Structures at Risk From an Intermetatarsal Screw for Lapidus Bunionectomy: A Cadaveric Study

The Lapidus bunionectomy is performed to treat hallux valgus. Recurrence of the deformity remains a concern. A transverse intermetatarsal screw spanning the base of the first metatarsal to the base of the second can increase stability. The neurovascular bundle is located within the proximity of this screw. In this study, we assessed the structures at risks with the use of this technique. In 10 specimens, a guide wire was placed, and a 4.0-mm cannulated screw was inserted. The neurovascular bundle was dissected and inspected for direct trauma to the neurovascular bundle, and the proximity of the screw was measured using a digital caliper. Ten cadaveric specimens were used. The dorsalis pedis artery and deep peroneal nerve were free from injury in 9 of 10 specimens. In those 9 specimens, the neurovascular bundle was located dorsal in relation to the screw. The mean distance of the screw to the neurovascular bundle was 7.1 ± 3.3 mm. The mean distance from the screw to the first tarsometatarsal joint (TMTJ) was 14.7 ± 4.3 mm. The mean distance from the screw as it entered the second metatarsal to the second TMTJ was 18.0 ± 7.2 mm. In 1 specimen, the screw was found to be traversing through the neurovascular bundle. The distance from the screw to the first TMTJ was 15.0 mm. The distance of the screw from where it entered the second metatarsal to the second TMTJ was 24.0 mm. Although the intermetatarsal screw avoided the neurovascular cases in most instances, there is some anatomic risk to the neurovascular bundle. Further study is warranted to evaluate clinical results using the intermetatarsal screw for the modified Lapidus procedure.     

Rural barriers to early lung cancer detection: Exploring access to lung cancer screening programs in New Hampshire and Vermont

BackgroundRural populations face many health disadvantages compared to urban areas. There is a critical need to better understand the current lung cancer screening landscape in these communities to identify targeted areas to improve the impact of this proven tool.MethodsData from the County Health Rankings of New Hampshire and Vermont was reviewed for population density, distribution of adult smokers, and level of education compared to the distribution of Lung Cancer Screening Facilities throughout these two states.ResultsScreening programs in southern counties of Vermont with lower levels of education have decreased access. In New Hampshire, there are no programs within 30 miles of the areas with the largest distribution of smokers, and decreased access in some areas with the lowest levels of education.ConclusionsImproving equitable access to high-quality screening services in rural regions and the creation of targeted interventions to address decreased access in areas of high tobacco use and low education is vital to decreasing the incidence of latestage presentations of lung cancer within these populations.     

Medical Child Abuse: An Unusual “Source” of Vaginal Bleeding

BackgroundMedical child abuse (MCA) is challenging to diagnose. Although young children are often affected, adolescents can be victims through caregiver coercion. Presentation is highly variable. Diagnosis is essential because of high associated morbidity and mortality.CaseWe describe the case of a 12-year-old girl who presented to multiple subspecialty clinics with reported menorrhagia. Despite reassuring clinical examinations, the family described menorrhagia that failed to respond to standard treatment. After an urgent evaluation for reported heavy bleeding revealed only scant blood, the diagnosis of MCA was made.Summary and ConclusionVaginal bleeding is a rare presentation of MCA, but must be considered whenever reported symptomatology does not follow physiologic patterns, respond to standard medical treatment, or correspond to clinical evaluation. Prompt identification is important to prevent further harm.