Steven K. Dailey

Management of complex elbow dislocations: a mechanistic approach.

Complex elbow dislocations (ie, fracture-dislocations) are challenging injuries to treat and may result in significant patient morbidity. Chronic instability, posttraumatic arthrosis, and poor functional outcomes are frequent. Orthopaedic surgeons should strive to optimize elbow function through restoration of articular congruity and stability coupled with early rehabilitation. Although most of these injuries require surgical management, not all complex elbow dislocations are equivalent. Understanding elbow biomechanics and the injury mechanism provides valuable insight into the variations of pathology that may be observed. Identifying the particular fracture pattern, such as an axial loading, valgus posterolateral rotatory, or varus posteromedial rotatory injury mechanism, helps guide appropriate treatment.

Proper Patient Positioning and Complication Prevention in Orthopaedic Surgery.

➤ The consequences of improper intraoperative positioning can be profound: it not only may cause substantial morbidity but also may be a major area of litigation, particularly when peripheral nerve injury occurs.➤ The ulnar nerve is most likely to be injured secondary to improper positioning. The elbow should be flexed ≤90° and the forearm placed in a neutral or slightly supinated position intraoperatively to minimize pressure in the cubital tunnel.➤ Pressure-related complications, such as pressure ulcers and alopecia, are best avoided by the use of adequate padding. Cushions on the operating-room table and armrest should be emphasized under osseous prominences.➤ Positioning the head in a non-neutral alignment or arm abduction of ≥90° may result in injury to the brachial plexus.➤ The hemilithotomy position increases intracompartmental pressure in the leg on the uninjured side. The risk of well-leg compartment syndrome can be minimized by avoiding this position if possible.

Open reduction and internal fixation of acetabulum fractures: does timing of surgery affect blood loss and OR time?

Objectives: The purpose of this study was to investigate the timing of surgical intervention for fractures of the acetabulum and its influence on perioperative factors. Design: Retrospective review. Setting: Level I trauma center. Patients: Two hundred eighty-eight consecutive patients who sustained either posterior wall (PW), associated both column (ABC), or anterior column posterior hemitransverse (ACPHT) acetabulum fractures were included in the study. Intervention: One hundred seventy-six PW fractures were treated through a Kocher–Langenbeck approach, and 112 ABC/ACPHT fractures were treated through an anterior intrapelvic approach. Main Outcome Measurements: Estimated blood loss (EBL), operative time. Results: EBL (800 vs. 400 mL), operative time (270 vs.154 minutes), and hospital stay (11 vs. 7 days) were greater for the ABC/ACPHT fractures compared with the PW fractures. When comparing early (⩽48 hours) versus late (>48 hours) treatment of PW fractures, there was no difference in EBL (400 vs. 400 mL, P = 0.37) or operative time (150 vs. 156 minutes, P = 0.50). In comparison of early versus late treatment of ABC/ACPHT fractures, no significant difference was noted in EBL (725 vs. 800 mL, P = 0.30) or operative time (258.5 vs. 272 minutes, P = 0.21). Conclusions: We found no advantage or disadvantage in terms of EBL or operative time for early (⩽48 hours) versus late (>48 hours) fixation for either PW or ABC/ACPHT acetabular fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Achieving Anatomic Acetabular Fracture Reduction-When is the Best Time to Operate?

Objectives: We hypothesize that earlier operative intervention for acetabular fractures improves the probability of achieving an anatomic reduction. Design: Retrospective review. Setting: Academic level I trauma center. Patients/Participants: Six hundred fifty acetabular fractures treated through open reduction and internal fixation (ORIF) between September 2001 and February 2014. Intervention: Acetabular fracture ORIF. Main Outcome Measurements: Reduction quality was assessed through postoperative radiographs. Displacement of ⩽1 mm was considered an anatomic reduction, 2–3 mm imperfect, and >3 mm poor. Results: Anatomic reductions were observed in 85% (n = 553) of cases, imperfect reductions in 11% (n = 74) of cases, and poor reductions in 4% (n = 23) of cases. Patients with anatomic reductions had significantly shorter times from injury to ORIF [odds ratio (OR) interval] (median, 3 d) when compared with either imperfect (median, 4.5 days, P = 0.02) or poor reductions (median, 7 days, P < 0.001) reductions. The OR interval of imperfect reductions was also significantly shorter than that of poor reductions (P = 0.02). Logistic regression analysis demonstrated that OR interval had an effect of −0.12, meaning that the log odds of anatomic reduction decreases by 0.12 with each day from injury to ORIF. Conclusion: The interval from injury to operative fixation of acetabular fractures affects reduction quality. Earlier intervention improves the probability of achieving an anatomic reduction; therefore, ORIF should be performed as early as possible, provided the patient is optimized for surgery. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of Routine Postoperative CT Scan After Open Reduction and Internal Fixation of the Acetabulum.

Objectives: The purpose of this study was to evaluate the efficacy of routine postoperative computed tomography (CT) scan after open reduction and internal fixation of acetabular fractures. Design: Retrospective review of prospectively collected acetabulum fracture database. Setting: Level I trauma center. Patients/Participants: A total of 606 consecutive patients underwent surgical fixation of 612 acetabular fractures. All patients were evaluated with intraoperative fluoroscopy in addition to 3 standard plain radiographs (AP pelvis and two 45 degrees oblique Judet views). Reduction and fixation were believed to be adequate and definitive before exiting the operative suite based on these imaging modalities. Intervention: Axial postoperative CT scan of the pelvis was obtained in 563 of the patients (93%) after 569 operative cases. Main Outcome Measurements: Revision acetabular surgery based on routine postoperative CT scan findings. Results: There were no significant differences between index and revision surgery groups regarding age, gender, body mass index, fracture pattern, mechanism of injury, or surgical approach (P > 0.05). Evaluation of 563 postoperative CT scans of the pelvis resulted in revision acetabular surgery for 2.5% of patients (n = 14). There were 6 (1.1%) cases of intraarticular hardware not recognized on the intraoperative fluoroscopy or pelvic radiographs. Four patients (0.7%) had residual intraarticular osteochondral fragments deemed too large to leave in the hip joint. There were 3 cases (0.5%) of unacceptable malreduction, and 1 case (0.2%) of both malreduction and an intraarticular osteochondral fragment. Conclusions: A small percentage of patients (2.5%) will benefit from a routine CT scan after acetabular fracture fixation. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Iatrogenic Radial Nerve Palsy After Humeral Shaft Nonunion Repair: More Common Than You Think.

Objectives: To determine the rate of iatrogenic radial nerve palsy (RNP) after surgical repair of established humeral shaft nonunion (HSNU). Design: Retrospective chart review. Setting: Level I trauma center. Patients/Participants: Fifty-four patients with HSNU, 10 (18.5%) of whom developed an iatrogenic RNP after nonunion repair. Intervention: HSNU repair with compression plate stabilization with or without autogenous bone graft. Main Outcome Measurements: Postoperative iatrogenic RNP. Results: Ten (18.5%) patients developed iatrogenic radial nerve palsies: 8 experienced complete resolution (mean, 2.5 months) and 2 experienced partial resolution. There were no statistically significant differences between patients who developed nerve palsy and those who did not in regard to age, gender, tobacco use, diabetic status, previous RNP, initial management (operative vs. nonoperative), surgical approach, presence of infected nonunion, number of previous surgeries, or operative time (P > 0.05). Conclusions: The occurrence of iatrogenic RNP for patients undergoing surgical repair of an HSNU was 18.5%. According to historical data, this rate is nearly 3 times higher than for those undergoing open reduction and internal fixation of either acute humeral shaft fractures or HSNUs. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of Levels of Evidence.

Assessment of pelvic fractures resulting from the 2010 Haiti earthquake: Opportunities for improved care

BACKGROUND On January 12, 2010, a catastrophic 7.0 magnitude earthquake shook the Haitian capital of Port-au-Prince. Because of their sudden and destructive nature, earthquakes can result in unfamiliar mass casualty situations accompanied by devastating orthopedic injuries. Evaluation of the pelvic fractures resulting from this earthquake revealed several factors that we hope will facilitate optimal preparation and planning for future disaster situations. METHODS A cohort of patients with earthquake-related pelvic ring fractures who were treated aboard the USNS Comfort was retrospectively analyzed. Anteroposterior radiographs of the pelvis were evaluated and categorized according to the Young-Burgess classification system. RESULTS Sixty-eight patients were included in the cohort. The mean (SD) age was 29.6 (14.4) years. Nineteen patients (29.7%) were male, and 49 (70.3%) were female. Pelvic fractures were categorized as anteroposterior compression in 7 patients, lateral compression (LC) in 47 patients, vertical shear (VS) in 8 patients, and combination of pelvic ring/acetabulum in 6 patients. Among the 23 patients treated operatively, the mean (SD) delay from injury to surgery was 19.2 (7.4) days. CONCLUSION Patients showed predominance toward LC injuries (69.1%), consistent with crush under rubble. Thirty-one percent of the fractures were considered unstable (anteroposterior compression Type III, LC Type III, VS, and combination of pelvic ring/acetabulum). The VS injuries observed (11.8%) may be the result of a previously unidentified injury mechanism, an upright individual being struck by falling rubble, violently applying a downward force to the body over an extended lower extremity. A substantial delay in the treatment observed in this series may lead to an underestimation of both quantity and severity of pelvic fractures as critically ill patients may have perished before evaluation and treatment. In addition, the application of pelvic sheeting techniques may be a lifesaving intervention for interval pelvic stabilization following earthquakes in which medical resources are scarce. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level V.

Chronic Bilateral Tibial Stress Fractures with Valgus Treated with Bilateral Intramedullary Nailing: A Case Report

Introduction: Stress fractures are overuse injuries most commonly seen in athletes, military recruits, and individuals with endocrine abnormalities. It has been demonstrated that chronic cases of anterior tibial stress fractures refractory to conservative management respond well to intramedullary nailing. To our knowledge, only one report has been published concerning patients with bilateral tibial stress fractures treated with bilateral intramedullary nailing. All patients in the series were high-level athletes. We present the case of a non-athletic patient with chronic bilateral tibial stress fractures and associated deformity successfully treated with bilateral intramedullary nails. Case Report: A 23-year-old Caucasian female full-time student presented with chronic bilateral shin pain for approximately five years. She had failed an extensive regimen of conservative management. She was diagnosed with chronic bilateral tibial stress fractures based on history, physical examination, and radiologic findings. She subsequently underwent sequential intramedullary nailing of her tibiae. Both tibiae were in valgus alignment; however, this did not preclude nail placement. The nails deformed upon insertion into the sclerotic canals to conform to the deformation. Post operatively the tibiae united and patient was relieved of her symptoms. Conclusion: Bilateral intramedullary nailing of chronic bilateral tibial stress fractures should be considered as a treatment option for all patients, not just high-level athletes, who fail a trial of conservative management. Additionally, mild to moderate tibial malalignment does not necessarily preclude tibial nailing as the smaller nails placed in sclerotic canals will likely deform on insertion and conform to the canal.

The Effectiveness of Mini–C-Arm Fluoroscopy for the Closed Reduction of Distal Radius Fractures in Adults: A Randomized Controlled Trial

PURPOSE Most distal radius (DR) fractures are initially managed with closed reduction and orthosis application. Mini-C-arm fluoroscopy provides assessment of reduction quality in real time. Our null hypothesis was that there would be no difference in the reduction quality of DR fractures in the emergency department when using mini-C-arm fluoroscopy during reduction compared with standard reduction techniques (evaluating reduction quality with orthogonal radiographs taken in an orthosis). METHODS Sixty-three consecutive patients with closed DR fractures requiring reduction between April 2015 and April 2017 were prospectively randomized to standard versus fluoroscopically aided reductions. Reductions were performed by orthopedic surgery residents. The primary outcome measurement was reduction quality (radial height, radial inclination, ulnar variance, and volar tilt) as measured on postreduction radiographs. RESULTS Standard reductions were performed in 34 patients and fluoroscopically aided reductions in 29 patients. The 2 groups were similar in regards to all potential confounders that were analyzed. No differences in postreduction radial height, radial inclination, ulnar variance, or volar tilt were noted. Overall reduction attempts and subjective difficulty of fracture reduction were increased when using fluoroscopy. The rate of initial operative management did not differ between groups. CONCLUSIONS The use of mini-C-arm fluoroscopy during the initial closed reduction of adult DR fractures results in equivalent postreduction radiographic parameters when compared with conventional reduction techniques. Additional research regarding time spent in the emergency department and overall cost could elucidate potential benefits of fluoroscopically aided DR fracture reduction. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

Complex elbow dislocations

Abstract Complex elbow dislocations include all elbow dislocations with an associated fracture. Complex elbow dislocations are debilitating for patients and can be challenging for the treating orthopedic surgeon. Evaluation of the patient with a complex elbow dislocation begins with a thorough neurovascular examination followed by appropriate imaging, including a computed tomography scan with reconstructions. Surgical intervention is typically required and may include open reduction and internal fixation, ligament repair, or even a hinged external fixator for more complex cases. Recurrent instability, stiffness, pain, heterotopic ossification, neurologic damage, and post-traumatic arthritis are among the most common complications. Improper management of these injuries and their complications may result in long-term dysfunction and significant pain. This chapter aims to educate the practitioner about these injuries and assist in complication prevention.