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Background: Ankle fracture displacement is an important outcome in clinical research examining the effectiveness of surgical and rehabilitation interventions. However, the assessment of displacement remains subjective without well-described or validated measurement methods. The aim of this study was to assess inter- and intrarater reliability of ankle fracture displacement radiographic measures and select measurement thresholds that differentiate displaced and acceptably reduced fractures. Methods: Eight fellowship-trained orthopaedic surgeons evaluated a set of 26 postoperative ankle fracture radiographs on 2 occasions. Surgeons followed standardized instructions for making 5 measurements: coronal displacement (3) talar tilt (1), and sagittal displacement (1). Inter- and intraobserver interclass correlations were determined by random effects regression models. Logistic regression was used to determine the optimal sensitivity and specificity for the measurements with the highest correlation. Results: Three of the 5 measures had excellent interobserver reliability (correlation coefficient > 0.75): (1) coronal plane distance between the lateral border of tibia and lateral border of talus, (2) coronal plane talar tilt, and (3) sagittal plane displacement. The threshold that best discriminated displaced from well-aligned fractures was 2 mm for coronal plane distance (sensitivity 82.1%, specificity 85.4%), 3 degrees for talar tilt (sensitivity 80.4%, specificity 82.2%), and 5 mm for sagittal plane distance (sensitivity 83.9%, specificity 84.9%). Conclusion: This study identified 3 reliable measures of ankle fracture displacement and determined optimal thresholds for discriminating between displaced and acceptably reduced fractures. These measurement criteria can be used for the design and conduct of clinical research studying the impact of surgical treatment and rehabilitation interventions.

OBJECTIVES To evaluate the perceived utility and associated charges of the anteroposterior (AP) radiograph during rotational ankle fracture postoperative follow-up. DESIGN Survey study with charge analysis using published data at 50 orthopaedic hospitals in the United States. SETTING Not Applicable. PARTICIPANTS Orthopaedic Trauma Association Members with an active e-mail address who were invited and interested in answering a survey. RESULTS 94% of respondents stated that they did routinely obtain an AP radiograph during rotational ankle fracture follow-up. However, 57% thought that the AP view should be eliminated from standard follow-up and only 51% found this view useful after initial treatment. CHARGE ANALYSIS The mean difference between a 2-view and 3-view ankle radiograph series was $102.00. Using this value and the assumption that each patient with a rotational ankle fracture gets 3 follow-up radiographs, there is the potential for a charge reduction of $306 per patient. Assuming over 134,000 rotational ankle fractures, a charge reduction of 41 million U.S. dollars (USD) per year is possible if the AP image is routinely removed. Actual savings are likely to be less based on agreed upon payer rates. Although less easy to quantify, there is also potential reduction of radiation exposure, radiologists' interpretation time, and data storage. CONCLUSION Routine AP radiographs should potentially be eliminated from routine postoperative ankle x-ray protocols based on this survey of experienced orthopaedic surgeons. If this specific radiograph is ordered on a case-by-case basis then significant savings may occur. LEVEL OF EVIDENCE Diagnostic Level V. See Instructions for Authors for a complete description of levels of.

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.

Supplemental Digital Content is Available in the Text., Objectives: To (1) demonstrate that the AO Spine Sacral Classification System can be reliably applied by general orthopaedic surgeons and subspecialists universally around the world and (2) delineate those injury subtypes that are most difficult to classify reliably to refine the classification before evaluating clinical outcomes. Design: Agreement study. Setting: All-level trauma centers, worldwide. Participants: One hundred seventy-two members of the AO Trauma and AO Spine community. Intervention: The AO Sacral Classification System was applied by each surgeon to 26 cases in 2 independent assessments performed 3 weeks apart. Main Outcome Measurements: Interobserver reliability and intraobserver reproducibility. Results: A total of 8097 case assessments were performed. The kappa coefficient for interobserver agreement for all cases was 0.72/0.75 (assessment 1/assessment 2), representing substantial reliability. When comparing classification grading (A/B/C) regardless of subtype, the kappa coefficient was 0.84/0.85, corresponding to excellent reliability. The kappa coefficients for interobserver reliability were 0.95/0.93 for type A fractures, 0.78/0.79 for type B fractures, and 0.80/0.83 for type C fractures. The overall kappa statistic for intraobserver reliability was 0.82 (range 0.18–1.00), representing excellent reproducibility. When only evaluating morphology type (A/B/C), the average kappa value was 0.87 (range 0.18–1.00), representing excellent reproducibility. Conclusion: The AO Spine Sacral Classification System is universally reliable among general orthopaedic surgeons and subspecialists worldwide, with substantial interobserver and excellent intraobserver reliability.

Talar fractures and pantalar dislocations are usually the results of high-energy trauma. Dislocations and open injuries are managed urgently. Temporary stabilization with splinting, Kirschner wires, or external fixation may be performed until the soft tissues are ready for definitive fixation. A CT scan is critical to identify all injuries and is helpful in planning treatment including reduction of dislocations and definitive fixation. Lateral and posterior process fractures are often missed initially and require a high index of suspicion.

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.

OBJECTIVES To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation. DESIGN Retrospective. SETTING Nine trauma centers. PATIENTS This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation. RESULTS We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant. CONCLUSIONS In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: Unstable pelvic ring injuries produced by external rotation of the hemipelvis and a symphyseal disruption are most often treated with internal fixation of the anterior ring, with percutaneous treatment of the posterior ring as needed. In some clinical situations, patients are treated with external fixation for their anterior injuries and the long-term functional outcomes associated with external fixation are not well understood. We ask if there is a difference in functional outcome, between treatment of these injuries with internal versus external fixation, when measured at a minimum of three years after injury. Method: This was a retrospective cohort study performed at a level one regional trauma center. Trauma database review identified 128 patients, with 70 subsequently excluded, with unstable anterior posterior compression (APC) pelvic ring injuries (OTA 61B2.3 & 61C1.2) treated with surgery with minimum three years of follow-up. An intervention of internal fixation versus external fixation of anterior pelvic ring was performed, and depending on the injury, supplemented with posterior iliosacral screw fixation. Main outcome was measured with the Majeed functional outcome score (0-100). Results: Patients treated with external fixation reported a Majeed score of 70 (95% CI 28-100) compared to 79 (95% CI 36-100) in those with internal fixation (p-value 0.28). Subgroups of the Majeed score were not significantly different (p value > 0.05). Open fractures, severity of injury, and ISS were worse in those treated with external fixation. There was no differential loss to follow-up. Conclusion Patients with unstable pelvic ring injuries with symphyseal disruptions treated with external fixation as definitive treatment versus internal fixation may fare no different in the long term.

Objectives To evaluate a large series of open fractures of the forearm following gunshot wounds in order to determine complication rates and factors that may lead to infection, nonunion, or compartment syndrome. Design Multi-center retrospective review. Setting Nine Level 1 Trauma CentersPatients/Participants: 168 patients had 198 radius and ulna fractures due to firearm injuries. All patients were adults, had a fracture due to a firearm injury and at least one year clinical follow-up or follow-up until union. Average follow-up was 831 days. Intervention Most patients (91%) received antibiotics. Formal irrigation and debridement in the operating room was performed in 75% of cases along with either internal fixation (75%), external fixation (6%), or I&D without fixation (19%). Main outcome measures Complications including neurovascular injuries, compartment syndrome, infection and nonunion. Results Twenty-one percent of patients had arterial injuries and 40% had nerve injuries. Nine patients (5%) developed compartment syndrome. Seventeen patients (10%) developed infections, all in comminuted or segmental fractures. Antibiotics were not associated with a decreased risk of infection. Infections in the ulna were more common in fractures with retained bullet fragments and bone loss. Twenty patients (12%) developed a nonunion. Nonunions were associated with high velocity firearms and bone defect size. Conclusions Open fractures of the forearm from gunshot wounds are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at increased risk of nonunion and should be treated with stable fixation and proper soft tissue handling. Ulna fractures are at particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from gunshot wounds should be followed until union to identify long term complications. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To determine if the relative distance between the acetabular teardrops on unstressed and lateral compressive stress examination under anesthesia (EUA) pelvic fluoroscopic images is reproducible between independent reviewers. DESIGN Retrospective database review. SETTING Level 1 trauma center. PATIENTS/INTERVENTION Fifty-eight patients with a lateral compression type 1 pelvic ring injury who underwent EUA. MAIN OUTCOME MEASURE Validation of EUA objective measurements between blinded, independent reviewers using interclass and intraclass correlation coefficients. RESULTS There was excellent interobserver and intraobserver reliability between all reviewers. Values for each intraclass correlation coefficients (including 95% confidence intervals) were between 0.96 (0.95-0.098) and 0.99 (0.99-0.99) for all measurements. P values were

We investigated the sensitivity of a screening test for pelvic ring disruption, the AP pelvis radiograph, for clinically serious U-type sacral fractures which merit consultation with an orthopedic trauma specialist and may require transfer to a higher level of care. Retrospective clinical cohort of 63 consecutive patients presenting with U-type sacral fractures at one level 1 trauma referral center from January 2006 through December 2019. The sensitivity of the first AP pelvis radiograph obtained on admission, interpreted without reference to antecedent or concomitant pelvis computed tomography (CT) by a radiologist and a panel of three blinded orthopedic traumatologists, was determined against a reference diagnosis made from review of all pelvis radiographs, CT images, operative reports, and clinical documentation. Sensitivity of AP pelvis radiograph for U-type sacral fractures was 2% as interpreted by a radiologist and mean 12% (range 5–27%) as interpreted by orthopedic traumatologists with poor inter-rater agreement (Fleiss’ κ = 0.11). 94% of sacra were at obscured by radiographic artifact. The sensitivity of an AP pelvis radiograph is poor for U-type sacral fractures, whether interpreted by radiologists or orthopedic traumatologists. Pelvis CT should be considered as a screening test to rule out sacral fracture when the patient reports posterior pelvic pain, even if plain radiography demonstrates no injury or a minimally displaced pelvic ring disruption. Diagnostic level III

We present our technique for screw stabilization and our clinical experience treating a series of patients presenting with proximal tibiofibular joint fracture-dislocations.

Open reduction internal fixation of tibial plateau and pilon fractures may be complicated by deep surgical site infection requiring operative debridement and antibiotic therapy. The management of superficial surgical site infection is controversial. We sought to determine whether superficial infection is associated with an increased risk of deep infection requiring surgical debridement after fixation of tibial plateau and pilon fractures.This is a secondary analysis of data from the VANCO trial, which included 980 adult patients with a tibial plateau or pilon fracture at elevated risk of infection who underwent open reduction internal fixation with plates and screws with or without intrawound vancomycin powder. An association of superficial surgical site infection with deep surgical site infection requiring debridement surgery and antibiotics was explored after matching on risk factors for deep surgical site infection.Of the 980 patients, we observed 30 superficial infections (3.1%) and 76 deep infections (7.8%). Among patients who developed a superficial infection, the unadjusted incidence of developing a deep infection within 90 days was 12.8% (95% confidence interval [CI] 1.3-24.2%). However, after a 3:1 match on infection risk factors, the 90-day marginal probability of a deep surgical site infection after sustaining a superficial infection was 6.0% (95% CI - 6.5-18.5%, p = 0.35).Deep infection after superficial infection is uncommon following operative fixation of tibial plateau and pilon fractures. Increased risk of subsequent deep infection attributable to superficial infection was inconclusive in these data.Prognostic Level II.

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

Objectives To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample. Design Consecutive retrospective cohort review. Setting Eighteen academic orthopedic trauma centers. Patients/participants Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery. Intervention Humeral shaft nonunion repair and assessment of postoperative radial nerve function. Main outcome Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery. Results Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved. Conclusion In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background The optimal treatment of acetabular fractures in the senior cohort is undetermined. Total hip arthroplasty in the setting of an acetabular fracture is increasing in popularity. However, there is concern regarding the fixation of a prosthetic cup in a fractured acetabulum. The purpose of this study is to map the area of stable articular surface and bone corridors available for cup fixation in this fracture cohort. Methods CT scans of acetabular fractures in 131 consecutive geriatric patients older than 65 years from two level 1 academic trauma centers were analyzed. Acetabular fractures were classified using the Letournel classification, the available stable articular surface, and the bone corridors available for fixation. Results Fractures involving the anterior column were the most common fracture type seen. The dome only pattern was the most common stable articular surface pattern. The sciatic corridor was available for fixation in all fracture types, followed by the gluteal pillar corridor. Most fractures had at least two corridors (93%) available for screw fixation. Conclusions The findings of this study may aid in the development and evaluation of fixation strategies for acetabular cups allowing geriatric acetabular fracture patients earlier weight bearing after primary hip arthroplasty.

Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism).This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups.Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures).Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.

We present a case report of an elderly patient with a displaced lateral compression type II pelvic ring injury and describe a novel technique for maintaining a percutaneously obtained reduction during percutaneous fixation using a supra-acetabular Schantz pin attached to a mechanical limb positioner.The mechanical limb positioner used allows the surgeon to hold a multidirectionally obtained reduction of the hemipelvis with ease.

Injuries to the posterior pelvic ring are often stabilized with fixation across the sacroiliac joint (SIJ). However, the compensatory changes at the neighboring L5/S1 facet joint are unknown. The objective of this study was to determine the compensatory change in pelvic kinematics and contact forces at the L5/S1 facet joint after fixation across the sacroiliac joint (SIJ) using a cadaveric model.Five fresh-frozen cadaveric pelvis specimens were dissected to remove non-structural soft tissue. Retroreflective markers were fixed to the L5 body, S1 body and bilateral anterior superior iliac spines to represent the motion of L5, S1 and the ileum, respectively. Pressure sensors were inserted in both L5/S1 facet joints. Testing was performed using a robotic system that applied load to mimic ambulation. Testing was performed prior to SIJ fixation, after unilateral SIJ fixation and bilateral fixation.Contact force at the L5/S1 facet joint significantly increased by 55% from 48.4 N to 75.2 N following unilateral fixation (p = 0.0161) and increased by 100% to 96.9 N after bilateral fixation (p = 0.0038). Unilateral SIJ fixation increased flexion of the ilium relative to L5 from 1.2° to 2.0° (p = 0.01) and increased axial rotation of L5 relative to S1 from 0.7° to 1.6° (p = 0.001). Bilateral fixation increased flexion of the ilium relative to L5 to 2.0° from 1.2° prior to fixation (p = 0.001), increased axial rotation of L5 relative to S1 to 1.2° from 0.7° prior to fixation (p = 0.002) and increased flexion of L5 relative to S1 to 2.4° from 1.5° prior to fixation (p = 0.04).The L5/S1 facet joint experiences compensatory increased motion under increased contact force after unilateral and bilateral SIJ fixation, possibly predisposing it to adjacent segment arthritis.V, cadaveric study.

Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions.

Removal of internal fixation implants previously placed to stabilize posterior pelvic ring injuries may be technically challenging. Described techniques for extraction require specialized equipment, extensile measures, or purchase of additional implants. We describe a technique for removal of large diameter cannulated screws and washers from the posterior pelvic ring, which requires no additional equipment or implants beyond the instrumentation used for implant insertion, as well as a series of 15 cases in which the technique was applied.

OBJECTIVES In patients with traumatic pelvic fracture urethral injuries (PFUI), the interaction between urethral management and orthopaedic decision making remains unknown. We aimed to survey orthopaedic and urologic surgeons to assess interdisciplinary interactions in the management of PFUI. METHODS An anonymous cross-sectional survey of members of the Orthopaedic Trauma Association (OTA) and the Society of Genitourinary Reconstructive Surgeons (GURS) was conducted between September 2017 and August 2018. Participants were queried regarding the impact of urethral injuries and their management on orthopaedic operative decision making. RESULTS Fifty-three GURS and 64 OTA members responded (17% response rate). For urethral injury management, 73% of OTA respondents preferred that suprapubic tubes (SPTs) were not placed for urethral injury management, whereas 43% of GURS respondents preferred SPTs (P = 0.08). Ninety-two percent of OTA respondents stated that SPTs increase hardware infection risks in patients undergoing pelvic open reduction with internal fixation (ORIF), whereas only 8% of GURS respondents agreed (P < 0.01). Although 66% of GURS respondents reported not considering the operative plans of orthopaedics when determining urethral management, 75% of OTA respondents reported that they were less inclined to proceed with ORIF, and 70% would perform external fixation in the setting of an SPT, despite 78% believing that this resulted in an inferior outcome for the patient. CONCLUSIONS There is discordance between urologists and orthopaedists as to the optimal management of PFUI patients, with significant disagreement regarding the infectious risks of SPT in the setting of ORIF. Improved data and interdisciplinary dialogue are required to maximize patient outcomes. LEVEL OF EVIDENCE Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Background: The plantar fascia attaches to the tuberosity of the calcaneus, which produces a distinct plantar medial avulsion (PMA) fracture fragment in certain calcaneal fractures. We hypothesized that tongue-type fractures, as described by the Essex-Lopresti classification, were more likely to be associated with this PMA fracture than joint depression fractures. Methods: A retrospective chart review was performed at 2 distinct Level I trauma centers to identify patients sustaining calcaneal fractures. Radiographs were then reviewed to determine the Essex-Lopresti classification, OTA classification, and presence of a PMA fracture. Results: The review yielded 271 total patients with 121 (44.6%) tongue-type (TT), 110 (40.6%) joint depression (JD), and 40 (14.8%) fractures not classifiable by the Essex-Lopresti classification. In the TT group, 73.6% of the patients had the PMA fracture whereas only 8.2% of JD and 15.0% of nonclassifiable fractures demonstrated a PMA fragment ( P < .001). Conclusion: Plantar medial avulsion fractures occurred in 38.4% of the calcaneal fractures reviewed with a significantly greater proportion occurring in TT (73.6%) as opposed to JD (8.2%). Given the plantar fascia attachment to the PMA fragment, there may be clinical significance to identifying this fracture and changing treatment management; however, this requires further investigation. Level of Evidence: Level III, comparative study.

We investigated the sensitivity of a screening test for pelvic ring disruption, the AP pelvis radiograph, for clinically serious U-type sacral fractures which merit consultation with an orthopedic trauma specialist and may require transfer to a higher level of care.Retrospective clinical cohort of 63 consecutive patients presenting with U-type sacral fractures at one level 1 trauma referral center from January 2006 through December 2019. The sensitivity of the first AP pelvis radiograph obtained on admission, interpreted without reference to antecedent or concomitant pelvis computed tomography (CT) by a radiologist and a panel of three blinded orthopedic traumatologists, was determined against a reference diagnosis made from review of all pelvis radiographs, CT images, operative reports, and clinical documentation.Sensitivity of AP pelvis radiograph for U-type sacral fractures was 2% as interpreted by a radiologist and mean 12% (range 5-27%) as interpreted by orthopedic traumatologists with poor inter-rater agreement (Fleiss' κ = 0.11). 94% of sacra were at obscured by radiographic artifact.The sensitivity of an AP pelvis radiograph is poor for U-type sacral fractures, whether interpreted by radiologists or orthopedic traumatologists. Pelvis CT should be considered as a screening test to rule out sacral fracture when the patient reports posterior pelvic pain, even if plain radiography demonstrates no injury or a minimally displaced pelvic ring disruption.Diagnostic level III.

Background: Supination-adduction (SAD) type II ankle fractures can have medial tibial plafond and talar body impaction. Factors associated with the development of posttraumatic arthritis can be intrinsic to the injury pattern or mitigated by the surgeon. We hypothesize that plafond malreducton and talar body impaction is associated with early posttraumatic arthrosis. Methods: A retrospective cohort of skeletally mature patients with SAD ankle fractures at 2 level 1 academic trauma centers who underwent operative fixation were identified. Patients with a minimum of 1-year follow-up were included. The presence of articular impaction identified on CT scan was recorded and the quality of reduction on final intraoperative radiographs was assessed. The primary outcome was radiographic ankle arthrosis (Kellgren-Lawrence 3 or 4), and postoperative complications were documented. Results: A total of 175 SAD ankle fractures were identified during a 10-year period; 79 patients with 1-year follow-up met inclusion criteria. The majority of injuries resulted from a high-energy mechanism. Articular impaction was present in 73% of injuries, and 23% of all patients had radiographic arthrosis (Kellgren-Lawrence 3 or 4) at final follow-up. Articular malreduction, defined by either a gap or step >2 mm, was significantly associated with development of arthrosis. Early treatment failure, infection, and nonunion was rare in this series. Conclusion: Malreduction of articular impaction in SAD ankle fractures is associated with early posttraumatic arthrosis. Recognition and anatomic restoration with stable fixation of articular impaction appears to mitigate risk of posttraumatic arthrosis. Investigations correlating postoperative and long-term radiographic findings to patient-reported outcomes after operative treatment of SAD ankle fractures are warranted. Level of Evidence: Level IV, retrospective case series.