Forearm Fractures: Diagnosis and Contemporary Treatment Strategies.

Diaphyseal forearm fractures represent a spectrum of injury patterns that include isolated radial shaft fractures, isolated ulnar shaft fractures, both-bone forearm fractures, Galeazzi fracture-dislocations, and Monteggia fracture-dislocations. Although less common than distal radius fractures, diaphyseal forearm fractures are still a frequently encountered clinical entity seen by orthopaedic surgeons, both as isolated injuries and in the patient with polytrauma. It is important to review the epidemiology of diaphyseal forearm fractures and the classification systems used to describe them, as well as to discuss the principles of the initial evaluation and management of these fractures. It is important to know the indications for nonsurgical and surgical management, along with the goals of surgical management, options for internal fixation, and surgical approaches to the forearm.

Why do nurses leave their jobs? Understanding person-related hostility in the healthcare sector of Pakistan.

Nursing is considered indigent and oppressed because of uneven organizational hierarchies and unsatisfactory work environments. This study aimed to highlight the critical aspects of organizational culture in the nursing profession and, in general, those propagating hostile behaviours among female nursing staff that result in dissatisfaction and intention to leave the organization. A quantitative research approach was applied and a survey research strategy was used to collect the data. Convenience sampling was applied and data were collected from female nurses who were easily accessible and willing to participate in the research. A total of 707 questionnaires were collected from 14 hospitals and the data was analyzed using SmartPLS 4. Lack of administrative support and gender discrimination positively affected person-related hostility. In contrast, person-related hostility mediated the relationship between gender discrimination and lack of administrative support with the intention to leave. Direct or indirect person-related hostility factors can severely damage organizational reputation and quality and may cause the loss of employees with specific organizational knowledge and exposure. Losing an experienced employee to a newer one cannot replace the costs incurred on hiring, training, and providing knowledge to older employees. HR managers in organizations should devise strategies and policies that allow for the timely resolution of issues of nursing staff based on fair work performance.

Discriminatory practices and poor job performance: A study of person-related hostility among nursing staff.

This study highlights the organisational-level factors that become the reason for propagating hostile behaviours among female nurses. Freire's theory of oppression has been used as an underpinning theory for developing the conceptual framework. This study empirically verifies the conceptual framework of the study that gender discrimination and lack of administrative support are the antecedents of person-related hostility, which is the reason for poor job performance in the healthcare sector. We applied a quantitative research approach, using questionnaires to collect data. Total of 707 survey forms were collected from female nurses working in public sector hospitals in four main cities of Pakistan. The software SPSS 20 and SmartPLS 3 were used for the final data analysis. All hypotheses regarding the direct and indirect relationship of variables were accepted. Gender discrimination and lack of administrative support were positively associated with person-related hostility. Moreover, person-related hostility also mediated the relationship between independent variables (gender discrimination, lack of administrative support) and dependent variable (poor job performance). Future research is directed to study person-related hostility among nursing staff of semi-urban areas and small towns with low literacy rates, considering other dependent variables like burnout, mental well-being, and mental health. HR strategies and policies for fair performance evaluation and timely promotions of nursing professionals are proposed in the study for building an overall healthy environment.

Race may not affect [correct] outcomes in operatively treated tibia fractures.

BACKGROUND: A recent review of the literature found worse outcomes and longer length of stay for minorities undergoing TKAs and THAs when compared with whites. It is unclear if this association exists for the operative treatment of tibia fractures. QUESTIONS/PURPOSES: The purpose of this study is to determine if there is a difference in etiology or the rate of complications for operative treatment of tibia fractures as a function of racial heritage. Secondary objectives include definition of etiology, mechanism, and fracture location as a function of race in the urban setting, and an attempt to determine if differences in etiology or complications depend on race and fracture location for tibial plateau or shaft fractures. METHODS: A retrospective chart review was conducted at our Level 1 urban trauma center from January 1, 2005 to December 31, 2009 using ICD-9 code 823 to identify patients with tibia fractures. Charts were reviewed to confirm operative intervention, location of fracture, mechanism, demographic data, length of stay, and complications (infection, reoperation, compartment syndrome, deep venous thrombosis, pulmonary embolism, death). RESULTS: There was no difference in the rate of infection within 90 days with respect to race. There also was no difference in the rate of reoperation, deep venous thrombosis, pulmonary embolism, mortality, and length of stay between white patients and minority patients. Subgroup analysis showed no difference in the rate of infection for plateau or shaft fractures. Compartment syndrome was more frequent in white patients, specifically white patients with tibia shaft fractures. Minority patients were more likely to have a gunshot wound as a mechanism of injury. CONCLUSION: With the possible exception of an increased risk of compartment syndrome in white patients, there is no difference in outcomes with respect to race for operatively treated tibia fractures, regardless of fracture location. Gunshot wounds have become an increasingly prevalent mechanism of injury in minority patients. LEVEL OF EVIDENCE: Level IV, prognostic study. See the Guidelines for Authors for a description of levels of evidence.

Talent acquisition and technology: A step towards sustainable development.

Purpose: The purpose of the research is to highlight the use of social media and information technology in employee recruitment by providing a conceptual recruitment model in the aspects of theoretical foundations and empirical evidence on the factors and outcomes leading to the use of social media recruiting technology (SMART). Design/methodology/approach: A total of 4,481 organizations are listed as the population of the study, and a total of 589 responses are used in the study for data analysis. Selection of the sample is done based on the simple random sampling technique. Appropriateness of sample size is confirmed with the help of G*Power (3.1.9.2) software, which calculated a sample size of 326 with 99% power, a multiple correlation (R) of 0.30, and at a significance level of 0.05. Findings: The paper provides empirical insights into the elements of the extended unified theory of acceptance and use of technology; i.e., performance expectancy, effort expectancy, social influence, facilitating conditions, hedonic motivation, habit, and price value have positive relations with the intention to adopt social media recruiting technology, and the intention impacts use of social media recruiting technology. Furthermore, the use of social media recruiting technology impacts outcome variables, i.e., social media recruiting time, cost, and recruitment quality, which establish the extension of the recruitment model with all factors and outcomes. Originality: This study provides a model of employee recruitment to win the battle of acquiring human capital using social media recruiting technology as a step toward sustainable development, which has been conceptually defined and empirically tested. The comprehensiveness of the model has never been discussed in earlier studies. Practical implications: Through this research, organizations will get an opportunity to experience enhancement in the scope of recruitment as a whole instead of considering recruitment as a traditional procedure, and the use of information technology can be expanded for progressive measures for future purposes and pandemic situations.

Impact of COVID-19 and Consortium Factors on Mental Health: Role of Emotional Labor Strategies in Achieving Sustainable Development Goals.

The COVID-19 pandemic that began in 2019 has created an acute fear of economic crisis, and people have experienced the state of perceived job insecurity. Several measures were taken to control this deadly pandemic, but it still affected the majority of global operational activities. This study addresses the United Nation's Sustainable Development Goal (SDG) number 8 that relates to decent work and economic growth. This quantitative study examines the impact of fear associated with economic crisis and perceived job insecurity on mental health with the moderating effect of surface and deep acting. Surface acting is displaying fake emotions, and deep acting is modifying inner feelings according to the required emotions. This study used sample data from private-sector employees and applied SmartPLS for structural model assessment. As many organizations took more challenging decisions to sustain their business operations, the study therefore analyzes the impact of the pandemic on private sector employees. The two main findings of the study are: (i) surface acting moderates the relationships of fear of economic crisis and perceived job insecurity with mental health and declines the impact of both on mental health, (ii) while deep acting negatively moderates the relationships of fear of economic crisis and perceived job insecurity with mental health and improved mental health even in the presence of both. The study highlighted the importance of deep acting at workplaces to sustain employees' mental and psychological stability. Organizations could introduce emotional labor strategies and strengthen the mental health of their employees against the underlying fear of economic crisis and perceived job insecurity.

Management of gunshot pelvic fractures with bowel injury: is fracture debridement necessary?

BACKGROUND: Low-velocity pelvic gunshot injuries occur commonly in urban trauma centers, occasionally involving concomitant intestinal viscus injury leading to potential fracture site contamination. Surgical debridement of the fractures may be necessary to prevent osteomyelitis, although not routinely performed in many centers. The purpose of this study was to determine whether fracture debridement should be done to prevent osteomyelitis in these injuries. METHODS: A 5-year retrospective review of all patients older than 12 years with low-velocity gunshot pelvic fractures was performed at an urban Level I trauma center. Medical records and radiographs/computed tomographic scans were reviewed, and data regarding fracture location, concomitant intestinal viscus injury, orthopedic surgical intervention, antibiotic treatment, and bone and/or joint infection were recorded. RESULTS: Of a total of 103 patients identified, 19 had expired within 48 hours and were excluded, resulting in a total of 84 study subjects for review. Fifty of 84 patients (59%) had a perforated viscus with 31 large bowel injuries and 30 small bowel injuries. Eighteen patients (21%) had intra-articular fractures, 15 of which involved the hip joint. Orthopedic surgical fracture debridement was done only in intra-articular fractures with retained bullet fragments (seven cases). Deep infection occurred in one patient with a missile injury to the hip joint with concomitant intestinal spillage. Immediate joint debridement was performed in this case, but successful missile fragment removal was not achieved until the second debridement after 48 hours. No infections occurred in any extra-articular fractures, regardless of the presence of intestinal spillage. CONCLUSIONS: Extra-articular gunshot pelvic fractures do not require formal orthopedic fracture debridement even in cases with concomitant intestinal viscus injury. However, debridement with bullet removal should be done in cases with intra-articular involvement, particularly if there are retained bullet fragments in the joint, to prevent deep infection.

Temporal and spatial expression of osteoactivin during fracture repair.

We previously identified osteoactivin (OA) as a novel secreted osteogenic factor with high expression in developing long bones and calvaria, and that stimulates osteoblast differentiation and matrix mineralization in vitro. In this study, we report on OA mRNA and protein expression in intact long bone and growth plate, and in fracture calluses collected at several time points up to 21 days post-fracture (PF). OA mRNA and protein were highly expressed in osteoblasts localized in the metaphysis of intact tibia, and in hypertrophic chondrocytes localized in growth plate, findings assessed by in situ hybridization and immunohistochemistry, respectively. Using a rat fracture model, Northern blot analysis showed that expression of OA mRNA was significantly higher in day-3 and day-10 PF calluses than in intact rat femurs. Using in situ hybridization, we examined OA mRNA expression during fracture healing and found that OA was temporally regulated, with positive signals seen as early as day-3 PF, reaching a maximal intensity at day-10 PF, and finally declining at day-21 PF. At day-5 PF, which correlates with chondrogenesis, OA mRNA levels were significantly higher in the soft callus than in intact femurs. Similarly, we detected high OA protein immunoexpression throughout the reparative phase of the hard callus compared to intact femurs. Interestingly, the secreted OA protein was also detected within the newly made cartilage matrix and osteoid tissue. Taken together, these results suggest the possibility that OA plays an important role in bone formation and serves as a positive regulator of fracture healing.

Orthopaedic Surgery Resident Financial Literacy: An Assessment of Knowledge in Debt, Investment, and Retirement Savings.

Most orthopedic residents carry significant debt and may enter their practice with little knowledge of business management, minimal retirement savings, and overall poor financial literacy. This study aimed to gauge financial literacy, debt, and retirement planning in United States orthopedic surgery residents. Willingness to participate in formalized financial education was also assessed. Eighty-five allopathic orthopedic surgery residents in the United States completed a 14-question anonymous online survey in 2016. The survey assessed demographic data, self-assessed financial knowledge, amount of credit card debt and loans, preparation for retirement, and willingness to participate in formal didactic education on these topics. Most respondents derive their financial knowledge from personal research (51%), whereas only 4 per cent have a formal curriculum. Despite most respondents reporting more than $200,000 in outstanding loans, only 31 per cent create and stick to a budget. Few programs offer retirement advice, and 48 per cent of respondents save $0 toward retirement. Eighty-five per cent of residents expressed interest in learning about personal investment, savings, and retirement planning. Orthopedic surgery residents carry significant debt and do not achieve their high-income potential until disproportionately later in life. Only 4 per cent of residents have formal training in investing, personal finance, or retirement despite a majority who desire such a curriculum. In fact, almost 75 per cent of those surveyed felt less prepared for retirement than their peers outside of medical training. This study suggests a role for formal financial education in the orthopedic curriculum to prepare residents for retirement, improve financial literacy, and enhance debt management.

Administration of intravenous antibiotics in patients with open fractures is dependent on emergency room triaging.

BACKGROUND: Recent literature has demonstrated that emergent administration of antibiotics is perhaps more critical than even emergent debridement. Most recent studies recommend patients receive antibiotics no later than 1 hour after injury to prevent infection. The objective of this study is to evaluate the time to antibiotic administration after patients with open fractures arrive to a trauma center depending on triaging team. METHODS: A retrospective study at a level 1 Trauma center from January 2013 to March 2015 where 117 patients with open fractures were evaluated. Patients who presented with open fractures of the extremities or pelvis were considered. Subjects were identified using Current Procedural Terminology (CPT) codes. Patients aged 18 and older were analyzed for Gustilo type, antibiotics administered in the emergency room (ER), presence of an antibiotic allergy, post-operative antibiotic regimen and number of debridements, among others. Additionally, whether a patient was triaged by ER doctors or trauma surgeons (and made a trauma activation) was evaluated. Outcome measurements included time to intravenous (IV) antibiotic administration and time to surgical debridement. RESULTS: Patients received IV cefazolin a median of 17 minutes after arrival. Eighty-five patients who were made trauma activations received cefazolin 14 minutes after arrival while 24 non-trauma patients received cefazolin 53 minutes after arrival (p = <0.0001). The median time to gentamicin administration for all patients was 180 minutes. Patients not upgraded to a trauma received gentamicin 263 minutes after arrival, while patients upgraded received gentamicin 176 minutes after arrival. There was no statistically significant difference between the timing to cefazolin or gentamicin based on Gustilo type. CONCLUSIONS: Overall, patients that arrive at our institution with open fractures receive IV cefazolin significantly faster when trauma surgeons evaluate the patient. Additionally, delays in gentamicin administration are demonstrated in both triaging groups. This is due to the fact that cefazolin is stocked in the hospital ER, while gentamicin is commonly not due to weight-based dosing requirements precluding a standard dose. Improvements can be made to antibiotic administration of non-trauma patients and those requiring gentamicin via improved education and awareness of open fractures.

Efficacy and Safety of Tranexamic Acid in Orthopaedic Fracture Surgery: A Meta-Analysis and Systematic Literature Review.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic drug that has been shown to be effective in reducing blood loss and the need for transfusions after several orthopaedic surgeries. However, the effectiveness of TXA use in orthopaedic fracture surgeries still remains unclear. The purpose of this meta-analysis was to review existing literature with interest in the effectiveness and safety of TXA treatment in reducing total blood loss and transfusion rates for patients who underwent surgery for fracture repairs. METHODS: An electronic literature search of PubMed, Embase, OVID, and the Cochrane Library was conducted to identify studies published before December 2016. All randomized controlled trials and cohort studies evaluating the efficacy of TXA during fracture repair surgeries were identified. Primary outcome measures included the number of patients receiving a blood transfusion and perioperative total blood loss. Data were analyzed using Comprehensive Meta-Analysis (CMA) statistical software. RESULTS: Seven studies encompassing 559 patients met the inclusion criteria for the meta-analysis. Our meta-analysis indicated that when compared with the placebo control group, the use of TXA in fracture surgeries significantly reduced total blood loss by approximately 330 mL (P = 0.009), reduced the transfusion rate with a relative risk of 0.54 (P < 0.001), and decreased the drop of hemoglobin by 0.76 g/dL (P < 0.001). There was no significant difference between the number of thromboembolic events among the study groups (P = 0.24). CONCLUSIONS: This study demonstrated that tranexamic acid may be used in orthopaedic fracture surgeries to reduce total blood loss, transfusion rates, and the drop in hemoglobin level, without increasing risk of venous thrombo-embolism. A limitation to these findings is the small number of studies available. Further studies need to be conducted to confirm these findings. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Obturator Artery Injury Resulting in Massive Hemorrhage From a Low-Energy Pubic Ramus Fracture.

Pelvic ring fractures are common in the elderly population and are usually a result of low-energy trauma, such as falls from standing. In most cases, low-energy pelvic ring injuries can be treated with appropriate analgesia and early mobilization. Arterial injury resulting in hemodynamic instability from a low-energy pelvic ring injury is rare but, given the poor compliance of vessels in the elderly population, possible. These patients must be carefully monitored after the initial injury. The purpose of this report is to describe an elderly patient who sustained a superior pubic ramus fracture and arterial injury following a low-energy fall from standing that required angiographic intervention. Elderly patients who sustain low-energy or pelvic insufficiency fractures are unlike the younger population with high-energy pelvic fractures and hemodynamic collapse. Elderly patients can have a delayed presentation of arterial injury and require careful physical examination and close monitoring. Additionally, the authors provide a review of the literature for low-energy pelvic fractures. [Orthopedics. 2017; 40(3):e546-e548.].

Patient Comprehension and Compliance Survey to Assess Postoperative Pain Regimens in the Orthopaedic Trauma Population.

OBJECTIVE: This study aims to determine the groups of patients who are at risk for noncompliance and misunderstanding of their pain regimen. DESIGN: Survey-based cohort study. SETTING: Suburban Level-I trauma center. PATIENTS/PARTICIPANTS: A total of 171 patients between the ages of 18-89 years who underwent surgical fixation of fractures involving the pelvis, long bones, or periarticular regions of the knee, ankle, elbow, and wrist. MAIN OUTCOME MEASUREMENTS: Patients who cannot accurately reproduce their prescribed pain medication list and patients who modify this pain medication regimen were analyzed by age, employment status, income level, education level, time between surgery and follow-up, and whether pain interfered with activities of daily living. RESULTS: Overall, 147 patients completed the survey. Seventy percent (n = 114) of patients could not accurately reproduce their pain medication regimen, regardless of age, employment status, income level, education level, time between surgery and follow-up, and whether pain interfered with activities of daily living. Patients (61.2%; n = 90), regardless of the 6 aforementioned demographic factors, also admitted to modifying their pain medication regimen with non-prescribed medications, with 55.8% (n = 82) of patients adding over-the-counter medications to surgeon-prescribed narcotic medications. CONCLUSIONS: Misunderstanding and noncompliance of surgeon-prescribed pain regimens are prevalent across all patient demographics. Knowledge of the potential effects these augmentative medications can have on fracture healing and any drug-drug interactions that may arise is an important aspect of patient postoperative care. Surgeons must be wary of these trends and screen for any unintended side effects a patient's pain regimen may have. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

"Hidden" Preoperative Blood Loss With Extracapsular Versus Intracapsular Hip Fractures: What Is the Difference?

PURPOSE: Excessive blood loss with hip fracture management has been shown to result in increased rates of complications. Our goal is to compare blood loss and transfusion rates between patients with intracapsular and extracapsular (both intertrochanteric (IT) and subtrochanteric (ST)) hip fractures. METHODS: 472 patients were evaluated over a five-year period. Those who presented to the hospital with a proximal femur fracture (femoral neck, IT or ST) were considered for the study. Exclusion criteria included polytrauma, gunshot injuries, periprosthetic fractures, and non-operative management. Primary endpoint was hemoglobin (Hgb) drop from admission to day of surgery (DOS); secondary endpoint was need for pre-op transfusion and discharge location. RESULTS: 304 patients were analyzed who sustained a proximal femur fracture. Median IC Hgb drop was 0.6g/dL; median EC Hgb drop was 1.1g/dL from admission to DOS (p = 0.0272). Rate of pre-operative transfusions was higher in EC (36/194 = 18.6%) than IC fractures (5/105 = 4.5%) (p = 0.0006), and overall transfusion rates remained higher throughout hospital stay (55.7% EC vs. 32.7% IC; p = 0.0001). Breakdown of bleeding rate and tranfusion rates between IT and ST fractures were not significant (p = 0.07; p = 0.4483). Extracapsular hip fractures were more likely to be discharged to a skilled nursing facility (SNF) (84.4% EC vs. 73.8% IC; p = 0.027). CONCLUSION: Intracapsular hip fractures have significantly less pre-operative blood loss and fewer pre-operative transfusions than their extracapsular counterparts. These findings can be used to establish appropriate pre-operative resuscitative efforts, ensuring that hip fracture protocols account for the increased likelihood of blood loss in extracapsular fractures.

Misuse of Opioids in Orthopaedic Postoperative Patients.

OBJECTIVE: In light of the recent uptrend in the prescription of opioids, this study seeks to identify patterns of opioid misuse among orthopaedic postoperative patients and principal external sources in obtaining these medications. DESIGN: Ten-month survey-based study. SETTING: Two Level I trauma centers (urban and suburban). PATIENTS/PARTICIPANTS: Two hundred seven patients between the ages of 18 and 89 years who underwent surgical fixation of fractures involving the pelvis, long bones, or periarticular regions of the knee, ankle, elbow, and wrist. MAIN OUTCOME MEASUREMENTS: Patients who believed they were undermedicated, used prescribed opioids at higher than recommended doses, and took extra opioids in addition to their prescribed analgesics were analyzed by age, employment, income, education, controlled substance use, pain interference with activities of daily living, and anatomic surgical site. RESULTS: One hundred eighty-two patients completed the survey; 19.2% of patients (n = 35) felt undermedicated [unemployed (P < 0.05), low income (P < 0.05), and self-reported controlled substance users (P < 0.05)]; 12.6% of patients (n = 23) admitted to using pain medications at a higher dose than prescribed [unemployed (P < 0.05), lower income (P < 0.05), nonhigh school graduates (P < 0.05), and previous controlled substance users (P < 0.05)]; 9.3% (n = 17) admitted to using external opioids [unemployed patients (P < 0.05) and self-reported controlled substance users (P < 0.05)]. Major sources of extraneous opioids include family/friends (n = 5) and other doctors (n = 4). CONCLUSION: Unemployed and lower-income patients were significantly more likely to believe that their surgeon was not prescribing them enough pain medications as well as use their prescribed opioid medications at a higher than recommended dose compared with their employed counterparts with higher incomes. Unemployed patients were also significantly more likely to use additional opioid analgesics in addition to those prescribed to them by their primary surgeon. Surgeon awareness of a patient's socioeconomic background and associated risk of opioid misuse is crucial to prescribe the safest most effective pain regimen. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Optimizing Radiation Dose in Computed Tomography of Articular Fractures.

OBJECTIVES: To determine whether a substantially lowered radiation protocol would provide satisfactory information for the surgeon, using the distal tibia as a model. METHODS: Eleven adult cadaveric distal tibia specimens were used to create Orthopaedic Trauma Association (OTA/AO) 43C distal tibia fractures with varying displacements in 2 planes. Each specimen was scanned at 3 modified protocols, which were then subsequently read by both qualified attending orthopaedists and midlevel residents. Observer reliability was evaluated, as well as confidence levels of identifying fracture pattern and treatment protocols. RESULTS: On average, there was less than a millimeter of variability in the measured gap to true gap as a whole (mean = 0.74 mm, P < 0.0001). With regard to measurements in gap, pattern, and treatment plans, no significant difference was found between CT images acquired with standard (110 mAs) compared with medium (60 mAs; mean 0.0 mm, P = 1.0; k = 0.14, P = 0.56; k = 0.38, P = 0.13, respectively) and low protocols (45 mAs; mean 0.01 mm, P = 0.95; k = 0.24, P = 0.32; k = 0.31, P = 0.13, respectively). Furthermore, no significant difference was found in measuring step-off across standard, medium, and low radiation dose (0.21 mm, P = 0.46; 0.28 mm, P = 0.39; -0.16 mm, P = 0.48, respectively). CONCLUSION: The results of this study show no significant difference when evaluating current standard and low-dose CT scans using less than one-half the amount of exposure. This suggests that in complex extremity fractures, a new CT protocol may potentially be used. Our initial data show promise that we may retain satisfactory imaging to formulate a treatment plan while also reducing the collective radiation burden to the population.

Arthroscopically-assisted removal of retrograde intramedullary femoral nails.

Retrograde nailing of femoral shaft fractures has become more prevalent as a result of its growing acceptance and familiarity to orthopaedic surgeons. Nail removal is occasionally indicated, which may require a formal arthrotomy. We describe an arthroscopic removal technique that has several advantages. The percutaneous technique imparts less morbidity than a more extensive arthrotomy. More importantly, additional intra-articular pathology can be thoroughly assessed and treated, such as meniscal tears and chondral injury, which may have occurred at the time of injury. These are potential causes of knee pain, which usually cannot be properly diagnosed without arthroscopy. Our findings also support the existence of a stable fibrous cap, which forms over the entry portal of a well-seated retrograde femoral nail as well as no evidence of intra-articular metallosis.

Management of the Morel-Lavallée Lesion.

Morel-Lavallée lesions are closed degloving injuries sustained during violent soft tissue shear that separate the subdermal fat from its strong underlying fascia. Lesions most often occur in the peritrochanteric region, and patients may have concomitant polytrauma. As a result, a hematoma develops that has a high rate of acute bacterial colonization and chronic recurrence. Conservative treatment outcomes are best for those managed acutely. However, diagnosis is often delayed or missed. Furthermore, there is no universally accepted treatment algorithm. Diagnosis and treatment depend on a surgeon's thorough understanding of the cause, pathophysiology, imaging characteristics, and treatment options of Morel-Lavallée lesions.

Management of Adult Elbow Fracture Dislocations.

Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.

Management of Major Traumatic Upper Extremity Amputations.

Traumatic upper extremity amputation is a life-altering event, and recovery of function depends on proper surgical management and postoperative rehabilitation. Many injuries require revision amputation and postoperative prosthesis fitting. Care should be taken to preserve maximal length of the limb and motion of the remaining joints. Skin grafting or free tissue transfer may be necessary for coverage to allow preservation of length. Early prosthetic fitting within 30 days of surgery should be performed so the amputee can start rehabilitation while the wound is healing and the stump is maturing. Multidisciplinary care is essential for the overall care of the patient following a traumatic amputation of the upper limb.