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Trauma Care in the Himalayas

David Lhowe Trauma Surgeon at Mass General Hospital David Lhowe, MD is an Orthopedic Trauma and Hip & Knee Replacement surgeon in the Department of Orthopaedic Surgery, Massachusetts General Hospital, and Assistant Clinical Professor of Orthopedic Surgery at Harvard Medical School.

Sandwiched between its gigantic neighbors, China and India, the tiny nation of Bhutan is making a rapid transition from an isolated kingdom to a modern Asian democracy. Its 600,000 residents are almost exclusively Buddhist, and are dispersed over a landscape that remains largely forested with relatively little arable terrain. The population clusters in valleys, separated by Himalayan mountain barriers which have only recently become connected by two-lane roads. Through most of its history the country has been isolated from even its closest neighbors, and has only opened to Western tourists in the last 20 years. While visiting Bhutan from the United States is now possible it doesn’t come cheaply. The Bhutanese government charges US citizens a substantial daily tax for the duration of their visits. Continue reading

Orthopedic Trauma Initiative Launched

Mark Vrahas Mass General Trauma Surgeon Mark Vrahas, MD is the Chief of Partners Orthopaedic Trauma Service and Vice Chairman of the MGH Department of Orthopaedic Surgery.

In March 2014, Harvard Medical School welcomed the Harvard Medical School Orthopedic Trauma Initiative as part of an elite group of twenty-two Institutes, Centers, Divisions and Initiatives. We are proud to be part of this group and our new name is reflected in our updated masthead. The primary purpose of this Initiative is to foster collaboration amongst the orthopedic trauma services at all four Harvard Teaching Hospitals in Boston: Mass General, Children’s, Brigham and Women’s, and Beth Israel Deaconess. This effort (and a long effort it was) formalizes our dedication to ensuring excellent educational opportunities in musculoskeletal trauma for HMS students, our HCORP Residents, and Fellows in the Harvard Orthopedic Trauma Fellowship Program. As a group, our trauma surgeons will work together to develop clinical pathways, collaborate on clinical research, and be – in large part because of our size – the premier research center nationally and internationally. 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

THA for Femoral Neck Fractures

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
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Intra-articular Distal Radius Fractures

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
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Femur Fractures Around Hip Implants

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.
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