R. Glenn Gaston

Phalangeal Fractures: Displaced/Nondisplaced

Nonsurgical management is the preferred treatment of stable, extra-articular fractures of the proximal and middle phalanx, most distal phalanx fractures, and, rarely, nondisplaced intraarticular fractures in elite athletes. Techniques that afford maximal strength with minimal dissection, thus allowing earlier return to play, are ideal. Open reduction with internal fixation with plate fixation is most often chosen for unstable phalangeal shaft fractures in high-demand athletes to provide rigid internal fixation and allow immediate range of motion and more rapid return to sport. It is our practice to routinely treat unicondylar fractures with surgery with percutaneous headless compression screws in elite athletes.

Postoperative Infections: Prevention and Management

Postoperative infections continue to be a challenging problem. The incidence of bacterial antibiotic resistance such as methicillin-resistant Staphylococcus aureus is rising. There are numerous intrinsic patient factors that should be optimized before surgery to minimize the risk of surgical site infections. When postoperative infections develop, treatment must be individualized. This article outlines the principles that can help guide treatment.

Football Commentary: Phalangeal Fractures—Displaced/Nondisplaced

ic s. co m In addition to fracture pattern, the management of phalangeal fractures in professional football players is in large dictated by nonbiologically related factors such as the remaining games in the season, player position, and hand dominance. The treatment of an unstable, displaced transverse proximal phalanx fracture in the nondominant hand of a lineman may vary considerably from the identical fracture in the throwing hand of a quarterback. Unique considerations for management of these common fractures in high-level football players are briefly reviewed. The decision for operative versus nonoperative fracture management is typically determined by the stability of the fracture, as outlined in the above article. There are instances, however, when exceptions to this rule may be made. For instance, some nondisplaced fractures at risk for displacement, such as a condylar fracture, may be selected for percutaneous screw fixation to allow more rapid rehabilitation and return to play. Similarly, a long nondisplaced spiral fracture in the throwing hand of a quarterbackmay be selected for percutaneous screw fixation to allow for more rapid return to sport. Risks and benefits of arguably unnecessary surgery must be clearly explained and documented. These decisions are usually the product of a “team approach” of discussion amongst the player, treating physician, trainer, coach, and, at times, the player’s agent. Also, the timing of surgery may vary depending on the point in the season. For example, the same fracture presenting during preseason, midseason, and with 1 week re-

Fractures of the Lesser Sesamoids: Case Series

We present 3 cases of sesamoid fractures involving the index, ring, and little finger metacarpophalangeal joints. These injuries present similar to more common sprains of the finger metacarpophalangeal joint and may be difficult at times to appreciate on standard posteroanterior and lateral x-rays. Oblique images can aid in making the diagnosis at times. Whereas we still recommend immobilization as the initial treatment for these injuries, all 3 of our cases failed nonoperative management and eventually required sesamoid excision.

Low Median Nerve Transfers (Opponensplasty)

Opposition is the placement of the thumb opposite the fingers into a position from which it can work. This motion requires thumb palmar abduction, flexion, and pronation, which are provided by the abductor pollicis brevis, flexor pollicis brevis (FPB), and opponens pollicis. In the setting of a median nerve palsy, this function is typically lost, although anatomic variations and the dual innervation of the FPB may prevent complete loss at times. There are multiple well described and accepted tendon transfers to restore opposition, none of which have been proven to be superior to the others.

Postoperative Infections : Prevention and Management

More than 290,000 surgical site infections (SSIs) are reported annually in the United States according to recent reports from the Centers for Disease Control and Prevention (CDC). Annual direct and indirect cost estimates as a result of SSIs are in excess of

An Update on Upper Extremity Tendon Transfers.

1 billion and

Scaphoid fractures in professional football players.

10 billion, respectively. An SSI has been defined by the CDC as an infection occurring within 30 days of an operative procedure or within 1 year in the event of material implantation. These infections can be further classified as either superficial (confined to the skin and subcutaneous tissues around the incision) or deep (involving the fascia, muscle, bone, or implant). The most common causative organism involved with SSIs parallels that found in normal skin flora and is Staphylococcus aureus. A recent epidemiologic study reported that in adults, 50% to 80% f SSI isolates are pure S aureus, with 12% mixed flora. Gram-negative organisms are ore common in immunocompromised hosts such as people with diabetes and ntravenous drug abusers. Recently there has been an alarming and increasing trend toward methicillinesistant S aureus (MRSA) isolates in SSIs. In a review of 761 patients in a 3-year eriod from 2001 to 2003, the incidence of community-acquired MRSA in hand

Tendon Transfers in the Upper Limb

Tendon transfers have been a proven method of upper extremity reconstruction for well over 150 years. We are indebted to the pioneering hand surgeons such as Paul Brand, Richard Smith, Sterling Bunnell, Joseph Boyes, and many others who contributed the concepts that are still regarded as the guiding principles in tendon transfers performed today. While the anatomy, biomechanics, and fundamentals of tendon transfers haven’t changed, many advances in tendon transfer surgery have been made over the last decade. In addition, our field is seeing tremendous growth in nerve repair, reconstruction, and nerve transfers, yet the need for tendon transfers to restore shoulder, elbow, wrist, and hand function will remain a necessary and powerful technique in regaining lost function of the arm. In this issue of Hand Clinics, the core principles and biomechanics of upper extremity transfers are reviewed. Common transfers such as radial, median, and ulnar nerve tendon transfers are reviewed along with several pearls for success. Tendon transfers for specific conditions such as congenital hand deformity, rheumatoid arthritis,