Faculty Bibliography

OBJECTIVES: It is well recognized that operative treatment of a fracture of the distal humerus requires handling of the ulnar nerve, which can cause nerve dysfunction; however, the incidence of postoperative ulnar nerve dysfunction is not well studied. Our purpose was to determine the incidence of ulnar nerve dysfunction after open reduction and internal fixation of distal humerus fractures and identify factors associated with its development. DESIGN: Retrospective cohort study from two university-based institutions. PATIENTS: The medical records of 69 patients with a minimum of 12 months follow-up (median, 15 months; range, 12-72 months) after open reduction and plate and screw fixation of a bicolumnar fracture of the distal humerus (Orthopaedic Trauma Association Types 13A and C) that did not have preoperative ulnar nerve dysfunction were reviewed retrospectively. INTERVENTION: Surgical repair of a distal humerus fracture with or without ulnar nerve transposition. MAIN OUTCOMES: Ulnar nerve function was graded immediately postoperatively and at final follow-up according to a modified system of McGowan. Those with and without ulnar neuropathy were analyzed for differences in final position of the nerve (anterior versus in the cubital tunnel), open injury, multiple procedures, ipsilateral injury, and demographic factors. RESULTS:: The incidence of immediately postoperative ulnar nerve dysfunction documented in the medical record was seven of 69 patients (10.1%) (McGowan grades: 1 [57%], 2 [43%], 3 [0%]). The incidence of ulnar nerve dysfunction at final follow-up was 16% (11 of 69 patients) (McGowan grades: 1 [72%], 2 [28%], 3 [0%]). No demographic, injury, or treatment factors were associated with a risk of postoperative ulnar nerve dysfunction. CONCLUSION: There is a substantial incidence of postoperative ulnar nerve dysfunction after open reduction and plate and screw fixation of the distal humerus, which is likely underestimated by this retrospective analysis. Prospective studies using careful preoperative nerve evaluation and systematic postoperative nerve assessment are likely to identify an even higher incident of postoperative ulnar nerve dysfunction. Transposition was not protective in this analysis

BACKGROUND: Ethnic disparities have been demonstrated in the treatment of chronic diseases, such as diabetes and heart disease. It is unclear if similar ethnic disparities appear with respect to recovery following fracture care. METHODS: We retrospectively reviewed 496 individuals (253 whites, 100 blacks, and 143 Latinos) with a fracture of the distal part of the radius. Assessment of physical function and pain was conducted at three, six, and twelve months following treatment. The Disabilities of the Arm, Shoulder and Hand (DASH) score was used to assess physical function, and a visual analog scale was used to assess pain. Multiple linear regression was used to model physical function and pain across ethnicity while controlling for age, sex, mechanism of injury, level of education, type of fracture, type of treatment (operative or nonoperative), and Workers' Compensation status. RESULTS: Both blacks and Latinos exhibited poorer physical function and greater pain than whites did at most follow-up points. Latinos reported more pain at each follow-up point in comparison with blacks and whites (p < 0.001 at three, six, and twelve months). These significant differences remained after controlling for Workers' Compensation status, which was also strongly associated with both pain and function. CONCLUSIONS: These findings suggest that recovery is different between ethnic groups following a fracture of the distal part of the radius. These ethnic disparities may result from multifactorial sociodemographic factors that are present both before and after fracture treatment

Obesity has been increasing steadily in the US population over the past 50 years. In trauma patients, obesity is associated with higher morbidity and mortality. There are reported increases in the incidence of cardiovascular, pulmonary, venous thromboembolic, and infectious complications in obese trauma patients. Obese patients who sustain high-energy traumatic injuries often sustain orthopedic injuries to the pelvis or lower extremities. Obese orthopedic trauma patients may be at higher risk for nerve injuries secondary to positioning, intraoperative complications, loss of reduction after surgery, increased intraoperative estimated blood loss, and increased operative times. Orthopedic surgeons must be aware of these results when treating these fractures in obese trauma patients

Low-energy shotgun fractures involving the arm are complex injuries. Previously published reports have emphasized various problems associated with these injuries. This case report describes a low-energy shotgun wound managed by a staged treatment protocol involving: (1) a spanning external fixator and immediate soft tissue management, followed by (2) osteosynthesis and autogenous bone grafting and (3) epineural suturing of injured radial nerve, with a successful outcome. Although adequate debridement of the fracture and soft tissue wound is the key to open fracture management, some difference of opinion exists with regard to the timing of bone reconstruction and grafting. In severe type III open fractures, or in wounds that are marginal, it may be best to delay cancellous bone grafting until soft tissue has stabilized following acute trauma when the risk of infection has been minimized. If early coverage of vital structures is not possible, local or remote flap coverage may be necessary

Distal radius fractures are the most common upper extremity fracture, representing one-sixth of all fractures treated in emergency departments nationwide. Beyond the initial reduction and immobilization of these fractures, providing proper followup to ensure maintenance of the reduction and identify complications is necessary for optimal recovery of forearm and wrist functions. We sought to identify the clinical and demographic factors that characterize patients with distal radius fractures who do not return for followup and to assess the underlying causes for their poor followup rates. Compared with patients who were compliant with followup, those lost to followup had lower Physical and Mental Health scores on the SF-36 forms, more often were treated nonoperatively, and more likely had not surpassed secondary education. However, we found no difference between these two groups based on age, gender, mechanism of injury, marital status, or hand dominance. Early identification of patients who potentially are noncompliant can result in additional measures being taken to ensure the patient's return to the treating hospital and physicians. This in turn will prevent complications attributable to lack of followup and allow more accurate assessment of results, thereby improving patient outcomes

BACKGROUND: To our knowledge, no study to date has compared the use of spinal and general anesthesia in patients undergoing operative fixation of an unstable ankle fracture. The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients. METHODS: Between October 2000 and November 2006, 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively. Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia. All patients were evaluated at three, six, and twelve months postoperatively with use of standardized, validated general and limb-specific outcome instruments. Standard and multivariable analyses comparing outcomes at these intervals were performed. RESULTS: Four hundred and sixty-six patients (93%) who had been followed for a minimum of one year met the inclusion criteria. Compared with the general anesthesia group, the spinal anesthesia group had a greater mean age (p = 0.005), higher classification on the American Society of Anesthesiologists system (p = 0.03), and a greater number of patients with diabetes (p = 0.02). There was no difference in sex distribution between the groups. At three months, patients who received spinal anesthesia had significantly better pain scores (p = 0.03) and total scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 0.02). At six months, patients in the spinal anesthesia group continued to have better pain scores (p = 0.04), but there was no longer a difference in total scores (p = 0.06). At twelve months, no difference was detected between the groups in terms of functional or pain scores. There was no difference in complication rates between the groups. CONCLUSIONS: Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period. We recommend that, unless there is a specific contraindication, patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence

OBJECTIVE: This study was performed to evaluate the results of operative treatment of ankle fractures in patients who required syndesmotic stabilization in addition to malleolar fracture fixation compared with patients who required malleolar fixation alone. DESIGN: The authors conducted a retrospective review of prospectively collected data. SETTING: Academic medical center. PATIENTS: Between October 2000 and November 2006, 347 patients who underwent surgical repair of an unstable ankle fracture were enrolled in a prospective database. INTERVENTION: Patients who had an associated syndesmotic disruption requiring surgical stabilization in association with either an ankle fracture or a fracture-dislocation were identified and compared with a cohort treated during the same time period who had sustained an ankle fracture or fracture-dislocation without syndesmotic disruption. MAIN OUTCOME MEASUREMENTS: All patients were followed and evaluated at 3, 6, and 12 months with clinical and radiographic examination as well as functional status (Short Musculoskeletal Functional Assessment, American Orthopaedic Foot and Ankle Society). Patient-reported pain and postoperative complications were recorded as well. RESULTS: Three hundred forty-seven patients met the inclusion criteria and had 1-year minimum follow up. Seventy-nine patients (23%) who had syndesmotic stabilization were identified and compared with 268 patients (77%) who did not. No differences were found between the two groups with respect to age or American Society of Anesthesiologists status; however, there was a greater percentage of men in the syndesmotic injury group (P = 0.04). There was a greater percentage of Type C fractures requiring syndesmosis stabilization, whereas Type B fractures were less likely to require syndesmosis stabilization (P = 0.001) At 6- and 12-month follow up, there was a clear difference in outcome based on American Orthopaedic Foot and Ankle Society and Short Musculoskeletal Functional Assessment scores; patients who underwent syndesmotic stabilization had worse American Orthopaedic Foot and Ankle Society scores with lower function ratings (P = 0.04) and worse pain ratings (P = 0.02). Short Musculoskeletal Functional Assessment scores were also worse at 12 months in patients who had syndesmotic stabilization because the dysfunction index was higher in the syndesmotic injury group (P = 0.009). Radiographically, 18 of 144 (13%) syndesmotic screws were noted to be broken on follow-up radiographs, eight of which were subsequently removed. There were no other differences in complication rates. CONCLUSION: Patients who required syndesmotic stabilization in addition to malleolar fracture fixation had poorer outcomes at 12 months compared with patients who required malleolar fracture fixation alone. This information is important for patient counseling to manage expectations regarding outcomes after injury

Femoral neck fractures in young patients are a relatively rare event and are often the consequence of a high-energy injury. Concomitant injuries are present more than 50% of the time. Previous reports have found the rate of nonunion and avascular necrosis in this population to be as high as 35% and 45%, respectively. The salvage options, which tend to yield more acceptable results in elderly patients with femoral neck fractures, yield disproportionately poor results in young, active patients who are often productive members of the labor force. Many reports exist in the literature evaluating the various treatment options of these injuries. This review will address the epidemiology and diagnosis of the injury. In addition, the various treatment options in the acute presentation, as well as options available for treating the sequelae of femoral neck fractures in the young, will be discussed. Although longer life expectancy and the sustained activity level of many people previously considered elderly has blurred the definition of 'young,' this review will use the available literature dealing with skeletally mature patients up to the age of 60 years

Background: When challenged with extremity wounds that require further debridement, edema reduction and decreased bacterial content, temporarily implanting vacuum-assisted closure reticulated open-cell foam dressings is an effective adjunct for temporary wound closure and results in enhanced flap tissue survival. Methods: A retrospective review was performed in 13 consecutive patients with a lower extremity surgical wound and exposed hardware, joint, tendon or bone who received the two-stage wound closure treatment. Primary endpoints included time to closure, total wound duration, and wound closure status upon discharge. Results: Mean time from the initial procedure until definitive closure was 4 days (range, 2-8 days). Mean wound duration before the procedure was 54 days (range, 5-120 days). All 13 wounds had delayed primary closure or random pattern flap upon discharge and remained closed throughout the length of follow-up. Conclusions: Temporarily implanted vacuum-assisted closure may be a safe and effective adjunctive therapy when applied to the undersurface of newly developed flaps