A Quality Improvement Project for Safe and Effective Patient Positioning During Robot-Assisted Surgery

During the initiation of a new robotic surgery program, a quality improvement team explored different techniques for positioning patients in the lithotomy and steep Trendelenburg position during robot-assisted procedures. Concerns associated with placing patients in the steep Trendelenburg position include the patient slipping toward the head of the bed and experiencing hemodynamic changes that may result in a rise in blood pressure, increased intraocular and intracranial pressures, and difficulty with ventilation, particularly in patients with a high body mass index. Skin integrity is also of concern because perioperative personnel are responsible for protecting the patient's skin from excessive sheer, friction, and injury. The quality improvement team evaluated and compared two positioning devices: an air-inflated positioning device and high-density foam padding. Both methods allowed personnel to position the patient without compromise; the surgeons performing the robot-assisted procedures preferred the high-density foam padding.     

Perioperative Care of the Morbidly Obese Patient in the Lithotomy Position

The lithotomy position is used daily in the OR to position patients for vaginal, rectal, and urologic procedures. Use of this position requires a careful nursing assessment to ensure that the patient can tolerate having his or her legs placed in the stirrups and to ensure that no pressure points exist for the duration of the surgery. Caring for a patient who is morbidly obese and who requires surgery in the lithotomy position can be especially challenging, and the possibility of injury to the patient or staff members should be considered. A case study involving the care of a patient who weighed almost 600 lb undergoing surgery in the lithotomy position demonstrates ways to provide safe care for this type of challenging patient.     

Thrombosis of external iliac and common femoral arteries secondary to blunt trauma due to handlebar injury

BackgroundVascular injuries are uncommon following a bicycle handlebar injury in children. However, they are associated with an extremely high morbidity including limb loss and asymmetric limb growth.Case presentation11 year old previously healthy female who presented to a pediatric emergency department immediately after sustaining blunt trauma to her abdomen by a bicycle handlebar. She complained of pain in her right lower extremity without paresthesia and was noted to have a painful superficial laceration to the right lower abdomen with tenderness on palpation. The extremity was noted to be mottled, cool to touch, with decreased sensations and delayed capillary refill but intact motor function. The peripheral pulses in the extremity were noted to be absent on exam, which was confirmed by a bedside Doppler. A Computed Tomography Angiography (CTA) of the abdomen and pelvis revealed an occluding thrombus in the external iliac and right common femoral arteries which required surgical repair. She subsequently developed occlusion secondary to traumatic dissection and compartment syndrome in the same extremity requiring repeat surgical intervention.ConclusionIn managing patients with blunt force trauma to the abdomen from handlebars, clinicians should have a high index of suspicion for vascular injuries even with low-risk mechanism of injury and superficial injuries noted on exam. Their assessment should include immediate examination of bilateral peripheral pulses of the lower extremities to evaluate for clinical findings associated with acute lower limb ischemia as well as bedside Doppler exams and early consideration of CTA to assess for occult vascular injury.     

Injury Prevention in Baseball: from Youth to the Pros

Purpose of Review

This review examines recent literature on injury epidemiology and prevention in the sport of baseball from youth to professional levels.

Recent Findings

Overuse is the predominant mechanism of injury in youth baseball players. Newer stretching and exercise protocols may help prevent these injuries. At the professional level, however, overuse has not been proven to correlate with increased injury incidence, but pitch counts are still monitored. There continues to be a rise in operations performed for baseball-related injuries, including ulnar collateral ligament (UCL) reconstruction, particularly in younger athletes. As the level of play increases, there is significant loss of participation due to injuries, such as the UCL in the upper extremity and the hamstrings in the lower extremity.

Summary

Baseball is a widely popular sport, which has led to a focus on injury epidemiology and prevention. While the majority of research regarding baseball injuries focuses on pitchers, fielders and catchers are also at risk. In an attempt to decrease non-contact injuries in the upper and lower extremities, stretching and strengthening exercises are vitally important. Because injury profiles demonstrate significant variability from youth to professional baseball, unique prevention strategies are likely necessary at each level. More research is needed to develop and validate appropriately targeted injury prevention programs.

     

改良手术截石位托腿架在手术中的应用

目的探讨改良截石位托腿架在手术体位摆放中的应用,旨在比较对照组与实验组体位架优势。方法将38例截石位手术患者分成两组,对照组和实验组。每组各19例,对照组采用传统手术体位托腿架,实验组用改良手术托腿架。通过彩色多普勒测定,监测腘静脉直径、平均血流速度及血流量,术后了解下肢腓总神经损伤情况。结果对照组中腘静脉直径显著增大,与实验组比较差异有统计学意义(P0.01),平均血流速度及血流量显著减少,与实验组比较差异也有统计学意义(P0.01);术后下肢疼痛、麻木等不良反应显著高于实验组,差异有统计学意义(P0.05)。结论实验组优于对照组,其优势在于有利于血液的回流,可改善因体位导致血液回流不畅,降低术后下肢深静脉血栓发生的风险,减少腓总神经损伤;同时减少了因操作不当引起的护理纠纷,确保了手术患者的生命安全。     

Identifying Risk Factors of Upper Extremity Injuries in Collegiate Baseball Players: A Pilot Study

BackgroundRepetitive pitching places tremendous forces on the shoulder and elbow which can lead to upper extremity (UE) or lower extremity (LE) overuse injuries.PurposeThe purpose of this study was to evaluate pre-season physical measurements in collegiate baseball players and track in-season baseball throwing volume to determine which factors may predict throwing overuse injuries.Study DesignRetrospective Cohort study.MethodsBaseline preseason mobility, strength, endurance, and perception of function were measured in 17 collegiate baseball pitchers. Participants were then followed during the course of the season to collect rate of individual exposure, estimated pitch volume, and rating of perceived exertion in order to determine if changes in workload contributed to risk of injury using an Acute-to-Chronic Workload ratio (ACWR).ResultsParticipants developing an injury had greater shoulder internal rotator strength (p=0.04) and grip strength in a neutral position (p=0.03). A significant relationship was identified between ACWR and UE injuries (p <0.001). Athletes with an ACWR above or below 33% were 8.3 (CI₉₅ 1.8-54.1) times more likely to suffer a throwing overuse injury occurring to the upper or lower extremity in the subsequent week.ConclusionACWR change in a positive or negative direction by 33% was the primary predictor of subsequent injury. This finding may assist sports medicine clinicians by using this threshold when tracking pitch volume to ensure a safe progression in workload during a baseball season to reduce the risk of sustaining overuse upper or lower extremity injuries.Level of Evidence3b     

Pickleball-Related Injuries Treated in Emergency Departments

BackgroundPickleball is a paddle sport that combines many of the elements of tennis, badminton, and ping-pong. It is reported to be one of the faster growing sports in the United States and is popular among older adults. There is limited published information on pickleball-related injuries.ObjectiveThe objective of this study was to describe pickleball-related injuries treated in U.S. emergency departments (EDs).MethodsAn analysis was performed of pickleball-related injuries using data from the National Electronic Injury Surveillance System (NEISS) of the U.S. Consumer Product Safety Commission during 2001–2017.ResultsA total of 300 pickleball-related injuries were identified, resulting in a national estimate of 19,012 injuries. The annual estimated number of injuries increased during 2013–2017. Patients 50 years or older accounted for 90.9% of the patients; 50.4% were male. The injury occurred at a sports or recreational facility in 74.3% of the cases. The most common injuries were strain or sprain (28.7%) and fracture (27.7%). The affected body part was the lower extremity in 32.0% of the cases and upper extremity in 25.4%. The patient was treated or evaluated and released from the ED in 88.0% of the cases.ConclusionsBased on NEISS data, pickleball-related injuries have been increasing in recent years. Although pickleball-related injuries have many similarities with those associated with other racquet sports, there were various differences (e.g., increasing trend and older patient age) that may need to be considered for the prevention and management of injuries related to the sport.     

不同体位护理在持续性枕横位和枕后位高龄产妇足月妊娠分娩中的应用效果

目的探讨不同体位护理在持续性枕横位和枕后位高龄产妇足月妊娠分娩中的应用效果。方法选取我院2019年4—10月收治的持续性枕横位和枕后位高龄足月妊娠产妇90例作为研究对象。将产妇按照第二产程胎头拨露或着冠时体位的差异分成坐位组、站位组、跪趴位组、蹲位组、侧卧位组和截石位组6个组,各15例。比较各组分娩方式,产程时间,产后2 h疼痛、焦虑情况,并记录会阴损伤情况以及新生儿窒息情况。结果侧卧位组顺产人数占比高于截石位组,而剖宫产人数占比低于截石位组(P<0.05)。坐位组、站位组、跪趴位组、蹲位组、侧卧位组第一产程、第二产程时间短于截石位组,而侧卧位组第一产程、第二产程时间均短于坐位组、站位组、跪趴位组、蹲位组(P<0.05)。侧卧位组产后2 h疼痛、焦虑评分低于坐位组、站位组、跪趴位组、蹲位组、截石位组(P<0.05)。侧卧位组产后会阴损伤人数占比低于坐位组、站位组、跪趴位组、蹲位组、截石位组(P<0.05)。结论侧卧位在持续性枕横位和枕后位高龄产妇足月妊娠分娩中的应用效果明显,有利于降低剖宫产以及会阴损伤发生率,同时缩短产程时间,缓解产妇的产后疼痛、焦虑情况,值得临床推广应用。     

Injury patterns related to ultralight aircraft crashes

Purpose

Flying ultralight aircraft is a popular and growing form of recreation. However, there is considerable risk involved in this activity. This study was undertaken to catalogue the injury patterns, surgical procedures, and complications of patients involved in ultralight crashes in southwest Michigan.

Basic procedures

The trauma registry at Bronson Methodist Hospital was used to retrospectively identify all ultralight crashes between 1983 and 2006. All patients who survived to the hospital were included in the study.

Main findings

Seventeen patients were identified, all males with a mean age of 48.5 years. Mean injury severity score was 23, with all patients sustaining multiple injuries. Mortality was 17%. Lower extremity fractures were most common, followed by head/neck/facial injuries. Orthopedic extremity procedures were most commonly performed.

Principal conclusions

Ultralight crashes result in complex high-energy injury patterns. These patients are likely to require the resources of designated trauma centers. Increased oversight may help prevent ultralight-related injuries.     

改良截石位联合自制棉套预防妇科腹腔镜手术患者下肢并发症的效果

目的探讨改良截石位联合自制棉套预防妇科腹腔镜手术患者下肢并发症的效果。方法将320例行腹腔镜下广泛全宫切除和深部浸润型子宫内膜异位症病灶切除手术患者随机分为实验组和对照组,每组各160例。对照组患者采用传统截石位,单纯使用绿洲立体轮廓垫保护小腿及腘窝处,实验组在对照组基础上调整髋关节和膝关节角度,使用绿洲立体轮廓垫和自制棉套保护小腿及腘窝处。比较两组患者术后足背温度,足部皮肤颜色变化及并发症发生情况。结果术后两组患者足背温度比较,P0.01,差异具有统计学意义,实验组明显高于对照组;术后两组患者足部皮肤苍白、压红,疼痛、肿胀麻木发生率比较,均P0.05,差异具有统计学意义,实验组明显低于对照组。结论改良截石位联合自制棉套保护小腿及腘窝处可有效预防下肢并发症,提高患者舒适度,值得临床推广应用。     

Elbow flexion contractures in brachial plexus birth injury: function and appearance related factors

Abstract

Purpose: The purpose of this study was to identify the functional and aesthetic factors associated with an elbow flexion contracture in children with a brachial plexus birth injury who identified their elbow flexion contracture as a problem.

Materials and methods: A retrospective cross-sectional study of children with brachial plexus birth injury between 7 and 18 years was conducted to compare the characteristics of children who had treatment for an elbow flexion contracture with those who did not.

Results: Fifty of the 200 children included in the study had treatment (one surgical release, 49 serial casting/splinting) for the elbow flexion contracture. Children who had treatment were an average 12.4 years of age, which was significantly older than those who did not have treatment. Elbow extension passive range of motion was an average ?40.6° prior to treatment. Stepwise logistical regression model indicated that children who had treatment had greater severity in elbow contracture, higher Brachial Plexus Outcome Measure Activity scores, and lower Brachial Plexus Outcome Measure Self-Evaluation Appearance scores.

Conclusions: In addition to severity of contracture and function, perceived appearance of the limb is important factor to evaluate in the management of elbow flexion contractures.

• Implications for rehabilitation

• Priority is often given to evaluate the functional implications of elbow flexion contractures in brachial plexus birth injury to determine recommendations for rehabilitation interventions such as serial casting and splinting.

• Findings in this study indicate that severity of contracture, upper extremity activity function, and perceived upper extremity appearance are important factors in the management of elbow contractures.

• In addition to upper extremity function, routine evaluation of perceived upper extremity appearance in children and adolescents is important in the management of elbow flexion contractures.

     

The Non-injured Leg Can Be Used as a Reference for the Injured Leg in Single-legged Hop Tests

BackgroundSingle-legged hop tests are frequently used in substantiating return to sport decisions following lower extremity injury. Evidence for using the non-injured leg as a reference for the injured leg in the return to sport decision-making at the criterion-based point of return to sport following lower extremity injury is lacking.PurposeTo compare absolute values in single-legged hop tests between the non-injured leg of athletes returning to high-impact sports after lower extremity injury and the matched leg of healthy athletes.Study DesignCross-sectional study.MethodsOne hundred and sixty-nine athletes returning to high-impact sports after lower extremity injury and 169 matched healthy athletes executed five single-legged hop tests. Differences between athletes returning to high-impact sports after lower extremity injury and matched healthy athletes on five single-legged hop tests were analyzed using paired t-tests.ResultsThere were no statistically significant differences between the non-injured leg of athletes returning to sport and the matched leg of healthy athletes. Effect sizes ranged from 0.05 to 0.14 indicating negligible effects.ConclusionClinicians can use the non-injured leg as a reference for the injured leg in single-legged hop tests for deciding on return to high-impact sports after lower extremity injuries.Level of Evidence3b     

Low-Voltage Electricity–Associated Burn Damage of Lung Parenchyma: Case Report and Literature Review

BackgroundElectrical injuries are common in daily life. The severity of electrical injury depends on the electric current, and assessing electrical damage is difficult because there appears to be no correlation between skin burns and visceral injury. We report a case of bilateral lung injury with pulmonary hemorrhage after exposure to low-voltage electricity.Case ReportA 23-year-old man was shocked by a low-voltage (110 V) electric current while at work. He had temporary loss of consciousness and twitching in the extremities, but soon regained consciousness and spontaneously stopped twitching. Electrical burn wounds were discovered on his back and forehead. Dyspnea and hemoptysis were noted. A computed tomography scan of the chest revealed patchy infiltration and consolidation of both lungs. The patient received treatment of tranexamic acid and prophylactic antibiotics for electricity-induced lung injury and pulmonary hemorrhage. Resolution of chest radiograph abnormalities was recorded on day 7. The mild dyspnea ceased approximately 2 weeks later.Why Should an Emergency Physician Be Aware of This?Electricity-induced lung injury should be considered in patients with electrical injury through a suspicious electrical current transmission pathway, respiratory symptoms, and corresponding imaging findings. Pulmonary complications can be serious and require early intervention.     

两种手术体位在胃肠外科腹腔镜手术中安全性的随机对照研究

目的探讨截石位和剪刀位在胃肠外科腹腔镜手术中的安全性。方法选择胃肠外科腹腔镜手术患者258例为研究对象,随机分为截石位组和剪刀位组,每组各129例。观察两组安置手术体位所耗时间、术毕体位恢复水平卧位时间、术后体位相关并发症(下肢深静脉血栓、肌力下降等),以及术后患者主观感受(下肢麻木、腿痛等)。结果截石位组安置体位所耗时间为(427±61)s,术毕体位恢复水平卧位时间为(252±57)s,剪刀位组安置体位所耗时间为(185±43)s,术毕体位恢复水平卧位时间为(144±47)s。与截石位组比较,剪刀位组体位安置时间和体位恢复水平卧位时间均明显缩短,差异有统计学意义(P0.05);截石位组发生1例下肢深静脉血栓,剪刀位组0例,差异无统计学意义(P0.05);截石位组肌力小于Ⅴ级7例,剪刀位组肌力小于Ⅴ级2例,差异有统计学意义(P0.05);术后第一天截石位组患者自述下肢麻木有23例,腿痛12例(疼痛评分3分3例、2分9例),剪刀位组患者自述下肢麻木6例,腿痛1例(疼痛评分3分0例、2分1例),差异有统计学意义(P0.05)。结论剪刀位较截石位应用于胃肠外科腹腔镜手术中,更加安全有效。     

Critical review of the impact of core stability on upper extremity athletic injury and performance

BACKGROUND:

Programs designed to prevent or rehabilitate athletic injuries or improve athletic performance frequently focus on core stability. This approach is based upon the theory that poor core stability increases the risk of poor performance and/or injury. Despite the widespread use of core stability training amongst athletes, the question of whether or not sufficient evidence exists to support this practice remains to be answered.

OBJECTIVES:

1) Open a dialogue on the definition and components of core stability. 2) Provide an overview of current science linking core stability to musculoskeletal injuries of the upper extremity. 3) Provide an overview of evidence for the association between core stability and athletic performance.

DISCUSSION:

Core stability is the ability to control the position and movement of the trunk for optimal production, transfer, and control of forces to and from the upper and lower extremities during functional activities. Muscle capacity and neuromuscular control are critical components of core stability. A limited body of evidence provides some support for a link between core stability and upper extremity injuries amongst athletes who participate in baseball, football, or swimming. Likewise, few studies exist to support a relationship between core stability and athletic performance.

CONCLUSIONS:

A limited body of evidence exists to support the use of core stability training in injury prevention or performance enhancement programs for athletes. Clearly more research is needed to inform decision making when it comes to inclusion or emphasis of core training when designing injury prevention and rehabilitation programs for athletes.