Michael T. Mazurek

Upper extremity peripheral nerve anatomy: current concepts and applications.

The nerve anatomy of the upper extremity is studied constantly through surgical findings, electrodiagnostic studies, and cadaveric dissections. Although it is recognized that the anatomy is not changing rapidly, knowledge of the anatomic relationships and their significance is increasing. The purpose of the current study is to provide a comprehensive analysis of the nerve anatomy of the upper extremity to include innervation patterns, critical landmarks, and clinical applications, with particular focus on recent contributions in the literature.

Extremity war injuries: challenges in definitive reconstruction.

&NA; The third annual Extremity War Injuries Symposium was held in January 2008 to review challenges related to definitive management of severe injuries sustained primarily as a result of blast injuries associated with military operations in the Global War on Terror. Specifically, the symposium focused on the management of soft‐tissue defects, segmental bone defects, open tibial shaft fractures, and challenges associated with massive periarticular reconstructions. Advances in several components of soft‐tissue injury management, such as improvement in the use of free‐tissue transfer and enhanced approaches to tissue‐engineering, may improve overall care for extremity injuries. Use of distraction osteogenesis for treatment of large bone defects has been simplified by the development of computer‐aided distraction protocols. For closed tibial fractures, evidence and consensus support initial splinting for transport and aeromedical evacuation, followed by elective reamed, locked intramedullary nail fixation. Management of open tibial shaft fractures sustained as a result of high‐energy combat injuries should include serial débridements every 48 hours until definitive wound closure and stabilization are recommended. A low threshold is recommended for early utilization of fasciotomies in the overall treatment of tibial shaft fractures associated with war injuries. For management of open tibial fractures secondary to blast or high‐velocity gunshot injuries, good experiences have been reported with the use of ring fixation for definitive treatment. Treatment options in any given case of massive periarticular defects must consider the specific anatomic and physiologic challenges presented as well as the capabilities of the treating surgeon.

Biomechanical Comparison of Locking versus Nonlocking Volar and Dorsal T-plates for Fixation of Dorsally Comminuted Distal Radius Fractures

Objectives: The purpose of this study was to gain insight into the effect of plate location and screw type for fixation of extra-articular distal radius fractures with dorsal comminution (Orthopaedic Trauma Association Type 23-A3.2). Methods: Sixteen pairs of cadaver radii were randomized to four plating configurations: dorsal locking, dorsal nonlocking, volar locking, and volar nonlocking. A standard 1-cm dorsal wedge osteotomy was used. Cyclic axial loads were applied for 5000 cycles. Stiffness and fragment displacement were recorded at 500 cycle-intervals. Pre- and postcyclic loading radiographs were analyzed. An axial load to failure test followed and construct stiffness and failure strength recorded. Biomechanical data were analyzed using a two-way analysis of variance (P < 0.05). Failure modes were descriptively interpreted. Results: Cyclic testing data revealed no difference between constructs at any interval. Within all construct groups, displacement that occurred did so within the first 500 cycles of testing. Pre- and postcyclic loading radiographic analysis showed no differences in construct deformation. Load to failure testing revealed no differences between groups, whereas volar constructs approached significance (P = 0.08) for increased failure strength. Dorsal constructs failed primarily by fragment subsidence and fragmentation, whereas volar constructs failed by plate bending. Conclusions: No difference in all measured biomechanical parameters supports equivalence between constructs and surgeon discretion in determining operative method. Minimal fragment displacement and construct deformation during physiological testing support previous data that early postoperative motion can be recommended. Fragment displacement that occurs does so in the early periods of motion.

Successful reimplantation of a large segment of femoral shaft in a type IIIA open femur fracture: a case report.

Segmental bone loss associated with high-energy open fractures is a difficult problem. The more perplexing and controversial problem is that faced when the extruded segment of bone is retrieved from the field and available for potential reimplantation. Here we present successful reimplantation of a 13-cm segment of meta-diaphyseal femur in a 15-year-old boy. Successful reimplantation of the fragment was attributed to the anatomic location of the injury, meticulous wound care, multiple debridements, sterilization of the extruded fragment in chlorhexidine, and the patients age.

THERMAL NECROSIS COMPLICATING REAMED INTRAMEDULLARY NAILING OF A CLOSED TIBIAL DIAPHYSIS FRACTURE: A CASE REPORT

A case report of thermal necrosis of the tibia after reamed intramedullary nailing is presented. Given the consequences of this complication, the proper use of reaming technique and equipment is emphasized.

Salmonella osteomyelitis presenting as fibrous dysplasia. A case report.

Salmonella osteomyelitis is uncommon in healthy patients. Because of its slow, indolent course and often remote presentation, its diagnosis may be difficult. A case of osteomyelitis of the tibia secondary to Salmonella enteritidis was diagnosed after a biopsy for presumed fibrous dysplasia was performed.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Sensitivity of the saline load test with and without methylene blue dye in the diagnosis of artificial traumatic knee arthrotomies.

Objectives: To determine whether methylene blue dye significantly improves the sensitivity of the saline load test for detection of a traumatic arthrotomy of the knee. Design: Randomized, prospective. Setting: Orthopaedic department, tertiary care medical center. Patients/Participants: Subjects scheduled for elective outpatient knee arthroscopy were prospectively enrolled and randomized to a normal saline group or a methylene blue group. A total of 58 subjects were enrolled (methylene blue 29, normal saline 29). Intervention: In the course of routine elective knee arthroscopy, a standard inferior lateral arthrotomy was created and then normal saline or methylene blue solution was injected while observing for fluid outflow from the arthrotomy site. Main Outcome Measurements: The volume of fluid injected at the time of outflow was recorded with 180 mL set as the maximum injection volume. Results: The false-negative rate was 67% (methylene blue 69%, normal saline 66%). In patients with a positive test, mean volume of injected fluid at outflow was 105 mL in the methylene blue group and 95 mL in the normal saline group (P = 0.61). Conclusions: The sensitivity of the saline load test is unacceptably low. The addition of methylene blue does not improve the diagnostic value of the saline load test. Therefore, these results indicate that the saline load test, regardless of the inclusion of methylene blue, is not an accurate test for diagnosing small traumatic knee arthrotomies. Level of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Moderators' summary: stabilization of long bones.

Two common themes pervade this symposium. First, advances in body armor and far-forward surgical capability have resulted in increased survivability of the injured military combatant. Along with improved survivability has come a relative increase in the quantity and severity of extremity trauma. Second, the magnitude of soft-tissue and bony injury, regardless of mechanism of injury, dictates treatment at all levels of care. Far-forward stabilization of longbone trauma in the global war on terrorism is performed mostly by orthopaedic surgeons positioned at level II (the second echelon of care). Significant equipment limitations exist at the lower levels of care—specifically, lack of power equipment and fluoroscopy. At the most forward locations, these equipment deficiencies make formal open reduction and internal fixation (ORIF) difficult, if not impossible. More important, however, are the limits imposed by the lack of a sterile environment. Even with the proper equipment, ORIF would be ill-advised at best in unclean environments. Having orthopaedic surgeons positioned at far-forward areas has two very distinct advantages. First, the orthopaedic surgeon has more knowledge of extremity anatomy than does the general surgeon. This allows better and safer débridement, thus limiting surgical insult, preserving maximal function and limb viability, and preventing infection. Second, knowledge of the options for definitive care enables the orthopaedic surgeon to perform provisional stabilization and débridement of extremity wounds on the battlefield that does not limit the definitive treatment options available to the receiving surgeon. Casualties with long-bone fracture are not returned to the battlefield. Instead, they are quickly medevac’d to one of the large military treatment facilities (usually in the continental United States [CONUS]) for definitive treatment, where the environment is sterile and advanced soft-tissue care (eg, plastic surgery) is available. This session of the symposium focused on five specific issues: (1) What can be done to maximize treatment of extremities on the battlefield? (2) What is appropriate conversion of battlefield extremity long bone shaft fractures from external to definitive external or internal fixation? (3) What is appropriate conversion of battlefield periarticular fractures from external to definitive fixation? (4) When is it best to use external fixation as definitive treatment? (5) What is the difference between blast and high-velocity gunshot wounds (GSWs)? Current treatment of battlefield casualties at level II and III medical treatment facilities involves initial débridement and provisional stabilization. New technologies are needed that help the surgeon judge the adequacy of wound débridement; even for a surgeon with a wealth of experience, assessing tissue viability in these high-energy injuries can be challenging. Continued education on débridement techniques is imperative if we are to remain effective in preventing infection in the farforward surgical setting. We must continue to develop advanced mobile wound care and wound containment methods, such as the wound VAC (Kinetic Concepts, Inc, San AnCDR Michael T. Mazurek MD,

Open Midfoot Blast Trauma Treated with Ring External Fixation: Case Report

Level of Evidence: V, Case Report