Injury
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COVID-19 has had profound management implications for orthopaedic management due to balancing patient outcomes with clinical safety and limited resources. The BOAST guidelines on outpatient orthopaedic fracture management took a pragmatic approach. At Great Western Hospital, Swindon, a closed loop audit was performed looking at a selection of these guidelines, to assess if our initial changes were sufficient and what could be improved.
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Many advocate screw fixation of fractures to the metaphyseal-diaphyseal junction of the fifth metatarsal base, better known as Jones fractures (JF), to facilitate quicker ambulation and return to sport. Maximizing screw parameters based on fifth metatarsal (MT5) anatomy, alongside understanding the anatomic structures compromised by screw insertion, may optimize surgical outcomes. This study aims to (1) correlate the proximity of JF to the peroneus brevis (PB) and plantar fascia (PF) footprints and (2) quantify optimal screw parameters given MT5 anatomy. ⋯ This study underscores the challenges associated with surrounding MT5 anatomy as they relate to optimal JF treatment. Both the extent of JF as well as a clinically achievable positioned screw violate the PB and PF footprints - although the degree to which even partial disruption of these footprints has on outcome remains unclear. To minimize damage to surrounding structures, including the PB and PF footprint, while allowing a screw length approximately two thirds of the metatarsal length, the CA screw position is recommended. This position balances the desire to maximize pull out strength while avoiding cortical penetration or inadvertent fracture site distraction.
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Defects of the lower limb are generally difficult to correct, especially in patients with associated pathologies, and they represent a challenge for the reconstructive surgeon. The sural flap provides considerable versatility for lower limb reconstructions, successfully covering defects located between the knee and the ankle or the heel. ⋯ When use of a local flap is insufficient, free flaps must be used, as they provide a wider coverage of defect. We report the successful surgical management of a case of a lower extremity injury consisting of a tibial pilon fracture, proximal fibula and lateral malleolus fractures, and a medium-to-large defect on both sides (internal and external) of the left ankle, on a 61 year-old patient, insulin dependent diabetic, heavy smoker, and with poor hygiene.
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Burn contractures of the anterior neck result in severe functional and aesthetic deformities. The release of wide contractures leads to defects that cannot be closed with local flaps. In these cases, tissue expansion of local tissues may be a solution. ⋯ Overall, pre-expansion decreased the amount of total skin grafted area in the donor site. Pre-expanded ALT perforator flap can be a good option in extensive burns with wide contractures where the regional donor areas are also affected. This technique has several advantages: 1) large flaps can be safely harvested, 2) the expanded skin thins out making it more aesthetically appropriate to resurface superficial defects, 3) expansion period of the thigh is well tolerated by the patients, 4) two teams can work simultaneously, decreasing the operating time, 5) the donor area can be closed either primarily or with minimal skin graft application, and 6) there is no functional loss in the donor area and the donor scar stays under the clothes.