Instructional course lectures
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Pediatric musculoskeletal infections can cause devastating complications (including death) in this era of methicillin-resistant Staphylococcus aureus and other virulent bacterial strains. The complexity and severity of these infections require timely diagnosis and treatment. A thorough emergency department evaluation, diagnostic workup, and early surgical intervention can influence outcomes. ⋯ Because of genetic changes and inducible resistance, methicillin-resistant Staphylococcus aureus causes more complex infections than in the past. Deep, soft-tissue abscesses; pyomyositis; osteomyelitis; and septic arthritis often occur concurrently, causing destruction of musculoskeletal tissue. Severe and life-threatening complications, such as septic emboli, deep venous thrombosis, and multiorgan system failure may result from these infections.
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Intra-articular fractures of the tibial plateau, pilon, and calcaneus often present a challenge for the treating orthopaedic surgeon. These injuries can have substantial comminution in the joint and the metaphyseal areas and are often accompanied by considerable soft-tissue trauma. ⋯ These myths include the beliefs that most patients with intra-articular fractures will have poor outcomes even with good surgical treatment, severe intra-articular fractures require a later reconstructive procedure regardless of the treatment, and the surgical treatment of comminuted intra-articular fractures has a high complication rate and may result in infection and limit the available options for limb salvage. A review of the literature regarding the treatment of common intra-articular fractures is helpful in determining if these myths concerning treatment options can be confirmed or disproved.
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Pain management is a major concern for patients contemplating total knee replacement surgery and is one of the leading causes of dissatisfaction after knee replacement. Substantial progress has been made over the past several years in improving pain control after total knee replacement using multimodal pain control, preemptive analgesia, and periarticular injections.
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An increasing percentage of emergency departments are reporting an inadequate number of on-call specialists. This situation is causing a growing crisis in emergency department on-call coverage for patients requiring orthopaedic care. Many orthopaedic surgeons are electing to opt out of emergency department on-call service. ⋯ Initially, it may be necessary to incentivize on-call service so more surgeons are willing to participate. Incentives may include improving the group governance and bylaws to avoid confusion on the rules for providing on-call coverage. The on-call experience may require financial improvements, outsourcing with locum tenens, or a complete restructuring of the on-call arrangement with the formation of a hospitalist program.
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The scaphoid is the most commonly fractured carpal bone of the wrist. It is an unusual carpal bone in that it bridges both the proximal and the distal rows; this subjects it to continuous shearing and bending forces. Approximately 80% of the scaphoid is covered by cartilage, which limits its ligamentous attachment and vascular supply. ⋯ There also has been a significant improvement in the management of difficult scaphoid nonunions, with or without deformity. Improved techniques include open and dorsal approaches and vascularized bone grafting of resistant scaphoid nonunions. Declining in popularity is the prolonged immobilization of unstable fractures when surgical stabilization may have been a better treatment option.