Complications of K-wire fixation in procedures involving the hand and wrist

PURPOSE

Surgeons often use smooth K-wires for bone stabilization in the hand and wrist. The purposes of this study were to observe the incidence of postoperative complications of K-wire fixation in the hand and wrist and to identify associated risk factors.

METHODS

A total of 189 patients underwent bone and soft tissue procedures in the hand and wrist with insertion of 408 smooth K-wires. All patients were instructed to comply with a uniform pin care protocol and were observed for a minimum of 1 examination after pin removal. Complications were categorized as minor or major, with 3 subcategories for infectious complications. We compared total complications and infectious complications with patient age, comorbidities, soft tissue integrity, pin exposure (external or buried), number of pins inserted, pin location, compliance with pin site care, and empiric antibiotic treatment.

RESULTS

We found that 39 patients experienced postoperative complications involving 58 K-wires (14% of all pins). Most complications were minor, commonly superficial pin track infection (24 pins, 6% of all pins). Major complications occurred less frequently (11 pins, 3% of all pins) and included complications that led to additional surgery (deep infection, malunion, or nonunion) and fractures through the pin track. The development of an infectious complication was associated with 2 factors: pin location in the hand versus the wrist and poor compliance with pin site care. Patient age, medical comorbidities, soft tissue integrity, pin exposure, number of pins inserted, and empiric antibiotic treatment had no statistically significant relationships to the occurrence of complications.

CONCLUSIONS

Complications with smooth K-wire fixation in the hand and wrist are relatively uncommon. Most complications involve minor, superficial pin track infections. Location of pins in the hand as compared with the wrist and poor patient compliance with pin site care may increase the risk of infection.

Complications of K-wire fixation of fractures and dislocations in the hand and wrist

Kirschner wire (K-wire) fixation of fractures and dislocations of the hand and wrist is a common procedure. Of the 590 K-wire fixations performed on 236 patients, 36 (15.2%) experienced complications which included osteomyelitis, tendon rupture, nerve lesion, pin tract infection, pin loosening or migration. There were no deep soft-tissue pin infections or pyarthrosis. Technical failure, mainly when the procedure was performed by residents, and poor patient compliance were the major causes of complications. K-wire fixation is a simple but demanding procedure that cannot be left to an inexperienced resident. Elimination of technical failure, supervision in the operating room, close monitoring, prompt treatment upon discovery of a complication, and improvement of patient compliance can reduce the rate of complications.

High-frequency ultrasound examination of the wrist and hand

High-frequency ultrasound (US) is an efficient, rapid and inexpensive altenative to magnetic resonance imaging (MRI) for investigation of diseases in the soft tissues of the wrist and hand. US allows detection of foreign bodies and the reliable identification of a variety of traumatic lesions affecting tendons, annular pulleys, ligaments, vessels and nerves. Inflammatory diseases of tendons, including acute and chronic tenosynovitis and some degenerative conditions in the wrist and hand, can also be diagnosed. In entrapment neuropathies, US is able to identify nerve shape changes and possible extrinsic space-occupying lesions that may cause nerve compression within the tunnels. In patients with localized swelling of the hand or wrist, US is able to assess the presence of an expansile lesion and to characterize its nature in most cases. The objective of this article is to review the main findings and the primary indications of US in the investigation of disorders of the hand and wrist.

One-stage flap repair with vascularised tendon grafts in a dorsal hand injury using the "Chinese" forearm flap

A one-stage flap repair is described for complicated dorsal injuries of the hand involving loss of skin and tendon based on the principle of the "Chinese" radial artery forearm flap in which vascularised tendons are transferred to reconstruct the missing extensor tendons.

Imaging of hamate bone fractures in conventional X-rays and high-resolution computed tomography. An in vitro study

RATIONALE AND OBJECTIVES

To examine the ability to image fractures of the body and hook of the hamate bone in conventional X-rays and high-resolution computed tomography (HR-CT).

MATERIALS AND METHODS

In an in vitro experiment using 18 cadaver hands, the hamate bone was fractured at different places. Before and after fracture, conventional X-rays were taken in different planes (anteroposterior, lateral, oblique, and carpal tunnel), and HR-CT was performed with 2-mm layer thickness in the axial, sagittal, and coronal plane.

RESULTS

Taking into account all the conventional X-ray projections applied, the in vivo experiment revealed a sensitivity of 72.2%, a specificity of 88.8%, and an accuracy of 80.5%. For the HR-CT, the sensitivity was 100%, the specificity was 94.4%, and the accuracy was 97.2%.

CONCLUSIONS

Fractures of the body and hook of the hamate cannot always be detected with certainty in the conventional X-ray image, even if different projectional planes are used. The HR-CT is the imaging procedure of choice for further clarification, and an axial or sagittal plane should be selected.

Sonographic evaluation of digital annular pulley tears

OBJECTIVE

To evaluate the sonographic (US) appearance of digital annular pulley (DAP) tears in high-level rock climbers.

DESIGN AND PATIENTS

We performed a retrospective analysis of the US examinations of 16 high-level rock climbers with clinical signs of DAP lesions. MRI and surgical evaluation were performed in five and three patients respectively. The normal US and MRI appearances of DAP were evaluated in 40 and three normal fingers respectively.

RESULTS

Nine of 16 patients presented a DAP tear. In eight subjects (seven with complete tears involving the fourth finger and one the fifth finger), US diagnosis was based on the indirect sign of volar bowstringing of the flexor tendons. Injured pulleys were not appreciated by US. Tears concerned the A2 and A3 in six patients and the A3 and A4 in two patients. A2 pulley thickening and hypoechogenicity compatible with a partial tear was demonstrated in one patient. MRI and surgical data correlated well with the US findings. Four patients had tenosynovitis of the flexor tendons but no evidence of pulley disruption. US examinations of three patients were normal. In the healthy subjects US demonstrated DAP in 16 of 40 digits.

CONCLUSION

US can diagnose DAP tears and correlates with the MRI and surgical data. Because of its low cost and non-invasiveness we suggest US as the first imaging modality in the evaluation of injuries of the digital pulley.

Hand problems in an accident and emergency department

We present a prospective study of 1,074 consecutive hand problems which were presented to our Accident and Emergency Department over an eight week period. This number accounted for 1 in 5 of all accident attendances. Over 40% of these patients were males aged 12-29 years. Nearly half of the hand patients presented within two hours of injury. Over half the patients needed only reassurance or a simple dressing but 55 patients (5%) had to be admitted for surgery.

Evaluation of fasciocutaneous perforators using color duplex imaging

Technological improvements in conventional ultrasound, including color duplex imaging, have greatly facilitated the evaluation of vascular-related problems for virtually every specialty. Higher-frequency transducers now permit the scanning of superficial depths beneath the skin surface with high sensitivity for an analysis specific to the microcirculation. This attribute has already been recognized as a valuable tool for the preoperative mapping of musculocutaneous perforators. A logical extension of this capability would be for the localization and calibration of deep fascial perforators, which may have even greater clinical significance because anomalies at this level are more the rule rather than the the exception. Over the preceding 10-month period, all eight elective fasciocutaneous flaps performed in eight patients had initial scans using color duplex imaging to identify and calibrate all relevant cutaneous perforators. All fasciocutaneous flap subtypes were included. If feasible at the time of flap elevation, all identified perforators were dissected and measured. All were found at the exact site as marked preoperatively, and their diameter closely approximated that predicted. The occasional unanticipated presence in vivo of minor perforators suggests that color duplex imaging may not be reliable for fascial perforators less than 0.5 mm in diameter. Since perforator caliber qualitatively is a major determinant of flow, color duplex imaging can then objectively establish a hierarchy of the importance of perforators in a given region. From such data, the definition of new and more reliable fasciocutaneous flap donor territories should be forthcoming.(ABSTRACT TRUNCATED AT 250 WORDS)

Extraarticular hand fractures in adults: a review of new developments

This report cites new developments in the treatment of extra-articular hand fractures in adults. Recent reports confirm that small amounts of metacarpal shortening or dorsal angulation cause minimal functional impairment. Unilateral excision of the lateral band and oblique fibers of the extensor apparatus of the metacarpophalangeal joint facilitates proximal phalangeal fracture exposure and may improve functional recovery. Results using open mini screw fixation of oblique extra-articular metacarpal and phalangeal fractures may be comparable to those of percutaneous Kirschner wire fixation. Bicortical self-tapping mini screw fixation of extra-articular oblique metacarpal and phalangeal fractures simplifies screw insertion and provides stability comparable to that of fractures fixed with lag screws. Percutaneous intramedullary wire fixation may afford suitable fixation for unstable extra-articular oblique as well as transverse metacarpal fractures. Locked intramedullary nails may offer similar advantages. Unicortical screw fixation of mini plates securing transverse extra-articular metacarpal fractures affords stability comparable to that of bicortical screw fixation while creating less bone damage. The dissection required for plate fixation and the small surface area of transverse fractures delay and occasionally impair bone healing. Primary bone grafting of diaphyseal defects in clean stable wounds may shorten and simplify treatment and decrease morbidity. As little as 1.7 mm of flexor tendon excursion during the first 4 weeks after reduction or repair may substantially diminish peritendonous adhesions at the fracture site. Synchronous wrist and digital exercises may also reduce peritendonous fracture adhesions. Early motion of adjacent joints in closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting fracture alignment and leads to earlier return to work.

LEVEL OF EVIDENCE

Level V (expert opinion).

Hand and fingertip injuries in children

BACKGROUND

Hands are frequently injured in children. To date, the literature has focused on the type and treatment of hand injuries. This study examines the epidemiology of hand and fingertip injuries in children who present to an emergency department (ED).

DESIGN

Retrospective chart review.

SETTING

Pediatric emergency center of an urban ED.

PARTICIPANTS

All patients over a period of 8 months who presented with a chief complaint of hand injury.

METHODS

A total of 17,859 charts were reviewed during the study period; 382 patients were enrolled in the study (male preponderance of 1.4:1; median age, 10 y).

RESULTS

The most frequent injury setting was outdoors (47%). The most frequent injuries were lacerations (30%), followed by fractures (16%). Only five patients required hospitalization (1.3%). The digits are the most commonly injured part of the hand, particularly the thumb (19%). Fingertips are involved in 21% of cases. Radiographs and consultations were obtained in 64% and 16% of cases, respectively. Infection occurred in 14 (3.7%) patients.

CONCLUSION

Hand injuries occur in a bimodal distribution in children. Children younger than 2 years suffered fingertip injuries in the home, and children aged 12 to 16 years suffered hand injuries. Sports injuries tend to present late and are the most common cause of hand fractures.

The usefulness of quantitative evaluation of three-phase scintigraphy in the diagnosis of post-traumatic reflex sympathetic dystrophy

Quantitative analysis of three-phase bone scintigrams was done in 70 patients with reflex sympathetic dystrophy (RSD) and in 30 patients who did not have RSD after injury to the hand or wrist. Regions of interest were selected and the uptake ratios (affected/unaffected) were calculated. Significant differences between affected and unaffected patients were seen in the metacarpal area in phase 2 of the scintigrams as well as in the metacarpophalangeal joints and metacarpal bones in phase 3. Combination of these images had the greatest diagnostic value. Sensitivity and specificity of 80% were achieved in the regions of interest in phase 3. The duration of RSD and the predisposing injury significantly affected the results of bone scintigraphy. It was also noted that a fracture may cause increased fixation of the tracer in each phase of three-phase bone scintigraphy in asymptomatic patients.

The posterior interosseous flap: a review of 81 clinical cases and 100 anatomical dissections--assessment of its indications in reconstruction of hand defects

Based on our experience of 100 cadaveric dissections and a series of 81 clinical cases, we have assessed the indications for the posterior interosseous flap in reconstruction of the hand. Large fasciocutaneous island flaps can be harvested, even when the radial or ulnar pedicles are damaged, sacrificing only vessels of secondary importance to the perfusion of the hand. Compound flaps can be dissected based on muscular, musculoperiosteal and fascioperiosteal branches. The primary indications for using this flap are dorsal hand defects up to the metacarpal joints, reconstruction of the first web space up to the interphalangeal joint of the thumb and extensive lesions on the ulnar border of the hand.

High-pressure injection injuries of the hand: review of 25 patients managed by open wound technique

This article reviews the outcome of injury of the hand in 25 patients treated at our institution by the open wound technique: wide débridement, drainage, open packing, and delayed closure. The results obtained are superior to those reported in the literature: Among the patients, 84% of the involved hands or fingers were salvaged, 64% had essentially normal hand function at the time of final follow-up, and 92% were able to return to their previous jobs. We propose that aggressive treatment by the open wound technique improves the outcome of high-pressure injection injuries of the hand.

The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries

We report a retrospective study of the prognostic value of 2-phase technetium 99m bone scanning performed in 92 patients who presented to Chamonix Hospital with severe frostbite of the extremities in the past 12 years. The results of this study show that an initial bone scan (as early as day 3) has excellent specificity in evaluating the severity of frostbite injury. There was a direct correlation between the demarcation zone of uptake in the phalanges and the eventual level of amputation (positive predictive value, 0.84). A second scan on approximately day 7 was even more sensitive and informative. A strong correlation existed between positive uptake and eventual healing (negative predictive value, 0.99). This study showed that (99m)Tc bone scanning in the first few days after frostbite injury indicates the level of amputation in severe frostbite in more than 84% of cases. We propose an algorithm based on the results of this study that can be used to evaluate new medical and surgical management of frostbite injury.

The carpal boss. A 20-year review of operative management

Between 1969 and 1989, 116 patients were evaluated and treated surgically for symptomatic carpal boss. Their mean age was 32 years and male and female patients were equally affected. 28 patients gave a history of previous injury. Surgical treatment consisted of excision of the localized bony abnormality and the associated degenerative arthritic process to the level of normal articular surfaces and normal adjacent cancellous bone. The mean follow-up period for the patients in this study was 42 months. Complete symptomatic relief was observed in 94% of the patients undergoing surgical treatment. Recurrence or persistence of symptoms developed in seven surgical patients. Six had a second operation with more extensive removal of sclerotic bone and degenerate cartilage, and all patients had relief of symptoms.

Three-phase radionuclide scintigraphy of the hand

Three-phase radionuclide scintigraphy of the hand was performed on 116 patients. Normal and abnormal patterns for radionuclide angiography, immediate post-injection blood-pool images, and delayed scans (3-4 hr.) were established. Of 80 patients with normal circulation, 61 (76%) had equal radial and ulnar artery flow bilaterally, while in 19 (24%) either the radial or ulnar artery was dominant. Abnormal studies were grouped into three categories: suspected vascular lesions (Group I), pain of uncertain etiology (Group II), and patients evaluated before and after reconstructive surgery (Group III). The diagnosis was correct in 89% of the patients in Group I (34/38), 89% of those in Group II (57/64), and all of those in Group III (14/14). Three-phase scintigraphy of the hand yields significant information about perfusion and bone metabolism.

Searching for bone fractures: a comparison with pulmonary nodule search

RATIONALE AND OBJECTIVES

We aimed to determine if the characteristics and principles of visual search described for the detection of pulmonary nodules apply to extremity fractures.

METHODS

The eye positions of staff orthopedic radiologists, radiology residents, and medical students were monitored as they searched hand and wrist X-ray images for fractures and a chest image for nodules.

RESULTS

More systematic scanning patterns were observed for experienced observers than inexperienced observers. Positive decisions for bone images were associated with prolonged gaze durations; prolonged gaze durations were significantly longer for false-negative versus true-negative decisions. Intercluster jump distances were found to be greater for chest images than bone images.

CONCLUSIONS

A search for bone fractures can be qualitatively characterized by classifying observer scan paths, dwell times, and jump distances. Gaze duration can be a useful predictor of bone image locations containing potential missed fractures. Perceptual feedback could aid observers in the detection of inconspicuous fractures.

Fractures of the hands and feet in child abuse: imaging and pathologic features

PURPOSE

To determine the imaging and histopathologic appearance of fractures of the hands and feet in abused infants.

MATERIALS AND METHODS

The imaging findings in 11 abused infants with fractures of the hands and feet were examined retrospectively. All 11 infants underwent skeletal surveys; five infants also underwent nuclear bone scanning. Postmortem radiographs of the specimen and histopathologic data were available in two infants.

RESULTS

A total of 22 fractures were noted. Six infants had fractures of the hands: six metacarpal and nine proximal phalangeal fractures. Five infants had fractures of the feet: six metatarsal fractures and one proximal phalangeal fracture. Torus fractures predominated, and these patterns were confirmed at the histologic examinations. These morphologic features were consistent with a mechanism of forced hyperextension. Oblique views of the hands and follow-up skeletal surveys aided in detection of these injuries. Four of six metatarsal fractures involved the first ray. Seven patients had three or more additional fractures that involved the long bones of the upper and lower extremities, and seven patients had additional fractures of the ipsilateral extremity.

CONCLUSION

Fractures of the hands and feet are subtle but important injuries in abused infants. Well-collimated, high-detail radiographs of the hands and feet should be included in the skeletal survey performed for suspected child abuse.

Functional outcome of high-pressure injection injuries of the hand

BACKGROUND

High-pressure injection (HPI) injury of the hand is a serious injury that can be potentially devastating. There have been a number of publications on the results of its treatment, but we are not aware of a report on the functional outcome of these hands.

METHODS

We assessed the functional outcome of 15 patients with HPI injuries. All patients were treated operatively, with a mean delay of 11.7 hours. The patients were examined by a doctor and an occupational therapist using a work simulator.

RESULTS

Our study revealed a significant reduction of static and dynamic muscle testing parameters compared with the uninjured hand. Six patients lost a digit and four patients had to change their occupation after the injury.

CONCLUSION

Deterioration of hand function is a predictable outcome of HPI injury. This information should be shared with the patient at the outset so as to avoid subsequent disappointment.

Long-term utility of replanted arms

Images

Sonography of the hand and wrist

Not only is the anatomy of the hand and wrist complex, but also its pathologic conditions are quite diverse. Although plain radiographs, CT, arthrography, and MRI have traditionally been used to evaluate the hand and wrist, ultrasound is beginning to take its place alongside these more traditional imaging modalities and is being ordered with increasing frequency by orthopedic surgeons. This article reviews the pertinent gross anatomy and sonographic technique used to scan the hand and wrist and also describes the sonographic findings associated with the most common hand and wrist pathologic conditions. These include soft tissue tumors, tenosynovitis, tendinous and ligamentous injuries of the hand, Dupuytren's contracture, foreign bodies, and carpal tunnel syndrome (CTS).

Water bath evaluation technique for emergency ultrasound of painful superficial structures

Researchers have described the use of bedside emergency ultrasound as an effective way to evaluate for and accurately drain potential abscesses. Similarly, descriptions exist of long bone fracture evaluation in the wrist and hands. Tendon injury can also be detected with ultrasound and exploration can be obviated or at least focused. Sonographic examination of painful extremity pathology such as abscesses or lacerations involving the hand or foot can be challenging. Patients may be uncooperative if they experience significant pain when the transducer is placed on the area of interest. While ample amounts of ultrasound gel can decrease the need for firm transducer contact with the skin it is still difficult to obtain a good evaluation without causing any discomfort. The solution may lie in an old technique that has been recently brought back to life for use in hand evaluation in which the patient's extremity is placed in a water bath. The water bath replaces the need for ultrasound gel or contact between the ultrasound transducer and the patient's skin, thus eliminating discomfort. We describe 7 cases in which, despite aggressive attempts at pain control, adequate evaluation of extremity pathology was not possible without the use of the water bath technique. Patients reported no discomfort and superior quality images were obtained due to the water bath properties. Emergency sonologists should keep this technique in mind when contact between skin and the ultrasound transducer is likely to cause a patient significant discomfort.