Percutaneous Needle Fasciotomy Versus Collagenase Treatment for Dupuytren Contracture
Local disruption of the cord that causes contracture of the finger in Dupuytren disease can be achieved either through mechanical division by percutaneous needle fasciotomy (PNF) or through enzymatic digestion by injectable collagenase Clostridium histolyticum (CCH). #JBJS #VisualAbstract
Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations
The long-term effect of distal radial fracture malunion on activity limitations is unknown. https://bit.ly/2qYgOMh #JBJS
JBJS JOPA Image Quiz: 7-Year-Old Girl with an Injured Wrist
This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) presents the case of a 7-year-old girl who sustained a wrist injury from a fall off of monkey bars. An initial lateral radiograph is shown here. Clinicians attempted a closed reduction and applied a long arm cast. At the 1-week follow-up visit, radiographs showed additional displacement and increased dorsal angulation.
Select from among five possible choices for the greatest predictor of fracture displacement in the setting of distal radial metaphyseal fractures: increased fracture obliquity, a cast index ratio of less than or equal to 0.7, short arm casting, an intact ulna, or increased initial displacement of the radius.
What’s New in Orthopaedic Trauma
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, David Teague, MD, co-author of the July 7, 2016 Specialty Update on orthopaedic trauma, selected the eight most clinically compelling findings from among the 35 studies summarized in the Specialty Update.
Shoulder
–The randomized PROFHER trial found that surgical treatment of acute displaced proximal humeral fractures (with either ORIF or hemiarthroplasty) yielded no difference in patient outcomes compared with nonsurgical sling treatment at time points up to 2 years. Surgery was also significantly more expensive.1
Wrist
–A randomized trial of 461 patients with an acute dorsally displaced distal radial fracture found no difference at one year in primary or secondary outcomes between a group that received ORIF and a group that received Kirschner-wire fixation. K-wire fixation was also more cost-effective.2
Tibia
–A retrospective study of 137 type-III open tibial fractures concluded that both antibiotic prophylaxis and definitive wound coverage should occur as soon as possible for severe open tibial fractures. Prehospital antibiotic administration should be considered when transport is expected to take longer than one hour. 3
Ankle
–A randomized trial of 214 patients who received either supervised physical therapy or engaged in self-directed home exercise after six weeks of immobilization treatment for an ankle fracture found no difference in activity and quality-of-life outcomes at 1, 3, and 6 months.4
Managing Thromboembolism
–A registry study examining the incidence of deep venous thrombosis (DVT)/pulmonary embolism (PE) after surgery for a fracture distal to the knee identified the following risk factors for a thromboembolic event: previous DVT or PE, oral contraceptive use, and obesity.
Wound Care
–A randomized controlled trial of 2,447 patients compared irrigation with normal saline solution at various pressures to castile soap irrigation. Saline was superior in terms of reoperation rates after 12 months but irrigation pressure did not influence the reoperation rate.5
–A retrospective cohort study involving 104 patients who required a fasciotomy found that hospital stays were shorter among patients who underwent delayed primary closure (DPC) or a split-thickness skin graft on the first post-fasciotomy surgery. The authors noted limited utility of repeat surgeries to achieve DPT if fasciotomy wounds were not closed primarily on the first return trip.6
Obesity
–A prospective observational study of 376 trauma patients requiring orthopaedic surgery found that those with a BMI of >30 kg/m2 had an overall complication rate of 38% and had longer hospital stays, longer delays to definitive fixation, and higher infection rates than nonobese patients.7
References
- Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C,Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47.
- Costa ML, Achten J, Plant C, Parsons NR, Rangan A, Tubeuf S, Yu G, Lamb SEUK. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess.2015 Feb;19(17):1-124: v-vi
- Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, Bosse MJ. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015 Jan;29(1):1-6.
- Moseley AM, Beckenkamp PR, Haas M, Herbert RD, Lin CW; EXACT Team. Rehabilitation after immobilization for ankle fracture: the EXACT randomized clinical trial. JAMA. 2015 Oct 6;314(13):1376-85.
- Bhandari M, Jeray KJ, Petrisor BA, Devereaux PJ, Heels-Ansdell D, Schemitsch EH, Anglen J, Della RoccaGJ, Jones C, Kreder H, Liew S, McKay P, Papp S, Sancheti P, Sprague S, Stone TB, Sun X, Tanner SL,Tornetta P 3rd., Tufescu T, Walter S, Guyatt GH; FLOW Investigators. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015 Dec 31;373(27):2629-41. Epub 2015 Oct 8.
- Weaver MJ, Owen TM, Morgan JH, Harris MB. Delayed primary closure of fasciotomy incisions in the lower leg: do we need to change our strategy? J Orthop Trauma. 2015 Jul;29(7):308-11.
- Childs BR, Nahm NJ, Dolenc AJ, Vallier HA. Obesity is associated with more complications and longer hospital stays after orthopaedic trauma. J Orthop Trauma. 2015 Nov;29(11):504-9.
JBJS Case Connections—Wrong-Way Wrist Bones
The ability of the small and complexly connected wrist bones to function properly supports everything from activities of daily living and work to the creation of art and music. This month’s “Case Connections” article explores wrist dislocations that required open reduction and some form of fixation. Considering the high degree of anatomical derangement and instability in these cases, the outcomes were remarkably good, thanks to carefully planned and executed orthopaedic interventions.
The springboard case, from the July 27, 2016 edition of JBJS Case Connector, describes the treatment of a 47-year-old male bicyclist who was hit by a car and sustained complete scaphoid and lunate dislocations. Three additional JBJS Case Connector case reports summarized in the article focus on:
- a 22-year-old man who sustained volar dislocation of the hamate and scapholunate dissociation as a result of a motor-vehicle accident
- a 30-year-old man who experienced volar dislocation of the lunate as well as of the proximal pole of a fractured scaphoid after falling from a height of 15 feet with his outstretched hand and wrist in extension
- a 25-year-old man who fell from a height of 20 feet and dislocated the hand and wrist dorsally about the scaphoid and lunate.
Anatomical reduction frequently required both dorsal and volar exposures. In one case, a successful outcome was achieved without addressing ligamentous injuries.
JBJS JOPA Image Quiz: Golf-Related Wrist Injury
This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) highlights the case of a 34-year-old man who presented with a 1-month history of hand and wrist pain after driving his golf club into the ground during a swing. Anteroposterior (AP) and lateral radiographs of the wrist are shown, and findings from the physical exam are described.
The Image Quiz reviews the anatomy of the wrist, focusing on the symptoms and mechanisms of hamate injuries. The quiz question is: After standard AP and lateral radiographs, which imaging modality or view would be most helpful in arriving at a definitive diagnosis? Options for treating a fracture of the hook of the hamate are also discussed.
What’s New in Hand Surgery
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Sanjeev Kakar, MD, the author of the March 16, 2016 Specialty Update on hand surgery, to select the five most clinically compelling findings from among the more than 30 he cited in his article.
Wrist Trauma
–In the treatment of distal radius fractures, is volar plating superior to closed reduction and pin fixation? A prospective randomized trial of 461 adults with acute dorsally displaced distal radial fractures that were amenable to closed reduction found no clinically significant differences in Patient-Rated Wrist Evaluation (PRWE) scores among those who underwent percutaneous wire fixation and those who underwent locking-plate fixation. The findings led the authors to conclude that when looking at functional outcomes, treatments other than plate fixation may suffice.1
–Authors of a cost and utility analysis of 268 patients with a surgically treated distal radial fracture concluded that the routine use of radiographs made at two weeks postoperatively is of little clinical benefit, except in cases of patients with high-energy intra-articular fractures or those who sustain an injury after surgery.2
Wrist Arthritis
–To challenge conventional dogma that the contralateral wrist of rheumatoid arthritis patients who undergo wrist arthrodesis must maintain motion in order for them to perform activities of daily living, a long-term study followed 13 bilateral wrist arthrodesis patients for an average of 14 years. The major functional limitations noted were turning a door knob and opening a tight jar lid. Increasing age, preoperative corticosteroid use, and concomitant shoulder or elbow disorders were associated with worse outcomes. Ninety-three percent of the patients expressed satisfaction and said they would repeat the bilateral procedure.3
Carpal Tunnel Syndrome
–Should one perform staged or simultaneous carpal tunnel surgery? A cost-effectiveness study of simultaneous versus staged bilateral carpal tunnel release in 198 patients found that those who underwent simultaneous surgery had significantly fewer days off work and fewer postoperative follow-up visits, and they also incurred significantly lower costs in terms of mean amounts billed and fees collected.4
Trapeziometacarpal Joint Arthritis
–Is there an optimal suspension arthroplasty for the treatment of basilar thumb arthritis? A randomized controlled trial of 79 patients with trapeziometacarpal arthritis found that functional/clinical outcomes at 12 months were essentially the same between a group that underwent ligament reconstruction and tendon interposition (LRTI) and a group that underwent trapeziectomy and flexor carpi radialis weave around the abductor pollicis longus tendon. The notable exception was an improvement in PRWE scores at three months among those who underwent the LRTI procedure.5
References
- Costa ML, Achten J, Parsons NR, Rangan A, Griffin D, Tubeuf S, Lamb SE;DRAFFT Study Group. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014;349:g4807. Epub 2014 Aug 5
- Stone JD, Vaccaro LM, Brabender RC, Hess AV. Utility and cost analysis of radiographs taken 2 weeks following plate fixation of distal radius fractures. J Hand Surg Am. 2015 Jun;40(6):1106-9. Epub 2015 Mar 31.
- Wagner ER, Elhassan BT, Kakar S. Long-term functional outcomes after bilateral total wrist arthrodesis. J Hand Surg Am. 2015 Feb;40(2):224-228.e1. Epub 2014 Dec 13.
- Phillips P, Kennedy J, Lee T. Cost effective analysis of simultaneous versus staged bilateral carpal tunnel release. Read at the American Association for Hand Surgery Annual Meeting; 2015 Jan 21-24; Paradise Island, Bahamas. Paper no. 104.
- VermeulenGM, Spekreijse KR, Slijper H, Feitz R, Hovius SE, Selles RW.Comparison of arthroplasties with or without bone tunnel creation for thumb basal joint arthritis: a randomized controlled trial. J Hand Surg Am. 2014 Sep;39(9):1692-8. Epub 2014 Jun 10.
History of Diabetes Predicts Symptom Recurrence after Steroid Injection for CTS
Among a prospectively enrolled group of 49 patients (54 wrists) with mild or moderate carpal tunnel syndrome (CTS) who received a single corticosteroid injection, 79% experienced symptom relief at six weeks. Reporting in the October 7, 2015 edition of The Journal of Bone & Joint Surgery, Blazar et al. found that the rate of freedom from symptom recurrence in this cohort was 53% at six months and 31% at one year after injection. During the study period, 19 wrists underwent surgical carpal tunnel release at a median time of 181 days post-injection.
Diabetic patients in the study (13% of the wrists enrolled) were at a 2.6-fold greater risk of reporting recurring symptoms within one year of follow-up. In a univariable analysis, a 1-point increase in the baseline Boston Carpal Tunnel Questionnaire symptom score increased the risk of patients reporting post-injection symptoms by 5%, but that association became nonsignificant during multivariable analysis. Pre-injection symptom duration, patient age, and pre-injection electrophysiologic grade did not predict either symptom recurrence or subsequent intervention.
Blazar et al. add that their exclusion of people with normal electromyography results and those with severe carpal tunnel syndrome created a rather homogenous study population. Thus, they say, “these results may not be generalizable to all patients who present with clinical signs or symptoms of carpal tunnel syndrome.” Still, the findings should help orthopaedists counsel patients with CTS about the results they might expect from a single corticosteroid injection.
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