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Brachial Plexus Blockade Causes Subclinical Neuropathy: A Prospective Observational Study

Perretta, Donato J; Gotlin, Matthew; Brock, Kenneth; Paksima, Nader; Gottschalk, Michael B; Cuff, Germaine; Rettig, Michael; Atchabahian, Arthur
Background: The objective of this study is to determine subclinical changes in hand sensation after brachial plexus blocks used for hand surgery procedures. We used Semmes-Weinstein monofilament testing to detect these changes. We hypothesized that patients undergoing brachial plexus nerve blocks would have postoperative subclinical neuropathy detected by monofilament testing when compared with controls. Methods: In total, 115 hand surgery adult patients were prospectively enrolled in this study. All patients undergoing nerve-related procedures were excluded as well as any patients with preoperative clinically apparent nerve deficits. Eighty-four patients underwent brachial plexus blockade preoperatively, and 31 patients underwent general anesthesia (GA). Semmes-Weinstein monofilament testing of the hand was performed preoperatively on both the operative and nonoperative extremities and postoperatively at a mean of 11 days on both hands. Preoperative and postoperative monofilament testing scores were compared between the block hand and the nonoperated hand of the same patient, as well as between the block hands and the GA-operated hands. Results: There were no recorded clinically relevant neurologic complications in the block group or GA group. A statistically significant decrease in sensation in postoperative testing in the operated block hand compared with the nonoperated hand was noted. When comparing the operated block hand with the operated GA hand, there was a decrease in postoperative sensation in the operated block hand that did not reach statistical significance. Conclusions: Brachial plexus blockade causes subtle subclinical decreases in sensibility at short-term follow-up, without any clinically relevant manifestations.
PMID: 28082843
ISSN: 1558-9447
CID: 2412812

Bennett Fractures A Review of Management

Guss, Michael S; Kaye, David; Rettig, Michael
A Bennett fracture is a common injury that involves an intra-articular fracture at the base of the first metacarpal. This fracture typically results in a dorsally and radially displaced metacarpal shaft relative to the well-anchored volar ulnar fragment. Most Bennett fractures are treated with operative fixation, including closed reduction and percutaneous fixation, open reduction and internal fixation, or arthroscopically assisted fixation. However, the optimal surgical approach is controversial. There is a paucity of literature comparing the outcomes of the various treatments, leaving the surgeon without a clear treatment algorithm. Moreover, there is no consensus on acceptable reduction parameters, including articular gap or step-off, with some series stating that up to 2 mm of displacement is acceptable.
PMID: 27620542
ISSN: 2328-5273
CID: 2257832

Acute Scapholunate Ligament Instability

Guss, Michael S; Bronson, Wesley H; Rettig, Michael E
PMID: 26143964
ISSN: 1531-6564
CID: 1662522

Galeazzi fracture with volar dislocation of the distal radioulnar joint

Kim, Suezie; Ward, James P; Rettig, Michael E
Galeazzi fracture dislocations are fractures of the distal one-third of the radial diaphysis with traumatic disruption of the distal radioulnar joint (DRUJ). This injury results in subluxation or dislocation of the ulnar head. We present a case of a Galeazzi fracture with a volar dislocation of the DRUJ. Open reduction of the DRUJ with Kirschner wire fixation in pronation was necessary to reduce the joint and maintain anatomic alignment. Repair of the triangular fibrocartilage complex was also necessary to maintain stability of the DRUJ.
PMID: 23431520
ISSN: 1078-4519
CID: 932342

Extensor indicis proprius and extensor digitorum communis rupture after volar locked plating of the distal radius--a case report

Ward, James P; Kim, L T Suezie; Rettig, Michael E
Distal radius fractures are among the most commonly en-countered fractures in the extremities. Volar plating of distal radius fracture has gained popularity in recent years with the introduction of the locked plating system. Complications of volar plating include extensor and flexor tendon rupture. Here we present a case report of an extensor indicis proprius and extensor digitorum communis to index finger tendon rupture after open reduction and internal fixation of distal radius fracture with locked plate.
PMID: 23267455
ISSN: 1936-9719
CID: 216092

Avulsion injuries of the flexor digitorum profundus tendon

Ruchelsman, David E; Christoforou, Dimitrios; Wasserman, Bradley; Lee, Steve K; Rettig, Michael E
Avulsions of the flexor digitorum profundus tendon may involve tendon retraction into the palm and fractures of the distal phalanx. Although various repair techniques have been described, none has emerged as superior to others. Review of the literature does provide evidence-based premises for treatment: multi-strand repairs perform better, gapping may be seen with pullout suture-dorsal button repairs, and failure because of bone pullout remains a concern with suture anchor methods. Clinical prognostic factors include the extent of proximal tendon retraction, chronicity of the avulsion, and the presence and size of associated osseous fragments. Patients must be counseled appropriately regarding anticipated outcomes, the importance of postoperative rehabilitation, and potential complications. Treatment alternatives for the chronic avulsion injury remain patient-specific and include nonsurgical management, distal interphalangeal joint arthrodesis, and staged reconstruction
PMID: 21368096
ISSN: 1067-151x
CID: 134139

Outcome Following Acute Primary Distal Ulna Resection for Comminuted Distal Ulna Fractures at the Time of Operative Fixation of Unstable Fractures of the Distal Radius

Ruchelsman, David E; Raskin, Keith B; Rettig, Michael E
Optimal acute management of the highly comminuted distal ulna head/neck fracture sustained in conjunction with an unstable distal radius fracture requiring operative fixation is not well established. The purpose of the present study was to determine the clinical, radiographic, and functional outcomes following acute primary distal ulna resection for comminuted distal ulna fractures performed in conjunction with the operative fixation of unstable distal radius fractures. Between 2000 and 2007, 11 consecutive patients, mean age 62 years (range, 30-75) were treated for concomitant closed, comminuted, unstable fractures of the distal radius and ulna metaphysis. All 11 patients underwent distal ulna resection through a separate dorsal ulnar incision with ECU tenodesis following surgical fixation of the distal radius fracture. According to the Q modifier of the Comprehensive Classification of Fractures, there were six comminuted fractures of the ulnar neck (Q3) and five fractures of the head/neck (Q5). Operative fixation of the distal radius fracture included volar plate fixation in four patients and spanning external fixation with supplemental percutaneous Kirschner wires in seven patients. At a mean of 42 months (range, 18-61 months) postoperatively, clinical, radiographic, and wrist-specific functional outcome with the modified Gartland and Werley wrist score were evaluated. At latest follow-up, mean wrist range of motion measured 53 degrees flexion (range, 35-60 degrees ), 52 degrees extension (range, 30-60 degrees ), 81 degrees pronation (range, 75-85 degrees ), and 77 degrees supination (range, 70-85 degrees ). Mean grip strength measured 90% of the contralateral, uninjured extremity (range, 50-133%). No patient had distal ulna instability. Final radiographic assessment demonstrated restoration of distal radius articular alignment. According to the system of Gartland and Werley as modified by Sarmiento, there were seven excellent and four good results. No patient has required a secondary surgical procedure. Acute primary distal ulna resection yields satisfactory clinical, radiographic, and functional results in appropriately selected patients and represents a reliable alternative to open reduction and internal fixation when anatomic restoration of the distal ulna/sigmoid notch cannot be achieved. Primary distal ulna resection with distal radius fracture fixation may help avoid secondary procedures related to distal ulna fixation or symptomatic post-traumatic distal radioulnar joint arthrosis
PMID: 19241113
ISSN: 1558-9447
CID: 94373

Newest advances in the operative treatment of basal joint arthritis

Croog, Alexander S; Rettig, Michael E
Osteoarthritis of the basal joint of the thumb is common, particularly in postmenopausal females, and can cause considerable pain and disability. Incompetence of the volar beak ligament is thought to be the inciting event that eventually leads to joint degeneration in a predictable pattern. The clinical history and examination can reliably lead to the diagnosis. Radiographs are used to stage the severity of the arthritis. Conservative treatment can be effective in early disease. Operative treatment has been shown to be successful in relieving pain and restoring thumb function in advanced disease. The majority of reconstructive procedures include partial or complete trapeziectomy with beak ligament reconstruction and tendon interposition. Secondary metacarpophalangeal joint hyperextension and associated carpal tunnel syndrome must be diagnosed and addressed to prevent poor outcomes.
PMID: 17539765
ISSN: 1936-9719
CID: 73030

Distal Radius Fractures: External Fixation and Supplemental K-Wires

Raskin KB; Rettig ME
The primary treatment goal for fractures of the distal radius is fracture reduction and stabilization to permit restoration of pain-free wrist function. Recognition of fracture instability based on the radiographic evaluation of fragment comminution and displacement is the focus of current classifications. Although closed reduction and cast immobilization remain a reliable treatment method for stable fractures, similar management for unstable fractures is prone to failure. Ligamentotaxis employing a spanning external fixator in conjunction with supplemental Kirschner wires has proved to be a reliable means of maintaining an accurate reduction of unstable fractures. Successful uncomplicated treatment of distal radius fractures with external fixation is related directly to precise, reproducible surgical technique. The frequently reported pin-related complications can be reduced significantly by several key steps to surgical application. Open bicortical half pin placement avoids soft tissue, tendon, and nerve iatrogenic injuries, and minimizes the risk of unicortical pin insertion that can result in metacarpal or radial shaft fractures or subsequent loosening or infection. Pin inflammation and superficial infection often can be resolved by oral antibiotics, physician pin care, and gauze dressing. Properly applied ligamentotaxis will allow healing of the distal radius fracture without complications related to overdistraction [12,13]. External fixation frames have been modified to allow for early wrist range of motion during the acute healing phase in an attempt to prevent potential residual wrist stiffness. Despite this attractive concept, there appears to be no significant additional benefit to dynamic fixation of these fractures compared with the traditional static wrist immobilization until completion of union. Although ligamentotaxis is effective in restoring length and inclination, it will not restore articular congruity consistently in fractures characterized by marked articular displacement. Restoration of articular congruity can be accomplished by open treatment [14]. Additional stability with improved restoration of volar tilt can be accomplished by closed manipulation in conjunction with multiple percutaneous smooth K-wires inserted from the volar aspect of the radial styloid into the intact dorsal ulnar cortex of the proximal shaft. Excessive flexion or ulnar deviation should be avoided, as these positions potentate the risk of median nerve compression at the wrist level. External fixation with supplemental K-wires is an excellent method for stabilizing displaced unstable distal radius fractures. When properly used, complications can be minimized, and an excellent radiographic and functional recovery can be achieved. Meticulous attention to surgical detail and a comprehensive postoperative program are the key components to a reliable and reproducibly successful recovery
ISSN: 1082-3131
CID: 69281

Extensor carpi radialis longus to extensor carpi ulnaris tendon transfer for rheumatoid arthritis of the wrist

Lutsky, K; Rettig, ME
Deformity of the wrist in patients with RA is the result of synovitis and soft tissue destruction leading to instability and altered joint biomechanics. Operative treatment is reserved for patients who have persistent pain, loss of function, or progressive deformity despite conservative treatment. In patients with supple wrist deformity and minimal radiographic changes, the ECRL to ECU tendon transfer may be effective in restoring more normal joint mechanics and preventing progression of the deformity.
ISSN: 1082-3131
CID: 570102