IMPORTANCENo consensus has been reached to date regarding the optimal treatment for distal radius fractures. The international rate of operative treatment has been increasing, despite higher costs and limited functional outcome evidence to support this shift. OBJECTIVESTo compare functional, clinical, and radiologic outcomes after operative vs nonoperative treatment of distal radius fractures in adults. DATA SOURCES The PubMed/MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception to June 15, 2019, for studies comparing operative vs nonoperative treatment of distal radius fractures. STUDY SELECTION Randomized clinical trials (RCTs) and observational studies reporting on the following: acute distal radius fracture with operative treatment (internal or external fixation) vs nonoperative treatment (cast immobilization, splinting, or bracing); patients 18 years or older; and functional outcome. Studies in a language other than English or reporting treatment for refracture were excluded. DATA EXTRACTION AND SYNTHESIS Data extraction was performed independently by 2 reviewers. Effect estimates were pooled using random-effects models and presented as risk ratios (RRs) or mean differences (MDs) with 95% CIs. Data were analyzed in September 2019. MAIN OUTCOMES AND MEASURES The primary outcome measures included medium-term functional outcome measured with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the overall complication rate after operative and nonoperative treatment.RESULTS A total of 23 unique studies were included, consisting of 8 RCTs and 15 observational studies, that described 2254 unique patients. Among the studies that presented sex data, 1769 patients were women [80.6%]. Overall weighted mean age was 67 [range, 22-90] years). The RCTs included 656 patients (29.1%); observational studies, 1598 patients (70.9%). The overall pooled effect estimates the showed a significant improvement in medium-term (Յ1 year) DASH score after operative treatment compared with nonoperative treatment (MD,]; P = .005; I 2 = 84%). No difference in complication rate was observed (RR, 1.03 [95% CI, 0.69-1.55]; P = .87; I 2 = 62%). A significant improvement in grip strength was noted after operative treatment, measured in kilograms (MD, 2.73 [95% CI,]; P = .04; I 2 = 79%) and as a percentage of the unaffected side (MD, 8.21 [95% CI,]; P = .007; I 2 = 76%). No improvement in mediumterm DASH score was found in the subgroup of studies that only included patients 60 years or older (MD, −0.98 [95% CI, −3.52 to 1.57]; P = .45; I 2 = 34%]), compared with a larger improvement in (continued)

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IMPORTANCE Prehospital trauma triage protocols are used worldwide to get the right patient to the right hospital and thereby improve the chance of survival and avert lifelong disabilities. The American College of Surgeons Committee on Trauma set target levels for undertriage rates of less than 5%. None of the existing triage protocols has been able to achieve this target in isolation.OBJECTIVE To develop and validate a new prehospital trauma triage protocol to improve current triage rates. DESIGN, SETTING, AND PARTICIPANTSIn this multicenter cohort study, all patients with trauma who were 16 years and older and transported to a trauma center in 2 different regions of the Netherlands were included in the analysis. MAIN OUTCOMES AND MEASURES A new prediction model was developed in the CentralNetherlands region based on prehospital predictors associated with severe injury. Severe injury was defined as an Injury Severity Score greater than 15. A full-model strategy with penalized maximum likelihood estimation was used to construct a model with 8 predictors that were chosen based on clinical reasoning. Accuracy of the developed prediction model was assessed in terms of discrimination and calibration. The model was externally validated in the Brabant region. RESULTSUsing data from 4950 patients with trauma from the Central Netherlands region for the design data set (58.3% male; mean [SD] age, 47 [21] years) and 6859 patients for the validation Brabant region (52.2% male; mean [SD] age, 51 [22] years), the following 8 significant predictors were selected for the prediction model: age; systolic blood pressure; Glasgow Coma Scale score; mechanism criteria; penetrating injury to the head, thorax, or abdomen; signs and/or symptoms of head or neck injury; expected injury in the Abbreviated Injury Scale thorax region; and expected injury in 2 or more Abbreviated Injury Scale regions. The prediction model showed a C statistic of 0.823 (95% CI, 0.813-0.832) and good calibration. The cutoff point with a minimum specificity of 50.0% (95% CI, 49.3%-50.7%) led to a sensitivity of 88.8% (95% CI, 87.5%-90.0%). External validation showed a C statistic of 0.831 (95% CI, 0.814-0.848) and adequate calibration. CONCLUSIONS AND RELEVANCEThe new prehospital trauma triage prediction model may lower undertriage rates to approximately 10% with an overtriage rate of 50%. The next step should be to implement this prediction model with the use of a mobile app for emergency medical services professionals.Question Can a new prehospital prediction model for trauma triage lower the undertriage rate to approximately 10%, with a maximum overtriage rate of 50%?Findings In this multicenter cohort study that included 4950 patients with trauma, 8 highly significant predictors associated with injury severity were selected for the prediction model. The new prehospital trauma triage prediction model was externally validated and may lower the undertriage rate to 11.2% with an overtriage rate of 50.0%. Meaning This prediction model can be integrated in a mobile...

When treating introchanteric fractures with PFNA reduction in neutral or even slight valgus, aiming for a TAD < 25 mm and a correct position of the blade within the femoral head reduced the risk for secondary varus displacement significantly. Furthermore, we suggest to aim for a central nail-shaft axis.

BACKGROUND In recent years, there has been a growing interest in operative treatment for multiple rib fractures and flail chest. However, to date, there is no comprehensive study that extensively focused on the incidence of complications associated with rib fracture fixation. Furthermore, there is insufficient knowledge about the short- and long-term outcomes after rib fracture fixation. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The MEDLINE, EMBASE, and Cochrane databases were searched to identify studies reporting on complications and/or outcome of surgical treatment after rib fractures. Complications were subdivided into (1) surgery- and implant-related complications, (2) bone-healing complications, (3) pulmonary complications, and (4) mortality. RESULTS Forty-eight studies were included, with information about 1,952 patients who received rib fracture fixation because of flail chest or multiple rib fractures. The overall risk of surgery- and implant-related complications was 10.3%, with wound infection in 2.2% and fracture-related infection in 1.3% of patients. Symptomatic nonunion was a relatively uncommon complication after rib fixation (1.3%). Pulmonary complications were found in 30.9% of patients, and the overall mortality was 2.9%, of which one third appeared to be the result of the thoracic injuries and none directly related to the surgical procedure. The most frequently used questionnaire to assess patient quality of life was the EuroQol-5D (EQ-5D) (n = 4). Four studies reporting on the EQ-5D had a weighted mean EQ-5D index of 0.80 indicating good quality of life after rib fracture fixation. CONCLUSION Surgical fixation can be considered as a safe procedure with a considerably low complication risk and satisfactory long-term outcomes, with surgery- and implant-related complications in approximately 10% of the patients. However, the clinically most relevant complications such as infections occur infrequently, and the number of complications requiring immediate (surgical) treatment is low. LEVEL OF EVIDENCE Systematic Review, level III.

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The treatment after open and infected fractures with extensive soft tissue damage and bone deficit remains a challenging clinical problem. The technique described by Masquelet, using a temporary cement spacer to induce a membrane combined with reconstructive soft tissue coverage, is a possible solution. This study describes the work-up, operative procedure, complications, and the outcome of a homogenous group of patients with an open and infected tibia fracture and segmental bone loss treated with the Masquelet technique (MT).This retrospective study evaluates patients having sustained an open tibia fracture treated with the MT between 2008 and 2013 with a follow up of at least 1 year. The defect was either primary, caused by a high-grade open fracture or secondary due to a non-union after an open fracture. Prerequisite conditions prior to the procedure of the Masquelet were a defect zone with eradicated infection, an intact soft tissue cover and stability provided by an external fixation.Volume of the defect, time until the implantation of the spacer, time of the spacer in situ and the time to clinical and radiological union were evaluated. Patient records were screened for reoperations and complications. The functional clinical outcome was measured.Eight patients were treated with a follow up over 1 year. The spacer was implanted after a median of 11 (2–70) weeks after the accident. The predefined conditions for the Masquelet phase were reached after a median of 12 (7–34) operations.Seven patients required reconstructive soft tissue coverage. The volume of the defect had a median of 111 (53.9–621.6) cm3, the spacer was in situ for a median of 12 (7–26) weeks. Radiological healing was achieved in 7 cases after a median time of 52 (26–93) weeks.Full weight bearing was achieved after a median time of 16 (11–24) weeks. Four patients needed a reoperation. The lower limb functional index was a median of 60% (32–92%).Seven out of 8 patients treated in this group of severe open and infected tibia fractures did both clinically and radiologically heal. Due to the massive destruction of the soft tissue, patients needed several reoperations with soft tissue debridements and reconstruction before the spacer and the bone graft could be implanted.

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