Isolated Traumatic Subscapularis Tear in a 12-Year-Old Male Gymnast: A Case Report

Isolated avulsion fractures of the lesser tuberosity are rarely encountered in younger and older populations. However, because the tendon of the subscapularis insertion is stronger in skeletally immature individuals, isolated tears to the tendon occur more commonly in adults than children and adolescents. Most studies have been limited to case reports that mainly describe traumatic subscapularis tears in adolescent athlete-patients. We present a 12-year-old male gymnast who reported to our clinic with pain and weakness in the right shoulder at 2 months after the initial injury. We performed open repair with suture anchor fixation for treatment of an isolated subscapularis tear. At 6 months postoperatively, the child felt no pain, regained full range of shoulder motion and strength, and returned to highly competitive physical activity. Isolation of the subscapularis insertion during physical examination can be essential to initial diagnosis, allowing for successful and early operative treatment

Sciatic Nerve Palsy After Operative Treatment of Subtrochanteric Femur Fracture Resulting from Postoperative Hematoma: A Case Report

Treatment of subtrochanteric femur fractures can be difficult owing to high risk of complications. No cases of sciatic nerve palsy after hematoma following open reduction and intramedullary nailing of a subtrochanteric femur fracture have been reported. We describe a 28-yearold man who presented with a subtrochanteric fracture in the left femur after a motor-vehicle collision, in whom open reduction and intramedullary nailing led to an immediate postoperative hematoma and sciatic nerve palsy. Prompt diagnosis and early wound exploration resulted in complete resolution of the palsy at 1 month postoperatively. Our findings reinforce the importance of prompt diagnosis and treatment in limiting long-term complications for patients who develop postoperative sciatic nerve palsy associated with hematoma after undergoing operative treatment of subtrochanteric femur fractures

Comparison of Narcotic Prescribing Habits Between Trainee and Attending Orthopaedic Surgeons

Background: Orthopaedic surgeons are among the highest prescribing physicians of narcotics to opioidnaïve patients. Despite the current opioid epidemic, few studies have specifically quantified the appropriate amount of opioids necessary for postoperative pain control. We hypothesized a significant variability in the quantity of postoperative opioids prescribed among trainee (ie, residents and fellows) and attending surgeons at a single institution. Methods: Postoperative narcotic prescribing habits were assessed using an anonymous survey. Ultimately, 28 trainee physicians and 17 attending physicians responded to the survey (86.5%). The survey recorded the amount of 5-mg oxycodone tablets that were commonly prescribed to manage pain after various typical orthopaedic procedures (eg, total knee arthroplasty). Non-narcotic analgesic use was also measured. Mean, standard deviation, and variance values were calculated, with significance set at α = 0.05. Results: After the following procedures, the respondents reported prescribing the following quantities of 5-mg oxycodone tablets: total knee arthroplasty, 56 (SD, 16); total hip arthroplasty, 53 (SD, 13); anterior cruciate ligament reconstruction, 38 (SD, 16); partial meniscectomy, 23 (SD, 14); arthroscopic rotator cuff repair, 39 (SD, 16); carpal tunnel release, 10 (SD, 10); A1 pulley release for treating trigger finger, 9 (SD, 9); open reduction and internal fixation (ORIF) for treating distal radius fractures, 32 (SD, 16); and ORIF for treating ankle fractures, 39 (SD, 15). Statistically significant variation existed between trainee and attending physicians for total hip arthroplasty and A1 pulley release. There was no difference for acetaminophen or nonsteroidal anti-inflammatory drugs, with about 70% of patients receiving at least one of these adjuncts. Conclusions: Variability exists in postoperative opioid prescribing habits between trainee and attending physicians at the academic training institution we accessed. In light of the ongoing opioid epidemic, institutions may benefit from standardized postoperative pain protocols

Multimodal Analgesia in Orthopaedic Surgery and Presentation of a Comprehensive Postoperative Pain Protocol: A Review

Rising opioid use in the United States has now been termed an epidemic. Opioid use is associated with considerable morbidity, mortality, and cost to the healthcare system. Orthopaedic surgeons play a key role in the opioid epidemic by prescribing postoperative narcotics. Although our understanding of the quantity of narcotics to prescribe postoperatively for analgesia is progressing, there is still a paucity of data focused on routine postoperative pain protocols. The purpose of this article is to review the current options for both opioid and non-opioid analgesia and put forth a multisubspecialty orthopaedic protocol of postoperative pain. On the basis of study findings and the individual experiences of surgeons within our orthopaedic department, our comprehensive pain protocol includes the following considerations: use of non-steroidal antiinflammatory drugs on an individual basis, limited use of benzodiazepines, use of diazepam in only pediatric patients undergoing major procedures, lower doses of gabapentin after hip and knee arthroplasty, higher doses of gabapentin after spine procedures, general use of oxycodone owing to its accessibility, use of isolated opioids rather than combined forms, and close collaboration with anesthesiologists for determining use of peripheral nerve block. Our resultant comprehensive pain protocol can provide orthopaedic surgeons with a framework to build upon, which will benefit greatly from future studies that examine narcotic use with specific procedures

Correlating Patient-Specific Anthropometric Variables With Soft-Tissue Thickness at the Superolateral Arthrocentesis Entry Site to the Knee

Background: Irrigation for treating septic joints in adults in the emergency department is possible but requires the development of novel systems that fit all body habitus. However, varying body habitus and age of patients may affect the amount of soft tissue surrounding the knee joint capsule. We examined whether the dimensions of the soft-tissue thickness at the superolateral approach of entry to the arthrocentesis site correlated with patient anthropometric data such as age, sex, height, weight, and body mass index (BMI, kg/m2). Methods: Using the diagnosis code 844.2 (International Classification of Diseases, Ninth Revision), we reviewed findings of magnetic resonance imaging (MRI) of knees from 100 consecutive patients and gathered anthropometric data for each patient at the time of the MRI. We measured the soft-tissue thickness at the standard entry point for superolateral arthrocentesis. Results: Soft-tissue thickness at the arthrocentesis site ranged from 5.5 mm to 38 mm and averaged 13.8 mm. Of the independent variables considered, BMI was the most closely correlated with joint-space size albeit poorly (R2 = 0.46). Every unit of increase in BMI correlated with a predicted average soft-tissue thickness increase of 0.61 mm. Conclusions: The anthropometric data obtained from this study may help create a single, universal device for use in bedside joint irrigation. The correlation between BMI and soft-tissue thickness can guide future device designs