AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

Iatrogenic Injury to the Deep Motor Branch of the Ulnar Nerve in Percutaneous Pinning of 5th Carpometacarpal
Fracture Dislocations: A Cadaveric Study
Institution where the work was prepared: Albert Einstein Medical Center, Philadelphia, PA, USA
Minn Saing, MD; James Raphael; Albert Einstein Medical Center
Background:
Fracture dislocations of the 4th and 5th carpometacarpal joints are well described in the literature. However, there is little commentary available with regards
to ulnar nerve injury related to these fractures and their management. A handful of case reports exist describing various levels of neuropraxia of the ulnar deep
motor branch and postulate several theories to include repetitive trauma, initial fracture displacement, compression from hematoma, traction injury and iatrogenic
injury from percutaneous pinning. We will report 3 case reports of patients with documented loss of ulnar nerve motor function post closed reduction
and percutaneous pinning of a 5th carpometacarpal fracture-dislocation.
Methods:
5 cadaver specimens were thawed and under mini c-arm fluoroscopic guidance, a 0.045 in kirshner wire was placed in standard fashion, percutaneously from
the dorsal lateral border of the 5th metacarpal base, across the hamatometacarpal joint and into the body of the hamate. The Kirshner wire is directed towards
and into the body of the hamate. A dissection was then carried out to evaluate the proximity of the deep motor branch to the k-wire should the volar cortex
be violated with our Kirshner wire.
Results:
Our results confirm the close proximity of the deep motor branch of the ulnar nerve to the base of the hook of the hamate. In all 5 cadaver hands, the deep
motor branch was within 2mm of the base of the hook of the hamate. The penetrated K-wire through the volar cortex of the hamate was within ≤1mm of
the deep motor branch in all 5 cadavers.
Conclusions:
Our study confirms the extremely close proximity of the deep motor branch to the volar cortex of the base of the hook of the hamate and also demonstrates
the potential for injury during percutaneous pinning of 5th carpometacarpal fracture-dislocations.
Clinical Relevance:
Care should be taken not to penetrate the volar cortex when performing closed reduction and percutaneous pinning of 5th carpometacarpal fracture-dislocations
to prevent iatrogenic injury to the deep motor branch of the ulnar nerve.
Outcomes in Upper Extremity Replantation: a National Study of 16,128 Replants
Institution where the work was prepared: Yale University, New Haven, CT, USA
Michael Chen, MD; Yale University
Background:
For many complex surgical procedures, there is an inverse relationship between volume and complications. Previously, our group has shown that as reimbursements
for reconstructive procedures have declined, teaching hospitals are doing not only more of the upper extremity replants, but also more of the complex,
multiple digit or hand replants. The purpose of this study was to determine whether this increase in replantation volume has led to less complications and better
outcomes
Methods:
We searched a national database of patients (the 1993-2002 Nationwide Inpatient Sample (NIS)) for failed upper extremity replants, defined as those patients
who had had a subsequent amputation after their replantation. We then compared failure rates at teaching versus non-teaching hospitals. Furthermore, we
examined the effect multiple replantation had on failure rates.
Results:
3,219 upper extremity replants were coded in the NIS, representing 16,128 replants performed in the U.S. from 1993-2002. Multiple digit/hand replants were
more often subsequently amputated than single digit/hand replants (8.7% vs 5.2%). Furthermore, these failures led to an increased length of stay (7.5 days vs
5.8days, p