Joseph J. Thoder

Operative Treatment of Metacarpal and Phalangeal Shaft Fractures

&NA; Diaphyseal fractures of the metacarpals and phalanges are common injuries that can lead to impairment of hand function. The fracture pattern and soft‐tissue injury vary with the mechanism of injury. The imbalance of the flexor and extensor forces created by displaced fractures will often produce a secondary angulatory deformity. Nonoperative treatment is indicated for reducible and stable fracture configurations. Irreducible or unstable fracture patterns require open or closed reduction and fixation. Reduction must be assessed in flexion and extension to ensure correct rotatory alignment. Fracture fixation can be achieved with the use of Kirschner wires, interfragmentary screws, or plates. The outcome after surgery is greatly influenced by the condition of the surrounding soft tissues; therefore, surgical trauma should be minimized to optimize the result.

De quervain tenosynovitis of the wrist.

De quervain disease, or stenosing tenosynovitis of the first dorsal compartment of the wrist, is a common wrist pathology. Pain results from resisted gliding of the abductor pollicis longus and the extensor pollicis brevis tendons in the fibro-osseus canal. de Quervain tenosynovitis of the wrist is more common in women than men. Diagnosis may be made on physical examination. Radiographs are helpful in ruling out offending bony pathology. Nonsurgical management, consisting of corticosteroid injections and supportive thumb spica splinting, is usually successful. In resistant cases, surgical release of the first dorsal compartment is done, taking care to protect the radial sensory nerve and identify all accessory compartments. Repair of the extensor retinaculum by step-cut lengthening or other techniques is rarely required.

Upper extremity limb-length discrepancy in brachial plexus palsy.

Residual limb shortening is common after obstetric brachial plexus palsy. The exact limb-length discrepancy remains undetermined, and the purpose of this paper is to determine the resultant discrepancy. Twenty-two skeletally immature patients with obstetric brachial plexus palsies were examined. Radiographs of both the involved and uninvolved humerii and forearms were obtained with a radiographic ruler placed adjacent to the extremity. Each limb segment was measured and the discrepancy calculated as a percentage compared with the normal side. Twenty-one of the 22 children had some shortening of the limb at both the humerus and forearm level. The involved limb averaged 92% of the uninvolved limb. The humeral length averaged 93% and the forearm length averaged 90%. Children with upper brachial plexus lesions had significantly less forearm and total limb shortening compared with those with global lesions. There was no correlation between age and percentage difference of the humeral, forearm, and total length.

Scaphoid fractures: dorsal versus volar approach.

Twenty-six patients with scaphoid fractures were treated with internal fixation using a cannulated differential pitch compression screw. Sixteen patients underwent a dorsal approach (group 1) 10 patients a volar approach (group 2). Average time from injury to surgery was 6.6 months (range: 0.3-19 months) for group 1 and 8.3 months (range: 0.3-24 months) for group 2. The rate of union, determined by radiographs and clinical examination, was 81% in group 1 and 80% in group 2. No significant differences were noted between the groups for dorsiflexion/palmar flexion, radial deviation, grip strength, and pain level.

Is Antibiotic Prophylaxis Necessary in Elective Soft Tissue Hand Surgery

Antibiotic prophylaxis for clean soft tissue hand surgery is not yet defined. Current literature focuses on overall orthopedic procedures, traumatic hand surgery, and carpal tunnel release. However, a paucity of data exists regarding the role of antibiotic prophylaxis in a broader variety of soft tissue hand procedures. The goal of the current study was to evaluate the rates of surgical site infection following elective soft tissue hand surgery with respect to administration of prophylactic antibiotics.A multicenter, retrospective review was performed on 600 consecutive elective soft tissue hand procedures. Procedures with concomitant implant or incomplete records were excluded. Antibiotic delivery was given at the discretion of the attending surgeon. Patient comorbidities were recorded. Outcomes were measured by the presence of deep or superficial infections within 30 days postoperatively. The 4 most common procedures were carpal tunnel release, trigger finger release, mass excision, and first dorsal compartment release. The overall infection rate was 0.66%. All infections were considered superficial, and none required surgical management. In patients who received antibiotic prophylaxis (n=212), the infection rate was 0.47%. In those who did not receive prophylaxis (n=388), the infection rate was 0.77%. These differences were not statistically significant (P=1.00).

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 …

Evolving Incidence of MRSA in Urban Hand Infections

Methicillin-resistant Staphylococcus aureus (MRSA) is the most commonly cultured bacteria in hand infections. Understanding the most common bacteria involved in hand infections allows appropriate and efficient administration of antibiotics. Delay in treatment may lead to increased morbidity, including stiffness, contracture, and amputation. The purposes of this study are to determine whether the incidence of MRSA in culture-positive hand infections continues to increase and whether MRSA is a risk factor for increased length of stay. Electronic medical records were queried to identify patients admitted to a large, academic urban medical center with the diagnosis of a hand infection between January 1, 2005, and December 31, 2009. Methicillin-resistant S aureus accounted for 220 of the positive cultures over the 5-year study period. Polymicrobial infection represented 81 positive cultures, and MRSA was only present in 10 of these cases. Patients with MRSA were found to have a mean length of hospital stay of 4.1 days compared with 4.5 days in non-MRSA infections. Understanding the most common bacteria involved in hand infections allows appropriate and efficient administration of antibiotics. Methicillin-resistant S aureus is the most commonly cultured bacteria in the hand. However, polymicrobial infections have become increasingly more common. Although incidences of polymicrobial infections increased over the study period in this series, clinical judgment should be exercised before initiating broad-spectrum antibiotic coverage.

The radiographic analysis of web height

Web creep is a common complication following surgical release of syndactyly. Currently, normal web height has not been objectively determined, which prevents accurate analysis of the degree of web creep after surgery. The purpose of this study was to design a technique to reproducibly measure web height and to define the standard web height in a control population. Four hundred thirty-seven standard left posteroanterior hand x-rays of children without any upper extremity pathology were evaluated. Web height was measured as a relative ratio to digital length using standard landmarks. All measurements were tabulated according to gender, age, and web space. Statistical analysis was performed to determine the reliability of this technique and to delineate any differences between web space, gender, and age. There was no significant intraobserver or interobserver difference and web height was similar in males and females. There was a significant difference between web height with respect to web location and age. Normal ranges of web height with regard to age and web position were determined and plotted as graphs. Using this measurement method, web creep can be evaluated and comparison studies of different surgical techniques performed.

Treatment of distal radius malunions with an intramedullary nail.

Malunion of the distal radius are the most common complications of distal radius fractures. Increased angulation of the distal radius can result in altered load concentrations on the wrist, decreased range of motion, decreased grip strength, and residual incongruence of the radiocarpal and distal radioulnar joints. Multiple options exist for fixation of corrective osteotomies of the distal radius, including intramedullary nails. The use of an intramedullary nail provides the benefits of a percutaneous insertion technique, low-profile implant, load-sharing design, and fixed-angle locking screws in the distal fragment. We describe an innovative technique for intramedullary fixation for corrective osteotomies of extraarticular distal radius malunions.

Interposition arthroplasty options for carpometacarpal arthritis of the thumb.

Carpometacarpal (CMC) arthritis of the thumb affects half of postmenopausal women and up to 25% of elderly men. This disease can cause significant disability in affected patients often necessitating surgical intervention. Various surgical options have been used to treat refractory CMC arthritis. Any successful surgical intervention must address three goals: removal of diseased joint surfaces, reconstruction of ligamentous stabilizers, and preservation of the joint space. In this article we will discuss various interposition arthroplasty options for CMC arthritis of the thumb.