Exaggerated inflammatory response and bony resorption from BMP-2 use in a pediatric forearm nonunion.

The Food and Drug Administration (FDA) indicates that bone morphogenetic protein (BMP) products are contraindicated in pediatric patients. However, it acknowledges the off-label use of BMP in difficult cases. Although the relative safety of BMP in children has been reported for lower extremity and spine procedures, little information exists for the safety of BMP used in the pediatric upper extremity. We present a case of a massive inflammatory reaction after use of recombinant human BMP-2 for repair of a symptomatic ulnar nonunion in a child. The case illustrates the potential difficulties of using the dose-dependent properties of BMP in the treatment of pediatric upper extremity nonunions when the dose calculations of BMP for children have not yet been defined.

Duration of postoperative dressing after mini-open carpal tunnel release: a prospective, randomized trial.

PURPOSE: In this prospective, randomized, controlled study, we hypothesized that there would be no difference in short-term functional, subjective, and blinded wound outcome measures between patients treated after mini-open carpal tunnel release (CTR) with a postoperative bulky dressing for 2 weeks and those with dressing removal and placement of an adhesive strip after 48 to 72 hours. METHODS: A total of 94 consecutive patients underwent mini-open CTR and placement of a bulky dressing and were randomized to either bandage removal at 48 to 72 hours with placement of an adhesive strip or continuation of the postoperative dressing until initial follow-up at approximately 2 weeks. We evaluated patient demographics, Levine-Katz scores, range of motion, strength, and a blinded assessment of wound healing at approximately 2 weeks and between 6 and 12 weeks. We conducted paired and independent sample t-tests to evaluate for statistical significance. RESULTS: There was no significant difference in Levine-Katz scores between groups at either the first follow-up or final visit. One patient with a longer dressing duration had evidence of a wound dehiscence. CONCLUSIONS: Removal of a bulky dressing after mini-open CTR and replacement with an adhesive strip at 48 to 72 hours causes no wound complications and results in equal short-term clinical and subjective outcome measures compared with using a bulky dressing for 2 weeks. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Ulnar collateral ligament injury of the thumb metacarpophalangeal joint.

Injury to the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal (MCP) joint is a common entity encountered by the sports physician and orthopedic surgeon. The term "gamekeeper's thumb," which is sometimes used incorrectly to mean any injury to this ligament, refers to a chronic injury to the UCL in which it becomes attenuated through repetitive stress. In contrast, the term "skier's thumb" refers to an acute ligament injury as seen in skiers who fall on an abducted thumb or athletes who sustain a valgus force on an abducted thumb. If the patient allows a clinical examination, valgus stress testing can diagnose a complete UCL rupture when there is no solid endpoint with the thumb held in 30 degrees of MCP flexion and with the thumb held in extension. In cases with complete UCL tears, operative treatment has been shown to produce excellent results and is recommended. If there is a firm endpoint to valgus stress testing, a partial UCL tear is diagnosed and nonoperative treatment usually favored.

Key factors in primary and revision surgery for shoulder instability.

The diagnosis and treatment of shoulder instability are predicated on a sound understanding of the patient's history and injury pattern as well as the examination and radiographic findings. The arthroscopic repair of instability is increasingly successful. However, glenohumeral bone loss, capsular injuries, and associated injury patterns have been linked to unsuccessful outcomes after either surgical or nonsurgical treatment. A comprehensive approach, from patient history to surgical technique, can increase the likelihood of a successful primary or secondary instability repair.

How to measure outcomes of distal radius fracture treatment.

There is no established outcome measure designated as the superior measure when evaluating the results of distal radius fracture management. Although there are many used in the literature, there are only a few that have been validated to specifically predict recovery after a distal radius fracture. Additionally, there are few comparative trials that attempt to directly measure the predictive abilities of specific outcome measures. This article discusses the common scales and scores used to measure the functional recovery after distal radius fracture management and provides evidence-based literature to assess the reliability of these measures to predict outcomes.

Mini-C-arm fluoroscopy for emergency-department reduction of pediatric forearm fractures.

BACKGROUND: Reduction of pediatric forearm fractures with the patient under sedation in the emergency department is a common practice throughout the United States. We hypothesized that the use of a mini-c-arm fluoroscopy device as an alternative to routine radiographs for evaluation of fracture reduction would (1) allow a more anatomic fracture reduction, (2) decrease the number of repeat reductions or subsequent procedures, (3) reduce overall radiation exposure to the patient, and (4) decrease the orthopaedic consultation time in the emergency department. METHODS: A retrospective cohort analysis of 279 displaced forearm and wrist fractures treated with closed reduction and casting with the patient under sedation in the emergency department of a level-I pediatric trauma center was performed, and the data were compared with historical controls. One hundred and thirteen fracture reductions were assessed with a mini-c-arm device, and 166 fracture reductions were evaluated with radiographs. All patients had radiographs of the injury. Blinded, independent reviewers graded the quality of reduction for residual angulation and translation of the reduced fracture. Radiation exposure was determined by the average number of radiographs made through either modality. Emergency department and outpatient charts were reviewed to determine the total orthopaedic consultation time and the need for repeat reductions or operative intervention. RESULTS: Pediatric forearm fractures undergoing closed reduction with assistance of the mini c-arm had a significant improvement in reduction quality (average angulation [and standard deviation], 6° ± 4° vs. 8 ± 6°; p = 0.02), a decrease in repeat fracture reduction and need for subsequent operative treatment (two [2%] of 113 fractures vs. fourteen [8.4%] of 166 fractures; p = 0.0001), and a decrease in radiation exposure to the patient (mean, 14.0 ± 10.3 mrem vs. 50.0 ± 12.7 mrem). The average orthopaedic consultation time was decreased with use of a mini c-arm (28 ± 12 min vs. 47 ± 19 min, p < 0.001). CONCLUSIONS: Use of the mini c-arm to assist in the closed reduction of pediatric forearm and wrist fractures in the emergency department can improve the quality of the reduction, decrease the radiation exposure to the patient, and decrease the need for repeat fracture reduction or additional procedures. Mini-c-arm imaging can also decrease the average orthopaedic consultation time for fracture reduction.