Gunshot-related lower extremity nerve injuries.

OBJECTIVE: The purpose of this study was to describe the frequency of nerve injury associated with lower extremity ballistic trauma, the associated skeletal and soft tissue injuries, and the rate of neurologic recovery. DESIGN AND SETTING: A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS: This was an institutional review board approved retrospective cohort study of patients over 16 years of age presenting with ballistic-related traumatic injury to the lower extremities between May 2018 and May 2019. All patients identified with lower extremity ballistic trauma were included in this study. The rate of nerve palsy, associated skeletal injury, and operative fixation were recorded for each anatomic zone. Rates of associated concomitant vascular injury, fracture, and compartment syndrome were collected through a review of the electronic medical records. Chart review was performed to evaluate outcomes and nerve recovery. RESULTS: Twenty-one patients (21 extremities, 21/148, 14%) were diagnosed by attending physicians, fellowship-trained in orthopedic trauma, as having ballistic-related nerve injuries. Seventy-three percent of patients with a documented neurologic injury (11/15) demonstrated complete nerve recovery as measured by the MRC and sensory scale assessment at most recent follow-up, while the rest demonstrated no improvement in their neurologic deficits from presentation. The rate of associated vascular injury in patients with lower extremity nerve palsies was 38% (8/21). While the rate of vascular injury in the absence of neurologic injury was 3% (4/127). CONCLUSIONS: This series of lower extremity nerve injuries in a large sample of urban lower extremity ballistic trauma noted a high rate of concomitant nerve injuries. An associated diagnosis of a vascular injury appears to portend a higher risk of neurologic injury. Treating surgeons should have a high index of suspicion for associated vascular injury in patients presenting with a ballistic lower extremity nerve palsy.

Articular Involvement with Retrograde Headless Compression Screw Fixation of the Metacarpal.

PURPOSE: Retrograde headless compression screw (RHCS) fixation for metacarpal fractures can lead to metacarpal head articular cartilage violation. This study aimed to quantify the articular surface loss after insertion of the RHCS and determine the functional range of motion (ROM) of the metacarpophalangeal (MCP) joint at the point of contact between the proximal phalangeal (P1) base and the articular defect. METHODS: Ten fresh-frozen cadaveric hand specimens were analyzed for prefixation MCP joint ROM. After screw insertion, the ROM at which the dorsal portion of the P1 base begins to engage the screw tract defect, as well as the ROM at which the midsagittal portion of the P1 bisector engages the screw tract defect, was recorded. The distal axial articular surface of the metacarpal and the defects from screw insertion were measured using a digital image software program. RESULTS: Nine men and one woman (mean age, 69 years) were examined. The prefixation mean extension-flexion arc for all MCP joints ranged from 1° to 85°. After screw insertion, the mean MCP ROM at which the dorsal P1 articular surface first engaged the screw tract was 31°. Only 7 digits had screw tract engagement with the midsagittal bisector of the P1 base at a mean flexion angle of -18° (18° hyperextension). Mean articular surface violation increased from the index finger moving ulnarly, with an average of 3.9% involvement. CONCLUSIONS: Articular surface loss of the metacarpal head following RHCS insertion is negligible in a cadaveric model, with minimal engagement between the corresponding defect and the P1 base during functional ROM. CLINICAL RELEVANCE: Retrograde headless compression screw fixation of metacarpals inevitably damages the cartilage. However, the actual defect is small in proportion to the articular surface area and not engaged during functional activity. These biomechanical features may mitigate the surgeon's concern about joint destruction, while ensuring the benefits of early rehabilitation and minimal invasiveness of this technique.

Temporal Relationship of Corticosteroid Injection and Open Release for Trigger Finger and Correlation With Postoperative Deep Infections.

PURPOSE: Previous single-institution studies have shown a relationship between corticosteroid injection and infection after surgery if open trigger release occurs within 90 days. We queried an insurance claims database to evaluate the temporal relationship between a corticosteroid injection and the development of a surgical site infection requiring secondary surgery in patients undergoing trigger release. METHODS: The PearlDiver database was queried for adults who underwent unilateral trigger finger release surgery from 2012 to 2018. The total number of injections, time from last injection to surgery, and preoperative antibiotic use were determined, in addition to the rates of postoperative administration of antibiotics and deep infection requiring surgery at 30, 60, and 90 days after surgery. Logistic regression analysis was used to evaluate the odds of deep infection at 30, 60, and 90 days. RESULTS: A total of 14,686 patients were included; at least 1 corticosteroid injection was administered to 5,173 patients prior to surgery. When grouped based on whether a corticosteroid injection was administered prior to surgery, the postoperative infection rates between the groups were similar at 30, 60, and 90 days. When surgery was performed within 1 month of injection, increased odds of deep infection requiring irrigation and debridement were seen at 60 (odds ratio 2.92 [1.01-7.52]) and 90 days (odds ratio 3.01 [1.13-7.25]). Postoperative antibiotic use in the groups with and without a preoperative injection was similar at all queried time points, but patients who underwent open trigger finger release within 1 month of a prior injection had significantly increased odds (odds ratio 5.77 [1.41-22.06]) of using antibiotics after surgery. Male sex, a higher Elixhauser comorbidity index, and rheumatoid arthritis were additional independent risk factors for a deep infection. CONCLUSIONS: Patients who undergo open trigger release within 1 month of a corticosteroid injection are at increased odds of developing a postoperative infection requiring surgical debridement. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Gunshot-Related Upper Extremity Nerve Injuries at a Level 1 Trauma Center.

PURPOSE: Gunshot wounds can result in a spectrum of injuries to nerves, with little data to guide definitive treatment. We performed a retrospective evaluation of gunshot-related upper extremity injuries in an urban trauma center to analyze epidemiology, associated injuries, and short-term outcomes. We hypothesized that gunshot-related injuries would involve soft tissue cavitation, inducing axonotmesis and neuropraxia rather than neurotmesis injuries. METHODS: All patients over the age of 16 with upper extremity gunshot trauma from May 2018 to May 2019 were identified through the University of Chicago orthopaedic and general surgery trauma databases. Initial nerve injuries were identified by physical examination. Patient demographic data, soft tissue and skeletal injury, treatment modality, and return of function were collected. RESULTS: Ballistic injuries in 1302 patients were treated over 12 months. We identified 126 upper extremity gunshot injuries in 117 patients. Thirty-eight upper extremities (38 patients) had a documented nerve deficit (38/126, 30%) with a follow-up rate of 94% (34/36) at a mean of 351 days after injury (median, 202 days; range, 13-929 days). One patient had a subacute transradial amputation, and 1 patient was deceased at final follow-up. The presence of vascular injury and fracture increased the rate of neurologic injury after gunshot injuries. At the most recent follow-up, 68% (23/34) of patients with upper extremity injury had improvement in nerve function as measured by objective clinical assessment, with 24% (8/34) experiencing full recovery at an average of 368 days (median, 261 days; range, 41-929 days). CONCLUSIONS: Nerve injury after ballistic trauma to the upper extremity is common. Vascular injury and fractures were associated with a higher risk of nerve injury. Short-term improvement in nerve function was seen in over half the cohort, suggesting a predominance of neuropraxic effects. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Acute Hematogenous Osteomyelitis of the Scapula: A Case Report.

CASE: We present the case of a previously healthy 4-year-old boy with aggressive acute hematogenous osteomyelitis (AHO) of the scapula. Despite only 3 days of symptoms, he had a large abscess, prolonged bacteremia, and significant bony destruction. He required multiple debridements and intravenous antibiotics to control the infection but ultimately had full restoration of bony anatomy and normal function. CONCLUSIONS: Reported cases of AHO in the scapula are extremely rare. This case highlights the surgical approach to this problem and the importance of repeat advanced imaging and repeat debridements when clinically necessary.