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Soft-Tissue Injuries Associated With High-Energy Extremity Trauma: Principles of Management.

The management of high-energy extremity trauma has evolved over the past several decades, and appropriate treatment of associated soft-tissue injuries has proved to be an important factor in achieving a satisfactory outcome. Early evaluation of the severely injured extremity is crucial. Severe closed injuries require serial observation of the soft tissues and early skeletal stabilization. Open injuries require early aggressive debridement of the soft tissues followed by skeletal stabilization. Temporary wound dressings should remain in place until definitive soft-tissue coverage has been obtained. Definitive soft-tissue closure will be expedited by serial debridements performed every 48 to 72 hours in a sterile environment. Skeletal union is facilitated by early bone grafting and/or modification of the stabilizing device. Aggressive rehabilitation, includ-ing early social reintegration, are crucial for a good functional outcome. Adherence to protocols is especially beneficial in the management of salvageable severely injured extremities.

Seeing the Signs of Resident Burnout

Strategies  for mitigating stress may help avoid serious problems

  Orthopaedic surgical residency programs have experienced  a great deal of change in the last decade, including implementation of the  80-hour work week, greater use of simulator training, and increased  documentation required of residents via caselogs and the Accreditation Council  for Graduate Medical Education (ACGME) Milestone Program. All of these  adjustments have been aimed at improving resident education and enhancing  patient care.

HOT TOPIC: Update on the Management of Nonunion

A fracture nonunion represents a disturbance of the bone healing process. Nonsurgical treatment options for nonunion include nutritional enhancements, bracing, correction of endocrinopathy or metabolic disorder, and electromagnetic and ultrasonic bone stimulation. Surgical options include internal fixation, bone grafting, osteotomy, and distraction osteogenesis/bone transport. Amputation may also be considered for recalcitrant nonunions that have failed multiple operations designed to heal the bone, and are surrounded by a deficient soft-tissue envelope. Appropriate treatment is based on the type of nonunion and its anatomic location, because that will aid in the analysis of why the bone failed to heal and what it may need to achieve union. This article is an update on a previously published OKO topic on nonunion, with particular focus on diagnostic and nonsurgical therapeutic interventions and some new developments in surgical management.

Proximal Humerus Fractures

Proximal humerus fractures make up approximately 5% of all fractures in adults and occur primarily in the elderly population, typically as a result of low-energy falls. Younger patients may sustain these injuries due to higher-energy mechanisms. Women are more commonly affected than men, by a ratio varying from 2:1 to 5:1. Approximately three fourths of proximal humerus fractures have only minor displacement and should be managed nonsurgically. This article reviews the identification and surgical treatment of displaced fractures of the proximal humerus.