Advancing orthopaedic trauma care through WhatsApp:An analysis of clinical and non-clinical applications,challenges,and future directions

The integration of WhatsApp,a widely-used instant messaging application(IMA),into the realm of orthopaedics and trauma surgery has emerged as a significant development in recent years.This paper explores the multifaceted role of WhatsApp in orthopaedics,focusing on its clinical and non-clinical applications,advantages,disadvantages,and future prospects.The study synthesizes findings from various research papers,emphasizing the growing reliance on mobile technology in healthcare.WhatsApp’s role in orthopaedics is notable for its ease of use,real-time communication,and accessibility.Clinically,it facilitates triage,teleconsultation,diagnosis,treatment,patient advice,and post-operative monitoring.Non-clinically,it supports telemedicine,teleradiology,virtual frac-ture clinics,research,and education in orthopaedic surgery.The application has proven beneficial in enhancing communication among healthcare teams,providing quick responses,and motivating junior physicians.Its use in educational settings has been shown to improve learner’s understanding and patient care.However,the use of WhatsApp in orthopaedics is not without challenges.Risks include the potential spread of misleading information,privacy concerns,and issues with image quality affecting diagnosis and treatment decisions.The paper acknowledges the importance of maintaining professional boundaries and the need for oversight measures to ensure content accuracy.Looking forward,the potential of WhatsApp and similar IMAs in orthopaedics lies in their ability to streamline data collection and retrieval,improve doctor-patient communication,and address challenges like bureaucratic red tape and limited resources.The paper suggests that future orthopaedic practice,particularly in emergency departments,will increasingly rely on such technologies for efficient patient management.This shift,however,must be approached with an understanding of the ethical,legal,and practical implications of integrating social media and mobile technology in healthcare.

Surgical Site Infections in Trauma and Orthopaedics at Bouaké Teaching Hospital (Côte d’Ivoire)

Background: Surgical site infections are serious healthcare problems. The aim was to describe the epidemiological, diagnostic, therapeutic, and prognostic aspects of surgical site infections in Trauma and Orthopaedics at Bouaké Teaching Hospital. Method: This retrospective, descriptive, and analytical study was conducted from January 2019 to December 31, 2021. The data studied included prevalence, initial lesions, type of surgical intervention, type of SSI, bacteria involved, treatment, and outcomes. Results: Forty-four (11%) of the 399 patients included in the study developed a surgical site infection. The mean age was 27 years, with 36 male and 8 female. Initial lesions were predominantly open fractures (n = 31;70%), with a mean delay of 48 hours for surgical management. Emergency interventions accounted for 70% (n = 31) of cases. The NNISS infection risk score was 1 in 80% (n = 35) of cases. Superficial infections (n = 34;77%) appeared early, on a mean 6 days postoperatively. Bacteriological analysis primarily identified Pseudomonas aeruginosa (n = 10;23%), sensitive to Imipenem and Chloramphenicol but resistant to Amoxicillin-clavulanic acid, Ceftriaxone, Gentamicin, and Ciprofloxacin. Multidrug-resistant bacteria were found in 89% (n = 8) of cases, with all bacteria resistant to Ceftriaxone. Surgical revision was performed in 10 patients (23%), primarily involving debridement with hardware retention (n = 7;70%). Chloramphenicol was the most commonly used antibiotic post-antibiogram (61%). Outcomes were favourable in 98% of cases. Identified risk factors included the type of lesion according to NRC classification, the delay in managing open fractures, and the NNISS score. Conclusion: The prevalence of surgical site infection was 11%, favoured by the delayed operation of open fractures.

Development of an experimental method for well-controlled blast induced traumatic limb fracture in rats

Heterotopic ossification(HO)is a consequence of traumatic bone and tissue damage,which occurs in 65%of military casualties with blast-associated amputations.However,the mechanisms behind blast-induced HO remain unclear.Animal models are used to study blast-induced HO,but developing such models is challenging,particularly in how to use a pure blast wave(primary blast)to induce limb fracture that then requires an amputation.Several studies,including our recent study,have developed platforms to induce limb fractures in rats with blast loading or a mixture of blast and impact loading.However,these models are limited by the survivability of the animal and repeatability of the model.In this study,we developed an improved platform,aiming to improve the animal's survivability and injury repeatability as well as focusing on primary blast only.The platform exposed only one limb of the rat to a blast wave while providing proper protection to the rest of the rat's body.We obtained very consistent fracture outcome in the tibia(location and pattern)in cadaveric rats with a large range of size and weight.Importantly,the rats did not obviously move during the test,where movement is a potential cause of uncontrolled injury.We further conducted parametric studies by varying the features of the design of the platform.These factors,such as how the limb is fixed and how the cavity through which the limb is placed is sealed,significantly affect the resulting injury.This platform and test setups enable well-controlled limb fracture induced directly by pure blast wave,which is the fundamental step towards a complete in vivo animal model for blast-induced HO induced by primary blast alone,excluding secondary and tertiary blast injury.In addition,the platform design and the findings presented here,particularly regarding the proper protection of the animal,have implications for future studies investigating localized blast injuries,such as blast induced brain and lung injuries.

Review and update on the management of triangular fibrocartilage complex injuries in professional athletes

Triangular fibrocartilage complex injuries are common in amateur and professional sports.These injuries are mainly caused by acute or chronic repetitive axial loads on the wrist,particularly on the ulnar side and in association with rotations or radial/ulnar deviations.In order to treat professional athletes,a detailed specific knowledge of the pathology is needed.Moreover,the clinician should fully understand the specific and unique environment and needs of the athletes,their priorities and goals,the type of sport,the time of the season,and the position played.An early diagnosis and appropriate management with the quickest possible recovery time are the uppermost goals for both the athlete and the surgeon.A compromise between conservative vs surgical indications,athletes’needs and expectations,and financial implications should be achieved.Arthroscopic procedures should be timely planned when indicated as they could allow early diagnosis and treatment at the same time.Conservative measures are often used as first line treatment when possible.Peripheral lesions are treated by arthroscopic repair,whilst central lesions are treated by arthroscopic debridement.Further procedures(such as the Wafer procedure,ulnar osteotomies,etc.)have specific indications and great implications with regard to rehabilitation.

Effect of angioembolisation versus surgical packing on mortality in traumatic pelvic haemorrhage: A systematic review and meta-analysis

BACKGROUND: The management of complex pattern of bleeding associated with pelvic trauma remains a big challenge for trauma surgeons. We aimed to conduct a comprehensive meta-analysis to compare the outcomes of angioembolisation and pelvic packing in patients with pelvic trauma.METHODS: We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the CENTRAL; the World Health Organization International Clinical Trials Registry; Clinical Trials.gov; ISRCTN Register, and bibliographic reference lists. The primary outcome was defined as mortality. Combined overall effect sizes were calculated using randomeffects models. Results are reported as the odds ratio(OR) and 95% confidence interval(CI).RESULTS: We identified 3 observational studies reporting a total of 120 patients undergoing angioembolisation(n=60) or pelvic packing(n=60) for pelvic trauma. Reporting of the Injury Severity Score(ISS) was variable, with higher ISS in the pelvic packing group. The risk of bias was low in two studies, and moderate in one. The pooled analysis demonstrated that angioembolisation did not significantly reduce mortality in patients with pelvic trauma compared to surgery(OR=1.99; 95% CI= 0.83–4.78, P=0.12). There was mild between-study heterogeneity(I^2=0%, P=0.65).CONCLUSION: Our analysis found no significant difference in mortality between angioembolisation and pelvic packing in patients with traumatic pelvic haemorrhage. The current level of evidence in this context is very limited and insufficient to support the superiority of a treatment modality. Future research is required.

Surgical management of the diabetic foot:The current evidence

The prevalence of diabetes mellitus and its associated complications,particularly diabetic foot pathologies,poses significant healthcare challenges and economic burdens globally.This review synthesises current evidence on the surgical management of the diabetic foot,focusing on the interplay between neuropathy,ischemia,and infection that commonly culminates in ulcers,infections,and,in severe cases,amputations.The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies,as diabetic foot complications are a leading cause of hospital admissions among diabetic patients,significantly impacting morbidity and mortality rates.This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers,infections,and skeletal pathologies such as Charcot arthropathy,emphasising the critical role of early diagnosis,comprehensive management strategies,and interdisciplinary care in mitigating adverse outcomes.In addressing surgical interventions,this review evaluates conservative surgeries,amputations,and reconstructive procedures,highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies.The integration of advanced diagnostic tools,novel surgical techniques,and postoperative care,including offloading and infection control,are discussed in the context of optimising healing and preserving limb function.

Subtalar dislocations:Mechanisms,clinical presentation and methods of reduction

Subtalar joint is a complex joint in hindfoot formed by the talus superiorly and the calcaneus and navicular inferiorly.Subtalar dislocations are high-mechanism injuries,which are caused by simultaneous dislocation of both talonavicular and talocalcaneal joints,without major fracture of the talus.They are usually classified as medial(most common),lateral,anterior and posterior dislocations,based on the position of foot in relation to talus and the indirect forces that have been applied to cause this significant injury.They are usually diagnosed by X rays,but computed tomography and magnetic resonance imaging can be used to identify associated intra-articular fractures and peri-talar soft tissue injuries respectively.Majority being closed injuries,can be managed in ED by closed reduction and cast immobilisation,but if they are open,have poor outcomes.Complications that ensue open dislocations are post-traumatic arthritis,instability and avascular necrosis.

Artificial Intelligence;a Pragmatic Approach to Implementation in Medicine, a Review of the literature and a Survey of Local Practice in Midlands in UK

The use of Artificial Intelligence (AI) for clinical pathway management and decision making is believed to improve clinical care and has been used to improve pathways for treatment in most medical disciplines. Methods: A literature review was undertaken to identify the hurdles and steps required to introduce supported clinical decision-making using AI within hospitals. This was supported by a survey of local hospital practice within the Midlands of the United Kingdom to see what systems had been introduced and were functioning effectively. Results: It is unclear how to practically implement systems using AI within medicine easily. Algorithmic medicine based on a set of rules calculated from data only takes a clinician so far to deliver patient centred optimal treatment. AI facilitates a clinician’s ability to assimilate data from disparate sources and can help with some of the analysis and decision making. However, learning remains organic and the subtleties of difference between patients, care providers who exhibit non-verbal communication for instance make it difficult for an AI to capture all the pertinent information required to make the correct clinical decision for any given individual. Hence it assists rather than controls any process in clinical practice. It also must continually renew and adapt considering changes in practise and trends as the goalposts change to meet fluctuations in resources and workload. Precision surgery is benefiting from robotic-assisted surgery in parts driven by AI and being used in 80% of trusts locally. Conclusion: The use of AI in clinical practice remains patchy with it being adopted where research groups have studied a more effective method of monitoring or treatment. The use of robotic-assisted surgery on the other hand has been more rapid as the precision of treatment that this provides appears attractive in improving clinical care.

Lateral femoral tunnel preparation and graft fixation for anterior cruciate ligament reconstruction–A discussion

This article provides a discussion and commentary around the recent advances in arthroscopic anterior cruciate ligament reconstruction(ACLR),with a focus on the aspects of lateral femoral tunnel preparation and graft fixation techniques.The paper explores and comments on a recently published review by Dai et al,titled"Research progress on preparation of lateral femoral tunnel and graft fixation in ACLR",while providing insight into its relevance within the field of ACLR,and recommendations for future research.

Robotics in total knee replacement:Current use and future implications

Robotic total knee replacement(TKR)surgery has evolved over the years with the aim of improving the overall 80% satisfaction rate associated with TKR surgery.Proponents claim higher precision in executing the pre-operative plan which results in improved alignment and possibly better clinical outcomes.Opponents suggest longer operative times with potentially higher complications and no superiority in clinical outcomes alongside increased costs.This editorial will summarize where we currently stand and the future implications of using robotics in knee replacement surgery.

Outcome of meniscal repairs in paediatric population:A tertiary centre experience

BACKGROUND Meniscal sparing surgery is a widely utilised treatment option for unstable meniscal tears with the aim of minimising the risk of progression towards osteoarthritis.However,there is limited data in the literature on meniscal repair outcomes in skeletally immature patients.AIM To evaluate the re-operation rate and functional outcomes of meniscal repairs in children and adolescents.METHODS We performed a retrospective review of all patients who underwent arthroscopic meniscal repair surgery between January 2007 and January 2018.All patients were under the age of 18 at the time of surgery.Procedures were all performed by a single surgeon.Information was gathered from our hospital Electronic Patient Records system.The primary outcome measure was re-operation rate(need for further surgery on the same meniscus).Secondary outcome measures were surgical complications and patient reported outcome measures that were International Knee Documentation Committee(IKDC),Tegner and Lysholm scores.RESULTS We identified 59 patients who underwent 66 All-inside meniscal repairs(32 medial meniscus and 34 Lateral meniscus).Meniscal repairs were performed utilizing FasT-Fix(Smith and Nephew)implants.There were 37 males and 22 females with an average age of 14 years(range 6-16).The average follow-up time was 53 months(range 26-140).Six patients had concomitant anterior cruciate ligament reconstruction surgery along with the meniscal repair.There were no requiring further meniscal repairs and 9 patients underwent partial meniscectomies.The mean postoperative IKDC score was 88(44-100),Tegner score was 7(2-10)and Lysholm score was 94(57-100).CONCLUSION Our results showed that arthroscopic repair of meniscal tears in the paediatric population is an effective treatment option that has a low failure rate and good postoperative clinical with the advantage of preserving meniscal tissues.

Randomised controlled trial of triclosan coated vs uncoated sutures in primary hip and knee arthroplasty

BACKGROUND Triclosan-coated vicryl plus suture(Ethicon, Inc.) was developed to reduce microbial colonisation during surgical procedures. However, its effect on wound healing and surgical site infections remain unclear after hip and knee arthroplasty surgery.AIM To determine the effect of triclosan-coated sutures(TCS) vs non-coated sutures on wound healing, following primary hip and knee arthroplasties.METHODS A single-centred, double-blind randomised controlled trial(RCT) was undertaken. We randomly allocated patients to receive either the triclosan-coated sutures(TCS vicryl plus) or non-coated sutures(NCS vicryl) during the closure of unilateral primary hip and knee arthroplasties. We utilised the ASEPSIS wound scoring system to evaluate wound healing for the first 6 weeks post-operatively.RESULTS One hundred and fifty patients undergoing primary total hip or knee arthroplasty over a one-year period were included. Eighty-one were randomised to the TCS group and 69 to the NCS group. Despite no statistically significant difference in the ASEPSIS scores among the study groups(P = 0.75), sensitivity analysis using the Mann Whitney test(P = 0.036) as well as assessment of the wound complications at 6 weeks follow up, demonstrated significantly higher wound complication rates in the TCS group(8 vs 1, P = 0.03).CONCLUSION No clear advantage was demonstrated for using the TCS. However, larger multicentred RCTs are required to validate their use in hip and knee arthroplasty surgery.

Management of acute spinal cord injury:A summary of the evidence pertaining to the acute management,operative and non-operative management

Acute traumatic spinal cord injury is often a lifechanging and devastating event with considerable mortality and morbidity.Over half a million people suffer from traumatic spinal cord injury annually with the majority resulting from road traffic accidents or falls.The Individual,societal and economic costs are enormous.Initial recognition and treatment of acute traumatic spinal cord injury are crucial to limit secondary injury to the spinal cord and to provide patients with the best chance of some functional recovery.This article is an overview of the management of the acute traumatic spinal cord injury patient presenting to the emergency department.We review the initial assessment,criteria for imaging and clearing the spine,and evaluate the literature to determine the optimum timing of surgery and the role of non-surgical treatment in patients presenting with acute spinal cord injury.

Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification

AIM To undertook a systematic review to determine factors that increase a patient's risk of developing lower limb periprosthetic joint infections(PJI).METHODS This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio(OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias. RESULTS Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies(14.8%) reviewed PJI of the hip, 3(11.21%) of the knee, and 20(74.1%) reviewed both joints. Nineteen studies(70.4%) were retrospective and 8(29.6%) prospective. Record bias was identified in the majority of studies(66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids(OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50(OR = 18.3, P < 0.001), tobacco use(OR = 12.76, 95%CI: 2.47-66.16, P= 0.017), body mass index below 20(OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes(OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease(OR = 5.10, 95%CI: 1.3-19.8, P = 0.017).CONCLUSION We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.

Cost analysis and outcomes of simple elbow dislocations

AIM: To evaluate the management, clinical outcome and cost implications of three different treatment regimes for simple elbow dislocations.METHODS: Following institutional board approval, we performed a retrospective review of all consecutive patients treated for simple elbow dislocations in a Level Ⅰ trauma centre between January 2008 and December 2010. Based on the length of elbow immobilisation(LOI), patients were divided in three groups(Group I, < 2 wk; Group Ⅱ, 2-3 wk; and Group Ⅲ, > 3 wk). Outcome was considered satisfactory when a patient could achieve a pain-free range of motion ≥ 100°(from 30° to 130°). The associated direct medical costs for the treatment of each patient were then calculated and analysed.RESULTS: We identified 80 patients who met the inclusion criteria. Due to loss to follow up, 13 patients were excluded from further analysis, leaving 67 patients for the final analysis. The mean LOI was 14 d(median 15 d; range 3-43 d) with a mean duration of hospital engagement of 67 d(median 57 d; range 10-351 d). Group Ⅲ(prolonged immobilisation) had a statistically significant worse outcome in comparison to Group Ⅰ?and Ⅱ(P = 0.04 and P = 0.01 respectively); however, there was no significant difference in the outcome between groups Ⅰ?and Ⅱ(P = 0.30). No statistically significantdifference in the direct medical costs between the groups was identified.CONCLUSION: The length of elbow immobilization doesn't influence the medical cost; however immobilisation longer than three weeks is associated with persistent stiffness and a less satisfactory clinical outcome.

Intraosseous device for arthrodesis in foot and ankle surgery: Review of the literature and biomechanical properties

BACKGROUND Arthrodesis is the surgical fusion of a diseased joint for the purposes of obtaining pain relief and stability.There have been numerous fixation devices described in literature for foot and ankle arthrodesis,each with their own benefits and drawbacks.AIM To review the use of intraosseous devices in foot and ankle surgery.METHODS There were 9 papers included in the review(6 clinical and 3 experimental studies)all evaluating arthrodesis in the foot and ankle using the IOFIX device(Extremity Medical™,Parsippany,NJ,United States).Outcome scores,union rates,as well as complications were analysed.RESULTS IOFIX appears to be safe and effective in achieving arthrodesis of the 1st metatarsophalangeal,and talonavicular joints with early rehabilitation.In comparison to plate/screw constructs there were fewer soft tissue complications and issues of metalwork prominence.Cadaveric and biomechanical studies on the use of intramedullary fixation for fusion of the tarsometatarsal and ankle joint showed decreased load to failure,cycles to failure and stiffness in comparison to traditional fusion methods using plates and screws,however IOFIX devices produced higher compressive forces at the joint.CONCLUSION We describe the reasons for which this biomechanical behavior of the intraosseous fixation may be favorable,until prospective and comparative studies with largersample size and longer follow-up confirm the effectiveness and limitations of the method.

Update on surgical procedures for carpal tunnel syndrome:What is the current evidence and practice?What are the future research directions?

Carpal tunnel syndrome(CTS)is a multifactorial compression neuropathy.It is reported to be very common and rising globally.CTS’s treatment varies from conservative measures to surgical treatments.Surgery has shown to be an effective method for more severe cases.However few unclear aspects and room for further research and improvements still remains.We performed a narrative literature review on the most up to date progress and innovation in terms of surgical treatments for CTS.The simple algorithm of leaving the choice of the surgical method to surgeons’preference and experience(together with consideration of patients’related factors)seem to be the best available option,which is supported by the most recent metanalysis and systematic reviews.We suggest that surgeons(unless in presence of precise indications towards endoscopic release)should tend to perform a minimally invasive open approach release,favoring the advantage of a better neurovascular structures visualization(and a consequent higher chance to perform a complete release with long term relief of symptoms)instead of favoring an early reduction(in the first postoperative days)of immobilization and pain.Research towards a universally accepted standardization should be aimed for by the researchers,who have failed to date to sufficiently limit bias and limitations.

Patents and intellectual property in orthopaedics and arthroplasty

The provision of musculoskeletal services comes at a cost.This is,in part,due to the expense of patent-protected orthopaedic implants.However,patents have a finite lifespan.Patents of the most successful implants are now beginning to expire.They will be exposed to competition from generic but equivalent implants.The net effect is potentially a dramatic diminution in cost.One company,Orthimo,has taken advantage of this and begun manufacturing generic implants with identical design specifications to the most bio-durable hip prostheses.This will ultimately have a radical impact upon musculoskeletal healthcare provision with regard to cost and accessibility.The expiration of drug patents,with the subsequent use of generic drugs saves£7.1 billion annually in the United Kingdom and$254 billion in the USA.Estimates suggest the introduction of equivalent implants could result in an annual cost saving to the United Kingdom National Health Service of£120 million.Intellectual property remains an enigmatic area of law.It encompasses anodyne principles that seek to protect innovation but are open to manipulation and exploitation.The last decade has seen the emergence of undesirable practices in the medical industry such as"patent trolling".Here we explore patents and their repercussions for musculoskeletal care.

Evaluating learning and change in orthopaedics: What is the evidence-base?

Learning and change are key elements of clinical governance and are responsible for the progression of our specialty.Although orthopaedics has been slow to embrace quality improvement,recent years have seen global developments in surgical education,quality improvement,and patient outcome research.This review covers recent advances in the evaluation of learning and change and identifies the most important research questions that remain unanswered.Research into proxies of learning is improving but more work is required to identify the best proxy for a given procedure.Learning curves are becoming commonplace but are poorly integrated into postgraduate training curricula and there is little agreement over the most appropriate method to analyse learning curve data.With various organisations promoting centralisation of care,learning curve analysis is more important than ever before.The use of simulation in orthopaedics is developing but is yet to be formally mapped to resident training worldwide.Patient outcome research is rapidly changing,with an increased focus on quality of life measures.These are key to patients and their care.Costutility analysis is increasingly seen in orthopaedic manuscripts and this needs to continue to improve evidence-based care.Large-scale international,multi-centre randomised trials are gaining popularity and updated guidance on sample size estimation needs to become widespread.A global lack of surgeon equipoise will need to be addressed.Quality improvement projects frequently employ interrupted time-series analysis to evaluate change.This technique’s limitations must be acknowledged,and more work is required to improve the evaluation of change in a dynamic healthcare environment where multiple interventions frequently occur.Advances in the evaluation of learning and change are needed to drive improved international surgical education and increase the reliability,validity,and importance of the conclusions drawn from orthopaedic research.

Pulmonary Embolism after Bilateral Upper Limb Surgeries: A Case Report and Review of Literature

Pulmonary embolism following upper limb surgery is a very rare complication. Here we present a unique case report of a 54-year-old young, fit and healthy, and non-smoker male who developed bilateral pulmonary embolism (PE) 26 days post-operatively with no associated upper or lower limb Deep Vein Thrombosis (DVT). This patient had minimal preoperative as well as intra-operative risk factors. He did not develop any thromboembolic symptoms until the 26th-day post-surgery when he developed sudden, sharp, pleuritic chest pain and laboured breathing. Initial baseline bloods showed a raised D-Dimer and the patient subsequently had a CT pulmonary angiogram that confirmed the presence of bilateral massive PEs. However, subsequent extremity ultrasound showed no upper or lower deep venous thrombosis. Thorough review of literature suggests that sudden development of PEs after upper limb surgery is possible, with a few cases being reported in the past. Symptoms such as sudden upper limb swelling, troubled breathing and systemic symptoms should be evaluated aggressively with a CT pulmonary angiogram, given the fact that an ultrasound of the extremities may be negative for deep venous thrombosis.