Isolated Upper Extremity Compartment Syndrome: A Case of Rhabdomyolysis-induced Myoglobinuria and Acute Kidney Injury after Opioid Overdose.

Introduction: The association between rhabdomyolysis secondary to traumatic crush injuries and the resultant acute kidney injury has been well described . The pathway of opioid overdose and acute kidney injury (AKI) has been documented but not fully elucidated. This process is believed to be multifactorial in its pathophysiology, but it remains obscure. Acidosis, systemic hypoxia, hypothermia, muscle compression, immunologic, or direct toxic effects have been identified as contributing factors to opioid-induced AKI. Musculoskeletal crush injuries account for one of the most common causes of rhabdomyolysis leading to AKI. However, the vast majority of crush injuries documented involve large regions of the body and most commonly involve the lower extremity. This is hypothesized to be due to the need for a considerable amount of muscle necrosis and sufficient myoglobinuria to cause AKI. There is a paucity of literature describing isolated upper extremity crush injuries severe enough to cause AKI. The case described herein outlines a patient who developed isolated right upper extremity compartment syndrome and resultant rhabdomyolysis leading to AKI in the setting of an opioid overdose. Case Report: Rhabdomyolysis may be caused by a variety of metabolic events. The pathophysiology of rhabdomyolysis secondary to acute crush injuries with resultant AKI is well documented. However, the literature describing cases of acute kidney injury caused by upper extremity compartment syndrome-induced rhabdomyolysis is limited. We present the case of a 33-year-old male who developed right upper extremity compartment syndrome after being incapacitated following an opioid overdose. He subsequently underwent emergent fasciotomies and was found to have an AKI secondary to rhabdomyolysis in the acute post-operative period. Conclusion: This case describes a patient who was found to have isolated right upper extremity compartment syndrome and subsequent rhabdomyolysis, which resulted in AKI following an opioid overdose. This case highlights that an isolated incidence of upper extremity rhabdomyolysis is sufficient to cause acute kidney injury. The literature describing this pathology in isolated upper extremity injuries is limited as this phenomenon is typically encountered in the setting of lower extremity compartment syndrome.The pathophysiology and mechanism of this pathology are of particular importance to the fields of orthopedic surgery, nephrology, and internal medicine. This case highlights the need for early and adequate fluid resuscitation in patients with isolated upper extremity injuries to minimize the risk of subsequent AKI.

Postoperative Bracing after Medial Patellofemoral Ligament Reconstruction.

It is unclear if bracing is necessary after isolated medial patellofemoral ligament reconstruction (MPFLr) for recurrent patellar instability. We hypothesize that patients who did not use a brace will have similar outcomes to those who were braced postoperatively. A retrospective review of patients who underwent isolated MPFLr from January 2015 to September 2020 at a single institution was performed. Those with less than 6 weeks of follow-up were excluded. The braced group was provided a hinged-knee brace postoperatively until the return of quadriceps function, which was determined by the treating physical therapist (brace, "B"; no brace, "NB"). Time to straight leg raise (SLR) without lag, recurrent instability, and total re-operations were determined. Univariate analysis and logistic regression were used to evaluate outcomes (statistical significance, p < 0.05). Overall, 229 isolated MPFLr were included (B: 165 knees, 146 patients; NB: 64 knees, 58 patients). Baseline demographics were similar (all p > 0.05). Median time to SLR without lag was shorter in the NB group (41 days [interquartile range [IQR]: 20-47] vs. 44 days [IQR: 35.5-88.3], p = 0.01), while return to sport times were equivalent (B: 155 days [IQR: 127.3-193.8] vs. NB: 145 days [IQR: 124-162], p = 0.31). Recurrent instability rates were not significantly different (B: 12 knees [7.27%] vs. NB: 1 knee [1.56%], p = 0.09), but the re-operation rate was higher in the brace group (20 knees [12.1%] vs. 0 [0%], p = 0.001). Regression analysis identified brace use (odds ratio [OR]: 19.63, 95% confidence interval [CI]: 1.43-269.40, p = 0.026) and female patients (OR: 2.79, 95% CI: 1.01-7.34, p = 0.049) to be associated with needing reoperation. Recurrent instability rates and return to sport times were similar between patients who did or did not use a hinged knee brace after isolated MPFLr. Re-operation rates were higher in the braced group. Retrospective Comparative Study, Level III.

Team Approach: Treatment of Shoulder Instability in Athletes.

¼: Shoulder instability is a complex problem with a high rate of recurrence in athletes. Treatment of a first-time subluxation or dislocation event is controversial and depends on patient-specific factors as well as the identified pathology. ¼: Athletic trainers and physical therapists are an integral part of the treatment team of an in-season athlete who has experienced a shoulder instability event. Through comprehensive physiological assessments, these providers can effectively suggest modifications to the patient's training regimen as well as an appropriate rehabilitation program. ¼: Surgical intervention for shoulder stabilization should use an individualized approach for technique and timing. ¼: A team-based approach is necessary to optimize the care of this high-demand, high-risk population.

Teres minor and quadrilateral space syndrome: A review.

The teres minor is one of four rotator cuff muscles that is involved in many shoulder pathologies. The integrity of the teres minor can be indicative of treatment success for disorders including rotator cuff tears, impingement syndrome, and quadrangular space syndrome. Quadrangular or quadrilateral space syndrome is a debilitating disorder that may require surgical intervention in chronic cases and can lead to atrophy of the teres minor. A review of the diagnostic techniques and treatment methods for disorders involving teres minor, with a focus on quadrilateral space syndrome, are presented in order to summarize the current understanding of these pathologies.

A comprehensive review of malignant hyperthermia: Preventing further fatalities in orthopedic surgery.

Most frequently associated with orthopedic surgery, malignant hyperthermia is a rare genetic condition linked to volatile anesthetics and succinylcholine. If not treated quickly with appropriate measures, death may result. To aid in the prevention of further fatalities, this review seeks to educate clinicians and staff on the presentation and treatment of this disease, as well as to provide a comprehensive overview by further addressing prevalence, similar conditions, pathogenesis and other aspects. Although the number of deaths due to malignant hyperthermia has greatly declined in the last several years, increased knowledge may eliminate associated mortalities, particularly in the orthopedic setting.