Acute-Phase Reactants in Operatively Treated Upper Extremity Infections: A Retrospective Review.

Background: There are limited data on the use of acute-phase markers in the diagnosis of upper extremity infections. The goal of this study was to determine the percentage of patients with elevated white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) in the setting of an upper extremity infection requiring operative debridement. Methods: In a retrospective review over 12 years, 61 patients who met the inclusion criteria were identified. Results: C-reactive protein was the most sensitive test in the detection of culture-positive infection compared with ESR and WBC (P < .001, P < .0001, respectively). Ninety percent of patients (55 of 61) presented with an abnormal CRP value. The WBC count and ESR were abnormal in 54% and 67% of our cohort, respectively. Conclusions: C-reactive protein is the most sensitive laboratory test when evaluating upper extremity infections that necessitate debridement. The WBC count and ESR should be interpreted with caution and can be normal even in the presence of an infection.

Failed Extensor Tendon Repairs: Extensor Tenolysis and Reconstruction.

Extensor tendon injuries are common and require a complex treatment strategy to appropriately manage them, including initial repair, revision/reconstruction options, and postoperative protocols. Intrinsic and extrinsic components of the extensor mechanism contribute to a complex anatomic apparatus but also allow for numerous reconstructive options. Tenolysis, tendon grafting, and local tissue reconstruction are all options that can be used to treat complex extensor tendon injuries, but the type of repair is dependent on which of the eight extensor zones and accompanying structures are injured. To adequately assess and treat these injuries, a working knowledge of the anatomy, reconstructive techniques, and rehabilitation is imperative.

Electrical Injuries of the Hand and Upper Extremity.

High-voltage electrical injuries are relatively rare injuries that pose unique challenges to the treating physician, yet the initial management follows well-established life-saving, trauma- and burn-related principles. The upper extremities are involved in most electrical injuries because they are typically the contact points to the voltage source. The amount of current that passes through a specific tissue is inversely proportional to the tissue's intrinsic resistance with electricity predominantly affecting the skeletal muscle secondary to its large volume in the upper extremity. Therefore, cutaneous burns often underestimate the true extent of the injury because most current is through the deep tissues. Emergent surgical exploration is reserved for patients with compartment syndrome; otherwise, initial débridement can be delayed for 24 to 48 hours to allow tissue demarcation. Early rehabilitation, wound coverage, and delayed deformity reconstruction are important concepts in treating electrical injuries.

Surgical Management of the Posttraumatic Stiff Elbow: A Step-Wise Algorithm for Open Osteocapsular Release.

Posttraumatic elbow stiffness is common with the primary indication for contracture release being limited motion that affects functional activities which has not adequately improved after intensive therapy and rehabilitation. Preoperative evaluation focuses on the history of previous nonoperative and/or operative treatment, physical exam with particular attention paid to the status of the ulnar nerve, and imaging consisting of radiographs and computed tomography. There are multiple intrinsic and extrinsic causes of posttraumatic contracture. In general, limitation of motion in one direction can be attributed to a mechanical block and/or opposing contracture or tightness. Open elbow contracture release has been shown to improve motion, patient health status and disability scores with the specific surgical approach based upon the contracture pathology and surgeon preference. A step-wise algorithm is presented for open osteocapsular release. An anterior and posterior release is performed first through a lateral approach with the addition of a medial approach if ulnar nerve dysfunction exists or inadequate release has been obtained from the lateral approach. A previous posterior incision can be utilized by raising full thickness flaps. After release, gentle manipulation is performed and intraoperative stability is assessed with stress testing under fluoroscopy. Postoperatively, pain is managed with an in-dwelling nerve catheter and rehabilitation commences immediately. Significant improvement in range of motion can be expected with adequate surgical release and postoperative rehabilitation.

Opioid Use After Upper Extremity Surgery.

Ever since the institution of pain as the fifth vital sign, there has been a rising opioid epidemic in the United States, with Americans now consuming 80% of the global opioid supply while representing only 5% of the world's population. Surgeons are tasked with the duty of both managing patients' pain in the perioperative period and following responsible prescribing behaviors. Several articles have been published with the goal of evaluating opioid use after upper extremity surgery, risk factors for opioid misuse/abuse, the impact of anesthetic type, and the role of multimodal pain management regimens. These studies have found that, on average, surgeons prescribe 2 to 5 times more opioids than patients consume. Multimodal pain management strategies are effective for decreasing postoperative opioid consumption. Risk factors for prolonged opioid use and/or misuse are younger age, history of substance abuse, psychological disorders, and previous pain diagnoses. Use of regional blockade anesthesia, particularly with long-acting agents or indwelling catheters, can be helpful in the management of postoperative pain. This review article summarizes the available literature regarding opioid use after upper extremity surgery to provide the surgeon with additional information to make informed decisions regarding postoperative opioid prescription.

Acquired Upper Extremity Growth Arrest.

This study reviewed the clinical history and management of acquired growth arrest in the upper extremity in pediatric patients. The records of all patients presenting from 1996 to 2012 with radiographically proven acquired growth arrest were reviewed. Records were examined to determine the etiology and site of growth arrest, management, and complications. Patients with tumors or hereditary etiology were excluded. A total of 44 patients (24 boys and 20 girls) with 51 physeal arrests who presented at a mean age of 10.6 years (range, 0.8-18.2 years) were included in the study. The distal radius was the most common site (n=24), followed by the distal humerus (n=8), metacarpal (n=6), distal ulna (n=5), proximal humerus (n=4), radial head (n=3), and olecranon (n=1). Growth arrest was secondary to trauma (n=22), infection (n=11), idiopathy (n=6), inflammation (n=2), compartment syndrome (n=2), and avascular necrosis (n=1). Twenty-six patients (59%) underwent surgical intervention to address deformity caused by the physeal arrest. Operative procedures included ipsilateral unaffected bone epiphysiodesis (n=21), shortening osteotomy (n=10), lengthening osteotomy (n=8), excision of physeal bar or bone fragment (n=2), angular correction osteotomy (n=1), and creation of single bone forearm (n=1). Four complications occurred; 3 of these required additional procedures. Acquired upper extremity growth arrest usually is caused by trauma or infection, and the most frequent site is the distal radius. Growth disturbances due to premature arrest can be treated effectively with epiphysiodesis or osteotomy. In this series, the specific site of anatomic growth arrest was the primary factor in determining treatment. [Orthopedics. 2017; 40(1):e95-e103.].

Functional Outcomes After Operative Management of Extra-Articular Glenoid Neck and Scapular Body Fractures.

BACKGROUND: This study's purpose was to assess patient-based functional outcomes following open reduction and internal fixation (ORIF) of displaced scapular body and glenoid neck fractures. This series represents a 9-year experience at a level-I trauma center and referral destination for this injury. METHODS: A database was established to record surgical and functional outcomes of scapular fractures treated with ORIF. For this report, the cases of all patients who had a glenoid neck or scapular body fracture (AO/OTA 14-A3 or 14-C1) without intra-articular involvement were reviewed. Operative indications included medial/lateral displacement of ≥20 mm, angulation of ≥45°, medial/lateral displacement of ≥15 mm with angulation of ≥30°, double disruptions of the superior shoulder suspensory complex with both displaced ≥10 mm, a glenopolar angle of ≤22°, and an open fracture. The results of clinical testing, including measurements of range of motion and strength and scores on the Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) questionnaires, were recorded at each follow-up appointment. RESULTS: Between 2002 and 2011, 61 patients with an extra-articular scapular fracture were treated surgically within 20 days after the injury; 19 patients (31%) had ≥2 operative indications. Of the 61 patients, 49 (80%) were followed for ≥1 year (mean, 33 months; range, 12 to 138 months) following surgery. There was a 100% union rate at the time of final follow-up, with a mean DASH score of 12.1 points (range, 0 to 54 points). For all parameters, the mean SF-36 scores of the study patients were comparable with normative population scores. The range of motion of the operatively treated and contralateral shoulders averaged, respectively, 154° and 159° of forward flexion, 106° and 108° of abduction, and 66° and 70° of external rotation. The strength of the operatively treated and contralateral shoulders averaged, respectively, 20 and 23 lb (89.0 and 102.3 N) of force in forward flexion, 14 and 16 lb (62.3 and 71.2 N) in abduction, and 19 and 23 lb (84.5 and 102.3 N) in external rotation. Complications and/or secondary surgery were recorded for 8 patients (16%). CONCLUSIONS: Displaced scapular body and glenoid neck fractures that meet current published standards for ORIF can be treated operatively with predictably good functional outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes after operative management of symptomatic rib nonunion.

OBJECTIVE: To report the outcomes of rib reconstruction after painful nonunion. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Between November 2007 and May 2013, 10 patients who presented with 16 rib nonunions and disabling pain were treated with reconstruction of their nonunited rib fractures. INTERVENTION: Rib nonunion reconstruction predominately with iliac crest bone graft and a tension band plate with a locked precontoured plating system for ribs. MAIN OUTCOME MEASUREMENTS: Demographic data, mechanism of injury, and number of rib nonunions were recorded. Operative procedure, length of follow-up, complications, Short Form Survey 36, and a patient questionnaire were also captured and documented. RESULTS: Eight of the 10 patients sustained their original fractures from a fall. Outcomes were available for the 10 patients at a mean follow-up of up of 18.6 months (range, 3-46 months). All 16 ribs went on to union with a mean time from reconstruction to union of 14.7 weeks (range, 12-24 weeks). At final follow-up, the mean mental and physical component Short Form Survey 36 scores were 54.4 and 43.5, respectively. Eight of the 10 patients were able to return to work and/or previous activities without limitations. Complications included 1 wound infection that resolved after irrigation and debridement with adjunctive antibiotics. One symptomatic implant was removed. CONCLUSIONS: Ten patients with 16 symptomatic rib nonunions were reconstructed using autologous bone graft and implant/mesh fixation manifesting in successful union with improved patient function and a low rate of complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pre- and postoperative function after scapula malunion reconstruction: a novel kinematic technique.

This report describes a novel kinematic analysis technique that was used to assess a floating shoulder malunion before and after corrective osteotomy. The patient underwent this analysis pre- and postoperatively using electromagnetic motion sensors and monitoring software. Pre- and postoperative motion curves were compared with normal subject data to determine if shoulder girdle movement was more or less similar to subjects without any shoulder pathology. Additionally, strength, range of motion, and patient-based questionnaires, including DASH and SF-36, were obtained. The preoperative DASH score was 30 and decreased to 3 in 18 months after surgery. Kinematic analysis demonstrated improved postoperative resting position of the scapula and motion patterns more consistent with healthy subject data.

Surgical and functional outcomes after operative management of complex and displaced intra-articular glenoid fractures.

BACKGROUND: Operative treatment is indicated for displaced fractures of the glenoid fossa. However, little is known regarding functional outcomes in these patients. This study assesses surgical and functional results after treatment of displaced, high-energy, complex, intra-articular glenoid fractures. METHODS: Thirty-three patients with displaced intra-articular fractures of the glenoid were treated surgically between 2002 and 2009. The indications for operative treatment included articular fracture gap or step-off of ≥ 4 mm. Twenty-five patients also had extra-articular scapular involvement. A posterior approach was utilized in twenty-one patients, an anterior approach in seven, and a combined approach in five. Functional outcomes, including Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores, shoulder motion and strength, and return to work and/or activities, were obtained for thirty patients (91%). RESULTS: At a mean follow-up of twenty-seven months (range, twelve to seventy-three months), all patients had radiographic union of the fracture. The mean DASH score was 10.8 (range, 0 to 42). All mean SF-36 subscores were comparable with those of the normal population. Twenty-six patients (87%) were pain-free at the time of follow-up, and four had mild pain with prolonged activity. Twenty-seven (90%) of thirty patients returned to their preinjury level of work and/or activities. CONCLUSIONS: Our data suggest that surgical treatment for complex, displaced intra-articular glenoid fractures with or without involvement of the scapular neck and body can be associated with good functional outcomes and a low complication rate.

Management of scapular fractures.

With the exception of displaced articular glenoid fractures, management of scapular fractures has largely consisted of benign neglect, with an emphasis on motion as allowed by the patient's pain. Better understanding of this injury has resulted in greater acceptance of surgical management of highly displaced variants. However, little agreement exists on indications for surgery, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures. Scapular fractures are the result of high-energy mechanisms of injury, and they often occur in conjunction with other traumatic injuries. In addition to performing meticulous physical and neurologic examination, the surgeon should obtain plain radiographs, including AP shoulder, axillary, and scapular Y views. Three-dimensional CT is used to determine accurate measurements in surgical candidates. Surgical approach, technique, and timing are individualized based on fracture type and other patient-related factors.

Anterior pelvic external fixator versus subcutaneous internal fixator in the treatment of anterior ring pelvic fractures.

OBJECTIVES: To compare the short-term results of anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) applied subcutaneously in the context of surgical treatment of pelvic ring injuries. DESIGN: A single center retrospective chart review. SETTING: A level 1 trauma center. METHODS: A consecutive series of 48 patients who underwent surgical stabilization of their anterior pelvic ring (24 utilizing APIF and 24 utilizing APEF) by 2 surgeons at a single hospital were studied. The choice to use either APEF or APIF was left up to each surgeon, the indications for use are the same. Data collected included surgical or postoperative complications including infection, implant failure, reoperation, documented surgical site pain persisting to clinical follow-up visits, and radiographic union. Measurements on inlet and outlet pelvic radiographs were made immediately postoperation and at all follow-up clinic visits to determine whether there were differences in maintaining pelvic fracture reduction. Statistical analysis was performed to evaluate significant differences between the 2 groups with regard to each of these variables. RESULTS: The APIF group was found to have a significantly lower incidence of wound complication (P < 0.05) and a lower occurrence of associated morbidity events as compared with the APEF group. In addition, the APIF group was found to have a significantly lower rate of surgical site pain persisting through all clinical follow-up intervals (P = 0.05). There was no difference between the 2 groups in terms of maintenance of pelvic reduction in the early postoperative phase or at final follow-up. No other significant differences were observed between the 2 groups. CONCLUSIONS: The present study, which was based on our initial experience with the subcutaneous anterior pelvic fixator, demonstrated encouraging clinical outcomes in terms of a lower wound complication rate and associated morbidity, and surgical site symptoms, although maintaining equivalent reduction. These findings suggest that further analysis of this technique is warranted to determine if it can be definitively recommended for general use. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radiographic follow-up of 84 operatively treated scapula neck and body fractures.

BACKGROUND: Certain scapula fractures may warrant surgical management to restore shoulder anatomy and promote optimal function. The purpose of this study is to determine the early radiographic follow-up of open reduction internal fixation (ORIF) for displaced, scapular fractures involving the glenoid neck and body. METHODS: Eighty-four patients with a scapula body or neck fracture (with or without articular involvement) underwent ORIF between 2002 and 2010 at a single level I trauma centre. This study represents a retrospective review of data prospectively collected into a dedicated scapula fracture database. All patients met at least one of the following operative criteria: ≥20 mm medial/lateral (M/L) displacement (lateral border offset), ≥45° of angular deformity on a scapular-Y X-ray, the combination of angulation ≥30° plus M/L displacement ≥15 mm, double disruptions of the superior shoulder suspensory complex both displaced ≥10 mm, glenopolar angle (GPA) ≤22° and open fractures. Eighty-eight percent (74/84) had sufficient follow-up defined as at least 6 months. Measured outcomes included rates of scapula union and malunion, as well as surgical complications and re-operations. RESULTS: All fractures were caused by high-energy trauma with 24 (29%) resulting from motor-vehicle collisions. Associated injuries occurred in 94% of patients, most commonly involving the chest (70%) and ipsilateral shoulder girdle (43%). Forty-eight patients had M/L displacement as an operative indication with a mean displacement of 25.7 mm (range=20-40). Thirty-eight (45%) had ≥2 operative indications. A single surgeon performed ORIF in all patients using a posterior approach. Five patients also required an anterior (deltopectoral) approach. The fixation strategy included lateral and vertebral border stabilisation with dynamic compression and reconstruction plates, respectively. Union was achieved in all cases. There were three cases of malunion based on a GPA difference >10° from the uninjured shoulder. Re-operations included removal of hardware (seven patients) and manipulation under anaesthesia (three patients). There were no infections or wound dehiscence. CONCLUSIONS: ORIF for displaced scapula fractures is a relatively safe and effective procedure for restoration of anatomy and promotion of union. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Surgical technique: a minimally invasive approach to scapula neck and body fractures.

BACKGROUND: The approach of choice for open reduction internal fixation of displaced fractures involving the scapula neck or body is from posterior. We describe a new approach that minimizes the surgical insult to the soft tissues but preserves the ability to restore alignment and stability to the fracture. DESCRIPTION OF TECHNIQUE: Based on the fracture pattern, incisions are made along the anatomic bony perimeter to access the scapula borders for reduction and fixation. Since the incisions are centered over sites of "perimeter" fracture displacement of this relatively flat bone, minimal soft tissue retraction and less muscular stripping are necessary, while indirect reduction of the intervening scapula body is accomplished to restore anatomic alignment. PATIENTS AND METHODS: We retrospectively reviewed seven men with a mean age of 39 years (range, 19-75 years) who underwent open reduction internal fixation of a displaced scapula body or neck fracture using this minimally invasive approach. The minimum followup was 12 months (mean, 16 months; range, 12-23 months). RESULTS: Six of the seven patients returned to their original occupation/activities. The mean Disabilities of the Arm, Shoulder and Hand score at followup was 8.1 (range, 0-52; normative mean, 10.1). For all parameters, the mean SF-36 scores of the study patients were comparable to those of the normal population. Both strength and motion returned to equivalency with the uninjured shoulder. There were no intraoperative or postoperative complications. CONCLUSIONS: This novel surgical approach to the scapula allows visualization of fracture reduction without an extensile incision or muscular or subcutaneous flaps and was associated with high functional scores. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.