Ultrasound visualization of the thumb annular pulleys: A cadaveric validation study.

BACKGROUND: The thumb annular pulley system is unique from the other digits and is integral to normal thumb function. Injuries to this pulley system can present a diagnostic challenge. No prior study has evaluated the ability of ultrasound (US) to evaluate all four thumb pulleys. OBJECTIVE: To validate the sonographic visualization of all four thumb pulleys. DESIGN: Prospective cadaveric laboratory investigation. SETTING: Academic center procedural skills laboratory. PARTICIPANTS: Twelve unembalmed cadaveric hands from seven adult male donors ages 78-89 years with body mass index 21.9-26.6 kg/m2 . INTERVENTIONS: Based on anatomic descriptions, a single examiner used a standardized protocol and high-frequency linear transducers to identify the A1, variable (Av), oblique (Ao), and A2 pulleys of the thumb in 10 cadaveric hands. As part of the validation process, the presumed Ao pulley was injected with diluted colored latex using US guidance. Two additional cadaveric specimens were dissected for detailed study of the thumb pulley system. MAIN OUTCOME MEASURES: Correlation between the four anatomic pulleys as revealed by dissection and the US findings, including identification of latex location with respect to the Ao pulley. RESULTS: US correctly identified all four thumb pulleys as distinct anatomic structures and the sonographic appearance of the pulleys correlated with the dissection in all 10 specimens. Latex was observed in the Ao pulley in 100% of the cadavers. CONCLUSIONS: Ultrasound can be used to accurately identify all four thumb pulleys, including distinct Ao and Av pulleys, and should be considered in the evaluation of thumb pulley injuries. This is the first study to validate the US visualization of the annular pulley system of the thumb.

Precontoured parallel plate fixation of AO/OTA type C distal humerus fractures.

OBJECTIVES: To determine the clinical effectiveness of precontoured parallel plating for the management of Orthopaedic Trauma Association (OTA) type C distal humerus fractures. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Between 2001 and 2005, 37 patients with OTA type C distal humerus fractures underwent open reduction and internal fixation exclusively with the Mayo Elbow Congruent Plating system. Thirty-two patients consented to participate in the study. INTERVENTION: All patients underwent open reduction and internal fixation with a precontoured bicolumn parallel plating system. MAIN OUTCOME MEASUREMENTS: Range of motion, Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score (DASH), complication rate, and radiographic evaluation. RESULTS: At a mean of 27 months follow up, the mean arc of elbow flexion-extension motion was 97 degrees (range, 10 degrees -145 degrees ). The mean Mayo Elbow Performance Score was 82 points and the mean DASH score was 24 points. There were no implant failures and all distal humerus fractures healed. A total of 24 complications occurred in 17 patients (53%) with five patients (16%) having postoperative nerve injuries. CONCLUSIONS: Open reduction and internal fixation with a precontoured parallel plating system is an effective treatment method for OTA type C distal humerus fractures. Despite this, the fact that over half of the patients had a significant complication will require utmost vigilance on the part of the surgeon to avoid intraoperative complications. Patient counseling is paramount.

The economic impact of electric saw injuries to the hand.

PURPOSE: Injuries from electric saws cause considerable hand trauma. This study is designed to provide information detailing the costs of these injuries. METHODS: The study was performed in a tertiary referral academic medical center. The records of patients injured by electric table saws were reviewed. Information regarding demographics, injury severity, medical expense, and time lost from work was analyzed. The patients were stratified by injury severity for further analysis. The mean wage for the region was used to estimate costs of time away from work. The Consumer Protection Agency's review was used to estimate the nationwide burden of these injuries. RESULTS: The study group included 134 patients. Of these patients, 126 were male and 8 were female. The dominant hand was injured in 20; the nondominant, in 114. The mean age was 47.0 years. The mean time lost from work was 64 days. The mean cost of medical expenses for all patients was $22,086, with $8,668 in lost wages, for a total of $30,754 mean cost per injury. The total economic burden for the injuries in this study is $4,121,097. These injuries represent a spectrum of severity, with minor injuries incurring lower hospital fees and requiring less time off work as compared to more involved injuries. CONCLUSIONS: Electric saws cause a wide spectrum of injuries that result in not only tremendous physical and emotional pain but also substantial economic impact as well. Technologies that would prevent such injuries would be a socioeconomic advancement. Federal mandates to implement such technologies should be encouraged.

Total knee arthroplasty after anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) injuries are common, and many of these patients go on to ACL reconstruction. At a later date, some may develop symptomatic osteoarthritis and require total knee arthroplasty (TKA). This raises the question: Does prior ACL reconstruction have a deleterious impact on the outcome of knee arthroplasty? Thirty-six cases of patients who underwent ACL reconstruction and then TKA at a later date were retrospectively reviewed. A cohort of patients without ACL injuries who underwent TKA for the diagnosis of primary osteoarthritis were selected to serve as controls. The results of this study demonstrate that previous ACL reconstruction does not have a negative impact on the outcome of future TKA with respect to range of motion, outcome scores, infection, or patella baja.

Pulmonary embolism following rotator cuff repair.

BACKGROUND: Previous studies have provided data on the incidence of pulmonary embolism following shoulder arthroplasty and repair of fractures of the proximal humerus. However, there is no information on the risk of pulmonary embolism following the surgical management of rotator cuff tears. METHODS: We performed a review of 1176 patients who underwent operative procedures for rotator cuff tears between January 1(st), 2001 and December 31(st), 2005 to identify all patients who developed a symptomatic pulmonary embolism postoperatively. RESULTS: Three patients developed pulmonary embolisms that were diagnosed with computed tomography angiography. The overall incidence was calculated to be 0.26%. None of the patients died as a result of the pulmonary embolism. CONCLUSIONS: The data from this review indicates that the risk of pulmonary embolism following surgery for rotator cuff repair is low, but not nonexistent. The most common presenting symptoms of pulmonary embolism were chest pain, shortness of breath, and hypoxia. This study should raise surgeons' awareness about this possible complication following rotator cuff repair surgery.

Clinical course of open metatarsal fractures.

Little information exists regarding open fractures of the foot and no studies have reported open metatarsal fractures. Limited local soft tissue coverage makes this a distinct type of injury. Ten patients with open metatarsal fractures were treated. Six sustained Gustilo Grade I or II injuries; all healed without the need for additional soft tissue coverage. Four patients with Gustilo IIIB developed complications and all went on to eventually require amputation. This data indicates less severe open metatarsal fractures heal without complications, but more severe injuries require amputation.

Pulmonary embolism after operative treatment of proximal humeral fractures.

There have been multiple studies on the prevalence of pulmonary embolism, the probability of death from a pulmonary embolism, and the risk factors for the development of pulmonary embolism after lower extremity and pelvic trauma. However, there is no information on the risk of pulmonary embolism after the surgical management of proximal humeral fractures. A review of 137 consecutive patients who underwent operative treatment for acute, isolated proximal humeral fractures at our institution between January 1, 1998, and December 31, 2003, was performed to identify all who sustained a pulmonary embolism. Postoperatively, 7 patients sustained a pulmonary embolism that was confirmed by computed tomography. Of these, 4 had been treated with a hemiarthroplasty and 3 had undergone open reduction-internal fixation. The overall incidence of pulmonary embolism in this series was 5.1%. None of the patients sustained a fatal pulmonary embolus. These data suggest that the rate of pulmonary embolism after operative treatment of proximal humeral fractures is not low. This study raises the question of whether prophylactic anticoagulation is needed after routine proximal humeral repair.

Arthroscopic treatment of gunshot wounds to the shoulder.

Two cases are presented that demonstrate the utility of arthroscopic intervention for the management of gunshot wounds to the shoulder. The first report involves a 24-year-old man with a retained bullet in his glenohumeral joint after a drive-by shooting The intra-articular bullet was retrieved arthroscopically avoiding chondral injury from the mechanical effects of a loose body as well as the potential local and systemic effects of lead toxicity. Irrigation and debridement was performed to evacuate joint debris, which could have served as a nidus for infection or inflammation. The other case describes a 19-year-old man who sustained a gunshot wound to the lateral portion of his upper arm resulting in a proximal humerus fracture along with a retained bullet in his subacromial space. The bullet was successfully removed arthroscopically avoiding a traditional exposure, which would have complicated his fracture care.