Dual Construct Fixation of the Scaphoid.

Dual construct fixation has been increasingly used in complex peri-articular or peri-prosthetic long bone fractures, those with poor bone quality and in revision situations. We describe the utilisation of a screw-plate construct in the setting of a juxta-articular distal pole scaphoid fracture, review the literature and provide recommendations for future use. Level of Evidence: Level V (Therapeutic).

Acute Mallet Finger Injuries-A Review.

Acute disruptions of the terminal extensor tendon are common and can result in significant dysfunction if not recognized and treated appropriately. This article provides a topical review of the contemporary literature concerning acute mallet finger injuries. It also proposes a modification to the Doyle classification to make it more encompassing and less prone to interobserver error.

The Anatomy of Nerve Transfers Used in Tetraplegic Hand Reconstruction.

PURPOSE: To evaluate the anatomy of nerve transfers used to reconstruct wrist extension, hand opening, and hand closing in tetraplegic patients. METHODS: Nerve transfers were completed on 18 paired cadaveric upper limbs. The overlap of donor and recipient nerves was measured, as well as the distance to the target muscle. Axons were counted in each nerve and branch, with the axon percentage calculated by dividing the donor nerve count by that of the recipient. RESULTS: Transfers with overlap of the donor and recipient nerve were from the radial nerve branch to extensor carpi radialis brevis to anterior interosseous nerve (AIN) and from the branch(es) to supinator to posterior interosseous nerve. The extensor carpi radialis brevis to AIN had the shortest distance to the target, with the branch to brachialis to AIN being the longest. The nerve transfers for wrist extension had the highest axon percentage. Of the transfers for hand closing, the brachialis to AIN had the highest axon percentage, and the branch to brachioradialis to AIN had the lowest. CONCLUSIONS: The anatomical features of nerve transfers used in tetraplegic hand reconstruction are variable. Differences may help explain clinical outcomes. CLINICAL RELEVANCE: This study demonstrates which nerve transfers may be anatomically favorable for restoring hand function in tetraplegic patients.

Evidence for efficacy of new developments in reconstructive upper limb surgery for tetraplegia.

Nerve transfers are increasingly utilized for upper limb reconstruction in tetraplegia. We reviewed the literature for results achieved by nerve transfers for elbow extension, wrist control and finger and thumb flexion and extension. Muscle strength grading was the only outcome measure consistently reported. The results confirm that nerve transfers can effectively reanimate muscles in selected cases, with comparable strength with those achieved with tendon transfer for elbow extension but inferior strength for finger and thumb flexion. Transfer of supinator nerve branches to the posterior interosseous nerve appears to be reliable and offers increased span and better hand opening than is observed after tendon transfers. Only one publication demonstrated how reinnervation of muscles with nerve transfers translated into improved function, activity and participation for patients. More prospective studies, using standardized outcome measures, are needed to define the precise role of nerve transfers.

Midcarpal Arthrodesis Biomechanics: Memory Staples versus Cannulated Screws.

BACKGROUND: Midcarpal arthrodesis is a treatment of choice in patients with midcarpal arthritis. Traditionally a four corner fusion has been favoured, however recent research has shown improved results when the triquetrum and scaphoid are excised. There is no clear evidence as to which remaining bones should be fused or which implants should be used. The purpose of this study is to compare the biomechanics of midcarpal arthrodesis after scaphoid and triquetrum excision, using memory staples or cannulated screws, in recognised construct patterns. METHODS: 36 identical sets of carpal bones were 3D printed from acetyl butyl styrene. Midcarpal arthrodeses were performed in three configurations with shape memory alloy staples or headless compression screws. This gave 6 treatment groups; lunocapitate single staple or screw, lunocapitate with 2 staples or screws, three corner fusion with 2 staples or screws. Peak torque to distraction was measured and analysed. RESULTS: The peak torque to distraction was significantly greater in almost all constructs utilizing screws compared to staples, with two lunocapitate screws having the highest peak torque at both 1 and 3 mm distraction with 244 Nmm and 749 Nmm respectively (p < 0.05). CONCLUSIONS: Constructs utilizing screws have a peak torque to distraction significantly higher when compared to staples. Our recommendation when performing a midcarpal arthrodesis after scaphoid and trapezium excision is to fuse the midcarpal joint with 2 headless compression screws.

An assessment of 2 objective measurements of web space position.

PURPOSE: To describe 2 simple objective clinical methods of measuring the web position between fingers and to determine their intra-observer and inter-observer reliabilities. METHODS: Two observers examined the second, third, and fourth web spaces on both hands of 30 adult healthy volunteers. The web index measured the web height as a relative ratio to constant anatomical landmarks on both fingers subtending the web. The dorsal web index took reference from the distance between the metacarpophalangeal and proximal interphalangeal joints, whereas the palmar web index was measured in relation to the distance between the most proximal basal digital and proximal interphalangeal joint creases. The intraclass correlation coefficient was used to determine intra-observer and inter-observer reliability. RESULTS: Intraclass correlation coefficient values for intra-observer and inter-observer reliability were greater than 0.80, indicating excellent agreement. There was no statistically significant difference between the dorsal or palmar measurement methods in terms of reliability. CONCLUSIONS: The dorsal or palmar measurement method may be reliably used in healthy adults to establish a web index that describes the web position. The palmar method is considered easier to perform. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Simultaneous four finger metacarpophalangeal joint fusions - indications and results.

PURPOSE: To review the results and indications of simultaneous four finger metacarpophalangeal joint fusions. METHODS: The clinical records and X-rays of nine patients undergoing the above procedure were reviewed. The indication for surgery was to reverse severe metacarpophalangeal joint flexion deformities in eight patients, and following a traumatic four finger amputation in one. Seven patients returned for follow-up assessment. The fusions were performed with a tension band wire technique, aiming for 20 degrees of flexion for index and middle fingers and 40 degrees in the ring and little fingers. Time to radiological fusion and position of fusion, and improvement in function and appearance were assessed. RESULTS: All joints were radiologically fused between six and 12 weeks. The average position of fusion of index and middle fingers was 20 degrees (range: 15-30) and ring and little fingers was 40 degrees (range: 35-50). Appearance was improved in all patients. Improved function was reported by four patients, and improved ease of hygiene and general care in four patients with non-functioning or poorly functioning hands. DISCUSSION: Simultaneous fusion of all four finger metacarpophalangeal joints may be considered as a primary procedure to reconstruct destroyed metacarpophalangeal joints due to inflammatory arthropathy or trauma, and for inability to correct deformity or maintain the correction with soft tissue procedures for patients with cerebral palsy, adult brain injury and arthrogryposis.

Rehabilitation of speech and swallowing after burns reconstructive surgery of the lips and nose.

Rehabilitation of speech and swallowing postburns reconstructive surgery has not been previously described in detail in the literature. Severe facial burn injury requiring subsequent reconstructive surgery may result in complications including circumoral contracture and aesthetic and functional irregularities. These complications may manifest as facial and labial sensation deficits, poor oral access for intubation and oral/dental hygiene, and inadequate oral competence causing chronic drooling and poor articulation. This report describes the physical rehabilitation of a patient with full-thickness burns to the nose, lips, mouth, and chin following electrical burn injury. The severity of injury sustained placed the patient at high risk for microstomia, dysphagia, and speech disorder. A multidisciplinary team approach was used to coordinate the planning of reconstructive procedures, facilitate patient recovery, and optimize functional and aesthetic outcomes. Speech pathology intervention aimed to 1) facilitate safe transition from nonoral to oral intake, 2) improve articulation and speech intelligibility, and 3) minimize oral contracture development. At 6 months postinjury, the patient can safely tolerate a soft diet, demonstrate speech clarity at preinjury level, and has recovered functional oral range of movement. Rehabilitation of speech and swallowing is an essential factor to consider when planning postburn reconstructive procedures.

Massive hemorrhage in facial fracture patients: definition, incidence, and management.

BACKGROUND: Significant hemorrhage from fractures of the midface is a recognized phenomenon, but because it is an uncommon occurrence, there is little in the literature to guide management of these patients. METHODS: The authors performed a retrospective study of life-threatening hemorrhage in facial fracture patients attending the Royal Adelaide Hospital over 20 years and report four recent cases. RESULTS: The incidence of massive hemorrhage was found to be 0.33 percent of patients with fracture of the midface or skull base over the 20 years before 2004 and 1.7 percent in the subsequent year. Of the 19 patients identified from case notes and recent experience, seven died. In terms of management of hemorrhage, three patients had packing alone, 10 had balloon catheters inserted, and five had ligation of a vessel. Most patients had multiple other injuries, including six patients with head injuries. The mean number of units of packed red cells transfused was 9.5 (median, 7.5). In five of the cases identified, there was a delay in recognizing that facial fractures were the major source of hemorrhage. CONCLUSIONS: Massive hemorrhage from facial fractures is an underrecognized and inconsistently managed phenomenon. Although low in incidence, its timely recognition and better management may reduce the high mortality rate in this group of patients.

An effective automated nutrition screen for hospitalized patients.

OBJECTIVE: Screening for malnutrition-related complications (MRCs) in hospitalized patients would identify those requiring nutritional intervention and improve resource allocation. Brugler's simplified screening tool (MRCS) ranks the binary pattern of six readily available variables (categorical cutoff values for serum albumin [<31.5 g/L], lymphocyte count [<1.202 x 10(9)/L], and hemoglobin [<99.5 g/L], the presence of high-risk illness, poor nutritional intake and the presence of a wound) to enable automated computerized screening. This study compared the MRCS with a simpler Automated Nutrition Score (ANS; the number of abnormal results from the six variables) and ANS(B) (the number of abnormal results from the three blood measurements) with the Subjective Global Assessment (SGA) for prediction of complications. METHODS: Of 148 consecutive surgical patients, 143 underwent the SGA on admission. Morbidity was prospectively recorded. The six variables of the MRCS were tabulated and correlated with the frequency of complications. Receiver operating characteristic analysis compared the MRCS with the SGA, ANS, and ANS(B). RESULTS: Twenty-two patients had moderate to severe complications, a pretest probability of 15.3%. Patients stratified as higher risk by the SGA, ANS(B), and ANS had post-test probabilities of complications of 28.7%, 37.8%, and 29.3%, respectively. However, a clinically useful prediction of low risk (post-test probability of 1.5%) was demonstrated when the ANS was