The Orthopedic Literature 2015
Michael C. Bond MD, Jason V. Brown MD, Stephen P. Shaheen MD,
Michael K. Abraham MD, MS
PII:
DOI:
Reference:

S0735-6757(16)30144-9
doi: 10.1016/j.ajem.2016.05.034
YAJEM 55813

To appear in:

American Journal of Emergency Medicine

Received date:
Revised date:
Accepted date:

3 May 2016
13 May 2016
14 May 2016

Please cite this article as: Bond Michael C., Brown Jason V., Shaheen Stephen P.,
Abraham Michael K., The Orthopedic Literature 2015, American Journal of Emergency
Medicine (2016), doi: 10.1016/j.ajem.2016.05.034

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The Orthopedic Literature 2015
a

Michael C. Bond, MD , Jason V. Brown, MD , Stephen P. Shaheen, MD , Michael K. Abraham, MD, MS

Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA

Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, MD 21201, USA

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*Corresponding Author:

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email address: mbond@em.umaryland.edu (M.C. Bond).

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Key Words: Orthopaedic injuries

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Running head: Orthopaedic Literature 2015

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1. Acute Compartment Syndrome
Large TM, Agel J, D Holtzman DJ, Benirschke SK, Krieg JC. Interobserver variability in the measurement of lower leg

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compartment pressures. J Orthop Trauma 2015;29(7):316321

Acute compartment syndrome (ACS) remains a difficult clinical entity to diagnose because of complex

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presentations and uncooperative patients. Traditional teachings recommend looking for the six Pspallor,
paralysis, paresthesias, pain with passive stretch, pulselessness, poikilothermia, and increased pressurein
1

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addition to a firm/full feeling of the skin; however, the sensitivity and specificity of these findings are low .
Morbidity for this injury is high and the consequences of missed or delayed diagnosis range from loss of function to

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amputation to death. During the mid-1990s, multiple investigators tried to identify the compartment pressure that
would result in significant loss of perfusion, ultimately resulting in the commonly accepted P of <30 mg Hg

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(diastolic blood pressure [DBP] minus compartment pressure) Multiple modalities for the measurement of
compartment pressures have been developed. Intermittent measurement of pressures with the intra-

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compartmental pressure monitor (STIC monitor manufactured by Stryker Orthopaedics) is used in most US
2, 3

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hospitals; the accuracy of this device has been documented in multiple trials in controlled settings .
Despite its ease of use, the STIC monitor carries the potential for error through alterations in technique

monitor.

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and incorrect use of the product. Large and colleagues set out to assess the inter-user variability of the STIC

Thirty-eight physicians from a level 1 trauma center participated in the study, 27 of them were
orthopaedists, and the others were general surgeons and emergency medicine practitioners. The majority (19 of
the 38) were residents (no further delineation of the level of training was provided). Four cadaveric specimens,
thawed and un-embalmed, were used in the study. In each of these specimens, normal saline was infused into the
four compartments of the lower leg. Compartments were maintained at a target of 47 mm Hg by continuous
indwelling slit catheters, and the pressures were documented before and after each participant began the
procedure. Deviations from the goal pressure were adjusted with increased or decreased saline infusion until a
return to baseline.

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The participants were instructed to measure pressures in all four zones (anterior, lateral, superficial, and
deep posterior) according to the manufacturers instructions. The participants were then scored into one of three

categories based on their level of proficiency: proper technique, minor technical alterations, or catastrophic

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errors.

After a simple examination of the specimen, 18 study participants (47%) expressed concern about the

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possibility of ACS. All of them were given the opportunity to read the STIC monitor instructions, but only 15 (39%)
chose to review them. In 152 total measurements, catastrophic errors were recorded in 45 (30%). Anatomic

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errors (5) were made at a higher rate by non-orthopaedic physicians (4). Forty-seven measurements (31%) were

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noted to have correct technique; only 6 (16%) of 38 the participants scored this level in all four compartments.
Among the practitioners who made accurate measurements, there was no trend in training level, prior experience,
or instruction reading. As noted in the article, only one of four compartments with an elevated P is required to

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recommend surgical intervention; 4 (11%) of the 38 participants failed to gain a single P that led to the correct

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decision.

This trial was small, based at a single center, based on a cadaveric model that has not been validated, and

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full of many variables and unknowns; however, it brings to light concern about the individual error that can result

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from inappropriate use of the STIK monitor. More importantly, it raises question as to the true accuracy of this
device, even when it is used in accordance with the manufacturers instructions. The authors call for further
studies, continued training, and clinical judgment when this device is used to determine whether a patient needs
fasciotomy for ACS.
For the emergency medicine provider, it is important to know that compartment pressure measurements
can vary based on the technique used by the individual practitioner. Subsequent readings by an orthopedist or
repeat readings may be needed to ensure the diagnosis. If in doubt, consultation with an orthopedist is warranted,
because the consequences of untreated ACS can be devastating. Ultimately, this is a safe, easy procedure that
emergency medicine providers should have the equipment and skill to comfortably perform, which ultimately can
help expedite patients going for operative treatment.

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2. Scaphoid Fractures
Yin ZG, Zhang JB, Gong KT. Cost-effectiveness of diagnostic strategies for suspected scaphoid fractures. J Orthop

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Trauma 2015;29(8):e245-e252
Because of the anatomy of the scaphoid bone, malunion or nonunion caused by fracture can cause

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significant morbidity. Traditionally, questionable injuries are immobilized for at least 2 weeks and then reevaluated, even if the initial plain radiographs were negative. This strategy carries significant economic factors: the

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cost of radiographic imaging, the costs and time associated with health care visits, and work/life limitations from
wearing a splint. When these are taken into account, with the low rate of true fractures in patients suspected of

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having the injury (~14%), a more targeted treatment plan would be ideal. Yin and colleagues sought to quantify the
benefits of using computed tomography (CT) and magnetic resonance imaging (MRI) for the initial evaluation to

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avoid prolonged indeterminate management strategies.

The authors created a decision-tree model with seven management strategies they believe are reasonable

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for the evaluation of scaphoid fractures. They range from the conservative (immobilization for 2 weeks followed by

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plain radiographs) to more aggressive (CT in the ED). Radiologic analysis included plain radiographs, CT, MRI, and
bone scans; bone scan and MRI were not included in the initial, immediate evaluation because of access limitations

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for a large number of health care providers. Data were pooled from three previous studies that assessed the
diagnostic accuracy of these imaging studies. MRI was a top performer, with 97.2% sensitivity and 99.3%
specificity; of note, CT had a sensitivity of 90.7% and specificity of 98.2%, and repeat radiographs, a sensitivity of
91.1% and specificity of 99.8%. Plain radiographs were, by far, the cheapest to obtain at $39, followed by CT, $212;
MRI, $282; and bone scans, $310. Productivity loss was constructed using the Department of Labors wage
statistics ($769) combined with a reduction factor of 50%, based on one clinical trial on wrist immobilization in the
workplace.
Analyses were completed using an incremental cost-effectiveness ratio (ICER) for all methods of interest
in this study. These data give a comparison between strategies by looking at cost differences in conjunction with
diagnosis rates in regard to best case, sensitivity, and best case/worst case sensitivity.

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Results showed that immediate CT performed well. In the best case analyses, it was very effective; it was
much cheaper than MRI, although the latter did boast a higher detection rate. Plain radiographs, as expected, were

inexpensive but had a significant labor cost factor penalty, as did any test not performed immediately. The authors

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also attempted to determine an exact tipping point for the value of plain radiographs with the understanding that
not all patients will lose a full 50% of their workplace efficiency. At 8%, or $62, two-week radiographs were

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surpassed by immediate CT. In addition, if the fracture prevalence rose, the overall winner did not change, but MRI
at 3 days and 2 weeks was more competitive. Of note, when immediate MRI was performed, its ICER at baseline

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settings (compared with CT) was $7483 per detected scaphoid fracture, improving to $4000 with a higher

scaphoid fractures, albeit at a higher cost.

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prevalence; this shows that MRI can be a possible clinical pathway because it does detect a higher percentage of

Overall, the authors report that immediate CT should be considered a viable means to diagnose scaphoid

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fractures when there is a high suspicion of them, because of the economic factors involved with a prolonged

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questionable diagnosis. MRI performed well in the cost-effectiveness strategies, getting as low as $4000 per
additional detection. Radiographs alone did well only when there was a very minimal change to loss of

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productivity.

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This study has several limitations. First, soft-tissue or ligamentous injuries can occur in the absence of
fracture, still requiring immobilization and continued care. Also, because of the anatomic component, not all
scaphoid fractures are created equal; this study focused on prevention of non-union fractures.
This study raises good questions with regard to the detection of scaphoid fractures and should prompt
further discussion about the benefits of immediate advanced radiology versus the traditional method of splinting
and follow-up care. At a minimum emergency medicine providers should consider expediting an outpatient CT
scan of the wrist in order to exclude an occult fracture in individuals that need to return to work as soon as
possible.
3. Hip Fractures in the Elderly..

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Roberts KC, Brox WT. AAOS Clinical Practice Guideline: management of hip fractures in the elderly. J Am Acad
Orthop Surg 2015;23(2):131-140

Hip fractures, especially in the elderly, are a significant source of morbidity. In 2010, approximately

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258,000 hip fractures occurred in the United States and projections indicate a likely rise as life expectancies
increase. The incidence appears to be decreasing, but the aging of the American population points to an uptick in
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overall volume. In addition, hip fractures account for significant health care expenditures (in the top 15 of
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Medicares most expensive diagnoses for 2011). The patients affected by this injury have increased risk for

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secondary fractures and decreased ambulation, requiring higher levels of care and monitoring.

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In 2011, the American Academy of Orthopedic Surgeons (AAOS), with input from a number of other
specialty groups and associations, conducted a literature search to create a clinical practice guideline that

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delineates best-care practices for this patient population. Only primary research in peer-reviewed journals was
included (bibliographies of systematic reviews were searched for applicable material). The final recommendations

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were assigned a rating (limited, moderate, or strong) based on the available literature. Strong recommendations
were given to those with the highest evidence. A moderate rating was granted to those that had weaknesses in

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literature support but indicated a clear benefit or harm.

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The overarching theme was that the highest level of care is achieved when a multidisciplinary approach is
applied to hip fracture patients. Several topics are of specific interest to emergency medicine (EM) providers. The
minimization of delirium through management of narcotic dosing, early surgery, regional/multimodal anesthesia,
and good nutrition constitute the basis for many of the recommendations. In addition, the prevention and
recognition of secondary fractures and risk factors improve care. With regard to imaging, the work group
recognized that although MRI is the current best-evidence imaging of choice, patients should not be transferred if
it is not available. There were concerns that CT imaging might miss occult fractures, leading the authors to ask for
future studies on modality comparisons and the relevance of those findings.
Strong recommendations pertinent to EM providers:

Regional anesthesia as a mode of preoperative pain control (e.g., femoral nerve blocks)

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A transfusion threshold no higher than 8 g/dL

Multidisciplinary care programs for patients with dementia

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Moderate recommendations pertinent to EM providers:

MRI is the imaging of choice for patients with suspected hip fractures not visualized on radiograph (but
there is no need to transfer the patient if MRI capabilities are not available).
Avoid preoperative hip traction.

Surgery within 48 hours is associated with improved outcomes.

A posterior approach to arthroplasty is associated with a higher dislocation rate when compared to the

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anterior approach.

Administer prophylaxis against venous thromboembolism.

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Limited recommendations pertinent to EM providers:

Do NOT delay surgery for patients taking antiplatelet or anticoagulant agents.

Ascertain albumin and creatinine levels pre-operatively, as risk assessment.

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As with any guideline, the onus of care falls on clinical judgment. The recommendations presented above

available.

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are best practice based on the literature through 2013 and are open to modification as new information becomes

4. Cervical Spine Clearance

Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma
patient. J Trauma Acute Care Surg 2015;78(2):430-441
Some people have advocated that a negative CT scan of the cervical spine (C-spine) does not exclude all
significant C-spine injuries and that definitive identification of all injuries requires a MRI.
significance of some MRI findings has been contested.

8-10

6, 7

However, the

This uncertainty created the impetus for continuing

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studies, which suggested that a negative CT of the C-spine alone is sufficient for clearance. In 2007, Stelfox et al
reported that clearance with high-quality CT alone resulted in statistically significant reductions in cervical collar

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complications, fewer days of mechanical ventilation, and shorter ICU/hospital stays without a difference in hospital
mortality.

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This uncertainty also resulted in a wide variety of practice patterns throughout the country. In 2015, the Eastern

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Association for the Surgery of Trauma (EAST) published a systematic review of 12 articles (all either retrospective
or prospective cohort studies) to determine whether additional imaging was necessary after a negative high13

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quality CT was obtained during the evaluation of obtunded, adult blunt trauma patients. The authors sought
accounts of adult blunt trauma patients over the age of 16 who underwent CT imaging of the C-spine with slices <3

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mm thick and who were obtunded. Subjects were considered obtunded if they had a Glasgow Coma Scale (GCS)

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score <15, were unconscious or intubated, had altered mental status, were unreliable, had a distracting injury, or
were NEXUS positive. Studies involving CT slices >3 mm and those in which the thickness of the slices was not

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reported were excluded.

Primary outcomes were the development of paraplegia or quadriplegia after cervical collar removal and

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the identification of unstable injuries on adjunct imaging. Secondary outcomes were identification of stable

removal.

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injuries on adjunct imaging, false-negative CT imaging on review, pressure ulcers, and time to cervical collar

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The development of paraplegia or quadriplegia was reported in five studies that included 1,017 subjects,
however, no reported instances of paralysis. Similarly, 11 studies that involved 1,718 subjects reported no unstable
C-spine injuries on adjunct imaging. MRI was the most commonly employed adjunct imaging modality.
Furthermore, the use of adjunct imaging in the 11 studies involving 1,718 subjects found 161 stable C-spine
injuries (9%). Most of these injuries were ligamentous in nature and none required surgical intervention.
Based on these data, EAST has conditionally recommended the removal of cervical collars in obtunded,
adult blunt trauma patient following a negative, high-quality CT scan of the C-spine. This decision is attributable to
a worst-case 9% incidence of stable C-spine injury and a high negative predictive value of 100% for unstable Cspine injury following a negative, high-quality CT scan of the C-spine. This represents the first definitive
recommendation for clearance of the cervical spine in obtunded patients and should expedite cervical collar

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removal, thereby decreasing the incidence of pressure ulcers and facilitating airway management in these
patients.

Ultimately, emergency medicine providers need to be comfortable with the image quality of their CT

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scanner and the ability of their radiologist to read the scan. Ideally, a negative CT scan will allow providers to
remove the patients cervical collar, and prevent negative outcomes (e.g.: pressure ulcers, airway issues).

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6. Ankle Injuries

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Skelley NW, Ricci WM. A single-person reduction and splinting technique for ankle injuries. J Orthop Trauma

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2015;29:e172-e177

Injuries to the ankle are one of the most common presenting complaints in the ED. Treatment of these
injuries can require reduction and splinting, which can be difficult to perform, requiring a significant investment of

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time by the physician and support staff. In 1959, Quigly described a technique in which a large stockinette is used

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to cover the leg and then hung from a height to allow the weight of the leg to auto-reduce the ankle and provide
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support while a splint is applied. Skelly and Ricci have developed a variation on this technique, which they used

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successfully on 51 patients.

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Their modified technique employs the ingenious use of common supplies and a simple setup to allow a
single care provider to reduce and splint any ankle injury with relative ease. Patient positioning is key for this
technique. The supplies that are needed are one length of 4- to 6-inch gauze rolls, one length of 2-inch width gauze
rolls, and splinting materials. Patients are placed in the supine position and the length of a 4- to 6-inch gauze rolls
is placed under the patients affected leg as a sling just proximal to the knee while the knee is flexed to 90 degrees.
The knee is then extended beyond 90 degrees and the gauze roll is fastened to the stretcher just over the patients
ipsilateral or contralateral shoulder for varus or valgus injuries, respectively. [Figure 1] After securing the affected
leg to the stretcher, the foot is suspended from an IV pole using 2-inch gauze. A tension lock loop is placed around
the first and second toes of the affected foot and the other end is then attached to the IV pole so that the knee is
flexed to 90 degrees. [Figure 2]

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Reduction is achieved by recreating the injury mechanism while applying traction. After reduction, the
assembled apparatus will maintain the reduction while the sole practitioner applies a posterior and stirrup splint.

This technique was used from 2011 to 2014 on 51 patients with a wide range of injury patterns, which

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included fractures (unimalleolar, bimalleolar, trimalleolar, Jones, pilon) and soft-tissue injuries (sprains and Achilles
tendon rupture). Only 4 of the 51 patients required revisions (3 for malreduction and 1 for insufficient padding).

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The authors reported no complications associated with or failures of the apparatus.

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This technique is easy to set up and is helpful in maintaining the reduction, allowing an EM provider to
splint the fracture with minimal assistance.

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In the emergency department where we are often running low on staff, and resources this is a great
technique for a solitary provider to be able to reduce and splint ankle fractures without any assistance.

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7. Sports Medicine

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Lee H, Sullivan SJ, Schneiders AG, et al. Smartphone and tablet apps for concussion road warriors (team clinicians):

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a systematic review for practical users. Br J Sports Med 2015;49:499-505

The subject of concussions has been at the forefront of medical and current news. The high-profile issues

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of the National Football League and the release of the Hollywood movie Concussion have sparked debates about
sports-related injuries. Many tools have been developed to evaluate concussions and determine if an injured
player can return to the activity. The Sideline Concussion Assessment Test 2 (SCAT2), the most widely used
assessment tool, has been developed with input from international sports federations including the Fdration
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Internationale de Football Association and the International Olympic Committee. The use of handheld devices on
the sidelines in the world of sports is increasing, as it is in the medical field. The combination of the two for sideline
testing for concussions is inevitable. Lee and colleagues performed a systematic review of available apps to
determine if they are comparable to the SCAT2 or Pocket SCAT2.
The authors performed a systematic review of the available apps using specific key words. They
eliminated apps that do not use English or are solely for the dissemination of information. The apps were not

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limited by platform (e.g., iTunes or Google Play) A total of 18 apps were selected for this review. The authors
developed a 10-point checklist to compare the app to the corresponding SCAT 2 or Pocket SCAT2 scoring system,

respectively. They devised the following scoring system to rate the app on whether it measure/documented the

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criteria in SCAT 2. The scoring was 2, present and complete; 1, present but incomplete; and 0, not included/not
specified. A maximum score of 20 was attainable. The final data were presented as a compliance score, as a

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percentage of the SCAT2. If the app was designed for non-medical personnel, the Pocket SCAT2 was used for
comparison.

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The results from this manuscript are interesting since they show wide variability in the accuracy and

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availability of current apps. Not including the app versions of the SCAT2, the apps range from 0 to 100% compliant
with the SCAT2. The variability in compliance is noteworthy, as the use of these apps by the general population will
continue to grow. The expanding availability of these programs increases the likelihood of the improper use of a

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sideline assessment tool that is not validated for decisions regarding return to play. The SCAT2 has an app and

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should be utilized for most assessments, but it is limited to medical personnel and should be used with caution by
untrained practitioners.

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The observations in this paper should encourage developers of future apps to include critical aspects of

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the SCAT in them. Updates to SCAT2 have already been published, and the sideline use of this application should
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replace the current SCAT2 use. It is inevitable that the use of handheld devices for the assessment and
management of concussion will continue to grow. Ultimately, emergency care providers will need to know how the
initial assessment was made, i.e., with which app and by whom and have familiarity with the scoring systems in
order to care for these patients.
8. Clavicular Fractures
Melean PA, Zuniga A, Marsalli M, et al. Surgical treatment of displaced middle-third clavicular fractures: a
prospective, randomized trial in a working compensation population. J Shoulder Elbow Surg. 2015;24(4):587-592
The clavicle is frequently injured in both work and contact sports. The use of operative repair for middlethird clavicular fractures has been debated in the orthopedic literature for some time. The standard of care has

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been conservative treatment because the clavicle heals quite well. Currently, most Emergency care providers
prefer a conservative management for these fractures, with close follow-up by orthopedic specialists. The benefit
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of operative repair of clavicle fractures has been explored.

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Melean and colleagues conducted a prospective randomized study that looked at 76 mid-shaft clavicular
fractures. The patients were randomized to either conservative treatment (n=42) or surgical treatment (n=34).

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Patients were included if they had a displaced middle-third clavicular fracture and were older than 18 years of age.
Conditions for exclusion were lateral or medial fractures, open fractures, or a lapse of more than 21 days since the

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injury. The objective of the study was to compare union rates, functional outcomes at follow-up, and time until

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complete return to work. The patients were evaluated using radiologic and clinical evaluations at 12 weeks and at
6 and 12 months. There was no difference in age or tobacco use between the two groups or differences in
shortening. The surgical group had a shorter time to return to work than the conservative group (the difference

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was statistically significant). Approximately 10% of patients in the conservative group went on to non-union

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compared with no patients in the surgical group.

This is a nicely done prospective randomized controlled trial that evaluated the operative management of

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clavicle fractures. The authors took care in assigning control groups and the results show that the groups are not

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significantly different. It is interesting to note that the authors included patients from a workman's compensation
group with a very specific type of clavicular fracture. This does introduce a small amount of bias into the study, as
it may not be applicable to all patient populations. The main reason this study is relevant to the general ED
population is that early referral for surgical evaluation of middle-third clavicular fractures seems to be warranted.
Walton B, Meijer K, Melancon K, et al. A cost analysis of internal fixation versus nonoperative treatment in adult
midshaft clavicle fractures using multiple randomized controlled trials. J Orthop Trauma 2015;29(4):173-180
Fractures of the clavicle are often encountered in the ED. Traditional teaching has favored conservative
management as an initial strategy for displaced midshaft fractures instead of surgical intervention, and this
approach has been supported by studies reporting a low rate of non-union as well as high patient satisfaction.

19-23

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More recently, however, a number of studies have challenged this therapeutic strategy by demonstrating higher
levels of non-union as well as lower patient satisfaction.

24-29

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Further complicating this decision is the question of cost. Althausen et al. sought to determine the

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difference between initial surgical intervention and conservative treatment. Survey results from 149 patients
revealed a significantly lower financial impact with initial surgical fixation ($12, 976 versus $18, 068), largely driven

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by earlier return to work and a reduction in lost wages.

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Conversely, Walton et al. analyzed multiple randomized controlled trials to determine whether
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conservative or surgical intervention is more costly from the perspective of a single payer. They constructed a

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decision tree from the data of four randomized controlled trials, with reoperation in patients who initially received
surgical management and delayed operative fixation of conservatively treated patients as endpoints. An estimate

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of cost was made using 2013 national average Medicare reimbursement for physicians, facility costs, and
anesthesia fees. In an effort to more accurately estimate costs incurred by private payers, all estimated Medicare

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costs were multiplied by 2.56 to account for the discount feeds Medicare reimburses.

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Their analysis favored conservative treatment over initial surgical fixation. Expected cost of operative
management was $14,763 compared with $3,112 for conservative management, for a total saving of $11, 650. This

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total was preserved in a two-way sensitivity analysis over a wide range of probabilities, favoring conservative
treatment until reoperation of initial surgical patients fell below 15% and delayed operative treatment in the
conservative group exceeded 95%. These findings were consistent even in subgroup analysis, excluding patients
initially treated surgically with intramedullary nailing.
Using these results, the authors determined that conservative treatment with delayed operation is
preferred in a single-payer model. However, the authors failed to account for the cost to the patient. Patients who
undergo surgery require less pain medication and less physical therapy and return to work sooner, resulting in
lower total cost compared with those who receive conservative surgery.

30, 32

In the end, physicians need to look at

the individual patient, including activity level and occupation, to determine what would be the most cost-effective
and safe treatment plan.

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Over the last several years, multiple studies have shown that patients actually benefit from surgical repair
and that surgical outcomes are not as horrendous as the original Neer article reported.

21, 33, 34

Emergency medicine

providers should refer their active patients with clavicle fractures to orthopaedics early for consideration of

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operative repair.

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Figure 1: A 4 or 6 stockinette is placed as a sling under the patients ipsilateral knee. The Knee is flexed to 90
and the stockinette is tied securely behind the patient to the stretcher.

Figure 2: A: Using rolled gauze a slip knot is tied to the first two toes and the leg is suspended from an IV pole. B:

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This panel shows the patient in their final position. The ankle will often self-reduce in this position, and the setup
allows the patient to be splinted in the proper position by a single provider. Once the splint is applied and dry, the

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rolled gauze and stockinette can be cut and removed.

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Figure 1

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Figure 2