A three-dimensional computed tomography study of the palmar ulnar corner fragment in distal radial fractures.

Fixing palmar ulnar corner fragments of distal radial fractures can be challenging. We described the palmar ulnar corner fragment morphology in a retrospective cohort study of 40 patients who underwent preoperative wrist computed tomography scans. Palmar ulnar corner fractures were categorized based on articular cross-sectional area, sagittal angulation relative to the radius long axis, palmar cortical length, radioulnar width and associated palmar radiocarpal subluxation. Three types emerged: type 1 fragments involved 37% (SD 10) of the radiocarpal articular surface and were extended in the sagittal plane; type 2 fragments involved 28% (SD 10) of the articular surface and had a long palmar cortex, of which 57% had palmar carpal subluxation; and type 3 fragments involved 13% (SD 2) of the articular surface, had a short palmar cortex and all had palmar carpal subluxation. Understanding palmar ulnar corner fragment morphology may guide optimal reduction and fixation strategy and prevent palmar radiocarpal subluxation, especially in type 3 fractures.Level of evidence IV.

A Simple and Versatile Test for Elbow Posterolateral Rotatory Instability.

BACKGROUND: Posterolateral rotatory instability (PLRI) results from lateral ulnar collateral ligament (LCL) deficiency. The lateral pivot shift test is used to diagnose PLRI but can be difficult to perform and is poorly tolerated. We present a new maneuver, the Posterior Radiocapitellar Subluxation Test (PRST), that we believe is easier to perform. The purpose of this study was to compare the efficacy and reproducibility of the PRST with the lateral pivot shift test. METHODS: We obtained 10 cadaveric upper extremity specimens, performed a Kocher approach on each, released the LCL origin in 5, then closed. The specimens were randomized, and 3 attending orthopedic surgeons and 1 resident blindly performed the PRST then the lateral pivot shift test after re-randomization and assessed presence or absence of PLRI. This process was repeated the following day. The data for each test were analyzed for sensitivity, specificity, and accuracy. RESULTS: For the blinded testing when comparing PRST with the pivot shift test, overall accuracy was 77.5%, compared with 67.5% (P = .03), sensitivity was 75.0%, compared with 50.0% (P = .003), and specificity was 80.0%, compared with 85.0% (P = .55). Conclusions: The PRST appears to be at least as accurate as the lateral pivot shift test, with comparable intraobserver and interobserver reliability.

The Lumbricals Are Not the Workhorse of Digital Extension and Do Not Relax Their Own Antagonist.

That the lumbrical muscles are the workhorse of digital extension and that they can relax their own antagonist have been time-honored principles. However, we believe this dogma is incorrect and an oversimplification. We base our assertion on anatomy, innervation, and the notion that muscle architecture is the most important determinant of muscle function. Wang and colleagues proposed the lumbrical to be a sophisticated tension monitoring device. We elaborate on their well-supported thesis, further proposing that the lumbricals also function as a constant tension spring within the closed loop composed of the digital flexors and the extensor mechanism.

Heterotopic ossification after local steroid injection.

Pachydermodactyly (PDD) is a rare, benign disease associated with progressive swelling of the periarticular soft tissue of phalangeal hand joints typically treated with local steroid injections. We present a case of a 37-year-old man with PDD treated with local steroid injections. He later developed heterotopic ossification and para-articular calcifications in the injection sites. Heterotopic ossification is not associated with PDD nor is it a recognised complication of local steroid injections. This is the first case in literature of heterotopic ossification occurring after local steroid injection and brings to attention a new potential complication of a widely performed procedure.

Management of soft tissue tumors of the upper extremity: a review.

INTRODUCTION: Management of malignant tumors of the hand and wrist is challenging and is generally approached by limb salvage or amputation. With advances in care, amputation has been superseded by limb salvage as the treatment of choice. METHODS: A narrative literature review was performed to identify articles on the topic of management of soft tissue tumors of the upper extremity, including surgical management, adjuvant radiation therapy, and chemotherapy. RESULTS: A total of 29 articles were selected. Earlier reports favored radical tumor resection, which often led to amputation, whereas later articles demonstrated limb salvage as the preferential treatment modality. CONCLUSIONS: Given the detrimental effects on function and psychologic outcomes, amputation has been superseded by limb salvage in most cases, although it can occasionally be the only option. A variety of adjuvant therapies have been described, including radiation or brachytherapy, chemotherapy, and regional hyperthermia. Radiation treatment, and specifically brachytherapy, is beneficial to select patients. Controversy surrounds chemotherapy in certain subtypes, and regional hyperthermia requires further investigation.

Transhumeral Anterior Radial Nerve Transposition to Simplify Anticipated Future Humeral Reconstruction.

Anterior transhumeral radial nerve transposition has been described in the treatment of humeral shaft fracture to protect the nerve from implant irritation or callus entrapment. Transposing the radial nerve through a facilitating humeral defect also simplifies revision surgery should nonunion result. Here we describe a surgical technique for anterior transhumeral radial nerve transposition for complex humeral reconstruction when subsequent revision surgery is anticipated. Three cases are used for illustration: (1) revision of a total elbow arthroplasty with periprosthetic fracture; (2) revision of a total elbow arthroplasty after aseptic loosening from an allograft/prosthesis composite; and (3) septic humeral nonunion with substantial bone loss. These 3 patients underwent a total of 16 operations, 6 of which took place after the radial nerve transposition. Transhumeral radial nerve transposition allowed less worrisome dissection during revision surgery despite the multiple previous procedures. We advocate transhumeral radial nerve transposition when the duration and frequency of revisions is uncertain and the anticipated future revision may require a posterior, posterolateral, or anterolateral approach to the humerus.

Compartment Syndrome of the Hand.

Hand compartment syndrome has many etiologies; untreated, it has dire functional consequences. Intracompartmental pressure exceeding capillary filling pressure causes decreased tissue perfusion resulting in progressive ischemic death of compartment contents. Clinical findings can evolve. Serial physical examinations are recommended and, if equivocal, interstitial pressure monitoring is indicated. Definitive management is emergent fasciotomies with incisions designed to decompress the involved hand compartments, which could include the thenar, hypothenar, and interosseous compartments, and the carpal tunnel. Careful wound care, edema management, splinting, and hand therapy are critical. Therapy should start early postoperatively, possibly before wound closure.

Scaphoid and Lunate Dislocation with Complete Soft-Tissue Avulsion: A Case Report.

CASE: We describe an intercarpal dislocation with proximal and rotatory displacement of the lunate and with volar and radial dislocation of the scaphoid; both bones were stripped of soft tissue. Treatment involved ORIF (open reduction and internal fixation). Three years postoperatively, the patient had a DASH (Disabilities of the Arm, Shoulder and Hand) score of 10, equivalent grip strength and 50% wrist palmar flexion and 98% wrist dorsiflexion compared with the uninjured side, and radiographic evidence of posttraumatic arthritis. CONCLUSION: Treatment of simultaneous divergent lunate and scaphoid dislocation with loss of nearly all soft-tissue attachments and vascular supply by means of ORIF and repair of soft-tissue structures can result in a favorable intermediate-term functional outcome and may be superior to other salvage procedures such as proximal row carpectomy.

Hand infections.

Many acute hand and upper extremity infections should be treated as surgical emergencies to avoid stiffness, contracture, pain, and amputation. Proper treatment requires understanding of anatomy and how this influences the behavior of certain infections, common offending organisms, antibiotic treatment, management of host factors, and surgical intervention. This article reviews the microbiology, antibiotic coverage, and surgical treatment of the most common infections in the hand: paronychia, felon, herpetic whitlow, flexor tenosynovitis, deep space infections, septic arthritis, bites from humans and animals, necrotizing fasciitis, mycobacterium infections, and fungal infections. Recommendations are based on the most recent available evidence.

Functional consequence of distal brachioradialis tendon release: a biomechanical study.

PURPOSE: Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, this common procedure has the potential to decrease elbow flexion strength. To determine the potential morbidity associated with brachioradialis release, we measured the change in elbow torque as a function of incremental release of the brachioradialis insertion footprint. METHODS: In 5 upper extremity cadaveric specimens, we systematically released the brachioradialis tendon from the radius and measured the resultant effect on brachioradialis elbow flexion torque. We defined release distance as the distance between the release point and the tip of the radial styloid. RESULTS: Brachioradialis elbow flexion torque dropped to 95%, 90%, and 86% of its original value at release distances of 27, 46, and 52 mm, respectively. Importantly, brachioradialis torque remained above 80% of its original value at release distances up to 7 cm. CONCLUSIONS: Our data demonstrate that release of the brachioradialis tendon from its insertion has minor effects on its ability to transmit force to the distal radius. CLINICAL RELEVANCE: These data imply that release of the distal brachioradialis tendon during distal radius open reduction internal fixation can be performed without meaningful functional consequences to elbow flexion torque. Even at large release distances, overall elbow flexion torque loss after brachioradialis release would be expected to be less than 5% because of the much larger contributions of the biceps and brachialis. Use of the brachioradialis as a tendon transfer donor should not be limited by concerns of elbow flexion loss, and the tendon could be considered as an autograft donor.

A randomized comparison of infraclavicular and supraclavicular continuous peripheral nerve blocks for postoperative analgesia.

BACKGROUND: Although the efficacy of single-injection supraclavicular nerve blocks is well established, no controlled study of continuous supraclavicular blocks is available, and their relative risks and benefits remain unknown. In contrast, the analgesia provided by continuous infraclavicular nerve blocks has been validated in randomized controlled trials. We therefore compared supraclavicular with infraclavicular perineural local anesthetic infusion following distal upper-extremity surgery. METHODS: Preoperatively, subjects were randomly assigned to receive a brachial plexus perineural catheter in either the infraclavicular or supraclavicular location using an ultrasound-guided nonstimulating catheter technique. Postoperatively, subjects were discharged home with a portable pump (400-mL reservoir) infusing 0.2% ropivacaine (basal rate of 8 mL/hr; 4-mL bolus dose; 30-min lockout interval). Subjects were followed up by telephone on an outpatient basis. The primary outcome was the average pain score on the day after surgery. RESULTS: Sixty subjects were enrolled, with 31 and 29 randomized to receive an infraclavicular and supraclavicular catheter, respectively. All perineural catheters were successfully placed per protocol. Because of protocol violations and missing data, an intention-to-treat analysis was not used; rather, only subjects with catheters in situ and whom we were able to contact were included in the analyses. The day after surgery, subjects in the infraclavicular group reported average pain as median of 2.0 (10th-90th percentiles, 0.5-6.0) compared with 4.0 (10th-90th percentiles, 0.6-7.7) in the supraclavicular group (P = 0.025). Similarly, least pain scores (numeric rating scale) on postoperative day 1 were lower in the infraclavicular group compared with the supraclavicular group (0.5 [10th-90th percentiles, 0.0-3.5] vs 2.0 [10th-90th percentiles, 0.0-4.7], respectively; P = 0.040). Subjects in the infraclavicular group required less rescue oral analgesic (oxycodone, in milligrams) for breakthrough pain in the 18 to 24 hrs after surgery compared with the supraclavicular group (0.0 [10th-90th percentiles, 0.0-5.0] vs 5.0 [10th-90th percentiles, 0.0-15.0], respectively; P = 0.048). There were no statistically significant differences in other secondary outcomes. CONCLUSIONS: A local anesthetic infusion via an infraclavicular perineural catheter provides superior analgesia compared with a supraclavicular perineural catheter.

Quantification of partial or complete A4 pulley release with FDP repair in cadaveric tendons.

PURPOSE: Repair of a lacerated flexor digitorum profundus (FDP) tendon underneath or just distal to the A4 pulley can be technically challenging, and success can be confounded by tendon triggering and scarring to the pulley. The purpose of this study was to quantify the effect of partial and complete A4 pulley release in the context of a lacerated and repaired FDP tendon just distal to the A4 pulley. METHODS: Tendon biomechanics were tested in 6 cadaveric hands secured to a rigid frame, permitting measurement of tendon excursion, tendon force, and finger range of motion. After control testing, each finger had laceration and repair of the FDP tendon at the distal margin of the A4 pulley using a 6-strand core suture technique and epitendinous repair. Testing was then repeated after the following interventions: (1) intact A4 pulley, (2) release of the distal half of the A4 pulley, (3) complete release of the A4 pulley, and (4) continued proximal release of the sheath to the distal edge of A2 (release of C2, A3, and C1 pulleys). Release of the pulleys was performed by incision; no tissue was removed from the specimens. RESULTS: From full extension to full flexion, average FDP tendon excursion for all intact digits was 37.9 ± 1.5 mm, and tendon repair resulted in average tendon shortening of 1.6 ± 0.4 mm. Flexion lag increased from <1 mm to >4 mm with venting of the A4 pulley, complete A4 release, and proximal sheath release, respectively. Compared to the intact state, repair of the tendon with an intact A4 pulley, release of half the A4 pulley, complete A4 release, and proximal sheath release resulted in percentage increases in work of flexion of 11.5 ± 3.1%, 0.83 ± 2.8%, 2.6 ± 2.4%, and 3.25 ± 2.2%, respectively. CONCLUSIONS: After FDP laceration and repair in the region of the A4 pulley, work of flexion did not increase by more than 3% from control conditions after partial or complete A4 pulley release, and work of flexion was significantly less than that achieved by performing a repair and leaving the A4 pulley intact.

Immediate interpersonal and intermanual referral of sensations following anesthetic block of one arm.

OBJECTIVES: To explore whether interpersonal and intermanual sensory referral occurs following anesthetic block of a limb and to test theories of disinhibition of mirror neuron activity and transcallosal referral. DESIGN: Case series. SETTING: Outpatient surgery at the University of California San Diego Medical Center. PATIENTS: Six patients who underwent orthopedic surgery. MAIN OUTCOME MEASURES: Patient verbal ratings. RESULTS: Patients with brachial plexus blocks experienced touch sensations in the anesthetized arm when watching another person's arm being touched or when the contralateral intact hand was touched. CONCLUSIONS: To our knowledge, this is the first demonstration of rapid reorganization of functional connectivity in the adult human brain, most likely in S2 neurons. This finding suggests that conscious perception of touch results from fluctuating mosaics of cortical excitation and inhibition between different regions within the patient's own S2 neurons and, more remarkably, from viewing others' sensations.

Simultaneous dorsal dislocations of the carpometacarpal joints of all four fingers.

A 57-year-old right-hand-dominant woman was involved in a motor vehicle collision. Upon examination, her right hand was markedly deformed and swollen, with limited range of movement. Plain radiographs revealed dorsal dislocations of the index, long, ring, and small finger carpometacarpal joints and an avulsion fracture of the dorsal aspect of the capitate. Closed reduction was unsuccessful. Closed reduction under general anesthesia was successful on the carpometacarpal joint of the ring and small fingers, however, the long and index fingers remained irreducible. An open approach revealed that a joint capsule was interposed in the carpometacarpal joints of the long and index fingers, preventing reduction. Kirschner wires were placed through the base of the small and ring finger metacarpals into the carpus. Additional K-wires were placed across the base of the index and long finger metacarpals into the carpus, and removed at 6 weeks. The avulsion fracture of the capitate was not addressed. Follow-up at 24 months demonstrated full range of motion in all fingers. Her DASH Outcome Measure score was 1.7. She was pain free, had full grip strength, and returned to work full-time. Whether patients are treated closed or open, appropriate treatment of carpometacarpal dislocations usually leads to excellent outcomes. If closed reduction is unsuccessful, open treatment is required to address any soft tissue that is preventing reduction. Although urgent treatment is preferred, delay in reduction of up to 4 weeks has been shown not to compromise results.

Ultrasound guidance versus electrical stimulation for infraclavicular brachial plexus perineural catheter insertion.

OBJECTIVE: Electrical stimulation (ES)- and ultrasound-guided placement techniques have been described for infraclavicular brachial plexus perineural catheters but to our knowledge have never been previously compared in a randomized fashion, leaving the optimal method undetermined. We tested the hypothesis that infraclavicular catheters placed via ultrasound guidance alone require less time for placement and produce equivalent results compared with catheters placed solely via ES. METHODS: Preoperatively, patients receiving an infraclavicular perineural catheter for distal upper extremity surgery were randomly assigned to either ES with a stimulating catheter or ultrasound guidance with a nonstimulating catheter. The primary outcome was the catheter insertion duration (minutes) starting when the ultrasound transducer (ultrasound group) or catheter placement needle (stimulation group) first touched the patient and ending when the catheter placement needle was removed after catheter insertion. RESULTS: Perineural catheters placed with ultrasound guidance took a median (10th-90th percentile) of 9.0 (6.0-13.2) minutes compared with 15.0 (4.9-30.0) minutes for stimulation (P < .01). All ultrasound-guided catheters were successfully placed according to the protocol (n = 20) versus 70% in the stimulation group (n = 20; P < .01). All ultrasound-guided catheters resulted in a successful surgical block, whereas 2 catheters placed by stimulation failed to result in surgical anesthesia. Six catheters (30%) placed via stimulation resulted in vascular punctures compared with none in the ultrasound group (P < .01). Procedure-related pain scores were similar between groups (P = .34). CONCLUSIONS: Placement of infraclavicular perineural catheters takes less time, is more often successful, and results in fewer inadvertent vascular punctures when using ultrasound guidance compared with ES.

Ultrasound-guided perineural catheter and local anesthetic infusion in the perioperative management of pediatric limb salvage: a case report.

Local anesthetic perineural infusion has emerged as an effective analgesic technique in pediatric patients, but it can also complement surgical perioperative management in complex cases that require optimal tissue perfusion such as limb salvage. We report the successful use of brachial plexus perineural infusion in the care of a child following near-amputation of her dominant hand. An ultrasound-guided infraclavicular brachial plexus catheter was placed in the recovery room after complex reconstructive surgery and a continuous infusion of 0.2% ropivacaine maintained for 24 days. The resultant sympathectomy was integral to providing distal limb perfusion despite partial restenosis of the surgical revascularization.