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Septic arthritis following surgical treatment of a tibial plateau fracture is a rare complication, but it does occur, and the impact on long-term function is relatively unknown. The purpose of this study was to determine the long-term sequelae of septic arthritis among patients treated with internal fixation for a tibial plateau fracture and to determine the effect of timing (early or late infection) on the rate of such sequela. A retrospective comparative study was designed using the trauma database of a single level I academic trauma center. Patients who developed culture-positive septic knee arthritis after internal fixation of a tibial plateau fracture, with 1-year follow-up, were included in the study. The number of debridement procedures required was recorded. Rates of long-term complications and implant removal were identified. Complications rates were compared between patients who developed early (within 30 days of definitive fixation) and late (more than 30 days) septic arthritis. The mean number of debridement procedures per patient was six. Fourteen patients (88%) required implant removal, and thirteen (81%) developed knee arthritis. There was a significantly lower rate of complications in the early septic arthritis group compared to the late group (3 of 6 patients or 50%, vs 10 of 10 patients or 100%; p = 0.036). Patients who developed septic arthritis following internal fixation of a tibial plateau fracture were likely to endure long-term sequelae. Early infection and detection led to fewer complications. Surgeons treating infectious complications in tibial plateau fracture patients should specifically seek to rule out septic arthritis, anticipate that implant removal may be necessary, and counsel these patients appropriately regarding the anticipated natural history of their condition. III.

Acute exertional compartment syndrome (AECS) involving the upper extremity is a rare form of compartment syndrome that occurs after physical activity. Despite its infrequent occurrence, AECS has devastating sequelae, including muscle necrosis and nerve injury. It is imperative to promptly evaluate for AECS in any patient who has notable pain and sensory changes in the context of recent physical activity because of the dire consequences of a missed diagnosis. A 34-year-old man presented to the emergency department with excruciating pain and diffuse paresthesias in his bilateral arms and forearms after participating in a push-up contest. He also had pain with passive stretch of his triceps. Because of these physical examination findings and uncontrollable pain, a clinical diagnosis of AECS was made and was managed with fasciotomies. Postoperatively, the patient's pain and paresthesias slowly resolved, and he was eventually able to return to work at full capacity as a construction worker. This example of AECS of bilateral upper extremities emphasizes that it is a condition that, although rare, is real and must be taken seriously. With appropriate clinical suspicion, a prompt diagnosis can be made, and potentially devastating consequences can be avoided.

UNLABELLED Dead space is defined as the residual tissue void after tissue loss. This may occur due to tissue necrosis after high-energy trauma, infection, or surgical debridement of nonviable tissue. This review provides an update on the state of the art and recent advances in the management of osseous and soft tissue defects. Specifically, our focus will be on the initial dead space assessment, provisional management of osseous and soft tissue defects, techniques for definitive reconstruction, and dead space management in the setting of infection. LEVEL OF EVIDENCE Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Nonunions are uncommon sequelae of tibial pilon fractures, but they can present a challenging problem to the treating surgeon. Treatment strategies can range from isolated bone grafting to revision plating depending on the type of nonunion and patient factors. Here, we present our technique and clinical results for intramedullary nailing of tibial pilon nonunions.

To analyze a patient cohort who sustained a tibial pilon fracture and report the incidence of interposed posteromedial soft tissue structures.Retrospective cohort review.Regional Level 1 Trauma Center.About 394 patients with 420 pilon fractures treated between January 2005 and November 2011.Each patient's preoperative radiographs and computed tomography (CT) images were reviewed. The axial and reconstructed images were used in bone and soft tissue windows to identify any posteromedial soft tissue structures incarcerated within the fracture.Medical charts reviewed for the presence of preoperative neurologic deficit, separate posteromedial incision, and whether attending radiology CT interpretation noted the interposed structure.40 patients with 40 fractures (9.5%) had an entrapped posteromedial structure. The tibialis posterior tendon was interposed in 38/40 fractures (95%) and the posterior tibial neurovascular bundle in 4/40 fractures (10%). Preoperative neurologic deficit occurred in 5/40 patients (12%). A posteromedial incision was used in 11/40 fractures (27%). The attending radiology CT interpretation noted the interposed structure in 8/40 fractures (20%).In addition to the osseous injuries, CT imaging can demonstrate the posteromedial soft tissue structures. In our series, the tibialis posterior tendon was commonly incarcerated. In some cases, removal of the entrapped structure(s) may not be possible through the more commonly used anterolateral and anteromedial surgical approaches, and a separate posteromedial exposure may be required. Failure to recognize the presence of an interposed structure could lead to malreduction, impaired tendon function, neurovascular insult, and the need for further surgery.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The authors have identified a subset of bicondylar tibial plateau fractures with a hyperextension varus deformity (HEVBTP). The radiographic hallmarks of this pattern are (1) sagittal plane malalignment with loss of the normal posterior slope of the tibial plateau, (2) tension failure of the posterior cortex, (3) compression of the anterior cortex, and (4) varus deformity in the coronal plan. The purpose of this study was to describe this fracture pattern, to compare the associated injuries with non-HEVBTP fractures, and to suggest treatment strategies that may allow for improved reduction and stabilization.Retrospective Cohort Study.Level 1 trauma center.Preoperative radiographs and CT scans were reviewed in 208 patients who sustained 212 bicondylar tibial plateau fractures (OTA 41C). Twenty-five fractures in 23 patients fulfilled the radiographic criteria for HEVBTP fracture pattern. The remaining 187 bicondylar tibial plateau fractures were used as a control group.Initial spanning external fixation, followed by open reduction internal fixation and bone grafting with/without augmentation.Associated injury rate compared with OTA 41C patients without HEVBTP pattern, nonunion rates, and loss of reduction rates.Thirty-two percent of the HEVBTP fractures demonstrated significant associated injuries compared with 16% in the control group. The incidence of popliteal artery disruption requiring repair was 12% in the HEVBTP group compared with 1% in the control group. Patients with HEVBTP had either partial or complete peroneal nerve injury in 16% of cases (8% in control group) and 12% of patients developed a leg compartment syndrome (10% in control group).The HEVBTP pattern is a unique fracture. The surgeon must recognize the possible associated injuries that accompany this injury. We suggest fixation strategies that address this injury's individual components which may help to avoid failure.Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: Knee stiffness is an important complication after periarticular fracture, but a systematic evaluation of risk factors for this complication and outcomes of treatment has not been undertaken, to our knowledge. The aims of this study were to evaluate risk factors for knee stiffness requiring manipulation after periarticular fracture and to document the clinical outcomes of the manipulation. Methods: This study was designed as a case-control study in which patients requiring manipulation under anesthesia after periarticular fracture were compared with those who did not require manipulation. Using billing data from a regional level-I trauma center, we identified twenty-four knees requiring manipulation for refractory stiffness over a six-year period. These were matched, on the basis of the AO/OTA classification, with forty-three control knees that did not develop stiffness requiring manipulation. Descriptive statistics were used for frequency and mean analysis. Results: Univariate analysis revealed that extensor mechanism disruption (chi square = 0.05), fasciotomy (chi square = 0.020), wounds requiring ongoing management and precluding knee motion (p = 0.001), and the need for more than two surgical procedures to achieve definitive fracture fixation and soft-tissue coverage (p = 0.003) all placed patients at increased risk for knee stiffness requiring manipulation. The mean improvement in knee motion following all procedures targeting knee stiffness was 62°. Mean final flexion was significantly less in the case group (107°) compared with the control group (124°; p = 0.01). Conclusions: To our knowledge, this is the first study to systematically evaluate the risk factors for knee stiffness after periarticular fracture and document the outcomes of manipulation under anesthesia. It demonstrates that injury characteristics that delay or prevent postoperative knee motion place patients at increased risk for refractory knee stiffness. Although knee motion remains compromised, late surgery aimed at improving knee motion leads to improvements in flexion. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Failure of fracture fixation after plating often leads to challenging surgical revision situations. Careful analysis of all patient and fracture variables is helpful in both determining the causes of the fixation failure and maximizing the success of subsequent interventions. Biologic and mechanical factors must be considered. Biologic considerations include traumatic soft-tissue injury and atrophic fracture site. Common mechanical reasons for failure include malreduction, inadequate plate length or strength, and excessive or insufficient construct stiffness. Reliance on laterally based implants in the presence of medial comminution may be a cause of fixation failure and subsequent deformity, particularly with conventional nonlocking implants. Management of dead space with cement or beads has been effective in conjunction with staged approaches. An antibiotic cement rod in the diaphysis may provide fracture stabilization. Locking full-length constructs should be considered for osteoporotic fractures.

A concerning number of patients referred to our clinic with knee dislocations have not been thoroughly evaluated for popliteal injury. The objective of this study is to present our experience and attempt to identify possible causes for this trend. Thirty-one consecutive patients with knee dislocations referred over a 1-year period were evaluated. Patients were assigned to either of two groups: Group I included all patients initially evaluated with an evidence-based protocol for identifying clinically significant vascular injury associated with knee dislocation, and Group II included all patients who had not received an evidence-based evaluation. The main outcome measure was delay in the diagnosis of a limb threatening vascular injury (>8 h) within each group. Six out of the 31 patients referred, were evaluated for vascular injury without an evidence-based protocol. These patients were significantly more likely to have had a delay in the diagnosis of their vascular injury beyond 8 h (P = 0.032) and were less likely to have been evaluated at a level I trauma center (P < 0.001). As expected, evidence-based protocols are superior when compared to initial pedal pulse examination alone for identifying surgically significant vascular injury within 8 h. The consequences of a delay in diagnosis beyond 8 h can be catastrophic and one patient in this series required an above-knee amputation. This is not new information, however, a significant number of patients with knee dislocations continue to be evaluated solely by initial pedal pulse examination. Though effective protocols exist, orthopedic surgeons must work to facilitate the implementation of these protocols at their referring institutions.

Fractures of the tibial pilon may present an array of problems and potential complications. Staged treatment with initial spanning external fixation of the ankle has proven to be a successful strategy for the treatment of these difficult fractures in many cases. A subset of the tibial pilon fractures, with an oblique extension to the diaphysis may constitute a treatment problem, as these long fractures may be difficult to reduce at the time of definitive fixation, often 1-3 weeks post-injury due to interposed soft tissues, hematoma and/or early callus. Anatomic reduction of this fracture may thus require more extensive dissection than might be desirable in this injury. We offer a technique to assist in the treatment of the subset of these difficult fractures. In appropriate cases, a small fragment plate may be applied to the diaphyseal component of the fracture in an anti-glide type plate application, through a small incision proximal to the area of greatest injury. This re-establishes the length, rotation and alignment of this fragment which is commonly attached to either the Chaput anterolateral or the Volkmann posterolateral fragment. It additionally provides the intimate contact that may favor early union or minimize the need for secondary procedures. The fracture is thereby converted from a complete articular AO/OTA 43-C type pattern to a partial articular, or AO/OTA 43-B type pattern.

Open diaphyseal and meta-diaphyseal fractures of the lower extremity remain therapeutically challenging. Currently accepted treatment methods consist of a thorough irrigation and debridement of nonviable tissue combined with locked intramedullary nailing. Although exact reduction parameters remain controversial, achievement of a satisfactory reduction becomes increasingly difficult with fracture comminution and overt bone loss. We describe the simple technique of using multiple associated devitalized tibial bone fragments to obtain an accurate reduction prior to intramedullary nailing. This technique can be extended to other long bone fractures.

In isolation, dislocations of the hip and knee require emergent reduction to minimize the risks of serious complications, including vascular and neurologic injury, osteonecrosis of the femoral head, and loss of motion and function. With simultaneous dislocation of the ipsilateral hip and knee, as in the situation of hip dislocation with concomitant femoral shaft fracture, reduction of the hip may prove difficult because of the inability to control the femoral segment. In this setting, general anesthesia is commonly required. We present the case of a patient who sustained an ipsilateral hip and knee dislocation who underwent closed reduction of the knee in the emergency department but required general anesthesia and the insertion of Schanz pins in the femur to reduce the hip dislocation.

This article considers the role of knowledge translation as an important aspect of the current United Nations campaign called the Decade of Action for Road Traffic Safety (2011-2020). There are 5 tiers to this safety program: improving health care services, improving management of road safety, improving road network safety, improving vehicular safety, and improving road safety legislation. The authors review published, practical research in each of these 5 areas, focusing on identifying areas that need additional research. They note that much research focuses only on whether crashes result in survivors or fatalities, rather than characterizing crash victims who may experience ongoing disabilities as a result of a crash. This is true especially when categorizing orthopedic injuries in patients who survive crashes. The authors call for the development of a method of capturing different orthopedic injuries into an appropriate database that can then be correlated with disability in survivors of road traffic crashes. Other topics covered include the need for changes in basic transportation infrastructure, including that designed for use by bicyclists and pedestrians; the role of redesigned vehicle bumpers for pedestrian and bicyclist safety; the role of 2-wheeled motorized vehicles, particularly in the developing world; returning to driving after an orthopedic injury to the arms, legs, and/or pelvis; and legislation designed to improve vehicular safety.

Bicondylar tibial plateau fractures result from high-energy injuries. Fractures of the tibial plateau can involve the tibial tubercle, which represents a disruption to the extensor mechanism and logically must be stabilised. The purpose of this study was to identify the incidence of an independent tibial tubercle fracture in bicondylar tibial plateau fractures, and to report management strategies and potential complications. We retrospectively reviewed a prospectively collected orthopaedic trauma database for the period January 2003 to December 2008, and identified 392 bicondylar fractures of the tibial plateau, in which 85 tibial tubercle fractures (21.6%) were identified in 84 patients. There were 60 men and 24 women in our study group, with a mean age of 45.4 years (18 to 71). In 84 fractures open reduction and internal fixation was undertaken, either with screws alone (23 patients) or with a plate and screws (61 patients). The remaining patient was treated non-operatively. In all, 52 fractures were available for clinical and radiological assessment at a mean follow-up of 58.5 weeks (24 to 94). All fractures of the tibial tubercle united, but 24 of 54 fractures (46%) required a secondary procedure for their tibial plateau fracture. Four patients reported pain arising from prominent tubercle plates and screws, which in one patient required removal. Tibial tubercle fractures occurred in over one-fifth of the bicondylar tibial plateau fractures in our series. Fixation is necessary and can be reliably performed with screws alone or with a screw and plate, which restores the extensor mechanism and facilitates early knee flexion. Cite this article: Bone Joint J 2013;95-B:1697–1702.

Consideration of the individual, his or her needs, and what he or she hopes to gain through surgery is of primary importance in determining a surgical plan for the rheumatoid patient. Nevertheless, procedures undertaken to save life or prevent neurologic demise must, of course, take precedence. Alleviation of pain and correction of disabling deformity take next priority. Many other considerations go into the formulation of the list of surgical priorities. A full understanding of these considerations and a well-integrated team approach to the rheumatoid patient provide the best chance for optimal outcome following surgery.

Young surgeons and their spouses experience a myriad of stresses in the first few years of practice. Issues related to job search, moving to a new community, learning one's craft, time management, changes to spouse's career, child rearing, and the ever blurring line between work time and free time may all contribute to a decline in a couple's relationship. Recognizing these issues as obstacles to a healthy relationship and working to stay attuned to each other's emotional needs is of paramount importance. Some couples experiencing problems benefit from couples counseling, although many will ultimately go on to split and divorce. Going through a divorce can be an extremely consuming process, which may leave a person emotionally and financially depleted. Efforts to maintain other supports systems and to limit excessive work responsibilities may allow for a smoother passage through this commonly difficult period of life.

Objective The purpose of this study was to examine the efficacy of a fluoroscopically guided hip capsulotomy. Methods Ten fresh-frozen paired cadaveric hips were injected under fluoroscopic guidance with saline sufficient to generate an intra-articular pressure greater than 58 mmHg. The pressure was monitored continuously using a percutaneous transducer. A limited lateral approach to the proximal femur was performed by one of two senior orthopaedic trauma surgeons. Using a scalpel under fluoroscopic guidance, each surgeon made one attempt at an anterior capsulotomy. Changes in intra-articular pressure were recorded throughout the procedure. The specimens were then dissected to measure the extent of each capsulotomy as well as the distance from the capsulotomy to nearby neurovascular structures. Results A rapid and substantial decrease in intra-articular pressure was seen in all hips. The mean intra-articular pressure postcapsulotomy was 8.4 mmHg. The capsulotomies averaged 15.1 mm in length. None of the attempts at capsulotomy lasted longer than 90 seconds. The average distance between capsulotomy and the lateral-most branch of the femoral nerve was 19.5 mm. The femoral artery was on average 40.3 mm from the capsulotomy. There was no correlation between the side on which capsulotomy was performed and its extent or proximity to neurovascular structures. Conclusions Fluoroscopically guided hip capsulotomy through a small lateral incision appears to be a safe, effective, and expedient method, which may substantially reduce intra-articular pressure after minimally displaced femoral neck fractures.

OBJECTIVES: The purpose of this study was to determine the ability of intramedullary fibular fixation to maintain reduction until healing and to determine the overall complication rate in high-energy pilon fractures associated with fibular fractures. DESIGN: Retrospective study. SETTING: Level I university trauma center. PATIENTS/PARTICIPANTS: From 2000 to 2007, 972 pilon fractures were treated at our institution, 38 of which were treated with an intramedullary device for the associated fibular fracture. Two patients had acute amputations and two died; 1-year follow-up was obtained in 27 of the remaining patients. Average length of follow-up was 21 months. INTERVENTION: A retrospective chart and radiograph review was conducted of all patients for data extraction. MAIN OUTCOME MEASUREMENTS: Fibular fixation type and length, fibular healing, and complications. RESULTS: Average patient age was 36 years (range, 18-59 years). Four of the fibular fractures were segmental. All fractures had at least 50% of the cortex intact to prevent shortening. The average height of the fibular fractures from the distal tip was 6.9 cm (range, 1.3-22.2 cm). In 20 patients, a 3.5-mm fully threaded cortical screw was used for stabilization, and in the remaining seven, a 2.5-mm wire was used. The intramedullary implant extended 8.5 cm above the most proximal fracture line on average (range, 1.6-29.8 cm). Fibular alignment was within 3 degrees of anatomic in all cases after initial fixation. At final follow-up, fibular alignment had not changed more than 1 degrees in any case. No complications related to the fibular incision occurred, and all fibula fractures healed within 3 months. CONCLUSIONS: In axially and rotationally stable fibular fracture patterns associated with pilon fractures, intramedullary fibular stabilization was effective in maintaining fibular alignment. This technique led to reliable fracture healing in appropriately selected fractures and may be particularly advantageous in patients with compromised lateral and posterolateral soft tissues.

Objective: To assess the results of a standardized staged treatment strategy for displaced open calcaneal fractures with medial wounds. Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Fourteen displaced open Type II or Type IIIA Orthopaedic Trauma Association (OTA) 73 Type B or C calcaneal fractures treated between January 2000 and December 2007 who were managed with a standardized regimen. Intervention: Patients were treated in a staged fashion with antibiotics, irrigation, debridement, and percutaneous Kirschner wire fixation followed by definitive open reduction and internal fixation when soft tissues were amenable to fixation. Main Outcome Measures: Data regarding demographics, injury characteristics, time to fixation, interventions, and treatment complications were documented. The complication rate, time to bony union, and additional procedures were determined. Results: There were four OTA 73B and 10 OTA 73C injuries with open Type II or Type IIIA wounds on the medial side. All patients had debridement, irrigation, and percutaneous fixation within 8 hours of presentation. Definitive fixation was carried out on average 18 days after initial presentation with 10 patients only requiring the initial debridement and stabilization procedure followed by definitive fixation All 14 patients underwent definitive fixation through an extensile lateral approach. A superficial infection developed in one patient and a deep infection in one patient. All patients went on to union at an average follow up of 19 months. Conclusion: Open Type II and IIA wounds associated with displaced OTA Type 73 B or C calcaneal fractures represent high-energy injuries with potential increased risk for wound complications. In our series, a staged treatment strategy consisting of urgent debridement, provisional internal stabilization, and late definitive reconstruction offers a protocol that may reduce infections associated with open calcaneal fractures.

The use of postsurgical drains have a long history in thoracic and abdominal surgery. In orthopedics these devices have been used to decrease local edema, lessen the potential for hematoma or seroma formation, and to aid in the efflux of infection. However, the role of postoperative surgical drains in clean, elective cases has not been firmly established. In fact, most studies fail to show a statistical difference in outcome between drained and undrained patients. Despite the paucity of clinical evidence demonstrating any benefit supporting their use, drains continue to be placed after elective orthopedic procedures.

Bicondylar tibial plateau fracture management remains therapeutically challenging, partly because of multiplanar articular comminution. This study was performed to evaluate the frequency and morphologic characteristics of the posteromedial fragment in this injury pattern.Retrospective chart and radiographic review.Urban Level 1 university trauma center.Fifty-seven patients sustaining 57 Orthopedic Trauma Association (OTA) C-Type bicondylar tibial plateau fractures formed the study group.Between May 2000 and March 2003, 170 OTA C-Type bicondylar tibial plateau fractures were identified using an orthopaedic database. One hundred and forty-six fractures had computed tomographic (CT) scans performed prior to definitive fixation and were reviewed using the Picture Archiving and Communication System (PACS). Sixty-six (45.2%) injuries had fractures that involved the medial articular surface. Nine with suboptimal CTs were excluded, leaving 57 injuries for review. Forty-two patients demonstrated coronal plane posteromedial fragments. Morphologic evaluation of the posteromedial fragment included articular surface area, maximum posterior cortical height (PCH), and sagittal fracture angle (SFA).Forty-two of 57 injuries (74%) demonstrated a posteromedial fragment that comprised a mean of 58% of the articular surface of the medial tibial plateau (range, 19%-98%) and a mean of 23% of the entire tibial plateau articular surface (range, 8%-47%). Mean posteromedial fragment height was 42 mm (range, 16-59 mm), and mean sagittal fracture angle was 81 degrees (range, 33 degrees to 112 degrees). Six patients demonstrated fracture patterns not accurately identified by the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fracture classification system.A posteromedial fragment was observed in nearly one third of the bicondylar plateau fractures evaluated. The morphologic features of this fragment may have clinical implications when using currently available laterally applied fixed-angle screw/plate implants to stabilize these injuries. Alternate or supplementary fixation methods may be required when managing this injury pattern.

UNLABELLED Using the Thompson test for Achilles tendon rupture as a model, we developed the biceps squeeze test to test the integrity of the distal biceps tendon. We wanted to determine if failure to elicit supination with the biceps squeeze test would indicate complete distal biceps rupture. We also wanted to determine if surgical reattachment of the tendon would reestablish the supination response of the biceps squeeze test, and if patients who did not have surgery would have the same response to the biceps squeeze test months after injury. Twenty-five consecutive patients with 26 presumptive distal biceps tendon ruptures were evaluated with the biceps squeeze test. The biceps squeeze test was positive in 24 patients. Twenty-two patients had surgical repair. Twenty-one of 22 patients had operative confirmation of a complete distal biceps tendon rupture. All patients who had surgery had return of supination with the biceps squeeze test immediately after reattachment and at 3 months followup. Two patients with a positive biceps squeeze test declined surgery and did not have a return of supination with the biceps squeeze test at 3 months followup. Sixty-five patients with no history of upper extremity trauma were evaluated with the biceps squeeze test as a control group. All 65 patients had supination of the forearm in response to the test. The biceps squeeze test is simple, reliable, cost-effective, and aids in the diagnosis of distal biceps tendon ruptures. LEVEL OF EVIDENCE Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients-with universally applied reference "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.

Intramedullary nailing of tibial shaft fractures is the preferred treatment of most displaced, unstable tibial shaft fractures. In open tibia fractures, direct exposure of the fracture segments for irrigation and debridement is required prior to fracture stabilization. We propose a method of provisional stabilization using commonly available implants placed through the associated traumatic open wound prior to intramedullary nailing. This technique, particularly helpful to surgeons operating with limited assistance, employs a temporarily applied 3.5-mm dynamic compression plate or limited contact dynamic compression plate implant secured with unicortical screws, allowing reaming and intramedullary nailing of a reduced, stabilized tibia fracture.