High-Resolution Ultrasound in the Diagnosis and Surgical Management of Ulnar Neuropathy at the Elbow.

High-resolution ultrasound (HRU) has recently demonstrated the potential to facilitate diagnosis and treatment of upper extremity compression neuropathy. The authors hypothesized that HRU can improve preoperative evaluation of ulnar neuropathy at the elbow (UNE) and that changes in ulnar nerve cross-sectional area (CSA) after cubital tunnel release may correlate with outcomes. Nineteen adult patients diagnosed with UNE who were scheduled for surgical decompression by a single hand surgeon were enrolled. Electrodiagnostic (EDX) testing, HRU of the ulnar nerve, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and McGowan grade were obtained pre- and postoperatively. Fourteen patients completed the study. Statistically significant improvements were found in CSA measurements and QuickDASH scores. High-resolution ultra-sound was found to confirm UNE in all 7 patients with positive results on EDX, and additionally detected UNE in 3 of 6 patients with negative results on EDX and in 1 patient with equivocal (nonlocalized) EDX testing. All 4 of these additional HRU-detected cases improved clinically and by CSA measurements after surgery. In this series, HRU was superior to EDX testing in the diagnosis of UNE and demonstrated objective improvement in ulnar nerve CSA after successful cubital tunnel release. This modality, which is better tolerated, less costly, and less time-consuming than EDX testing or magnetic resonance imaging, should therefore be considered in the diagnosis and surgical management of UNE, particularly in cases with negative or equivocal results on EDX testing, or when outcomes are suboptimal. [Orthopedics. 2021;44(5):285-288.].

Suture Suspension Arthroplasty for the Treatment of Thumb Carpometacarpal Arthritis.

PURPOSE: Most studies have demonstrated little difference in the outcome of the various techniques proposed for the surgical treatment of thumb carpometacarpal (CMC) arthritis. However, the difficulty and time required to perform each technique vary widely. In addition, the introduction of recent implants has increased the cost of the overall procedure. We hypothesize that using a simple, yet stable, suture suspension technique without tendon interposition or ligament reconstruction yields similar results to conventional approaches with less operative time. METHODS: Three hundred twenty consecutive patients underwent thumb CMC arthroplasty by trapezial excision and metacarpal suspension using #2 high-strength orthopedic suture locked weave alone passed from the distal most abductor pollicis longus and flexor carpi radialis insertions without K-wire fixation or tendon transfer. Average duration of preoperative symptoms was 17.8 months. Patient radiographs were graded for arthritis severity and a visual analog scale (VAS) pain score (scale 0-10) obtained. Postoperative clinical and radiological follow-up averaged 5.4 years (minimum, 24 months). RESULTS: The average age at surgery was 57.3 years and there were 221 women (243 procedures) and 65 men (77 procedures). Average total operative time was 23.4 minutes. The dominant hand was involved in 52% of patients. All had prior treatment including orthoses and nonsteroidal anti-inflammatory drugs with 312 having had at least 1 steroid injection. Five patients had stage 1, 134 had stage 2, 164 had stage 3, and 17 had stage 4 disease on radiographs. Average trapezial space height on final follow-up radiographs was 0.8 cm. Two patients had complete trapezial space collapse and required a revision procedure. The average VAS score was 0.6 with pain eliminated in 269 thumbs, minimal in 49, and unchanged/worse in 2. All patients that were employed at the time of surgery returned to work at an average of 2.3 months (range, 3-16 weeks). CONCLUSIONS: Suture suspension thumb CMC arthroplasty provides comparable clinical results and several advantages over many current techniques that are described in the literature. The advantages include shortened operative time, inherent stability of the thumb metacarpal height, and no necessity for K-wire fixation, tendon transfers, or implants. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pediatric Supracondylar Humerus Fractures: Does After-Hours Treatment Influence Outcomes?

OBJECTIVE: To compare the outcomes of pediatric supracondylar humerus fractures treated during daytime hours to those treated after-hours. DESIGN: Retrospective. SETTING: Academic Level I trauma center. PATIENTS/PARTICIPANTS: Two hundred ninety-eight pediatric patients treated with surgical reduction and fixation of closed supracondylar fractures were included. INTERVENTION: Seventy-seven patients underwent surgery during daytime hours (06:00-15:59 on weekdays). One hundred eighty-six patients underwent surgery after-hours (16:00-05:59 on weekdays and any surgery on weekends or holidays). MAIN OUTCOME MEASURES: Surgeon subspecialty, operative duration, and radiographic and clinical outcomes, including range of motion and carrying angle, were extracted from the patient medical records. RESULTS: There were no patient-related demographic differences between the daytime hours and after-hours groups. Daytime surgery was more likely to be performed by a pediatric orthopaedic surgeon than after-hours surgery. Fractures treated after-hours had more severe injury patterns. After-hours surgery was not independently associated with rate of open reduction, operative times, complications, achievement of functional range of motion, or radiographic alignment. A late-night surgery subgroup analysis demonstrated an increased rate of malunion in patients undergoing surgery between the hours of 23:00 and 05:59. CONCLUSIONS: There is no difference in the operative duration or outcomes after surgical treatment of pediatric supracondylar humerus fractures performed after-hours when compared with daytime surgery. However, late-night surgery performed between 23:00 and 05:59 may be associated with a higher rate of malunion. Surgeons can use these data to make better-informed decisions about the timing of surgery in this patient population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical techniques for the treatment of carpal ligament injury in the athlete.

Treatment of intercarpal ligament injuries in the athlete requires special attention due to several practical and biomechanical considerations. Optimally, the athlete will maintain as much function and range of motion as possible with return to high-impact and load-bearing activity in a timely fashion. Several cutting-edge techniques have arisen in treatment. This article discusses injury patterns in the athlete with scapholunate injury, lunotriquetral injury, scaphotrapezial-trapezoidal injury, and extrinsic ligamentous injury, and the various approaches to addressing these injuries, with a review of the classic as well as newer, innovative techniques.

Small catheter tube thoracostomy: effective in managing chest trauma in stable patients.

BACKGROUND: Image-guided small catheter tube thoracostomy (SCTT) is not currently used as a first-line procedure in the management of patients with chest trauma. We adopted a practice recommendation to use SCTT as a less invasive alternative in the treatment of chest injuries. We reviewed our trauma registry to evaluate our change in practice and the effectiveness of SCTT. METHODS: Retrospective review of all tube thoracostomies (TT) performed in patients with chest injury at a level I trauma center from September 2002 through March 2006. Data collected included age, sex, indications and timing for TT, use of antibiotics, length of stay, complications, and outcomes. Large catheter tube thoracostomy (LCTT) not performed in the operating room or trauma room and all SCTT were deemed nonemergent. RESULTS: There were 565 TT performed in 359 patients. Emergent TT was performed in 252 (70%) and nonemergent TT in 157 (44%) patients, of which 63 (40%) received LCTT and 107 (68%) received SCTT. Although SCTT was performed later after injury than nonemergent LCTT (5.5 days vs. 2.3 days, p < 0.001), average duration of SCTT was shorter (5.5 days vs. 7 days, p < 0.05). Rates of hemothoraces were similarly low for SCTT versus nonemergent LCTT (6.1% vs. 4.2%, p = NS) and rates of residual/recurrent pneumothoraces were not significantly different (8% vs. 14%, p = NS). The rate of occurrence of fibrothorax, however, was significantly lower for SCTT compared with nonemergent LCTT (0% vs. 4.2%, p < 0.05). In patients receiving a single nonemergent TT, SCTT was performed in 55 (61%) and LCTT in 35 (39%). A comparison of these groups revealed that SCTT was performed in older patients (p < 0.05), and was associated with a lower Injury Severity Score (p < 0.05) and shorter length of stay (p = 0.05). SCTT was increasingly used in younger and more seriously injured patients as our experience grew. CONCLUSION: SCTT is effective in managing chest trauma. It is comparable with LCTT in stable trauma patients. This study supports adopting image-guided small catheter techniques in the management of chest trauma in stable patients.

Early intubation in the management of trauma patients: indications and outcomes in 1,000 consecutive patients.

BACKGROUND: The Eastern Association for the Surgery of Trauma Practice Management Guidelines identify indications (EI) for early intubation. However, EI have not been clinically validated. Many intubations are performed for other discretionary indications (DI). We evaluated early intubation to assess the incidence and outcomes of those performed for both EI and DI. METHODS: One thousand consecutive intubations performed in the first 2 hours after arrival at our Level I trauma center were reviewed. Indications, outcomes, and trauma surgeon (TS) intubation rates were evaluated. RESULTS: During a 56-month period, 1,000 (9.9%) of 10,137 trauma patients were intubated within 2 hours of arrival. DI were present in 444 (44.4%) and EI in 556 (55.6%). DI were combativeness or altered mental status in 375 (84.5%), airway or respiratory problems in 21 (4.7%), and preoperative management in 48 (10.8%). Injury Severity Score was 14.6 in DI patients and 22.7 in EI patients (p < 0.001). Predicted versus observed survival was 96.6% versus 95.9% in DI patients and 75.2% versus 75.0% in EI patients (p < 0.001). Head Abbreviated Injury Scale score of >or=3 occurred in 32.7% with DI and 52.0% with EI (p < 0.001). Seven (0.7%) surgical airways were performed; two for DI (0.2%). Eleven (1.1%) patients aspirated during intubation and five (0.5%) suffered oral trauma. There were no other significant complications of intubation for either DI or EI and complication rates were similar in the two groups. Delayed intubation (early intubation after leaving the trauma bay) was required in 67 (6.7%) patients and 59 (88.1%) were for combativeness, neurologic deterioration, or respiratory distress or airway problems. Intubation rates varied among TS from 7.6% to 15.3% (p < 0.001) and rates for DI ranged from 3.3% to 7.4% (p < 0.001). There was a statistically insignificant trend among TS with higher intubation rates to perform fewer delayed intubations. CONCLUSIONS: Early intubation for EI as well as DI was safe and effective. One third of the DI patients had significant head injury. Surgical airways were rarely needed and delayed intubations were uncommon. The intubation rates for EI and DI varied significantly among TSs. The Eastern Association for the Surgery of Trauma Guidelines may not identify all patients who would benefit from early intubation after injury.