Hand Trauma Call: A Blessing or a Curse? No abstract available

Interposition Arthroplasty of the Elbow Utilizing a Lateral Epicondyle Osteotomy Management of severe elbow arthritis in young or active patients presents a challenging problem. Interposition arthroplasty is a useful salvage procedure for these patients but has a significant failure rate associated with postoperative instability. Previous studies have sought to preserve the integrity of the medial elbow ligament complex to decrease postoperative instability and the need for external fixation. Our lateral epicondylar osteotomy technique preserves the native lateral elbow ligament complex. Potential advantages include bone-to-bone healing of the osteotomy, decreased postoperative instability, and the decreased need for and associated costs and potential complications of supplemental external fixation.

The Saline Load Test is Effective at Diagnosing Traumatic Arthrotomies of the Wrist Background: The saline load test has previously been shown to be an effective tool to diagnose traumatic arthrotomies, but no studies have assessed the test’s efficacy in the wrist. The purpose of this study was to investigate the amount of fluid required during a saline load test to detect intra-articular wrist involvement of traumatic wounds with high sensitivity. Methods: A cadaveric study was conducted using 7 thawed, fresh-frozen forequarter amputations from 7 different donors (3 male, 4 female). Specimen age (mean: 67.7 y, range: 52 to 80 y), laterality (1 right, 6 left), body weight (mean: 164.3 lbs, range: 100 to 223 lbs), and wrist range of motion (ROM) was assessed before testing. The wrist capsule was punctured with an 11-blade scalpel through the 6R radiocarpal portal site under fluoroscopic guidance to ensure the injury was intra-articular. A 19-G needle was then placed through the 3,4 radiocarpal portal site and confirmed with fluoroscopy to ensure intra-articular placement. Normal saline was then injected at a steady rate into the 3,4 radiocarpal portal site until extravasation of the saline was observed from the 6R radiocarpal arthrotomy site. The volume of saline required for extravasation from the 6R radiocarpal arthrotomy was recorded as the volume required to detect the arthrotomy. A plot of saline volumes (by percentile) was created, and a logarithmic distribution was calculated. A Wilcoxon rank-sum test was used to compare injection volumes between male and female specimens, and Pearson Coefficients were used to determine any correlations between injection volume and ROM. Results: The average amount of saline that resulted in extravasation was 4 mL (range: 2 to 7 mL). In order to identify 75%, 90%, 95%, and 99% of the simulated wrist arthrotomies, 5 (95% confidence interval: 3-7), 6 (4-9), 7 (4-10), and 9 (5-14) mL were required, respectively. Pretest ROM did not correlate with saline volume. Conclusions: This study demonstrates the efficacy of the saline load test in detecting traumatic arthrotomies of the wrist joint with 95% sensitivity after loading 7 mL of saline. Prompt and accurate diagnosis of traumatic arthrotomies is paramount to guide management and optimize postinjury outcomes.

The FDP-FDS-FDP Dual Tendon Transfer: A Simple, Single-stage Reconstruction Technique for Chronic, Isolated Flexor Digitorum Profundus Tendon Injuries The reconstruction of chronic flexor tendon injuries remains one of the more challenging injuries facing the hand and upper extremity surgeon. In the setting of an intact flexor digitorum superficialis (FDS), there are few indications for isolated flexor digitorum profundus (FDP) reconstruction. Because of the interplay of the FDP system, the reestablishment of normal tension of the FDP tendons and lumbricals is particularly challenging, and postoperative stiffness, quadriga, or lumbrical plus phenomena can actually lead to a deterioration of digital function with surgery. We present a technique for single-stage reconstruction of chronic FDP lacerations, particularly in the setting of “lumbrical plus” fingers. The key features of this technique are: the FDS is detached from the middle phalanx and advanced to the distal FDP stump; and the proximal stump of the FDP is advanced to reestablish proper lumbrical tension and sewn to the FDS tendon proximally. Postoperative therapy is according to standard, well-accepted flexor tendon rehabilitation protocols. This procedure avoids the need for tendon autograft harvest, and avoids the tensioning challenges of other FDP reconstruction techniques; it addresses the potential paradoxical extension with lumbrical tension by eliminating the retraction of the lumbrical and eliminates the potential for quadriga by separating FDP function from the adjacent digit. An illustrative case is presented. Level of Evidence: Level V.

A Novel Technique for the Surgical Management of Chronic Lateral Epicondylitis Lateral epicondylitis is the most common condition affecting the elbow and is self-limiting in most cases. However, when conservative treatment fails, surgery is required for resistant cases. In this study, we describe a novel technique for the management of chronic lateral epicondylitis. The advantage of our technique is that all the 3 major components of the disease (as also all types of failure described by Morrey) are simultaneously dealt with, that is, pathology of the tendon, posterior interosseous nerve compression and intra-articular pathology are all addressed. We prospectively reviewed 14 consecutive cases of resistant lateral epicondylitis operated with our technique at our Institute from 2008 to 2013 with a minimum 2 years follow up. We included patients between 18 and 65 years of age who in addition to lateral epicondylitis also had an intra-articular pathology along with symptoms/signs suggestive of posterior interosseous nerve compression and had undergone a conservative trial of atleast 12 months. Excluded were those cases with localized infection and severe ankylosis, whereas previous surgery on the same elbow was a relative contraindication. Postoperatively all patients showed improvement in the VAS score and grip strength. Twelve of the 14 patients (85.7%) in our series had good to excellent functional outcomes on the Mayo Elbow Performance Index. This technique can therefore be recommended for wider surgical use; however, prospective randomized studies with a longer follow-up would add further evidence about the effectiveness of our technique.

Reconstruction of Chronic Boutonniere Deformity of the Thumb in a Golf Player We present the case of a professional golf player who gradually developed a boutonniere deformity of the thumb due to chronic repetitive injury to the thumb and was treated with reconstruction of its insertion onto the proximal phalangeal base. The athlete showed an insertion variation of the extensor pollicis brevis, where some slips attached onto the extensor hood and the other slips ran along with the extensor pollicis longus to the distal phalanx, providing no slip to the proximal phalanx. The slips inserting to the distal phalanx were transferred to the base of the proximal phalanx and sagittal band reconstruction. As a result, the boutonniere deformity of the thumb fully recovered with satisfactory outcomes. Level of Evidence: Level V.

Novel Technique for Toe-to-Hand Transplantation: The Fourth-toe as an Alternative Option for Toe-to-Hand Transplantation for Pediatric Patients The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons’ skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique’s development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.

Suture Anchor Repair of Avulsed Adductor Pollicis Injury, Secondary to Motor Vehicle Collision: Case Report and Technique The thenar eminence of the thumb is made up of 4 intrinsic muscles: abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and the adductor pollicis (ADD). While both heads of the ADD insert on the medial base of the thumb proximal phalanx, the oblique head originates on the capitate and second and third metacarpals, and the transverse head originates on the distal half of the third metacarpal. We present the case of a 36-year-old man who was involved in a motor vehicle collision and sustained a laceration in the first webspace with 1 cm extrusion of the ADD and no neurovascular deficiencies on examination. X-ray imaging noted no bony abnormalities. The only identifiable injury was to the ADD muscle which was avulsed from its origin and was extruded through the open wound in the first webspace. A double-row running locking 3-0 fiberwire suture technique was used to have a solid anchor point with which to secure the muscle to its origin. It was secured to the second metacarpal with Mitek mini suture anchors that was sutured on the opposing side of the double-row fiberwire suture and anchored to the second metacarpal proximally and distally in the metacarpal. We report good clinical outcomes postoperative, with intact range of motion and no surgical complication at the 6-month follow-up visit. The patient has ongoing physical therapy to reduce any residual strength deficits.

Augmented External Fixation of Ulnar Carpometacarpal Joint Fracture Dislocations Ulnar-sided carpometacarpal (CMC) joint fracture dislocations are relatively uncommon, frequently associated with fractures of the metacarpal base and/or hamate, and often sustained by young male individuals secondary to striking a hard object. The complexity of ulnar-sided CMC fracture dislocations necessitates careful restitution of anatomic alignment and joint congruency for mobility and stability. Miniaturization of the external fixation device has allowed application to the hand. Spanning external fixation utilizes the principles of “ligamentotaxis”—indirect reduction through distraction forces of capsule-ligamentous structures. Treatment options for ulnar-sided CMC fracture dislocations are varied. Our surgical technique involving an external fixation device is reviewed. Clinical and chart review was performed on the last 10 patients undergoing acute surgical repair of ulnar-sided CMC fracture dislocations with intra-articular comminution by the senior author. Surgical technique used percutaneous Kirschner wire fixation and a spanning, miniature, external fixation device. Minimal follow-up was 1 year. Radiographs from the most recent appointment were evaluated by 2 independent reviewers. Patients rated their level of pain and assessed function using a subjective outcome instrument. Mean total active motion, when comparing traumatized digit to same digit in contralateral hand, was 100%. All fractures healed primarily with maintenance of congruent joint space and without radiographic displacement or arthrosis. Patient satisfaction was high and all patients returned to preinjury level of function. Our study demonstrates the use of an external fixation device in the management of ulnar-sided CMC fracture dislocations to be effective in reestablishing and maintaining normal hand anatomy, reducing pain, increasing function, and preserving motion.

Treatment of Proximal Pole Scaphoid Fracture Nonunions With Intramedullary Cancellous Autograft and Cannulated Headless Compression Screw Management of proximal pole scaphoid nonunion remains a challenging problem. Multiple surgical techniques have been described, although no treatment has proven superior. Recent studies have questioned the need for vascularized bone grafting, even in in the setting of avascular proximal poles. We present a relatively simple technique of intramedullary autogeneous cancellous bone grafting that does not disturb the intact cortical shell of the nonunion, which has so far provided gratifying clinical results.