Comparing the Intensity of Pain and Incidence of Flare Reaction Following Trigger Finger Injections Using Betamethasone and Methylprednisolone: A Double-Blinded, Randomized Controlled Trial.

BACKGROUND: Considerable evidence supports corticosteroid injection as an effective treatment for trigger finger. One common side effect, the flare reaction, is a well-documented phenomenon of increased pain following steroid injections. Its incidence and intensity may be related to steroid composition. The purpose of this study was to determine whether betamethasone and methylprednisolone injections for trigger fingers have differing intensity of pain or incidence flare reaction. METHODS: Patients with symptomatic trigger finger were recruited during their hand surgery visits. Patients were randomized into 2 treatment groups: betamethasone (40 mg) and methylprednisolone (6 mg) mixed with lidocaine 1%. Treatment group assignment was blinded to the patients and investigators. Visual analog scale pain measurements were taken prior to injection, 5 minutes postinjection, and daily thereafter for 7 days. RESULTS: Sixty-four patients were randomized into the 2 treatment groups. Patients in the betamethasone group reported slightly higher baseline pain compared with the methylprednisolone group, but lower pain on day 1. None of the following days showed a statistically significant difference. CONCLUSIONS: The incidence of flare and severe flare reactions of betamethasone injections for trigger finger management was roughly double that of methylprednisolone, but this difference was not statistically significant. Further studies are required to evaluate the relative course of nonflare postinjection pain for different corticosteroid injections for trigger finger injections.

Distal Ulna Fracture Fixation with the Specialized Threaded Pin.

Purpose: Distal ulna fractures can often be treated nonsurgically; however, many surgeons consider significant displacement or instability, especially following fixation of an associated distal radius fracture, an indication for surgical fixation because of potential problems associated with malunion of these fractures. Traditionally, these fractures have been addressed with plate fixation but hardware in this location is often prominent and associated with a high rate of symptomatic hardware and subsequent hardware removal. We proposed a method of intramedullary fixation using a specialized threaded pin. As this fixation is intramedullary, it avoids many of the problems associated with traditional surgical treatment methods for this fracture. We present a series of nine patients treated in this manner, all of whom had associated distal radius fractures. Methods: Preoperative and postoperative radiographs were reviewed, after which patients were contacted via phone. Patient-reported outcome measures, including QuickDASH and visual analog scale scores, were assessed. Results: The average QuickDASH score was 13.6 (range, 0-100), with a median of 9.1. Three patients reported occasional ulnar-sided wrist pain, with an average visual analog scale score of 1.3 (range, 0-10) and a median of 0.5. All patients returned to all activities except one patient who could not resume playing musical instruments because of stiffness. No patient required removal of the threaded pin, but one patient underwent removal of the radial volar plate. No other patients underwent secondary procedures. Conclusions: Threaded pin fixation is a viable alternative to existing options for distal ulnar neck fractures and may have an advantage over plate fixation because of a lack of hardware prominence. Type of study/level of evidence: Therapeutic IV.

Percutaneous Threaded Pin Fixation of Distal Radius Fracture in the Athlete.

BACKGROUND: The purpose of this study was to examine the outcomes and return to play with early rehabilitation in athletes who sustained unstable extra-articular distal radius fractures treated with a purpose-designed threaded pin technique. METHODS: This prospective study examined athletes with displaced and unstable distal radius fractures treated surgically with purpose-designed threaded pins. Patients were enrolled in an early rehabilitation protocol, with formal therapy initiated on postoperative days 1 to 3. Range of motion and strength measurements were documented throughout the postoperative period, noting the time until return to athletic competition. These results were compared with historical values using other forms of fixation. RESULTS: Nineteen athletes, average age of 35 years, were treated with threaded pin technique with early rehabilitation; all had complete healing and maintained alignment based on radiographic evaluation. The average time span between surgery and release to competition was 8 weeks, with all but 1 patient returning to sport within 12 weeks of injury. Average postoperative flexion measured 58°, extension was 57°, pronation was 81°, and supination was 74°. JAMAR grip strength in position 3 measured 25.22 kg, which equated to 73% of the uninjured side's grip strength at the time of release to play. CONCLUSIONS: Surgical fixation using a purpose-designed threaded pin is a useful alternative to volar plating for isolated radial styloid and extra-articular distal radius fractures in athletes. The purpose-designed threaded pin may afford athletes rapid recovery during the early postoperative period, preserving strength and dexterity and minimizing time lost before return to play.

Dorsal Coaptation for the Treatment of Digital Neuroma.

PURPOSE: The formation of a symptomatic neuroma after digital tip amputation presents a vexing problem. There is currently no procedure that completely and consistently prevents hypersensitive neuroma formation. This report presents the results of a technique designed to limit axon regeneration and mechanical irritation by neuroma excision, dorsal transposition, and coaptation with the corresponding digital nerve. METHODS: A retrospective chart review was conducted to assess the effectiveness of neuroma excision with dorsal transposition and epineurial coaptation for postamputation symptomatic digital neuromas. Neuromas were excised using a midlateral fish-mouth incision. Digital nerves were mobilized to the dorsum of the digital tip and coapted using 9-0 nylon epineurial suture. The procedure was modified to salvage viable fingernails or to avoid excessive tension. Mass et al's criteria system was used to evaluate effectiveness. RESULTS: Twenty-four patients with painful neuromas of the radial and ulnar digital nerves after traumatic amputation were included. Thirty-two digits underwent dorsal coaptation. This procedure was associated with a result considered good or excellent in 28 of 32 digits. Twenty-seven of 32 digits registered no pain or stump anesthesia after dorsal coaptation. Twenty-five of 32 digits demonstrated no interference with activities of daily living. Twenty-one of 24 patients returned to work. CONCLUSIONS: Neuroma excision with dorsal transposition and epineurial coaptation is an effective treatment for postamputation symptomatic digital neuroma. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Excision of a Rare Triquetral Body Fracture Nonunion.

Aside from the more common dorsal avulsion fractures, isolated triquetral body fractures are a rare injury and often missed. When they are identified, conservative treatment via immobilization is often the standard of care for initial treatment. Rarely, triquetral body fractures can develop into symptomatic nonunions, causing considerable pain and disability. Multiple classification schemes have been described to categorize triquetrum fractures; however, distal triquetrum fractures fit into none of the established models. There is scarce literature describing treatment of triquetral body fracture nonunions. The few reports that exist often use a variation of open reduction internal fixation with or without grafting as treatment. We present the case of an unusual triquetral body fracture nonunion that was successfully treated via surgical excision of the ununited distal fragment.

Threaded Pin and Volar Plate Fixation of Distal Radius Fractures: Early Functional Recovery.

Purpose: To assess the results of threaded pin fixation and volar plate fixation of extra-articular distal radius fractures. Methods: A retrospective case comparison study of patients undergoing operative fixation of distal radius fracture and postoperative therapy at 1 hand clinic was performed. Clinical variables included implant type along with the assessment of the volar tilt; radial height; postoperative wrist flexion, extension, pronation, and supination; key pinch; and grip strength. The duration of postoperative hand therapy was recorded. An independent Student t test was used to compare the 2 groups. Results: Forty-three patients were identified (21 threaded pin and 22 volar plate). The mean ages were 46 years and 54 years for the threaded pin and the volar plate groups, respectively. Preoperative and postoperative radiographic parameters were similar for both the groups. No loss of reduction was observed. There were no statistically significant differences for postoperative range of motion or pinch and grip strength at the time of discharge from therapy. The threaded pin group had a mean duration of 65 days of therapy, and the volar plate group had a mean duration of 132 days of therapy. Conclusions: Both groups achieved equivalent range of motion and functional recovery; however, the threaded pin group required significantly less therapy than the volar plate group. At the time of discharge from therapy, radiographic and clinical outcomes were similar for both types of implants, but the patients treated with a threaded pin required significantly less therapy and were discharged from therapy an average of 67 days sooner than the patients undergoing volar plate fixation. Type of study/level of evidence: Therapeutic IV.

Distal Radius Fracture Fixation With the Specialized Threaded Pin Device.

This study investigated the outcomes of extra-articular distal radius fractures and simple intra-articular radial styloid fractures stabilized with a novel threaded cannulated device. This was a retrospective study of 24 distal radius fractures treated with the T-Pin device (Union Surgical LLC, Philadelphia, Pennsylvania), with a minimum of 1 year of postoperative follow-up. Outcome data included wrist range of motion, grip strength, and pinch strength. Radiographs were analyzed to determine volar tilt and radial height. At final follow-up, patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. At an average of 2 years after surgery (range, 1-4 years), flexion was 89%, extension was 96%, supination was 99%, and pronation was 100% of contralateral wrist motion. Grip strength was 93% (range, 40%-137%) and lateral pinch strength was 99% (range, 48%-130%) of the contralateral upper extremity. The average final DASH score was 4.4 (range, 0-35). One patient lost 6 mm of radial height from the initial postoperative radiograph to the final follow-up radiograph. One patient elected to have the quiescent threaded pins removed, and 1 patient had tenderness with wrist range of motion that resolved after pin removal. After hardware removal, neither patient had further symptoms. No postoperative soft tissue complications occurred, and this was an expected benefit of the minimally invasive approach and intramedullary placement of the device. The stability of fixation allows patients to begin active range of motion early in the postoperative course. The threaded pin offers reliable fracture fixation for the treatment of extra-articular and simple articular distal radius fractures.

Radial nerve motor palsy following seasonal influenza vaccination: a case report.

This case report describes the course of a 26-year-old male who developed a dense motor palsy of the radial nerve after receiving a seasonal influenza vaccination. The palsy developed within 12 to 16 hours of inoculation and demonstrated no clinical recovery until 5 months postinjury. Electromyographic and nerve conduction studies obtained at six weeks postinjury were consistent with complete motor denervation. Sensory function was preserved. The injury was successfully treated nonoperatively with physical therapy and wrist splinting, and the palsy gradually resolved over the next several months.

Allograft reconstruction for digital nerve loss.

PURPOSE: To investigate the outcomes of digital nerve repairs using processed nerve allograft for defects measuring 30 mm or less. METHODS: Seventeen patients with 21 digital nerve lacerations in the hand underwent reconstruction with processed nerve allograft. Outcome data for 14 patients with 18 digital nerve lacerations were available for analysis. Postoperative outcome data were recorded at a minimum of 12 months and an average of 15 months. The average nerve gap measured 11 mm (range, 5-30 mm). Outcome measures included postoperative sensory examination as assessed by Semmes-Weinstein monofilaments and static and moving 2-point discrimination. Pain was graded using a visual analog scale throughout the recovery period. In addition, patients completed the Quick Disabilities of the Arm, Shoulder, and Hand survey before and after surgery. RESULTS: Using Taras outcome criteria, 7 of 18 (39%) digits had excellent results, 8 of 18 (44%) had good results, 3 of 18 (17%) digits had fair results, and none had poor results. At final follow-up, Semmes-Weinstein monofilament testing results ranged from 0.08 g to 279 g. Quick Disabilities of the Arm, Shoulder, and Hand scores recorded at the patient's first postoperative visit averaged 45 (range, 2-80), and final scores averaged 26 (range, 2-43). There were no signs of infection, extrusion, or graft reaction. CONCLUSIONS: The data suggest that processed nerve allograft provides a safe and effective alternative for the reconstruction of peripheral digital nerve deficits measuring up to 30 mm.

Reconstruction of digital nerves with collagen conduits.

PURPOSE: Digital nerve reconstruction with a biodegradable conduit offers the advantage of providing nerve reconstruction while providing a desirable environment for nerve regeneration. Many conduit materials have been investigated, but there have been few reports of human clinical trials of purified type I bovine collagen conduits. METHODS: We report a prospective study of 22 isolated digital nerve lacerations in 19 patients reconstructed with a bioabsorbable collagen conduit. The average nerve gap measured 12 mm. An independent observer performed the postoperative evaluation, noting the return of protective sensation, static 2-point discrimination, and moving 2-point discrimination, and recording the patient's pain level using a visual analog scale. Minimal follow-up was 12 months and mean follow-up was 20 months after surgery. RESULTS: All patients recovered protective sensation. The mean moving 2-point discrimination and static 2-point discrimination measured 5.0 and 5.2 mm, respectively, for those with measurable recovery at final follow-up visit. Excellent results were achieved in 13 of 22 digits, good results in 3 of 22 digits, and fair results in 6 of 22 digits, and there were no poor results. Reported pain scores at the last postoperative visit were measured universally as 0 on the visual analog scale. CONCLUSIONS: Our data suggest that collagen conduits offer an effective method of reconstruction for digital nerve lacerations. This study confirms that collagen conduits reliably provide a repair that restores nerve function for nerve gaps measuring less than 2 cm.

New concepts in the treatment of distal radius fractures.

Fracture of the distal radius is the type of fracture most commonly seen in emergency departments. The understanding of nonsurgical and surgical care of distal radius fractures is evolving with recently developed methods of fixation. It is worthwhile to review some new methods of treatment, the role of bone grafting and synthetic substitutes, the principles of complex fracture management, and the treatment of common complications of distal radius fractures.

Treatment of distal radius fractures.

The clinical practice guideline is based on a systematic review of published studies on the treatment of distal radius fractures in adults. None of the 29 recommendations made by the work group was graded as strong; most are graded as inconclusive or consensus; seven are graded as weak. The remaining five moderate-strength recommendations include surgical fixation, rather than cast fixation, for fractures with postreduction radial shortening >3 mm, dorsal tilt >10 degrees , or intra-articular displacement or step-off >2 mm; use of rigid immobilization rather than removable splints for nonsurgical treatment; making a postreduction true lateral radiograph of the carpus to assess dorsal radial ulnar joint alignment; beginning early wrist motion following stable fixation; and recommending adjuvant treatment with vitamin C to prevent disproportionate pain.

Acellular dermal regeneration template for soft tissue reconstruction of the digits.

PURPOSE: Trauma to the digits often leaves soft tissue defects with exposed bone, joint, and/or tendon that require soft tissue replacement. The objective of this study was to evaluate the effectiveness of acellular dermal regeneration template combined with full-thickness skin grafting for soft tissue reconstruction in digital injuries with soft tissue defects. METHODS: Acellular dermal regeneration template was used to reconstruct digital injuries with exposed bone, joint, tendon, and/or hardware not amenable to treatment with healing by secondary intention, rotation flaps, or primary skin grafts. Acellular dermal regeneration template was applied to 21 digits in 17 patients. Nineteen digits had exposed bone, 8 digits had exposed tendon, 6 digits had exposed joints, and 2 digits had exposed hardware. The acellular dermal regeneration template was sutured over the soft tissue defect. Over 3 weeks, a neodermis formed. The superficial silicone layer of the acellular dermal regeneration template was removed, and the digits received full-thickness epidermal autografting with cotton bolster. RESULTS: The duration of postoperative follow-up extended to a minimum of 12 months. For the injury sites where acellular dermal regeneration template was applied, the total area of application ranged from 1 cm(2) to 24 cm(2), with the largest individual site measuring 12 cm(2). Twenty of 21 digits demonstrated 100% incorporation of the acellular dermal regeneration template skin substitute. One digit that had sustained multilevel trauma developed necrosis requiring revision amputation. Full-thickness epidermal autografting was performed an average of 24 days after acellular dermal regeneration template skin substitute application and demonstrated a 100% take in 16 of 20 digits and partial graft loss of 15% to 25% in 4 of 20 digits that did not require further treatment. CONCLUSIONS: Acellular dermal regeneration template combined with secondary full-thickness skin grafting is an effective method of skin reconstruction in complex digital injuries with soft tissue defects involving exposed bone, tendon, and joint. The neodermis increases tissue bulk and facilitates epidermal autografting with digital injuries that otherwise would require flap coverage or skeletal shortening of the digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reconstruction after flexor tendon injury: state of the art.

The methods used to treat intrasynovial flexor tendon injuries are the result of decades of clinical experience coupled with advances in understanding the biomechanical, physiologic, and cellular milieu of the repair. Successful treatment requires optimizing the factors that can be controlled and ameliorating those that cannot be controlled.

Repair of lacerated peripheral nerves with nerve conduits.

Peripheral nerve lesions are relatively common injuries encountered by hand surgeons. These injuries are notorious for causing significant and potentially long-standing impairment to hand function. Numerous surgical techniques with varying degrees of success have been described to treat this injury. The evolution of peripheral nerve repair has led to the development of the nerve conduit, a surgical technique that functionally bridges the gap between transected nerves. We discuss a brief history and evolution of nerve conduits and offer our preferred technique for peripheral nerve repair with a collagen nerve conduit. In addition, we offer case studies and postoperative rehabilitation goals and present early results associated with this type of repair.

Staged reconstruction for chronic rupture of both peroneal tendons using Hunter rod and flexor hallucis longus tendon transfer: a long-term followup study.

BACKGROUND: Long-term followup (over 5 years) of staged reconstruction for chronic ruptures of both peroneal tendons using a Hunter rod and the flexor hallucis longus (FHL) tendon is presented. METHODS: Seven patients with chronic ruptures of both peroneal tendons who had at least two previous surgeries that failed were treated with excision of the remaining portion of the peroneal tendons and implantation of a Hunter rod to the insertion of the peroneus brevis. Patients performed passive range of motion exercises for 3 months before removal of the Hunter rod and transfer of the FHL into the newly formed sheath, attaching it to the insertion of the peroneus brevis on the fifth metatarsal. The patients' ages ranged from 30 to 57 (average 38) years. All were women. All had at least two previous failed procedures (range two to six). The average time from initial injury to the index surgery was 4.6 (range 2 to 7) years. Patients were evaluated by physical examination and a questionnaire. The average range of followup was 8.5 years (range 143 to 167 months). RESULTS: All wounds healed without complications. One patient (a workers' compensation patient) had continued complaints of pain and ambulated with a molded ankle-foot orthosis (MAFO). The remaining six patients reported complete relief of symptoms and returned to full preinjury levels of activity. One patient required a Broström ankle ligament repair 2 years after tendon transfer for a new injury but has remained pain free for the last 62 months. There were five excellent, one good, and one fair result. All patients stated they would repeat the surgery. CONCLUSION: Staged reconstruction with excision of the remaining portion of the peroneal tendons and reconstruction with a Hunter rod and FHL transfer has been shown to be an effective long-term treatment for chronic peroneal tendon ruptures.

T-Pin for distal radius fracture.

Distal radius fractures are among the most common fractures treated by orthopedic surgeons. Numerous techniques have been devised to address these fractures and the factors associated with these injuries. The T-Pin (Union Surgical, LLC, Philadelphia, PA) is a novel instrumentation designed to use standard percutaneous techniques in the treatment of extra-articular distal radius fractures. The T-Pin allows for early active range of motion, as well as earlier return to functional activities. This article discusses the instrumentation, the techniques of insertion and extraction, and postoperative care.