Incarceration of the Posterior Tibial Tendon in an Isolated Comminuted Medial Malleolus Fracture.

Isolated medial malleolar fractures are a less common presentation of an ankle fracture. Treatment is not universally accepted, although many have agreed that any displacement warrants anatomic reduction and fixation. We present a case of an isolated, comminuted medial malleolar fracture that was displaced secondary to entrapment of the posterior tibial tendon between the fracture fragments requiring surgical intervention. The patient was treated with prompt open reduction and internal fixation and had an excellent functional outcome at 1 year. When open reduction and internal fixation of the medial malleolus is indicated, a thorough exploration of the zone of injury is required to identify and adequately address any surrounding pathologic features beyond just the disrupted bony anatomy. To the best of our knowledge, this specific injury has never been previously reported and emphasizes the importance of understanding the local anatomy and how restoration of the distorted anatomy is vital to optimize patient function.

Perceived comfort level of medical students and residents in handling clinical ethics issues.

BACKGROUND: Studies have shown that medical students and residents believe that their ethics preparation has been inadequate for handling ethical conflicts. The objective of this study was to determine the self-perceived comfort level of medical students and residents in confronting clinical ethics issues. METHODS: Clinical medical students and residents at the University of Maryland School of Medicine completed a web-based survey between September 2009 and February 2010. The survey consisted of a demographic section, questions regarding the respondents' sense of comfort in handling a variety of clinical ethics issues, and a set of knowledge-type questions in ethics. RESULTS: Survey respondents included 129 medical students (response rate of 40.7%) and 207 residents (response rate of 52.7%). There were only a few clinical ethics issues with which more than 70% of the respondents felt comfortable in addressing. Only a slight majority (60.8%) felt prepared, in general, to handle clinical situations involving ethics issues, and only 44.1% and 53.2% agreed that medical school and residency training, respectively, helped prepare them to handle such issues. Prior ethics training was not associated with these responses, but there was an association between the level of training (medical students vs residents) and the comfort level with many of the clinical ethics issues. CONCLUSIONS: Medical educators should include ethics educational methods within the context of real-time exposure to medical ethics dilemmas experienced by physicians-in-training.

The Hallux Metatarsophalangeal Capsule: An Anatomic Study With Respect to Percutaneous Hallux Valgus Correction.

BACKGROUND: Minimally invasive surgery for the treatment of hallux valgus deformities has become increasingly popular. Knowledge of the location of the hallux metatarsophalangeal (MTP) proximal capsular origin on the metatarsal neck is essential for surgeons in planning and executing extracapsular corrective osteotomies. A cadaveric study was undertaken to further study this anatomic relationship. METHODS: Ten nonpaired fresh-frozen frozen cadaveric specimens were used for this study. Careful dissection was performed, and the capsular origin of the hallux MTP joint was measured from the central portion of the metatarsal head in the medial, lateral, dorsal, plantarmedial, and plantarlateral dimensions. RESULTS: The ten specimens had a mean age of 77 years, with 5 female and 5 male. The mean distances from the central hallux metatarsal head to the MTP capsular origin were 15.2 mm dorsally, 8.4 mm medially, 9.6 mm laterally, 19.3 mm plantarmedially, and 21.0 mm plantarlaterally. CONCLUSION: The MTP capsular origin at the hallux metatarsal varies at different anatomic positions. Knowledge of this capsular anatomy is critical for orthopaedic surgeons when planning and performing minimally invasive distal metatarsal osteotomies for the correction of hallux valgus. TYPE OF STUDY: Cadaveric Study.

Oncological outcomes of hand-assisted laparoscopic radical nephrectomy for clinically localized renal cell carcinoma: a single-institution study with >or=3 years of follow-up.

OBJECTIVE: To evaluate the intermediate-term outcomes of hand-assisted laparoscopic radical nephrectomy (HALRN) for clinically organ-confined renal cell carcinoma (RCC). PATIENTS AND METHODS: We retrospectively reviewed patients who had HALRN for clinically organ-confined RCC at the University of Wisconsin from 1996 to 2003. All patients with pathologically confirmed RCC and with >or=3 years of follow-up were included in a retrospective chart review of variables before, during and after HALRN, as well as the clinical outcomes. RESULTS: In all, 75 patients had HALRN in the study period; their mean age was 59 years, body mass index 29 kg/m(2), operative duration 227 min, estimated blood loss 130 mL, and none required conversion to open nephrectomy. The median time to first oral intake was 2.5 days and the median hospital stay 4 days. On pathological examination the mean tumour size was 5.8 cm; 70% were pT1, 26% pT2 and 4% pT3; 82% were clear cell, 9% papillary, 8% chromophobe and 1% collecting duct carcinoma. Of the 65 patients who had a follow-up of >or=36 months (mean 46, range 36-117), the 3- and 5-year disease-free survival rate was 93.4% and 90.2%, respectively; the 3- and 5-year cancer-specific survival rate was 96.5% and 94.4%, respectively. CONCLUSION: Our study suggests that HALRN is a safe and minimally invasive treatment for managing clinically organ-confined RCC, with good intermediate-term oncological outcomes.

Rotator Cuff Tear Consequent to Glenohumeral Dislocation.

The patient was a 21-year-old collegiate running back who was tackled during a football game and sustained a posterior glenohumeral dislocation. He was referred to an orthopaedist and presented 3 weeks after the injury, and, following examination, further imaging was ordered by the orthopaedist due to rotator cuff weakness. Magnetic resonance imaging showed a complete tear of the supraspinatus and infraspinatus, as well as a posterior Bankart lesion, a subscapularis tear, and a dislocation of the biceps long head tendon into the reverse Hill-Sachs lesion. J Orthop Sports Phys Ther 2016;46(8):708. doi:10.2519/jospt.2016.0413.

Sustentaculum Lunatum: Appreciation of the Palmar Lunate Facet in Management of Complex Intra-Articular Fractures of the Distal Radius.

Fracture of the distal radius is the most common wrist injury. Treatment of complex intra-articular fractures of the distal radius requires an accurate diagnosis of the fracture pattern and a thoughtful approach to fixation. We propose a new term, sustentaculum lunatum, for the palmar lunate facet. The sustentaculum lunatum deserves specific attention because of its importance in load transmission across the radiocarpal joint. It is also key to restoring the anatomy of the palmar distal radial metaphysis during internal fixation. We provide a review of the structure and function of the sustentaculum lunatum and describe fixation techniques. This article is intended to promote awareness of this fragment in the treatment of fractures of the distal radius.

Renal angiomyolipoma with inferior vena caval thrombus in a 32-year-old male.

Renal angiomyolipoma (AML) rarely presents with evidence of extension into the renal vein, inferior vena cava (IVC) or atrium. We report a case of a renal AML with a tumor thrombus to the IVC in a 32-year-old male. The patient subsequently underwent a right radical nephrectomy with IVC tumor thrombectomy. To our knowledge, there are four published cases of renal AML presenting with tumor thrombus in males. This case report describes the management of the youngest male ever to develop a renal AML with IVC tumor thrombus.