Recalcitrant trigger finger managed with flexor digitorum superficialis resection.

Although trigger finger is a condition commonly treated by orthopedic surgeons, we have not found sufficient studies in the literature addressing the treatment of trigger finger that persists following A1 pulley release. We identified 12 fingers in 11 patients with symptoms of trigger finger following A1 pulley release who subsequently underwent resection of 1 or both slips of the flexor digitorum superficialis tendon. Ten patients (11 fingers) presented for follow-up at a mean of 21 months after surgery. All patients had resolution of their symptoms with a mean visual analog score of 1.5 and a mean DASH score of 17. Grip and pinch strength were comparable to the contralateral side. Mean total active range of motion of the affected digit was 252°. Resection of 1 or both slips of the flexor digitorum superficialis is an effective method for treatment of recalcitrant trigger finger.

Extracorporeal membrane oxygenation for diffuse alveolar hemorrhage and severe hypoxemic respiratory failure from silicone embolism.

Liquid silicone is an inert material that may be used for cosmetic procedures by physicians as well as illegally by non-medical personnel. The use of silicone may result in severe complications, disfigurement, and even death. In addition, the indications for extracorporeal membrane oxygenation (ECMO) support have been increasing as a salvage therapy for a variety of life-threatening conditions. The patient is a 27-year-old woman with no significant medical conditions who developed silicone emboli, and subsequent diffuse alveolar hemorrhage after being injected with silicone in her gluteal region without medical supervision. She became profoundly hypoxemic and suffered a brief asystolic cardiac arrest in this setting. The patient was placed on veno-venous ECMO support for 14 days. Medical care during ECMO was complicated by pulmonary hemorrhage, hemothorax, pneumothorax, and blood clot, resulting in oxygenator change-out. A modified adult ECMO circuit (Jostra QuadroxD, Maquet Cardiopulmonary, Rastatt, Germany) was used to transport the patient from a nearby community affiliate hospital and then reconfigured for the medical intensive care unit on a standard HL-20 heart-lung console. Although the use of ECMO for severe hypoxemic respiratory failure has been widely reported, to our knowledge, this is the first reported successful use of ECMO for silicone embolism syndrome associated with diffuse alveolar hemorrhage and severe hypoxemic respiratory failure.

Combined dislocation of the trapezium and the trapezoid: a case report with review of the literature.

Dislocation of the either the trapezium or the trapezoid are both rare injuries, even among carpal dislocations. We report a case of combined volar trapezium dislocation and dorsal trapezoid dislocation with other concomitant injuries. A review of the literature regarding trapezium and trapezoid dislocations as well as the treatment of these injuries is presented.

Ossification of the proximal humerus in children with residual brachial plexus birth palsy: a magnetic resonance imaging study.

BACKGROUND: Children with residual brachial plexus birth palsy may develop deformities of the humeral head and the glenoid. Surgical treatment has been described to maximize function and to lessen deformity by means of glenohumeral remodeling. The timing and technique of surgical intervention have not been resolved. The timing of the appearance on magnetic resonance imaging of the ossific nuclei in patients with brachial plexus birth palsy has not been described. We examined the timing of ossification about the proximal humerus. Our hypothesis was that the timing of ossification of the proximal humerus differs between the side involved in brachial plexus palsy and the uninvolved side. METHODS: A retrospective study was performed of 117 children with residual brachial plexus birth palsy (aged 5 mo to 10 y) who had magnetic resonance imaging scans of the bilateral shoulders performed at our institution between 2000 and 2007. All axial slices were reviewed by a single observer for evidence of ossification of the humeral head epiphysis, the greater tuberosity, and the lesser tuberosity, as well as for evidence that the 3 were coalesced. Statistical analysis was performed to compare the involved and uninvolved sides. RESULTS: The appearance of the greater tuberosity ossific nucleus on the involved side was significantly delayed. There was a trend towards delay in the appearance of the lesser tuberosity ossific nucleus and the coalescence of the 3 ossific nuclei on the involved side. The duration during which ossification of the involved brachial plexus side occurred was generally shorter compared with the uninvolved side. CONCLUSION: There is delay in the ossification of the involved side in brachial plexus birth palsy, and a shorter duration of ossification.

The biceps tendon as a measure of rotational deformity in residual brachial plexus birth palsy.

BACKGROUND: Children with residual brachial plexus birth palsy often develop internal rotation contractures with subsequent glenohumeral dysplasia seen on axial imaging. Coronal deformity (characterized by humeral head subluxation), and angular deformity (characterized by glenoid retroversion) have been defined. We hypothesize that the location of the biceps tendon characterizes rotational deformity. METHODS: A retrospective study was performed on 91 children (average age 3.2+/-2.2 y) who lacked external rotation beyond neutral and had magnetic resonance imaging (MRI) scans of bilateral shoulders performed at our institution between 2000 and 2007. The charts were reviewed for the measurement of the external rotation of the involved shoulder with the arm adducted and the scapula stabilized. The glenoscapular angle (glenoid version), the percentage of the humeral head anterior to the middle of the glenoid fossa (PHHA), and the angle of rotation of the biceps tendon (biceps angle) were measured on MRI scans of both shoulders. Statistical analysis was performed to compare these MRI measurements for the involved and uninvolved sides, and to identify the correlations between them and the external rotation. RESULTS: The average biceps angle was 47.9+/-15.2 degrees on the uninvolved side and 26.2+/-15.0 degrees on the involved side. The average differences between the 2 shoulders in the biceps angle (21.7+/-20.5 degrees), the version (18.9+/-15.0 degrees), and the PHHA (19.8+/-13.6%) were all significant (P<0.001). Only the biceps angle correlated significantly with external rotation (P<0.001). This correlation remained significant even when the version and the PHHA were held constant (P=0.004). CONCLUSION: The biceps angle is a measure of rotational deformity in patients with residual brachial plexus birth palsy, and correlates better with external rotation than either the glenoid version or the PHHA. The biceps angle may be a useful measure of rotational glenohumeral deformity before and after surgery.

Correction of Blount's disease by a multi-axial external fixation system.

BACKGROUND: Blount's disease is a multi-planar deformity affecting the pediatric population which leads to varus alignment of the lower extremities. The Multi-Axial Correction (MAC) monolateral external fixation system (Biomet, Parsippany, NJ, USA) is a non-circular fixator that was developed as a response to the technical difficulty for both patients and physicians of placing, managing, and tolerating a circular fixator. The purpose of this study was to determine the efficacy of the MAC system for the treatment of pediatric patients with Blount's disease. METHODS: A retrospective analysis of 17 consecutive patients with surgically corrected Blount's disease using the MAC system with tibial and fibular osteotomies was identified. Patient charts and radiographs at three different time points (pre-operative, fixator removal, and final follow-up) were reviewed. The mechanical axis deviation (MAD), tibial-femoral angle (TFA), medial proximal tibial angle (MPTA), and posterior proximal tibial angle (PPTA) were measured in the MAC group at the three time points mentioned previously. The total wear time, total operative time, and post-operative complications were noted. RESULTS: The MAC system was able to correct the deformity of Blount's disease as measured by a decrease in the MAD (40.2 +/- 29.3 mm; P

Treatment of Blount disease: a comparison between the multiaxial correction system and other external fixators.

BACKGROUND: Many surgical procedures have been proposed for treatment of Blount disease (tibia vara). Gradual correction of Blount disease has been described with both unilateral and circular external fixators. The purpose of this study was to compare the clinical and radiographic results of gradual correction for severe or recurrent Blount disease using the Biomet Multi-Axial Correction (MAC; Biomet Trauma, Parsippany, NJ) external fixator to our historical controls using other devices (such as the Ilizarov and Garche T-clamp). METHODS: A total of 58 corrections were performed on the 54 limbs in 38 patients. Charts were analyzed to evaluate the presence of complications during the course of external fixator treatment. The tibiofemoral, anatomic medial proximal tibial, and proximal posterior tibial angles were measured on radiographs taken before application of the external fixator and after removal to compare the correction achieved by the MAC fixator and the other fixators. RESULTS: The mean values for the tibiofemoral angle, anatomic medial proximal tibial angle, and proximal posterior tibial angle were similar between the 2 groups after treatment and at follow up. The rate of complications between the 2 groups was also not significantly different. CONCLUSIONS: The MAC external fixator provides an acceptable alternative for gradual correction of Blount disease. LEVEL OF EVIDENCE: Level III.

Coronoid fixation using suture anchors.

Fractures of the coronoid process of the ulna generally occur in relatively high-energy injuries and are commonly associated with injuries to other structures around the elbow. Damage to the coronoid process in addition to other elbow structures may complicate treatment. Several approaches have been used in the management of coronoid process fractures. This paper reports a method of coronoid process fracture fixation using suture anchors.

Plastic laryngeal foreign bodies in children: a diagnostic challenge.

OBJECTIVE: To review Children's Hospital and Regional Medical Center experience with pediatric airway foreign bodies, and examine the incidence and treatment of laryngeal foreign bodies. To determine if plastic laryngeal foreign bodies present differently than other laryngeal foreign bodies. METHODS: A retrospective review of all cases of children (1874 patients) undergoing direct laryngoscopy and/or bronchoscopy from 1st January 1997 to 9th September 2003 at a tertiary care children's hospital. Patients with endoscopically documented laryngeal foreign bodies were identified and the medical record reviewed in more detail. Patient age, gender, foreign body location, foreign body type, duration of foreign body presence, radiographic findings, endoscopic findings and treatment complications were recorded. RESULTS: One hundred and five aspirated foreign bodies were identified. The nine laryngeal foreign bodies included five clear plastic radiolucent items, two radiolucent food items, and two sharp radioopaque pins. Time to diagnosis and treatment was on average 11.6 days with 17.6 days for thin/plastic foreign bodies and 1.6 days for metal/food foreign bodies. CONCLUSION: Laryngeal foreign bodies represent a small portion of all pediatric airway foreign bodies. Difficulty in identifying laryngeal foreign bodies, especially thin, plastic radiolucent foreign bodies can delay treatment. Thin plastic foreign bodies can present without radiographic findings, can be difficult to image during endoscopy and can be particularly difficult to diagnose. A history of choking and vocal changes is associated with laryngeal foreign bodies. Laryngeal foreign bodies should be in the differential diagnosis of all children presenting with atypical upper respiratory complaints especially if a history suggestive of witnessed aspiration and dysphonia can be obtained.

The emergency department as a potential site for smoking cessation intervention: a randomized, controlled trial.

OBJECTIVE: To assess the effect of physician counseling and referral on smoking cessation rates and attendance at a smoking cessation program. METHODS: This was a prospective, randomized clinical trial set in a suburban, community teaching hospital emergency department (ED). During study hours, dedicated research associates enrolled consecutive, stable, oriented patients who were smokers. Eligible, consenting patients were randomized to one of two intervention groups. The control group received a two-page "Stop Smoking" pamphlet from the American Heart Association (AHA). Patients in the intervention group were given the AHA pamphlet along with pharmacologic information and standardized counseling by the attending emergency physician, including written and oral referral to a smoking cessation program. The primary outcome measures were telephone contact/attendance at the smoking cessation program by the intervention group and the rate of smoking cessation in both study groups at three months post-ED visit. Categorical data were analyzed by chi-square and Fisher's exact tests. Rank data were analyzed by Mann-Whitney tests and continuous data by t-tests. All tests were two-tailed with alpha set at 0.05. RESULTS: One hundred fifty-two patients were enrolled; 78 were randomized to the intervention group. Nearly 70% of patients (103) were available for telephone follow-up. The study groups were statistically similar with regard to baseline demographic characteristics and the prevalence of moderate or severe nicotine addiction. None of the patients (0%) in the intervention group contacted or attended the smoking cessation program during the study period (95% CI = 0-4%). The percentages of patients who stopped smoking after three months were similar in the two groups [10.4% (5/48) control vs 10.9% (6/55) intervention; p = 1]. CONCLUSION: The authors found no difference in the smoking cessation rates between ED patients who received written material and those who were counseled by emergency physicians. Referral of patients who smoked to a cessation program was unsuccessful.

Programa educacional y de investigación sobre diagnóstico y tratamiento de otitis media en latinoamérica / Latin americana otitis media research and trining program

La otitis media en Latinoamérica es a causa más importante de deterioro de la audición en la población infantil, originando además repercusiones en el lenguaje y aprendizaje. Sus complicaciones infecciosas intra y extratemporales son además padecimientos que ponen en peligro la vida del paciente. Todo esto puede ser prevenido de manera simple y económica. El programa educacional y de investigación sobre la otitis media en Latinoamérica es un proyecto internacional multidisciplinario, diseñado para mejorar su diagnóstico y tratamiento; más de 200 profesionistas al cuidado de la salud han participado en los seminarios piloto presentados en Brasil, Costa Rica y México. Los cursos teórico-prácticos con apoyo audiovisual destacan el papel de la otoscopia neumática y se concluye que este programa de educación médica continua contribuye significativamente a la atención primaria y mejora el nivel de la salud infantil