Cost and Complications of Percutaneous Fixation of Hand Fractures in a Procedure Room Versus the Operating Room.

BACKGROUND: The purpose of this study was to compare closed reduction and percutaneous pinning of metacarpal and phalanx fractures performed in the operating room (OR) versus the procedure room of the emergency department with primary outcomes being infection rate, radiographic union, and monetary cost. METHODS: From January 2006 to December 2010, all closed reduction and percutaneous pinnings of metacarpal and phalanx fractures (CPT codes: 26608; 26727) by a single board-certified hand surgeon (A.M.H.) were retrospectively reviewed. Patients were placed into 2 groups: Group 1 was patients treated in the OR, and group 2 was patients in an emergency department procedure room. Infection, malunion, and nonunion rates were compared using a chi-square test. Charges were compared using a t-test, and cost of supplies and labor was evaluated. RESULTS: A total of 189 patients met final inclusion criteria for this study: 130 in group 1 and 59 in group 2. There was no statistically significant difference in infection rates ( P = .13), nonunion ( P = .40), malunion rates ( P = .89), and hardware failure with revision ( P = .94) between the 2 groups. The procedure room patients had an average hospital charge of $1358.55 compared with $3691.85 for OR-treated patients (P = .001). The total cost of supplies and nonphysician labor was $432.31 per OR case and $179.59 per procedure room case. CONCLUSIONS: Metacarpal and phalanx fractures of the hand amendable to closed reduction and percutaneous pinning can be treated in the procedure room with no increase in risk of infection, malunion, or nonunion rates. In addition, these surgeries can be performed in a procedure room with lower cost and less charges to patients than in the operating room.

Tendon entrapments and dislocations in ankle and hindfoot fractures: evaluation with multidetector computed tomography.

The purpose of this study was to assess the incidence of tendon entrapments and tendon dislocations associated with ankle and hindfoot fractures in patients studied by multidetector computed tomography (MDCT). Additionally, we describe particular tendon injuries associated with specific fractures. This was a retrospective review of all individuals with a trauma-protocol CT for suspected ankle and/or hindfoot fractures during a consecutive 41-month time period at a single Level I Trauma Center. Each patient's images were evaluated by two radiologists and an orthopedic surgeon for tendon entrapment, tendon dislocation, and bone(s) fractured or dislocated. There were 398 patients with ankle and/or hindfoot fractures that showed tendon entrapment or dislocation in 64 (16.1 %) patients. There were 30 (46.9 %) patients with 40 tendon entrapments, 31 (48.4 %) patients with 59 tendon dislocations, and three (4.7 %) patients with both tendon entrapment and dislocation. All patients with tendon entrapments were seen with either pilon fractures and/or a combination of posterior, medial, or lateral malleolar fractures. The most frequently entrapped tendon was the posterior tibialis tendon (PTT) in 27 patients (27/30, 90.0 %). The peroneal tendons were the most frequently dislocated, representing 27 (87.1 %) of patients with tendon dislocation; all resulted from a talar or calcaneal fracture or subluxation. This study demonstrates that tendon entrapments and tendon dislocations are commonly seen in complex fractures of the ankle and hindfoot. Pilon fractures were associated with the majority of tendon entrapments, whereas calcaneus fractures were associated with the majority of tendon dislocations.

Quantification of bone changes in a collagen-induced arthritis mouse model by reconstructed three dimensional micro-CT.

BACKGROUND: Inflammatory arthritis is a chronic disease, resulting in synovitis and subchondral and bone area destruction, which can severely affect a patient's quality of life. The most common form of inflammatory arthritis is rheumatoid arthritis (RA) in which many of the disease mechanisms are not well understood. The collagen-induced arthritis (CIA) mouse model is similar to RA as it exhibits joint space narrowing and bone erosion as well as involves inflammatory factors and cellular players that have been implicated in RA pathogenesis. Quantitative data for disease progression in RA models is difficult to obtain as serum blood markers may not always reflect disease state and physical disease indexes are subjective. Thus, it is important to develop tools to objectively assess disease progression in CIA. RESULTS: Micro-CT (Computed Tomography) is a relatively mature technology that has been used to track a variety of anatomical changes in small animals. In this study, micro-CT scans of several joints of control and CIA mice were acquired at 0, 4, 7, and 9 weeks after the immunization with collagen type II. Each micro-CT scan was analyzed by applying a segmentation algorithm to individual slices in each image set to provide 3-dimensional representations of specific bones including the humerus, femur, and tibia. From these representations, the volume and mean density of these bones were measured and compared. This analysis showed that both the volume and the density of each measured bone of the CIA mice were significantly smaller than those of the controls at week 7. CONCLUSIONS: This study demonstrates that micro-CT can be used to quantify bone changes in the CIA mouse model as an alternative to disease index assessments. In conclusion, micro-CT could be useful as a non-invasive method to monitor the efficacy of new treatments for RA tested in small animals.

Anatomic guide and sonography for surgical repair of leg muscle lacerations.

BACKGROUND: There were over 110,000 leg laceration cases reported in the United States in 2011. Currently, muscle laceration is repaired by suturing epimysium to epimysium. Tendon-to-tendon repair is stronger, restores the muscle's resting length, and leads to a better functional recovery. Tendons retract into the muscle belly following laceration and surgeons have a difficult time finding them. Many surgeons are unfamiliar with leg muscle anatomy and the fact that the leg muscles have long intramuscular tendons that are not visible in situ. A surgical anatomic guide exists to help surgeons locate forearm tendons; no such guide exists for tendons in the leg. MATERIALS AND METHODS: The leg tendon ends of 11 cadavers were dissected, measured, and recorded as percentages of leg length. High-frequency ultrasound was used to locate tendon ends in three additional cadavers. These locations were compared with the actual tendon ends located via dissection. RESULTS: There was little variation in tendon end position within the cadaver group, between men and women or right and left legs. The data are presented as an anatomic guide to inform surgeons of the tendon ends' likely locations in the leg. CONCLUSION: The location of leg intramuscular tendon ends is predictable and the anatomic guide will help surgeons locate tendon ends and perform tendon-to-tendon repairs. Ultrasound is a potentially effective tool for detection of accurate location of repairable tendon ends in leg muscle lacerations.

Prevalence of hypovitaminosis D among children with upper extremity fractures.

BACKGROUND: Recent publications show a high rate of hypovitaminosis D among children in general as well as among children with fractures. 25-hydroxyvitamin D levels were analyzed from hospital records to determine the prevalence of hypovitaminosis D, with the goal of using that information in fracture management and nutritional counseling. METHODS: We retrospectively reviewed the records of 213 children with upper extremity fractures that were treated during a 14-month period. For 181 of those patients, the 25-hydroxyvitamin D level was measured at the time of emergency department presentation or at the first clinic appointment within 2 weeks after the initial presentation. The following information was collected from the charts: fracture mechanism (high or low energy), age, sex, race, and body mass index. Vitamin D levels were categorized as normal (≥ 32 ng/mL), insufficient (20 to 32 ng/mL), or deficient (< 20 ng/mL). The levels were analyzed with respect to fracture pattern and race. RESULTS: Of the 181 patients, 24% had deficient vitamin D levels, 41% had insufficient levels, and 35% had normal levels. There was no significant correlation with vitamin D level and mechanism of injury. African American children were more likely to have insufficient or deficient levels of vitamin D. CONCLUSIONS: Hypovitaminosis D is common among children with upper extremity fractures. Further investigation is warranted on the use of the 25-hydroxyvitamin D level as a screening tool to predict risk of fracture and to design proper nutritional programs for children with fractures. LEVEL OF EVIDENCE: Retrospective chart review; Level III evidence.

High frequency ultrasound evaluation of traumatic peripheral nerve injuries.

OBJECTIVE: Accurate diagnosis and localization of peripheral nerve traumatic injury remains difficult. Early diagnosis and repair of nerve discontinuity lesions lead to better outcome than delayed repair. MATERIALS AND METHODS: We used new high frequency ultrasound to evaluate 24 patients with 29 traumatic nerve injuries. There were a variety of causes including gunshot wounds, blunt injuries, burns, stabbings, and motor vehicle accidents. The patients were then either treated surgically with nerve status directly observed or followed clinically for recovery of nerve function. RESULTS: The ultrasound findings correspond with the clinical outcome of 28 of the 29 nerves. CONCLUSION: While this is a study limited by a small patient number, ultrasound evaluation should be considered in the evaluation of nerve injury and can lead to early diagnosis and treatment of surgical nerve injuries.

New technique for humerus shaft fracture retrograde intramedullary nailing.

Humeral shaft fracture intramedullary nailing is less invasive than plates and screws. Antegrade technique has postoperative shoulder pain, increased rehab time, and frequent reoperation for rod removal. Published retrograde technique is not collinear with the shaft, has insertion site fractures (5% to 15%), and radial nerve palsies (5%). Our retrograde technique is collinear with the humerus shaft, simpler, and decreases operative fracture risk. The supine patient's elbow is fully flexed. A guide pin is inserted through the triceps tendon to the olecranon fossa roof, aligned with the humerus shaft, and drilled thought the cortex followed by the 6.5 mm cannulated drill through a small triceps splitting incision. The guide pin is passed along the humerus shaft and across the fracture. A small incision is made to identify and protect the radial nerve during reduction, reaming, and rod insertion. Flexible reamers are used and the nail placed and locked at least distally to prevent distal migration. An institutional review broad approved retrospective review of Louisiana State University Health Sciences Center adult humeral shaft fractures with retrograde technique from 1999 to January of 2009 was carried out. Sixteen patients were treated without perioperative fracture or nerve palsy.

Technique for and an anatomic guide to forearm tendon repair.

Forearm lacerations involving muscle bellies are usually treated by repairing muscle fascia. Repair of tendons themselves is stronger and restores normal muscle anatomy better. Tendon repair requires good knowledge of forearm muscle and tendon anatomy. We have made cadaver measurements to produce graphical maps of locations of individual muscles tendons of origin and insertion, some practical guides for finding tendon ends and a simple grasping stitch for intramuscular tendons.

The effects of diabetes and/or peripheral neuropathy in detecting short postural perturbations in mature adults.

BACKGROUND: This study explored the effects of diabetes mellitus (DM) and peripheral neuropathy (PN) on the ability to detect near-threshold postural perturbations. METHODS: 83 subjects participated; 32 with type II DM (25 with PN and 7 without PN), 19 with PN without DM, and 32 without DM or PN. Peak acceleration thresholds for detecting anterior platform translations of 1 mm, 4 mm, and 16 mm displacements were determined. A 2(DM) × 2(PN) factorial MANCOVA with weight as a covariate was calculated to compare acceleration detection thresholds among subjects who had DM or did not and who had PN or did not. RESULTS: There was a main effect for DM but not for PN. Post hoc analysis revealed that subjects with DM required higher accelerations to detect a 1 mm and 4 mm displacement. CONCLUSION: Our findings suggest that PN may not be the only cause of impaired balance in people with DM. Clinicians should be aware that diabetes itself might negatively impact the postural control system.

Modeling avian kinematics using software developed for the human musculoskeletal system.

Using an interactive computer graphic system developed for the simulation of human musculoskeletal kinematics and detailed Computerized Tomography (CT) imaging of the domestic turkey, a kinematic structure of the avian trunk and wings is defined. The result is a simulation that provides interactive study of avian muscle-tendon joint kinematics, the ability to elucidate the essential components of bird flight and visual verification of heuristic muscle-tendon-joint models through real-time, 3D interaction. This application demonstrates the flexibility and applicability of this simulation software to define the kinematic structure of any animal or robotic mechanism given a segmented, 3D skeletal structure and to define the necessary and sufficient joints (linked revolutes and degrees-of-freedom) and muscle-tendon paths for that animal. The result is an interactive, real-time, 3D, kinematic model providing immediate understanding of muscle-tendon-joint function specific to that animal.

A system for measurement and calibration of nonorthogonal joints and limbs in humans.

Human limbs are a multilinked system in which the revolute joints are not orthogonal to the limb segments or to each other. The standard method for movements of multilinked systems is the Denavit-Hartenberg (DH) representation, which is useful for orthogonal systems. When applied to non-orthogonal systems, the DH representation projects the reference frames outside of the limb segments. Computer graphics techniques move arrays of points in bodies that move about arbitrary revolute joints. This computational model has been modified to calculate both position (X, Y, Z) and orientation (yaw, pitch, and roll) of limbs and their individual segments. This method allows a simplified representation for the kinematics of animal limbs.