Prolonged cardiac arrest complicating a massive ST-segment elevation myocardial infarction associated with marijuana consumption.

Recreational substance use and misuse constitute a major public health issue. The annual rate of recreational drug overdose-related deaths is increasing exponentially, making unintentional overdose as the leading cause of injury-related deaths in the United States. Marijuana is the most widely used recreational illicit drug, with approximately 200 million users worldwide. Although it is generally regarded as having low acute toxicity, heavy marijuana usage has been associated with life-threatening consequences. Marijuana is increasingly becoming legal in the United States for both medical and recreational use. Although the most commonly seen adverse effects resulting from its consumption are typically associated with neurobehavioral and gastrointestinal symptoms, cases of severe toxicity involving the cardiovascular system have been reported. In this report, the authors describe a case of cannabis-associated ST-segment elevation myocardial infarction leading to a prolonged cardiac arrest.

Assessing the utility of ICU admission for octogenarians.

BACKGROUND: Advanced age is associated with increased severity of acute critical illnesses and admission to ICU. Despite advances in the support for older critically ill patients, the short- and long-term mortality rates remain substantial. The purpose of this study is to analyze the factors influencing the outcome of a geriatric population admitted to the ICU. METHODS: A single-center, prospective, observational study was conducted among all geriatric patients, 80 years or older, admitted to ICU during a 6-month study period. RESULTS: Fifty-two patients were admitted. Mean age was 85.1 years (range 80-96), mean APACHE-II score was 24.7 (range 11-40), and mean frailty score was 5.8 (range 3-8). Thirty-nine (75 %) patients received mechanical ventilation, and 31 (59.7 %) were on vasoactive therapy. Twenty-four (46.3 %) patients died during their hospital admission, and 13 (25 %) of them expired in ICU. DISCUSSION: Advanced age, needs for vasopressor therapy, and mechanical ventilation are independent predictive factors of adverse outcome. Pre-admission functional status was not independently associated with unfavorable outcome.

Novel Use of Synthetic Acellular Dermal Matrix for Coverage of a Tibial Defect Following Resection of an Osteochondroma: A Case Report.

The application of an artificial dermal matrix (Integra Life Sciences, Plainsboro, NJ) in the management of substantial burn injuries has been extensively documented. Use of an artificial dermal matrix has resulted in excellent outcomes and is free of the morbidity associated with harvesting free-tissue flaps. However, coverage of bony defects where the periosteum has been removed is often challenging. In the current report, we present a case wherein the use of an acellular synthetic dermis combined with split-thickness skin grafting resulted in successful coverage of a tibial defect following resection of an osteochondroma.

Fracture pattern characteristics and associated injuries of high-energy, large fragment, partial articular radial head fractures: a preliminary imaging analysis.

BACKGROUND: High-energy radial head injuries often present with a large partial articular displaced fragment with any number of surrounding injuries. The objective of the study was to determine the characteristics of large fragment, partial articular radial head fractures and determine any significant correlation with specific injury patterns. MATERIALS AND METHODS: Patients sustaining a radial head fracture from 2002-2010 were screened for participation. Twenty-five patients with documented partial articular radial head fractures were identified and completed the study. Our main outcome measurement was computed tomography (CT)-based analysis of the radial head fracture. The location of the radial head fracture fragment was evaluated from the axial CT scan in relation to the radial tuberosity used as a reference point. The fragment was characterized by location as anteromedial (AM), anterolateral (AL), posteromedial (PM) or posterolateral (PL) with the tuberosity referenced as straight posterior. All measurements were performed by a blinded, third party hand and upper extremity fellowship trained orthopedic surgeon. Fracture pattern, location, and size were then correlated with possible associated injuries obtained from prospective clinical data. RESULTS: The radial head fracture fragments were most commonly within the AL quadrant (16/25; 64 %). Seven fracture fragments were in the AM quadrant and two in the PM quadrant. The fragment size averaged 42.5 % of the articular surface and spanned an average angle of 134.4(°). Significant differences were noted between AM (49.5 %) and AL (40.3 %) fracture fragment size with the AM fragments being larger. Seventeen cases had associated coronoid fractures. Of the total 25 cases, 13 had fracture dislocations while 12 remained reduced following the injury. The rate of dislocation was highest in radial head fractures that involved the AM quadrant (6/7; 85.7 %) compared to the AL quadrant (7/16; 43.7 %). No dislocations were observed with PM fragments. Ten of the 13 (78 %) fracture dislocations had associated lateral collateral ligament (LCL)/medial collateral ligament tear. The most common associated injuries were coronoid fractures (68 %), dislocations (52 %), and LCL tears (44 %). CONCLUSION: The most common location for partial articular radial head fractures is the AL quadrant. The rate of elbow dislocation was highest in fractures involving the AM quadrant. Cases with large fragment, partial articular radial head fractures should undergo a CT scan; if associated with >30 % or >120(°) fracture arc, then the patient should be assessed closely for obvious or occult instability. These are key associations that hopefully greatly aid in the consultation and preoperative planning settings. LEVEL OF EVIDENCE: Diagnostic III.

Prognostic factors associated with adverse outcome among critically ill elderly patients admitted to the intensive care unit.

INTRODUCTION: Despite concerns over the appropriateness and quality of care provided in the intensive care unit (ICU) at the end of life, the number of elderly patients who receive critical care is increasing. Despite this, many physicians have doubts as to whether elderly patients are good candidates for ICU care because of the apparently poor outcome during and after critical care in this population. The objective of the present study was to describe the clinical characteristics and outcome of a geriatric population admitted to the ICU. MATERIALS AND METHODS: A single-center, prospective, observational study was carried out among geriatric patients, aged 75 years or older, admitted to ICU. RESULTS: A total of 71 patients were admitted to ICU during the study period. Their mean age was 83 years (range 75-98 years), with a mean Acute Physiology and Chronic Health Evaluation-II score of 21.8 (range 8-39) on admission to ICU. A total of 48 patients (68%) required mechanical ventilation, and 39 (55%) received at least one vasoactive drug. The mean ICU length of stay was 4.6 days (range 1-18 days), and it was similar for ICU survivors and non-survivors (4.7 vs 4.5). A total of 14 patients (19.7%) were admitted after cardiac arrest, and eight (57.1%) of them died in ICU. A total of 28 patients (39.4%) died in the hospital, and 18 (25.4%) died in ICU. CONCLUSION: Advanced age, critical illness, cardiopulmonary resuscitation, and needs for mechanical ventilation and/or vasopressor therapy are independent risk factors associated with adverse outcome in elderly patients admitted to ICU. Alternatives for ICU admission should be considered in geriatric patients with severe critical illnesses.

Exposures of the humerus for fracture fixation.

The care of humeral shaft fractures is undergoing a transition to more aggressive treatment methods with more frequent operative fixation. The upper arm has an extensive network of nerves, arteries, and veins that must be protected during any operative exposure. The ultimate goal of fixation of a humerus fracture is rigid stabilization to allow early range of motion, protection of the neurovascular structures, and preservation of the triceps mechanism posteriorly and the anterior elbow flexor muscles.

The use of skin substitutes in the treatment of the hand and upper extremity.

The introduction of skin substitutes in the last decade has dramatically changed how we think about the concept of "non-healing" wounds. Their use has improved prognosis and reduced morbidity in the treatment of open wounds. This article aims to summarize the development of tissue-engineered skin substitutes, discuss their use, and highlight some specific applications in different clinical settings.

Extensor digitorum brevis manus muscle in association with a metacarpal boss.

Awareness of the existence of accessory muscles in the hand, such as the extensor digitorum brevis manus (EDBM) muscle, is important when making a differential diagnosis and considering the treatment of mass lesions with similar appearances. Cases of EDBM with associated dorsal wrist ganglion have been reported in earlier published reports. This report describes an unusual case of the EDBM muscle in association with carpometacarpal (CMC) boss. To the best of the authors' knowledge this has not been previously reported.

Chronic scaphoid nonunion of 28-year duration treated with nonvascularized iliac crest bone graft.

Scaphoid nonunions present a challenging clinical problem, particularly if the diagnosis of nonunion is missed or delayed. The optimal management technique can vary from free vascularized bone grafts to scaphoid excision and limited wrist fusion. The classic method of open reduction, nonvascularized corticocancellous bone grafting and internal fixation is still an effective technique. In this report, we describe a case of a 28-year-old chronic scaphoid nonunion treated with nonvascular iliac crest bone graft and internal fixation.

The role for prophylaxis inferior vena cava filters in patients undergoing bariatric surgery: replacing anecdote with evidence.

The number of patients choosing surgical alternatives for weight reduction continues to increase. Despite common thromboembolic preventive methods, which include perioperative subcutaneous heparin injections, early mobilization, and sequential compression devices, postoperative deep vein thrombosis/pulmonary embolism remains a devastating complication after bariatric surgery. The role prophylactic inferior vena cava (IVC) filters may play in bariatric surgery remains controversial, and this article aims to address the risks and benefits of prophylactic IVC filters in high-risk bariatric patients and suggest an evidence-based algorithm for their use.

Corrective osteotomy and local bone grafting for extra-articular malunion of the proximal phalanx.

Corrective osteotomies are often utilised to treat finger deformities that may occur due to a phalangeal malunion. Rotational or angular malalignment, in addition to shortening of the digit may negatively affect hand function and be aesthetically displeasing. Thorough preoperative examination of the malunion and its associated deformities is crucial in determining the type of osteotomy technique to be used. Osteotomies can create bony defects that need to be filled with bone graft or some type of graft substitute. We describe an opening wedge osteotomy with local cancellous bone graft combined with dual plating to treat a dorsal angular deformity in a proximal phalangeal malunion.

Closed sagittal band injury due to low energy trauma.

Sagittal band injury is a relatively common cause of extensor tendon subluxation caused by inflammatory disease or high-energy trauma. However, there are few reports in the literature describing sagittal band injury due to low energy trauma. In this report, we describe successful nonsurgical management of a closed sagittal band injury and extensor tendon subluxation associated with low-energy trauma. Patients in 2 cases had no rheumatoid arthritis or history of inflammatory diseases. Conservative treatment resulted in relief of symptoms and corrected the instabilities with no complications.

Percutaneous screw fixation without bone grafting of scaphoid non-union.

BACKGROUND: Delays in diagnosis and inadequate treatment of acute scaphoid fractures can lead to non-unions, presenting surgeons with unique challenges regarding optimal management. OBJECTIVES: To evaluate the clinical and radiographic outcome of scaphoid non-unions treated with percutaneous screw fixation. METHODS: The study group comprised 12 patients with scaphoid non-unions of an average duration of 8.7 months. There were 11 males and 1 female with an average age of 24 years (range 14-47 years). All patients were initially treated with percutaneous screw fixation without bone grafting. A volar percutaneous approach was used in eight patients and a dorsal percutaneous approach in four. Wrist range of motion (ROM) and disabilities of the arm, shoulder, and hand (DASH) questionnaires were used to assess clinical outcomes. Postoperative radiographs were reviewed to assess the fracture union, carpal alignment and screw position. RESULTS: Eleven of the 12 (92%) fractures united successfully with no additional procedures. These fractures achieved radiographic union at an average of 4 months. One patient with sickle cell anemia required revision fixation, which consisted of repeat percutaneous fixation and bone grafting. In this patient his non-union healed 3 months after the revision procedure. The average DASH score at final followup was 6 (range 0-16). Average wrist ROM was extension of 66 degrees (range 50-80) and flexion 71 degrees (range 55-90). None of the patients showed radiographic signs of osteoarthritis, osteonecrosis of the scaphoid, or hardware-related complications. CONCLUSIONS: For scaphoid waist non-unions without collapse, percutaneous fixation without supplementary bone grafting provides satisfactory results with a high union rate, early return of function and minimal complications.

Isolated radial shaft fracture with unreducable posterior dislocation of the radial head and rupture of the lateral collateral ligament: A case report.

Combined injuries associated with forearm shaft fractures and elbow dislocations are well recognized. We describe an uncommon case of an isolated radial shaft fracture with an unreducable posterior dislocation of the radial head and associated rupture of the lateral collateral ligament of the elbow.

Treatment of dorsal perilunate dislocations and fracture-dislocations using a standardized protocol.

BACKGROUND: The aims of this study were to evaluate the associated injuries occurring with acute perilunate instability and to assess the clinical and radiographic outcomes of perilunate dislocations and fracture-dislocations treated with a combined dorsal and volar approach. METHODS: A total of 45 patients (46 wrist injuries) with perilunate dislocations and fracture-dislocations were prospectively evaluated. The size of the mid-carpal ligament tear, the location of the scapholunate ligament tear, and the presence of osteochondral fragments and of the dorsal radiocarpal ligament avulsions were recorded at injury. Final clinical and radiographic outcomes were evaluated in 25 cases (25 wrists) with a minimum of 6 months of follow-up. RESULTS: Intraoperative examination of the 46 cases with operative treatment showed the volar carpal ligament tear to be present 100 % of the time and to be an average length of 3.4 cm. Complete avulsion of the dorsal extrinsic radiocarpal ligaments was found in 65.2 % of cases. The scapholunate ligament was torn in 35 cases. Osteochondral fragments were found either volarly or dorsally in 74 % of the cases. The average flexion-extension arc was 82°, forearm rotation was 155°, and grip strength averaged 59 % of the uninjured hand. The average final scapholunate angle was 55° and the scapholunate gap was 2.2 mm. CONCLUSION: Treatment of perilunate fracture-dislocations with a combined volar and dorsal approach results in reasonable and functional clinical results. The incidence of associated injuries with these carpal dislocations is high. Although the perilunate fracture-dislocations have a slightly better radiologic alignment than the dislocation group, the clinical outcome is similar.

Transplanted blood-derived endothelial progenitor cells (EPC) enhance bridging of sheep tibia critical size defects.

The angiogenic events that accompany bone regeneration function as a "limiting factor" and are the primary regulatory mechanisms that direct the healing process. The general aim of this study was to test whether blood-derived progenitor cells that have endothelial characteristics (EPC), when applied to a large segmental defect, would promote bone regeneration. We established a critical-sized gap platform in sheep tibiae. Our model system takes advantage of the physiological wound healing process that occurs during the first two weeks following injury, and results in the gap being filled with scar tissue. EPC were expanded ex-vivo and 2 x 10(7) cells/0.2 ml were implanted into a wedged-shaped canal excavated in the fibrotic scar tissue. Sham treated sheep served as controls. Bone regeneration was followed every two weeks for three months by X-ray radiography. At the end of the experimental period, the regenerating segments were subjected to micro-computed tomographic (microCT) analysis. While minimal bone formation was detected in sham-treated sheep, six out of seven autologous EPC-transplanted sheep showed initial mineralization already by 2 weeks and complete bridging by 8-12 weeks post EPC transplantation. Histology of gaps 12 weeks post sham treatment showed mostly fibrotic scar tissue. On the contrary, EPC transplantation led to formation of dense and massive woven bone all throughout the defect. The results of this preclinical study open new therapeutic opportunities for the treatment of large scale bone injuries.