Asif M. Ilyas

The Sensitivity and Specificity of Ultrasound for the Diagnosis of Carpal Tunnel Syndrome: A Meta-analysis

BackgroundCarpal tunnel syndrome (CTS) is the most commonly diagnosed compression neuropathy of the upper extremity. Current AAOS recommendations are to obtain a confirmatory electrodiagnostic test in patients for whom surgery is being considered. Ultrasound has emerged as an alternative confirmatory test for CTS; however, its potential role is limited by lack of adequate data for sensitivity and specificity relative to electrodiagnostic testing.Questions/purposesIn this meta-analysis we determined the sensitivity and specificity of ultrasound in the diagnosis of CTS.MethodsA PubMed/MEDLINE search identified 323 articles for review. After applying exclusion criteria, 19 articles with a total sample size of 3131 wrists were included for meta-analysis. Three groups were created: a composite of all studies, studies using clinical diagnosis as the reference standard, and studies using electrodiagnostic testing as the reference standard.ResultsThe composite sensitivity and specificity of ultrasound for the diagnosis of CTS, using all studies, were 77.6% (95% CI 71.6–83.6%) and 86.8% (95% CI 78.9–94.8%), respectively.ConclusionsThe wide variations of sensitivities and specificities reported in the literature have prevented meaningful analysis of ultrasound as either a screening or confirmatory tool in the diagnosis of CTS. The sensitivity and specificity of ultrasound in the diagnosis of CTS are 77.6% and 86.8%, respectively. Although ultrasound may not replace electrodiagnostic testing as the most sensitive and specific test for the diagnosis of CTS given the values reported in this meta-analysis, it may be a feasible alternative to electrodiagnostic testing as the first-line confirmatory test.Level of Evidence Level III, systematic review of Level III studies. See Guidelines for Authors for a complete description of levels of evidence.

Community-Acquired Methicillin-Resistant Staphylococcus aureus Infections of the Hand: Prevalence and Timeliness of Treatment

PURPOSE The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (ca-MRSA) appears to be increasing, but the timeliness of appropriate antibiotic delivery is often delayed. We retrospectively reviewed the prevalence of ca-MRSA infections in an urban setting, time from presentation to the hospital to appropriate antibiotic delivery, and differences in length of stay between the ca-MRSA and non-MRSA hand infections. METHODS We retrospectively reviewed all visits for hand infection cases to the emergency room of an urban academic medical center over a 12-month period. A formal hand infection algorithm was used in the treatment of each patient. All patients with culture-positive hand infections were included for evaluation. Infections determined to be nosocomial or not community-acquired were excluded. Patient demographics, laboratory studies, culture results, antibiotic delivery, and length of stay data were collected. RESULTS A total of 85 patients (55 male) with an average age of 39 years met the inclusion criteria. The overall prevalence rate of ca-MRSA hand infections was 55%. The average time to appropriate antibiotic delivery for ca-MRSA infection was 12 hours, versus 2.64 hours for non-MRSA hand infections (p > .5). The average length of stay was 4.0 days for ca-MRSA infections and 3.5 days for non-MRSA infections (p > .05). Univariate and multivariate analysis identified intravenous drug abuse and a serum white blood cell count of >8.7 as independent risk factors for ca-MRSA hand infections. CONCLUSIONS Community-acquired methicillin-resistant S. aureus infections of the hand continue to increase in urban settings. With the use of a formal hand infection treatment algorithm, we did not identify a statistical difference in appropriate antibiotic delivery time and length of stay between ca-MRSA and non-MRSA hand infections.

Nonsurgical Treatment for de Quervain's Tenosynovitis

N D c m Q f c HE PATIENT 33-year-old, left-handed woman who is a homeaker reports 2 months of left wrist pain. The pain is orse when lifting her children, opening bottles, or urning doorknobs. She has seen her primary care docor who diagnosed her with “tendonitis” and prescribed er an unscheduled nonsteroidal anti-inflammatory rug (NSAID) and a wrist splint. Physical exam idenifies tenderness and swelling along the first dorsal ompartment. Pain is elicited with ulnar deviation of the rist with the thumb in a clenched-fist position. There s no pain with palpation, movement, or compression of he trapeziometacarpal joint.

Upper extremity compartment syndrome secondary to acquired factor VIII inhibitor. A case report.

C ompartment syndrome of the upper extremity is a surgical emergency that is usually the result of trauma, most commonly fractures1. We present a case of atraumatic compartment syndrome of the right forearm in an elderly woman who required fasciotomy. The compartment syndrome was a result of spontaneous bleeding due to an acquired factor VIII inhibitor. The patient was informed that data concerning the case would be submitted for publication. A sixty-seven-year-old black woman with a medical history of hypertension and chronic obstructive pulmonary disease but no history of a bleeding disorder presented with a two-day history of increasing pain and swelling in the right forearm. The patient took aspirin (325 mg daily) as well as medications for the treatment of pulmonary disease and hypertension. There was no history of trauma. The patient reported a distinct onset of pain after lifting her coat with the affected arm. The following day, approximately twenty-four hours after the onset of pain, the patient noted increased pain and swelling in the right forearm, hand, and fingers. Approximately forty-eight hours after the onset of symptoms, she presented to the emergency department. Physical examination revealed that the patient had mild discomfort secondary to pain in the right upper extremity. Clinically relevant findings on examination were limited to the right forearm, hand, and digits. There was tenderness to palpation extending from the right forearm to the distal aspects of the digits; the tenderness was greater dorsally than volarly. Radial and ulnar pulses were palpable at the wrist. The patient had mild forearm swelling with soft compartments, intact sensation to touch, and warm skin throughout the extremity. The site of greatest swelling was the mobile wad of Henry. There was minimal discomfort to passive extension of the digits at the metacarpophalangeal joints, with the greatest discomfort …

Intramedullary Fixation of Distal Radius Fractures

Intramedullary fixation has recently received increased enthusiasm as an option for distal radius fracture fixation. Indications for this fracture fixation technique should be limited to predominately displaced extra-articular or simple intra-articular distal radius fractures. Intramedullary fixation permits limited soft tissue dissection and insertion of a low-profile implant that acts as an internal splint. Purported benefits include a familiar fracture fixation technique, less soft tissue irritation, and locked fixed-angle technology. Thorough understanding of the radial and dorsal approaches to the distal radius is a prerequisite. Important aspects of intramedullary fixation of distal radius fractures include proper fracture selection, good fracture reduction, protection of sensory nerves, and avoidance of inadvertent intra-articular screw placement. Relevant surgical anatomy, technique, postoperative care, and a review of complications are presented.

Risk Factors Associated With Clindamycin-Resistant, Methicillin-Resistant Staphylococcus aureus in Hand Abscesses

PURPOSE To identify risk factors for clindamycin resistance in acute hand abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA). METHODS We performed a retrospective review of 247 consecutive culture-positive hand abscesses from 2010 to 2012 at an urban hospital. Historical and laboratory data from patients with abscesses that grew MRSA with and without clindamycin resistance were compared in a multivariate analysis. RESULTS Methicillin-resistant Staphylococcus aureus grew on culture from 103 abscesses; 16% of those isolates were resistant to clindamycin. Multivariate analysis showed that younger age, intravenous drug use, and nosocomial acquired MRSA were significant risk factors for concurrent clindamycin resistance. Patients with a history of intravenous drug use and nosocomial acquired MRSA were, respectively, 11 and 5 times more likely to have concurrent clindamycin resistance. History of MRSA infection and human immunodeficiency virus were not identified as risk factors. CONCLUSIONS Patients with a history of intravenous drug use or recent contact with health care facilities appear to be a potential reservoir for emerging multidrug-resistant MRSA. Selection of clindamycin as an empiric antibiotic should be especially avoided for these groups. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.

The role of locking technology in the upper extremity

The technique of locked plating has been a major advance in Orthopaedic fracture surgery and has had an equal impact on the management of upper extremity fractures. The recognition of the role of vascularity and soft tissues in fracture healing was central to the research and development of newer plate designs that left minimal footprints on the surface of the bone. Subsequently, innovative locking technology has improved our ability to manage cases with extensive communition, inadequate bone stock, and peri-articular fractures. This paper will review the role of locking technology in the management of fractures of the upper extremity.

Osteoarthritis: Pathophysiology, Treatment, and What Muslims Need to Know Prior to Joint Replacement Surgery

DOI: http://dx.doi.org/10.5915/40-4-4435 Osteoarthritis is the most common type of arthritis. The joints most commonly involved include the knees, hips, fingers and thumbs, and the spine. Risk factors include age (>50 years), obesity, joint hypermobility/instability, prolonged occupational/sports stress, and previous joint injury. The pathogenesis of osteoarthritis is multifactorial, but the ultimate endpoint is the alteration of the articular cartilage. The diagnosis of osteoarthritis can usually be made by a detailed history and physical examination and reliably confirmed by plain radiographs. The primary goals of treatment for osteoarthritis are improved function and quality of life. Treatment modalities include patient education, physical therapy, pharmacotherapy, intra-articular injections, and surgery. Joint replacement surgery has been steadily growing in frequency and success. Hips and knees are the most commonly replaced joints. After successful joint replacement of a Muslim’s hips or knees, the resulting range of motion under normal circumstances may not allow sufficient motion to perform salat in the standard format.