As a part of the American healthcare system's response to the Coronavirus Disease 2019 (COVID-19) global pandemic, the Association of American Medical Colleges recommended that medical schools temporarily remove students from clinical settings and transition to an entirely online learning environment. This posed an unprecedented challenge to students in the clinical years of their medical education. To address this unexpected shift, we modified an in-person workshop to teach orthopaedic trauma basics to 5-week virtual course for third year medical students from several schools in New Jersey and Pennsylvania. We focused on moving students toward the Level-1 milestones for basic fracture care with a combination of weekly lectures and virtual interactive small group sessions, all conducted via WebEx and proctored by an orthopaedic attending or resident. The course was well received by students. Participation in the course was completely voluntary and did not count for credit at any institution. The course was valuable to students because the students who registered chose to fully complete the 5-week course and no student missed more than one small group session. On a postcourse survey, 100% of students said they would be highly likely to recommend the course to a future student, and the average rating for educational value of the course was 4.98 of 5. Given the current limitations in clinical education because of the COVID-19 pandemic, our course provides a reasonable alternative to clinical experience and prepares students with the knowledge and many of the skills that are required to succeed as orthopaedic interns. Furthermore, the success of our course this year suggests that similar programing may be a useful adjunct to clinical experiences even when it is safe to return to more traditional medical school scheduling.

Acute, major articular bone loss associated with an open fracture is an uncommon injury. These injuries typically occur after high-energy trauma and are challenging to treat. Various approaches to treatment include allografts, prosthetic composite structures, custom implants, and total joint arthroplasty. These treatment options provide a wide array of variability in outcomes, costs, and challenges, especially in young and active patients. Two patients presented to our institution with open elbow injuries that included structural bone loss of the lateral column including the entire capitellar articular surface and a portion of the lateral trochlea. With the limited portions of bone available, the surgical principles for distal humerus fracture of articular repair followed by medial and lateral column restoration were followed. Each patient was treated with repair of the residual remnant of the articular surface. Then, repair of the columns of the distal humerus was performed by using a combination of internal fixation and hinged external fixation. In both cases, a plate was inserted to repair the medial column and a hinged external fixation was applied laterally to protect the lateral column. Immediate motion was allowed and progressed within each patient's tolerance. The lateral, hinged external fixator was removed at 8 weeks after injury and converted to a lateral column plate fixed distally into the lateral portion of the residual trochlea. At follow-up, both patients had radiographic evidence of reconstitution of the lateral column of the distal humerus and were able to return to heavy manual labor. [ Orthopedics . 2022;45(3):e162–e167.]

Purpose Reducing waste is at the forefront for healthcare administrators, and one area to target is routine pre-operative testing. Despite the availability of professional/societal guidelines, physicians continue to order routine preoperative tests. Preoperative tests rarely influence surgical management, and there is data supporting safety without preoperative testing in low-risk surgeries for healthy patients. We believe these principles can be extrapolated to low-risk orthopedic procedures in healthy patients, such as isolated distal extremity fractures. We believe there will be enough wasted expenditure with unnecessary preoperative workup in isolated orthopedic trauma to warrant change in preoperative management. Methods A retrospective analysis of 209 cases of isolated distal extremity fractures from July 2019-July 2020 was conducted. Charts were queried for preoperative tests completed. Each case’s respective series of preoperative tests were compared to what professional/societal guidelines deemed appropriate. A decision-making analysis was performed to assess physician overordering. Total number of unnecessary tests was calculated, and cost analysis was completed to determine potential waste. Results 98% of cases had at least one unnecessary test. Coagulation profiles and blood type tests were the most commonly over-ordered tests at 90% of the time. Cost analysis revealed $262,624 in potentially wasted expenditure. Blood type tests and chest x-rays represented the largest portion, with $129,654 and $71,694 of wasted expenditure respectively. Conclusion We recommend the implementation of multimodal interventions in clinics treating these injuries. Interventions should include components of provider education, provider audit and feedback, and EMR ordering restrictions to reduce this area of waste.

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