Brian D. Rust

OBJECTIVES: To characterize injury patterns, treatment differences, and clinical outcomes associated with ballistic and blunt forearm fractures. METHODS: Design: Retrospective cohort study. Setting: Single Level 1 tertiary trauma center, 2018-2023. Patient Selection Criteria: The study included adults (≥18) who underwent operative fixation of diaphyseal radius and/or ulna fractures. Exclusion criteria were ipsilateral intraarticular or unstable elbow injuries, pathologic fractures, or fractures involving preexisting implants. Patients were stratified into 2 groups: ballistic and blunt injuries, which were further subclassified as blunt-closed or blunt-open. Outcome Measures and Comparisons: Primary outcomes included nerve deficit, complication rate, unplanned reoperation, nonunion, and postoperative infection. RESULTS: The study included 395 patients with 398 forearm fractures: 81 ballistic fractures in 78 patients [32 years (18–69), 88.9% male], 213 blunt-closed fractures [41 years (18–82), 59.2% male], and 104 blunt-open fractures [46 years (19–92), 71.2% male]. Ballistic fractures had significantly higher rates of nerve deficits (48.2% vs. 6.3%, P < 0.001), complications (38.5% vs. 21.1%, P = 0.020), and unplanned reoperation (30.8% vs. 14.2%, P = 0.012) compared with blunt injuries. Infection rates were similar between ballistic and blunt groups (10.3% vs. 5.8%, P = 0.294). Nonunion differed only between ballistic and blunt-closed fractures (18.0% vs. 5.6%, P = 0.042), not blunt-open fractures (18.0% vs. 9.2%, P = 0.228). On multivariable analysis, injury group remained an independent predictor of nerve deficit ( P < 0.001), complication ( P = 0.008), and unplanned reoperation ( P = 0.015), with ballistic injuries demonstrating the highest rates. CONCLUSIONS: Ballistic forearm fractures posed unique challenges compared with blunt injuries. They were associated with significantly higher rates of nerve deficit, unplanned reoperations, and overall complications, with higher nonunion observed when compared with blunt-closed injuries. These injuries warrant a high index of suspicion for nerve injury and close long-term follow-up to optimize patient outcomes and address the needs of a disproportionately affected, high-risk population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To evaluate whether a machine learning-based system can accurately measure coronal knee alignment parameters from routine postoperative radiographs following surgical fixation of distal femur fractures. Methods: Design : Retrospective cohort study. Setting: Single-center academic orthopedic trauma practice. Patient Selection Criteria: Adult patients 50 years of age or older who underwent surgical fixation of low-energy OTA/AO 33A and 33C distal femur fractures (including periprosthetic fractures) between November 2020 and December 2024 were retrospectively identified. Outcome Measures and Comparisons: A machine learning-based automated alignment assessment system was trained to identify standard radiographic landmarks, including the femoral intercondylar notch, femoral condyles, tibial spines, and tibial plateaus, and automatically calculate commonly used coronal alignment parameters including joint line convergence angle (JLCA), anatomic femorotibial angle (aFTA), anatomic lateral distal femoral angle (aLDFA), and anatomic medial proximal tibial angle (aMPTA). Automated measurements were compared with manual measurements annotated by a trained observer and validated by an orthopedic surgeon. Results: A total of 287 postoperative AP knee and distal femur radiographs were obtained as part of routine postoperative care and randomly divided into training and testing datasets for model development and validation. The cohort was 78.0% female with a mean age of 72.3 years (range: 50 to 97 years). Automated measurements demonstrated strong agreement with surgeon-validated measurements. Mean absolute error was 1.1° for JLCA (range: 0.0° to 3.5°), 1.5° for aFTA (range: 0.0° to 4.4°), 1.0° for aLDFA (range: 0.0° to 3.1°), and 2.3° for aMPTA (range: 0.1 to 6.4°). Pearson correlation coefficients ranged from 0.4 to 1.0, and Bland-Altman analysis demonstrated minimal systematic bias, with 95% of differences falling within a clinically acceptable range of ±5°. Conclusions: Automated alignment assessment utilizing a machine learning-based system using routine postoperative radiographs provided accurate measurements in distal femur fracture patients and may serve as a practical adjunct for longitudinal surveillance in orthopedic trauma practice. Level of Evidence: Level III

Purpose: Body mass index (BMI) is a recognized risk factor for infection in distal femur fracture management, but the role of local subcutaneous fat thickness at incision sites remains unclear. This study evaluated whether local adiposity independently predicts surgical site infection (SSI) after open reduction internal fixation (ORIF) and compared its predictive value to BMI. Methods: We conducted a retrospective case–control study of 302 adults who underwent ORIF for distal femur fractures at a Level 1 trauma center (2021–2024). Subcutaneous fat depth was measured at lateral, prepatellar, and, when available, medial sites on plain radiographs. The primary outcome was SSI requiring irrigation and debridement within 1 year. Logistic regression assessed the predictive value of fat thickness and BMI, with subgroup analysis of periprosthetic fractures. Results: Nineteen patients (6.3%) developed SSI. On univariate analysis, greater lateral, prepatellar, medial fat, and BMI were significantly associated with infection. Logistic regression showed lateral and prepatellar fat predicted SSI, but these effects were lost once BMI was included, confirming BMI as the stronger independent predictor. In the periprosthetic subgroup, neither BMI nor adiposity predicted infection. Conclusion: In distal femur fractures, BMI outperformed local fat thickness as a predictor of SSI, supporting its use as a practical risk stratification tool. While greater local adiposity correlated with reoperation, these associations diminished when BMI was considered. In periprosthetic fractures, no predictors were identified, highlighting the need for larger studies to clarify whether implants alter infection risk.

Surgical treatment of unicondylar distal femur fractures remains a challenge. Achieving stable fixation to allow early range of motion and weightbearing is complicated by poor bone quality and articular surface comminution, commonly leading to poor outcomes. Multiple treatment strategies have been previously described including small fragment, large fragment, and anatomical plate fixation. However, given the variability of fracture patterns, anatomical implants often lack the appropriate geometry and fixation options required to provide adequate stabilization. With knowledge and application of the principles of fracture fixation, these injuries can be effectively treated with standard non-anatomically shaped, contourable implants. The objective of this report was to describe a technique that provides effective fixation in these cases and report on outcomes of a small series. This technique utilizes a dual-implant construct that includes a small or large fragment plate positioned to buttress the metaphyseal apex of the fracture, and a small fragment reconstruction plate contoured in the shape of a “J” (J-plate) that wraps around the femoral condyle and onto the anterior cortex of the femur. There are advantages to this technique compared to anatomically contoured plates, including precise placement of implants in biomechanically advantageous locations, orthogonal fixation, and decreased implant costs.

Introduction: Pediatric tibial plateau fracture-dislocations are extremely rare but can involve serious neurovascular and growth complications, requiring prompt evaluation, appropriate fixation, and long-term monitoring. This is the first case report of a tibial plateau fracture-dislocation in the pediatric population. Case Report: A 13-year-old male fell off a motorized scooter, sustaining a tibial plateau fracture-dislocation. He underwent urgent reduction and application of external fixator with subsequent extraphyseal fixation. He had an excellent outcome at both 1-year and 5-year follow-up. Conclusion: This unusual injury pattern requires thoughtful and comprehensive evaluation, followed by appropriately timed open reduction and stable internal fixation to allow for the early joint range of motion and optimized function. The management of this case serves as an example of how to best approach a rare injury such as this. Patients should be followed until skeletal maturity for potential leg-length discrepancy or malalignment. Keywords: Pediatric, tibial plateau, fracture-dislocation.