Rupture of the Flexor Pollicis Longus Tendon from the Metacarpophalangeal Sesamoid and Joint in a Rheumatoid Patient: A Case Report.

CASE: A 54-year-old woman with rheumatoid arthritis presented with a flexor pollicis longus (FPL) rupture at the level of the metacarpophalangeal joint secondary to attritional damage from metacarpophalangeal (MCP) degenerative changes and exostoses from the radial sesamoid. She underwent direct tendon repair with debridement of the MCP joint and radial sesamoidectomy. CONCLUSION: Rheumatoid arthritis can potentially lead to rupture of the FPL tendon in locations distal to the carpus, namely at the level of the MCP joint. Contrary to other reports, a quality outcome may be obtained with direct repair and may not necessarily require tendon transfer, fusion, or grafting.

Conservative Management with Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis.

BACKGROUND: Historically, humeral shaft fractures have been successfully treated with nonoperative management and functional bracing; however, various surgical options are also available. In the present study, we compared the outcomes of nonoperative versus operative interventions for the treatment of extra-articular humeral shaft fractures. METHODS: This study was a network meta-analysis of prospective randomized controlled trials (RCTs) in which functional bracing was compared with surgical techniques (including open reduction and internal fixation [ORIF], minimally invasive plate osteosynthesis [MIPO], and intramedullary nailing in both antegrade [aIMN] and retrograde [rIMN] directions) for the treatment of humeral shaft fractures. The outcomes that were assessed included time to union and the rates of nonunion, malunion, delayed union, secondary surgical intervention, iatrogenic radial nerve palsy, and infection. Mean differences and log odds ratios (ORs) were used to analyze continuous and categorical data, respectively. RESULTS: Twenty-one RCTs evaluating the outcomes for 1,203 patients who had been treated with functional bracing (n = 190), ORIF (n = 479), MIPO (n = 177), aIMN (n = 312), or rIMN (n = 45) were included. Functional bracing yielded significantly higher odds of nonunion and significantly longer time to union than ORIF, MIPO, and aIMN (p < 0.05). Comparison of surgical fixation techniques demonstrated significantly faster time to union with MIPO than with ORIF (p = 0.043). Significantly higher odds of malunion were observed with functional bracing than with ORIF (p = 0.047). Significantly higher odds of delayed union were observed with aIMN than with ORIF (p = 0.036). Significantly higher odds of secondary surgical intervention were observed with functional bracing than with ORIF (p = 0.001), MIPO (p = 0.007), and aIMN (p = 0.004). However, ORIF was associated with significantly higher odds of iatrogenic radial nerve injury and superficial infection than both functional bracing and MIPO (p < 0.05). CONCLUSIONS: Compared with functional bracing, most operative interventions demonstrated lower rates of reoperation. MIPO demonstrated significantly faster time to union while limiting periosteal stripping, whereas ORIF was associated with significantly higher rates of radial nerve palsy. Nonoperative management with functional bracing demonstrated higher nonunion rates than most surgical techniques, often requiring conversion to surgical fixation. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Percent articular exposure of the distal humerus with triceps fascial tongue approach compared with olecranon osteotomy.

BACKGROUND: Distal humerus fractures are common and can be difficult to treat. No one approach to the distal humerus has been shown to be superior to another; however, the olecranon osteotomy remains the gold standard for complex, intra-articular fractures. Understanding the percent of articular exposure with approaches to the distal humerus is important for success. The goal of this study is to show the percent of articular exposure of the triceps fascial tongue approach as compared with the olecranon osteotomy. METHODS: Twelve fresh frozen cadavers were separated randomly into 2 groups of 6 each. The first group of 6 specimens was allocated to the triceps fascial tongue approaches with the collaterals maintained and with the collaterals released off the ulna and elbow dislocated. The second group of 6 was allocated to the triceps fascial tongue approach while maintaining the collaterals followed by an olecranon osteotomy. The articular exposure was marked after performing each approach, and the percent of articular exposure was quantified by using 3D scanning. Standard deviations were calculated for each. RESULTS: The average percent visualization of the distal humerus articular surface in the fascial tongue approach while maintaining the collaterals was 36% in the first cohort and 37% in the second cohort with a standard deviation of 5% in both cohorts. The average percent of the distal humerus articular surface exposed in the fascial tongue approach with the collaterals released off the ulna and elbow dislocated was 85.09% with a standard deviation of 4%. The average percent of the distal humerus articular surface exposed in the olecranon osteotomy group was 57.9% with a standard deviation of 5%. CONCLUSION: The triceps fascial tongue approach allows for visualization of about one-third of the joint, which may be adequate for many intra-articular distal humerus fractures. For added exposure of the articular surface, the collaterals may be elevated from the ulna and the elbow dislocated allowing for a substantial increase in percent of articular exposure compared with the collateral retaining fascial tongue approach and the olecranon osteotomy.

Avoiding the blood supply to the femoral head during cannulated screw fixation: A comparison of two techniques.

OBJECTIVES: To compare the strength of the inverted triangle (IT) versus the L-shaped cannulated screw fixation technique for stabilizing a Pauwels 2 femoral neck fracture. To demonstrate the risk to the blood supply to the femoral head from a posterior-superior screw. METHODS: The IT construct was compared with the L-shaped design in 10 composite femurs. A Pauwels 2 fracture was made with a 5 mm gap. Each specimen was loaded over 5000 cycles, measuring angular/shear displacement then loaded to failure. The data were analyzed using Mann-Whitney U test. Three separate fresh frozen cadavers were injected with low-viscosity epoxy. The intraosseous bloody supply was inspected in each femoral head (no fixation, IT, L-shaped). RESULTS: There was no difference in angular (P = .3) or shear displacement (P = .99) between either screw design after cyclical loading. Also, there was not statistical difference in load to failure testing between either construct (P = .99). The average load to failure in the IT group was 3204.4 N. The average was 3180.2 N in the L-shaped design. We demonstrated the presence of the intraosseous portion of the lateral epiphyseal vessel in the specimen without screw fixation. This was preserved in the specimen with the L-shaped design but absent in the specimen following IT fixation. CONCLUSIONS: The strength of the L-shaped construct was not statistically different than the strength of the IT design. The posterior-superior screw may put the main blood supply to the femoral head at risk and should be avoided.

Traumatic Conus Medullaris Syndrome: A Case Report and Review of the Literature.

CASE: A twenty-six-year-old man was diagnosed with conus medullaris syndrome (CMS) after sustaining a traumatic L1 burst fracture. Surgical decompression and stabilization was performed within ninety-six hours of admission; postoperatively, normal bladder function rapidly returned. CONCLUSION: CMS is difficult to diagnose because of the clinically variable presentation. There is no consensus regarding the natural history of conus medullaris injury or regarding the necessity, approach, or timing for decompression. Higher-level evidence is needed to guide treatment for acute traumatic CMS.

Electroconvulsive therapy pre-treatment with low dose propofol: comparison with unmodified treatment.

BACKGROUND: Whilst electroconvulsive therapy (ECT) is routinely administered under anesthesia in developed nations, in many developing countries, ECT is still administered unmodified. This practice has attracted considerable scrutiny with calls to ban unmodified ECT. However, there are no affordable alternatives for many poor, acutely ill psychiatric patients. We evaluated whether administration of intravenous propofol 0.5 mg/kg for sedation by the ECT psychiatrist just prior to otherwise unmodified treatment improved acceptance of and reduced anxiety surrounding the treatment. METHOD: We conducted an open label trial at The King George's Medical University in Lucknow, India. Forty-nine patients received propofol pre-treatment and 50 patients received unmodified treatment as usual. RESULTS: Socio-demographic profiles, diagnoses and clinical responses were comparable. Patients who received propofol experienced less anxiety monitored by the State-Trait Anxiety Inventory just prior to ECT (p < 0.001), and had a more favorable attitude towards treatment assessed by an established questionnaire (Freeman and Kendell, 1980). Propofol patients were less likely to experience post-ictal delirium monitored by the CAM-ICU (p = 0.015) and had fewer cognitive side-effects on the MMSE (p = 0.004). There were no adverse events associated with propofol administration. CONCLUSION: Whilst unmodified ECT should never be used when modified ECT under anesthesia is available, we have found low dose propofol can be safely administered by the ECT psychiatrist to sedate patients pre-treatment who would otherwise receive completely unmodified treatment. The intervention was associated with reduced anxiety and a more positive attitude towards ECT, without compromising efficacy. A randomized double blind controlled study is necessary to confirm these benefits.