Nader Paksima

Distal Radial Fractures in the Elderly: Operative Compared with Nonoperative Treatment

BACKGROUND There is much debate regarding the optimal treatment of displaced, unstable distal radial fractures in the elderly. The purpose of this retrospective review was to compare outcomes for elderly patients with a displaced distal radial fracture who were treated with or without surgical intervention. METHODS This case-control study examined ninety patients over the age of sixty-five who were treated with or without surgery for a displaced distal radial fracture. All fractures were initially treated with closed reduction and splinting. Patients who failed an acceptable closed reduction were offered surgical intervention. Patients who did not undergo surgery were treated until healing with cast immobilization. Patients who underwent surgery were treated with either plate-and-screw fixation or external fixation. Baseline radiographs and functional scores were obtained prior to treatment. Follow-up was conducted at two, six, twelve, twenty-four, and fifty-two weeks. Clinical and radiographic follow-up was completed at each visit, while functional scores were obtained at the twelve, twenty-four, and fifty-two-week follow-up evaluations. Outcomes at fixed time points were compared between groups with standard statistical methods. RESULTS Forty-six patients with a mean age of seventy-six years were treated nonoperatively, and forty-four patients with a mean age of seventy-three years were treated operatively. Other than age, there was no difference with respect to baseline demographics between the cohorts. At twenty-four weeks, patients who underwent surgery had better wrist extension (p = 0.04) than those who had not had surgery. At one year, this difference was not seen. No difference in functional status based on the Disabilities of the Arm, Shoulder and Hand scores and pain scores at any of the follow-up points was seen between the groups. Grip strength at one year was significantly better in the operative group. Radiographic outcome was superior for the patients in the operative group at each follow-up interval. There was no difference between the groups with regard to complications. CONCLUSIONS Our findings suggest that minor limitations in the range of wrist motion and diminished grip strength, as seen with nonoperative care, do not seem to limit functional recovery at one year. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Treatment of external fixation pins about the wrist: a prospective, randomized trial.

BACKGROUND Pin-track infection remains one of the most troublesome complications of external fixation, in some cases compromising otherwise successful fracture treatment. METHODS One hundred and eighteen patients (120 wrists) who had been managed with the placement of an external fixation device for the treatment of a displaced, unstable, distal radial fracture were randomized into one of three treatment groups: (1) weekly dry dressing changes without pin-site care; (2) daily pin-site care with a solution of one-half normal saline solution and one-half hydrogen peroxide; and (3) treatment with the placement of chlorhexidine-impregnated discs (Biopatch) around the pins, with weekly changes of the discs by the treating surgeon. The patients were followed at weekly intervals until the external fixator was removed. Radiographs were made biweekly. The patients were evaluated with regard to (1) erythema, (2) cellulitis, (3) drainage, (4) clinical or radiographic evidence of pin-loosening, (5) the need for antibiotics, and (6) the need for pin removal before fracture-healing due to infection. Differences in complication rates among the three groups, with adjustment for patient age, gender, and the performance of an associated open procedure, were evaluated. RESULTS The average age of the patients was fifty-four years. Forty-seven wrists had an open procedure (either bone-grafting or open reduction and internal fixation) in addition to treatment with the external fixator. The fixators remained in place for an average of 5.9 weeks. Twenty-three patients (19%) had a complication related to the pin track, with twelve of these patients requiring oral antibiotics for the treatment of a pin-track infection. There were no significant differences among the three groups with regard to the prevalence of pin-site complications. The age of the patient was found to be significantly associated with an increased risk of postoperative pin-track complications (p = 0.04). CONCLUSIONS We found a high rate of local wound complications around external fixation pin sites; however, most complications were minor and could be observed or treated with oral antibiotics. The prevalence of these complications was not decreased in association with the use of hydrogen peroxide wound care or chlorhexidine-impregnated dressings. On the basis of these results, we do not recommend additional wound care beyond the use of dry, sterile dressings for pin-track care after external fixation for the treatment of distal radial fractures.

Cold exposure injuries to the extremities

&NA; Cold exposure injuries comprise nonfreezing injuries that include chilblain (aka pernio) and trench, or immersion, foot, as well as freezing injuries that affect core body tissues resulting in hypothermia of peripheral tissues, causing frostnip or frostbite. Frostbite, the most serious peripheral injury, results in tissue necrosis from direct cellular damage and indirect damage secondary to vasospasm and arterial thromboses. The risk of frostbite is influenced by host factors, particularly alcohol use and smoking, and environmental factors, including ambient temperature, duration of exposure, altitude, and wind speed. Rewarming for frostbite should not begin until definitive medical care can be provided to avoid repeated freeze‐thaw cycles, as these cause additional tissue necrosis. Rewarming should be rapid and for an affected limb should be performed by submersion in warm water at 104° to 107.6°F (40° to 42°C) for 15 to 30 minutes. Débridement of necrotic tissues is generally delayed until there is a clear demarcation from viable tissues, a process that usually takes from 1 to 3 months from the time of initial exposure. Immediate escharotomy and/or fasciotomy is necessary when circulation is compromised. In addition to the acute injury, frostbite is associated with late sequelae that include altered vasomotor function, neuropathies, joint articular cartilage changes, and, in children, growth defects caused by epiphyseal plate damage.

The effects of pronator quadratus repair on outcomes after volar plating of distal radius fractures.

Objectives: The purpose of this study was to evaluate forearm rotation after volar plating of the distal radius fractures with and without pronator quadratus repair. Design: This was an institutional review board–approved retrospective review of prospectively collected data. Setting: The study was conducted at an Academic Medical Center. Patients: Over a 5-year period, 606 patients with distal radius fractures (OTA classifications 23-A through 23-C) were enrolled in an institutional review board–approved, prospectively collected, distal radius database. One hundred and seventy-five patients underwent open reduction and internal fixation with volar plating. Of these, 112 patients had complete 1-year follow-up (6 weeks, 3, 6, and 12 months) and were included in this study. Intervention: Volar plating of the distal radius was performed with pronator quadratus repair (group A), versus volar plating without pronator quadratus repair (group B). Surgeries in group A were performed by a fellowship trained hand surgeon utilizing volar plates from Depuy Orthopedics (Warsaw, IN), whereas the surgeries in group B were performed by a fellowship trained orthopedic trauma surgeon utilizing volar plates from Stryker (Mahwah, NJ). Main Outcome Measurements: Primary outcomes include forearm range of motion. Secondary outcomes include grip strength, pain levels, functional outcomes (DASH scores), radiographs, and complications. Results: Baseline and demographic characteristics of the patients were similar between the 2 groups. There was no difference in mean pronation (P = 0.08) at 1 year. Among secondary analyses, radial deviation was significantly different (P = 0.03); however, pain (P = 0.13) and DASH scores (P = 0.14) were not. The only patient that requested plate removal had the pronator repaired (group A). Conclusions: We conclude that there is no advantage in repairing the pronator quadratus during volar plating of distal radius fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Prospective, Randomized, Controlled Trial of 2-Octylcyanoacrylate Versus Suture Repair for Nail Bed Injuries

PURPOSE To prospectively compare the efficacy of 2-octylcyanoacrylate (Dermabond; Ethicon Inc, Somerville, NJ) with standard suture repair in the management of nail bed lacerations. METHODS Forty consecutive patients with acute nail bed lacerations were enrolled in this study. Eighteen patients were randomized to nail bed repair using Dermabond (2-octylcyanoacrylate), and 22 were randomized to standard repair using 6-0 chromic suture. At presentation, demographic information and laceration characteristics were recorded. The time required for nail bed laceration repair with each method was documented, and cosmetic and functional outcomes were assessed at 1, 3, and 6 months after injury. Comparisons between treatment groups were made using unpaired Students t-tests. RESULTS The Dermabond repair group was composed of 10 males and 8 females with a mean age of 32.3 years. The suture repair group was composed of 17 males and 5 females with a mean age of 29.5 years. The mean follow-up was 5.1 months (range 4-11 months) and 4.8 months (range 4-11 months) for the Dermabond group and suture group, respectively. There was no difference between the two treatment groups with respect to age, comorbidities, and length of follow-up (p>.05). The average time required for nail bed repair using Dermabond was 9.5 minutes, which was significantly less than that required for suture repair (27.8 minutes) (p<.0003). At each follow-up time point, there was no statistical difference in physician-judged cosmesis, patient-perceived cosmetic outcome, pain, or functional ability between the Dermabond and suture treatment cohorts (p>.05). CONCLUSIONS Nail bed repair performed using Dermabond is significantly faster than suture repair, and it provides similar cosmetic and functional results. In the management of acute nail bed lacerations, Dermabond is an efficient and effective repair technique. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

A Biomechanical Study of Extensor Tendon Repair Methods: Introduction to the Running-Interlocking Horizontal Mattress Extensor Tendon Repair Technique

PURPOSE Extensor tendon injuries are common; however, relatively few studies have evaluated extensor tendon repair methods. The purpose of this study was to investigate the properties of the running-interlocking horizontal mattress repair method with regard to tendon shortening, stiffness, strength, and time needed to perform the repair, compared with the modified Bunnell method and the augmented Becker method. METHODS Twenty-four extensor tendons from 8 fresh-frozen cadaveric hands were harvested from zone 6. The harvested tendons were randomly assigned into 1 of 3 repair groups: augmented Becker, modified Bunnell, and running-interlocking horizontal mattress repair methods. The running-interlocking horizontal mattress repair combines a running suture with an interlocking horizontal mattress suture. Each repaired tendon was measured for length before and after repair and tested for stiffness, ultimate load to failure, and time required to perform the repair. RESULTS The running-interlocking horizontal mattress repair was significantly stiffer (8,506 N/m) than the augmented Becker (5,971 N/m) and the modified Bunnell (6,719 N/m) repairs. The running-interlocking horizontal mattress repair resulted in significantly less shortening (1.7 mm) than the augmented Becker (6.2 mm) and modified Bunnell (6.3 mm) repairs. The running-interlocking horizontal mattress repair took significantly less time to perform without a significant difference in the ultimate load to failure (running-interlocking horizontal mattress repair, 51 N; augmented Becker, 53 N; modified Bunnell, 48 N). CONCLUSIONS The running-interlocking horizontal mattress repair is significantly stiffer and faster to perform than either the augmented Becker or the modified Bunnell repairs, and it results in less shortening than either of these methods. The running-interlocking horizontal mattress repair should be strong enough to withstand some early motion.

Regional anesthesia improves outcome after distal radius fracture fixation over general anesthesia.

Objective: To compare the efficacy of anesthetic type on clinical outcomes after operative treatment of distal radius fractures. Design: Retrospective review of prospectively collected data. Setting: Academic medical center. Patients: One hundred eighty-seven patients with a distal radius fracture (OTA type 23) were identified within a registry of 600 patients. Intervention: Patients with operative distal radius fractures underwent open reduction and internal fixation with a volarly applied plate and screws under regional or general anesthesia. Main Outcome Measurements: Clinical, radiographic, and patient-based functional outcomes were recorded at routine postoperative intervals. Complications were recorded. Results: One hundred eighty-seven patients met inclusion criteria and had a minimum of 1-year follow-up. There were no differences between the groups with regard to patient demographics or fracture types treated. At both 3 and 6 months post surgery, pain was diminished among those patients who received a regional block. Wrist and finger range of motion for patients who received regional versus general anesthesia was improved at all follow-up points. Patients who received regional anesthesia also had higher functional scores as measured by the Disabilities of the Arm, Shoulder and Hand at 3 months (P = 0.04) and 6 months (P = 0.02). Conclusion: Patients who are candidates should be offered regional anesthesia when undergoing repair of a displaced distal radius fracture. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A New Technique for Reconstruction of the Ulnar Collateral Ligament of the Thumb

Background Several previous studies have described reconstructive methods for the treatment of an injury to the ulnar collateral ligament of the thumb. However, there are few biomechanical studies to date to analyze the strength of the surgical reconstruction. Purpose To evaluate 2 reconstruction techniques with use of a cadaveric model (1) reconstruction with the use of a free tendon graft placed in a figure-of-8 fashion through drill holes in the metacarpal and proximal phalanx of the thumb, and (2) reconstruction with the use of the Bio-Tenodesis Screw System. Study Design Controlled laboratory study. Methods Eight matched pairs of cadaveric specimens underwent removal of the proper and accessory ulnar collateral ligaments. One of the 2 reconstruction methods was performed, and specimens were mounted on a materials-testing machine. The specimens were subjected to valgus stress to failure at 30° of flexion. Failure was defined as valgus laxity of 30° at the metacarpophalangeal joint. Results The peak load to failure was 23.5 ± 11.4 N for the figure-of-8 reconstruction and 24.3 ± 12.3 N for the reconstruction using the Bio-Tenodesis Screw System. Comparing the 2 groups, there was no statistically significant difference in peak loads to failure (P = .88). Conclusion There was no statistically significant difference between the peak loads to failure of the 2 reconstructions. Clinical Relevance The Bio-Tenodesis Screw System may provide another viable option for surgical reconstruction of the ulnar collateral ligament of the thumb.

Percutaneous Pinning of Middle Phalangeal Neck Fractures: Surgical Technique

Extra-articular middle phalangeal neck fractures are uncommon fractures of the hand that are often difficult to treat. Surgery is indicated when closed reduction fails; 1 option is closed reduction and percutaneous pinning. Maintaining closed reduction while inserting K-wires is challenging. We present a new technique for percutaneous pinning of these fractures that was developed to address these issues. Our technique uses flexion of the interphalangeal joints during K-wire insertion to maintain fracture reduction and improve fixation.

Ethnic and Gender Diversity in Hand Surgery Trainees

PURPOSE To evaluate whether the lack of diversity in plastic and orthopedic surgery persists into hand surgery through assessment of trainee demographics. METHODS Demographic data were obtained from compilations on graduate medical education by the Journal of the American Medical Association. Ethnic diversity was assessed using the proportions of minority trainees. We analyzed the trends in ethnic diversity in hand, orthopedic, and plastic surgery from 1995 to 2012 by evaluating changes in proportions of African American, Hispanic, and Asian trainees. In addition, we compared the proportions of minority trainees in various surgical specialties during 2009 to 2012. Trends in gender diversity were similarly analyzed using the proportions of female trainees. RESULTS During 1995 to 2012, the proportions of minority and female trainees increased significantly in the fields of orthopedic, plastic, and hand surgery. To assess the current state of diversity in various specialties, we compared minority and female population proportions using pooled 2009 to 2012 data. The percentage of non-Caucasian trainees in hand surgery was significantly higher than that in orthopedic sports medicine and orthopedic surgery and significantly lower than in general surgery. The percentage of female trainees in hand surgery was significantly higher than that in orthopedic sports medicine and orthopedic surgery and significantly lower than in plastic and general surgery. CONCLUSIONS Ethnic and gender diversity in hand surgery increased significantly between 1995 and 2012. Women constitute a fifth of hand surgery trainees. Efforts to increase diversity should be further pursued using proven strategies and innovating new ones. CLINICAL RELEVANCE Diversity in the medical field has shown to be a beneficial factor in many aspects including research productivity and patient care. Understanding how the field of hand surgery has changed with regard to the diversity of its trainees may aid in providing more equitable and effective health care.