Management of an extended clivus fracture: a case report

Background: Clivus fractures are highly uncommon. The classification by Corradino et al. divides the different lesions in longitudinal, transverse and oblique fractures. Longitudinal types are associated with the highest mortality rate between 67 – 80%. Clivus fractures are often found after high velocity trauma, especially traffic accidents and falls. The risk of neurologic lesions is high, because of the anatomic proximity to neurovascular structures like the brainstem, the vertebrobasilar artery, and the cranial nerves. Longitudinal clivus fractures have a special risk of causing entrapment of the basilar artery and thus ischemia of the brainstem. Case presentation: This lesion in our patient was a combination-fracture of the craniocervical junction with a transverse clivus fracture. In this case, the primary closed reduction of the clivus fracture and the immobilization with a halo device was the therapy of choice and led to consolidation of the fracture. Conclusion: Therapy advices and examples in the literature are scarce. We present a patient with a clivus fracture, who could be well treated by a halo device. Through detailed research of the literature a therapy algorithm has been developed.<br

An unusual cause of ankle pain: fracture of a talocalcaneal coalition as a differential diagnosis in an acute ankle sprain: a case report and literature review

Background: The acute ankle sprain is one of the most common injuries seen in trauma departments. Ankle sprains have an incidence of about one injury per 10 000 people a day. In contrast tarsal coalition is a rare condition occurring in not more than one percent of the population. Case presentation: We present the case of a 23 year old male patient with pain and local swelling after an acute ankle sprain. Initial clinical and radiological examination showed no pathologies. Due to prolonged pain, swelling and the inability of the patient to weight bear one week after trauma further diagnostics was performed. Imaging studies (MRI and CT) revealed a fracture of a talocalcaneal coalition. To the knowledge of the authors no fracture of a coalition was reported so far. Conclusion: This report highlights the presentation of symptomatic coalitions following trauma and furthermore, it points out the difficulties in the diagnosis and treatment of a rare entity after a common injury. A diagnostic algorithm has been developed to ensure not to miss a severe injury.<br

Risk factors for infectious complications after open fractures; a systematic review and meta-analysis

__Purpose__ The purpose of this study was to identify risk factors for the development of infection after open fracture fixation. __Methods__ A comprehensive search in all scientific literature of the last 30 years was performed in order to identify patient-, trauma-, diagnosis- and treatment-related risk f

Evidence-Based Recommendations for Local Antimicrobial Strategies and Dead Space Management in Fracture-Related Infection

Summary:Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. However, debridement is often associated with the formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention not only for local antimicrobial activity but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI.Level of Evidence:Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence

General treatment principles for fracture-related infection: recommendations from an international expert group

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients’ short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group. Level of evidence: Level V

Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design

Background: Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF’s. Methods: This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months. Discussion: Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility. Trial registration: ClinicalTrials.gov: NCT03598530

The Anatomy of Glenoid Concavity—Bony and Osteochondral Assessment of a Stability-Related Parameter

Glenoid concavity is a crucial factor for glenohumeral stability. However, the distribution of this stability-related parameter has not been focused on in anatomical studies. In this retrospective study, computed tomography (CT) data and tactile measurements of n = 27 human cadaveric glenoids were analyzed with respect to concavity. For this purpose, the bony and osteochondral shoulder stability ratio (BSSR/OSSR) were determined based on the radius and depth of the glenoid shape in eight directions. Various statistical tests were performed for the comparison of directional concavity and analysis of the relationship between superoinferior and anteroposterior concavity. The results proved that glenoid concavity is the least distinctive in anterior, posterior, and anterosuperior direction but increases significantly toward the superior, anteroinferior, and posteroinferior glenoid. The OSSR showed significantly higher concavity than the BSSR for most of the directions considered. Moreover, the anteroposterior concavity is linearly correlated with superoinferior concavity. The nonuniform distribution of concavity indicates directions with higher stability provided by the anatomy. The linear relationship between anteroposterior and superoinferior concavity may motivate future research using magnetic resonance imaging (MRI) data to optimize clinical decision-making toward more personalized treatment of glenoid bone loss

Treatment strategies for scapular spine fractures: a scoping review

Fractures of the scapular spine are relatively rare and can occur without (1) or with (2) association to a reverse shoulder arthroplasty (RSA). To date there are only limited data on the topic. The aim of this scoping review was to identify all available literature and report current treatment concepts. A scoping review was conducted by searching PubMed for relevant studies between 2000 and October 2020. All studies were included which gave detailed descriptions of the treatment strategy. A total of 21 studies with 81 patients were included for the analysis. The mean age over all patients was 62 years (range: 24 to 89 years) and 77% of the patients were female. In 19.8% of cases, the fracture occurred after a traumatic fall from standing height. Eighty-six per cent of the patients had an RSA-associated scapular spine fracture (2). These patients were older compared to group (1) (47 ± 19.6 vs. 76 ± 5.6 years, p = 0.0001) and the majority were female (85%). The majority from group (1) underwent operative treatment with plate fixation. Most patients regained full function and range of motion. RSA-associated fractures (2) were mainly treated non-operatively, with moderate clinical outcome. A high rate of nonunions was reported. Scapular spine fractures without RSA are mainly treated operatively with good clinical results. In association with RSA, scapular spine fractures are mainly treated non-operatively and lead to inferior clinical and radiological results. This scenario seems to be problematic and further research is required to sharpen treatment concepts in this group

Blunt Chest Trauma in Polytraumatized Patients: Predictive Factors for Urgent Thoracotomy

Purpose: Current guidelines on urgent thoracotomy of polytraumatized patients are based on data from perforating chest injuries. We aimed to identify predictive factors for urgent thoracotomy after chest-tube placement for blunt chest trauma in a civilian setting. Methods: Polytraumatized patients (Injury Severity Score ≥16) with blunt chest trauma, submitted to a level I trauma centre during a period of 12 years that received at least one chest tube were included. Trauma mechanism, chest-tube output, haemoglobin values, need for cellular blood products, coagulopathies, rib fracture pattern, thoracotomy, and mortality were retrospectively analysed. Results: 235 polytraumatized patients were included. Patients that received urgent thoracotomy (UT, n = 10) showed a higher mean chest-tube output within 24 h with a median (Mdn) of 3865 (IQR 2423–5156) mL compared to the group with no additional thoracic surgery (NT, n = 225) with Mdn 185 (IQR 50–463) mL (p < 0.001). The cut-off 24-h chest-tube output value for recommended thoracotomy was 1270 mL (ROC-Curve). UT showed an initial haemoglobin of Mdn 11.7 (IQR 9.2–14.3) g/dL and an INR value of Mdn 1.27 (IQR 1.11–1.69) as opposed to Mdn 12.3 (IQR 10–13.9) g/dL and Mdn 1.13 (IQR 1.05–1.34) in NT (haemoglobin: p = 0.786; INR: p = 0.215). There was an average number of 7.1(±3.4) rib fractures in UT and 6.7(±4.8) in NT (p = 0.649). Conclusions: Chest-tube output remains the single most important predictive factor for urgent thoracotomy also after blunt chest trauma. Patients with a chest-tube output of more than 1300 mL within 24 h after trauma should be considered for transfer to a level I trauma centre with standby thoracic surgery

Male Sex Is Associated with Higher Mortality and Increased Risk for Complications after Surgical Treatment of Proximal Humeral Fractures

Aims: The best surgical treatment of multi-fragmentary proximal humeral fractures in the elderly is a highly controversial topic. The aim of this study is to assess for sex-related differences regarding mortality and complications after reverse total shoulder arthroplasty (RTSA) and locking plate fixation (LPF). Patients and Methods: All patients from the largest German healthcare insurance (26.5 million policy holders) above the age of 65 years that were treated with LPF or RTSA after a multi-fragmentary proximal humerus fracture between January 2010 and September 2018 were included. Multivariable Cox regression models were used to assess the association of sex with overall survival, major adverse events and surgical complications. Results: A total of 8264 (15%) men and 45,707 (85%) women were followed up for a median time of 52 months. After 8 years, male patients showed significantly higher rates for death (65.8%; 95% CI 63.9–67.5% vs. 51.1%; 95% CI 50.3–51.9%; p 0.05), whereas men showed a significantly increased risk after RTSA (HR 1.86; 95% CI 1.56–2.22; p < 0.001) with more revision surgeries performed (HR 1.76, 95% CI 1.46–2.12; p < 0.001) compared to women. Conclusion: The male sex is an independent risk factor for death and major adverse events after both LPF and RTSA. An increased risk for surgical complications after RTSA suggests that male patients benefit more from LPF. Sex should be considered before making treatment decisions