1/7. Teleconsultations in Pohnpei State, Federated States of micronesia.A case report of 6 years old female who sustained a difficult right subtronchanteric fracture of the femur is outlined. She was treated successfully, with local materials, over the internet with assistance of the orthopaedic surgeons at the Tripler Army Medical Center in Honolulu. Pohnpei State spends 10% of the health budget in referring patients off-island for tertiary treatments and this serves less than 1% of the total population. Before the use of the internet, approximately $US1,500 per month was spend on telephone bills, for outside consultations. After connection to the internet and the consult webpage, particularly at Tripler, this cost was reduced to below $US500 per month. To date, fifty consults, via the internet, have been sent to the TAMC Consult Webpage. The introduction of this service has resulted in cost saving in terms of referral communication and perhaps avoided unnecessary off island evacuations. The difficulties so far have been limitation of on-line access and computer illiteracy amongst physicians.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/7. Long bone fractures in extreme low birth weight infants at birth: obstetrical considerations.BACKGROUND: cesarean section is a common delivery route for breech fetuses < 1000 gm to prevent trauma. However, abdominal and vaginal delivery maneuvers are similar. cesarean section avoids the risk of head entrapment but long bone trauma can still occur. CASES: We identified three neonates with femoral fractures during a one year period. All mothers were in active labor. All were premature newborns less than 32 weeks gestation, in breech presentation and delivered by a low vertical cesarean section. review of all cesarean sections done due to mal presentation (n = 26) during that time showed 11 classic and 15 lower segment vertical incisions (both vertical and transverse). CONCLUSIONS: The interest to reduce maternal morbidity may prompt physicians to perform a low segment vertical incision for delivery of a preterm breech. This decision may increase the chances of trauma by providing less area for the required obstetric maneuvers.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/7. Differential diagnosis of a femoral neck/head stress fracture.STUDY DESIGN: Resident's case problem. BACKGROUND: Identifying stress fractures of the hip can be a challenging differential diagnosis. pain presentation is not always predictable and radiographs may not show the fracture, especially during its early stages. hip stress fractures left untreated can displace and necessitate open reduction internal fixation or total hip arthroplasty. diagnosis: A 70-year-old woman presented to the physical therapy clinic with complaints of right hip pain. She had been evaluated by a physician and radiographs of the hip, which revealed some arthritic changes, were otherwise normal. Upon examination, the physical therapist observed an antalgic gait, a noncapsular pattern of limitation of hip motion, an empty painful end feel at the end range of motion (ROM) for hip abduction, external rotation, and flexion, and extreme tenderness to palpation over the anterior hip region. The therapist suspected a more pernicious problem than osteoarthritis and discussed his suspicion with the physician. The physician subsequently requested an MRI that revealed a femoral neck and head stress fracture that was later confirmed with a bone scan. The patient was provided with a walker for ambulation with a non-weight-bearing status for 6 weeks, after which she returned to physical therapy for progressive weight bearing and strengthening. She was discharged with a relatively pain-free hip and was ambulating with a cane. A 2-month follow-up examination revealed a pain-free hip and a return to all premorbid activities, including ambulation without an assistive device. DISCUSSION: The presence of a normal radiograph of the hip should not be considered conclusive in ruling out a stress fracture in the hip region. The current case demonstrates how careful evaluation can reveal occult pathologies and prevent potentially catastrophic morbidity.- - - - - - - - - - ranking = 3keywords = physician (Clic here for more details about this article) |
4/7. Surgical stabilization of pathological neoplastic fractures.The most important factor to consider in deciding between treatment options in the management of metastatic bone disease is the level of the patient's dysfunction and pain. Severe dysfunction or pain demands a treatment that predictably leads to a quick resumption of the painless activities of daily living. A treatment that predictably will restore function in months may seem reasonable in patients with a normal remaining life span, but is untenable if those months represent a high percentage of remaining life span, as they do in metastatic disease afflicted patients. The treating physician needs also to understand the basis for the patient's dysfunction. A destroyed joint will not return to painless function even if the metastasis responsible is totally eliminated. A bone that has lost its structural integrity, even though not grossly fractured, will not support weight bearing for months even if the metastasis is eliminated. Control of the metastatic tumor does not always equate with return to function. Treatment options in the management of metastatic bone disease are not mutually exclusive. In many patients treatment options are combined. Surgical stabilization may best return the patient's function while he is being treated postoperatively with radiotherapy or chemotherapy for good neoplasm control. Neoplasm control should not be such an overriding concern that function is not addressed. Function can almost always be returned to the patient, but neoplasm "cure" is rarely achieved in this group of patients. It is a reasonable goal to avoid allowing bone metastasis to progress to pathological fracture. Routine periodic examinations and bone scans should commonly alert the treating physician to the presence of metastatic bone disease well before fracture occurs. Pathological fracture narrows the range of treatment options, mitigates against full functional restoration, demands a rehabilitation hiatus, and acutely frightens the patient who does not have time to participate fully in treatment decisions. An impending pathological fracture can be treated with surgery, radiotherapy, chemotherapy, or hormonal manipulation. The options are basically operative or nonoperative. Lesions that predictably will fracture short term, involve joints, or will cause catastrophic consequences if fracture occurs should be strongly considered for surgical stabilization. Other factors to consider are the location of the metastasis, the primary tumor, and the expected response to nonoperative therapy. The patient becomes a surgical candidate for the above reasons and not because of any estimated life span.(ABSTRACT TRUNCATED AT 400 WORDS)- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
5/7. Occult fractures in the production of gait disturbance in childhood.Trauma to the lower extremities is the principal cause of gait disturbance in early childhood. Three cases are presented to emphasize the relative frequency of children hospitalized for diagnostic evaluation of altered gait who have occult fractures. The cases may refresh the primary physician of the variables that serve as obstacles to accurate diagnosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/7. Torsional fractures and the third dimension of fracture management.Torsional strength is the weakest structural property of bone. Fractures produced by common indirect mechanisms are likely to have significant rotational components that bear on their management. The characteristics of torsional fracture lines in bone specimens are completely predictable and reproducible. The physician who is aware of these biomechanical consistencies can use them for fracture reduction and can anticipate and treat fracture deformities accentuated by torsional loading.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/7. Management of a multiply injured Jehovah's Witness with severe acute anemia.The refusal of blood products by jehovah's witnesses creates ethical and medicolegal dilemmas for the treating physician. Appropriate management involves some understanding of the beliefs of the jehovah's witnesses and knowledge of a variety of techniques to minimize blood loss. This case report describes the treatment of a Jehovah's Witness with severe anemia and multiple skeletal injuries. The need to keep blood loss to a minimum influenced the management of this patient.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |