Clifton Meals

Hand Fractures: A Review of Current Treatment Strategies

Fractures of the tubular bones of the hand are common and potentially debilitating. The majority of these injuries may be treated without an operation. Surgery, however, offers distinct advantages in properly selected cases. We present a review of hand fracture management, with special attention paid to advances since 2008. The history and mechanisms of these fractures are discussed, as are treatment options and common complications. Early mobilization of the fractured hand is emphasized because soft tissue recovery may be more problematic than that of bone.

Management of adult diaphyseal both-bone forearm fractures.

Simultaneous diaphyseal fractures of the radius and ulna, often referred to as both-bone forearm fractures, are frequently encountered by orthopaedic surgeons. Adults with this injury are typically treated with open reduction and internal fixation because of the propensity for malunion of the radius and ulna and the resulting loss of forearm rotation. Large case series support the use of plate and screw fixation for simple fractures. More complex fractures are managed according to strain theory, with the intention of controlling rather than eliminating motion at the fracture site. This can be achieved with flexible plate and screw constructs or intramedullary nails. In general, results of surgical fixation have been good, with only modest losses of forearm strength and rotation. Notable complications include nonunion, malunion, and refracture after device removal.

Ketamine infusion for sickle cell crisis pain in an adult.

To the Editor: There is no single drug or combination of medications that completely alleviates sickle cell crisis pain. Sickle cell crises may occur in the setting of chronic or recurrent pain, chronic opioid use, and relative opioid tolerance, making crises particularly difficult to treat. A variety of adjunctive analgesics have been tried, including ketamine. By blocking theN-methyl-D-aspartate (NMDA) receptor, ketamine impairs sensitization of spinal neurons to nociceptive stimuli and may, therefore, impede development of and blunt neuropathic pain. Ketamine was demonstrated to be useful in a small pediatric population with sickle cell crisis pain. Ketamine is used widely in adults with severe pain not related to sickle cell disease. Subramaniam et al. performed a systematic review of 37 randomized, double-blind, clinical trials of ketamine used as an adjunct to opioids in postsurgical patients (both children and adults). They concluded that lowdose ketamine is helpful and safe when added to opioid analgesia in postoperative patients. In a second meta-analysis, Bell et al. reported a similar role for ketamine in a postsurgical population. Ketamine has been shown, anecdotally, to help manage a variety of adult opioid-refractory nonsurgical pains as well. Given this experience, we hypothesized that ketamine might be useful in the management of adult sickle cell crises. Few or no reports exist, however, describing this particular use of the drug. We describe the case of a 31-yearold man in sickle cell crisis treated with ketamine as an adjunct to opioids.

The biomechanical stability of salvage procedures for distal radioulnar joint arthritis

PURPOSE To test distal forearm stability after 3 surgical procedures for distal radioulnar joint (DRUJ) arthritis. METHODS We tested 11 cadaver limbs with the DRUJ intact, after distal ulna-matched hemiresection, after Darrach distal ulna resection, and after unlinked total DRUJ arthroplasty. We evaluated distal forearm stability in neutral rotation, full pronation, and full supination in unweighted and 1-kg-weighted conditions. We measured dorsal/palmar translation and convergence/divergence of the distal radius relative to the ulna. RESULTS Under neutral rotation, whether weighted or unweighted, matched hemiresection and Darrach specimens demonstrated significant radioulnar convergence relative to intact specimens. Weighted and unweighted, DRUJ arthroplasty demonstrated similar radioulnar convergence to intact. Weighted and unweighted, only Darrach specimens showed significant radius-palmar translation compared with intact, hemiresected, and DRUJ arthroplasty. In pronation, no testing scenario, either weighted or unweighted, demonstrated statistically significant radioulnar convergence relative to intact state. In unweighted pronation, palmar translation of the radius was significantly different from the intact state for all surgical scenarios and the Darrach was significantly worse than the other procedures. In weighted pronation, palmar translation of the radius was significantly different from the intact state for all surgical scenarios and the matched hemiresection was significantly better than the other procedures. In supination, weighted and unweighted, Darrach specimens had significant radioulnar convergence relative to intact. Either weighted or unweighted, the hemiresection and arthroplasty groups demonstrated similar radioulnar convergence relative to intact. Unweighted, all scenarios demonstrated similar dorsal translation of the radius. Weighted, the Darrach group showed significant radius-dorsal translation relative to intact specimens. CONCLUSIONS For tested procedures, DRUJ arthroplasty overall was biomechanically superior to the other conditions except that we found greater stability in the hemiresected group in weighted pronation. CLINICAL RELEVANCE Knowledge of baseline biomechanical characteristics of DRUJ arthritis procedures will aid surgical decision-making and patient counseling.

Origins of eponymous orthopaedic equipment.

BackgroundOrthopaedists make great use of eponymous equipment, however the origins of these tools are unknown to many users. This history enriches, enlightens, and enhances surgical education, and may inspire modern innovation.Questions/purposesWe explored the origins of common and eponymous orthopaedic equipment.MethodsWe selected pieces of equipment named for their inventors and in the broadest use by modern orthopaedists. We do not describe specialized orthopaedic implants and instruments owing to the overwhelming number of these devices.ResultsThe history of this equipment reflects the coevolution of orthopaedics and battlefield medicine. Additionally, these stories evidence the primacy of elegant design and suggest that innovation is often a process of revision and refinement rather than sudden inspiration. Their history exposes surgical innovators as brilliant, lucky, hardworking, and sometimes odd. These stories amuse, enlighten, and may inspire modern orthopaedists to develop creative solutions of their own.ConclusionsThe rich history of the field’s eponymous instruments informs an ongoing tradition of innovation in orthopaedics.

Tendon Versus Nerve Transfers in Elbow, Wrist, and Hand Reconstruction: A Literature Review

Upper extremity reconstruction forces the surgeon to chose between several available procedures, among them tendon and nerve transfer. Few guidelines exist to assist the surgeon in this regard, and the authors, therefore, undertook a retrospective review of case series describing tendon and nerve transfer. The authors discovered a scarcity of robust reporting, particularly in regard to tendon transfer, making an objective comparison between the two techniques difficult. Tendon transfers are popular and familiar. Nerve transfers promise distinct advantages; however, excellent evidence of their superiority is lacking.

Instrumented reduction of a fixed C1-2 subluxation using occipital and C2/C3 fixation: A case report.

Background Different strategies exist for reduction of the cervical spine. Placement of C1 lateral mass screws is a powerful technique but may be impossible in a degenerative or revision setting. We report the open, posterior-only, and instrumented reduction of a fixed C1–2 subluxation using occipital and C2/C3 fixation. The patient had rheumatoid arthritis and had undergone previous surgery of the cervical spine. Methods We performed a retrospective chart review and focused appraisal of the literature. Results Satisfactory reduction was achieved with this infrequently reported technique. Conclusions/Level of Evidence Spine surgeons may consider the described procedure a viable treatment alternative in problematic subluxations of the cervical spine. Level V.

Rings May Be Removed With a Tie From a Surgical Mask

central lesions in patients presenting with acute vestibular syndrome. The studies included in this review were of varying methodology, and all included cohorts with a relatively high prevalence of central disease. These limitations should not, however, dissuade the experienced practitioner from using the HINTS examination to assist in clinical decisionmaking in the management of select patients with acute vestibular syndrome. In regard to the selective use of delayed magnetic resonance imaging (MRI) in 2 of the studies, this criticism is not entirely accurate. All patients in the study by Kattah et al, including those initially classified as having a peripheral cause of their vertigo, were admitted to evaluate for any evolution of clinical findings and underwent repeated imaging as indicated. In the study by Newman-Toker et al, repeated MRI was obtained if clinical signs suggested a central lesion or if any new neurologic signs appeared after hospital admission. Although neither study reported the number of patients undergoing delayed MRI, or the results of the HINTS examination for those patients, there is no indication that delayed MRI was obtained only for those with a positive HINTS examination result. It is correctly noted that the included studies consisted of patient populations with a moderate to high prevalence of central lesions. As stated in the review, caution must be exercised when attempting to use this tool for a lower-risk population. This does not, however, preclude its use entirely. Although the positive predictive value of the HINTS examination would likely be decreased by its use in a low-risk population, resulting in a higher proportion of patients with a positive test result actually having peripheral acute vestibular syndrome, its sensitivity should remain unchanged, and it is unlikely that patients with central acute vestibular syndrome would be misclassified as having peripheral acute vestibular syndrome. The negative predictive value of the test would actually be increased in populations at lower risk of central disease. I agree that the primary strength of the HINTS examination lies in its ability to diagnose a central lesion rather than its ability to exclude one. Delays in the diagnosis of posterior circulation stroke can be devastating, with an 8-fold increase in mortality, and extreme care should be taken when assigning a diagnosis of peripheral acute vestibular syndrome. MRI with diffusion-weighted imaging is often used early in the evaluation of patients with vertigo either in the emergency department or after admission to the hospital. A normal MRI result early in the course of disease does

The incidence of hypovitaminosis-D in hip fracture, a retrospective study

BackgroundHip fracture is a major and expanding problem faced by orthopaedic surgeons. Accepted risk factors for hip fracture include age, female sex, and osteoporosis. Emerging evidence suggests that hypovitaminosis-D, by contributing to osteoporosis, also may predispose to hip fracture. Despite this theorys obvious interest to orthopaedists, few related studies exist in the orthopaedic literature. MethodsWe hypothesized that most patients presenting to our institution with acute hip fracture would have suboptimal levels of vitamin-D, and we sought to identify the incidence of hypovitaminosis-D in this population. We undertook a retrospective chart review of 50 patients for whom vitamin-D levels were obtained after presenting to our institutions emergency department with acute hip fracture. Patients were stratified according to type of fracture, sex, and age. Standard statistical values were calculated. ResultsMost (80%) of the study population demonstrated insufficient (32%) or deficient (48%) levels of vitamin-D. ConclusionsInadequate vitamin-D likely is one of many interrelated risk factors for hip fracture. Further study and the attention of orthopaedists are indicated to detail the nature of this risk and to optimize interventions.

Viability of Hand and Wrist Photogoniometry

Background: No goniometric technique is both maximally convenient and completely accurate, although photogoniometry (ie, picture taking to facilitate digital angle measurement) shows promise in this regard. Our purpose was to test the feasibility and reliability of a photogoniometric protocol designed to measure wrist and digit range of motion in general. Methods: Two independent observers examined a sample of joints in both normal and abnormal hands according to a photogoniometric protocol. Interrater and intrarater correlation were calculated, and these measurements were compared with measurements made by a third independent examiner with a manual goniometer. Results: The photo-based measurements were reliable within and between observers; however, only a minority of these measurements were in agreement with manually collected values. Conclusions: At present, photogoniometry is not an acceptable alternative to manual goniometry for determining wrist and digit range of motion in general. Joint-specific photogoniometry should be the subject of future study, as should relevant imaging and software technology.