Supernumerary extensor pollicis longus tendon masking an extensor pollicis longus rupture following non-surgical treatment of a distal radius fracture.

Extensor pollicis longus tendon pathology is a recognised complication following non-surgical treatment of non-displaced distal radius fractures. Tendon entrapment typically presents with pain, but preservation of thumb retropulsion during complete rupture results in loss of active thumb retropulsion and tenodesis effect. We present the case of a 52-year-old woman who developed extensor pollicis longus tendon entrapment with full active thumb extension following a non-displaced distal radius fracture. During her elective third dorsal compartment release, the extensor pollicis longus tendon was found to be completely ruptured and a rare supernumerary extensor pollicis longus tendon was found emerging from the fourth dorsal compartment. Gentle traction of this tendon resulted in thumb interphalangeal joint extension and simultaneous index finger metacarpophalangeal joint extension. An extensor indicis proprius to extensor pollicis longus tendon transfer was performed. At her final 6-month follow-up, she had painless full active thumb motion comparable to her contralateral side.

Why Not Life and Limb? Vasopressor Use in Intensive Care Unit Patients the Cause of Acute Limb Ischemia.

Background: Acute limb ischemia (ALI) of the upper extremity is a rare yet severe condition in intensive care unit (ICU) patients that generally leads to amputation. The aim of this study is to determine risk factors for development of upper extremity limb ischemia in ICU patients requiring vasopressor support. Methods: This is a retrospective study conducted from 2010 to 2015. Patients who received vasopressors during ICU admission were considered for the study. Patients were identified via Current Procedural Terminology (CPT) billing codes. ALI patients were matched to control patients based on diagnosis and Acute Physiology and Chronic Health Evaluation II score. Days on pressors, number of pressors, total doses, and level of ischemia were recorded. Primary end point was doses, types, and days on vasopressors. Secondary end point was level of ALI. Results: Patients in the ALI group were more likely to be started on a higher number of different types of pressors (2.6 vs 1.3 pressors). ALI patients received pressors for 8.5 days compared with 1.6 days in control patients, and received 12.8 doses compared with 3.0 doses in control patients. In addition, vasopressors with alpha-adrenergic activity were more likely to be used in the ALI group. Level of ischemia was not linked to any of the tested variables. Conclusion: Patients admitted to the ICU are more likely to sustain an acute ischemic event of an upper extremity with more vasopressor usage. Patients who received alpha-adrenergic activating vasopressors were more likely to sustain limb ischemia. When discoloration of an extremity is detected, patients should receive counteractive treatments in an effort to salvage the extremity and prevent function loss.

MRSA Incidence and Antibiotic Trends in Urban Hand Infections: A 10-Year Longitudinal Study.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is the most reported pathogen in hand infections at urban medical centers throughout the country. Antibiotic sensitivity trends are not well known. The purposes of this study were to examine and determine the drug resistance trends for MRSA infections of the hand and to provide recommendations for empiric antibiotic treatment based on sensitivity profiles. Methods: A 10-year longitudinal, retrospective chart review was performed on all culture-positive hand infections encountered at a single urban medical center from 2005 to 2014. The proportions of all organisms were calculated for each year and collectively. MRSA infections were additionally subanalyzed for antibiotic sensitivity. Results: A total of 815 culture-positive hand infections were identified. Overall, MRSA grew on culture in 46% of cases. A trend toward decreasing annual MRSA incidence was noted over the 10-year study period. There was a steady increase in polymicrobial infections during the same time. Resistance to clindamycin increased steadily during the 10-year study, starting at 4% in 2008 but growing to 31% by 2014. Similarly, levofloxacin resistance consistently increased throughout the study, reaching its peak at 56% in 2014. Conclusions: The annual incidence of MRSA in hand infections has declined overall but remains the most common pathogen. There has been an alternative increase in the number of polymicrobial infections. MRSA resistance to clindamycin and levofloxacin consistently increased during the study period. Empiric antibiotic therapy for hand infections should not only avoid penicillin and other beta-lactams but should also consider avoiding clindamycin and levofloxacin for empiric treatment.

Forearm Compartment Syndrome: Evaluation and Management.

Compartment syndrome of the forearm is uncommon but can have devastating consequences. Compartment syndrome is a result of osseofascial swelling leading to decreased tissue perfusion and tissue necrosis. There are numerous causes of forearm compartment syndrome and high clinical suspicion must be maintained to avoid permanent disability. The most widely recognized symptoms include pain out of proportion and pain with passive stretch of the wrist and digits. Early diagnosis and decompressive fasciotomy are essential in the treatment of forearm compartment syndrome. Closure of fasciotomy wounds can often be accomplished by primary closure but many patients require additional forms of soft tissue coverage procedures.

Triggering of the abductor pollicis longus in association with deQuervain's tenosynovitis.

DeQuervain's tenosynovitis is a common cause of radial-sided wrist pain. Symptoms result from a narrow first dorsal compartment and associated tendinosis of the enclosed extensor pollicis brevis and/or abductor pollicis longus (APL). Surgical intervention, offered when conservative measures fail to adequately relieve symptoms, requires a detailed understanding of potentially aberrant anatomy in order to avoid persistence or recurrence of symptoms. We describe a case whereby the patient presented with complaints of thumb triggering in extension and associated disabling first dorsal compartment tendinosis. Intraoperatively, after supernumerary tendons were identified and addressed, the APL was at risk for subluxation over a prominent fibroosseous ridge. Routine first dorsal compartment release alone may have failed to address all of this patient's pathology.

The Effects of Early Antibiotic Administration on Bacterial Culture Growth From Hand Abscesses.

BACKGROUND: Traditional management of hand abscesses consists of withholding antibiotics prior to drainage to optimize bacterial culture growth and outcome. The purpose of this study was to determine the effect of preoperative empiric antibiotics on the rate of culture growth and rate of adverse events in patients with acute hand abscesses. METHODS: We performed a retrospective review of prospectively collected data on 88 consecutive hand abscesses that received empiric antibiotics prior to incision and drainage from 2012 to 2013 at an urban academic institution. We analyzed patient demographics, bacteriology, culture growth results, time to surgery, and frequency of adverse events. RESULTS: The overall rate of positive culture growth was 90% (n = 79) despite running the antibiotics for a mean of 31 hours prior to debridement. Furthermore, 96% of the isolates were given a susceptible antibiotic during that time. The mean number of debridements was 1.5 per patient, but 4 re-operations were necessary for wound complications. No patients required an amputation or were upgraded to intensive care. CONCLUSIONS: Preoperative empiric antibiotic administration does not appear to greatly reduce bacterial culture growth from hand abscesses. The adverse events are relatively few for simple abscesses treated with pre-surgical antibiotics and decompression within 24 hours.

Management of Major Traumatic Upper Extremity Amputations.

Traumatic upper extremity amputation is a life-altering event, and recovery of function depends on proper surgical management and postoperative rehabilitation. Many injuries require revision amputation and postoperative prosthesis fitting. Care should be taken to preserve maximal length of the limb and motion of the remaining joints. Skin grafting or free tissue transfer may be necessary for coverage to allow preservation of length. Early prosthetic fitting within 30 days of surgery should be performed so the amputee can start rehabilitation while the wound is healing and the stump is maturing. Multidisciplinary care is essential for the overall care of the patient following a traumatic amputation of the upper limb.

Povidone-iodine soaks for hand abscesses: a prospective randomized trial.

PURPOSE: To determine the effect of povidone-iodine soaks on outcomes of hand infections after operative drainage. METHODS: We performed a single-center, prospective, randomized trial to evaluate 100 consecutive hand infections. Forty-nine patients received povidone-iodine soaks 3 times daily, and 51 patients received only daily dressing changes. Outcome measures were the number of operations, readmissions, reoperations for wound complications, and days spent in the hospital. RESULTS: Patients treated with povidone soaks averaged 1.6 operations, and patients treated with daily dressing changes averaged 1.4 operations, a statistically insignificant difference. The mean number of operations was also not different between groups for the dorsal hand or dorsal finger abscess subcategories. No significant differences were found in length of stay, number of readmissions, or number of reoperations for wound complications. CONCLUSIONS: Povidone-iodine soaks are not helpful in the postoperative management of hand infections TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Intrinsic contracture of the hand: diagnosis and management.

Intrinsic contracture of the hand may result from trauma, spasticity, ischemia, rheumatologic disorders, or iatrogenic causes. In severe cases, the hand assumes a posture with hyperflexed metacarpophalangeal joints and hyperextended proximal interphalangeal joints as the contracted interossei and lumbrical muscles deform the natural cascade of the fingers. Considerable disability may result because weakness in grip strength, difficulty with grasping larger objects, and troubles with maintenance of hygiene commonly encumber patients. Generally, the diagnosis is made via history and physical examination, but adjunctive imaging, rheumatologic testing, and electromyography may aid in determining the underlying cause or assessing the severity. Nonsurgical management may be appropriate in mild cases and consists of occupational therapy, orthoses, and botulinum toxin injections. The options for surgical management are diverse and dictated by the cause and severity of contracture.

Evolving incidence of MRSA in urban hand infections.

Methicillin-resistant Staphylococcus aureus (MRSA) is the most commonly cultured bacteria in hand infections. Understanding the most common bacteria involved in hand infections allows appropriate and efficient administration of antibiotics. Delay in treatment may lead to increased morbidity, including stiffness, contracture, and amputation. The purposes of this study are to determine whether the incidence of MRSA in culture-positive hand infections continues to increase and whether MRSA is a risk factor for increased length of stay. Electronic medical records were queried to identify patients admitted to a large, academic urban medical center with the diagnosis of a hand infection between January 1, 2005, and December 31, 2009. Methicillin-resistant S aureus accounted for 220 of the positive cultures over the 5-year study period. Polymicrobial infection represented 81 positive cultures, and MRSA was only present in 10 of these cases. Patients with MRSA were found to have a mean length of hospital stay of 4.1 days compared with 4.5 days in non-MRSA infections. Understanding the most common bacteria involved in hand infections allows appropriate and efficient administration of antibiotics. Methicillin-resistant S aureus is the most commonly cultured bacteria in the hand. However, polymicrobial infections have become increasingly more common. Although incidences of polymicrobial infections increased over the study period in this series, clinical judgment should be exercised before initiating broad-spectrum antibiotic coverage.

Is antibiotic prophylaxis necessary in elective soft tissue hand surgery?

Antibiotic prophylaxis for clean soft tissue hand surgery is not yet defined. Current literature focuses on overall orthopedic procedures, traumatic hand surgery, and carpal tunnel release. However, a paucity of data exists regarding the role of antibiotic prophylaxis in a broader variety of soft tissue hand procedures. The goal of the current study was to evaluate the rates of surgical site infection following elective soft tissue hand surgery with respect to administration of prophylactic antibiotics.A multicenter, retrospective review was performed on 600 consecutive elective soft tissue hand procedures. Procedures with concomitant implant or incomplete records were excluded. Antibiotic delivery was given at the discretion of the attending surgeon. Patient comorbidities were recorded. Outcomes were measured by the presence of deep or superficial infections within 30 days postoperatively. The 4 most common procedures were carpal tunnel release, trigger finger release, mass excision, and first dorsal compartment release. The overall infection rate was 0.66%. All infections were considered superficial, and none required surgical management. In patients who received antibiotic prophylaxis (n=212), the infection rate was 0.47%. In those who did not receive prophylaxis (n=388), the infection rate was 0.77%. These differences were not statistically significant (P=1.00).

Interposition arthroplasty options for carpometacarpal arthritis of the thumb.

Carpometacarpal (CMC) arthritis of the thumb affects half of postmenopausal women and up to 25% of elderly men. This disease can cause significant disability in affected patients often necessitating surgical intervention. Various surgical options have been used to treat refractory CMC arthritis. Any successful surgical intervention must address three goals: removal of diseased joint surfaces, reconstruction of ligamentous stabilizers, and preservation of the joint space. In this article we will discuss various interposition arthroplasty options for CMC arthritis of the thumb.

Treatment of distal radius malunions with an intramedullary nail.

Malunion of the distal radius are the most common complications of distal radius fractures. Increased angulation of the distal radius can result in altered load concentrations on the wrist, decreased range of motion, decreased grip strength, and residual incongruence of the radiocarpal and distal radioulnar joints. Multiple options exist for fixation of corrective osteotomies of the distal radius, including intramedullary nails. The use of an intramedullary nail provides the benefits of a percutaneous insertion technique, low-profile implant, load-sharing design, and fixed-angle locking screws in the distal fragment. We describe an innovative technique for intramedullary fixation for corrective osteotomies of extraarticular distal radius malunions.

Intramedullary fixation of displaced distal radius fractures: a preliminary report.

PURPOSE: This study presents the preliminary experience of using an intramedullary nail for fixation of primarily extra-articular fractures and "simple" intra-articular fractures of the distal radius in 10 patients. This article will review the surgical technique, indications, and complications. METHODS: Ten patients (average age 55) with AO Type A and C distal radius fractures had fixation of the fracture with an intramedullary nail (Micronail, Wright Medical Technologies, Arlington, TN) with an average follow-up of 21 months (12-28 months). RESULTS: At final follow-up, the average volar tilt was dorsal angulation of 2.2 degrees (range, +10 degrees to -20 degrees ), radial inclination was 24.1 degrees (range, 20-34 degrees ), radial height was 12.1 mm (range, 11-14 mm), and ulnar variance was -0.6 mm (range, +2 to -2 mm). All cases maintained reduction of the fracture between immediate postoperative and final radiographs, except for 2 cases that had a loss of volar tilt by greater than 5 degrees , both in AO Type A3 fractures. Range of motion included wrist flexion of 67 degrees (range, 45-90 degrees ), wrist extension of 71 degrees (range, 45-80 degrees ), supination of 82 degrees (range, 70-90 degrees ), pronation of 85 degrees (range, 75-90 degrees ), radial deviation of 23 degrees (range, 10-30 degrees ), and ulnar deviation of 38 degrees (range, 15-45 degrees ). Grip strength of the injured limb relative to the uninjured limb was 91%. According to the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the results were 8 excellent, 1 good, and 1 poor. The average DASH score was 8.1 (range, 0-57). There were 2 cases of transient superficial radial sensory neuritis and 3 cases of screw penetration into the distal radioulnar joint (DRUJ), 1 leading to symptomatic late DRUJ arthritis. There were no cases of infection, tendon injury, hardware failure or removal. CONCLUSIONS: Our preliminary report finds that using the intramedullary nail in the treatment of displaced distal radius fractures can result in good functional outcome, but a high incidence of complications. We did not experience any long-term soft tissue problems. The indication for using the intramedullary nail should continue to be limited to extra-articular and simple intra-articular distal radius fractures until additional data can be obtained. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

CMC arthroplasty of the thumb: a review.

Arthritis of the first carpometacarpal (CMC) joint of the hand is a common and often debilitating disease. Diagnosis can be readily made with history, physical exam, and radiographic evaluation. Patients with advanced disease who have failed conservative treatment modalities have multiple surgical options including ligament reconstruction, resection arthroplasty, silicone implantation, tendon interposition, or total joint arthroplasty. This article will describe the variety of approaches to treatment as well as the author's preferred method.

Scaphoid fractures: dorsal versus volar approach.

Twenty-six patients with scaphoid fractures were treated with internal fixation using a cannulated differential pitch compression screw. Sixteen patients underwent a dorsal approach (group 1) 10 patients a volar approach (group 2). Average time from injury to surgery was 6.6 months (range: 0.3-19 months) for group 1 and 8.3 months (range: 0.3-24 months) for group 2. The rate of union, determined by radiographs and clinical examination, was 81% in group 1 and 80% in group 2. No significant differences were noted between the groups for dorsiflexion/palmar flexion, radial deviation, grip strength, and pain level.

Upper extremity limb-length discrepancy in brachial plexus palsy.

Residual limb shortening is common after obstetric brachial plexus palsy. The exact limb-length discrepancy remains undetermined, and the purpose of this paper is to determine the resultant discrepancy. Twenty-two skeletally immature patients with obstetric brachial plexus palsies were examined. Radiographs of both the involved and uninvolved humerii and forearms were obtained with a radiographic ruler placed adjacent to the extremity. Each limb segment was measured and the discrepancy calculated as a percentage compared with the normal side. Twenty-one of the 22 children had some shortening of the limb at both the humerus and forearm level. The involved limb averaged 92% of the uninvolved limb. The humeral length averaged 93% and the forearm length averaged 90%. Children with upper brachial plexus lesions had significantly less forearm and total limb shortening compared with those with global lesions. There was no correlation between age and percentage difference of the humeral, forearm, and total length.