Faculty Bibliography

Fracture-dislocation of the elbow is a signiicant injury with mixed outcomes. The purpose of the study was to evaluate patient perceived outcome following surgical stabilization of these complex injuries. Twenty-nine available patients (76%) from 37 identiied with 'terrible triad' injury patterns, in- cluding ulnohumeral dislocation, radial head fracture, and coronoid fracture, were available for a minimum 1-year follow-up (mean, 27 months). All patients were evaluated by their treating physician. Radiographic outcome was evaluated at latest follow-up. Functional outcome was based upon DASH, Mayo elbow performance, and Broberg-Mor- rey scores. Complications were recorded. Results included that the average lexion-extension arc of elbow motion was 109 degrees +/- 27 degrees , and the average pronation-supination arc was 128 degrees +/- 44 degrees . Grip strength averaged 72% of the contralateral extremity. The Mayo score was a mean of 81 (range, 45 to 100), the Broberg-Morrey mean was 77 (range, 33 to 100) The mean DASH was 28 (range, 0 to 72). When compared to the age-based normal values, the mean patient's DASH score was 1.4 SD worse than an average person of the same age None of the injury characteristics, patient demographics or treatment modalities was signiicantly associated with a poor outcome at the 95% conidence interval. Conclusions are that the results with terrible triad injuries are often unsatisfactory, but surgical management with the use of a systematic approach may be beneicial. Our approach led to the restoration of elbow joint stability in all patients

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 purpose of this study was to analyze the relative bio- mechanical stability of three types of internal ixation with cancellous bone graft in a cadaveric, scaphoid nonunion model. A scaphoid nonunion model was created by remov- ing a volar wedge of bone from the waist of the scaphoid in 18 fresh frozen human cadavers. Cancellous sawbone graft was inserted into the osteotomy site and three groups of six cadavers each were then internally ixed with a pair of parallel 0.045-inch K-wires, Mini-Acutrak screws, or Standard Acutrak screws, respectively for each group. The potted specimens were tested using an Instron(R) tensile testing machine by applying force to the distal pole of the scaphoid. The load and stiffness were calculated at 2 mm and 4 mm of displacement. Results showed that both the Mini-Acutrak screw and the Standard Acutrak screw were statistically stronger and stiffer at 2 mm displacement than the pair of parallel 0.045-inch K-wires. No statistically sig- niicant difference between the Standard and Mini-Acutrak screws was noted at 2 mm displacement. At higher loads (4 mm displacement), the Standard Acutrak became statisti- cally stronger and stiffer than the Mini-Acutrak screw. It was concluded that the Standard Acutrak screw followed by the Mini-Acutrak screw may be a better option than a pair of parallel 0.045-inch K-wires when treating scaphoid nonunions. The screws have increased strength of ixation and stiffness when compared to K-wires. Also, unlike the K wires, the Acutrak screws enhance fracture healing by achieving interfragmentary compression. Even in a cancel- lous bone graft model, interfragmentary compression was achieved and our concern that the bone graft would 'spit out' was allayed

BACKGROUND: Pin-track infection remains one of the most troublesome complications of external fixation, in some cases compromising otherwise successful fracture treatment. METHODS: One hundred and eighteen patients (120 wrists) who had been managed with the placement of an external fixation device for the treatment of a displaced, unstable, distal radial fracture were randomized into one of three treatment groups: (1) weekly dry dressing changes without pin-site care; (2) daily pin-site care with a solution of one-half normal saline solution and one-half hydrogen peroxide; and (3) treatment with the placement of chlorhexidine-impregnated discs (Biopatch) around the pins, with weekly changes of the discs by the treating surgeon. The patients were followed at weekly intervals until the external fixator was removed. Radiographs were made biweekly. The patients were evaluated with regard to (1) erythema, (2) cellulitis, (3) drainage, (4) clinical or radiographic evidence of pin-loosening, (5) the need for antibiotics, and (6) the need for pin removal before fracture-healing due to infection. Differences in complication rates among the three groups, with adjustment for patient age, gender, and the performance of an associated open procedure, were evaluated. RESULTS: The average age of the patients was fifty-four years. Forty-seven wrists had an open procedure (either bone-grafting or open reduction and internal fixation) in addition to treatment with the external fixator. The fixators remained in place for an average of 5.9 weeks. Twenty-three patients (19%) had a complication related to the pin track, with twelve of these patients requiring oral antibiotics for the treatment of a pin-track infection. There were no significant differences among the three groups with regard to the prevalence of pin-site complications. The age of the patient was found to be significantly associated with an increased risk of postoperative pin-track complications (p = 0.04). CONCLUSIONS: We found a high rate of local wound complications around external fixation pin sites; however, most complications were minor and could be observed or treated with oral antibiotics. The prevalence of these complications was not decreased in association with the use of hydrogen peroxide wound care or chlorhexidine-impregnated dressings. On the basis of these results, we do not recommend additional wound care beyond the use of dry, sterile dressings for pin-track care after external fixation for the treatment of distal radial fractures

Peripheral nerve injuries are commonly seen as a result of domestic, industrial, or military trauma. Sharp objects usually cause these nerve injuries. When assessing these injuries, it is important to evaluate each nerves' motor and sensory function. One must be cognizant of associated injuries such as fractures, vascular damage, and musculotendinous lacerations. The time since the injury, level of injury, and age of the patient are important prognosticators impacting the return of function. Intraoperatively, one must assess the vascularity of the soft tissue bed and the nerve itself, the nerve gap, conduction, and the topography of the fascicles to insure proper orientation. Application of the principles of nerve repair (magnification, minimal tension, meticulous soft tissue handling, experienced surgeon and staff) can enhance the chances for a successful result. Additionally, to maximize functional recovery following peripheral nerve repair, a carefully planned program of postoperative occupational therapy and rehabilitation must be instituted

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