Proximal Pole Scaphoid Nonunion Reconstruction With 1,2 Intercompartmental Supraretinacular Artery Vascularized Graft and Compression Screw Fixation.

PURPOSE: To review the incidence of union of patients with proximal pole scaphoid fracture nonunions treated using a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) vascularized graft and a small compression screw. METHODS: This is a retrospective case series of 12 patients. Calculations of the size of the proximal pole fragment relative to the total scaphoid were performed using posteroanterior view scaphoid radiographs with the wrist in ulnar deviation and flat on the cassette. Analyses were repeated 3 times per subject, and the average ratio of proximal pole fragment relative to the entire scaphoid was calculated. We reviewed medical records, radiographs, and computed tomography (CT) scans of these 12 patients. The CT scans that were performed after an average of 12 weeks were ultimately used to confirm union of the scaphoid fractures. One patient was unable to have a CT so was excluded from the final calculation. RESULTS: All 11 (100%) scaphoid fractures that were assessed by CT were found to be healed at the 12-week assessment point. The mean proximal pole fragment size was 18% (range, 7%-27%) of the entire scaphoid. CONCLUSIONS: The 1,2 ICSRA vascularized graft and compression screw was an effective treatment for patients with proximal pole scaphoid fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Delayed-Onset Digital Ischemia After Local Anesthetic With Epinephrine Injection Requiring Phentolamine Reversal.

The use of low-dose epinephrine in hand surgery has made it possible to perform a wide range of surgical procedures in the office setting. Low-dose epinephrine use is safe, and its vasoconstrictive effects are reversible with phentolamine. In this report, we present late-onset finger ischemia beginning 3 hours after an ipsilateral carpal tunnel and A1 pulley release of the middle finger anesthetized with local anesthetic and low-dose epinephrine (1:100,000). Finger ischemia lasted 14 hours until rescued with phentolamine injection.

Effects of Volar Tilt, Wrist Extension, and Plate Position on Contact Between Flexor Pollicis Longus Tendon and Volar Plate.

PURPOSE: Volar plates positioned at, or distal to, the watershed line have been shown to have a higher incidence of attritional rupture of the flexor pollicis longus (FPL). In this study, we aimed to evaluate the effect of wrist extension and volar tilt on the contact between the plate and the FPL tendon in a cadaver model. We hypothesized that, following volar plate application, loss of native volar tilt increases the contact between the FPL and the plate at lower degrees of wrist extension. METHODS: A volar locking plate was applied on 6 fresh-frozen cadavers. To determine the contact between the plate and the FPL tendon, both structures were wrapped with copper wire and circuit conductivity was monitored throughout wrist motion. A lateral wrist radiograph was obtained at each circuit closure, indicating tendon-plate contact. Baseline measurements were obtained with plate positioned at Soong grades 0, 1, and 2. An extra-articular osteotomy was made and contact was recorded at various volar tilt angles (+5°, 0°, -5°, -10°, -15°, and -20°) in 3 different plate positions. A blinded observer measured the degree of wrist extension on all lateral radiographs. Data were analyzed using linear mixed-effects regression model. RESULTS: Plates placed distal to the watershed line had the most contact throughout wrist range of motion. Significantly, less wrist extension was required for contact in wrists with neutral or dorsal tilt and in distally placed volar plates. Volar tilt, wrist extension, and plate position were 3 independent risk factors determining contact between plate and tendon. CONCLUSIONS: Loss of volar tilt, increased wrist extension, and higher Soong grade plate position result in greater contact between wire-wrapped FPL tendon and plate. CLINICAL RELEVANCE: The FPL/plate contact chart generated in this study may be used to assess the risk of rupture in the clinical setting.

Transcanal surgical excision of an intracochlear schwannoma.

An intracochlear schwannoma is a rare cause of sensorineural hearing loss, which is little discussed in the literature. This case report details the presentation of a patient with a sensorineural hearing loss due to an intracochlear schwannoma. The patient was initially managed conservatively; however, as her symptoms and serial imaging indicated progression, the lesion was surgically resected via a transcanal/transotic approach. Diagnosis and management of this unusual schwannoma are reviewed.

Overcoming Barriers to Hand Surgical Care in Low-Resource Settings.

There is a growing need for surgical treatment of hand injuries in low- and middle-income countries (LMICs). This rise in disease burden places more pressure on these health care systems that are already struggling to provide access to surgical care for their patients. Hand surgery outreach initiatives have increased in recent years and provide much needed care and relief to these countries. There are significant patient-, physician-, institution-, and infrastructure-related barriers associated with developing an outreach initiative. Understanding these barriers is essential in establishing a successful and meaningful outreach initiative.

Advances in Proximal Interphalangeal Joint Arthroplasty: Biomechanics and Biomaterials.

Proximal interphalangeal (PIP) joint arthritis is a debilitating condition. The complexity of the joint makes management particularly challenging. Treatment of PIP arthritis requires an understanding of the biomechanics of the joint. PIP joint arthroplasty is one treatment option that has evolved over time. Advances in biomaterials have improved and expanded arthroplasty design. This article reviews biomechanics and arthroplasty design of the PIP joint.

The Role of Triangular Fibrocartilage Complex in Axial Stability of the Forearm.

Background The triangular fibrocartilage complex (TFCC) provides stability to the wrist and disruption of this complex can result in axial instability which can lead to ulnocarpal abutment. Purpose This article determines the individual contributions of the volar radioulnar ligament (VRUL), dorsal radioulnar ligament (DRUL), and foveal attachment of the TFCC to longitudinal stability of the forearm under axial load. Materials and Methods Eighteen cadaveric specimens were randomly assigned into three groups representing the component of the TFCC to be initially transected: VRUL, DRUL, and foveal attachment. Prior to transection, posterioranterior radiographs of the wrist were obtained at 0, 44.5, and 90 N of axial load. Serial transection of the TFCC components were performed with radiographs obtained at each of the aforementioned loads. Ulnar variance was assessed with two-way repeated measures analysis of variance and paired t -tests. Results Transection of the foveal attachment demonstrated a significant change in ulnar variance of 1.5 and 0.6 mm under 45 and 90 N of load, respectively. At 0 N of load, there was no significant change in ulnar variance between an intact wrist and a wrist with all three ligaments transected; however, a significant change in ulnar variance, 1.0 mm, was observed under 90 N of load. Conclusion The foveal attachment of the TFCC provides the largest contribution to axial stability. Clinical Relevance The TFCC provides axial stability to the wrist and disruption of the TFCC may result in change in ulnar variance observed on an axial loaded wrist radiograph.

The Effect of Axial Loading on Ulnar Variance.

Background Forearm rotation results in change in ulnar variance. Axial loading of the wrist is required to maintain daily activities. Change in ulnar variance during axial loading has not been investigated previously. Purpose To measure the change in ulnar variance on axially loaded wrists. Patients and Methods We examined 21 asymptomatic individuals and 24 patients with unilateral ulnar-sided wrist pain. All patients underwent standard neutral posteroanterior wrist radiographs without load and under axial loading on bilateral wrists. Axial loading was standardized at 18.1 kgf using an analog weight scale. A magnetic resonance (MR) arthrogram was obtained only in patients with ulnar-sided wrist pain. Beighton flexibility score was recorded on healthy volunteers. Change in ulnar variance between 0 and 18.1 kgf was compared for each wrist among all subjects. A correlation was sought between the change in ulnar variance, MR arthrogram findings, and physical examination. Results In individuals without wrist pain, on average, 0.4 mm increase in ulnar variance was measured between 0 and 18.1 kgf. There was no difference between the dominant and nondominant side. No correlation was found with increasing age. In contrast, patients with ulnar-sided wrist pain displayed an average increase of 0.8 mm in ulnar variance. Compared with the contralateral wrist, more than 1 mm increase in ulnar variance was correlated with intra-articular pathologies including dorsoulnar ligament disruption, central triangular fibrocartilage complex (TFCC) perforation, and foveal detachment. Conclusion Compared with contralateral side, more than 1 mm increase in ulnar variance is suggestive of longitudinal instability or TFCC pathology. Level of Evidence Level II, diagnostic.

Positional Occlusion of an Interposition Vein Graft for Brachial Artery Reconstruction Following Open Elbow Dislocation in a Pediatric Patient: A Case Report.

CASE: We present a case of positional occlusion of the brachial artery after open elbow dislocation and vein graft reconstruction in a pediatric patient. Two years after reconstruction, arterial Doppler studies demonstrated occlusion of the artery; however, an angiogram revealed a widely patent artery. Given the clinical findings of pain and cold intolerance, the patient underwent surgical exploration. Arterial occlusion was found to coincide with elbow flexion. The redundant segment of the basilic vein graft was resected and repaired end-to-end. CONCLUSIONS: Vein graft reconstruction of the brachial artery should be checked for patency in flexion prior to closing the incision. Vein grafts with lengths in excess of a defect may kink in flexion due to redundant graft and the relatively thin walls of veins compared to arteries. This case report emphasizes that an understanding of routine tests is invaluable when eliciting the etiology of contradictory test results.