Risk factors for complications following open reduction internal fixation of distal radius fractures

PURPOSE

A national surgical database was used to determine risk factors for complications in patients undergoing open reduction internal fixation (ORIF) for distal radius fractures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database for the 2006-2012 years was queried to identify all patients who underwent an ORIF of a distal radius fracture based on Current Procedural Terminology codes 25607, 25608, or 25609. The database is a statistically representative sample of prospectively collected perioperative surgical data from hospitals primarily in the United States. Demographics, comorbidities, preoperative laboratory values, and 30-day complications were compared between the patient groups with and without a postoperative complication. Multivariate analysis was performed to identify patient characteristics and comorbidities that were independently associated with early postoperative complications.

RESULTS

This retrospective analysis identified 3,003 patients who underwent an ORIF of the distal radius over 7 years. The number of patients with a complication within 30 days after surgery was 62 (2%), totaling 90 complications. Incidence of return to the operative room for the entire study population was 1.1%. Multivariate analysis, adjusting for confounding variables, showed that patients with a complication were more likely to have hypertension, congestive heart failure, preoperative chemotherapy or radiotherapy, longer operating time, and manifest preoperative impairment in independent living.

CONCLUSIONS

Approximately 2% of patients sustained a complication within 30 days following ORIF of a distal radius fracture. Recognition of the risk factors may help avoid complications in the identified high-risk patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

THE EFFECTS OF FOREARM ROTATION ON THREE WRIST MEASUREMENTS: RADIAL INCLINATION, RADIAL HEIGHT AND PALMAR TILT

The purpose of this study was to evaluate and quantify the effects of forearm rotation on radial inclination, radial height and palmar tilt. Seventeen arms, nine cadaveric and eight volunteer, were examined using a radiolucent device that allowed for the controlled rotation of each arm. Lateral and posterior-anterior X-rays were taken at 5° increments which were then measured by two physicians using standardised protocol. The results revealed that all three measurements were significantly affected by forearm rotation with forearm supination increasing the apparent measurements and forearm pronation decreasing the apparent measurements. This relationship was well characterised by linear trend modelling such that forearm pronation of 10° decreased the apparent radial inclination, radial height and palmar tilt by 2.8°, 1.6 mm and 4.4°, respectively. This study demonstrates that forearm rotation is an important factor in the accurate evaluation of wrist measurements, and that slight rotation of the wrist during radiographic imaging may significantly alter management decisions given established surgical criteria.

Anatomy of the coronoid process

PURPOSE

Coronoid injuries are classified according to the size of the coronoid fracture. The purpose of this study was to provide a detailed anatomic description of the coronoid process, with specific focus on the coronoid height, the coronoid width, and the olecranon-coronoid angle.

METHODS

Thirty-five cadaveric arms were dissected. All soft tissue was removed and the ulna was disarticulated from the humerus, radius, and the carpal bones. A 3-dimensional digitizing system was used to locate 19 anatomic landmarks on each specimen. By using the 3-dimensional coordinates of the landmarks, the coronoid heights, proximal ulnar widths, and olecranon-coronoid angles were determined.

RESULTS

The coronoid height, with its base defined by the trough of the trochlear notch and the slope change of the distal coronoid process, measured 15 mm and was 42% of the ulnar height. The coronoid height, with its base defined by the transverse groove of the sigmoid notch at the guiding ridge and the distal insertion of the brachialis muscle, measured 15 mm and was 43% of the ulnar height. The olecranon-coronoid angle ranged between 33 degrees and 38 degrees .

CONCLUSIONS

For lateral radiographic classification of coronoid fractures, coronoid height is best defined by the trough of the trochlear notch and the slope change of the distal coronoid process. For anatomic studies, coronoid height is best defined by the transverse groove of the sigmoid notch at the guiding ridge and the distal insertion of the brachialis muscle. The olecranon-coronoid angle is best defined by the angle formed by the lines from the olecranon tip through the coronoid tip and through the slope change of the distal coronoid process. The coronoid anatomy measurements reported in this study may help to improve coronoid fracture classification.

The future of flexor tendon surgery

Clinical outcomes following flexor tendon repair have made significant improvements in the last 50 years. In that time standard treatment has evolved from secondary grafting to primary repair with postoperative rehabilitation protocols. Unfortunately, excellent results are not yet attained universally following treatment. Improving understanding of tendon healing at the cellular, molecular, and genetic levels will likely enable surgeons to modulate the normal repair process. We now look toward biologic augmentation of flexor tendon repairs to address the problems of increasing tensile strength while reducing adhesion formation following injury and operative repair.

Flexor tendon pulley reconstruction

Pulley reconstruction remains a challenging intellectual and technical exercise. When performed correctly, however, it can be a gratifying procedure that provides much improved function of the digit. As described in this article, there are many different techniques by which the pulley can be reconstructed. Each of these techniques has distinct advantages and disadvantages. The hand surgeon should be familiar with each of these techniques and the general principles of pulley reconstruction as laid out in this article. With this knowledge base, the treating surgeon is able to tailor the procedure performed to the exact anatomy and clinical situation of each patient. Although great strides have been made over the past half century, more clinical research is needed to determine the best technique, not just in the cadaver model, but also in the complex model of the living human hand.

Vascular problems of the upper extremity: a primer for the orthopaedic surgeon

A focused history and thorough physical examination, combined with a working knowledge of the normal vascular anatomy, can help identify most vascular abnormalities of the upper extremity. Technologic improvements now allow accurate diagnosis by noninvasive methods. Most abnormalities can be categorized into one of five major diagnostic groups: traumatic, compressive, occlusive, tumoral (malformation), and vasospastic. Behavioral modifications and pharmacologic agents may improve symptoms. Appropriately selected surgical candidates often experience pain relief and functional improvement.

Diagnosis and treatment of post-traumatic medial and lateral elbow ligament incompetence

Elbow instability may occur secondary to soft tissue or bony injuries. Predictable patterns of instability do occur. Identification of disrupted osseous or ligamentous constraints allows for an algorithmic and predictable treatment plan. Maintaining a high index of suspicion allows early recognition and treatment of elbow instability. Treatment based on recognized principles is the key to preventing recurrent instability and late arthrosis while maintaining functional elbow motion.

Occipitocervical neutral position. Possible surgical implications

STUDY DESIGN

The study defines the occipitocervical neutral position using cervical radiographs from 30 subjects.

OBJECTIVE

To identify reproducible radiographic measures of the occipitocervical neutral position that can be used during surgery to optimize fusion position.

SUMMARY OF BACKGROUND DATA

When performing rigid internal fixation of the occiput to the cervical spine, the ability to determine that the occiput is in a neutral position in relation to the cervical spine is important. Currently, no objective radiographic measures for the occipitocervical neutral position exist.

METHODS

Thirty flexion, extension, and neutral lateral cervical spine radiographs radiographs interpreted as normal by an experienced radiologist were studied. The occipitocervical angle and occipitocervical distance were defined and calculated. Two investigators, an orthopedic resident and an experienced orthopedic spine surgeon, measured the occipitocervical angle and occipitocervical distance independently on all radiographs in a blinded manner. Correlation coefficients were obtained to determine interobserver reliability.

RESULTS

The mean occipitocervical angles were 24.2 degrees, 44.0 degrees, and 57.2 degrees in flexion, neutral, and extension, respectively. The mean occipitocervical distances were 21.5 mm in neutral, 28.0 mm in flexion, and 14.8 mm in extension. The differences in the occipitocervical angle and occipitocervical distance in neutral, flexion, and extension were statistically significant (P < 0.05 and < 0.001, respectively). There were no significant interobserver differences in any of the measurements.

CONCLUSIONS

The radiographic measures of the occipitocervical neutral position reported in this study are reliable, repeatable, and simple to determine on routine lateral radiographs. These measurements should be a valuable intra-operative tool for achieving occipitocervical fusion in appropriate alignment.

Biomechanical changes of cadaveric finger flexion: the effect of wrist position and of the transverse carpal ligament and palmar and forearm fasciae

This study was designed to investigate whether the position of the wrist or sectioning of the transverse carpal ligament (TCL), as well as the palmar fascia and forearm fascia, modifies the biomechanical behavior of the finger flexion, as defined by changes of excursion, load (force), and work of the flexor tendons. The parameters were measured in fresh-frozen cadaver hands with the wrist in 30 degree extension, neutral, and 30 degree flexion, before and after division of the TCL. Having the wrist in extension improved excursion efficiency, whereas flexing the wrist produced the opposite effect, with a 16% decrease in excursion efficiency after division of the TCL. Change in excursion efficiency between the intact and cut TCL was 8% in the flexed position, 5% in the neutral position, and 0.3% in the extended position. Change in load efficiency between intact and cut TCL was 11% in the flexed position, 6% in the neutral position, and 0% in the extended position. Change in the work efficiency between intact and cut TCL groups was noted most with the wrist in the flexed position (13%), compared to a small change (3%) in neutral wrist position and no change in wrist extension. A significant decrease in the excursion efficiency of the flexor tendons was demonstrated when the wrist was in the flexed position. Any increase in the excursion of the flexor tendons could clinically result in decreased grip strength when the wrist is flexed. Furthermore, the effects of TCL division were not significant when wrist position was in extension.

Tensile strength of flexor tendon repairs in a dynamic cadaver model

Twenty-six fresh-frozen cadaver hands (78 tendons) underwent sharp zone II profundus tendon transection and repair with Bunnell, Kessler, Kessler with circumferential epitenon, or epitenon-alone sutures. Suture assignment was randomized, and core sutures were placed either palmarly or dorsally (also randomized) within the flexor tendon. Ten trials of each suture type and placement were performed. Flexion of the repaired digit at a constant excursion rate was performed up to tendon rupture. In all cases, dorsally placed sutures provided significantly more tensile strength than palmarly placed sutures. In light of the previous evidence that tendon viability is dependent on diffusion and not dependent on the vascular supply, we believe that a dorsally placed core suture and circumferential epitenon repair for zone II profundus repairs should be considered because of their increased strength. All future testing of tendon repairs should be performed in an anatomic "curvilinear" model because it simulates the specific biomechanical conditions that are unique to the flexing digit.

The flexor synovial sheath anatomy of the little finger: a macroscopic study

Anatomy texts describe the flexor synovial sheath of the little finger as extending proximally into the palm to join with the ulnar bursa in 80% of cases. Based on this, one would expect frequent extension of little finger flexor synovial sheath infections into the forearm. Methylene blue injection followed by open tenogram was used to define the anatomy of the flexor synovial sheath of the little finger in 60 cadaver hands. In 27 hands, the flexor synovial sheath extended proximally from the bony profundus tendon insertion to terminate at the palmar aponeurosis pulley. A stricture of varying length separated the flexor synovial sheath from the more proximal ulnar bursa. In 19 hands, the flexor synovial sheath was continuous with the ulnar bursa, conforming to the conventional textbook description. In 14 hands, the flexor synovial sheath stopped at the proximal border of the A1 pulley. An inconsistent defect from 1 to 10 mm was noted. The clinical implications of these findings suggest that many little finger flexor synovial sheath infections, when caught early and after careful physical examination, need only be managed by drainage at the distal palmar level.

Current and future delegation of pharmacy activities to technicians in Tennessee

Pharmacists in charge of community and institutional pharmacies in Tennessee were surveyed to identify which activities they currently delegate to technicians and which activities they might consider delegating in the future. Survey questionnaires were mailed to all pharmacists-in-charge registered with the board of pharmacy. Respondents were asked to indicate which of 38 listed pharmacy activities were currently delegated to technicians and which currently undelegated activities would be delegated in the future if legal and policy barriers were removed and if technician training programs were available. Respondents also ranked six types of technician training programs in order of preference and were asked whether they thought technicians should receive official recognition through certification or licensure. A total of 947 questionnaires were returned, for a response rate of 62%. Of the 24 activities that were delegated by significantly different numbers of pharmacists in community and institutional settings, 23 were delegated more frequently by institutional pharmacists. Activities related to drug therapy were delegated least frequently by either group, although community pharmacists delegated the task of recommending nonprescription drugs more often than did institutional pharmacists. If barriers were removed and training programs were available, more pharmacists would delegate activities to technicians than currently do. Most respondents preferred a formal, in-house training program for technicians; more than 65% of pharmacists favored certification of technicians. Pharmacists in Tennessee currently delegate a number of activities to technicians, and more pharmacists would do so if barriers toward technician use were removed and if more trained technicians were available.