Antibiotic Treatment for Pyogenic Flexor Tenosynovitis Following Animal Bites.

BACKGROUND: Pyogenic flexor tenosynovitis (PFT) is a common and severe hand infection. Patients who present early can be treated with intravenous antibiotics. OBJECTIVES: To determine whether PFT caused by animal bites and treated with antibiotics leads to a different outcome than other disease etiologies due to the extensive soft tissue insult and different bacterial flora. METHODS: We conducted a retrospective cohort study of 43 consecutive patients who presented with PFT between 2013 and 2020. The 10 patients who presented with PFT following an animal bite were compared to those who presented with PFT caused by any other etiology. RESULTS: Patients who were bitten pursued medical attention sooner: 1.9 ± 1.4 days compared with 5.3 ± 4.7 days (P = 0.001). Despite the quicker presentation, patients from the study group received similar antibiotic types and duration as controls. All patients were initially treated with intravenous antibiotics under surveillance of a hand surgeon. One patient (10%) from the study group and four controls (12%) were treated surgically (P = 1). Average follow-up was 17 ± 16 days. At the end of follow-up, one (10%) patient from the study group and three (9%) controls sustained mild range of motion limitation and one (3%) patient from the control group had moderate limitations (P = 0.855). CONCLUSIONS: Intravenous antibiotic treatment, combined with an intensive hand surgeon follow-up, is a viable option for the treatment of PFT caused by animal bites.

Volar Locking Plating of Extra-articular Distal Radius Fracture: A Retrospective Clinical Study Comparing Locking Screws versus Smooth Locking Pegs.

Background Open reduction and internal fixation of distal radius fractures is one of the most common procedures performed in wrist surgery. The use of volar locking plate has gained increasing interest in the past decade. Epiphyseal fixation can be done either with locking screws or smooth locking pegs, with no evidence supporting the use of one rather than the other. Purpose The aim of this study is to compare the stability of distal radius fixation by volar locking plate using locking screws or smooth locking pegs. Methods Adult patients with A2-A3 AO fractures treated with a volar plate with locking screws only or smooth locking pegs only were retrospectively included. Radiographic assessment was performed to evaluate extra-articular parameters in the intraoperative postreduction and fixation period and after bony healing. Forty-seven distal radius fractures were included. Results Twenty-four fractures had fixation with locking screws and 23 had fixation with smooth locking pegs. For both groups, all radiographic parameters measured showed a statistically significant difference between the intraoperative postreduction and fixation period and the remote postoperative period after union of the fracture ( p < 0.05) attesting a slight loss of reduction. Nevertheless, there were no significant differences between the groups in radiographic extra-articular parameters. Conclusion This clinical study shows that there is no difference in stability fixation between locking screws or smooth locking pegs in A2-A3 distal radius fractures. Clinical Relevance The use of smooth locking pegs only for epiphyseal fixation appears to be safe in volar plating of A2-A3 distal radius fractures in adult patients and could be an alternative to locking screws. More clinical data are needed to confirm these results. Level of Evidence Level III; retrospective comparative study.

A novel pulsed electromagnetic field device as an adjunct therapy to surgical treatment of distal radius fractures: a prospective, double-blind, sham-controlled, randomized pilot study.

INTRODUCTION: The purpose of this study is to evaluate whether using a Fracture Healing Patch (FHP) device that generates pulsed electromagnetic fields (PEMF), applied at the fracture site immediately after open reduction and internal fixation surgery, can accelerate healing of acute distal radius fractures. METHODS: In a prospective, double-blind, randomized, and sham-controlled study, thirty-two patients with DRFs treated with ORIF were included. Patients were allocated to a PEMF (active) group (n = 15) or a control (sham) group (n = 17). All patients were assessed with regard to functional Patient-Rated Wrist Evaluation (PRWE), SF12, and radiological union outcomes (X-rays and computed tomography (CT) scans) at 2, 4, 6, and 12 weeks postoperatively. RESULTS: Patients treated with the FHP demonstrated significantly bone bridging at 4 weeks as assessed by CT (70% vs 54%, p = 0.05). Mean grip strength in the active group was significantly higher as compared to control (16 ± 9 kg vs 7 ± 3.5 kg, respectively, p = 0. 02). The function subscale of the PRWE was significantly better in PEMF-treated group at 6 weeks after surgery (27.2 VS 35.5, p = 0.04). No statistically significant differences were found in SF12. CONCLUSION: PEMF application after ORIF of DRFs is safe, may accelerate bone healing which could lead to an earlier return to daily life activities and work. LEVEL OF EVIDENCE: I.

The "Selfie Test": A Novel Test for the Diagnosis of Lateral Epicondylitis.

Background: Lateral epicondylitis (LE) is one of the most diagnosed elbow pathologies. The purpose of this study was to determine the diagnostic test accuracy of a new test (selfie test) for the diagnosis of LE. Methods: Medical data were collected from adult patients who presented with LE symptoms and ultrasound findings that supported the diagnosis. Patients underwent a physical examination, including provocative tests for diagnosis as well as the selfie test, and were asked to fill out the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire and subjectively rate the activity of their affected elbow. Results: Thirty patients were included in this study (seventeen females, 57%). The mean age was 50.1 years old (range of 35 to 68 years). The average duration of symptoms was 7 ± 3.1 months (range of 2 to 14 months). The mean PRTEE score was 61.5 ± 16.1 (range of 35 to 98), and the mean subjective elbow score was 63 ± 14.2 (range of 30 to 80). Mill's, Maudsley's, Cozen's, and the selfie tests had sensitivities of 0.867, 0.833, 0.967, and 0.933, respectively, with corresponding positive predictive values of 0.867, 0.833, 0.967, and 0.933. Conclusions: The selfie test's active nature, which allows patients to perform the assessment themselves, could be a valuable addition to the diagnostic process, potentially improving the accuracy of the diagnosis of LE (levels of evidence: IV).

The Effects of Novel Pulsed Electromagnetic Field Therapy Device on Acute Distal Radius Fractures: A Prospective, Double-Blind, Sham-Controlled, Randomized Pilot Study.

BACKGROUND: this pilot study aimed at determining whether the application of a novel new method of generating pulsed electromagnetic field (PEMF), the Fracture Healing Patch (FHP), accelerates the healing of acute distal radius fractures (DRF) when compared to a sham treatment. METHODS: 41 patients with DRFs treated with cast immobilization were included. Patients were allocated to a PEMF group (n = 20) or a control (sham) group (n = 21). All patients were assessed with regard to functional and radiological outcomes (X-rays and CT scans) at 2, 4, 6 and 12 weeks. RESULTS: fractures treated with active PEMF demonstrated significantly higher extent of union at 4 weeks as assessed by CT (76% vs. 58%, p = 0.02). SF12 mean physical score was significantly higher in PEMF treated group (47 vs. 36, p = 0.005). Time to cast removal was significantly shorter in PEMF treated patients, 33 ± 5.9 days in PEMF vs. 39.8 ± 7.4 days in sham group (p = 0.002). CONCLUSION: early addition of PEMF treatment may accelerate bone healing which could lead to a shorter cast immobilization, thus allowing an earlier return to daily life activities and work. There were no complications related to the PEMF device (FHP).

Electric Scooter-Related Upper Limb Fractures: Analysis of 458 Cases.

PURPOSE: To perform an analysis of electric scooter (e-scooter)-related upper limb fractures (ULFs), which have increased dramatically in parallel with the rapid rise in the use of e-scooters and shared e-scooter services in recent years. METHODS: We retrospectively reviewed the medical charts of e-scooter-related emergency department visits between January 2017 and January 2020 at a level I trauma center. All patients with ULFs were included in the study, and their data were analyzed for demographics, fracture diagnosis, associated injuries, and required surgical treatment. RESULTS: This study included 356 patients (50% men) with 458 ULFs, of which 23 (5%) were open fractures. The mean age of the cohort was 32.9 years (standard deviation, 10.1 years). The most common mechanism of injury was rider fall (92.1%). The nondominant hand was injured in 53.1% of cases, and 32.1% of all fractures were treated with surgery. A total of 120 (33.7%) patients sustained more than 1 ipsilateral ULF, and 27 (7.6%) patients had a concomitant contralateral ULF. Radial head fracture was the most common fracture type (n = 123, 26.8%), of which 16 (13%) were bilateral. The fifth ray was injured most frequently among the metacarpal and phalangeal fractures (n = 33, 47.1%). Most of the nonextremity-associated injuries were those of the head and maxillofacial bones. CONCLUSIONS: The most common ULF associated with e-scooters was the radial head fracture. Physicians should be alert to and seek associated fractures during initial assessments of e-scooter-related upper limb injuries. Further investigation may be warranted to evaluate the effectiveness of protective measures in reducing the number of injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Rethinking Conservative Treatment of Humeral Diaphyseal Fractures in Elderly Patients With Dementia.

OBJECTIVES: To assess outcomes and complications of conservatively managed humeral diaphyseal fractures in elderly patients, with an emphasis on the subgroup diagnosed with dementia. DESIGN: Retrospective. SETTING: Upper extremity surgery unit at an academic Level I trauma center. PATIENTS/PARTICIPANTS: Consecutive patients 65 years of age and older who were managed conservatively for humeral diaphyseal fractures between 2007 and 2015. INTERVENTION: Conservatively managed humeral diaphyseal fractures. MAIN OUTCOME MEASUREMENTS: Complications and radiographic outcomes. RESULTS: One-hundred twenty-four patients who were conservatively managed for humeral diaphyseal fractures were identified. Their mean age was 77 (65-92) years, 36 (30%) of them were male and 88 (70%) were female. Fifty-seven (46%) patients experienced complications associated with their treatment, and 33 (27%) patients were eventually treated surgically. Seventeen (14%) patients were diagnosed with dementia. This subgroup had 64% fracture-related complications, and all of them were operated (P-value <0.01 compared with age-matched patients among the other 107 participants in the study). CONCLUSION: Conservative management of humeral diaphyseal fractures seems to be associated with greater morbidity in elderly patients, especially in those diagnosed with dementia. Therefore, early surgical treatment should be considered. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

In-hospital production of 3D-printed casts for non-displaced wrist and hand fractures.

OBJECTIVES: To examine the clinical feasibility and results of a multidisciplinary workflow, employing rapid three-dimensional (3D) scanning and modeling software along with a high-speed printer, for in-hospital production of patient-specific 3D-printed casts, for the treatment of non-displaced wrist and hand fractures. METHODS: Consenting adult patients admitted to the emergency department (ED) due to wrist or hand fractures between January and February 2021 were prospectively enrolled. The study participants underwent conversion of the standard plaster of Paris cast to a 3D-printed cast one week after the ED visit, and follow-up examinations were performed around two, six, and twelve weeks later. The primary objective was to examine the clinical feasibility in terms of complexity and length of the overall procedure. Secondary outcomes were patient-reported impressions and radiological results. RESULTS: Twenty patients (16 males, mean age 37 ± 13.1 years) were included. The entire printing workflow took a mean of 161 ± 8 min. All patients demonstrated clinical improvement and fracture union at final follow-up, with no pressure sores or loss of reduction. Patient-reported comfort and satisfaction rates were excellent. The mean Visual Analog Scale was 0.9 ± 1.1 and 0.6 ± 1, and the mean Disabilities of the Arm, Shoulder, and Hand score was 18.7 ± 9.5 and 7.6 ± 7.6 at 2 and 6 weeks after application of the 3D-printed cast, respectively. CONCLUSION: The in-hospital workflow was feasible and efficient, with excellent clinical and radiographic results and high patient satisfaction and comfort rates. Our medical center now routinely provides this cast option for non-displaced wrist and hand fractures. LEVEL OF EVIDENCE: IV, Therapeutic Study.

Wrist arthroscopy for diagnosis and treatment of acute and chronic conditions.

Wrist arthroscopy is a constantly evolving procedure. Allowing direct visualization and dynamic testing of intra-articular structures led to a novel approach toward traumatic and degenerative lesions based on most of the classifications routinely used in wrist surgery. The development of specific instrumentation, combined with a novel understanding of the local anatomy, progressively allowed wrist surgeons to describe more ambitious and complex surgeries. Wrist arthroscopy has become an increasingly useful tool in hand and wrist surgeons' panoply and seems promised to have further development in the future. This paper discusses the surgical technique and the various pathologies that can be treated by arthroscopy of the wrist.

Peri-Implant Olecranon Tip Fracture: Complication of Olecranon Osteotomy Plating.

Several anatomic plates for fixation of the olecranon after a fracture or an osteotomy are commercially available. They serve as an alternative for tension band wiring, which is associated with a relatively high complication rate. Plating of the olecranon reportedly might result in nonunion or malunion and eventually may require revision surgery or plate removal because of skin irritation. The authors describe a proximal periprosthetic avulsion fracture of the tip of the olecranon as a unique complication associated with the use of an anatomic plate for fixation of an olecranon osteotomy. This retrospective case series included 35 patients with comminuted distal humerus fractures treated by open reduction and internal fixation through an olecranon osteotomy with an anatomic olecranon plate. Of the 35 patients, 6 (17.1%) had postoperative olecranon tip fracture, just proximal to the osteotomy site. In all cases, the fracture line coursed through the proximal cluster of screws situated on the proximal part of the plate. Avulsion fractures of the tip of the olecranon after plating of the olecranon osteotomy could have occurred as a result of biomechanical factors. The short design of the proximal part of the plate and the high screw density in the proximal part of the olecranon could lead to increased mechanical stress during contraction of the triceps. This complication should prompt further biomechanical evaluation of the plate design. [Orthopedics. 2021;44(4):e583-e587.].

Radial head excision and Achilles allograft interposition arthroplasty for the treatment of chronic pediatric radiocapitellar pathologies: A report of four cases.

BACKGROUND: Severe radiocapitellar pathologies represent a unique problem in the pediatric population, as radial head excision can lead to substantial long-term complications. We present a case series of four pediatric patients treated by a novel technique-radial head excision followed by Achilles allograft interposition arthroplasty. METHODS: Four children (ages 12-15 years) are described. Their clinical and radiographic outcomes were assessed by a visual analog scale, the Mayo Elbow Performance Score, the Disabilities of the Arm, Shoulder and Hand questionnaire, grip strength, and range of motion. RESULTS: At a mean follow-up of two years, the average flexion-extension arc of motion improved from 107° to 131°, and the rotation arc improved from 100° to 154°. The average visual analog scale, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand scores were 2, 92.5, and 11.5, respectively. Two patients required subsequent additional procedures-manipulation under anesthesia and ulnar shortening osteotomy. Proximal migration of the radius was observed in three out of the four patients. DISCUSSION: Combined radial head excision and Achilles allograft interposition arthroplasty represents a viable option for the treatment of chronic pediatric radiocapitellar pathologies, with good results in terms of clinical and functional outcomes as well as patient satisfaction in the short-medium term.

Manipulation under anesthesia for the postsurgical stiff elbow: a case series and review of literature.

INTRODUCTION: Elbow joint stiffness is a common complication following elbow trauma or surgery. Current practices include first-line treatment with physiotherapy and various types of splints. In cases where early postoperative loss of elbow motion interferes with activities of daily living, manipulation under anesthesia (MUA) is considered a viable treatment option, but there is currently only limited data on the results of this procedure and its complications. MATERIALS AND METHODS: This retrospective study was comprised of 12 consecutive patients who underwent MUA for the treatment of postsurgical elbow stiffness in one institution between 2010 and 2017. Their pre- and post-manipulation range of motion and their functional scores were assessed. RESULTS: MUA was performed at a mean of 52 days (range 39-91 days) following the last surgical intervention, and the patients were followed for a mean of 3 years (range 0.75-7 years). The average flexion-extension arc of motion improved by 53.8°, and the average rotation arc improved by 57°. The average Mayo Elbow Performance Score was 73 (range 0-100) at the latest follow-up. Two patients eventually underwent an open elbow contracture release due to poor post-manipulation results. There were no post-MUA complications. CONCLUSIONS: MUA of a postoperative stiff elbow can improve both flexion-extension and rotatory arc of motion in cases of early evolving postoperative stiffness and should be part of the armamentarium for the treatment of this often debilitating condition.

Repeated closed reduction attempts of distal radius fractures in the emergency department.

INTRODUCTION: Repeated attempts of closed reduction of distal radius fractures (DRF) are performed in the emergency department setting to optimize fracture alignment and avoid surgery. The additional manipulation of the fracture may, however, increase dorsal comminution and lead to loss of reduction in the cast. This retrospective cohort study has investigated the effect of second reduction attempt on fracture alignment and comminution. MATERIALS AND METHODS: Six-hundred-eighteen patients with DRF were treated in the medical center in 2007-2010. Seventy-six (12.3%) DRF who underwent two reductions were included in the study. Radiographs taken after the first and second reduction attempts were reviewed for changes in fracture alignment parameters (radial height, radial inclination, volar tilt) and dorsal comminution length. Patients were also followed retrospectively to determine the rates of secondary displacement in a cast. RESULTS: A second closed reduction attempt improved mean radial height by 1.43 mm, mean radial inclination by 1.62° and mean volar tilt by 8.75°. Mean dorsal comminution length increased by 1.6 mm. Of the 19 (25%) patients with acceptable alignments after two reduction attempts, follow-up radiographs were available for 12, which showed successful reduction in four cases (33.3 or 5.2% of total 76 patients). CONCLUSIONS: A second closed reduction attempt improved immediate fracture alignment, but also worsened dorsal comminution. Only 5.2% of patients who underwent two reduction attempts had an acceptable final alignment and did not require surgery. Increased dorsal comminution may further compromise fracture stability, complicate surgery and have negative effect on the postoperative course.

Hairline fractures following volar plating of the distal radius: a recently recognized hardware-related complication.

OBJECTIVES: Intraoperative hairline longitudinal fractures were recently reported in association with distal radius volar plating. Our aim was to further analyze this newly described complication. METHODS: A retrospective radiographic and chart review was performed on 225 patients who underwent distal radius plating between June 2013 and June 2015. The Acu-Loc/Acu-Loc2© plating system (Acumed, Hillsboro, OR, USA) was used in 208 cases, and the VariAx© plating system (Stryker, Kalamazoo, MI, USA) was used in 17 cases. Three independent reviewers performed a blind evaluation of all relevant radiographs for the occurrence of longitudinal fractures around the plate, and validity was considered only when there was agreement among all three of them. RESULTS: Hairline longitudinal fractures were identified in 57 cases (25%), 55 with the Acu-Loc/Acu-Loc2© system and 2 with the VariAx© system. All fractures occurred with volar plating. Fracture occurrence was associated with age over 59 years, female gender, extra-articular fractures, and the use of Hexalobe screws (Acu-Loc/Acu-Loc2© system). CONCLUSIONS: We believe that the source of fracture occurrence lies within the screw design and that better screw design and possibly tapping in patients at risk may reduce the occurrence of intraoperative hairline longitudinal fractures. Further clinical and biomechanical research is needed to better understand this newly reported complication.

Functional outcome of glenohumeral fusion in brachial plexus palsy: a report of 54 cases.

PURPOSE: The restoration of shoulder function is a major issue in brachial plexus palsy. Although several tendon and nerve transfers have been described, shoulder arthrodesis remains a reliable technique in this context. This study planned to compare surgical and functional outcomes of 2 glenohumeral arthrodesis bone graft techniques: massive subacromial corticocancellous versus cancellous only grafts. METHODS: We reviewed 54 patients who had shoulder arthrodesis according to 2 parameters after a mean follow-up of 37 months. The primary outcome measure was the rate of fusion according to the surgical technique. A total of 26 patients received a massive subacromial corticocancellous bone autograft, and 28 patients received only cancellous bone. The secondary outcome measure was the range of scapulothoracic motion measured by a video-assisted method according to type of neurological lesion. Brachial plexus palsy was complete in 32 cases and partial in 22 cases. All patients had recovered active elbow flexion before undergoing shoulder arthrodesis. Of the 54 patients, 48 had no postoperative immobilization. RESULTS: The overall fusion rate was 76% after the first surgical procedure and 94% at last follow-up. Reoperation led to fusion in 10 cases, whereas 3 cases never fused. Pseudarthrosis rate after first surgery was 4% in the group with massive subacromial graft versus 43% in the group with cancellous bone graft. The mean range of motion was 59° in abduction (57° for complete palsy and 62° for partial palsy) with 42 cases 45° or greater. The mean range of motion was 48° in rotation (50° for complete palsy and 46° for partial palsy) with 35 cases 45° or greater. CONCLUSIONS: Shoulder fusion provided active abduction greater than 45° in more than 75% of cases and active rotation greater than 45° in almost 65% of cases. Using a massive subacromial graft significantly reduced pseudarthrosis rate (P < .001). TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.