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BACKGROUND: Blood loss is the most significant cause of mortality in trauma cases. In injured patients, rapid evaluation and appropriate transfusion is lifesaving. The present study aims to analyze the blood/blood products requirement based on available data and find any associations between the transfusion requirements and injury severity scores (ISS) and anatomical locations of injuries of transfused patients. METHODS: Between 30 July 2014 and 30 July 2016, casualties admitted to the urban terrain hospital (UTH) and transfused at least one unit of red blood cell (RBC) were included. UTH Transfusion Record Notebook data included patients' age, mechanism and anatomical location(s) of the injury, admission hemoglobin (g/dL) level, injury severity score (ISS), transfused units of erythrocyte suspension (ES), warm fresh whole blood (WFWB), fresh frozen plasma (FFP), and massive transfusion (MT) rate. RESULTS: In this study, all patients were male; the mean age was 28.7±7.8 years. Overall, 59 of 579 (10%) patients were transfused 458 units of RBC (ES+WFWB). Torso (thorax ± abdomen) injury was present in 61% of the casualties who underwent transfusion, and 93% of these patients underwent massive transfusion. In 71% of patients, the ISS was >15, and there was statistically significant high blood/blood products use and MT rate in these patients, respectively (p=0.021, p=0.006). CONCLUSION: Anatomical location of injuries and ISS are valuable in the rapid determining of MT and survival rates of casualties. Especially in torso injuries, bleeding control is difficult and transfusion requirement and mortality rates are high. This study presents the trauma of urban terrain conflict-related transfusion data from a UTH.

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PURPOSE: The purpose of this study is to compare knee laxity and graft function (tissue force) between anatomic and non-anatomic posterolateral (PL) bundle augmentation. METHODS: Twelve (n = 12) fresh-frozen mature, unpaired porcine knees were tested using a robotic testing system. Four knee states were compared: (a) intact anterior cruciate ligament (ACL), (b) deficient PL and intermediate bundles, (c) anatomic PL augmentation, and (d) non-anatomic PL augmentation. Anterior tibial translation (ATT), internal rotation (IR) and external rotation (ER), and the in situ tissue force were measured under an 89.0-N anterior tibial load and 4.0-N m internal and external tibial torques. RESULTS: Both anatomic and non-anatomic PL augmentation restored the ER, IR, and ATT of the intact knee at all knee flexion angles (n.s.). Both anatomic and non-anatomic PL augmentation restored the in situ tissue force of the ACL during ER and IR loading and ATT loading at all knee flexion angles except at 60° of knee flexion, where the non-anatomic PL augmentation did not restore the in situ tissue force of the ACL during external rotation loading and the anatomic PL augmentation did not restore the in situ tissue force of the ACL during IR loading. Furthermore, there were no differences in ATT, IR, ER, and in situ tissue force under anterior tibial loading, IR and ER loading between the two reconstruction groups. CONCLUSION: There were no significant differences between anatomic and non-anatomic PL augmentation using the porcine knee model.

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BACKGROUND: The interest in regional anesthesia procedures for the management of upper-extremity emergencies has increased. Toward that end, supraclavicular, interscalene, or infraclavicular approaches, with or without ultrasound guidance, are used for brachial plexus nerve blocks. Although many studies have reported on the use of ultrasound-guided supraclavicular and interscalene brachial plexus blocks for upper-extremity dislocations, very few studies have reported on the use of ultrasound-guided infraclavicular brachial plexus blocks. CASE REPORT: We present an adult patient with posterior elbow dislocation that is treated with reduction after applying an ultrasound-guided infraclavicular brachial plexus block. Additionally, we describe the infraclavicular block in detail and demonstrate the technique using images. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Based on our experience, the ultrasound-guided infraclavicular block is a fast, safe, and efficient anesthesia technique that can be an excellent alternative to sedoanalgesia and other brachial plexus blocks for the management of elbow dislocations in the emergency department.

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BACKGROUND: Coordination of an emergency response team is an important determinant of prompt treatment for combat injuries in hospitals. The authors hypothesized that instant messaging applications for smartphones could be appropriate tools for notifying emergency response team members. The objective of this study was to investigate the efficiency of a commercial instant messaging application (WhatsApp, Mountain View, CA) as a communication tool for the emergency team in a level-I trauma center. METHODS: We retrospectively evaluated the messages in the instant messaging application group that was formed to coordinate responses to patients who suffered from combat injuries and who were transported to our hospital via helicopter during an 8-week period. We evaluated the response times, response time periods during or outside of work hours, and the differences in the response times of doctors, nurses, and technicians among the members of the emergency team to the team leader's initial message about the patients. RESULTS: A total of 510 emergency call messages pertaining to 17 combat injury emergency cases were logged. The median time of emergency response was 4.1 minutes, 6 minutes, and 5.3 minutes for doctors, nurses, and the other team members, respectively. The differences in these response times between the groups were statistically significant (p=0.03), with subgroup analyses revealing significant differences between doctors and nurses (p=0.038). However, no statistically significant differences were observed between the doctors and the technicians (p=0.19) or the nurses and the technicians (p=1.0). From the team leader's perspective, using this application reduced the workload and the time loss, and also encouraged the team. CONCLUSION: Instant messaging applications for smartphones can be efficient, easy-to-operate, and time-saving communication tools in the transfer of medical information and the coordination of emergency response team members in hospitals.

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BACKGROUND: Patellar dislocation is an orthopedic emergency and its reduction can be painful. The aim of this case is to show that the ultrasound-guided femoral nerve blockage can be effectively used in the pain management of patellar reduction in the emergency department (ED). CASE REPORT: A 21-year-old man was admitted to our ED after suffering a fall down a flight of stairs. The initial physical examination and plain radiography showed a patellar dislocation in the right knee. We performed an ultrasound-guided femoral nerve blockage to provide a pain-free and comfortable patellar reduction. To our best knowledge, there is no manuscript except an old case series about use of the ultrasound-guided femoral nerve blockage in the management of patellar reduction in the medical literature. Procedural sedation is the preferred method used for this purpose in ED, but these medications need to be closely monitored because of their potential complications, such as nausea, vomiting, allergic reactions, and respiratory depression. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound-guided femoral nerve blockage gave rapid and effective pain control without any complication during the reduction in this patient. Therefore, we suggest this technique be used for pain management during the reduction of a dislocated patella in the ED.

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INTRODUCTION: Management and long-term results of operatively treated clubfoot deformity still remains controversial. The aim of this study was to evaluate the radiological and clinical results of adult clubfoot patients treated with posteromedial release. MATERIALS AND METHODS: Between 2005 and 2012, we evaluated patients with congenital foot deformities regarding clubfoot who were operatively treated with complete posteromedial release. Out of 320 patients evaluated, 29 patients (40 feet) were included the study. We also included foot radiographies of 40 healthy adults. Talocalcaneal angle on the dorsoplantar projection (TC-DP) and lateral projection (TC-L) and talus-first metatarsal angle on the dorsoplantar projection (TFM-DP) were measured for both clubfeet and control groups. Laaveg-Ponseti functional rating system was used for clinical evaluation and measurement of lower leg circumference was used for detection of atrophy. RESULTS: The average age was 21.5 years (range 19-34). The mean TC-DP angle was 16.97 in the clubfeet group and 21.03 in the control group. The mean TC-L angle was 23.34 in the clubfeet group and 33.98 in the control group. The mean TFM-DP angle was 9.02 in the clubfeet group and 7.9 in control group. There were statistically significant difference between clubfoot and control groups regarding the TC-DP angle and the TC-L angle. The average Laaveg-Ponseti score was 74 points (range 42-96). While no significant correlations could be detected between the TC-DP angle, the TC-L angle, the TFM-DP angle and the functional score, a significant correlation was detected between circumferential measurement of lower leg and functional score (p = 0.04). CONCLUSION: Functional outcome may be affected by lower leg muscular atrophy instead of foot alignment disturbance. Lastly we believe that results for treatment of clubfoot-a three-dimensional deformity-need to be evaluated with three-dimensional imaging techniques.

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Paget's disease of the bone is a focal chronic disorder proceeding with elevated osteoblastic and osteoclastic activity in the affected area. The most common sites are pelvis, femur, lower lumbar vertebrae and skull. Monostotic disease is reported in 15-30% of all cases. We report a case of monostotic Paget's disease of the second metacarpal, which is a rare location even for polyostotic disease.

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PURPOSE: Quadriceps tendon grafts have renewed interest for ACL reconstruction; however, biomechanical studies comparing anatomic single-bundle (SB) and double-bundle (DB) reconstruction techniques are rare. The purpose of this study was to compare the knee biomechanics in four different types of anatomic ACL reconstruction techniques, using the quadriceps tendon in a human cadaver. METHODS: Four different tibial (T) and femoral (F) tunnel configurations, (a) DB-2F-2T, (b) DB-2F-1T, (c) SB-1F-1T and (d) DB-1F-2T, were used for ACL reconstruction using the split quadriceps tendon with patella bone. Ten cadaver knees were subjected to an 89 N anterior tibial load and combined 7 N m valgus and 5 N m internal torques. The anterior tibial translation (ATT) and in situ force were measured using a robotic system for the ACL-intact, ACL-deficient and ACL-reconstructed knees. RESULTS: DB reconstructions mostly restored ATT to the intact ACL. The in situ forces under the anterior load in the DB reconstructions were similar to the intact ACL, but that of the SB reconstruction was different at 30°, 60° and 90° of flexion (P < 0.05). Under combined torques, the in situ force of the SB graft was less than that of intact ACL at 0°, 15° and 30° of knee flexion (P < 0.05), while that of the ACL DB reconstruction was similar to the intact ACL. CONCLUSION: DB ACL reconstruction using quadriceps tendon can restore biomechanics of the knee to that of the intact ACL regardless of whether three or four tunnels are used, but SB reconstruction does not.

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This is a case of a 17-year-old boy who was admitted to the clinic suffering from right hip-inguinal region pain which began after a soccer match. He had an avulsion fracture in the anterior inferior iliac spine and CT/MR images showed similarities to a bone tumor. These fractures are especially seen in the apophyses which are within the ossification process. The radiological appearance of these fractures during the healing period may be involved with bone tumors. In the control MRI of the patient after one year, the fracture was almost healed completely. Treatment is generally conservative. Good results have been reported with rest, analgesic and anti-inflammatory drugs. Familiarity with radiological findings of these avulsion fractures in this region not only protects the patient from invasive procedures but also avoids the involvement of the practitioner in legal consequences resulting from a misdiagnosis of sarcoma.

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INTRODUCTION: Perilunate dislocations represent one of the most devastating injuries to the carpus. Fortunately, these injuries are relatively rare, constituting approximately 10% of all carpal injuries. One of the problems associated with this injury is the difficulty of its accurate and early recognition. PRESENTATION OF CASE: In this study, an uncommon case of bilateral dorsal trans-scaphoid perilunate fracture-dislocation following trauma has been reported. The injury was missed initially and the patient was subsequently operated after two weeks. Anatomic reduction was achieved by closed reduction. After closed reduction, percutaneous pin fixation of the carpus was performed using Kirschner wires. Finally, the scaphoid was stabilized with a headless screw percutaneously. The same procedure was repeated for the other wrist. This was followed by an uneventful post-operative period, with a satisfactory functional outcome at the two-year follow-up, despite non-union of the scaphoid in one side. DISCUSSION: The case was examined in detail, and compared to the findings in the literature; observations regarding fracture prognosis were also made. Most authors agree that closed reduction is the initial treatment of choice for trans-scaphoid perilunate fracture-dislocations. In addition, treatment often requires intercarpal fixation within the proximal carpal row. CONCLUSION: We believe that closed reduction in these cases should be attempted regarding the potential risks of avascular necrosis and non-union of the affected carpal bones due to open reduction.

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OBJECT: Nerve compressions due to osteochondromas are extremely rare. The aim of this retrospective study was to investigate the mechanisms, diagnostic evaluations, and treatment of nerve lesions due to osteochondromas, and to review the literature. METHODS: The authors retrospectively reviewed their clinic data archive from 1998 through 2008, and 20 patients who were operated on due to peripheral nerve injuries caused by osseous growth were enrolled in the study. Patients' age, duration of symptoms, localizations, intraoperative findings, and modified British Medical Research Council (MRC) and electromyography data obtained from hospital records were evaluated. The literature on this topic available in PubMed was also reviewed. All 20 patients underwent surgery, which consisted of tumor excision performed by orthopedic surgeons and nerve decompression performed by neurosurgeons. RESULTS: There were 17 men and 3 women included in the study, with a mean age of 21 years (range 18-25 years). Three patients had multiple hereditary exostoses, and 17 had a solitary exostosis. All of the patients underwent en bloc resection. The most common lesion site was the distal femur (45%). The peroneal and posterior tibial nerves were the structures that were affected the most frequently. The mean follow-up was 3.9 years (range 2-7 years). After the surgery, all patients (100%) experienced good sensory recovery (modified MRC Grade S4 or S5). CONCLUSIONS: To the authors' knowledge, no large series have reported peripheral nerve compression due to exostoses. The authors have several recommendations as a result of their findings. First, all patients with peripheral nerve compression due to an osteochondroma should undergo surgery. Second, preoperative electromyographic examinations and radiographic evaluation, consisting of MRI and CT to provide optimal information about the lesion, are crucially important. Third, immediate treatment is mandatory to regain the best possible recovery. And fourth, performing nerve decompression first and en bloc resection of osteochondroma consecutively in a multidisciplinary fashion is strongly recommended to avoid peripheral nerve injury.

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OBJECTIVE: The aim of this study was to evaluate the demographic characteristics of patients with bilateral bisphosphonate-related low-energy femoral shaft fractures. METHODS: The clinical registry was reviewed for patients with bisphosphonate-related low-energy fractures localized at femoral shaft between January 2008 and January 2012. Patients with a diagnosis of postmenopausal osteoporosis, bisphosphonate usage of at least 5 years and prodromal pain prior to fracture were included the study. RESULTS: Five women met the inclusion criteria. All patients had bilateral low-energy sequential femoral shaft fractures. Fracture patterns were similar and atypical (transverse-short oblique fractures with lateral cortical thickening). Mean period of bisphosphonate treatment was 8.6 years. Mean patient age was 76.2 years. Union time of three patients was between 20 and 28 weeks. The remaining two fractures were revised for delayed union or nonunion. CONCLUSION: Long-term (over 5 years) use of bisphosphonates may cause insufficiency fractures due to increased fragility and brittleness which have a close relationship with depressed bone remodeling. While there is still no causal relationship between bisphosphonates and atypical, low-energy femoral shaft fractures, we have some concerns about the optimal usage time and long-term safety of bisphosphonate drugs.

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The elbow is the second most commonly dislocated joint in adults. Simple lateral dislocation of the elbow joint is a rare traumatic injury, and successful closed reduction is difficult and even rarer. Our proposition is to report this rare case of traumatic simple lateral dislocation treated with closed reduction under sedation emphasizing the use of this simple technique initially in order to avoid possible complications with general anesthesia and surgery.

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INTRODUCTION: Notchplasty is frequently performed by many orthopaedic surgeons during anterior cruciate ligament (ACL) reconstruction. The effect of notchplasty on tunnel placement and knee biomechanics with ACL reconstruction is not known. METHODS: Twelve (n = 12) porcine knees were tested using a robotic testing system. Four knee states were compared: (1) intact ACL, (2) ACL-deficient, (3) anatomic single bundle (SB) ACL reconstruction and (4) anatomic SB ACL reconstruction with a 5-mm notchplasty. The graft was fixed at 60° of flexion (full extension of porcine knee is 30°) with an 80-N tension. The knees were subjected to two loading conditions: an 89-N anterior tibial load (ATT) and 4 Nm internal (IR) and external tibial (ER) rotational torques. The kinematics and in situ force obtained from the different knee conditions were compared. RESULTS: There were no significant differences between pre- and post-notchplasty in the ER at 30° and 60° of knee flexion (n.s.). However, a significant difference was found between pre- and post-notchplasty in ATT at 30° and 60° of flexion (p < 0.05). The in situ force in the anatomic SB reconstruction with notchplasty was significant lower than the intact and anatomic reconstructed ACL pre-notchplasty at 30°, 60° and 90° of knee flexion (p < 0.05). In response to the IR tibial torque, there were significant differences between pre- and post-notchplasty in IR at 60° (p < 0.05) of knee flexion. CONCLUSION: Notchplasty had greater effect on anterior stability than rotational stability. This change in knee kinematics could be detrimental to a healing bone graft, ligamentization and could lead to failure of the reconstruction in early post-operative period.

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OBJECTIVES: This study aims to prospectively analyze of the long-term results of the Colville's technique for the treatment of chronic lateral ankle instabilities. PATIENTS AND METHODS: Twenty-eight ankles of 28 male patients (mean age 24.6 years; range 20 to 35 years) which were treated using Colville's technique were evaluated with a mean follow-up of 76.1 months (range 60 to 106 months). Ankle instability, ankle functions and outcomes in the last visit were assessed and statistically compared. Stress radiographs with the TELOS device were repeated at six-months and five-years after surgery and compared with the stability of the uninjured ankle. RESULTS: Twenty-three of the results were excellent and five were good according to the criteria of Chrisman and Snook. All patients returned to normal daily activity levels at an average of eight months following surgery. Radiographic analysis revealed the significant preservation of stability at least five years after surgery with no sign of arthritis. The difference between preoperative and sixth-months postoperative values of both the talar tilt and the anterior draw tests were found statistically significant, indicating significant correction of the laxity. On contrary, difference between sixth months and five year values were not statistically significant, indicating the preservation of the correction. CONCLUSION: Anatomical augmented reconstruction procedure of Colville's is a long-lasting and good alternative compared to other more complex techniques of reconstruction with minimum long-term complications.

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Skin grafts and local flaps are conventional methods of repair for congenital syndactyly, but the results obtained are not always as functional and aesthetic as desired and frequently leave postoperative scars and residual syndactyly. In this article, we describe a new surgical technique for web reconstruction in the correction of simple, incomplete syndactyly. The technique consists of a dorsal separated V-Y advancement flap and a volar triangular flap to cover the newly created web space, thus avoiding skin graft in this space. In all, 15 web spaces in 10 patients were treated using this method. A follow-up period of 6 months to 2 years showed neither recurrence of the deformity nor web creep of any degree. The technique is rapid, safe, easily performed, and reproducible and requires a single surgical procedure. It uses donor tissue identical in color, texture, and thickness, which renders acceptable cosmesis in cases of simple, incomplete syndactyly, therefore, avoiding the use of skin grafts and resulting postoperative scar contracture in the web space.

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The surgical procedures for unicameral solitary calcaneal bone cysts have ranged from simple curettage and grafting to subperiosteal resection with internal fixation and grafting. In this article, an endoscopically assisted technique is proposed for the curettage of a simple calcaneal cyst that takes advantage of direct visualization of the cyst wall and contents and permits accurate assessment of the extent of the lesion. After curettage, percutaneous filling of the defect with corticocancellous allograft makes the technique a complete, minimally invasive surgical approach for this condition. The technique uses 2 lateral portals, one for viewing and the other for manipulation, both of which are created under fluoroscopic control. Once the cyst has been located, the 30 degrees arthroscope is used to evacuate fluid, after which more solid cyst contents are fragmented and removed. Thereafter, curettage of the inner surface of the cavernous cyst wall is performed. Finally, complete packing of the previously cystic cavity with crushed corticocancellous allograft is performed under endoscopic visualization and confirmed radiographically.

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Fillet flaps harvested from the non-replantable or unsalvageable amputated segment can be used to cover tissue defects. We discuss the case of a patient who had suffered a severe high-energy landmine injury, including severe leg damage, resulting in a below-knee amputation and soft-tissue defect around the forearm region. We successfully harvested the fillet from the amputated part of the extremity to the forearm region. We conclude that harvesting of a fillet flap from severely injured lower extremity, resulting from a high-energy landmine explosion, is technically feasible.

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