Dorsal Approach for Dorsal Impaction Distal Radius Fracture-Visualization, Reduction, and Fixation Made Simple.

Distal radius fractures with dorsal articular surface impaction comprise a difficult fracture pattern to operatively reduce using a standard volar approach. Distal radius open reduction internal fixation using a dorsal approach allows direct visualization and reduction. The surgical technique video presented demonstrates technical pearls for optimal visualization, reduction, and fixation.

Ulnar collateral ligament strain of the thumb metacarpophalangeal joint: biomechanical comparison of two postoperative immobilization techniques.

BACKGROUND: The aim of this study was to compare postoperative immobilization techniques of the thumb metacarpophalangeal (MP) ulnar collateral ligament (UCL) in a cadaver model of a noncompliant patient. METHODS: A cadaveric model with fresh-frozen forearms was used to simulate pinch under two immobilization conditions: (1) forearm-based thumb spica splint alone and (2) forearm-based thumb spica splint with supplemental transarticular MP Kirschner wire fixation. Pinch was simulated by thumb valgus loading and flexor pollicis longus (FPL) loading. Ulnar collateral ligament displacements were measured and strain values calculated. Statistical analysis was performed using a repeated measures analysis of variance model. RESULTS: With valgus thumb loading, we noted a significantly lower UCL strain in the splint and pin group compared to splint immobilization alone. Increased load was associated with a statistically significant increase in UCL strain within each immobilization condition. FPL loading resulted in negative displacement, or paradoxical shortening, of the UCL in both immobilization groups. CONCLUSIONS: While immobilized, valgus thumb force, as opposed to MP flexion, is a likely contributor to UCL strain during simulated pinch representing noncompliance during the postoperative period. Supplemental thumb MP pin fixation more effectively protects the UCL from valgus strain. UCL shortening with FPL loading likely represents paradoxical MP extension due to flexion of the distal phalanx against the distal splint, suggesting attempted thumb flexion with splint immobilization alone does not jeopardize UCL repair. CLINICAL RELEVANCE: This study provides a foundation to aid clinical decision-making after UCL repair. It reinforces the practice of surgeons who routinely pin their MP joints, but also brings to attention that the use of temporary MP pin fixation may be considered in difficult cases, such as those with potential noncompliance or tenuous repair.

Functional outcomes and height restoration for patients with multiple myeloma-related osteolytic vertebral compression fractures treated with kyphoplasty.

STUDY DESIGN: A retrospective review of pathologic vertebral fractures related to multiple myeloma. OBJECTIVE: To report the functional status and height restoration of 32 patients treated with kyphoplasty for multiple myeloma-related vertebral compression fractures. SUMMARY OF BACKGROUND DATA: Multiple myeloma can cause significant bony resorption, and vertebral involvement is extremely common. Compression fractures due to myelomatous vertebral metastases result in significant pain and can lead to kyphosis and sagittal imbalance. Nonoperative treatment can result in deformity and continued pain, and large surgical procedures have significant morbidity. Percutaneous cement augmentation (kyphoplasty and vertebroplasty) is a minimally invasive technique that can improve pain in these patients. Kyphoplasty also has the potential to provide mild deformity correction in addition to fracture stabilization. METHODS: Study participants were patients with biopsy-proven multiple myeloma presenting with compression fracture treated with kyphoplasty. Data were compiled from patient charts and preoperative and postoperative radiographs. Patient self-reported functional status were obtained through the use of the Oswestry Disability Index. The degree of vertebral body collapse and deformity was evaluated using the method of Genant and analyzed using paired Student t test. RESULTS: Thirty-two consecutive patients who underwent kyphoplasty at a total of 76 levels for myelomatous vertebral compression fractures were identified. Sixteen fractures were at the thoracolumbar junction. The mean age was 64.3 years. The average Genant grade for the involved levels improved from 1.9 preoperative to 1.53 postoperative, which was statistically significant (P<0.0001). The postoperative Oswestry Disability Index score was obtained at a mean of 24 months, with a mean of 29.6%. Complications occurred in 12 (37.5%) patients, all consisting of minimal intraoperative cement extravasation without clinical sequelae. No changes in the neurological status were observed. The average hospital stay was 1.34 days postprocedure. CONCLUSION: Kyphoplasty for vertebral compression fractures due to multiple myeloma is a safe and effective procedure that can lead to pain relief and vertebral height restoration.

Predictors of pain during and the day after corticosteroid injection for idiopathic trigger finger.

PURPOSE: Some patients report a transient increase in pain the day after a corticosteroid injection. We investigated factors associated with greater pain during and the day after a corticosteroid injection for idiopathic trigger finger. METHODS: A total of 100 patients with trigger finger completed questionnaires measuring heightened illness concern, catastrophic thinking, depression, perceived health, expected pain, pain with injection, and pain the day after injection. We performed bivariate analysis to determine variables associated with pain with injection, next-day pain, and next-day pain greater than 4 points on an 11-point ordinal scale. We entered variables with a significant correlation into multivariable linear regression models. RESULTS: The average pain with injection and the day after injection were 4.3 (SD 2.8) and 1.8 (SD 2.0), respectively. Expected pain, heightened illness concern, catastrophic thinking, depression, physician, and gender correlated with pain with injection. A multivariable regression model conducted in backward stepwise fashion demonstrated that physician, depression, expected pain, and female gender explained 28% of the variance in pain with injection. Pain with injection was the only significant predictor of next-day pain and pain greater than 4 points the day after injection. CONCLUSIONS: Our data suggest that psychosocial factors are the strongest correlates of pain with corticosteroid injection, but a large portion of the variability remains unexplained. Future research will investigate cognitive/behavioral methods for decreasing pain with injection. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

Meniscal repair with the MaxFire device: a cadaveric study.

OBJECTIVE: To use a cadaver model to evaluate an all-inside meniscal repair device (MaxFire). METHODS: Six fresh-frozen cadaveric knees (ages 30-84 years) without evidence of prior surgery were used for this study. The knees were rigidly mounted and arthroscopy performed using standard anteromedial and anterolateral portals. Four MaxFire devices were placed into the medial and lateral meniscus according to the technique provided by the manufacturer. The devices were placed in a vertical or horizontal mattress fashion systematically from posterior to anterior. Implants were placed from either the ipsilateral- or contralateral-portal at the discretion of each surgeon. Placement into the medial meniscus was performed with the knee in approximately 10° of flexion and into the lateral meniscus in 45° of flexion. RESULTS: In all, 54 MaxFire devices were placed. Twenty-six devices were used medially, and 28 laterally. Forty-five (83%) were placed successfully. Of those, 3 (7%) were placed in a "top hat" fashion. The nine failures (17%) were related to final device tensioning. Three of the sutures broke, one suture would not reduce, and three implants pulled out of the meniscus. The devices were successfully removed arthroscopically with a grasper or oscillating shaver. Pulling of implants out of menisci occurred in degenerative knees with degenerative meniscal tissue and did not occur with healthy appearing menisci. CONCLUSION: The MaxFire device is easy to use, has a low risk of complications, and can be inserted expeditiously by arthroscopy.

Shoulder sequelae of neonatal brachial plexus injuries: orthopedic assessment and management.

Brachial plexus birth palsy occurs at a rate of 1/1000-4/1000 live births despite advances in prenatal and obstetric care. The majority of children recover spontaneously, however some are left with permanent neurologic deficit. Shoulder pathology results from muscle imbalance created by pairing of weak or paralyzed muscles with unaffected muscle groups around the shoulder. This imbalance results in soft tissue contracture and can cause progressive glenohumeral joint morphological changes. Contractures of internal rotation are most common and may be a source of disability for the child. Treatment of the infant with brachial plexus palsy is initially centered around therapy and prevention of contracture. Surgical intervention can improve global shoulder function, and is reserved for patients who develop functionally limiting contractures, glenohumeral joint morphological changes, or findings of instability. A thorough physical examination, appropriate imaging, and assessment of the goals and expectations of the family are warranted prior to proceeding with any treatment course. The progressive and functionally limiting course of the shoulder sequelae in brachial plexus palsy emphasizes the need for early recognition and appropriate management. The purpose of this manuscript is to review orthopedic evaluation and management of neonatal brachial plexus palsy (NBPP) to promote early recognition and prompt referral.

Hinged external fixation of the elbow.

Hinged external fixation of the elbow provides the advantages of static fixation with the benefits of continued motion through the joint. Indications for the use of this method of fixation include traumatic instability, distraction interposition arthroplasty, instability after contracture release, and instability after excision of heterotopic ossification. Orthopedic surgeons should be familiar with hinged fixators and their application when faced with an unstable ulnohumeral joint.