Percutaneous reduction and flexible intramedullary nailing for monteggia fracture in a skeletally mature patient

INTRODUCTION: Monteggia lesions are defined as a fracture of the proximal ulna with an associated radial head dislocation. Management of these injuries varies depending upon the patient population, ranging from non-operative treatment with closed reduction and immobilization to surgical fixation. Percutaneous techniques of radial head reduction are often reserved for skeletally immature patients. PRESENTATION OF CASE: In this case report, a 14-year-old female presented with left elbow pain three days after a fall. Radiographs and CT images from an outside hospital revealed a displaced left radial head fracture and a non-displaced proximal olecranon fracture, consistent with a Monteggia equivalent fracture. The patient underwent percutaneous reduction and internal fixation of the radial head with a flexible intramedullary nail (Metaizeau technique), and open reduction and internal fixation of the olecranon. She developed a 25 degree left elbow flexion contracture and, five months after her index procedure, underwent arthroscopic release and removal of hardware. The radial head reduction was near anatomic and she regained full extension. DISCUSSION: This report demonstrates that percutaneous reduction with intramedullary nailing and fixation techniques can be performed successfully in skeletally mature patients. CONCLUSION: Given their less invasive nature, we recommend attempting percutaneous interventions in some skeletally mature individuals for fracture reduction and fixation

DS_10.1177_1558944718789406 – Supplemental material for Trends in Utilization of Upper Extremity Reconstructive Surgery Following Traumatic Brain Injury and Stroke

<p>Supplemental material, DS_10.1177_1558944718789406 for Trends in Utilization of Upper Extremity Reconstructive Surgery Following Traumatic Brain Injury and Stroke by Bryan G. Beutel, Bryan J. Marascalchi and Eitan Melamed in HAND</p

The Ottawa Knee Rule: Examining Use in an Academic Emergency Department

INTRODUCTION: The Ottawa Knee Rule is a validated clinical decision rule for determining whether knee radiographs should be obtained in the setting of acute knee trauma. The objectives of this study were to assess physician knowledge of, barriers to implementation of, and compliance with the Ottawa Knee Rule in academic emergency departments (EDs), and evaluate whether patient characteristics predict guideline noncompliance. METHODS: A 10 question online survey was distributed to all attending ED physicians working at three affiliated academic EDs to assess knowledge, attitudes and self-reported practice behaviors related to the Ottawa Knee Rule. We also performed a retrospective ED record review of patients 13 years of age and older who presented with acute knee trauma to the 3 study EDs during the 2009 calendar year, and we analyzed ED records for 19 variables. RESULTS: ED physicians (n = 47) correctly answered 73.2% of questions assessing knowledge of the Ottawa Knee Rule. The most commonly cited barriers to implementation were “patient expectations” and system issues, such as “orthopedics referral requirement.” We retrospectively reviewed 838 records, with 260 eligible for study inclusion. The rate of Ottawa Knee Rule compliance was retrospectively determined to be 63.1%. We observed a statistically significant correlation between Ottawa Knee Rule compliance and patient age, but not gender, insurance status, or provider type, among others. CONCLUSION: Compliance with the Ottawa Knee Rule among academic ED healthcare providers is poor, which was predicted by patient age and not other physician or patient variables. Improving compliance will require comprehensive educational and systemic interventions

The Ottawa Knee Rule: Examining Use in an Academic Emergency Department

Introduction: The Ottawa Knee Rule is a validated clinical decision rule for determining whether knee radiographs should be obtained in the setting of acute knee trauma. The objectives of this study were to assess physician knowledge of, barriers to implementation of, and compliance with the Ottawa Knee Rule in academic emergency departments (EDs), and evaluate whether patient characteristics predict guideline noncompliance.Methods: A 10 question online survey was distributed to all attending ED physicians working at three affiliated academic EDs to assess knowledge, attitudes and self-reported practice behaviors relatedto the Ottawa Knee Rule. We also performed a retrospective ED record review of patients 13 years of age and older who presented with acute knee trauma to the 3 study EDs during the 2009 calendar year, and we analyzed ED records for 19 variables.Results: ED physicians (n = 47) correctly answered 73.2% of questions assessing knowledge of the Ottawa Knee Rule. The most commonly cited barriers to implementation were “patient expectations” and system issues, such as “orthopedics referral requirement.” We retrospectively reviewed 838 records, with 260 eligible for study inclusion. The rate of Ottawa Knee Rule compliance was retrospectively determined to be 63.1%. We observed a statistically significant correlation betweenOttawa Knee Rule compliance and patient age, but not gender, insurance status, or provider type, among others.Conclusion: Compliance with the Ottawa Knee Rule among academic ED healthcare providers is poor, which was predicted by patient age and not other physician or patient variables. Improving compliance will require comprehensive educational and systemic interventions. [West J Emerg Med. 2012;13(4):366-373.