Biomechanical Modeling of Connecting Intermetacarpal K-Wires in the Treatment of Metacarpal Shaft Fractures.

BACKGROUND: Clinical series have been published using the configuration of 2 intercarpal Kirschner wires (K-wires) adjacent to the fracture being connected, but biomechanical analysis is lacking. The objective of this pilot biomechanical study was to model and compare the effects of externally connecting 2 intermetacarpal K-wires for the stabilization of transverse metacarpal shaft fractures. Our research hypothesis was that the connected constructs would be stiffer than the unconnected K-wires. METHODS: A 3-dimensional computer-based model of small finger transverse metacarpal fracture stabilization was designed with 3 transverse 1.1 mm K-wires being anchored to the adjacent metacarpal. Three arrangements were tested: all 3 K-wires in parallel, the middle K-wire angled toward the proximal wire, and the middle angled K-wire being rigidly fixed to the proximal K-wire. The proximal wire was proximal to the fracture. A finite element analysis was performed by applying a cantilever force of 100 N at the head of the metacarpal. The metacarpal was considered to be uniform in composition with parameters typical for human bone. Kirschner wire parameters for stainless steel were used. Force (N) versus displacement was measured. RESULTS: The configuration with the middle angled K-wire being rigidly fixed to the proximal K-wire showed greater stiffness (12 N/mm) than nonattached constructs. The connected construct was 2.3 times more stiff than the unattached parallel construct and 2.5 times more stiff than angling the middle K-wire without attachment. CONCLUSIONS: In a computer model simulation, our results show that attaching 2 K-wires adjacent to the fracture provides more than twice the stiffness of unconnected K-wires.

Outcomes for late presenting lateral condyle fractures of the humerus in children: A case series.

BACKGROUND: Fractures of lateral condyle of humerus are very common in children. While the management of acute displaced and rotated lateral condyle fracture of humerus with early open reduction and internal fixation yields good results, the results of late treatment are less clear. We conducted this study to analyse the results of operative treatment of late presenting fractures and see if it is dependent on the patient's age, fracture type, or the time until treatment. MATERIALS & METHODS: A retrospective study of 40 patients with a symptomatic lateral condyle fracture beyond 3 weeks, who underwent open reduction and internal fixation between January 2002 and December 2011, was conducted. Fractures were described as per Jakob's classification. Patients radiographs were evaluated, and clinical evaluation was done with Mayo elbow scoring and Dhillon scoring system as well as range of motion. RESULTS: Thirty-nine fractures united with average time of 7.8 weeks except one who had previous surgery done for the fracture and developed avascular necrosis. The average Mayo score was 93 and average Dhillon score was 7.6. The average improvement in the arc of motion was 40.32° (77.3-117.6°). Younger age and shorter time to operation had a statistically significant but weak effect on outcomes. CONCLUSIONS: Functional outcomes of fractures managed surgically revealed good results, even in the fractures presenting more than 12 weeks after injury. Families with children presenting late should be offered ORIF to improve function and decrease symptoms.

Median Nerve Entrapment in the Ulna in a Both-Bone Pediatric Forearm Fracture: Case Report and Review of the Literature.

This case report presents entrapment with subsequent complete disruption of the median nerve in the distal ulna in a both-bone fracture of the forearm in a 9-year-old girl. Closed fractures of the radius and ulna commonly occur in pediatric populations. Postinjury nerve dysfunction is often seen. Severe nerve injury is rare. There are only 3 reports of the median nerve becoming entrapped in an ulnar fracture in a child, with no reports of entrapment in the distal forearm. Features seen on examination and the radiographs supported possible nerve entrapment. Although uncommon, nerve entrapment or transection should be considered in all forearm fractures with sensory or motor nerve dysfunction. If suspicions are high, an early diagnosis of nerve entrapment may be obtained with magnetic resonance imaging evaluation.

The Use of tPA in the Treatment of Frostbite: A Systematic Review.

BACKGROUND: The use of tissue plasminogen activator (tPA) for the treatment of frostbite has been reported and advocated, but its efficacy has not been well established. We conducted a systematic review to guide physicians on the role of tPA in the treatment of frostbite. Our hypothesis was that the use of tPA improves clinical outcomes, as measured by amputation rate. METHODS: We searched MEDLINE (PubMed) and EMBASE for primary research articles on the use of tPA for the treatment of extremity frostbite. Information related to study design, outcomes, and complications was extracted. A total of 204 citations were screened, and then 35 abstracts and 24 reports were reviewed. Fifteen studies met the standard for final review. RESULTS: One randomized, prospective study; 3 cohort studies; 8 case series; and 3 case reports were found. A total of 208 patients were treated. Differences in protocols, inclusion criteria, and outcomes measures prevented combining the study results. In all the studies, the authors reported that the use of tPA was or may have been useful in reducing amputation rates or increasing tissue salvage. Complication rates ranged from 0% to 100%, with a combined rate of 13%. The quality of the evidence was low. CONCLUSIONS: Due to the low scientific quality of the studies, the efficacy of tPA in reducing amputation rates cannot currently be established. Randomized, prospective trials or well-controlled cohort studies are needed to better assess the role of tPA. Consideration should be given to limiting its use to research protocols.

Offering the Influenza Vaccine in a Pediatric Hand Surgery Clinic Increases Vaccination Rates.

PURPOSE: The purpose of this study was to evaluate the utility of providing immediate access to the influenza vaccination for patients seen in a pediatric hand surgery clinic. Our hypothesis was that providing access would increase the rate of vaccination. METHODS: This pilot study was a randomized, controlled, prospective clinical trial that included all patients seen by a single surgeon, on a single day each week, in a hospital-based pediatric hand surgery practice clinic from October 18, 2016, to March 14, 2017. All patients between 6 months and 18 years of age seen during their initial visit during the study period were included. All patients were questioned on their vaccine status. For the intervention group, the influenza vaccine was offered. If requested, after providing educational materials, written consent from the parent or guardian was obtained. The vaccine was given by the registered nurse ordinarily assigned to the clinic. Demographic information and vaccine status for both groups at the end of clinic, including the date of receiving the vaccine, were recorded. RESULTS: Similar proportions of patients in each group had received the vaccine prior to being seen in the clinic. In the intervention group, 80 children (67%) had received the vaccine by the end of clinic, compared with 29 (25%) in the control group. Patients who were offered the vaccine had a statistically significant higher vaccination rate. Of the 80 patients in the intervention group who received the vaccine, 47 (59%) received it in the hand clinic. CONCLUSIONS: This project demonstrated that offering the influenza vaccine in a nontraditional setting, an outpatient hand surgery clinic, increased the proportion of patients receiving the vaccine. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Can Physical Examination Create a Stener Lesion?

BACKGROUND: The purpose of this study is to determine whether a Stener lesion can be created while testing stability of the ulnar collateral ligament (UCL) of the thumb. Testing was performed in a manner that reproduced clinical examination. METHODS: Six fresh frozen hand and forearm specimens underwent sequential sectioning of the accessory UCL, the proper UCL, and the ulnar sagittal band. Measurements of radial deviation of the metacarpophalangeal (MCP) joint were taken with the thumb in neutral rotation, pronation and supination, both with 0 degrees and with 30 degrees of flexion of the MCP joint. Visual examination was performed to assess the presence of a Stener lesion. RESULTS: No Stener lesion was created in any position as long as the fascial origin of the ulnar sagittal band at the adductor pollicis longus remained intact. After creating a defect in the ulnar sagittal band, a Stener lesion was created in two specimens, but only when the thumb was flexed and supinated. Pronation provided more stability, and supination provided less stability, with one or both components cut, especially when testing at 30° of flexion. Compared to both components cut without flexion or rotation, there was a statistically significant difference in angulation with the 30 degrees of MCP joint flexion in both neutral rotation in supination. CONCLUSIONS: Performing a physical examination to assess the amount of instability of an ulnar collateral ligament injury did not create a Stener lesion if the exam was performed in a controlled, gentle manner with the thumb held without rotation. If the thumb is held in neutral rotation during the exam, an iatrogenic Stener lesion should not be created.

Complications of Distal Phalanx Fractures in Children.

PURPOSE: To determine whether the incidence of complications varies between among types of distal phalangeal fractures in a pediatric population. METHODS: We retrospectively reviewed the medical records and radiographs of patients seen in the pediatric hand surgery clinic from 2011 to 2012 with a diagnosis of distal phalanx fracture. Patients were identified by International Classification of Diseases-Ninth Revision code (816.02 or 816.12). We reviewed 206 charts and included them in the study. Demographic data, location of the fracture, specific diagnosis, mechanism of injury, outcomes, and complications were recorded. The treating physicians clinically identified the outcomes and complications. RESULTS: Average age of patients was 7.5 years. Fracture distribution was tuft (37%), mallet (18%), Salter-Harris I/II (13%), shaft (11%), base (11%), Seymour (6%), Salter-Harris III/IV (2%), and tip amputation (1%). Complications occurred in 31% of patients. The highest rates were for Salter-Harris IV (100%), Seymour (62%), and mallet fractures (49%). There was a statistically significant difference in complication rate by diagnosis. The most common complications were infection (22%), stiffness (15%), and nail deformity (13%). CONCLUSIONS: Complications of distal phalanx fractures in children are frequent. The incidence varies by fracture type, the highest of which are for Salter-Harris IV, Seymour, and mallet fractures. Special care needs to be taken to reduce the complication rates of these common fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

An Experimental Survey on the Effect of Using the CTS-6 Tool on the Diagnosis of Carpal Tunnel Syndrome by Hand Surgeons.

BACKGROUND: This controlled randomized experiment tested the research hypothesis that providing the CTS-6 quantitative diagnostic information to hand surgeons affects the diagnosis of carpal tunnel syndrome. METHODS: Surgeon members of American Association for Hand Surgery participated in an online survey. Demographic and practice pattern information was collected. Few surgeons routinely use diagnostic questionnaires or algorithms. Each member was given four clinical scenarios. The respondents were randomized, The experimental group was given the same scenarios as the control group plus the quantitative results of the CTS-6 diagnostic tool. RESULTS: There were statistically significant differences between the groups in the diagnostic decisions. Using the CTS-6 quantitative diagnostic tool affected the diagnosis of carpal tunnel syndrome, especially for patients with the lowest number of findings associated with carpal tunnel syndrome. CONCLUSIONS: While accurate diagnostic decisions are dependent on the incorporation of all of the pertinent information gathered during the history and physical exams, the results of the CTS-6 may help the clinician focus their thinking and revise their diagnostic probabilities.

Epidemiology of Women's Flat Track Roller Derby Injuries in Kansas City.

This cross-sectional descriptive retrospective epidemiological pilot study determined the frequency, circumstances, type, and outcome of injuries in the members of a Kansas City women's flat track roller derby league. Injuries were reported by 79% of the respondents, with 50% having sustained multiple injuries. Medical attention was required by 64%. The risk of injury in the sport is high. Further study is needed to identify specific factors that can be modified to decrease the injury rate.

Biomechanical Comparison of 2 Methods of Intramedullary K-Wire Fixation of Transverse Metacarpal Shaft Fractures.

PURPOSE: To determine the relative importance of intramedullary wire (IMW) diameter and IMW number in conferring stability to a metacarpal fracture fixation construct. Our research hypothesis was that the stiffness of IMW fixation for metacarpal shaft fractures using a single 1.6-mm-diameter (0.062-in) wire would be greater than three 0.8-mm-diameter (0.031-in) wires. METHODS: Our study compared the biomechanical stiffness between one 1.6-mm K-wire and three 0.8-mm K-wires in a composite, fourth-generation, biomechanical metacarpal construct under cantilever testing to treat transverse metacarpal shaft fractures. Six composite bone-wire constructs were tested in each group using constant-rate, nondestructive testing. Stiffness (load/displacement) was measured for each construct. RESULTS: All constructs demonstrated a linear load-displacement relationship. Wires were all tested in their elastic zone. The mean stiffness of the 1-wire construct was 3.20 N/mm and the mean stiffness of the 3-wire construct was 0.76 N/mm. These differences were statistically significant with a large effect size. CONCLUSIONS: The stiffness of IMW fixation for metacarpal shaft fractures using a single 1.6-mm-diameter wire was significantly greater than using three 0.8-mm-diameter wires. CLINICAL RELEVANCE: When IMW fixation is clinically indicated for the treatment of metacarpal fractures, the increased stiffness of a single large-diameter construct provides more stability in the plane of finger flexion-extension.

Prospective comparison of the six-item carpal tunnel symptoms scale and portable nerve conduction testing in measuring the outcomes of treatment of carpal tunnel syndrome with steroid injection.

BACKGROUND: We prospectively studied patients clinically diagnosed with carpal tunnel syndrome (CTS) and treated with the injection of corticosteroid into their carpal tunnel in order to compare changes in the six-item CTS symptoms scale and portable nerve conduction study (NCS) parameters as outcome tools. Our pilot study was the first to assess the utility of the six-item CTS symptom scale (CTS-6) with steroid injections as a patient-directed outcome measure for the treatment of CTS. METHODS: We enrolled patients who presented to our county hospital orthopedic surgery clinic from August 2012 through August 2013. The patients were clinically diagnosed with CTS. After completing the six-item CTS symptoms scale questionnaire, portable NCS was obtained. Each patient then received an injection of 1 ml of triamcinolone acetonide 40 mg/ml mixed with 1 ml of 1 % lidocaine into the carpal tunnel. Six weeks postinjection, each patient repeated a CTS-6 questionnaire and underwent a repeat portable NCS. The CTS-6 and NCS results were analyzed using the paired samples t test. A Pearson correlation was used to assess the correlation between the changes in the CTS-6 and the NCS measurements. Statistical significance was set at P < 0.05. RESULTS: Thirty-two wrists in 20 patients were evaluated. There was a statistically significant difference between the CTS-6 scores before and after injection. There were also statistically significant changes in the five of the NCS parameters. None of the correlations between the CTS-6 and the NCS parameters were statistically significant. CONCLUSIONS: The six-item CTS symptoms scale and portable NCS are both useful measures for evaluating the results of steroid injections. The CTS-6 is an effective tool because of its ease of use, low cost, correspondence with changes in NCS, and ability to monitor the outcome of steroid treatment for carpal tunnel syndrome.

Radiographic indicators of a shared epiphysis in radial polydactyly.

BACKGROUND: Thumb epiphyses cannot be visualized on radiographs in infants with radial polydactyly, making it difficult to classify by Wassel type. The purpose of this study was to identify radiographic features that distinguish a separate epiphysis from a shared epiphysis. This may assist in operative planning and establishing prognosis. METHODS: The charts of 34 radial polydactyly patients treated with surgical reconstruction from 2008 through 2012 were retrospectively reviewed. Measurements of the most proximal bones involved in the duplication, including length, width at shaft, width at base, distance between radial and ulnar thumb, and angle between radial and ulnar thumb, were taken from PA radiographs of the thumb by four blinded individuals. The interclass correlation coefficient was calculated to determine inter-observer reliability. Operative notes were reviewed to distinguish between shared and separate epiphyses. Several indices were created from these measurements. RESULTS: Radiographic measurements showed high inter-observer reliability. There were statistically significant differences between patients with separate and shared epiphyses for indices for the width shaft index, interspace distance, the angle × interspace distance, and the angle × interspace index. CONCLUSION: Radiographic differences exist between children with separate and shared epiphyses. In patients with shared epiphyses, the radial thumb tends to be smaller, closer to the ulnar thumb, and less divergent. Threshold values were identified for predicting the status of the epiphysis based on the angle × interspace distance and the angle × interspace index. These values may be used to help determine in advance of surgery if a shared epiphysis exists.

Frostbite of the hand.

Frostbite is damage caused by the freezing of tissue owing to exposure to extreme cold. Clinically, it is often difficult to identify the severity of frostbite injury. There may be a wide discrepancy between the extent of damage to the skin versus that to the deeper structures. The initial clinical impression is usually worse than actual tissue damage. In addition to physical examination, diagnostic imaging, especially triple-phase bone scan, has been proposed to help differentiate between superficial and deep damage. Principles of treatment involve rapid rewarming to thaw the tissues and halt direct cellular damage, methods to minimize progressive dermal ischemia, and active wound care to promote timely healing. Pharmacological adjuncts, such as fibrinolytics, have been proposed to minimize tissue damage. Surgical therapy is postponed until there is clear demarcation between healthy and necrotic tissue.

Upper extremity injuries in Homer's Iliad.

Homer's Iliad remains a fascinating source of medical history. This epic poem, compiled around 800 BCE, describes several weeks of the last year of the 10-year siege of Troy (Ilion) by the Achaeans. Homer composed the epic by combining and formalizing oral poems, legends, customs, and experiences that originated in the later Mycenaean age (1600-1100 bce). The story centers on the rage of the great warrior Achilles. The Iliad remains the oldest record of Greek medicine and a unique source of surgical history. This study examines the upper extremity injuries described in the Iliad and compares them to those other sites of injury.

Thrombosis of digital arteries associated with tamoxifen use: case report.

Arterial thrombosis in the upper extremity occurs often at the wrist. We report a unique case of thrombosis that involved multiple digital arteries, without radial or ulnar artery involvement, which developed only after using tamoxifen despite chronic occupational blunt percussive hand use. Revascularization was achieved after thrombectomy. Multiple digital arterial thromboses may complicate the use of tamoxifen.

Polydactyly in the Southwest: art or anatomy-a photo essay.

Rock art in the Four Corners area often includes pictures of hands and feet, which may be representational or symbolic. There is correlation between actual metatarsal bones and carvings of polydactyl feet. No duplicated hand bones have been found, but we postulate petroglyphs of polydactyl hands are a reflection of a real congenital difference.

Astley Cooper: his life and surgical contributions.

Sir Astley Paston Cooper (1768-1841) was a successful and influential British surgeon during the early decades of the 19th century. He was a dedicated anatomist, an accomplished researcher, an inspiring teacher, and a skillful surgeon. Cooper published about the cause and treatment of Dupuytren's disease 10 years before Dupuytren. His contributions were widespread and substantially advanced the understanding and treatment of breast disease, vascular aneurysms, and abdominal wall hernias, along with orthopedic, otologic, and hand surgery. His contributions to surgical science have endured and are being used today.

César Roux and his original 1893 paper.

The Roux-en-Y type of gastrointestinal anastomosis, originated by the Swiss surgeon César Roux, is a valuable technique used in drainage of the stomach, esophagus, and the pancreatico-biliary tree. It is now frequently used in reconstructing the GI tract after resections for a number of diseases, and known by the general public due to its importance in bariatric surgery. This article presents, along with a brief biographical sketch, an English translation and discussion of Roux's original 1893 French report on gastrointestinal surgery that was published in Revue de Chirurgie.