Bradley A. Palmer

Cubital tunnel syndrome.

Cubital tunnel syndrome is the second most common compression neuropathy in the upper extremity. Patients complain of numbness in the ring and small fingers, as well as hand weakness. Advanced disease is complicated by irreversible muscle atrophy and hand contractures. Ulnar nerve decompression can help to alleviate symptoms and prevent more advanced stages of dysfunction. Many surgical treatments exist for the treatment of cubital tunnel syndrome. In situ decompression, transposition of the ulnar nerve into the subcutaneous, intramuscular, or submuscular plane, or medial epicondylectomy have all been shown to be affective in the treatment of this disease process. Comparative studies have shown some short-term advantages to one or another technique, but overall results between the treatments have essentially been equivocal. The choice of surgical treatment is based on multiple factors, and a single surgical approach cannot be applied to all clinical situations. Through careful consideration of the potential sites of nerve compression and the etiologies for these local irritations, the appropriate surgical technique can be selected and a good outcome anticipated in most patients.

Flexor Tendon Repairs: Techniques, Eponyms, and Evidence

The evolution in surgical technique and suture technology has provided an abundance of options for flexor tendon repairs. Multiple biomechanical studies have attempted to identify the best surgical technique based on suture properties, technical modifications, and repair configurations. However, the burgeoning amount of research on flexor tendon repairs has made it difficult to follow, and no gold standard has been determined for the optimal repair algorithm. Therefore, it seems that repairs are usually chosen based on a combination of familiarity from training, popularity, and technical difficulty. We will discuss the advantages, disadvantages, and technical aspects of some of the most common core flexor tendon repairs in the literature. We will also highlight the nomenclature carried through the years, drawings of the repairs referred to by that nomenclature, and the data that support those repairs.

Arthroscopically assisted elbow interposition arthroplasty without hinged external fixation: surgical technique and patient outcomes.

BACKGROUND Total elbow arthroplasty is successful in older, lower demand patients but not in the younger, more active individual with severe elbow arthritis. Interposition arthroplasty is an alternative for younger patients who hope to minimize the degree to which arm use is restricted. Interposition arthroplasty traditionally involves release of all ligaments and capsule. As a result, the postoperative care included the use of a hinged external fixator of the elbow to apply distraction and to permit motion during the early phases of healing. We describe a novel surgical technique without a hinged external fixator that allows secure fixation of the interposition graft through arthroscopic assistance and maintains the integrity of the medial collateral ligament with only a takedown and repair of the lateral collateral ligament complex. METHODS A retrospective chart review was performed to analyze 4 patients with an average age of 57 years who underwent surgery between 2007 and 2011. The patients were also contacted to assess elbow-specific American Shoulder and Elbow Surgeons and Disabilities of the Arm, Shoulder, and Hand scores. RESULTS The average follow-up was 3.6 years (range, 2.5-6 years), and 1 patient was converted to a total elbow arthroplasty after 2.5 years because of persistent pain. The remaining 3 patients have done well with regard to pain control, stability, and functional use of the operative extremity. There were no postoperative complications. DISCUSSION On the basis of our small series of patients, an arthroscopically assisted elbow interposition arthroplasty without hinged external fixation can provide satisfactory medium-term outcomes as a salvage procedure for a difficult condition with limited options.

Evidence-based medicineNecrotizing Fasciitis

THE PATIENT A 54-year-old diabetic male presents to the emergency department for evaluation of 12 hours of worsening right hand and forearm pain after falling outside. The patient is in visible distress, with a temperature of 38.5 C and a heart rate of 100 bpm. There is a small dorsal hand wound with diffuse erythema, swelling, bullae, and extreme tenderness extending up the forearm. Pain limits the motor examination but sensation is intact distally. Radiographs demonstrate soft tissue swelling and subcutaneous gas in the hand and forearm.

Comparing Biomechanical Properties, Repair Times, and Value of Common Core Flexor Tendon Repairs

Background: The aim of the study was to compare biomechanical strength, repair times, and repair values for zone II core flexor tendon repairs. Methods: A total of 75 fresh-frozen human cadaveric flexor tendons were harvested from the index through small finger and randomized into one of 5 repair groups: 4-stranded cross-stitch cruciate (4-0 polyester and 4-0 braided suture), 4-stranded double Pennington (2-0 knotless barbed suture), 4-stranded Pennington (4-0 double-stranded braided suture), and 6-stranded modified Lim-Tsai (4-0 looped braided suture). Repairs were measured in situ and their repair times were measured. Tendons were linearly loaded to failure and multiple biomechanical values were measured. The repair value was calculated based on operating room costs, repair times, and suture costs. Analysis of variance (ANOVA) and Tukey post hoc statistical analysis were used to compare repair data. Results: The braided cruciate was the strongest repair (P > .05) but the slowest (P > .05), and the 4-stranded Pennington using double-stranded suture was the fastest (P > .05) to perform. The total repair value was the highest for braided cruciate (P > .05) compared with all other repairs. Barbed suture did not outperform any repairs in any categories. Conclusions: The braided cruciate was the strongest of the tested flexor tendon repairs. The 2-mm gapping and maximum load to failure for this repair approached similar historical strength of other 6- and 8-stranded repairs. In this study, suture cost was negligible in the overall repair cost and should be not a determining factor in choosing a repair.

An Unusual Cause for Noninfectious Subcutaneous Emphysema of the Upper Extremity

Subcutaneous emphysema after trauma should raise immediate suspicion for a necrotizing soft-tissue infection. However, there are certain circumstances in which subcutaneous emphysema is the result of a benign or noninfectious process. In the literature, subcutaneous emphysema has been reported secondary to high-pressure injection injuries, factitious self-injection of air and chemical substances in the extremities, elbow arthroscopy, air-sucking phenomenon from traumatic lacerations, and iatrogenic use of hydrogen peroxide in the face and extremities1-13. Surgical evaluation should be obtained for the assessment of subcutaneous emphysema so that, if necessary, immediate surgical intervention can be performed. We report a case of noninfectious subcutaneous emphysema of the upper extremity with an unusual cause. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A forty-six-year-old right-hand-dominant woman fell on some ice and landed on the left elbow, causing a 2-cm laceration over the olecranon process. The patient reported that she initially had managed the wound with intermittent hydrogen peroxide irrigation and gauze dressing. She was a medical assistant for a primary care physician who evaluated the wound at work approximately twelve hours after the initial injury. At that time, she had not experienced any symptoms in the upper extremity except for localized pain around the wound. She continued to work with a sterile dressing over the wound, but did not have the wound closed. Approximately twenty-four hours after the fall, she presented to our emergency room with the symptom of subjective pain (rated 5 of 10) in the entire upper extremity, especially with elbow range of motion. She also described a “crunchy” feeling in the forearm that had worsened over the course of the day and copious drainage from the laceration site. She denied numbness or tingling distally and any systemic symptoms …

Establishing an Animal Model of Dupuytren’s Contracture by Profiling Genes Associated with Fibrosis

Dupuytren’s disease (DD) is characterized by the progressive development of a scar-like collagen-rich cord within the palmar fascia of the hand that results in permanent finger contracture. Currently, DD is most commonly treated by surgical resection of the diseased tissue. To date, no directly analogous animal model has been described in which to evaluate potential nonsurgical treatments for Dupuytren’s contracture. In the present study, we endeavor to establish an animal model that may ultimately serve as a platform in which to compare various treatments for DD. Hypothesizing that fibroblasts are the cellular effectors of the Dupuytren’s phenotype, we have transplanted fibroblasts derived from DD palmar fascia into the forepaw of nude rats. Our initial examinations showed that DD-derived fibroblasts persisted successfully in the forepaws of nude rats up to 56 days. Initial studies with quantitative real-time RT-PCR (qRT-PCR) using RNA derived from forepaw tissues harvested at 8 weeks showed that mRNA levels of alpha-smooth muscle actin (α-SMA) and type I collagen were significantly elevated in the forepaws of nude rats injected with DD-derived fibroblasts. The increase in α-SMA suggests an in vivo fibroblast to myofibroblast transformation that ultimately may result in scar formation and contracture.