Michael M. Vosbikian

Acute Compartment Syndrome of the Hand

THE PATIENT A 35-year-old male laborer presented to the emergency department with pain and swelling in his hand after a crush injury. Radiographs did not demonstrate any fractures. His blood pressure at the time of examination was 145/70 mm Hg. He described the pain as extreme. He denied any numbness. On physical exam, the diffuse swelling of his hand was found to be tense. Vascular exam noted capillary refill that was approximately 2 seconds. Passive adduction and abduction of the fingers at the extended metacarpophalangeal joints resulted in pain. Intracompartmental pressures of 30 mm Hg were measured.

Optimal Positioning for Volar Plate Fixation of a Distal Radius Fracture: Determining the Distal Dorsal Cortical Distance

Distal radius fractures are currently among the most common fractures of the musculoskeletal system. With a population that is living longer, being more active, and the increasing incidence of osteoporosis, these injuries will continue to become increasingly prevalent. When operative fixation is indicated, the volar locking plate has recently become the treatment of choice. However, despite its success, suboptimal position of the volar locking plate can still result in radiographic loss of reduction. The distal dorsal cortical distance is being introduced as an intraoperative radiographic tool to help optimize plate position and minimize late loss of fracture reduction.

Accuracy of measurement of hand compartment pressures: a cadaveric study.

PURPOSE To determine the accuracy of digital palpation for clinical assessment of elevated intracompartmental pressure compared with needle manometry in a simulated compartment syndrome of the hand. METHODS Three cadaveric hands were configured with interstitial fluid infusion and an arterial line pressure monitor to create and continuously measure intracompartmental pressure in the thenar and hypothenar compartments. Seventeen assessors clinically judged the presence or absence of compartment syndrome based on digital palpation for firmness and then measured pressures with a handheld manometer. An intracompartmental pressure threshold of 30 mm Hg or greater was used to diagnose compartment syndrome. RESULTS The sensitivity and specificity of digital palpation of the thenar eminence were 49% and 79%, respectively, with a positive predictive value (PPV) of 86% and negative predictive value (NPV) of 37%. Using the handheld manometer, the sensitivity and specificity increased to 97% and 86% with a PPV of 95% and NPV of 92%. The sensitivity and specificity of digital palpation of the hypothenar eminence were 62% and 83%, respectively, with improvement of 100% and 100%, respectively, with a handheld manometer. For the hypothenar compartment, use of a handheld manometer improved the PPV from 92% to 100% and the NPV from 40% to 100% compared with digital palpation. CONCLUSIONS Digital palpation alone was insufficient to detect elevated compartment pressures in hands at risk for compartment syndrome. Handheld invasive pressure measurement was a useful adjunct for detecting elevated interstitial tissue pressures and may aid in diagnosing compartment syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.

Does the Ulnar Nerve Enlarge After Surgical Transposition

The purpose of this study was to test the hypothesis that symptomatic transposed ulnar nerves have a larger average cross‐sectional area (CSA) than symptomatic in situ ulnar nerves.

Recurrent cubital tunnel syndrome treated with revision neurolysis and amniotic membrane nerve wrapping

BACKGROUND Perineural scarring of the ulnar nerve is a predominant cause of symptom recurrence after surgical treatment for primary cubital tunnel syndrome (CuTS). We report our preliminary experience in revision ulnar nerve decompression and nerve wrapping with an amniotic membrane allograft adhesion barrier for treatment of recurrent CuTS. METHODS We performed a retrospective review with prospective follow-up of patients with recurrent CuTS who were treated with revision neurolysis with amniotic membrane nerve wrapping. Preoperative elbow motion, grip and pinch strengths, pain level on the visual analog scale level, and the 11-item version of the Disabilities of the Arm, Shoulder and Hand functional outcome score were compared with postoperative values using paired t testing. Symptom characteristics, physical examination findings, complications, and level of satisfaction were also obtained. RESULTS Eight patients (mean age, 47.5 years) who had undergone at least 2 prior ulnar nerve operations satisfied study inclusion. At mean postoperative follow-up of 30 months, significant improvements were noted across all patients in visual analog scale pain levels (-3.5 vs. preoperatively; P < .0001), 11-item version of the Disabilities of the Arm, Shoulder and Hand scores (-30 vs. preoperatively; P < .0001), and grip strength (+25 pounds vs. preoperatively; P < .0001). Pinch strength and elbow motion were also significantly improved for those patients with comparative preoperative data available. All patients expressed subjective satisfaction with their results. No adverse reactions or complications occurred in any patients. CONCLUSIONS Ulnar nerve wrapping with amniotic membrane allograft, when combined with revision neurolysis, was a safe and subjectively effective treatment for patients with debilitating recurrent CuTS.

Neurolysis with Amniotic Membrane Nerve Wrapping for Treatment of Secondary Wartenberg Syndrome: A Preliminary Report

BACKGROUND Entrapment of the superficial sensory branch of the radial nerve (SRN) commonly results in debilitating pain of the dorsoradial wrist. Symptom relief following SRN neurolysis is often incomplete or temporary due to recurrent perineural scarring. METHODS We performed a retrospective review with prospective follow-up of all patients with SRN neuropathy who were treated with neurolysis and nerve wrapping using an amnion-based allograft adhesion barrier over a one-year interval. Measured outcomes included pain rated by Visual Analog Scale (VAS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) functional outcome scores. RESULTS Three females satisfied inclusion. At mean follow-up of 28.9 months, all three patients exhibited improved pain (mean VAS change -4.7 ± 0.6), function (mean QuickDASH change -40 ± 5), and subjective satisfaction. No adverse events or reactions to the implanted tissue occurred. CONCLUSIONS SRN entrapment neuropathy was safely and effectively treated with neurolysis and amnion nerve wrapping in this small series. Use of this technique for perineural scar prevention warrants additional study in larger groups of patients and in other upper extremity entrapment neuropathies.

The Ice and Salt Challenge: An Atypical Presentation of a Cold Injury

Case:We present a case of a healthy seventeen-year-old adolescent with a cold injury to the hands from a new phenomenon known as the “ice and salt challenge,” where adolescents hold an ice cube and salt against their skin in competition to see which participant can withstand the discomfort the longest. This competition results in a characteristic injury pattern to the hands. The patient was treated with local wound care and had no long-term deficits. Conclusion:It is important for orthopaedic surgeons to be aware of the ice and salt challenge because they may be the first health-care providers to witness its effects. A high index of suspicion is critical in order to properly diagnose, treat, and counsel these patients against risk-taking behaviors.

Treatment of a Chronic Multidrug-Resistant Cutaneous Mycobacterium chelonae Infection of the Hand with Wide Debridement and Skin-Grafting

Case: We present a case of a healthy thirty‐seven‐year‐old woman with a chronic cutaneous Mycobacterium chelonae infection of the hand recalcitrant to antibiotics and excisional biopsies. She was treated with wide excision of the lesion and staged full‐thickness skin‐grafting. At the sixth‐month follow‐up, she reported no activity limitations and demonstrated full painless digital motion without evidence of recurrent infection. Conclusion: The technique presented offers the advantage of early digital range of motion with temporary soft‐tissue coverage prior to definitive coverage with a full‐thickness skin graft while laboratory analysis is performed.