Achieving Bone Healing Non-Operatively in Humeral Fractures in Two Patients with Risk Factors for Nonunion Utilizing a Specialized Orthosis.

We report the treatment of two patient with humeral fractures with one or more risk factors for nonunion. The first patient was elderly with a previously diagnosed central nervous sys-tem injury. The second elderly patient previously sustained a cerebral vascular accident affecting the fractured arm. The fracture was oblique in the proximal third of the humerus. We achieved bone healing non-operatively utilizing a spe-cialized plastic orthosis that included a deforming element made of dense foam. This device asymmetrically increases the soft tissue pressure around the fracture.

The Anatomic Position of the Sciatic Nerve During Percutaneous Retrograde Posterior Column Fixation Is Determined by Hip Position.

OBJECTIVES: There are multiple established patient positions for placement of a percutaneous retrograde posterior column screw for fixation of acetabulum fractures. The sciatic nerve is at risk of injury during this procedure because it lies adjacent to the start point at the ischial tuberosity. The purpose of this study was to define how the position of the sciatic nerve, relative to the ischial tuberosity, changes regarding the patient's hip position. METHODS: In a cohort of 11 healthy volunteers, ultrasound was used to measure the absolute distance between the ischial tuberosity and the sciatic nerve. Measurements were made with the hip and knee flexed to 90 degrees to simulate supine and lateral positioning and with the hip extended to simulate prone positioning. In both positions, the hip was kept in neutral abduction and neutral rotation. RESULTS: The distance from the lateral border of the ischial tuberosity to the medial border of the sciatic nerve was greater in all subjects in the hip-flexed position versus the extended position. The mean distance was 17 mm (range, 14-27 mm) in the hip-extended position and 39 mm (range, 26-56 mm) in the hip-flexed position ( P < 0.001). CONCLUSIONS: The sciatic nerve demonstrates marked excursion away from the ischial tuberosity when the hip is flexed compared with when it is extended. The safest patient position for percutaneous placement of a retrograde posterior column screw is lateral or supine with the hip flexed to 90 degrees.

A 7-year perspective on femoral neck fracture management in New York State-Do Level 1 trauma centers provide better care?

INTRODUCTION: Patients with femoral neck fractures are at a substantial risk for medical complications and all-cause mortality. Given this trend, our study aims to evaluate postoperative outcomes and the economic profile associated with femoral neck fractures managed at level-1 (L1TC) and non-level-1-trauma centers (nL1TC). METHODS: The SPARCS database was queried for all geriatric patients sustaining atraumatic femoral neck fractures within New York State between 2011 and 2017. Patients were then divided into two cohorts depending on the treating facility's trauma center designation: L1TC versus nL1TC. Patient samples were evaluated for trends and relationships using descriptive analysis, Student's t-tests, and Chi-squared. Multivariable linear-regressions were utilized to assess the effect of trauma center designation and potential confounders on patient mortality and inpatient healthcare expenses. RESULTS: In total, 44,085 femoral neck fractures operatively managed at 161 medical centers throughout New York during a 7-year period. 4,974 fractures were managed at L1TC while 39,111 were treated at nL1TC. Following multivariate regression analysis, management at L1TC was the most significant cost driver, resulting in an average increased cost of $6,330.74 per fracture. CONCLUSION: Our results suggest that femoral neck fractures treated at L1TC have more comorbidities, higher in-hospital mortality, longer LOS, and greater hospital costs.

Successful management of mucormycosis infection secondary to motor vehicle accident in a healthy adolescent: A case report.

Mucormycosis in healthy adolescents is a rare etiology of infection that does not have a commonly known protocol for management. This report describes an adolescent male who developed soft tissue mucormycosis secondary to a motor vehicle accident with severe lower extremity injuries. Treatment involved topical amphotericin B washouts and beads, serial aggressive debridement, and isavuconazole. To our knowledge, this is one of few documented cases of successful lower extremity salvage in an immunocompetent adolescent infected with mucormycosis and treated with isavuconazole.

Team Approach: Management of Geriatric Acetabular Fractures.

¼: Geriatric acetabular fractures are defined as fractures sustained by patients who are ≥60 years old. With the rapidly aging American populace and its increasingly active lifestyle, the prevalence of these injuries will continue to increase. ¼: An interdisciplinary approach is necessary to ensure successful outcomes. This begins in the emergency department with hemodynamic stabilization, diagnosis of the fracture, identification of comorbidities and concomitant injuries, as well as early consultation with the orthopaedic surgery service. This multifaceted approach is continued when patients are admitted, and trauma surgery, geriatrics, and cardiology teams are consulted. These teams are responsible for the optimization of complex medical conditions and risk stratification prior to operative intervention. ¼: Treatment varies depending on a patient's preinjury functional status, the characteristics of the fracture, and the patient's ability to withstand surgery. Nonoperative management is recommended for patients with minimally displaced fractures who cannot tolerate the physiologic stress of surgery. Percutaneous fixation is a treatment option most suited for patients with minimally displaced fractures who are at risk for displacing the fracture or are having difficulty mobilizing because of pain. Open reduction and internal fixation is recommended for patients with displaced acetabular fractures who are medically fit for surgery and have a displaced fracture pattern that would do poorly without operative intervention. Fixation in combination with arthroplasty can be done acutely or in delayed fashion. Acute fixation combined with arthroplasty benefits patients who have poorer bone quality and fracture characteristics that make healing unlikely. Delayed arthroplasty is recommended for patients who have had failure of nonoperative management, have a fracture pattern that is not favorable to primary total hip arthroplasty, or have developed posttraumatic arthritis.

The Quality of Online Orthopaedic Oncology Information.

"Cancer" is one of the top three health-related Internet searches, yet research shows over 30% of patients are confused after searching for medical information. The quality and accuracy of Internet oncology literature varies widely and can affect patient perceptions or seeking of care. Purpose: This study hypothesizes that online patient resources for orthopaedic oncology are often inconsistent, inaccurate, or incomprehensible by the standard patient and examines the readability, quality, and accuracy of common orthopaedic oncology websites. Methods: Three common search terms were searched in three popular search engines. The first 25 nonsponsored websites were identified for each term; randomized to search term; and evaluated via a 25-question quality score, DISCERN treatment-based score, predetermined accuracy score, and Flesch-Kincaid reading level. Results: Forty-eight websites were included. Website quality, DISCERN score, accuracy score, and reading level were not statistically different based on search term. Quality and DISCERN scores were markedly higher from websites without commercial gain. Websites were consistently written above the recommended reading level. Discussion: Online orthopaedic oncology literature is frequently confusing and complicated. The orthopaedic surgeon should be aware that patients frequently access this information and should ensure that patients receive accurate primary source material relevant to their care.

Does an antibiotic nail made in a lubricated tube release antibiotic?

INTRODUCTION: The treatment of long-bone osteomyelitis has long been a difficult problem. Recently, antibiotic-impregnated intramedullary rods for the treatment of infected long-bone fractures have been gaining popularity but they are quite difficult to fabricate. Recently, a new technique that utilizes mineral oil to coat the inside of a chest tube mold prior to introduction of cement has been proven to ease fabrication. We hypothesized that the use of mineral oil would alter the elution characteristics of tobramycin from the intramedullary device. METHODS: Two groups of antibiotic nails were fabricated under sterile conditions. The control group utilized a chest tube mold. The study group utilized a chest tube that was coated with mineral oil prior to cement injection. Each intramedullary nail was placed in pooled human serum and incubated under physiologic conditions. The level of tobramycin in each sample was measured at timepoints 0, 1, 6, and 24 h. RESULTS: There was no significant difference when comparing control with the experimental group at any timepoint. Antibiotic nails eluted tobramycin at a rapid rate in the first 6 h of exposure to serum, regardless of their preparation with oil or without oil. The rate of elution fell precipitously between 6 and 24 h. CONCLUSION: We believe that although this study, as with any study, cannot perfectly recreate in vivo conditions, we have clearly shown that mineral oil has no significant effect on elution of tobramycin from antibiotic nails.

A Specialized Orthosis for Suppressing Bony Destruction from Multiple Myeloma and to Enhance Healing of a Pathologic Fracture in an Appendicular Lesion.

Appendicular metastasis from multiple myeloma (MM) frequently presents with a pathologic fracture. In this case report, a patient with a long history of MM and an associated pathologic fracture was treated using a specialized brace. This orthosis uses a deforming element to asymmetrically increase the soft tissue pressure around the pathologic fracture. The patient experienced rapid pain relief and bony healing without surgical intervention.

Local soft tissue compression enhances fracture healing in a rabbit fibula.

Local soft tissue compression of fractures enhances fracture healing. The mechanism remains uncertain. Past studies have focused on intermittent soft tissue compression. We report a preliminary study assessing the relationship between constant soft tissue compression and enhanced fracture healing in an osteotomy model designed to minimize confounding variables. Fibulae of nine New Zealand white rabbits were bilaterally osteotomized, openly stabilized, and fitted with spandex stockinets. Soft tissue at the osteotomy site was unilaterally compressed using a deforming element (load = 26 mmHg). The contralateral side was saved as the control and was not compressed. Osteotomies were monitored with weekly radiographs. All fibulae in both groups were healed 6 weeks postoperatively. Micro-CT analysis of bone mineral density (BMD) and bone volume (BV) was then performed on both the experimental and control sides. Radiographic measurement of transverse callus-to-shaft ratios (TCSR) was compared. BMD of the experimental callus was greater than the noncompressed controls. BV and TCSR were not different between controls and experimental osteotomies. Constant local soft tissue compression produced significant increases in BMD, but not in BV or transverse callus size, indicating significant measurable increases in callus composition without significant change in gross dimensions. Our experimental design minimizes confounding factors, such as micromotion, immobilization, and altered venous flow, suggesting that these are not the primary mechanisms for fracture healing enhancement. Further studies with more animals and study groups are necessary to confirm efficacy and identify optimal compression pressures and schedules.

Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients.

OBJECTIVES: The Wong-Baker FACES Pain Rating Scale (WBS), used in children to rate pain severity, has been validated outside the emergency department (ED), mostly for chronic pain. The authors validated the WBS in children presenting to the ED with pain by identifying a corresponding mean value of the visual analog scale (VAS) for each face of the WBS and determined the relationship between the WBS and VAS. The hypothesis was that the pain severity ratings on the WBS would be highly correlated (Spearman's rho > 0.80) with those on a VAS. METHODS: This was a prospective, observational study of children ages 8-17 years with pain presenting to a suburban, academic pediatric ED. Children rated their pain severity on a six-item ordinal faces scale (WBS) from none to worst and a 100-mm VAS from least to most. Analysis of variance (ANOVA) was used to compare mean VAS scores across the six ordinal categories. Spearman's correlation (rho) was used to measure agreement between the continuous and ordinal scales. RESULTS: A total of 120 patients were assessed: the median age was 13 years (interquartile range [IQR] = 10-15 years), 50% were female, 78% were white, and six patients (5%) used a language other than English at home. The most commonly specified locations of pain were extremity (37%), abdomen (19%), and back/neck (11%). The mean VAS increased uniformly across WBS categories in increments of about 17 mm. ANOVA demonstrated significant differences in mean VAS across face groups. Post hoc testing demonstrated that each mean VAS was significantly different from every other mean VAS. Agreement between the WBS and VAS was excellent (rho = 0.90; 95% confidence interval [CI] = 0.86 to 0.93). There was no association between age, sex, or pain location with either pain score. CONCLUSIONS: The VAS was found to have an excellent correlation in older children with acute pain in the ED and had a uniformly increasing relationship with WBS. This finding has implications for research on pain management using the WBS as an assessment tool.

Fewer active motors per vesicle may explain slowed vesicle transport in chick motoneurons after three days in vitro.

Vesicle transport in cultured chick motoneurons was studied over a period of 3 days using motion-enhanced differential interference contrast (MEDIC) microscopy, an improved version of video-enhanced DIC. After 3 days in vitro (DIV), the average vesicle velocity was about 30% less than after 1 DIV. In observations at 1, 2 and 3 DIV, larger vesicles moved more slowly than small vesicles, and retrograde vesicles were larger than anterograde vesicles. The number of retrograde vesicles increased relative to anterograde vesicles after 3 DIV, but this fact alone could not explain the decrease in velocity, since the slowing of vesicle transport in maturing motoneurons was observed independently for both anterograde and retrograde vesicles. In order to better understand the slowing trend, the distance vs. time trajectories of individual vesicles were examined at a frame rate of 8.3/s. Qualitatively, these trajectories consisted of short (1-2 s) segments of constant velocity, and the changes in velocity between segments were abrupt (<0.2 s). The trajectories were therefore fit to a series of connected straight lines. Surprisingly, the slopes of theses lines, i.e. the vesicle velocities, were often found to be multiples of ~0.6 mum/s. The velocity histogram showed multiple peaks, which, when fit with Gaussians using a least squares minimization, yielded an average spacing of 0.57 mum/s (taken as the slope of a fit to peak position vs. peak number, R(2)=0.994). We propose that the abrupt velocity changes occur when 1 or 2 motors suddenly begin or cease actively participating in vesicle transport. Under this hypothesis, the decrease in average vesicle velocity observed for maturing motoneurons is due to a decrease in the average number of active motors per vesicle.

Warm lidocaine/tetracaine patch versus placebo before pediatric intravenous cannulation: a randomized controlled trial.

STUDY OBJECTIVE: We compare the pain of intravenous (IV) cannulation in pediatric emergency department (ED) patients after applying a topical lidocaine/tetracaine patch versus placebo. We hypothesized that application of the active patch would reduce the pain of IV cannulation by at least 15 mm. METHODS: We conducted a randomized, double-blind, placebo-controlled trial in a suburban academic ED. Patients aged 3 to 17 years who required nonemergency IV cannulation were eligible for enrollment. At triage, a nurse placed a commercially available topical lidocaine/tetracaine patch or an identical-looking placebo patch over the antecubital or hand vein in patients for whom an IV catheter was anticipated. After IV cannulation by the treating nurse, the pain of cannulation was measured on a validated 100-mm visual analogue scale or Wong Baker scale. Outcomes were compared between groups with Mann-Whitney U, Student t, and chi(2) tests. A sample of 40 patients had 80% power to detect a 13-mm difference in pain scores. RESULTS: Forty-five patients were randomized to lidocaine/tetracaine patch (22) or placebo (23), and IV cannulation was attempted in 40 of these patients. Mean age was 10 years (SD=4.3), 35% were female patients. The median pain of IV cannulation in the active treatment group (18 mm [interquartile range (IQR) 1 to 40 mm]) was significantly lower than in the placebo group (35 mm [IQR 20 to 59 mm]; P=.04). Adequate pain relief was more common in the active treatment group (75% [95% confidence interval (CI) 53% to 89%] versus 35% [95% CI 18% to 57%]; difference 40% [95% CI 6% to 64%]). The number of successful IV cannulations after the first attempt was similar in both the lidocaine/tetracaine and the placebo groups (90% [95% CI 70% to 97%] versus 85% [95% CI 64% to 95%]; difference 5% (95% CI -21% to 30%). CONCLUSION: Application of a topical lidocaine/tetracaine patch resulted in a modest reduction in the pain of IV cannulation in pediatric ED patients and did not alter the rate of successful cannulations.

Speckled microtubules improve tracking in motor-protein gliding assays.

Gliding assays of motor proteins such as kinesin, dynein and myosin are commonly carried out with fluorescently labeled microtubules or filamentous actin. In this paper, we show that speckled microtubules (MTs), prepared by copolymerizing 98% unlabeled tubulin with 2% rhodamine-labeled tubulin, can be localized to +/-7.4 nm (24 measurements) in images acquired every 125 ms. If the speckled MTs move at about 800 nm s(-1), ten images are sufficient to determine their velocity to a precision of +/-6.8 nm s(-1) (6 microtubules, 24 measurements). This velocity precision is four-fold better than manual methods for measuring the gliding velocity of uniformly labeled MTs by end-point localization. The improved velocity precision will permit the determination of velocity-force curves when one, two and three kinesin motors pull a single load in vitro.