Complications associated with hinged external fixation for chronic elbow dislocations.

PURPOSE: To evaluate the outcomes of patients who underwent application of hinged external fixators for chronic elbow fracture-dislocations. We hypothesized that patients treated for this injury pattern can achieve satisfactory outcomes but encounter many complications and require numerous additional procedures. METHODS: We performed a retrospective review of 7 patients who were surgically treated with application of a hinged external fixator for chronic ulnohumeral elbow fracture-dislocation. Patients were included only if they had complete ulnohumeral dislocation of greater than 1 month's duration. Demographics, injury pattern, and range of motion were documented. Preoperative and postoperative range of motion was recorded and any treatment complications or additional surgeries were noted. RESULTS: The interval between the initial injury and index procedure averaged 8 months. All patients underwent initial treatment with open reduction internal fixation. Average arc of ulnohumeral motion improved from 26° (range, 0° to 60°) to 120° (range, 100° to 145°). Overall, 4 of 7 patients developed at least one complication during treatment. Three patients required additional procedures aside from removal of the hinged external fixator. These 3 patients underwent a total of 13 additional procedures. CONCLUSIONS: Although patients can achieve good outcomes, realistic expectations should be set. Patients should be aware that surgery can be associated with a high risk of complications, potential treatment failure, and a need for additional surgical procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Fracture pattern characteristics and associated injuries of high-energy, large fragment, partial articular radial head fractures: a preliminary imaging analysis.

BACKGROUND: High-energy radial head injuries often present with a large partial articular displaced fragment with any number of surrounding injuries. The objective of the study was to determine the characteristics of large fragment, partial articular radial head fractures and determine any significant correlation with specific injury patterns. MATERIALS AND METHODS: Patients sustaining a radial head fracture from 2002-2010 were screened for participation. Twenty-five patients with documented partial articular radial head fractures were identified and completed the study. Our main outcome measurement was computed tomography (CT)-based analysis of the radial head fracture. The location of the radial head fracture fragment was evaluated from the axial CT scan in relation to the radial tuberosity used as a reference point. The fragment was characterized by location as anteromedial (AM), anterolateral (AL), posteromedial (PM) or posterolateral (PL) with the tuberosity referenced as straight posterior. All measurements were performed by a blinded, third party hand and upper extremity fellowship trained orthopedic surgeon. Fracture pattern, location, and size were then correlated with possible associated injuries obtained from prospective clinical data. RESULTS: The radial head fracture fragments were most commonly within the AL quadrant (16/25; 64 %). Seven fracture fragments were in the AM quadrant and two in the PM quadrant. The fragment size averaged 42.5 % of the articular surface and spanned an average angle of 134.4(°). Significant differences were noted between AM (49.5 %) and AL (40.3 %) fracture fragment size with the AM fragments being larger. Seventeen cases had associated coronoid fractures. Of the total 25 cases, 13 had fracture dislocations while 12 remained reduced following the injury. The rate of dislocation was highest in radial head fractures that involved the AM quadrant (6/7; 85.7 %) compared to the AL quadrant (7/16; 43.7 %). No dislocations were observed with PM fragments. Ten of the 13 (78 %) fracture dislocations had associated lateral collateral ligament (LCL)/medial collateral ligament tear. The most common associated injuries were coronoid fractures (68 %), dislocations (52 %), and LCL tears (44 %). CONCLUSION: The most common location for partial articular radial head fractures is the AL quadrant. The rate of elbow dislocation was highest in fractures involving the AM quadrant. Cases with large fragment, partial articular radial head fractures should undergo a CT scan; if associated with >30 % or >120(°) fracture arc, then the patient should be assessed closely for obvious or occult instability. These are key associations that hopefully greatly aid in the consultation and preoperative planning settings. LEVEL OF EVIDENCE: Diagnostic III.

Repeat emergency room visits for hand and wrist injuries.

PURPOSE: To characterize patients with hand or wrist injuries presenting to our university-based emergency department (ED) after a previous evaluation by an outside ED. We hypothesized that a majority of these patients did not require emergent care, most arrived during working hours, and a disproportionate number were uninsured. METHODS: We retrospectively reviewed 3,047 orthopedic hand consults from 2002 to 2010. Patients were included if our ED was the patient's second ED evaluation within 30 days for the same complaint. Demographics, diagnosis, referral instructions from the initial institution, date and time of ED visit, treatment received, and insurance status were recorded. Clinical urgency was quantified on an ordinal scale. RESULTS: A total of 325 patients met the inclusion criteria. The most common diagnoses were distal radius and metacarpal fractures. There were 266 (82%) patients with nonurgent diagnoses. A junior-level orthopedic resident treated and discharged 97% of patients from the ED. Sixty-two percent of the patients were uninsured, 32% had Medicaid, and 6% had commercial insurance or Medicare. There was a disproportionate percentage of uninsured and Medicaid patients compared with the payer mix of our state, orthopedic department, and ED. Ninety percent of patients presented on weekdays, and 84% arrived between 6 am and 6 pm. CONCLUSIONS: Most patients who met our inclusion criteria presented to our ED during regular business hours. Most were uninsured and did not have a condition that warranted urgent or emergent evaluation and treatment. With limited resources, it is important that an appropriate follow-up plan from the initial ED be in place so that patients do not have to present to a second ED for the same problem. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Hand-Specific External Fixation for Treatment of Complex Proximal Interphalangeal Joint Injuries.

Background: Complex proximal interphalangeal joint (PIPJ) fractures are challenging injuries to treat. There are multiple established treatment methods available for these injuries, including dynamic external fixation. This study reports the outcomes of complex PIPJ fractures treated with a hand-specific external fixation device. Methods: Twenty-five fingers in 25 patients were treated with the DigiFix external fixator device for treatment of a PIPJ dorsal fracture dislocation (n = 16) or pilon fracture (n = 9). There were 16 males and 9 females with a mean age of 40 years (range: 14-75 years) at the time of injury. The median time from injury to surgery was 10 days (interquartile range [IQR]: 5; range: 3-49). Chart and radiographic data were reviewed retrospectively. Results: The average duration of external fixation was 41 days (range: 26-62 days). At a mean follow-up of 28 weeks (range: 12-105 weeks), the mean PIPJ flexion was 82 (range: 30-105 degrees), extension was -10° (range: -30 to 0 degrees), and flexion/extension arc of motion was 72 degrees (range: 30-95 degrees). Final mean Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 21.5 (range: 0-65.8). There were zero major complications and six (24%) minor complications, including superficial cellulitis (4) and stiffness (2). Conclusion: Dynamic external fixation for the treatment of complex PIPJ injuries allows for early range of motion and leads to favorable outcomes. This hand-specific external fixator has a reproducible technique which results in predictable and reliable PIPJ distraction.

Longitudinal Tear of the Central Slip Causing Painful and Unusual Snapping of the Finger: A Case Report.

The most common cause for catching or snapping in the finger is stenosing tenosynovitis, that is, trigger finger. Although less common, snapping can also occur as a result of extensor mechanism injury. Among these injuries, sagittal band rupture is most common and leads to snapping at the metacarpophalangeal joint. Snapping at the proximal interphalangeal (PIP) joint is rare with only 4 reported cases; reported mechanisms of PIP joint snapping include retinacular ligament injury or tendon impingement. We present a unique case of painful finger snapping at the PIP joint as a result of longitudinal tear of the central slip, leading to sudden subluxation of one-half of the central slip and conjoint lateral band with flexion of the PIP joint.

Continuous Passive Elongation Through an External Fixator: A Versatile and Beneficial Adjunct Technique to Treat Severe and Recurrent Cases of Dupuytren Contracture.

Dupuytren disease and its associated digit contracture often negatively impact the quality of life for patients. Severe cases of Dupuytren contracture and symptom recurrence are both difficult for hand surgeons to treat. Improved treatment options are therefore needed. One method is continuous passive elongation (CPE). In CPE, a device is affixed to the digit, which applies a continuous extending force to pull the affected finger out of flexion. Multiple external fixators used to induce CPE have been reported. However, a low-profile, hand-specific external fixator, the DigiFix, provides benefits over previously reported devices. We present the technique of CPE using DigiFix as a beneficial and versatile adjunct treatment for severe and recurrent cases of Dupuytren contracture.

Comparative analysis of intramedullary nail fixation versus casting for treatment of distal radius fractures.

PURPOSE: Intramedullary fixation is one treatment option for distal radius fractures. Our purpose was to compare the outcomes of intramedullary nailing to those of casting for these injuries. METHODS: From 2006 to 2009, we reviewed 63 adult patients with isolated distal radius fractures. Thirty-one patients had surgical fixation with an intramedullary device (IMN group) within 4 weeks of the injury, and 32 (cast group) had casting as definitive treatment of the fracture. Clinical outcomes (grip strength; Disabilities of the Arm, Shoulder, and Hand scores; active wrist range of motion; and complications) and radiographic indices (radial inclination, radial height, ulnar variance, and tilt) of both groups were analyzed for the 1-, 2-, 4-, 6-, and 12-month follow-up periods. RESULTS: The flexion-extension arc was significantly higher in the IMN group than in the cast group at 2-, 6-, and 12-month follow-up. The IMN group exhibited significantly greater grip strength and lower DASH scores throughout the follow-up period. At final follow-up, all radiographic indices were significantly better in the IMN group than in the cast group. There was no significant difference between the initial reduction to final position in the IMN group, but the cast group showed an increase in ulnar variance and a significant change in dorsal-volar tilt. In addition, the cast group experienced more clinical complications in the delayed period compared to the IMN group. CONCLUSIONS: Intramedullary nail fixation, as compared to casting, results in less functional disability, not only in the early postoperative period but also up to a year after treatment. On the basis of our data, intramedullary fixation should be considered for patients with unstable extra-articular or simple intra-articular distal radius fractures.

Unusual Anatomic Location of the Median Nerve Within the Pronator Teres Muscle: A Case Report.

CASE: A 57-year-old man presented with pain and paresthesia in both hands and was diagnosed with pronator teres syndrome. Surgical decompression of the left elbow and forearm revealed the median nerve in an unusual anatomic location, specifically running within the pronator teres muscle. CONCLUSION: Anatomic anomalies of the pronator teres muscle and the path of the median nerve have been described. However, there are no reports of the median nerve entering and traveling within the pronator teres. Surgeons should be aware of this anomaly to avoid potential iatrogenic injury when performing an anterior surgical approach to the elbow and proximal forearm.

Treatment of extra-articular distal radial malunions with an intramedullary implant.

PURPOSE: Malunited distal radius fractures pose considerable problems, especially for young, active individuals. Surgical correction with osteotomy, bone grafting, and internal fixation with plates and screws has been the treatment of choice. Locked intramedullary fixation is an alternative technique to provide bony stability while minimizing soft tissue irritation in the management of acute distal radius fractures, with acceptable clinical results. The purpose of this study was to describe our experience with the use of an intramedullary device combined with grafting to repair distal radial malunions. This fixation device is inserted through the radial styloid and obtains distal fixation with 3 fixed-angle locking screws. METHODS: Thirteen patients underwent distal radius malunion repair with an intramedullary implant and grafting. There were 6 male and 7 female participants with an average age of 51 years (range, 18-72 y). Patients were evaluated at an average follow-up of 24 months (range, 13-38 mo). Clinical outcome was measured by range of motion of the wrist and forearm, and grip strength, and by using the Disabilities of the Arm, Shoulder, and Hand questionnaire. We analyzed radiographs to determine time to union and adequacy of correction. RESULTS: All of the malunions healed, with an average time to healing of 11 weeks. Patients' average range of motion at follow-up was 56 degrees of flexion, 66 degrees extension, 85 degrees pronation, and 84 degrees supination. Mean grip strength was 83% of the unaffected side, and the average Disabilities of the Arm, Shoulder, and Hand score was 21. Radiographs taken on the latest follow-up showed correction to the following average parameters: 20.6 degrees radial inclination, 11.0 mm radial height, +1.0 mm ulnar variance, and 2.1 degrees volar tilt. CONCLUSIONS: The technique presented in this report demonstrates the effectiveness of an intramedullary nail combined with bone graft or graft substitute in repairing malunited fractures of the distal radius. The results show reliable correction of the deformity and good functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Stratification of the risk factors of community-acquired methicillin-resistant Staphylococcus aureus hand infection.

PURPOSE: Several recent studies showed an increase in methicillin-resistant Staphylococcus aureus (MRSA) hand infections. The purpose of this study was to determine the prevalence of community-acquired MRSA hand infections in an urban setting and to determine independent risk factors for such infections. METHODS: A retrospective chart review of patients with hand infections was performed from 2002 to 2009. Those with community-acquired hand infections who had surgical irrigation and debridement and intraoperative culture were entered into the study. Patient demographics-including age and gender; mechanism of injury; infection risk factors (diabetes, chronic hepatitis, intravenous intravenousdrug use, and immune-compromised conditions); place of residence/housing status; history of hospitalization, prior antibiotics use and surgery; and culture results, erythrocyte sedimentation rate, C-reactive protein, and white blood cell count-were extracted from the medical records. Regression analyses were performed to identify significant risk factors for MRSA infection. RESULTS: A total of 102 patients met our inclusion criteria. The MRSA organism was identified in 32 patients. In the analysis of all the potential risk factors, only intravenous drug use showed significant correlation with MRSA infection. CONCLUSIONS: In our patients, only intravenous drug use correlated with community-acquired MRSA hand infections. Patient education about intravenous drug use and empiric treatment with MRSA-appropriate antibiotics for intravenous drug users presenting with hand infections are recommended. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Effects of nonsteroidal anti-inflammatory drugs on flexor tendon adhesion.

PURPOSE: Besides its anti-inflammatory effects, nonsteroidal anti-inflammatory drug therapy may affect tendon healing and the development of peritendinous adhesions. The purpose of this study was to compare the effect of nonselective (ibuprofen) and COX-2 selective (rofecoxib) nonsteroidal anti-inflammatory drugs on the adhesion formation after tendon repair. METHODS: We assigned 67 rabbits to one of 3 (placebo, ibuprofen, or rofecoxib) groups. The deep flexor tendon was transected, followed by a primary repair. Dosing of the medication began the day after surgery and continued for 27 days. The animals were immobilized in a cast for the first 14 days. Postoperatively, tendon adhesion formation was assessed histologically by calculating the total adhesion in serial axial tendon sections at 3 and 6 weeks and by range of motion measurements at 6 and 12 weeks. We measured range of motion by fixing the metacarpal, applying increasing weight to the free end of the flexor digitorum profundus, and measuring the flexion angle between the metacarpal and the proximal phalanx. Comparison was performed between the treatment groups, as well as to the unoperated forepaws. RESULTS: Based on histology, we found no difference between the treatment groups when determining the percentage of adhesion between the flexor tendon and its sheath. Control unoperated forepaws had a significantly greater range of metacarpophalangeal joint flexion than the surgically repaired groups. At 12 weeks, range of motion in the ibuprofen group was significantly better than the placebo (p=.009) and rofecoxib (p=.009) groups. CONCLUSIONS: Ibuprofen has a more important effect in limiting adhesion formation compared with rofecoxib after flexor tendon repair. Because ibuprofen inhibits both COX-1 and COX-2, whereas rofecoxib only inhibits COX-2, ibuprofen therapy appears to offer a greater beneficial effect on tendon repair by reducing formation of adhesions.

Acute forearm compartment syndrome secondary to local arterial injury after penetrating trauma.

BACKGROUND: Acute compartment syndrome (ACS) is a well-described surgical emergency that requires an immediate diagnosis and emergent operative intervention. Failure to either make the diagnosis or to implement the appropriate treatment quickly can result in severe long-term morbidity. The purpose of this article is to document evidence that penetrating trauma which results in arterial injury may cause acute forearm compartment syndrome. As a result, this mechanism should alert surgeons to the possibility of acute compartment syndrome secondary to arterial injury. METHODS: A retrospective review of all penetrating trauma patients treated at our Level 1 Trauma Center was performed within 2001 and 2005. Patients who sustained penetrating injuries to the forearm were reviewed in detail and all patients diagnosed with acute forearm compartment syndrome in this setting were included in this article. RESULTS: Five cases of ACS of the forearm secondary to a mechanism rarely described in the surgical literature were documented over five years. All cases in this series were the result of a named forearm arterial injury sustained by penetrating trauma. Every patient in this article was taken emergently to the operating room for a fasciotomy following diagnosis. CONCLUSION: This article establishes the incidence of a specific mechanism of ACS in our penetrating trauma population. As a result of these findings, a thorough evaluation of the forearm vasculature and a careful search for arterial injury is recommended at the time of fasciotomy. Securing a rapid diagnosis and executing early definitive management will result in fewer devastating long-term outcomes.

A comparison of the effects of ibuprofen and rofecoxib on rabbit fibula osteotomy healing.

BACKGROUND AND PURPOSE: Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase (COX) activity, which is the rate-limiting enzyme in the synthesis of prostaglandins. Previous studies have indicated that NSAID therapy, and in particular NSAIDs that specifically target the inflammatory cyclooxygenase (COX-2), impair bone healing. We compared the effects of ibuprofen and rofecoxib on fibula osteotomy healing in rabbits to determine whether nominal, continuous inhibition of COX-2 with rofecoxib would differentially affect fracture healing more than cyclical inhibition of COX-2 using ibuprofen, which inhibits COX-1 and COX-2 and has a short half-life in vivo. METHODS: Bilateral fibula osteotomies were done in 67 skeletally mature male New Zealand white rabbits. The rabbits were treated with placebo, rofecoxib (12.5 mg once a day), or ibuprofen (50 mg 3 times a day) for 28 days after surgery. Plasma ibuprofen levels were measured by HPLC analysis. Bone healing was assessed by histomorphometry at 3 and 6 weeks after osteotomy, and at 6 and 12 weeks by torsional mechanical testing. RESULTS: Plasma ibuprofen levels peaked and declined between successive doses. Fracture callus morphology was abnormal in the rofecoxib-treated rabbits and torsional mechanical testing showed that fracture healing was impaired. Ibuprofen treatment caused persistence of cartilage within the fracture callus and reduced peak torque at 6 weeks after osteotomy as compared to the fibulas from the placebo-treated rabbits. In the specimens allowed to progress to possible healing, non-union was seen in 5 of the 26 fibulas from the rofecoxib-treated animals as compared to 1 of 24 in the placebo group and 1 of 30 in the ibuprofen treatment group. INTERPRETATION: Continuous COX-2 inhibition as modeled by rofecoxib treatment appears to be more deleterious to fracture repair than cyclical cyclooxygenase inhibition as modeled by ibuprofen treatment. Ibuprofen treatment appeared to delay bone healing based upon the persistence of cartilage within the fracture callus and diminished shear modulus. Despite the ibuprofen-induced delay, rofecoxib treatment produced worse fracture (osteotomy) healing than ibuprofen treatment.

Coban Method for Removing a Constricting Ring.

BACKGROUND: Various techniques have been described for removal of a tight constricting ring from a finger. A novel procedure is described in this article. METHODS: The method is a modification of the string wrap or winding technique. A 1-inch Coban wrap, lubricant, and pickups are all that is required. RESULTS: The author has used this method to remove constricting rings from swollen and arthritic fingers in 5 patients. The technique has been successful in all cases, and no complications occurred. CONCLUSIONS: The Coban method is a quick, easy, and inexpensive technique for ring removal from a finger. The technique should be taught to and known by every clinician who treats hand problems.

Variation in digital rotation and alignment in normal subjects.

PURPOSE: The purpose of this study is to quantify finger/digit rotation, overlap, parallelism, and convergence to the scaphoid tuberosity in normal volunteers to establish standards for comparison. METHODS: We examined 240 uninjured fingers in 30 volunteers. There were 14 men and 16 women with an average age of 35 years. Rotation was determined with the palm flat and fingers extended. Digit overlap, parallelism (angular relationship between the index, ring, and small fingers with respect to the middle finger) and scaphoid convergence were determined with simultaneous flexion of metacarpophalangeal and proximal interphalangeal joints. Linear and angular measurements were performed with imaging software. RESULTS: Rotation, parallelism, and scaphoid convergence measurements were similar comparing left with right hands. Rotation: All digits were found to be in supination relative to the horizontal plane; the small fingers averaged 9 degrees, the ring fingers 4 degrees, the middle fingers 8 degrees, and the index fingers 12 degrees. Parallelism: Angular measurements between the middle finger and the small finger averaged 19 degrees, between the middle finger and the ring finger 9 degrees, and between the middle finger and the index finger 11 degrees. Scaphoid convergence: In no hand did all 4 fingers converge onto scaphoid tuberosity. Whereas small and ring finger trajectories averaged -0.1 to 1.2 mm from the scaphoid tubercle, the middle finger averaged 4.0 to 4.6 mm and the index finger 8.1 to 9.5 mm. Overlap: Ninety percent of individuals demonstrated digit overlap, although none covered more than 50% of the adjacent nail plate. Seventy-seven percent of these were bilateral, and 73% were asymmetric. CONCLUSIONS: This study establishes the normal parameters for digit rotation, overlap, parallelism, and scaphoid convergence. For digit rotation, parallelism, and scaphoid convergence, the contralateral (uninjured) hand can be used reliably for comparison. However, for digit overlap, the contralateral hand should not be used for comparison because of side-to-side asymmetry and variability. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Foreign-body reaction to the Artelon CMC joint spacer: case report.

The Artelon CMC spacer (Small Bone Innovations, Inc., Morrisville, PA) is a relatively new device that was developed for the treatment of basal joint arthritis. It is composed of a biodegradable polycaprolactone-based polyurethane urea that acts to resurface the distal part of the trapezium and stabilize the trapeziometacarpal joint by augmenting the joint capsule. This is a case report of a foreign-body tissue reaction to the Artelon CMC spacer.

Carpometacarpal joint disease: addressing the metacarpophalangeal joint deformity.

The successful surgical treatment of arthrosis of the carpometacarpal articulation of the thumb requires a thorough understanding and evaluation of the intercalated axis of the first ray. A hyperextension/adduction deformity commonly occurs at the metacarpophalangeal joint of the thumb with advanced stages of carpometacarpal arthrosis. Failure to recognize and treat the metacarpophalangeal deformity may result in continued pain and poor outcomes. Additionally, the stability of the ligament reconstruction may become compromised, resulting in recurrence of deformity and longitudinal collapse. This article presents an orderly means of clinical and radiographic evaluation of this deformity and recommends surgical treatments to correct hyperextension and maximize functional outcomes. A treatment algorithm is provided.

Deep Friction Massage Versus Steroid Injection in the Treatment of Lateral Epicondylitis.

BACKGROUND: The aim of the study was to determine the efficacy of deep friction massage in the treatment of lateral epicondylitis by comparing outcomes with a control group treated with splinting and therapy and with an experimental group receiving a local steroid injection. METHODS: A randomized clinical trial was conducted to compare outcomes after recruitment of consecutive patients presenting with lateral epicondylitis. Patients were randomized to receive one of 3 treatments: group 1: splinting and stretching, group 2: a cortisone injection, or group 3: a lidocaine injection with deep friction massage. Pretreatment and posttreatment parameters of visual analog scale (VAS) pain ratings, Disabilities of the Arm, Shoulder and Hand (DASH) scores, and grip strength were measured. RESULTS: Outcomes were measured at early follow-up (6-12 weeks) and at 6-month follow-up. There was a significant improvement in VAS pain score in all treatment groups at early follow-up. DASH score and grip strength improved in the cortisone injection group and the deep friction massage group at early follow-up; these parameters did not improve in the splinting and stretching group. At 6-month follow-up, only patients in the deep friction massage group demonstrated a significant improvement in all outcome measures, including VAS pain score, DASH score, and grip strength. CONCLUSIONS: Deep friction massage is an effective treatment for lateral epicondylitis and can be used in patients who have failed other nonoperative treatments, including cortisone injection.