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Research Type: Level 4 – Case series Introduction/Purpose: Hindfoot nail placement can be challenging for several reasons including normal anatomic alignment. While commonly believed that nail alignment should be parallel with the tibial axis, in theory a straight nail aligned as such has either perforated the medial calcaneal or has resulted in varus malalignment and/or foot medialization. In this investigation we examine nail/tibial angulation utilizing computer-generated nail placements overlaid on WBCT scans of individuals with normal hindfoot alignment. Second, we determine the amount of iatrogenic hindfoot malpositioning that would be required if the nail were placed parallel to the tibial anatomic axis and within the calcaneal body. We hypothesize that valgus angulation of the nail is necessary to maintain normal hindfoot alignment while ensuring proper intraosseous placement. Methods: Fifty weightbearing computed tomography (WBCT) scans were utilized from patients (mean age 43.4 years) without pathologies and with clinically normal hindfoot alignment (mean hindfoot alignment angle: 3.8°; Meary’s angle: 5.3°). After cross-referencing axial, coronal, and sagittal reconstructions, a 10 mm computer-generated hindfoot nail was superimposed on the coronal view (Figure 1). First, the virtual hindfoot nail was positioned to ensure calcaneal intraosseous placement, defined as at least 2 mm of bone between the medial border of the nail and the medial calcaneal cortex. The angle between the tibial anatomic axis and the simulated nail was then measured. Second, the hindfoot nail was then repositioned to align centrally within the tibial intramedullary canal, parallel to the tibial axis. The frequency of medial calcaneal cortex breach and the distance between the medial calcaneal cortex and the center of the simulated nail were measured. Results: The simulated hindfoot nail required an average valgus of 5.1° (standard deviation[SD] 2.3) relative to the tibial anatomic axis to (1) ensure acceptable intraosseous positioning within the calcaneal body and (2) to maintain the patient’s native normal hindfoot alignment. When the simulated nail was realigned aligned parallel to the tibial axis and centered in the tibial canal, 49 of 50 patients demonstrated medial calcaneal cortical breach. The mean distance from the nail center to the medial calcaneal cortex was 3.8 mm, suggesting that 10.8 mm of iatrogenic medial foot translation would be necessary to preserve at least 2 mm of calcaneal osseous margin. Finally, >= 7.4° (mean+1SD) of iatrogenic varus hindfoot malalignment would be needed to ensure full intraosseous calcaneal placement without medial cortical breach. Conclusion: This study demonstrates that a valgus orientation of approximately 5° is needed for a straight hindfoot nail to (1) maintain proper calcaneal intraosseous placement and (2) preserve physiologic hindfoot alignment. Strictly aligning the nail with the tibial anatomic axis risks medial calcaneal perforation and/or can lead to >= 5° of iatrogenic varus hindfoot malalignment or >= 1.0cm of inappropriate medial foot translation. Incorporating a valgus angulation of the straight hindfoot nail relative to the tibial anatomic axis appears necessary for safe intraosseous positioning and to maintain normal hindfoot alignment.

Category: Trauma Introduction/Purpose: Surgical fixation of Jones fractures is often recommended to facilitate recovery and achieve union. Iatrogenic fracture displacement during intramedullary screw fixation is a commonly encountered technical issue. This may be related to fracture location in relation to the surrounding ligamentous attachments, namely the robust intermetatarsal ligaments found at the proximal articulation of the 4th and 5th metatarsals. This study examines the relationship between fracture line and its location in regards to the surrounding ligamentous structures and its effect on Jones fracture displacement, reduction and fixation in a cadaveric model. Methods: Eighteen fresh-frozen cadaveric feet were dissected with preservation of all ligamentous attachments. Given the similar anatomic distal extent of the dorsal and plantar intermetatarsal ligaments on the 5th metatarsal, measurements were obtained detailing the anatomic position of the dorsal intermetatarsal ligament (DIL) only. The specimens were divided into two groups with modelled fractures created at the 4th & 5th metatarsal articulation proximal to the distal extent of the DIL (Group 1) or just distal to the DIL (Group 2). Fractures were fixed in standard fashion with serial fluoroscopic images obtained to study fracture gapping and rotation. Results: There was approximately 5 mm of fracture gapping created iatrogenically during tapping with no statistically significant differences between Group 1 and Group 2 (4.53 mm versus 5.25 mm, p=0.5430). The distal aspect of the DIL was anatomically located 2.77 mm (Range 1.58 mm – 4.46 mm) distal to the 4th & 5th metatarsal articulation. Conclusion: Considerable iatrogenic fracture gapping occurs during intramedullary screw fixation of Jones fractures in a cadaveric model regardless of fracture location in relation to the intermetatarsal ligamentous attachments. Intraoperative displacement may be related to iatrogenic distraction caused by canal tapping when utilizing a common surgical method. Specific techniques may be required to maintain anatomic alignment during tapping and screw fixation to prevent iatrogenic displacement.

Training curricula and healthcare delivery should align with patients’ needs. Balance complaints are the second commonest complaint in general neurology clinics. That vestibular neurology is not core in the UK neurology training curriculum, serves our patients poorly. Why so? First ‘neuro-otology’ indicates an ear problem. However, most of the vestibular system is ‘central’, and the commonest diagnoses are brain-related. Second, few neurologists are exposed to tertiary vestibular neurology, so under-appreciate what is possible for balance patients. Diagnostic clarification for complex cases allows us to treat the treatable and leave alone the untreatable – simultaneously providing benefit and avoiding iatrogenic harm. In hyperacute vestibular syndromes, expert clinical assessment is diagnostically superior to DWI-MRI. But such expertise is acquired as an apprenticeship not realisable for most given the lack of centres, partly from the superficiality of the required vestibular competency. Vestibular neurology is enjoyable, hands-on and cross-cutting, with huge variety. From cerebellar ‘DBN’ syndromes, bilateral vestibular failure, neurodegeneration and falls, functional dizziness ‘PPPD’ (mostly iatrogenic in genesis), brainstem syndromes in MS/neuroinflammation with imbalance/eye-movement problems, complex TBI vestibular dysfunction with vestibular agnosia, to holistic balance assessments in elderly fallers. It’s time we match our training and skills to patients’ needs.bmseem@ic.ac.uk

INTRODUCTION:Rapidly expanding lingual hematoma can result in life-threatening airway compromise. We describe a rare case of iatrogenic large tongue hematoma in a patient on Rivaroxaban after securing the endotracheal tube tightly with a thread for an ERCP.CASE DESCRIPTION/METHODS:An 82-year-old male with history of atrial fibrillation on rivaroxaban, and newly-diagnosed adenocarcinoma of the pancreatic head. He had recently undergone endoscopic placement of an uncovered self-expanding metal metal stent (SEMS), and after deployment, a very tight waist was noted. He presented to the emergency department 5 days after ERCP with vomiting and fever. Laboratory data were significant for AST 3075 IU/L, ALT 1311 IU/L, ALP 1432 IU/L, and total bilirubin of 10.4 mg/dL. CT abdomen and pelvis showed evidence of possible biliary stent occlusion versus incomplete expansion. An ERCP was performed during which a plastic stent was inserted through the SEMS. The day after the procedure, the patient developed tongue swelling and speech difficulty. IV diphenhydramine was administered with no improvement. An emergent flexible nasolaryngoscopy was performed demonstrating tongue edema with dark red/black discoloration extending to the floor of the mouth and swelling of the aryepiglottic folds (Figure 1a). He was treated with IV dexamethasone, famotidine, and diphenhydramine, and was transferred to the ICU for closer observation. The hematoma was thought to have resulted from tightly securing the endotracheal tube with a thread during the ERCP (Figure 2b). The patient was observed for 24 hours in the ICU after which he improved clinically and tongue swelling subsided without need for further intervention.DISCUSSION:This case illustrates a rare and a serious iatrogenic injury to the tongue as a result of securing the endotracheal tube too tightly with a thread. Lingual hematoma should be identified early to avoid impending airway compromise. Recognition of this potential complication by anesthesiologists and interventional endoscopists is necessary to prevent it.

IntroductionCT-guided lung biopsy (CTGB) is a minimally invasive procedure that enables histological diagnosis and aids with personalized patient care. However, this procedure has its own significant risks and complications with pneumothorax being the commonest complication. We present the important characteristics of patients that developed pneumothorax in our tertiary care centre caused as a result of CTGB.MethodsA retrospective analysis of all requests for CTGB lung from 1/01/2023 till 31/12/2023 was conducted. This service is provided 5 days a week in our busy tertiary care hospital. Total number of patients undergoing procedure and developing pneumothorax were identified and common characteristics were recorded in patients that developed pneumothorax in detail. The management of the iatrogenic pneumothorax was also studied.ResultsOf the 173 patients that underwent CTGB, 53 (30.63%) developed iatrogenic pneumothorax. Majority of these patients (n=34, 64.15%) were managed conservatively. However, 19 patients had interventions (35.84%). 44 patients developed small pneumothorax (83.01%), 5 had large (9.43%) with 4 moderate pneumothoraxes (7.54%) as per radiological reports and features.23 patients who developed pneumothorax had background emphysema (43.39%) whilst 30 did not have emphysema (56.60%). The mean age of patients developing pneumothorax was 71 years. 33(62.26%) of them were male patients and 20 were females (37.73%).The most common position for the nodules in patients developing pneumothorax was RUL (n=18) followed by RLL (n=14), LLL (N=10), LUL (N=9) and RML (N=2). Majority of lesions were >3 cm (N=39), followed by lesions 1–2 cm (N=12) and there was 1 lesion that was 2–3 cm. In 5 patients the lesions were crossing the fissure whilst it was not crossing in 43 patients. 40 (75.47%) patients with iatrogenic pneumothorax had their lung functions recorded before the CTGB. FEV1 was >80% in 24 patients and between 50–80% in 16 patients.Abstract P82 Figure 1[Image Omitted. See PDF.]ConclusionIatrogenic pneumothorax is a well recognised complication of CTGB which can lead to invasive interventions, the rates of invasive interventions being variable in different centres and hospital admissions. We provided an overview of the common important risk factors and characteristics of patients that developed iatrogenic pneumothorax from our cohort.

BackgroundCardiac tamponade is a life-threatening and challenging condition involving fluid accumulation in the pericardium. Coroners in the United Kingdom must write publicly available preventing future deaths (PFD) reports if they identify contributing factors that could prevent recurrence of mortality. We sought to analyze these reports for cardiac tamponade.MethodsWe formulated new software to download and extract PFD reports’ text data using Pdfminer and Pytesseract for 4650 reports from 01/08/2013 to 07/10/2024. We processed and indexed the data to make it searchable with Tantivy, and searched for ‘cardiac tamponade’ and ‘tamponade’.ResultsWe identified 13 PFD reports accounting for 15 total deaths mentioning cardiac tamponade. Of these 15 deaths, cardiac tamponade was the cause of death in 11, and incidental in the remaining 4. Where directly attributable, 6 (55%) of cardiac tamponade deaths were at the management level, secondary to iatrogenic injury judged to be avoidable. Four of these were among neonates during central line insertion for umbilical venous catheterization. The other two were during insertion of a pacemaker and pacing wires for percutaneous coronary intervention. Four cases were at the diagnosis level: two premature discharges resulted in out-of-hospital sudden death secondary to tamponade from a missed aortic root aneurysm and dissection, another was due to missed heart failure from sepsis leading to tamponade, while the fourth was a missed ventricular fibrillation secondary to aortic dissection and resulting tamponade. The final preventable death was at the public health level, where the improper layout of a road junction led to a motor vehicle collision causing a traumatic tamponade.ConclusionIatrogenic injury and missed diagnoses were common themes of preventable deaths related to cardiac tamponade. Targeted quality improvement interventions involving education on clinical recognition, procedural up-skilling, and appropriate safety-netting may reduce mortality secondary to tamponade.