Retrospective Review of Air Transportation Use for Upper Extremity Amputations at a Level-1 Trauma Center.

INTRODUCTION: Air transportation to tertiary care centers of patients with upper extremity amputations has been utilized in hopes of reducing the time to potential replantation; however, this mode of transportation is expensive and not all patients will undergo replantation. The purpose of this study is to review the appropriateness and cost of air transportation in upper extremity amputations. MATERIALS AND METHODS: Consecutive patients transported by aircraft with upper extremity amputations in a 7-year period at a level-1 trauma center were retrospectively reviewed. The distance traveled was recorded, along with the times of the injury, referral, transportation duration, arrival, and start of the operation. The results of the transfer were defined as replantation or revision amputation. RESULTS: Overall, 47 patients were identified with 43 patients going to the operating room, but only 14 patients (30%) undergoing replantation. Patients arrived at the tertiary hand surgery center with a mean time of 182.3 minutes following the injury, which includes 105.2 minutes of transportation time. The average distance traveled was 105.4 miles (range, 22-353 miles). The time before surgery of those who underwent replantation was 154.6 minutes. The average cost of transportation was $20,482. DISCUSSION: Air transportation for isolated upper extremity amputations is costly and is not usually the determining factor for replantation. The type of injury and patients' expectations often dictate the outcome, and these may be better determined at the time of referral with use of telecommunication photos, discussion with a hand surgeon, and patient counseling. LEVEL OF EVIDENCE: III.

Nerve entrapment syndromes in musicians.

Nerve entrapment syndromes are common in instrumental musicians. Carpal tunnel syndrome, ulnar neuropathy at the elbow, and thoracic outlet syndrome appear to be the most common. While electrodiagnostic studies may confirm the diagnosis of nerve entrapment, they may be falsely normal in musicians. Non-operative treatment with instrument and technique modification may help. Involvement with the musician's teacher to implement appropriate treatment is recommended. Outcomes for both non-operative and operative treatment for various nerve entrapment syndromes have yielded mostly good to excellent results, similar to the general population.

Reliability and accuracy of templating humeral and ulnar components for total elbow arthroplasty.

We conducted a study to examine intraobserver reliability, interobserver reliability, and accuracy of preoperative templating in approximating humeral and ulnar component sizes in total elbow arthroplasty (TEA). Twenty-two patients underwent cemented TEA with 1 of 2 commonly used implants. Four independent reviewers performed templating in 2 separate sessions spaced a minimum of 2 weeks apart. Reviewers were blinded to patient information and used appropriately magnified templates provided by the implant manufacturer. Preoperative and postoperative films were assessed for humeral and ulnar stem width and length. For both implants combined, there was substantial (κ > 0.7) intraobserver reliability for humeral width, humeral length, and ulnar length. Interobserver reliability was fair for humeral width (κ = 0.28), substantial for humeral length (κ = 0.64), and moderate for both ulnar width (κ = 0.44) and ulnar length (κ = 0.49). Preoperative templating accurately predicted exact stem size 72.7% of the time and within 1 size variation 96.9% of the time. Attending surgeons were slightly more accurate than fellows (75.5% vs 71.5%) in predicting stem sizes. Preoperative templating is moderately reliable and largely accurate in planning TEA.

Displaced dorsal metaphyseal cortex associated with delayed extensor pollicis longus tendon entrapment in a pediatric Smith's fracture.

Extensor pollicis longus (EPL) tendon entrapment has been rarely reported as a complication of closed treatment of a pediatric Smith's type distal radius fractures. This article presents the unique case of an initially functional EPL tendon that became entrapped in fracture callus in a 9-year-old boy, the youngest reported in the literature.

Outcomes of hook of hamate fracture excision in high-level amateur athletes.

PURPOSE: To determine the overall long-term postoperative clinical and functional results of high-level amateur athletes after hook of hamate excision, based on complications; return to sport; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and a self-reported questionnaire. METHODS: We evaluated 11 patients representing 12 cases of hook of hamate excision. All patients were high-level amateur athletes (rising collegiate or collegiate level). We performed a retrospective chart review to elicit information pertaining to the patient's injury. We assessed long-term postoperative outcomes with a self-reported questionnaire, the DASH form, and the DASH Sport/Performing Arts Module form. RESULTS: All patients successfully returned to full participation in their respective sports an average of 6 weeks after surgery. The average postoperative DASH score was less than 1, and all patients scored a 0 on the DASH Sports form. There was a significant improvement in preoperative pain after surgical intervention. There was no significant difference between preinjury and postoperative performance scores. Finally, every patient was very satisfied with the surgical outcome. There was only 1 postoperative complication in which a patient developed transient ulnar nerve paresthesias, which completely resolved by 6 weeks after surgery. CONCLUSIONS: Surgical excision of hook of hamate fractures in high-level amateur athletes allows for successful return to sports participation at preinjury performance levels, achievement of normal function as measured by validated objective outcome measures, significant reduction in pain, and high overall patient satisfaction. We consider surgical excision to be a safe and effective technique to restore normal function and hasten return to play for high-level amateur athletes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Radiographic outcomes of volar locked plating for distal radius fractures.

PURPOSE: To assess the ability of volar locked plating to achieve and maintain normal radiographic parameters for articular stepoff, volar tilt, radial inclination, ulnar variance, and radial height in distal radius fractures. METHODS: We performed a retrospective review of 185 distal radius fractures that underwent volar locked plating with a single plate design over a 5-year period. We reviewed radiographs and recorded measurements for volar tilt, radial inclination, ulnar variance, radial height, and articular stepoff. We used logistic regression to determine the association between return to radiographic standard norms and fracture type. RESULTS: At the first and final postoperative follow-up visits, we observed articular congruence less than 2 mm in 92% of fractures at both times. Normal volar tilt (11°) was restored in 46% at the first follow-up and 48% at the final one. Radial inclination (22°) was achieved in 44% at the first follow-up and 43% at the final one, and ulnar variance (01 ± 2 mm) was achieved in 53% at the first follow-up and 53% at the final one. In addition, radial height (14 ± 1mm) was restored in 14% at the first follow-up and 12% at the final one. More complex, intra-articular fractures (AO class B and C and Frykman types 3, 4, 7, and 8) were less likely to be restored to normal radiographic parameters. However, because of the small sample size for some fracture types, it was difficult to discover significant associations between fracture type and radiographic outcome. CONCLUSIONS: Volar locked plating for distal radius fractures achieved articular stepoff less than 2 mm in most fractures but only restored and maintained normal radiographic measurements for volar tilt, radial inclination, and ulnar variance in 50% of fractures. The ability of volar locked plating to restore and maintain ulnar variance and volar tilt decreased with more complex intra-articular fracture types. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Hand and body radiation exposure with the use of mini C-arm fluoroscopy.

PURPOSE: To determine whole body and hand radiation exposure to the hand surgeon wearing a lead apron during routine intraoperative use of the mini C-arm fluoroscope. METHODS: Four surgeons (3 hand attending surgeons and 1 hand fellow) monitored their radiation exposure for a total of 200 consecutive cases (50 cases per surgeon) requiring mini C-arm fluoroscopy. Each surgeon measured radiation exposure with a badge dosimeter placed on the outside breast pocket of the lead apron (external whole body exposure), a second badge dosimeter under the lead apron (shielded whole body exposure), and a ring dosimeter (hand exposure). RESULTS: Completed records were noted in 198 cases, with an average fluoroscopy time of 133.52 seconds and average cumulative dose of 19,260 rem-cm(2) per case. The total measured radiation exposures for the (1) external whole body exposure dosimeters were 16 mrem (for shallow depth), 7 mrem (for eye depth), and less than 1 mrem (for deep depth); (2) shielded whole body badge dosimeters recorded less than 1 mrem; and (3) ring dosimeters totaled 170 mrem. The total radial exposure for 4 ring dosimeters that had registered a threshold of 30 mrem or more of radiation exposure was 170 mrem at the skin level, for an average of 42.5 mrem per dosimeter ring or 6.3 mrem per case. CONCLUSIONS: This study of whole body and hand radiation exposure from the mini C-arm includes the largest number of surgical cases in the published literature. The measured whole body and hand radiation exposure received by the hand surgeon from the mini C-arm represents a minimal risk of radiation, based on the current National Council on Radiation Protection and Management standards of annual dose limits (5,000 mrem per year for whole body and 50,000 mrem per year to the extremities).

Driving with an arm immobilized in a splint: a randomized higher-order crossover trial.

BACKGROUND: The aim of this study was to determine whether immobilization of an arm has detrimental effects on driving performance. METHODS: Thirty-six healthy officers-in-training were assigned a sequence of fiberglass splints (left and right-sided above-the-elbow thumb spica and below-the-elbow splints) with use of a randomized higher-order crossover design. Runs were scored on a cone-marked driving course used for officer certification with predetermined passing requirements. Driving time, the number of cones hit per course section, and the cone-adjusted total time (a five-second penalty per hit cone) were recorded. A linear mixed-effect model with random environmental and learning effects for cone-adjusted time analysis was used. Participants rated perceived driving difficulty and safety with each splint, and ratings were compared with the Wilcoxon signed-rank test. RESULTS: Thirty participants completed the entire set of runs. Analysis of total cone-adjusted time revealed a significant performance decrease with the left arm in an above-the-elbow thumb spica splint (average, 22.2 seconds; p < 0.001) and with the left arm in a below-the-elbow splint (average, 16.2; p = 0.007). Analysis of forward-only course sections revealed poorer performance trends with all splints, with the worst performance with the left arm in an above-the-elbow thumb spica splint. Driving with the left arm in an above-the-elbow thumb spica splint had the highest perceived difficulty (median, 8.0) and lowest perceived safety (median, 3.0). CONCLUSIONS: Driving performance as measured with a standardized track and scoring system was significantly degraded with splint immobilization of the left arm. Further studies are required to determine the effect of arm immobilization on normal driving conditions.

Precontoured fixed-angle volar distal radius plates: a comparison of anatomic fit.

PURPOSE: To compare distal radius volar fixed-angle plates for anatomic fit. METHODS: Twenty embalmed radii were stripped of soft tissues. The volar lip (watershed line) on the volar distal radius served as a reference line. Seven volar fixed-angle plates were tested (Acumed Acu-loc Standard, Hand Innovations DVRAW and DVRAN, Synthes Juxta-articular [JA], Synthes Extra-articular [EA], Trimed Volar Bearing, Zimmer Volar Lateral Column). Four parameters of anatomic fit were studied: (1) site of best fit; (2) percent plate contact; (3) pin-subchondral bone distance; and (4) extraosseous penetrations. The Wilcoxon signed rank test and Pearson's correlation coefficient were used to compare interobserver plate placement. A Kruskal-Wallis analysis of variance was used to compare percent plate contact and pin-subchondral bone distance across all plates. The Bonferroni correction for multiple comparisons was used to compare pin-subchondral bone distances for all possible plate combinations. RESULTS: There was no difference between observers for plate placement. Each plate had a specific site of best fit, and the 7 plates varied widely in best fit location. Percent contact (range, 3% to 6%) between plates was significantly different. Pin-subchondral bone distance across all plates was significantly different. Analysis of all possible plate combinations showed that the Synthes EA pin-subchondral bone distances were significantly different than those of all plates except Zimmer. Amongst the 140 plate insertions, the radiocarpal joint was penetrated in 17, the styloid in 7, (with 6 associated with the DVRAW plate), and the distal radioulnar joint in 9 (all associated with the DVRAW plate). CONCLUSIONS: There was considerable variation in ideal plate location among the 7 plates tested. Total contact was minimal for all plates tested. The Synthes EA pin-subchondral bone distance was significantly greater than those of other plates tested. Joint penetration was relatively common, necessitating use of fluoroscopy and proper plate width.

Management of acute complex instability of the elbow with hinged external fixation.

We report the experience of a single surgeon who treated 20 patients, over a 9-year period, with acute complex instability of the elbow with hinged external fixation. Patients who presented greater than 6 months after the original injury were excluded. The mechanism of injury was typically a fall or a motor vehicle accident. Fixators were placed at a mean of 26 days (range, 0-66 days) after injury and initial management. Reconstruction of the collateral ligaments was not performed, but soft tissues were repaired en bloc to the humerus. All patients were available for follow-up at a mean of 2.1 years. Flexion-extension arcs averaged 93 degrees , whereas pronation-supination arcs averaged 96 degrees. Posttraumatic arthrosis was commonly seen at follow-up, with moderate or severe changes developing in 55% of patients. Arthrosis did not correlate with functional outcomes, however. Outcomes were measured by use of the Mayo Elbow Performance Index and the Hospital for Special Surgery Total Elbow Scoring System, with mean scores of 75 and 71 points, respectively. Although the severity of injury often precludes obtaining a high percentage of good and excellent results, the outcomes after treatment of acute complex elbow instability with hinged external fixation by use of the technique detailed in this series are comparable to those of similar series.

Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation.

BACKGROUND: Bioabsorbable implants have restricted indications because of their unique biochemical properties and their inferior biomechanical properties compared with those of conventional metallic implants. The purpose of this prospective study was to assess the efficacy of screws made of polylevolactic acid (PLLA) in the treatment of syndesmotic disruptions associated with ankle fractures and fracture-dislocations. METHODS: Thirty-three consecutive patients with a syndesmotic disruption were managed with standard metallic plate-and-screw fixation of the malleolar fracture and with 4.5-mm polylevolactic acid screws, with purchase in four cortices, for fixation of the syndesmosis. Intraoperative radiographs confirmed reduction of the syndesmosis, and all of the patients were managed with a non-weight-bearing plaster splint or brace for six weeks. Clinical and radiographic assessment and functional evaluation with use of the Olerud-Molander scoring system were performed at the time of follow-up. RESULTS: Ten patients were lost to follow-up prior to the twenty-four-month evaluation, leaving twenty-three patients with an average duration of follow-up of thirty-four months (range, twenty-four to forty-three months). All of the malleolar fractures healed in an anatomical position at an average of three months, and no postoperative displacement of the syndesmosis or widening of the medial clear space was detectable on radiographs. No episodes of osteolysis or late inflammation secondary to the hydrolyzed polylactide occurred. Nineteen patients (83%) had an excellent result, and four patients (17%) had a good result. All twenty-three patients returned to their preinjury level of work and activities of daily living. No patient had malunion, nonunion, loss of reduction, or complications attributable to the biomechanical or biochemical properties of the implants. CONCLUSIONS: Polylevolactic acid screws are effective in stabilizing disruption of the syndesmosis during healing of unstable ankle fractures. In this small series, the bioabsorbable screw was well tolerated, and there was no need for a second operation to remove it.