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Background: Distal radius fractures (DRFs) are one of the most common major fractures. Despite their frequency, the tradeoffs in different outcomes after casting or surgery for closed extraarticular DRFs in older adults are unknown., Questions/purposes: (1) For adults older than 60 years with closed extraarticular DRFs, what are the tradeoffs in outcomes for choosing casting versus surgery? (2) In what settings would surgery be preferred over casting?, Method: This is a secondary analysis of data from the Wrist and Radius Injury Surgical Trial (WRIST), a randomized, multicenter clinical trial that enrolled patients from April 10, 2012 to December 31, 2016. For WRIST, researchers recruited patients older than 60 years who sustained closed extraarticular distal radius fractures from 24 sites in the United States, Canada, and Singapore. We conducted a secondary analysis using data from WRIST, which had longitudinal data from a robust collection of covariates for patients who underwent surgery and casting. Among the 296 patients recruited in the WRIST study, 59% (174) of patients (mean age 71 ± 9 years) with complete sociodemographic data and 12-month follow-up for each primary outcome were included in the main analysis. More patients underwent surgery than casting (72% [126 of 174] versus 28% [48 of 174]). Most sociodemographic variables were similar between the surgery and casting groups, except for age and volar tilt. The surgical cohort was composed of patients randomized to external fixation, closed reduction percutaneous pinning, or volar locking plate internal fixation. The casting cohort consisted of patients who elected to be treated with closed reduction and casting. A tree-based reinforcement statistical learning method was used to determine the best treatment, either surgery or casting, to maximize functional and esthetic outcomes while minimizing pain. Tree-based reinforcement learning is a statistical learning method to build an unsupervised decision tree within a causal inference framework that will identify useful variables and their cutoff values to tailor treatment assignment accordingly to achieve the best health outcome desired. The primary outcome was minimization of pain (12-month Michigan Hand Outcomes Questionnaire pain subdomain score), maximization of grip strength, total ROM (supination and wrist arc of motion), and esthetics (12-month Michigan Hand Outcomes Questionnaire esthetics subdomain score)., Results: Casting was the best treatment to reduce pain and maximize esthetics, whereas surgery maximized grip strength and ROM. When the patient favored gaining ROM over pain reduction (more than 80:20), surgery was the preferred treatment. When the patient prioritized the importance of grip strength over pain reduction (more than 70:30), surgery was also the preferred treatment., Conclusion: There are tradeoffs in outcomes after treating patients older than 60 years with closed extraarticular distal radius fractures with casting or surgery. When patients are attempting to balance minimizing pain and improving functional outcomes, unless they desire maximal functional recovery, casting may be the better treatment. Surgery may be beneficial if patients want to regain as much grip strength and ROM as possible, even with the possibility of having residual pain. These findings can be referenced for more concrete preoperative counseling and patient expectation management before treatment selection., Level of Evidence: Level III, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: As there is a current increasing tendency to treat displaced tibial shaft fractures in adolescents surgically, it has become more important to predict failure of cast treatment for these patients. In the past, redisplacement of pediatric tibial shaft fractures has been reported at rates of 20% to 40%. Although the efficacy of the three-point index (TPI), gap index, and cast index has been demonstrated for upper extremity fractures in children, to date no index has been shown to accurately predict redisplacement for pediatric tibial shaft fractures. The aim of this study was to determine the predictive factors for redisplacement in pediatric tibial shaft fractures., Methods: In all, 157 displaced pediatric tibial shaft fractures were evaluated retrospectively. Patient age, initial and postreduction fracture angulation, shortening and translation, quality of reduction, obliquity of fracture, associated fibular fractures, and 3 indices (TPI, cast index, and gap index) were analyzed. Receiver operating characteristic analysis was performed to determine the cutoff points and logistic regression was used to show the risk factors of redisplacement., Results: There were 53 female and 104 male patients with a mean age of 9.1 (5 to 15 y) and 45 patients developed redisplacement during the follow-up. Mean TPI and gap index and initial and postreduction fracture translation were higher in patients with redisplacement, while TPI>0.855 and postreduction translation >18% were the only independent risk factors for fracture redisplacement. No differences were observed regarding associated fibular fracture, quality of reduction, initial/postreduction angulation, and shortening., Conclusions: The TPI>0.855 and postreduction translation >18% are independent risk factors for redisplacement of tibial shaft fractures in children. Although the gap index can be useful, the cast index is not an appropriate tool for these fractures., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Closed reduction (CR) is sufficient to reduce the majority of femur fractures treated with flexible intramedullary nailing (FIN). No previous study has examined factors associated with failed CR of pediatric femoral shaft fractures treated with FIN. We sought to determine preoperative factors associated with failed CR. We hypothesized that fracture, patient, and surgeon characteristics would impact the need for open reduction (OR)., Methods: A retrospective review of children treated for femur fracture between 2012 and 2017 at a tertiary pediatric hospital was performed. Comparisons were made between 2 groups: FIN with CR group and FIN that required OR group. Demographic and baseline characteristics were compared between treatment groups using either χ tests or Fisher exact tests for categorical variables and general linear models for continuous variables. Odds ratios with 95% confidence intervals were calculated using univariate logistic regression tests., Results: Of 449 consecutive pediatric femur fractures treated at our center, 85 children were treated with FIN and constituted the study cohort. CR failed in 14 patients (16.5%) necessitating OR of the fracture site. Significant differences between study groups were found in fracture location (P=0.018), the mechanism (P=0.003), and displacement on the anteroposterior radiograph (P=0.027). Surgical time was found to be longer in the OR group (P=0.010). We identified 3 preoperative predictors of OR for FIN including fractures caused by high energy mechanisms (odds ratio=7.5), distal third fractures (odds ratio=15.3), and fracture displacement on the anteroposterior view (odds ratio=1.06). Surgeon years in practice, patient weight, age, and time from injury to surgery were not associated with OR., Conclusions: This study presents 3 preoperative risk factors that predict the need for OR of femur fractures treated with FIN. Surgical time was longer in cases that required OR. Our findings suggest that surgeons should avoid lengthy attempts at CR and consider a lower threshold for OR of at-risk fractures or use another technique other than flexible nails., Level of Evidence: Level III-prognostic.

Background: The purpose of this study was to describe the functional outcomes and complications of unstable supination external rotation (SER) and pronation external rotation (PER) ankle fractures in adolescents. A secondary outcome was to compare functional outcomes of SER stage IV injuries that were treated definitively with closed reduction and cast application to a similar group of minimally displaced fractures treated with open reduction and internal fixation (ORIF)., Methods: A retrospective review of adolescents aged 10 to 18 years with unstable ankle fractures treated at a single institution between 2009 and 2017 was conducted. All patients had functional outcomes data from the Foot and Ankle Ability Measure obtained at a minimum of 1-year follow-up., Results: In total, 67 adolescents (41 SER, 26 PER) were included (mean follow-up: 52.3±24.8 mo). A total of 56 were treated with ORIF and 11 were closed reduced and casted. No patients treated nonsurgically had a loss of reduction and none required subsequent surgical intervention. Preoperative radiographic predictors of syndesmotic injury (>6 mm of tibiofibular clear space or <2 mm of tibiofibular overlap) were not sensitive and only moderately specific predictors of intraoperative syndesmotic injury. There was no difference in functional outcome between the 11 SER stage IV fractures treated nonoperatively and a group of minimally displaced SER injuries treated with ORIF. Patients with open or partially open physes had better functional outcomes. Patients with syndesmotic injuries, medial malleolus fractures, or fracture-dislocations were not associated with lower functional outcome scores in our adolescent cohort., Conclusions: Unstable SER and PER injuries in adolescents have favorable functional outcomes at intermediate-term follow-up, though a minority continue to have impaired ankle function. Minimally displaced SER stage IV injuries with near anatomic alignment after closed reduction can be successfully treated with continued closed management, and have no difference in functional outcomes compared with similar injuries treated with ORIF., Level of Evidence: Level III.

Bilateral Posterior Fracture Dislocation (BPFD) of the shoulder is an uncommon but not rare presentation. We describe etiology, diagnostics, treatments and outcome and give a historic review and with a current approach of this pathology. We reviewed 55 cases (110 shoulders), mostly men (49/55), with a mean age of 49.2 years, mean follow up 21.9 months, mean delay until diagnose of 12.7 days (0-112 days), with a seizure as the cause in 80.0% . Other causes are electrocution, trauma or other. If the mechanism is not clear an epileptic insult should be considered the cause until proven otherwise. Closed reduction or mini open reduction is common in the more dated literature, but gives a overall good outcome. Arthroplasty is the prefered method in the more recent literature. Autografts from the shoulder treated with arthroplasty can be used to reconstruct the articular surface of the contralateral shoulder. High index of suspicion is important and a CT is most important diagnostic tool.

Background: Pediatric supracondylar humerus fractures are the most common elbow injury in children, accounting for 12% to 17% of all childhood fractures. A lack of information exists regarding complication rates on the basis of fellowship status and geography., Methods: The American Board of Orthopaedic Surgery (ABOS) Part-II database was used to identify candidates who performed either percutaneous or open treatment of humeral supracondylar or transcondylar fractures between 2002 and 2016 on patients aged 0 to 12 years. Candidates were categorized by fellowship training experience. Information analyzed included fellowship status, surgical procedure, complications, and geographic location of treatment. Data were analyzed utilizing the χ and Fischer exact tests and were considered significant if P≤0.05., Results: A total of 9169 cases (mean, 5.36+2.27 y; range, 0 to 12) were identified between 2002 and 2016, 8615 of which were treated with closed reduction and percutaneous pinning, whereas 554 were treated with an open procedure. The 5 most common fellowships treating these fractures were listed as pediatrics (4106), sports medicine (1004), none (912), trauma (732), and hand/upper extremity (543). Pediatrics performed the highest number of open reduction and internal fixation (ORIF), however, reported the statistically lowest percentage of ORIF. A statistically significant difference was identified between surgical complication rates and fellowship specialties, with pediatrics having the lowest complication rate (7.0%), followed by no fellowship (8.2%), trauma (9.0%), sports medicine (9.8%), and hand/upper extremity (11.2%) (P<0.001). This significant difference was also present when analyzing closed reduction and percutaneous pinning alone (P=0.002), however, not with the analysis of ORIF., Conclusions: Early career pediatric fellowship-trained orthopaedic surgeons are more likely to treat pediatric supracondylar humerus fractures. Overall, although they treat more patients with ORIF than any other group, their percentage treated with ORIF is statistically the lowest. A significant difference in reported complication rates was found to be associated with specific fellowship training, with pediatric fellowship-trained surgeons having the fewest complications and foot/ankle fellowship-trained surgeons associated with the highest rate of reported surgical complications., Level of Evidence: Level III-retrospective cohort study.

Importance: Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed., Objective: To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures., Design, Setting, and Participants: This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019., Main Outcomes and Measures: Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care., Results: Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03)., Conclusions and Relevance: The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

Background: No consensus exists for the management of closed tibia fractures in the adolescent population., Methods: The Kids' Inpatient Database was used to extract data on patients aged 10 to 18 years with closed diaphyseal tibia fractures. The frequency of closed reduction and internal fixation (IF) was calculated, and the temporal trends were evaluated., Results: Between 1997 and 2012, the rate of IF for closed tibia fractures in the adolescent population increased by 29.8%. The rate of increase in IF between patients aged 10 to 12 years, 13 to 15 years, and 16 to 18 years was not statistically different (P = 0.092). Analysis of hospital variables demonstrated that large hospitals were more likely to perform IF compared with small- and medium-sized hospitals (P < 0.001). A significant difference exists between the IF and closed reduction groups in the length of hospital stay (3.85 ± 0.07 versus 2.44 ± 0.07; P < 0.001) and cost ($37,400 ± $890 versus $15,300 ± $670; P < 0.001)., Discussion: The results of this study show a shift in the management of closed tibia shaft fractures in the adolescent population admitted to the hospital, with an absolute rate increase of 29.8% in patients aged 10 to 18 years over a 15-year period., Level of Evidence: Level III. A retrospective, comparative study.

Background: Forearm fractures are among the most frequently encountered orthopedic injuries in children. The maintenance of satisfactory alignment can be problematic and postreduction displacement with resultant malunion can occur., Objectives: The objective of the study was to evaluate pediatric emergency medicine (PEM) physicians' performance on forearm fracture reduction to determine the impact of a Process Improvement Intervention Program (PIIP) on postreduction displacement rates after initial reduction. The PIIP was designed to improve our PEM physicians' skills and knowledge in how to properly apply and mold casts to better maintain the alignment of reduced forearm fractures., Methods: A PIIP was implemented during 2015-2016 when orthopedic surgeons mentored postfellowship-trained PEM physicians. Patient cohorts from pre- and post-PIIP implementation were investigated and compared to evaluate the impact of the PIIP on PEM physicians' initial fracture reduction success rates and postreduction displacement rates. Descriptive and analytical statistics including univariate and multivariate models were tested to understand changes in physicians' performance., Results: Pre- and postcohorts had similar demographic and clinical characteristics and similarly high initial reduction success rates. When distal and midshaft fracture types were combined, there was no significant difference in postreduction displacement rates between the 2 cohorts, but when stratified based on fracture type, the distal radius postcohort showed a statistically significant improvement in postreduction maintenance., Conclusions: A PIIP by pediatric orthopedic surgeons did not change the PEM physicians' initial fracture reduction success rate, but it did result in a statistically significant improvement in maintenance of reduction rates., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background:  Surgical treatment of pediatric tibia shaft fractures has gained popularity despite closed reduction and cast-immobilization providing good long-term results. There is no consensus about optimal methods and satisfactory quality of treatment., Materials and Methods:  During 2010 to 2014, 226 pediatric patients were treated under anesthesia for tibia shaft fractures in Finland's five university hospitals. A total of 164 (73%) patients had closed fractures of the tibia or both tibia and fibula without other injuries (62 tibia only and 102 both tibia and fibula). Forty-one (18%) had open tibia fractures, 16 had additional fractures, and 5 (2%) had sustained a polytrauma (Injury Severity Score [ISS] > 15). Treatment methods, follow-up protocols, complications, and the outcome were analyzed., Results:  A total of 143 (63%) of the tibia fractures were treated surgically: 87 (53%) closed fractures, 36 (88%) open fractures, 15 (94%) with additional fractures, and 5 (2%) polytrauma patients. The rate of surgical treatment of closed tibia fractures was significantly higher in patients older than 10 and in patients with a concomitant fibula fracture. Fasciotomy was done in 33 (15%) patients. Reoperations were performed in 13 (6%) patients because of unsatisfactory treatment (inappropriate primary reduction 6, malunion 6, and non-union 1). There were no differences between the five university hospitals in treatment or follow-up protocols., Conclusion:  Internal fixation is used for the majority of tibia shaft fractures treated under anesthesia in university hospitals in Finland. Serious fracture or treatment related complications are very rare, but the percentage (6%) of re-operations because of unsatisfactory standard of treatment should be lower and could probably be improved by concentrating internal fixation to fewer hands. A prospective randomized controlled trial comparing non-operative treatment to intramedullary nailing in pediatric tibia fractures should be performed., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: The aim of this study was to evaluate the effect on union results of the application of cerclage cable around the lateral femoral wall (LFW) in postoperative fracture displacement., Patients and Methods: A retrospective evaluation was made of all the cases of reverse intertrochanteric fractures over a 7-year period in a trauma center. The study included 69 fractures treated with intramedullary nailing. The age of the patients, postoperative reduction quality and complications such as mechanical failure and non-union (1.4%) were obtained from the medical records. Changes in the neck-shaft angle, the amount of LFW displacement and telescoping of proximal femoral nail antirotation blades and lag screws were measured on anteroposterior and lateral radiographs. The functional evaluation of the Harris Hip Score was recorded at the final follow-up examination., Results: The mean age of the patients was 56.31 years (range 18-93 years). Closed reduction was applied in 37 (53.7%) cases, open reduction in 10 (14.5%) and with cerclage cable in 22 (31.8%). Mechanical failure developed in 8 (11.5%) cases where cerclage cable was not used. In 2 of these 8 cases, open reduction was successful. In the patients where cerclage cable was applied, no mechanical failure developed and no case underwent revision surgery. In the cases where cerclage cable was not used, a significantly higher rate of telescoping was found. (p = 0.001). The application of cerclage cable was seen to significantly reduce the amount of LFW displacement (2.23 mm vs 8.86 mm) and shorten the time to partial weight bearing (p = 0.000)., Conclusion: In reverse intertrochanteric fractures, the application of circumferential cerclage cable with cephalomedullary nailing contributes to primary stability and accelerates mobilization. Therefore, it can be considered a good option. It reduces the risk of failure internal fixation for intertrochanteric fracture.

Objectives: Hip dislocations are highly morbid injuries necessitating prompt reduction and post-reduction assessment for fracture and incarcerated fragments. Recent literature has questioned the need for initial pelvic radiographs for acute trauma patients, resulting in computed tomography (CT) scans as the initial evaluation. This study investigates the relationship between choice of pre-reduction imaging and treatment of acute hip dislocations., Design: Retrospective Case-Control., Setting: Single Academic Level I Trauma Center., Methods: All acute hip dislocations from 2011 to 2016 were reviewed. Exclusion criteria were diagnosis of dislocation at another facility, death prior to reduction, emergent surgical or ICU intervention, and periprosthetic dislocation. Patients were grouped by those with only a radiograph prior to reduction, Group I, versus those with a pre-reduction CT scan, Group II. The primary outcomes were time to reduction and the acquisition of a second CT scan., Results: Of the 123 hip dislocations identified, 35 patients were excluded, mostly for transfer with a known dislocation. Group I included 29 patients and Group II included 59 patients. The mean time to reduction was 74 min in Group I and 129 min in Group II for a difference of 55 min (p < 0.001). The rate of repeat CT scan was 0 in Group I versus 48 (81%) in Group II (p < 0.001)., Conclusion: Initial trauma pelvic radiography prior to CT is still important in the setting of suspected hip pathology to decrease time to hip reduction and unnecessary radiation exposure., Level of Evidence: Prognostic Level III., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Although mandibular condylar fractures are among the most common fractures of maxillofacial region, the ideal method for treatment of these fractures is still a controversy. The objective of this study was to compare functional outcomes of open vs closed treatment of unilateral mandibular condylar fractures., Methods: This study was carried out at Department of Oral and Maxillofacial Surgery, Armed Forces Institute of Dentistry, Rawalpindi. All patients, included in our study, were randomly put in open and closed treatment groups. Patients were assessed for maximal mouth opening, deviation of mandible on opening and occlusal status six months postoperatively. Maximal mouth opening was assessed by maximal interincisal distance, deviation of mandible on opening by calculating the midline discrepancy during mouth opening and occlusion was assessed by clinical examination according the modified criteria described by Singh V et al. Independent samples t-test was used to compare means of variables in open and closed treatment groups., Results: After six months of follow up the mean mouth opening was 36.39±4.72 mm in open treatment group while it was 33.74±4.72 mm in closed treatment group and difference was statistically significant. While deviation of mandible on opening was found to be 0.48±0.99 mm in open treatment group and 1.09±1.60 mm in closed treatment group. The mean occlusal disturbance was found to be 1.17±0.38 in closed treatment group while it was 1.10±0.30 in open treatment group.., Conclusions: Open treatment of unilateral mandibular condylar fractures results in better functional outcomes particularly in terms of mobility of mandible (mouth opening).

Background: Seymour fractures are distal phalanx fractures in children with a juxta-epiphyseal pattern. The purpose of our study was to investigate the treatments, outcomes, operative ;indications, and antibiotic choice for acute Seymour fractures (presenting within 24 h of injury), to better define optimal management. We hypothesized that: (1) cephalexin provides adequate antibiotic coverage for acute Seymour fractures; (2) most injuries will achieve good outcomes with management in the emergency department (ED) alone; and (3) indication for operative intervention is unsuccessful or unstable reduction in the ED., Methods: We performed a retrospective study of patients under 18 years old treated at a large pediatric hospital from 2009 to 2017 for an acute Seymour fracture. Study outcomes included management and antibiotic type, infection, fracture healing, malunion, physeal disturbance, nail dystrophy, antibiotic failure, and need for unplanned operative intervention., Results: Mean age of patients was 10 years, with 43 males and 22 females sustaining 65 Seymour fractures. Fifty-eight cases (89%) were initially managed in the emergency department. Seven cases were initially managed with an operative intervention that included I&D, open reduction, and K-wire fixation. The most commonly cited surgical indication was unsuccessful closed reduction. Four patients initially managed in the ED required an unplanned operation, usually because of fracture redisplacement. Complications were rare, with superficial infections being most common., Conclusions: Most acute Seymour fractures can be successfully managed in the emergency department if stable reduction is achieved., Level of Evidence: Level IV, therapeutic.

Introduction: The Appropriate Use Criteria for the treatment of supracondylar humerus fractures (SCHFs), developed by American Academy of Orthopaedic Surgeons, recommends pinning for all type II SCHFs. However, previous studies have suggested that, with close follow-up some of the less severe type II SCHF's can be successfully treated without surgery. Our purpose was to analyze data collected prospectively on a large cohort of type II SCHF's., Methods: We reviewed clinical and radiographic information on all type II pediatric SCHF (n=1120) that were enrolled in a prospective registry and were followed for a minimum of 8 weeks. The characteristics of the patients who were treated without surgery were compared with those of patients who were ultimately treated surgically. Treatment outcomes, as assessed by the final clinical and radiographic alignment, range of motion of the elbow, and complications were compared between the groups to define clinical and radiographic features that related to success or failure of nonoperative management., Results: Ultimately, 812 fractures (72%) were treated nonoperatively, and 309 fractures (28%) were treated surgically. At final follow-up, outcome measures of change in carrying angle, range of motion, and complications did not show clinically significant differences between treatment groups. Binary logistic regression analysis indicated that initial radiographic features, specifically rotational deformity, varus malalignment, valgus malalignment, and a shaft-condylar angle of <30 degrees were strongly related to selection for surgery. Patients with isolated extension deformity, but none of the other features, were more likely to complete successful nonoperative management., Conclusions: Pinning all type II SCHF, as recommended by the Appropriate Use Criteria, would have resulted in unnecessary surgery in 72% of patients in this series. Given the wide range of injury severity within the type II category of SCHF, better discrimination of factors commonly associated with successful nonoperative treatment is required. In this particular series, fractures with an isolated extension deformity (without rotational or coronal malalignment) were more likely to complete successful nonoperative management.

Background: Distal radius fracture (DRF) is a common fracture of the upper extremity. The role of concurrent injuries in patients treated for DRFs is poorly elucidated. The authors sought to determine whether remote injuries were associated with worse outcomes after management of DRFs., Methods: A retrospective cohort study including all consecutively seen patients by a university hospital hand service between 2010 and 2015. Preoperative radiographs were analyzed, and patients were managed by surgeon preference and evaluated postoperatively using pain scores. Remote injury was defined as any other injury sustained at the time of fracture not localized to affected extremity. Univariate analysis was performed to identify factors associated with risk of complication. A multivariate logistic regression analysis was performed, controlling for confounding factors., Results: A total of 181 DRFs in 176 patients were treated over the 5-year period of the study. Forty-eight (26.5%) of the fractures were managed nonoperatively with casting, 12 (6.6%) with closed reduction and pinning, and 119 (65.7%) with open reduction and plating. The mean follow-up was 5.2 months. The complication rate was 18.2%. The most common complication was persistent pain in 5 patients, followed by median neuropathy, loss of reduction, arthritis, and distal radioulnar joint instability. After controlling for age, body mass index, hand surgeon, and other confounders, remote injury was associated with a significantly increased risk of complications ( P = .04, odds ratio: 6.03, 95% confidence interval: 1.05-34.70)., Conclusions: Patients with remote injuries have a 6-fold increased risk of complications after DRF treatment. The additional risk in these patients should be considered during patient/family counseling and clinical decision-making in DRF management.

Purpose: Most patients recover well from a distal radius fracture (DRF). However, approximately one-fifth have severe disability after 1 year when evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. In the present study, we evaluated this subgroup of patients in our register with an inferior outcome. We hypothesized that the patient-reported outcome would improve with time., Methods: Since 2001, patients 18 years and older with a DRF, at the Department of Orthopedics, Skåne University Hospital (Lund, Sweden) are prospectively registered in the Lund Wrist Fracture Register. We have previously defined a DASH score above 35 at the 1-year follow-up as the cutoff of major disability. Between 2003 and 2012, 17% of the patients (445 of 2,571) in the register exceeded this cutoff. Three hundred eighty-eight were women and 57 men and the mean age was 69 years (range, 18-95 years). One-fourth had been surgically treated. In December 2014, 2 to 12 years after the fracture, a follow-up DASH questionnaire was sent to the 346 of 445 patients still alive., Results: Seventy-three patients (27%) had initially been treated surgically and 196 (73%) nonsurgically for their DRF. Two hundred sixty-nine of 346 patients (78%) returned the follow-up DASH questionnaire at 2 to 12 years (mean, 5.5 years) after the fracture. The overall median DASH score improved from 50 at 1 year to 36 at the 2- to 12-year follow-up, (P < .05). Forty-seven percent had improved to a score below the cutoff 35, but 53% remained at a high suboptimal level., Conclusions: The subjective outcome after a DRF improves over time for patients with an inferior result at 1 year, but more than half of the patients continue to have major disability., Type of Study/level of Evidence: Prognostic II., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To explore differences in patient, fracture, accident and treatment characteristics between patients treated for a mandibular condyle fracture in the University Centres of Dresden and Groningen, as an explanation for differences treatment results., Materials and Methods: Patients' fracture, accident and treatment characteristics were obtained from the medical records of Dresden and Groningen from January 1, 2008, to August 31, 2011, and were analysed using logistic regression analysis., Results: In Dresden, compared to Groningen, patients were generally older (OR 1.03, 95% CI 1.02; 1.05, per year), were more often male (OR 2.54, 95% CI 1.48; 4.34) and more often had intracapsular (OR 2.95, 95% CI 1.67; 5.22) and low condylar (OR 1.86, 95% CI 1.14; 3.04) fractures. In Groningen 98% of patients received closed treatment and in Dresden 42%., Conclusion: Significant differences in patients and fractures and treatments were found between both Centres. These differences can partly be explained by the demographics of the cities and differences in imaging techniques (e.g., computed tomography, Orthopantomogram, Towne projection) applied to identify fractures. This study illustrates that differences in diagnosis, treatment and outcome are not only related to the health care system but also to differences in patient characteristics between centres., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Despite an 88% increase in the number of pediatric fractures treated in ambulatory surgery centers (ASCs) over a 10-year period, few studies have compared outcomes of fracture treatment performed in a freestanding ASC compared with those performed in the hospital (HOSP) or hospital outpatient department (HOPD). The purpose of this study was to compare clinical and radiographic outcomes, treatment times, and costs for treatment of Gartland type II supracondylar humeral (SCH) fracture in the ASC, HOSP, and HOPD., Methods: Retrospective review identified pediatric patients with isolated Gartland type II SCH fractures who had closed reduction and percutaneous pinning (CRPP) by board-certified orthopaedic surgeons from January 2012 to September 2016. On the basis of the location of their treatment, patients were divided into 3 groups: HOSP, HOPD, and ASC. All fractures were treated with CRPP under fluoroscopic guidance using 2 parallel or divergent smooth Kirschner wires. Radiographs obtained before and after CRPP and at final follow-up noted the anterior humeral line index (HLI) and Baumann angle. Statistical analysis compared all 3 groups for outcomes, complications, treatment time/efficiency, and charges., Results: Record review identified 231 treated in HOSP, 35 in HOPD, and 50 in ASC. Radiographic outcomes in terms of Baumann angle and HLI did not differ significantly between the groups at any time point except preoperatively when the HLI for the HOSP patients was lower (P=0.02), indicating slightly greater displacement than the other groups. Overall complication rates were not significantly different among the groups, nor were occurrences of individual complications. The mean surgical time was significantly shorter (P<0.0001) in ASC patients than in HOPD and HOSP patients, and total charges were significantly lower (P<0.001)., Conclusions: Gartland type II SCH fractures can be safely treated in a freestanding ASC with excellent clinical and radiographic outcomes equal to those obtained in the HOSP and HOPD; treatment in the ASC also is more efficient and cost-effective., Level of Evidence: Level III-retrospective comparative study.

Introduction: Repeated attempts of closed reduction of distal radius fractures (DRF) are performed in the emergency department setting to optimize fracture alignment and avoid surgery. The additional manipulation of the fracture may, however, increase dorsal comminution and lead to loss of reduction in the cast. This retrospective cohort study has investigated the effect of second reduction attempt on fracture alignment and comminution., Materials and Methods: Six-hundred-eighteen patients with DRF were treated in the medical center in 2007-2010. Seventy-six (12.3%) DRF who underwent two reductions were included in the study. Radiographs taken after the first and second reduction attempts were reviewed for changes in fracture alignment parameters (radial height, radial inclination, volar tilt) and dorsal comminution length. Patients were also followed retrospectively to determine the rates of secondary displacement in a cast., Results: A second closed reduction attempt improved mean radial height by 1.43 mm, mean radial inclination by 1.62° and mean volar tilt by 8.75°. Mean dorsal comminution length increased by 1.6 mm. Of the 19 (25%) patients with acceptable alignments after two reduction attempts, follow-up radiographs were available for 12, which showed successful reduction in four cases (33.3 or 5.2% of total 76 patients)., Conclusions: A second closed reduction attempt improved immediate fracture alignment, but also worsened dorsal comminution. Only 5.2% of patients who underwent two reduction attempts had an acceptable final alignment and did not require surgery. Increased dorsal comminution may further compromise fracture stability, complicate surgery and have negative effect on the postoperative course.

Background and purpose - The optimal treatment of displaced Salter-Harris (SH) II fractures of the distal tibia is controversial. We compared the outcomes of operative and nonoperative treatment of SH II distal tibial fractures with residual gap of >3 mm. Factors that may be associated with the incidence of premature physeal closure (PPC) were analyzed. Patients and methods - We retrospectively reviewed 95 patients who were treated for SH II distal tibial fractures with residual gap of >3 mm after closed reduction. Patients were assigned to 1 of 2 groups: Group 1 included 25 patients with nonoperative treatment, irrespective of size of residual gap (patients treated primarily at other hospitals). Group 2 included 70 patients with operative treatment. All patients were followed for ≥ 12 months after surgery, with a mean follow-up time of 21 months. Logistic regression analyses were performed to identify risk factors for the occurrence of PPC. Results - The incidence of PPC in patients who received nonoperative treatment was 13/52, whereas PPC incidence in patients who received operative treatment was 24/70 (p = 0.1). Multivariable logistic regression analysis determined that significant risk factors for the occurrence of PPC were age at injury, and injury mechanism. The method of treatment, sex, presence of fibular fracture, residual displacement after closed reduction, and implant type were not predictive factors for the occurrence of PPC. Interpretation - Operative treatment for displaced SH II distal tibial fractures did not seem to reduce the incidence of PPC compared with nonoperative treatment. We cannot exclude that surgery may be of value in younger children with pronation-abduction or pronation-external rotation injuries.

Background: The treatment of proximal humerus fractures (PHF) is largely surgeon dependent with no clear guidelines for selecting the optimal method of treatment., Aims: The aim of this study was to evaluate trends and variations in treatment methods of PHF in the United States from 2004 to 2012 and to determine the regional differences in treatment., Methods: The National Inpatient Sample was used to identify all patient discharges with diagnosis codes for PHF and the data were classified based on ICD-9 procedure codes. Patient and hospital demographics were also analyzed. Simple linear regression analyses were performed for each treatment modality to evaluate current treatment trends and to extrapolate the future trends of PHF treatment over the next 20 years., Results: A national estimate of 550,116 PHF discharges was identified over the time period. Significant correlations between change over time and treatment modality were found for reverse shoulder arthroplasty (RSA) (r = 0.903, p < 0.001), open reduction internal fixation (r = 0.876, p = 0.002), and closed reduction internal fixation (r = -0.922, p < 0.001). The RSA regression model showed that by the year 2032, PHF treated with RSA will increase 100% from 2012., Discussion: There were significant changes in treatment modalities for PHF from 2004 to 2012; The projected number of RSA used to treat PHF will be about 9115 in 2032, compared to 340 in 2004., Conclusion: Overall, there was a growth in proximal humerus fractures treated in an inpatient setting in the United States. RSA had the greatest proportional increase over time, but only accounted for less than 2% of total interventions.

Introduction: Subtrochanteric fractures are more difficult to treat than other proximal femoral fractures. The aim of this study was to report the outcomes for patients with subtrochanteric fractures treated using a cephalomedullary nail following open reduction and cerclage wiring versus closed reduction alone, regarding health-related quality of life (HRQoL) and social function., Materials and Methods: We performed a prospective cohort study including patients aged 60 years or older suffering fragility subtrochanteric fractures of the femur treated with cephalomedullary nails, with a minimum 2-year follow-up. We defined two treatment groups: one treated with closed reduction manoeuvres (60 patients), and another treated with open reduction and cerclage wiring (30 patients). The outcomes were mortality, orthopaedic complications (reoperation and no-union), social function (Jensen Index), and HRQoL (EQ-5D index score)., Results: There were no differences regarding sex, age, side affected, type of implant, anaesthetic risk, 1-year mortality, and orthopaedic complications. Surgical time was longer in the cerclage wire group, but length of stay was 2 days shorter for the cerclage group and reduction was better. Patients treated with cerclage wiring had significantly better EQ-ED at 12 months (0.66 ± 0.22 points vs. 0.78 ± 0.15 points); and social status at 12 and 18 months (2.77 ± 1.00 points vs. 2.10 ± 1.22 points)., Conclusions: Better reduction is achieved when using cerclage wires for fragility subtrochanteric fractures. These fractures had a negative effect on quality of life and social function, but better outcomes were observed in the cerclage group.

Background: Closed reduction of pediatric fractures is commonly performed by orthopaedic residents using conscious sedation in the emergency department (ED). The purpose of this study was to determine the rate of satisfactory reductions as performed by residents, and to determine the outcomes of these procedures., Methods: A retrospective review was performed of all fractures that underwent closed reduction under conscious sedation in the ED of a level 1 pediatric trauma center between January 1, 2010 and November 30, 2014. Initial and subsequent radiographs were reviewed and a determination was made as to whether the initial reduction was satisfactory, based on predetermined criteria for angulation and displacement. If a second reduction attempt in the operating room was necessary, this was noted. Chart notes were reviewed until a documented endpoint was reached, such as uneventful healing, malunion, nonunion, or growth arrest., Results: A total of 838 subjects were identified. The upper extremity was involved in 85% of the fractures. Of the initial 838 fracture reductions performed, 39 (4.7%) were unsatisfactory. Residents on their first pediatric orthopaedic rotation had a higher unsatisfactory reduction rate compared with more experienced residents (7.0% vs. 3.4%, P=0.01). A second reduction was performed for 94 of 749 (12.6%) fractures. Of these, 35 (37.2%) required an open procedure to accomplish a satisfactory reduction. Fractures with initially satisfactory reductions were significantly less likely to require a second reduction attempt than those with initially unsatisfactory reductions (9.2% vs. 80.0%, P<0.01). The likelihood of a satisfactory reduction was significantly higher in the upper extremity than in the lower extremity. Overall, the vast majority (99.2%) of fractures had a satisfactory final outcome., Conclusions: Most attempts at closed reduction of pediatric fractures in the ED by orthopaedic residents are successful, and the likelihood of a satisfactory reduction was associated with increased levels of resident experience. Fractures with an initially successful reduction were far less likely to require remanipulation., Level of Evidence: Level IV-this is a therapeutic case series.

Background: Disparities exist in access to outpatient pediatric orthopaedic care. The purpose of this study was to assess whether disparities also exist in elective pediatric orthopaedic surgical procedures such as implant removal, and to determine which demographic and socioeconomic factors may be associated with differences in treatment., Methods: Children aged 7 to 18 inclusive who sustained femoral shaft fractures between the years 1997 and 2010 were identified in the New York State SPARCS database. Patient age, sex, race/ethnicity, insurance status, education, and poverty were identified. Factors associated with the method of fracture treatment were assessed through multivariate regression analysis. The subset of patients that received internal fixation were followed up until 2011 inclusive for implant removal. Factors associated with implant removal were assessed using a Cox proportional hazards survival analysis (time to implant removal)., Results: Of the 3220 closed femoral shaft fractures identified, 2609 (81%) were treated with internal fixation, 9 (0.3%) had open treatment without implants, 203 (6.3%) were treated with external fixation, and 399 (12.4%) with closed methods. Patients with No Fault/Accident insurance by No Fault/Accident insurance were more likely to undergo internal fixation compared with patients with private insurance (P<0.001). Of the 3220 patients, 2572 were included in the implant removal subanalysis. Implant removal was performed in 725 (28.2%) patients. In the multivariate model, patients were more likely to undergo removal if they were younger (P<0.001), white [vs. black (P<0.001), vs. Hispanic (P=0.035), vs. other (P=0.001)], and lived in neighborhoods with less poverty (P=0.016). Insurance status was not a statistically significant predictor of implant removal., Conclusions: There is an association between implant removal and younger age, white race, and higher socioeconomic status in children. Awareness of these disparities should prompt further evaluation of causation, whether it be from lack of evidence-based guidelines for implant removal, surgeon bias, variations in reimbursement, or disparities in access to care. Further study is recommended to better elucidate the indications for implant removal in children and the causes for the disparities identified here., Level of Evidence: Level III-retrospective cohort study.

Purpose: Dislocation of the shoulder is rare in the prehospital setting. The medical specialities of the emergency physicians are heterogeneous, and the level of experience is different. Aim of this study was to evaluate the feasibility, sufficiency, and need of prehospital reduction., Methods: Over 12 months, 16 rescue stations in Germany and Austria documented cases. Points of examination were: incidence of reduction, influence of pathological findings, therapy and effectiveness of reduction., Results: We included 70 patients. A reduction was undertaken in n = 47 (66.6 %). In n = 70 (100 %) perfusion was without pathological finding after reduction, all n = 7 (10 %) neurological pathologies declined after reduction. There was no significance in total implementation of prehospital reduction between surgeons and anaesthetists. N = 63 (90 %) of all patients received an immobilisation of the shoulder. N = 68 (97 %) of all patients were transported to a hospital. Time to arrival in hospital was in n = 50 (71.4 %) ≤10 min, in n = 17 (24.2 %) ≤20 min and in n = 3 (4.4 %) ≤30 min., Conclusion: Implementation of reduction is independent of pathological neurological or vascular findings. Knowledge and skill is enough to perform a reduction quiet effectively in all emergency physicians. No specific technique can be recommended for prehospital use, the importance of being skilled is more important than one method. Early reduction was performed most rapidly in surgeons, but as well in the recommended time by other medical disciplines. On documented timings to admission hospital waiver of reduction is doubt. Therefore, a reduction in the prehospital setting is possible, but not obligatory.

Background: The objective of this study was to describe the fracture pattern for hand fractures in the Arctic region of Norway., Materials and Methods: Using the hospital's radiological information system and picture archiving and communication system all traumatic hand fractures in the year of 2010 were registered. Fractures in the carpal, metacarpal, and phalangeal bones were included in the study., Results: A total of 593 patients with 691 fractures including 80 carpal, 200 metacarpal, and 411 phalangeal fractures were registered. The most commonly affected bone was the 5th metacarpal bone with a total of 99 fractures (14%), 22 of these (22%) were classified as subcapital or "boxer's fracture". Among male patients, the highest frequency of fractures was seen in the age group 10-60 years with a peak between 10-24 years. Adult female patients had most fractures in the age group 50-70 years. Generally, there were no seasonal variations, although a marked decrease of fractures could be seen in December. Triquetral fractures were more common during the winter season. Falling was the most common trauma mechanism., Conclusion: With a few exceptions, hand fractures were not related to particular seasons or weekdays in this material. The distribution of hand fractures was related to age and gender, and some trauma mechanisms were dominating.

Objectives: We sought to determine the effect of reaming on 1-year 36-item short-form general health survey (SF-36) and short musculoskeletal function assessment (SMFA) scores from the Study to Prospectively Evaluate Reamed Intramedullary Nails in patients with Tibial Fractures., Design: Prospective randomized controlled trial.1319 patients were randomized to reamed or unreamed nails. Fractures were categorized as open or closed., Setting: Twenty-nine academic and community health centers across the US, Canada, and the Netherlands., Patients/participants: One thousand three hundred and nineteen skeletally mature patients with closed and open diaphyseal tibia fractures., Intervention: Reamed versus unreamed tibial nails., Main Outcome Measurements: SF-36 and the SMFA. Outcomes were obtained during the initial hospitalization to reflect preinjury status, and again at the 2-week, 3-month, 6-month, and 1-year follow-up. Repeated measures analyses were performed with P < 0.05 considered significant., Results: There were no differences between the reamed and unreamed groups at 12 months for either the SF-36 physical component score [42.9 vs. 43.4, P = 0.54, 95% Confidence Interval for the difference (CI) -2.1 to 1.1] or the SMFA dysfunction index (18.0 vs. 17.6, P = 0.79. 95% CI, -2.2 to 2.9). At one year, functional outcomes were significantly below baseline for the SF-36 physical componentf score, SMFA dysfunction index, and SMFA bothersome index (P < 0.001). Time and fracture type were significantly associated with functional outcome., Conclusions: Reaming does not affect functional outcomes after intramedullary nailing for tibial shaft fractures. Patients with open fractures have worse functional outcomes than those with a closed injury. Patients do not reach their baseline function by 1 year after surgery., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Fractures of the proximal humerus in children are rare and represent approximately 0.45% of all paediatric fractures. These injuries are common in patients up to an age of 16 years. The treatment of displaced subcapital fractures is still controversially discussed in literature. Therefore the aim of this study was to evaluate the short-term outcome and to provide guidelines for surgical treatment of these fractures in children and adolescents., Methods: Clinical and radiological results of 231 patients between 0 and 17 years with subcapital humerus fractures were evaluated. Patients were devided according to their treatment as followed (1) conservative treatment group (2) operative treatment group., Results: A total of 191 patients (82.7%) underwent conservative treatment and 40 (17.3%) underwent operative treatment. Surgical treatment consisted of open reduction and internal fixation (ORIF) (35.0%) or closed reduction and internal fixation (CRIF) (52.5%). In all operated patients an axial deviation of more than 20° was observed preoperatively. According to our groups; the surgical group presented in 90% (N = 36) of the patients with an excellent result, in 5% (N = 2) an average result was observed and in 5% (N = 2) a poor result according to Constant Murley Score was achieved. In the conservative treatment group in 185 patients (96.9%) excellent results were achieved and in 6 patients (3.1%) an average result in the Constant Murley Score was achieved., Conclusion: Conservative treatment in children < 10 years and an angulation angle < 20°, as well as surgical treatment with ORIF or CRIF in patients > 10 years and with an angulation angle > 20° leads to excellent short-term outcome. However, studies with longer observation time are needed to evaluate long-term complications like limb length discrepancy.

Unlabelled: PURPOSE OF THE STUDY Although supracondylar humeral fractures represent a major part of the pediatric fractures, no classification system or radiological characteristics describes which supracondylar fractures require open reduction. We aim to evaluate the factors that lead us to perform open reduction during operation. MATERIAL AND METHODS We retrospectively evaluated 57 patients who underwent operation for type III supracondylar fracture, and divided them into two groups; those with open reduction and internal fixation, and those with closed reduction and percutaneous fixation. The two groups were compared based on age, gender, BMI by age, medial spike angle of the fracture, medial spike-skin distance and rotation angle between the fractured fragments. RESULTS Of all patients, 46 (81.71%) underwent closed reduction and percutaneous fixation (CRPF) and 11 (19.29%) were treated with open reduction and internal fixation (ORIF). BMI by age was remarkably higher in the ORIF group (p = 0.00). And medial spike angle was smaller in the ORIF group (p = 0.014). DISCUSSION Closed reduction and percutanous fixation is the main treatment of supracondylar humeral fractuers. Open reduction in supracondylar humeral fractures could be associate with complications and cosmetic lesions. Many studies indicates that obesity is high risk factor for complex fractures as well as preoperative and postoperative complications. A prominant medial spike could associate with muscle entrapment, and obliquity of the fracture line. It could be also an indirect finding of instablity of the fracture. CONCLUSION We suggest that a smaller medial spike angle and a higher BMI in children with Type III supracondylar humeral fractures may require open reduction, and it is unreasonable to avoid open reduction in cases where closed reduction is not achieved., Key Words: supracondylar humerus, open reduction, obesity, medial spike angle.