demonstrate the olecranon nail performs favourably when compared with an intramedullary screw, with the added benefit of offering a low profile, intramedullary construct.

Fracture of the distal radius is the most common wrist injury. Treatment of complex intra-articular fractures of the distal radius requires an accurate diagnosis of the fracture pattern and a thoughtful approach to fixation. We propose a new term, sustentaculum lunatum, for the palmar lunate facet. The sustentaculum lunatum deserves specific attention because of its importance in load transmission across the radiocarpal joint. It is also key to restoring the anatomy of the palmar distal radial metaphysis during internal fixation. We provide a review of the structure and function of the sustentaculum lunatum and describe fixation techniques. This article is intended to promote awareness of this fragment in the treatment of fractures of the distal radius.

This report presents a case of progressive septic arthritis and osteomyelitis caused by a rare pathogen, Pasteurella multocida, thought to be provoked by the use of systemic corticosteroids. Despite initial improvement after antibiotics and surgical procedure, the patient returned with new, associated symptoms 1 month later. This concurrent set of circumstances leading to a life-threatening condition has not been reported, to the best of our knowledge. Physicians aware of such a case will be better prepared to diagnose, treat, and educate their patients. Additionally, the diagnostic challenge presented by this case report emphasizes the need for vigilance and thoroughness in obtaining histories from patients presenting with seemingly benign complaints, especially in vulnerable populations, such as infants, pregnant women, and immunocompromised adults.

The purpose of this study was to investigate motorcycle crash thumb injury patterns. We hypothesized that ulnar collateral ligament injuries at the thumb metacarpophalangeal joint would be most common and there would be a side predilection due to the clutch and brake positions. Motorcyclist admissions following injury between 2002 and 2013 were reviewed, and phalangeal and metacarpal injuries treated acutely identified. Demographics, injury, and treatment characteristics were recorded. Association between laterality and injury type was assessed. Of 128 patients, 59 underwent acute treatment for thumb injuries. Eleven patients sustained thumb ulnar collateral ligament injuries; 27 sustained thumb carpometacarpal injuries. Most carpometacarpal injuries were fracture-dislocations (19/27). Thumb carpometacarpal injuries had no overall side predilection; ulnar collateral ligament injuries occurred more on the right. Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, probably due to the mechanics of gripping handlebars and the high-energy force directed into the palm and against the metacarpal base. Level of evidence: Level IV

The objective of this study was to compare intramedullary (IM) nail and IM screw fixation for reattachment of the proximal ulna. Preserved elbow anatomy served as the primary outcome and was defined as the distance between the coronoid process and the olecranon. A retrospective cohort study of 31 patients treated with IM fixation of the proximal ulna was performed. Radiographs were used to compare displacement distances between the coronoid process and the olecranon, with average follow-up of approximately 5 months. IM nail fixation corresponded to a mean displacement of -0.65 mm between the olecranon and coronoid process, versus 0.23 mm for IM screw fixation. No patients were identified with loss of reduction of bone fragments. Both IM fixation techniques maintained the functional anatomy of the elbow. Minimal displacement of bone fragments and no identified loss of reduction suggest that both techniques could be reasonable alternatives to more traditional approaches.