K-wire Fixation of Closed Hand Fractures Outside the Main Operating Room Does Not Increase Infections.

Closed reduction and internal fixation (CRIF) of closed hand fractures in the main operating room (OR) is much more expensive than outside of the OR. However, there is a reluctance to fix fractures out of the OR due to the perceived increase in infections. Our goal was to prospectively analyze the infection rates of performing CRIF of closed metacarpal and phalangeal fractures in these two settings. Methods: A multicenter prospective analysis of patients undergoing CRIF of metacarpal or phalangeal fractures inside or outside the OR was performed. Demographic data, injury characteristics, surgery information and postoperative infectious complications were recorded, including cellulitis, frank pus, and osteomyelitis. Results: The study involved 1042 patients with a total of 2265 Kirschner-wires (K-wires). Infection rates were not statistically higher in the 719 patients who had CRIF outside of the OR (cellulitis 2.5%, frank pus 1.4%) compared with the 323 patients with CRIF in the OR group (cellulitis 3.4%, frank pus 2.5%). The OR group had a longer time to operation and a longer procedure time, but a shorter time with the K-wires in place. Conclusion: K-wire fixation of closed hand fractures outside of the OR under field sterility is safe because it does not increase infectious complications compared to CRIF in the main OR under full sterility.

How Many Trigger Fingers Resolve Spontaneously Without Any Treatment?

INTRODUCTION: There is very little information in the literature evaluating the natural history of adult trigger fingers and their rate of spontaneous resolution over time. METHODS: A consecutive case series of patients with trigger finger was generated. For each patient, we recorded whether the patient's disease resolved from either no treatment versus active treatment options and over what time period. RESULTS: Three hundred forty-three patients with trigger finger were included in the study. Fifty-two percent of patients resolved without any treatment whatsoever after waiting a mean (and median) of 8 months from initial consultation. The thumb was the most frequent digit to resolve without treatment (72%). CONCLUSIONS: We found that just over half of patients with trigger fingers who are referred to our office resolve spontaneously without any intervention.

HISTORIQUE: Très peu de publications portent sur l'évolution naturelle des doigts à ressort chez les adultes et sur leur taux de résolution spontanée au fil du temps. MÉTHODOLOGIE: Les chercheurs ont produit une série de cas consécutifs de patients ayant un doigt à ressort. Pour chaque patient, ils ont vérifié si le problème s'était résolu sans traitement ou après un traitement actif ainsi que le laps de temps nécessaire pour parvenir à ce résultat. RÉSULTATS: Au total, 343 patients ayant un doigt à ressort ont participé à l'étude. Le problème s'est résolu sans traitement chez 52 % des patients au bout d'une période moyenne (et médiane) de huit mois après la première consultation. C'est le pouce qui guérissait le plus souvent sans traitement (72 %). CONCLUSION: Les chercheurs ont découvert qu'un peu plus de la moitié des patients ayant un doigt à ressort qui sont dirigés vers leur bureau guérissent spontanément sans intervention.

Teaching medical students and residents how to inject local anesthesia almost painlessly.

The objective of the present study was to determine whether it is possible to consistently and reliably teach medical students and resident learners how to administer local anesthetics in an almost painless manner. Using the published technique, 25 consecutive medical students and residents were taught how to inject local anesthetics for carpal tunnel release by watching the senior author perform the technique once. The learner then independently administered the anesthesia to the next patient who then scored the learner's ability to inject the local anesthetic from a pain perspective. The teaching technique is demonstrated in an accompanying online video. The learners were consistently capable of administering local anesthetics with minimal pain. During the injection process, the patients only felt pain once ('hole-in-one') 76% of the time. This pain was attributed to the first 27-gauge needle poke. The other 24% of the time, patients felt pain twice (eagle) during the 5 min injection process. All 25 patients rated the entire pain experience to be less than 2/10. Eighty-four per cent of the patients indicated that the experience was better than local anesthetic given at the dentist's office. Medical students and residents can quickly and reliably learn how to administer local anesthesia for carpal tunnel release with minimal pain to the patient.

La présente étude visait à déterminer s'il est possible d'enseigner de manière constante et fiable aux étudiants en médecine et aux résidents à administrer un anesthésique local de manière pratiquement indolore. Au moyen de la technique publiée, 25 apprenants consécutifs, des étudiants en médecine et des résidents, se sont fait enseigner à injecter un anesthésique local en vue de libérer le nerf médian au niveau du canal carpien en regardant l'auteur chevronné effectuer la technique une fois. L'apprenant administrait ensuite seul l'anesthésique au patient suivant, qui évaluait la capacité de l'apprenant à injecter l'anesthésique local selon la douleur ressentie. La technique d'enseignement est démontrée dans une cybervidéo d'accompagnement. De manière uniforme, les stagiaires étaient en mesure d'administrer l'anesthésique local en causant une douleur minimale. Pendant le processus d'injection, les patients ne ressentaient la douleur qu'une fois (trou d'un coup) dans 76 % des cas. Cette douleur était attribuée à la première piqûre d'aiguille de calibre 27. Dans les 24 % d'autres cas, les patients ressentaient de la douleur deux fois (aigle) pendant le processus d'injection de cinq minutes. Les 25 patients ont classé l'expérience globale de douleur à moins de 2/10. Quatre-vingt-quatre pour cent des patients ont indiqué que l'expérience était moins douloureuse qu'un anesthésique local administré au cabinet du dentiste. Les étudiants en médecine et les résidents peuvent apprendre rapidement et de manière fiable à administrer un anesthésique local en vue de libérer le nerf médian au niveau du canal carpien en causant une douleur minimale au patient.

Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.

BACKGROUND: Over 70% of Canadian carpal tunnel syndrome (CTS) operations are performed outside of the main operating room (OR) with field sterility and surgeon-administered pure local anesthesia [LeBlanc et al., Hand 2(4):173-8, 14]. Is main OR sterility necessary to avoid infection for this operation? This study evaluates the infection rate in carpal tunnel release (CTR) using minor procedure room field sterility. METHODS: This is a multicenter prospective study reporting the rate of infection in CTR performed in minor procedure room setting using field sterility. Field sterility means prepping of the hand with iodine or chlorhexidine, equivalent of a single drape, and a sterile tray with modest instruments. Sterile gloves and masks are used, but surgeons are not gowned. No prophylactic antibiotics are given. RESULTS: One thousand five hundred four consecutive CTS cases were collected from January 2008 to January 2010. Six superficial infections were reported and four of those patients received oral antibiotics. No deep postoperative wound infection was encountered, and no patient required admission to hospital, incision and drainage, or intravenous antibiotics. CONCLUSIONS: A superficial infection rate of 0.4% and a deep infection rate of 0% following CTR using field sterility confirm the low incidence of postoperative wound infection using field sterility. This supports the safety and low incidence of postoperative wound infection in CTR using minor procedure field sterility without prophylactic antibiotics. The higher monetary and environmental costs of main OR sterility are not justified on the basis of infection for CTR cases.

Delayed immediate surgery for orbital floor fractures: Less can be more.

Orbital floor fractures can result in diplopia, enophthalmos, hypoglobus and infraorbital dysthesia. Currently, the most common treatment for orbital floor fractures is immediate surgical intervention. However, there are a number of well-documented cases of unoperated orbital floor fractures in the literature, culminating in diplopia or enophthalmos in few patients. Of these, none reported the diplopia or enophthalmos to be bothersome. As reported previously in the ophthalmology literature, most orbital floor fracture-induced diplopia resolves as the swelling settles, and the few patients with remaining diplopia can successfully be treated with surgery on the uninvolved eye. It has also been commented that most patients with enophthalmos are asymptomatic. The authors' institution has more than 50 surgeon-years experience with delaying immediate surgery for two weeks to allow time for the swelling-induced diplopia to resolve. In the authors' experience, true entrapment of the inferior rectus muscle is rare. The present article describes a study of late follow-up (average 945 days) of 11 nonoperated patients with orbital floor fractures. In the eight patients who initially presented with diplopia, there was resolution of functionally limiting double vision. Only one patient had asymptomatic, but measurably significant, enophthalmos at -3 mm. All patients had full restoration of extraocular movements and resolution of infraorbital dysthesia. None of the patients were exposed to the operative risks of ectropion, infection, implant extrusion, bleeding or blindness. The present study provides level IV evidence that delaying surgery up to two weeks after orbital floor fracture may avoid unnecessary surgical risks and inconveniences in many patients with orbital floor fracture.

Wide-awake trapeziectomy: video detailing local anesthetic injection and surgery.

UNLABELLED: The use of local anesthesia with epinephrine and no tourniquet/no sedation is becoming an excellent alternative for hand surgeries. This wide-awake approach is the most commonly used method of anesthesia for carpal tunnel release in Canada. The purpose of this paper is to provide a video detailing this technique for trapeziectomy for trapeziometacarpal joint osteoarthritis. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11552-011-9367-z) contains supplementary material, which is available to authorized users.

Avoiding flexor tendon repair rupture with intraoperative total active movement examination.

BACKGROUND: Wide-awake flexor tendon repair in tourniquet-free unsedated patients permits intraoperative Total Active Movement examination (iTAMe) of the freshly repaired flexor tendon. This technique has permitted the intraoperative observation of tendon repair gapping induced by active movement when the core suture is tied too loosely. The gap can be repaired intraoperatively to decrease postoperative tendon repair rupture rates. The authors record their rupture rate in the first 15 years of experience with iTAMe. METHODS: This was a retrospective chart review of 102 consecutive patients with wide-awake flexor tendon repair (no tourniquet, no sedation, and pure locally injected lidocaine with epinephrine anesthesia) in which iTAMe was performed by two hand surgeons in two Canadian cities between 1998 and 2008. Intraoperative gapping and postoperative rupture were analyzed. RESULTS: The authors observed intraoperative bunching and gap formation with active movement in flexor tendon repair testing (iTAMe) in seven patients. In all seven cases, they redid the repair and repeated iTAMe to confirm gapping was eliminated before closing the skin, and those seven patients did not rupture postoperatively. In 68 patients with known outcomes, four of 122 tendons ruptured (tendon rupture rate, 3.3 percent) in three of 68 patients (patient rupture rate, 4.4 percent). All three patients who ruptured had accidental jerk forced rupture. All those patients who did what we asked them did not rupture. CONCLUSIONS: Tendons can gap with active movement if the core suture is tied too loosely. Gapping can be recognized intraoperatively with iTAMe and repaired to decrease postoperative rupture.