Glute Injection

Glute (buttock) injection is a universal procedure that is commonly used around the world. Selecting the proper site that avoids injury to the neurovascular structures is important. The sciatic nerve could be at risk for injury during a buttock injection.  The buttocks is divided into quadrants. Divide the buttock halfway down the middle and halfway across.  Injection is given in the center of the upper outer quadrant. Avoid the other quadrants. Injection into the other quadrants may cause injury to the neurovascular structures and damage the sciatic nerve.  Another helpful method that could confirm a safe site for injection is to draw a line from the posterior superior edge of the iliac spine to the greater trochanter. This area above the line is considered to be the safe zone for intramuscular injection.

Corachobrachialis Muscle Anatomy

The coracobrachialis muscle arises from the tip of the coracoid process. The coracobrachialis muscle may have a conjoint tendon with the short head of the biceps muscle.  The coracobrachialis lies lateral to the pectoralis minor muscle. Close to the origin of the coracobrachialis is the origin of the coraco-clavicular ligaments. The conoid ligament is medial and the trapezoid ligament is lateral. The coracobrachialis muscle inserts into the middle third of the medial border of the humeral shaft.  The innervation of the coracobrachialis, biceps brachii, and brachialis muscle comes from the musculocutaneous nerve.  The brachialis has dual innervation. The medial part of the muscle innervation is from the musculocutaneous nerve and the lateral part of the muscle gets innervation from the radial nerve. The musculocutaneous nerve will also give the lateral antebrachial nerve with its anterior and posterior divisions. It is the primary nerve supply of the muscles of the anterior compartment of the upper arm it supplies sensation to the lateral half of the forearm. The coracobrachialis muscle flexes and adducts the arm at the shoulder joint.  The coracobrachialis muscle originates from the coracoid, and the musculocutaneous nerve is close to the muscle. The musculocutaneous nerve pierces the coracobrachialis about 3-8 cm distal to the coracoid where it then gives a branch to the coracobrachialis muscle. Some studies show that the nerve may be 1-5 cm from the coracoid. The nerve runs between the biceps and the brachialis muscles on the anterior compartment of the arm. The musculocutaneous nerve is close to approaches of the anterior shoulder especially with retraction of the conjoint tendon of the coracobrachialis and short head of the biceps. When the musculocutaneous nerve is injured, we may not be able to measure the deficit except for decreased sensation on the area supplied by the lateral antebrachial cutaneous nerve, which is a terminal branch that will give sensation to the forearm. The lateral antebrachial cutaneous nerve could be injured during distal biceps repair. Be careful when retracting the conjoint tendon during anterior shoulder surgery (avoid injury to the musculocutaneous nerve). Occasional, coracoid osteotomy is done to enhance exposure to the shoulder joint and the conjoint tendon will be easily retracted without compromising the musculocutaneous nerve.

Simple Acts of Kindness to Relieve Patient Pain

In general, doctors treat patients for pain due to injury or surgery. Pain intensity varies from person to person and it can be related to stress, distress, coping strategies, and physiological factors. The physician should work with the patient for better pain control and for safer prescribing of medications.  The best pain relief is self-efficacy and resilience. We have found that giving the patient a teddy bear helps to relieve their pain and anxiety, giving the patient comfort and confidence in the system.

Acetabular Fracture Associated BOTH Columns

https://www.youtube.com/watch?v=5RxEh9yKqes

Associated BOTH column fracture is a fracture of both columns of the acetabulum. Both columns are separated from each other and from the axial skeleton, resulting in a floating acetabulum. This is the most complex type of acetabular fracture. The fracture type used to be called “central acetabular fracture.” This fracture pattern may be associated with central dislocation and no part of the articular surface remains attached to the axial skeleton. The acetabular fragments become free and rotate around each other. They may appear to maintain congruity to the femoral head. There is dissociation of the articular surface from the axial skeleton. Because of this secondary congruity, traction may be used in the treatment of associated both column fracture in the elderly. You will see the “spur sign” above the acetabulum on the obturator oblique view and this is diagnostic for associated BOTH column fracture. In the obturator view, you will find the anterior column (iliopectineal line) is disrupted and you will find the “spur sign.” The “spur sign” is the posterior inferior aspect t of the intact posterior ilium. Another feature of the associated BOTH column acetabular fracture is the Judet sign of the curved line. The Judet sign of the curved line occurs due to interruption by the fracture of the iliopectineal line. The curved line belongs to the greater sciatic notch and if after fixation anteriorly, the patient has a positive curved line sign, and then the posterior column is probably not reduced. The roof of the acetabulum is involved either totally or partially. When you see an x-ray and the roof of the acetabulum is in pieces, then this injury is probably an associated BOTH column fracture. You will see a coronal plane fracture through the iliac wing. In general see coronal for column fracture. If you have BOTH column fracture and there is an additional fracture going to the ilium then this is an associated BOTH column fracture. In CT scan, the fracture will be coronal. T-shaped fracture of the acetabulum is different from an associated BOTH column fracture of the acetabulum. In associated BOTH column fracture of the acetabulum, the fracture goes through the ilium. The acetabulum is floating and is disconnected from the axial skeleton. If you see extension of the transverse fracture of the acetabulum through the medial wall of the acetabulum and the fracture is going through the obturator ring, then this is a T-shaped fracture. The ilioinguinal approach is the main approach used to treat associated BOTH column fractures.

Flexion Distraction Injury of the Lumbar Spine

Flexion Distraction Injury of the Lumbar Spine

It is sometimes called a seat belt injury or “chance fracture”. Usually, the patient is restrained, back seat passenger that is involved in a car accident and the person is wearing only a lap seat belt. The chance fracture is a variant of the flexion/distraction injury. The terminology is sometimes confusing, but a chance fracture could indicate a bony injury. It may present itself with a minimal compression fracture of the vertebral body, however, in this case all three columns of the spine are injured from distraction and tension. When you deal with a traumatic compression fracture in a young patient that is involved in a car accident, rule out a seat belt injury or “chance fracture”. This condition could be misdiagnosed or not diagnosed. Bowel trauma occurs in these cases due to crushing of the bowel between the lap seat belt and the spinal column, which results in devascularization and acute bowel rupture. In flexion/distraction injury, there will be an anterior wedge fracture of the vertebral body plus horizontal fracture of the posterior elements or distraction of the facet and the spinous processes. If it goes unrecognized, it may lead to progressive kyphosis with pain and deformity. This injury usually occurs in the thoracolumbar junction or in the midlumbar are. The posterior column fails first because of the axis of rotation is anterior to the vertebral body. The flexion/distraction injury is unstable in flexion and usually needs surgery to restore the disrupted tension band and prevent progressive deficit and pain, as well as enhance the functional recovery of the patient. In patients with flexion/distraction injury of the lumbar spine, up to 50% of these patients have associated potential life threatening injures such as visceral and gastrointestinal injury. Look for transabdominal ecchymosis; you will probably need to consult a general surgeon, and this condition occurs more in children. The hallmark of this injury is the axial split of the pedicle which is seen on the sagittal CT scan. There will be little comminution and since the center of rotation is the anterior longitudinal ligament, the posterior ligaments will be disrupted or the posterior neural arch is fractured transversely. Flexion/distraction injury or seat belt injury can be purely bony, purely ligamentous, or mixed. The treatment of flexion/distraction injury, especially if the injury is ligamentous, is usually a posterior reconstruction of the tension part of the spine with short segment fusion with instrumentation. Ligamentous injuries of the spine do not heal (needs to be fused). The bony chance fracture can be stable in extension and the fracture can heal. The fracture could heal, but the fracture will probably need long term follow-up. The fracture could be treated in a TLSO (Thoracic Lumbar Sacral Orthosis) brace and watch the fracture for the development of kyphosis.

Brown-Sequard Syndrome

Brown-Sequard Syndrome (BSS)

Brown-Sequard Syndrome results from an injury to one half of the spinal cord as seen in penetrating injuries. The spinothalamic tract fibers cross the midline below the level of the lesion resulting in contralateral loss of pain and temperature sensation. The posterior column and the corticospinal tracts carry vibration, position, light touch sensation, and motor function that are lost from the ipsilateral side of the body. The prognosis is usually good. 90% of the patients recover. If the patient has a wound on the right side, the patient will feel it on the left side. It is a hemisection lesion. There is loss of vibratory, light touch and motor on the same side while pain and temperature is lost on the other side.

Open Fractures of the Tibia

Open Fractures of the Tibia

25% of tibial shaft fractures can be open. Open fractures can lead to complications including wound problems, osteomyelitis, nonunions, and infected nonunions. The treatment of open fractures of the tibia can be challenging. A lot of the concepts are not black and white; they may be in the grey zone. We don’t know the best time for debridement. We don’t know what the optimal irrigation solution is and what the optimal pressure for the fluid is. We don’t know for sure the ideal duration of giving antibiotic prophylaxis, but we know that it is important to give the appropriate antibiotics early and do meticulous debridement. We know that the IM rod is better than the plate fixation or external fixator, and the result of the reamed IM rod or unreamed IM rod is the same. We need to close or cover the wound before 1 week and the vac can be used provisionally when we cannot close the wound, primarily at the optimal time. A grade I fracture is less than 1 cm. a grade II fracture is 1-10cm. A grade III fracture is more than 10 cm, and there is contamination. Grade III fractures are divided into three types. Grade IIIa fractures require adequate tissue for closure (or skin graft). Grade IIIb fractures require extensive periosteal stripping and the patient will need a flap (rotational or free flap). Grade IIIc fractures have a vascular injury that requires repair or amputation. The relative indication for amputation is warm ischemia for more than 6 hours, absent plantar sensation and severe ipsilateral foot trauma.

The most predictive factor for amputation is the severity of the soft tissue injury in the ipsilateral extremity. When comparing limb salvage versus amputation, the patient’s outcome is generally the same at 1-5 years. Lack of plantar sensation does not predict poor outcome after limb salvage. Segmental fractures are Grade III fractures, even if the open fracture is 1 cm. The ideal irrigation solution and the pressure used to controversial. Timing of the initial debridement is controversial. Irrigation and debridement within 6 hours was the gold standard in the past. Debridement is performed as a priority procedure no later than the morning after admission. There is no difference in infection rate for a patient who has the initial surgery before or after 6 hours, including patients with Type III open fractures. More than 40% of the patients usually wait longer than 6 hours for their initial surgery after arrival at the hospital. Delayed surgery for less severe fractures is acceptable as long as the debridement is done as a priority the following day. Unless there is a gross contamination, evidence is not clear as to when is the best time for the debridement. It seems like giving the patient antibiotics promptly is more important than the time of debridement. The preferred solution is normal saline and low pressure irrigation. Low pressure lavage may reduce reoperation rates due to infection, nonunions, and wound healing problems. Normally the tradition is to use 3, 6, and 9 liters of solution for Type I, Type II, and Type III open fractures (just recommendations). There is increased risk of wound healing with antibiotic solution. Meticulous irrigation and debridement of open fractures is important in decreasing the infection risk. Prophylaxis should be started as soon as possible. All patients with open fractures should receive first generation Cephalosporin’s that will cover gram-positive bacteria. You can give penicillin for farm injuries and clostridia prone wounds. You will give clindamycin if there is a penicillin allergy. In Type III open fractures, add aminoglycoside, such as gentamicin. It was found that local antibiotics delivery at the site of injury decreased the infection risk, such as cement beaded loaded with antibiotics. Antibiotic should be given within 3 hours of the time of injury (preferably given as soon as possible). There is reduction of 59% of acute infection in patients with open fractures treated with antibiotics. The infection rate is 1.6 times greater if antibiotics are given after 3 hours. Type I and Type II open fractures require antibiotic coverage for 24 hours after wound closure. For Type III open fractures, antibiotic administration should be given for a period of 72 hours after the injury and no more than 24 hours after wound closure. After the initial debridement, the patient will need staged debridement within 24-48 hours. There is a reduction infection rate, acute and chronic, for Type III open fractures with the use of systemic antibiotics and aminoglycoside cement beads compared with antibiotics alone. This combination of antibiotics lowers the infection rate for any open tibial fracture that is treated with an IM rod. Its affect is more noticed in Type III injuries. Plating of open fractures may cause chronic infection and infected nonunion. The healing time is doubled with plated open fractures. The IM rod resulted in a better alignment and lower reoperation rate than using external fixator. Also, no difference in the infection rate between the IM rod and the external fixator. You can use a reamed nail or an unreamed nail. They both have a comparable result and no difference in the outcome.

When reaming, you can use a bigger rod that provides better stability. Reamed nailing is superior in closed tibial fractures, but it is not superior in open tibial fractures. Reaming can cause increased pressure and disruption of the endosteal blood supply, can cause thermal necrosis and fat embolism with increased intramedullary risk of infection. The unreamed rod uses smaller nails and results in less stability but preserves the endosteal blood supply. Unreamed IM tibial rod appears to have a shorter time to union and fewer incidence of knee contractures when compared with circular wire external fixator. Nowadays, more and more orthopedic surgeons are using reamed nails for open fractures of the tibia. If you have a spiral fracture of the distal 1/3 of the tibia, you will need to get a CT scan of the ankle to identify a posterior malleolar fracture, which should be fixed before insertion of the IM rod. There is a lack of evidence to support the value of external fixator over the IM rod in open factures of the tibia. Due to patient discomfort, the high incidence of pin tract infection and loss of alignment, external fixator should not be used as a definitive fixation. Use external fixator temporarily (less than 4 weeks) and replace it with a rod in about 14 days. External fixator may be utilized for severely contaminated open fractures. Tibial fractures treated with a shorter duration of external fixator has reduction of the infection risk by 80%. When there is a shorter interval between removal of the external fixator and insertion of the IM rod of the tibia, there is a reduction of the risk of infection by 85%. In less severe soft tissue injuries, you do primary closure without tension. In cases of delayed closure, soft tissue coverage should be done within 7 days. Soft tissue coverage beyond 7 days will increase the infection. There is no difference in the incidence of infection in patients who had primary closure and delayed closure of the wound. It is recommended to do primary closure for Type I, Type II, and Type IIIa fractures with tension free closure and after timely antibiotic prophylaxis and adequate debridement. Intraoperative culture after debridement has no value. It does not predict future infection. In the upper 1/3 of the tibia, you can treat it by a medial gastrocnemius flap. In the middle 1/3 of the tibia, you can treat it by a soleus rotational flap. The use of a free flap for soft tissue coverage was less likely to have wound complications than the use of a rotational flap. The zone of injury may be larger than expected, and it may include the rotated muscle flap. The negative pressure wound therapy (the vac) is used frequently. The vac provides provisional coverage for wounds where the physician cannot do primary closure. There is decreased infection rate when using the vac. The vac is used for coverage after the initial debridement of the open fracture until the definitive coverage is done. It is a good temporizing dressing and can also be used in fasciotomy wounds. The vac promotes local wound healing. Bone morphogenetic protein (BMP2) decreases the need for secondary surgery and is used in acute open tibial fractures treated with IM rod.