Infections of the Upper Extremity: New Developments and Challenges.

Hand infections are common in all patient populations. However, because of variability in presentation and severity, they can be challenging to correctly diagnose and complex to manage. It is important to be aware of special populations such as children, individuals who are immunocompromised, those with diabetes, and intravenous drug users who may have uncommon pathogens or unusual types of infection. Atypical or rare bacterial and fungal infections, even in an immunocompetent host, can be equally challenging to manage. In each of these scenarios, it is critical to be familiar with associated conditions to avoid mismanagement and initiate an appropriate team-based approach for care involving surgery and consultation with an infectious disease specialist.

Avascular Necrosis of the Lunate Following Reconstruction of the Scapholunate Ligament Using the Scapholunate Axis Method (SLAM).

Various surgical treatment options have been described to address chronic scapholunate dissociation. The Scapholunate Axis Method (SLAM) is a new technique used to reconstruct the scapholunate interosseous ligament. It is biomechanically advantageous compared with other ligament reconstruction techniques but clinical studies are lacking. We describe a previously unreported complication of avascular necrosis of the lunate after the SLAM procedure.

Factors used by program directors to select hand surgery fellows.

PURPOSE: To identify factors and attributes hand surgery fellowship program directors consider important in selecting applicants for interview and ranking. METHODS: A web-based questionnaire was sent to all hand fellowship program directors in the United States. The questionnaire was designed to identify the most important criteria in granting an interview, sources of letters of recommendation, the interview process, and factors used to rank a candidate. Each criterion was ranked in importance on a 1 to 5 Likert scale, with 1 being not important and 5 being critical. All responses were anonymous. The most important criterion for each section of the survey was determined by comparing the average Likert scores. RESULTS: Fifty-two of 76 program directors responded (68%). The criteria with the highest mean Likert scores for offering an applicant an interview were, in order, quality letters of recommendation from hand surgeons, completion of an orthopedic surgery residency, comments regarding the applicant's technical competence, applicant having an MD degree (as opposed to a DO degree), and residency program reputation. The letters of recommendation with the highest value were from the division chief of hand surgery and another hand surgeon in the division/department. The most important features of the interview were maturity of applicant, ability of applicant to articulate thoughts, ability to listen well, self-confidence, and relevant questions asked. The most important factors in ranking a candidate were applicant integrity, commitment to hard work, quality of letters of recommendation, quality of the interview, and ability to work well with other members of the hand surgery team. CONCLUSIONS: There are identifiable factors considered important by hand surgery fellowship directors when selecting and ranking an applicant. This information may be valuable to medical students and residents contemplating careers in hand surgery.

The Ioban drape: a simple method to improve finger surgery safety and efficiency.

Surgery involving the fingers can be technically challenging especially when utilizing fluoroscopic imaging. The surgical field is often obscured by the remaining fingers and attempts to position the hand may expose the surgeon and assistants to additional radiation exposure. This paper describes a simple and effective technique to remove the uninvolved fingers from the surgical field allowing for a more efficient operative procedure with less radiation exposure.

An individualized approach to severe elbow burn contractures.

UNLABELLED: Contracture of the antecubital fossa is a common occurrence following thermal burn injury to the upper extremity. Scarring of the superficial tissues can be treated with a variety of surgical methods to provide release and coverage. However, complex scarring of the elbow, which involves the deeper structures, requires a patient-specific technique for which each scarred, shortened, or contracted component is purposefully addressed during the operation. In addition, severe elbow contractures may be complicated by other conditions, such as peripheral neuropathy and heterotopic ossification. This article will discuss the evaluation of the patient with a severe elbow burn contracture and emphasize the importance of an individualized and comprehensive surgical approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Sea urchin injuries to the hand: a case report and review of the literature.

Sea urchin injuries to the hand are uncommon. A variety of home remedies can be found on the internet and other sources for dealing with this problem in the acute setting. Many long term complications such as granulomas, arthritis, and tenosynovitis can result from a neglected sea urchin injury. We report an unusual case of a patient with a remote sea urchin injury who presented with ulnar digital nerve paresthesias. A traumatic neuroma was found on surgical exploration. We review the literature on injuries to the hand caused by sea urchins and their management. Management of sea urchin injuries to the hand with retained spines requires surgical debridement in order to prevent significant long term complications including stiffness, tenosynovitis, granulomas, and arthritis.

Pilomatrixoma of the forearm: a case report.

Pilomatrixoma is a benign neoplasm derived from hair follicle matrix cells. Involvement of the upper extremities is relatively uncommon and can be mistaken for malignancy. We present the case of a 52-year-old woman with a pilomatrixoma of the forearm, and we review the literature regarding pilomatrixomas in the upper extremity.

Sports-related wrist injuries in adults.

BACKGROUND: Wrist injuries are common in sports. Those who are involved in the care of athletes should be familiar with hand and wrist anatomy, common wrist injuries, and clinical examination; they should also know how to recognize emergent problems. LEVEL OF EVIDENCE: Level V, expert opinion.

MDCT and radiography of wrist fractures: radiographic sensitivity and fracture patterns.

OBJECTIVE: The purpose of our study was to determine which wrist fractures are not prospectively diagnosed at radiography using CT as a gold standard and to identify specific fracture patterns. MATERIALS AND METHODS: Through a search of radiology records from January 1 to December 31, 2005, 103 consecutive patients were identified as having radiographic and CT examinations of the wrist. After excluding incomplete or nondiagnostic examinations and those with a greater than 6-week interval between imaging studies, the final study group consisted of 61 wrist examinations in 60 patients. Two musculoskeletal radiologists and one emergency radiologist blindly reviewed CT examinations, and each bone (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate, metacarpals, distal radius, distal ulna) was categorized as normal or fractured, with agreement reached by consensus. Each prospective radiographic report was categorized as either normal or fracture/equivocal for each osseous structure. Results were compared using the chi-square and Fisher's exact tests. RESULTS: In the proximal carpal row, lunate and triquetrum fractures were often radiographically occult (0% and 20%, respectively, detected at radiography); whereas in the distal carpal row, trapezoid, capitate, and hamate fractures were often occult (0%, 0%, and 40% detected at radiography, respectively). Hamate fractures were significantly associated with metacarpal fractures, and distal radius fractures were associated with scaphoid and ulna fractures. CONCLUSION: Thirty percent of wrist fractures were not prospectively diagnosed on radiography, suggesting that CT should be considered after a negative radiographic finding if clinically warranted. The location of a dorsal scaphoid avulsion fracture emphasizes the need for specific radiographic views or cross-sectional imaging for diagnosis.

Internal fixation of acute, nondisplaced scaphoid waist fractures via a limited dorsal approach: an assessment of radiographic and functional outcomes.

PURPOSE: To evaluate the clinical and radiographic outcomes of a consecutive series of patients who had internal fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach. METHODS: Twenty consecutive patients had surgical fixation of a nondisplaced scaphoid waist (Herbert B2) fracture via a limited dorsal approach. Eighteen patients were available for follow-up evaluation at a mean duration of 98 weeks after surgery (range, 12-272 wk). Fifteen males and 3 females with a mean age of 25 years (range, 16-62 y) were examined. Wrist range of motion; grip strength; visual analog and numeric pain scores; and a Disabilities of the Arm, Shoulder, and Hand (DASH) outcomes questionnaire were assessed. Postoperative radiographs were reviewed in a blinded fashion to assess the fracture union and screw position. RESULTS: Seventeen of 18 fractures healed at a mean duration of 8 weeks. No case of proximal pole avascular necrosis occurred. All patients were satisfied and returned to their pre-injury level of employment. Five of 6 collegiate or professional athletes returned to play without limitations. The mean subjective and visual analog pain scores were 0.3 and 0.4 (maximum of 10 for each scale). The mean DASH score was 6.12 (out of 100), which is consistent with an excellent functional outcome. Central axis screw position was achieved on anteroposterior and lateral radiographs in 17 of 18 patients. CONCLUSIONS: Fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach is safe and effective. The limited dorsal approach allows for accurate insertion of the screw in the central scaphoid, which is biomechanically advantageous for fracture union and early restoration of function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Flexor tendon sheath ganglions: results of surgical excision.

The purpose of our study was to review the clinical features and determine the results following surgical excision of a flexor tendon sheath ganglion. A retrospective analysis of 24 consecutive patients (25 ganglions) who underwent excision of a painful flexor tendon sheath ganglion by the same surgeon was performed. The patient's medical and operative records were reviewed. Each patient was invited to return for an evaluation, which consisted of a clinical interview, completion of a questionnaire, and physical examination. Those patients that were unable to return underwent a detailed telephone interview. Sixteen patients returned for a clinical evaluation, while eight patients underwent a telephone interview. There were 15 women and nine men, with an average age of 43 years (range, 21-68 years). The dominant hand was involved in 15 patients. The long finger was most commonly involved (11 cases). The ganglion arose from the A1 pulley in 13 cases, between the A1 and A2 pulleys in three cases, and from the A2 pulley in nine cases. At an average follow-up of 18.5 months (range, 5-38 months), all of the patients were satisfied with their final result. No patient developed a recurrence and all returned to their previous functional level. There were two minor complications that resolved uneventfully; one patient experienced mild incisional tenderness, while an additional patient experienced transient digital nerve paresthesias. We conclude that surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath.

The use of routine wrist radiography is not useful in the evaluation of patients with a ganglion cyst of the wrist.

The purpose of this study was to evaluate the cost-effectiveness of routine wrist radiography in the evaluation of patients with a wrist ganglion. In the setting of a University-based hand surgery practice, 103 consecutive patients with a dorsal or volar wrist ganglion underwent posteroanterior, lateral, and oblique radiographs of the involved wrist. There were 24 men and 79 women with an average age of 34 years (range 4-67 years). A retrospective review of the medical records was performed. Abnormalities on plain radiographs were noted in only 13 patients (13%). Findings included six cases of thumb carpometacarpal joint arthritis and one case each of an enchondroma, congenital distal radioulnar joint (DRUJ) anomaly, DRUJ degenerative changes, intraosseous ganglion, carpal boss, radiocarpal arthritis, and thumb metacarpophalangeal joint osteoarthritis. In only one case (1%) did the findings alter the management. At our institution, the professional and technical charge for three views of the wrist is $172. This confers a cost of $17,716 per therapeutically significant finding in our series. We conclude that routinely performing wrist radiography is not cost-effective in the evaluation and treatment decision-making process in patients with a wrist ganglion.

Cannulated variable pitch compression screw fixation of scaphoid fractures using a limited dorsal approach.

Scaphoid fractures are common in the young, active patient. Treatment is challenging because of the complex three-dimensional anatomy of the scaphoid and the tenuous blood supply. Traditionally, cast immobilization has been used for the management of non-displaced fractures with satisfactory outcomes reported in the literature. However, non-surgical treatment may result in a delayed union or nonunion particularly if the fracture is unstable, displaced, or involves the proximal pole. Recently there has been increased interest in the fixation of non-displaced scaphoid fractures. The proposed advantages for operative treatment include avoiding the morbidity and inconvenience of prolonged cast immobilization and a lower incidence of delayed union or nonunion. A variety of surgical approaches for fixation of an acute scaphoid fracture have been described. The most common techniques include percutaneous fixation, arthroscopically assisted reduction and fixation, or open reduction and internal fixation via a volar approach. The senior author favors a limited dorsal approach with compression screw fixation of all proximal pole fractures as well as displaced and non-displaced fractures of the waist region. The technique is simple permitting accurate screw placement in the central axis of the scaphoid, which is biomechanically advantageous and important for achieving union.

Wrist arthrodesis.

Wrist arthrodesis results in a high degree of patient satisfaction and predictable pain relief in most patients. Most patients are able to return to gainful employment, many without impairment. Some patients require restrictions and employment in a less strenuous occupation. Successful fusion rates have been reported in the vast majority of patients overall. Although the functional outcome is acceptable for most patients,some adaptation is necessary, because certain activities such as perineal care and manipulating the hand in tight spaces are difficult. Activities that require forceful gripping with the hand ina fully pronated or supinated position also may be difficult to accomplish. Preoperative counseling of the patient should include a candid discussion of the potential postoperative functional difficulties. The most common indication for a wrist arthrodesis is advanced symptomatic arthritis secondary to a degenerative, post-traumatic, inflammatory, or postinfectious condition. Wrist arthrodesis also may improve function, hygiene,and cosmesis in the patient who has a contracted or flail wrist associated with cerebral palsy, traumatic brain injury, or brachial plexus injury.Various techniques have been described for achieving a successful arthrodesis. The type of operative technique used depends on the underlying condition, quality of bone, presence of bi-lateral disease, condition of the remaining joints of the involved extremity, and surgeon's preference. Intramedullary rod or Steinman pin fixation has been successful in patients who have inflammatory arthritis. Dorsal plate and screw fixation is preferred for patients who have post-traumatic or degenerative arthrosis. Rigid fixation with a dorsal plate is advocated because of the ease of implant application, the high rates of fusion achieved, and the avoidance of prolonged postoperative cast immobilization. Precontoured low profile plates have been developed to position the hand appropriately and to minimize extensor tendon irritation. Controversy still exists as to the ideal position of the hand. Generally the wrist is placed in slight dorsiflexion and ulnar deviation to optimize power grip. In cases of bilateral involvement, the nondominant hand may be placed in 5 degrees -10 degrees of flexion to better assist in such activities as perineal care. Complications are frequent but can be minimized with attention to detail and good surgical technique. Fortunately most complications are amenable to nonoperative treatment. Major complications include nonunion, deep wound infection, neuroma formation, DRUJ arthritis,ulnocarpal impaction, CTS, and painful retained hardware. Minor complications include hematoma formation, partial wound dehiscence, and transient paresthesias involving the radial, ulnar,or median nerves. Donor site morbidity remains a concern when the iliac crest is used. Complications include hematoma formation, infection, injury to the lateral cutaneous femoral nerve, and prolonged discomfort. Successful outcomes have been reported with the use of local autogenous cancellous bone graft from the distal radius metaphyseal region.