What a Ratchet! A Gripping Case Report of an Entrapped Finger with an Unyielding Wrench.

Finger entrapment with rings or ring-like objects is an uncommon possible hand emergency. In cases in which noncutting removal is ineffective, ring cutters or dental drills with carbide or diamond burs have been successfully used. However, objects composed of hard metallic alloys, such as lug nuts or wrenches, are often resistant to such equipment. In these instances, larger diameter metal cutting burrs or rasps may be more advantageous. Due to their increased size and cutting power, these tools are better suited to handle the toughness of hard metals. In this case report, we present the effective and efficient removal of a stainless steel wrench from an entrapped digit using a helicoidal rasp. Availability of this instrument within orthopedic departments may prevent the delays often described in the treatment of finger entrapment when traditional cutting equipment fails.

Pronator Quadratus Muscle Flap for Prevention of Flexor Tendon Rupture after Distal Radius Volar Plating.

Background: Flexor tendon rupture is a serious but rare complication that can occur after volar plating of distal radius fractures. This study aims to introduce a novel surgical technique that uses a pronator quadratus (PQ) muscle flap transposition to protect the flexor tendons from rupture or irritation and evaluate its outcomes. Methods: A retrospective review was conducted on 204 patients with unstable distal radius fractures who underwent a standard volar flexor carpi radialis approach with extended release of the PQ muscle during exposure. A PQ muscle flap was harvested and transposed over the distal edge of the plate after open reduction and internal fixation of the distal radius. Postoperatively, patients were evaluated for flexor tendon irritation and rupture. Patients who had this injury before the use of the PQ flap were compared with the patients who received the PQ flap. Results: Of the 204 patients, 119 received the PQ flap, and 85 did not. The mean follow-up time was 30.4 months. Among the patients who did not receive the PQ flap, five (5.9%) required plate removal or conservative treatment for tendon irritation or rupture. In contrast, only one patient (0.8%) who received the PQ flap required plate removal for flexor tendon irritation. Conclusions: The PQ muscle flap is a quick and effective surgical technique that reduces the risk of flexor tendon rupture or irritation during distal radius fracture fixation. The PQ muscle flap acts as a buffer between the plate and tendon and is more effective than not transposing the muscle.

Comparison of Collagen and Human Amniotic Membrane Nerve Wraps and Conduits for Peripheral Nerve Repair in Preclinical Models: A Systematic Review of the Literature.

BACKGROUND: Collagen and human amniotic membrane (hAM) are Food and Drug Administration (FDA)-approved biomaterials that can be used as nerve wraps or conduits for repair of peripheral nerve injuries. Both biomaterials have been shown to reduce scarring and fibrosis of injured peripheral nerves. However, comparative advantages and disadvantages have not been definitively shown in the literature. The purpose of this systematic review is to comprehensively evaluate the literature regarding the roles of hAM and collagen nerve wraps and conduits on peripheral nerve regeneration in preclinical models. METHODS: The MEDLINE database was queried using the PubMed search engine on July 7, 2019, with the following search strategy: ("amniotic membrane" OR "amnion") OR ("collagen conduit" OR "nerve wrap")] AND "nerve." All resulting articles were screened by two independent reviewers. Nerve type, lesion type/injury model, repair type, treatment, and outcomes were assessed. RESULTS: Two hundred and fifty-eight articles were identified, and 44 studies remained after application of inclusion and exclusion criteria. Seventeen studies utilized hAM, whereas 27 studies utilized collagen wraps or conduits. Twenty-three (85%) of the collagen studies utilized conduits, and four (15%) utilized wraps. Six (35%) of the hAM studies utilized conduits and 11 (65%) utilized wraps. Two (9%) collagen studies involving a conduit and one (25%) involving a wrap demonstrated at least one significant improvement in outcomes compared with a control. While none of the hAM conduit studies showed significant improvements, eight (73%) of the studies investigating hAM wraps showed at least one significant improvement in outcomes. CONCLUSION: The majority of studies reported positive outcomes, indicating that collagen and hAM nerve wraps and conduits both have the potential to enhance peripheral nerve regeneration. However, relatively few studies reported significant findings, except for studies evaluating hAM wraps. Preclinical models may help guide clinical practice regarding applications of these biomaterials in peripheral nerve repair.

A characterization of home maintenance equipment-related hand and lower arm injuries.

Background: Thousands of Americans sustain injuries from various household appliances each year, though injury patterns have not been well characterized. We thus sought to determine the incidence, characteristics, and trends of household appliance-related hand injuries over the past decade. Methods: The National Electronic Injury Surveillance System database (NEISS) was queried from 2010 through 2019. Our analysis grouped patients into 10-year age groups. We defined types of appliances and injuries Chi-square tests were used to compare the most common injury mechanisms by age group. Results: Between 2010 and 2019, 30,336 total cases of home workshop equipment-related upper extremity injuries were recorded; 2,574 (8.48%) of these affected females, compared to 27,762 (91.52%) of the cases affecting males. Across all age groups, males were between 6 and 13 more times likely to be injured than females (p < 0.001). Between 2010 and 2019, we recorded a decline in total injuries from 168,795 to 147,584, with a Pearson correlation coefficient of -0.68 (p = 0.031). The appliances most likely to injure those in their 10s through 40s were mechanical tools such as screwdrivers. Meanwhile, those in their 50s through 70s were most likely to be injured by saws. Both amputations and avulsions were found to significantly increase with age (p = 0.038, p = 0.027, respectively). Most injuries result from manual tools and saws. Discussion: Males are significantly more likely to incur injuries than females from maintenance equipment, and risk of avulsions and amputations increase significantly with age. This aligns with previous research which also suggested that older saws were most likely to injure older individuals; namely, following new regulations on saws, older adults were more likely to be affected. This is especially worrisome in light of recent research showing that older adults with amputations are less likely to be offered replantations. Overall, these results can continue to guide and optimize community interventions on an epidemiological basis.

Comparison of human amniotic membrane and collagen nerve wraps around sciatic nerve reverse autografts in a rat model.

Human amniotic membrane (hAM) and collagen nerve wraps are biomaterials that have been investigated as therapies for improving outcomes of peripheral nerve regeneration; however, their efficacy has not been compared. The purpose of this study is to compare the efficacy of collagen and human amniotic membrane nerve wraps in a rodent sciatic nerve reverse autograft model. Lewis rats (n = 29) underwent sciatic nerve injury and repair in which a 10-mm gap was bridged with reverse autograft combined with either no nerve wrap (control), collagen nerve wrap or hAM nerve wrap. Behavioral analyses were performed at baseline and 4, 8 and 12 weeks. Electrophysiological studies were conducted at 8, 10 and 12 weeks. Additional outcomes assessed included gastrocnemius muscle weights, nerve adhesions, axonal regeneration and scarring at 12 weeks. Application of both collagen and hAM nerve wraps resulted in improvement of functional and histologic outcomes when compared with controls, with a greater magnitude of improvement for the experimental group treated with hAM nerve wraps. hAM-treated animals had significantly higher numbers of axons compared to control animals (p < 0.05) and significantly less perineural fibrosis than both control and collagen treated nerves (p < 0.05). The ratio of experimental to control gastrocnemius weights was significantly greater in hAM compared to control samples (p < 0.05). We conclude that hAM nerve wraps are a promising biomaterial that is effective for improving outcomes of peripheral nerve regeneration, resulting in superior nerve regeneration and functional recovery compared to collagen nerve wraps and controls.

Latissimus Dorsi Flap in Breast Reconstruction: Recent Innovations in the Workhorse Flap.

BACKGROUND: Surgeons employ the latissimus dorsi flap (LDF) for reconstruction of a large variety of breast cancer surgery defects, including quadrantectomy, lumpectomy, modified radical mastectomy, and others. The LDF may be used in delayed or immediate reconstruction, in combination with tissue expanders for a staged reconstruction, with implant-based immediate reconstruction, or alone as an autogenous flap. METHODS: The authors discuss the historical uses and more recent developments in the LDF. More recent advancements, including the "scarless" approach and augmentation with the thoracodorsal artery perforator flap, are discussed. RESULTS: The LDF is a reliable means for soft tissue coverage providing form and function during breast reconstruction with acceptable perioperative and long-term morbidities. CONCLUSIONS: When there is a paucity of tissue, the LDF can provide tissue volume in autologous reconstruction, as well as a reliable vascular pedicle for implant-based reconstruction as in the setting of irradiated tissue.

The Relationship of Bacterial Biofilms and Capsular Contracture in Breast Implants.

Capsular contracture is a common sequelae of implant-based breast augmentation. Despite its prevalence, the etiology of capsular contracture remains controversial. Numerous studies have identified microbial biofilms on various implantable materials, including breast implants. Furthermore, biofilms have been implicated in subclinical infections associated with other surgical implants. In this review, we discuss microbial biofilms as a potential etiology of capsular contracture. The review also outlines the key diagnostic modalities available to identify the possible infectious agents found in biofilm, as well as available preventative and treatment measures.

Trends in the incidence and treatment of necrotizing soft tissue infections: an analysis of the National Hospital Discharge Survey.

Necrotizing soft tissue infections are a rare but potentially fatal condition of the soft tissues caused by virulent, toxin-producing bacteria. In the United States, there is an estimated annual incidence of 0.04 cases per 1000 annually, but previous estimates of the Centers for Disease Control and Prevention had the incidence at 500 to 1500 cases yearly. Early reports of mortality were variable with rates ranging from 46 to 76% but outcomes have been improving over time. The National Hospital Discharge Survey was analyzed to study current trends in the demographics, incidence, use, and mortality of patients diagnosed with necrotizing soft tissue infections. The authors analyzed the 1999, 2002, and 2007 National Hospital Discharge Survey by using a sampling weighting method. A total of 13,648 cases of necrotizing soft tissue infections were identified in 2007. This represents an increase from 12,153 cases in 2002 and 6612 cases in 1999. In the 9 years from 1999 to 2007 the gross incidence of necrotizing soft tissue infections more than doubled. Hospital stay was essentially unchanged within study years, at 16 days. Mean age increased from approximately 50 years in 1999 to 54 years in 2007. Further, mortality went from 10.45% in 1999 to 9.75% in the 2007 survey. The population-adjusted incidence rate increased 91% in the studied years. Rising use of immunosupression, exponential growth in the incidence of obesity, and type 2 diabetes could be a major contributing factor. The mortality rate is far below the rate in reports published from as early as 20 years ago, and at 9.75% compares with modern case series, but is a more accurate measure of mortality in this condition.

Revision decompression and collagen nerve wrap for recurrent and persistent compression neuropathies of the upper extremity.

BACKGROUND: Recurrent or persistent compression neuropathies of the upper extremity, including carpal and cubital tunnel syndrome, present a difficult treatment challenge to the hand or peripheral nerve surgeon. Collagen conduits have been used successfully for decades in nerve injury repair, but have not been studied in the treatment of compression neuropathy. METHODS: Patients with recurrent or persistent compression neuropathies treated with a repeat decompression and collagen wrap from a 5-year period were retrieved from the Computerized Patient Record System database and 15 patient records were identified. A systematic review was performed for all articles from 1946 to 2012 on secondary carpal and cubital tunnel syndrome. RESULTS: The mean age of the 15 patients treated was 63.3 years and ranged from 35 to 86 years. The patients with revision carpal tunnel decompression had an 89% subjective response rate, whereas those with revision cubital tunnel decompression had an 83% resolution or improvement of symptoms. Visual analog scale decreased from a preoperative mean 2.47 to 0.47 postoperatively and the mean number of opiate medications decreased from 0.67 to 0.40. We identified 32 papers using various treatment strategies for recurrent carpal tunnel syndrome with success rates ranging from 53% to 100%. We identified 18 papers on recurrent cubital tunnel syndrome, with success rates ranging from 33% to 100%, with a weighted success of 78.1% overall but 71.7% in the submuscular transposition group. CONCLUSIONS: Here we report on the novel technique of using a collagen matrix wrap in recurrent compression neuropathies with good success. The collagen wrap allows nerve gliding, protection from perineural scar formation, and a favorable microenvironment. Submuscular transposition seems to be no better than other methods of decompression for recurrent cubital tunnel syndrome in contrary to traditional teaching.

Merkel cell carcinoma of the hand and upper extremity: current trends and outcomes.

Merkel cell carcinomas represent an uncommon yet aggressive skin cancer. We sought to identify changes in incidence and predictors of outcomes and survival of patients with Merkel cell carcinomas of the hand and upper extremity. The Surveillance, Epidemiology and End Results database was used to identify all patients with Merkel cell carcinomas of the skin located specifically in the hand and upper extremity. Overall, 5211 cases were identified in the period from 1986 through 2009. The age-adjusted incidence of Merkel cell carcinoma of the hand and upper extremity increased from 0.02 cases per 100,000 in 1986 to 0.14 cases per 100,000 in 2009. The mean age of these patients was 75 years and positive regional lymph nodes were identified in 33%. Rate of metastasis was 4.1%. Overall survival for the study cohort was 49%. Multivariate analysis identified tumor size >5 cm, positive regional lymph nodes and metastasis at diagnosis as independent predictors of mortality. The incidence of Merkel cell carcinomas has increased substantially over the study period. Overall survival for Merkel cell carcinomas of the body and hand and upper extremity is related to tumor size and extent of disease at time of clinical presentation. Merkel cell carcinomas of the hand and upper extremity tend to be diagnosed at an earlier stage with lower rates of regional and systemic spread, and subsequently have a higher overall survival rate.

Trends in the surgical treatment of cubital tunnel syndrome: an analysis of the national survey of ambulatory surgery database.

PURPOSE: To ascertain trends in the surgical treatment of ulnar nerve compression at the elbow within the United States. METHODS: We analyzed the National Survey of Ambulatory Surgery to study trends in the treatment of cubital tunnel syndrome from 1994 to 2006. The National Survey of Ambulatory Surgery provides a comprehensive overview of ambulatory surgical procedures performed in the United States. Patients identified in the database with surgically treated cubital tunnel syndrome were verified by members of our research staff and compiled into these 3 groups: decompression, transposition, and other. The data were then statistically analyzed for trends in treatment, utilization, and demographics. RESULTS: A total of 52,133 surgical procedures were recorded in the National Survey of Ambulatory Surgery for the treatment of ulnar nerve compression in 2006. This represents an increase from 26,283 in 1994 and 35,406 in 1996. In the 11 years from 1996 to 2006, the total surgical procedures on the ulnar nerve increased by 47%. Transposition went from 49% of all cubital tunnel procedures in the 1990s to 38% in 2006. In 2006, women were much more likely to have a simple decompression (70%) than a transposition or other technique. Decompression had a mean surgical time of 48 minutes, and transposition had a mean surgical time of 59 minutes. CONCLUSIONS: The percentage of transpositions used in the treatment of cubital syndrome has decreased to 37% in the last survey. Possible reasons include expanded indications or changing surgical preferences. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome.

BACKGROUND: Recurrent and persistent carpal tunnel syndrome is an uncommon but potentially difficult surgical dilemma. Many surgical treatment options have been described in the literature without comparative data on outcome. METHODS: A systematic review on recurrent carpal tunnel syndrome was performed for all articles from 1946 to 2012 in MEDLINE, EMBASE, CENTRAL, and hand-searched reference lists from all identified articles. Twenty-three articles were screened and identified from the time period 1972 to 2012, representing two general treatment groups: decompression with flap interposition and repeated open decompression. A meta-analysis was then performed, generating forest and funnel plots of the data. RESULTS: In total, 294 patients from 14 studies in the flap arm of the meta-analysis had a weighted success rate of 86 percent (95 percent CI, 0.75 to 0.96), and 364 patients from nine studies in the nonflap arm had a weighted 75 percent success rate (95 percent CI, 0.66 to 0.84). Heterogeneity was statistically analyzed and revealed low heterogeneity with the I statistic. Forest plots were created and analyzed between subgroups, and chi-square analysis revealed a highly statistically significant difference (p = 0.001). The odds ratio of success in the nonflap group was 0.50 (95 percent CI, 0.33 to 0.75). CONCLUSIONS: Decompression with the use of vascularized flap coverage appears to have a higher success rate over simple repeated decompression. The relevance of these data is pertinent to all hand surgeons, as they could have an impact on treatment guidelines for this relatively uncommon but problematic condition, but further prospective study is needed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Inferior pedicle breast reduction: a retrospective review of technical modifications influencing patient safety, operative efficiency, and postoperative outcomes.

BACKGROUND: The inferior pedicle technique remains the most popular approach to breast reduction in the United States. Modifications to this procedure have enhanced versatility, patient safety, and outcome satisfaction in patients with all degrees of macromastia. METHODS: A 6-year retrospective review of 241 patients who underwent bilateral inferior pedicle breast reduction was conducted at our institution. Modifications analyzed included methylene blue tattooing to provide preoperative landmarks, preoperative hydrodissection to reduce intraoperative blood loss, incorporation of inframammary darting to reduce tension at the "T-junction," preservation of superomedial volume for enhanced medial fullness, and dermatome blade-guided tissue resection. RESULTS: Inframammary darting reduced the incidence of wound dehiscence. Preoperative hydrodissection reduced intraoperative blood loss by a factor of 2. Dermatome blade use reduced operative times at no increased incidence of postoperative seromas or hematomas. CONCLUSIONS: Outcomes resulting from these modifications appear to be at least comparable to, and perhaps better than, those previously reported.

Emergency department assessment and management of facial trauma from war-related injuries.

Facial trauma related to combat injury is of increasing prevalence and complex in nature when associated with the multiply injured trauma victim. Although rarely life-threatening, the treating physician must be aware of the presence of facial trauma and its associated injuries to seamlessly treat the combat casualty in accordance to the Advanced Trauma Life Support protocol while maintaining the armed forces' ultimate goals of returning "the greatest possible number of soldiers to combat and the preservation of life, limb and eyesight in those who must be evacuated." To this end, the treating physician must maintain a high index of suspicion for injury and have various maneuvers available to handle immediate threats to life, limb, or sight. This article will review the proper emergency department assessment and management of prevalent injuries associated with war-related facial trauma.

Chest wall reconstruction in a pediatric patient with ectopia cordis.

Ectopia cordis is defined as a congenital malposition of the heart outside of the thoracic cavity. It is a rare condition, and complete ectopia cordis can be a fatal condition. Successful surgical reconstruction of this defect has been reported but is uncommon. The general approach to reconstructing the chest wall involves repositioning the heart and providing adequate coverage of the chest wall defect. We describe our experience with a patient who had complete thoracic ectopia cordis treated with staged chest wall reconstruction. The first stage involved temporary closure with synthetic material, and the second stage involved definitive reconstruction with autologous bone and cartilage grafts supported with plates. The patient has been active and without complaints since the second stage and is awaiting tracheal decannulation. There have been a few descriptions of how to approach chest wall reconstruction in patients with ectopia cordis. The 2 stage method described can be considered to repair the chest wall defect in complete thoracic ectopia cordis.

The treatment of gustilo grade IIIB tibia fractures with application of antibiotic spacer, flap, and sequential distraction osteogenesis.

Gustilo grade III (GIII) B-C open tibia shaft fractures have a wide spectrum of injury to the bone and soft tissues. At the severe end of the spectrum are GIII B tibia fractures that combine segmental bone loss with soft tissue injuries which require flap reconstruction. These complex injuries can be treated combining circular tensioned wire fixation and distraction histiogenesis with flap reconstruction. GIII B tibia shaft fractures were retrospectively reviewed at an urban Level One Trauma Center from 1992 to 2008 which were treated with the Ilizarov method. Seventy-six patients with 78 fractures were treated. Thirty-eight fractures were treated with flaps. Out of this cohort, a subset of 19 fractures were treated using the protocol of initial multiple debridements, half pin resuscitation external fixation, soft tissue reconstruction over antibiotic spacers and delayed Ilizarov reconstruction after stabilization of the soft tissue envelope. The fractures had multiple aggressive debridements removing nonviable bone. Thirteen free flaps and 6 rotation flaps were applied. Flaps were applied a mean time of 34 days (12-77) after initial injury. Two free flaps failed and had a second successful application. Flap survival was 17 of 19 (89%). There was one partial necrosis and one flap hematoma. There was no flap complication from delayed elevation and spacer removal. Mean tibial bone defect was 9.4 cm (5-17). Reconstruction time was 26.5 months (12-73). Eighteen of 19 fractures were reconstructed with union and no deep infection or osteomyelitis. One fracture had a hypertrophic nonunion in a noncompliant patient. The use of antibiotic spacers and flaps to construct a soft tissue tunnel combined with distraction histiogenesis is an effective technique to salvage complex GIII B tibia fractures with segmental bone loss.