Outcomes of Non-surgical Management of Zygomaticomaxillary Complex Fractures

Introduction

With little evidence available in the literature, this study tries to clinically determine the efficiency and outcomes of non-surgical management of post-traumatic Zygomaticomaxillary complex (ZMC) fractures.

Materials and Methods

One hundred and three patients with post-traumatic isolated ZMC fractures managed conservatively for various reasons were identified. The patients were classified based on the Zingg et al. criteria into Types A, B, and C. We evaluated the resolution of signs and symptoms of six standard parameters over 6 months-persistent pain, restriction in mouth opening, infraorbital nerve (ION) paresthesia, aesthetic deformity, infraorbital step deformity with associated tenderness on palpation, and ophthalmic status. The study variables were then statistically analyzed using Cochran's Q test with an associated confidence interval of 95%.

Results

A six-month follow-up revealed persisting residual deformities for all three groups. However, Type A and Type B showed significant improvement in pain reduction, mouth opening, and infraorbital nerve (ION) paresthesia. No significant improvement was noted in any of the groups for aesthetic deformity, infraorbital step deformity, and ophthalmic status. Type C, which had comminuted fracture patterns, exhibited significant defects in all the parameters. Significant inter-variable relationship between certain paired parameters was also observed.

Conclusion

The Type A group is most suited for non-surgical management. Type B with a mono-bloc fracture is a crucial group that demands broader, long-term studies to extract a proper treatment protocol. Type C with severe fracture displacement validates surgical correction.

Surgical treatment of proximal humerus fractures: a systematic review and meta-analysis

INTRODUCTION

The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing surgical interventions for proximal humerus fractures.

METHODS

Systematic review of Medline, Embase, Scopus, and Google Scholar, including all level 1-3 studies from 2000 to 2022 comparing surgical treatment with ORIF, IM nailing, hemiarthroplasty, total and reverse shoulder arthroplasty (RTS) was conducted. Clinical outcome scores, range of motion (ROM), and complications were included. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ² and I² statistics.

RESULTS

Thirty-five studies were included in the analysis. Twenty-five studies had a high risk of bias and were of low and very low quality. Comparisons between ORIF and hemiarthroplasty favored ORIF for clinical outcomes (p = 0.0001), abduction (p = 0.002), flexion (p = 0.001), and external rotation (p = 0.007). Comparisons between ORIF and IM nailing were not significant for clinical outcomes (p = 0.0001) or ROM. Comparisons between ORIF and RTS were not significant for clinical outcomes (p = 0.0001) but favored RTS for flexion (p = 0.02) and external rotation (p = 0.02). Comparisons between hemiarthroplasty and RTS favored RTS for clinical outcomes (p = 0.0001), abduction (p = 0.0001), and flexion (p = 0.0001). Complication rates between groups were not significant for all comparisons.

CONCLUSIONS

This meta-analysis for surgical treatment of proximal humerus fractures demonstrated that ORIF is superior to hemiarthroplasty, ORIF is comparable to IM nailing, reverse shoulder arthroplasty is superior to hemiarthroplasty but comparable to ORIF with similar clinical outcomes, ROM, and complication rates. However, the study validity is compromised by high risk of bias and low level of certainty. The results should therefore be interpreted with caution. Ultimately, shared decision making should reflect the fracture characteristics, bone quality, individual surgeon's experience, the patient's functional demands, and patient expectations.

LEVEL OF EVIDENCE

Level III; systematic review and meta-analysis.

Use of ketamine sedation for the management of displaced paediatric forearm fractures

AIM

To determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department.

METHODS

Following an agreed interdepartmental protocol, fractures of the radius and ulna (moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and post manipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken.

RESULTS

During the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate (3), fractures of both radius and ulna (6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of £1470, the overall study saving being £14700.

CONCLUSION

Ketamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.