Operative treatment of distal radius fractures involving the volar rim-A systematic review of outcomes and complications.

PURPOSE: Distal radius fractures involving the volar rim are a subset of unstable and extremely distal fractures involving the volar lunate and/or scaphoid facets. Volar rim fractures (VRF) are challenging to manage and different treatment options have been described. This study aimed to compare outcomes and assess the rates of complications and implant removal for different treatment methods of wrist fractures involving VRF. METHODS: A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the operative outcomes of VRF. Data on patient demographics, implant usage, postoperative outcomes, complications, and implant removal were compiled. RESULTS: Twenty-six studies met the inclusion criteria with a total of 617 wrists. The most commonly used implants were 2.4 mm variable-angle volar rim plate (DePuy Synthes) (17.5%), Acu-Loc II (Acumed) (14%) and standalone hook plates (13%). The average outcome measures were Q-DASH (10.9 ± 7), MWS (85.8 ± 7.5), PRWE (15.9 ± 12.1), and DASH (14 ± 8.5). The overall complication rate was 14% (n = 87), with 44% (n = 38) involving flexor tendon problems. The implant removal rate was 22%, with routine removal being performed in 54% and non-routine removal in 46% of cases. CONCLUSION: The current treatment of VRF yields favorable functional outcomes across different treatment options. However, these fractures have a high rate of complications and re-interventions, particularly for symptomatic implants. LEVEL OF EVIDENCE: Therapeutic IV.

Circumferential periosteal block versus hematoma block for the reduction of distal radius and ulna fractures: a randomized controlled trial.

PURPOSE: To assess the analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB). METHODS: This study was a prospective single-center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on the severity of pain was analyzed in multivariate regression. Finally, complications and end outcomes were compared across both techniques. RESULTS: Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p = < 0.0001). There were no significant differences between groups at baseline (P = 0.55) and injection (P = 0.40) stages. CONCLUSION: The CPB provides a superior analgesic effect over the conventional HB with no documented complications in either technique. LEVEL OF EVIDENCE: Therapeutic Level II.

Comparison of pain and extent of anesthesia in digital blocks for isolated finger lacerations: A randomized controlled trial.

OBJECTIVES: Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block (SV) technique. Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anesthetized regions. METHODS: This is a single-center prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anesthesia along with the anesthesia onset time. RESULTS: A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5.00] vs. 3.00 [2.00, 4.00], respectively, P = 0.006). However, anesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anesthesia was more predictable in the dorsal block compared to the volar block. CONCLUSION: The single-injection volar subcutaneous blocks are less painful with a similar anesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anesthesia of the region.

Caution against precaution: A case report on silent hypoxia in COVID-19.

INTRODUCTION: Silent hypoxia is an entity that has been described in patients diagnosed with COVID-19. It is typically described as objective hypoxia in the absence of proportional respiratory distress. The physiological basis for this phenomenon is controversial, and its prognostic value is unclear. We present a case below, of a 66-year-old female presenting with severe hypoxia that was managed without mechanical ventilation. PRESENTATION OF CASE: A 66 year old female with multiple comorbidities initially presented with a cough, fever and an oxygen saturation of 70% on room air in the absence of respiratory distress or altered mentation. She subsequently tested positive for COVID-19 and was admitted to the intensive care unit; received oxygen via high flow nasal cannula and continuous positive pressure mask. The patient remained in the intensive care unit for 40 days under close observation and exhibited multiple episodes of silent hypoxia on weaning oxygen. She was discharged on room air with an oxygen saturation >90% after 56 days. The patient was not intubated during her stay. DISCUSSION AND CONCLUSION: Clinicians face a clinical dilemma on whether to intubate a "silently hypoxemic" patient, who displays hypoxia out of proportion to clinical examination. The decision is confounded by a lack of clear evidence on whether the benefits of precautionary intubation outweighs the risks, especially in the current COVID-19 pandemic. A recent paradigm shift that recommends delaying intubation further displays the need for clearer analysis of the situation. Our case demonstrates a favorable outcome of the latter approach, yet emphasizes a case-by-case approach until clearer recommendations are available.