Maximillian Soong

Chronic exertional compartment syndrome (CECS) is characterized by activity-induced pain, swelling, and decreased muscle function due to increased pressure and decreased circulation within a confined muscle compartment. Although well-known to occur in the leg, involvement of the hand has rarely been reported in the literature. We present a 44 year old male with CECS involving bilateral thenar and hypothenar compartments. Symptoms were reproduced on exam by driving screws into wood with a screwdriver. Elevated compartment pressures were confirmed with a hand-held digital device which employs a rigid needle that is readily directed to specific compartments. Selective releases of the thenar and hypothenar compartments were performed under local anesthesia and forearm tourniquet in the ambulatory surgery center. At 3-month follow-up, the patient reported full use of his right hand, including woodworking, with excellent relief of symptoms. At 5 months postoperatively, he underwent identi...

To describe current evaluation and treatment of metacarpal fractures in athletes RECENT FINDINGS: Biomechanical and clinical studies involving lower-profile, locking, shorter length, and double-row or separate-dual plate configurations, as well as intramedullary screw fixation, have demonstrated the potential benefits of internal fixation with promising results. Treatment should be customized to the specific athlete and injury, and is often successful without surgery, or with percutaneous pin fixation. Internal fixation of metacarpal fractures has improved with new hardware and new techniques, and may expedite return to play, although further clinical studies are needed.

We investigated whether written guidelines for surgeons and educational handouts for patients regarding safe and effective opioid use after hand surgery could reduce prescription sizes while achieving high patient satisfaction and a low refill rate. All patients undergoing isolated carpal tunnel release or distal radius volar locked plating in a hand surgery group practice during a 6-month period were prospectively enrolled. Surgeons prescribed analgesics at their own discretion based on written guidelines. Patients received an educational handout regarding safe opioid use and disposal, a diary to record daily pain visual analog scale score and consumption of opioid and over-the-counter (OTC) analgesics, and a pain catastrophizing scale questionnaire. Collected data were compared with a retrospective cohort of the same surgeons, procedures, and period 1 year earlier. In the carpal tunnel release group (121 patients), average prescription size was 10 opioid pills, compared with 22 in the prior year. Average consumption was 3 opioid pills, supplemented with 11 OTC pills. In the volar locked plating group (24 patients), average prescription size was 25 opioid pills, compared with 39 in the prior year. Average consumption was 16 opioid pills, supplemented with 20 OTC pills. Patient satisfaction was comparably high in both groups. Eight patients required opioid refills overall. Patients with pain catastrophizing scale greater than 10 used more than twice as many opioid pills. Of 109 patients with leftover opioids, 10 reported proper disposal. Written guidelines and educational handouts significantly reduced the number of prescribed opioid pills by 35% to 55% while achieving high patient satisfaction and a low refill rate. We recommend 5 to 10 opioid pills for carpal tunnel release and 20 to 30 for distal radius volar plating. Pain catastrophizing is associated with greater opioid consumption and may help target patients for additional support. Potential for opioid abuse and diversion may persist despite these interventions. Therapeutic II.

The literature suggests that radiographs may be unnecessary in the initial evaluation of lateral epicondylitis because treatment is rarely altered as a result of the radiographic findings. The most commonly reported radiographic finding is calcification at the lateral epicondyle. Our goal was to perform a quantitative and qualitative analysis of this finding to determine its importance and possible relationship with various clinical factors and patient-reported measures. All patients diagnosed with lateral epicondylitis by a single surgeon during a 5-year period were retrospectively reviewed. Age, sex, laterality, hand dominance, pain visual analog scale, duration of symptoms, Quick-Disability of the Arm, Shoulder, and Hand questionnaire score, and history of steroid injection were recorded. Calcifications on standard elbow radiographs, acquired digitally and viewed at 200% magnification on a 24-inch monitor, were characterized by size and relationship with the lateral epicondyle. W...

ABSTRACT To examine the results of radiofrequency ablation (RFA) of osteoid osteoma in the upper extremity. Twenty-nine patients with a clinical and radiographic diagnosis of an upper-extremity osteoid osteoma were referred for treatment between 1990 and 2003. All had computed tomography-guided percutaneous RFA performed by the senior investigator. Records were reviewed for patient age and gender, lesion size and location, prior treatment, and pathology results. Outcomes were determined by questionnaire via mail or telephone. Complete success was defined as complete resolution of pain without further treatment. Partial success was defined as occasional pain with activities that did not require another procedure. Failure was defined as recurrence, no change in symptoms, and/or the need for another procedure. Follow-up data were available for 25 patients at a minimum of 1 year. Lesion locations included 17 humerus, 5 scapula, 2 radius, 1 ulna. Results for 19 patients were rated completely successful, 4 were rated partially successful, and 2 were rated failures. Two patients whose results were not completely successful received decreased RFA temperature or duration because of the proximity of a neurovascular bundle. There were no complications. Outcomes did not correlate with any patient or tumor characteristics. Radiofrequency ablation is a safe and effective treatment for most osteoid osteomas in the shoulder, arm, and forearm. Lesions that do not allow a safe distance between the electrode and a major neurovascular structure may require surgical excision. This may be of particular importance in lesions of the hand and carpus. Therapeutic, Level IV.

Prior to volar locked plating and early motion protocols, ligamentous injuries incidentally associated with distal radius fractures may have been indirectly treated with immobilization. Our goal was to determine the prevalence of scapholunate instability in our population, while identifying those who may have had progression of instability. We retrospectively reviewed 221 distal radius fractures treated with a volar locking plate during a 6-year period. Average patient age was 59 years. Standard posteroanterior and lateral radiographs from the first and last postoperative visits were analyzed for scapholunate instability, using the criteria of scapholunate gap ≥3 mm and scapholunate angle ≥60°. Six patients (3 %) met neither or only one criterion for instability at the first postoperative visit and did not have ligament repair and then went on to meet both criteria at the last postoperative visit after an early motion protocol. Seven patients (3 %) met both criteria at the first and last postoperative visits and did not have ligament repair. Five patients (2 %) underwent primary scapholunate ligament repair at the time of distal radius fixation. In our representative population, scapholunate instability was uncommon, either from initial injury or possible progression of occult ligament injury, despite early motion without operative treatment of the ligament. Thus, we did not find strong evidence for routinely delaying motion or pursuing further workup. When early radiographs clearly demonstrate acute scapholunate instability, more aggressive treatment may be appropriate for selected patients.

Large segmental bone defects of the phalanges reportedly have been treated with free vascularized grafts from the hand, foot, or knee, or with nonvascularized grafts from the iliac crest. A nonvascularized structural corticocancellous graft from a local site would be advantageous. The olecranon has been used as a source of both cancellous and corticocancellous graft. The authors describe a unique case of the use of nonvascularized corticocancellous olecranon bone graft for structural purposes in a mutilating thumb injury. The patient injured the left thumb with a miter saw, resulting in a large degloving wound over a severely comminuted fracture of the proximal phalanx, with segmental bone loss between a base fragment and displaced condylar fragments. Provisional pin fixation was performed at the time of initial emergent irrigation and debridement, along with repairs of the extensor pollicis longus, radial digital nerve, and dorsal digital nerve. This was followed 3 weeks later by non-vascularized corticocancellous bone grafting from the olecranon to the proximal phalanx under regional anesthesia. The thumb was mobilized at 11 weeks, and solid union was radiographically confirmed at 6 months. The patient achieved moderate active range of motion and was able to return to work as a physical therapist. The elbow healed uneventfully and without pain or fracture at the donor site. This case shows that robust structural bone graft for the phalanges may be obtained from the nearby olecranon, under regional anesthesia, without microsurgery, and with potential advantages over the iliac crest.

Neurofibromatosis is well known to orthopedic surgeons for causing spinal curvature and tibial bowing. However, skeletal abnormalities of the hand related to this condition have rarely been reported. We present a unique case of neurofibromatosis causing bony changes possibly contributing to carpometacarpal instability. A 29-year-old man with neurofibromatosis type 1 presented with right hand pain after striking a wall. Swelling was difficult to assess as the hand was deformed due to a large plexiform neurofibroma over the ulnar side of the hand. Radiographs showed dorsal dislocation of the fourth and fifth carpometacarpal joints. Erosions, cystic changes, and rounding of the articulations were noted. Closed reduction and splinting were performed in the emergency room, but immediate redislocation occurred. Because of the inherent instability demonstrated clinically and radiographically, fixation was recommended; however, an open procedure was avoided to avoid dissecting through the neurofibroma. Percutaneous pin fixation was performed 1 week after injury, taking care to avoid the nerve lesion. Pins were removed at 6 weeks, and the patient was placed in a cast for an additional 4 weeks. At 6 months after injury, the patient was asymptomatic and had returned to prior level of function. Radiographs showed stable reduction.

Acute compartment syndrome (ACS) is a well-described surgical emergency that requires an immediate diagnosis and emergent operative intervention. Failure to either make the diagnosis or to implement the appropriate treatment quickly can result in severe long-term morbidity. The purpose of this article is to document evidence that penetrating trauma which results in arterial injury may cause acute forearm compartment syndrome. As a result, this mechanism should alert surgeons to the possibility of acute compartment syndrome secondary to arterial injury. A retrospective review of all penetrating trauma patients treated at our Level 1 Trauma Center was performed within 2001 and 2005. Patients who sustained penetrating injuries to the forearm were reviewed in detail and all patients diagnosed with acute forearm compartment syndrome in this setting were included in this article. Five cases of ACS of the forearm secondary to a mechanism rarely described in the surgical literature were documented over five years. All cases in this series were the result of a named forearm arterial injury sustained by penetrating trauma. Every patient in this article was taken emergently to the operating room for a fasciotomy following diagnosis. This article establishes the incidence of a specific mechanism of ACS in our penetrating trauma population. As a result of these findings, a thorough evaluation of the forearm vasculature and a careful search for arterial injury is recommended at the time of fasciotomy. Securing a rapid diagnosis and executing early definitive management will result in fewer devastating long-term outcomes.

The ideal method of irrigation and débridement for severe extremity wounds has yet to be determined. This report demonstrates the use of hydrosurgical débridement in the treatment of highly contaminated acute forearm fractures in a 22-year-old man ejected during a motor vehicle crash in a farm area. The result was rapid, selective, and effective débridement of deeply embedded material, which allowed for expeditious reconstruction with internal fixation, tendon transfers, and groin flap coverage while avoiding infection and injury to vital structures. The technique is described in detail and the current literature is reviewed.

To describe the clinical features and outcome of a series of patients with complete motor and sensory ulnar nerve palsy associated with a fracture of the distal radius. Retrospective case series. Level 1 trauma center. Five adults with acute complete motor and sensory ulnar nerve palsy associated with fracture of the distal radius were treated during a 2 year period. There were 3 men and 2 women, with an average age of 42 years (range, 33 to 56 years). All 5 distal radius fractures were high energy and widely displaced. Three patients had an associated ulna fracture (2 styloid, 1 styloid and distal diaphysis), and 1 had a complete triangular fibrocartilage complex (TFCC) avulsion from the distal ulna (associated with an open wound). Two patients had open fractures. Open reduction and internal fixation of the distal radius fracture in 4 patients and external fixation in 1 patient. Three patients had exploration and release of the ulnar nerve because it was associated with an acute carpal tunnel syndrome. Recovery of ulnar nerve function. At an average follow-up of 17 months, 4 patients had complete or near-complete recovery of ulnar nerve function. One patient had moderate motor and mild sensory dysfunction. Acute ulnar nerve palsy may occur in association with high-energy, widely displaced fractures of the distal radius. These are usually neurapraxic injuries that recover to normal or near-normal strength and sensation. We recommend exploration and release of a complete ulnar nerve palsy associated with a fracture of the distal radius fracture when there is an open wound or an acute carpal tunnel syndrome, and observation without exploration otherwise.

Flexor tendon injury is a recognized complication of volar plate fixation of distal radial fractures. A suspected contributing factor is implant prominence at the watershed line, where the flexor tendons lie closest to the plate. Two parallel series of patients who underwent volar locked plating of distal radial fractures from 2005 to 2008 and with at least six months of follow-up were retrospectively reviewed. Group 1 included seventy-three distal radial fractures that were treated by three orthopaedic hand surgeons with use of a single plate design at one institution, and Group 2 included ninety-five distal radial fractures that were treated by four orthopaedic hand surgeons with use of a different plate design at another institution. On the postoperative lateral radiographs, a line was drawn tangential to the most volar extent of the volar rim, parallel to the volar cortical bone of the radial shaft. Plates that did not extend volar to this line were recorded as Grade 0. Plates volar to the line, but proximal to the volar rim, were recorded as Grade 1. Plates directly on or distal to the volar rim were recorded as Grade 2. In Group 1, the average duration of follow-up was thirteen months (range, six to forty-nine months). Three cases of flexor tendon rupture were identified among seventy-three plated radii (prevalence, 4%). Grade-2 plate prominence was found in two of the three cases with rupture and in forty-six cases (63%) overall. In Group 2, the average duration of follow-up was fifteen months (range, six to fifty-six months). There were no cases of flexor tendon rupture and no plates with Grade-2 prominence among ninety-five plated radii. Flexor tendon rupture after volar plating of the distal part of the radius is an infrequent but serious complication. The plate used in Group 1 is prominent at the watershed line of the distal part of the radius, which may increase the risk of tendon injury. We found no ruptures in Group 2, perhaps as a result of the lower profile of the plate. Further studies are needed before recommending one plate over another. Regardless of plate selection, surgeons should avoid implant prominence in this area.

Hip dislocation has long been one of the major complications after total hip arthroplasty (THA). From 1980 to 1994, we performed 2728 THAs (including primary and revision cases). There were 97 hips (3. 6%) with the complication of dislocation, 62 of which were followed up for at least 2 years (mean 5.3 years; range 2-12 years). Single dislocations occurred in 40% and recurrent dislocations in 60%. More than half of the dislocations (58%) occurred within 3 months after the index operation. The dislocation rate was not related to sex, age, previous revision surgery, or types of prosthesis, but was related to a smaller size of the femoral head. The rate of recurrent dislocation was not related to a history of previous surgery, but was related to a smaller femoral head, late onset of dislocation (> 3 months), soft-tissue imbalance, and cup malposition in both anteversion and inclination. If the size of the femoral head was 26 mm or smaller, a posterior approach was not recommended. Closed reduction followed by 1-2 weeks of skin traction was the treatment of choice. The success rate for the first attempt at closed reduction for the treatment of dislocation was 41%; the success rate decreased gradually with the number of attempts. For the recurrent dislocation group, bracing for 4-6 weeks with training was recommended for the postural type and bracing for 3 months with muscle training for the soft-tissue imbalance type. Only 15% of the dislocated hips needed re-operation, and most of the patients resolved the problem after being informed and undergoing muscle training.