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Procedural Sedation in the Emergency Department

Procedural sedation options in the emergency department now allow for more effective and safer care and facilitate the delivery of orthopaedic care that would otherwise require operating room anesthesia. Traditional sedation agents, such as nitrous oxide, midazolam, fentanyl, and ketamine, have a persistent role. Etomidate and propofol are relatively recent additions that are highly effective. Combination regimens, such as ketamine-midazolam and ketamine-propofol, may be superior because they benefit from synergistic traits. Despite these sedation regimens, use of local blocks in adults continues to be effective, and intranasal delivery in children has emerged as a viable option. Orthopaedic surgeons should be aware of the appropriateness of different sedation regimens and other options for specific clinical scenarios.

Tubular diskectomy minimizes collateral damage

By Raymond J. Gardocki, MD

A logical progression moves spine surgery forward

Minimally invasive spine surgery (MISS) has recently gained popularity, partly because achieving spinal decompression or stabilization without disrupting normal functioning anatomy intuitively makes sense. Much of the demand for MISS comes from patients who have seen family and friends benefit from these techniques.

Percutaneous Pin Fixation for Treatment of Distal Radius Fractures

Fractures of the distal radius are among the most frequently encountered injuries by the orthopaedic surgeon. The ideal definitive treatment of these fractures, however, remains a subject of debate. Closed reduction and percutaneous pinning offers a reliable, minimally invasive technique for fixation of two-part and three-part distal radius fractures, with excellent long-term results. The surgical technique is relatively straightforward, may be performed in a relatively short amount of time, and is relatively inexpensive compared with alternative surgical options for comparable fractures. In this article we present and demonstrate our surgical technique for percutaneous pinning of distal radius fractures, and provide an overview of reported outcomes and complications of this procedure.

Aneurysmal Bone Cyst

Aneurysmal bone cyst (ABC) is a benign but locally aggressive bone tumor that most frequently involves the long bones of the extremities, pelvis, and the posterior elements of the spine. ABCs comprise 1% to 6% of all primary bone tumors and have an overall prevalence of 0.32 per 100,000 individuals. There is an equal prevalence among genders, and the median age at presentation is 11.1 years. The true etiology and natural history of ABCs are not well understood, but there is consensus that thorough intralesional curettage and removal of the entire tumor must be performed to minimize the risk of local recurrence. Other treatment options include en bloc excision, selective arterial embolization, external beam radiation therapy, and curettage with locally applied adjuvant therapy, such as argon beam coagulation, liquid nitrogen, phenol, or hydrogen peroxide.

Elbow Fractures in Children

Elbow fractures are common injuries in children, and often require surgical treatment. Evaluation and diagnosis of these injuries can be difficult in this population of patients because of the presence of secondary ossification centers of the elbow that develop over time, sometimes mimicking fractures. The additional challenge of recognizing occult fractures makes this one of the most demanding sets of injuries to manage in children. Successful treatment of an elbow fracture in a pediatric patient requires an understanding of the normal order of fusion of the secondary growth centers, the mechanism of injury, the natural histories of the different treatments for elbow fractures, and the potential complications of treatment. This article reviews the diagnostic and management strategies for the most common elbow fractures seen in pediatric patients.