Instructional course lectures
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Pediatric musculoskeletal infections can cause devastating complications (including death) in this era of methicillin-resistant Staphylococcus aureus and other virulent bacterial strains. The complexity and severity of these infections require timely diagnosis and treatment. A thorough emergency department evaluation, diagnostic workup, and early surgical intervention can influence outcomes. ⋯ Because of genetic changes and inducible resistance, methicillin-resistant Staphylococcus aureus causes more complex infections than in the past. Deep, soft-tissue abscesses; pyomyositis; osteomyelitis; and septic arthritis often occur concurrently, causing destruction of musculoskeletal tissue. Severe and life-threatening complications, such as septic emboli, deep venous thrombosis, and multiorgan system failure may result from these infections.
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The metaphyseal deformity, in even a mild slipped capital femoral epiphysis (SCFE), results in acetabular labral and cartilage injury. SCFE is the most extreme form of femoroacetabular impingement, and the mechanism of cartilage and labral injuries is similar. ⋯ In situ pinning is the most effective treatment to halt short-term slip progression; outcomes are favorable in many hips. In medical centers with substantial experience with hip preservation techniques, open or arthroscopic osteochondroplasty can be used to treat mild SCFE, and a modified Dunn epiphyseal reorientation can be used for more severe deformities to decrease the potential for secondary osteoarthritis.
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Multimodal pain management techniques using femoral and sciatic nerve blocks can dramatically improve a patient's experience after total knee arthroplasty. Nerve blocks reduce postoperative pain and the need for parenteral opioids and result in fewer medical complications associated with opioid use. ⋯ Although it is difficult to isolate the added benefit of sciatic nerve blocks, there is a growing body of evidence for using femoral and/or sciatic nerve blocks as part of a multimodal approach to pain management. With many years of experience and published results on thousands of patients, it is clear that the risks of peripheral nerve blocks are minimal, whereas the benefits are substantial.
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Unstable posterior pelvic ring injuries are commonly treated with percutaneous iliosacral screw fixation. Despite the efficiency of the minimally invasive technique, complications and failures occur. To maximize reduction quality and fixation stability, open techniques for pelvic ring fixation exist. Timing, approaches, clamp positioning, and implant options determine the effectiveness of the open techniques.
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An increasing percentage of emergency departments are reporting an inadequate number of on-call specialists. This situation is causing a growing crisis in emergency department on-call coverage for patients requiring orthopaedic care. Many orthopaedic surgeons are electing to opt out of emergency department on-call service. ⋯ Initially, it may be necessary to incentivize on-call service so more surgeons are willing to participate. Incentives may include improving the group governance and bylaws to avoid confusion on the rules for providing on-call coverage. The on-call experience may require financial improvements, outsourcing with locum tenens, or a complete restructuring of the on-call arrangement with the formation of a hospitalist program.