Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial.

INTRODUCTION: The majority of fifth metacarpal neck fractures (boxers fracture) are treated conservatively without surgery. The purpose of this prospective, randomized, multicenter trial was to determine if the outcomes of soft wrap and buddy taping (SW) was noninferior to reduction and cast (RC) in boxer's fracture with palmar angulation ≤70° and no rotational deformity. MATERIALS AND METHODS: Sixty-eight patients with similar characteristics were prospectively enrolled and randomized at four institutions. Our primary outcome was measured by the shortened Disabilities of the Arm, Shoulder and Hand (quickDASH) questionnaire at 4 months. Noninferiority was claimed if there was no more than +10 points difference in the quickDASH. Other secondary radiographic and clinical outcomes were measured. RESULTS: At 4 months, mean difference in the quickDASH between the two groups was -10.4 (95 % confidence interval, -27.0; +6.2) which was under the pre-specified margin. There was no significant difference between both groups' secondary outcomes of pain, satisfaction with the esthetic appearance, mobility of the metacarpophalangeal-joint at flexion and extension, or power grip. Increased fracture angulation, as measured on follow-up radiographs, was not significantly different between both groups. The degree of palmar fracture angulation was not related to work leave or profession. Duration of time off from work was 11 days shorter in SW compared to RC (P = 0.03). CONCLUSION: This study supports the use of soft wrap and buddy taping for treatment of boxer's fracture with palmar angulation ≤70° and no rotational deformity. Although there was no statistical difference in satisfaction with the esthetic appearance, the patient must be willing to accept the loss of the "knuckle" with this treatment method.

Anthropometry of the Human Scaphoid Waist by Three-Dimensional Computed Tomography.

Published measurements for the scaphoid are scarce. The purpose of this study is to define anthropometric norms for the waist of the scaphoid to assist in optimizing bone graft quantity and implant use. Computed tomography images of the wrist were reviewed by three surgeons. Anthropometric data were gathered, including the scaphoid waist diameter in two dimensions and the scaphoid waist volume. Each study was measured twice, allowing for determination of inter- and intraobserver reliability. Forty-three studies were examined (23 female and 20 male). Average measurements of the scaphoid waist were 11.28 ± 0.26 mm in the sagittal plane and 8.70 ± 0.17 mm in the coronal plane, and the waist volume was 715 ± 33.0 mm3. Specific measures of the narrowest portion of the scaphoid are provided by this study. Measurements of the scaphoid waist through the use of three-dimensional imaging are an accurate method with good inter- and intraobserver reliability. The measurements obtained from this study can be applied to guide graft and implant selection for treatment of scaphoid waist fractures and nonunions.

Treatment of split-thickness skin graft-related forearm scar contractures with a carbon dioxide laser protocol: 3 case reports.

Split-thickness skin grafts in the forearm can lead to motion restriction and disability through the dense scarring of the skin and formation of graft-tendon adhesions. Three patients were referred for laser treatment of motion-limiting scar-associated split-thickness skin grafts to the forearm. All patients had reached a plateau in range of motion despite aggressive hand therapy and underwent serial laser scar treatments at 6- to 8-week intervals. Treatments were performed in a clinic setting and were initiated 2 to 5 months after reconstructive surgery. Rapid subjective functional and objective improvements in range of motion were noted after laser therapy. Results were cumulative and durable at final follow-up ranging from 10 to 15 months after the initial treatment. No complications were noted. Fractionated carbon dioxide laser therapy is a promising adjunct to hand therapy when the main restraint to motion is superficial skin scarring and skin-tendon adhesions.

Hand infections.

Hand infections are commonly seen by orthopedic surgeons as well as emergency room and primary care physicians. Identifying the cause of the infection and initiating prompt and appropriate medical or surgical treatment can prevent substantial morbidity. The most common bacteria implicated in hand infections remain Staphylococcus aureus and Streptococcus species. Methicillin-resistant S aureus infections have become prevalent and represent a difficult problem best treated with empiric antibiotic therapy until the organism can be confirmed. Other organisms can be involved in specific situations that will be reviewed. Types of infections include cellulitis, superficial abscesses, deep abscesses, septic arthritis, and osteomyelitis. In recent years, treatment of these infections has become challenging owing to increased virulence of some organisms and drug resistance. Treatment involves a combination of proper antimicrobial therapy, immobilization, edema control, and adequate surgical therapy. Best practice management requires use of appropriate diagnostic tools, understanding by the surgeon of the unique and complex anatomy of the hand, and proper antibiotic selection in consultation with infectious disease specialists.

Two unusual cases of coronal lunate fracture.

Volar lunate fractures are rare injuries, usually seen as a result of high-energy trauma and often in association of other carpal injuries. We present 2 unusual cases of coronal volar lunate fractures. The first case involved a proximal pole scaphoid fracture in association with a volar lunate fracture. During surgical exposure, the lunate fracture was found to be rotated 180 degrees volarly. This displaced lunate fracture, although appearing small on radiographs, consisted of the entire volar half of the capitate facet of the distal lunate. Both the scaphoid and lunate fractures were anatomically reduced with fixation across the fractures. The second case was the result of a high-energy injury and included a transscaphoid, transtriquetral, translunate facture dislocation with a comminuted radial styloid fracture and a small ulnar styloid fracture. Operative reduction and internal fixation was performed of the scaphoid and lunate. The triquetral and comminuted radial styloid fractures were stabilized with K-wires. In both cases, following splinting and rehabilitation, an excellent functional outcome was obtained. Early recognition and operative treatment of these unusual lunate fractures in association with treatment of the concomitant injuries using an extended volar approach with open reduction internal fixation can lead to an excellent anatomic and functional outcome in these types of cases.

Arthroscopic hemitrapeziectomy for first carpometacarpal arthritis: results at 7-year follow-up.

The purpose of this study was to determine the outcome of arthroscopic hemitrapeziectomy combined with thermal capsular plication and temporary K-wire fixation in patients with painful thumb basal joint due to either osteoarthritis or posttraumatic arthritis. There were 18 thumbs that were evaluated in this retrospective study of arthroscopic hemitrapeziectomy of the distal trapezium in addition to a pancapsular thermal shrinkage at an average of 7.6-year follow-up. No patient has required further surgery. A subjective improvement in pain, pinch activities, strength, and range of motion (ROM) was noted in all patients, and no patient had further surgery on their thumb. On exam, no patient had a first carpal-metacarpal grind or laxity. Total ROM of the thumb axis decreased by 20%, but all patients could oppose to the fifth finger. Grip strength remained unchanged, key pinch improved from 8 to 11 lbs, and tip pinch improved from 4 to 5 lbs. Radiographs showed a metacarpal subsidence of 1.8 mm (0-4 mm). Four complications were noted: two cases of dorsal radial nerve neuritis, one rupture of the flexor pollicis longus, and one prolonged hematoma. Results demonstrate that arthroscopic hemitrapeziectomy and capsular shrinkage for first carpometacarpal arthritis is an effective technique that provides high patient satisfaction, a functional pain-free thumb, and a reliable rate of return to activity.

Comparison of 2 methods of immobilization of fifth metacarpal neck fractures: a prospective randomized study.

PURPOSE: The objective of this study was to prospectively compare the effectiveness of 2 methods of cast immobilization for fifth metacarpal neck fractures with respect to the time required for cast application, durability and tolerability of the cast, efficacy of maintaining reduction, and postimmobilization range of motion. METHODS: After closed reduction, 81 predominately young, active-duty patients were prospectively randomized to a short-arm cast with volar outriggers (SAC-VOR) or to a short-arm cast extended to the proximal interphalangeal joint with a 3-point mold (MCP-ext). Radiographs were obtained before reduction and after reduction at 1 and 4 weeks. Outcome measures (Disabilities of the Arm, Shoulder, and Hand questionnaire), cast durability, radiographic parameters, and complications were evaluated at each visit. Final range of motion and grip strengths were obtained at the 3-month follow-up. RESULTS: The average time for cast application was less for the MCP-ext group compared with that of the SAC-VOR group. An equal number of casts in each group (7) required replacement during treatment. There were no statistically significant differences in range of motion or final grip strength between the 2 techniques. Radiographic callus was seen in all patients at 4 weeks, and there was no difference in the 4-week postreduction angulation in the lateral or posteroanterior planes. In comparing the maintenance of the reduction, there was no difference in alignment in either the posteroanterior or lateral planes based on cast type. CONCLUSIONS: There was no difference between the 2 groups on maintaining the reduction on final lateral radiographs. Stiffness was not a complication of either group. Advantages of the MCP-ext cast include quicker application and, to a much lesser degree, better tolerability, range of motion, and final grip strength.

Treatment of advanced carpometacarpal joint disease: trapeziectomy and hematoma arthroplasty.

Some surgical treatment options of painful basal joint arthritis do not require complex arthroplasty or suspensionplasty techniques. Simple trapeziectomy with temporary pinning of a slightly overdistracted thumb metacarpal can provide reliable pain relief, good motion, and functional stability. Recent literature supports alternative options when compared with formal ligament reconstruction or suspensionplasty procedures. Simple trapeziectomy is associated with less morbidity due to shorter operative times and the lack of need for graft harvest and ligament reconstruction.

Zone I rupture of the flexor digitorum profundus tendon caused by blunt trauma: a case report.

Traumatic ruptures of flexor tendons as a result of blunt trauma without an associated pathologic condition are rare. This is a case of a midsubstance flexor tendon rupture as a result of closed direct trauma. The patient sustained a flexor digitorum profundus (FDP) rupture 1 cm proximal to its insertion on his right ring finger without any accompanying laceration. Additionally, this case highlights the utility of ultrasound in diagnosing ruptured flexor tendon, which has been demonstrated in prior studies.

Hypersensitivity to polymethylmethacrylate following shoulder hemiarthroplasty.

Acrylic resins have been used for many years in several health-related applications due to their ease of use, favorable material properties, and relative cost. Cements containing polymethylmethacrylate (PMMA), in particular, have been widely accepted for use in orthopedic surgery, as well as in other fields of medicine. Although relatively rare, the potential for acrylic resins such as PMMA to induce hypersensitivity reactions via cutaneous or mucosal exposures has been reported; however, comparatively few cases have been described of patients reacting adversely to acrylic resins used as permanent cements during surgical procedures. This article reports a hypersensitivity reaction to PMMA cement applied in a right shoulder hemiarthroplasty, which initially presented as a possible postoperative infection. It is believed to be the first case in the literature of such a reaction occurring in an upper extremity prosthesis.

Injuries sustained to the upper extremity due to modern warfare and the evolution of care.

The formation of the American Society for Surgery of the Hand was related to world conflicts and hostilities. Therefore, it is appropriate that upper-extremity surgeons understand injuries resulting from modern-day combat. Because of ongoing warfare, many countries have experienced a large increase in the number of wounded service members and civilians, particularly wounds of the extremities. As a result of increased rate of survival in battlefield trauma in part because of the use of modern body armor, there is increasing complexity of extremity injuries that require complex reconstructions. Decreased mortality and a consequent increase in the incidence of injured extremities underline the need for the development of new treatment options. The purpose of this presentation is to describe upper-extremity injury patterns in modern warfare, the levels of care available, and the treatment at each level of care based on the experience of the United States Military Medical Support System.

A unique case of ulnar tunnel syndrome in a bicyclist requiring operative release.

The continued growth of recreational and competitive sports is accompanied by the need for health care providers to recognize and treat conditions in athletes that have been traditionally associated with other occupational injury. This is particularly important when early diagnosis and prompt intervention for prevention and treatment may alter the outcome. We present an interesting case of ulnar tunnel syndrome in a high-performance bicyclist with compressive ulnar neuropathy refractory to nonoperative management but successfully treated with surgical release. We review evaluation, diagnosis, and historical and current treatment algorithms.

The diagnostic utility of midcarpal anesthetic injection in the evaluation of chronic wrist pain.

The evaluation of chronic wrist pain can be a diagnostic dilemma. Lidocaine injections combined with corticosteroids are often used for both diagnosis and therapy. The purpose of this study was to determine if a midcarpal injection of lidocaine could serve as a diagnostic tool in patients with chronic wrist pain. Specifically, the relationship of pain relief from the injection and improvement of grip strength were compared to the presence of intracarpal pathology as confirmed by wrist arthroscopy. Forty-five patients with chronic wrist pain underwent a midcarpal injection of lidocaine with or without corticosteroids. Forty of the 45 underwent comcomitant steroid injections; a majority of the 40 patients reported relief of pain for two or more weeks. Improvement of pain and improvement of grip strength were determined. Each of these patients subsequently underwent a radiocarpal and midcarpal arthroscopy, and the pathologic findings of arthroscopy were compared to the improvement of pain and grip strength. These data were compared to a cohort of six volunteers without history of wrist pain or trauma that underwent midcarpal injection of lidocaine. Statistical analysis was performed using Receiver-Operator-Characteristic analysis. The average age of patients with chronic pain was 30.3 years, with an average of 9.8 months of wrist pain. The ultimate diagnoses included 35 patients with carpal instability dissociative, two with nondissociative instability, seven with complex instability of the carpus, three with extensor carpi ulnaris tendonitis and one with deQuervain's tenosynovitis. After lidocaine injection, the normal cohort had a mean loss of 2 kg (-5.3%) (p = 0.02) in grip strength, whereas the experimental cohort had a mean improvement in grip strength of 5.73 kg (34.4%). Improvement of pain after injection did not correlate with pathologic arthroscopic findings (p = 0.92). Improvement in grip strength after midcarpal lidocaine injection of 6 kg or 28% had a 73% sensitivity and a 70% specificity (p = 0.02) of having intracarpal pathology at the time of arthroscopy. Of the chronic wrist pain patients, only four had a normal arthroscopy, and the remainder had at least one area of significant pathology attributing to their pain. We conclude that a midcarpal injection of lidocaine can serve as an effective diagnostic tool in the evaluation of the patient with chronic wrist pain. Improvement of grip of 28% with or without relief of pain is highly correlated with intracarpal pathology.