Ryan D. Katz

Functional Reconstruction of Subtotal Thumb Metacarpal Defect With a Vascularized Medial Femoral Condyle Flap: Case Report

Devastating hand injuries require customized reconstructive strategies to maximize functional outcomes. We report a case of thumb metacarpal reconstruction using a vascularized medial femoral condyle osteocutaneous flap in the setting of nearly complete metacarpal loss. In addition to achieving the traditional goals of reconstructing thumb length and providing stability, the medial femoral condyle flap allowed motion at the carpometacarpal joint. The patients hand function was further optimized by a component transfer of a proximally injured but distally preserved index finger to the amputated middle finger position. The patient regained satisfactory grip and thumb function with minimal donor site morbidity. This case highlights the role of both creative and established approaches to reconstruct composite tissues following devastating hand injury.

Inadvertent Intra-Arterial Drug Injections in the Upper Extremity: Systematic Review

PURPOSE To review the literature pertaining to inadvertent intra-arterial drug injection in the upper extremity, explore the various treatment options and their outcomes, and identify risk factors for limb amputation following intra-arterial injection. METHODS A systematic review of Medline, EMBASE, and Cochrane databases (inception to March 2013) was completed for patients presenting with intra-arterial drug injection of the upper extremity. Details on intervention and outcome were extracted and subjected to pooled analysis with amputation as the primary outcome. RESULTS A total of 25 articles (209 patients) were included for review. Mean patient age was 31 ± 8 years (male, 71%; female, 29%). Prescription opioids (33%) were the most commonly injected substance, and the brachial artery (39%) was the most common site. The overall weighted mean amputation incidence was 29%. Anticoagulants were the most common treatment used (77%). From pooled analysis, conditions requiring antibiotic use were significantly associated with a higher incidence of amputation; whereas use of steroids was associated with a lower incidence of amputation. Patients presenting 14 hours or more after injection and those injecting crushed pills rather than pure substances had significantly higher incidences of amputation. CONCLUSIONS Intra-arterial drug injection of the upper extremity carries an amputation incidence of nearly 30%. Conditions requiring adjunctive antibiotic use and delay in receiving care were both significantly associated with higher incidences of amputation. No single treatment protocol to date has established superiority. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Coccidioidomycosis Causing Osteomyelitis of the Hand in an Immunocompetent Patient

Coccidioidomycosis osteomyelitis is a rare entity considered even more rare when identified in the immunocompetent patient. In non-endemic areas, the diagnosis of a fungus-causing osteomyelitis is often delayed or overlooked. This results in delayed or inappropriate treatment. We present the case of a 35-year-old immunocompetent male immigrant from India who was ultimately diagnosed as having Coccidioidomycosis immitis osteomyelitis of his ring finger metacarpal. His initial surgery included drainage and bacterial cultures only. When he failed to improve, he presented for a second opinion. The patient’s origin and travel history coupled with the appearance of rapid bone destruction on plain radiographs prompted a second operation for tissue biopsy and culture for bacteria, fungus, and mycobacteria cultures. This case highlights the importance of a thorough clinical history in deriving an appropriate differential diagnosis prior to surgical intervention.

Upper Extremity Neuromuscular Disorders

Medical caregivers of patients with upper extremity neuromuscular disorders should use a multidisciplinary approach in order to maximize their patients’ function and minimize related adverse events. Nonsurgical treatment options are often trialed initially and typically consist of one or more of the following: limb-specific therapy including stretching and strengthening, functional or hygienic splinting, sensory and/or motor reeducation, and oral or injectable medications. Surgical treatment options can be broadly considered within one or more of the following categories: local nerve repair, grafting, or transfers; local tendon grafting or transfers, free muscle, tendon, and/or nerve flap transfers involving microsurgery; and joint releases, reconstructions, or fusions.

Changes in Wrist Motion After Simulated Scapholunate Arthrodesis: A Cadaveric Study

PURPOSE A high incidence of nonunion and relatively poor outcomes with prior fixation techniques has precluded scapholunate (SL) arthrodesis as a standard treatment for SL instability. Our purpose was to determine the impact on range of motion (ROM) of simulated SL arthrodesis via headless screw fixation. METHODS We performed baseline wrist ROM for 10 cadaveric wrists using a standardized mounting-and-weights system. Extension, flexion, radial deviation, ulnar deviation, dart-throwers extension, and dart-throwers flexion were assessed. Two 3.0-mm headless compression screws were inserted across the SL joint to simulate SL arthrodesis. Goniometric measurements and fluoroscopic imaging were repeated to assess ROM differences after simulated SL arthrodesis. We assessed SL angle and gap during testing to ensure there was no significant motion between the scaphoid and lunate, thus confirming stable simulated fusion. Differences in ROM were compared between baseline and simulated SL arthrodesis using paired t tests. RESULTS Mean SL angle remained constant between pre- and post-arthrodesis imaging (47° ± 6° vs 46° ± 4°) and did not change during post-arthrodesis ROM testing, indicating a stable simulated fusion. Compared with baseline, SL arthrodesis had a statistically significant reduction in maximum flexion of 6° and 9° based on fluoroscopy and goniometry, respectively, in dart-throwers extension of 5° and 9° based on fluoroscopy and goniometry, respectively, and in dart-throwers flexion of 6° for both fluoroscopy and goniometry. No other ROMs after simulated SL arthrodesis were significantly different compared with baseline. CONCLUSIONS The effects of simulated SL arthrodesis on radiocarpal and midcarpal motion compare favorably with motion after SL soft tissue repair and other reconstructive techniques that have been previously reported. The statistically significant decreases in wrist flexion and dart-throwers extension-flexion after simulated SL arthrodesis are of questionable clinical importance. CLINICAL RELEVANCE These results may support reconsidering SL arthrodesis as a viable treatment option for acute or chronic SL instability with regard to apparent minimal adverse effects on functional wrist ROM.

Chronic thrombosis in the descending genicular artery during harvest of a medial femoral condyle corticocancellous flap: a case report

Since its original description [10], the vascularized medial femoral condyle (MFC) corticoperiosteal free flap has gained increased popularity due to its versatility and reliability. While the flap was initially proposed for small bone nonunions [5], its favorable characteristics and osteogenic potential have led to its application in long bone nonunions [4]. The advantages of this flap include minimal donor side morbidity, a long noncritical vascular pedicle, and relatively reliable anatomy [7]. To date, there have been few disadvantages or complications of this flap reported in the literature. Those cited include persistent nonunion, seroma formation, knee pain, flap failure, and femur fracture [1, 3]. We present the case of a chronic arterial thrombosis in the descending genicular artery (DGA) identified during the harvest of a MFC corticocancellous flap for a humeral nonunion.

Soft-tissue coverage for upper extremity injuries

The injured upper extremity presents a reconstructive challenge to hand surgeons who must balance form with function. Any effort to provide soft-tissue coverage to the upper extremity should have well-defined preoperative goals and should take into account donor site morbidity, aesthetic acceptability, functional gains, and possible future operations. Today, the reconstructive arsenal is replete with skin grafts, allografts, local rotational flaps, and free tissue transfers of muscle, fascia, fat, skin, and combinations thereof. In an effort to further the knowledge of reconstructive surgeons and benefit patients with soft-tissue injuries of the upper extremity, this review will draw from the current body of literature to discuss the uses of many of the above options.