Ivan S. Tarkin

Patterns of mortality and causes of death in polytrauma patients--has anything changed?

INTRODUCTION Numerous articles have examined the pattern of traumatic deaths. Most of these studies have aimed to improve trauma care and raise awareness of avoidable complications. The aim of the present review is to evaluate whether the distribution of complications and mortality has changed. MATERIALS AND METHODS A review of the published literature to identify studies examining patterns and causes of death following trauma treated in level 1 hospitals published between 1980 and 2008. PubMed was searched using the following terms: Trauma Epidemiology, Injury Pattern, Trauma Deaths, and Causes of Death. Three time periods were differentiated: (n=6, 1980-1989), (n=6, 1990-1999), and (n=10, 2000-2008). The results were limited to the English and/or German language. Manuscripts were analysed to identify the age, injury severity score (ISS), patterns and causes of death mentioned in studies. RESULTS Twenty-two publications fulfilled the inclusion criteria for the review. A decrease of haemorrhage-induced deaths (25-15%) has occurred within the last decade. No considerable changes in the incidence and pattern of death were found. The predominant cause of death after trauma continues to be central nervous system (CNS) injury (21.6-71.5%), followed by exsanguination (12.5-26.6%), while sepsis (3.1-17%) and multi-organ failure (MOF) (1.6-9%) continue to be predominant causes of late death. DISCUSSION Comparing manuscripts from the last three decades revealed a reduction in the mortality rate from exsanguination. Rates of the other causes of death appear to be unchanged. These improvements might be explained by developments in the availability of multislice CT, implementation of ATLS concepts and logistics of emergency rescue.

Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery.

&NA; The optimal timing of surgical stabilization of fractures in the multitrauma patient is controversial. There are advantages to early definitive surgery for most patients. Early temporary fixation using external fixators, followed by definitive fixation (ie, the damage control approach), may increase the chance for survival in a subset of patients with severe multisystem injuries. Improved understanding of the pathophysiology of trauma has led to a greater ability to identify patients who would benefit from damage control surgery. A patient is classified as physiologically stable, unstable, borderline, or in extremis. The stable patient can undergo fracture surgery as necessary. An unstable patient should be resuscitated and adequately stabilized before receiving definitive orthopaedic care. The decision whether to perform initial temporary or definitive fixation in the borderline patient is individualized based on the clinical condition. In patients presenting in extremis, lifesaving measures are pivotal, followed by a damage control approach to their injuries.

New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

Mapping of Scapular Fractures with Three-Dimensional Computed Tomography

BACKGROUND Fractures of the scapula involve a unique and challenging set of considerations, which must be understood to provide optimal treatment. The primary goal of this study was to create a frequency map of a series of surgically treated scapular fractures that specifically involved the scapular body and/or neck. METHODS A prospective database was used in the collection of consecutive radiographic imaging studies of patients undergoing operative treatment of scapular fractures. Scanned three-dimensional computed tomography images were superimposed and oriented to fit a model scapular template. Size dimensions were normalized by aligning specific scapular landmarks. Fracture lines were identified and traced over the combined three-dimensional computed tomography model to create a scapular fracture map. RESULTS Of ninety fractures that met the criteria for inclusion, 68% involved the inferior aspect of the glenoid neck and 71% involved the superior vertebral border. Seventeen percent of the patterns included articular extension, and 22% of the fractures entered the spinoglenoid notch. Of fractures involving the inferior aspect of the glenoid neck at the lateral scapular border, 84% traversed medially to exit just inferior to the medial extent of the scapular spine, and 59% of these inferior neck fractures also had propagation to the inferior third of the vertebral border. Among the fractures involving the spinoglenoid notch, the most common pattern was demonstrated by coexisting fracture lines; 60% of the fractures of the spinoglenoid notch exited just inferior to the glenoid, 65% extended to the superior-medial vertebral border, and 45% extended to the inferior-medial vertebral border. In contrast, articular fractures did not follow predictable patterns; they demonstrated the greatest variability in trajectory, which was almost random, and there was a wide distribution of exit points along the vertebral border. CONCLUSIONS Surgically treated scapular fractures display very common patterns. The most common pattern is the lateral border fracture immediately inferior to the glenoid, which extends to the superior vertebral border in more than two-thirds of cases. A smaller proportion of scapular fractures enter the spinoglenoid notch or the articular surface. There is great variation in the patterns of fractures involving the articular surface.

Early Complications Following the Operative Treatment of Pilon Fractures with and without Diabetes

Background: An increased rate of complications has been clearly shown in diabetic patients undergoing operative treatment for displaced ankle fractures. To date, no studies have specifically looked at the complication rates following the operative management of pilon fractures in this difficult patient population. We performed a retrospective review to determine the rates of complications in diabetic patients undergoing operative fixation of tibial pilon fractures compared with a control group of patients without diabetes. Materials and Methods: The trauma registry was utilized to identify all patients who underwent primary treatment for a tibial pilon fracture between January 2005 and June of 2007 at a single Level 1 trauma center. A minimum of 6-month followup was required for inclusion. A chart and radiographic review was completed to identify the complications seen in each patient population. Specifically, we looked at the rate of infection (superficial and deep), the rate of nonunion or delayed union, and the rate of surgical wound complications. Results: A total of 14 fractures in 13 diabetic patients, and 69 fractures in 68 non-diabetic patients met inclusion criteria. In the diabetic patient group, the average age was 48 years, the average BMI was 35, and 36% of the fractures were open. In the non-diabetic group, the average age was 47 years, the average BMI was 29, and 35% of the fractures were open. Only the difference in BMI was statistically significant. The infection rate was 71% for diabetic patients (43% deep infection), and 19% for non-diabetic patients (9% deep infection) [p < 0.001, odds ratio 10.719 (95% confidence interval 2.914 to 39.798)]. Overall, the rate of non-union/delayed union was 43% in the diabetic group versus 16% in the non-diabetic group [p = 0.02, odds ratio 3.955 (95% confidence interval 1.145 to 13.656)]. The rate of surgical wound complications was 7% in both the non-diabetic and diabetic patient groups. Conclusion: The management of tibial pilon fractures in diabetic patients is difficult, with a high rate of complications compared to non-diabetic patients. These results mirror those previously reported for ankle fractures in diabetic patients. Level of Evidence: IV, Retrospective Case Series

Prolonged operative time increases infection rate in tibial plateau fractures

BACKGROUND Fractures of the tibial plateau present a treatment challenge and are susceptible to both prolonged operative times and high postoperative infection rates. For those fractures treated with open plating, we sought to identify the relationship between surgical site infection and prolonged operative time as well as to identify other surgical risk factors. METHODS We performed a retrospective controlled analysis of 309 consecutive unicondylar and bicondylar tibial plateau fractures treated with open plate osteosynthesis at our institutions level I trauma centre during a recent 5-year period. We recorded operative times, injury characteristics, surgical treatment, and need for operative debridement due to infection. Operative times of infected cases were compared to uncomplicated surgical cases. Multivariable logistic regression analysis was performed to identify independent risk factors for postoperative infection. RESULTS Mean operative time in the infection group was 2.8h vs. 2.2h in the non-infected group (p=0.005). 15 fractures (4.9%) underwent four compartment fasciotomies as part of their treatment, with a significantly higher infection rate than those not undergoing fasciotomy (26.7% vs. 6.8%, p=0.01). Open fracture grade was also significantly related to infection rate (closed fractures: 5.3%, grade 1: 14.3%, grade 2: 40%, grade 3: 50%, p<0.0001). In the bicolumnar fracture group, use of dual-incision medial and lateral plating as compared to single incision lateral locked plating had statistically similar infection rates (13.9% vs. 8.7%, p=0.36). Multivariable logistic regression analysis of the entire study group identified longer operative times (OR 1.78, p=0.013) and open fractures (OR 7.02, p<0.001) as independent predictors of surgical site infection. CONCLUSIONS Operative times approaching 3h and open fractures are related to an increased overall risk for surgical site infection after open plating of the tibial plateau. Dual incision approaches with bicolumnar plating do not appear to expose the patient to increased risk compared to single incision approaches.

PCR rapidly detects methicillin-resistant staphylococci periprosthetic infection.

Optimal treatment of methicillin-resistant staphylococcal periprosthetic infections is predicated on rapid and reliable detection of these organisms. Culture has served as the gold standard for identification of these organisms despite shortcomings with sensitivity and processing time. The objective of the current study was to investigate a polymerase chain reaction assay aimed at rapid genomic detection of methicillin-resistance in staphylococci (mecA gene). The feasibility of the molecular approach first was validated using a septic arthritis model consisting of 73 synovial fluid samples inoculated with methicillin-resistant staphylococci and four negative controls. MecA polymerase chain reaction then was done on 35 clinical samples from 18 patients obtained at the time of revision arthroplasty. Results of the polymerase chain reaction were compared with culture. MecA polymerase chain reaction successfully predicted the presence of methicillin-resistant staphylococci in the septic arthritis model. In the clinical samples studied, the polymerase chain reaction results were concordant with culture results in 34 of the 35 samples tested. The one discordant result represented a false-positive culture result. The molecular assay was processed in less than 5 hours compared with 2 to 3 days for culture. Detection of methicillin-resistant staphylococci involved in periprosthetic infections by the polymerase chain reaction is a rapid and reliable approach.

Use of the ‘reamer irrigator aspirator’ system for non-infected tibial non-union after failed iliac crest grafting

Autologous bone graft represents the gold standard treatment modality for managing atrophic nonunions associated with bone loss by virtue of its osteoinductive and osteoconductive properties. Traditionally, the commonest harvesting site for autologous bone graft has been the iliac crest. However, there have been concerns about iliac crest bone grafts because of limited volume and considerable donor site morbidity. Alternative autologous bone graft can be harvested from the femoral bone cavity, using a newly developed technique that combines intramedullary reaming and aspiration of the reamed content. Use of the ‘reamer irrigator aspirator’ (RIA) technique results in a voluminous amount of bone graft, which seems to be superior in growth potential to iliac crest bone graft and may therefore exceed the abilities of pelvic crest bone graft. We report a case of open tibial shaft fracture (Gustilo IIIb) with significant bone loss. After failed iliac crest bone grafting, bone graft from the femoral

Anterior plate supplementation increases ankle arthrodesis construct rigidity.

Background: The success of ankle arthrodesis for the treatment of post-traumatic ankle arthritis depends on achieving and maintaining rigid fixation of the prepared tibiotalar interface. The purpose of this study was to examine the biomechanical effect of anterior plate supplementation of a popular three-screw fusion construct. Methods: Six fresh-frozen cadaver ankles were prepared and instrumented with three partially threaded screws compressing the tibiotalar interface. Testing was done with and without supplementary anterior plate fixation under three different decoupled loading conditions: plantarflexion/dorsiflexion, inversion/eversion, and rotation. Motion at the tibiotalar interface was recorded. Results: Anterior plating increased construct stiffness by a factor of 3.5, 1.9, and 1.4 for the sagittal, coronal, and torsion modes, respectively. Less motion occurred at the tibiotalar interface in all to the three different loading conditions (p = 0.031) with plate supplementation. Conclusions: Compared to screws alone, anterior plate supplementation increases construct rigidity and decreases micromotion at the ankle fusion interface.

Rotator Cuff Tears in Adolescent Athletes

Musculoskeletal injuries of the shoulder in competitive adolescent athletes are common and include both acute traumatic injuries and overuse syndromes. Common patterns of injury involving the shoulder girdle have been described, including Little League shoulder, proximal humerus fracture, clavicle fracture, and glenohumeral instability. However, rotator cuff injuries in adolescents have rarely been reported. Rotator cuff tears commonly involve patients who are older than 40 years. Age-related changes reduce the mechanical properties of the rotator cuff, predisposing older individuals to these injuries. Significant trauma to the upper extremity is often a prerequisite for rotator cuff failure in the younger patient. However, overhead-throwing athletes have been reported to sustain rotator cuff tears believed to be owing to chronic overuse. Subacromial impingement due to occult shoulder instability and internal impingement of the rotator cuff on the posterior glenoid are described mechanisms of injury. Rotator cuff injuries in adolescents may be overlooked as a cause of disability, leading to significant delays in diagnosis before appropriate treatment is instituted. Most of the previously reported cases involving injury to the rotator cuff in adolescents are tuberosity avulsions, typically the lesser tuberosity. The objective of this report was to present 4 athletic adolescent patients between the ages of 12 and 14 years who presented with rotator cuff abnormality without tuberosity avulsion or fractures. CASE 1