The quantitative role of flexor sheath incision in correcting Dupuytren proximal interphalangeal joint contractures.

UNLABELLED: Controversy exists regarding intra-operative treatment of residual proximal interphalangeal joint contractures after Dupuytren's fasciectomy. We test the hypothesis that a simple release of the digital flexor sheath can correct residual fixed flexion contracture after subtotal fasciectomy. We prospectively enrolled 19 patients (22 digits) with Dupuytren's contracture of the proximal interphalangeal joint. The average pre-operative extension deficit of the proximal interphalangeal joints was 58° (range 30-90). The flexion contracture of the joint was corrected to an average of 28° after fasciectomy. In most digits (20 of 21), subsequent incision of the flexor sheath further corrected the contracture by an average of 23°, resulting in correction to an average flexion contracture of 4.7° (range 0-40). Our results support that contracture of the tendon sheath is a contributor to Dupuytren's contracture of the joint and that sheath release is a simple, low morbidity addition to correct Dupuytren's contractures of the proximal interphalangeal joint. Additional release of the proximal interphalangeal joint after fasciectomy, after release of the flexor sheath, is not necessary in many patients. LEVEL OF EVIDENCE: IV (Case Series, Therapeutic).

The value of post-operative radiographs in clinical management of AO type A distal radius fractures.

The value of post-operative radiographs following stabilization of Arbeitsgemeinschaft für Osteosynthesefragen (AO) type A distal radius fractures with volar locking plates is unclear. We examined the value of post-operative radiographs of type A fractures treated with volar locking plates. A retrospective review was performed on all AO type A distal radius fractures treated with volar locking plates between 2007 and 2010 at two institutions. A total of 158 patients receiving 446 sets of post-operative radiographs were included. Reviewing all clinic, emergency, and operative notes, we found that 94% of radiographs were performed as routine follow-up, with no set of post-operative radiographs demonstrating findings of hardware/fracture site complications. All cases requiring further workup or interventions were heralded by patient complaints. Routine post-operative radiographs following volar locking plates for extra-articular distal radius fractures did not demonstrably alter clinical decision making; this is an area where a reduction in resource utilization would not seem to alter clinical quality care, but further studies with larger populations are needed to establish the incidence of radiographic problems prior to symptom occurrence. Level of evidence: Diagnostic III.

Overview of indications, preferred methods and technical tips for hand fractures from around the world.

This article presents techniques used by six senior surgeons from different parts of the world. Our commentaries on treating hand fractures are included, together with the methods we use. While non-operative treatment is appropriate and effective for the majority of the hand fractures (including those many practitioners currently treat surgically), we describe how we try to manage difficult cases with less invasive surgical methods. We recommend simple, efficient, non-operative or less invasive operative methods for almost all fractures, except for some open or very complex injuries.

Surgical findings in the treatment of Dupuytren's disease after initial treatment with clostridial collagenase (Xiaflex).

We investigated the difficulty of surgical fasciectomy after previous treatment with clostridial collagenase injection. The 35 clinicians who had participated in the initial trials of this injection were contacted via email. Twenty-eight responded, nine of whom reported on 15 patients. Most (seven of nine) felt there was no significant distortion of anatomy and rated the level of technical difficulty as equivalent to a primary Dupuytren's fasciectomy at the observed degree of contracture (nine of 15 cases). One respondent (four of 15 cases) reported significantly more difficulty and grossly distorted anatomy. One surgical complication, a wound dehiscence, was reported.

The effect of observer experience on magnetic resonance imaging interpretation and localization of triangular fibrocartilage complex lesions.

This study investigates the effect of experience of the interpreter on the ability of magnetic resonance imaging (MRI) to identify the presence and anatomic location of a triangular fibrocartilage complex (TFCC) lesion. Fifty-one patients who underwent wrist arthroscopy with preoperative MRI studies were reviewed retrospectively. Two radiologists with different levels of training and experience evaluated the MRI scans in a blinded manner. The sensitivity rates of the 2 observers for detection of TFCC lesions were 86% and 80%. The specificity rates were 96% and 80%. The accuracy rates for prediction of a TFCC tear were 83% and 61% for the 2 observers. The correct location of a TFCC lesion was predicted by the more experienced observer for 12 of 19 central, 3 of 4 radial, and 6 of 12 peripheral lesions. The less experienced observer correctly identified 8 of 19 central, 2 of 4 radial, and 2 of 12 peripheral tears. The overall accuracy rates for prediction of a TFCC lesion and its location were 69% and 37%. Our data indicate that the published accuracy rates for prediction of TFCC lesion location may be reproducible only in very specialized centers.

Fractures of the proximal interphalangeal joint.

Fractures of the proximal interphalangeal joint constitute a broad spectrum of injuries. An understanding of the anatomy, the potential for joint instability, and the treatment options is essential to management of these fractures. Commonly observed fracture patterns involve one or both condyles of the proximal phalanx or the base of the middle phalanx. Fractures of the middle phalanx may involve the palmar lip or the dorsal lip or may be a "pilon" type of injury involving both the palmar and the dorsal lip with extensive intra-articular comminution. Intra-articular injuries may lead to joint subluxation or dislocation and must be identified in a timely manner to limit loss of motion, degenerative changes, and impaired function. These injuries range from those requiring minimal intervention to obtain an excellent outcome to those that are challenging to the most experienced surgeon. The treatment options include extension-block splinting, percutaneous pinning, traction, external fixation, open reduction and internal fixation, and volar-plate arthroplasty. Prompt recognition of the complexity of the injury and appropriate management are essential for an optimal functional outcome.

Complications of hand and wrist surgery in the athlete.

The hand injuries reviewed in this article are those about which the treating physician should be suspicious, whether an athlete presents with them on the field or shortly thereafter in the emergency department or clinic. Education on the part of the physician and the patient are the primary safeguards to limiting complications.

Spontaneous detachment of the deltoid muscle origin.

Three patients with four affected shoulders with spontaneous detachment of the deltoid origin are reported. In this group spontaneous detachment of the deltoid origin was associated with chronic massive rotator cuff defects. Detachment of the deltoid origin was associated with an acute, sudden onset of shoulder weakness. Pain was not a prominent complaint, and shoulder function was poor because of weakness. Spontaneous detachment of the deltoid origin can occur with chronic massive rotator cuff tears and can be responsible for an acute onset of shoulder weakness.

Anteroposterior instability of the distal clavicle after distal clavicle resection.

Resection of the lateral end of the clavicle disrupts the acromioclavicular articulation and creates the potential for abnormal postoperative motion. Seventeen isolated distal clavicle resections were reviewed to assess translation of the acromioclavicular articulation in the anteroposterior plane and its relationship to patient outcome. Stress radiographs were used to quantitate the translation of the distal clavicle and the amount of bone resected. Radiographs of the contralateral shoulder served as a control. Patients completed a questionnaire on shoulder function and pain and were examined preoperatively and postoperatively. The total translation (anterior plus posterior) in the anteroposterior plane averaged 8.7 mm (range, 3-21 mm) for surgically treated shoulders and was significantly greater than that for the contralateral shoulders (mean, 3.2 mm; range, 1-6 mm). Patients' postoperative visual analog pain scales correlated with the magnitude of anteroposterior translation. The amount of translation and the postoperative pain scores did not correlate with the apparent joint space seen on radiographs after surgery. The correlation of pain scores with the amount of translation shows that excessive anteroposterior instability of the distal clavicle can cause postoperative shoulder pain and poor surgical outcome.

Train injuries in children.

OBJECTIVE: To describe the pattern of injuries sustained in pediatric victims of train accidents. DESIGN: Retrospective review of patients identified in a search of two trauma registries for the years 1984-1994. SETTING: Two pediatric level one trauma centers in one metropolitan area. PATIENTS: Between 1984 and 1994, seventeen children were identified as treated for injuries sustained in train accidents. Children pronounced dead at the scene and those injured when a car was struck by a train were excluded. INTERVENTION: ATLS protocols were followed. All open musculoskeletal injuries were treated with multiple operative irrigation and debridement procedures and broad spectrum antibiotics. MAIN OUTCOME MEASUREMENTS: Variables included the following: age, sex, mechanism of injury, circumstances surrounding the injuries, all injuries sustained, operations performed during the acute hospitalization, subsequent operations, level of amputation(s), complications, and cost and length of hospitalization. RESULTS: Presenting injuries included eight patients with ten complete amputations and eight patients with ten near-complete amputations. The average number of operative procedures for the survivors during the initial hospitalization was 5.7 (range three to sixteen). Five patients (five extremities) required amputation revision to a more proximal level after the initial surgical intervention but prior to definitive wound closure. Secondary surgical procedures have been required in 50% of survivors to date. The financial cost of these injuries is substantial, with acute hospitalization costs averaging $61,000. CONCLUSION: Pediatric survivors of train-pedestrian accidents are likely to suffer isolated musculoskeletal injuries, the majority of which are amputations of the lower extremity. These injuries require multiple operative debridements and frequent revision to higher levels of amputation are expected. The percentage of these injuries in children at play around railroad tracks emphasizes the need for limitation of access to railroad areas and for prevention through public education.