Andrew P. Harris

Carpal Tunnel Release: Do We Understand the Biomechanical Consequences?

Carpal tunnel release is a very common procedure performed in the United States. While the procedure is often curative, some patients experience postoperative scar sensitivity, pillar pain, grip weakness, or recurrent median nerve symptoms. Release of the carpal tunnel has an effect on carpal anatomy and biomechanics, including increases in carpal arch width and carpal tunnel volume and changes in muscle and tendon mechanics. Our understanding of how these biomechanical changes contribute to postoperative symptoms is still evolving. We review the relevant morphometric and biomechanical changes that occur following release of the transverse carpal ligament.

Isolated dorsal dislocations of the talonavicular and calcaneocuboid articulations (Chopart joints) from a low-energy mechanism

The transverse tarsal (Chopart) joints are defined as the talonavicular and calcaneocuboid articulations [1]. Dislocations of Chopart joints, although uncommon, have been reported from a variety of high-energy mechanisms, resulting in medial, lateral, plantar, or dorsal displacement [2]. In this article, we describe a case of isolated dorsal fracture dislocations of the talonavicular and calcaneocuboid articulations in a 25-yearold man after a low-energy missed-step mechanism. The mechanism of injury, diagnosis, andmanagement in the emergency department, operative intervention, and follow-up are discussed. Given the high rate of missed and delayed diagnosis of Chopart dislocations, emergency medicine physicians must be aware of this debilitating injury [3,4]. The transverse tarsal (Chopart) joints consist of the talonavicular and calcaneocuboid articulations [1]. The talonavicular joint derives its stability from the spring ligament, which consists of the superior medial calcaneonavicular and inferior calcaneonavicular ligament. The calcaneocuboid joint derives its support plantarly from the superficial and deep inferior calcaneocuboid ligaments and superiorly by the lateral limb of the bifurcate ligament. Reported isolated fracture dislocations of the Chopart joints, although rare, have been attributed to high-energy mechanisms given the inherent stability of these robust periarticular ligaments, and often have associated injuries in the polytrauma patient [5]. We describe the case of a 25-year-old man sustaining an isolated dorsal fracture dislocation of the Chopart joints resulting from a relatively lowenergy mechanism, missing a step while walking down stairs. A 25-year-old man was transferred from an outside hospital to our emergency department at a level 1 trauma center after missing a step while walking down stairs. The patient reported immediate pain in the left foot and an inability to bearweight on the extremity. Orthopedic surgery was consulted and evaluated the patient in the emergency department. No neurovascular deficits, signs of compartment syndrome, or associated injuries were found at the time of evaluation. Initial radiographs of the left foot revealed dorsal dislocations of the talonavicular and calcaneocuboid joints (Fig. 1A-C). The patient subsequently underwent conscious sedation in the emergency department, closed reduction of the traverse tarsal joints (Fig. 2), and application of a wellpadded plaster short-leg splint (Fig. 3). Postreduction radiographs revealed a persistent dorsal subluxation of the talonavicular joint (Fig. 4). A computed tomographic scan of the left footwas then obtained showing a comminuted fracture of the navicular and persistent subluxation of the talonavicular joint (Fig. 5A, B). The patient was admitted to the orthopedic surgery service and underwent open reduction internal fixation of the talonavicular joint. Postoperative radiographs showed a concentrically reduced talonavicular and calcaneocuboid joint with appropriately placed hardware (Fig. 6A–C). The patient returned to the http://dx.doi.org/10.1016/j.ajem.2015.12.054 0735-6757/© 2016 Elsevier Inc. All rights reserved. Please cite this article as: Harris AP, et al, Isolated dorsal dislocations of the low-energy mechanism, Am J Emerg Med (2016), http://dx.doi.org/10.101 orthopedic surgery floor and was discharged home without incident 2 days postoperatively with strict instruction to remain non–weight bearing. At 2-week follow-up, the incision was well healed and sutures were removed. The transverse tarsal (Chopart) joints include the talonavicular and calcaneocuboid joints. Main and Jowett [4] classified a series of 71 transverse tarsal joint injuries according to the direction of the deforming force and the resulting displacement: medial forces, longitudinal forces, lateral forces, plantar forces, and crush injury. In this series, only 2 cases of transverse tarsal joint dislocations were reported: pure plantar transverse tarsal joint dislocation and plantar subtalar dislocation associated with plantar dislocation of the talonavicular joint [4]. Current literature review reveals 2 cases of isolateddorsal transverse tarsal joint dislocations resulting from high-energy mechanisms including falls from height [2,6]. To the best of our knowledge, this is thefirst reported case of isolated dorsal transverse tarsal joint dislocation from a low-energy mechanism. Isolated dislocations of transverse tarsal joints are rare due to strong periarticular ligamentous structural support. The inferior calcaneocuboid ligament, calcaneonavicular (spring) ligament, and bifurcate ligament all confer stability to the transverse tarsal joints and are important to the support of the foot arch. For this reason, dislocations in the dorsal direction are infrequent, requiring disruption of these plantar ligaments [6]. As reported byWilson et al [7], transverse tarsal joint injuries occur in nearly 10% of polytrauma patients as a result of motor vehicle accidents, with 41% of these injuries having a delay in diagnosis. Emergency medicine physicians must have a high suspicion for these injuries when presented with a polytrauma patient for this reason. Initial radiographs of the foot should be obtained if there is suspicion for a foot injury. Further delineation of foot injuries may require a computed tomographic scan to detect small fractures, or possible dislocations that reduced prior to evaluation [8]. Any dislocations should be emergently reduced and immobilized tomitigate the consequences of delayeddiagnosis; avascular necrosis, osteoarthritis, or surgical intervention that may have been avoided (Figs. 2 and 3) [9]. Orthopedic surgery consultation should ensue, as studies have shown open reduction and internal fixation results in improved maintenance of the transverse tarsal joint reduction, especially when these joints are unstable after closed reduction [5,10]. Isolated dorsal transverse tarsal joint dislocations are rare injuries, but have been reported to occur in 10% of polytraumatized patients in motor vehicle accidents [7]. Emergency medicine physicians must be aware of this association with high-energy trauma and in rare cases of isolated dorsal dislocations to avoid a delay in diagnosis treatment. Although often seen in high-energy situations, our case report demonstrates that emergency medicine providers must remain vigilant, as these serious injuries can result from low-energymechanisms. All dislocations should be emergently reduced with covering of any open talonavicular and calcaneocuboid articulations (Chopart joints) from a 6/j.ajem.2015.12.054 Fig. 1. Injury radiographs demonstrating dorsal transverse tarsal joint dislocations on anteroposterior (A), lateral (B), and oblique views (C). Fig. 2. Reduction maneuver for transverse tarsal (Chopart) joints. 1. Place thumb over the navicular bone (C) and (B). 2. With contralateral hand, grab the talus and calcaneus as a unit (C). 3. Apply dorsal to plantar pressure on the navicular while stabilizing the talus. 2 A.P. Harris et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx wounds. Orthopedic surgery consultation should follow for further evaluation and treatment, as irreducible dislocations are an indication for urgent operative intervention; although stable, closed reductions may be managed nonoperatively or operatively on a delayed outpatient basis [10]. Andrew P. Harris MD Joey Johnson MD Gregory R. Waryasz MD Department of Orthopaedics, Alpert Medical School of Brown University, Providence, RI Corresponding author. Department of Orthopaedics, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903 Tel.: + 1 401 444 4030; fax: + 1 401 444 6182 E-mail addresses: andrew_harris@brown.edu, aharri26@gmail.com http://dx.doi.org/10.1016/j.ajem.2015.12.054

Management of partial fingertip amputation in adults: Operative and non operative treatment

BACKGROUND Hand and finger injuries account for approximately 4.8 million visits to emergency departments each year. These injuries can cause a great deal of distress for both patients and providers and are often initially encountered in urgent care clinics, community hospitals, and level one trauma centers. Tip amputation injuries vary widely in mechanism, ranging from sharp lacerations to crush injuries that present with varying degrees of contamination. The severity of damage to soft tissue, bone, arteries and nerves is dependent upon the mechanism and guides treatment decision-making. The management algorithm can oftentimes be complex, as a wide variety of providers, including orthopedists, general surgeons, plastic surgeons and emergency physicians, may care for these injuries, depending on location and local culture. We review the common mechanisms for tip amputation and the optimal treatment in adults, based on the severity of the injury, degree of wound contamination, and the facilities available to the provider. METHODS Pubmed was searched using text words for articles related to management of fingertip injuries in adults. Bibliographies of matching articles were searched for additional relevant articles, which were then also reviewed. 107 articles were reviewed in total, and 61 were deemed relevant for inclusion. All clinical studies and reviews were included. Particular attention was paid to articles published within the past 15 years. RESULTS In the United States, up to 90% of fingertip amputations are treated with non-replant techniques. In comparison, the majority of amputations in Asian countries are replanted due to moral values and importance of body integrity. Tip amputation injuries can be managed with local debridement, complex reconstruction, or simply with irrigation and application of a sterile dressing. CONCLUSION In the United States, most fingertip amputations in adults are treated with non-replant techniques. However, the precise management of a fingertip injury in adults depends on the degree of injury itself, and a number of operative and non-operative techniques may be successfully employed.

Cobalt toxicity after revision to a metal-on-polyethylene total hip arthroplasty for fracture of ceramic acetabular component

Cobalt metallosis after revision metal-on-polyethylene total hip arthroplasty for catastrophic failure of ceramic components is uncommon but a potentially devastating complication. Common findings associated with heavy metal toxicity include cardiomyopathy, hypothyroidism, skin rashes, visual disturbances, hearing changes, polycythemia, weakness, fatigue, cognitive deterioration, and neuropathy. We report a case of a 57-year-old woman who presented with complaints of progressively worsening hip pain, fatigue, memory loss, lower extremity sensory loss, persistent tachycardia, and ocular changes 5 years after synovectomy and revision of a failed ceramic-on-ceramic total hip arthroplasty to metal-on-polyethylene components. A cobalt level of 788.1 ppb and chromium level of 140 ppb were found on presentation and subsequently decreased to 468.8 ppb and 105.9 ppb, respectively, 2 weeks after revision to a ceramic-on-polyethylene total hip arthroplasty. Improvement of symptoms accompanied this decrease in cobalt and chromium levels. Revision of failed ceramic arthroplasties with later-generation ceramics to avoid this potential complication is recommended.

Lunate and Perilunate Dislocations

The lunate derives its name from its similarity in shape to the moon. It is the middle carpal bone of the proximal carpal row and plays an integral part in carpal kinematics. Dislocation of the lunate is a serious injury to the wrist and requires surgical stabilization. Failure to recognize this injury at initial presentation is associated with poor patient outcomes.

Dupuytren’s Disease

Dupuytren’s disease is a common disease of the hand and fingers. Specific fascial structures are involved in the disease process. Mild forms of the disease may be monitored, while more severe forms inhibiting function require intervention. Surgical intervention is often required.

Comprehensive Review of Skiing and Snowboarding Injuries

Skiing and snowboarding have increased in popularity since the 1960s. Both sports are responsible for a substantial number of musculoskeletal injuries treated annually by orthopaedic surgeons. Specific injury patterns and mechanisms associated with skiing and snowboarding have been identified. No anatomic location is exempt from injury, including the head, spine, pelvis, and upper and lower extremities. In these sports, characteristic injury mechanisms often are related to the position of the limbs during injury, the athletes expertise level, and equipment design. Controversy exists about the effectiveness of knee bracing and wrist guards in reducing the incidence of these injuries. Understanding these injury patterns, proper training, and the use of injury prevention measures, such as protective equipment, may reduce the overall incidence of these potentially debilitating injuries.

Management of Diabetic Trigger Finger

Diabetics have a much greater prevalence of trigger finger than nondiabetics and are more likely to have severe symptoms. Diabetic trigger finger may be more accurately described on a spectrum of diabetic hand pathology alongside carpal tunnel syndrome and cheiroarthropathy. Recent publications have called into question the current treatment algorithm for diabetic trigger finger. Although some evidence supports the use of corticosteroid injections, a recent cost analysis reported that immediate surgical release of the A1 pulley in the clinic is the most cost-effective management of diabetic trigger finger. In addition to traditional treatment with injection and open release, percutaneous release with or without simultaneous corticosteroid injection has shown promising results and may have a role in patient care. The appropriate treatment algorithm in terms of efficacy, safety, and cost remains controversial.

Cost-Effectiveness of Initial Revision Digit Amputation Performed in the Emergency Department Versus the Operating Room

Background: The objective of this study was to determine the comparative cost-effectiveness of performing initial revision finger amputation in the emergency department (ED) versus in the operating room (OR) accounting for need for unplanned secondary revision in the OR. Methods: We retrospectively examined patients presenting to the ED with traumatic finger and thumb amputations from January 2010 to December 2015. Only those treated with primarily revision amputation were included. Following initial management, the need for unplanned reoperation was assessed and associated with setting of initial management. A sensitivity analysis was used to determine the cost-effectiveness threshold for initial management in the ED versus the OR. Results: Five hundred thirty-seven patients had 677 fingertip amputations, of whom 91 digits were initially primarily revised in the OR, and 586 digits were primarily revised in the ED. Following initial revision, 91 digits required unplanned secondary revision. The unplanned secondary revision rates were similar between settings: 13.7% digits from the ED and 12.1% of digits from the OR (P = .57). When accounting for direct costs, an incidence of unplanned revision above 77.0% after initial revision fingertip amputation in the ED would make initial revision fingertip amputation in the OR cost-effective. Therefore, based on the unplanned secondary revision rate, initial management in the ED is more cost-effective than in the OR. Conclusions: There is no significant difference in the incidence of unplanned/secondary revision of fingertip amputation rate after the initial procedure was performed in the ED versus the OR.

The Trapezium Dislocation: Case Presentation, Review of the Literature, Radiographic Analysis, Proposed Classification, and Treatment

Background: Trapezium dislocations are rare injuries. Methods: A PubMed search of the term “trapezium dislocation” was conducted. Publications reporting a complete trapezium dislocation were included in the review. Results: The PubMed search resulted in 168 results. Fourteen publications reporting on 16 complete trapezium dislocations met inclusion criteria. A case of delayed diagnosis of a trapezium dislocation is presented. The literature is reviewed for pertinent clinically relevant information with respect to trapezium dislocations. A systematic method for radiographic analysis of trapezium dislocations and classification are described, and a treatment algorithm is presented. Conclusions: Trapezium dislocations are infrequent injuries with few cases reported in the literature. Given the rarity of this injury, diagnosis and appropriate treatment may be delayed due to difficulty in recognition. Using the described method of radiographic analysis, delayed diagnosis may be avoided with implementation of timely treatment.