When a Hemi is Only Semi-right
William Macaulay, MD
Department of Orthopaedic Surgery
Columbia University, New York, NY
Grand Rounds presented on October 20, 2011 at the O’Keefe Auditorium, Massachusetts General Hospital, Boston, MA
Filed under: Grand Rounds, Hip, Joint Replacement, Physician Education, Trauma, Videos | Tagged: femoral neck fractures, Hemi arthroplasty, Hip arthritis, hip fracture, hip replacement, Joint Replacement | Leave a Comment »
Samantha Spencer, MD is a pediatric orthopaedist at Children’s Hospital, Boston, specializing in trauma, lower extremity, vascular anomalies, osteogenesis imperfecta and skeletal dysplasias.
Pediatric supracondylar fractures are the most common elbow fractures in children. Approximately 7-10% of supracondylar fractures and up to 50% of severely displaced Type III supracondylar fractures present with a neurologic injury: radial nerve (41.2%); median nerve (36%); ulnar nerve (22.8%). Vascular injury is seen in 1% of displaced supracondylar fractures. Nondisplaced fractures/minimally displaced Type II fractures can be safely managed with 3 weeks of immobilization. The standard of care for displaced fractures is reduction/pin fixation for 3-4 weeks, then early mobilization.
Problematic Fractures: Tips for Identification
The majority (90-95%) of displaced supracondylar fractures can be managed with closed reduction and pinning with excellent outcomes. However, a subset of fractures need open reduction and are at risk for neurovascular sequelae. A problematic fracture should be suspected whenever there is less than a fully intact neurovascular exam or severe fracture displacement.
An adequate neurovascular exam can be difficult in a child but should always be documented, or – should an adequate exam not be possible – whatever can be obtained should be documented. Capillary refill should be immediate; sluggish refill should raise concern for vascular injury or entrapment. Similarly, nerve deficits or paresthesias signify nerve stretch or entrapment. These fractures need urgent treatment.
Radiographically, the direction of the proximal metaphyseal spike predicts the likely neurovascular injury: anterior (direct posterior extension type)-median nerve/brachial artery, medial (posterolateral extension type or flexion type)-ulnar nerve, lateral (posteromedial extension type)-radial nerve. Figure 1 shows a severely displaced extension type which had entrapped median nerve and brachial artery.
Figure 1: Elbow x-ray demonstrating severely displaced supracondylar fracture.
How to Open Reduce & Fix Pediatric Supracondylar Fractures
Once a fracture has been identified as possibly problematic and has unsatisfactory closed reduction, it is important to have appropriate setup with a hand table, sterile tourniquet, C-arm and hand instrument set. A vascular surgeon should be available if needed.
When opening pediatric fractures, it is best to always open over the tear in the periosteum. For supracondylar fractures, a 3-5 cm anterior incision in the elbow crease usually allows easy exposure of the fracture and the neurovascular structures. These are often tented over the proximal fracture fragment. Once any entrapped muscle and/or nerves/vessels are cleared, the fracture can be open reduced and pinned in the usual fashion. The nerves and vessels can then be assessed with the tourniquet down. It often takes warming and dripping vasodilative agents on the brachial artery for 10-15 minutes to relieve vasospasm. If pulsatile flow returns – which is common – standard closure and bivalved casting can proceed. If flow does not return or an arterial injury is visible, a vascular surgery assessment for need of brachial artery repair must occur.
After either closed or open reduction and pinning of a supracondylar fracture (Figure 2), children should be comfortable with little narcotic requirement and no negative change to their preoperative neurologic exam. Significant pain and increasing pain medicine requirements are the best indicators in children of evolving compartment syndrome or missed arterial injury or entrapped nerve. Entrapment should particularly be suspected if pain increases and nerve function is decreased after closed reduction and pinning. These issues require emergent surgical exploration.
Figure 2: Postoperative AP and Lateral x-rays of pin configurations.
Conclusions
The majority of displaced supracondylar fractures can be managed with closed reduction and pin fixation in a regularly scheduled OR time. However, displaced fractures with preoperative neurovascular deficits should raise concern for neurovascular entrapment and injury. Indications for open reduction of closed pediatric supracondylar fractures include inadequate hand perfusion after pinning, inability to obtain an adequate reduction, and evidence of iatrogenic neurovascular injury postoperatively. When open reduction is performed, an anterior antecubital crease incision affords access to the torn periosteum as well as the neurovascular structures.
Bibliography
1. White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire: J Pediatr Orthop 2010; 30(4):328-35.
2. Campbell CC, et al, Neurovascular injury and displacement in type III supracondylar humerus fractures: J Pediatr Orthop 1995; 15(1):47-52.
3. Kasser JR and Beaty JH, Supracondylar Fractures of the Distal Humerus: Chap 14 In Rockwood and Wilkins, Fractures in Children, 6th ed. Lippincott Williams & Wilkins; Philadelphia, PA. 2006: 543-589.
Filed under: Elbow, Pediatric, Physician Education, Trauma, Trauma Rounds | Tagged: Elbow, fixation, fractures, pediatric | 2 Comments »
Advances in Hip Arthroscopy
Joseph McCarthy, MD
Department of Orthopaedic Surgery
Newton Wellesley Hospital, and
Massachusetts General Hospital, Boston, MA
Grand Rounds presented on Feb 24, 2011 at the O’Keefe Auditorium, Massachusetts General Hospital, Boston, MA
Filed under: Grand Rounds, Hip, Joint Replacement, Physician Education, Videos | Tagged: Grand Rounds, Hip arthritis, Hip arthroscopy, Physician Education, total hip replacement | Leave a Comment »
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Jesse Jupiter, MD is a Hand & Upper Extremity Orthopaedic Surgeon, at the Massachusetts General Hospital.
Filed under: Elbow, Joint Replacement, Physician Education, Trauma, Trauma Rounds | Tagged: Elbow, fractures | 1 Comment »
Nurse Practitioner Anne Fiore educates a patient about his upcoming surgery.
During a visit to our doctor’s offices, patients will likely be treated by several members of our professional staff, including Nurse Practitioners (NPs) and Physician Assistants (PAs). Patients often ask how NPs and PAs are involved in their care and what training they have.
NPs and PAs are highly skilled, licensed professionals, who practice medicine with physician supervision. They are an integral part of every medical and surgical practice and coordinate peri-operative and inpatient care of our patients.
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Filed under: Orthopaedic, Patient Education | Tagged: Nurse Practioners, Patient Education | Leave a Comment »
Michael Weaver, MD is an Orthopaedic Trauma Surgeon, at Brigham & Women’s Hospital.
The reduction and fixation of displaced femoral neck fractures has an unacceptably high rate of failure, particularly in the geriatric population. Reconstruction with either hemiarthroplasty or total hip arthroplasty (THA) is the accepted treatment for these fractures. In active patients reconstruction with a total hip has advantages in terms of pain relief, functional outcome, and prosthesis longevity (1).
While many surgeons are skilled in performing THA for degenerative conditions of the hip – including osteoarthritis and avascular necrosis – patients with femoral neck fractures present several unique challenges. Here are my experiences:
Intraoperative Fracture
Femoral neck fractures are fragility fractures associated with poor bone quality, a marker of osteoporosis. The trend in arthroplasty has been toward press-fit femoral components that allow for bone ingrowth and long-term stability. Thus, I use ingrowth femoral stems with a more canal-filling geometry instead of taper-type stems to reduce hoop stresses and prevent fracture. A doubled up 16-gauge circlage wire should be placed prophylactically between the greater and lesser trochanters prior to broaching.
Care must also be taken with placement and impacting of the acetabular component. There is usually no subchondral sclerosis, and it can be easy to breach the medial wall with the acetabular reamers. Supplementing acetabular fixation with at least 2 screws can prove useful.
Pre-operative pelvic AP is the template to guide radiographic placement of the cup. Adjust the C-arm orientation to recreate this image.
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Filed under: Hip, Joint Replacement, Physician Education, Trauma, Trauma Rounds | Tagged: fractures, hip replacement, Physician Education, total hip replacement, Trauma | 2 Comments »
The James H Herndon Lecture
Coming Transformation of Healthcare
David M Cutler, PhD
Department of Economics and Kennedy School of Government
Harvard University, Cambridge, MA
Grand Rounds presented on March 31, 2011 at the O’Keefe Auditorium, Massachusetts General Hospital, Boston, MA
Filed under: Grand Rounds, Healthcare Reform, Videos | Tagged: Healthcare Reform | Leave a Comment »
Our orthopaedic doctors and research scientists are world renowned for their clinical and research expertise. Our laboratories are some of the most reputed and productive with nearly a 100 papers published each year. Much of our research gets presented at premier society meetings around the world. The Orthopaedic Research Society and the American Academy of Orthopaedic Surgeons are the two largest society meeting and each year many of our scientists and physicians attend and present their research and clinical findings there.
Here is a complete list of papers presented by our scientists and physicians at the 2011 Orthopaedic Research Society (Long Beach, CA , Jan 13-16, 2011) and the American Academy of Orthopaedic Surgeons (San Diego, CA, Feb 15-19, 2011). An impressive list and congratulations to all presenters.
List of MGH Papers @ AAOS 2011
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The core is commonly thought of as only your abs, but consists of multiple muscle groups in your abdomen, back and pelvis. Core muscles are engaged during all activities requiring a coordinated movement of the upper and lower body. They generate the force and power required for many activities, while simultaneously playing a foundational role in stabilizing the torso.
Our modern sedentary lifestyle does nothing to working these important core muscles and over time result in their weakening, and the consequent injuries from seemingly simple tasks.
There are various ways to strengthen these core muscles. The PLANK, for instance, is easy to perform, effective and appropriate for any age and fitness level. With no special equipment, the plank can be performed on a carpeted floor or mat in your living room, in the gym between sets of other exercises, or at the end of a workout. Also, the plank literally only takes a minute!
In performing the plank, you hold a steady position by isometrically contracting the deep stabilizing abdominal muscles (transverse abdominus), while keeping the lower back (erector spinae and multifidi) stable, fighting fatigue and simultaneously building endurance. This exercise is not appropriate if you have any shoulder weakness or injury.
The Plank was demonstrated by Julie Schlenkerman, certified personal trainer at the Clubs at Charles River Park, Boston, MA. Julie is an avid runner and ran the 2009 Boston Marathon in 3:16:14!
Filed under: Exercises & Stretches, Fitness, Health, Patient Education | Tagged: core muscles, core strength, Exercises & Stretches, Fitness, Patient Education, Plank | Leave a Comment »
