Wednesday, April 10, 2013
"What Reason Weaves, by Passion is Undone" or, Why Pick the Right Screw
Despite seeming obscenely simple, there is a remarkable amount of specificity required in choosing the right bone screws for a case. The variability exists in more than length and thread diameter; the surgeon must chose between entirely or partially threaded, self-tapping or non-self-tapping, solid or cannulated, and cancellous or cortical.
General terms:
Pitch= distance btwn threads
Root= Inner core of screw (Screw minus thread)
Tapping= Cutting grooves in the bone for the threads to insert
- Decreases torque on the bone, Increases holding strength
Self Tapping= cut their own grooves as they insert
Larger thread diameter vs. Larger Root diameter-
Afraid of screw pulling out (soft bone)? Use wider threads
Afraid of failure d/t fatigue (hard bone)? Use wider root
**LAG SCREWS
GOAL: to transform torque into compression
Threads should be seated only into the distal fracture part; so the proximal part should have the screws root only. NO threads across the fracture line for optimal compression....
UNLESS you want to pre-cut a groove as wide as the screw, which allows you to use a fully threaded screw
Cortical- Narrow thread spacing, narrow thread --> Increase SURFACE AREA of cortical attachment
Cancellous- Wide thread spacing, wide thread --> Increase PURCHASE into cancellous soft bone
Locking Screws: self tapping, give tight fixation to plate
DCS= Dynamic Compressive Screw; think about what youve seen put in an intertroch fx of an elderly lady. With sliding lag screw put through the side plate, there is compression that is CONTROLLED so that the screw isn't pulled up through the osteoporotic femoral head.
References:
Title Quotation- Alexander Pope, The Essay on Man.
Canale and Beaty. Campbell's Operative Orthopaedics.
Handbook of Fractures
Saturday, March 30, 2013
Lover's Fracture -- Video of the Week
Video of the week
LOVERS FRACTURE--
Surgical Approach to the Calcaneus: http://olc.metrohealth.org/olcvideos/Calcaneus_NEW.wmv
(Image property of the Journal of Foot and Ankle surgery)
LOVERS FRACTURE--
Surgical Approach to the Calcaneus: http://olc.metrohealth.org/olcvideos/Calcaneus_NEW.wmv
(Image property of the Journal of Foot and Ankle surgery)
Not sure why the file name says "New".... Its definitely a bit dated; but lots of good tips on
exposure, closure, positioning the plate for internal fixation, and properly identifying the
anatomy around the Sural nerve branches.
Thursday, February 28, 2013
OPINION: Academic Docs Fear They Might Need to Start Seeing Patients Soon...
I returned home from clinic this evening to see a well-timed editorial in this week's New England Journal of Medicine. The title of the article (and yes, it's free to download) is Open but Not Free — Publishing in the 21st Century; and it's written by the executive director of the American Physiological society, Dr. Martin Frank, PhD. While Dr. Frank may not have trained to be a clinician, it is fair to assume that his viewpoint is shared by plenty of clinician-investigators in large, academic tertiary care centers. NEJM published this article as one of four editorial pieces debating whether or not to release clinically relevant research on a digital medium- pro bono publico.
I could confidently argue that the Open-Access model is conceptually not much different than that of Libertarian government policy. Libertarian may not be my political affiliation on paper, but I strongly believe that we have neglectfully allowed the federal government to throw a metal pipe into the gears of evolution. They have made us all feel infantile by showing us just how effortlessly (keep in mind I chose that adverb for a reason) they ruin even Donald Trump's perfect life with one single roll of red tape. In this same fashion, I don't care how life-saving your 5 years of translational cancer research is, no one gets through the JAMA velvet rope without dancing the bureaucratic 2-step. The argument I would like to make is : the fewer the obstacles between supply and demand, the better. As physicians in training, we develop the wonderfully neurotic habit of skepticism. This works out well for our patients, as it functions like an intrinsic quality control- reinforcing evidence-based principles and discouraging medicine based off marketing. We should not fear the dispersal of questionable studies; because there will always be more than enough physicians willing to refute poor science. Just as human beings have shown they can prosper better without an overbearing government, the scientific community doesn't need layers of suits pre-processing our information for us.
Aside from intentionally delaying the movement of knowledge, the executive branches of medical journals behave like somewhat of an ol' boy's club. Irrespective of the subject matter and the stimulating writing style, it remains impossible for a passionate, young academic-hopeful to get published in one of the major journals without the assistance of a highly-ranked chair. Conversely, I hear from some that they get published with very little effort, just for being in the right place at the right time. This is more than enough to deflate someone's motivation to write. Afterall, who would continue to pour their sacred little spare-time into something that's almost certain to remain fruitless? (*Gulp....)
Essentially, the point is this - every governing body needs its members to remain driven and reinforced. Increasing my taxes just as I finally get the raise I've been slaving myself for (aside from desecrating the constitutional pursuit of happiness) guarantees me to be both unsatisfied and unmotivated. There should always be a way to submit a great article and have a fair chance to get published. Great articles take incredible amounts of time from people that don't have much time at all. This is ESPECIALLY true in cases of lesser known physicians at community hospitals, who may be performing independent research without monetary expectations. Regardless of their name recognition, their contribution to the (medical) greater good should be prioritized and publicized. I may have barely been potty-trained for a quarter of a century, but it is dead obvious to me that the GOAL-DRIVEN man remains smarter, faster, stronger, and more efficient. We need to encourage the scientific global market to operate at its full capacity. Have enough faith in your peers and colleagues that if something needs to be scrutinized, it will be (in a manner that does not require Sensitivity Training by HR).
We are guilty of accepting certain overbearing "necessities" that do nothing but hinder our growth and development. Right at this moment, just as there are millions of unemployed citizens enabled by their government to live mediocre lives, there is similarly an acceptance amongst students that authoring a manuscript is a lucky hand-out. With growth of open access portals, a new generation of young clinicians and scientists will be YEARNING to contribute more time and effort for the progress of medicine. Allow the public forum of trained physicians to read, interact, and debate the literature just as they had done for thousands of years. Fear of medical misinformation is analogous to fear that your child will begin to date: it's bound to happen at some point, so it's better to openly communicate and set a good example, than to home-school them and retard their interpersonal development.
Let's stop convincing ourselves that we need this many hands in the pot. We need full access to the latest information as physicians; yet both the time and expense required for publishing is a substantial deceleration of progress. The government and the physician have yet again cooperated on funding an inefficient middle man. If you havent figured it out, the other middle man I'm referring to is govt/insurance plans. The interdependent relationship between a patient, their insurance company, and comprehensive health care is ridiculously disorienting. By the time the medicare patient gets through their goverment's bureaucratic obstacle course, their dementia and probable pain syndrome reaches a new pinnacle.We don't need ten government-funded "non profit" organizations to make a small row of trees in the city, and we don't need large chunks of government-funded grants to dissolve literally just from transitioning words to paper. I mean, have scientists even discovered whether the early hominids survived without Nonprofit organizations or Federal income tax???
Let me clarify my certainty that mankind's true potential is enormous; and I don't want that to be overshadowed in this article by my frustration with the system. But if we want to evolve as rapidly as our potential allows, then the only rate-limiting step should be the amount of time it takes to complete the study and write/revise the manuscript. We need to be actively seek efficiency from every party involved in the transmission of medical information. To believe we could, in fact, reach our collective potential, there are several assumptions we must make:
A. Everyone involved (physicians, students, etc.) wants to play a vital role in the progress of both scientific discovery and direct patient-care.
B. We do not mind spinning the hamster wheel harder PRN to address the issues that we feel individually passiomate about.
C. EFFICIENCY!! To achieve any amount of success, physicians and construction workers alike, are expected to maintain a high level of efficiency. It is imperative that we demand a reciprocated level of efficiency from the labor born of our taxes. (The majority of grant funding has been siphoned directly/indirectly from federal money.)
Feel free to discuss. Whether you agree with me or not, I hope we all agree that the goal is always better patient care.
Addendum: It is far too obvious to discuss in detail, but some executives/editors in big chairs may stand to lose the power, money, and recognition that theyve grown fond of. We should consider this secondary (or primary) gain in this debate. HOWEVER, there are more than enough brilliant editors/chairs of medical journals that DO work hard as dedicated clinicians and scientists. I would not ever write an article claiming that they all neglect their much needed practice of patient care.
N Engl J Med 2013; 368:787-789. February 28, 2013. DOI: 10.1056/NEJMp1211259
I could confidently argue that the Open-Access model is conceptually not much different than that of Libertarian government policy. Libertarian may not be my political affiliation on paper, but I strongly believe that we have neglectfully allowed the federal government to throw a metal pipe into the gears of evolution. They have made us all feel infantile by showing us just how effortlessly (keep in mind I chose that adverb for a reason) they ruin even Donald Trump's perfect life with one single roll of red tape. In this same fashion, I don't care how life-saving your 5 years of translational cancer research is, no one gets through the JAMA velvet rope without dancing the bureaucratic 2-step. The argument I would like to make is : the fewer the obstacles between supply and demand, the better. As physicians in training, we develop the wonderfully neurotic habit of skepticism. This works out well for our patients, as it functions like an intrinsic quality control- reinforcing evidence-based principles and discouraging medicine based off marketing. We should not fear the dispersal of questionable studies; because there will always be more than enough physicians willing to refute poor science. Just as human beings have shown they can prosper better without an overbearing government, the scientific community doesn't need layers of suits pre-processing our information for us.
Aside from intentionally delaying the movement of knowledge, the executive branches of medical journals behave like somewhat of an ol' boy's club. Irrespective of the subject matter and the stimulating writing style, it remains impossible for a passionate, young academic-hopeful to get published in one of the major journals without the assistance of a highly-ranked chair. Conversely, I hear from some that they get published with very little effort, just for being in the right place at the right time. This is more than enough to deflate someone's motivation to write. Afterall, who would continue to pour their sacred little spare-time into something that's almost certain to remain fruitless? (*Gulp....)
Essentially, the point is this - every governing body needs its members to remain driven and reinforced. Increasing my taxes just as I finally get the raise I've been slaving myself for (aside from desecrating the constitutional pursuit of happiness) guarantees me to be both unsatisfied and unmotivated. There should always be a way to submit a great article and have a fair chance to get published. Great articles take incredible amounts of time from people that don't have much time at all. This is ESPECIALLY true in cases of lesser known physicians at community hospitals, who may be performing independent research without monetary expectations. Regardless of their name recognition, their contribution to the (medical) greater good should be prioritized and publicized. I may have barely been potty-trained for a quarter of a century, but it is dead obvious to me that the GOAL-DRIVEN man remains smarter, faster, stronger, and more efficient. We need to encourage the scientific global market to operate at its full capacity. Have enough faith in your peers and colleagues that if something needs to be scrutinized, it will be (in a manner that does not require Sensitivity Training by HR).
We are guilty of accepting certain overbearing "necessities" that do nothing but hinder our growth and development. Right at this moment, just as there are millions of unemployed citizens enabled by their government to live mediocre lives, there is similarly an acceptance amongst students that authoring a manuscript is a lucky hand-out. With growth of open access portals, a new generation of young clinicians and scientists will be YEARNING to contribute more time and effort for the progress of medicine. Allow the public forum of trained physicians to read, interact, and debate the literature just as they had done for thousands of years. Fear of medical misinformation is analogous to fear that your child will begin to date: it's bound to happen at some point, so it's better to openly communicate and set a good example, than to home-school them and retard their interpersonal development.
Let's stop convincing ourselves that we need this many hands in the pot. We need full access to the latest information as physicians; yet both the time and expense required for publishing is a substantial deceleration of progress. The government and the physician have yet again cooperated on funding an inefficient middle man. If you havent figured it out, the other middle man I'm referring to is govt/insurance plans. The interdependent relationship between a patient, their insurance company, and comprehensive health care is ridiculously disorienting. By the time the medicare patient gets through their goverment's bureaucratic obstacle course, their dementia and probable pain syndrome reaches a new pinnacle.We don't need ten government-funded "non profit" organizations to make a small row of trees in the city, and we don't need large chunks of government-funded grants to dissolve literally just from transitioning words to paper. I mean, have scientists even discovered whether the early hominids survived without Nonprofit organizations or Federal income tax???
Let me clarify my certainty that mankind's true potential is enormous; and I don't want that to be overshadowed in this article by my frustration with the system. But if we want to evolve as rapidly as our potential allows, then the only rate-limiting step should be the amount of time it takes to complete the study and write/revise the manuscript. We need to be actively seek efficiency from every party involved in the transmission of medical information. To believe we could, in fact, reach our collective potential, there are several assumptions we must make:
A. Everyone involved (physicians, students, etc.) wants to play a vital role in the progress of both scientific discovery and direct patient-care.
B. We do not mind spinning the hamster wheel harder PRN to address the issues that we feel individually passiomate about.
C. EFFICIENCY!! To achieve any amount of success, physicians and construction workers alike, are expected to maintain a high level of efficiency. It is imperative that we demand a reciprocated level of efficiency from the labor born of our taxes. (The majority of grant funding has been siphoned directly/indirectly from federal money.)
Feel free to discuss. Whether you agree with me or not, I hope we all agree that the goal is always better patient care.
Addendum: It is far too obvious to discuss in detail, but some executives/editors in big chairs may stand to lose the power, money, and recognition that theyve grown fond of. We should consider this secondary (or primary) gain in this debate. HOWEVER, there are more than enough brilliant editors/chairs of medical journals that DO work hard as dedicated clinicians and scientists. I would not ever write an article claiming that they all neglect their much needed practice of patient care.
N Engl J Med 2013; 368:787-789. February 28, 2013. DOI: 10.1056/NEJMp1211259
Sunday, February 24, 2013
Prefemoral Fat Pad Impingement Syndrome
Prefemoral Fat Pad Impingement Syndrome: Identification and Diagnosis
Presenting with continuous anterior patellofemoral pain, the diagnostic imaging remains less than obvious to even the seasoned Sports Medicine surgeon. Here is a wonderfully thorough evaluation and summary of current diagnostic knowledge by a multidisciplinary team from the University of Miami.
Keep in mind- the American Journal of Orthopaedics provides a free (limited) online subscription for medical students and residents. Register so that you may join in on future discussions about their articles.
Prefemoral Fat Pad Impingement Syndrome: Identification and Diagnosis. Borja MJ, Jose J, Vecchione D, Clifford PD, Lesniak BP. Am J Orthop. 2013;42(1):E9-E11.
Please share any relevant cases you've seen, prioritizing patient confidentiality and citation of literature.
Prefemoral Fat Pad Impingement Syndrome: Identification and Diagnosis. Borja MJ, Jose J, Vecchione D, Clifford PD, Lesniak BP. Am J Orthop. 2013;42(1):E9-E11.
Please share any relevant cases you've seen, prioritizing patient confidentiality and citation of literature.
Video of the Week
Video of the Week
A Pain in Your Neck: Discussion of Cervical Degenerative Disk Disease
Peter Grossi, MD, of Duke Neurosurgery of Raleigh, talks about neck pain and the degenerative diseases associated with it.
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