Journal of Orthopaedic Trauma

Journal of Orthopaedic Trauma is devoted exclusively to the diagnosis and management of hard and soft tissue trauma, including injuries to bone, muscle, ligament, and tendons, as well as spinal cord injuries. Under the guidance of a distinguished international board of editors, the journal provides the most current information on diagnostic techniques, new and improved surgical instruments and procedures, surgical implants and prosthetic devices, bioplastics and biometals; and physical therapy and rehabilitation. The Official Publication of: Orthopaedic Trauma Association AO Trauma North America​ Belgian Orthopaedic Trauma Association Canadian Orthopaedic Trauma Society Foundation for Orthopedic Trauma International Society for Fracture Repair The Japanese Society for Fracture Repair
Journal of Orthopaedic Trauma - Current Issue
  1. imageObjective: To evaluate the difference in the quality of fracture reduction between the sinus tarsi approach (STA) and extensile lateral approach (ELA) using postoperative Computed Tomography (CT) scans in displaced intra-articular calcaneal fractures (DIACFs). Design: Retrospective. Setting: Level 1 and level 2 academic centers. Patients: Consecutive patients undergoing operative fixation of DIACFs with postoperative CT scans and standard radiographs. Methods: Patients were identified based on Current Procedural Terminology code and chart review. All operative calcaneal fractures treated between 2012 and 2018 by fellowship-trained orthopaedic trauma surgeons were evaluated. Those with both postoperative CT scans and radiographs were included. Exclusion criteria included extra-articular fractures, malunions, percutaneous fixation, ORIF and primary fusion, and those patients without a postoperative CT scan. The Sanders classification was used. Cases were divided into 2 groups based on ELA versus STA. Bohler angle and Gissane angle were evaluated on plain radiographs. CT reduction quality grading included articular step off/gap within the posterior facet, and varus angulation of the tuberosity: CT reduction grading included: excellent (E): no gap, no step, and no angulation; good (G): 1 mm step, 5 mm gap, and/or 3 mm step, >10 mm gap, and/or >15° angulation. Results: Seventy-seven patients with 83 fractures were included. Average age was 42 years (range, 18–74 years), with 57 men. Four fractures were open. There were 37 Sanders II and 46 Sanders III fractures; 36 fractures were fixed using the STA, whereas 47 used the ELA. Average days to surgery were 5 for STA and 14 for ELA (P 0.001). A normal Bohler angle was achieved more often with the ELA (91.5%) than with STA (77.8%) (P 0.001). There was no difference by approach for Gissane angle (P = 0.5). ELA had better overall reduction quality (P = 0.02). For Sanders II, there was no difference in reduction quality with STA versus ELA (P = 0.51). For Sanders III, ELA trended toward better reduction quality (P = 0.06). Conclusions: The ELA had a better overall reduction of Bohler angle on plain radiographs and of the posterior facet and tuberosity on postoperative CT scans. For Sanders type II DIACFs, there was no difference between STA and ELA. Importantly, for Sanders III DIACFs, ELA trended toward better reduction quality. In addition to fracture reduction, surgeon learning curve, early wound complications, and long-term outcomes must be considered in future studies comparing the ELA and STA. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
  2. imageObjective: To analyze the correlation between surgical timing and outcomes for calcaneus fractures treated using a sinus tarsi approach (STA). Setting: Single Level-1 trauma center. Design: Retrospective. Patients/Participants: Seventy consecutive intra-articular calcaneus fractures (OTA/AO 82C; Sanders II-IV) treated operatively using STA with a minimum of 1-year follow-up. Intervention: Open management using STA. Main Outcome Measurement: Surgery timing, wound complications, American Orthopaedic Foot and Ankle Society ankle and hindfoot and Patient-reported Outcomes Measurement System scores. Results: Patients were primarily men (68.6%) averaging 46 years (range, 18–77 years). Nineteen (27%) were obese, 27 (38.6%) were smokers, and 3 (4.3%) were diabetic, and 10 (14.3%) had open fractures. Sanders III fracture patterns were most common (45.7%). Mean time to surgery was 4.9 days (range, 0–23 days). Three patients (4.2%) developed postoperative infections requiring surgical debridement and antibiotics. Forty patients (57%) underwent operative repair within 72 hours of injury, 9 (22.5%) of which had open fractures. Of this group, only one patient developed wound necrosis. Restoration of Bohler angle and angle of Gissane and reductions in calcaneal varus angle and heel width were achieved (all P 0.001). No differences in Ankle Society ankle and hindfoot or Patient-reported Outcomes Measurement System scores were noted between patients treated within or beyond 72 hours from injury. Conclusion: Intra-articular calcaneus fractures can be treated acutely within 72 hours of injury using STA with minimal wound complications and without compromising short-term functional outcome. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
  3. imageObjective: To evaluate the rate of subtalar arthrodesis based on a computed tomography (CT) scan after open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneal fractures. Design: Retrospective chart review. Setting: Single tertiary care practice. Patients: A retrospective chart review was performed to identify patients who sustained an acute, displaced, intra-articular calcaneal fracture and underwent open reduction and primary subtalar arthrodesis. Thirty-five patients participated in the study. Intervention: Each patient included in the study was treated with open reduction and primary subtalar arthrodesis. Main Outcome Measures: All patients were evaluated with CT for arthrodesis of the posterior facet of the subtalar joint, which was quantitated. Other outcome measures included radiographic parameters, the Veterans RAND Item Health Survey, and the Foot and Ankle Ability Measure. Results: The median patient age was 47.8 years (range 21.5–79.5 years). The median patient follow-up was 34.4 months (range 4.6–104.1 months). The Sanders classification was as follows: 3% (1/35) type II, 40% (14/35) type III, and 57% (20/35) type IV. Based on a CT scan, primary subtalar union occurred in 94.3% (33/35) of patients. Conclusions: Open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneus fractures has a high rate of union and good pain and function outcomes. It should be strongly considered for patients with significant cartilage injury and comminution of the posterior facet. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
  4. imageObjectives: To compare the deep infection rates after immediate versus staged open reduction internal fixation (ORIF) for pilon fractures. Design: Retrospective cohort study. Setting: Three academic Level I trauma centers. Patients: Four hundred one patients with closed OTA/AO type 43C distal tibia fractures treated with ORIF. Sixty-six percent were men, and the mean age was 45.6 years. The median (interquartile range) follow-up was 1.7 (1.0–3.7) years. Intervention: Acute, primary (24 hours). Main Outcome Measurement: Deep infection or wound complication as defined by return to operating room for surgical irrigation and debridement. Results: Patients were grouped by time from presentation to surgery: acute ORIF (n = 99) and delayed ORIF (n = 302). Acute ORIF was more frequent in patients with OTA/AO type 43C1 fractures, low-energy mechanisms (ie, fall from standing), younger and female patients. Patients who demonstrated severe swelling (242, 80%), swelling and fracture blisters (26, 9%), swelling and ecchymosis precluding planned surgical approach (4, 1%), polytrauma requiring resuscitation (20, 6%), who were transferred from an outside facility with external fixator in place (6, 2%), who had evolving compartment syndrome (2, 1%), and who required medical clearance (2, 1%) underwent staged, delayed fixation. There were significantly more 43C1 fractures in the acute fixation group (31% vs. 7%, P 0.001) and significantly more 43C3 fractures in the delayed group (63% vs. 37%, P 0.001). The overall deep infection rate was 17%. Early surgery was not associated with an increased risk of postoperative wound complication (early 12% vs. delayed 18%, P = 0.235). Multivariate analysis adjusted for timing of surgery found high-energy trauma [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.1–13.8], smoking (OR 2.4, CI 1.3–4.6), male sex (OR 2.1, CI 1.0–4.1), and increasing age (OR 1.02, CI 1.00–1.04, P = 0.040) to be independent predictors of deep infection. Diabetes demonstrated a nonstatistically significant increased risk (OR 2.6, 95% CI 0.9–7.3, P = 0.063). Conclusions: This study confirms the high risk of infection after the fixation of tibial plafond fractures. If early definitive fixation is considered, extreme care should be taken to carefully evaluate the soft tissue envelope and assess for other risk factors (such as age, male sex, smokers, diabetics, and those with higher-energy fracture patterns) that may predispose the patient to a postoperative soft tissue infection. Our study has shown that the judicious use of early definitive fixation in closed pilon fractures, in the appropriate patient, and with careful evaluation of the soft tissue envelope, is likely safe and does not seem to increase the risk of wound complications and deep infection in the hands of experienced fracture surgeons. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
  5. imageObjectives: We studied the safety of immediate weight-bearing as tolerated (IWBAT) and immediate range of motion (IROM) after open reduction internal fixation (ORIF) of selected malleolar ankle fractures (defined as involving bony or ligamentous disruption of 2 or more of the malleoli or syndesmosis without articular comminution) and attempted to identify risk factors for complications. Design: Retrospective case–control study. Setting: Level 1 Urban Trauma Center and multiple community hospitals, orthopedic specialty hospitals, and outpatient surgicenters within one metropolitan area. Patients/Participants: Of 268 patients at our level 1 trauma center who underwent primary ORIF of a selected malleolar fracture from 2013 to 2018, we identified 133 (49.6%) who were selected for IWBAT and IROM. We used propensity score matching to identify 172 controls who were non–weight-bearing (NWB) and no range of motion for 6 weeks postoperatively. The groups did not differ significantly in age, body mass index, Charleston Comorbidity Index, smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB), posterior malleolus (24.1% IWBAT, 26.7% NWB), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, P = 0.85). Intervention: IWBAT and IROM after ankle ORIF versus NWB for 6 weeks. Main Outcome Measurements: Postoperative complications, including delayed wound healing, superficial or deep infection, and loss of reduction. Results: There was no significant difference in total complications (P = 0.41), nonoperative complications (P = 0.53), or operative complications, including a loss of reduction (P = 0.89). We did not identify any factors associated with an increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, or preinjury-assisted ambulation. Conclusions: We failed to demonstrate a difference in complications in general and loss of reduction in particular when allowing immediate weight-bearing/ROM in selected cases of operatively treated malleolar fractures, suggesting this may be safe. Future prospective randomized studies are necessary to determine if immediate weight-bearing/ROM is safe and whether it offers any benefits to patients with operatively treated malleolar fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
  6. imageObjective: To identify whether timing to surgery was related to major 30-day morbidity and mortality rates in periprosthetic hip and knee fractures [OTA/AO 3 (IV.3, V.3), OTA/AO 4 (V4)]. Design: Retrospective database review. Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patients: Patients in the NSQIP database with periprosthetic hip or knee fractures between 2007 and 2015. Intervention: Surgical management of periprosthetic hip and knee fractures including revision or open reduction internal fixation. Main Outcome Measurements: Major 30-day morbidity and mortality after operative treatment of periprosthetic hip or knee fractures. Results: A total of 1265 patients, mean age 72, including 883 periprosthetic hip and 382 periprosthetic fractures about the knee were reviewed. Delay in surgery greater than 72 hours is a risk factor for increased 30-day morbidity in periprosthetic hip and knee fractures [relative risk = 2.90 (95% confidence interval: 1.74–4.71); P-value ≤ 0.001] and risk factor for increased 30-day mortality [relative risk = 8.98 (95% confidence interval: 2.14–37.74); P-value = 0.003]. Conclusions: Using NSQIP database to analyze periprosthetic hip and knee fractures, delay to surgery is an independent risk factor for increased 30-day major morbidity and mortality when controlling for patient functional status and comorbidities. Although patient optimization and surgical planning are paramount, minimizing extended delays to surgery is a potentially modifiable risk factor in the geriatric periprosthetic lower extremity fracture patient. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
  7. imageObjective: Paradoxically, overweight and obesity are associated with lower odds of complications and death after hip fracture surgery. Our objective was to determine whether this “obesity paradox” extends to patients with “superobesity.” In this study, we compared rates of complications and death among superobese patients with those of patients in other body mass index (BMI) categories. Methods: Using the National Surgical Quality Improvement Program database, we identified >100,000 hip fracture surgeries performed from 2012 to 2018. Patients were categorized as underweight (BMI 18.5), normal weight (BMI 18.5–24.9), overweight (BMI 25–29.9), obese (BMI 30–39.9), morbidly obese (BMI 40–49.9), or superobese (BMI ≥50). We analyzed patient characteristics, surgical characteristics, and 30-day outcomes. Using multivariate regression with normal-weight patients as the referent, we determined odds of major complications, minor complications, and death within 30 days by BMI category. Results: Of 440 superobese patients, 20% had major complications, 33% had minor complications, and 5.2% died within 30 days after surgery. When comparing patients in other BMI categories with normal-weight patients, superobese patients had the highest odds of major complications [odds ratio (OR): 1.6, 95% confidence interval (CI), 1.2–2.0] but did not have significantly different odds of death (OR: 0.91, 95% CI, 0.59–1.4) or minor complications (OR: 1.2, 95% CI, 0.94–1.4). Conclusion: Superobese patients had significantly higher odds of major complications within 30 days after hip fracture surgery compared with all other patients. This “obesity paradox” did not apply to superobese patients. Level of Evidence: Prognostic Level III. See Instructions for Authors for a Complete Description of Levels of Evidence.
  8. imageObjectives: To evaluate the need for reoperation of geriatric intertrochanteric hip fractures treated with 10-mm cephalomedullary nails versus those treated with nails larger than 10 mm. Design: Retrospective review at a single institution. Setting: Level I trauma center. Patients/Participants: All patients age 60 and over treated with cephalomedullary fixation for an intertrochanteric femur fracture at a single institution. Intervention: Cephalomedullary fixation with variable nail diameters. Main Outcome Measurements: Reoperation rates of geriatric intertrochanteric fractures treated with a size 10-mm diameter cephalomedullary nail compared with patients treated with nails larger than 10 mm. Results: There were no significant differences in reoperation rates when the 10-mm cohort was compared with an aggregate cohort of all nails larger than 10 mm (P = 0.99). This result was true for both all-cause reoperation and noninfectious reoperation. There was no difference between cohorts in regards to age, gender, or fracture pattern. Conclusions: A 10-mm cephalomedullary nail can be used in lieu of a larger diameter fixation in patients age 60 and older with intertrochanteric femur fractures while still maintaining a comparable rate of reoperation. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
  9. imageObjectives: The iliopectineal fascia (IPF) serves as an important anatomical compass during the ilioinguinal and anterior intrapelvic approaches. The purpose of this investigation is to qualitatively and quantitatively describe the IPF by cadaveric dissection. Methods: Dissections were performed on 7 paired fresh-frozen cadaveric pelvic specimens. Measurements were made with surgical rulers to determine attachments of the IPF relative to surrounding anatomy. Results: The IPF is the thickened anterior portion of the iliopsoas fascia, attached superolaterally at the iliac crest for a mean insertion distance of 2.5 cm (range, 2.0–3.0 cm), immediately posterior to the origin of the inguinal ligament. Inferomedially, the IPF attaches to a bony ridge along the apex of the iliopectineal eminence, between the pelvic brim posteriorly and the anterior wall of the acetabulum anteriorly (mean distance, 4.3 cm; range, 3.1–5.6 cm). The attachment at the iliopectineal eminence is 7.8 cm (range, 6.0–10.0 cm) from the pubic symphysis, measured curvilinearly along the brim. The mean length of the IPF between its superolateral and inferomedial attachments is 9.2 cm (range, 8.0–11.8 cm). Anterolaterally, the IPF is the site of attachment of the internal oblique and transversus abdominis. Posteriorly, the IPF continues as the iliopsoas fascia. Conclusions: The authors have sought clarity and reconciliation of the myriad terms and descriptions of the IPF and its surrounding anatomy. We recommend a thorough understanding of this anatomy to enable safe and effective surgery via the ilioinguinal and anterior intrapelvic approaches to the acetabulum.
  10. imageObjectives: To correlate domains of the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) in open upper extremity injuries with type of definitive soft-tissue closure, complication rates, and unanticipated return to the operating room for complication. Design: Retrospective review of prospectively collected data. Setting: Level I trauma center. Patients: Two hundred thirty-four consecutive open upper extremity fractures. Intervention: Operative management of open upper extremity fractures. Main outcome measurements: Type of definitive closure, 90-day wound complication, and wound complication necessitating return to the operating room. Results: Two hundred eighty injuries were identified, and 234 had sufficient data for analysis. Eighty-four percent (196/234) of open wounds were closed primarily, 7% (16/234) required a skin graft, and 4% (9/234) required rotational or free flap. Thirteen percent (22/166) of those followed for 90 days had a wound complication, and 50% of those with complication required a return to the OR. All OTA-OFC classifications statistically significantly correlated with type of closure (P 0.001), with skin having a high correlation (r = 0.79), muscle (r = 0.49) and contamination (r = 0.47) moderate correlations, and arterial (r = 0.32) and bone loss (r = 0.33) low correlations. OTA-OFC muscle classification was predictive of 90-day wound complication (OR 0.31, 95% confidence interval 0.07–0.21). OTA-OFC domains correlated variably with return to the OR. Conclusion: OTA-OFC clinically correlates with definitive wound management and 90-day wound complication in open upper extremity fractures. OTA-OFC skin classification has a high correlation with the type of definitive wound closure. OTA-OFC muscle was the only domain that correlated with 90-day wound complication and was predictive of 90-day wound complication. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
  11. imageObjectives: (1) Evaluate intentional temporary limb deformation for closure of soft-tissue defects as a reconstruction strategy in open tibia fractures and (2) analyze the deformity parameters required for such reconstruction. Design: Multicenter retrospective cohort. Setting: Level I trauma center. Patients/Participants: Nineteen patients 18 years of age and older at the time of initial trauma, with a Gustilo–Anderson type IIIB or IIIC open tibia fracture treated with hexapod external fixation and intentional bony deformity created to facilitate soft-tissue closure. Intervention: Intentional limb deformation for soft-tissue closure, followed by gradual correction with a hexapod external fixator. Outcome Measurements: Radiographic healing, radiographic assessment of limb alignment, and functional and bony Application of the Method of Ilizarov Group score. Results: The average age was 45.3 (20–70), and 79% of patients were men. The most common mechanism of injury was motor vehicle accidents. The distal 1 of 5 of the tibia was the most common fracture location, with 37% of these involving the articular surface at the plafond. After wound closure, deformity correction was initiated after 30 days on average. Varus and apex posterior were the most common initial deformity required for primary soft-tissue closure. Bony and functional Application of the Method of Ilizarov Group outcomes were good or excellent in 94% of patients. Conclusion: Intentional deformation followed by a gradual correction can be an effective strategy to obtain bone union and soft-tissue coverage in certain open fractures. This technique, in essence, converts these injuries from type IIIB to IIIA. This strategy obviates the need for flap coverage and results in satisfactory outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
  12. imageObjective: To compare complications and functional outcomes between supination adduction type II (SAD) injuries and torsional ankle injuries (TAI). Design: Retrospective cohort. Setting: Level 1 trauma center. Patients and Methods: Patients (n = 1531) treated for ankle fractures (OTA/AO 43B or 44) over 16 years were identified. The most recent 200 consecutive adult patients treated for TAI (OTA/AO 44, not SAD) served as controls. Main Outcome Measures: Complications, unplanned secondary procedures, and patient-reported functional outcome scores, as measured by the Foot Function Index and Short Musculoskeletal Function Assessment. Results: Sixty-five patients with SAD injuries (4.2%) were included. They were younger (43.2 vs. 47.7 years, P = 0.08) and more commonly involved in a motorized collision, (58.5% vs. 29.0%) and more often multiply injured: other orthopaedic injuries (66.2% vs. 31.0%) and other nonorthopaedic injuries (40.0% vs. 7.5%, all P 0.001 vs. TAI). Overall complication and unplanned secondary procedure rates were not different between groups. Those with a SAD injury had more posttraumatic arthrosis (80.0% vs. 40.9%, P = 0.004), but no differences were noted in infection, wound healing, malunion, or nonunion. The mean functional outcome scores were worse for SAD patients over 6 years after injury among all the Foot Function Index and Short Musculoskeletal Function Assessment categories; however, these differences were not significant. Conclusions: SAD injuries represented 4.2% of all ankle fractures, occurring in younger patients through higher-energy mechanisms and more often associated with polytrauma. Despite 80% of SAD patients developing posttraumatic arthrosis, secondary procedures were not more common, and functional outcomes after a SAD injury were not different from TAI. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
  13. imageObjectives: To determine outcomes of radial head replacement (RHR) for acute fractures using 3 different implant designs with or without cement fixation. Design: Retrospective. Setting: Tertiary referral hospital. Patients/Participants: One hundred fourteen elbows underwent RHR for an acute radial head fracture using either (1) a nonanatomic design and smooth stem (n = 60), (2) a nonanatomic design with a grit-blasted, ingrowth, curved stem (n = 21), or (3) an anatomic design with a grit-blasted ingrowth straight stem (n = 33). Cemented (25%) or uncemented (75%) fixation was used at the discretion of the treating surgeon. Intervention: RHR. Main Outcome Measurements: The primary outcome was implant survivorship free of revision or removal for any reason. All elbows were evaluated clinically (the Mayo Elbow Performance Score and reoperations/complications) and radiographically. Results: Fourteen implants (12%) were revised. Of elbows with a minimum 2-year clinical follow-up, the average Mayo Elbow Performance Score was 88. The rate of survivorship free from revision was 92% [95% confidence interval (CI) = 87%–98%] at 2 years, 90% (CI = 84%–96%) at 5 years and 84% (CI = 75%–94%) at 10 years. The differences in survivorship between the 3 implants did not reach statistical significance, but the nonanatomic design with a grit-blasted ingrowth curved stem had a hazard ratio of 4.6 (95% CI = 0.9%–23%) for failure. There were no differences in survivorship between cemented versus uncemented stems. For those elbows with a minimum of 2 years of radiographic follow-up, implant tilt was observed in 10 (16%) elbows and loosening in 16 (26%) elbows. Stress shielding was present in 19 (42%) of well-fixed implants. Conclusions: RHR for acute trauma leads to survivorship greater than 80% at 10 years. Radiographic changes (loosening, stress shielding, and implant tilting) can be expected in a substantial portion of elbows at long-term follow-up. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
  14. imageObjective: To identify risk factors for posttraumatic stress disorder (PTSD) after traumatic injury. Setting: Single urban Level I trauma center. Design: Prospective. Patients/Participants: Three hundred men (66%) and 152 women treated for traumatic injuries were administered the PTSD checklist for a Diagnostic and Statistical Manual of Mental Disorders fifth edition (PCL-5) survey during their first post-hospital visit over a 15-month period. Intervention: Screening for PTSD in trauma patients. Main Outcome Measurement: The prevalence of disease and risk factors for the development of PTSD based on demographic, medical, injury, and treatment variables. Results: One hundred three patients screened positive for PTSD (26%) after a mean of 86 days after injury. Age less than 45 years was an independent risk factor for the development of PTSD [odds ratio (OR) 2.64, 95% confidence interval (CI) (1.40–4.99)]. Mechanisms of injury associated with the development of PTSD included pedestrians struck by motor vehicles [OR 7.35, 95% CI (1.58–34.19)], motorcycle/all terrain vehicle crash [OR 3.17, 95% CI (1.04–9.65)], and victims of crime [OR 3.49, 95% CI (0.99–9.20)]. Patients sustaining high-energy mechanism injuries and those who were victims of crime scored higher on the PCL-5 [OR 2.39, 95% CI (1.35–4.22); OR 4.50, 95% CI (2.52–8.05), respectively]. Conclusions: One quarter of trauma patients screened positive for PTSD at 3 months after their injury. A mechanism of injury is a risk factor for PTSD, and younger adults, victims of crime, and pedestrians struck by motor vehicles are at higher risk. These findings offer the potential to more effectively target and refer vulnerable patient populations to appropriate treatment. Level of Evidence: Prognostic Level II. See Instructions for Authors for a compete description of levels of evidence.
  15. imageSummary: We present a technique of fixation of trimalleolar fractures with additional fracture of the anterior tibial tubercle (“quadrimalleolar”) or anterior fibular rim (“quadrimalleolar equivalent”). Twenty-four patients with a mean age of 60 years were treated with open reduction and internal fixation of all 4 malleoli. There were 17 quadrimalleolar and 6 quadrimalleolar equivalent fractures. One patient had both anterior tibial and fibular avulsion fracture in addition to a trimalleolar ankle fracture. Surgical approaches and internal fixation were tailored individually. Twenty patients were operated in the prone position with direct fixation of the posterior malleolus and 4 patients in the supine position with anterior to posterior screw fixation of the posterior malleolus. After fixation of al 4 malleoli, only 1 patient (4%) required a syndesmotic screw for residual syndesmotic instability on intraoperative testing. There were no infections and no wound healing problems. All patients went on to solid union. Nineteen patients (79%) were followed for a mean of 77 months (range, 15–156 months). The Foot Function Index averaged 15 (range, 50 to 0), the Olerud and Molander Score averaged 79 (range, 45–100), and the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale averaged 87 (range, 39–100). Fixation of the anterior and posterior tibial fragments increases syndesmotic stability by providing a bone-to-bone fixation. Anatomic reduction of the anterior and posterior tibial rim restores the physiological shape of the tibial incisura and therefore facilitates fibular reduction.