At-Risk Median Motor Branch to the Thenar Musculature Crossing Under the Flexor Carpi Radialis in the Forearm: A Case Report.

CASE: A 77-year-old woman who sustained a distal radius and ulna fracture underwent open reduction internal fixation through a standard flexor carpi radialis (FCR) approach. On dissection, a proximal division of the median nerve was identified, with an aberrant motor branch crossing radial to ulnar deep to FCR and superficial to flexor pollicis longus. CONCLUSION: Although many anatomic variants of the median nerve have been described, the current case demonstrates a particularly important median motor branch variant, imposing a substantial risk of iatrogenic injury during a standard FCR approach.

Intravenous Cefazolin Achieves Sustained High Interstitial Concentrations in Open Lower Extremity Fractures.

BACKGROUND: Infection remains a serious clinical concern in patients with open fractures, despite timely antibiotic administration and surgical debridement. Soft tissue and periosteal stripping may alter local tissue homeostasis and antibiotic pharmacokinetics in the injured limb. The tissue (interstitial) concentration of intravenously administered antibiotics at an open fracture site has not been characterized using direct sampling techniques. QUESTION/PURPOSE: We performed this study to evaluate the concentration and pharmacokinetics of intravenously delivered cefazolin at an open fracture site after surgical debridement. METHODS: Twelve patients with an open fracture distal to the knee who presented at a regional Level I trauma center were approached for enrollment in this nonrandomized, observational study. Of the 12 patients, eight adults (one female, seven male) with a median age of 32 years (range 23 to 51 years) were enrolled and underwent successful sample collection for analysis. Three patients had incomplete datasets because of equipment malfunction and one elected not to participate. Seven patients had open tibia fractures, and one patient had an open fibula fracture associated with a closed tibia fracture. There were six Gustilo-Anderson Type II injuries and two Type IIIA injuries. Empiric antibiotics were administered in the prehospital setting or in the emergency department according to institutional protocol. When patients were taken to the operating room, a 2-g intravenous dose of cefazolin was administered. After surgical debridement, fracture stabilization, and wound closure, a microdialysis catheter was placed transdermally into the injury zone (within 5 cm of the fracture site) and a second catheter was placed in the contralateral uninjured (control) limb. Additional doses of cefazolin were administered every 8 hours postoperatively. Baseline and periodic interstitial fluid and whole blood (plasma) samples were collected in the operating room and at prespecified times for 24 hours postoperatively. Free cefazolin in the interstitial fluid and plasma samples were analyzed by ultra-high-performance liquid chromatography using C 18 column separation with quadrupole time-of-flight mass spectrometry detection. Data from the second postoperative dose of cefazolin were used to characterize pharmacokinetic parameters through a noncompartmental analysis using time-concentration curves of free cefazolin and assuming first-order elimination. For pharmacodynamic analyses, the modal cefazolin minimum inhibitory concentration (MIC) of Staphylococcus aureus (1 µg/mL) was used. RESULTS: With the samples available, no difference was observed in the median free cefazolin exposure over 24 hours ( f area under the curve [AUC] 0→24hrs ) between injured limbs (352 µg∙hr/mL [IQR 284 to 594 µg∙hr/mL]) and uninjured limbs (341 µg∙hr/mL [IQR 263 to 438 µg∙hr/mL]; p = 0.64). The median time to achieve the maximum concentration of free cefazolin ( f T max ) for injured limbs was delayed (2.7 hours [IQR 2.2 to 3.1 hours]) compared with control limbs (1.7 hours [IQR 1.2 to 2.0 hours]; p = 0.046). The time to the maximum concentration for plasma was not different from that of control limbs (p = 0.08). The time the cefazolin concentration was above the modal S. aureus MIC (T > MIC) in the injured and control limbs over 24 hours was 100% (IQR 100% to 100%) and 100% (IQR 97% to 100%), respectively. CONCLUSION: These preliminary findings suggest that current prophylactic cefazolin dosing regimens result in successful antibiotic delivery to the traumatized limb in moderately severe open fractures. Although cefazolin delivery to open-fracture wound beds was delayed compared with healthy tissues, the cefazolin concentration was sustained above the European Union Committee Antimicrobial Susceptibility Testing modal MIC for S. aureus , demonstrating a high likelihood of a prophylactic antimicrobial environment at an open fracture site with this empiric antimicrobial regimen. Importantly, patients in this analysis had Gustilo-Anderson Types II and IIIA injuries. Further research with a larger patient cohort is needed to determine whether antibiotic delivery to traumatized soft tissues in patients with higher-grade open fractures (Gustilo-Anderson Types IIIB and IIIC) demonstrates similar pharmacokinetic characteristics. LEVEL OF EVIDENCE: Level II, therapeutic study.

Overall Safety and Risks Associated with Blood Flow Restriction Therapy: A Literature Review.

INTRODUCTION: Blood flow restriction therapy (BFRT) is used in scenarios ranging from muscle building in athletic performance to decreasing recovery time in postoperative orthopedic rehabilitation. The efficacy of BFRT for treating diseases has been increasingly researched; however, there has been less literature focused on establishing the safety of this therapy. MATERIALS AND METHODS: An extensive literature review pertaining to BFRT and any deleterious events related to its usage was completed by searching multiple databases, including PubMed, EMBASE, and Cochrane Library using the terms "blood flow restriction therapy" or "KAATSU." RESULTS: Ten case reports, five case series, two national surveys, two questionnaires, six randomized controlled studies, and one systematic review were included. A total of 1,672 individuals reported an adverse event following BFRT use out of 25,813 individuals. Commonly reported adverse events were numbness, dizziness, subcutaneous hemorrhage, and rhabdomyolysis. There were unique adverse effects of this therapy reported in individuals with comorbid conditions, such as hypertension and thoracic outlet syndrome, which included isolated cases of central retinal vein occlusion and Paget-Schroeder syndrome. CONCLUSION: Blood flow restriction provides tremendous opportunity with a potential for accelerated exercise rehabilitation and injury prevention. This modality could be used in the military setting to help injured active duty personnel expeditiously return to deployable status. Further prospective randomized controlled trials are warranted to further support BFRT safety; however, from this literature review, it can be concluded that BFRT can be utilized safely in the proper patient population when administered by qualified professionals who have undergone the appropriate training.

Avoiding Complications in Distal Radius Fractures.

SUMMARY: Managing fractures of the distal radius is a fundamental skill for orthopaedic surgeons. Given the prevalence of these fractures, complications following operative management are well described and frequently encountered. Surgeons should be observant in the acute phase for emergent conditions such as acute carpal tunnel syndrome. Careful radiographic examination intra-operatively can help prevent delayed complications by identifying surgical errors such as hardware malposition or malreduction. Many problems that arise during the treatment of distal radius fractures are the result of technical errors and can be anticipated.

Technological Advances in Prosthesis Design and Rehabilitation Following Upper Extremity Limb Loss.

PURPOSE OF REVIEW: The complexity of the human extremity, particularly the upper extremity and the hand, allows us to interact with the world. Prosthetists have struggled to recreate the intuitive motor control, light touch sensation, and proprioception of the innate limb in a manner that reflects the complexity of its native form and function. Nevertheless, recent advances in prosthesis technology, surgical innovations, and enhanced rehabilitation appear promising for patients with limb loss who hope to return to their pre-injury level of function. The purpose of this review is to illustrate recent technological advances that are moving us one step closer to the goal of multi-functional, self-identifiable, durable, and intuitive prostheses. RECENT FINDINGS: Surgical advances such as targeted muscle reinnervation, regenerative peripheral nerve interfaces, agonist-antagonist myoneural interfaces, and targeted sensory reinnervation; development of technology designed to restore sensation, such as implanted sensors and haptic devices; and evolution of osseointegrated (bone-anchored) prostheses show great promise. Augmented and virtual reality platforms have the potential to enhance prosthesis design, pre-prosthetic training, incorporation, and use. Emerging technologies move surgeons, rehabilitation physicians, therapists, and prosthetists closer to the goal of creating highly functional prostheses with elevated sensory and motor control. Collaboration between medical teams, scientists, and industry stakeholders will be required to keep pace with patients who require durable, high-functioning prostheses.

Acute subdural hematoma in an elite-level rugby union player.

Acute subdural hematoma is a rare but potentially fatal medical condition in athletes. This condition has been reported in both contact and non-contact sports. Patients who survive an acute subdural hematoma typically have lifelong deficits and require extensive rehabilitation. Prompt recognition of this condition and access to a hospital with an available neurosurgeon is critical. To our knowledge, this is the first report of a subdural hematoma in an elite-level rugby player.

Characteristics of US combat veterans (2001-2011) who remain on active duty after upper extremity amputations.

OBJECTIVES: Return to duty following traumatic amputations has been extensively studied in those with lower extremity amputation. As upper extremity amputations occur less frequently, the issue of return to duty for those with upper extremity amputations has received relatively little research. The purpose of this study was to determine the rate at which service members remain on active duty at least one year after having sustained traumatic upper extremity amputations during Operation Iraqi Freedom, Operation Enduring Freedom, and other overseas contingency operations of the Global War on Terrorism. DESIGN: Retrospective. SETTING: Military, Academic Level 1 trauma center. PATIENTS: One hundred eighteen patients who sustained combat-related upper extremity amputations between October 2001 and December 2011. INTERVENTION: Data was obtained from the medical record for these 118 patients. MAIN OUTCOME MEASUREMENTS: Percentage of service member remaining on active duty one year following an upper extremity amputation, and evaluation of demographic and injury related factors associated with retention. RESULTS: The overall rate for the upper extremity amputees studied at one year from injury who remained on active duty was 47%. Officers were more likely to remain on active duty than their enlisted counterparts (P=.021) and patients who sustained burns were also more likely to remain on active duty than patients with similar amputation types without concomitant burn injuries (P=.039). CONCLUSIONS: The rate of service members with traumatic upper extremity amputations who were still on active duty status 1-year postinjury was 47%. The presence of burns and rank were significant factors when examining retention on active duty. Further study on war casualties who sustain upper-extremity traumatic amputations with and without burns is required to optimize outcomes in this population.