Perilunate injuries most commonly occur in high energy trauma situations; however, they are rare ... more Perilunate injuries most commonly occur in high energy trauma situations; however, they are rare and frequently missed. Familiarity with the complex bony and ligamentous anatomy is required to fully understand these complex injury patterns. Careful orthogonal imaging and evaluation is required to ensure timely diagnosis of a perilunate injury. Early recognition and management of acute perilunate injuries has been demonstrated to correlate with better patient outcomes. Delayed treatment of chronic injuries can result in post-traumatic osteoarthritis and carpal collapse requiring salvage interventions. Here, we review the anatomy, basic evaluation, and management of this frequently missed injury.
Etiologies of elbow contractures can be classified into intrinsic versus extrinsic causes. Posttr... more Etiologies of elbow contractures can be classified into intrinsic versus extrinsic causes. Posttraumatic elbow stiffness is the most common intrinsic cause and HO formation is the most common extrinsic cause of elbow contractures. Patients who sustain significant elbow trauma and have one or more risk factors for HO formation should be given prophylaxis against HO formation in the form of either indomethacin or radiation therapy. Early excision of HO has been shown to be safe and effective. Nonoperative measures are most effective if used within 6 months of contracture onset. These measures include physical therapy and an aggressive splinting program. If nonoperative measures are unsuccessful and the patient has functionally limiting elbow ROM, then surgical intervention should be considered. Careful preoperative assessment of the ulnar nerve is mandatory, as it may need to be transposed. Satisfactory results have been reported with arthroscopic elbow contracture releases. However, this procedure is technically challenging, with the potential for serious neurovascular complications. Satisfactory results have been published for open procedures as well. The direction of the greatest limitation of motion, the presence of ulnar nerve dysfunction, and the location of osteophytes all help to dictate which surgical approach should be selected.
The diagnosis and treatment of patients with tenosynovitis disorders of the hand and wrist are co... more The diagnosis and treatment of patients with tenosynovitis disorders of the hand and wrist are complex and must take into account the heterogeneity and natural history of each condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This review serves to summarize some of the recent publications in the field of hand surgery that have made important contributions to our understanding and care of the patient with tenosynovitis. Updates in the field of hand surgery are constant, and the current level of evidence for the effectiveness of specific treatment modalities in patients with tenosynovitis of the hand and wrist was reviewed. We searched the PubMed database and identified clinical trials, meta-analyses, reviews, and guidelines contributing important findings and knowledge to extensor and flexor compartment tenosynovitis of the hand and wrist. Our understanding of tenosynovitis disorders of the hand and wrist continues to grow and expand. Nevertheless, a paucity of randomized controlled trials and higher evidence research may contribute to the variability in current practices among providers. By elucidating these gaps, we can more purposefully delegate our time and resources into targeted areas of research and treatment. This review contains 10 figures, 1 table and 86 references. Key words: corticosteroid injection, de Quervain disease, hand/wrist pain, tendonitis, tenosynovitis, trigger finger
A 29-year-old female presented with pain and a palpable mass in the left wrist. Imaging demonstra... more A 29-year-old female presented with pain and a palpable mass in the left wrist. Imaging demonstrated a multiloculated cystic mass adjacent to the radial aspect of the scaphoid, which was intimately associated with and appeared to arise from the wall of the radial artery and its dorsal branch. The mass was surgically resected. The histological analysis confirmed the presence of adventitial cystic disease (ACD) of the radial artery. In addition, within a year time span, a second 34-year-old male patient presented with a palpable mass in the right hand. Imaging demonstrated a cystic mass encasing the dorsal carpal branch of the radial artery and its terminal vessels to the thumb and index finger. The diagnosis of ACD was raised based on MR imaging. Histological analysis confirmed the presence of an adventitial cyst. ACD of the arteries is a rare disorder of unknown etiology, which usually involves the popliteal artery. Less common sites of involvement include the external iliac, common femoral, radial, and ulnar arteries. To our knowledge, there have only been six previous case reports of adventitial cystic disease involving the radial artery. The imaging features, histology, differential diagnosis, pathogenesis, and treatment are discussed.
Chronic elbow dislocations, while rare, may cause significant loss of function for patients. Due ... more Chronic elbow dislocations, while rare, may cause significant loss of function for patients. Due to significant soft tissue contractures and intra-articular fibrosis, treatment for these injuries is challenging and is approached on an individual basis based on the nature of the injury and the patient’s goals. Presented here is a case of a 27-year-old male with a 2-week-old elbow fracture dislocation treated with open reduction, internal fixation of the ulna, radial head replacement, and lateral ulnar collateral ligament repair along with a 1-year follow-up. The intraoperative considerations, treatment algorithms, and management of a common complication, heterotopic ossification, are outlined.
Child abuse continues to be a serious problem that is likely to be encountered in all medical spe... more Child abuse continues to be a serious problem that is likely to be encountered in all medical specialties, with orthopaedic surgeons commonly evaluating children having sustained musculoskeletal injuries. In busy emergency departments and clinics, junior residents shoulder much of the responsibility in identifying cases of abuse. We report the case of an otherwise healthy 18-month-old child, who presented to the emergency room with bilateral humeral shaft and corner fractures. These injuries were originally presented to the orthopaedic resident as having occurred from an accidental fall from a crib. The appropriate evaluation for a patient suspected of sustaining an injury from child abuse is reviewed.
Distal radioulnar joint (DRUJ) arthritis presents a challenging problem. Surgical interventions i... more Distal radioulnar joint (DRUJ) arthritis presents a challenging problem. Surgical interventions include resection arthroplasties, such as the Darrach procedure and hemiresection arthroplasty, the Sauve-Kapandji procedure, and more recently prosthetic replacement for either the ulnar head or the entire DRUJ. Resection arthroplasties have been associated with complications, including instability and radioulnar convergence. The prosthetic replacements have been designed in an attempt to restore more normal DRUJ kinematics. This paper provides a review of the anatomy and biomechanics of the DRUJ and discusses the outcomes of the available surgical options for symptomatic DRUJ arthritis. The arthritic distal radioulnar joint (DRUJ) is a difficult problem. Many of the surgical interventions developed for this condition are associated with complications,such as instability and radioulnar convergence. Recently, prosthetic replacement of either the ulnar head or the entire DRUJ has been advocated in order to better restore the kinematics of the joint. A review of the anatomy and biomechanics of the DRUJ and a discussion of the numerous surgical options and their outcomes is provided.
Many options exist for the management of post-traumatic thumb reconstruction. While the single mo... more Many options exist for the management of post-traumatic thumb reconstruction. While the single most important factor for determining the most appropriate procedure is the level of the amputation, many other factors must be considered including patient considerations regarding function and cosmesis as well as the nature of the injury and the expertise of the surgeon. Patients must be included in the decision-making process and their needs and expectations must be clearly defined and addressed. The patient who is most concerned with cosmesis rather than function is more likely to be satisfied with a prosthesis than with even the most cutting-edge surgical procedure.
Purpose: To report radiographic, clinical, and patient-based functional outcomes following contem... more Purpose: To report radiographic, clinical, and patient-based functional outcomes following contemporary operative treatment of patients who sustained an open distal radius fracture and compare them to a similar group of patients treated operatively for closed distal radius fractures. Methods: Over five years, 601 patients with a distal radius fracture presented to our academic medical center, including one Level 1 trauma hospital, and were prospectively enrolled in an upper extremity trauma database. Patients with open distal radius fractures underwent irrigation, debridement, and operative fixation within 24 hours of presentation. Closed distal radius fractures requiring operative fixation were treated electively. Retrospective review of the database identified eighteen open fractures of the distal radius (11 type I, 6 type II, 1 type IIIa). The open fracture patients were individually matched with eighteen closed distal radius fracture patients who underwent surgical fixation based on age, sex, injury to dominant extremity, fracture pattern, and method of fracture fixation. Clinical, radiographic, patient- based functional outcomes, and complications were recorded at routine postoperative intervals. Results: Follow-up was greater than 77% in both groups at all time points. The open and closed groups were similar in regards to age, gender, BMI, race, tobacco use, income, employment status, hand dominance, injury to dominant extremity, mechanism of injury, fracture classification, method of fracture fixation, and presence of concomitant injury. Postoperative complications and reoperation rates were similar between the open and closed groups. Union rates and radiographic alignment one year postoperatively were similar between the open and closed fracture groups. At final follow-up, range of motion parameters, grip strengths, DASH indices, and subjective pain scores were similar between both groups. Discussion: Open distal radius fractures treated with early debridement and fixation achieved similar outcomes to surgically treated closed fractures of the distal radius when followed for a year or more postoperatively.
The literature on the effect of ulnar styloid fractures (USFs) on concomitant distal radius fract... more The literature on the effect of ulnar styloid fractures (USFs) on concomitant distal radius fractures (DRFs) is mixed. We conducted a study to determine if associated ipsilateral USFs affect outcomes of DRFs. We retrospectively evaluated 315 DRFs treated (184 operatively, 131 nonoperatively) over a 7-year period. Concomitant USFs were identified. Mean follow-up was 12 months. Disabilities of the Arm, Shoulder, and Hand (DASH) and 36-Item Short Form Health Survey (SF-36) outcome scores, and grip strength and wrist range of motion data, were collected. Statistical analysis was performed with Student t test and analysis of variance. Incidence of concomitant USF and DRF was higher (P < .0002) in the operative group (64.6%) than in the nonoperative group (39.1%). Patients with USFs had worse mean (SD) pain score, 1.80 (2.43) versus 0.80 (1.55) (P = .0001), DASH score, 17.03 (18.94) versus 9.21 (14.06) (P = .001), and SF-36 score, 77.16 (17.69) versus 82.68 (16.10) (P = .022). In the operative group, patients with USFs had more pain and poorer DASH Functional scores than patients without USFs. Results were similar in the nonoperative group. There was no difference in healing time between intra-articular and extra-articular fractures or between presence and absence of USFs. Concomitant occurrence of USFs and DRFs-which is associated with worse pain scores and lower functioning compared with USFs without DRFs-should prompt clinicians to counsel patients about delayed recovery.
Surgical neck fractures are the most common type of proximal humerus fractures. Surgical neck fra... more Surgical neck fractures are the most common type of proximal humerus fractures. Surgical neck fractures occur in all age groups, affecting pediatric, young adult, and geriatric individuals. The majority of surgical neck of the proximal humerus fractures are nondisplaced or minimally displaced and do not require operative intervention. Displaced fractures can disrupt the function of the upper extremity, however, and often necessitate operative care. Standard radiographs should include an anteroposterior view taken in the scapular plane, a scapular "Y" lateral, and an axillary view. If the patient is in too much discomfort to obtain a standard axillary view, a Velpeau axillary can be obtained. Nondisplaced fractures, greater tuberosity fractures with less than 5-ram displacement, and surgical neck fractures with less than 1-cm displacement and 45 ° angulation should be treated by nonoperative means. The reduction maneuver involves longitudinal traction on the arm to disimpact the fracture. The arm is abducted approximately 70 °, and then a posterior force is applied to the shaft of the humerus to correct the apex anterior angulation. Slight external rotation of the shaft may be necessary. The fracture can then be impacted for increased stability. Displaced surgical neck fractures can be stabilized by a variety of techniques. Some of the commonly used techniques involve percutaneous pin fixation, suture techniques, antegrade and retrograde insertion intramedullary rods, a combination of Ender nails and suture techniques, plate and screw fixation, and external fixation. In this article, we will discuss the use of these techniques, the details of percutaneous pinning, and the technique of Ender nail and suture fixation. KEY WORDS: proximal humerus fracture, Ender nail, suture fixation, percutaneous pinning Fractures of the proximal humerus account for 4% to 5% of all fractures, 1-3 and may involve the anatomic neck, the greater and lesser tuberosities, and the surgical neck. Surgical neck fractures are the most common type of proximal humerus fractures. The surgical neck is the region of the proximal humerus that is proximal to the diaphysis but distal to the physeal scar. Surgical neck fractures occur in patients at any age. The majority of surgical neck of the proximal humerus fractures are nondisplaced or minimally displaced and do not require operative intervention. Displaced fractures can disrupt the function Of the upper extremity, however, and often require operative care. 4-6
The management of distal radius fractures has evolved over time from a largely nonoperative parad... more The management of distal radius fractures has evolved over time from a largely nonoperative paradigm to a more commonly performed operative procedures today. Surgical trends have similarly developed, with dorsal plating falling out of favor due to complications involving extensor tendon pathology as well as due to the ubiquity of the volar plate along with the advent of locking plate technology. However, with the improvement in design of newer generation dorsal plates, this technique should be used in the appropriate clinical situation, including dorsal comminution and angulation with concomitant carpal pathology. Outcome data supports dorsal plating and has been shown to be comparable to that of volar plating, with some unique advantages. As such, the technique of dorsal plating should have a role in surgical management of these injuries.
Purpose: In order to identify predictors for hand stiffness following distal radius fractures and... more Purpose: In order to identify predictors for hand stiffness following distal radius fractures and understand the consequences of this common clinical finding, we studied 260 patients. Our null hypothesis was that we would find no predictors of post injury hand stiffness. Methods: Baseline demographics and injury characteristics were obtained at distal radius fracture presentation. Treatment and healing was documented. Stiffness was defined as tip to palm distance greater than 1 cm for any one finger. Outcome parameters obtained at regular intervals included wrist and hand range of motion, radiographs, visual analog pain scales, and Disability of the Arm Shoulder and Hand (DASH) questionnaires. Results: Forty-nine of 260 patients (19%) patients were considered to be "stiff" by our criteria. Grip strength was weaker for stiff patients as well. Patient demographics were similar in both groups with the "stiff" cohort having a greater mean age, p = 0.05. There was no significant difference in stiffness seen in operative cases versus nonoperative cases. Injury ulnar variance was 3.1mm (SD = 3.5) in the "stiff" cohort and 1.8 (SD = 2.9) in the "non-stiff" cohort (p= 0.02). Functional disability as measured by the DASH differed (p = 0.001) between stiff and non-stiff patients for both 6 month and 1 year follow-up time points. Stiff patients were more likely than non-stiff patients to have lower grip strength at 12-month post fracture (p = 0.001). Conclusion: Older patients who present with significant ulnar variance at injury are more likely to experience hand stiffness at some time during their recovery. The development of hand stiffness is associated with poorer functional outcome than those who do not develop stiffness.
The association of radial nerve palsy and humeral shaft fracture is well known. Primary explorati... more The association of radial nerve palsy and humeral shaft fracture is well known. Primary exploration and fracture fixation is recommended for open fractures and vascular injury while expectant management remains the standard of care for closed injuries. In the absence of nerve recovery, exploration and reconstruction is recommended 3 to 5 months following injury. When direct repair or nerve grafting is unlikely to achieve a suitable outcome, nerve and tendon transfers are potential options for the restoration of wrist and finger extension.
Compartment syndrome of the extremity is a diagnosis that requires emergent intervention. It is c... more Compartment syndrome of the extremity is a diagnosis that requires emergent intervention. It is characterized as an elevation of tissue pressure resulting in impaired perfusion. Although commonly associated with fractures, there are a number of intrinsic and extrinsic causes. Early intervention can reduce the extent of permanent muscle and neurovascular damage, impairment, and the late sequela, specifically Volkmann ischemic contracture. The goal of surgical treatment is to restore tissue perfusion with emergent decompression/fasciotomy. Ensuring a complete release of all affected compartments is imperative to achieve a good clinical outcome and mitigate complications.
Journal of Bone and Joint Surgery, American Volume, 2021
Ultrasonography as a diagnostic and therapeutic tool has become a resource for musculoskeletal in... more Ultrasonography as a diagnostic and therapeutic tool has become a resource for musculoskeletal injuries. It can be a useful imaging modality for clinical correlation of physical examination findings as well as an aid for image-guided procedures. Understanding the settings in which it is a helpful adjunct will have implications on efficiency and cost utility. The objectives of this chapter are to provide a background of ultrasonography as a musculoskeletal imaging modality, provide clinical correlation for ultrasonographic findings for common upper extremity pathology, review the diagnostic efficacy of ultrasonography for image-guided procedures, and provide insight into the cost utility of ultrasonography guidance for therapeutic injections.
Perilunate injuries most commonly occur in high energy trauma situations; however, they are rare ... more Perilunate injuries most commonly occur in high energy trauma situations; however, they are rare and frequently missed. Familiarity with the complex bony and ligamentous anatomy is required to fully understand these complex injury patterns. Careful orthogonal imaging and evaluation is required to ensure timely diagnosis of a perilunate injury. Early recognition and management of acute perilunate injuries has been demonstrated to correlate with better patient outcomes. Delayed treatment of chronic injuries can result in post-traumatic osteoarthritis and carpal collapse requiring salvage interventions. Here, we review the anatomy, basic evaluation, and management of this frequently missed injury.
Etiologies of elbow contractures can be classified into intrinsic versus extrinsic causes. Posttr... more Etiologies of elbow contractures can be classified into intrinsic versus extrinsic causes. Posttraumatic elbow stiffness is the most common intrinsic cause and HO formation is the most common extrinsic cause of elbow contractures. Patients who sustain significant elbow trauma and have one or more risk factors for HO formation should be given prophylaxis against HO formation in the form of either indomethacin or radiation therapy. Early excision of HO has been shown to be safe and effective. Nonoperative measures are most effective if used within 6 months of contracture onset. These measures include physical therapy and an aggressive splinting program. If nonoperative measures are unsuccessful and the patient has functionally limiting elbow ROM, then surgical intervention should be considered. Careful preoperative assessment of the ulnar nerve is mandatory, as it may need to be transposed. Satisfactory results have been reported with arthroscopic elbow contracture releases. However, this procedure is technically challenging, with the potential for serious neurovascular complications. Satisfactory results have been published for open procedures as well. The direction of the greatest limitation of motion, the presence of ulnar nerve dysfunction, and the location of osteophytes all help to dictate which surgical approach should be selected.
The diagnosis and treatment of patients with tenosynovitis disorders of the hand and wrist are co... more The diagnosis and treatment of patients with tenosynovitis disorders of the hand and wrist are complex and must take into account the heterogeneity and natural history of each condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This review serves to summarize some of the recent publications in the field of hand surgery that have made important contributions to our understanding and care of the patient with tenosynovitis. Updates in the field of hand surgery are constant, and the current level of evidence for the effectiveness of specific treatment modalities in patients with tenosynovitis of the hand and wrist was reviewed. We searched the PubMed database and identified clinical trials, meta-analyses, reviews, and guidelines contributing important findings and knowledge to extensor and flexor compartment tenosynovitis of the hand and wrist. Our understanding of tenosynovitis disorders of the hand and wrist continues to grow and expand. Nevertheless, a paucity of randomized controlled trials and higher evidence research may contribute to the variability in current practices among providers. By elucidating these gaps, we can more purposefully delegate our time and resources into targeted areas of research and treatment. This review contains 10 figures, 1 table and 86 references. Key words: corticosteroid injection, de Quervain disease, hand/wrist pain, tendonitis, tenosynovitis, trigger finger
A 29-year-old female presented with pain and a palpable mass in the left wrist. Imaging demonstra... more A 29-year-old female presented with pain and a palpable mass in the left wrist. Imaging demonstrated a multiloculated cystic mass adjacent to the radial aspect of the scaphoid, which was intimately associated with and appeared to arise from the wall of the radial artery and its dorsal branch. The mass was surgically resected. The histological analysis confirmed the presence of adventitial cystic disease (ACD) of the radial artery. In addition, within a year time span, a second 34-year-old male patient presented with a palpable mass in the right hand. Imaging demonstrated a cystic mass encasing the dorsal carpal branch of the radial artery and its terminal vessels to the thumb and index finger. The diagnosis of ACD was raised based on MR imaging. Histological analysis confirmed the presence of an adventitial cyst. ACD of the arteries is a rare disorder of unknown etiology, which usually involves the popliteal artery. Less common sites of involvement include the external iliac, common femoral, radial, and ulnar arteries. To our knowledge, there have only been six previous case reports of adventitial cystic disease involving the radial artery. The imaging features, histology, differential diagnosis, pathogenesis, and treatment are discussed.
Chronic elbow dislocations, while rare, may cause significant loss of function for patients. Due ... more Chronic elbow dislocations, while rare, may cause significant loss of function for patients. Due to significant soft tissue contractures and intra-articular fibrosis, treatment for these injuries is challenging and is approached on an individual basis based on the nature of the injury and the patient’s goals. Presented here is a case of a 27-year-old male with a 2-week-old elbow fracture dislocation treated with open reduction, internal fixation of the ulna, radial head replacement, and lateral ulnar collateral ligament repair along with a 1-year follow-up. The intraoperative considerations, treatment algorithms, and management of a common complication, heterotopic ossification, are outlined.
Child abuse continues to be a serious problem that is likely to be encountered in all medical spe... more Child abuse continues to be a serious problem that is likely to be encountered in all medical specialties, with orthopaedic surgeons commonly evaluating children having sustained musculoskeletal injuries. In busy emergency departments and clinics, junior residents shoulder much of the responsibility in identifying cases of abuse. We report the case of an otherwise healthy 18-month-old child, who presented to the emergency room with bilateral humeral shaft and corner fractures. These injuries were originally presented to the orthopaedic resident as having occurred from an accidental fall from a crib. The appropriate evaluation for a patient suspected of sustaining an injury from child abuse is reviewed.
Distal radioulnar joint (DRUJ) arthritis presents a challenging problem. Surgical interventions i... more Distal radioulnar joint (DRUJ) arthritis presents a challenging problem. Surgical interventions include resection arthroplasties, such as the Darrach procedure and hemiresection arthroplasty, the Sauve-Kapandji procedure, and more recently prosthetic replacement for either the ulnar head or the entire DRUJ. Resection arthroplasties have been associated with complications, including instability and radioulnar convergence. The prosthetic replacements have been designed in an attempt to restore more normal DRUJ kinematics. This paper provides a review of the anatomy and biomechanics of the DRUJ and discusses the outcomes of the available surgical options for symptomatic DRUJ arthritis. The arthritic distal radioulnar joint (DRUJ) is a difficult problem. Many of the surgical interventions developed for this condition are associated with complications,such as instability and radioulnar convergence. Recently, prosthetic replacement of either the ulnar head or the entire DRUJ has been advocated in order to better restore the kinematics of the joint. A review of the anatomy and biomechanics of the DRUJ and a discussion of the numerous surgical options and their outcomes is provided.
Many options exist for the management of post-traumatic thumb reconstruction. While the single mo... more Many options exist for the management of post-traumatic thumb reconstruction. While the single most important factor for determining the most appropriate procedure is the level of the amputation, many other factors must be considered including patient considerations regarding function and cosmesis as well as the nature of the injury and the expertise of the surgeon. Patients must be included in the decision-making process and their needs and expectations must be clearly defined and addressed. The patient who is most concerned with cosmesis rather than function is more likely to be satisfied with a prosthesis than with even the most cutting-edge surgical procedure.
Purpose: To report radiographic, clinical, and patient-based functional outcomes following contem... more Purpose: To report radiographic, clinical, and patient-based functional outcomes following contemporary operative treatment of patients who sustained an open distal radius fracture and compare them to a similar group of patients treated operatively for closed distal radius fractures. Methods: Over five years, 601 patients with a distal radius fracture presented to our academic medical center, including one Level 1 trauma hospital, and were prospectively enrolled in an upper extremity trauma database. Patients with open distal radius fractures underwent irrigation, debridement, and operative fixation within 24 hours of presentation. Closed distal radius fractures requiring operative fixation were treated electively. Retrospective review of the database identified eighteen open fractures of the distal radius (11 type I, 6 type II, 1 type IIIa). The open fracture patients were individually matched with eighteen closed distal radius fracture patients who underwent surgical fixation based on age, sex, injury to dominant extremity, fracture pattern, and method of fracture fixation. Clinical, radiographic, patient- based functional outcomes, and complications were recorded at routine postoperative intervals. Results: Follow-up was greater than 77% in both groups at all time points. The open and closed groups were similar in regards to age, gender, BMI, race, tobacco use, income, employment status, hand dominance, injury to dominant extremity, mechanism of injury, fracture classification, method of fracture fixation, and presence of concomitant injury. Postoperative complications and reoperation rates were similar between the open and closed groups. Union rates and radiographic alignment one year postoperatively were similar between the open and closed fracture groups. At final follow-up, range of motion parameters, grip strengths, DASH indices, and subjective pain scores were similar between both groups. Discussion: Open distal radius fractures treated with early debridement and fixation achieved similar outcomes to surgically treated closed fractures of the distal radius when followed for a year or more postoperatively.
The literature on the effect of ulnar styloid fractures (USFs) on concomitant distal radius fract... more The literature on the effect of ulnar styloid fractures (USFs) on concomitant distal radius fractures (DRFs) is mixed. We conducted a study to determine if associated ipsilateral USFs affect outcomes of DRFs. We retrospectively evaluated 315 DRFs treated (184 operatively, 131 nonoperatively) over a 7-year period. Concomitant USFs were identified. Mean follow-up was 12 months. Disabilities of the Arm, Shoulder, and Hand (DASH) and 36-Item Short Form Health Survey (SF-36) outcome scores, and grip strength and wrist range of motion data, were collected. Statistical analysis was performed with Student t test and analysis of variance. Incidence of concomitant USF and DRF was higher (P < .0002) in the operative group (64.6%) than in the nonoperative group (39.1%). Patients with USFs had worse mean (SD) pain score, 1.80 (2.43) versus 0.80 (1.55) (P = .0001), DASH score, 17.03 (18.94) versus 9.21 (14.06) (P = .001), and SF-36 score, 77.16 (17.69) versus 82.68 (16.10) (P = .022). In the operative group, patients with USFs had more pain and poorer DASH Functional scores than patients without USFs. Results were similar in the nonoperative group. There was no difference in healing time between intra-articular and extra-articular fractures or between presence and absence of USFs. Concomitant occurrence of USFs and DRFs-which is associated with worse pain scores and lower functioning compared with USFs without DRFs-should prompt clinicians to counsel patients about delayed recovery.
Surgical neck fractures are the most common type of proximal humerus fractures. Surgical neck fra... more Surgical neck fractures are the most common type of proximal humerus fractures. Surgical neck fractures occur in all age groups, affecting pediatric, young adult, and geriatric individuals. The majority of surgical neck of the proximal humerus fractures are nondisplaced or minimally displaced and do not require operative intervention. Displaced fractures can disrupt the function of the upper extremity, however, and often necessitate operative care. Standard radiographs should include an anteroposterior view taken in the scapular plane, a scapular "Y" lateral, and an axillary view. If the patient is in too much discomfort to obtain a standard axillary view, a Velpeau axillary can be obtained. Nondisplaced fractures, greater tuberosity fractures with less than 5-ram displacement, and surgical neck fractures with less than 1-cm displacement and 45 ° angulation should be treated by nonoperative means. The reduction maneuver involves longitudinal traction on the arm to disimpact the fracture. The arm is abducted approximately 70 °, and then a posterior force is applied to the shaft of the humerus to correct the apex anterior angulation. Slight external rotation of the shaft may be necessary. The fracture can then be impacted for increased stability. Displaced surgical neck fractures can be stabilized by a variety of techniques. Some of the commonly used techniques involve percutaneous pin fixation, suture techniques, antegrade and retrograde insertion intramedullary rods, a combination of Ender nails and suture techniques, plate and screw fixation, and external fixation. In this article, we will discuss the use of these techniques, the details of percutaneous pinning, and the technique of Ender nail and suture fixation. KEY WORDS: proximal humerus fracture, Ender nail, suture fixation, percutaneous pinning Fractures of the proximal humerus account for 4% to 5% of all fractures, 1-3 and may involve the anatomic neck, the greater and lesser tuberosities, and the surgical neck. Surgical neck fractures are the most common type of proximal humerus fractures. The surgical neck is the region of the proximal humerus that is proximal to the diaphysis but distal to the physeal scar. Surgical neck fractures occur in patients at any age. The majority of surgical neck of the proximal humerus fractures are nondisplaced or minimally displaced and do not require operative intervention. Displaced fractures can disrupt the function Of the upper extremity, however, and often require operative care. 4-6
The management of distal radius fractures has evolved over time from a largely nonoperative parad... more The management of distal radius fractures has evolved over time from a largely nonoperative paradigm to a more commonly performed operative procedures today. Surgical trends have similarly developed, with dorsal plating falling out of favor due to complications involving extensor tendon pathology as well as due to the ubiquity of the volar plate along with the advent of locking plate technology. However, with the improvement in design of newer generation dorsal plates, this technique should be used in the appropriate clinical situation, including dorsal comminution and angulation with concomitant carpal pathology. Outcome data supports dorsal plating and has been shown to be comparable to that of volar plating, with some unique advantages. As such, the technique of dorsal plating should have a role in surgical management of these injuries.
Purpose: In order to identify predictors for hand stiffness following distal radius fractures and... more Purpose: In order to identify predictors for hand stiffness following distal radius fractures and understand the consequences of this common clinical finding, we studied 260 patients. Our null hypothesis was that we would find no predictors of post injury hand stiffness. Methods: Baseline demographics and injury characteristics were obtained at distal radius fracture presentation. Treatment and healing was documented. Stiffness was defined as tip to palm distance greater than 1 cm for any one finger. Outcome parameters obtained at regular intervals included wrist and hand range of motion, radiographs, visual analog pain scales, and Disability of the Arm Shoulder and Hand (DASH) questionnaires. Results: Forty-nine of 260 patients (19%) patients were considered to be "stiff" by our criteria. Grip strength was weaker for stiff patients as well. Patient demographics were similar in both groups with the "stiff" cohort having a greater mean age, p = 0.05. There was no significant difference in stiffness seen in operative cases versus nonoperative cases. Injury ulnar variance was 3.1mm (SD = 3.5) in the "stiff" cohort and 1.8 (SD = 2.9) in the "non-stiff" cohort (p= 0.02). Functional disability as measured by the DASH differed (p = 0.001) between stiff and non-stiff patients for both 6 month and 1 year follow-up time points. Stiff patients were more likely than non-stiff patients to have lower grip strength at 12-month post fracture (p = 0.001). Conclusion: Older patients who present with significant ulnar variance at injury are more likely to experience hand stiffness at some time during their recovery. The development of hand stiffness is associated with poorer functional outcome than those who do not develop stiffness.
The association of radial nerve palsy and humeral shaft fracture is well known. Primary explorati... more The association of radial nerve palsy and humeral shaft fracture is well known. Primary exploration and fracture fixation is recommended for open fractures and vascular injury while expectant management remains the standard of care for closed injuries. In the absence of nerve recovery, exploration and reconstruction is recommended 3 to 5 months following injury. When direct repair or nerve grafting is unlikely to achieve a suitable outcome, nerve and tendon transfers are potential options for the restoration of wrist and finger extension.
Compartment syndrome of the extremity is a diagnosis that requires emergent intervention. It is c... more Compartment syndrome of the extremity is a diagnosis that requires emergent intervention. It is characterized as an elevation of tissue pressure resulting in impaired perfusion. Although commonly associated with fractures, there are a number of intrinsic and extrinsic causes. Early intervention can reduce the extent of permanent muscle and neurovascular damage, impairment, and the late sequela, specifically Volkmann ischemic contracture. The goal of surgical treatment is to restore tissue perfusion with emergent decompression/fasciotomy. Ensuring a complete release of all affected compartments is imperative to achieve a good clinical outcome and mitigate complications.
Journal of Bone and Joint Surgery, American Volume, 2021
Ultrasonography as a diagnostic and therapeutic tool has become a resource for musculoskeletal in... more Ultrasonography as a diagnostic and therapeutic tool has become a resource for musculoskeletal injuries. It can be a useful imaging modality for clinical correlation of physical examination findings as well as an aid for image-guided procedures. Understanding the settings in which it is a helpful adjunct will have implications on efficiency and cost utility. The objectives of this chapter are to provide a background of ultrasonography as a musculoskeletal imaging modality, provide clinical correlation for ultrasonographic findings for common upper extremity pathology, review the diagnostic efficacy of ultrasonography for image-guided procedures, and provide insight into the cost utility of ultrasonography guidance for therapeutic injections.
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Papers by Nader Paksima