The electronic medical office: optimizing solutions.

Optimizing the care for patients in the orthopaedic clinical setting involves a wide range of issues. Surgical techniques, preoperative and postoperative care, long-term outcomes follow-up, continuing education, and patient communication are a few of the important areas that surgeons deal with on a regular basis. Successful management of this information has an impact on clinical outcomes, direct patient care, financial decisions, and management of the surgeon's time. The development of a comprehensive electronic medical office is a powerful and probably necessary tool to successfully manage such information and achieve the goals of an effective and safe orthopaedic practice.

Emergent pelvic fixation in patients with exsanguinating pelvic fractures.

BACKGROUND: An alternative to embolization or external pelvic fixation (EPF) in patients with multiple pelvic fractures and hemorrhage is a pelvic orthotic device (POD), which may easily be placed in the resuscitation area. Little published information is available about its effectiveness. This study evaluated the efficacy of the POD compared with EPF in patients with life-threatening pelvic fractures. STUDY DESIGN: We evaluated patients with blunt pelvic fractures over a 10-year period. Inclusion required multiple pelvic fractures with vascular disruption and severe retroperitoneal hematoma, open book fracture with symphysis diastasis, or sacroiliac disruption with vertical shear. Patients with EPF were compared with those in whom a POD was used. Outcomes included transfusions, hospital stay, and mortality. RESULTS: There were 3,359 patients with pelvic fractures who were admitted: 186 (6%) met entry criteria; 93 had EPF and 93 had POD. There were no differences in age or shock severity. Both 24-hour (4.9 versus 17.1 U, p < 0.0001) and 48-hour transfusions (6.0 versus 18.6 U, p < 0.0001) were reduced with POD. Twenty-three percent of each group underwent pelvic angiography, and 24-hour transfusion amounts for those patients were also reduced with POD (9.9 versus 21.5 U, p < 0.007). Hospital length of stay (16.5 versus 24.4 days, p < 0.03) was less with POD. Although there was decreased mortality with POD (26%) versus EPF (37%), it was not statistically significant (p=0.11). CONCLUSIONS: The therapeutic shift to POD has substantially reduced transfusion requirements and length of hospital stay, and has reduced mortality in patients with unstable pelvic fractures. POD has made a major contribution to the care of critically injured patients with the most severe pelvic fractures.

Grafting long bone fractures with demineralized bone matrix putty enriched with bone marrow: pilot findings.

In this pilot study, the preliminary effectiveness of a composite graft consisting of demineralized bone matrix (DBM) putty (Grafton DBM) and aspirated bone marrow was evaluated for treating long bone fractures. Patients were ssigned randomly to treatment with the DBM putty composite (n = 10) or iliac crest autograft (n = 8), and had a minimum of 12 months of radiographic follow-up. Ninety percent of DBM patients (9/10) achieved full bone formation compared to 75% of autograft patients (6/8) (P = .41). Additionally, all 10 DBM patients were healed compared with 63% of autograft patients (5/8) (P = .07). These findings suggest that DBM putty enriched with bone marrow may be comparable to autograft for treating long bone fractures.

Factors associated with Short Form-36 outcomes in nonoperative treatment for ipsilateral fractures of the clavicle and scapula.

Twenty consecutive patients with ipsilateral fractures of the clavicle and scapula were treated nonoperatively with immobilization and physical therapy. Results were evaluated using the Herscovici, Rowe, and Constant scoring systems and the Short Form-36 (SF-36) questionnaire. The average comprehensive SF-36 score was lower than the scores obtained using the other scoring systems. In the SF-36 questionnaire, physical scores were strongly associated with nonphysical scores (P<.001). No association was found between SF-36 physical scores and age (P=.37), fracture pattern (clavicle, P=.81; scapula, P=.18), fracture displacement (P=.18), or injury severity score (P=.52). Outcomes were found to relate more to nonphysical factors than to the physical injury.

Ledge plating technique for unstable posterior sternoclavicular dislocation.

Of eight sternocostoclavicular joint dislocations treated at our institution over an 18-month period, two unstable posterior dislocations were treated with a safe and simple "ledge plating" technique. The ledge of plate left without screws prevents posterior loss of reduction without the use of wires or pins and provides enough stability to allow early motion and rehabilitation.

Acute compartment syndrome of the hand after a wasp sting: a case report.

UNLABELLED: Compartment syndrome of the hand is an uncommon entity in children and is usually the result of trauma or burns. Insects, such as wasps, produce a wide variety of toxins such as amines, peptides, and enzymes that can cause local and systemic inflammatory reactions after a sting. This inflammation can, in rare cases, lead to the development of a compartment syndrome. We present the case of a 5-year-old boy who developed a compartment syndrome of the hand after a single wasp sting that required emergent fasciotomy. To our knowledge, this has not been reported previously in the literature. An institutional review board approved review of the case. The clinical presentation, laboratory studies, radiographs, and possible-exacerbating factors leading to the development of a compartment syndrome, as well as the surgical procedure and postoperative course, were reviewed. Preoperative, intraoperative, and postoperative photographs are also presented. A 5-year-old boy presented to the emergency department 18 h after a single wasp sting to the dorsum of his hand. Based on his history and physical examination, hand compartment pressures were measured in his hand and found to be elevated. He underwent emergent fasciotomies with delayed wound closure. The patient healed uneventfully and at 5-month follow-up had full use of his hand, full range of motion, and normal 2-point discrimination in all the fingers. In conclusion, while wasp and other insect stings are common in children, this case is the first, to our knowledge, of a compartment syndrome of the hand after a wasp sting. Local measures used to treat insect stings such as heat and elevation may have played a role in the development of a compartment syndrome. It is important to have a high index of suspicion for this condition in a patient who presents with signs and symptoms of a compartment syndrome after an insect sting. LEVEL OF EVIDENCE: IV.