Faculty Bibliography

Cold exposure injuries comprise nonfreezing injuries that include chilblain (aka pernio) and trench, or immersion, foot, as well as freezing injuries that affect core body tissues resulting in hypothermia of peripheral tissues, causing frostnip or frostbite. Frostbite, the most serious peripheral injury, results in tissue necrosis from direct cellular damage and indirect damage secondary to vasospasm and arterial thromboses. The risk of frostbite is influenced by host factors, particularly alcohol use and smoking, and environmental factors, including ambient temperature, duration of exposure, altitude, and wind speed. Rewarming for frostbite should not begin until definitive medical care can be provided to avoid repeated freeze-thaw cycles, as these cause additional tissue necrosis. Rewarming should be rapid and for an affected limb should be performed by submersion in warm water at 104 degrees to 107.6 degrees F (40 degrees to 42 degrees C) for 15 to 30 minutes. Debridement of necrotic tissues is generally delayed until there is a clear demarcation from viable tissues, a process that usually takes from 1 to 3 months from the time of initial exposure. Immediate escharotomy and/or fasciotomy is necessary when circulation is compromised. In addition to the acute injury, frostbite is associated with late sequelae that include altered vasomotor function, neuropathies, joint articular cartilage changes, and, in children, growth defects caused by epiphyseal plate damage

Clavicle fractures are common skeletal injuries that are typically managed nonoperatively, which results in a high rate of fracture union with few or no long-term sequelae. Type II distal clavicle fractures are an exception, with reported rates of nonunion ranging from 22% to 44%. This high rate of nonunion has led to controversy regarding the appropriate treatment of type II injuries. The following case report describes a type IIB distal clavicle fracture, in which nonoperative management was complicated by the breakdown of skin over the fracture site and the subsequent development of infection. This is a rare complication of conservative management. Thorough operative debridement, fracture stabilization via external fixation, and identification of the causative organism allowed for successful outcome in the management of this complex presentation

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

The role of medical, social, and functional covariates on mortality after hip fracture was examined over a 16-year period. A total of 1109 patients with hip fractures were included in a prospective database. The inclusion criteria were patients who were age 65 years or older, ambulatory prior to fracture, cognitively intact, living in their own home at the time of the fracture, and had sustained a nonpathological femoral neck or intertrochanteric chip fracture. Data were analyzed using a Cox proportional hazards model. Mortality was compared with a standardized population, and standardized mortality ratios were calculated for 1, 2, 3, 5, and 10 years,respectively. The 1-, 2-, 5- and 10-year mortality rates were 11.9%, 18.5%, 41.2%, and 75.3%, respectively.The predictors of mortality were advanced age, male gender, high American Society of Anesthesiologists (ASA)classification, the presence of a major postoperative complication, a history of cancer, chronic obstructive pulmonary disorder, a history of congestive heart failure,ambulating with an assistive device, or being a household ambulator prior to hip fracture. The increased mortality risk was highest during the first year after hip fracture and returned to the risk of the standard population 3 years postoperatively. Males who are 65 to 84 years had the highest mortality risk

Complete anaesthesia in the cutaneous distribution of the ulnar nerve following submuscular anterior transposition of the ulnar nerve has not been previously reported. We postulate vascular insult as the etiology of this condition and suggest there may be clinical importance to preserving the ulnar nerve blood supply during submuscular anterior transposition

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group

Isolated fractures of the trapezoid bone have been rarely reported in the literature, the mechanism of injury being an axial or bending load transmitted through the second metacarpal. We report a case of an isolated, nondisplaced trapezoid fracture that was sustained by direct trauma and subsequently treated successfully in a short-arm cast. Diagnostic and treatment strategies for isolated fractures of the trapezoid bone are reviewed as well as the results of operative and nonoperative treatment

BACKGROUND: Several previous studies have described reconstructive methods for the treatment of an injury to the ulnar collateral ligament of the thumb. However, there are few biomechanical studies to date to analyze the strength of the surgical reconstruction. PURPOSE: To evaluate 2 reconstruction techniques with use of a cadaveric model: (1) reconstruction with the use of a free tendon graft placed in a figure-of-8 fashion through drill holes in the metacarpal and proximal phalanx of the thumb, and (2) reconstruction with the use of the Bio-Tenodesis Screw System. STUDY DESIGN: Controlled laboratory study. METHODS: Eight matched pairs of cadaveric specimens underwent removal of the proper and accessory ulnar collateral ligaments. One of the 2 reconstruction methods was performed, and specimens were mounted on a materials-testing machine. The specimens were subjected to valgus stress to failure at 30 degrees of flexion. Failure was defined as valgus laxity of 30 degrees at the metacarpophalangeal joint. RESULTS: The peak load to failure was 23.5 +/- 11.4 N for the figure-of-8 reconstruction and 24.3 +/- 12.3 N for the reconstruction using the Bio-Tenodesis Screw System. Comparing the 2 groups, there was no statistically significant difference in peak loads to failure (P = .88). CONCLUSION: There was no statistically significant difference between the peak loads to failure of the 2 reconstructions. CLINICAL RELEVANCE: The Bio-Tenodesis Screw System may provide another viable option for surgical reconstruction of the ulnar collateral ligament of the thumb