The Twist X-Ray: A Novel Test for Dynamic Scapholunate Instability.

Background Scapholunate instability (SLI) is the most common form of carpal instability. Early detection of SLI is imperative as early reconstructive procedures can potentially prevent the natural history of progressive degenerative arthritis. After wrist arthroscopy, magnetic resonance imaging (MRI) remains the next best noninvasive diagnostic option; however, access still remains costly and is often limited in many health care systems worldwide. In this article, we describe a novel device that allows for dynamic X-rays to be taken, accentuating the scapholunate (SL) widening. Description of Technique Twist X-ray views are generated by the patient clenching a device that combines the standard clenched fist views with ulnar deviation and supination. The test is easy to perform and functions by combining a higher grip force with the ulnar deviation and pronation effects of the extensor carpi ulnaris tendon, thus accentuating the SL gap in dynamic instability. Patients and Methods We present a series of four patients with dynamic SLI and compare the findings of the Twist X-rays with conventional wrist X-rays series, including standard anteroposterior, lateral, radial, and ulna deviation, clenched fist, and pencil grip views. Results In all the four patients, there was substantial dynamic SL widening. The SL interval increased from a mean of 1.8 mm (range: 1.5-2.8) on posteroanterior X-rays to 6.3 mm (range: 4.6-8.2) with the Twist views. Interestingly, on the pencil grip view, the mean widening was only 1.5 mm (range: 1-2.8 mm). Conclusion The authors describe a novel device that allows for improved detection of dynamic SL ligament instability when performing stress X-ray views of the wrist. Level of Evidence This is a Level IV study.

A blinded, randomized trial comparing bicolumnar arthrodesis to radioscapholunate arthrodesis in scapholunate advanced collapse II arthritis: a pilot study.

The purpose of this study was to compare the outcome of scaphoid excision with capitolunate and triquetrohamate arthrodesis (bicolumnar arthrodesis) to radioscapholunate arthrodesis in patients with scapholunate advanced collapse (SLAC) II wrist arthritis. Twelve patients with symptomatic SLAC II arthritis were recruited and randomized to receive either bicolumnar arthrodesis or radioscapholunate arthrodesis. The primary outcome was wrist function as assessed by the patient rated wrist evaluation. Secondary outcomes included range of motion, grip strength and the Mayo wrist score. A linear mixed-effects model was used to evaluate the effects of bicolumnar arthrodesis and radioscapholunate arthrodesis in treating SLAC II arthritis. Patients receiving bicolumnar arthrodesis had more improvement in their wrist function compared with patients receiving radioscapholunate arthrodesis. A high rate of re-operation was observed in patients receiving radioscapholunate arthrodesis. In SLAC II arthritis, the expected benefit of preserving the midcarpal joint was not observed. Scapholunate ligament disruption makes radioscapholunate arthrodesis a technically challenging operation. LEVEL OF EVIDENCE: I.

Treatment of toxic epidermal necrolysis by a multidisciplinary team. A review of literature and treatment results.

BACKGROUND: Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are mucocutaneous hypersensitivity reactions, usually to drugs or their metabolites. TEN is the most severe involving greater than 30% of the total body surface area (TBSA). Management of these patients usually benefits from a large multidisciplinary team for both wound and medical management. Treatment of these patients varies between centers and physicians and there is lack of a standardized treatment protocol in the medical literature. OBJECTIVES: To review the literature and complete a retrospective review of patients treated at Vancouver General Hospital over a 11-year period. METHODS: A retrospective chart review of all patients diagnosed with SJS/TEN and treated at Vancouver General Hospital from 2001 to 2011 was completed. Data collected include patient demographics, time to transfer to a burn center, SCORTEN calculation, suspected cause of TEN, %TBSA involved, length of stay in hospital and ICU, medications, dressings, infections/cultures, fluids, mucosal involvement, teams involved, associated complications, morbidity and mortality. Data is reported quantitatively. RESULTS: A total of 67 patients were identified (28 SJS, 21 SJS/TEN overlap, 18 TEN). In SJS/TEN overlap and TEN patients, oral mucosa and trunk were the primary sites involved. SCORTEN calculations were highest in the TEN group. Plastic surgery was consulted in 53% of TEN cases, 52% of SJS/TEN cases and 25% of SJS cases. Patients were admitted to a burn unit in 74% of TEN cases, 57% of TEN/SJS cases and 21% of SJS cases. Time from symptoms to diagnosis and transfer to a burn unit was highest for TEN patients. Time from presentation to diagnosis was highest in SJS/TEN overlap. Triggers were identified in 67-82% of cases. Treatment varied widely. Patients were treated conservatively, with steroids, IVIg, and cyclosporine alone or in combination. Observed mortality was higher than predicted by SCORTEN for patients treated with IVIg and lower for those treated with Cyclosporin. Dressings varied greatly and were often changed throughout a patients stay. Total mortality was 20.9% being the highest in the TEN group (35%). CONCLUSIONS: SJS and TEN are a spectrum of severe mucocutaneous reactions that have unclear treatment recommendations within the literature and within our Level 1 hospital. Information gleaned from this research will help educate physicians involved in the treatment and management of patients with these diagnoses and has resulted in development of treatment guidelines in our hospital.

Venous thromboembolism in burn patients is not prevented by chemoprophylaxis.

BACKGROUND: Venous thromboembolisms (VTE) including deep venous thrombosis and pulmonary embolism are serious complications following burn trauma. There are inconsistencies in the literature regarding thromboembolic prevention strategies and data suggests that complications occur despite chemoprophylaxis. OBJECTIVE: To determine the prevalence of deep venous thromboembolism and pulmonary embolism in burn patients who are actively being treated with VTE prophylaxis and to determine factors that help predict which anti-coagulated patients are at risk for VTE and may benefit from further treatment. MATERIALS AND METHODS: Retrospective analysis of burn data registry and patient Charts 1980-2012. RESULTS: Out of 1549 burn patients in the registry fifty patients (3.2%) had a VTE but charts were only available for 26 of these for further analysis. Of these, 12 patients (46%) had a VTE while on chemoprophylaxis and 14 (54%) without chemoprophylaxis. There were no differences between groups, but 90% of DVT complications occurred to Caucasian patients and none to Asians. The VTE group had significantly higher rate of inhalation injury, higher TBSA, longer hospital stay and ICU stay than matched controls. CONCLUSIONS: Chemoprophylaxis does not prevent VTEs. Burn severity predisposes to venous thromboembolic complications.

Propionibacterium Acnes Infection of a Metacarpophalangeal Joint Arthroplasty.

Neglected and underestimated in the past, Propionibacterium acnes is currently the most prevalent organism associated with deep prosthetic infections around the shoulder. Surprisingly, it has never been reported as a cause of infection in the hand. Here we report a case of a late presentation of a P. acnes infection in a metacarpophalangeal joint replacement, resulting in chronic low-grade pain with movement. The patient underwent a 2-stage revision, with initial removal of the prosthesis. Positive cultures for P. acnes required 15 days of extended incubation. The patient subsequently had 6 weeks of oral antibiotics followed by a second-stage revision with a Silastic implant.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: An Analysis of Triggers and Implications for Improving Prevention.

BACKGROUND: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe mucocutaneous adverse drug reactions characterized by extensive epidermal detachment. The mortality rates have been reported to vary between 1% and 5% for Stevens-Johnson syndrome and 25% and 35% for patients with toxic epidermal necrolysis. Studies have shown that early recognition and prompt withdrawal of the causative agent leads to increased patient survival. METHODS: A retrospective chart review was conducted on 64 patients admitted to Vancouver General Hospital with a diagnosis of Stevens-Johnson syndrome or toxic epidermal necrolysis from 2001 to 2011. The aim of this study was to identify the medications most often implicated in triggering Stevens-Johnson syndrome and toxic epidermal necrolysis, as well as to delineate the timeline of identification and removal of these triggers. RESULTS: A trigger was identified in 75% of cases. Allopurinol was the single most common offending agent (20% of cases). Anticonvulsants and antibiotics were common triggers. The offending agent was often removed at time of hospital admission/diagnosis but not at onset of symptoms. A history of prior culprit drug exposure with previous mucocutaneous adverse reaction was noted in 19% of cases with identified triggers. Asians and Native North Americans had a higher mortality than whites, and Asians more frequently had allopurinol as a trigger. CONCLUSIONS: The onset and high mortality rate of Stevens-Johnson syndrome/toxic epidermal necrolysis may be related to unawareness of the early signs and symptoms of Stevens-Johnson syndrome and toxic epidermal necrolysis, the common drug triggers that cause it, and what investigations (human leukocyte antigen typing in Asians) can be done to prevent it.

Retrospective review of Stevens-Johnson syndrome/toxic epidermal necrolysis treatment comparing intravenous immunoglobulin with cyclosporine.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are mucocutaneous reactions, typically to medications, that are associated with a high patient mortality. Controversy exists over which systemic treatments decrease mortality associated with SJS/TEN. OBJECTIVE: In this study we sought to determine whether intravenous immunoglobulin (IVIg) or cyclosporine use for SJS/TEN results in better patient outcomes. METHODS: We undertook a retrospective chart review of 71 patients admitted between 2001 and 2011 for SJS/TEN at a tertiary care center of which 64 cases were included in the data analysis. Predicted severity-of-illness score for TEN mortality was compared with actual mortality for patients treated with either cyclosporine or IVIg. RESULTS: Our cohort demonstrated a relative mortality benefit to the use of cyclosporine in the treatment of SJS/TEN with a standardized mortality ratio of 0.43, over the use of IVIg with a standardized mortality ratio of 1.43. LIMITATIONS: This is single-center retrospective study. CONCLUSIONS: The use of cyclosporine over IVIg may offer a greater mortality benefit in the treatment of SJS/TEN.

Pediatric flexor tendon injuries: A 10-year outcome analysis.

BACKGROUND: Primary flexor tendon repair was first introduced in the 1960s. Since then, major advances in the understanding of flexor tendon anatomy and biology have led to improved outcomes following repair. Relative to the adult population, sparse knowledge exists as to which operative and postoperative treatments are most successful in children. This is due, in part, to the rarity of pediatric tendon lacerations compared with the adult population, but also related to challenges when working with smaller anatomy and the decreased compliance in children with respect to rehabilitation protocols. Published reports indicate that the incidence of 'good' flexor tendon repair outcomes is as low as 53%. OBJECTIVE: To determine the injury pattern and demographics of pediatric flexor tendon injuries involving zones I, II and III over the past decade, and to report results and identify treatment paradigms that are associated with optimal outcomes. METHODS: A retrospective chart review of all flexor tendon injuries involving zones I, II and III between April 2001 and December 2010 was performed. Parameters reviewed included demographics, injury mechanism, repair technique, outcomes and complications. RESULTS: A total of 47 patients with a median age of eight years experienced 100 tendon injuries. The most common cause of injury was glass (n=22), with the most common digit injured being the small finger (n=30). Tendon injuries included the following: flexor digitorum superficialis (n=46); flexor digitorum profundus (n=45), flexor pollicis longus (n=8); and adductor pollicis longus (n=1). Zone III had the highest number of injuries (n=47), followed by zone II (n=39). Ninety tendons were repaired using polyester suture, the most common size being 4-0. The modified Kessler technique was used in the majority of cases (n=62). Only 22 tendons underwent an epitendinous repair. Splint immobilization was used in 30 patients and a full cast in 17. The median duration of immobilization was four weeks. Forty-two patients underwent postoperative hand therapy. Using the American Society for Surgery of the Hand Total Active Motion (TAM) score, 40 of 47 patients experienced 100% recovery with no functional limitations. Two patients had a score <100%, not necessitating further surgery. A second operation was required for five patients. All patients in this group demonstrated 100% TAM at one year. CONCLUSION: Pediatric flexor tendon injuries remain rare and usually involve the dominant hand holding or manipulating an object. An excellent outcome was found in 95.9% of patients assessed by TAM scores. Repair technique was chosen according to the size of tendon involved. Patients not treated with hand therapy and not immobilized in a cast were often too young to participate in rehabilitation. Based on the results, immobilization of young children for four weeks is safe and does not worsen functional outcomes. Of the patients requiring a second procedure, no predictive variables for poorer outcomes were found on analysis of age, outcome, cause, location, repair technique, rehabilitation protocol or zone of injury.

HISTORIQUE: La réparation primaire du tendon fléchisseur a été utili-sée pour la première fois dans les années 1960. Depuis, la compréhension de l'anatomie et de la biologie du tendon fléchisseur a énormément progressé, ce qui a favorisé de meilleures issues. Par rapport à la population adulte, on ne sait pas vraiment quels traitements opératoires et postopératoires fonctionnent le mieux chez les enfants. Ce phénomène est partiellement attribuable au peu de lacérations du tendon en pédiatrie par rapport à la population adulte, mais également à la difficulté de travailler sur une plus petite anatomie et à la moins bonne adhésion des enfants aux protocoles de réadaptation. Selon des rapports publiés, l'incidence de réparations du tendon fléchisseur ayant une incidence positive n'atteindrait pas plus de 53 %. OBJECTIF: Déterminer le profil des blessures et les caractéristiques démographiques des patients d'âge pédiatrique présentant une blessure du tendon fléchisseur des zones I, II et III depuis dix ans, rendre compte des résultats et décrire les paradigmes thérapeutiques associés aux issues optimales. MÉTHODOLOGIE: Les chercheurs ont effectué une analyse rétrospective des dossiers de toutes les blessures des zones I, II et III du tendon fléchisseur entre avril 2001 et décembre 2010. Les paramètres qu'ils ont analysés sont les caractéristiques démographiques, le mécanisme de blessure, la technique de réparation, les issues et les complications. RÉSULTATS: Au total, 47 patients ayant un âge médian de huit ans ont subi 100 blessures du tendon, surtout causées par du verre (n=22) et touchant le petit doigt (n=30). Les blessures du tendon s'établissaient comme suit : fléchisseur commun superficiel (n=46), fléchisseur commun profond (n=45), long fléchisseur du pouce(n=8) et long adducteur du pouce (n=1). Le plus grand nombre de blessures s'observait sur la zone III (n=47), suivi de la zone II (n=39). Quatre-vingt-neuf tendons ont été réparés à l'aide d'une suture de polyester, généralement de dimension 4-0. Dans la majorité des cas, les chirurgiens ont privilégié la technique de Kessler modifiée (n=62). Seulement 22 tendons ont subi une réparation épitendineuse. Trente patients ont été immobilisés au moyen d'une attelle, et 17, au moyen d'un plâtre complet, pendant une durée médiane de quatre semaines. Quarante-deux patients ont subi une thérapie postopératoire de la main. Selon l'indice de mouvement actif total de la main (TAM) de l'American Society for Surgery, 40 des 47 patients ont présenté un rétablissement complet, sans limites fonctionnelles. Deux patients ont présenté un indice inférieur à 100 %, qui n'a toutefois pas nécessité d'autre opération. Cinq patients ont dû subir une deuxième opération. Tous les patients de ce groupe présentaient un indice de TAM de 100 % au bout d'un an. CONCLUSION: Les blessures du tendon fléchisseur demeurent rares en pédiatrie et touchent généralement la main dominante qui tient ou manipule un objet. D'après l'indice TAM, 95,9 % des patients évalués ont présenté une excellente issue. La technique de réparation était sélectionnée selon la dimension du tendon touchée. Les patients qui ne subissaient pas de thérapie de la main et qui n'étaient pas immobilisés dans un plâtre étaient souvent trop jeunes pour participer à la réadaptation. D'après les résultats, l'immobilisation des jeunes enfants pendant quatre semaines est sécuritaire et n'empire pas les issues fonctionnelles. Chez les patients qui ont besoin de subir une deuxième intervention, les chercheurs n'ont pas obtenu de variables prédictives d'issues plus négatives à l'analyse de l'âge, de l'issue, de la cause, du foyer, de la technique de réparation ou de la zone de blessure.

Histopathological changes in anatomical distribution of inflammatory bowel disease in children: a retrospective cohort study.

BACKGROUND: Anatomical progression of pediatric inflammatory bowel disease is under-reported. The aim of this work was to examine possible changes in the anatomical distribution of IBD in pediatric patients at diagnosis and at follow up. METHODS: In a retrospective cohort study, the medical records of children with inflammatory bowel disease were examined. Patients who had at least 2 endoscopic/colonoscopic examinations were included. Primary outcome was histopathological progression based on histopathological examination of biopsies taken during endoscopic and colonoscopic bowel examination. Factors predictive of disease progression were also examined. RESULTS: A total of 98 patients fulfilled inclusion criteria (49 female, 54 with ulcerative colitis, range 2 - 17 years, mean age at diagnosis was 10.6 years, SD ± 3.67), the mean duration of follow up was 32.9 months (range 0.1 - 60 months, SD ± 8.54). In the ulcerative colitis group, 41% had disease progression and none of the examined variables (age, gender, laboratory markers, growth and disease activity at diagnosis) appeared to effect disease progression. In the Crohn's disease group, 75% had disease progression. Girls (OR = 0.13, 95% CI 0.02 - 0.79) and patients with high erythrocytic sedimentation rate (OR=0.942, 95% CI 0.894 - 0.99) were predictive for disease progression. CONCLUSIONS: Despite maximum therapy, the majority of children with Crohn's disease appeared to have histopathological disease progression. Female sex and high erythrocytic sedimentation rate seemed to be predictive for disease progression. None of the factors analyzed seemed predictive of disease progression in ulcerative colitis.

Trace elements and vitamins at diagnosis in pediatric-onset inflammatory bowel disease.

AIM: To compare serum vitamin and mineral levels at diagnosis in children with inflammatory bowel disease (IBD) versus a control group without. METHODS: In a retrospective cohort study, serum levels of iron, zinc, folate, selenium, vitamin B( 12), vitamin A, and vitamin E in children with IBD at diagnosis were compared with gender- and age-matched controls. RESULTS: A total of 154 patients with IBD (mean age 11.27 ± 3.74 years, 83 boys, 80 with Crohn's disease) were recruited. The mean duration of symptoms prior to diagnosis was 5.4 ± 3.2 months for patients with Crohn's disease and 4.6 ± 2.9 months for patients with ulcerative colitis. A control group of 64 children was recruited. The mean serum zinc levels were 11.33 ± 4.16 µmol/L for ulcerative colitis, 8.74 ± 2.08 µmol/L for Crohn's disease and 11.49 ± 1.63 µmol/L for controls (P < .001). CONCLUSIONS: In newly diagnosed children with IBD, serum zinc levels are significantly lower compared with children without IBD.

Bone mineral density, vitamin D, and disease activity in children newly diagnosed with inflammatory bowel disease.

BACKGROUND AND AIM: The aim of this study was to examine bone mineral density and serum 25-hydroxy vitamin D in relation to disease activity in children newly diagnosed with IBD. METHODS: In a cross-sectional analytic study, 60 children newly diagnosed with IBD (39 with Crohn's disease [CD], mean age 12.2 ± 2.1 years; and 21 with ulcerative colitis [UC], mean age 12.4 ± 3.7 years) were recruited. Fifty-six age- and sex-matched children without IBD were invited as controls (mean age 11.3 ± 4.2 years). Serum 25-hydroxy vitamin D for patients and controls was measured at diagnosis. Patients' adjusted lumbar spine bone mineral density (BMD) z scores were measured. Activity indices for both CD and UC were calculated. RESULTS: The serum level of 25-hydroxy vitamin D was significantly lower in children with IBD compared to the control group (P = 0.04). BMD was significantly lower in patients with CD compared to those with UC (P = 0.039). There was no correlation between vitamin D levels, BMD z scores or disease activity indices for both CD and UC. CONCLUSIONS: Serum vitamin D level is significantly lower in children with newly diagnosed IBD compared to those without. However, vitamin D levels are not affected by disease severity. It seems that BMD status may not be affected by vitamin D levels or disease severity in this cohort. Larger prospective controlled studies are needed to confirm these findings.