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IntroductionAcute extremity compartment syndrome requires rapid decompression. In remote locations, distance, weather and logistics may delay the evacuation of patients with extremity trauma beyond the desired timeline for compartment release. The aim of this study was to establish the feasibility of performing telementored surgery for leg compartment release and to identify methodological issues relevant for future research.MethodsThree anaethetists and one critical care physician were recruited as operators. They were directed to perform a two-incision leg fasciotomy on a Thiel-embalmed cadaver under the guidance of a remotely located orthopaedic surgeon. The operating physician and the surgeon (mentor) were connected through software that allows for real-time supervision and the use of a virtual pointer overlaid onto the surgical field. Two experienced orthopaedic traumatologists independently assessed the adequacy of compartment decompression and the presence of iatrogenic complications.Results14 of 16 compartments (in four leg specimens) were felt to have been completely released. The first evaluator considered that the deep posterior compartment was incompletely released in two specimens. The second evaluator considered that the superficial posterior compartment was incompletely released in two specimens. The only complication was a large laceration of the soleus muscle that occurred during a period of blurred video signal attributed to a drop in bandwidth.ConclusionsThis study suggests that surgical telementoring may enable physicians to safely perform two-incision leg fasciotomy in remote environments. This could improve the chances of limb salvage when compartment syndrome occurs far from surgical care. We found interobserver variation in the assessment of compartment release, which should be considered in the design of future research protocols.

IntroductionUltrasound-assisted external fixation of long bones has the potential to enhance extremity damage control surgery in locations without fluoroscopy, such as forward surgical elements, the intensive care unit, and spacecraft. This pre-clinical study specifically sought to evaluate orthopaedic surgeons' ability to sonographically define fracture patterns and the associated zone of injury in order to improve surgical decision-making and safely insert Schanz pin percutaneously.MethodsWe encased small composite femurs in a cylindrical echogenic gelatin matrix to simulate a human thigh. Three orthopaedic trauma surgeons with no prior ultrasound experience were taught to use sonography to diagnose fractures and assist external fixation. The surgeons were then presented with five specimens in a randomized sequence: three diaphyseal fractures (32-A2, 32-C2 and 32-C3); a distal femur fracture (33-A1.2); and an intact femur, all encased in an opaque black gelatin matrix to blind the participants to the underlying pathology. If they diagnosed a diaphyseal fracture, the surgeons were instructed to insert two Schanz pins proximal and two distal to the fracture, no closer than 40 mm from the fracture edges.ResultsFracture diagnosis and surgical decision-making were correct in all cases. All intact femurs were recognized as such. The need for a knee-spanning external fixator was recognized for all distal femur fractures. The three surgeons performed appropriate ultrasound-assisted pin placement in every case of diaphyseal fracture. The pins adjacent to the fracture site were on average 58 mm (SD ±11 mm) from the edge of the fracture. No pins were inserted in the fracture or in the knee joint.ConclusionsThe current study results suggest that with minimal training, orthopaedic surgeons can use portable ultrasound to diagnose femur fractures, decide the appropriate external fixator configuration, and safely insert Schanz pins outside the zone of injury.

There are several options for the treatment of long bone fractures in skeletally immature patients. Surgeon experience, type of fracture, and the possibility of damage to the physeal area dictate individual fracture management patterns. Notably, nail devices have not gained popularity in this patient group. Intramedullary locking nails have become the standard of care in adult patients due to decreased morbidity and mortality. A novel nail has been developed for humeral shaft fractures that uses a lateral starting position to avoid damage to the rotator cuff in humeral fracture fixation. This is possible because of the nail's transient flexibility during insertion. This study illustrates that it is feasible to insert this type of nail through multiple entry portals for both tibial and femoral fracture fixation, without damaging the physeal blood supply or growth areas.

This study evaluates the safety and outcome of a minimally invasive technique for inserting a standard dynamic hip screw for intertrochanteric fractures.

To assess the rate of anatomic reconstructions as well as approach-related morbidity and complications in the treatment of complex acetabular fractures through a modified extended iliofemoral approach.