Calcaneus Fractures: A Possible Musculoskeletal Emergency.

BACKGROUND: Calcaneal fractures are commonly seen and treated in the emergency department. There are subsets of calcaneal fractures that pose a high risk to the adjacent soft tissue of the heel and can result in full-thickness tissue necrosis. OBJECTIVE: To identify which calcaneal fractures need to be managed within hours and triaged to the orthopedic team and which can be temporized in a neutral or plantarflexed ankle splint and seen in an outpatient setting. DISCUSSION: Tongue-type calcaneal fractures and tuberosity fractures must be triaged appropriately within the first few hours of presentation to prevent skin compromise. This requires the emergency physician to understand the radiographic morphology of the fracture as well as the clinical signs of skin compromise. Communication with the orthopedic surgery service is essential and splinting in a specific manner is important to stabilize the soft tissue envelope. CONCLUSION: Recognizing the calcaneal injury pattern and implementing the correct treatment strategy is paramount to having successful patient outcomes. A delay or error in treatment can turn a closed fracture into an open fracture.

Hematocrit as a predictor of preoperative transfusion-associated complications in spine surgery: A NSQIP study.

BACKGROUND CONTEXT: Preoperative optimization of medical comorbidities prior to spinal surgery is becoming an increasingly important intervention in decreasing postoperative complications and ensuring a satisfactory postoperative course. The treatment of preoperative anemia is based on guidelines made by the American College of Cardiology (ACC), which recommends packed red blood cell transfusion when hematocrit is less than 21% in patients without cardiovascular disease and 24% in patients with cardiovascular disease. The literature has yet to quantify the risk profile associated with preoperative pRBC transfusion. PURPOSE: To determine the incidence of complications following preoperative pRBC transfusion in a cohort of patients undergoing spine surgery. STUDY DESIGN: Retrospective review of a national surgical database. PATIENT SAMPLE: The national surgical quality improvement program database OUTCOME NEASURES: Postoperative physiologic complications after a preoperative transfusion. Complications were defined as the occurrence of any DVT, PE, stroke, cardiac arrest, myocardial infarction, longer length of stay, need for mechanical ventilation greater than 48 h, surgical site infections, sepsis, urinary tract infections, pneumonia, or higher 30-day mortality. METHODS: The national surgical quality improvement program database was queried, and patients were included if they had any type of spine surgery and had a preoperative transfusion. RESULTS: Preoperative pRBC transfusion was found to be protective against complications when the hematocrit was less than 20% and associated with more complications when the hematocrit was higher than 20%. In patients with a hematocrit higher than 20%, pRBC transfusion was associated with longer lengths of stay, and higher rates of ventilator dependency greater than 48 h, pneumonia, and 30-day mortality. CONCLUSION: This is the first study to identify an inflection point in determining when a preoperative pRBC transfusion may be protective or may contribute to complications. Further studies are needed to be conducted to stratify by the prevalence of cardiovascular disease.

Acute exertional compartment syndrome of the lumbar paraspinal muscles in a weightlifter. A case report.

BACKGROUND: Compartment syndrome (CS) is a well-known phenomenon in orthopaedics associated with traumatic injury to an extremity or over exertion which ultimately leads to prolonged and elevated intrafascial pressures. CS was initially described by Volkmann in 1881[1]. With any active muscle, there is a transient rise in intrafascial pressure from resting range of approximately 3 mmHg to 7.95 mmHg [2]. When this increase in pressure is too great or not transient, then a subsequent compartment syndrome develops. The consequences of such physiologic imbalance can induce muscle necrosis, nerve damage, vascular compromise, functional deficits, and potentially loss of limb[3,4]. Typical initial presentation of CS includes pain out of proportion to the severity of injury, which is intensified with passive motion of the muscle within the affected fascial compartment.[4] Non musculoskeletal manifestations of CS generally present themselves as the syndrome progresses and can include rhabdomyolysis, myoglobinuria, acute kidney injury, or acute tubular necrosis [4]. These non musculoskeletal manifestations of CS are potential etiologies causing patients to present for treatment [4]. PURPOSE: There have been approximately 20 previous case reports on paraspinal compartment syndrome with a combination of surgical and medical treatments in these patients. We will present a case of paraspinal CS in an avid weightlifter and discuss diagnostic and treatment options surrounding this syndrome. STUDY DESIGN: Case Report. PATIENT SAMPLE: This is a report of a single patient who presented to Duke University Medical Center. METHODS: We report the case of a 29 year old male with paraspinal compartment syndrome who was treated with fasciotomies. This was considered an IRB exempt study by our IRB as such informed consent was not obtained by the patient prior to publication. RESULTS: This patients had resolution of symptoms after surgical intervention which continued through follow up. CONCLUSION: Paraspinal compartment syndrome can be effectively treated with surgical fasciotomy.

Results of the Gravity Stress Examination in the Normal Patient Population.

In ankle fractures, the result of a gravity stress radiographic examination is clinically used to determine if a patient may need surgical intervention. The purpose of this study is to report the results of a gravity stress examination in the normal patient population. Fifty study participants were prospectively enrolled and complete ankle radiographs were obtained, including a nonweightbearing gravity stress examination. The mean medial clear space in the gravity stress view was 3.6 mm. This compared to a mean medial clear space of 3.3 mm, and 3.1 mm in the anteroposterior and mortise views. These values were statistically significantly different from the gravity stress view ( P = .006 and P < .001, respectively). There was no statistically significant difference between the talar tilt as measured on the anteroposterior and gravity stress radiographs ( P = .22). No participant had medial clear space widening with gravity stress to more than 5.2 mm or an increase in their widening by more than 0.2 mm. In conclusion, this study helps guide surgeons by providing normative radiographic data for a gravity stress examination and supports the notion that measureable medial clear space widening or talar tilt on gravity stress examination represents an unstable injury. LEVELS OF EVIDENCE: Level II: Prospective.