Julia A. Katarincic

Complex elbow instability.

Complex elbow instability consists of dislocation of the ulnohumeral joint with a concomitant fracture of one or several of the bony stabilizers of the elbow, including the radial head, proximal ulna, coronoid process, or distal humerus. Recurrent instability is not often associated with simple dislocation, but an improperly managed complex dislocation may be a prelude to chronic, recurrent elbow instability. Complex instability is significantly more demanding to manage than simple instability. Radial head, coronoid, and olecranon fracture associated with dislocation each must be assessed and often require surgery. Long-term outcome with surgical management of complex elbow injuries is unknown. A few published series examine combinations of different injury patterns managed with various methods. Recently, however, several well-designed prospective outcome studies have evaluated management of several different individual fracture-dislocation patterns with a unified treatment algorithm. Fixation or replacement of injured bony elements, ligamentous repair, and hinged fixation may be used to successfully manage complex elbow instability.

Fluoroscopic Evaluation of Intra-Articular Screw Placement During Locked Volar Plating of the Distal Radius: A Cadaveric Study

PURPOSE To evaluate specific fluoroscopic views for assessment of intra-articular screw placement during locked volar plating of the distal radius. METHODS The distal radius of a cadaver forearm was plated with a fixed-angle volar plate according to the surgical technique guide of the manufacturer. A goniometer was used to place the specimen at various described angles in the fluoroscope including standard posteroanterior (PA), tilt PA (11 degrees ), standard lateral, and tilt lateral (15 degrees , 23 degrees , 30 degrees ) views. Radiographic images of each screw individually and in various combinations were digitally captured. RESULTS Only the tilt PA view correctly showed all 4 screws to be extra-articular. On the standard PA view, the 2 ulnar screws appeared intra-articular. Lower angle tilt lateral views (15 degrees and 23 degrees ) correctly visualized the ulnar screws but not the styloid screw. The highest angle lateral view (30 degrees ) correctly visualized the radial screws but not the sigmoid (most ulnar) screw. The styloid screw appeared to be intra-articular on every lateral view except at 30 degrees and was correctly visualized on both the PA and tilt PA views. CONCLUSIONS Multiple oblique views are required for evaluation of intra-articular screw placement during locked volar plating of the distal radius. Lower angle tilt lateral views are more specific for the ulnar screws, and higher angle views are more specific for the radial screws. We suggest first placing the ulnar screws whenever possible, using lower angle tilt lateral views (15 degrees to 23 degrees ) to evaluate for intra-articular placement. The styloid screw may be placed last and can then be evaluated on the PA and tilt PA views.

Ring and Little Finger Metacarpal Fractures: Mechanisms, Locations, and Radiographic Parameters

PURPOSE To describe a series of ring and little finger metacarpal fractures with regard to mechanism, location, midshaft diameter, and isthmus diameter, to better define injury patterns and assist the surgeon in selection of appropriately sized implants. METHODS We reviewed all metacarpal fractures in skeletally mature patients who presented to a single surgeon over a 2-year period. Fractures of the ring and little finger metacarpals were analyzed with regard to mechanism and fracture location. Metacarpal midshaft and minimum isthmus diameters were measured on posteroanterior radiographs. RESULTS A total of 101 fractures involved the ring and little finger metacarpals. Punching-type injuries accounted for most fractures in the little finger metacarpal (49 of 67) and ring finger metacarpal (26 of 34). Among these punching-related ring and little finger metacarpal fractures, the most common fracture location was the little finger metacarpal neck (34 of 75), followed by the ring finger metacarpal shaft (21 of 75). Among men in this series, the metacarpal midshaft and minimum isthmus diameters were significantly narrower in the ring finger metacarpal than in the little finger (7.4 vs 8.7 mm, p < .001; and 2.2 vs 3.8 mm, p < .001). CONCLUSIONS Whereas punching injuries tended to cause neck fractures in little finger metacarpals in this series, they caused shaft fractures in ring finger metacarpals, which may thus be considered a variant boxers fracture. Furthermore, in men with fractures, the ring finger metacarpal is significantly narrower than the little finger, both in midshaft diameter and isthmus diameter, which surgeons should consider when planning internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.

Complications associated with retained implants after plate fixation of the pediatric forearm.

Objective: Our present study examines the complications of pediatric patients treated with plate fixation for forearm fractures. Design: Case series of pediatric patients after their forearm fracture was fixed using a plate, with the majority of patients retaining their implants. Setting: Level 1 Trauma Center. Methods: From 1999 to 2009, 58 patients between the ages of 6 and 15 years had fixation of their forearm fracture with plates. Thirty-three of these patients were available for a long-term follow-up with an average of 6.4 years. The patients were interviewed over the phone, and a physician filled out a questionnaire with regard to their clinical course. Records and x-ray data were reviewed for each patient. Factors such as implant complications, functional activity level, pain score, and clinical symptoms were studied. Results: Fractures occurred in 7.1% (2/28) of the patients who chose to retain their implants. Of the 28 patients who initially chose to leave the implants in place, 17.9% (5/28) had a partial or complete removal of the implants because of irritation. These patients reported the following symptoms: mild pain 42.3% (11/26), clicking 34.6% (9/26), ability to feel the plates 73.1% (19/26), and mild weakness 26.9% (7/26). The number of patients who reported return to the preinjury level of activity was 88.5% (23/26), and 96.2% (25/26) reported being satisfied with their clinical outcome when implants were retained. Females had a significantly greater subjective weakness of 60.0% (6/10) compared with that of males, which was 14.3% (3/21; P = 0.009) after a forearm fracture. The inability to return to the preinjury level of activity was significantly greater for females, which was 30.0% (3/10) versus 0.0% (0/21) for males (P = 0.008). Conclusions: We concluded that retaining the plates in pediatric forearm fractures does not increase the refracture rate compared with the removal from the historical rates in the literature. Patients should be warned of possible symptoms and complications that may be present with retained plates. Also, a more aggressive physical therapy may be considered for females because they were observed to have more subjective weakness and dysfunction at long-term follow-up. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Diaphyseal Forearm Fractures in Children

Both bone forearm fractures are common orthopedic injuries. Optimal treatment is dictated not only by fracture characteristics but also patient age. In the pediatric population, acceptable alignment can tolerate greater fracture displacement due to the bone’s ability to remodel with remaining growth. Generally, these fractures can be successfully managed with closed reduction and casting, however operative fixation may also be required. The optimal method of fixation has not been clearly established. Currently, the most common operative interventions are open reduction with plate fixation versus closed or open reduction with intramedullary fixation. Plating has advantages of being more familiar to many surgeons, being theoretically superior in the ability to restore radial bow, and providing the possibility of hardware retention. Recently, intramedullary nailing has been gaining popularity due to decreased soft tissue dissection; however, a second operation is needed for hardware removal generally 6 months after the index procedure. Current literature has not established the superiority of one surgical method over the other. The goal of this manuscript is to review the current literature on the treatment of pediatric forearm fractures and provide clinical recommendations for optimal treatment, focusing specifically on children ages 3-10 years old.

Flexor Tendon Repair With Looped Suture: 1 Versus 2 Knots

PURPOSE To assess the strength of flexor tendon repair with looped suture. We hypothesized that, after passing the intact looped suture in the desired repair configuration, splitting the loop and tying 2 independent knots would increase the strength of flexor tendon repair. METHODS Thirty-two flexor tendons were harvested and were sharply transected in zone II. The tendons were repaired with a 4-strand core suture repair using 3-0 looped nonabsorbable nylon suture. The harvested tendons were randomly assigned and repaired with either a 1- or a 2-knot construct. The repaired flexor tendons were fixed in a servohydraulic material testing system and were loaded to failure either with uniaxial tension or cyclically. RESULTS The average force at failure was 43 N for the 1-knot repair and 28 N for the 2-knot repair. The mode of failure of 15 of the flexor tendon repairs that were cyclically loaded to failure was suture pull-out. The average number of cycles and force in cyclic testing that caused failure of flexor tendon repairs was 134 cycles and 31 N for tendons repaired with looped 3-0 suture tied with 1 knot and 94 cycles and 33 N for tendons repaired with looped 3-0 suture tied with 2 knots. CONCLUSIONS Our hypothesis was disproved by the results of this study. CLINICAL RELEVANCE This study suggests that, when using looped suture, tying 2 independent knots instead of tying a single knot does not increase the strength of the flexor tendon repair.

Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review

Surgical site infections remain a dreaded complication of orthopaedic surgery, affecting both patient economics and quality of life. It is important to note that infections are multifactorial, involving both surgical and patient factors. To decrease the occurrence of infections, surgeons frequently use local modalities, such as methicillin-resistant Staphylococcus aureus screening; preoperative bathing; intraoperative povidone-iodine lavage; and application of vancomycin powder, silver-impregnated dressings, and incisional negative-pressure wound therapy. These modalities can be applied individually or in concert to reduce the incidence of surgical site infections. Despite their frequent use, however, these interventions have limited support in the literature.

Efficacy of a radial-based thumb metacarpophalangeal-stabilizing orthosis for protecting the thumb metacarpophalangeal joint ulnar collateral ligament

Study Design: Basic research (biomechanics). Introduction: The high degree of motion that occurs at the thumb metacarpophalangeal (MCP) joint must be taken into account when immobilizing a partially torn or repaired thumb ulnar collateral ligament. Purpose of the Study: To determine the efficacy of a radial‐based thumb MCP‐stabilizing orthosis in resisting abduction across the thumb ulnar collateral ligament. Methods: Ten fresh cadaveric hands were mounted to a custom board. An anteroposterior radiograph of the thumb was obtained with a 2 N preload valgus force applied to the thumb, and the angle between the Kirschner wires was measured as a baseline. Subsequently, 20, 40, 60, 80, and 100 N valgus forces were applied 15 mm distal to the MCP joint. Anteroposterior radiographs of the thumb were obtained after each force was applied. The angle of displacement between the wires was measured and compared with the baseline angle. The angles were measured with an imaging processing tool. A custom radial‐based thumb MCP‐stabilizing orthosis was fashioned for each cadaveric thumb by a certified hand therapist. The aforementioned loading protocol was then repeated. Results: The radial‐based thumb MCP‐stabilizing orthosis significantly reduced mean abduction angles at each applied load. Discussion: We found that our orthosis, despite being hand‐based and leaving the thumb IP and CMC joints free, significantly reduced mean abduction angles at each applied load. Conclusions: This investigation provides objective evidence that our radial‐based thumb MCP‐stabilizing orthosis effectively reduces the degree of abduction that occurs at the thumb MCP joint up to at least 100 N. Level of Evidence: n/a (cadaveric).

Diagnosis and Management of Dermatofibrosarcoma Protuberans in a 3-Year-Old Patient

In this case report, we present a 3-year-old boy with a diagnosis of dermatofibrosarcoma protuberans (DFSP) on the dorsum of his right hand. Although rarely metastatic, DFSP is highly locally invasive and can cause considerable local morbidity. In the hand, DFSP is uncommon in the young pediatric patient. In our patient, the tumor extended down to the second and third metacarpal heads and was treated with a multistaged excision of his tumor to achieve negative margins under slow Mohs micrographic surgery.

Evaluating a Flexor Tendon Laceration with the Tenodesis Effect

A 17-year-old, right-hand dominant male presented to the emergency department after accidentally lacerating his left proximal palm while cleaning a kitchen knife at home (Figure 1). He had a small amount of bleeding and an inability to flex his left index finger. On examination, the finger was found to rest in full extension (Figure 1). He had intact sensation on the radial and ulnar side of his left index finger but when isolating either his proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints, he was unable to flex them. He was however, able to weakly flex his metacarpophalangeal (MCP) joint 20 -30 . When the tenodesis effect was elicited by passively flexing and extending his wrist, it was noted that the position of his index finger remained unchanged, and the neighboring digits flexed and extended appropriately (Figure 2; available at www.jpeds.com). Injuries to the hand account for up to 20% of all visits to the emergency department. These injuries frequently involve flexor tendons on the volar (palm) side or the extensor tendons on the dorsal side. Flexor tendon laceration rates may be as high as 92.5% when the injury is deep and penetrating through a stab wound. Young adult males have a disproportionate number of these injuries. The physical examination for evaluation of flexor tendon injury is essential for all emergency department and primary caregivers because prompt recognition will allow for early surgical intervention and the best prognosis (Video; available at www.jpeds.com). The timing of the injury, the mechanism, and the offending object should be noted