Misdiagnosed pneumothorax interpreted as necrotizing fasciitis of the chest wall: case report of a potentially preventable death.

BACKGROUND: Subcutaneous emphysema is an uncommon clinical finding associated both with benign sources and potentially deadly necrotizing infections. Wide ranges of causes exist including trauma, iatrogenic injuries, factitious disorders and necrotizing infections. CASE PRESENTATION: A 49-year old male presented to the emergency room with extensive subcutaneous emphysema following blunt trauma. The orthopaedic surgery service was consulted for treatment of suspected necrotizing fasciitis due to his subcutaneous emphysema. A careful patient history and physical examination correlated with laboratory and radiographic findings revealed rib fractures and a long-standing, undiagnosed pneumothorax as the cause for emphysema. Treatment of the underlying condition with chest tubes led to eventual resolution of the emphysema, though multisystem organ failure ultimately resulted in patient death. CONCLUSION: This case illustrates the importance of rapidly and appropriately evaluating trauma patients, and in this case specifically diagnosing and treating the underlying cause of subcutaneous emphysema. The late diagnosis of pneumothorax resulted in delayed definitive treatment, which may have contributed to the patient's ultimate demise. In acute and sub-acute trauma situations a high level of suspicion for life threatening injuries must be maintained. Decision making for initial treatment should be based on the basic tenants of Advanced Trauma Life Support to primarily address these injuries and help prevent further disability or death.

Medial patellofemoral ligament (MPFL) reconstruction for the treatment of patellofemoral instability.

Patellofemoral instability can be a disabling problem. Numerous techniques are employed for its treatment. Medial patellofemoral ligament (MPFL) reconstruction in combination with other procedures has been explored by many orthopedic surgeons. The purpose of the study was to determine the effectiveness of isolated MPFL reconstruction in treating the symptoms associated with patellofemoral instability, preventing recurrence of patella dislocation, and returning patients to preinjury level of activity. This is a case series study. We conducted a clinical follow-up study on 56 knees (49 patients) after MPFL reconstruction for recurrent patellar instability with a mean follow-up of 4.3 years (range, 1.1-6.8). A single MPFL reconstruction technique was performed in all cases. Patient outcomes were evaluated using: International Knee Documentation Committee (IKDC) subjective knee form, Tegner activity score, functional hop test, and radiographs. Mean age at time of surgery was 24 years old (range, 13-49). Females comprised 75% of the sample. Mean interval from injury to surgery was 7.2 ± 8.6 years (range, 51 days-37 years). At follow-up, there were no recurrent dislocations reported, patella subluxation in 6 (11%) cases, and radiographic degenerative changes were none to mild in all patients. The series mean IKDC scores at follow-up was 76.3 ± 19.2 (range, 30-99), and Tegner activity scores were 5.6 ± 2.5. MPFL reconstruction is an option for treating the symptoms of patellar instability, preventing recurrent dislocation, and returning patients near to their preinjury level of activity. The level of evidence is IV.

Closed suction irrigation for the treatment of postoperative wound infections following posterior spinal fusion and instrumentation.

STUDY DESIGN: Retrospective review of clinical cases. OBJECTIVE: This study describes the success rate of closed suction irrigation system (CSIS) in the treatment of post operative spinal infections. SUMMARY OF BACKGROUND DATA: Given the widening use of spinal instrumentation, the management of related postoperative deep wound infections has become increasingly important. In the literature, there have been reports of several treatment methods yet no firmly established protocol for management of postoperative deep wound infections exists. The goal of this study was to determine the effectiveness of our protocol employing (CSIS) in the treatment of postoperative deep wound infections. METHODS: A retrospective record review of 500 posterior instrumented fusions between 1990 and 2002. Twenty-eight consecutive infections (5%) were diagnosed and treated by a standardized treatment protocol of Incision and Drainage, and CSIS. Cultures were obtained, wounds closed primarily, and appropriate intravenous antibiotic treatments initiated. For statistical evaluation, patients were assigned a risk factor (RF) described by Levi et al (J Neurosurg. 1997;86:975-980). Point values were assigned to medical comorbidities that may contribute to postoperative infection risk; higher RF values indicate an increased risk. RESULTS: Twenty-one acute and 7 late (>6 months) infections were followed for 22.3 months (1-86 months), post-CSIS treatment. Twenty-one (75%) resolved without recurrence with one CSIS treatment. Seven acute infections (25%) required a second course of treatment. Hospitalization for the index procedure averaged 15.4 days; 28.9 days for reinfections. No patient with an acute infection required implant removal. The reinfection group had higher blood loss, more levels fused, and longer hospitalization. The reinfection group was comprised entirely of pediatric patients. CONCLUSION: No correlation was found between RF values and greater risk of recurrent infection. Removal of implants is unnecessary in acute infections, provided the infection does not return. CSIS is an effective method for treatment of postoperative wound infections following instrumented spinal fusion avoiding the need for secondary closure.

Ipsilateral anterior then irreducible posterior hip dislocation without fracture: a case report.

Anterior hip dislocations and posterior hip dislocations are injuries that commonly result from high-energy trauma. Different mechanisms of injury and forces are typically required for anterior and posterior hip dislocations. We present the case of a patient who sustained an injury that initially resulted in an anterior hip dislocation. After reduction and without experiencing further significant trauma, the patient dislocated posteriorly while being transferred from a stretcher to a table in radiology some 14 hours later. To our knowledge, there have been no such presentations in the literature.