Metacarpophalangeal joint dislocation.

Traumatic dislocation of the metacarpophalangeal joint is a relatively uncommon injury. The dislocation may be easily reducible (ie, simple) or require surgical intervention (ie, complex). The flexor tendons, lumbrical muscle, natatory ligament, and superficial transverse metacarpal ligament combine with the displaced volar plate to create a tight noose, preventing reduction. Surgical approach may be dorsal or volar; however, the radial digital nerve to the index finger is especially at risk through the volar approach. Reported complications include stiffness, arthritis, osteonecrosis of the metacarpal head, and even premature closure of the physis.

Functional capacity before and after simulated thumb carpometacarpal joint fusion.

Lateral pinch strength, grooved pegboard test time, and 22 activities of daily living (ADLs) were assessed in 10 asymptomatic patients initially without and then with splinting of the thumb carpometacarpal (CMC) joint (simulating thumb CMC fusion). Before immobilization, all patients rated a perfect total score of 88 on the 22 ADLs. After immobilization, mean total score dropped to 78.3, with particular difficulty noted in manipulating money, cutting meat, turning a doorknob, using a can opener, using scissors, and writing. Lateral pinch strength decreased from 22.4 lb without immobilization to 20.8 lb after splinting. Mean grooved pegboard test time increased from 53.1 to 58.3 seconds with immobilization. Thumb CMC fusion is not without particular functional defects. Patients' understanding of these difficulties allows for informed decisions regarding whether surgical treatment for thumb CMC arthritis is desired.

Retrieving tendon ends in zone II flexor tendon injuries.

Suturing the tendons to the catheter often leads to a bulky mass that makes passage through the pulleys difficult.

Florid reactive periostitis of the hand.

Florid reactive periostitis is a relatively rare lesion that most often develops in the tubular bones of the hands and feet. This lesion can easily be confused with malignant or infectious processes. Correlation of physical examination and radiographic findings with histologic findings usually is diagnostic. Excisional biopsy with careful removal of all diseased tissue is most often curative. However, recurrent cases have been described as sometimes requiring ablative procedures.

The role of prophylactic antibiotics in elective hand surgery.

The current literature has poorly defined the role of antibiotic agents in elective hand surgery. The reason for this may be due to a small number of well-designed studies specifically addressing the efficacy of antibiotics in hand surgery. Our purpose is to critically review the current literature in an attempt to more precisely define the role of prophylactic antibiotics in elective hand surgery.

Resident selection: how we are doing and why?

Selection of the best applicants for orthopaedic residency programs remains a difficult problem. Most quantifiable factors for residency selection evaluate test-taking ability and grades rather than other aspects, such as patient care, professionalism, moral reasoning, and integrity. Four current department members on our resident selection committee ranked four consecutive classes of orthopaedic residents interviewed for residency. We ranked incoming residents in order of best to least qualified and compared those rankings with rank lists by the same faculty on completion of residency. Rankings also were compared with the residents' United States Medical Licensing Examination (USMLE) Part I scores, American Board of Orthopaedic Surgery (ABOS) Part I scores, and fourth-year Orthopaedic-in-Training Examination (OITE) scores. We found fair or poor correlations between the residents' initial rankings, rankings on graduation, and their USMLE, ABOS, and OITE scores. The only relatively strong correlation found was between the OITE and ABOS scores. Despite the faculty's consensus regarding selection criteria, interviewers did not agree in their rankings of residents on graduation. Additional work is necessary to refine the inexact yet important science of selecting residency applicants.

Septic arthritis of the shoulder, elbow, and wrist.

Septic arthritis of the shoulder, elbow, or wrist is not commonly described in the literature. We evaluated the micro- biology of these infections and the diagnostic role of joint aspirate findings. This retrospective study includes 52 patients, diagnosed from 1994 to 2004, with septic arthritis of the shoulder (n = 17), elbow (n = 23), or wrist (n = 12). The mean age was 44.3 years, and 54% of patients (28/52) had comorbidities. The prevalence of Staphylococcus aureus was 76%. Ninety-six percent of aspirates with positive cultures had a polymorphonuclear differential count greater than 85% of the total aspirate white blood cell count. Staphylococcus aureus is the most prevalent organism. A high index of suspicion for septic arthritis is necessary for all patients with upper extremity joint complaints, irrespective of age and medical status. The joint aspirate differential white blood cell count may be helpful in the diagnosis.

Fixation of distal radius fractures using a fragment-specific system.

UNLABELLED: Operative treatment for distal radius fractures continues to evolve, but small-fragment fixation has some advantages compared with previous methods. We assessed two groups of patients. Group 1 was an initial series of patients treated with small-fragment fixation at a large institution in the United States, and Group 2 was a review of patients treated in Lund, Sweden. The first group was evaluated for return to routine activity. Return to work or routine daily activity averaged 6 weeks (range, 3-16 weeks). The second group was evaluated for early grip strength and range of motion compared with the uninjured extremity. The grip strength at final followup averaged 67% compared with the uninjured extremity. Wrist flexion averaged 46 degrees, extension averaged 57 degrees, pronation averaged 80 degrees, and supination averaged 73 degrees. LEVEL OF EVIDENCE: Therapeutic study, level IV.

New onset diabetes mellitus in patients presenting with extremity infections.

Although a relationship between diabetes and extremity infections has been established, the current literature notes little regarding the initial diagnosis of a patient's diabetic condition being made at the time of presentation with an extremity infection. The current study is an analysis of patients with extremity infections being diagnosed with diabetes for the first time. A chart review of 1166 patients who were admitted to the orthopaedic infection service revealed 385 patients with an admission glucose of 120 mg/dL or greater. One hundred seventy-four of these patients (45%) were diagnosed with diabetes. Thirty of these 174 patients (17.2%) previously had not been diagnosed with diabetes.

Negative pressure dressings as an alternative technique for the treatment of infected wounds.

Coverage of wounds caused by infection and subsequent treatment often are variable because of the location of the wound and wound size. Although much research has been done to expand the indications of negative pressure wound treatment systems, little investigation has been done to quantify the reduction of wound size for vacuum-assisted closure treatment in the presence of infection. In this series, 14 patients who had wounds caused by infections were treated with the vacuum-assisted wound closure system. All wounds were greater than 20 cm2. The duration of treatment averaged 10 days (range, 2-27 days), and the initial wound size averaged 70 cm2 (range, 22.5-288 cm2). After the course of treatment, the final wound size averaged 39 cm2 (range, 10-147 cm2). The average wound size reduction was 43%. This method seems to enhance the rapidity of wound reduction, and because it is a closed system of treatment, it has the added benefit of minimizing exposure of staff and other patients to communicable diseases. Vacuum-assisted wound closure systems add another option in the care of musculoskeletal infections.