Secondary Bony Defects after Soft Tissue Reconstruction in Limb-Threatening Lower Extremity Injuries: Does the Approach to Flap Elevation Matter?

BACKGROUND: Limb-threatening lower extremity injuries often require secondary bone grafting after soft tissue reconstruction. We hypothesized that there would be fewer wound complications when performing secondary bone grafting via a remote surgical approach rather than direct flap elevation. METHODS: A retrospective cohort study was performed at a single Level 1 trauma center comparing complications after secondary bone grafting in patients who had undergone previous soft tissue reconstruction after open tibia fractures between 2006 and 2020. Comparing bone grafting via a remote surgical incision versus direct flap elevation, we evaluated wound dehiscence requiring return to the operating room as the primary outcome. Secondary outcomes were deep infection and delayed amputation. RESULTS: We identified 129 patients (mean age: 40 years, 82% male) with 159 secondary bone grafting procedures. Secondary bone grafting was performed via a remote surgical approach in 54% (n = 86) and direct flap elevation in 46% (n = 73) of cases. Wound dehiscence requiring return to the operating room occurred in one patient in the flap elevation group (1%) and none of the patients in the remote surgical approach. The odds of deep wound infection (OR, 1.77; p = 0.31) or amputation (OR, 1.43; p = 0.73) did not significantly differ between surgical approaches. No significant differences were found in complications between the reconstructive surgeon elevating and re-insetting the flap and the orthopaedic trauma surgeon performing the flap elevation and re-inset. CONCLUSION: Direct flap elevation for secondary bone grafting after soft tissue reconstruction for open tibia fractures did not result in more complications than bone grafting via a remote surgical approach. These findings should reassure surgeons to allow other clinical factors to influence the surgical approach for bone grafting.

Risk Factors for Wound Failure After Primary Closure of Type IIIA Open Tibia Fractures.

The objective of our investigation was to explore risk factors associated with primary closure of type IIIA tibial fractures resulting in subsequent flap coverage. A retrospective study identified 278 patients with acute type IIIA open tibial fractures who underwent primary closure at a single center during an 8-year period. Treatment factors, including the number of debridements before closure, duration of external fixation, and timing of wound closure, were reported. The primary outcome was complication requiring unplanned operation of the study injury resulting in flap coverage. Fifty-five (20%) patients underwent flap coverage following complication after attempted primary closure. Patients who required a flap experienced a 42% complication rate after delayed flap coverage. The limb salvage rate was 95% for the study population. Three significant complication predictors were identified: 3 or more debridements before closure (odds ratio [OR], 29.8; 95% CI, 5.9-150.1; P<.001), wound closure more than 2 days after injury (OR, 9.8; 95% CI, 1.6-60.2; P=.01), and external fixation more than 14 days (OR, 7.3; 95% CI, 1.6-34.6; P=.01). Patients who had 3 or more debridements before closure had a 70.7% chance of having a complication resulting in a flap (29 of 41) compared with only a 6.8% chance of complication for those who had 2 or fewer debridements (14 of 205; P<.001). Risk factors for complication after primary closure of type IIIA open tibial fractures include number of debridements, wound closure after 2 days, and external fixation use for more than 14 days. Wounds requiring 3 or more debridements failed 70.7% after closure, suggesting alternative approaches should be considered in more severe cases. [Orthopedics. 2024;47(2):108-112.].

Preoperative Factors Associated With Worse PROMIS Pain Interference 2 Years After Hand and Wrist Surgery.

BACKGROUND: The purpose of this study was to identify preoperative factors associated with worse postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores 2 years after hand and wrist surgery. We hypothesized that older age, more comorbidities, increased substance use, and lower socioeconomic status would correlate with worse 2-year PROMIS PI scores. METHODS: This study was a retrospective review of prospectively acquired data on 253 patients. Surveys were administered within 1 week of surgery and 2 years postoperatively. Bivariate and multivariable analyses were conducted to identify significant predictors of worse 2-year PROMIS PI scores and change in PROMIS PI scores. RESULTS: Older age, higher body mass index, more comorbidities, lower preoperative expectations, more prior surgeries, unemployment, smoking, higher American Society of Anesthesiologists (ASA) score, and multiple other socio-demographic factors were correlated with worse 2-year PROMIS PI scores (P ≤ .018). Similar factors were also correlated with less improvement in 2-year PROMIS PI scores (P ≤ .048). Worse scores on all preoperative patient-reported outcome measures correlated with worse 2-year PROMIS PI scores (P ≤ .007). Multivariable analysis identified smoking history, less frequent alcohol consumption, worse preoperative PROMIS social satisfaction and Numeric Pain Scale whole body scores, and higher ASA scores as independent predictors of worse 2-year PROMIS PI. The same factors in addition to better baseline PROMIS PI were predictive of less improvement in 2-year PROMIS PI. CONCLUSION: Numerous preoperative factors were predictive of worse postoperative 2-year PROMIS PI and less improvement in 2-year PROMIS PI for patients undergoing hand and wrist surgery.

Preoperative Expectations in Hand Surgery Patients.

Introduction Studies have shown a link between patients' preoperative expectations and their postoperative satisfaction. However, limited studies exist concerning patient factors associated with higher preoperative expectations in the hand surgery population. This study analyzed preoperative expectation scores of patients undergoing hand surgery and aimed to determine associated patient characteristics. Materials and Methods A total of 418 elective hand surgery patients aged 15 years and older enrolled in a prospectively collected orthopaedic registry from June 2015 to December 2018 were analyzed. Patients were administered preoperative questionnaires including six Patient-Reported Outcome Measurement Information System domains and other activity and pain scales. Expectation scores were measured using the six domains of the Musculoskeletal Outcomes Data Evaluation and Management System expectations questionnaire. Bivariate and multivariable analyses were conducted to identify independent predictors of higher expectations. Results Overall, patients had high expectations (≥ 80.0) of their hand surgery. Higher mean expectation scores were seen with females, college graduates, better baseline health status, and fewer prior hand surgeries ( p < 0.05 for all). No significant associations were found among the Common Procedural Terminology codes and expectations. Multivariable analysis confirmed that college degree ( p = 0.023) and less pain ( p = 0.008) were predictive of higher baseline expectations. Conclusion In sum, more educated patients with less pain at baseline and better baseline health status have higher expectations of their hand surgery. Hand surgeons can use these results to help focus their preoperative counseling and expectation management.

Financial Toxicity Is Common in Patients After Tibia Fracture.

OBJECTIVES: To evaluate the presence of financial distress and identify risk factors for financial toxicity in patients after tibial shaft fracture. DESIGN: A cross-sectional analysis. SETTING: Level I trauma center. PATIENTS: All patients within 4 years after tibial shaft fracture (open, closed, or fracture that required flap reconstruction). INTERVENTION: Injury-related financial distress. MAIN OUTCOME MEASUREMENTS: Financial distress related to the injury, as reported by the patient in a binary question. Financial toxicity using the LIMB-Q, scored from 0 to 100, with higher scores indicating more financial toxicity. RESULTS: Data were collected from 142 patients after tibial shaft fracture [44% closed (n = 62), 41% open (n = 58), and 15% flap (n = 22)]. The mean age was 44 years (SD 17), 61% were men, and the mean time from injury was 15 months. Financial distress was reported by 64% of patients (95% confidence interval, 56% to 72%). Financial toxicity did not differ by fracture severity ( P = 0.12). Medical complications were associated with a 14-point increase in financial toxicity ( P = 0.04). Age older than 65 years (-15 points, P = 0.03) and incomes of $70,000 or more ($70,000-$99,999, -15 points, P = 0.02; >$100,000, -19 points, P < 0.01) protected against financial toxicity. CONCLUSION: We observed financial distress levels more than twice the proportion observed after cancer. Medical complications, lower incomes, and younger age were associated with increased financial toxicity. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

What Outcomes Are Most Important to Patients Following a Lower Extremity Limb-threatening Injury?

OBJECTIVE: To determine what outcomes are most important to patients after a limb-threatening injury, and if those preferences vary based on the patients' treatment (salvage vs amputation), health, demographics, or time since injury. BACKGROUND: The preferences that motivate the patients' choice of treatment following a limb-threatening injury are poorly understood. Discrete choice experiments (DCEs) are a robust survey methodology to quantify preferences. METHODS: Patients with a history of traumatic limb-threatening injury, January 2010 to December 2020, completed a survey with our DCE and the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. The DCE attributes included recovery time, function, appearance, cost, and time in hospital. We used conditional logit modeling to estimate the relative importance of each attribute on a scale of 0% to 100%, determine willingness to pay for improvements in the included attributes, and assess variation in preferences based on patient characteristics, including PROMIS score. RESULTS: A total of 150 patients completed the survey (104 limb salvage, 46 amputation; mean age, 48±16 years; 79% male). Regaining preinjury function [relative importance=41%; 95% confidence interval (CI), 37%-45%] and minimizing costs (24%; 95% CI, 21%-28%) were of greatest importance. Changes in appearance were least important (7%; 95% CI, 5%-9%). The hierarchy of preferences did not vary between those who had limb salvage or amputation, but patient age, physical and mental health, and income were associated with preference variation. CONCLUSIONS: Patients with limb-threatening injuries most valued gains in function and reduced out-of-pocket costs.

Use of the HemaClear™ elastic tourniquet reduces blood loss in operative treatment of humeral shaft fractures.

BACKGROUND: To determine if the use of a narrower elastic tourniquet compared to a standard pneumatic tourniquet reduces operative blood loss in the operative fixation of humeral shaft fractures. METHODS: This retrospective cohort study was performed at a level I trauma center and included 134 patients, aged 18 to 90 years, with a humeral shaft fracture treated with open reduction internal fixation (ORIF) from January 2007 through June 2018. The primary variable of interest was the application of a HemaClear™ elastic tourniquet versus a standard pneumatic tourniquet during the fixation of a humeral shaft fracture. The primary outcome was estimated blood loss (EBL) during the humerus ORIF surgery as recorded in the operative record. The secondary outcomes were total tourniquet time and operative time. The primary purpose of the study was to compare the above outcomes between the two tourniquet types. RESULTS: Estimated blood loss was 42% lower (95% CI: 11% to 73%, p < 0.01) in the elastic tourniquet group when compared to the standard pneumatic tourniquet group. The use of the elastic tourniquet was also associated with a 67% increase (95% CI: 35% to 100%, p < 0.01) in tourniquet time compared to the standard pneumatic tourniquet. No difference in the total operative time between the two groups (difference, -3%; 95% CI: -21 to 14, p = 0.72) was observed. CONCLUSION: Elastic tourniquet use was associated with 42% less blood loss in the fixation of humeral shaft fractures compared to use of a traditional pneumatic tourniquet, although this may be of unclear clinical importance given the relatively low estimated blood loss in this cohort. The potential benefit of reduced blood loss associated with the narrower elastic tourniquet is likely caused by the increased tourniquet time, without a change in overall operative time.

Iatrogenic thrombosis of the deep inferior epigastric artery during diagnostic angiography-a rare complicating factor during rectus free flap harvest.

We describe a 28-year-old man who sustained an open IIIB left ankle fracture dislocation with heel pad avulsion. The patient underwent formal angiography of the left lower extremity, followed by free tissue transfer of a rectus abdominis flap several days later. Intraoperatively, a thrombus was identified in the deep inferior epigastric artery above the femoral artery access site requiring thrombectomy. Histologic analysis estimated the thrombus age at 12 to 72 hours, raising concern that the thrombus was induced during angiogram instrumentation. Donor and recipient site-specific risks of arterial instrumentation (including invasive diagnostics) should be considered when planning free tissue transfer.

The impact of COVID-19 restrictions on participant enrollment in the PREPARE trial.

Background: At the initiation of the COVID-19 pandemic, restrictions forced researchers to decide whether to continue their ongoing clinical trials. The PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities) trial is a pragmatic cluster-randomized crossover trial in patients with open and closed fractures. PREPARE was enrolling over 200 participants per month at the initiation of the pandemic. We aim to describe how the COVID-19 research restrictions affected participant enrollment. Methods: The PREPARE protocol permitted telephone consent, however, sites were obtaining consent in-person. To continue enrollment after the initiation of the restrictions participating sites obtained ethics approval for telephone consent scripts and the waiver of a signature on the consent form. We recorded the number of sites that switched to telephone consent, paused enrollment, and the length of the pause. We used t-tests to compare the differences in monthly enrollment between July 2019 and November 2020. Results: All 19 sites quickly implement telephone consent. Fourteen out of nineteen (73.6%) sites paused enrollment due to COVID-19 restrictions. The median length of enrollment pause was 46.5 days (range, 7-121 days; interquartile range, 61 days). The months immediately following the implementation of restrictions had significantly lower enrollment. Conclusion: A pragmatic design allowed sites to quickly adapt their procedures for obtaining informed consent via telephone and allowed for minimal interruptions to enrollment during the pandemic.

Association of Radial Head Fracture Treatment With Long-Term Function.

BACKGROUND: Radial head fractures are often associated with poor outcomes. Both open reduction and internal fixation (ORIF) and radial head arthroplasty (RHA) might be considered in operative cases. This study aimed to compare long-term patient-reported functional outcomes among patients with operatively treated radial head fractures. METHODS: A cross sectional study conducted at a Level I trauma center was used to identify patients with a radial head fracture who underwent ORIF or RHA between 2006 and 2018, and agreed to complete a survey in 2020. The primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. RESULTS: Seventy-six patients participated in the study. No significant differences in outcomes were observed between groups. QuickDASH scores were similar for both groups (ORIF: mean = 15.7, SD = 18.4; RHA: mean = 22.8, SD = 18.6; mean difference = 0.2 [-9.0 to 9.3], P = .97). Nineteen (37%) ORIF patients and 12 (48%) RHA patients reported a need for pain medication (adjusted odds ratio [OR] = 0.8 [0.3-2.4], P = .70). Thirteen (25%) ORIF patients and 6 (24%) RHA patients required additional surgery (adjusted OR = 1.7 [0.5-6.2], P = .39). A subgroup analysis of multi-fragmentary fractures revealed similar findings. CONCLUSION: Patient-reported outcomes, which included a subgroup analysis of multi-fragmentary fractures, were similar between ORIF and RHA groups at an average of 7.5 years from surgery. Reconstructing the radial head might not result in worse outcomes than RHA when both options are employed according to the best judgment of the operating surgeon.

Acute Hematogenous Osteomyelitis Resulting in Atraumatic Pediatric Forearm Compartment Syndrome.

Acute hematogenous osteomyelitis is well described after minor trauma in the pediatric population, with an incidence of 1 to 13 cases per 100,000 individuals. Compartment syndrome (CS) in children is a rare, but potentially devastating disease, classified as "cannot miss diagnosis." Compared with adults, CS may exhibit a variable presentation with a wide range of symptoms in children, often leading to delayed diagnosis. Expeditious diagnosis and treatment of CS is paramount in minimizing adverse sequelae and maximizing potential functional outcome, regardless of etiology. Here, we present a rare case of atraumatic CS resulting from ruptured subperiosteal abscess secondary to acute hematogenous osteomyelitis in a pediatric male patient with 2 weeks of forearm pain and evolving neurologic deficits with initial delay in presentation to our facility. The ramifications of delayed diagnosis or misdiagnosis of CS emphasize the importance of a high index of suspicion despite atypical presentations in the pediatric patient.

Preoperative Opioid Use in Patients Undergoing Common Hand Surgeries.

BACKGROUND: The objectives of this study were to determine the baseline patient characteristics associated with preoperative opioid use and to establish whether preoperative opioid use is associated with baseline patient-reported outcome measures in patients undergoing common hand surgeries. METHODS: Patients undergoing common hand surgeries from 2015 to 2018 were retrospectively reviewed from a prospective orthopedic registry at a single academic institution. Medical records were reviewed to determine whether patients were opioid users versus nonusers. On enrollment in the registry, patients completed 6 Patient-Reported Outcomes Measurement Information System (PROMIS) domains (Physical Function, Pain Interference, Fatigue, Social Satisfaction, Anxiety, and Depression), the Brief Michigan Hand Questionnaire (BMHQ), a surgical expectations questionnaire, and Numeric Pain Scale (NPS). Statistical analysis included multivariable regression to determine whether preoperative opioid use was associated with patient characteristics and preoperative scores on patient-reported outcome measures. RESULTS: After controlling for covariates, an analysis of 353 patients (opioid users, n = 122; nonusers, n = 231) showed that preoperative opioid use was associated with higher American Society of Anesthesiologists class (odds ratio [OR], 2.88), current smoking (OR, 1.91), and lower body mass index (OR, 0.95). Preoperative opioid use was also associated with significantly worse baseline PROMIS scores across 6 domains, lower BMHQ scores, and NPS hand scores. CONCLUSIONS: Preoperative opioid use is common in hand surgery patients with a rate of 35%. Preoperative opioid use is associated with multiple baseline patient characteristics and is predictive of worse baseline scores on patient-reported outcome measures. Future studies should determine whether such associations persist in the postoperative setting between opioid users and nonusers.

Intramedullary Screw Fixation of Olecranon Fractures Reduces the Risk of Early Unplanned Reoperation: A Retrospective Review of 556 Patients.

OBJECTIVES: To determine the effect of intramedullary screw-based fixation on early postoperative complications after olecranon fractures. We hypothesized that intramedullary screw-based fixation results in decreased need for reoperation compared with plate and screw-based and tension band-based fixation. DESIGN: Retrospective cohort. SETTING: Two academic Level-1 trauma centers. PATIENTS/PARTICIPANTS: Five hundred fifty-six patients treated with a tension band-based, plate and screw-based, or intramedullary screw-based construct for an olecranon fracture over a 10-year period. INTERVENTION: Open reduction and internal fixation. MAIN OUTCOME MEASUREMENT: Unplanned reoperation. Demographic, injury type and severity, supplemental fixation, and length of follow-up data were viewed as potential confounders and analyzed as such. RESULTS: We identified 556 relevant patients. One hundred ninety-nine patients were treated with an intramedullary screw-based construct, 229 with a plate and screw-based construct, and 128 with a tension band-based construct. We observed significant differences in the age, fracture type, percentage of open fractures, use of supplemental fixation, and treating institution between the treatment groups. Ninety-five patients (17.1%) had an unplanned reoperation. When we adjusted for confounders, intramedullary screw-based fixation reduced the odds of an unplanned reoperation by 54% compared with plate and screw-based treatment. In the adjusted analysis, we did not observe a difference between plate and screw-based treatment and tension band-based fixation. CONCLUSIONS: Intramedullary screw-based fixation of olecranon fractures results in decreased need for early reoperation compared with more common olecranon fixation strategies. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Assessing Soft Tissue Perfusion Using Laser-Assisted Angiography in Tibial Plateau and Pilon Fractures: A Pilot Study.

OBJECTIVES: To determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. DESIGN: Prospective cohort study. SETTING: Academic trauma center. PATIENTS: Eight pilon fracture patients and 19 tibial plateau fracture patients who underwent open reduction internal fixation. MAIN OUTCOME MEASURES: Skin perfusion (fluorescence units) as measured by LA-ICGA. RESULTS: Six patients were classified as Tscherne grade 0, 9 as grade 1, 10 as grade 2, and 2 as grade 3. Perfusion decreased by 14 fluorescence units (95% confidence interval, -21 to -6; P < 0.01) with each increase in Tscherne grade. Sixteen patients underwent staged fixation with an external fixator (mean time to definitive fixation 14.1 days). The mean perfusion increased significantly at the time of definitive fixation by a mean of 13.9 fluorescence units (95% confidence interval 4.8-22.9; P = 0.01). CONCLUSIONS: LA-ICGA perfusion measures are associated with severity of soft tissue injury surrounding orthopaedic trauma fractures and appear to improve over time when fractures are stabilized in an external fixator. Further research is warranted to investigate whether objective perfusion measures are predictive of postoperative wound healing complications and whether this tool can be used to effectively guide timing of safe surgical fixation. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Implementing stakeholder engagement to explore alternative models of consent: An example from the PREP-IT trials.

INTRODUCTION: Cluster randomized crossover trials are often faced with a dilemma when selecting an optimal model of consent, as the traditional model of obtaining informed consent from participant's before initiating any trial related activities may not be suitable. We describe our experience of engaging patient advisors to identify an optimal model of consent for the PREP-IT trials. This paper also examines surrogate measures of success for the selected model of consent. METHODS: The PREP-IT program consists of two multi-center cluster randomized crossover trials that engaged patient advisors to determine an optimal model of consent. Patient advisors and stakeholders met regularly and reached consensus on decisions related to the trial design including the model for consent. Patient advisors provided valuable insight on how key decisions on trial design and conduct would be received by participants and the impact these decisions will have. RESULTS: Patient advisors, together with stakeholders, reviewed the pros and cons and the requirements for the traditional model of consent, deferred consent, and waiver of consent. Collectively, they agreed upon a deferred consent model, in which patients may be approached for consent after their fracture surgery and prior to data collection. The consent rate in PREP-IT is 80.7%, and 0.67% of participants have withdrawn consent for participation. DISCUSSION: Involvement of patient advisors in the development of an optimal model of consent has been successful. Engagement of patient advisors is recommended for other large trials where the traditional model of consent may not be optimal.

Immediate Weight Bearing of Plated Both-Bone Forearm Fractures Using Eight Cortices Proximal and Distal to the Fracture in the Polytrauma Patient Is Safe.

INTRODUCTION: Rehabilitation of trauma patients is facilitated by surgical stabilization permitting weight bearing (WB) of the fractured extremity. Both-bone forearm fracture (BBFx) plate osteosynthesis is an accepted technique with high union and low complication rates; yet, postoperative WB protocols have not been adequately investigated. There exists concern for increased complications in plated BBFx fractures for patients prescribed immediate WB. We hypothesized that immediate WB of surgically treated BBFxs results in acceptable rates of complications. METHODS: Patients presenting to a Level-1 trauma center from 2007 to 2016 with a BBFx were identified retrospectively. Patients were skeletally mature, surgically treated with prescribed immediate WB protocol, and followed for 6 months or to fracture union. Collected data included demographics, fracture characteristics, associated injuries, and WB protocols for all extremities. Complications recorded included nonunion, hardware failure, and infection. Standard statistical comparisons were used to evaluate the risk of complication in polytrauma patients with modified lower extremity WB protocols (polytrauma group) and patients with no lower extremity WB restrictions (isolated group). RESULTS: Two hundred thirteen patients were included with 75 (35%) females and 138 (65%) males. Mean age was 40 years and mean follow-up was 46 weeks. There were 142 (67%) patients in the poly-trauma and 71 (33%) patients in the isolated groups. In the poly-trauma group 21 (10%) patients had bilateral lower extremity WB restrictions. There were 11 (6%) complications noted: 2 non-unions, 4 hardware failures, and 5 infections. Demographics did not vary between the two groups. There was no difference in complications in the isolated (5.7%) versus poly-trauma groups (5.0%) (P = 0.75). CONCLUSION: Immediate WB rehabilitation after BBFx plate osteosynthesis seems to be safe and associated with low nonunion and complication rates. Our results demonstrate that polytrauma patients using ambulatory aids for lower extremity injuries can immediately WB without increased risk compared with isolated BBFx patients.

Surgical Elbow Dislocation Approach to the Distal Humerus for Apparent Capitellar and Lateral Condyle Fractures in Adults.

OBJECTIVES: Access to fractures of the distal humeral capitellum, trochlea, and lateral condyle is difficult through traditional approaches due to limited anterior articular exposure for direct reduction and fixation. The purpose of this study is to evaluate the relative articular exposure of a surgical dislocation (SD) approach to the distal humerus compared with olecranon osteotomy (OO). METHODS: Eight paired elbows from 4 cadavers underwent either SD or OO approach. Methylene blue staining demarcated visualized articular surface before disarticulation of the elbows. The main outcome measures were average visualized total distal humeral articular surface and anterior and posterior surface, and capitellar surface relative to the total surfaces was compared for each surgical approach using unpaired parametric t-tests. RESULTS: Intraclass correlation between raters was 0.995. The median exposed articular surface for SD and OO approaches was 90.0% and 62.8%, respectively. The overall exposure was significantly greater for the dislocation technique (P = 0.0003). With respect to specific regions of the distal humeral articular surface, SD allowed significantly greater visualization of the anterior surface (95.9% vs. 48.9%, P < 0.0001) and capitellum (100% vs. 40.4%, P < 0.0001). CONCLUSION: The surgical elbow dislocation approach to the distal humerus permits near total exposure of the anterior articular surface and the entire capitellum. Our data support this approach for anterior articular fractures of the distal humerus, to include those fractures that extend to the medial surface of the trochlea.

Double Spiral Dupuytren's Disease: Case of Ulnar and Radial Spiral Cords in Shared Digit.

Dupuytren's disease is a benign fibroproliferative disorder resulting in progressive contraction of palmar and digital fascia. Diseased fascia of the hand condenses into tensile cords, manifesting in various anatomical combinations. The spiral cord variant is especially troublesome, as the cord travels under the digital neurovascular bundle and places it at risk during surgical resection. In severe cases, limited fasciectomy is required to release contracture and restore finger extension. Here, we present the case of a 79-year-old right-handed man with a history of severe Dupuytren's disease of both hands, who was found to have ulnar and radial spiral cords in his right ring finger. Diseased tissue was removed en bloc, restoring extension and function. To our knowledge, this is the first case of a digit with two spiral cords affecting both neurovascular bundles. It is important to be aware of the anatomical variations possible in Dupuytren's disease to avoid iatrogenic injury.

Management of vasopressor induced ischemia.

PURPOSE: We evaluated a cohort of patients who developed vasopressor-induced limb ischemia and the management options to prevent progression or minimize morbidity of digital necrosis. METHODS: We reviewed all current literature on pressor-induced limb ischemia and report options for the management of patients requiring vasopressors who developed limb ischemia. We then retrospectively reviewed presentation, treatment, and short-term outcomes for patients at our tertiary referral academic medical center that developed this complication. Finally, we recommend guidelines for the tiered management of these complex patients. RESULTS: Thirty-six patients were included. Twenty-six patients (72%) required resuscitation with more than one vasopressor. Vasopressors were initiated for septic-shock (52.7%), cardiogenic-shock (16.7%), hypovolemic-shock (13.9%), acute transplant rejection (13.9%), and neurogenic-shock (2.8%). According to the tiered management recommendations, patients were managed with phase 1 care (19%), phase 2 care (8.3%), phase 3 care (50%) or phase 4 care (5.6%). The patient expired in the acute setting in 13.9% of cases. CONCLUSION: Life-saving vasopressors risk digital ischemia and necrosis. Early recognition, reporting, and treatment of this complication are important in minimizing morbidity. Using a tiered approach helps organize the healthcare team's management of this iatrogenic complication while respecting the treatment paradigm of "life over limb," and may be safely performed with acceptable outcomes.

Patients' preferences for occupational therapy after upper extremity fractures: a discrete choice experiment.

OBJECTIVE: Occupational therapy is often prescribed after the acute treatment of upper extremity fractures. However, high out-of-pocket expenses and logistical constraints can reduce access to formal therapy services. We aimed to quantify preferences of patients with upper extremity fracture for attending occupational therapy, when considering possible differences in clinical outcomes. DESIGN: Discrete choice experiment. SETTING: Level 1 trauma centre in Baltimore, Maryland, USA. PARTICIPANTS: 134 adult patients with upper extremity fractures. PRIMARY OUTCOME MEASURES: The scenarios were described with five attributes: cost, duration of therapy session, location of therapy, final range of motion and pain. We report the relative importance of each attribute as a proportion of total importance, and the willingness to pay for benefits of the therapy services. RESULTS: Of the 134 study participants, the mean age was 47 years and 53% were men. Cost (32%) and range of motion (29%) were the attributes of greatest relative importance. Pain (17%), duration of therapy (13%) and location of therapy (8%) were of lesser importance. Patients were willing to pay $85 more per therapy session for a 40% improvement in their range of motion. Patients were willing to pay $43 more per therapy session to improve from severe pain to mild pain. Patients were indifferent to whether the therapy treatment was home-based or in a clinical environment. CONCLUSIONS: When deciding on an upper extremity fracture therapy programme, out-of-pocket costs are a paramount consideration of patients. Improvements in range of motion are of greater importance than residual pain, the duration of therapy sessions and the location of service provision. Patients with upper extremity fracture should be prescribed occupational therapy services that align with these patients' preferences.