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Orthopaedic Perspective of the Boston Marathon Bombing

Orthopaedic Perspective on the Boston Marathon Bombing by Mitch HarrisMitchel Harris, MD Chief of Orthopedic Trauma at the Brigham & Women’s Hospital, Boston, MA.


Michael Weaver, MD is an is an attending traumatologist on the Orthopedic Trauma Service at Brigham & Women’s Hospital, Boston, MA.


First run in 1897, the Boston Marathon is the oldest, continuous running marathon in America. It is generally considered the most prestigious annual running event that is open to the public, once qualifications are met. Prior to its 117th consecutive running, it had not been generally viewed as a target for a “terrorist attack”. However, on April 15, 2013, two brothers allegedly placed explosive filled backpacks with remote detonator switches within yards of each other and the finish line of the Boston Marathon. The following essay will highlight the extraordinary response by the medical community of Boston.

Boston and Patriots’ Day
Boston is well known as a highly resourced and sophisticated academic medical community. It has 6 Academic Medical Centers (AMC’s): Beth Israel Deaconess Medical Center (BIDMC); Boston Medical Center (BMC); Brigham & Women’s Hospital (BWH); Boston Children’s Hospital (CHB); Massachusetts General Hospital (MGH); and Tufts Medical Center (Tufts); each with an American College of Surgeon’s certified level one trauma center. Each of these medical centers provides cradle-to-grave medical services to their respective local communities and function as New England’s regional referral centers. Continue reading

Femoroplasty for Hip Fractures

figure from Femoroplasty for Hip Fractures posted by Arun Shanbhag in Trauma RoundsE Kenneth Rodriguez, MD, PhD is Chief of Orthopaedic Trauma at Beth Israel Deaconess Medical Center, Boston, MA.


Hip fractures in geriatric patients are associated with mortality rates of 20-30% at one year. Many more patients experience significant loss of function and independence (1). The number of hip fractures worldwide was estimated at 1.7 million (1990) and is expected to rise to 6.3 million by 2050 (2). Continue reading

Geriatric Fracture Patient Co-management

Michael Weaver, MD is an Orthopaedic Trauma Surgeon, at Brigham & Women’s Hospital.


In the United States, hip fractures represent a significant medical burden. The annual cost of caring for geriatric patients with hip fractures is $10 – 15 billion. As the Baby Boomer generation continues to age, the number of patients with hip fractures is expected to rise dramatically. The rate of mortality at one year in this patient population runs between 12 and 37% (1). Continue reading

Healing Critical Defects in the Femur

Christopher Evans, PhD, is the Maurice Mueller Professor of Orthopaedic Surgery and Director of the Center for Advanced Orthopaedic Studies in the Department of Orthopaedic Surgery at Beth Israel Deaconess Medical Center.

Vaida Glatt, PhD, is a Senior Research Fellow with the Trauma Research Group of the Institute of Health and Biomedical Innovation at Queensland University of Technology Brisbane, Queensland.


Introduction
Large segmental defects heal poorly and often present clinical challenges. Approaches used to improve healing include autograft and allograft bone, distraction osteogenesis, vascularized bone grafts and the application of BMP-2 and BMP-7. We wanted to determine whether modulation of the mechanical environment could improve bone healing in a rat femoral segmental defect model. Continue reading

Treating Injuries from the War Zone

George Dyer, MD is a Hand and Upper Extremity surgeon at the Brigham & Women’s Hospital, Boston; Director of the Harvard Combined Orthopaedic Residency Program and a member of the Partners Orthopaedic Trauma Service.

Trevor Owen, MD, is our graduating trauma fellow. He is joining the faculty of the Carilion Clinic in Roanoke, VA, as an orthopaedic trauma surgeon.


Introduction
In late October 2011, 22 rebels injured during the Libyan Civil War were admitted to Spaulding Hospital in Salem, MA. Our Trauma team provided care to six patients with complex nonunions, malunions, and nerve injuries. This opportunity allowed us to apply techniques we use for more routine care to severe wartime injuries and their sequelae. It showed us how the careful practice of surgical principles can be effective, even when treating devastating injuries. Continue reading

Crush Injuries to the Forefoot

John Kwon Foot and Ankle Surgeon at the Mass General HospitalJohn Kwon, MD is an orthopaedic surgeon at the Massachusetts General Hospital, Boston and a member of the Foot & Ankle Service, as well as the Partners Orthopaedic Trauma Service. Dr. Kwon specializes in foot & ankle fractures, sports injuries and correction of foot & ankle deformities.


Effect of a Steel Toe Cap

Crush injuries to the foot are a common workplace injury, causing significant morbidity, disability and lost wages. A report by the Bureau of Labor Statistics estimated that more than 60% of workplace injuries involve the musculoskeletal system, and 10% of these are foot and ankle injuries (1). Continue reading

Recovering From Injury

David RingDavid Ring, MD, PhD is an Orthopaedic Hand Surgeon at the Massachusetts General Hospital, Boston, specializing in arm fractures, post-traumatic reconstruction, hand surgery and elbow surgery.


Some fractures frustrate us. Adverse events always affect us. But nothing takes the wind from our sails more than a patient who has greater pain and disability than expected. We are used to having answers and knowing what to do. For diagnoses like open fracture, compartment syndrome, or an elbow that will not stay reduced, we feel like we can make a difference. But when our patients have stiff fingers, a stiff elbow, or persistent disabling pain the answers do not always come easily (1). Continue reading

William Macaulay: When a Hemi is only Semi-right

Bill Macaulay Mass General Grand Rounds Femoral neck fracturesWhen 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
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Pediatric Supracondylar Fractures

Samantha SpencerSamantha 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.
Trauma Rounds Pediatric Supracondylar Fractures, Samantha Spencer Childrens Hospital Boston

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.
Trauma Rounds Pediatric Supracondylar Fractures, Samantha Spencer Childrens Hospital Boston

Trauma Rounds Pediatric Supracondylar Fractures, Samantha Spencer Childrens Hospital Boston

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.

Fractures of the Distal Humerus

Jesse JupiterJesse Jupiter, MD is a Hand & Upper Extremity Orthopaedic Surgeon, at the Massachusetts General Hospital.


Fractures of the distal end of the humerus, while relatively uncommon, continue to stimulate discussion as to the optimal method of treatment. Unfortunately, there are relatively few Level I or even Level II studies to guide the fracture surgeon.1 I will attempt to identify and clarify a number of contemporary issues and provide a perspective of 30 years experience in the study and management of these injuries.
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