Retained wooden splinter migrated within a digital flexor tendon sheath: Ultrasonographic diagnosis for presurgical planning.

A 29-year-old right-handed woman presented to an outside emergency department with right small finger pain, swelling, and concern for a retained wooden splinter. Diagnosis and treatment were delayed for 2 weeks due to the inability to identify the foreign body clinically or radiographically. Ultimately, ultrasonography by a fellowship-trained specialist was used to localize the wooden splinter. It was embedded within the flexor tendon sheath but had migrated away from its initial point of entry. The patient underwent subsequent surgical extraction, irrigation, and debridement. Two weeks following surgery, she had regained full range of motion through her digit without signs of infection. This case highlights the use of diagnostic ultrasound to identify a radiolucent foreign body, such as a wooden splinter, and to guide subsequent surgical extraction.

Investigation Into the Effects of Intra-Articular Steroid on Post-Traumatic Osteoarthritis in Distal Radius Fractures: A Randomized Controlled Pilot Study.

PURPOSE: The aim of this prospective, randomized, controlled, double-blinded pilot study was to determine the rates of post-traumatic osteoarthritis and assess joint space width in the presence or absence of a single intra-articular injection of corticosteroid after an acute, intra-articular distal radius fracture (DRF). METHODS: Forty patients received a single, intra-articular, radiocarpal joint injection of 4 mg of dexamethasone (DEX) (n = 19) or normal saline placebo (n = 21) within 2 weeks of a surgically or nonsurgically treated intra-articular DRF. The primary outcome measure was minimum radiocarpal joint space width (mJSW) on noncontrast computed tomography scans at 2 years postinjection. Secondary outcomes were obtained at 3 months, 6 months, 1 year, and 2 years postinjection and included Disabilities of the Arm, Shoulder, and Hand; Michigan Hand Questionnaire; Patient-Rated Wrist Evaluation; wrist range of motion; and grip strength. RESULTS: At 2-year follow-up, there was no difference in mean mJSW between the DEX group (2.2 mm; standard deviation, 0.6; range, 1.4-3.2) and the placebo group (2.3 mm; standard deviation, 0.7; range, 0.9-3.9). Further, there were no differences in any secondary outcome measures at any postinjection follow-up interval. CONCLUSIONS: Radiocarpal joint injection of corticosteroid within 2 weeks of an intra-articular DRF does not appear to affect the development of post-traumatic osteoarthritis within 2 years follow-up in a small pilot cohort. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Dynamic Seeding versus Microinjection of Adipose-Derived Mesenchymal Stem Cells to Acellular Nerve Allograft Reconstructions.

BACKGROUND: Functional recovery following acellular nerve allograft (ANA) reconstructions remains inferior to autologous nerve grafting, but have demonstrated improved outcomes with the addition of adipose-derived mesenchymal stem cells (MSC). Controversy exists regarding the optimal cell delivery method to enhance ANA reconstructions. We investigated the functional recovery of ANAs after dynamic seeding versus microinjection of MSCs. METHODS: Forty Lewis rats underwent reconstruction of a 10-mm sciatic nerve defect. Animals were divided into four groups: reversed autograft, ANA alone, ANA dynamically seeded, or ANA injected with MSCs. During the survival period, ultrasound measurements of the tibialis anterior (TA) muscle cross-sectional area were performed. At 12 weeks, functional recovery was evaluated using measurements of ankle contracture, compound muscle action potential (CMAP), maximum isometric tetanic force (ITF), muscle mass, histomorphometry, and immunofluorescence. RESULTS: The dynamic seeding and microinjection groups demonstrated higher cross-sectional TA muscle area recovery than autografts and ANAs alone at week 8 and week 4 and 8, respectively. The ankle contracture and CMAP amplitude recovery were superior in autografts and both seeding methods compared to ANAs alone. The microinjection group demonstrated significantly higher ITF, muscle mass, and number of axons compared to ANAs alone. Both seeding methods showed higher CD34 densities compared to ANAs alone. No significant differences between dynamic seeding and microinjection were observed for both functional and histological outcomes. CONCLUSIONS: The addition of MSCs to ANAs demonstrated earlier motor regeneration compared to autografts and ANAs alone. Both seeding methods improved functional outcomes in the rat sciatic nerve defect model. CLINICAL RELEVANCE STATEMENT: Future clinical applications of stem cell-based nerve reconstructions are dependent on determining optimum delivery methods, which are technically feasible, reproducible, cost-efficient, and timely.

Update to Management of Acute Scaphoid Fractures.

The scaphoid is the most commonly fractured carpal bone. With high clinical suspicion and negative radiographs, expedient evaluation by CT or MRI has been recommended. When treating nondisplaced or minimally displaced scaphoid waist and distal pole fractures, immobilization below the elbow without inclusion of the thumb is an option. Comparatively, early surgical intervention for nondisplaced or minimally displaced scaphoid waist fractures allows for quicker return of function, but with increased risk of surgical complications and no long-term outcomes differences compared with cast immobilization. For most patients with such fractures, consideration for aggressive conservative treatment involving 6 weeks of immobilization with CT assessment to guide the need for continued casting, surgical intervention, or mobilization is advocated. Determination of union is best done with a CT scan at 6 weeks and at least 50% continuous trabecular bridging across the fracture site deemed sufficient to begin mobilization. Nonsurgical and surgical management of scaphoid fractures requires a thorough understanding of fracture location, fracture characteristics, and patient-specific factors to provide the best healing opportunity of this notoriously difficult fracture and return the patient to full function.