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CASE: Bean bag projectiles (BBPs) are less lethal munition composed of a cloth bag filled with lead pellets and marking powder housed in a plastic casing fired from a 12-gauge shot gun. Two patients sustained penetrating BBP injuries that resulted in open fractures and retained BBP. Patient clothing and all BBP components were found deep in the wounds with marking powder surrounding fracture edges. Both patients healed without infection. CONCLUSION: Surgical exploration of penetrating BBP injuries is recommended to remove marking powder, fabric, plastic, and potentially other forms of contamination. Fracture stabilization should adhere to existing guidelines pertaining to open contaminated wound conditions.

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CASE: A 32-year-old man presented with a type II open both-bone forearm fracture and segmental bone loss because of complete extrusion of a diaphyseal fragment (3 cm) of ulna. The patient presented to our level 1 trauma center after a motor vehicle collision. The extruded segment underwent sterilization and immediate reimplantation with internal fixation approximately 6 hours after arrival. Our patient achieved union by 7-month follow-up, demonstrated excellent functional outcomes, and was free from infection at 1-year follow-up. CONCLUSION: In select cases, successful reimplantation can be achieved by meticulous debridement, sterilization, and immediate reimplantation with internal fixation.

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CASE: A 19-year-old woman sustained an open ankle fracture with complete destruction of the left medial malleolus and significant soft-tissue loss. After temporizing external fixation and coverage with a rotational posterior tibial artery perforator flap, the medial malleolus was reconstructed with an autologous iliac crest bone graft and direct repair of the deltoid ligament. The patient achieved excellent improvement in functional outcomes at 21 months with adequate restoration of ankle motion. CONCLUSION: This case shows reconstruction of the medial malleolus with autologous iliac crest bone graft after traumatic loss can be a viable treatment option for young patients.

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CASE: A 34-year-old man was a restrained passenger involved in a high-speed rollover motor vehicle crash. The patient sustained a type 5 AC joint separation, severely comminuted intra-articular glenoid fracture with extension to the coracoid process base, displaced open scapular body fracture, a posterior shoulder dislocation of the glenohumeral joint, and a 2-part proximal humerus fracture. CONCLUSION: To our knowledge, this is the first report describing this injury pattern involving the superior shoulder suspensory complex with an associated open proximal humerus fracture-dislocation.

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BACKGROUND: Large bone defects require complex treatment, multidisciplinary resources, and expert input, with surgical procedures ranging from reconstruction and salvage to amputation. The aim of this study was to provide the results of a case series of open comminuted intra-articular distal femoral fractures with significant bone loss that were managed by early fixation using anatomical plates and a modified Masquelet technique with the addition of surgical propylene mesh. METHODS: This retrospective study included all patients referred to our institution with OTA/AO C3 distal femur open fractures and meta-diaphyseal large bone loss between April 2019 and February 2021. We treated the fractures with irrigation and debridement, acute primary screw and plate fixation in the second look operation, and Masquelet method using shell-shaped antibiotic beads supplemented by propylene surgical mesh to keep the cements in place. The second step of the procedure was conducted six to eight weeks later with bone grafting and mesh augmentation to contain bone grafts. Surprisingly, hard callus formation was observed in all patients at the time of the second stage of Masquelet procedure. RESULTS: All five patients' articular and meta-diaphyseal fractures with bone loss healed without major complications. The average union time was 159 days. The mean knee range of motion was 5-95 degrees. The average Lower Extremity Functional Score (LEFS) was 49 out of 80. CONCLUSIONS: Combination of early plate fixation and the modified Masquelet technique with polypropylene mesh is an effective method for managing large bone defects in open intra-articular distal femoral fractures with bone loss, resulting in shorter union time possibly associated with the callus formation process. This technique may also be applicable to the management of other similar fractures specially in low-income and developing areas.

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INTRODUCTION: War injuries are remarkably different situations with profound severity and significant contamination compared to civilian injuries. Delayed definitive management makes the situation much more complicated. This study aimed to report the outcomes of limb reconstruction of neglected war injuries with a previous decision of amputation. PATIENTS AND METHODS: From 2010 to 2021, 1104 patients with war-related fractures from conflict-zone countries were referred to our center including 589 open tibial fractures. Of these tibial fractures, amputation had already been decided in 54 cases, and the patients were looking for a trial of reconstruction and avoiding amputation. These cases were included in the current study. The treatment approach was a single-stage procedure with bone and soft tissue reconstruction. RESULTS: This study included 54 male patients with a mean age of 26.3 years. Infection was the predominant feature in 43 cases (79.6 %). CT angiography revealed a one-vessel limb in 17 patients. Peripheral nerve injuries affected 15 patients. The mean time from injury to presentation was 8.5 weeks. The bone gap (2-13 cm) was evident in 44 cases. In four cases, the contralateral limb was amputated below the knee. There were associated injuries in nine cases. Rotational flap coverage was done in the same setting for 19 legs. Gastrocnemius flap was done in two cases. The mean follow-up duration was 45.1 months. The treatment methods included bifocal management (33 cases), trifocal management (17 cases), fibular transfer (two cases), and a mono-focal approach in two cases. All fractures healed successfully. The mean external fixation period was 7.6 months. Recurrence of infection occurred in three patients. A non-displaced refracture developed in one case. Five cases had a residual angular deformity. Eventually, the ASAMI bone and functional results were good in all cases. CONCLUSIONS: Neglected war injuries constitute a complex problem where amputation may be indicated. Our approach includes one-stage limb reconstruction with the corticotomy-first technique, conservative debridement of the docking site, concomitant osteoplastic procedure, and gradual distraction to tackle all the aspects of the problem. The good results obtained in the presented series make it a valid approach to avoid amputation in neglected war injuries.

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AIM: This study assessed the functional outcome, and the clinical modifiers that influence them with the aim to assist the clinician plan a better management strategy in Paediatric Floating Knee (PFK) injuries. METHODS: A quasi-prospective, single-center observational study was designed to determine the functional and radiological outcomes in children ( 4 cm of bone loss (p < 0.01) but poor correlation with age at injury (p = 0.5), open fracture (p = 0.17), comminuted femoral and/or tibial fracture patterns (p > 0.05) and loss of soft tissue cover (p = 0.08). CONCLUSIONS: Early recognition of clinical modifiers such as high ISS and bone loss > 4 cm warrants targeted limb reconstruction strategy and can help to prognosticate outcome.

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BACKGROUND: Choosing the appropriate treatment approach for a multifocal comminuted open fracture of humerus with severe soft tissue defect is a challenging issue, which could be interesting for every orthopedic surgeon especially for those working in the trauma centers. CASE PRESENTATION: This study described an innovative approach using titanium elastic nailing to treat a multifocal comminuted open fracture of humerus with severe soft tissue defect. In this study, we report a 40-year-old Persian female patient in whom the treatment achieved complete fracture union and skin graft healing by elastic medullary nailing, vacuum dressing, and skin grafting. CONCLUSIONS: Elastic medullary nailing is a viable option for reconstruction of simultaneous comminuted fracture and soft tissue defect.

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OBJECTIVES: To assess the ability of computed tomography angiography identified infrapopliteal vascular injury to predict complications in tibia fractures that do not require vascular surgical intervention. DESIGN: Multicenter retrospective review. SETTING: Six Level I trauma centers. PATIENTS AND INTERVENTION: Two hundred seventy-four patients with tibia fractures (OTA/AO 42 or 43) who underwent computed tomography angiography maintained a clinically perfused foot not requiring vascular surgical intervention and were treated with an intramedullary nail. Patients were grouped by the number of vessels below the trifurcation that were injured. MAIN OUTCOME MEASUREMENTS: Rates of superficial and deep infection, amputation, unplanned reoperation to promote bone healing (nonunion), and any unplanned reoperation. RESULTS: There were 142 fractures in the control (no-injury) group, 87 in the one-vessel injury group, and 45 in the two-vessel injury group. Average follow-up was 2 years. Significantly higher rates of nerve injury and flap coverage after wound breakdown were observed in the two-vessel injury group. The two-vessel injury group had higher rates of deep infection (35.6% vs. 16.9%, P = 0.030) and unplanned reoperation to promote bone healing (44.4% vs. 23.9%, P = 0.019) compared with controls, as well as increased rates of any unplanned reoperation compared with control and one-vessel injury groups (71.1% vs. 39.4% and 51.7%, P < 0.001), respectively. There were no significant differences in rates of superficial infection or amputation. CONCLUSIONS: Tibia fractures with two-vessel injuries were associated with higher rates of deep infection and unplanned reoperation to promote bone healing compared with those without vascular injury, as well as increased rates of any unplanned reoperation compared with controls and fractures with one-vessel injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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OBJECTIVE: The information on firearm- or explosive-related extremity injuries in children is very limited. Reports of segmental bone loss due to these types of fractures are even rarer and the treatment remains a problem. There has been no report of distraction osteogenesis with limb reconstruction system (LRS) specifically in children. We evaluated the treatment results of Gustilo-Anderson type 3 open fractures with segmental bone loss due to firearm injuries by distraction osteogenesis performed with LRS in skeletally immature patients. METHODS: Nine patients with Gustilo-Anderson (GA) type 3 open fractures with segmental bone loss due to firearm injuries who had not completed their skeletal development were included. Two of the patients had GA type 3a, four had type 3b, and the remaining three had type 3c. Bony and functional assessment was conducted using Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. RESULTS: Mean follow-up period was 20.1 months (range 5.5-35 months). The mean bone loss was 45.5 mm (range 15-80 mm) before the treatment started. The mean time of external fixation (day) was 180.6. The mean distraction index (distraction period per cm) was 11.3 day/cm. The mean time for bone union index (duration of bony union per cm) was 33.7 days/cm. Bony union was achieved in all patients at the end of the treatment. Bony results as per ASAMI score were excellent in seven fractures and good in three. Functional results were excellent in five patients, good in two, and fair in two. We had no fair or poor results with respect to bony results but had two fair functional results. CONCLUSIONS: LRS provides a good treatment choice for children with fractures with segmental bone loss due to firearm injuries. It also provides easy access to the wound with its monolateral construction.

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CASE: A 17-year-old boy presented with an open talus fracture complicated by soot contamination after a chimney-related accident. Standard irrigation and debridement (I&D) methods were used, but complete removal of soot was not possible. At the latest follow-up, there was no evidence of infection, hardware failure, or avascular necrosis. CONCLUSION: There is a lack of well-established guidelines regarding I&D of traumatic wounds contaminated with fine particulates. A review of potential debridement methods is discussed. Orthoapedic surgeons should be aware of hydrosurgical debridement as a potential treatment approach in these unique scenarios.

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CASE: A 14-year-old adolescent girl sustained an open fracture of the foot after jumping off a building. Initial radiographs revealed large bone defect in the distal metaphysis of the comminuted tibia. The comminuted distal tibia was reconstructed by external fixation and internal fixation with bridge plating, followed by the Masquelet technique. After 12 months, the fracture healed without infection, and the patient could walk independently. CONCLUSION: In the case of a comminuted fracture of the contaminated distal tibia with a large bone defect, plate fixation and the Masquelet technique produced good outcomes.

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INTRODUCTION: The natural history of diaphyseal tibial butterfly fragments is poorly documented. Numerous studies have analyzed risk factors for nonunions in the tibial shaft with known factors including Gustilo classification, ASA class, and cortical contact. However, the healing potential and ideal management of nonsegmental butterfly fragments in this setting remains unknown. The aim of this study was to determine the nonunion rate of diaphyseal tibial fractures with a butterfly fragment. METHODS: A performed a retrospective review of patients at a single academic Level 1 Trauma Center from 2000-2020 who underwent intramedullary nailing of tibial shaft fractures. Those with non-segmental butterfly fragments (OTA/AO: 42-B) and minimum 12 month follow up were included. Morphologic measurements of butterfly fragments were performed to measure location, size, and displacement, and mRust scores at final follow up were calculated. Outcome measures were surgery to promote union, and mRust scores. RESULTS: A total of 99 patients were included with 21 patients requiring revision surgery to promote union. Thirty six patients had open fractures and 77% of patients were male with a mean age of 34 (range: 12-80). Average follow up was 19 months (3 months - 12 years). The most common location of the butterfly fragment was the anterior cortex (42%), with a mean length of 7.8cm (SD: 3.3) and width of 1.8cm (SD: 0.5cm). At final follow-up 37% of fractures had persistent lucency without callus at the site of the butterfly while only 31% of fractures had remodeled cortex. Average time to complete healing was 13.3 months. Open fractures with butterfly fragments were more likely to go on to nonunion than closed (44% vs 9.2%, p=<0.001). The length of the butterfly fragment was not different between the union and nonunion groups (7.7 vs 7.5, P=0.42). CONCLUSIONS: Open tibial shaft fractures with a butterfly fragment have a high risk of nonunion. Further research may seek to determine if adjunct treatment of butterfly fragments (ie inter-fragmentary compression) in the acute setting could improve healing rates.

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INTRODUCTION: The objective of this study was to compare the rates of radiological and clinical complications after sequential treatment of a tibial shaft fracture by external fixation followed by secondary nailing with an early-stage conversion (C1S) versus a two-stage late conversion (C2S). The hypothesis of this work was that treatment with C1S does not increase the risk of surgical site infections compared to C2S, and allows faster healing with a lower malunion rate. MATERIAL AND METHODS: We carried out a retrospective and comparative study based on the files of the traumatology department of the Édouard Herriot University Hospital in Lyon. We reviewed the records of patients who presented with a Gustilo grade 1, 2 or 3a open tibial fracture treated with external fixation with conversion by intramedullary nailing within 6 months from January 2010 to December 2020. We assessed the occurrence of Surgical Site Infections (SSI), consolidation time, time until resumption of weight bearing and the malunion rate. RESULTS: Of the 55 patients included, a C1S procedure was performed in 25 cases (45.5%) versus 30 cases (54.5%) for C2S. No significant difference was found concerning the occurrence of SSI after intramedullary nailing between the two groups (p=0.81). A significant difference was observed in terms of bone healing (p=0.036) and the malunion rate (0.0013) in favor of nailing in one stage. DISCUSSION: The strategy of converting an open leg fracture early, in one stage (C1S), after initial external fixator placement allows for faster healing and weight bearing, while ensuring a lower malunion rate compared to that of a late two-stage conversion. In the absence of a scar at the time of intramedullary nailing, C1S does not increase the risk of surgical site infections. While the choice of a late and sequential two-stage operation is likely related to the surgeon's apprehension around conversion of an open leg fracture by intramedullary nailing, this study could promote the use of C1S in a greater number of situations. LEVEL OF EVIDENCE: IV.

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BACKGROUND: Management of open fractures of tibia is still a matter of debate due to high incidence of infections. Traditionally external fixators have been advocated in managing open tibial fractures. Due to limited efficacy of systemic antibiotics, recently antibiotic coated intramedullary interlocking nails have been developed for the management of open tibia fractures. Therefore, we conducted this prospective randomized study to compare the functional and radiological outcomes of primary ring fixator versus antibiotic coated nail in open diaphyseal tibial fractures. METHODS: The study included 32 patients with Gustilo-Anderson type II and type IIIA fractures of tibial diaphysis. Out of them 16 patients were managed with Ring External Fixator (Group I) and 16 were managed with OssiproÒ gentamicin intramedullary interlocking tibial nail (Group II). The radiological and functional outcomes were assessed at final follow-up according to and SMFA criteria. Statistical analysis of the data was performed using IBM SPSS statistics 2.0 software. Chi square test and independent student t-test were used and a P value <0.05 was considered statistically significant RESULTS: Union was achieved in 15 patients (93.8%) in group I and 13 patients (81.2%) in group II. Pin tract infection was seen in 6 patients (37.5%) in group I, whereas infection was present in 2 patients (12.5%) in group II. Bone results were excellent in 13 patients (81.3%), good in 2 patients (12.5%), poor in one patient (6.3%). In group II, bone results were excellent in 12 patients (75%), good in one patient (6.2%), poor in 3 patients (18.8%). At 1 year of final follow up, mean SMFA score was 24.41±5.87 in group I, whereas mean SMFA score was 23.703±8.02 in group II. CONCLUSION: Ring fixator as well as antibiotic coated tibial interlocking nail achieved comparable rates of union in the present study. Complication rates were similar in both the groups and the functional and radiological outcomes were comparable in both groups. Results of this study indicate that although ring fixation is an established option for management of open tibial fractures, antibiotic-coated intramedullary nail is also a reliable option in open Grade II and grade IIIA injuries. LEVEL OF EVIDENCE: Level II.

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Open pelvic fractures are devastating injuries with high mortality and morbidity that require aggressive treatment and multidisciplinary approach to achieve the best results. We present three cases of open pelvic fracture with a Faringer I zone injury, which were treated at our level I trauma centre in 2020. The patients were treated with external fixation without the need for fecal diversion. None of the patients died. Early control of bleeding, appropriate treatment of soft tissues and prevention of fecal contamination are critical for the treatment of patients with open pelvic fractures. A multidisciplinary approach relying on an experienced and trained team is essential for successful treatment of these injuries. Key words: pelvis fracture, open fracture, trauma.

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BACKGROUND: Open knee fracture-dislocation is a rare orthopedic injury. However, the importance of its correct management could not be overstated. To the best of our knowledge, this is the fifth study reporting a case with simultaneous Hoffa fracture and knee dislocation and the 1st study describing a patient with open plateau fracture-dislocation accompanied with Hoffa fracture, patella fracture, and patellar tendon tear. In addition, this report is noticeable as our case had no gross ligament injury unlike frequent association of knee dislocation with knee collateral ligament damage. CASE PRESENTATION: In this study, we describe a 34-year-old motorcyclist referred to our center following a motor car accident. Further work-up revealed an open irreducible posterolateral knee dislocation, type 5 Hohl and Moore plateau fracture, lateral femoral condyle Hoffa's fracture, patellar fracture, and patellar tendon tear of his right knee. During an open reduction, it turned out that an entrapped lateral meniscus prevented the joint to be reduced by closed means. After applying a temporary external fixator, the patient was finally managed with open reduction and internal fixation. CONCLUSION: Irreducible knee dislocation needs further work up to rule out any interposed soft tissue into the joint. Aggressive irrigation/ debridement, early anatomic reduction, and internal fixation may help reduce open fracture complications including infection, non-union, and stiffness.

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OBJECTIVES: To investigate if any injury to the three primary branches of the popliteal artery in open tibia fractures lead to increased soft-tissue complications, particularly in the area of the affected angiosome. DESIGN: Retrospective cohort comparative study. SETTING: Two academic level one trauma centers. PATIENTS/PARTICIPANTS: Sixty-eight adult patients with open tibia fractures with a minimum one-year follow up. INTERVENTION: N/A. MAIN OUTCOME MEASUREMENTS: Soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture related infection (FRI) at time of final follow-up. RESULTS: Eleven (15.1%) tibia fractures had confirmed arterial injuries via CTA (7), direct intraoperative visualization (3), intraoperative angiogram (3). Ten (91.0%) were treated with ligation and 1 (9.1%) was directly repaired by vascular surgery. Ultimately, 6 (54.5%) achieved radiographic union and 4 (36.4%) required amputation performed at a mean of 2.62 ± 2.04 months, with one patient going on to nonunion diagnosed at 10 months. Patients with arterial injury had significantly higher rates of wound healing complications, FRI, nonunion, amputation rates, return to the OR, and increased time to coverage or closure. After multivariate regression, arterial injury was associated with higher odds of wound complications, FRI, and nonunion. Ten (90.9%) patients with arterial injury had open wounds in the region of the compromised angiosome, with 7 (70%) experiencing wound complications, 6 (60%) FRIs, and 3 (30%) undergoing amputation. CONCLUSIONS: Arterial injuries in open tibia fractures with or without repair, have significantly higher rates of wound healing complications, FRI, delayed time to final closure, and need for amputation. Arterial injuries appear to effect wound healing in the affected angiosome. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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