Prognostic and therapeutic potential of microRNAs for fracture healing processes and non-union fractures: A systematic review

BACKGROUND

Approximately 10% of all bone fractures result in delayed fracture healing or non-union; thus, the identification of biomarkers and prognostic factors is of great clinical interest. MicroRNAs (miRNAs) are known to be involved in the regulation of the bone healing process and may serve as functional markers for fracture healing.

AIMS AND METHODS

This systematic review aimed to identify common miRNAs involved in fracture healing or non-union fractures using a qualitative approach. A systematic literature search was performed with the keywords 'miRNA and fracture healing' and 'miRNA and non-union fracture'. Any original article investigating miRNAs in fracture healing or non-union fractures was screened. Eventually, 82 studies were included in the qualitative analysis for 'miRNA and fracture healing', while 19 were selected for the 'miRNA and fracture non-union' category.

RESULTS AND CONCLUSIONS

Out of 151 miRNAs, miR-21, miR-140 and miR-214 were the most investigated miRNAs in fracture healing in general. miR-31-5p, miR-221 and miR-451-5p were identified to be regulated specifically in non-union fractures. Large heterogeneity was detected between studies investigating the role of miRNAs in fracture healing or non-union in terms of patient population, sample types and models used. Nonetheless, our approach identified some miRNAs with the potential to serve as biomarkers for non-union fractures, including miR-31-5p, miR-221 and miR-451-5p. We provide a discussion of involved pathways and suggest on alignment of future research in the field.

Immunohistochemical Analysis of CCN2 in Experimental Fracture Healing Models

Skeletal fractures are most common large-organ traumatic injuries that impact the functions and esthetic outcomes and quality of life. Unfortunately, infection during the fracture healing process and inadequate blood supply to the bone impede reduced ability to produce cartilage and effective bone callus formation, leading to nonunion or delayed union fracture. Therefore, studying the mechanism of fracture healing is an important task in solving the problem of fracture healing failure. Animal models of bone fracture healing are important tools to investigate the pathogenesis and develop treatment strategies. This protocol introduces researchers to a bone repair model utilizing the ribs of rats and the immunohistological expression of cellular communication network factor/connective tissue growth factor (CTGF/CCN2) during the fracture healing processes.

Stem Cells and Their Derivatives: An Implication for the Regeneration of Nonunion Fractures

Despite advances in biomedical research, fracture nonunion rates have remained stable throughout the years. Long-bone fractures have a high likelihood of nonunion, but the specific biological pathways involved in this severe consequence are unknown. Fractures often heal in an organized sequence, including the production of a hematoma and an early stage of inflammation, the development of a soft callus and hard callus, and eventually the stage of bone remodeling. Deficient healing can result in a persistent bone defect with instability, discomfort, and loss of function. In the treatment of nonunions, mesenchymal stem cells (MSCs) prove to be a promising and safe alternative to the standard therapeutic strategies. Moreover, novel scaffolds are being created in order to use a synergistic biomimetic technique to rapidly generate bone tissue. MSCs respond to acellular biomimetic matrices by regenerating bone. Extracellular vesicles (EVs) derived from MSCs have recently gained interest in the field of musculoskeletal regeneration. Although many of these techniques and technologies are still in the preclinical stage and have not yet been approved for use in humans, novel approaches to accelerate bone healing via MSCs and/or MSC derivatives have the potential to reduce the physical, economic, and social burdens associated with nonhealing fractures and bone defects. In this review, we focus on providing an up-to-date summary of recent scientific studies dealing with the treatment of nonunion fractures in clinical and preclinical settings employing MSC-based therapeutic techniques.

Osteoporosis: An Update on Screening, Diagnosis, Evaluation, and Treatment

Osteoporosis screening, diagnosis, and treatment have gained much attention in the health care community over the past 2 decades. During this time, creation of multispecialty awareness programs (eg, "Own the Bone," American Orthopedic Association; "Capture the Fracture," International Osteoporosis Foundation) and improvements in diagnostic protocols have been evident. Significant advances in technology have elucidated elements of genetic predisposition for decreased bone mineral density in the aging population. Additionally, several novel drug therapies have entered the market and provide more options for primary care and osteoporosis specialists to medically manage patients at risk for fragility fractures. Despite this, adherence to osteoporosis screening and treatment protocols has been surprisingly low by health care practitioners, including orthopedic surgeons. Continued awareness and education of this skeletal disorder is crucial to effectively care for our aging population. [Orthopedics. 2023;46(1):e20-e26.].

Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures

Importance

Management of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture.

Objective

To characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures.

Design, Setting, and Participants

In this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021.

Main Outcomes and Measures

Primary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications.

Results

A total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P < .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P < .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications.

Conclusions and Relevance

This study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.

Advances in the application of ultrasound for fracture diagnosis and treatment

Fractures are commonly encountered in clinical practice. Early diagnosis and individualized treatment are the basis for achieving high-quality fracture healing and functional recovery. Radiographic examinations play an important role in the diagnosis and treatment of fractures. In recent years, with the innovation in ultrasonic examination technology and equipment, its application in the diagnosis and treatment of fractures has greatly increased. Long bone, rib, radius and ulnar, metacarpal, cartilage, nasal bone, and occult are common fracture types. Ultrasound has long been used in fracture diagnosis and treatment. This narrative review summarizes and discusses the application of ultrasound in the diagnosis and treatment of fractures.

The COVID-19 Pandemic: Effects on Pediatric Fracture Patterns in the Emergency Department and Subspecialty Follow-up Care

PURPOSE

The COVID-19 pandemic affected pediatric fracture injury patterns and volume. There is a paucity of research evaluating this trend throughout the pandemic and also follow-up to orthopaedic subspecialty care after emergency fracture management.

METHODS

This retrospective cohort study reviewed patients 2 to 18 years of age presenting for fracture care to an urban pediatric emergency department. We assessed patient demographics, clinical care, and follow-up to surgical subspecialist. Time periods investigated included March 30 to September 4, 2020 (pandemic), March 30 to September 4, 2019, and March 30 to September 4, 2018 (prepandemic). Subanalysis within the pandemic was during the "stay-at-home order" verses the phased re-opening of the state. Descriptive statistical analysis, Pearson's χ 2 or Fisher exact tests, and Mann-Whitney U tests were performed.

RESULTS

In this population, fractures overall declined by 40% (n=211) during the pandemic compared with 2019 (n=349) and 28% compared with 2018 (n=292). Lower extremity fractures accounted for a greater percentage of injuries during the pandemic compared with prepandemic. Time to surgical subspecialty follow-up was shortest during the 2020 pandemic peak at 9 days and was significantly longer during phased reopening (phase 1: 18 d, P =0.001; phase 2: 14 d, P =0.005). These patterns were also consistent for days to repeat imaging.

CONCLUSIONS

We found differences in fracture prevalence, mechanisms, and follow-up care during the pandemic. Time to subspecialty follow-up care was longer during pandemic phased reopening despite overall fewer fractures. Plans to absorb postponed visits and efficiently engage redeployed staff may be necessary to address difficulties in follow-up orthopaedic management during public health crises.

LEVEL OF EVIDENCE

Level II.

[Fracture-related infections]

Fracture-related infections (FRI) is a challenging complication with a high risk of devastation outcomes for the patients. Diagnosing FRI is often difficult, and treatment frequently requires the effort of a multidisciplinary team. Recently, an international consensus group of experts from various scientific and medical organisations has published standardised guidelines of diagnosis and treatment. This review provides a summary of the latest studies and the general principles with respect to diagnosis, treatment and aftercare of patients with FRI.

[Limb fractures in pet rabbits (Oryctolagus cuniculus f. domestica) - A case series of orthopedic long-term effects in fracture patients]

OBJECTIVE

Limb fractures account for a large proportion of all orthopedic diseases in pet rabbits and are a common reason for presentation. The fracture etiologies and characteristics vary considerably in comparison to trauma of the extremities in cats and dogs. For this reason, conservative and surgical treatment options need to be adapted. To our knowledge, long-term effects of limb fracture therapies in pet rabbits have not been described scientifically.

MATERIALS AND METHODS

This article features a case series of 13 pet rabbits with limb fractures. Their medical records were analyzed retrospectively and all patients were presented for a follow-up examination including clinical and orthopedic examination.

RESULTS

Orthopedic anomalies (abducted limb postures) were identified in four patients. Arthrotic ossification was found in twelve of thirteen animals - in six cases to a high extent. Measurement of the fractured bones revealed a shortening in ten of thirteen cases.

CONCLUSION AND CLINICAL RELEVANCE

Orthopedic long-term complications following fracture treatments were commonly detected in the patient population of this study. Permanent issues may result in anomalies of limb posture or postural control which are not noticed by the rabbit owners in every case. Ultimately, the patients should be examined routinely after the conclusion of fracture therapy in order to detect and adequately treat possible orthopedic complications.

Prolonged ileus in traumatic pelvic ring injury patients who underwent arterial angio-embolization: A retrospective study

Paralytic ileus occurs in up to 18% of the patients with pelvic bone fractures. The aim of this study is to determine if massive bleeding requiring arterial angio-embolization is related with the duration of ileus in patients with traumatic pelvic ring injuries. This retrospective study included 25 patients who underwent arterial angio-embolization for traumatic pelvic ring injuries. Data were collected from prospectively maintained databases of two independent hospitals. Demographic characteristics (such as age, sex, body mass index, and Charlson Comorbidity Index), cause of trauma, and severity of pelvic injuries were similar in the non-prolonged and prolonged ileus groups. As expected, the prolonged ileus group had a significantly longer duration of ileus than the non-prolonged ileus group (8.0 ± 4.2 days vs 1.2 ± 0.4 days, respectively; P < .001). The mortality rate was higher in the prolonged ileus group (20% vs 0%), but it was not significantly different (P = .13). Interestingly, the prolonged ileus group received significantly higher amounts of packed red blood cell transfusions (6.1 ± 2.1 units vs 3.8 ± 2.5 units; P = .02). The amount of packed red blood cell transfusions was associated with a greater risk of prolonged ileus development (P = .03, odds ratio = 2.04, 95% confidence interval = 1.08-3.88). This study supports the idea that the duration of the ileus is related with the amount of bleeding caused by the traumatic pelvic ring injury. In order to prevent further complications, conservative treatments of the ileus should be considered.

Impact of the COVID-19 Pandemic on Pediatric Elbow Fractures: Marked Change in Management and Resource Utilization, Without a Change in Incidence

BACKGROUND

Elbow fractures are the most common pediatric fractures requiring operative treatment. Although recent reports have suggested that the COVID-19 pandemic has markedly reduced the incidence of pediatric fractures, no study has specifically evaluated the impact on pediatric elbow fractures. This study aimed to evaluate changes in the incidence, severity, and resource utilization for managing pediatric elbow fractures during the COVID-19 pandemic, compared with prepandemic years.

METHODS

A prepandemic (2007 to 2017) cohort and a COVID-19 pandemic period (March 2020 to March 2021) cohort of pediatric elbow injuries from a single tertiary hospital were retrospectively examined and compared. Exclusion criteria included outside treatment or lack of diagnosis by an orthopedist. Presentation information, injury patterns, transport, and treatment requirements were collected.

RESULTS

Although the incidence of pediatric elbow fractures and rate of neurovascular injury were comparable, seasonal patterns were not sustained and the rate of fracture displacement was found to be significantly elevated in the COVID-19 period compared with nonpandemic years. Likewise, marked changes to where patients first presented (emergency department vs. Clinic), how the patients were transported, and the distance traveled for care were observed. Specifically, patients were more likely to present to the clinic, were more likely to self-transport instead of using emergency medical service transportation, and traveled a greater distance for care, on average. Aligning with these changes, the resources utilized for the treatment of pediatric elbow fracture markedly changed during the COVID-19 period. This study found that there was an increase in the overall number of surgeries performed, the total operative time required to treat elbow fractures, and the number of patients requiring admission during the COVID-19 period.

CONCLUSIONS

These data provide a contrasting viewpoint to prior reports, illustrating that the incidence of elbow fractures remained consistent during the COVID-19 period, whereas the operative volume and need for hospital admission increased compared with years prior. Furthermore, this study demonstrated how the COVID-19 pandemic altered the interface between pediatric patients with elbow fractures and our institution regarding the location of presentation and transportation.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Clinical characteristics and distribution of paediatric hand fractures at a tertiary hospital in South China: a retrospective analysis

The aim of this study was to evaluate the characteristics of paediatric hand fractures (PHF) at a tertiary hospital in South China based on sex, age, mechanism of injury and anatomical region. A retrospective observational study was performed on children aged 15 years and younger who were referred for actual or suspected hand fractures between January 2016 and December 2020. Medical records and radiographs were reviewed for age at the time of injury, sex, site and fracture pattern and mechanism of injury. A total of 436 consecutive children with 478 hand fractures were reviewed. Hand fractures was more common in boys (281/436; 64.4%) than in girls (155/436; 35.6%), although most fractures occurred in children aged 0-3 years (198/436; 45.4%). Distal phalanges were the most commonly injured bones (184/478; 38.5%), and the base fractures were most common (151/476; 31.7%); the fifth digit was most commonly injured (150/478; 31.3%). Crush injuries were the leading cause of fracture in children younger than 6 years of age (207/325; 63.7%), whereas punch injuries were the major cause of injury in older age groups (55/153; 35.9%); 60.1% of the fractures were managed nonsurgically. This study showed patterns of PHF in a tertiary hospital in South China. It illustrates the local variability across sex, age group, injury type and injury mechanism. Such demographic data will be valuable for optimally resourcing healthcare systems locally and help guide prevention policies.

Common and Consequential Fractures That Should Not Be Missed in Children

Missed or delayed diagnosis of fractures in children is not uncommon owing to their immature skeletons, unique fracture patterns, and distinctive radiologic findings. The term occult is used to describe radiographically subtle fractures. Some of these fractures can be associated with excellent outcomes despite the pitfalls of delayed diagnosis. However, a subset of these injuries have more guarded prognoses when missed, despite their harmless radiographic appearance. A high index of suspicion should be maintained when treating pediatric extremity injuries with clinical findings disproportionate to a benign-appearing radiograph. Moreover, overreliance on radiology reports can perpetuate diagnostic error. In cases of discrepancy, timely follow-up for repeat examination or immediate advanced imaging can help avoid missed diagnoses. Most critically, the one diagnosis not to miss is nonaccidental trauma, as continued exposure to abuse puts the child at risk of further injury and death. [Pediatr Ann. 2022;51(9):e357-e363.].

Traditional bone setting and trauma care in South-Eastern Chad

Background

Traditional bonesetters are the main providers of fracture treatment and trauma care in much of Africa. However, there is a paucity of literature on bonesetters in Chad.

Objectives

Our study sought to investigate Chadian bonesetter practices, their relationship to the community, and the complex local perspectives on trauma care in Am Timan, Chad.

Methods

Thirty-three semi-structured interviews were conducted with community members, traditional bonesetters, and physicians in Am Timan using a constructivist grounded theory approach. Responses were coded, categorized, and compared within and across study populations to identify themes.

Results

Most community members (n=25) interviewed preferred bonesetters for trauma care due to their affordability, continuity and convenience of care, and the community's fear of Western medical practices. Although the Chadian bonesetters' fracture management mirrored bonesetters in neighboring African countries, the Chadian bonesetters have a much wider scope of practice, including treatment for both medical and spiritual ailments. Both Jabari (n=6) and physicians (n=2) emphasized the need for more training and collaboration.

Conclusion

As in much of Africa, bonesetters perform a major role in providing trauma care in Chad. Our research identifies an opportunity to maximize trauma care in Chad through dialogue, training, and collaboration between bonesetters and physicians.

The current management of scaphoid fractures in the emergency department across an Australian metropolitan public health service: A retrospective cohort study

BACKGROUND

Scaphoid fractures are commonly present to emergency departments (EDs), challenging medical practitioners to achieve accurate diagnosis and management. This is because of the prevalence of radiographically occult scaphoid fractures and complications associated with missed diagnoses. Clinical Guidelines are limited for treatment of suspected scaphoid fractures, and heterogeneity in the literature further complicates management. This study aimed to explore the differences in management between practitioners in the ED and determine if immobilizing clinically suspected scaphoid fractures is supported by current evidence. This study also aimed to establish if there are predictors to assist in the diagnosis of a scaphoid fracture in the ED.

METHODS

A retrospective cohort study analyzed clinical data from patient's charts who attended the ED for a scaphoid fracture in 2019. Using retrospective patient chart audits and a Data Extraction Form, the clinical data regarding the assessment, treatment, diagnosis, and follow-up outcomes were collected. Descriptive analysis and multivariable logistic regression were performed to assess current management and find out predictors of a scaphoid fracture.

RESULTS

There was significance between practitioners performing physical assessments and providing treatment (P < .001). Physiotherapists performed assessment and education combined treatment more frequently than nurse practitioners and doctors. Thirty-four cases (11.7%) were negative for fracture in ED and positive in follow-up at the orthopedic clinic. There was an estimated loss of income of $327,433.60 (Australian dollar) for 221 patients who missed work due to overtreatment with immobilization. The strongest predictors for a confirmed scaphoid fracture were of male gender (odds ratio, 3.2; 95% confidence interval, 2.1-5.0; P < .001) and a positive x-ray in ED (odds ratio, 36.6; 95% confidence interval, 17.4-77.0; P < .001).

CONCLUSION

Management of scaphoid fractures across the Gold Coast Hospital Health Service ED followed commonly accepted practices involving x-ray and immobilization; however, this conservative approach to management is associated with increased health costs and low rates of conversion to a confirmed scaphoid fracture. Male gender was the only significant predictor associated with a scaphoid fracture.

Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK

BACKGROUND

The most common fractures in children are torus (buckle) fractures of the wrist. Controversy exists over treatment, which ranges from splint immobilisation and discharge to cast immobilisation, follow-up, and repeat imaging. This study compared pain and function in affected children offered a soft bandage and immediate discharge with those receiving rigid immobilisation and follow-up as per treating centre protocol.

METHODS

In this randomised controlled equivalence trial we included 965 children (aged 4-15 years) with a distal radius torus fracture from 23 hospitals in the UK. Children were randomly allocated in a 1:1 ratio to the offer of bandage group or rigid immobilisation group using bespoke web-based randomisation software. Treating clinicians, participants, and their families could not be masked to treatment allocation. Exclusion criteria included multiple injuries, diagnosis at more than 36 h after injury, and inability to complete follow-up. The primary outcome was pain at 3-days post-randomisation measured using Wong-Baker FACES Pain Rating Scale. We performed a modified intention-to-treat and per protocol analysis. The trial was registered with ISRCTN registry, ISRCTN13955395.

FINDINGS

Between Jan 16, 2019, and July 13, 2020, 965 children were randomly allocated to a group, 489 to the offer of a bandage group and 476 to the rigid immobilisation group, 379 (39%) were girls and 586 (61%) were boys. Primary outcome data was collected for 908 (94%) of participants, all of whom were included in the modified intention-to-treat analysis. Pain was equivalent at 3 days with 3·21 points (SD 2·08) in the offer of bandage group versus 3·14 points (2·11) in the rigid immobilisation group. With reference to a prespecified equivalence margin of 1·0, the adjusted difference in the intention-to-treat population was -0·10 (95% CI -0·37 to 0·17) and-0·06 (95% CI -0·34 to 0·21) in the per-protocol population.

INTERPRETATION

This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up.

FUNDING

UK National Institute for Health and Care Research.

Pelvic Avulsion Fractures in Adolescent Athletes: Analyzing the Effect of Delay in Diagnosis

OBJECTIVE

To evaluate whether delay in the diagnosis of pelvic avulsion fractures in young athletes leads to prolonged treatment and prolonged return toward sport activities, whether fractures at certain locations are associated with a greater risk of diagnostic delay, and what reasons may exist for delay in diagnosis.

DESIGN

Retrospective chart review of young patients who presented with pelvic region avulsion fracture to a community-based sports medicine clinic over a 19-year period.

SETTING

Private practice, primary care sports medicine clinic.

PATIENTS

Patients younger than 20 years diagnosed with pelvic region avulsion fracture.

INTERVENTIONS

None, this was a retrospective study.

MAIN OUTCOME MEASURES

Clearance for return toward sport activities.

RESULTS

Two hundred twenty-five cases were reviewed for reasons for delay in diagnosis; 208 cases met criteria for the duration of treatment and return to play activities portions of the study. The mean time from date of injury diagnosis was 19.59 days, and the mean duration from date of injury to clearance for return to play advancement was 67.20 days. Duration of treatment varied slightly depending on timing of diagnosis, whereas duration from date of injury to clearance for return to play advancement varied greatly depending on diagnostic delay. Those who did not sense a "pop" at the time of injury were more likely to experience diagnostic delay, as were athletes with ischial tuberosity fractures. The most common cause of diagnostic delay was patient/family decision on when to seek care; misdiagnosis as a muscle strain was also common.

CONCLUSIONS

Diagnostic delay of adolescent pelvic avulsion fractures may unnecessarily prevent athletes from returning to play within an optimal time frame. Our observations highlight a need for educating athletes and their families on when to seek initial or follow-up medical care as well as educating medical providers regarding the diagnosis of pelvic avulsion fractures.

Pediatric Fracture Epidemiology and US Emergency Department Resource Utilization

OBJECTIVE

Fractures are common childhood injuries that result in emergency department (ED) visits. National trends in pediatric fracture epidemiology and resource utilization are not well described. Our objective is to analyze national trends in pediatric fracture epidemiology, ED disposition, and ED resource utilization from 2010 to 2015.

METHODS

This is an epidemiological study of fracture care in US EDs from 2010 to 2015 for children 0 to 18 years old using the Nationwide Emergency Department Sample. We calculated frequencies and national rates using weighted analyses and census data. We used the test for linear trend to analyze incidence, hospital admission, transfer, and procedural sedation over time. Multivariate logistic regression analyses identified encounter- and hospital-level predictors of transfer, admission, operative care, and use of procedural sedation.

RESULTS

During the study period, from 2010 to 2015, a total of 5,398,827 children received ED care for fractures. The pediatric fracture rate was 11.5 ED visits/1000 persons (95% confidence interval [CI], 10.6-12.5) and decreased over time. The admission rate for pediatric fracture patients was 5% and stable over time. The transfer rate increased from 3.3 to 4.1/100 fracture visits (linear trend: odds ratio, 1.06; 95% CI, 1.03-1.09). Utilization of procedural sedation increased from 1.5% to 2.9% of fracture visits (linear trend: odds ratio, 1.17; 95% CI, 1.09-1.25). Predictors associated with disposition and resource utilization include patient age, fracture location, insurance type, hospital type, and region.

CONCLUSIONS

The national incidence rate of pediatric fractures decreased slightly. Emergency department resource utilization increased over time. With high national volume, understanding pediatric fracture epidemiology and resource utilization is important to the health care system.

Common Finger Fractures and Dislocations

Finger fractures and dislocations are commonly seen in the primary care setting. Patients typically present with a deformity, swelling, and bruising with loss of function. Anteroposterior, lateral, and oblique radiography should be performed to identify fractures and distinguish uncomplicated injuries from those requiring referral. Uncomplicated distal phalanx fractures, caused by a crush injury to the end of the finger, require splinting of the distal interphalangeal joint for four to six weeks. Uncomplicated dorsal avulsion fractures (mallet finger) of the distal interphalangeal joint, caused by forced flexion against resistance, require strict splint immobilization for eight weeks. Flexor digitorum profundus fractures are caused by forceful extension of the distal interphalangeal joint when in a flexed position, resulting in an avulsion fracture at the volar base of the distal phalanx, and usually require surgery. Uncomplicated middle and proximal phalanx fractures, typically caused by a direct blow, can be treated with buddy splinting if there is minimal angulation (less than 10 degrees); however, larger angulations, displacement, and malrotation often require reduction or surgery. Dorsal proximal interphalangeal joint dislocations require reduction and buddy splinting in slight flexion with an extension-block splint. Volar proximal interphalangeal joint dislocations require reduction and splinting in full extension for four to six weeks. Distal interphalangeal joint dislocations require reduction and splinting in full extension (for volar dislocations) or 15 to 30 degrees of flexion (for dorsal dislocations) for two to three weeks. Dorsal metacarpophalangeal joint dislocations are managed with reduction and splitting, but referral to an orthopedic specialist is required if the dislocation is not easily reduced. Volar metacarpophalangeal dislocations are rare and warrant referral.

Extravasation and outcomes in computed tomography and angiography in patients with pelvic fractures requiring transcatheter arterial embolization: A single-center observational study

BACKGROUND

Extravasation on contrast-enhanced computed tomography (CECT) is a helpful indicator of the need for transcatheter arterial embolization (TAE) for pelvic fractures. However, previous reports were inconsistent on cases in which angiography is necessary, even though there is no extravasation on computed tomography. This study aimed to describe and analyze the contradictory findings in cases where extravasation is observed on angiography but not on CECT, to contribute to improved management of patients with pelvic fractures.

METHODS

This was a retrospective single-center study. Patients with pelvic fractures who underwent CECT and TAE between 2014 and 2020 were included. We classified the patients into three groups: CECT and angiography with extravasation (CT+Angio+), CECT with no extravasation and angiography with extravasation (CT-Angio+), and CECT with extravasation and angiography without extravasation (CT+Angio-).

RESULTS

A total of 113 patients were included in the study: the CT+Angio+ group had 54 patients, CT-Angio+ group, 47; and CT+Angio- group, 12. The CT-Angio+ group had a significantly longer time from arrival to CECT than the CT+Angio+ group (27 minutes vs. 23 minutes, p < 0.05). The CT-Angio+ group had significantly more blood transfusions (fresh frozen plasma, platelets) within 24 hours than the CT+Angio- group did (p < 0.05), and ventilator management days (p < 0.05) and intensive care unit stays (p < 0.05) were significantly longer.

CONCLUSION

There was no significant difference in outcomes among the three groups. There was no difference in severity, transfusion volume, or mortality in patients with pelvic fractures needing TAE, classified as CT-Angio+, compared with that of CT+Angio+ patients. Even in the absence of extravasation in the pelvic region on CECT, angiography or TAE may still be necessary.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

Low-Intensity Pulsed Ultrasound Stimulation for Bone Fractures Healing: A Review

Low-intensity pulsed ultrasound (LIPUS) is a developing technology, which has been proven to improve fracture healing process with minimal thermal effects. This noninvasive treatment accelerates bone formation through various molecular, biological, and biomechanical interactions with tissues and cells. Although LIPUS treatment has shown beneficial effects on different bone fracture locations, only very few studies have examined its effects on deeper bones. This study provides an overview on therapeutic ultrasound for fractured bones, possible mechanisms of action, clinical evidences, current limitations, and its future prospects.