An Unusual Foreign Object Attached to a Child's Finger: Emergency Department Management and Subsequent Intervention.

ABSTRACT: Strangulation injuries due to foreign objects are uncommon presentations of hand and finger injuries presenting to the emergency department (ED). Ring avulsion and hair tourniquet injuries are more commonly recognized mechanisms of strangulation, and algorithms for subsequent management and emergent treatment exist for these injuries. It is important to distinguish between hand injuries that can be managed in the setting of the ED and those that need emergent surgical management upon patient presentation. Nonemergent presentations of finger injuries include metallic bands or other objects trapped on digits without signs of neurovascular compromise. A 2-year-old girl presented to our ED with her right index finger trapped within a stainless steel salt shaker (2.55 in. H × 3.5 in. W × 4.9 in. D). The distal aspect of the digit was unable to be visualized, and communication with the patient was difficult secondary to distress and young age. Multiple attempts were made to remove the object in the ED by multiple health care providers, when concern for degloving injury prompted the patient to be taken to the operating room for removal with an electric saw by the hand surgeon and orthopedic team.

Restoring Isometry in Lateral Ulnar Collateral Ligament Reconstruction.

PURPOSE: To ascertain whether placing the humeral attachment of the lateral ulnar collateral ligament (LUCL) at the humeral center of rotation (hCOR) on the humerus would provide the most isometric reconstruction. METHODS: We analyzed 13 cadaver limbs from mid-humerus to the hand. The morphology of the ligament complex was assessed. The hCOR was then found using radiographic parameters. We chose 7 points on the humerus located at and around the hCOR and 3 points paralleling the supinator crest of the ulna and then calculated distances from these points using a digital caliper at 0°, 30°, 60°, 90°, and 130° flexion. Differences in potential ligamentous lengths (termed graft elongation) were then calculated and statistical analysis was performed. RESULTS: There was no perfectly isometric point along the humerus or ulna. However, in all specimens the hCOR was the most isometric point for the humeral reconstruction site, with an average graft elongation of 1.1 mm. Differences in humeral tunnel position dramatically affected graft elongation at all 3 ulnar insertions. Overall, ulnar position had a minimal effect on graft elongation. CONCLUSIONS: Although no perfectly isometric points were found, the humeral center of rotation consistently reproduced the most isometry when assessing graft elongation over range of motion. These data may assist surgeons in proper tunnel placement in LUCL reconstruction. CLINICAL RELEVANCE: In LUCL reconstruction, the humeral tunnel should be placed as close as possible to the center of rotation, whereas placement on the ulna is less critical.

Arthroscopic Management of Subspinous Impingement in Borderline Hip Dysplasia and Outcomes Compared With a Matched Cohort With Nondysplastic Femoroacetabular Impingement.

BACKGROUND: Arthroscopic management of femoroacetabular impingement (FAI) in the setting of borderline hip dysplasia is controversial. Recently, there has been increased awareness of a prominent anterior inferior iliac spine (AIIS) resulting in subspinous impingement. PURPOSE/HYPOTHESIS: The purpose was to report outcomes of arthroscopic subspinous decompression in patients with symptomatic hip impingement and borderline hip dysplasia compared with a matched cohort with nondysplastic FAI. Addressing a prominent subspinous region and cam/pincer lesion in the borderline dysplastic hip may lead to favorable outcomes comparable with those of patients undergoing arthroscopic management of nondysplastic FAI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients with symptomatic hip impingement, borderline dysplasia (lateral center-edge angle [LCEA], 18°-24°), and prominent AIIS (BDSI group) whose nonoperative management failed and who subsequently underwent arthroscopic subspinous decompression were retrospectively identified. Three-dimensional computed tomography imaging was used to categorize AIIS morphology into type 1, 2, or 3 (Hetsroni classification). Patient-reported outcome (PRO) scores consisting of the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at an average of 44 months postoperatively (range, 23-61 months). Exclusion criteria were Tönnis osteoarthritis grade >1 and a history of previous hip procedures. An age-, sex-, and body mass index-matched cohort of patients without dysplasia (LCEA, >25°) who underwent arthroscopic FAI surgery with a minimum 2-year follow-up were selected to serve as the control group. RESULTS: Eighteen patients, 19 hips (14 women and 4 men; average age, 28 years) were included. Of the 19 hips in the BDSI group, the average LCEA and alpha angle were 21.8° and 66.2°, respectively; 14 hips were Hestroni type 2, and 5 hips were type 1. There were no postoperative complications or additional procedures performed since the last follow-up. Repeated-measures analysis of variance revealed a significant improvement in all PRO scores from preoperatively to the last follow-up: mHHS, 64.7 to 87.7 (P < .001); HOS-ADL, 62.1 to 92.1 (P < .001); HOS-SSS, 26.5 to 87.1 (P < .001). An analysis of covariance revealed that patients with type 2 AIIS had a significantly higher postoperative mHHS than those with a type 1 morphology (88.3 and 95.6, respectively; P < .01) The BDSI group had a significantly lower preoperative HOS-SSS (26.5; P < .001) in comparison with the control group. However, there was no significant difference in postoperative outcome scores between groups. The BDSI group underwent significantly more microfracture, capsular plication, and ligamentum teres debridement (15.8%; P = .04). CONCLUSION: Arthroscopic AIIS decompression in patients with coexisting borderline dysplasia and subspinous impingement is a safe and effective method of treatment that produces outcomes comparable with those of a cohort with nondysplastic FAI.

Ultrasound Evaluation for Incomplete Carpal Tunnel Release.

Background: Ultrasound can provide evaluation of the anatomy of the carpal tunnel in a convenient, noninvasive office setting. This study is intended to determine the accuracy and diagnostic performance of ultrasound, used by surgeons, for the evaluation of completeness of carpal tunnel release (CTR). Methods: Ten cadaver arms underwent randomized sectioning of 0%, 25%, 50%, 75%, or 100% of the transverse carpal ligament. Following a brief training session, a blinded observer used ultrasound to evaluate the percentage of the transverse carpal ligament release. The release amount was then confirmed with an open exposure of the transverse carpal ligament. Results: Cronbach α and Pearson correlation coefficients were 0.92 and 0.87, demonstrating excellent reliability and validity of the technique. Diagnostic performance including sensitivity, specificity, positive predictive value, and negative predictive value was 100%, 75%, 86%, and 100%, respectively, for the diagnosis of incomplete release of the transverse carpal ligament by a novice sonographer orthopedic surgeon. Conclusions: The ultrasound is a highly accurate tool for the diagnosis of incomplete transverse carpal ligament release and requires a minimal amount of training to use for this purpose. It provides a rapid means of diagnosing incomplete release of the transverse carpal ligament following CTR.

Single-Bundle vs Double-Bundle (Anatomical) Reconstruction of the Thumb Ulnar Collateral Ligament: Biomechanical Study.

Background: The goal of this study is to compare the biomechanical properties of anatomic (double-bundle) versus single-bundle reconstruction of the thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) in a cadaveric model. Methods: Twelve fresh frozen cadaver hands were randomly assigned to single- or double-bundle reconstruction groups using a palmaris longus autograft and tenodesis screws. Two blinded examiners performed mechanical testing and measurements using fluoroscopic imaging. We evaluated MCP joint congruence and angle in the coronal plane at 0°, 30°, and 60° of flexion with valgus loads of 1.36 and 2.72 kg. Maximum MCP flexion and extension with a 0.45 kg load was also measured. Results: There was no significant difference between single- versus double-bundle reconstruction in ulnar congruence or MCP angle. With varying amounts of flexion, there was no significant difference in MCP valgus angle between the 2 techniques, suggesting comparable joint congruity and coronal MCP angle along the arc of thumb MCP motion. Conclusions: Single- and double-bundle UCL reconstructions of the thumb MCP joint have comparable biomechanical properties in regard to joint congruity under valgus load.

Ulnar Nerve Management with Distal Humerus Fracture Fixation: A Meta-Analysis.

Ulnar nerve dysfunction following distal humerus fractures is a well-recognized phenomenon. There is no consensus regarding optimal handling of the ulnar nerve during surgical management of these fractures between in situ management and transposition. Using an electronic database to identify retrospective studies involving surgical fixation of distal humerus fractures yielded 46 studies, 5 trials meeting the authors' inclusion criteria, totaling 362 patients. An overall incidence of 19.3% for ulnar neuropathy was identified. Of those patients undergoing in situ release, the incidence was 15.3%. Of those who underwent transposition, there was a 23.5% incidence of ulnar neuropathy.

Radiographic Patterns of Radiocarpal and Midcarpal Arthritis.

INTRODUCTION: The purpose of this study was to determine the specific locations of radiocarpal and/or midcarpal joint osteoarthritis (RC/MC OA). METHODS: A total of 1,007 wrist radiographs were screened for the presence of RC/MC OA. The locations of the degenerative changes were identified. In addition, the observers then determined whether the observed patterns fell under the scapholunate advanced collapse (SLAC) pattern. RESULTS: The SLAC pattern did not represent the majority of observed degenerative changes. Almost one-third of the patients had degenerative changes present at the radiolunate or scaphocapitate articulations in the absence of radioscaphoid changes. Women have a lower risk of arthritis compared with men (odds ratio, 0.306; P < 0.05). Increasing age correlated with the presence of arthritis (odds ratio, 1.05; P < 0.05). CONCLUSION: Contrary to the previous reports in the literature, our cohort demonstrated that <50% of wrist OA fell into the category of SLAC arthritis.

Flexor Carpi Radialis to Palmaris Longus Tendon Transfer for Spontaneous Rupture of the Flexor Carpi Radialis Tendon-A Review of an Uncommon Finding and Surgical Technique for Operative Correction.

Spontaneous ruptures of the flexor carpi radialis tendon (FCR) are rare and associated with systemic inflammatory diseases, localized tendinopathy related to scaphotrapezial-trapezoidal arthritis, or chronic immunosuppression from corticosteroids. While most cases do not require operative intervention, some patients develop weakness, impaired range of motion, and persistent pain. Previously reported surgical options include synovectomy, tendon stump resection, and osteophyte removal. We describe a surgical technique for patients with persistent symptomatology following FCR rupture in which the FCR is transposed end-to-side to the palmaris longus tendon. Three cases using this technique are presented with follow-up of 4-9 months that were collected at Lenox Hill Hospital. All three patients did well regarding specific outcome measures: grip strength, range of motion, and functional activity. FCR transfer to palmaris is an alternative to other surgical options for the spontaneous rupture of the FCR tendon in patients who remain symptomatic despite a course of non-operative therapy.