Orthopedics
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This article presents a case of undiagnosed sesamoid arthritis with coexisting trigger thumb. A 25-year-old woman presented with a 2-year history of metacarpophalangeal joint pain and triggering of the thumb. She was a right-handed bank employee and recalled a trivial thumb sprain. ⋯ Orthopedic surgeons often overlook pathologies around the metacarpophalangeal joint, especially those related to triggering. A high index of suspicion and clinical findings consistent with intermittent mechanical obstruction and tenderness in the palmar aspect of the metacarpophalangeal joint warrant inclusion of sesamoid arthritis as a differential diagnosis for metacarpophalangeal joint pathology. Detailed physical examinations should be performed and proper radiographs taken in all patients with tenderness in the metacarpophalangeal joint even if triggering of the thumb is present.
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Case Reports
Compartment syndrome in patients with massive venous thrombosis after inferior vena cava filter placement.
Massive venous thrombosis, which can occur acutely after inferior vena cava filter placement, has 2 forms: phlegmasia cerulea dolens and phlegmasia alba dolens. In phlegmasia cerulea dolens, complete occlusion of venous outflow occurs. In the milder phlegmasia alba dolens version, collateral venous flow out of the limb remains despite the venous thrombosis. ⋯ A multidisciplinary approach with the vascular service and the intensivists is required in the treatment of patients with massive venous thrombosis. Treatment goals include preventing additional propagation of the thrombus via anticoagulation, with strong consideration for catheter-directed thrombolysis or thrombectomy and fasciotomies for compartment syndrome. The orthopedic surgeon should keep phlegmasia cerulea dolens and phlegmasia alba dolens in the differential for compartment syndrome, especially in patients who have had a history of acute or chronic inferior vena cava filter placement.
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Upper-extremity deep venous thrombosis (DVT) is considered an uncommon clinical event with considerable potential for morbidity. This article presents a case of upper-extremity DVT following a clavicular fracture. A 25-year-old man presented with pain and distortion of the left midclavicular area after falling on his left shoulder during martial arts practice. ⋯ The patient was placed in a sling instead of a figure-of-8 bandage to immobilize the arm, while anticoagulation therapy with enoxaparin was started (1 mg/kg every 12 hours, 80 mg subcutaneous daily for 3 months). The swelling was reduced after 5 days. At 2-week follow-up, the patient had no pain and the swelling had completely disappeared.
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Controlled Clinical Trial
Local infiltration analgesia in TKA patients reduces length of stay and postoperative pain scores.
Numerous postoperative pain protocols exist for patients undergoing total knee arthroplasty (TKA). We compared the length of stay, early range of motion (ROM), and pain scores of a control group with a femoral nerve block to those of a group with femoral nerve block and local infiltration analgesia following TKA. In a consecutive series of patients undergoing primary TKA at a Veteran's Administration hospital, 40 patients (40 TKAs) who had local infiltration analgesia were compared to a historical group of 43 patients (43 TKAs) who had a long-acting femoral nerve block without local infiltration analgesia. ⋯ Mean pain scores were lower in the local infiltration analgesia group on postoperative day 1 (P=.04), but not on postoperative day 2 or 3. Maximum visual analog scale scores (P<.01) were reduced in the local infiltration analgesia group. Our early experience with local infiltration analgesia demonstrated a significantly reduced length of stay due to decreased postoperative pain.