Medial femoral circumflex artery pseudoaneurysm following intramedullary nailing for intertrochanteric fracture.

CASE: We present the case of a 92-year-old woman who developed a medial femoral circumflex artery (MFCA) pseudoaneurysm intraoperatively while obtaining reduction during intramedullary nailing (IMN) for intertrochanteric fracture. CONCLUSIONS: Pseudoaneurysms are rare vascular complications in hip fracture surgery. Early recognition of signs and symptoms of this phenomenon are essential for diagnosis and treatment. Close post-operative monitoring and serial hemoglobin should be considered for unexplained intra-operative bleeding. A low threshold for angiography should be entertained if active bleeding and clinical decompensation occur during instrumented percutaneous pertrochanteric fracture reduction. This patient underwent conventional angiography with successful coil embolization and exclusion of the MFCA pseudoaneurysm.

Low-energy suspiciously open proximal humerus fracture management in older adult patient: A case report.

Although fractures of the proximal humerus are common among older adults, open fractures following low-energy trauma are exceptionally rare. Prior studies have alluded to the existence of this injury, but there are no detailed reports on its presentation, management, or long-term follow-up. We present the case of a 78-year-old man that sustained a suspiciously open proximal humerus fracture of the dominant hand following a fall down a few stairs. Management consisted of early intravenous antibiotics followed by open reduction and internal fixation with irrigation and debridement. Intraoperative soft tissue assessment revealed a wound extending from bone to skin. The patient suffered no complications, regained full function of his arm, and is pain free. Considering the rarity of this injury and its potential for highly morbid complications, this case serves as a reminder that we should continue to have a low suspicion threshold for open fracture when punctures or lesions are present around proximal humerus fractures, even for low-energy injuries. Prompt and thorough examination, initiation of antibiotics, and surgical intervention are keys to providing best care for this uncommon injury.

What You Need to Know About Hand Hygiene and Dermatitis During the Coronavirus Pandemic.

Increased attention towards infection control measures during the COVID-19 pandemic have brought to light the dermatological consequences of intensified hand hygiene measures. Healthcare workers are inherently at an increased risk of developing both allergic and irritant contact dermatitis. Individuals with a history of atopy are especially vulnerable given their impaired native skin barriers and increased sensitivities at baseline. Examination gloves not only induce contact allergies from manufacturing chemicals, but also serve as an occlusive catalyst for facilitating contact sensitization and irritant dermatitis. Similarly, handwashing practices with soap and alcohol-based hand rubs (ABHRs) undermine the natural skin barriers with increasing frequency of use. We highlight clinical pearls for the frontline healthcare worker experiencing COVID-19 surges and offer practical measures to minimize the development of hand-based dermatitis.

Clinical Decision Support Intervention and Time to Imaging in Older Patients with Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is the leading cause of elderly trauma admissions. Previous research identified that each minute delay to TBI diagnosis was associated with a 2% mortality increase, delaying treatment to older patients (age ≥70 years) who do not meet trauma activation criteria. A TBI protocol and clinical decision support intervention (CDS-I) were developed to reduce time to imaging in older patients with head trauma not meeting trauma activation criteria. STUDY DESIGN: An emergency department (ED) head CT protocol and CDS-I were developed and implemented to facilitate rapid imaging of older patients. Patients age ≥ 70 years, with TBI and receiving anticoagulation, met inclusion criteria. The primary outcomes measure was time from ED arrival to head CT imaging comparing before (PRE: January 1, 2016 to December 31, 2016) vs after (POST: August 1, 2018 to April 3, 2019) protocol implementation. Negative binomial regression models evaluated the association of intervention on time to imaging. LOWESS (locally weighted scatterplot smoothing) was used to evaluate the association of intervention on mortality over time. RESULTS: The study examined 451 patients (269 PRE and 182 POST). Positive head CTs were seen in 78 (17.3%), and 57 of 78 (73%) patients had a Glasgow Coma Scale > 13. POST-intervention decreased time to head CT from 56 to 27 minutes (interquartile range [IQR] PRE: 32 to 93 to POST:16 to 44, p < 0.001) and POST-intervention patients had reduced hospital length of stay (incidence rate ratio [IRR] 0.83, 95% CI 0.72 to 0.86, p = 0.01). CONCLUSIONS: A significant proportion of older patients receiving anticoagulation, but not meeting trauma activation criteria, had positive CT findings. Implementation of a rapid triage protocol with CDS-I reduced time to imaging and may reduce mortality in the highest-risk populations.