Christopher J. Hogan

Use of Dynamic Distraction External Fixation for Unstable Fracture-Dislocations of the Proximal Interphalangeal Joint

PURPOSE Unstable fracture-dislocations of the proximal interphalangeal (PIP) joint remain a difficult management problem, often leading to residual pain, stiffness, and recurrent instability. In a military setting, an easily applied, simple to operate, and inexpensive device becomes an attractive option. The purpose of this clinical investigation was to retrospectively review use of dynamic distraction external fixation (DDEF) for unstable fracture-dislocations and pilon injuries of the PIP joint in an active-duty population. METHODS The fixator is assembled under a local anesthetic from three 1.4-mm (0.045-inch) K-wires and rubber bands. It uses the principles of a lever and ligamentotaxis to assist and maintain reduction. Thirty-four members of the Armed Services, 27 men and 7 women (average age, 30 y), had DDEF for pilon fractures and unstable fracture-dislocations of the PIP joint. A retrospective review of these individuals was conducted. Final range of motion was determined from the clinical records at the final visit. RESULTS There were 26 PIP fracture-dislocations (3 chronic, average 6 weeks) and 8 PIP pilon injuries. The average follow-up period was 16 months (range, 6-84 months). The final arc of motion at the PIP joint averaged 88 degrees , and the average distal interphalangeal joint arc of motion was 60 degrees . Eight patients experienced superficial pin-track infections that were easily controlled with oral antibiotics. There were no cases of septic arthritis or osteomyelitis requiring intravenous antibiotics or premature fixator removal. Loss of reduction did not occur. All patients returned to their prior level of activity and duties. CONCLUSIONS Our results are comparable with other techniques used in the management of unstable PIP joint fracture-dislocations. Easily applied and simple to operate, DDEF is a valuable addition to the hand surgeons armamentarium. We recommend its use for both primary and adjunctive treatment of acute and chronic unstable PIP joint fracture-dislocations and for primary treatment of PIP pilon injuries. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

High-pressure Injection Injuries to the Upper Extremity: A Review of the Literature

Objectives The purpose of this review was to identify the relative impact of injected material, location of injury, time to debridement, injection pressure, infection, and the use of adjuvant steroid medication upon the need for amputation after high-pressure injection injuries to the upper extremity. Data Sources and Study Selection A Medline literature search extending from 1966 to December 2003 was performed, referencing the key words “high-pressure injection injury,” “grease gun injury,” “paint gun injury,” “pressure gun injury,” and “high-pressure injection.” The results were limited to the English language and to reports involving human subjects. Each abstract was reviewed to confirm that the described injury had occurred in the upper extremity and that it had truly been a high-pressure injection. The reference pages from each of the papers were reviewed to identify additional reports of high-pressure injection injury. Manuscripts describing injuries resulting from hand held syringes or other low-pressure mechanisms were excluded. Data Extraction All of the manuscripts were analyzed to identify the clinical outcome, age, hand dominance, site of injection, substance injected, injection pressure, elapsed time to wide debridement, use of steroids, and incidence of infection. These variables were subjected to a Pearson χ2 test to determine their impact upon the need for amputation. Results Four hundred thirty-five cases of high-pressure injection injury to the upper extremity were identified. The amputation rate after these injuries was 30%. The location of the injury and the material injected contributed significantly to the need for amputation. For injections of paint, paint thinner, gasoline, oil, or jet fuel (organic solvents), the amputation risk was lower if wide surgical debridement occurred within 6 hours of injury. Steroids did not impact the amputation rate or incidence of infection. The presence of infection did not affect the incidence of amputation. Conclusions The risk of amputation after high-pressure injection injury to the upper extremity is highest with organic solvent injection into the fingers. Injections into the thumb or palm result in a much lower frequency of tissue loss. Emergent surgical debridement reduces the amputation risk after injections of organic solvents. From the available data, no conclusions could be reached regarding functional outcomes, other than amputation, after high-pressure injection injury.

Three Cast Techniques For The Treatment Of Extra-articular Metacarpal Fractures: Comparison Of Short-term Outcomes And Final Fracture Alignments

BACKGROUND Most extra-articular metacarpal fractures can be managed nonoperatively. While the conventional wisdom is that the metacarpophalangeal joint should be immobilized in a position of flexion, alternative methods for cast immobilization have been described. The purpose of this study was to retrospectively evaluate three methods of closed treatment; specifically, we investigated whether the position of immobilization of the metacarpophalangeal joint or the absence of a range of motion of the interphalangeal joints affected the short-term outcome or fracture alignment. METHODS Between November 2000 and April 2004, extra-articular metacarpal fractures were immobilized for five weeks in one of three ways: with the metacarpophalangeal joints in flexion and full interphalangeal joint motion permitted (Group 1); with the metacarpophalangeal joints in extension and full interphalangeal joint motion permitted (Group 2); and with the metacarpophalangeal joints in flexion, the interphalangeal joints in extension, and no interphalangeal joint motion permitted (Group 3). Radiographs and the range of motion were evaluated at five weeks after application of the cast, and the range of motion and grip strength were assessed at nine weeks. RESULTS Two hundred and sixty-three patients met the inclusion criteria. At five weeks, there was no difference among the treatment methods with regard to the range of motion or the maintenance of fracture reduction. At nine weeks, there was no significant difference with regard to the range of motion or grip strength. CONCLUSIONS When immobilization was discontinued by five weeks, the position of the metacarpophalangeal joints and the absence or presence of interphalangeal joint motion during the immobilization had little effect on motion, grip strength, or fracture alignment. This finding contradicts the conventional teaching that the metacarpophalangeal joint must be immobilized in flexion to prevent long-term loss of joint extension. Patient comfort, ease of application, and the surgeons familiarity with the technique should influence the choice of immobilization. LEVEL OF EVIDENCE Therapeutic Level III.

The ECU Synergy Test: An Aid to Diagnose ECU Tendonitis

PURPOSE Chronic dorsal ulnar-sided wrist pain challenges even the most experienced physicians. The close anatomic proximity and the possibility of coexistent injuries can render physical examination maneuvers ambiguous, making it difficult to discern between intra-articular and extra-articular pathology. Using the principle of synergism, we describe the extensor carpi ulnaris (ECU) synergy test as a novel means for diagnosing ECU tendonitis and document its benefit in the clinical setting. METHODS A retrospective chart review was performed, identifying adult patients experiencing greater than 4 months of dorsal ulnar-sided wrist pain. Physical examination findings, results of magnetic resonance imaging (MRI) and/or wrist arthroscopy, and clinical outcomes were compiled. RESULTS Fifty-five patients met inclusion criteria. Twenty-one patients (group 1) had no pain with the synergy test but had exams suggesting ulnar-sided intra-articular pathology. All had ulnar-sided intra-articular pathology on MRI and/or arthroscopy. Eleven patients (group 2) had positive synergy tests and no pain with the remainder of the exam. All had greater than 90% pain relief after ECU tendon sheath injection; 5 patients remained pain free. Six patients experienced temporary improvement and had MRI evaluation, confirming the diagnosis of isolated ECU tendonitis in 5 of the 6 patients. The remaining 22 patients (group 3) had positive synergy tests and exams that suggested concomitant ulnar-sided intra-articular pathology. After ECU sheath injection, 5 patients had persistent discomfort with either lunotriquetral ballottement or triangular fibrocartilage complex compression. All 5 patients had ulnar-sided intra-articular pathology confirmed by MRI and/or arthroscopy. Seventeen patients had greater than 90% pain relief after injection. Of these, 7 patients remained asymptomatic at latest follow-up, confirming the diagnosis of ECU tendonitis. Ten patients had recurrent symptoms, of which 6 patients demonstrated ulnocarpal pathology by MRI and/or wrist arthroscopy. CONCLUSIONS By differentiating between intra-articular and extra-articular pathology, the ECU synergy test composes part of a clinical algorithm that minimizes the need for wrist MRI and diagnostic arthroscopy. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction Techniques

Background Incompetence of the ulnar collateral ligament (UCL) of the elbow is career-threatening for high-performance throwing athletes. Although multiple reconstructions have been described, a procedure that combines a larger graft with improved fixation may demonstrate more favorable loading characteristics than current techniques. Hypothesis Ulnar collateral ligament reconstructions utilizing a semitendinosus graft and interference knot fixation will be biomechanically superior to previously reported techniques. Study Design Controlled laboratory study. Methods Thirty cadaveric elbows were stripped of all medial soft tissue superficial to the UCL. The proximal humeri were mounted on a materials testing system with the elbows flexed 90°. The intact UCL was loaded to failure at 4.5 deg/s. The torsional failure moment, torsional stiffness, and mode of failure were recorded. Three groups of 10 specimens were created. Group 1 underwent reconstruction using a palmaris tendon graft secured with interference knot fixation. Group 2 reconstructions utilized a palmaris graft and the docking technique. Group 3 specimens were reconstructed using a semitendinosus graft and interference knot fixation. All specimens were loaded to failure and the same parameters recorded. Results The torsional failure moments for group 1 (13.28 Nm) and group 2 (12.81 Nm) reconstructions were significantly (P < .05) inferior to that of their respective native values (21.3 Nm and 23.5 Nm). Semitendinosus reconstructions (20.5 Nm) were not significantly different (P = .24) from their native UCLs (23.0 Nm). All reconstructions were torsionally less stiff (P < .001) than the native UCL. There were no statistically significant differences in stiffness between the groups (P = .4). Conclusion Ulnar collateral ligament reconstruction utilizing semitendinosus graft and interference knot fixation restores the torsional strength of the intact UCL. Clinical Relevance Reconstructions using semitendinosus grafts may allow for accelerated rehabilitation and earlier return to competition.

Rice Bodies and a Partial Flexor Tendon Rupture in a Patient with Juvenile Idiopathic Arthritis

Case: We present a case of rice-body formation and partial flexor tendon rupture in a 3-year-old child with seronegative juvenile idiopathic arthritis (JIA), which presented as a painless soft-tissue mass of the volar aspect of the hand. The diagnosis was not confirmed until histologic examination. The patient was managed with a tenosynovectomy and oral medication; he made a full recovery. Conclusion: JIA is one of the most common rheumatologic conditions of childhood. Establishing the diagnosis can be challenging in very young children, particularly when clinical presentation is atypical and serology is negative. Surgical intervention may be warranted in the appropriately selected patient with JIA.

Posterior interosseous and ulnar nerve motor palsies after a minimally displaced radial neck fracture.

Peripheral nerve injury is a serious potential complication following an upper extremity fracture. A rare case of acute posterior interosseous nerve and ulnar nerve palsy following a minimally displaced radial neck fracture is reported. With nonsurgical management, both nerves demonstrated excellent functional recovery. Although rare, nerve palsies can occur during a variety of upper extremity clinical situations, including minimally displaced fractures, and the importance of a detailed neurologic examination cannot be overstated.