Closed Internal Degloving of the Toes: A Case Report.

Closed degloving injuries are uncommon, high-energy injuries that separate the bony structures from the soft tissue and frequently result in amputation. Because the epidermis is often intact, it is difficult to visualize the extent of the soft tissue damage. Although there is no gold standard of treatment for closed degloving injuries at present, previous cases have reported that neurovascular presentation is a key predictor of amputation Herein, we report a closed degloving injury involving the second through fifth phalanges of the left foot following a crushing injury with a forklift. Despite adequate capillary refill upon initial presentation, the patient ultimately underwent transmetatarsal amputation.

Implications of Admission and Surgical Timing on Hospital Length of Stay in Patients with Hip Fractures.

INTRODUCTION: Hospital reimbursements for geriatric hip fractures are contingent on patient outcomes and hospital length of stay (LOS). This study examined if the day of the week (DOTW) and time of day (TOD) of both admission and surgery are associated with increased LOS. METHODS: LOS, time from admission to surgery, DOTW of admission/surgery, TOD of admission/surgery, and demographics were retrospectively collected. The average LOS was 4.5 days. Patients were grouped into cohorts of LOS 1 to 4 days (short-stay) and 5 to 12 days (long-stay). The percentage of short-stay patients was compared with the percentage of long-stay patients for each DOTW/TOD of admission/surgery with chi square tests. RESULTS: One hundred patients were included, 58 short stays and 42 long stays. Both groups were similar regarding demographics. Long-stay patients were 4.2 times more likely to have been admitted ([95% confidence interval 1.2 to 14.6], P = 0.02) and 4.8 times as likely to have undergone surgery ([95% confidence interval 1.0 to 5.6], P = 0.01) on a Thursday, respectively. TOD of admission/surgery did not demonstrate any association with LOS. DISCUSSION: Thursday admission/surgery was associated with longer LOS. Delayed surgical optimization coupled with insurance companies' observance of regular business hours may delay admission to inpatient rehab or skilled nursing facilities, resulting in avoidable healthcare expenditures.

A Proposal for a Standardized Nomenclature of the C-arm Movements.

No formal didactic source exists concerning terminology for movement of the C-arm in the operating room (OR). Many terminologies exist, breeding confusion among OR staff. The objective of this study was to survey the existing C-arm movement terminologies among orthopaedic surgeons and radiologic technologists and propose a standardized nomenclature moving forward. Methods: Forty-six orthopaedic surgeons and 70 radiologic technologists were surveyed. Pertinent product manuals and literature from PubMed were reviewed to find existing terms for the C-arm movement. A focus group of orthopaedic surgeons and radiologic technologists was formed and a standardized nomenclature of the C-arm terminology was developed using the Delphi method. Results: The survey response rate was 71%. The mean percentage of agreement on terms to describe movement was 47% (range, 13% to 83%). Agreement on terms to describe direction was 46% (range, 23% to 73%), and multiple frames of reference were described. No consensus was found by searching the product manuals. Using the Delphi method, we arrived at a standardized nomenclature for the C-arm movement that is reproducible and familiar. Discussion: A standardized terminology for the C-arm movement is described that will help fill a void in OR communication, combat confusion, and provide reproducible results during orthopaedic cases.

Palliative Management of Nonoperative Femoral Neck Fractures With Continuous Peripheral Indwelling Catheters: Case-Control Series.

INTRODUCTION: This case-control study evaluates the success of indwelling pain catheters in nonoperatively treated femoral neck fractures (FNFs) for end-of-life pain management. METHODS: Patients older than 65 years with nonoperatively treated FNFs were retrospectively identified at a level 1 trauma center between March 2012 and September 2015. Twenty-three received indwelling continuous peripheral pain catheters (experimental) and 10 received traditional pain control modalities (control). Pain scores 24 hours before/after pain management interventions, ambulation status at admission and discharge, mortality at 30 days/1 year, and length of hospital stay (LOS) were compared between treatment groups. RESULTS: The experimental and control groups were similar with respect to demographics, differing only in pre-fracture ambulatory status (P = .03). The 30-day mortality was 52% versus 50% (odds ratio, OR: 1.1 [95% confidence interval, CI: 0.25-4.82], P = .99) and 1-year mortality was 87% versus 80% (OR: 1.67 [95% CI: 0.23-11.9], P = .63) for experimental and control groups, respectively. The LOS did not statistically significantly differ for experimental and control groups (5.3 ± 3.56 days vs 3.8 ± 1.81 days, P = .15), respectively. The experimental group experienced twice the improvement in ambulation status (1.0 ± 0.56 vs 0.5 ± 0.71, P = 0.03) and greater improvement in pain scores (4.5 ± 2.19 vs 1.2 ± 2.72, P = .002). DISCUSSION: Operative management of FNFs may not be indicated in patients with advanced age and comorbidities. Regardless, these patients require pain palliation and early mobilization while minimizing hospital LOS and opiate consumption. CONCLUSION: This case-control study demonstrates significant improvement in both pain level and ambulatory status for patients treated with indwelling continuous peripheral catheters. Future studies should further evaluate with a larger sample size; however, this study provides an excellent launching point for palliative management of this complex population.

Looking for Holes in Sterile Wrapping: How Accurate Are We?

BACKGROUND: Defects in sterile surgical wrapping are identified by the presence of holes through which light can be seen. However, it is unknown how reliably the human eye can detect these defects. QUESTIONS/PURPOSES: The purpose of this study was to determine (1) how often holes in sterile packaging of various sizes could be detected; and (2) whether differences in lighting, experience level of the observer, or time spent inspecting the packaging were associated with improved likelihood of detection of holes in sterile packaging. METHODS: Thirty participants (10 surgical technicians, 13 operating room nurses, seven orthopaedic surgery residents) inspected sterile sheets for perforations under ambient operating room (OR) lighting and then again with a standard powered OR lamp in addition to ambient lighting. There were no additional criteria for eligibility other than willingness to participate. Each sheet contained one of nine defect sizes with four sheets allocated to each defect size. Ten wraps were controls with no defects. Participants were allowed as much time as necessary for inspection. RESULTS: Holes ≥ 2.5 mm were detected more often than holes ≤ 2 mm (87% [832 of 960] versus 7% [82 of 1200]; odds ratio, 88.6 [95% confidence interval, 66.2-118.6]; p < 0.001). There was no difference in detection accuracy between OR lamp and ambient lightning nor experience level. There was no correlation between inspection time and detection accuracy. CONCLUSIONS: Defects ≤ 2 mm were not reliably detected with respect to lighting, time, or level of experience. Future research is warranted to determine defect sizes that are clinically meaningful. LEVEL OF EVIDENCE: Level II, diagnostic study.

Palliative Management of Nonoperative Femoral Neck Fractures With Continuous Peripheral Pain Catheters: 20 Patient Case Series.

INTRODUCTION: To identify the success of pain catheters in the management of pain in nonoperatively treated femoral neck fractures (FNFs) in supplement to current multimodal protocols for end-of-life pain management. METHODS: Twenty patients aged older than 50 years with FNFs were selected in a retrospective fashion at a level 1 trauma center. These patients were treated nonoperatively with indwelling continuous peripheral pain catheters to palliate pain. Adjunctive pain control for patients undergoing nonoperative management of FNFs was provided with an indwelling continuous intra-articular/peripheral nerve ropivacaine pain catheters. Pain scores 24 hours before/after continuous pain catheter placement, ambulation status before/after continuous pain catheter placement, mortality at 30 days/1 year, and length of hospital stay were measured. RESULTS: Twenty patients were identified with an average age of 84.55 years. The average length of stay was 4.85 days with a decrease of 4.45 points on the visual analog scale and an improvement of 90% in ambulation status. Thirty-day and one-year mortality were 65% and 95%, respectively. CONCLUSION: This case series provides orthopedic surgeons with an option for and data on the success of this adjunct to palliate patients who elect to undergo nonoperative management of FNFs. This study also helps define which patients may be candidates for nonoperative management of geriatric hip fractures.