Stephen A. Kennedy

The results of early primary open reduction and internal fixation for treatment of OTA 43.C-type tibial pilon fractures: a cohort study.

Objectives: The optimal treatment for pilon fractures remains controversial. We have used early single-stage open reduction and internal fixation (ORIF) to treat these injuries and the purpose of this study was to determine the safety and efficacy of this strategy. Design: Cohort study. Setting: Level I trauma center. Patients/Participants: Ninety-five patients with Orthopaedic Trauma Association type 43.C pilon fractures. Intervention: Primary ORIF. Main Outcome Measurement: Primary: Wound dehiscence or deep infection requiring surgery; secondary: quality of fracture reduction, functional outcomes (SF-36 and Foot and Ankle Outcome Score). Results: Primary ORIF was performed within 24 hours in 70% of cases and within 48 hours in 88%. Reduction was judged to be anatomic in 90% cases. Six patients developed a deep wound infection or dehiscence that required surgical débridement, four after open fractures (four of 21 [19%]) and two after closed fractures (two of 74 [2.7%]). Complications were associated with local scarring, chronic alcohol abuse, schizophrenia, diabetes, and peripheral neuropathy. Conclusions: Provided surgery is performed expeditiously by experienced orthopaedic trauma surgeons, most tibial pilon fractures can be stabilized by primary ORIF within a safe and effective operative window with relatively low rates of wound complications, a high quality of reduction, and functional outcomes that compare favorably with the published results for all other reported surgical treatments of these severe injuries.

Single- versus multiple-dose antibiotic prophylaxis in the surgical treatment of closed fractures: a meta-analysis.

Objectives: The use of prophylactic antibiotics in the surgical treatment of closed long bone fractures is well established. The duration and dosage of prophylaxis, however, vary significantly among surgeons. A systematic review and meta-analysis were performed to determine if multiple-dose perioperative antibiotic prophylaxis is more effective than a single preoperative dose in the prevention of surgical wound infections during the treatment of closed long bone fractures. Data Sources: Articles were identified by searching the following medical databases: Medline, Medline In Process & Other Non-indexed Citations, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews. Relevant conference proceedings and the reference section of selected manuscripts were also searched for additional studies. Study Selection: Studies were included if they were prospective randomized controlled trials of patients with closed fractures treated with surgical fixation or arthroplasty. The interventions must have directly compared a single preoperative prophylactic dose to a multiple-dose perioperative strategy. Studies were excluded if they involved open fractures. Data Extraction: The demographic information, prophylaxis strategy, wound infection rate, and risk ratio were extracted from each article. Data Synthesis: Seven trials and 3,808 patients were pooled using a random effects model. When compared to a regimen of multiple doses of prophylactic antibiotics, administration of a single preoperative dose has a risk ratio of 1.24 (95% CI 0.60-2.60). The pooled risk difference between the 2 strategies is 0.005 (95% CI −0.011-0.021). Neither result is significant. Conclusions: In the setting of closed long bone fractures, the pooled results failed to demonstrate superiority of multiple-dose prophylaxis over a single-dose strategy. The pooled estimates suggest that surgical wound infections are relatively rare events and that any potential difference in infection rates between prophylaxis strategies is likely quite small. However, because the confidence interval surrounding the pooled risk ratio spans 1.0 by such a large amount, we are unable to definitively recommend a preferred dosing regimen to prevent surgical wound infections. Although future research is required to ensure our prophylaxis decisions continue to be evidence based and cost-effective, it is unlikely that a single clinical trial will be able to provide the answer. The use of other quantitative methods, such as cost-effectiveness analysis, may be helpful in modeling an optimal prophylaxis strategy.

Human and other mammalian bite injuries of the hand: evaluation and management.

The hand is the most common site for bite injuries. Because of specific characteristics of hand anatomy, bite mechanics, and organisms found in human and animal saliva, even small wounds can lead to aggressive infections. Failure to recognize and treat hand bites can result in significant morbidity. Human and animal bites most commonly lead to polymicrobial bacterial infections with a mixture of aerobic and anaerobic organisms. Pasteurella species are commonly found in dog and cat bite wounds, and Eikenella is characteristic of human wounds. Staphylococcus, Streptococcus, and anaerobic bacterial species are common to all mammals. Although public health measures in developed countries have been highly effective at reducing rabies transmission, dog bites remain the most common source of rabies infection worldwide. Human bites can transmit HIV, hepatitis B, or hepatitis C, especially when contaminated blood is exposed to an open wound. Appropriate management of any mammal bite requires recognition, early wound cleansing, evaluation of injured structures, and infection prophylaxis. Structural repair is performed as indicated by the severity and contamination of the injury, and wounds may require delayed closure. Wound infections typically require débridement, empiric antibiotics, and delayed repair or reconstruction.

Association between psychosocial factors and pain in patients with trigger finger

PurposeTo test the hypothesis that psychological factors correlate with pain intensity in trigger finger (TF).MethodsPatients with TF were selected from two previous cohort studies measuring pain intensity and psychological parameters, 82 from one study and 72 from another. Correlation testing and multiple linear regression was performed. Measures included the pain catastrophizing scale (PCS), pain self-efficacy questionnaire (PSEQ), patient health questionnaire depression (PHQ-D) scale, center for epidemiologic studies depression (CES-D) scale, pain anxiety symptoms score (PASS), and the eysenck personality questionnaire (EPQ-R) scales.ResultsThere was moderate correlation between pain intensity and PCS (ρ = 0.52; P < 0.001) and PSEQ (ρ = − 0.36; P < 0.001). There was weak correlation between pain and PHQ-D (ρ = 0.23; P = 0.019). No significant correlation existed with CES-D or EPQ-R. PCS accounted for 26% of the variance in pain for patients awaiting surgery (P < 0.001).ConclusionSelf-reported pain in TF has moderate correlation with psychological factors, most predominantly pain catastrophizing.

Complex distal radius fractures.

Complex distal radius fractures are high-energy injuries of the wrist with articular disruption, ligamentous instability, significant comminution, soft tissue injury, and/or neurovascular impairment. The management of these injuries requires a thorough understanding of wrist functional anatomy and familiarity with a wide selection of approach and fixation options. This article reviews an approach that involves structured evaluation, aggressive soft tissue management, early reduction and skeletal stabilization, and a columnar approach to definitive care. Outcome is determined by multiple factors and depends greatly on the soft tissue injury, patient factors, and management and the adequacy of restoration of osseous and ligamentous relationships.

In brief: Mayfield et al. Classification: carpal dislocations and progressive perilunar instability.

According to Melsom and Leslie, the earliest description of perilunate dislocation was by Malgaigne in 1855, before the advent of radiography [7]. It later was described by Cousins, Destot, de Quervain, and others [7]. According to Melsom and Leslie [7] Tavernier reported the first series in 1906. Many years later, in 1968, the concept of the proximal row as an intercalated segment was described by Fisk [7]. In 1972, Linscheid et al. [4] modified the concept to develop models of dorsal and volar intercalated instability. The ligamentous pathoanatomy and classification of these injuries, however, had not been well described. In 1980, Mayfield et al. [5] performed a cadaveric study to better delineate the pathoanatomy and classify the degree of carpal instability after perilunate injury. Purpose

Acute Shoulder Trauma: What the Surgeon Wants to Know

Many excellent studies on shoulder imaging from a radiologic perspective have been published over the years, demonstrating the anatomy and radiologic findings of shoulder trauma. However, it may not always be clear what the surgeon, who bears the responsibility for treating the injured patient, really needs to know about the injury to predict outcomes and plan management. The authors review the relevant osseous, soft-tissue, and vascular anatomy and describe the clinically relevant concepts that affect management. Familiarity with the Neer classification system for proximal humerus fractures can have a significant impact on treatment. The length and displacement of the medial humeral metaphyseal fragment helps predict the risk of ischemia in proximal humerus fractures. The Nofsinger approach for measuring the area of glenoid fossa bone loss can help the surgeon determine the need for surgical repair of a bony Bankart lesion. The size of Hill-Sachs and reverse Hill-Sachs lesions is also an important predictor of stability. The Ideberg classification system for intraarticular fractures of the glenoid fossa, combined with information on instability and joint incongruity, helps determine the need for surgical fixation of glenoid fossa fractures. Awareness of what matters to the surgeon can help radiologists better determine where to focus their attention and efforts when describing acute shoulder trauma.

Does degree of immobilization influence refracture rate in the forearm buckle fracture

The aim of this study was to determine whether the degree of immobilization (method, extent, duration of treatment) affects the risk of refracture in the management of forearm buckle fractures. We performed a comprehensive systematic review of prospective trials using accepted epidemiological methods. Studies were selected in step-wise manner, in duplicate, with critical appraisal of identified studies. Results are presented in a summary table with primary and secondary outcomes described. Of the 869 studies identified by the search strategy, five studies met all eligibility criteria. 455 participants were included. No refractures were reported in any of the studies during the treatment period, regardless of degree of immobilization. One study followed patients for 6 months and found no late refractures in 75 participants. In conclusion, treatment in a removable splint does not increase risk of refracture or late displacement during the treatment period for buckle fractures of the distal forearm. Long-term data on refracture rate is limited. There tends to be improved function, patient acceptance, and caregiver satisfaction with the use of removable splints. Further study is needed to determine whether there are differences for longer periods of follow-up on a population basis.

Anomalous Forearm Muscles and Their Clinical Relevance

Despite their relatively low prevalence in the population, anomalous muscles of the forearm may be encountered by nearly all hand and wrist surgeons over the course of their careers. We discuss 6 of the more common anomalous muscles encountered by hand surgeons: the aberrant palmaris longus, anconeus epitrochlearis, palmaris profundus, flexor carpi radialis brevis, accessory head of the flexor pollicis longus, and the anomalous radial wrist extensors. We describe the epidemiology, anatomy, presentation, diagnosis, and treatment of patients presenting with an anomalous muscle. Each muscle often has multiple variations or subtypes. The presence of most anomalous muscles is difficult to diagnose based on patient history and examination alone, given that symptoms may overlap with more common pathologies. Definitive diagnosis typically requires soft tissue imaging or surgical exploration. When an anomalous muscle is present and symptomatic, it often requires surgical excision for symptom resolution.

CORR Insights®: To What Degree Do Pain-coping Strategies Affect Joint Stiffness and Functional Outcomes in Patients With Hand Fractures?

T he influence of psychological factors on functional outcomes in clinical orthopaedics is becoming increasingly recognized. The World Health Organization has concluded that depression better predicts general health status than angina, asthma, diabetes, or arthritis [5]. In musculoskeletal health, depression has been demonstrated to predict self-reported upper extremity health status for multiple diagnoses [7]. Depression, pain catastrophizing, and other psychological factors are the best available predictors of severity of pain and disability after ACL reconstruction, knee arthroplasty, and minor hand surgery [6, 8, 9]. Psychological symptoms are prevalent and inadequately recognized on clinical impression alone. After orthopaedic trauma, 45% of patients have clinically relevant symptoms of depression [1]; in spine patients, 64% have psychological distress on screening questionnaires [2], and after severe lower limb injuries, 48% of patients screen positive for a likely psychological disorder [3]. Controversies remain regarding the relationships among psychological factors associated with physical impairment (as opposed to perceived disability), the degree to which psychological factors can be modified in the orthopaedic patient, and whether this is practical to achieve. Roh et al. have focused on the role of pain-coping strategies on ROM and grip strength after hand fractures. They found that poor coping skills before surgery, as measured by high catastrophization and anxiety, were associated with weaker grip strength, decreased ROM, and increased disability after surgical treatment for hand fracture in the first 3 months after injury.