"One Note Higher": A Unique Pediatric Hand Fracture.

CASE PRESENTATION: An otherwise healthy, 12-year-old male presented to the emergency department after a fall down the stairs in which he landed on his right hand. Radiographs demonstrated a Salter-Harris II fracture at the base of the proximal phalanx of the fifth digit with ulnar deviation, also known as an "extra-octave" fracture. Orthopedic surgery was consulted and the fracture was reduced and placed in a short-arm cast. The patient was discharged and scheduled for orthopedic follow-up. DISCUSSION: A Salter-Harris II fracture at the base of the proximal phalanx of the fifth digit with ulnar deviation is referred to as an "extra-octave" fracture due to the advantage a pianist would gain in reach of their fifth phalanx if not reduced. However, reduction is needed if the fracture is displaced and can be achieved by several described methods including the "90-90" or "pencil" methods followed by cast or splint application. Percutaneous pinning is rarely needed. Complications include flexor tendon entrapment, collateral ligament disruption, and malunion leading to a "pseudo-claw" deformity. We recommend that all extra-octave fractures receive orthopedic follow-up in one to two weeks or sooner if severely displaced.

Alaska nurse practitioners' barriers to use of prescription drug monitoring programs.

BACKGROUND AND PURPOSE: Prescription drug monitoring programs (PDMPs) have begun to demonstrate themselves as useful tools in enhancing safe and responsible prescription of controlled substances. The purpose of this project was to describe current practice, beliefs, and barriers of Alaska nurse practitioners (NPs) regarding the Alaska PDMP. METHODS: A questionnaire was sent to 635 Alaskan NPs with a 33% return rate. The data depicted prescribing habits, barriers to use, barriers to registering, and opinions on how to make the PDMP more clinically useful. CONCLUSIONS: More attention is needed to maximize PDMP exposure and incorporation into daily workflow if it is to achieve full potential. Registered users should be able to delegate PDMP authority to select staff members to reduce time commitments and increase usage. Many providers felt that assigning unique patient identifiers could prevent consumers from filling prescriptions under aliases. Finally, an overwhelming majority of users wanted faster data entry and proactive reports. IMPLICATIONS FOR PRACTICE: This project explored the differences between PDMP users and nonusers and outlined NP suggestions for process improvement. A better understanding of PDMP use will aid providers in safe prescribing while curbing the prescription drug epidemic and ultimately reducing abuse, misuse, and death from overdose.

Risk Acceptance and Desire for Shared Decision Making in Pediatric Computed Tomography Scans: A Survey of 350.

OBJECTIVE: The dual goals of this study were to assess the level of radiation risk parents are comfortable with and also whether they expect a shared decision making conversation. METHODS: A convenience sample of adult patients in the emergency department was surveyed. Participants were educated regarding the associated radiation risk with computed tomography (CT) scans. They were then surveyed about their willingness to accept the risk of radiation exposure to their children given varying degrees of pretest probability of a clinically significant finding. Additionally, participants were surveyed regarding whether a physician should provide shared decision making. RESULTS: A total of 350 surveys were collected. For low, moderate, and high pretest probability of a positive finding on CT, the proportion of participants who would want a CT for their child was 37% (95% confidence interval [95% CI], 32-43%), 70% (95% CI, 65-75%), and 89% (95% CI, 85-92%), respectively. If the likelihood of a positive CT scan was very low (<5%), 24% (95% CI, 20-29%) were willing to have the study performed on their child. Participants would not want a CT for their child regardless of the probability of finding significant pathology in 9% of those surveyed (28/315). Participants wanted a physician to counsel them before ordering a potentially dangerous test in 93% of the surveys. In a test with an estimated 1:1000 risk of cancer, 91% of participants felt that a doctor should always discuss the risk before ordering the study. CONCLUSIONS: Parents are less willing to accept the risk of radiation from CT scan on their child as the likelihood of positive findings decrease. Parents overwhelmingly want an informed discussion before getting a potentially dangerous test.

Traumatic injury patterns associated with static line parachuting.

OBJECTIVE: We investigated the incidence and injury patterns of acute parachuting injuries evaluated at a level II military facility during a 5-year period to compile medical information that may assist in improving the safety of parachuting. METHODS: A retrospective chart review of all parachuting injuries that presented to the Madigan Army Medical Center emergency department in Tacoma, Washington, during a 5-year period from February 2005 to June 2011. RESULTS: A total 110 patient charts met inclusion criteria. Lower extremity injuries made up 65% of total injuries, followed by 22% head injuries, 22% neck or back injuries, and 19% upper extremity injuries. One patient died in the emergency department of head injuries, and 1 patient was transferred for an open-book pelvic fracture. The most common phase of the jump in which to sustain injury was at landing. A total of 15 patients were admitted to the hospital. It is of note that some patients had combined injuries. The mechanism of injury documented in 96 of 110 (87%) patients and 10 of 15 (66%) admitted patients was a difficult landing. CONCLUSIONS: The rate of injury for each area of the body is within previously reported rates, with lower extremity injuries making up the largest category and leading to the majority of admissions. The most common time to sustain an injury was during landing, which represented a majority of both emergency room visits and hospitalizations.