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Background: The study is intended to show that the operative quality of a resident in orthopedic trauma surgery is comparable to that of a senior physician in the most common orthopaedic trauma surgeries (Plate osteosynthesis in ankle fractures and distal radius fractures, ESIN in pediatric forearm fractures, implantation of a proximal femoral nail in pertrochanteric femur fractures and hemiarthroplasty in femoral neck fractures) with appropriate supervision by a senior physician. With only minimal deviations in the operating time, which is becoming increasingly relevant in everyday clinical practice, surgical training of residents could be supported., Material and Methods: 200 patients of the above-mentioned fracture patterns each, who were treated surgically between January 1, 2016 and December 31, 2020, were detected and categorized. In particular, a qualitative characteristic was determined for each fracture on the basis of the standard pre and postoperative X-rays taken during surgery and statistically evaluated with the surgery time, the fracture classification and the training status of the anonymized surgeon. Anonymized x-rays were evaluated by 2 senior physicians and 2 residents., Results: Operations were performed by residents in 33.5 % of the cases (ankle fractures 42.0%; distal radius fractures 30.5%; pediatric forearm fractures 30.5%; pertrochanteric femur fractures 50.5%; femoral neck fractures 14.0%). Surgical complication rate was 4.8% in the resident group and 9.0% in the attending surgeon group. Revision surgeries were performed in 2.1% of resident cases, and in 4.1% of attending surgeon cases. In the resident group, time of surgery was 7.4 min longer for ankle fractures, 4.4 min for distal radius fractures, 2.8 min for forearm fractures, 2.3 min longer in proximal femur fractures 8.2 min longer for femoral neck fractures. No statistically significant difference in radiological outcome was observed in any of the groups after evaluation of the x-rays., Conclusion: This study shows that only slightly more than one third of all mentioned operations are performed by residents, although there is no statistical difference in quality. The operating time is extended on average by only 5 minutes. The surgical complication rate as well as the revision rate is higher in the group of senior physicians, whereby the more complicated fractures were treated by them. Resident involvement in trauma surgery is therefore not associated with increased morbidity or mortality of patients., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Hip fractures are still associated with high morbidity and mortality. Despite international guidelines advocating for urgent surgical treatment, delays often occur, particularly for patients on long-term antithrombotic therapy. We hypothesised that urgent surgical care for the anticoagulated hip fracture patient is not associated with severe bleeding complications., Material and Methods: For the period from 2015 to 2021, we retrospectively reviewed clinical records of 1142 patients with proximal femur fractures treated within 24 h of admission to our trauma centre (mean age 80.4 ± 12.4 years; 761 females, 381 males). The cohort comprised 409 femoral neck and 733 trochanteric fractures, managed with either arthroplasty (n = 297), hip-preserving techniques (n = 147), or intramedullary nailing (n = 698). Of these, 583 patients (51.1 %) were on long-term antithrombotic therapy. The primary endpoints included transfusion rate and the difference in haemoglobin (Hb) levels from pre- to postoperative. Secondary endpoints were in-patient mortality and occurrence of postoperative haematomas requiring surgical revision. A regression analysis was performed., Results: The mean time to surgery was 10.3 h, with delays observed in patients on direct oral anticoagulants (DOACs). Overall, 25.9 % (n = 296) of the patients required blood transfusions. The transfusion rate was dependent on duration of the surgery, preoperative Hb level, and anticoagulation with DOACs. Similarly, the Hb difference was found to be dependent on the duration of surgery, preoperative Hb level, and anticoagulation with DOACs. In-patient mortality was 5.3 % (n = 60). Regression analysis indicated that mortality was dependent on a high ASA classification of 4 and the time to surgery, but not on the type of antithrombotic therapy. 3.1 % of the patients needed surgical revision due to postoperative haematoma with prolonged duration of surgery and antithrombotic therapy (PAI [OR = 3.7, 95 % CI: 1.1-12.7], DOACs [OR = 3.4, 95 % CI: 1.3-8.8], and VKA [OR = 5.5, 95 % CI: 1.8-17.1], p < 0.05) as independent risk factors., Conclusion: As postoperative haematoma and the need for transfusion are manageable situations, we conclude that immediate surgical treatment of hip fracture patients on long-term antithrombotic therapy within 24 h is feasible and patients may benefit., Competing Interests: Declaration of competing interest The authors declare no conflict of interest. No company influenced data collection or contributed to study conception, design, analysis, or writing. No additional funding was received., (Copyright © 2024. Published by Elsevier Ltd.)

Purpose: The surgical treatment of acute traumatic AC joint dislocations is still a subject of scientific debate in the literature. The arthroscopically assisted stabilization procedure with a suture button system has been successfully established and is widely used in daily practice. It is minimally invasive and allows the anatomical reconstruction of the torn coracoclavicular ligaments in one step with a permanent implant that does not have to be removed in a second operation. This clinical pilot study is the first to describe the new method of navigated suture button implantation with the future aim of further reducing surgical invasiveness and further increasing surgical precision., Materials and Methods: 10 patients with a Rockwood 3b/5 injury could be included in the prospective study (DRKS00031855) within 5 months according to inclusion and exclusion criteria. Surgical stabilization was performed with a suture button system via a navigated coracoclavicular drill tunnel. Demographic and radiological data as well as information on health and shoulder function were collected from patient records, X-rays, DVT scan and 3 questionnaires (DASH, NHS and Eq. 5D) at the preoperative, intraoperative and postoperative (discharge, 6 weeks and 3 months) time points., Results: All operations could be performed within 8.8 days (± 6.81) after trauma. The average operation time was 50.3 min (± 8.81). The mean distance of the drill hole in the clavicle to the AC joint was 26.6 mm (± 2.63). The radiologically measured vertical coracoclavicular distance was 38.8 mm (± 6.16) at discharge and 41.11 mm (± 7.51) at 3 months. This loss of reduction was not statistically significant. In contrast, the DASH, NHS and Eq. 5D results showed significant improvement from discharge to 3 months postoperatively., Conclusion: Image-guided 3D C-arm navigated AC joint suture button stabilization is feasible in everyday surgical practice. It may be possible to achieve a further reduction in invasiveness while at the same time increasing the accuracy of implant positioning. Further clinical studies with a larger number of patients and a longer follow-up period are necessary to enable a comparison with conventional methods., (© 2024. The Author(s).)

The current demographic development is leading to an increasing number of cases of osteoporosis-related fractures. Affected individuals are typically part of a vulnerable, predominantly geriatric patient group with limited physical resources. Additionally, the pathophysiological characteristics of osteoporotic bones with reduced bone quality and quantity, pose a significant challenge to the osteosynthesis techniques used. Achieving rapid postoperative mobilization and stable weight-bearing osteosynthesis to prevent postoperative medical complications are the main goals of the surgical management. In recent years augmentation techniques have gained in importance in the treatment of osteoporosis-related fractures by significantly enhancing the stability of osteosyntheses and reducing mechanical complication rates. The main options available are polymethyl methacrylate (PMMA) augmentation and various bioresorbable bone substitute materials with different properties. Implant augmentations can be applied at various locations in the extremity bones and standardized procedures are now available, such as for the proximal humerus and femur. When used correctly, low complication rates and promising clinical outcomes are observed. This article aims to provide an overview of available techniques and applications based on the current literature. Guidelines and substantial scientific evidence are still limited., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Introduction: Surgical treatment options for acromioclavicular joint separations are varied. Frequently, suspension devices (SD) are inserted for stabilization under arthroscopic view. This study investigates the feasibility and accuracy of three-dimensional (3D) digital-volume-tomography (DVT) C-arm navigated implantation with regard to the general trend toward increasingly minimally invasive procedures., Materials and Methods: The implantation of a TightRope ® suture button system (SD) via a navigated vertical drill channel through the clavicle and coracoid was investigated in 10 synthetic shoulder models with a mobile isocentric C-arm image intensifier setup in the usual parasagittal position. Thereby, in addition the placement of an additive horizontal suture cerclage via a navigated drill channel through the acromion was assessed., Results: All vertical drill channels in the Coracoclavicular (CC) direction could be placed in a line centrally through the clavicle and the coracoid base. The horizontal drill channels in the Acromioclavicular (AC) direction ran strictly in the acromion, without affecting the AC joint or lateral clavicle. All SD could be well inserted and anchored. After tensioning and knotting of the system, the application of the horizontal AC cerclage was easily possible. The image quality was good and all relevant structures could be assessed well., Conclusion: Intraoperative 3D DVT imaging of the shoulder joint using a mobile isocentric C-arm in the usual parasagittal position to the patient is possible. Likewise, DVT navigated SD implantation at the AC joint in CC and AC direction on a synthetic shoulder model. By combining both methods, the application in vivo could be possible. Further clinical studies on feasibility and comparison with established methods should be performed., (© 2023. The Author(s).)

Introduction: Fragility fractures (FF) are associated with increased morbidity and mortality and reflect a dramatic turning point in the life of older adults. The scientific discourse is dominated by proximal femoral fractures, but FF affect multiple parts of the body and often precede hip fractures. Orthogeriatric co-management has multiple shown to improve patient's outcome. We hypothesize that all geriatric patients with FF benefit from orthogeriatric co-management., Materials and Methods: We retrospectively evaluated all patients over 70 years with FF (hip joint, periprosthetic, spine, pelvic ring, and humerus) of our geriatric trauma center for the years 2019-2021, who received orthogeriatric co-management. Demographic data, fracture type, complications, discharge modality and in-hospital mortality were recorded. For patients transferred to geriatrics, the Barthel Index (BI) and the discharge modality were recorded. Primary outcome parameters were discharge modality and BI difference. Secondary outcome parameters were complication rates and in-hospital mortality. Logistic regression analysis was performed., Results: 555 patients (83.8 ± 6.5 years, 182 males, 373 females) were evaluated. 245 (44.1%) patients were referred to geriatrics for further orthogeriatric treatment. Positive predictors were age, surgery, and a high Charlson Comorbidity Index. The overall in-hospital mortality was 8.6% (n = 48) (5.8% (n = 32) during acute trauma care and 6.5% (n = 16) during stay in geriatrics). The mortality rate of nursing home residents was significantly higher compared to patients living at home (10.4% vs. 5.6%). The rate of non-surgical complications was 44.5%. 26.9% of patients living at home were discharged to a nursing home, while 51.3% were able to return home. The risk of admission to a nursing home was reduced for thoracolumbar fractures (OR = 0.22) and increased markedly for periprosthetic fractures (OR = 3.95). During orthogeriatric treatment, all fractures showed a significant increase in BI. Patients living at home benefited more than nursing home residents (20.5 ± 19.5 vs. 8.7 ± 18.0 points). The chance of a BI increase (> 19 points) was increased for hip and pelvic ring fractures. Devastating results showed patients with dementia. In comparison, mentally healthy patients had a 4.5-fold increased chance of increasing their BI (> 19 points)., Conclusions: Presented data shows that all patients with FF are at high risk for complications and could benefit from standardized orthogeriatric management. Modern patient care requires a holistic orthogeriatric approach to improve patient's outcome., (© 2023. The Author(s).)

Mental traumatization is associated with long-bone growth retardation, osteoporosis and increased fracture risk. We revealed earlier that mental trauma disturbs cartilage-to-bone transition during bone growth and repair in mice. Trauma increased tyrosine hydroxylase-expressing neutrophils in bone marrow and fracture callus. Here we show that tyrosine hydroxylase expression in the fracture hematoma of patients correlates positively with acknowledged stress, depression, and pain scores as well as individual ratings of healing-impairment and pain-perception post-fracture. Moreover, mice lacking tyrosine hydroxylase in myeloid cells are protected from chronic psychosocial stress-induced disturbance of bone growth and healing. Chondrocyte-specific β2-adrenoceptor-deficient mice are also protected from stress-induced bone growth retardation. In summary, our preclinical data identify locally secreted catecholamines in concert with β2-adrenoceptor signalling in chondrocytes as mediators of negative stress effects on bone growth and repair. Given our clinical data, these mechanistic insights seem to be of strong translational relevance., (© 2023. The Author(s).)

Background: Hip fractures in the elderly population are common and the number of patients is rising. For young and geriatric patients with undisplaced fractures osteosynthesis is the primary type of treatment. The dynamic hip screw (DHS) is around for many years and proved its value especially in displaced fractures. Since 2018 the femoral neck system (FNS) is available as an alternative showing promising biomechanical results. The aim of this study is to evaluate clinical results of the FNS and compare it to the DHS., Materials and Methods: Patients older than 18 years with Garden I-IV fractures that were treated with osteosynthesis in a level 1 trauma center were included in the study. Between January 2015 and March 2021, all patients treated with FNS (1-hole plate, DePuy-Synthes, Zuchwil, Switzerland) or DHS (2-hole plate, DePuy-Synthes, Zuchwil, Switzerland) for proximal femur fractures were included in the study. Closed reduction was achieved using a traction table. All operations were carried out by experienced orthopedic trauma surgeons. Primary outcome measures were rate of implant failure (cut out) and surgical complications (hematoma, infection). Secondary outcome measures were Hb-difference, length of hospital stay and mortality., Results: Overall, 221 patients were included in the study. 113 were treated with FNS, 108 with DHS. Mean age was 69 ± 14 years. There were 17.2% Garden I, 47.5% Garden II, 26.7% Garden III and 8.6% Garden IV fractures. No difference between the groups for age, body mass index (BMI), Charlson comorbidity index (CCI), time to surgery, Pauwels and Garden classification, rate of optimal blade position or tip apex distance was found. FNS showed lower pre- to postoperative Hb-difference (1.4 ± 1.1 g/l vs. 2.1 ± 1.4 g/l; p < 0.05), shorter operating time (36.3 ± 11.6 min vs. 54.7 ± 17.4 min; p < 0.05) and hospital stay (8.8 ± 4.3 d vs. 11.2 ± 6.8 d; p < 0.05). Surgical complications (FNS 13.3% vs. DHS 18.4%, p > 0.05), rate of cut out (FNS 12.4% vs. DHS 10.2%, p > 0.05) and mortality (FNS 3.5%; DHS 0.9%; p > 0.05) showed no difference between the groups. Logistic regression showed that poor blade position was the only significant predictor for cut out and increased the risk by factor 7. Implant related infection (n = 3) and hematoma/seroma (n = 6) that needed revision was only seen in DHS group., Conclusion: FNS proved to be as reliable as DHS in all patients with hip fractures. Not the type of implant but blade positioning is still key to prevent implant failure. Still due to minimal invasive approach implant related infections and postoperative hematomas might have been prevented using the FNS., (© 2022. The Author(s).)

Background In the modern Western world, activities and the daily routine of children have changed over time. Detailed analyses of the mechanisms of injuries and current fracture patterns in children are rare. The aim of the study was to elicit and investigate the most dangerous leisure and sporting activities leading to fractures in children today. Materials and methods This is a retrospective study focusing on children that were treated in a level-one trauma center in Germany between 2015 and 2020. All children who were 14 years of age or younger and suffered a traumatic injury treated in our emergency department were included in this study. From the database, mechanisms of injury, type of injury, age, and gender were analyzed. Results The study included 12508 patients, including 7302 males and 5206 females. Among the 10 most common mechanisms of injury were collisions (8.6%), falls (7.7%), injuries while playing (6.1%) or while running or walking (5.9%), soccer (5.9%), bicycle accidents (3.8%), and trampoline falls (3.4%). Road traffic accidents involving passengers or pedestrians caused 3.3% of the injuries but were the most common cause of death. The most common mechanisms of injury causing a fracture were falls, playing soccer, and bicycle accidents. Sorting the mechanisms of injury by the percentage that caused a fracture, the most dangerous activities were falling from heights above 2 meters, skiing and snowboarding, climbing and bouldering, skateboarding, and horseback riding. In the five-year study period, four out of six children died due to road traffic accidents. Conclusion Injured children must be provided with the best quality of care 24/7 in orthopedic trauma departments and have to be kept as a focus in the training of orthopedic trauma surgeons. Road traffic accidents are still the main cause of death in children, but they are overall less common. Falls and sports activities are the most likely to cause a fracture., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Schuetze et al.)

Background: Proximal humerus fractures are common injuries in the elderly. Locked plating showed high complication and reoperation rates at first. However, with second-generation implants and augmentation, minimally invasive locked plating might be a viable alternative to arthroplasty or conservative treatment., Material and Methods: A retrospective chart review was performed for all patients with proximal humerus fractures treated between 2014 and 2020 with locked plating. All patients over 60 years of age who underwent surgery for a proximal humerus fracture with plate osteosynthesis (NCB, Philos, or Philos with cement) during the specified period were included. Pathological fractures, intramedullary nailing, or arthroplasty were excluded. Primary outcome measurements included secondary displacement and surgical complications. Secondary outcomes comprised function and mortality within one year., Results: A total of 249 patients (mean age 75.6 +/- 8.9 years; 194 women and 55 men) were included in the study. No significant difference in the AO fracture classification could be found. Ninety-two patients were surgically treated with first-generation locked plating (NCB, Zimmer Biomet, Wayne Township, IN, USA), 113 patients with second-generation locked plating (Philos, Depuy Synthes, Wayne Township, IN, USA), and 44 patients with cement-augmented second-generation locked plating (Philos, Traumacem V+, Depuy Synthes). A 6-week radiological follow-up was completed for 189 patients. In all groups, X-rays were performed one day after surgery, and these showed no differences concerning the head shaft angle between the groups. The mean secondary varus dislocation (decrease of the head shaft angle) after six weeks for first-generation locked plating was 6.6 ± 12° ( n = 72), for second-generation locked plating 4.4 ± 6.5 ( n = 83), and for second-generation with augmentation 1.9 ± 3.7 ( n = 35) with a significant difference between the groups ( p = 0.012). Logistic regression showed a significant dependency for secondary dislocation for the type of treatment ( p = 0.038), age ( p = 0.01), and preoperative varus fracture displacement ( p = 0.033). Significantly fewer surgical complications have been observed in the augmented second-generation locked plating group (NCB: 26.3%; Philos 21.5%; Philos-augmented 8.6%; p = 0.015). Range of motion was documented in 122 out of 209 patients after 3 months. In the Philos-augmented group, 50% of the patients achieved at least 90° anteversion and abduction, which was only about a third of the patients in the other 2 groups (NCB 34.8%, n = 46; Philos 35.8%, n = 56; augmented-Philos 50.0%, n = 20; p = 0.429)., Conclusion: Minimally invasive locked plating is still a valuable treatment option for geriatric patients. With augmentation and modern implants, the complication rate is low and comparable to those of reverse shoulder arthroplasty reported in the literature, even in the challenging group of elderly patients.

Anticoagulative medication such as antiplatelet drugs (PAI, acetylsalicylic acid and direct platelet aggregation inhibitors), vitamin-K-antagonist Warfarin (VKA) or direct oral anticoagulants (DOAC) are common among hip fracture patients, and the perioperative management of these patients is a rising challenge in orthopaedic trauma. Our objective was to determine the effect of oral anticoagulation in patients receiving early endoprosthetic treatment within 24 h after their admission. For the period from 2016 to 2020, a retrospective chart review of 221 patients (mean age 83 ± 7 years; 161 women and 60 men) who were treated either with hemi- (n = 209) or total hip arthroplasty (n = 12) within 24 h after their admission was performed. We identified 68 patients who took PAI, 34 who took DOAC and 9 who took VKA medications. The primary outcome measures were the transfusion rate and the pre- and postoperative haemoglobin (Hb) difference. The secondary outcome measures were the in-patient mortality and the rate of postoperative haematomas that needed operative treatment. A logistic/ordinal regression was performed considering the related variables to prevent cofounding occurring. The mean time to surgery was significantly longer for the DOAC and VKA groups when they were compared to the controls (none 14.7 ± 7.0 h; PAI 12.9 ± 6.7 h; DOAC 18.6 ± 6.3 h; VKA 19.4 ± 5.5 h; p < 0.05). There was no difference in the preoperative Hb level between the groups. Overall, 62 patients (28%) needed blood transfusions during the in-patient stay with an ASA classification (p = 0.022), but the type of anticoagulative medication was not a significant predictor in the logistic regression. Anticoagulation with DOAC and grouped surgery times were positive predictors for a higher Hb difference in the patients who did not undergo an intraoperative blood transfusion (n = 159). Postoperative haematomas only occurred in patients taking anticoagulative medication (four cases in PAI group, and three cases in DOAC group), but the logistic regression showed that the anticoagulative medication had no effect. The in-patient mortality was significantly influenced by a high ASA grade (p = 0.008), but not by the type of anticoagulative medication in patients who were treated within 24 h. We conclude that the early endoprosthetic treatment of the anticoagulated hip fracture patient is safe, and a delayed surgical treatment is no longer justifiable.

Background: Fractures of the proximal femur in the elderly population are rising. Teaching the appropriate surgical treatment of these fractures is of paramount importance. The aim of the study was to evaluate differences in outcome of surgical procedures between supervised trainees and senior surgeons., Objective: Are there more surgical complications, poorer quality or an increased operating time if the procedure (in this case: fixation of proximal femur fractures) is performed by trainees under supervision in comparison to experienced surgeons., Material and Methods: All patients treated with the proximal femur nail antirotation (PFNA) between 2015 and 2016 at a level one trauma centre were included in this study. The retrospective review of the 299 patients compared supervised surgical trainees and senior surgeons. Parameters included operating time, tip apex distance, position of the blade, Hb-difference, transfusion rate, surgical complications as well as mortality, and were compared between the groups., Results: 153 of 299 procedures were performed by supervised surgical trainees. In comparison to senior surgeons, there was no significant difference in operating time (WA 54.48 min; OA 60.47 min; p > 0,05), Hb-difference (WA 2.8 g/dl; OA 2.6 g/dl; p > 0.05), tip-apex distance (WA 21.2 mm; OA 20.5 mm, p = 0.37) or rate of surgical complications. There was no difference in the rate of optimal blade positions between the groups (WA 87.5%; OA 89.0%; p = 0.366). Furthermore, mortality showed no difference between the groups, but was greater in older patients or high ASA grade., Conclusion: Supervised surgical training during treatment of proximal femur fractures shows no increase in operating time, complications or mortality and no difference in quality. With the fast growth of the elderly population, surgical training of fragility fractures should receive more attention in the future., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren erklären, dass kein Interessenkonflikt vorliegt., (Thieme. All rights reserved.)

Background: Pediatric femur fractures are a major trauma in children. Different treatment algorithms have been developed but indications for surgical treatment, especially in very young patients, are still controversial. Literature recommends surgical stabilization with elastic-stable intramedullary nailing (ESIN) starting at the age of 3 and non-operative treatment in younger patients. This study sought to present the outcome of patients younger than 3 years of age treated with ESIN for femur fractures., Materials and Methods: Inclusion criteria were patients younger than 3 treated with ESIN in femur fractures. Patient demographics, fracture characteristics, mechanism of injury, outcomes and complications were recorded using charts and X-rays. Primary outcome measures were time to mobility, fracture consolidation and surgical-related complications., Results: Between 2010 and 2020, 159 patients were treated with ESIN in femur fractures in our institution. A total of 30 patients met the criteria. The mean age was 2.1 ± 0.7 years (13 months-2.9 years). Most common mechanism was fall from standing height (60%). Other mechanisms were motor vehicle accidents as a pedestrian (10%) or as a passenger (10%) as well as direct blow trauma (20%). Femoral shaft fracture was the most common injury (80%). 5 subtrochanteric and one distal metaphyseal femur fractures were found. Mean length of stay was 2.0 ± 1.3 days. Radiographic controls were performed on day 1, 14 and 6 weeks after surgery if not otherwise specified or if complications occurred. 4.6 ± 1.2 (n 2-7) X-rays were performed on average after surgery. First radiographic consolidation signs were seen after 2.4 ± 0.6 weeks. Only one child showed surgical-related complication with a leg length discrepancy of 1 cm. In 10% of the patients, shortening after surgery of 1.7 ± 1.4 mm (0.3-3.1 mm) occurred. One child initially treated with traction therapy showed skin irritations and was operated with ESIN. No non-union or ESIN-related complications were found. Mean follow-up was 5.1 ± 4.4 months (4-24 months). First independent mobilization was seen at an average of 3.4 ± 1.1 weeks (2-6 weeks) after surgery. Implant removal was performed after 3.2 ± 1.3 months (2-8 months). No refracture after implant removal occurred., Conclusion: Early results with ESIN show a reasonable and safe treatment option for femur fractures in toddlers and young children under the age of 3 with easy postoperative care, fast fracture union and early independent mobilization., (© 2022. The Author(s).)

Background: Forearm fractures are one of the most common fractures in children. Over the last years, a tendency towards surgical treatment was seen, especially closed reduction and internal fixation with elastic stable internal nailing (ESIN). Despite an overall low complication rate being described, a risk of intraoperative complications remains., Material and Methods: A total of 237 patients (mean age 8.3 ± 3.4 (1-16) years) with forearm or radius fractures treated with ESIN between 2010 and 2020 were included in the study. The retrospective review of 245 focused on fracture pattern, pre- and postoperative fracture angulation, intra- and postoperative complications, and surgical approach for nail implant. The fracture pattern and pre- and postoperative angulation were measured radiographically. Complications such as ruptures of the extensor pollicis longus (EPL) tendon and sensibility disorders of the superficial radial nerve were further analyzed., Results: In 201 cases (82%), we performed a dorsal approach; 44 fractures (17.9%) were treated with a radial approach. In total, we found 25 (10%) surgery-related complications, of which 21 (8.6%) needed further surgical treatment. In total, we had 14 EPL ruptures (5.7%), 4 sensibility disorders of the superficial radial nerve (1.6%), 2 refractures after implant removal (0.8%), 2 superficial wound infections (0.8%), and 1 child with limited range of motion after surgery (0.4%). No statistical significance between pre- and postoperative angulation correlated to fracture patterns or diameter of the elastic nail was seen. As expected, there was a significant improvement of postoperative angulation. Using radial approach in distal radial fractures showed a lower rate of surgical related complications, 2.3% of which need further surgical treatment as well as better postoperative angulations compared to the dorsal approach (8.5%)., Conclusion: Especially due to the low risk of damaging the EPL tendon, the radial approach showed a lower complication rate which needed further surgical treatment. The risk of lesions of the superficial radial nerve remains.

Introduction: Femoral neck fractures in the elderly are a major event and are rising in incidence over the last decade. Advancing age and numerous comorbidities largely account for high mortality rate and require geriatric expertise. Treatment options are total hip arthroplasty (THA), hemiarthroplasty (HA) or osteosynthesis. Literature suggests THA or HA for better outcomes, although no clear guidelines exist., Material and Methods: A retrospective chart review was performed of 63 patients (80 ± 11 years; 32 women, 31 men) with Garden one femoral neck fractures treated between June 2018 and June 2020 with either HA or internal fixation with the Femoral Neck System (FNS). Primary outcome measures were surgical and non-surgical complication rates and best achievable mobilization during the hospital stay., Results: Thirty four patients were treated with HA, and 29 with the FNS. Mobilization was measured using the Charité Mobility Index (CHARMI). No difference between age, ASA, CCI or preoperative CHARMI was found. The CHARMI was significantly lower in the HA group. No difference in surgical complications was found. The HA cohort showed more non-surgical complications, a longer ICU stay and more blood transfusions. Hospitalization was significant longer in the HA than the FNS cohort (15.1 ± 5.1 vs 9.8 ± 3.8 days). Radiographic controls were performed after 6 and 12 weeks. The FNS group showed a mean shortening of 3.3 mm. 4 of 21 patient had shortening >5 mm. 20 of 21 patients showed radiographic signs of bone healing after 3 months., Conclusion: Early results with the FNS show faster recovery than patient with hemiarthroplasty. Internal fixation with the FNS may be an option in non-displaced femoral neck fractures. Further studies should be performed to better evaluate the FNS compared to traditional internal fixation methods and arthroplasty., Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: Mandatory bicycle helmet and booster seat laws for children are now common across Canada and the United States. Previous research has found that despite legislation, child compliance is often low. Our objectives were to identify and compare children's perspectives on barriers to and facilitators of their use of bicycle helmets and booster seats., Methods: Eleven focus groups were conducted with a total of 76 children; five groups of children between the ages of 4 and 8 years discussed booster seats and bicycle helmets, and six groups of children between the ages of 9 and 13 years discussed bicycle helmets. Efforts were made to include diverse participants from a variety of ethno-cultural and socioeconomic backgrounds., Results: Poor fit and physical discomfort were most often described as barriers to bicycle helmet use. Helmet appearance was a barrier for some children but acted as a facilitator for others. Booster seat facilitators included convenient features such as drink cup holders and being able to sit higher up in order to have a better view, while barriers included fear of being teased, and wanting to feel and be seen as more mature by wearing a seatbelt only., Conclusions: The main barriers to usage of bicycle helmets and booster seats identified by young people were modifiable and fit within a theory of planned behaviour framework that includes subjective norms, child attitudes towards safety equipment and perceived behavioural control of its usage. Recommendations were made regarding how these elements can be utilized in future injury prevention campaigns., (© 2020 John Wiley & Sons Ltd.)

To date, little work has compared similarities and differences between parent and young people's perceptions of barriers to and facilitators of bicycle helmet and booster seat usage. Our goal was to conduct such a comparison in order to inform future safety campaigns. Eleven focus groups with a total of 68 parents and 11 focus groups with a total of 76 young people were conducted. Recruitment was conducted and focus groups were held in diverse neighbourhoods to facilitate participation by families from a variety of cultural, linguistic, and socioeconomic backgrounds. Overall, parents and their children agreed on 50% of the barriers identified for bicycle helmet use and approximately 40% of the barriers for booster seats. Barriers common to both types of equipment for parents and children included comfort, style and design, and fear of teasing. Common facilitators included perceived safety, and comfort. While there was considerable overlap between the perspectives of parents and young people, there were also differences, underscoring the importance of addressing both perspectives. The barriers and facilitators identified were modifiable to a large extent; based on these, recommendations for future injury prevention campaigns were outlined.

Motor vehicle collisions and bicycle collisions and falls are a leading cause of death by preventable injury for children. In order to design, implement and evaluate campaigns and programs aimed at improving child safety, accurate surveillance is needed. This paper examined the challenges that confront efforts to collect surveillance data relevant to child traffic safety, including observation, interview, and focus group methods. Strategies to address key challenges in order to improve the efficiency and accuracy of surveillance methods were recommended. The potential for new technology to enhance existing surveillance methods was also explored.

There is increasing evidence that the biological activity of myostatin (MSTN), a negative regulator of muscle growth, is affected by training but also anabolic steroids. In this study, we analyzed the effects of the frequently abused anabolic steroid methandienone (Md) on the hypothalamic-pituitary-testicular axis and androgen-sensitive tissues in intact rats performing a treadmill training to simulate the situation of abusing athletes. The anabolic effects were correlated with the expression of members of the MSTN signaling cascade. Md treatment resulted in a significant stimulation of anabolic activity of the levator ani muscle, which was further increased by training, while prostate and seminal vesicle weights decreased in conformance with hormone concentrations of LH and testosterone. In gastrocnemius muscle, mRNA expression of genes of the MSTN signaling cascade (MSTN, Smad7 and MyoD) was reduced by training but not after Md treatment, in soleus muscle MSTN and its inhibitors, follistatin (FLST) and Smad-7 were only affected after training in combination with Md treatment. In summary, our data demonstrate that Md treatment of intact rats results in anabolic effects which are enhanced in combination with physical activity. Interestingly, the anabolic activity on the levator ani was increased in combination with training, although the levator ani muscle was not specifically stimulated by our training protocol. In the m. gastrocnemius and soleus, the anabolic effects correlate with changes in the expression patterns of genes involved in MSTN signaling. Our data provide evidence that the decrease in the weight of androgen-sensitive sexual glands, observed after Md treatment, is caused by a suppression of endogenous testosterone synthesis. These observations provide new insights into the molecular mechanisms of the interaction between anabolic steroids, training and MSTN signaling during skeletal muscle adaptation.

Background: To develop and grow most effectively, palliative care programs must consider how best to align their mission with that of their institution. To do so, programs must identify their institutional mission and needs, what palliative care can do to address those needs given available resources, and how the palliative care team can measure and document its value. Such an approach encourages the palliative care team to think strategically and to see themselves and their service as a solution to issues and concerns within the institution. It also helps a palliative care team decide which, among many potential opportunities and possible initiatives, is the one most likely to be supported by the institution and have a recognized and significant impact., Subjects and Methods: We present five case studies to demonstrate how successful programs identify and address institutional needs to create opportunities for palliative care program growth. These case studies can serve as models for other programs seeking to develop or expand their palliative care services.