Closed Transverse Pinning for Reduction and Fixation of Metatarsal Neck Fractures: Surgical Technique

Most metatarsal neck fractures can be successfully treated non-operatively in a cast boot. Displaced metatarsal neck fractures tend to be less stable and have a propensity for the distal fragment to angulate, secondary to the strong flexor tendons, which often forces the distal fracture fragment in a plantar direction and leads to relative metatarsal shortening. Most literature is focussed on antegrade fixation of metatarsal neck fractures using pre-bent K wires or thin elastic nails. Apart from the technical challenges, this technique is limited when bones are osteoporotic as the pre-bent distal end of the K-wire may penetrate the plantar cortex of the proximal metatarsal and prevent the wire from entering the medullary canal of the metatarsal and advancing to the fracture site. Furthermore, when the medullary canal is narrow especially in Asian patients, it may be difficult to pass a bent K-wire through the isthmus of the metatarsal shaft. We describe an innovative technique of closed transverse wiring of the metatarsal head necks that has a distinct advantage in Asian population with osteoporotic bones. With percutaneous manipulation using digital pressure, closed reduction of fracture fragments of the most displaced fracture is done under fluoroscopic guidance to achieve a satisfactory alignment followed by closed transverse wiring of the metatarsal heads. With this procedure, adjacent fractures remain stable within an acceptable range because of intermetatarsal ligaments connected to the adjacent intact head. Our technique has a relatively short operating time and allows for early motion of the metatarso-phalangeal joint. This is especially useful for those with osteoporosis, narrow canal, soft tissue compromise, intra-operative failure of ante-grade pinning and in scenarios of limited surgical equipment/expertise.     

A Novel Telemedicine System for Care of Statewide Hand Trauma

Background: Telemedicine is an evolving tool to increase patients’ access to subspecialty care. Since 2014, Arkansas has been utilizing telemedicine in the evaluation of patients with hand injuries. The purpose of this study is to assess the effect of this novel telemedicine system for the management of hand trauma on patient transfer. Methods: We reviewed data from the first year of the telemedicine program (2014) and compared it to data from the year prior (2013). Data collection from both years included number of hand consults and need for transfer. From the 2014 data, we also recorded the use of telemedicine, type of transfer, distance of transfer, and time to disposition. Results: During 2013 (pre-telemedicine), there were 263 hand traumas identified. In all, 191 (73%) injuries required transfer to a higher level of care, while 72 (23%) were managed locally. In the first year of the telemedicine program (2014), a total of 331 hand injuries were identified. A total of 298 (90%) resulted in telemedicine consultation with 65% (195) utilizing video encounters. After telemedicine consultation, local management was recommended for 164 injuries (55%) while transfer was recommended for 134 (45%). Using telemedicine, there was a significant decrease in the percentage of transfer for hand injuries (P < .001). Conclusions: The telemedicine program was well utilized and provided patients throughout the state with continuous access to fellowship trained hand surgeons including regions where hand subspecialty care is not available. The program resulted in a significant decrease in the number of hospital transfers for the management of acute hand trauma.     

Predictors of Hand Function Following Digit Replantation: Quantitative Review and Meta-Analysis

Background: Digit replantation affords the opportunity to restore hand function following amputation. To date, however, few studies have evaluated functional outcomes following replantation. Therefore, it was the objective of this study to perform a meta-analysis to better characterize the predictors of hand function. Methods: A literature search was performed using the PubMed database to identify studies that focused on digit amputation/replantation and functional outcomes. Studies were evaluated for patient- and injury-related factors and their respective effects on clinical outcomes of sensation, grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Statistical analysis was conducted across the pooled data set to identify significant trends. Results: Twenty-eight studies representing 618 replanted digits were included in this study. We found the average grip strength was 78.7% (relative to contralateral), the average 2-point discrimination (2PD) was 7.8 mm, and the average DASH score was 12.81. After conducting statistical analysis, we found patients with more proximal injuries had lower grip strength scores (P < .05). We found 2PD scores were influenced by age, mechanism of injury, and amputation level (P < .05). Finally, we found DASH scores after replantation were predicted by mechanism of injury and level of amputation (P < .05). The following variables did not influence outcomes: gender, tobacco use, ischemia time, and digit number. Conclusions: Digit replant does not restore premorbid hand function but does result in adequate hand function. Expected functional outcomes following replant should be considered in the decision-making process. These data can help risk-stratify patients, guide postreplant expectations, and influence the decision for replantation.     

Technique for Rapid Hand Transplant Donor Procurement Through the Elbow

Background: Hand and distal forearm allotransplantation has advanced over the last 20 years from experimental to a viable treatment option for bilateral upper extremity amputation. Despite widespread growth of this field, there are few technical reports that elaborate the details of donor arm procurement. This article details a technique for rapid donor procurement through the elbow for mid to distal forearm-level hand allograft procurement. Methods: Nine arm procurements were performed on deceased tissue-only donors provided by the local organ procurement organization, including two bilateral and five unilateral cases. Technique highlights include using a fishmouth incision through the lateral and medical epicondyles, identification of the neurovascular structures, and disarticulating the elbow joint. Results: Procuring through the elbow provides straightforward anatomy, bypasses the need to cut through bone, and allows tissue allotransplantation teams to achieve procurement, flushing, and packaging within 20 minutes. Conclusions: Procurement through the elbow is a simple procedure that streamlines the process for multi-organ donors by minimizing the time needed for hand allograft procurement. Team coordination and surgical rehearsals are essential for successful hand and upper extremity procurement and allotransplantation.     

Cranial floor fracture: A growing orbital roof fracture with encephalocele – Case Report

Orbital roof fractures are among the rarest of craniofacial fractures. The mechanism of injury is typically a high-impact blunt force vector directly to the orbit or forehead. Most patients are males between 20 and 40 years old, involved in motor vehicle accidents. Although most orbital roof fractures are managed conservatively, there is a significant risk of ophthalmologic and neurologic complications. Detailed craniofacial examination and high-resolution CT imaging is necessary for diagnosis. A multidisciplinary team approach is required for these challenging fractures.     

New technique for posterior intra-articular arthrodesis using a single-block graft in cases of atlantoaxial instability

A new method of posterior C1-2 arthrodesis, derived from the W. V. Cone and G. Bertrand, technique (Montreal, 1970) is described with two modifications: (1) the exact measurements of the ideal graft are determined preoperatively, using CT and a sterilized pasteboard horseshoe-shaped model; (2) in the sitting postion, single occipital block graft was cut out microsurgically, using the preoperative model. After decortication of the graft, posterior arches of C1 and 2, and microsurgical excision of the cartilage of the C1-2 lateral joints, the graft was imbedded into the entire C1-2 space, fixed, and tightened using a braid of nylacap yarn. A case report of rotatory luxation and associated atlantoaxial instability in a 10-year-old girl illustrates the excellent functional results of this technique.Presented at the XVII Annual Meeting of the International Society for Pediatric Neurosurgery, Bombay 1989     

Detection of traumatic myocardial injury by means of simultaneous T1-201/Tc-99m pyrophosphate tomography--report of three cases

Trauma to the chest can result in cardiac damage, which maybe missed by clinical examination because of associated injuries.Routinely performed non-invasive tests may also be non-diagnostic.Tc-99m pyrophos-phate (PPi) tomography, in this study combinedwith T1-201, is a promising addition to non-invasive evaluation.In three patients with cardiac injury, this technique successfullydetected and localized myocardial necrosis.     

Diagnosis and treatment of bronchial rupture from blunt thoracic trauma

目的　探讨外伤性支气管断裂的诊断与治疗。方法　回顾性分析 196 9年 6月— 1999年 6月我院收治的 31例外伤性支气管断裂的患者 ,全部行胸部X线摄片、支气管断层、支气管镜检查。并对其外科治疗和并发症进行探讨。结果　通过支气管断层、支气管镜检查全部得到明确诊断。 2 6例施行端端吻合术 ,4例施行全肺切除术 ,1例用带血管蒂的肋间肌、肋骨瓣修补破裂成功。 1例术后死于呼吸困难综合症 ,其余 30例效果满意。本给 81% (2 5 31)为延迟诊断与治疗。典型临床表现有 :皮下气肿、呼吸困难、伤后昏迷间期。X线表现 :纵隔气肿、气胸、萎陷肺下垂症、肺的阴影增宽。结论　支气管镜是最实用、最准确的诊断与治疗方法。术中使用支气管镜可较容易地找到支气管破裂处。术后肺功能恢复良好