Bioabsorbable Pin Fixation in Late Presenting Pediatric Radial Neck Fractures.

BACKGROUND: Current treatment algorithms for pediatric radial neck fractures reserve open treatment for severe residual angulation. There is a paucity of literature guiding treatment for delayed presentation resulting in malunion. Bioabsorbable pins have been used successfully for many other fracture types in the upper extremity. The purpose of this study is to determine whether open reduction, bioabsorbable fixation with an osteotomy when necessary is a reasonable treatment option in delayed pediatric radial neck fractures by assessing pain, range of motion, functional, and radiographic outcomes. METHODS: Radial neck fractures were evaluated in 7 children, 4 to 12 years old, with delayed initial presentation averaging 20 days. Patients presented with an average angular deformity of 63 degrees and translational deformity of 57% (6.1 mm) in the AP plane, all with painful and reduced range of motion. Patients underwent open reduction and fixation with Self-Reinforced Poly-L-Lactic Acid pins after failed closed reduction. Four patients required formal osteotomies. Postoperative follow-up averaged 9.2 months and consisted of radiographic and clinical evaluation with Wong-Baker FACES Visual Analog scale and the Mayo Elbow Performance (MEP) score. RESULTS: Final radiographs demonstrate an improvement in angular deformity by 56 degrees and translational deformity by 51%. Final clinical outcomes demonstrated significantly improved pain-free range of motion with excellent MEP scores in 6 of the 7 patients. One patient developed a radioulnar synostosis, subsequently undergoing synostosis excision with a final MEP score of 80/100. There was no evidence of physeal closure or avascular necrosis and no cases requiring hardware removal or complicated by local inflammatory reactions. CONCLUSIONS: This small series shows encouraging results in the treatment of pediatric radial neck fractures with delayed presentation using open reduction, bioabsorbable fixation, and when necessary an osteotomy. Bioabsorbable fixation may eliminate issues surrounding subsequent hardware removal and pin-site infections. Despite these encouraging results, radioulnar synostosis after open surgery is still a concern. LEVEL OF EVIDENCE: Level IV-case series.

Isolated Hamate Dislocation: A Case Report and Technique Guide.

Introduction: Isolated hamate dislocation is a rare case with potentially devastating complications, given the resultant instability of the carpus following the injury. This has been reported in the literature before with varying constructs and varying results but never with an internal bracing construct and early rehabilitation. Case Report: A 26-year-old male injured his left hand in an all-terrain vehicle accident. After initial misdiagnosis and subsequent persistent pain, he was diagnosed with a chronic dorsal hamate dislocation. An open reduction and internal brace fixation were performed resulting in an anatomic and stable reduction. By the final follow-up visit, the patient had no pain with near full range of motion and had returned to work with good to excellent outcome scores. Conclusion: Open reduction with ligament reconstruction utilizing an internal bracing technique provides a stable fixation and anatomic repair of the intercarpal and carpometacarpal ligaments. This is a feasible treatment option for hamate dislocations that allows for early rehabilitation in comparison to previously described methods and may result in good to excellent outcomes.

Intramedullary Suture Anchor Fixation of a Type Vb Flexor Digitorum Profundus Avulsion: A Case Report.

CASE: Flexor digitorum profundus avulsions are common injuries that manifest as tendinous or bony avulsions from the distal phalanx. Rarely, additional fractures can occur in the distal phalanx. For such injuries, repair of the avulsion and fracture is recommended but difficult because of limited bone stock for fixation. CONCLUSION: We present a case of a 28-year-old man with a combined flexor digitorum profundus bony avulsion and bony mallet finger, and describe a strategic fixation technique using an intramedullary suture anchor and dorsal button that provided stable fixation and resulted in excellent motion and function, with return to sport at 12 weeks.

An Aggressive Digital Papillary Adenocarcinoma and a Grossly Similar, Contralateral Callus: A Case Report.

CASE: This is a case of a 44-year-old man with 10 years of history of painful callus-like swellings of bilateral index fingers. Sudden enlargement of the left index finger prompted biopsy, which revealed aggressive digital papillary adenocarcinoma (ADPA) that was treated with partial amputation. Biopsy of the contralateral finger revealed acanthotic skin with no evidence of malignancy. CONCLUSION: Several case reports cite antecedent insult and chronic swelling before diagnosis. We describe a case of bilateral lesions with similar gross appearances, a long history of occupational repetitive trauma, and sudden enlargement of 1 lesion leading to the diagnosis of ADPA.

Radiation Exposure and Hand Dominance Using Mini C-Arm Fluoroscopy in Hand Surgery.

BACKGROUND: The mini C-arm is popular with hand surgeons, and they are particularly at risk for radiation exposure, as they cannot easily distance themselves from the radiation beam. We hypothesized that the nondominant hand receives more radiation exposure than the dominant hand as it is generally closer to the radiation source. This study seeks to determine whether a hand surgeon receives a different amount of radiation exposure to their hands based on hand dominance and then accounting for this, provide a more accurate assessment of hand radiation exposure from mini C-arm fluoroscopy. METHODS: Two fellowship-trained hand surgeons wore ring dosimeters on both hands during surgeries with mini C-arm fluoroscopy involving bony work of the forearm and hand. Radiation exposure to the hands was measured from ring dosimeters. RESULTS: Six-ring dosimeter pairs were worn during 64 cases, averaging 10.7 cases per ring. No ring met the minimal dose threshold of 30 mrem to record a numerical value. Each ring experienced an average of 413 seconds of fluoroscopy time and 66.3509 cGy*cm(2) of radiation output from the mini C-arm. CONCLUSIONS: The results do not allow comparison of radiation exposure related to hand dominance. Assuming worst-case scenario: each ring measured 29 mrem (just below the threshold), the surgeon's hands experienced 2.7 mrem per case. This would allow a hand surgeon to perform 18 391 cases per year before exceeding the allowable annual hand exposure limit of 50 000 mrem set by the National Council of Radiation Protection and Measurements and International Commission on Radiological Protection.

A Prospective Randomized Crossover Study on the Comparison of Cotton Versus Waterproof Cast Liners.

BACKGROUND: Many fractures are treated with casting which can cause complications likely from inability to wash the extremity. Gore-Tex-based waterproof cast liner has been compared with cotton liner and shown to be superior in physician and patient scoring but also has high cost and difficult application. The purpose of this study is to compare newer generation waterproof liners with traditional cotton liner. It is the first study to compare this new waterproof liner and cotton liner in a crossover model, allowing patients to swim in the pool with the cast. METHODS: Twenty patients (ages 3-30) with upper extremity injuries were randomized to waterproof-liner or cotton-liner casts made of fiberglass. Patients would switch cast liners halfway between their treatments to fulfill crossover criteria. All fractures were within a 2-week period from original incident. At each clinic visit, patients evaluated comfort parameters through questionnaires, and physicians rated skin condition. Patients were also asked which cast liner they preferred at the end of the study. RESULTS: There were no unscheduled cast changes. The waterproof-liner group had better scores for odor (P = .041), sweat (P = .016), and overall physician-rated score (P = .038). There was no significant difference in other patient-rated parameters. Seventy-five percent of patients preferred waterproof casting to the cotton liner. CONCLUSIONS: This new waterproof cast liner, compared with cotton cast liner, had better odor, sweat, and overall physician scores. The waterproof liners allow patients to rinse casts daily, and the majority of patients prefer waterproof to cotton liner.

Conversion of a surgical elbow arthrodesis to total elbow arthroplasty.

Arthrodesis of the elbow joint addresses pain due to intra-articular pathology, but with significant functional limitations. Loss of motion at the elbow is not completely compensated by the wrist and shoulder joints and elbow fusion is thus purely a salvage procedure. Advances in joint arthroplasty have allowed surgeons to address the functional limitations of arthrodesis, but despite these advances the elbow is still one of the joint replacements with higher complication rate. Conversion of a joint fusion to arthroplasty has been reported for the hip, knee, shoulder, and ankle. The takedown of a surgically fused elbow was reported in German literature in 2013. We present the first such case report in the English literature with a 49-year-old male whose status is elbow fusion performed for trauma 31 years prior.

Free vascularized fibula graft to treat chondroblastoma of the hip.

Chondroblastomas are rare tumors that present in the epiphysis of the long bones. Bone grafting following aggressive surgical curettage has yielded the best results. When present in the femoral head, they pose a higher risk of recurrence due to the difficulty of achieving an adequate resection without destroying the structural integrity of the weight-bearing surface. This article describes a case of surgical treatment of a chondroblastoma of the femoral head with the use of a free vascularized fibula graft. A 26-year-old woman had several months of increasing left hip pain and decreased range of motion. Imaging studies confirmed a large bubbly lesion with sclerotic borders in the left femoral head consistent with chondroblastoma. After performing an aggressive and complete excisional biopsy, a large cavitary defect remained in the femoral head. Reconstruction of the defect and structural support was achieved using a free vascularized fibula. Nine years postoperatively, the patient had full hip motion, no pain, and no radiographic evidence of collapse. A free vascularized fibula graft is an excellent option for the reconstruction of a large femoral head defect after chondroblastoma resection.

Evaluation of the learning curve for reverse shoulder arthroplasty.

This purpose of this study was to quantify the surgical learning curve and provide guidelines to surgeons interested in teaching and performing reverse shoulder replacement. Sixty-two consecutive primary reverse shoulder replacements performed by a single surgeon were retrospectively reviewed. Using data from consecutive cases, surgical time was plotted against patient case order, and the linear regression slope was calculated. Case length slope analysis demonstrated a significantly negative slope with the first 18 cases, which subsequently leveled thereafter. The number of cases needed to arrive at this flat slope was defined as the proficiency point.The proficiency point was then verified using the measurable variables of baseplate screw number and glenosphere overhang by dividing the series into 2 groups: Group A included patients who had surgery prior to the proficiency point, and group B included patients who had surgery after the proficiency point. In group A, only 33% (6/18) had all 4 glenoid baseplate screws placed as compared to 66% (29/44) in group B (P=.02). Glenosphere overhang increased from a mean of 1.02 mm (+/-1.29 mm) in group A to 2.58 mm (+/-1.89 mm) in group B (P=.003).A learning curve of approximately 18 cases was found in this series based on the technical aspects of performing reverse shoulder replacement. This curve is likely even longer for lower volume shoulder surgeons. We recommend specialized training prior to performing this procedure.