Reid W. Draeger

Management of Intra-Articular Metacarpal Base Fractures of the Second Through Fifth Metacarpals

Intra-articular fractures of the second through fifth metacarpal bases are uncommon injuries but can result in serious morbidity if improperly managed. These injuries usually occur because of forced flexion of the wrist with simultaneous extension of the arm, as occurs with a punch or a fall. As there are few large series of reports for these injuries, there is no consensus in the current literature on the most appropriate treatment for them. Whereas some authors have reported successful results after closed reduction, many recommend open reduction with internal fixation to ensure the integrity of the tendinous insertions of the extensor carpi radialis longus, extensor carpi radialis brevis, and extensor carpi ulnaris. This article reviews the case reports and case series extant in the literature concerning intra-articular fractures of the bases of the second through fifth metacarpals, and it provides important diagnostic and management considerations for these injuries.

Flexor tendon sheath infections of the hand

Abstract Flexor tendon sheath infections of the hand must be diagnosed and treated expeditiously to avoid poor clinical outcomes. Knowledge of the sheaths anatomy is essential for diagnosis and to help to guide treatment. The Kanavel cardinal signs are useful for differentiating conditions with similar presentations. Management of all but the earliest cases of pyogenic flexor tenosynovitis consists of intravenous antibiotics and surgical drainage of the sheath with open or closed irrigation. Closed irrigation may be continued postoperatively. Experimental data from an animal study have shown that local administration of antibiotics and/or corticosteroids can help lessen morbidity from the infection; however, additional research is required. Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. Patients with medical comorbidities or those who present late with advanced infection can expect poorer outcomes, including severe digital stiffness or amputation.

Traumatic Wound Debridement: A Comparison of Irrigation Methods

Objectives: To test wound debridement efficacy and soft tissue damage produced by high-pressure pulsatile lavage (HPPL), suction irrigation, and bulb syringe irrigation. Design: Randomized trial in an in vitro model. Setting: Medical school orthopaedic department. Patients/Participants: No patients were used in this study. Intervention: Beef flank steaks (100-g ± 10-g) were divided into 8 test groups and incised uniformly. Four test groups were contaminated with 2 g of rock dust and 4 were not. The specimens were then treated as follows: nothing (control), bulb irrigation, suction irrigation, or HPPL. Main Outcome Measurements: Runoff from the irrigation was collected, filtered, lyophilized, and ashed to allow for quantitative determination of organic and inorganic material removed from the wound by each irrigation method. Digital photographs of the tissue samples were subjected to blinded grading on a scale of 1 to 5 to assess macroscopic soft tissue damage. Results: Qualitatively, tissue samples treated with HPPL consistently received worse grades for tissue damage than samples in any other experimental group. Quantitative soft tissue damage analysis revealed that significantly more organic material was removed from samples treated with HPPL (141.3 ± 58.9 mg) than those treated with bulb syringe (50.7 ± 28.6 mg) or suction irrigation (108.7 ± 174.5 mg). Surprisingly, significantly less inorganic contaminant was removed from tissue samples treated with HPPL (1549.6 ± 77.3 mg) than those treated with bulb syringe (1834.9 ± 39.1 mg) or suction irrigation (1827 ± 39.4 mg). Conclusions: There has been some concern regarding damage produced by HPPL. According to our quantitative soft tissue damage data, tissue treated by HPPL was damaged significantly more than tissue treated with bulb syringe or suction irrigation. Our qualitative tissue damage grade data showed that HPPL treated test groups appeared more damaged than other irrigation groups. Surprisingly, HPPL removed significantly less inorganic contaminant than other debridement methods, and it is proposed that HPPL may drive some contaminants deeper into the tissue rather than removing them. This study seems to support the concept that suction and sharp debridement, as practiced by most surgeons, may remove foreign bodies well without the use of HPPL.

Acute Hand Infections

The continued emergence of antibiotic-resistant bacteria and the development of only a few new classes of antibiotics over the past 50 years have made the treatment of acute hand infections problematic. Prompt diagnosis and treatment are important, because hand stiffness, contractures, and even amputation can result from missed diagnoses or delayed treatment. The most common site of hand infections is subcutaneous tissue and the most common mechanism is trauma. An immunocompromised state, intravenous drug abuse, diabetes mellitus, and steroid use all predispose to infections.

Changes in Length of the First Ray with Two Different First MTP Fusion Techniques: A Cadaveric Study

Background: First metatarsophalangeal joint (MTP) fusions are performed as salvage procedures for a variety of conditions ranging from osteoarthritis, rheumatoid arthritis, hallux valgus, and failed first MTP arthroplasty. A number of bone preparation techniques have been described to fuse the first MTP joint, with varying degrees of success. The aim of this study was to characterize and compare the average shortening of the first ray with a conical reamer fusion technique versus flat bone cut technique. Materials and Methods: Six paired cadaver feet were divided into two groups with one foot from each pair in each group. Preoperative first ray lengths were measured radiographically. Each group then underwent arthrodesis of first MTP joint with one of two different bone cut techniques: flat cuts or conical reaming. The postoperative lengths of the first rays were measured and the data analyzed using a two-tailed Students t-tests. Results: The average shortening that occurred in both groups after the procedure was 7.1 mm for the flat cut group (Group I) and 5.7 mm for the machined conical reaming group (Group II). Comparing both groups, there was no statistically significant difference in the shortening between the groups. Conclusion: Both flat bone cut and conically reamed techniques caused shortening of the first ray after first MTP fusion. However, there was no statistically significant difference in the postprocedure lengths of the first ray between the two groups. Clinical Relevance: Neither technique is more likely to lead to transfer metatarsalgia since the shortening was similar.

The Influence of Patient Insurance Status on Access to Outpatient Orthopedic Care for Flexor Tendon Lacerations

PURPOSE To determine the effect of patient insurance status on access to outpatient orthopedic care for acute flexor tendon lacerations. METHODS The research team contacted 100 randomly chosen orthopedic surgery practices in North Carolina by phone on 2 different occasions separated by 3 weeks. The research team attempted to obtain an appointment for a fictitious 28-year-old man with an acute flexor tendon laceration. Insurance status was presented as Medicaid in 1 call and private insurance in the other call. Ability of an office to schedule an appointment was recorded. RESULTS Of the 100 practices, 13 were excluded because they did not perform hand surgery, which left 87 practices. The patient in the scenario with Medicaid was offered an appointment significantly less often (67%) than the patient in the scenario with private insurance (82%). The odds of the patient with private insurance obtaining an appointment were 2.2 times greater than the odds of the Medicaid patient obtaining an appointment. The Medicaid patient was more likely not to be offered an appointment owing to the lack of a hand surgeon at a practice (28% of appointment denials) than privately insured patients (13% of appointment denials). CONCLUSIONS For patients with acute flexor tendon lacerations, insurance status has an important role in the ability to obtain an orthopedic clinic appointment. We found that patients with Medicaid have more barriers to accessing care for a flexor tendon laceration than patients with private insurance. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

Quantifying normal ankle joint volume: an anatomic study.

Background: Many therapeutic and diagnostic modalities such as intraarticular injections, arthrography and ankle arthroscopy require introduction of fluid into the ankle joint. Little data are currently available in the literature regarding the maximal volume of normal, nonpathologic, human ankle joints. The purpose of this study was to measure the volume of normal human ankle joints. Materials and Methods: A fluoroscopic guided needle was passed into nine cadaveric adult ankle joints. The needle was connected to an intracompartmental pressure measurement device. A radiopaque dye was introduced into the joint in 2 mL boluses, while pressure measurements were recorded. Fluid was injected into the joint until three consecutive pressure measurements were similar, signifying a maximal joint volume. Results: The mean maximum ankle joint volume was 20.9 ± 4.9 mL (range, 16–30 mL). The mean ankle joint pressure at maximum volume was 142.2 ± 13.8 mm Hg (range, 122–166 mm Hg). Two of the nine samples showed evidence of fluid tracking into the synovial sheath of the flexor hallucis longus tendon. Conclusion: Maximal normal ankle joint volume was found to vary between 16–30 mL. This study ascertains the communication between the ankle joint and the flexor hallucis longus tendon sheath. Exceeding maximal ankle joint volume suggested by this study during therapeutic injections, arthrography, or arthroscopy could potentially damage the joint.

Debridement of cancellous bone: a comparison of irrigation methods.

Objective: This study tests the bone debridement efficacy and damage to cancellous bone produced by different wound irrigation methods. Methods: Cancellous bone slices of bovine distal femurs (3 cm × 3 cm) were divided into eight test groups and scored with a saw in a latticed pattern. Four test groups were contaminated with 1.0 g rock dust and four were not. The specimens were then treated as follows: no treatment (control), bulb irrigation, brush-suction irrigation, or high-pressure pulsatile lavage (HPPL). Runoff from the irrigation was collected, filtered, lyophilized, and ashed to allow for quantitative determination of organic and inorganic material removed from the bone by each irrigation method. The bone samples were subjected to blinded grading on two five-point scales to assess: 1) macroscopic tissue damage and 2) amount of contaminant remaining following treatment. Results: Significantly more (P ≤ 0.05) mean organic material was removed from samples treated with HPPL (744.8 ± 120.0 mg) than with bulb syringe (115.2 ± 11.9 mg) or brush-suction irrigation (95.1 ± 9.2 mg). Brush-suction irrigation removed statistically significantly more (P ≤ 0.05) of the 1.0 g of initial inorganic contaminant (937.7 ± 6.3 mg) than bulb syringe irrigation (866.2 ± 30.1 mg), while HPPL (900.2 ± 19.0 mg) did not. Conclusions: Past studies have shown HPPL to damage both soft tissue and bone structure. The tissue damage that HPPL produces has been accepted in the past in exchange for its presumed superiority in contaminant removal. In this study, HPPL damaged samples more than other irrigation methods by removing significantly more organic material from them. However, HPPL and bulb syringe removed a statistically similar amount of inorganic contaminant, while brush-suction irrigation removed a significantly greater amount of inorganic contaminant than bulb syringe. It is proposed that HPPL may drive some contaminants deeper into the tissue rather than removing them, rendering HPPL not only more deleterious to bone structure and healing, but also less efficacious at removing contaminant than brush-suction irrigation.

A Regional Assessment of Medicaid Access to Outpatient Orthopaedic Care: The Influence of Population Density and Proximity to Academic Medical Centers on Patient Access

BACKGROUND Access to care is limited for patients with Medicaid with many conditions, but data investigating this relationship in the orthopaedic literature are limited. The purpose of this study was to investigate the relationship between health insurance status and access to care for a diverse group of adult orthopaedic patients, specifically if access to orthopaedic care is influenced by population density or distance from academic teaching hospitals. METHODS Two hundred and three orthopaedic practices within the state of North Carolina were randomly selected and were contacted on two different occasions separated by three weeks. An appointment was requested for a fictitious adult orthopaedic patient with a potential surgical problem. Injury scenarios included patients with acute rotator cuff tears, zone-II flexor tendon lacerations, and acute lumbar disc herniations. Insurance status was reported as Medicaid at the time of the first request and private insurance at the time of the second request. County population density and the distance from each practice to the nearest academic hospital were recorded. RESULTS Of the 203 practices, 119 (59%) offered the patient with Medicaid an appointment within two weeks, and 160 (79%) offered the patient with private insurance an appointment within this time period (p < 0.001). Practices in rural counties were more likely to offer patients with Medicaid an appointment as compared with practices in urban counties (odds ratio, 2.25 [95% confidence interval, 1.16 to 4.34]; p = 0.016). Practices more than sixty miles from academic hospitals were more likely to accept patients with Medicaid than practices closer to academic hospitals (odds ratio, 3.35 [95% confidence interval, 1.44 to 7.83]; p = 0.005). CONCLUSIONS Access to orthopaedic care was significantly decreased for patients with Medicaid. Practices in less populous areas were more likely to offer an appointment to patients with Medicaid than practices in more populous areas. Practices that were farther from academic hospitals were more likely to offer an appointment to patients with Medicaid than practices closer to academic hospitals. CLINICAL RELEVANCE This study illustrates the barriers to timely outpatient orthopaedic care that patients with Medicaid face. The findings from our study imply that patients with Medicaid in more populous areas and in areas closer to academic medical centers are less likely to obtain an outpatient orthopaedic appointment than patients with Medicaid in less populous areas and in areas more distant from academic medical centers. A shift in policy to enhance access to orthopaedic care for patients with Medicaid, especially those in urban areas and areas close to academic medical centers, will become increasingly important as more patients become eligible for Medicaid through the Patient Protection and Affordable Care Act of 2010.

Access to outpatient care for adult rotator cuff patients with private insurance versus Medicaid in North Carolina.

BACKGROUND Access to orthopaedic care for pediatric patients has been shown in previous studies to be decreased for patients with Medicaid compared with those with private insurance. The relationship between type of insurance and access to care for adult patients with acute rotator cuff tears has not yet been examined. This study aimed to determine if type of health insurance would have an impact on access to care for an adult patient with an acute rotator cuff tear. METHODS Seventy-one orthopaedic surgery practices within the state of North Carolina were randomly selected and contacted on 2 different occasions separated by 3 weeks. The practices were presented with an appointment request for a fictitious 42-year-old man with an acute rotator cuff tear. Insurance status was reported as Medicaid for the first call and as private insurance during the second call. RESULTS Of the 71 practices contacted, 51 (72%) offered the patient with Medicaid an appointment, whereas 68 (96%) offered the patient with private insurance an appointment. The difference in these rates was statistically significant (P < .001). The likelihood of patients with private insurance obtaining an appointment was 8.8 times higher than that of patients with Medicaid (95% CI: 2.5, 31.5). CONCLUSION For patients with acute rotator cuff tears, access to care is decreased for those with Medicaid compared with those with private insurance. Patients with private insurance are 8.8 times more likely than those with Medicaid to obtain an appointment. LEVEL OF EVIDENCE Basic science, survey study.