Nathan N. OʼHara

Positional Change in Displacement of Midshaft Clavicle Fractures: An Aid to Initial Evaluation.

Objectives: To determine how change in position affects displacement of midshaft clavicle fractures. Design: Retrospective review. Setting: Level I Trauma Center. Patients: Eighty patients with displaced midshaft clavicle fractures and presence of supine and semiupright or upright chest radiographs taken within 2 weeks of each other. Intervention: Supine, semiupright, and upright chest radiographs. Main Outcome Measurements: Fracture shortening and vertical displacement on supine, semiupright, and upright radiographs. Results: Mean vertical displacement was 9.42 mm [95% confidence interval (95% CI), 8.07–10.77 mm], 11.78 mm (95% CI, 10.25–13.32 mm), and 15.72 mm (95% CI, 13.71–17.72 mm) in supine, semiupright, and upright positions, respectively. Fracture shortening was −0.41 mm (95% CI, −2.53 to 1.70 mm), 2.11 mm (95% CI, −0.84 to 5.07), and 4.86 mm (95% CI, 1.66–8.06 mm) in supine, semiupright, and upright positions, respectively. Change in position from supine to upright significantly increased both vertical displacement and fracture shortening (P < 0.001). In the upright position, the proportion of patients who met operative indications (fracture shortening >20 mm) was 3 times greater when compared with that in the supine position (upright 17.65%; supine 5.88%, P = 0.06). Positional changes in fracture displacement were not associated with body mass index, age, or gender. Conclusions: Patient position is associated with significant changes in fracture displacement. Over 3 times more patients meet operative indications when placed in the upright versus supine position. An upright chest radiograph should be obtained to evaluate midshaft clavicle fracture displacement, as it represents the physiologic stress across the fracture when considering nonoperative management. Level of Evidence: Prognostic level IV. See Instructions for Authors for a complete description of levels of evidence.

Survivorship after High-Energy Geriatric Trauma

Objectives: To evaluate in-hospital, 1-year, and 5-year survivorship of geriatric patients after high-energy trauma, to compare survivorship of geriatric patients who sustained high-energy trauma with that of those who sustained low-energy trauma, and to identify predictors for mortality. Design: Retrospective. Setting: Urban Level I trauma center. Patients: Study group of 1849 patients with high-energy trauma and comparison group of 761 patients with low-energy trauma. Intervention: Each patient was observed from the time of index admission through the end of the study period or until death or readmission. Main Outcome Measurement: Long-term survivorship based on the Social Security Death Index. Results: Survivorship between patients with high-energy and low-energy injuries was statistically significant. Among patients who sustained high-energy injuries, in-hospital mortality was 8%, 1-year mortality was 15%, and 5-year mortality was 25%. Among patients who sustained low-energy injuries, in-hospital mortality was 3%, 1-year mortality was 23%, and 5-year mortality was 40%. Low-energy mechanism of injury was an independent predictor for 1-year and 5-year mortality, even when controlling for Charlson Comorbidity Index (CCI), Injury Severity Score (ISS), age, sex, body mass index (BMI), and admission Glasgow Coma Scale (GCS) score. Conclusions: Geriatric patients with high-energy injuries and those with low-energy injuries seem to represent different patient populations, and low-energy mechanism seems to be a marker for frailty. High-energy mechanism was associated with lower long-term mortality rates, even when controlling for CCI, ISS, age, sex, BMI and admission GCS score. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Developing Orthopaedic Trauma Capacity in Uganda: Considerations From the Uganda Sustainable Trauma Orthopaedic Program.

Summary: Uganda, like many low-income countries, has a tremendous volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia and Makerere University that was initiated in 2007 to reduce the consequences of neglected orthopaedic trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through clinical training, skills workshops, system support, technology development, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anaesthesia, nursing, rehabilitation, and sterile reprocessing. Since the programs inception, the number of trained orthopaedic surgeons practicing in Uganda has more than doubled. Many of these newly trained surgeons provide clinical care in the previously underserved regional hospitals. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda.

Is Lateral Femoral Nailing Associated With Increased Intensive Care Unit Days? A Propensity-Matched Analysis of 848 Cases

Objective: The purpose of this study is to determine if lateral patient position during femoral nailing is associated with increases in intensive care unit (ICU) length of stay (LOS) or ventilator days when compared with femoral nailing in a supine position. Design: Retrospective cohort study. Setting: Level 1 trauma center. Patients/Participants: Patients with femoral shaft fractures treated with intramedullary fixation were identified. Propensity matching was performed to minimize selection bias using factors thought to be associated with surgeon selection of supine nailing at our institution (Injury Severity Score, Abbreviated Injury Score brain, and bilateral fractures). After matching, 848 patients were included in the analysis. Intervention: Femoral nailing in the lateral position compared with the supine position. Main Outcome Measurements: Our primary outcome measure was ICU LOS. Ventilator days were the secondary outcome. Results: Treating patients with femoral nailing in the lateral position was associated with a 1.88 days (95% confidence interval, 0.73–3.02; P = 0.001) reduction in ICU LOS in our adjusted model. Intramedullary nailing in the lateral position was associated with a 1.29 days (95% confidence interval, −0.12 to 2.69) decrease in postoperative time on a ventilator. However, this finding was not statistically significant (P = 0.07). Conclusion: Lateral femoral nailing was associated with decreased ICU LOS (P = 0.001) even after accounting for selection bias using propensity score matching. Our data indicate that lateral femoral nailing is likely not associated with the increased risk of pulmonary complication. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Making Safe Surgery Affordable: Design of a Surgical Drill Cover System for Scale.

Summary: Many surgeons in low-resource settings do not have access to safe, affordable, or reliable surgical drilling tools. Surgeons often resort to nonsterile hardware drills because they are affordable, robust, and efficient, but they are impossible to sterilize using steam. A promising alternative is to use a Drill Cover system (a sterilizable fabric bag plus surgical chuck adapter) so that a nonsterile hardware drill can be used safely for surgical bone drilling. Our objective was to design a safe, effective, affordable Drill Cover system for scale in low-resource settings. We designed our device based on feedback from users at Mulago Hospital (Kampala, Uganda) and focused on 3 main aspects. First, the design included a sealed barrier between the surgical field and hardware drill that withstands pressurized fluid. Second, the selected hardware drill had a maximum speed of 1050 rpm to match common surgical drills and reduce risk of necrosis. Third, the fabric cover was optimized for ease of assembly while maintaining a sterile technique. Furthermore, with the Drill Cover approach, multiple Drill Covers can be provided with a single battery-powered drill in a “kit,” so that the drill can be used in back-to-back surgeries without requiring immediate sterilization. The Drill Cover design presented here provides a proof-of-concept for a product that can be commercialized, produced at scale, and used in low-resource settings globally to improve access to safe surgery.