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To determine whether the prone or lateral position is associated with post-operative sciatic nerve palsy in posterior acetabular fracture fixation.Retrospective cohort study.Three Level I trauma centers.Patients with acetabular fractures treated with a posterior approach (n=1045).Posterior acetabular fixation in the prone or lateral positions.The primary outcome was the prevalence of post-operative sciatic nerve palsy by position. Secondary outcomes were risk factors for nerve palsy, using multiple regression analysis and propensity scoring.The rate of post-operative sciatic nerve palsy was 9.5% (43/455) in the prone position and 1.5% (9/590) in the lateral position (p0.001). Intraoperative blood loss and surgical duration were significantly higher for patients who developed a post-operative sciatic nerve palsy. Subgroup analysis showed that position did not influence palsy prevalence in posterior wall fractures. For other fracture patterns, propensity score analysis demonstrated a significantly increased odds ratio of palsy in the prone position (aOR 7.14 (2.22, 23.00); p=0.001).With the exception of posterior wall fracture patterns, the results of this study suggest that factors associated with increased risk for post-operative sciatic nerve palsy following a posterior approach are: fractures treated in the prone position, increased blood loss, and prolonged operative duration. These risks should be considered alongside the other goals (e.g., reduction quality) of acetabular fracture surgery when choosing surgical positioning.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To identify the patient, injury and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multi-center retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN Multi-center Retrospective Review. SETTING Sixteen Trauma Centers. PATIENTS One thousand and three consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures. MAIN OUTCOME MEASURES Fracture-related infection (FRI) in open ankle fractures. RESULTS The charts of 1,003 consecutive patients were reviewed and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction and/or implant failure; FRI was associated with higher rates of these complications (p=0.01). CONCLUSION Several patient, injury and surgical factors were associated with fracture-related infection in the treatment of open ankle fractures. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement. Methods A 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question. Results Nineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement. Discussion This study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.

The objective of this study was to compare instruments from the Patient-Reported Outcomes Information System (PROMIS) with previously validated acetabulum fracture outcome instruments.This study included adult patients presenting for routine follow-up at least 3 months after surgical treatment of an acetabulum fracture. Participants completed four different patient-reported outcomes in a randomized order: PROMIS Mobility, PROMIS Physical Function, Short Form 36 (SF-36), and Short Musculoskeletal Functional Assessment (SMFA). Primary outcomes were the correlations between instruments, floor/ceiling effects, and survey completion time. The effects of age, education, and race on survey completion time were also evaluated.Overall strong correlations were observed between PROMIS instruments and the SMFA/SF-36 (r = 0.73 to 0.86, P0.05) with weaker, more moderate correlations in those with18 months of follow-up (r = 0.41 to 0.76, P0.05). No instruments demonstrated notable floor or ceiling effects. The PROMIS outcomes required less time to complete (PROMIS [56 to 59 seconds] than SF-36 [5 minutes 22 seconds] and SMFA [6 minutes 35 seconds]; P0.001). Older individuals required more time to complete the PROMIS PF (0.5 s/yr, P = 0.03), SF-36 (2.35 s/yr, P = 0.01), and SMFA (3.85 s/yr, P0.01). Level of education did not affect completion time; however, African Americans took significantly longer than Caucasians to complete the SMFA and SF-36 by 151 and 164 seconds (P0.01).This study supports that the PROMIS Mobility and Physical Function surveys are much more efficient instruments for evaluating patients with acetabulum fractures when compared with the SMFA and SF-36. Convergent validity of the PROMIS instruments was overall strong but weaker and more moderate in those with a long-term follow-up, and additional study is suggested for longer-term outcomes. Level of education did not influence survey completion time; however, it took markedly longer time for older individuals and African Americans to complete the SMFA and SF-36.

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

To evaluate mechanical treatment failure in a large patient cohort sustaining a distal femur fracture treated with a distal femoral locking plate (DFLP).This retrospective case-control series evaluated mechanical treatment failures of DFLPs.The study was conducted at 8 Level I trauma centers from 2010 to 2017.One hundred one patients sustaining OTA/AO 33-A and C distal femur fractures were treated with DFLPs that experienced mechanical failure.The intervention included the treatment of a distal femur fracture with a DFLP, affected by mechanical failure (implant failure by loosening or breakage).The main outcome measures included injury and DFLP details; modes and timing of failure were studied.One hundred forty-six nonunions were found overall (13.4%) including 101 mechanical failures (9.3%). Failures occurred in different manners, locations, and times depending on the DFLPs. For example, 33 of 101 stainless steel (SS) plates (33%) failed by bending or breaking in the working length, whereas no Ti plates failed here ( P0.05). Eleven of 12 failures with titanium-Less Invasive Stabilization System (92%) occurred by lost shaft fixation, mostly by the loosening of unicortical screws (91%). Sixteen of 44 variable -angled-LCP failures (36%) occurred at the distal plate-screw junction, whereas only 5 of 61 other DFLPs (8%) failed this way ( P0.05). Distal failures occurred on average at 23.7 weeks compared with others that occurred at 38.4 weeks ( P0.05). Variable -angled-LCP distal screw-plate junction failures occurred earlier (mean 21.4 weeks).Nonunion and mechanical failure occurred in 14% and 9% of patients, respectively, in this large series of distal femur fracture treated with a DFLP. The mode, location, presence of a prosthesis, and timing of failure varied depending on the characteristics of DFLP. This information should be used to optimize implant usage and design to prolong the period of stable fixation before potential implant failures occur in patients with a prolonged time to union.Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To determine if anterior pelvic fracture pattern in lateral compression (LC) sacral fractures correlates with subsequent displacement on examination under anesthesia (EUA) or follow-up in both nonoperative and operative cases.Retrospective cohort study.Level 1 trauma center.Two hundred twenty-seven skeletally mature patients with traumatic LC (OTA/AO 61B1.1, 61B2.1-2, and 61B3.1-2) pelvic ring injuries treated nonoperatively, with EUA, or with pelvic fixation were included.The study intervention included retrospective review of patients' charts and radiographs.Displacement on EUA or follow-up radiographs (both operative and nonoperative) correlated with anterior pelvic ring fracture pattern.Independent of sacral fracture pattern (complete or incomplete), risk of subsequent displacement on EUA or at follow-up after both nonoperative and operative treatments correlated strongly with ipsilateral superior and inferior pubic rami fractures that were either comminuted (95.6%, P0.001) or oblique (100%, P0.001). Patients with transverse or lack of inferior pubic ramus fracture did not displace (0%, P0.001). Out of 21 LC injuries treated with posterior-only fixation, displacement at follow-up occurred in all 11 patients (100%) with comminuted and/or oblique superior and inferior pubic rami fractures. Nakatani zone I and II rami fractures correlated most with risk of subsequent displacement.Unstable anterior fracture patterns are characterized as comminuted and/or oblique fractures of ipsilateral superior and inferior pubic rami. EUA should be strongly considered in these patients to disclose occult instability, for both complete and incomplete sacral fracture patterns. Additionally, these unstable anterior fracture patterns are poor candidates for posterior-only fixation and supplemental anterior fixation should be considered. Irrespective of sacral fracture pattern (complete or incomplete), nonoperative management is successful in patients with transverse or lack of inferior pubic ramus fractures.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The rising trend of obesity in the United States has been a growing concern within the healthcare system for decades. Since the early 1960s, the prevalence of obesity has more than doubled among U.S. adults, and one out of every three Americans is now considered obese according to the National Health and Nutrition Examination Survey [1,2]. Significant medical comorbidities have been associated with obesity and increased Body Mass Index (BMI); these include hypertension, dyslipidemia, coronary artery disease, stroke, sleep apnea, type II diabetes mellitus and certain types of cancer.

The diagnosis of fracture nonunion following plate osteosynthesis is subjective and frequently ambiguous. Initially following osteosynthesis, loads applied to the bone are primarily transmitted through the plate. However, as callus stiffness increases, the callus is able to bear load proportional to its stiffness while forces through the plate decrease. The purpose of this study was to use a "smart" fracture plate to distinguish between phases of fracture healing by measuring forces transmitted through the plate. A wireless force sensor and small adapter were placed on the outside of a distal femoral locking plate. The adapter converts the slight bending of the plate under axial load into a transverse force which is measurable by the sensor. An osteotomy was created and then plated in the distal femur of biomechanical Sawbones. Specimens were loaded to simulate single-leg stance first with the osteotomy defect empty (acute healing), then sequentially filled with silicone (early callus) and then polymethyl methacrylate (hard callus). There was a strong correlation between applied axial load and force measured by the "smart" plate. Data demonstrate statistically significant differences between each phase of healing with as little as 150 N of axial load applied to the femur. Forces measured in the plate were significantly different between acute (100%), early callus (66.4%), and hard callus (29.5%). This study demonstrates the potential of a "smart" fracture plate to distinguish between phases of healing. These objective data may enable early diagnosis of nonunion and enhance outcomes for patients.

OBJECTIVES Compare blood loss and transfusion rates among reamer irrigator aspirator (RIA), iliac crest bone graft (ICBG), and proximal tibial curettage (PTC) for autograft harvest. DESIGN Retrospective Comparative Study. SETTING Level 1 Trauma CenterPatients/Participants: The study included 139 adult patients treated between 2011 and 2018. INTERVENTIONS Non-union repair of the femur or tibia utilizing either RIA (n=64), ICBG (n=59), or PTC (n=16) for autograft. MAIN OUTCOME MEASUREMENTS Estimated Blood Loss and Transfusion Rates. RESULTS Patient demographics, surgical indications, and medical comorbidities that affect bleeding did not differ among the groups. Estimated blood loss (mL) was significantly higher in the RIA group (RIA: 388 ±368 [50-2000], ICBG 286 ±344 [10-2000], PTC 196mL ±219 [10-700], p

To evaluate the functional outcomes of pediatric and adolescent patients (18 year old) who sustained acetabulum fractures that were treated with open reduction internal fixation (ORIF).Retrospective cohort.Level 1 trauma center.Thirty-four pediatric and adolescent patients underwent acetabulum fracture ORIF between 2001 and 2018. Of the operatively treated patients, 21 patients had sufficient follow-up (6 months), one died after fixation secondary to other traumatic injuries, and 12 patients were lost to follow-up.Acetabulum fracture ORIF.The SF-36 Health Survey and Short Musculoskeletal Functional Assessment (SMFA) were compared with population norms. The modified Merle d'Aubigné clinical hip score, Matta radiologic outcome, and postoperative complications were also documented.Functional outcome data were available at a mean of 5 years 2 months. Mean SF-36 scores were 44.8 and 50.1 for the physical component score and mental component scores, respectively, which did not differ significantly from US population norms (physical component score mean: 50, P = 0.061 and mental component score mean: 50, P = 0.973). Furthermore, the mean SMFA Bother Index score was 18.6, which is not significantly different from the population norm mean of 13.8 (P = 0.268). However, the function index mean was 31.9, which was significantly worse than the population norm mean of 12.7 (P = 0.001). Two patients with a delayed reduction (6 hours) of an acetabulum fracture dislocation had poor outcomes related to the development of avascular necrosis and post-traumatic osteoarthritis.In this small cohort, 86% (18/21) of these patients had a favorable functional outcome with the exception of the SMFA Functional Index that was significantly less than population norms. Although long-term follow-up is needed, we advocate for operative management of pediatric and adolescent acetabulum fractures when adult displacement and instability criteria are present.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The system described by Matta for rating acetabular fracture quality of reduction following ORIF has been used extensively throughout the literature. However, the reliability of this system remains to be validated. We sought to determine the interobserver and intraobserver reliability of this system when used by fellowship-trained pelvic and acetabular surgeons to evaluate intraoperative fluoroscopy.This is a retrospective evaluation of a prospectively collected acetabular fracture database at an academic level I trauma center. The quality of reduction of all acetabular fractures treated with open reduction internal fixation (ORIF) between May 2013 and December 2015 was assessed using three standard intraoperative fluoroscopic views (anteroposterior and two 45˚ oblique Judets). Displacement of ≤1 mm was considered to be an anatomic reduction, 2-3 mm imperfect, and3 mm poor according to the system described by Matta. A total of 107 acetabular fractures treated with ORIF with complete intraoperative fluoroscopic images during that time period were available for review. Acetabular fracture reductions were reviewed by the operative surgeon at the time of surgery and subsequently reviewed by two fellowship-trained pelvic and acetabular surgeons. All reduction assessments were performed in a blinded fashion. The primary outcome measure was interobserver reliability for assessing reduction quality. This was evaluated using a weighted kappa (κInterobserver reliability based on the initial assessment was low (κLow interobserver and intraobserver reliability was found when quality of reduction was assessed with intraoperative fluoroscopic images by the operative and two other pelvic and acetabular surgeons using the Matta system. Given the importance of an anatomic reduction on functional and radiographic outcomes, an accurate and reliable system for assessing intraoperative quality of reduction is essential.

Introduction Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). Methods This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. Results Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. Conclusions PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

OBJECTIVES To determine if surgeon subspecialty training affects perioperative outcomes for displaced femoral neck fractures treated with hemiarthroplasty. DESIGN Retrospective comparative study. SETTING One health system with 2 hospitals (Level I and Level III trauma centers). PATIENT AND PARTICIPANTS Patients who were treated with hemiarthroplasty for displaced femoral neck fractures between October 2012 and September 2017. OUTCOME MEASURES Leg length discrepancy, femoral offset, estimated blood loss (EBL), incidence of blood transfusion, time to surgery, operative time, and length of stay. Data were analyzed based on the treating surgeon's subspecialty training [arthroplasty (A), trauma (T), other (O)]. Hierarchical regression was used to compare the groups and control for confounding variables. RESULTS A total of 292 patients who received hemiarthroplasty for displaced femoral neck fractures were included (A = 158; T = 73; O = 61). Surgeon subspecialty had a statistically significant effect on operative time, with arthroplasty surgeons completing the procedure 9.6 minutes faster than trauma surgeons and 17.7 minutes faster than other surgeons (P < 0.01; ΔR = 0.03). Surgeon subspecialty did not significantly affect other outcomes, including leg length discrepancy (P = 0.26), femoral offset (P = 0.37), EBL (P = 0.10), incidence of transfusion (P = 0.67), time to surgery (P = 0.10), or length of stay (P = 0.67). CONCLUSIONS This study demonstrates that arthroplasty-trained surgeons perform hemiarthroplasty slightly faster than other subspecialists, but subspecialty training does not affect other perioperative outcomes, including leg length discrepancy, femoral offset, EBL, transfusion rate, time to surgery, or length of stay. This suggests that hemiarthroplasty can be adequately performed by various subspecialists, and deferring treatment to an arthroplasty surgeon might not have a clinically significant benefit in the perioperative period. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Femoral neck fractures in the elderly are increasingly common as a result of a growing geriatric population with 1-year mortality rates approaching 35%. While preoperative medical optimization and early time to surgery have reduced morbidity and mortality, patients with numerous medical comorbidities remain high risk for death in the perioperative period. Identifying those with greatest risk with a scoring system or nomogram may assist multidisciplinary teams in reducing mortality following hemiarthroplasty. Purpose: Identify predictors of 30-day mortality in elderly patients who underwent hemiarthroplasty for a femoral neck fracture to generate a predictive nomogram to determine the probability of post-operative mortality. Methods: Retrospective evaluation using data from the ACS-NSQIP database from 2005 to 2014 with CPT code 27125 for hip hemiarthroplasty. Multiple factors including demographics and comorbidities were compared in patients who experienced 30-day mortality and those who did not. T-test and chi-square tests were used to analyze data and a multivariate model was generated using logistic regression. Results: Advanced age (odds ratio (OR) 1.04), underweight BMI (OR 1.55), male sex (OR 1.80), reduced functional status (OR 2.04), heart failure within 30 days prior to surgery (OR 2.22), American Society of Anesthesiologists grade > 2 (OR > 2.50), disseminated cancer (OR 3.43) were all found to have statistically significant odds ratios for 30-day mortality following hemiarthroplasty. Conclusion: A tool based on easily identifiable risk factors, demographics, and comorbidities was developed that can help predict elderly patients who will experience mortality within 30 days of following hemiarthroplasty. In addition to identifying high risk patients, the nomogram can serve as a counseling tool for physicians to use with patients and their families to assist with better understanding of perioperative mortality risk.

Techniques for single-provider reductions are valuable methods for provisional stabilization of fractures. In the setting of a lower extremity fracture, these techniques often use stockinette or kerlex to suspend an extremity while a reduction maneuver is performed, cast padding is applied, and a plaster splint is placed with subsequent molding to maintain reduction. Obtaining and maintaining a suitable amount of tension to the soft material while securing the limb to the stretcher or hospital bed continues to make these reduction maneuvers difficult to perform. This challenge is exacerbated in the obese patient population. As such, we describe the adaptation of the taut-line hitch knot in the setting of single-provider reductions. This knot type permits adjustable tensioning of kerlex or stockinette while suspending a limb when force is applied perpendicular to the direction of tension. This facilitates positioning and maintenance of limb suspension during reductions of unstable lower extremity injuries.

Background Examination under anesthesia (EUA) has been used to identify pelvic instability. Surgeons may utilize percutaneous methods for posterior and anterior pelvic ring stabilization. We developed an intraoperative strategy whereby posterior fixation is performed, with reassessment using sequential EUA to determine the need for anterior fixation. Our aim in the current study was to evaluate whether this strategy reliably results in union with minimal displacement. Methods This was a multicenter retrospective study involving adult patients with closed lateral compression (LC) pelvic ring injuries treated during the period of 2013 to 2016. Included were patients who underwent percutaneous pelvic fixation based on sequential EUA. Data points included patient demographics, injury and fixation details, and displacement as observed on follow-up radiographs. Results Complete documentation was available for 74 patients (mean age, 41 years). The mean duration of follow was 11 months. Fifty-three of the patients had LC-1 injuries, 19 had LC-2 injuries, and 2 had LC-3 injuries. Twenty-five (47.2%) of the 53 patients with LC-1 and 11 (57.9%) of the 19 patients with LC-2 injuries did not undergo anterior fixation on the basis of the algorithm. The 36 LC-1 or LC-2 patients who underwent combined anterior and posterior fixation had no measurable displacement at union. Of the 36 LC-1 or LC-2 patients with no anterior fixation, 27 with unilateral rami fractures had no measurable displacement at union. The remaining 9 LC-1 or LC-2 cases with no anterior fixation had bilateral superior and inferior rami fractures; each of these patients demonstrated displacement (mean, 7.5 mm; range, 5 to 12 mm) within 6 weeks of fixation that remained until union. All patients had protected weight-bearing for 12 weeks. Conclusions A fixation strategy based on sequential intraoperative EUA reliably results in union with minimal displacement for unstable LC pelvic ring injuries. Injuries requiring combined anterior and posterior fixation healed with no displacement. Those without anterior fixation and a unilateral ramus fracture healed with no displacement. In the presence of bilateral rami fractures, even with a negative finding on sequential EUA, the pelvis healed with 7.5 mm average displacement. Surgeons may consider anterior fixation to prevent this displacement. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Academic medicine hinges on high-quality results from research. Surgeon scientists spend their career acquiring grants, writing papers, and educating a next generation of scientists. The real question is how well are we at playing this game? Does our research change surgical practice or affect patient care or government policy? Ideally, published research does and will continue to shape the way care is delivered. Key questions remain, however; what is the return on research investment in orthopaedics? How can surgeons decide which "evidence" matters, and does practice-change only refer to Level I evidence (randomized trials)? This review considers all these questions.

Marginal impaction of the acetabulum is typically accessible through fracture planes specific to the nature of the injury. Infrequently, however, incarcerated marginal impaction or free osteochondral fragments are not accessible through these existing fracture planes. As such, alternative methods to access these articular pieces must be considered to ensure adequate reduction. We describe an osteotomy of the posterior wall to access incarcerated fragments and marginal impaction of the acetabulum, enabling concentric articular reduction.

To identify the negative predictive value of examination under anesthesia (EUA) for determining pelvic ring stability and union without further displacement.Retrospective cohort study.Two academic Level 1 trauma centers.Thirty-four adult patients with closed pelvic ring injuries treated over a 5-year period.Pelvic stress EUA.Pelvic ring union and pelvic ring displacement at final follow-up.Thirty-four patients with closed pelvic ring injuries who underwent pelvic EUA during the study period and had a negative examination (indicating a stable pelvis) were identified. Mean age was 38 years (range 16-76), and 19 patients (55.9%) were male. Twenty-two patients (64.7%) had Young-Burgess lateral compression (LC)-1 injuries with complete sacral fractures, 4 patients (11.8%) had LC-2 injuries, and 8 patients (23.5%) had anteroposterior compression (APC)-1 injuries. Eight patients (23.5%) had associated injuries requiring restricted weight-bearing on one or both lower extremities and were excluded from the analysis. Immediate weight-bearing as tolerated was permitted bilaterally in the remaining 26 patients. Mean pelvic ring displacement at the time of injury was 3.8 mm (range 1-15 mm) for LC injuries and 9.1 mm (range 2-20 mm) for APC injuries. Patients were followed for a mean of 8 months (range 3-34 months). At final follow-up, mean displacement was 3.7 mm (range 0-17 mm) for LC injuries and 7.1 mm (range 2-19 mm) for APC injuries. Mean change in displacement from injury to union was -0.1 mm for LC injuries and -2.0 mm for APC injuries, indicating decreased pelvic ring displacement at union. All patients were able to tolerate full weight-bearing bilaterally with no pain, and there were no instances of delayed operative fixation after negative EUA.Negative pelvic EUA after closed pelvic ring injury accurately predicts pelvic stability and union without displacement after nonoperative treatment with full weight-bearing bilaterally. Unless otherwise dictated by associated injuries, immediate weight-bearing as tolerated seems safe in patients with pelvic ring injuries who have had a negative EUA.Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives The current literature focuses on wound severity, time to debridement, and antibiotic administration with respect to risk of infection after open fracture. The purpose of this analysis was to determine if either the incidence of posttraumatic infection or causative organism varies with treating institution or the season in which the open fracture occurred. Design Retrospective review. Setting Seven level 1 regional referral trauma centers located in each of the 7 climatic regions of the continental United States (Northwest, High Plains, Midwest/Ohio Valley, New England/Mid-Atlantic, Southeast, South, and Southwest). Patients/participants Five thousand one hundred twenty-seven skeletally mature patients with open extremity fractures treated between 2008 and 2012 at one of the 7 institutions. Intervention Open reduction and internal fixation of fracture following institutional protocol for antibiotic prophylaxis, debridement, and soft-tissue management. Main outcome measurements Seasonal variation on the incidence of infection and the causative organism after treatment for open fracture as recorded by each individual treating institution. Charts were analyzed to extract information regarding date of injury, Gustilo-Anderson type of open fracture, subsequent treatment for a posttraumatic wound infection, and the causative organisms. Patients were placed into one of the 4 groups based on the time of year that the injury occurred: spring (March-May), summer (June-August), fall (September-November), and winter (December-February). Univariate/multivariate analyses and Fisher test were used to assess whether any observed differences were of statistical significance. Results The overall incidence of infection for all open fractures across the 7 different institutions was 7.6% and this did not vary significantly by season. There were, however, significant differences in overall infection rates between the different institutions: Southeast 4.3%, Northwest 13%, Northeast 7.7%, Southwest 9.3%, Midwest/Ohio Valley 5.5%, High Plains 14.6%, and South 7.4%. The following institutions demonstrated a significant seasonal variation in the incidence of infection: Northwest = fall 11% versus winter 18.5%, Southwest = winter 1.5% and fall 17.3%, Northeast = winter 5.2% and spring 9.7%, and Southeast = fall 2.8% and spring 6.0%. The High Plains, Midwest/Ohio Valley, and Southern institutions did not demonstrate a significant seasonal variation in infection rates. Finally, the most commonly encountered causative organism varied not only by region, but by season as well. Staphylococcus aureus (both methicillin sensitive and resistant) continues to be the most prevalent organism in the continental United States. Conclusions A substantial seasonal and institutional variation exists regarding the incidence of infection and causative organisms for posttraumatic wound infection after open fractures. Although this may represent a difference in treatment regimens between individual surgeons and institutions, a decades-old general nation-wide empiric antibiotic prophylaxis regimen for all open fractures may in fact be outdated and suboptimal. We recommend that surgeons consult with their infectious disease colleagues to better understand the seasonal variation of infection and causative organism for their individual hospital, and adjust their prophylactic and treatment regimens accordingly. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To determine whether surgical intervention within 48 hours of injury results in decreased mortality in geriatric patients who have sustained acetabular fractures. DESIGN Retrospective case series. SETTING University Level 1 Trauma Center. PATIENTS/PARTICIPANTS One hundred eighty-three patients 65 years of age and older who were operatively treated for acetabular fractures between 2002 and 2017. The average age was 76 years. INTERVENTION Operative fixation of acetabular fracture. MAIN OUTCOME MEASUREMENTS Chi square tests were used to compare 30-day, 6-month, and 1-year mortality after operative intervention between patients treated within 48 hours and after 48 hours. A Cox proportional hazard model was used to determine predictors of mortality. RESULTS The overall 1-year morality was 15%. When patients were grouped by time to surgery (fracture fixation within 48 hours or after 48 hours), there were no statistically significant differences in 30-day, 6-month, or 1-year mortality between groups. In addition, there were no statistically significant differences in age, sex, mechanism of injury, fracture pattern, Charlson comorbidity index, length of hospital stay, presence of deep vein thrombosis, or quality of reduction. In the final multivariate Cox regression model of survival, increasing age was associated with a significantly increased hazard of death with a hazard ratio (HR) of 1.09 (95% confidence interval, 1.05-1.13) per year of age (P < 0.001). Patient sex, mechanism of injury, fracture pattern, estimated blood loss, and Charlson comorbidity index were not significant predictors of mortality. CONCLUSION In contrast to the clear mortality benefits of early surgical intervention in geriatric patients with proximal femur fractures, the results of our study suggest that surgical intervention after 48 hours of injury is not associated with increased mortality rates in geriatric patients with acetabular fractures. Increased mortality was independently associated with advancing age. Sex, mechanism of injury, and facture pattern were not associated with mortality. Time to surgery in geriatric patients with acetabular fractures should be determined on an individual basis. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Geriatric acetabular fractures tend to occur more frequently in elderly population as a result of low-energy mechanisms than are observed in younger patients, due to an increasing incidence of osteopenia and osteoporosis within this population. In the senior population, acetabular fractures tend to be associated with anterior column disruption, quadrilateral plate involvement, and dome impaction. Superomedial impaction or dome impaction occurs as a result of medialization of the femoral head into the acetabulum and has been associated with poor outcomes in elderly patients. Fractures of the quadrilateral plate result from similar mechanisms and are relatively common among elderly patients who sustain fractures involving the anterior column or wall. This chapter focuses on the operative management of two technically challenging fracture components that occur more frequently in geriatric acetabular fractures: dome impaction and quadrilateral plate comminution.

There is a significant burden of disease associated with infected fractures, and their management is challenging. Prevention of infection after musculoskeletal trauma is essential because treatment of an established infection continues to be a major obstacle. Despite the need for evidence-based decision making, there is a lack of consensus around strategies for prevention and surgical management of the infected fracture. The current evidence for the prevention of the infected fracture is reviewed here with a focus on evidence for antibiotic therapy and debridement, the induced membrane technique, management of soft-tissue defects, patient optimization, and adjuncts to prevent infection.

(1) Identify factors that predict blocking screw placement in the treatment of a distal femur fracture with retrograde nail fixation and (2) determine whether acceptable alignment and stability were achieved in fractures that received blocking screws.Retrospective Comparative Study.Level I Trauma Center.Between 2011 and 2017, we identified 84 patients with distal third femur fractures treated with a retrograde femoral nail. Data were analyzed according to those who did (BLOCK, n = 30) and did not (NO BLOCK, n = 54) receive blocking screws. Patients in both groups were treated by orthopaedic trauma surgeons; postoperative weight-bearing radiographs were obtained of every patient.Fixation using a retrograde femoral nail with or without blocking screws. Blocking screws were placed at the discretion of the treating surgeon to reduce malaligned fractures or improve stability.(1) Demographics, radiographic apparent bone gap (RABG), space available for the nail (SAFN), and distal segment length [as a ratio of bicondylar width (BCW)]; and (2) post-operative alignment and stability (change in alignment over time).Patients treated with blocking screws had a higher body mass index (BMI) (BLOCK: 29.0, NO BLOCK 25.7, P = 0.03). In addition, the BLOCK group had larger RABGs (BLOCK: 8.2 mm, NO BLOCK: 3.6 mm, P = 0.02), more SAFN (BLOCK: 51.4 mm, NO BLOCK: 39.8 mm, P = 0.02), and shorter distal segments (BLOCK: 1.7 × BCW, NO BLOCK: 2.0 × BCW, P = 0.01). In a multivariable logistic regression, the combination of these factors was significantly predictive of blocking screw placement with a large effect size (R = 0.36, P0.01). A distal segment length ≤ ×2 BCW was 77% sensitive for blocking screw placement, and a BMI ≥25 kg/m was 70% sensitive. Negative predictive values for blocking screw placement were distal segment length×2 BCW (79%), BMI25 kg/m (77%), RABG4 mm (76%), and SAFN50 mm (71%). Patients that received blocking screws had acceptable postoperative alignment and stability, similar to fractures that did not receive blocking screws (P0.05).This retrospective study of distal femur fractures treated with retrograde nails identified several factors that can be used to predict when blocking screw placement may be useful for increasing stability and maintaining alignment in distal third femur fractures treated with retrograde IM nails. Patients treated with blocking screws had a higher BMI, greater cortical bone loss, more SAFN, and shorter distal segments. There was no difference in postoperative alignment or stability between the 2 groups.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Multiple factors impact fracture healing; thus, endocrine optimization and nutritional optimization warrant investigation in the acute fracture and nonunion patient. This article presents current evidence regarding the role of the endocrinologists and the dietician in the fracture patient as well as the most recent data assessing the vitamin D axis in these populations. Similarly, the most recent information regarding the use and risks of NSAIDs in fracture healing are presented. The fracture surgeon must consider each individual patient and weigh the benefits versus the costs of host optimization.

We hypothesize that earlier operative intervention for acetabular fractures improves the probability of achieving an anatomic reduction.Retrospective review.Academic level I trauma center.Six hundred fifty acetabular fractures treated through open reduction and internal fixation (ORIF) between September 2001 and February 2014.Acetabular fracture ORIF.Reduction quality was assessed through postoperative radiographs. Displacement of ≤1 mm was considered an anatomic reduction, 2-3 mm imperfect, and3 mm poor.Anatomic reductions were observed in 85% (n = 553) of cases, imperfect reductions in 11% (n = 74) of cases, and poor reductions in 4% (n = 23) of cases. Patients with anatomic reductions had significantly shorter times from injury to ORIF [odds ratio (OR) interval] (median, 3 d) when compared with either imperfect (median, 4.5 days, P = 0.02) or poor reductions (median, 7 days, P0.001) reductions. The OR interval of imperfect reductions was also significantly shorter than that of poor reductions (P = 0.02). Logistic regression analysis demonstrated that OR interval had an effect of -0.12, meaning that the log odds of anatomic reduction decreases by 0.12 with each day from injury to ORIF.The interval from injury to operative fixation of acetabular fractures affects reduction quality. Earlier intervention improves the probability of achieving an anatomic reduction; therefore, ORIF should be performed as early as possible, provided the patient is optimized for surgery.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: To determine the relationship between injury severity surrogates and other patient factors with the development and severity of heterotopic ossification (HO) following ORIF of acetabular fractures treated with a posterior approach. DESIGN: Retrospective review SETTING:: Academic level 1 trauma center. PATIENTS/PARTICIPANTS: 241 patients who were treated through a posterior approach with a minimum of 6 month radiographic follow up were identified from an acetabular fracture database. INTERVENTION: None MAIN OUTCOME MEASUREMENTS:: The occurrence and severity (Brooker Grade III / IV) of heterotopic ossification (HO) six months post surgery. RESULTS: Length of stay (LOS) in the Intensive Care Unit (ICU), non-ICU LOS >10 days and HO prophylaxis with external radiation beam therapy (XRT) were significantly associated with the development of HO in a multivariate model [ICU LOS: 1-2 days OR = 4.33, 95% CI: 1.03-18.25; 3-6 days OR=4.1, 95% CI: 1.27-13.27; >6 days OR=11.7, 95% CI 3.24-42.22_; Non-ICU LOS >10 day (vs 0-6 days): OR = 7.6, 95% CI: 2.6-22.25; XRT HO prophylaxis: OR = 0.29, 95% CI: 0.10-0.85]. Other variables evaluated in multivariate modeling not significantly associated with development and severity of HO included age, gender, mechanism of injury, injury severity score (ISS), presence of neurologic injury, Letournel fracture type, occurrence of hip dislocation, interval from injury to surgery, operative time and estimated blood loss. CONCLUSIONS: Surrogates of injury severity including days in the ICU and non-ICU hospital LOS >10 days were associated with the development of HO in our cohort of acetabular fracture patients. Prophylaxis with XRT was significantly protective against the development of HO, and the ability to provide prophylaxis is very likely related to the severity of injury. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. Language: en

Several approaches to the pelvis and acetabulum involve subperiosteal dissection of the iliacus from the internal iliac fossa.Typically bleeding is encountered from the nutrient foramen located near the sacroiliac joint. Bone wax and electrocautery have traditionally been used to achieve hemostasis from this foramen but produce inconsistent results.The authors of this technical tip describe a novel technique of inserting a cortical screw directly into the foramen tocontrol osseous hemorrhage.This technique has been consistently effective at achieving hemostasis in cases of refractory bleeding and has produced no complications. (Journal of Surgical Orthopaedic Advances 27(3):246-250, 2018).

Pelvic fractures are common after high-energy trauma and are often associated with ligamentous injury. Treatment is guided by assessing stability of the pelvic ring, and unstable injuries frequently require surgery to achieve a desirable outcome. Assessment of pelvic ring stability is often possible with physical examination and standard imaging studies (plain radiographs and computed tomography); however, these "static" imaging modalities may not adequately identify dynamically unstable pelvic injuries that require surgery. Cadaveric and clinical data suggest that the injured pelvis may recoil significantly from the point of maximal displacement, and some unstable injuries may not be recognized until patients present with clinical symptoms. This article presents the case of a patient who sustained a minimally displaced pelvic ring injury that was stable on bedside examination and static imaging, but ultimately was unstable. She developed a substantial pelvic malunion with significant pain and activity limitations. The patient subsequently underwent successful pelvic ring reconstruction, and she remains asymptomatic at 2 years.

The purpose of this study is to characterize the distal anatomic end-point of a tibial intramedullary nail placed using modern surgical techniques. The goal is to improve reduction of distal tibia fractures.An intramedullary nail was placed in 14 skeletally mature legs. This included 8 patients with mid-shaft tibial fractures and 6 intact cadaveric legs. Each nail was a titanium cannulated tibial nail, size 10- or 11-mm. The nails were placed using a suprapatellar or transpatellar approach with an ideal starting point. All legs received post-nail insertion CT scans and fluoroscopy. The main outcome measure was the terminal location of the nail just proximal to the distal tibial physeal scar, as seen on axial CT and fluoroscopic views of the ankle (mortise and lateral). The end-point was measured as the (1) ratio of medial-lateral tibial width (ML ratio) and (2) ratio of anterior-posterior tibial width (AP ratio). Two-tailed Welch's t tests were used to compare the actual, observed position of the nail to the hypothesized center-center position (HAll enrolled patients (n = 8) and cadaveric legs were included (n = 6). On axial CT, the average distance from the medial tibial cortex to the nail center as a ratio of medial-lateral tibial width was 0.63, 95% CI 0.60-0.67, p 0.001 (Patient = 0.60, 95% CI 0.55-0.64, p = 0.001) (Cadaver = 0.68, 95% CI 0.64-0.73, p 0.001). On fluoroscopic mortise views, the distance from the medial cortex to the nail center as ratio of medial-lateral tibial width was 0.64, 95% CI 0.60-0.67, p 0.001 (Patient = 0.61, 95% CI 0.56-0.65, p 0.001) (Cadaver = 0.67, 95% CI 0.63-0.72, p 0.001). The AP ratio was not significantly different from 0.5 on either axial CT or fluoroscopic mortise views (p 0.05).The distal end-point of a tibial intramedullary nail is lateral (ML plane) and center (AP plane) in both cadaveric legs and patients with midshaft tibia fractures. These results suggest that the treatment of distal tibia fractures with intramedullary nails may be improved by positioning the nail slightly lateral in the distal segment.Diagnostic level I.

Advancements in surgical technique have resulted in the ability to reconstruct lower extremity injuries that would have previously been treated by amputation. Currently, a paucity of data is available specifically addressing limb amputation versus reconstruction for calcaneal fractures with severe soft tissue compromise. Reconstruction leaves the patient with their native limb; however, multiple surgeries, infections, chronic pain, and a poor functional outcome are very real possibilities. We present the case of a complex calcaneal fracture complicated by soft tissue injury and osteomyelitis that highlights the importance of shared decision-making between patient and surgeon when considering reconstruction versus amputation. This case exemplifies the need for open communication concerning the risks and benefits of treatment modalities while simultaneously considering the patient's expectations and desired outcomes.

OBJECTIVES The purpose of this study was to evaluate the efficacy of routine postoperative computed tomography (CT) scan after open reduction and internal fixation of acetabular fractures. DESIGN Retrospective review of prospectively collected acetabulum fracture database. SETTING Level I trauma center. PATIENTS/PARTICIPANTS A total of 606 consecutive patients underwent surgical fixation of 612 acetabular fractures. All patients were evaluated with intraoperative fluoroscopy in addition to 3 standard plain radiographs (AP pelvis and two 45 degrees oblique Judet views). Reduction and fixation were believed to be adequate and definitive before exiting the operative suite based on these imaging modalities. INTERVENTION Axial postoperative CT scan of the pelvis was obtained in 563 of the patients (93%) after 569 operative cases. MAIN OUTCOME MEASUREMENTS Revision acetabular surgery based on routine postoperative CT scan findings. RESULTS There were no significant differences between index and revision surgery groups regarding age, gender, body mass index, fracture pattern, mechanism of injury, or surgical approach (P > 0.05). Evaluation of 563 postoperative CT scans of the pelvis resulted in revision acetabular surgery for 2.5% of patients (n = 14). There were 6 (1.1%) cases of intraarticular hardware not recognized on the intraoperative fluoroscopy or pelvic radiographs. Four patients (0.7%) had residual intraarticular osteochondral fragments deemed too large to leave in the hip joint. There were 3 cases (0.5%) of unacceptable malreduction, and 1 case (0.2%) of both malreduction and an intraarticular osteochondral fragment. CONCLUSIONS A small percentage of patients (2.5%) will benefit from a routine CT scan after acetabular fracture fixation. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The ilioinguinal and anterior intrapelvic approaches to the acetabulum often involve different strategies for the treatment of acetabular fractures. The ilioinguinal approach allows access to the entire internal iliac fossa and pelvic brim, including indirect access to the quadrilateral surface. In contrast, the anterior intrapelvic approach allows access to the anterior elements from inside the pelvis with the surgeon standing opposite the fracture pathology. Therefore, the goal of this article is to clarify the advantages and disadvantages for each approach with respect to exposure, reduction, and fixation.

Ischial tuberosity avulsion fractures are infrequent injuries that primarily affect adolescent athletes1-8. Ischial avulsions can be easily mistaken for hamstring injuries and therefore missed on initial presentation1,6. Whereas some of these fractures heal spontaneously, they often can progress to painful nonunion1,2,9,10. Painful nonunion of an ischial avulsion fracture is generally treated operatively with open reduction and internal fixation. To our knowledge, three years is the longest time span reported in the literature between ischial tuberosity avulsion fracture injury and nonunion repair1,2,8,9,11,12. We present a case of a chronic ischial tuberosity avulsion fracture nonunion with a ten-year delay between the initial injury and definitive surgical management via fragment excision and primary hamstring repair. This case report presents a viable option for repair of chronic, painful ischial tuberosity avulsion nonunion. Furthermore, it demonstrates that patients can benefit from this procedure, even after an extensive interval from the index injury. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A twenty-seven-year-old professional skater presented with chronic pain in the right buttock. She reported that the pain had intensified after reinjuring the buttock during a roller derby scrimmage three weeks prior to presentation. Pertinent past medical history included an ischial avulsion fracture diagnosed ten years prior at an outside institution, which had been treated conservatively. Of note, she had experienced chronic pain in the ischial region throughout her adult life. On physical examination, she had tenderness posteriorly and medially over the ischium. She had pain with resisted leg extension and resisted knee flexion, and decreased range of motion at the hip. There was no tenderness in the …

Trimalleolar fractures are a common ankle fracture variant that has sparked controversy over whether or not to fix the posterior malleolus of these fractures. Recent literature has begun to support fixation of the posterior malleolus fragment to restore the contact force of the joint, as well as decrease the risk of posttraumatic osteoarthritis by increasing joint stability. This chapter focuses on fixation of the posterior malleolus using percutaneous screws.

Superomedial impaction of the anterior dome of the acetabulum is a known risk factor for poor outcomes after open reduction and internal fixation of acetabular fractures. The authors, using the anterior intrapelvic (modified Stoppa) approach to the acetabulum, describe a novel technique to help reduce and stabilize marginal impaction of the acetabular dome. In the senior author's experience, this technique has been helpful to achieve adequate reduction and stabilization.

BACKGROUND On January 12, 2010, a catastrophic 7.0 magnitude earthquake shook the Haitian capital of Port-au-Prince. Because of their sudden and destructive nature, earthquakes can result in unfamiliar mass casualty situations accompanied by devastating orthopedic injuries. Evaluation of the pelvic fractures resulting from this earthquake revealed several factors that we hope will facilitate optimal preparation and planning for future disaster situations. METHODS A cohort of patients with earthquake-related pelvic ring fractures who were treated aboard the USNS Comfort was retrospectively analyzed. Anteroposterior radiographs of the pelvis were evaluated and categorized according to the Young-Burgess classification system. RESULTS Sixty-eight patients were included in the cohort. The mean (SD) age was 29.6 (14.4) years. Nineteen patients (29.7%) were male, and 49 (70.3%) were female. Pelvic fractures were categorized as anteroposterior compression in 7 patients, lateral compression (LC) in 47 patients, vertical shear (VS) in 8 patients, and combination of pelvic ring/acetabulum in 6 patients. Among the 23 patients treated operatively, the mean (SD) delay from injury to surgery was 19.2 (7.4) days. CONCLUSION Patients showed predominance toward LC injuries (69.1%), consistent with crush under rubble. Thirty-one percent of the fractures were considered unstable (anteroposterior compression Type III, LC Type III, VS, and combination of pelvic ring/acetabulum). The VS injuries observed (11.8%) may be the result of a previously unidentified injury mechanism, an upright individual being struck by falling rubble, violently applying a downward force to the body over an extended lower extremity. A substantial delay in the treatment observed in this series may lead to an underestimation of both quantity and severity of pelvic fractures as critically ill patients may have perished before evaluation and treatment. In addition, the application of pelvic sheeting techniques may be a lifesaving intervention for interval pelvic stabilization following earthquakes in which medical resources are scarce. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level V.

Objectives To determine the rate of iatrogenic radial nerve palsy (RNP) after surgical repair of established humeral shaft nonunion (HSNU). Design Retrospective chart review. Setting Level I trauma center. Patients/participants Fifty-four patients with HSNU, 10 (18.5%) of whom developed an iatrogenic RNP after nonunion repair. Intervention HSNU repair with compression plate stabilization with or without autogenous bone graft. Main outcome measurements Postoperative iatrogenic RNP. Results Ten (18.5%) patients developed iatrogenic radial nerve palsies: 8 experienced complete resolution (mean, 2.5 months) and 2 experienced partial resolution. There were no statistically significant differences between patients who developed nerve palsy and those who did not in regard to age, gender, tobacco use, diabetic status, previous RNP, initial management (operative vs. nonoperative), surgical approach, presence of infected nonunion, number of previous surgeries, or operative time (P > 0.05). Conclusions The occurrence of iatrogenic RNP for patients undergoing surgical repair of an HSNU was 18.5%. According to historical data, this rate is nearly 3 times higher than for those undergoing open reduction and internal fixation of either acute humeral shaft fractures or HSNUs. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of Levels of Evidence.