P. Kaveh Mansuripur

Closed traumatic finger tip injuries in patients with artificial nails: removal of UV gel and acrylic nails

[1] Kim JK, Kook SH, Kim YK. Comparison of forearm rotation allowed by different types of upper extremity immobilization. J Bone Joint Surg 2012;94(5):455–60. [2] Bong MR, Egol KA, Leibman M, Koval KJ. A comparison of immediate postreduction splinting constructs for controlling initial displacement of fractures of the distal radius: a prospective randomized study of long-arm versus short-arm splinting. J Hand Surg [Am] 2006;31(5):766–70. [3] Mulford JS, Axelrod TS. Traumatic injuries of the distal radioulnar joint. Orthop Clin North Am 2007. http://dx.doi.org/10.1016/j.ocl.2007.03.007. [4] DeFroda SF, Gil JA, Bokshan S, Waryasz G. Upper extremity quad splint: indications and technique. Am J Emerg Med 2015;33(12):1818–22. [5] Denes AE, Goding R, Tamborlane J, Schwartz E. Maintenance of reduction of pediatric distal radius fractures with a sugar-tong splint. Am J Orthop 2007;36(2): 68–70. [6] Davis DI, Baratz M. Soft tissue complications of distal radius fractures. Hand Clin 2010;26:229–35. [7] Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg 2008;16:30–40. [8] Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician 2009;79:16–22. [9] Gannaway JK, Hunter JR. Thermal effects of casting materials. Clin Orthop Relat Res 1983:191–5. [10] Lavalette R, Pope MH, Dickstein H. Setting temperatures of plaster casts. The influence of technical variables. J Bone Joint Surg Am 1982;64:907–11.

Fixation Strength in Full and Limited Fixation of Osteoporotic Distal Radius Fractures

Background: The purpose of this investigation is to determine whether osteoporotic intra-articular distal radius fractures surgically treated by filling all 7 distal screws of a volar plate will have a higher load to failure than those treated by filling only 4 distal screws. Methods: Ten matched pairs of fresh frozen cadaveric forearms were randomized within each pair to be treated by using either all 7 of the distal holes of a volar plate or only 4 distal screws. The distal radius fixation was performed with unicortical screws going to but not through the dorsal cortex, and the most distal screws were placed within 4 mm of the joint surface. An AO C2 type fracture was then created. All specimens were tested cyclically, with an axial load of 60 N, at 3 Hz for 1000 cycles to simulate early postoperative motion. All specimens were subsequently tested to mechanical failure. Results: There were no failures in either group during cyclic testing. There was no difference detected between groups for mean stiffness, yield load, peak load, or load to clinical failure. In both groups, the yield load, peak load, and load to clinical failure were higher than the 60- to 100-N forces encountered during postoperative rehabilitation. Conclusions: There was no difference detected between osteoporotic intra-articular distal radius fractures treated by utilizing all 7 of the distal screws of a volar plate compared with those treated with only 4 distal screws.

Cobalt toxicity after revision to a metal-on-polyethylene total hip arthroplasty for fracture of ceramic acetabular component

Cobalt metallosis after revision metal-on-polyethylene total hip arthroplasty for catastrophic failure of ceramic components is uncommon but a potentially devastating complication. Common findings associated with heavy metal toxicity include cardiomyopathy, hypothyroidism, skin rashes, visual disturbances, hearing changes, polycythemia, weakness, fatigue, cognitive deterioration, and neuropathy. We report a case of a 57-year-old woman who presented with complaints of progressively worsening hip pain, fatigue, memory loss, lower extremity sensory loss, persistent tachycardia, and ocular changes 5 years after synovectomy and revision of a failed ceramic-on-ceramic total hip arthroplasty to metal-on-polyethylene components. A cobalt level of 788.1 ppb and chromium level of 140 ppb were found on presentation and subsequently decreased to 468.8 ppb and 105.9 ppb, respectively, 2 weeks after revision to a ceramic-on-polyethylene total hip arthroplasty. Improvement of symptoms accompanied this decrease in cobalt and chromium levels. Revision of failed ceramic arthroplasties with later-generation ceramics to avoid this potential complication is recommended.

INITIAL MANAGEMENT OF ANKLE FRACTURES IN THE OVERWEIGHT AND OBESE: THE PROVIDENCE PINCH

BACKGROUND Obese and overweight people have higher rates of ankle injury, particularly operative ankle fractures. The initial management of unstable ankle fractures includes closed reduction and splinting to limit soft tissue injury and articular cartilage damage until definitive operative fixation can be performed. Adequate reduction can be more difficult in the obese patient due to the weight and additional padding provided by the larger soft tissue envelope. DISCUSSION A novel technique, described herein by the authors, may be useful in obtaining a suitable reduction of the ankle in the initial management of unstable ankle fractures in the overweight and obese. CONCLUSIONS Obese patients have unique musculoskeletal injury profiles and special considerations in their management. The authors have found this technique useful in the management of their ankle fractures.

Traumatic/Revision Finger Amputation

Finger tip and finger amputation injuries are common. Revision amputation is the treatment of choice for the majority of traumatic amputations affecting the digits.

Three-Dimensional Carpal Kinematics after Carpal Tunnel Release

BACKGROUND Carpal tunnel release (CTR) has been shown to change carpal arch morphology. However, the effect of CTR on the three-dimensional kinematics of the carpal bones has not been demonstrated. PURPOSE This study examined whether release of the transverse carpal ligament (TCL) would alter the three-dimensional kinematics of the carpus, specifically the bony attachments of the TCL. METHODS The in vitro kinematics of the carpus was studied in five fresh-frozen cadaveric wrists before and after CTR using three-dimensional computed tomography. The specimens were evaluated in three positions: neutral, 60 degrees of flexion, and 60 degrees of extension. RESULTS The data indicate that carpal arch width increases significantly in all positions after CTR as measured between the trapezium and hamate. Second, the trapezium-hamate distance increases in both a translational and rotational component after CTR. Additionally, the pisiform rotates away from the triquetrum after CTR. CONCLUSIONS Carpal kinematics is significantly altered with a CTR, especially on the ulnar side of the wrist. CLINICAL RELEVANCE Although the kinematic changes are small, they may be clinically significant and potentially responsible for pillar pain or postoperative loss of grip strength.

Delayed Erosion of a Pelvic Reconstruction Plate into the Bladder Causing Recurrent Urinary Tract Infections

Case: A forty-seven-year-old woman presented with recurrent urinary tract infections eleven years after open fixation of a pelvic ring injury. Cystoscopy revealed that the pelvic reconstruction plate had eroded into the bladder, likely the source of the recurrent infections. Following removal of the involved pelvic hardware and repair of the bladder, the patient had no further urinary tract infections. Conclusion: Operative fixation of osseous pelvic injuries places metal implants in proximity to the bladder. Late erosion of hardware into the bladder can occur. A low threshold for urological work-up should be maintained for recurrent genitourinary symptoms in these patients.

Closed reduction of metatarsophalangeal joint dislocations in acute and subacute presentations: a novel technique.

The initial management of metatarsophalangeal (MTP) dislocations includes closed reduction and buddy taping to limit soft tissue injury and articular cartilage damage. Depending on postreduction stability, this is often the definitive treatment of these injuries. Reduction can be difficult in this region given the difficulty associated with the small size of the local anatomy. A novel reduction technique for these injuries is presented as well as a case report. Our patient is a 48-year-oldmanwhopresentedwith traumatic subacute first and second MTP joint dislocations. Multiple standard reduction attempts failed, whereafter our novel reduction technique was implemented successfully. Reducing MTP dislocations poses a unique challenge to emergency medicine providers given the small local anatomy. Given that some of these dislocations are truly irreducible, this reduction technique provides a powerful reduction and triage tool allowing for determination of those dislocations that are difficult vs those that truly require operative intervention. Metatarsophalangeal (MTP) dislocations are an uncommon but well documented and problematic orthopedic injury [1]. These injuries often occur after stubbing a toe or other axial load injuries to the toes, while the toes are in extension [2]. Although normally caused by low-energy mechanisms, MTP dislocations can also be caused by higher energy injuries and associated with other orthopedic injuries [3]. The initial management of these injuries includes prompt reduction and immobilization [2]. If the joint is congruent and stable after intervention, often reduction and immobilization are the only management required of these injuries [4]. Several instances have been described in the literature of irreducible MTP dislocations, most frequently of the great toe [1]. The reduction maneuver consists of axial traction and pressure over the joint in the opposite direction of the dislocation [4]. However, given the small size of the anatomy in this region, adequate traction is often difficult. Irreducible MTP joint dislocations are operative injuries; therefore, it is important to differentiate those that are truly impossible to reduce by closed means (due to interposed plantar plate, capsule, sesamoid, or deep ligament or tendon) from those that are possible but difficult to reduce due to inadequate traction and to reliably be able to reduce those in the latter group [1]. The authors describe a novel reduction technique that, in our experience has led to easier reduction in acute and subacute dislocations. A case of a subacute dislocation successfully reduced using this technique is also described. 0735-6757/© 2015 Elsevier Inc. All rights reserved. The patient is positioned supine and the stretcher lowered. After suitable analgesia is obtained, the knee is bent (if possible) to relax the gastrocnemius-soleus complex allowing moderate plantar flexion of the foot to relax the long toe flexors. Then, a section of 2-in roll bandage (Kerlix; Kendall, Tyco Healthcare, Mansfield, MA) is tied in a circle (Fig. 1). This piece of bandage is looped around the dislocated toe and an adjacent toe using a cow-hitch knot (Fig. 2), similar to the technique described previously for limb holding during surgical preparation [5]. Axial traction is applied to the bandage, while a posterior force is applied to the anterior tibia. Reduction can often be felt by the patient and the provider, and once reduction is obtained, postreduction x-rays are performed, and the dislocated toe is buddy taped to the adjacent toe. Our patient is a 48-year-old man who was struck by a truck while riding hismotorcycle. Hewas admitted to an outside hospital withmultiple injuries to his right lower extremity, including a bony Lisfranc injury and first and second metatarsophalangeal dislocations (Fig. 3). Attempted closed reduction of his toes was unsuccessful. Three days after his initial injury, he was transferred to our hospital for definitive management. At this time, his toes remained dislocated. Standard manipulation was again attempted without success. It was thought at this time that soft tissue contracture and swellingwere impeding reduction, and our novel reduction technique was then successfully performed (Fig. 4). Definitive operative management of his foot fractures was delayed until 1 week after the initial injury to allow for subsidence of the soft tissue swelling. Metatarsophalangeal dislocations are well-known injuries that are frequently seen by emergency medicine physicians. Reducing these injuries often presents a unique set of difficulties to the providers treating these patients [4]. Difficulties with these reductions, necessitating operative interventions have been described in the literature as far back as 1914 [6]. Given the small anatomy of the phalanges, gaining adequate grip for traction is often challenging. Previous descriptions of closed reduction techniques, although helpful, do not always adequately address the needed force required to reduce these injuries, as they often rely on muscle groups used for finemotor control, such as the intrinsic muscles of the hand, as opposed to themore powerful bicep and deltoidmuscles for reduction [4]. Given that a certain subset of metatarsophalangeal joint dislocations requires operative intervention, this reduction techniquewas devised to determinewhich dislocations are truly irreducible by closed means [1]. This reduction technique is intended as another tool both for definitive management by emergency department providers and as a diagnostic tool to accurately diagnose those dislocations that truly require operative intervention. Fig. 1. A and B, Demonstration of a section of roll bandage before application to patient toes. Fig. 2. A to E, Application of looped gauze bandage to patients toes in step-by-step manner. 1333.e4 J. Johnson et al. / American Journal of Emergency Medicine 33 (2015) 1333.e3–1333.e7