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Shoulder dislocations are among the most common orthopedic emergencies encountered in the emergency department (ED). Ultrasound-guided peripheral nerve blocks (USG-PNBs) are increasingly being used for acute pain management in the ED, but clinical evidence supporting their utility for shoulder dislocation is limited and often conflicting. The aim of this review was to summarize and evaluate the utility of USG-PNB for analgesia during closed reduction of dislocated shoulders in the ED. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search of the PubMed, Scopus, and Cochrane databases was performed from database inception to September 2022. We included clinical studies examining USG-PNB for pain management of dislocated shoulders in the ED. Information collected from eligible studies included patient demographic characteristics, USG-PNB approach, alternate analgesia techniques, anesthetic regimens, clinical outcomes, and adverse events. Five studies met inclusion criteria, all of which were randomized controlled trials comparing USG-PNB with procedural sedation and analgesia. Pooled patient satisfaction scores were similar for both analgesia methods (3.5 ± 0.6 vs. 3.9 ± 0.6 out of 5; p = 0.76). Patients managed with procedural sedation and analgesia achieved higher rates of overall shoulder reduction (100% vs. 67%; p < 0.001) and successful reduction on the first attempt (86% vs. 48%; p < 0.001). The USG-PNB groups in all but one study had shorter lengths of ED stay. Overall, USG-PNB was associated with a lower risk of adverse events and complications (3.9% vs. 24.9%; p < 0.001), especially adverse respiratory events (0% vs. 14.7%; p < 0.001). USG-PNBs performed by adequately trained emergency physicians should be considered a safe and effective alternative for analgesia during closed reduction of dislocated shoulders in the ED, particularly in patients with cardiorespiratory comorbidities. [ABSTRACT FROM AUTHOR]

Forearm chronic exertional compartment syndrome (CECS) can represent considerable functional impairment in certain active populations, particularly motorcycle racers. Patients with forearm CECS frequently require fasciotomy to relieve symptoms and return to sport (RTS).To evaluate the rate at which athletes RTS after fasciotomy for forearm CECS and to compare RTS outcomes between fasciotomy techniques.Systematic review; Level of evidence, 4.Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the PubMed, Scopus, and Cochrane databases was performed from database inception to December 2022 to identify all published reports of forearm CECS managed with fasciotomy. Included studies were analyzed for demographic information, surgical approaches, rehabilitation parameters, RTS rates, time from surgery at which athletes resumed sport, complications, and recurrence.A total of 38 studies (15 level 4 case series, 23 case reports) accounting for 500 patients (831 forearms) who underwent open fasciotomy (112 patients), minimally invasive fasciotomy (166 patients), and endoscopically assisted fasciotomy (222 patients) satisfied inclusion criteria. Most patients (88.0%) were motorcycle racers. The overall RTS rate at any level (RTS-A) was 94.2% (97.3%, 92.2%, and 98.5% for the open fasciotomy, minimally invasive fasciotomy, and endoscopically assisted fasciotomy groups, respectively; P = .010), and the overall RTS at preinjury level or higher was 86.8% (95.9%, 85.6%, and 95.2% for the open fasciotomy, minimally invasive fasciotomy, and endoscopically assisted fasciotomy groups, respectively; P = .132). There was a significant difference in RTS-A between the minimally invasive fasciotomy and endoscopically assisted fasciotomy groups (P = .004). The overall RTS time was 5.1 ± 2.3 weeks, patient satisfaction was 85.1%, and the recurrence rate was 2.4%, and there were no significant differences between fasciotomy approach groups (P = .456, P = .886, and P = .487, respectively).Patients who underwent fasciotomy for forearm CECS had high rates of RTS, quick RTS time, high levels of satisfaction, and low rates of recurrence. Outcomes were largely similar between the 3 fasciotomy approaches. [ABSTRACT FROM AUTHOR]

Background: Stress ultrasonography (SUS) has provided clinicians with an alternative means of evaluating ulnar collateral ligament (UCL) injury by dynamically assessing ulnohumeral joint space gapping under applied valgus stress. However, 3 previous cadaveric studies have evaluated the biomechanical effect of partial UCL tears at different anatomic locations with conflicting results. Purpose/Hypothesis: The purpose of this study was to use in vivo data from patients with magnetic resonance (MR)–confirmed partial UCL tears to determine if anatomic partial tear location influenced the resultant stability of the elbow in terms of ulnohumeral joint gapping on SUS. It was hypothesized that no difference would be seen in the amount of ulnohumeral joint gapping based on MR-identified anatomic partial UCL tear location. Study Design: Cohort study; Level of evidence, 3. Methods: All patients diagnosed with elbow injury from 2015 to 2020 were screened to identify competitive baseball pitchers with a partial UCL tear who received an SUS. Partial UCL tear was diagnosed via surgeon and radiologist interpretation of elbow MR imaging (MRI) as well as confirmation at the time of surgery as documented in the operative report. Demographic, injury, and treatment data were collected from the clinic notes, MRI reports, and stress ultrasound reports. Ulnohumeral joint gapping on SUS was calculated as the difference between ulnohumeral joint gapping without valgus stress versus ulnohumeral joint gapping with valgus stress (delta) as performed by a musculoskeletal radiologist. Results: Overall, 60 male baseball pitchers (age, 19.2 ± 2.1 years), including 22 (37%) high school, 26 (43%) collegiate, and 12 (20%) professional pitchers, were evaluated. Regarding the location of partial UCL tears, 32 (53%) pitchers had proximal tears and 28 (47%) had distal tears. The mean delta value cohort was 2.1 ± 1.1 mm, and 34 pitchers (57%) had delta values >2.0 mm. Ulnohumeral joint gapping (high school [1.9 mm] vs collegiate [2.6 mm] vs professional [1.6 mm]; P =.004) and the percentage of pitchers with delta values >2.0 mm (45% vs 77% vs 33%; P =.017) differed based on level of competition. After controlling for age, body mass index, and level of competition in a multivariate linear regression, tear location was not related to ulnohumeral joint gapping (P =.499). Conclusion: No difference was observed in the amount of ulnohumeral joint gapping on SUS in symptomatic baseball pitchers with MR-identified partial UCL tears at differing anatomic locations. The findings of this study are contrary to previous cadaveric studies that have evaluated the effects of UCL tear characteristics on delta laxity. [ABSTRACT FROM AUTHOR]

Severely ill patients with COVID-19 are challenging to sedate and often require high-dose sedation and analgesic regimens. Ketamine can be an effective adjunct to facilitate sedation of critically ill patients but its effects on sedation level and inflammation in COVID-19 patients have not been studied. This retrospective, observational cohort study evaluated the effect of ketamine infusions on inflammatory biomarkers and clinical outcomes in mechanically ventilated patients with SARS-CoV-2 infection. A total of 186 patients were identified (47 received ketamine, 139 did not). Patients who received ketamine were significantly younger than those who did not (mean (standard deviation) 59.2 (14.2) years versus 66.3 (14.4) years; P = 0.004), but there was no statistically significant difference in body mass index (P = 0.25) or sex distribution (P = 0.91) between groups. Mechanically ventilated patients who received ketamine infusions had a statistically significant reduction in Richmond Agitation-Sedation Scale score (–3.0 versus –2.0, P < 0.001). Regarding inflammatory biomarkers, ketamine was associated with a reduction in ferritin (P = 0.02) and lactate (P = 0.01), but no such association was observed for C-reactive protein (P = 0.27), lactate dehydrogenase (P = 0.64) or interleukin-6 (P = 0.87). No significant association was observed between ketamine administration and mortality (odds ratio 0.971; 95% confidence interval 0.501 to 1.882; P = 0.93). Ketamine infusion was associated with improved sedation depth in mechanically ventilated COVID-19 patients and provided a modest anti-inflammatory benefit but did not confer benefit with respect to mortality or intensive care unit length of stay. [ABSTRACT FROM AUTHOR]