Fifteen patients who underwent Girdlestone arthroplasty (proximal femoral head resection) were reviewed at The Johns Hopkins Hospital and Northwestern Memorial Hospital. Ages ranged from 24 to 57 years (mean 36.7 years). All patients were paraplegics or quadriplegics (C7–L3). All patients presented with signs of sepsis and had evidence of osteomyelitis. Soft-tissue reconstruction was most commonly performed with the vastus lateralis, and no femoral stabilization was used. There were no deaths. Recurrent ulcers at the site of the Girdlestone arthoplasty were found in 23 percent of patients in whom follow-up was possible. No recurrence was noted at the original site in 77 percent with a mean follow-up of 20 months. Additional pressure sores occurred at other nonsurgical sites in six patients at a mean of 23.3 months. Girdlestone arthroplasty with soft-tissue coverage is mandatory for successful treatment of pressure sores with hip joint involvement.

Clinical reasoning is essential to the practice of medicine. Such reasoning involves analytical (deductive) and non-analytical (recall) processes. Non-analytical reasoning is taught extensively in medical schools, and it dominates medical students' time as they review question banks and lecture notes, watch videos online, and memorize flashcards, algorithms, and illness scripts. However, few opportunities are provided in the curriculum to develop students' clinical reasoning skills, and when they are, the diverse levels of innate reasoning ability among students often lead to significant learning disparity. To address this deficiency, a pilot module on cranial nerve anatomy was developed to foster analytical clinical reasoning in an individualized manner. It was hypothesized that this module would not only introduce the foundations of an essential medical skill but also improve overall student understanding of the subject and reduce learning disparities among students. A comparative study was conducted using this module in one group and a didactic module in the other, employing pre- and post-testing measures. Results indicated a 26% improvement in average scores following the analytical module, whereas the control module showed no significant improvement. In addition, the disparity between students improving or not improving following the intervention was reduced, with 74% of students improving after the reasoning module and only 33% of students improving after the didactic module. A novel cranial nerve educational module introduced analytical reasoning in medical students' first few weeks of education, facilitating the learning of complex anatomy and reducing learning disparity between students.

Background: This case report documents a rare variation of a persistent median artery. Normally a transient vessel present during embryologic development of the limbs, the median artery typically regresses by the eighth week of life as the radial and ulnar arteries predominate the distal vascular supply of the hand. In a subset of the adult population, this artery remains as a persistent median artery which most often ends in the carpal tunnel or hand without significant vascular dependence. Case presentation: An 84-year-old female cadaver was found bilaterally to have an artery that penetrated the median nerve in the forearm, continued through the carpal tunnel, then joined the superficial arch, giving rise to the common digital artery to the second webspace. It also gave rise to the radialis indicis, the princeps pollicis, and an anastomotic branch to the radial artery. Conclusions: This anatomic variant of a persistent median artery piercing the median nerve, traversing the carpal tunnel, and providing aberrant primary blood supply to a large area of the hand are details clinically relevant to those who treat hand disorders and injuries.

Context: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. When mild to moderate in severity, nonoperative treatments including osteopathic manipulative treatment (OMT) have been found to be effective. Studies have been carried out to quantify the mechanism of such treatments with cadaver studies, magnetic resonance imaging (MRI), and ultrasound. Objectives: This pilot project investigated the mechanism of a previously undescribed technique of nonoperative carpal tunnel treatment, dorsal carpal arch muscle energy (DCA-ME), which focuses on the dorsal arch (trapezium, trapezoid, capitate, and hamate bones) manipulating the bones to redome the arch, round the tunnel, and increase its volume. Although the actual effectiveness of such manipulation in the treatment of CTS can only be assessed and quantified in patients with the disorder, this initial study was carried out to see if it was feasible for physical changes following DCA-ME to be quantified with ultrasound. Methods: A pilot study of 25 healthy volunteers with no prior history of CTS or related disorders was undertaken to quantify anatomical changes in carpal tunnel dimensions following OMT of the nondominant wrist, utilizing DCA-ME. The subjects were randomly assigned to either the OMT group (n=14) or the control group (n=11). The control group underwent a sham manipulation. Pre- and postultrasound measurements of carpal tunnel dimensions were made. The study employed a two-group, pre-/postmanipulation design to evaluate the anatomical changes resulting from the OMT manipulation compared to those following the control sham manipulation. Results: Comparison of the OMT and control groups revealed a mean increase in carpal tunnel depth from 0.45 mm ± 0.13 mm pre-OMT to 0.48 mm ± 0.13 mm post-OMT (p=0.0146, Cohen’s d=0.214, 95 % CI 0.0068 to 0.0517). There was also a mean increase in cross-sectional area from 1.83 mm² ± 0.56 mm² pre-OMT to 1.98 mm² ± 0.59 mm² post-OMT (p=0.0058, Cohen’s d=0.260, 95 % CI 0.0517 to 0.2490). There was no significant difference in canal width (p=0.5973) or transverse carpal ligament length (p=0.2673) following OMT intervention. The control group, which received the sham procedure, demonstrated no significant differences in the transverse carpal ligament length, carpal tunnel width, depth, or cross-sectional area before and after the sham intervention. Conclusions: Ultrasound measurements at the narrowest section of the carpal tunnel before and after DCA-ME OMT of healthy asymptomatic wrists demonstrated a significant increase in cross-sectional area as well as depth, with no significant change in the length of the transverse carpal ligament, suggesting that the cause of the increased volume is an alteration of dorsal arch shape. A limitation of the study is the small sample size, inclusion of only healthy wrists, the short period of time between manipulation and measurements, and the difficulty of assuring the same level and angle of ultrasound measurements.

When learning the Focused Assessment with Sonography in Trauma (FAST) exam, anatomical orientation can be difficult, especially in the subxiphoid and upper quadrant views. To facilitate understanding in these areas, a novel in-situ cadaver dissection was used to demonstrate anatomy related to the FAST exam. In situ, because the structures remained in normal positions with adjacent organs, layers, and spaces clearly visible from the point of view of the ultrasound probe. These views were then correlated with what was seen on the ultrasound screen. The right upper quadrant and subxiphoid anatomy were viewed in a mirror to match the ultrasound images, and the left upper quadrant was viewed directly from the examiner’s position, also matching the view on the ultrasound screen. The in-situ cadaver dissection was developed as a resource to correlate FAST exam ultrasound images in the upper quadrant and subxiphoid regions with related cadaver anatomy.