Jason J. Halvorson

Vascular injury associated with extremity trauma: initial diagnosis and management.

Abstract Vascular injury associated with extremity trauma occurs in <1% of patients with long bone fracture, although vascular injury may be seen in up to 16% of patients with knee dislocation. In the absence of obvious signs of vascular compromise, limb‐threatening injuries are easily missed, with potentially devastating consequences. A thorough vascular assessment is essential; an arterial pressure index <0.90 is indicative of potential vascular compromise. Advances in CT and duplex ultrasonography are sensitive and specific in screening for vascular injury. Communication between the orthopaedic surgeon and the vascular or general trauma surgeon is essential in determining whether to address the vascular lesion or the orthopaedic injury first. Quality evidence regarding the optimal fixation method is scarce. Open vascular repair, such as direct repair with or without arteriorrhaphy, interposition replacement, and bypass graft with an autologous vein or polytetrafluoroethylene, remains the standard of care in managing vascular injury associated with extremity trauma. Although surgical technique affects outcome, results are primarily dependent on early detection of vascular injury followed by immediate treatment.

Management of humeral shaft fractures.

&NA; Humeral shaft fractures account for approximately 3% of all fractures. Nonsurgical management of humeral shaft fractures with functional bracing gained popularity in the 1970s, and this method is arguably the standard of care for these fractures. Still, surgical management is indicated in certain situations, including polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical options include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing. Each of these techniques has advantages and disadvantages, and the rate of fracture union may vary based on the technique used. A relatively high incidence of radial nerve injury has been associated with surgical management of humeral shaft fractures. However, good surgical outcomes can be achieved with proper patient selection.

Management of venomous snakebite injury to the extremities.

Pit vipers (subfamily Crotalinae) are responsible for most venomous snakebites in the United States. The mixture of proteins with cytotoxic, proteolytic, and/or neurotoxic enzymes in snake venom varies by species. Treatment in the field consists of safe identification of the species of snake and rapid transport of the patient to the nearest health care facility. Swelling, bruising, and systemic symptoms are seen following snakebite. Most patients respond to elevation of the affected extremity and observation. Some require the administration of antivenin. Crotalidae Polyvalent Immune Fab (Ovine) (CroFab, BTG International, West Conshohocken, PA) antivenin is safe and effective for the management of local and systemic effects of envenomation. Rarely, compartment syndrome may develop in the affected limb because of edema and tissue necrosis. Close monitoring of the extremity via serial physical examination and measurement of compartment pressure is a reliable method of determining whether surgical intervention is required.

Value of 3-D CT in classifying acetabular fractures during orthopedic residency training.

The complex anatomy of the pelvis and acetabulum have historically made classification and interpretation of acetabular fractures difficult for orthopedic trainees. The addition of 3-dimensional (3-D) computed tomography (CT) scan has gained popularity in preoperative planning, identification, and education of acetabular fractures given their complexity. Therefore, the authors examined the value of 3-D CT compared with conventional radiography in classifying acetabular fractures at different levels of orthopedic training. Their hypothesis was that 3-D CT would improve correct identification of acetabular fractures compared with conventional radiography.The classic Letournel fracture pattern classification system was presented in quiz format to 57 orthopedic residents and 20 fellowship-trained orthopedic traumatologists. A case consisted of (1) plain radiographs and 2-dimensional axial CT scans or (2) 3-D CT scans. All levels of training showed significant improvement in classifying acetabular fractures with 3-D vs 2-D CT, with the greatest benefit from 3-D CT found in junior residents (postgraduate years 1-3).Three-dimensional CT scans can be an effective educational tool for understanding the complex spatial anatomy of the pelvis, learning acetabular fracture patterns, and correctly applying a widely accepted fracture classification system.

Combined acetabulum and pelvic ring injuries.

Combined fractures of the acetabulum and pelvic ring are more common than previously believed, with an incidence as high as 15.7%. Recent series that include combined injuries indicate that the incidence of lateral compression and anteroposterior compression pelvic ring injuries is similar and that transverse and both-column acetabular fractures are the most common acetabular fracture patterns. Combined injuries most often are the result of high-energy mechanisms, and, compared with patients who present with isolated pelvic or acetabular injury, patients with combined injury typically have higher injury severity scores, higher transfusion requirements, and lower systolic blood pressure, with reported mortality rates of 1.5% to 13%. Treatment requires a multidisciplinary approach. The first priority is resuscitation following the Advanced Trauma Life Support protocols. Once the patient is stable, acetabular fractures and pelvic ring injuries should be assessed individually, and the most appropriate treatment for each should be outlined. These treatments should then be integrated to develop the most appropriate overall treatment strategy. Although outcomes data are available for isolated acetabulum and pelvic ring disruptions, no such data currently exist for combined injuries.

Distal locking using an electromagnetic field-guided computer-based real-time system for orthopaedic trauma patients

Objectives: To compare the efficacy of distal interlocking during intramedullary nailing using a freehand technique versus an electromagnetic field real-time system (EFRTS). Design: A prospective, randomized controlled trial. Setting: Level I academic trauma center. Patients/Participants: Patients older than 18 years who sustained a femoral or tibial shaft fracture amenable to antegrade intramedullary nailing were prospectively enrolled between August 2010 and November 2011. Exclusion criteria included injuries requiring retrograde nailing and open wounds near the location of the distal interlocks (distal third of the femur, knee, or distal tibia). Intervention: Each patient had 2 distal interlocking screws placed: one using the freehand method and the other using EFRTS. Main Outcome Measurement: Techniques were compared on procedural time and number of interlocking screw misses. Two time points were measured: time 1 (time to find perfect circles/time from wand placement to drill initiation) and time 2 (drill initiation until completion of interlocking placement). Results: Twenty-four tibia and 24 femur fractures were studied. EFRTS proved faster at times 1 and 2 (P < 0.0001 and P < 0.0002) and total time (P < 0.0001). This difference was larger for junior residents, though reached statistical significance for senior residents. Senior residents were faster with the freehand technique compared with junior residents (P < 0.004), but the 2 were similar using EFRTS (P = 0.41). The number of misses was higher with free hand compared with EFRTS (P = 0.02). Conclusion: These results suggest that EFRTS is faster than the traditional freehand technique and results in fewer screw misses. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk of septic knee following retrograde intramedullary nailing of open and closed femur fractures

BackgroundOne potential complication of retrograde femoral nailing in the treatment of femur fractures is the risk of septic knee. This risk theoretically increases in open fractures as a contaminated fracture site has the potential to seed the instrumentation being passed in and out of the sterile intraarticular starting point. There are few studies examining this potential complication in a relatively commonly practiced technique.MethodsAll patients who received a retrograde femoral nail for femur fracture between September 1996 and November 2006 at a Level 1 trauma center were retrospectively reviewed. This yielded 143 closed fractures, 38 open fractures and 4 closed fractures with an ipsilateral traumatic knee arthrotomy. Patient follow-up records were reviewed for documentation of septic knee via operative notes, wound culture or knee aspirate data, or the administration of antibiotics for suspected septic knee.ResultsNo evidence of septic knee was found in the 185 fractures examined in the dataset. Utilizing the Wilson confidence interval, the rate of septic knee based on our population was no greater than 2%, with that of the open fracture group alone being 9%.ConclusionsBased on these results and review of the literature, the risk of septic knee in retrograde femoral nailing of both open and closed femoral shaft fractures appears low but potentially not insignificant.FundingThere was no outside source of funding from either industry or other organization for this study.

Orthopaedic management in the polytrauma patient

The past century has seen many changes in the management of the polytraumatized orthopaedic patient. Early recommendations for non-operative treatment have evolved into early total care (ETC) and damage control orthopaedic (DCO) treatment principles. These principles force the treating orthopaedist to take into account multiple patient parameters including hypothermia, coagulopathy and volume status before deciding upon the operative plan. This requires a multidisciplinary approach involving critical care physicians, anesthesiologists and others.

Anterolateral distal tibia locking plate osteosynthesis and their ability to capture OTAC3 pilon fragments

BACKGROUND Intra-articular Pilon fractures remain therapeutically challenging due to osteochondral fracturing and comminution, marginal impaction, and insult to the soft tissue envelope. The purpose of this study was to compare the efficacy of anterolateral distal tibial locking plates in capturing main fracture fragments in tibial plafond fractures. METHODS From May 2011 to Dec 2015, 169 OTA C-type pilon fractures met inclusion and exclusion criteria with computed tomographic (CT) scans performed prior to definitive fixation. For each patient, the fracture lines were mapped, digitized, and graphically superimposed to create a compilation of fracture lines. Based on these average measurements, three distal tibia sawbones had three different anterolateral plates applied. Axial CT scan images were used to determine the efficacy of screw purchase in main fracture fragments in pilon fractures. RESULTS The Smith & Nephew PERI-LOC plate secured the largest number of fracture lines (90.1%) but missed the Volkmann fragment with greatest frequency at 3.6%. The Synthes 2.7/3.5 mm VA-LCP captured 87.3% of the fracture lines while missing the Volkmann fragment 3.2% of the time. The Synthes 3.5 mm LCP captured 86.5% of the fracture lines but was the best at securing the Volkmann fragment (1.2% missed). All three implants were deficient in capturing the medial malleolar fragment. The PERI-LOC and 2.7/3.5 mm VA-LCP did not differ with respect to percentage of fragments captured (p = 0.721) but both outperformed the 3.5 mm LCP (p = 0.021 and p = 0.05, respectively). CONCLUSIONS This study was consistent with prior literature in defining three main fracture fragments: anterior, medial, and posterior. All three plates were deficient in capturing the medial malleolar fragment. The Smith and Nephew PERI-LOC plate secured the most number of fracture lines, while the Synthes 3.5 mm LCP was least likely to miss the Volkmann fragment and most likely to miss the medial malleolar fragment. No plate was found to be superior to the other in capturing all fracture lines of the OTAC3 pilon fragments. LEVEL OF EVIDENCE Three.

Treatment and complications of patients with ipsilateral acetabular and femur fractures: A multicenter retrospective analysis

Objectives: The purpose of this study was to review the treatment of patients with ipsilateral acetabular and femur fractures to provide descriptive demographic data, injury pattern classification, treatment, and evaluate the complication profile reflective of current practices. Study Design: Multicenter retrospective cohort. Setting: Eight Level 1 Trauma Centers. Patients/Participants: One hundred one patients met inclusion criteria. Intervention: Surgical treatment of both the acetabular and femur fractures. Main Outcome Measurements: The complications evaluated include avascular necrosis, heterotopic ossification, posttraumatic arthritis, deep venous thrombosis, pulmonary embolism and superficial/deep infection, fracture union, and secondary surgeries. Results: Forty-three patients had 31 type fractures (29A; 11B, and 3C), 60 had 32 type (37A, 8B; 15C), and 8 had 33 type (1A, 4B, 3C) femur fractures; 10 patients had combinations involving more than 1 femur fracture pattern. There were 35 62A type fractures, 47 62B, and 19 62C acetabular fractures. Age of 45 or older was associated with marginal impaction (P = 0.001). The aggregate infection rate was 17%. More than 30% of patients required secondary surgeries. The rate of avascular necrosis was higher in acetabular fractures combined with proximal femur fractures (P < 0.05). The rate of deep venous thrombosis was associated with increased age and time to surgical fixation (P < 0.05). Conclusions: We report the largest review of the surgical treatment and complications of ipsilateral acetabular and femoral fractures. This study provides useful information regarding the complications and provides some treatment recommendations regarding these injuries. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.