Microsurgical Techniques for Digital Nerve Injuries and Vascular Injuries.

Background: Tension-free end-to-end digital nerve repair or reconstruction under loupe or microscope magnification are surgical treatment options for lacerated digital nerves in patients with multiple injured digits, injuries to the border digits, or injuries to the thumb, with the goal of improved or restored sensation and a decreased risk of painful traumatic neuroma formation. Different techniques for primary repair have been described and include epineurial sutures, nerve "glues" including fibrin-based gels1,2, biologic or synthetic absorbable or nonabsorbable nerve wraps or conduits, or a combination of these materials. Nerve "glues" have demonstrated decreased initial gapping at the repair site3 and an increased tensile load to failure when utilized with a nerve wrap or conduit4,5. When there is a gap or defect in the nerve and primary repair is not feasible, nerve allograft and autograft provide similar results and are both better options than conduit reconstruction6. Concomitant or isolated digital vascular injuries may also be surgically treated with end-to-end repair in a dysvascular digit, with the goal of digit and function preservation. In the absence of complete circumferential injury or complete amputation, redundant or collateral flow may be present. Single digital artery injuries often do not need to be repaired because of the collateral flow from the other digital artery. Description: Digital nerve and vascular injuries are often found in the context of traumatic wounds. In such cases, surgical exploration is often required, with possible surgical extension of the wounds to facilitate identification of the neurovascular bundles. The proximal and distal ends of the transected nerve and/or artery are identified, and the traumatized ends are incised sharply, maintaining as much length as possible to facilitate end-to-end repair, interposition of a graft, and the use of a conduit. The proximal and distal aspects of the nerve and/or artery are appropriately mobilized by dissecting or releasing any scar tissue or soft tissue that may be tethering the structure. The defect is measured in the natural resting position of the digit. Gentle flexion of the digit may be performed to facilitate a primary repair in the setting of very small defects. Primary repair or reconstruction is selected, and an 8-0 or 9-0 nonabsorbable monofilament suture is utilized to anastomose the appropriate structures under magnification with use of a single or double stitch6. A tubular nerve conduit is placed prior to epineurial suturing, or a nerve conduit wrap is applied circumferentially around the repair site and augmented with a fibrin glue. The wound is then irrigated and closed in a standard fashion, as determined by the presence of any soft-tissue or structural injury. Alternatives: Alternatives to primary repair include the use of conduits or autologous or allogenic grafting. Factors that necessitate reconstruction include gapping and poor soft-tissue integrity, which can be related to the mechanism of injury. Alternatives to repair or reconstruction include treatment of the-soft tissue or structural injury without concomitant repair or reconstruction of the damaged digital nerves or vessels. Rationale: Primary end-to-end repair and reconstruction of digital nerves increases a patient's likelihood of sensation recovery, and arterial repair can preserve a digit and avoid the need for amputation. Sensation in the digits is very important for fine motor skills and interaction with the environment, and it is particularly important for patients who rely on their hands for work and/or recreation. For these reasons, the digital nerves to the border digits, such as the ulnar aspect of the small finger, radial aspect of the index finger, and both digital nerves to the thumb, are given particular attention. Expected Outcomes: Surgical intervention to repair or reconstruct the digital nerves increases the likelihood of recovering pre-injury sensation; however, the chance of complete recovery remains low. A systematic review of the outcomes of digital nerve repair in adults published in 2019 showed that the average percentage of patients who had undergone repair and reported a recovery to Highet grade 4 was 24% (range, 6% to 60%)8. The rate of adverse events was comparable between the operatively and nonoperatively treated patients, with complications including neuromas, hyperesthesia, and infection. Important Tips: The use of a microvascular background material can provide better visualization of the proximal and distal ends while performing the repair.It is important to sharply guillotine the ends of the nerve to freshen up the laceration and provide healthy nerve ends for repair.Repair sutures need to be passed through the epineurium, with care taken not to pass through the nerve fascicles. Acronyms and Abbreviations: OR = operating roomPIP = proximal interphalangealPT = prothrombin timePTT = partial thromboplastin time.

Complex Fractures of the Radial and Ulnar Shaft.

SUMMARY: Successful management of radial and ulnar shaft fractures is an essential skill for all orthopaedic surgeons. The frequent presentation of these injuries coupled with the nuanced anatomic considerations that must be observed for successful outcomes dictate that these injuries require a thorough understanding by the treating surgeon. Intraoperative care to restore the anatomic radial bow and rotation is essential for the resumption of functional forearm rotation postinjury. Often, problems arising during the operative treatment of radial and ulnar shaft fractures come in predictable patterns that can be mitigated with preoperative planning and sound technique. Cases of increased complexity with segmental bone defects and soft tissue defects require a variety of advanced reconstructive techniques.

Traumatic Transradial Forearm Amputation Temporized With Extracorporeal Membrane Oxygenation: A Brief Report.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions. MATERIALS AND METHODS: This is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained. RESULTS: This case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use. CONCLUSIONS: ECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases.

Free Functional Muscle Transfer and One Bone Forearm for Upper-Extremity Limb Salvage After High-Energy Ballistic Trauma.

Upper-extremity limb salvage following high-energy trauma poses unique challenges of massive soft tissue injury in the setting of large bone defects, traumatic segmental neurovascular injuries, and functional deficits. These complex injuries require multidisciplinary care to achieve requisite revascularization, bone stabilization, and preservation of remaining options for soft tissue coverage. This case presents a 45-year-old man who sustained a high-velocity gunshot resulting in a dysvascular limb. Through shared decision-making, upper-extremity limb salvage was pursued. Successful initial limb salvage included a reversed great saphenous vein graft from the brachial artery to the radial artery, followed by one bone forearm with nonvascularized graft from the ipsilateral distal ulna, latissimus dorsi free functioning muscle transfer with an end-to-side anastomosis to the brachial artery proximal to the vein graft, and coaptation of the anterior interosseous donor nerve from the proximal median nerve stump to the thoracodorsal recipient nerve.

Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review.

INTRODUCTION: Targeted Muscle Reinnervation (TMR) is a surgical technique utilized to alleviate post-amputation neuroma pain, reduce reliance on narcotic pain medication, and enhance control of prosthetic devices. Motor targets for upper extremity TMR vary depending on injury patterns and amputation levels, with conventional transfer patterns serving as general guides. This study aims to summarize the common patterns of TMR in transradial and transhumeral amputations, focusing on anatomic and surgical considerations. METHODS: A comprehensive systematic review of TMR literature was conducted by two independent physician reviewers (M.H.A. and D.M.G.R.) to identify the prevailing motor targets, while considering injury patterns and amputation levels. INCLUSION CRITERIA: 1) TMR techniques, outcomes, or advancements; 2) Original research, systematic reviews, meta-analyses, or clinical trials; 3) Peer-reviewed journal articles or reputable conference proceedings. EXCLUSION CRITERIA: non-English resources, editorials, opinion pieces, and case reports. The databases utilized include MEDLINE (PubMed), EMBASE (Scopus) and Cochrane CENTRAL, last searched 01APR2023. RESULTS: The reviewed literature revealed multiple motor targets described for upper extremity TMR out of our included 51 studies. However, the selection of motor targets is influenced by the availability of viable options based on injury patterns and amputation levels. Conventional transfer patterns provide useful guidance for determining appropriate motor targets in transradial and transhumeral amputations. DISCUSSION: TMR has played a significant role in military medicine, particularly in addressing the impact of blast-related injuries. The energy associated with such injuries often results in substantial soft tissue defects, higher amputation levels, and increased post-amputation pain. TMR, in conjunction with advancements in prosthetic technology and ongoing military research, offers improved outcomes to help achieve the goals of active-duty service members. The capabilities and applications of TMR continue to expand rapidly due to its high surgical success rate, technological innovations in prosthetic care, and favorable patient outcomes. As technology evolves to include implantable devices, osseointegration techniques, and bidirectional neuroprosthetic devices, the future of amputation surgery and TMR holds immense promise, offering innovative solutions to optimize patient outcomes. It is important to note, this review was limited to the data available in the included resources which was mostly qualitative; thus, it did not involve primary data analysis.

Medial Elbow Exposure: Modified Taylor-Scham Versus Flexor Carpi Ulnaris-Split.

OBJECTIVE: To compare the exposure of the coronoid process, anteromedial facet, and anterior band of the medial collateral ligament using the flexor carpi ulnaris (FCU)-splitting approach with the Taylor-Scham approach modified with an ulnar nerve transposition. METHODS: Thirty approaches were performed on 15 fresh cadavers using a randomized cross-over design and standardized incision. Access to key anatomic landmarks was assessed, and a calibrated digital image was taken from the surgeon's best perspective of each approach. Images were analyzed using ImageJ (National Institutes of Health) software to calculate the area of osseous exposure. RESULTS: All key anatomic landmarks were visualized using both approaches. The average area of exposure for the Taylor-Scham was 19.5 cm 2 compared with 13.6 cm 2 for the FCU-splitting ( P < 0.0001). The distal extent of the FCU-splitting approach is limited by the ulnar nerve and its branches to the humeral head of the FCU. CONCLUSION: The Taylor-Scham approach provides a more extensile exposure of the anteromedial coronoid and proximal ulna than the FCU-splitting approach while avoiding cross-tensioning of the ulnar nerve.

The One-Bone Forearm in Children: Surgical Technique and a Retrospective Review of Outcomes.

PURPOSE: The purpose of this study was to describe a technique of end-to-end rigid fixation of the distal radius to the proximal ulna. The shortening and radioulnar overlap in this technique yield a high union rate, large corrections, and few complications. METHODS: This retrospective chart review from 2 centers was undertaken in 39 patients (40 forearms) who underwent one-bone forearm operations between 2005 and 2019. There were 25 male and 14 female patients, with a mean age at surgery of 9.7 years (range 3 to 19 years; SD, 4.5 years). The diagnoses included brachial plexus birth injury, spinal cord injury, arthrogryposis multiplex congenita, cerebral palsy, ulnar deficiency with focal indentation, multiple hereditary exostosis, acute flaccid myelitis, and tumor. RESULTS: The average follow-up was 33.5 months (1.2-110.1 months; SD, 27.1 months). The 36 forearms in supination had an average supination contracture of 93° (range, 15° to 120°; SD, 15.4°). The 4 pronated arms had an average pronation contracture of 80° (range, 50° to 120°; SD, 29.2°). The average postoperative position was 22.8° of pronation (range, -15° to 45°; SD, 12.9°). The average correction obtained with our technique was 113° (range, 20° to 145°; SD, 22.9°). Radiographic union was demonstrated in 32 (80%) of the one-bone forearms by 10 weeks, 39 (97.5%) by 16 weeks, and 40 (100%) by 24 weeks. One patient had peri-implant fractures prior to union. No forearms required reoperation for nonunion. CONCLUSIONS: One-bone forearm performed with this technique allows reliable healing and a large degree of correction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Avoiding Complications in Distal Radius Fractures.

SUMMARY: Managing fractures of the distal radius is a fundamental skill for orthopaedic surgeons. Given the prevalence of these fractures, complications following operative management are well described and frequently encountered. Surgeons should be observant in the acute phase for emergent conditions such as acute carpal tunnel syndrome. Careful radiographic examination intra-operatively can help prevent delayed complications by identifying surgical errors such as hardware malposition or malreduction. Many problems that arise during the treatment of distal radius fractures are the result of technical errors and can be anticipated.

Lateral External-fixation Adjacent to Radial Nerve.

Introduction The aim of our study was to describe the injury pattern and outcomes of active-duty subjects that underwent humeral external fixation and to determine if the placement of external fixator pins outside of the radial nerve safe zones is correlated with injury to the radial nerve. Materials and methods We examined all US Service members treated with humeral external fixation at our facility from June 2005 through June 2015. The mechanism of injury, injury pattern, location of external fixation application, pre- and postoperative radial nerve function, presence or absence of radial nerve transection from injury or external fixation, anatomic location of pins in relation to the radial nerve safe zone, and final radial nerve outcomes were recorded. We defined the proximal safe zone as 5 cm distal to the acromion to 14.8 cm proximal to the lateral epicondyle, and we defined the distal safe zone as the proximal 70% of the transepicondylar width of the humerus when projected proximally from the lateral epicondyle. Results  For our study, 123 patients were identified over our date range, and 16 subjects were included with documentation regarding nerve function/injury characteristics, appropriate radiographs, and active duty status. Around 80% of injuries resulted from a blast mechanism, and 80% of injury patterns included either an intraarticular or open fracture. The radial nerve safe zone was violated in 15 of the 16 subjects (94%). The one subject with a safe construct did not sustain a nerve injury. Complete preoperative documentation on nerve function was only available for half of the subjects. Two of five subjects known to have intact function prior to external fixation had a postoperative neurologic deficit (40%). Of eight subjects with unknown radial nerve function prior to external fixation, seven subjects had full nerve function at the final follow up, and one subject had partial sensory function only. Of the three subjects with impaired preoperative radial nerve function, two made a full recovery, and the third recovered sensory function only. Around 50% of all subjects required medical retirement. Conclusion External fixation of upper extremity injuries in combat is rarely absolutely indicated, often results in the placement of pins outside of the radial nerve safe zone, and is associated with up to a 40% incidence of radial nerve injury.

An Unusual Variant of a Floating Forearm Injury: A Case Report and Review.

BACKGROUND: "Floating forearm" injuries, perilunate injuries, with an elbow dislocation, are rare and challenging to treat. METHODS: We present the case of an unusual variant of a floating forearm injury, trans-scaphoid perilunate fracture dislocation and elbow dislocation, with a concomitant open both-bone forearm fracture after a fall from a ladder. Treatment involved irrigation and debridement of the forearm wound, open reduction and internal fixation of the forearm and perilunate injury, and closed reduction of the elbow. RESULTS: At final follow-up, he had returned to his previous occupation. Radiographs demonstrated fully healing fractures without evidence of osteonecrosis or degeneration. CONCLUSIONS: A review of the presentation, evaluation, and management of this rare injury pattern is provided.

Combat-related bridge synostosis versus traditional transtibial amputation: comparison of military-specific outcomes.

The aim of our study was to determine military-specific outcomes for transtibial amputations of US Service members using either the traditional technique (Burgess) or the Ertl technique. All US Service members sustaining transtibial, combat-related amputation from September 2001 through July 2011 were reviewed. Amputation type, mechanism of injury, time interval to amputation, age, sex, branch of service, rank, force, nature, and injury severity score were recorded. Outcomes were determined by analyzing military-specific medical review results, to include the following: Physical Evaluation Board Liaison Office (PEBLO) rating (0-100), PEBLO outcome (permanent retirement, temporary disability retirement, separation without benefits, continuation of active duty, or fit for redeployment), and the rate of redeployment. Amputation type (Ertl vs. Burgess) was determined by reviewing postoperative radiographs and radiology reports. Data from all of the above categories were compared for both Ertl and Burgess amputees. Of 512 subjects identified, 478 had radiographs or radiology reports distinguishing between Ertl or Burgess transtibial amputation. A total of 406 subjects underwent the Burgess procedure, and 72 subjects underwent the Ertl procedure. There was not a significant difference between the two groups in review board rating (p = 0.858), review board outcome (p = 0.102), or ability to deploy (p = 0.106); however, subjects that underwent the Ertl procedure remained on active duty at a significantly higher rate (p = 0.021). There is a higher rate of remaining on active duty using the Ertl technique. This study suggests that there is an improvement in functional outcome with the Ertl technique.

Extrusion of the Hamate: A Case Report with Proposed Classification Amendment.

CASE: A thirteen-year-old right-hand-dominant girl sustained a right hamate fracture-extrusion with associated pisiform dislocation and volar degloving injury with open fractures of the scaphoid, capitate, lunate, and trapezoid following an all-terrain-vehicle rollover. She was noted to have paresthesias in the median nerve distribution. Treatment involved irrigation and debridement of the right wrist and internal fixation of the hamate, capitate, and scaphoid. At fifteen months of follow-up, she had returned to competitive softball as a pitcher. Radiographs demonstrated fully healed fractures. CONCLUSION: Complete extrusion of the hamate through an open wound can be treated with good functional outcomes.