Sterility of Miniature C-arm Fluoroscopy in Hand and Upper Extremity Surgery.

Previous studies have demonstrated that sterile equipment is frequently contaminated intraoperatively, yet the incidence of miniature c-arm (MCA) contamination in hand and upper extremity surgery is unclear. To examine this incidence, a prospective study of MCA sterility in hand and upper extremity cases was performed in a hospital main operating room (MOR) ( n = 13) or an ambulatory surgery center operating room (AOR) ( n = 16) at a single tertiary care center. Case length, MCA usage parameters, and sterility of the MCA through the case were examined. We found that MOR surgical times trended toward significance ( p = 0.055) and that MOR MCAs had significantly more contamination prior to draping than AOR MCAs ( p < 0.001). In MORs and AORs, 46.2 and 37.5% of MCAs respectively were contaminated intraoperatively. In MORs and AORs, 85.7 and 80% of noncontaminated cases, respectively, used the above hand- table technique, while 50 and 83.3% of contaminated MOR and AOR cases, respectively, used a below hand-table technique. Similar CPT codes were noted in both settings. Thus, a high-rate of MCA intraoperative contamination occurs in both settings. MCA placement below the hand-table may impact intraoperative contamination, even to distant MCA areas. Regular sterilization of equipment and awareness of these possible risk factors could lower bacterial burden.

Initial findings in traumatic peripheral nerve injury and repair with diffusion tensor imaging.

OBJECTIVE: Management of peripheral nerve injuries requires physicians to rely on qualitative measures from patient history, electromyography, and physical exam. Determining a successful nerve repair can take months to years for proximal injuries, and the resulting delays in clinical decision-making can lead to a negative impact on patient outcomes. Early identification of a failed nerve repair could prevent permanent muscle atrophy and loss of function. This study aims to test the feasibility of performing diffusion tensor imaging (DTI) to evaluate injury and recovery following repair of wrist trauma. We hypothesize that DTI provides a noninvasive and reliable assessment of regeneration, which may improve clinical decision-making and alter the clinical course of surgical interventions. METHODS: Clinical and MRI measurements from subjects with traumatic peripheral nerve injury, carpal tunnel syndrome, and healthy control subjects were compared to evaluate the relationship between DTI metrics and injury severity. RESULTS: Fractional anisotropy from DTI was sensitive to differences between damaged and healthy nerves, damaged and compressed nerves, and injured and healthy contralateral nerves. Longitudinal measurements in two injury subjects also related to clinical outcomes. Implications of other diffusion measures are also discussed. INTERPRETATION: DTI is a sensitive tool for wrist nerve injuries and can be utilized for monitoring nerve recovery. Across three subjects with nerve injuries, this study has shown how DTI can detect abnormalities between injured and healthy nerves, measure recovery, and determine if re-operation was successful. Additional comparisons to carpal tunnel syndrome and healthy nerves show that DTI is sensitive to the degree of impairment.

Augmented intramedullary screw tension band construct for olecranon fracture reduction and fixation: a review of literature and surgical technique.

Olecranon fractures, which make up 10% of upper extremity fractures in adults, often require anatomic reduction and stable internal fixation. Successful olecranon fracture osteosynthesis has classically been achieved via tension band wiring or plate fixation. This article reviews the indications, outcomes, and a surgical technique as an alternative construct for tension band wiring of olecranon fractures. The technique involves placement of an ulnar intramedullary partially threaded screw that is used as a proximal point of attachment for tension band wiring of the olecranon. Although infrequently used by orthopedic surgeons, this construct has been shown to be biomechanically and clinically superior to classic Kirschner wire tension banding techniques. This review is intended to familiarize surgeons with a surgical technique that can be applied to a variety of proximal ulna fractures.

The Effect of Carpal Tunnel Release on Typing Performance.

PURPOSE: To describe the effect of carpal tunnel release (CTR) on typing performance. METHODS: We prospectively studied 27 patients undergoing open CTR. Patient demographics and clinical characteristics including nerve conduction studies, electromyography results, and duration of symptoms were collected. Before surgery and at 8 time points after surgery, ranging from 1 to 12 weeks, typing performance for an approximately 500-character paragraph was assessed via an on-line platform. The Michigan Hand Questionnaire (MHQ) and the Boston Carpal Tunnel Questionnaire functional component (BCTQ-F) and symptom severity component (BCTQ-S) component were completed before surgery and at 1, 3, 6, and 12 weeks after surgery. We used repeated-measures analyses of variance and follow-up dependent-samples t tests to analyze change in typing performance across sessions, and linear regressions to assess relationships between typing performance and demographic and outcome measures. We compared typing speed with the MHQ, BCTQ-F, and BCTQ-S using the Pearson correlation test. RESULTS: Average typing speed decreased significantly from 49.7 ± 2.7 words per minute (wpm) before surgery to 45.2 ± 3.1 wpm at 8 to 10 days after surgery. Mean typing speed for the group exceeded the preoperative value between weeks 2 and 3, with continued improvement to 53.5 ± 3.5 wpm at 12 weeks after surgery. No clinical or demographic variables were associated with the rate of recovery or the magnitude of improvement after CTR. The MHQ, BCTQ-F, and BCTQ-S each demonstrated significant improvement from preoperative values over the 12-week period. The MHQ and BCTQ-F scores correlated well with typing speed. CONCLUSIONS: On average, typing speed returned to preoperative levels between 2 and 3 weeks after CTR and typing speed showed improvement beyond preoperative levels after surgery. The MHQ and BCTQ-F correlate well with typing speed after CTR. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Complications of Distal Radius Fixation.

Complications following any form of distal radius fixation remain prevalent. With an armamentarium of fixation options available to practicing surgeons, familiarity with the risks of newer plate technology as it compares with other conventional methods is crucial to optimizing surgical outcome and managing patient expectations. This article presents an updated review on complications following various forms of distal radius fixation.

Avoiding unplanned resections of wrist sarcomas: an algorithm for evaluating dorsal wrist masses.

Ganglion cysts, soft-tissue masses that commonly occur about the wrist, are often excised without imaging or biopsy. In this article, we report a series of incompletely excised soft-tissue sarcomas about the wrist and offer an algorithm for their evaluation. We describe a series of 4 consecutive patients who each presented after incomplete resection of a soft-tissue sarcoma mistakenly diagnosed as a ganglion cyst. We also retrospectively review the cases of 7 patients with incompletely excised sarcomas of the wrist. Three of the 4 patients with sarcomas mistaken for ganglion cysts did not have prior magnetic resonance imaging (MRI), 3 of the 4 did not have an attempted aspiration, and all 4 did not have transillumination. Common atypical characteristics included ulna-based lesions (3/4), symptoms for less than 6 months (3/4), and no appreciable fluctuation in size (3/4). Functional outcomes for all patients were poor because of multiple surgical procedures, re-excisions requiring flaps, and need for additional adjuvant therapies. Dorsal wrist masses with atypical characteristics should be approached with caution. Transillumination and aspiration are 2 accessible, cost-efficient methods for evaluating these masses. If either test is abnormal, an MRI should be performed.

Upper extremity myonecrosis caused by Edwardsiella tarda resulting in transhumeral amputation: case report.

Necrotizing soft tissue infections are rapidly progressive infections with a high rate of mortality. One type of necrotizing soft tissue infection is caused by marine gram-negative bacteria and commonly occurs in immunocompromised hosts. These types of infections are more common in patients with chronic liver disease, possibly because of impaired iron metabolism. We present the case of a rapidly progressive necrotizing soft tissue infection caused by Edwardsiella tarda, a marine gram-negative pathogen common in catfish. Few extraintestinal infections of E tarda have been described previously. Our patient had hepatitis C and was exposed to the bacteria by a puncture injury from a wild catfish. His infection required multiple debridements and ultimately required a transhumeral amputation for local control of the infection.

Outcomes of hook of hamate fracture excision in high-level amateur athletes.

PURPOSE: To determine the overall long-term postoperative clinical and functional results of high-level amateur athletes after hook of hamate excision, based on complications; return to sport; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and a self-reported questionnaire. METHODS: We evaluated 11 patients representing 12 cases of hook of hamate excision. All patients were high-level amateur athletes (rising collegiate or collegiate level). We performed a retrospective chart review to elicit information pertaining to the patient's injury. We assessed long-term postoperative outcomes with a self-reported questionnaire, the DASH form, and the DASH Sport/Performing Arts Module form. RESULTS: All patients successfully returned to full participation in their respective sports an average of 6 weeks after surgery. The average postoperative DASH score was less than 1, and all patients scored a 0 on the DASH Sports form. There was a significant improvement in preoperative pain after surgical intervention. There was no significant difference between preinjury and postoperative performance scores. Finally, every patient was very satisfied with the surgical outcome. There was only 1 postoperative complication in which a patient developed transient ulnar nerve paresthesias, which completely resolved by 6 weeks after surgery. CONCLUSIONS: Surgical excision of hook of hamate fractures in high-level amateur athletes allows for successful return to sports participation at preinjury performance levels, achievement of normal function as measured by validated objective outcome measures, significant reduction in pain, and high overall patient satisfaction. We consider surgical excision to be a safe and effective technique to restore normal function and hasten return to play for high-level amateur athletes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Radiographic outcomes of volar locked plating for distal radius fractures.

PURPOSE: To assess the ability of volar locked plating to achieve and maintain normal radiographic parameters for articular stepoff, volar tilt, radial inclination, ulnar variance, and radial height in distal radius fractures. METHODS: We performed a retrospective review of 185 distal radius fractures that underwent volar locked plating with a single plate design over a 5-year period. We reviewed radiographs and recorded measurements for volar tilt, radial inclination, ulnar variance, radial height, and articular stepoff. We used logistic regression to determine the association between return to radiographic standard norms and fracture type. RESULTS: At the first and final postoperative follow-up visits, we observed articular congruence less than 2 mm in 92% of fractures at both times. Normal volar tilt (11°) was restored in 46% at the first follow-up and 48% at the final one. Radial inclination (22°) was achieved in 44% at the first follow-up and 43% at the final one, and ulnar variance (01 ± 2 mm) was achieved in 53% at the first follow-up and 53% at the final one. In addition, radial height (14 ± 1mm) was restored in 14% at the first follow-up and 12% at the final one. More complex, intra-articular fractures (AO class B and C and Frykman types 3, 4, 7, and 8) were less likely to be restored to normal radiographic parameters. However, because of the small sample size for some fracture types, it was difficult to discover significant associations between fracture type and radiographic outcome. CONCLUSIONS: Volar locked plating for distal radius fractures achieved articular stepoff less than 2 mm in most fractures but only restored and maintained normal radiographic measurements for volar tilt, radial inclination, and ulnar variance in 50% of fractures. The ability of volar locked plating to restore and maintain ulnar variance and volar tilt decreased with more complex intra-articular fracture types. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Hand and body radiation exposure with the use of mini C-arm fluoroscopy.

PURPOSE: To determine whole body and hand radiation exposure to the hand surgeon wearing a lead apron during routine intraoperative use of the mini C-arm fluoroscope. METHODS: Four surgeons (3 hand attending surgeons and 1 hand fellow) monitored their radiation exposure for a total of 200 consecutive cases (50 cases per surgeon) requiring mini C-arm fluoroscopy. Each surgeon measured radiation exposure with a badge dosimeter placed on the outside breast pocket of the lead apron (external whole body exposure), a second badge dosimeter under the lead apron (shielded whole body exposure), and a ring dosimeter (hand exposure). RESULTS: Completed records were noted in 198 cases, with an average fluoroscopy time of 133.52 seconds and average cumulative dose of 19,260 rem-cm(2) per case. The total measured radiation exposures for the (1) external whole body exposure dosimeters were 16 mrem (for shallow depth), 7 mrem (for eye depth), and less than 1 mrem (for deep depth); (2) shielded whole body badge dosimeters recorded less than 1 mrem; and (3) ring dosimeters totaled 170 mrem. The total radial exposure for 4 ring dosimeters that had registered a threshold of 30 mrem or more of radiation exposure was 170 mrem at the skin level, for an average of 42.5 mrem per dosimeter ring or 6.3 mrem per case. CONCLUSIONS: This study of whole body and hand radiation exposure from the mini C-arm includes the largest number of surgical cases in the published literature. The measured whole body and hand radiation exposure received by the hand surgeon from the mini C-arm represents a minimal risk of radiation, based on the current National Council on Radiation Protection and Management standards of annual dose limits (5,000 mrem per year for whole body and 50,000 mrem per year to the extremities).

Driving with an arm immobilized in a splint: a randomized higher-order crossover trial.

BACKGROUND: The aim of this study was to determine whether immobilization of an arm has detrimental effects on driving performance. METHODS: Thirty-six healthy officers-in-training were assigned a sequence of fiberglass splints (left and right-sided above-the-elbow thumb spica and below-the-elbow splints) with use of a randomized higher-order crossover design. Runs were scored on a cone-marked driving course used for officer certification with predetermined passing requirements. Driving time, the number of cones hit per course section, and the cone-adjusted total time (a five-second penalty per hit cone) were recorded. A linear mixed-effect model with random environmental and learning effects for cone-adjusted time analysis was used. Participants rated perceived driving difficulty and safety with each splint, and ratings were compared with the Wilcoxon signed-rank test. RESULTS: Thirty participants completed the entire set of runs. Analysis of total cone-adjusted time revealed a significant performance decrease with the left arm in an above-the-elbow thumb spica splint (average, 22.2 seconds; p < 0.001) and with the left arm in a below-the-elbow splint (average, 16.2; p = 0.007). Analysis of forward-only course sections revealed poorer performance trends with all splints, with the worst performance with the left arm in an above-the-elbow thumb spica splint. Driving with the left arm in an above-the-elbow thumb spica splint had the highest perceived difficulty (median, 8.0) and lowest perceived safety (median, 3.0). CONCLUSIONS: Driving performance as measured with a standardized track and scoring system was significantly degraded with splint immobilization of the left arm. Further studies are required to determine the effect of arm immobilization on normal driving conditions.

Precontoured fixed-angle volar distal radius plates: a comparison of anatomic fit.

PURPOSE: To compare distal radius volar fixed-angle plates for anatomic fit. METHODS: Twenty embalmed radii were stripped of soft tissues. The volar lip (watershed line) on the volar distal radius served as a reference line. Seven volar fixed-angle plates were tested (Acumed Acu-loc Standard, Hand Innovations DVRAW and DVRAN, Synthes Juxta-articular [JA], Synthes Extra-articular [EA], Trimed Volar Bearing, Zimmer Volar Lateral Column). Four parameters of anatomic fit were studied: (1) site of best fit; (2) percent plate contact; (3) pin-subchondral bone distance; and (4) extraosseous penetrations. The Wilcoxon signed rank test and Pearson's correlation coefficient were used to compare interobserver plate placement. A Kruskal-Wallis analysis of variance was used to compare percent plate contact and pin-subchondral bone distance across all plates. The Bonferroni correction for multiple comparisons was used to compare pin-subchondral bone distances for all possible plate combinations. RESULTS: There was no difference between observers for plate placement. Each plate had a specific site of best fit, and the 7 plates varied widely in best fit location. Percent contact (range, 3% to 6%) between plates was significantly different. Pin-subchondral bone distance across all plates was significantly different. Analysis of all possible plate combinations showed that the Synthes EA pin-subchondral bone distances were significantly different than those of all plates except Zimmer. Amongst the 140 plate insertions, the radiocarpal joint was penetrated in 17, the styloid in 7, (with 6 associated with the DVRAW plate), and the distal radioulnar joint in 9 (all associated with the DVRAW plate). CONCLUSIONS: There was considerable variation in ideal plate location among the 7 plates tested. Total contact was minimal for all plates tested. The Synthes EA pin-subchondral bone distance was significantly greater than those of other plates tested. Joint penetration was relatively common, necessitating use of fluoroscopy and proper plate width.

Clostridium septicum myonecrosis complicating diarrhea-associated hemolytic uremic syndrome.

We report the case of a 19-month-old male child with diarrhea-associated hemolytic uremic syndrome (HUS) who developed swelling of the right arm at the site of a peripherally inserted central venous catheter (PICC), fever, and later, ecchymosis. Wound cultures at the time of surgical debridement grew Clostridium septicum. The child subsequently required amputation of the right arm and prolonged therapy with parenteral penicillin and clindamycin. Clostridium septicum infections in children with HUS have been associated with a high rate of mortality. Along with colon cancer, diarrhea-associated HUS comprises a clinical entity which appears to predispose to atraumatic C. septicum infection, where acidic and anaerobic conditions in the diseased colon favor C. septicum invasion. Though not well recognized among pediatric nephrologists, C. septicum infection constitutes a severe, albeit rare, complication of diarrhea-associated HUS, but one in which a high index of suspicion is warranted as aggressive surgical and antibiotic therapy may be life-saving.

Management of acute complex instability of the elbow with hinged external fixation.

We report the experience of a single surgeon who treated 20 patients, over a 9-year period, with acute complex instability of the elbow with hinged external fixation. Patients who presented greater than 6 months after the original injury were excluded. The mechanism of injury was typically a fall or a motor vehicle accident. Fixators were placed at a mean of 26 days (range, 0-66 days) after injury and initial management. Reconstruction of the collateral ligaments was not performed, but soft tissues were repaired en bloc to the humerus. All patients were available for follow-up at a mean of 2.1 years. Flexion-extension arcs averaged 93 degrees , whereas pronation-supination arcs averaged 96 degrees. Posttraumatic arthrosis was commonly seen at follow-up, with moderate or severe changes developing in 55% of patients. Arthrosis did not correlate with functional outcomes, however. Outcomes were measured by use of the Mayo Elbow Performance Index and the Hospital for Special Surgery Total Elbow Scoring System, with mean scores of 75 and 71 points, respectively. Although the severity of injury often precludes obtaining a high percentage of good and excellent results, the outcomes after treatment of acute complex elbow instability with hinged external fixation by use of the technique detailed in this series are comparable to those of similar series.