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Crush Injuries to the Forefoot

Posted on May 23, 2012 by Arun Shanbhag

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). (more…)

Filed under: Foot & Ankle, Trauma, Trauma Rounds | Tagged: , | 5 Comments »

Recovering From Injury

Posted on March 15, 2012 by Arun Shanbhag

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). (more…)

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THA for Femoral Neck Fractures

Posted on July 4, 2011 by Arun Shanbhag

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.
Trauma Rounds THA for Femoral Neck Fractures, Michael Weaver
(more…)

Filed under: Hip, Joint Replacement, Physician Education, Trauma, Trauma Rounds | Tagged: , , , , | 2 Comments »

Intra-articular Distal Radius Fractures

Posted on March 30, 2011 by Arun Shanbhag

Brandon Earp, MD, is an Hand & Upper Extremity Surgeon, at Brigham & Women’s Hospital and Instructor of Orthopaedic Surgery at Harvard Medical School.

Your patient comes in after a mechanical fall onto an outstretched hand. A significant deformity of the wrist and edema are noted clinically and the patient’s discomfort is obvious. Radiographs demonstrate a displaced, dorsally angulated distal radius fracture with loss of radial height, radial translation, and intra-articular involvement. You see the patient, perform an appropriate clinical workup, reduce and splint the fracture.

Post-injury PA view of the wrist demonstrates a displaced comminuted intra-articular distal fracture. CT scan was later obtained to better understand the fracture pattern for surgical planning. 
Trauma Rounds Intra-articular distal radius Fractures, Brandon Earp
(more…)

Filed under: Elbow, Hand, Physician Education, Trauma, Trauma Rounds, Wrist | Tagged: , , , , , | 5 Comments »

Matt Jimenez: Somatic Cells for Nonunions

Posted on March 9, 2011 by Arun Shanbhag

Matt Jimenez MGH Grand Rounds Somatic Cells for NonunionsSomatic Cells for Nonunions
Matt Jimenez, MD
University of Illinois at Chicago,
Department of Orthopaedic Surgery
Lutheran General Hospital, Chicago, IL
Grand Rounds presented on Jan 20, 2011 at the O’Keefe Auditorium, Massachusetts General Hospital, Boston, MA

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Femur Fractures Around Hip Implants

Posted on December 7, 2010 by Arun Shanbhag

David Lhowe, MD, is an Orthopedic Trauma Surgeon, at Massachusetts General Hospital and Assistant Clinical Professor of Orthopaedic Surgery at Harvard Medical School.

Approximately 200,000 total hip replacements and an equal number of hemiarthroplasties are performed annually in the United States. With the marked success of this procedure, patients are able to maintain active lifestyles for many more years. Consequently, millions of elderly are at risk for fracture around their prosthesis.

Periprosthetic fractures typically result from common household falls. The Mayo Clinic reported a 1% prevalence of periprosthetic fracture after primary THR, increasing to 4% following revision surgery (1). Barring dramatic improvements in treating osteoporosis or reducing falls in an aging population, periprosthetic fractures will become an increasing medical and societal burden.

Fortunately, the majority of periprosthetic fractures do not result in implant loosening and may be managed without the need for implant revision. These fractures include the isolated trochanteric fractures (Vancouver A), diaphyseal fractures about a well-fixed stem (Vancouver B1), and fractures well below the distal tip of the stem (Vancouver C). Complex management with revision of components is required when the femoral stem is loose (Vancouver B2) and loosening is further complicated by inadequate bone stock (Vancouver B3). These variants are appropriately referred to experienced hip revision surgeons.

Femur fracture around well-fixed total hip replacement
Femur fracture around a well-fixed cemented THR component. Note the presence of a medullary cement plug in the distal fragment.
(more…)

Filed under: Hip, Joint Replacement, Medical Education, Orthopaedic, Physician Education, Trauma, Trauma Rounds | Tagged: , , , , , , , , | 1 Comment »

Mission to Haiti, January 2010

Posted on September 2, 2010 by Arun Shanbhag

R Malcolm Smith, MD, FRCS
Chief of the Orthopedic Trauma Service,
Massachusetts General Hospital,
Associate Professor of Orthopaedic Surgery
Harvard Medical School, Boston, MA.

George Dyer, MD
Orthopaedic Surgeon
Brigham and Women’s Hospital
Instructor of Orthopaedic Surgery
Harvard Medical School, Boston, MA

People often ask, “How was Haiti?” For a while, we found it the most difficult question to answer. While on one hand we saw an unrivaled toll of human suffering, on the other we probably made the most valuable contributions we will ever make.

Perhaps the best answer is that it was a privilege; it was a privilege to treat the patients and a privilege to work with a team that proved to be the most resourceful, well motivated and superb group of clinicians we could hope to meet.

On January 12, 2010, Haiti was devastated by the worst human disaster for generations. Volunteering with Partners in Health we arrived in Port au Prince on the evening of January 16th crammed in a small airplane with sleeping bags, survival kits and boxes of all sizes packed with every medical item we could borrow or acquire. We were met by a small truck, unloaded the plane ourselves and left. No officials knew we were there, what we were carrying or where we were going.
Outside the airport we saw streets of collapsed concrete buildings and everywhere there seemed to be people walking about aimlessly. Since the main hospital in Port au Prince was barely functional, we were sent to St. Nicholas Hospital – a small public hospital 80 miles to the north in St. Marc – where we became the only relief service for a large and isolated group of earthquake victims.

Patients and families were lying on the floor on thin mattresses and blankets.

(more…)

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Evaluating the Cervical Spine

Posted on May 20, 2010 by Arun Shanbhag

Mitch Harris, MD, is Chief of the Orthopedic Trauma Service, at Brigham and Women’s Hospital, and Associate Professor of Orthopaedic Surgery at Harvard Medical School.
Here, Dr Harris shares a very useful algorithm for evaluating patients with trauma to the cervical spine.

Imagine getting called to the Emergency Department to evaluate a painful and swollen knee after a skiing accident. The plain x-rays are read as normal, with no evidence of acute fracture and demonstrate evidence of degenerative arthritis of the knee. If the patient is experiencing too much pain to allow for an adequate exam, a knee brace will be provided and the patient re-evaluated in the office in 7-10 days. If there is significant ligamentous injury, the brace will suffice for temporary stability and a follow-up MRI might be required to fully define the extent of the injury.

Now consider another presentation. This time the mechanism of injury is a fall from standing in an elderly woman and the area of concern is her cervical spine. The patient has a black eye, no history of loss of consciousness and complains of neck pain while in the collar. There are no other associated injuries. Plain x-rays of her cervical spine are read as normal, with no evidence of acute fracture and demonstrate evidence of degenerative arthritis of the neck. The questions now are: what should the next tests be, and can the patient be safely discharged in a collar for a follow-up appointment in 1-2 weeks?

Normal appearing Left and Right facets of the cervical spine from MD Computerized Tomography (MDCT) scan.
(more…)

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Mitch Harris: Our Haiti Experience to Date

Posted on March 27, 2010 by Arun Shanbhag

BWH: Our Haiti Experience to Date

  • Mitch Harris, MD Chief, BWH Orthopedic Trauma Service – Moderator
  • Malcolm Smith, MD Chief, MGH Orthopaedic Trauma
  • George Dyer, MD BWH Upper Extremity and Hand Service
  • Jonathan Gates, MD BWH Trauma, Burns and Critical Care
  • Selwyn Rogers, MD BWH Director of Surgical Care
  • Trish Powers, RN: BWH Operating Rooms

    • Grand Rounds presented on March 3rd, 2010 at the Bornstein Family Amphitheater, Brigham & Women’s Hospital, Boston, MA.

    Please leave a comment to share your thoughts.

    Filed under: Grand Rounds, Orthopaedic, Trauma, Videos | Tagged: , , , | 6 Comments »

    Malcolm Smith: Update from Haiti

    Posted on February 12, 2010 by Arun Shanbhag

    Dr Malcolm Smith, (Orthopaedic Surgeon at the Massachusetts General Hospital, Boston, MA has been providing valuable clinical service in Haiti. Read one of his email dispatches from Haiti.

    You can read more dispatches from Dr Malcolm Smith here.

    From Malcolm Smith, MD:
    Sent: Jan. 20, 2:50 pm

    Summary diary for today: Had a small disturbance this AM when limited visitors at gate to reduce numbers of people in the hospital. As you may expect a lot of care is given by families. Settled when interpreter and I explained to crowd. Was really only shouting pushing and a few fists and was improving when I got there. Completely calm since, have asked DC for UN security to maintain safety but feel OK.

    Argentinian UN military stopped for short visit then left promising to come back, did not. No more trouble. Lots of people but calm. Have been offered help from Congressman Capuano‬ ‘s office in DC. Sounds wonderful, hopefully can get supplies in to local soccer field by air. Expecting Akshay, our second anesthetist tonight and James, our own Hatian orthopedic resident, with more MGH nurses to fly tomorrow …

    Working very well as a team ourselves, so impressed with these people. Have raided local warehouse for stores, found lots of unopened aid boxes, some gloves, drapes, etc. but will need surgical supplies soon. Discovered the only blood tests we can do is a crit and cross match. No facilities to do electrolytes. Problem with rhabdo patients so watching urine color and volume pushing fluid and diagnosing acidosis clinically …

    Had to operate for a short time with head lights when power cut this evening … Finally about to do our first laparotomy as have Selwyn with us but being delayed by C section that just happened — our anesthetist helped baby looks fine. Life really just goes on.

    Filed under: News, Orthopaedic, Trauma, Trauma Rounds | Tagged: , , , , | Leave a Comment »

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