Imaging

Case

A 41-year-old woman presented to the ED with a 3-day history of posterior neck pain that radiated to the occipital region. The patient stated that the day prior to presentation, the pain had worsened to what she rated as a “9” on a pain scale of 0 to 10. The patient’s surgical history included a remote prior cervical fusion at C5-C6. A lateral radiograph of the cervical spine is shown above (Figure 1a).

What is the diagnosis? Is additional imaging necessary? If so, why?

 

Answer

The lateral view of the cervical spine demonstrated soft tissue swelling in the upper prevertebral region (red arrowheads, Figure 1b). (The soft tissues at this level in an adult normally measure less than 3 mm between the airway and the vertebral body.) The radiograph also showed an area of calcification within the prevertebral soft tissues (white arrow, Figure 1b).

The patient denied fevers, chills, dysphagia, visual changes, and nasal congestion. Physical examination demonstrated tenderness to palpation of the posterior neck, but there was no evidence of palpable mass or lymphadenopathy. Neck extension and lateral movement to the left were severely limited due to pain; neck flexion and lateral movement range of motion to the right were mildly decreased due to pain. The physical examination was otherwise normal.

Computed tomography (CT) of the neck was performed to further evaluate the soft tissue swelling and confirm the calcification (white arrow, Figure 2). The CT localized the abnormality to the expected location of the longus colli tendon. Magnetic resonance imaging (MRI) of the cervical spine with and without contrast was performed to directly visualize the tendon/effusion and to exclude prevertebral abscess. The MRI showed abnormally increased fluid signal about the longus colli tendon on Short tau inversion recovery (STIR) images (white arrows, Figure 3a). This fluid extended in all directions from the calcifications and lacked a defined enhancing wall on postcontrast images (white arrows, Figure 3b), suggesting that the fluid reflected reactive effusion rather than soft tissue abscess. A flexible fiberoptic laryngoscopic examination was normal, including the lack of bulging of the retropharyngeal wall. The constellation of these imaging and clinical findings was consistent with the diagnosis of longus colli (prevertebral) calcific tendinitis.

Longus colli (prevertebral) calcific tendinitis results from calcium hydroxyapatite deposition within the tendon. While the bilateral longus colli muscles extend from the atlas to the upper thoracic vertebral level, calcium hydroxyapatite crystals typically deposit at the C1-C2 level^1,2 (as seen in this case). Associated inflammation of the tendon can result in prevertebral fluid that may be confused for retropharyngeal abscess, particularly given the associated neck pain and stiffness, dysphagia, odynophagia, and possible mild leukocytosis and/or mild C-reactive protein elevation. ¹ However, imaging in this case confirmed that the prevertebral fluid extended from the calcium deposits in the tendon and excluded the presence of a rim-enhancing abscess collection. Knowledge of this clinical entity is important given its similar clinical presentation to other conditions with differing treatment strategies (eg, retropharyngeal abscess, meningitis).³

Longus colli (prevertebral) calcific tendinitis is a self-limiting condition that typically lasts 1 to 3 weeks, though it can be very painful during the acute phase.^1,2 Treatment is typically conservative, and the patient in this case received a course of oral corticosteroids and nonsteroidal anti-inflammatory drugs to help alleviate the associated inflammation.

Dr Bartolotta is an assistant professor of radiology at Weill Cornell Medical College in New York City and assistant attending radiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr Baradaran is a resident in the department of radiology at Weill Cornell Medical College in New York City. Dr Hentel is an associate professor of clinical radiology at Weill Cornell Medical College, New York. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology at New York-Presbyterian Hospital/Weill Cornell Medical Center; and associate editor, imaging, of the EMERGENCY MEDICINE editorial board.

Case

A 41-year-old woman presented to the ED with a 3-day history of posterior neck pain that radiated to the occipital region. The patient stated that the day prior to presentation, the pain had worsened to what she rated as a “9” on a pain scale of 0 to 10. The patient’s surgical history included a remote prior cervical fusion at C5-C6. A lateral radiograph of the cervical spine is shown above (Figure 1a).

What is the diagnosis? Is additional imaging necessary? If so, why?

 

Answer

The lateral view of the cervical spine demonstrated soft tissue swelling in the upper prevertebral region (red arrowheads, Figure 1b). (The soft tissues at this level in an adult normally measure less than 3 mm between the airway and the vertebral body.) The radiograph also showed an area of calcification within the prevertebral soft tissues (white arrow, Figure 1b).

The patient denied fevers, chills, dysphagia, visual changes, and nasal congestion. Physical examination demonstrated tenderness to palpation of the posterior neck, but there was no evidence of palpable mass or lymphadenopathy. Neck extension and lateral movement to the left were severely limited due to pain; neck flexion and lateral movement range of motion to the right were mildly decreased due to pain. The physical examination was otherwise normal.

Computed tomography (CT) of the neck was performed to further evaluate the soft tissue swelling and confirm the calcification (white arrow, Figure 2). The CT localized the abnormality to the expected location of the longus colli tendon. Magnetic resonance imaging (MRI) of the cervical spine with and without contrast was performed to directly visualize the tendon/effusion and to exclude prevertebral abscess. The MRI showed abnormally increased fluid signal about the longus colli tendon on Short tau inversion recovery (STIR) images (white arrows, Figure 3a). This fluid extended in all directions from the calcifications and lacked a defined enhancing wall on postcontrast images (white arrows, Figure 3b), suggesting that the fluid reflected reactive effusion rather than soft tissue abscess. A flexible fiberoptic laryngoscopic examination was normal, including the lack of bulging of the retropharyngeal wall. The constellation of these imaging and clinical findings was consistent with the diagnosis of longus colli (prevertebral) calcific tendinitis.

Longus colli (prevertebral) calcific tendinitis results from calcium hydroxyapatite deposition within the tendon. While the bilateral longus colli muscles extend from the atlas to the upper thoracic vertebral level, calcium hydroxyapatite crystals typically deposit at the C1-C2 level^1,2 (as seen in this case). Associated inflammation of the tendon can result in prevertebral fluid that may be confused for retropharyngeal abscess, particularly given the associated neck pain and stiffness, dysphagia, odynophagia, and possible mild leukocytosis and/or mild C-reactive protein elevation. ¹ However, imaging in this case confirmed that the prevertebral fluid extended from the calcium deposits in the tendon and excluded the presence of a rim-enhancing abscess collection. Knowledge of this clinical entity is important given its similar clinical presentation to other conditions with differing treatment strategies (eg, retropharyngeal abscess, meningitis).³

Longus colli (prevertebral) calcific tendinitis is a self-limiting condition that typically lasts 1 to 3 weeks, though it can be very painful during the acute phase.^1,2 Treatment is typically conservative, and the patient in this case received a course of oral corticosteroids and nonsteroidal anti-inflammatory drugs to help alleviate the associated inflammation.

Dr Bartolotta is an assistant professor of radiology at Weill Cornell Medical College in New York City and assistant attending radiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr Baradaran is a resident in the department of radiology at Weill Cornell Medical College in New York City. Dr Hentel is an associate professor of clinical radiology at Weill Cornell Medical College, New York. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology at New York-Presbyterian Hospital/Weill Cornell Medical Center; and associate editor, imaging, of the EMERGENCY MEDICINE editorial board.

Case

A 41-year-old woman presented to the ED with a 3-day history of posterior neck pain that radiated to the occipital region. The patient stated that the day prior to presentation, the pain had worsened to what she rated as a “9” on a pain scale of 0 to 10. The patient’s surgical history included a remote prior cervical fusion at C5-C6. A lateral radiograph of the cervical spine is shown above (Figure 1a).

What is the diagnosis? Is additional imaging necessary? If so, why?

 

Answer

The lateral view of the cervical spine demonstrated soft tissue swelling in the upper prevertebral region (red arrowheads, Figure 1b). (The soft tissues at this level in an adult normally measure less than 3 mm between the airway and the vertebral body.) The radiograph also showed an area of calcification within the prevertebral soft tissues (white arrow, Figure 1b).

The patient denied fevers, chills, dysphagia, visual changes, and nasal congestion. Physical examination demonstrated tenderness to palpation of the posterior neck, but there was no evidence of palpable mass or lymphadenopathy. Neck extension and lateral movement to the left were severely limited due to pain; neck flexion and lateral movement range of motion to the right were mildly decreased due to pain. The physical examination was otherwise normal.

Computed tomography (CT) of the neck was performed to further evaluate the soft tissue swelling and confirm the calcification (white arrow, Figure 2). The CT localized the abnormality to the expected location of the longus colli tendon. Magnetic resonance imaging (MRI) of the cervical spine with and without contrast was performed to directly visualize the tendon/effusion and to exclude prevertebral abscess. The MRI showed abnormally increased fluid signal about the longus colli tendon on Short tau inversion recovery (STIR) images (white arrows, Figure 3a). This fluid extended in all directions from the calcifications and lacked a defined enhancing wall on postcontrast images (white arrows, Figure 3b), suggesting that the fluid reflected reactive effusion rather than soft tissue abscess. A flexible fiberoptic laryngoscopic examination was normal, including the lack of bulging of the retropharyngeal wall. The constellation of these imaging and clinical findings was consistent with the diagnosis of longus colli (prevertebral) calcific tendinitis.

Longus colli (prevertebral) calcific tendinitis results from calcium hydroxyapatite deposition within the tendon. While the bilateral longus colli muscles extend from the atlas to the upper thoracic vertebral level, calcium hydroxyapatite crystals typically deposit at the C1-C2 level^1,2 (as seen in this case). Associated inflammation of the tendon can result in prevertebral fluid that may be confused for retropharyngeal abscess, particularly given the associated neck pain and stiffness, dysphagia, odynophagia, and possible mild leukocytosis and/or mild C-reactive protein elevation. ¹ However, imaging in this case confirmed that the prevertebral fluid extended from the calcium deposits in the tendon and excluded the presence of a rim-enhancing abscess collection. Knowledge of this clinical entity is important given its similar clinical presentation to other conditions with differing treatment strategies (eg, retropharyngeal abscess, meningitis).³

Longus colli (prevertebral) calcific tendinitis is a self-limiting condition that typically lasts 1 to 3 weeks, though it can be very painful during the acute phase.^1,2 Treatment is typically conservative, and the patient in this case received a course of oral corticosteroids and nonsteroidal anti-inflammatory drugs to help alleviate the associated inflammation.

Dr Bartolotta is an assistant professor of radiology at Weill Cornell Medical College in New York City and assistant attending radiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr Baradaran is a resident in the department of radiology at Weill Cornell Medical College in New York City. Dr Hentel is an associate professor of clinical radiology at Weill Cornell Medical College, New York. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology at New York-Presbyterian Hospital/Weill Cornell Medical Center; and associate editor, imaging, of the EMERGENCY MEDICINE editorial board.

Fractures of the superior and inferior pelvic rami are common in pelvic ring injuries.¹ These fractures are routinely treated successfully without surgery.² When the pelvic ring is injured, and ramus fracture or fractures represent a point of instability, surgical fixation can be performed to impart stability and reduce discomfort.³ Patients with pubic ramus fracture(s) have overall greater long-term morbidity and mortality.⁴ Operative stabilization of the superior pubic ramus can be achieved with open reduction and internal fixation, external fixation, and percutaneous medullary screw fixation.^5-8 Inferior ramus fractures are seldom treated directly and acutely with operative reduction and fixation, as the mechanical advantage inferior ramus fixation provides is unknown.

Persistent nonunion of the pelvic ring can cause pain and disability and make reconstruction increasingly difficult.⁹ Open and percutaneous fixation techniques have been used to address symptomatic nonunions of the superior pubic ramus.^9,10 There is limited evidence supporting surgical fixation of the inferior ramus. Open surgical fixation for symptomatic nonunions of the inferior ramus has been described.^11,12 The inferior ramus has an osseous fixation pathway (OFP) amenable to percutaneous screw placement.¹³ Placement of a percutaneous screw in the inferior ramus requires use of preoperative computed tomography (CT) and is technically demanding. Surgeons must understand use of intraoperative fluoroscopy to ensure that the screw is contained within bone and crosses the intended zone of nonunion.

In this article, we report 2 cases of adults with symptomatic hypertrophic nonunions of the inferior ramus, treated with percutaneous screw fixation. Both patients presented with focal groin pain and activity limitations. Each had concurrent ipsilateral hypertrophic nonunions of the superior ramus, treated with percutaneous antegrade intramedullary stabilization. The patients provided written informed consent for print and electronic publication of these case reports.

Case Reports

Case 1

A 45-year-old woman fell from a horse about 8 months before presenting to the orthopedic outpatient clinic. Pelvic radiographs obtained after the fall were negative for fracture, but subsequent pelvic magnetic resonance imaging led to the diagnoses of minimally displaced left superior and inferior pubic ramus fractures and associated right-sided sacral ala fracture. The patient was treated with protected weight-bearing according to symptoms, but increasing activity-related pain and discomfort in the left groin persisted for months after injury. These symptoms were treated with analgesic medication, physical therapy, and chiropractic manipulation. Repeat imaging showed hypertrophic nonunions of the left superior and inferior pubic rami (Figure 1). Findings of the serologic testing performed for infection and metabolic deficiencies were normal at that time. The patient was referred for surgical consultation.

On evaluation, she reported constant pain in the left groin with ambulation. Specifically, squatting, pushing and pulling activities were extremely uncomfortable. She had been unable to return to work either full-time or part-time. On physical examination, she walked with an antalgic gait with a decreased stance phase of the left lower extremity. She had tenderness to palpation medial to the hip joint without evidence of hernia or lymphadenopathy. The pelvis was stable to manual compression testing.

Pelvic CT showed the nonunion site and the osteology of the inferior and superior pubic ramus of the pelvis, as well as minimal displacement and good alignment of the rami.

The patient was placed supine on a flat radiolucent table (Mizuho OSI, Union City, California). Preoperative cephalosporin antibiotics were administered. After induction of general anesthesia, the lumbosacral spine was elevated under 2 folded blankets. Arms were abducted to allow for pelvic imaging, and all bony prominences were padded. A urinary catheter was inserted aseptically to decompress the bladder. The entire abdomen and bilateral flanks were shaved, prepared, and draped in usual sterile fashion. A partially threaded cannulated screw was placed using a percutaneous antegrade technique to address the hypertrophic superior ramus nonunion.

A C-arm fluoroscopy unit (Ziehm, Orlando, Florida) was positioned on the injured side. The surgeon stood on the contralateral side. A pelvic OOOCI (outlet obturator oblique combinative image) of the symphysis pubis was obtained. This view defined the medial and lateral extents of the inferior ramus. A 0.062-in smooth Kirschner wire was used to percutaneously locate an ideal starting point on the cranial aspect of the contralateral superior pubic ramus. The starting point was adjusted on this view until an ideal intended trajectory into the contralateral (affected) inferior pubic ramus was visualized (Figure 2A).

The C-arm beam was then oriented to an “excessive” pelvic inlet view tangential to the posterior cortical surface of the affected inferior pubic ramus (Figure 2B). The tip of the wire was then adjusted to position and aim it slightly anterior to the posterior cortical surface of the affected inferior ramus. The wire was advanced into the bone about 1 cm, and the location and direction of the wire were reconfirmed as accurate.

 

A vertical skin incision was then made around the wire, and the 4.5-mm cannulated drill was placed over the wire. A soft-tissue protective drill sleeve and oscillating technique were used to protect the soft-tissue anatomy. The trajectory of the drill was again confirmed on pelvic OOOCI and advanced into the bone. The intended path of the drill was from the cranial-medial symphyseal cortex of the contralateral superior ramus, through the symphysis pubis obliquely, and then into the medullary canal of the affected inferior ramus. Frequent biplanar fluoroscopic imaging followed this progression of the drill to the nonunion site. The cannulated drill was then removed and exchanged for a calibrated extra-long 2.5-mm drill bit, placed through the soft-tissue drill sleeve and into the glide hole created by the 4.5-mm cannulated drill. The C-arm unit ensured accurate positioning of the 2.5-mm drill on both pelvic OOOCI and “excessive” inlet view before advancement (Figures 3A, 3B). The 2.5-mm drill was advanced caudally, laterally, and anteriorly in the ramus, past the nonunion site, and then was stopped before it exited the cortex of the ischial tuberosity (Figures 4A, 4B).

 

The depth of the drill bit was assessed with a known-length protective drill sleeve and calibrated drill. Alternatively, depth can be assessed with another same-length calibrated drill bit positioned adjacent to the inserted drill bit. A fully threaded, blunt-tipped 4.5-mm cortical screw was then placed through the glide hole. Both fluoroscopic views were used to confirm that the screw followed the same trajectory as the drill. Finally, the screw was again checked on biplanar fluoroscopy to confirm it had remained in the OFP of the inferior ramus (Figures 5A, 5B).

Postoperative pelvic CT confirmed position and length of the screws. The patient was allowed weight-of-limb weight-bearing on her affected side after surgery. She was discharged the first day after surgery and allowed use of oral analgesics. Six weeks after surgery, pelvic radiographs showed partial healing, and she reported symptom relief. Resistive strengthening exercises were instituted, and progressive weight-bearing proceeded to full weight-bearing over the next 6 weeks. The patient reported almost complete relief of pain by 3 months, and she was able to return to work and daily activities without medication. Radiographs showed consolidation of the fractures. She was essentially symptom-free 17 months after surgery (Figure 6).

Case 2

An obese 51-year-old woman presented to the orthopedic clinic with a 6-month history of left groin pain that worsened with ambulation. She did not recall a specific injury but acknowledged a history of previous falls. Past medical history was significant for ulcerative colitis/irritable bowel syndrome and degenerative disease in the lumbar spine and right ankle. Previous pelvic radiographs showed no evidence of fracture or abnormality, but radiographs obtained before evaluation in the clinic showed hypertrophic nonunion of the left superior and inferior pubic ramus.

The patient had pain deep in the left groin with weight-bearing. On physical examination, she denied pain with log roll of the left hip or resisted straight leg raise. The pelvis was stable to manual compression. There was no sign of hernia or lymphadenopathy in the region of the left groin.

The patient had obtained a technetium-99 nuclear medicine scan of the pelvis in addition to standard preoperative CT of the nonunion area. The nuclear medicine scan showed uptake in the area of the superior and inferior ramus, and CT confirmed presence of a superior and inferior ramus that would accommodate a medullary screw.

The patient was taken to the operating room, where percutaneous fixation of the left superior and inferior ramus was performed (as described above). The patient was discharged on postoperative day 2 and followed the same weight-bearing protocol that the first patient used.

At 6 weeks, the patient returned to clinic with improved comfort. At 3 months, she denied left groin pain and was limited in activity only by preexisting arthrosis in the left ankle and lumbar spine. She was using a walker only for long distances and was symptom-free 13 months after surgery.

Discussion

Acute surgical fixation of the inferior ramus is seldom performed. The anatomical location of the inferior ramus and the lack of defined criteria for fixation often leave the inferior ramus ignored, unreduced, and without stabilization. In the setting of symptomatic nonunion, open stabilization has been used.^11,12 Plate fixation after open débridement of an inferior ramus nonunion requires more extensive dissection and may increase the risk for perioperative infection and hardware prominence compared with an intramedullary implant.¹⁴ If plate prominence becomes symptomatic, the plate must be removed in a second surgical procedure. Percutaneous medullary screw fixation avoids the risks of surgical soft-tissue dissection and placement of a surface implant on the bone and reduces the need for a second surgical procedure to remove bothersome hardware. Percutaneous pelvic fixation has been well described and shown to provide stability to the pelvis. It can also be used to treat hypertrophic nonunions of the pelvis when mechanical stability is required for healing.¹³

 

In the cases reported here, inferior ramus stabilization was combined with intramedullary fixation of the superior ramus. As each patient had deep groin pain that could not be localized to either ramus, both rami were stabilized after close assessment on preoperative CT. Solitary fixation of the superior ramus may or may not provide stability sufficient for inferior ramus union and should be performed when the OFP of the inferior ramus is unavailable.

The anatomy of the inferior ramus must be carefully reviewed before surgery, as it is seldom encountered in open and percutaneous orthopedic pelvic surgery. The inferior ramus extends from the symphysis pubis to the ischial tuberosity. The ramus is wider medially and thinner laterally near the obturator foramen. The anterior surface of the ramus is flat and concave, whereas the posterior surface is flat and convex. The anatomy of the inferior ramus varies somewhat, and any distortion (eg, fracture, nonunion) of the OFP can render it incapable of accommodating screw fixation.¹³

Percutaneous placement of a medullary screw in the inferior ramus requires an understanding of the fluoroscopy required. Challenges, including body habitus and unique osseous anatomy, must be recognized. Soft tissues must be protected with a drill sleeve during preparation of the screw pathway, and care must be taken to avoid placing the screw beyond the cortex of the ischial tuberosity. A prominent screw tip can irritate the patient in the hamstrings or while sitting.

Intramedullary screw fixation of the inferior ramus is a technically demanding surgical procedure. Meticulous evaluation of preoperative radiographic studies must accompany strict attention to surgical detail. A misplaced or malpositioned drill bit or screw can injure surrounding neurovascular structures. A screw that does not cross the fracture or is not in the OFP of the inferior ramus will be ineffective and
potentially dangerous.

Conclusion

We have presented a technique for percutaneous screw placement in the inferior ramus. This technique requires an understanding of the anatomy of the inferior ramus and of the intraoperative fluoroscopy required for screw placement. We have used this technique to successfully treat symptomatic hypertrophic nonunions of the inferior ramus that require skeletal stability for healing.

Fractures of the superior and inferior pelvic rami are common in pelvic ring injuries.¹ These fractures are routinely treated successfully without surgery.² When the pelvic ring is injured, and ramus fracture or fractures represent a point of instability, surgical fixation can be performed to impart stability and reduce discomfort.³ Patients with pubic ramus fracture(s) have overall greater long-term morbidity and mortality.⁴ Operative stabilization of the superior pubic ramus can be achieved with open reduction and internal fixation, external fixation, and percutaneous medullary screw fixation.^5-8 Inferior ramus fractures are seldom treated directly and acutely with operative reduction and fixation, as the mechanical advantage inferior ramus fixation provides is unknown.

Persistent nonunion of the pelvic ring can cause pain and disability and make reconstruction increasingly difficult.⁹ Open and percutaneous fixation techniques have been used to address symptomatic nonunions of the superior pubic ramus.^9,10 There is limited evidence supporting surgical fixation of the inferior ramus. Open surgical fixation for symptomatic nonunions of the inferior ramus has been described.^11,12 The inferior ramus has an osseous fixation pathway (OFP) amenable to percutaneous screw placement.¹³ Placement of a percutaneous screw in the inferior ramus requires use of preoperative computed tomography (CT) and is technically demanding. Surgeons must understand use of intraoperative fluoroscopy to ensure that the screw is contained within bone and crosses the intended zone of nonunion.

In this article, we report 2 cases of adults with symptomatic hypertrophic nonunions of the inferior ramus, treated with percutaneous screw fixation. Both patients presented with focal groin pain and activity limitations. Each had concurrent ipsilateral hypertrophic nonunions of the superior ramus, treated with percutaneous antegrade intramedullary stabilization. The patients provided written informed consent for print and electronic publication of these case reports.

Case Reports

Case 1

A 45-year-old woman fell from a horse about 8 months before presenting to the orthopedic outpatient clinic. Pelvic radiographs obtained after the fall were negative for fracture, but subsequent pelvic magnetic resonance imaging led to the diagnoses of minimally displaced left superior and inferior pubic ramus fractures and associated right-sided sacral ala fracture. The patient was treated with protected weight-bearing according to symptoms, but increasing activity-related pain and discomfort in the left groin persisted for months after injury. These symptoms were treated with analgesic medication, physical therapy, and chiropractic manipulation. Repeat imaging showed hypertrophic nonunions of the left superior and inferior pubic rami (Figure 1). Findings of the serologic testing performed for infection and metabolic deficiencies were normal at that time. The patient was referred for surgical consultation.

On evaluation, she reported constant pain in the left groin with ambulation. Specifically, squatting, pushing and pulling activities were extremely uncomfortable. She had been unable to return to work either full-time or part-time. On physical examination, she walked with an antalgic gait with a decreased stance phase of the left lower extremity. She had tenderness to palpation medial to the hip joint without evidence of hernia or lymphadenopathy. The pelvis was stable to manual compression testing.

Pelvic CT showed the nonunion site and the osteology of the inferior and superior pubic ramus of the pelvis, as well as minimal displacement and good alignment of the rami.

The patient was placed supine on a flat radiolucent table (Mizuho OSI, Union City, California). Preoperative cephalosporin antibiotics were administered. After induction of general anesthesia, the lumbosacral spine was elevated under 2 folded blankets. Arms were abducted to allow for pelvic imaging, and all bony prominences were padded. A urinary catheter was inserted aseptically to decompress the bladder. The entire abdomen and bilateral flanks were shaved, prepared, and draped in usual sterile fashion. A partially threaded cannulated screw was placed using a percutaneous antegrade technique to address the hypertrophic superior ramus nonunion.

A C-arm fluoroscopy unit (Ziehm, Orlando, Florida) was positioned on the injured side. The surgeon stood on the contralateral side. A pelvic OOOCI (outlet obturator oblique combinative image) of the symphysis pubis was obtained. This view defined the medial and lateral extents of the inferior ramus. A 0.062-in smooth Kirschner wire was used to percutaneously locate an ideal starting point on the cranial aspect of the contralateral superior pubic ramus. The starting point was adjusted on this view until an ideal intended trajectory into the contralateral (affected) inferior pubic ramus was visualized (Figure 2A).

The C-arm beam was then oriented to an “excessive” pelvic inlet view tangential to the posterior cortical surface of the affected inferior pubic ramus (Figure 2B). The tip of the wire was then adjusted to position and aim it slightly anterior to the posterior cortical surface of the affected inferior ramus. The wire was advanced into the bone about 1 cm, and the location and direction of the wire were reconfirmed as accurate.

 

A vertical skin incision was then made around the wire, and the 4.5-mm cannulated drill was placed over the wire. A soft-tissue protective drill sleeve and oscillating technique were used to protect the soft-tissue anatomy. The trajectory of the drill was again confirmed on pelvic OOOCI and advanced into the bone. The intended path of the drill was from the cranial-medial symphyseal cortex of the contralateral superior ramus, through the symphysis pubis obliquely, and then into the medullary canal of the affected inferior ramus. Frequent biplanar fluoroscopic imaging followed this progression of the drill to the nonunion site. The cannulated drill was then removed and exchanged for a calibrated extra-long 2.5-mm drill bit, placed through the soft-tissue drill sleeve and into the glide hole created by the 4.5-mm cannulated drill. The C-arm unit ensured accurate positioning of the 2.5-mm drill on both pelvic OOOCI and “excessive” inlet view before advancement (Figures 3A, 3B). The 2.5-mm drill was advanced caudally, laterally, and anteriorly in the ramus, past the nonunion site, and then was stopped before it exited the cortex of the ischial tuberosity (Figures 4A, 4B).

 

The depth of the drill bit was assessed with a known-length protective drill sleeve and calibrated drill. Alternatively, depth can be assessed with another same-length calibrated drill bit positioned adjacent to the inserted drill bit. A fully threaded, blunt-tipped 4.5-mm cortical screw was then placed through the glide hole. Both fluoroscopic views were used to confirm that the screw followed the same trajectory as the drill. Finally, the screw was again checked on biplanar fluoroscopy to confirm it had remained in the OFP of the inferior ramus (Figures 5A, 5B).

Postoperative pelvic CT confirmed position and length of the screws. The patient was allowed weight-of-limb weight-bearing on her affected side after surgery. She was discharged the first day after surgery and allowed use of oral analgesics. Six weeks after surgery, pelvic radiographs showed partial healing, and she reported symptom relief. Resistive strengthening exercises were instituted, and progressive weight-bearing proceeded to full weight-bearing over the next 6 weeks. The patient reported almost complete relief of pain by 3 months, and she was able to return to work and daily activities without medication. Radiographs showed consolidation of the fractures. She was essentially symptom-free 17 months after surgery (Figure 6).

Case 2

An obese 51-year-old woman presented to the orthopedic clinic with a 6-month history of left groin pain that worsened with ambulation. She did not recall a specific injury but acknowledged a history of previous falls. Past medical history was significant for ulcerative colitis/irritable bowel syndrome and degenerative disease in the lumbar spine and right ankle. Previous pelvic radiographs showed no evidence of fracture or abnormality, but radiographs obtained before evaluation in the clinic showed hypertrophic nonunion of the left superior and inferior pubic ramus.

The patient had pain deep in the left groin with weight-bearing. On physical examination, she denied pain with log roll of the left hip or resisted straight leg raise. The pelvis was stable to manual compression. There was no sign of hernia or lymphadenopathy in the region of the left groin.

The patient had obtained a technetium-99 nuclear medicine scan of the pelvis in addition to standard preoperative CT of the nonunion area. The nuclear medicine scan showed uptake in the area of the superior and inferior ramus, and CT confirmed presence of a superior and inferior ramus that would accommodate a medullary screw.

The patient was taken to the operating room, where percutaneous fixation of the left superior and inferior ramus was performed (as described above). The patient was discharged on postoperative day 2 and followed the same weight-bearing protocol that the first patient used.

At 6 weeks, the patient returned to clinic with improved comfort. At 3 months, she denied left groin pain and was limited in activity only by preexisting arthrosis in the left ankle and lumbar spine. She was using a walker only for long distances and was symptom-free 13 months after surgery.

Discussion

Acute surgical fixation of the inferior ramus is seldom performed. The anatomical location of the inferior ramus and the lack of defined criteria for fixation often leave the inferior ramus ignored, unreduced, and without stabilization. In the setting of symptomatic nonunion, open stabilization has been used.^11,12 Plate fixation after open débridement of an inferior ramus nonunion requires more extensive dissection and may increase the risk for perioperative infection and hardware prominence compared with an intramedullary implant.¹⁴ If plate prominence becomes symptomatic, the plate must be removed in a second surgical procedure. Percutaneous medullary screw fixation avoids the risks of surgical soft-tissue dissection and placement of a surface implant on the bone and reduces the need for a second surgical procedure to remove bothersome hardware. Percutaneous pelvic fixation has been well described and shown to provide stability to the pelvis. It can also be used to treat hypertrophic nonunions of the pelvis when mechanical stability is required for healing.¹³

 

In the cases reported here, inferior ramus stabilization was combined with intramedullary fixation of the superior ramus. As each patient had deep groin pain that could not be localized to either ramus, both rami were stabilized after close assessment on preoperative CT. Solitary fixation of the superior ramus may or may not provide stability sufficient for inferior ramus union and should be performed when the OFP of the inferior ramus is unavailable.

The anatomy of the inferior ramus must be carefully reviewed before surgery, as it is seldom encountered in open and percutaneous orthopedic pelvic surgery. The inferior ramus extends from the symphysis pubis to the ischial tuberosity. The ramus is wider medially and thinner laterally near the obturator foramen. The anterior surface of the ramus is flat and concave, whereas the posterior surface is flat and convex. The anatomy of the inferior ramus varies somewhat, and any distortion (eg, fracture, nonunion) of the OFP can render it incapable of accommodating screw fixation.¹³

Percutaneous placement of a medullary screw in the inferior ramus requires an understanding of the fluoroscopy required. Challenges, including body habitus and unique osseous anatomy, must be recognized. Soft tissues must be protected with a drill sleeve during preparation of the screw pathway, and care must be taken to avoid placing the screw beyond the cortex of the ischial tuberosity. A prominent screw tip can irritate the patient in the hamstrings or while sitting.

Intramedullary screw fixation of the inferior ramus is a technically demanding surgical procedure. Meticulous evaluation of preoperative radiographic studies must accompany strict attention to surgical detail. A misplaced or malpositioned drill bit or screw can injure surrounding neurovascular structures. A screw that does not cross the fracture or is not in the OFP of the inferior ramus will be ineffective and
potentially dangerous.

Conclusion

We have presented a technique for percutaneous screw placement in the inferior ramus. This technique requires an understanding of the anatomy of the inferior ramus and of the intraoperative fluoroscopy required for screw placement. We have used this technique to successfully treat symptomatic hypertrophic nonunions of the inferior ramus that require skeletal stability for healing.

Fractures of the superior and inferior pelvic rami are common in pelvic ring injuries.¹ These fractures are routinely treated successfully without surgery.² When the pelvic ring is injured, and ramus fracture or fractures represent a point of instability, surgical fixation can be performed to impart stability and reduce discomfort.³ Patients with pubic ramus fracture(s) have overall greater long-term morbidity and mortality.⁴ Operative stabilization of the superior pubic ramus can be achieved with open reduction and internal fixation, external fixation, and percutaneous medullary screw fixation.^5-8 Inferior ramus fractures are seldom treated directly and acutely with operative reduction and fixation, as the mechanical advantage inferior ramus fixation provides is unknown.

Persistent nonunion of the pelvic ring can cause pain and disability and make reconstruction increasingly difficult.⁹ Open and percutaneous fixation techniques have been used to address symptomatic nonunions of the superior pubic ramus.^9,10 There is limited evidence supporting surgical fixation of the inferior ramus. Open surgical fixation for symptomatic nonunions of the inferior ramus has been described.^11,12 The inferior ramus has an osseous fixation pathway (OFP) amenable to percutaneous screw placement.¹³ Placement of a percutaneous screw in the inferior ramus requires use of preoperative computed tomography (CT) and is technically demanding. Surgeons must understand use of intraoperative fluoroscopy to ensure that the screw is contained within bone and crosses the intended zone of nonunion.

In this article, we report 2 cases of adults with symptomatic hypertrophic nonunions of the inferior ramus, treated with percutaneous screw fixation. Both patients presented with focal groin pain and activity limitations. Each had concurrent ipsilateral hypertrophic nonunions of the superior ramus, treated with percutaneous antegrade intramedullary stabilization. The patients provided written informed consent for print and electronic publication of these case reports.

Case Reports

Case 1

A 45-year-old woman fell from a horse about 8 months before presenting to the orthopedic outpatient clinic. Pelvic radiographs obtained after the fall were negative for fracture, but subsequent pelvic magnetic resonance imaging led to the diagnoses of minimally displaced left superior and inferior pubic ramus fractures and associated right-sided sacral ala fracture. The patient was treated with protected weight-bearing according to symptoms, but increasing activity-related pain and discomfort in the left groin persisted for months after injury. These symptoms were treated with analgesic medication, physical therapy, and chiropractic manipulation. Repeat imaging showed hypertrophic nonunions of the left superior and inferior pubic rami (Figure 1). Findings of the serologic testing performed for infection and metabolic deficiencies were normal at that time. The patient was referred for surgical consultation.

On evaluation, she reported constant pain in the left groin with ambulation. Specifically, squatting, pushing and pulling activities were extremely uncomfortable. She had been unable to return to work either full-time or part-time. On physical examination, she walked with an antalgic gait with a decreased stance phase of the left lower extremity. She had tenderness to palpation medial to the hip joint without evidence of hernia or lymphadenopathy. The pelvis was stable to manual compression testing.

Pelvic CT showed the nonunion site and the osteology of the inferior and superior pubic ramus of the pelvis, as well as minimal displacement and good alignment of the rami.

The patient was placed supine on a flat radiolucent table (Mizuho OSI, Union City, California). Preoperative cephalosporin antibiotics were administered. After induction of general anesthesia, the lumbosacral spine was elevated under 2 folded blankets. Arms were abducted to allow for pelvic imaging, and all bony prominences were padded. A urinary catheter was inserted aseptically to decompress the bladder. The entire abdomen and bilateral flanks were shaved, prepared, and draped in usual sterile fashion. A partially threaded cannulated screw was placed using a percutaneous antegrade technique to address the hypertrophic superior ramus nonunion.

A C-arm fluoroscopy unit (Ziehm, Orlando, Florida) was positioned on the injured side. The surgeon stood on the contralateral side. A pelvic OOOCI (outlet obturator oblique combinative image) of the symphysis pubis was obtained. This view defined the medial and lateral extents of the inferior ramus. A 0.062-in smooth Kirschner wire was used to percutaneously locate an ideal starting point on the cranial aspect of the contralateral superior pubic ramus. The starting point was adjusted on this view until an ideal intended trajectory into the contralateral (affected) inferior pubic ramus was visualized (Figure 2A).

The C-arm beam was then oriented to an “excessive” pelvic inlet view tangential to the posterior cortical surface of the affected inferior pubic ramus (Figure 2B). The tip of the wire was then adjusted to position and aim it slightly anterior to the posterior cortical surface of the affected inferior ramus. The wire was advanced into the bone about 1 cm, and the location and direction of the wire were reconfirmed as accurate.

 

A vertical skin incision was then made around the wire, and the 4.5-mm cannulated drill was placed over the wire. A soft-tissue protective drill sleeve and oscillating technique were used to protect the soft-tissue anatomy. The trajectory of the drill was again confirmed on pelvic OOOCI and advanced into the bone. The intended path of the drill was from the cranial-medial symphyseal cortex of the contralateral superior ramus, through the symphysis pubis obliquely, and then into the medullary canal of the affected inferior ramus. Frequent biplanar fluoroscopic imaging followed this progression of the drill to the nonunion site. The cannulated drill was then removed and exchanged for a calibrated extra-long 2.5-mm drill bit, placed through the soft-tissue drill sleeve and into the glide hole created by the 4.5-mm cannulated drill. The C-arm unit ensured accurate positioning of the 2.5-mm drill on both pelvic OOOCI and “excessive” inlet view before advancement (Figures 3A, 3B). The 2.5-mm drill was advanced caudally, laterally, and anteriorly in the ramus, past the nonunion site, and then was stopped before it exited the cortex of the ischial tuberosity (Figures 4A, 4B).

 

The depth of the drill bit was assessed with a known-length protective drill sleeve and calibrated drill. Alternatively, depth can be assessed with another same-length calibrated drill bit positioned adjacent to the inserted drill bit. A fully threaded, blunt-tipped 4.5-mm cortical screw was then placed through the glide hole. Both fluoroscopic views were used to confirm that the screw followed the same trajectory as the drill. Finally, the screw was again checked on biplanar fluoroscopy to confirm it had remained in the OFP of the inferior ramus (Figures 5A, 5B).

Postoperative pelvic CT confirmed position and length of the screws. The patient was allowed weight-of-limb weight-bearing on her affected side after surgery. She was discharged the first day after surgery and allowed use of oral analgesics. Six weeks after surgery, pelvic radiographs showed partial healing, and she reported symptom relief. Resistive strengthening exercises were instituted, and progressive weight-bearing proceeded to full weight-bearing over the next 6 weeks. The patient reported almost complete relief of pain by 3 months, and she was able to return to work and daily activities without medication. Radiographs showed consolidation of the fractures. She was essentially symptom-free 17 months after surgery (Figure 6).

Case 2

An obese 51-year-old woman presented to the orthopedic clinic with a 6-month history of left groin pain that worsened with ambulation. She did not recall a specific injury but acknowledged a history of previous falls. Past medical history was significant for ulcerative colitis/irritable bowel syndrome and degenerative disease in the lumbar spine and right ankle. Previous pelvic radiographs showed no evidence of fracture or abnormality, but radiographs obtained before evaluation in the clinic showed hypertrophic nonunion of the left superior and inferior pubic ramus.

The patient had pain deep in the left groin with weight-bearing. On physical examination, she denied pain with log roll of the left hip or resisted straight leg raise. The pelvis was stable to manual compression. There was no sign of hernia or lymphadenopathy in the region of the left groin.

The patient had obtained a technetium-99 nuclear medicine scan of the pelvis in addition to standard preoperative CT of the nonunion area. The nuclear medicine scan showed uptake in the area of the superior and inferior ramus, and CT confirmed presence of a superior and inferior ramus that would accommodate a medullary screw.

The patient was taken to the operating room, where percutaneous fixation of the left superior and inferior ramus was performed (as described above). The patient was discharged on postoperative day 2 and followed the same weight-bearing protocol that the first patient used.

At 6 weeks, the patient returned to clinic with improved comfort. At 3 months, she denied left groin pain and was limited in activity only by preexisting arthrosis in the left ankle and lumbar spine. She was using a walker only for long distances and was symptom-free 13 months after surgery.

Discussion

Acute surgical fixation of the inferior ramus is seldom performed. The anatomical location of the inferior ramus and the lack of defined criteria for fixation often leave the inferior ramus ignored, unreduced, and without stabilization. In the setting of symptomatic nonunion, open stabilization has been used.^11,12 Plate fixation after open débridement of an inferior ramus nonunion requires more extensive dissection and may increase the risk for perioperative infection and hardware prominence compared with an intramedullary implant.¹⁴ If plate prominence becomes symptomatic, the plate must be removed in a second surgical procedure. Percutaneous medullary screw fixation avoids the risks of surgical soft-tissue dissection and placement of a surface implant on the bone and reduces the need for a second surgical procedure to remove bothersome hardware. Percutaneous pelvic fixation has been well described and shown to provide stability to the pelvis. It can also be used to treat hypertrophic nonunions of the pelvis when mechanical stability is required for healing.¹³

 

In the cases reported here, inferior ramus stabilization was combined with intramedullary fixation of the superior ramus. As each patient had deep groin pain that could not be localized to either ramus, both rami were stabilized after close assessment on preoperative CT. Solitary fixation of the superior ramus may or may not provide stability sufficient for inferior ramus union and should be performed when the OFP of the inferior ramus is unavailable.

The anatomy of the inferior ramus must be carefully reviewed before surgery, as it is seldom encountered in open and percutaneous orthopedic pelvic surgery. The inferior ramus extends from the symphysis pubis to the ischial tuberosity. The ramus is wider medially and thinner laterally near the obturator foramen. The anterior surface of the ramus is flat and concave, whereas the posterior surface is flat and convex. The anatomy of the inferior ramus varies somewhat, and any distortion (eg, fracture, nonunion) of the OFP can render it incapable of accommodating screw fixation.¹³

Percutaneous placement of a medullary screw in the inferior ramus requires an understanding of the fluoroscopy required. Challenges, including body habitus and unique osseous anatomy, must be recognized. Soft tissues must be protected with a drill sleeve during preparation of the screw pathway, and care must be taken to avoid placing the screw beyond the cortex of the ischial tuberosity. A prominent screw tip can irritate the patient in the hamstrings or while sitting.

Intramedullary screw fixation of the inferior ramus is a technically demanding surgical procedure. Meticulous evaluation of preoperative radiographic studies must accompany strict attention to surgical detail. A misplaced or malpositioned drill bit or screw can injure surrounding neurovascular structures. A screw that does not cross the fracture or is not in the OFP of the inferior ramus will be ineffective and
potentially dangerous.

Conclusion

We have presented a technique for percutaneous screw placement in the inferior ramus. This technique requires an understanding of the anatomy of the inferior ramus and of the intraoperative fluoroscopy required for screw placement. We have used this technique to successfully treat symptomatic hypertrophic nonunions of the inferior ramus that require skeletal stability for healing.

SAN DIEGO– After the first 90 days, there is very little difference in costs out to 3 years between CT angiography and functional testing in the initial evaluation of stable patients with new chest pain, an economic substudy of the PROMISE trial showed.

“CT coronary angiography may not be the ‘holy grail’ of diagnostic tests that we once envisioned, but its more liberal use based on the results of PROMISE may improve some aspects of patient care and I don’t think will be a major new economic burden on the health care system,” study author Dr. Daniel B. Mark said at the annual meeting of the American College of Cardiology.

The PROMISE trial, also presented at the ACA meeting, found no advantage with respect to hard clinical outcomes between the two initial testing strategies, but CTA led to fewer catheterizations showing no obstructive disease and a twofold increase in revascularizations.

The economic analysis involved initial test technical fees, hospital-based facility costs, and physician professional fees for testing and hospital services for 96% of the 9,649 patients in the study.

The estimated cost of CT angiography, including physician fees and technical fees, was $404, compared with $174 for exercise treadmill testing, $501 for echocardiography with pharmacologic stress, $514 for echo with exercise stress, $946 for nuclear testing with exercise stress, and $1,132 for nuclear testing with pharmacologic stress, said Dr. Mark, director of outcomes research at Duke Clinical Research Institute, Durham, N.C.

The trend toward higher costs with CT angiography was driven largely by more revascularizations, with very in little added costs occurring after 90 days, he noted.

An analysis that factored in what was done to patients after their initial test showed CT angiography was more expensive than functional testing by an average of $279 at 90 days, $358 at 1 year, $388 at 2 years, and $694 at 3 years. The 95% confidence intervals were wide, so none of the differences were statistically significant, he said.

Nick Piegari/Frontline Medical Communications

A number of patients underwent very expensive noncardiovascular procedures in the third year that bumped the average cost up in the CT arm, “but we don’t think this has anything to do with the strategies to which they were randomized,” Dr. Mark explained.

Caveats to the analysis include use of an external data source (Premier Research Database) for initial diagnostic testing costs, outpatient medications were not counted, and significant deviations in testing costs by centers that might alter cost results of the two strategies. Quality of life and employment status are also still being analyzed, Dr. Mark said.

A cost-effectiveness analysis was not performed because CT angiography outcomes were not superior as hypothesized in PROMISE.

The study was funded by the National Institutes of Health. Dr. Mark disclosed consulting for Milestone, Medtronic, CardioDx, and St. Jude Medical and research grants from the NIH, Eli Lilly, AstraZeneca, Gilead, AGA Medical, and Bristol-Myers Squibb.

pwendling@frontlinemedcom.com

SAN DIEGO– After the first 90 days, there is very little difference in costs out to 3 years between CT angiography and functional testing in the initial evaluation of stable patients with new chest pain, an economic substudy of the PROMISE trial showed.

“CT coronary angiography may not be the ‘holy grail’ of diagnostic tests that we once envisioned, but its more liberal use based on the results of PROMISE may improve some aspects of patient care and I don’t think will be a major new economic burden on the health care system,” study author Dr. Daniel B. Mark said at the annual meeting of the American College of Cardiology.

The PROMISE trial, also presented at the ACA meeting, found no advantage with respect to hard clinical outcomes between the two initial testing strategies, but CTA led to fewer catheterizations showing no obstructive disease and a twofold increase in revascularizations.

The economic analysis involved initial test technical fees, hospital-based facility costs, and physician professional fees for testing and hospital services for 96% of the 9,649 patients in the study.

The estimated cost of CT angiography, including physician fees and technical fees, was $404, compared with $174 for exercise treadmill testing, $501 for echocardiography with pharmacologic stress, $514 for echo with exercise stress, $946 for nuclear testing with exercise stress, and $1,132 for nuclear testing with pharmacologic stress, said Dr. Mark, director of outcomes research at Duke Clinical Research Institute, Durham, N.C.

The trend toward higher costs with CT angiography was driven largely by more revascularizations, with very in little added costs occurring after 90 days, he noted.

An analysis that factored in what was done to patients after their initial test showed CT angiography was more expensive than functional testing by an average of $279 at 90 days, $358 at 1 year, $388 at 2 years, and $694 at 3 years. The 95% confidence intervals were wide, so none of the differences were statistically significant, he said.

Nick Piegari/Frontline Medical Communications

A number of patients underwent very expensive noncardiovascular procedures in the third year that bumped the average cost up in the CT arm, “but we don’t think this has anything to do with the strategies to which they were randomized,” Dr. Mark explained.

Caveats to the analysis include use of an external data source (Premier Research Database) for initial diagnostic testing costs, outpatient medications were not counted, and significant deviations in testing costs by centers that might alter cost results of the two strategies. Quality of life and employment status are also still being analyzed, Dr. Mark said.

A cost-effectiveness analysis was not performed because CT angiography outcomes were not superior as hypothesized in PROMISE.

The study was funded by the National Institutes of Health. Dr. Mark disclosed consulting for Milestone, Medtronic, CardioDx, and St. Jude Medical and research grants from the NIH, Eli Lilly, AstraZeneca, Gilead, AGA Medical, and Bristol-Myers Squibb.

pwendling@frontlinemedcom.com

SAN DIEGO– After the first 90 days, there is very little difference in costs out to 3 years between CT angiography and functional testing in the initial evaluation of stable patients with new chest pain, an economic substudy of the PROMISE trial showed.

“CT coronary angiography may not be the ‘holy grail’ of diagnostic tests that we once envisioned, but its more liberal use based on the results of PROMISE may improve some aspects of patient care and I don’t think will be a major new economic burden on the health care system,” study author Dr. Daniel B. Mark said at the annual meeting of the American College of Cardiology.

The PROMISE trial, also presented at the ACA meeting, found no advantage with respect to hard clinical outcomes between the two initial testing strategies, but CTA led to fewer catheterizations showing no obstructive disease and a twofold increase in revascularizations.

The economic analysis involved initial test technical fees, hospital-based facility costs, and physician professional fees for testing and hospital services for 96% of the 9,649 patients in the study.

The estimated cost of CT angiography, including physician fees and technical fees, was $404, compared with $174 for exercise treadmill testing, $501 for echocardiography with pharmacologic stress, $514 for echo with exercise stress, $946 for nuclear testing with exercise stress, and $1,132 for nuclear testing with pharmacologic stress, said Dr. Mark, director of outcomes research at Duke Clinical Research Institute, Durham, N.C.

The trend toward higher costs with CT angiography was driven largely by more revascularizations, with very in little added costs occurring after 90 days, he noted.

An analysis that factored in what was done to patients after their initial test showed CT angiography was more expensive than functional testing by an average of $279 at 90 days, $358 at 1 year, $388 at 2 years, and $694 at 3 years. The 95% confidence intervals were wide, so none of the differences were statistically significant, he said.

Nick Piegari/Frontline Medical Communications

A number of patients underwent very expensive noncardiovascular procedures in the third year that bumped the average cost up in the CT arm, “but we don’t think this has anything to do with the strategies to which they were randomized,” Dr. Mark explained.

Caveats to the analysis include use of an external data source (Premier Research Database) for initial diagnostic testing costs, outpatient medications were not counted, and significant deviations in testing costs by centers that might alter cost results of the two strategies. Quality of life and employment status are also still being analyzed, Dr. Mark said.

A cost-effectiveness analysis was not performed because CT angiography outcomes were not superior as hypothesized in PROMISE.

The study was funded by the National Institutes of Health. Dr. Mark disclosed consulting for Milestone, Medtronic, CardioDx, and St. Jude Medical and research grants from the NIH, Eli Lilly, AstraZeneca, Gilead, AGA Medical, and Bristol-Myers Squibb.

pwendling@frontlinemedcom.com

Background

Emergency physicians and other clinicians frequently encounter patients presenting with soft-tissue complaints. Oftentimes, there is diagnostic uncertainty as to whether a patient has cellulitis, an abscess, or both. A prospective observational study by Tayal et al,¹ demonstrated that bedside ultrasound assisted in identifying and differentiating abscess versus cellulitis, altering management in half of the patients.

Anatomy

The soft-tissue layers that can be visualized by ultrasound include the epidermis/dermis, subcutaneous layer, fascia, muscle, and bone (Figure 1).

The epidermis and dermis are indistinguishable by ultrasound, and appear as a single thin bright layer. Below the epidermis and dermis, the subcutaneous layer appears as dark layer, which represents fat and bright connective tissue layer. Deep to that is the fascia, which is a linear bright layer. Below the fascia, muscle fascicles can be seen, which appear as bright striations in a fibrillar pattern.

Preparation and Technique

Soft-tissue ultrasound should be performed using a high frequency linear probe (5-12 MHz or greater) as this allows for higher resolution scanning of superficial structures. For deeper structures, a curvilinear probe can be used instead; however, these images will have a lower resolution.

For practical and infection-control purposes, a tegaderm barrier dressing is recommended for covering the end of the probe (Figure 2). Structures should be viewed in at least two planes (ie, longitudinal and short axis).

Cellulitis

Cellulitis is a common skin and soft-tissue condition, and one that can be visualized quite easily on ultrasound, though its appearance does vary to some degree depending on severity. Early cellulitis can be subtle with increased echogenicity of the skin/subcutaneous fat layers. As cellulitis progresses, it has the more characteristic appearance of “cobblestones,” areas of hyperechoic islands of fat lobules separated by hypoechoic fluid (Figure 3)

. This finding, however, is not specific to cellulitis alone, but can be seen in other conditions that cause interstitial swelling, such as congestive heart failure and peripheral edema.

Abscess

Abscess on ultrasound can be visualized as a hypoechoic collection in the subcutaneous space (Figure 4). It often contains material of mixed echogenicity, and there may be internal septations in the abscess. Simple cysts have the appearance of anechoic fluid collection. On ultrasound, a posterior acoustic enhancement artifact may be seen in both abscesses and cysts.

Putting a little downward pressure with the linear transducer over the abscess can produce swirling or movement within the abscess cavity, and has been informally coined “pustalsis” (Figure 5).

Lymph Nodes

It is sometimes important and useful to distinguish between an abscess and an enlarged lymph node, particularly in the axilla and groin region. Ultrasound can also assist in differentiating between these two conditions. Lymph nodes have an echogenic hilum or center with the periphery of the lymph node appearing darker. (Figure 6)

If color flow is placed on the area, blood flow into the node can be seen. Ultrasound can avoid unnecessary incision and drainage procedure in a patient with lymphadenopathy.

Conclusion

Bedside ultrasound is a useful and easily accessible tool to confirm the diagnosis and facilitate treatment in patients with soft-tissue complaints, including cellulitis, abscess, and lymphadenopathy. This modality is especially helpful in identifying vascular structures in areas such as the axilla or groin when incision and drainage are indicated, and can also help avoid mistaking an abdominal wall hernia for an abscess.

Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Taylor is an assistant professor and director of postgraduate medical education, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Beck is an assistant professor, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia.

Background

Emergency physicians and other clinicians frequently encounter patients presenting with soft-tissue complaints. Oftentimes, there is diagnostic uncertainty as to whether a patient has cellulitis, an abscess, or both. A prospective observational study by Tayal et al,¹ demonstrated that bedside ultrasound assisted in identifying and differentiating abscess versus cellulitis, altering management in half of the patients.

Anatomy

The soft-tissue layers that can be visualized by ultrasound include the epidermis/dermis, subcutaneous layer, fascia, muscle, and bone (Figure 1).

The epidermis and dermis are indistinguishable by ultrasound, and appear as a single thin bright layer. Below the epidermis and dermis, the subcutaneous layer appears as dark layer, which represents fat and bright connective tissue layer. Deep to that is the fascia, which is a linear bright layer. Below the fascia, muscle fascicles can be seen, which appear as bright striations in a fibrillar pattern.

Preparation and Technique

Soft-tissue ultrasound should be performed using a high frequency linear probe (5-12 MHz or greater) as this allows for higher resolution scanning of superficial structures. For deeper structures, a curvilinear probe can be used instead; however, these images will have a lower resolution.

For practical and infection-control purposes, a tegaderm barrier dressing is recommended for covering the end of the probe (Figure 2). Structures should be viewed in at least two planes (ie, longitudinal and short axis).

Cellulitis

Cellulitis is a common skin and soft-tissue condition, and one that can be visualized quite easily on ultrasound, though its appearance does vary to some degree depending on severity. Early cellulitis can be subtle with increased echogenicity of the skin/subcutaneous fat layers. As cellulitis progresses, it has the more characteristic appearance of “cobblestones,” areas of hyperechoic islands of fat lobules separated by hypoechoic fluid (Figure 3)

. This finding, however, is not specific to cellulitis alone, but can be seen in other conditions that cause interstitial swelling, such as congestive heart failure and peripheral edema.

Abscess

Abscess on ultrasound can be visualized as a hypoechoic collection in the subcutaneous space (Figure 4). It often contains material of mixed echogenicity, and there may be internal septations in the abscess. Simple cysts have the appearance of anechoic fluid collection. On ultrasound, a posterior acoustic enhancement artifact may be seen in both abscesses and cysts.

Putting a little downward pressure with the linear transducer over the abscess can produce swirling or movement within the abscess cavity, and has been informally coined “pustalsis” (Figure 5).

Lymph Nodes

It is sometimes important and useful to distinguish between an abscess and an enlarged lymph node, particularly in the axilla and groin region. Ultrasound can also assist in differentiating between these two conditions. Lymph nodes have an echogenic hilum or center with the periphery of the lymph node appearing darker. (Figure 6)

If color flow is placed on the area, blood flow into the node can be seen. Ultrasound can avoid unnecessary incision and drainage procedure in a patient with lymphadenopathy.

Conclusion

Bedside ultrasound is a useful and easily accessible tool to confirm the diagnosis and facilitate treatment in patients with soft-tissue complaints, including cellulitis, abscess, and lymphadenopathy. This modality is especially helpful in identifying vascular structures in areas such as the axilla or groin when incision and drainage are indicated, and can also help avoid mistaking an abdominal wall hernia for an abscess.

Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Taylor is an assistant professor and director of postgraduate medical education, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Beck is an assistant professor, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia.

Background

Emergency physicians and other clinicians frequently encounter patients presenting with soft-tissue complaints. Oftentimes, there is diagnostic uncertainty as to whether a patient has cellulitis, an abscess, or both. A prospective observational study by Tayal et al,¹ demonstrated that bedside ultrasound assisted in identifying and differentiating abscess versus cellulitis, altering management in half of the patients.

Anatomy

The soft-tissue layers that can be visualized by ultrasound include the epidermis/dermis, subcutaneous layer, fascia, muscle, and bone (Figure 1).

The epidermis and dermis are indistinguishable by ultrasound, and appear as a single thin bright layer. Below the epidermis and dermis, the subcutaneous layer appears as dark layer, which represents fat and bright connective tissue layer. Deep to that is the fascia, which is a linear bright layer. Below the fascia, muscle fascicles can be seen, which appear as bright striations in a fibrillar pattern.

Preparation and Technique

Soft-tissue ultrasound should be performed using a high frequency linear probe (5-12 MHz or greater) as this allows for higher resolution scanning of superficial structures. For deeper structures, a curvilinear probe can be used instead; however, these images will have a lower resolution.

For practical and infection-control purposes, a tegaderm barrier dressing is recommended for covering the end of the probe (Figure 2). Structures should be viewed in at least two planes (ie, longitudinal and short axis).

Cellulitis

Cellulitis is a common skin and soft-tissue condition, and one that can be visualized quite easily on ultrasound, though its appearance does vary to some degree depending on severity. Early cellulitis can be subtle with increased echogenicity of the skin/subcutaneous fat layers. As cellulitis progresses, it has the more characteristic appearance of “cobblestones,” areas of hyperechoic islands of fat lobules separated by hypoechoic fluid (Figure 3)

. This finding, however, is not specific to cellulitis alone, but can be seen in other conditions that cause interstitial swelling, such as congestive heart failure and peripheral edema.

Abscess

Abscess on ultrasound can be visualized as a hypoechoic collection in the subcutaneous space (Figure 4). It often contains material of mixed echogenicity, and there may be internal septations in the abscess. Simple cysts have the appearance of anechoic fluid collection. On ultrasound, a posterior acoustic enhancement artifact may be seen in both abscesses and cysts.

Putting a little downward pressure with the linear transducer over the abscess can produce swirling or movement within the abscess cavity, and has been informally coined “pustalsis” (Figure 5).

Lymph Nodes

It is sometimes important and useful to distinguish between an abscess and an enlarged lymph node, particularly in the axilla and groin region. Ultrasound can also assist in differentiating between these two conditions. Lymph nodes have an echogenic hilum or center with the periphery of the lymph node appearing darker. (Figure 6)

If color flow is placed on the area, blood flow into the node can be seen. Ultrasound can avoid unnecessary incision and drainage procedure in a patient with lymphadenopathy.

Conclusion

Bedside ultrasound is a useful and easily accessible tool to confirm the diagnosis and facilitate treatment in patients with soft-tissue complaints, including cellulitis, abscess, and lymphadenopathy. This modality is especially helpful in identifying vascular structures in areas such as the axilla or groin when incision and drainage are indicated, and can also help avoid mistaking an abdominal wall hernia for an abscess.

Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Taylor is an assistant professor and director of postgraduate medical education, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia. Dr Beck is an assistant professor, department of emergency medicine, Emory University School of Medicine, Atlanta, Georgia.

Safe and efficient advanced surgical skill training is of tremendous importance. With the recent increase in Internet use for medical education, there has been a concomitant increase in video recording of surgical procedures and techniques. Surgical recordings have been used in a variety of ways—as live webcasts for remote participants, as “coaching” opportunities for surgeons evaluating their own performance in the operating room, and even as informational resources for patients about to undergo the same surgery.

Surgical multimedia is being delivered through several different outlets. Many academic conferences and meetings showcase videos of different procedures, and several subspecialty societies (eg, Arthroscopy Association of North America) house archives of technical videos for viewing by members. In addition, the VuMedi website offers videos and allows members to comment on them and interact with the videographers. Surgeons are even posting technique videos on YouTube and other public websites.

A large proportion of surgical multimedia is recorded with conventional high-definition video cameras.¹ Besides being able to experience a case at any time and from outside the operating room, the audience can watch from numerous vantage points, angles, and zoom levels. Also, surgeons’ narration can be valuable in helping the audience follow along with the case.

Recording surgical multimedia historically required tight coordination and precise planning by surgeon and videographer. However, innovations in wearable technology now allow surgeons to literally wear video cameras and record procedures as they perform them, in real time—to act as both surgeon and videographer.

Two such products are Google Glass (Google, Mountain View, California) and GoPro Hero (GoPro, San Mateo, California), both of which allow surgeons to record exactly what they see during procedures (Figure 1). Using a wearable technology for surgical multimedia creation requires a deep familiarity with its capabilities and limitations. In this article, we summarize these products’ similarities and differences and provide a technical overview for using wearable technologies in surgical multimedia creation.

1. Choosing a device

When purchasing either wearable device, several factors must be considered, including budget, possible uses outside the operating room, and possible limitations of the technology (Table 1). At this time, Google Glass is significantly more expensive than GoPro Hero. The Google Glass base unit costs $1500, and the GoPro Hero 3 model costs approximately $200 (higher-priced Hero models are available). Both devices require accessories (eg, portable battery unit, dedicated hard drive).

Device capabilities must also be considered (Table 2). Google Glass consists of both hardware and software. Users can record what is seen and heard through the lens and then use apps to create text and e-mail portals to online gaming, social media, and even golf-course GPS. The app market for Google Glass is nascent but undoubtedly will increase in volume and scope as more users adopt the technology (Google Glass comes with both Bluetooth and Wi-Fi and can function tethered through a smartphone). GoPro is mainly a hardware unit that can record in various settings (it is popular with athletes who want to capture and broadcast their participation in action sports). Newer GoPro Hero versions offer Wi-Fi, which allows streaming of video content to a smartphone or tablet through an app. Having clearly defined goals for a device—‌‌as they pertain to use outside the operating room, such as outdoor activities and underwater recording—‌may help the surgeon decide which product is more suitable. Last, it is important to consider limitations. Google Glass resolution is 720p (1280×720) for video and 5 MP for still images, and GoPro resolution can reach 1080p (1920×1080) for video and 5 MP for stills.

Both devices require purchase of accessories. An external USB battery pack is useful for both devices, as is a password-encrypted hard drive for media storage. Lenswear does not come with the base version of Google Glass and is purchased separately from the company. GoPro users buy micro SD cards (~$50 per 64-GB high-speed transfer card) for storage on the device and may buy lithium-ion batteries as an alternative to the external USB battery pack.

Author Update

In January 2015, Google announced that it was temporarily suspending its “Explorer” program, which allowed individual users to buy and test the device for personal use. However, Google is continuing its development of Glass with health care technology, among other areas of growth and development.^2,3

2. Recording a successful surgical video

Unlike a camcorder, which typically is set on a tripod for conventional video recording of surgery, Google Glass and GoPro are intricately linked to the operator. Surgeons must be constantly aware of where they are during surgery and try not to let anything obstruct the camera’s view.

 

Before starting a case, the surgeon using either device must ensure that its battery is fully charged, as a full charge typically supports 1 hour of continuous recording (the Google Glass battery is a lithium-ion 670-mAh internal unit). A full charge should be enough to capture a short case. Newer GoPro models, with a battery listed at 1050 mAh, provide 1 to 2 hours of recording. When more than 1 hour is needed, an external USB battery pack can be used. This pack allows the device to remain plugged in throughout the case (the pack is kept in the surgeon’s back pocket). We recommend having an external battery pack that is at least 10,000 mAh (~$30 online retail), which easily provides 3+ hours of recording. Unfortunately, this arrangement can be cumbersome. Alternatively, with GoPro, additional batteries may be purchased, but the user needs to dismount the device in order to swap them in (may be difficult during surgery). With both units, partitioning a video into shorter segments conserves battery power and minimizes the risk of file corruption, which may occur if the battery dies or the device overheats.

Google Glass users can bypass manual operation of the device by giving it voice commands (eg, start video, take still image). The exception is for recording video for more than 10 seconds (current default setting). Unfortunately, the surgeon must touch the device to start this recording, which means using extra gloves to preserve operating field sterility. Still images can be made through a combination of voice and head gestures and without manual intervention (Figure 2). Last, users must ensure that the device is not actively connected through Bluetooth to a mobile phone, as incoming calls, text messages, and e-mails may disrupt active recording and become a distraction. The connection can be deactivated by disabling Bluetooth on the host smartphone or by placing the phone into airplane mode and turning off Wi-Fi.

Google Glass users can see what is being recorded through the viewfinder prism, whereas GoPro requires precise framing of the video before recording. Framing is done by grossly aiming the device in the desired direction. However, there is no way to ensure exact aim during recording. If at any point during a case there is slight repositioning of the GoPro, there is a risk of recording the case out of the center of view. An important advantage to newer GoPro versions is the ability to control the device through a wireless remote that can be placed under the surgeon’s gown. The remote can be used to pause and resume recording, without changing gloves, as is done with Google Glass. Last, because the minimum viewing distance from the surgical field is usually 18 inches or more, typically there is no loss of focus or blurring of the image from short-distance recording on either device.

3. File management and playback

Before using wearable technology in the operating room, surgeons must become aware of its limitations with respect to file storage and playback. Google Glass has a usable memory of about 12 GB (1 hour of video may require 1.5-2.0 GB). Conversely, GoPro’s capacity is defined by the micro SD card used. Therefore, the Google Glass hard drive must be regularly maintained well before being brought into the operating room, whereas recording can be extended (with respect to memory) for the GoPro if the media card is large enough.

Both devices allow for wired file transfer, which may be done with Windows Explorer (PC) or iPhoto (Macintosh). However, Google Glass also allows for wireless transfer, through portable storage supported by Google. Although this type of file transfer may be convenient for short, everyday clips made outside the operating room, it is prohibitive for surgical media, mainly because of patient privacy concerns. With wireless transfer to a nonsecure cloud platform, there is a risk of breach of patient confidentiality. We therefore recommend against using wireless upload when producing surgical multimedia, as patient identifiers are likely to be included in the recorded audio or video contents. Conversely, with GoPro, the micro SD card can be used as a portable hard drive to transfer files to a laptop or media reader, obviating the need for wired or wireless transmission. Last, when using traditional wire transfer or memory card to upload to a hard drive, users must ensure that the drive complies with patient privacy laws and regulations.

 4. Privacy and patient consent

As mentioned, great care must be taken to ensure that patient privacy laws are followed. This is especially relevant with content uploaded to online cloud storage, as with Google Glass. The upload may occur automatically if the unit is connected to a Wi-Fi hotspot. In addition, when using surgical media for a real-time webcast for education or demonstration purposes, surgeons must ensure that no protected health information is broadcast and that the patient and the surgical team are aware of the webcast and its purposes.

 

Before using wearable technology during patient care, patient consent must be obtained. Surgeons should ask the patient to consent to video recording of surgery or an encounter (eg, clinic visit) for education purposes. Our institution’s consent form includes a section for this particular type of consent. If an institution’s form lacks such a section, surgeons should consult their risk management department to ensure there is a proper avenue for obtaining patient consent to record the procedure or encounter. A separate, dedicated media consent form may be required. Last, whoever operates a wearable device should be careful to use the device only during encounters that have received explicit recording consent—as opposed to wearing the device in the hallways or elsewhere in the hospital, where protected health information might be inadvertently recorded.⁴

 5. Putting it all to use

After successful recording of surgery, an effort should be made to produce a high-quality video for education or demonstration purposes. Unfortunately, there is no built-in optical zooming with Google Glass or GoPro, and recording segments in which surgeons focus on detailed anatomy (with high-quality zoom) may prove difficult. Online descriptions of do-it-yourself modifications to place zoom capability on GoPro devices may be useful in surgical video recording, particularly for small surgical fields (hand or foot surgery). In addition, footage may be zoomed in on during postprocessing (Figure 3), though some resolution will be lost in the editing.

There is no practical way to incorporate Google Glass or GoPro while using surgical loupes or a surgical microscope. As a result, videos recorded with wearable technology may not reach the minimum resolution needed for useful surgical technique videos, as these traditionally are produced on high-definition camcorders with optical zoom, allowing detailed viewing of anatomical structures without resolution loss through digital zoom or postprocessing editing.

There has been tremendous benefit in incorporating wearable technology into our practice. Videos made with Google Glass and GoPro have been successfully used for surgical preparation and training, allowing orthopedic surgical residents to rehearse surgery before participating in it. Alternatively, having used Google Glass or GoPro to record a case, residents have then been able to review each surgical step on video—thereby reinforcing their knowledge of the steps, techniques, pearls, and pitfalls before performing the surgery again. Footage from surgeries recorded with Google Glass and GoPro has also been shown at weekly technique-focused conferences, allowing surgeons to analyze particular steps and highlight applicable learning points. Last, attending surgeons in our practice have used wearable technology in “coaching” mode, either reviewing case footage to identify areas for improvement or sharing footage with senior surgeons in order to elicit feedback and suggestions for possible improvement.

As new iterations of wearable video technology come to market, with advancements in both hardware and software, surgeons may be able to enhance education and teaching through seamless recording of surgical procedures. Use of wearable technology may also begin to extend beyond the operating room—to outpatient settings, such as preoperative and postoperative physical examinations. The latest versions of Google Glass and GoPro Hero allow surgeons to record surgical procedures with relative ease, without the personnel, equipment, and coordination required for traditional surgical videography.

Video 1. Coracoid harvest for transfer during Latarjet procedure performed and filmed by Dr. Jobin using GoPro Hero 3.

Video 2. Distal biceps repair performed by Dr. Makhni and Dr. Jobin, filmed by Dr. Makhni using Google Glass.

Safe and efficient advanced surgical skill training is of tremendous importance. With the recent increase in Internet use for medical education, there has been a concomitant increase in video recording of surgical procedures and techniques. Surgical recordings have been used in a variety of ways—as live webcasts for remote participants, as “coaching” opportunities for surgeons evaluating their own performance in the operating room, and even as informational resources for patients about to undergo the same surgery.

Surgical multimedia is being delivered through several different outlets. Many academic conferences and meetings showcase videos of different procedures, and several subspecialty societies (eg, Arthroscopy Association of North America) house archives of technical videos for viewing by members. In addition, the VuMedi website offers videos and allows members to comment on them and interact with the videographers. Surgeons are even posting technique videos on YouTube and other public websites.

A large proportion of surgical multimedia is recorded with conventional high-definition video cameras.¹ Besides being able to experience a case at any time and from outside the operating room, the audience can watch from numerous vantage points, angles, and zoom levels. Also, surgeons’ narration can be valuable in helping the audience follow along with the case.

Recording surgical multimedia historically required tight coordination and precise planning by surgeon and videographer. However, innovations in wearable technology now allow surgeons to literally wear video cameras and record procedures as they perform them, in real time—to act as both surgeon and videographer.

Two such products are Google Glass (Google, Mountain View, California) and GoPro Hero (GoPro, San Mateo, California), both of which allow surgeons to record exactly what they see during procedures (Figure 1). Using a wearable technology for surgical multimedia creation requires a deep familiarity with its capabilities and limitations. In this article, we summarize these products’ similarities and differences and provide a technical overview for using wearable technologies in surgical multimedia creation.

1. Choosing a device

When purchasing either wearable device, several factors must be considered, including budget, possible uses outside the operating room, and possible limitations of the technology (Table 1). At this time, Google Glass is significantly more expensive than GoPro Hero. The Google Glass base unit costs $1500, and the GoPro Hero 3 model costs approximately $200 (higher-priced Hero models are available). Both devices require accessories (eg, portable battery unit, dedicated hard drive).

Device capabilities must also be considered (Table 2). Google Glass consists of both hardware and software. Users can record what is seen and heard through the lens and then use apps to create text and e-mail portals to online gaming, social media, and even golf-course GPS. The app market for Google Glass is nascent but undoubtedly will increase in volume and scope as more users adopt the technology (Google Glass comes with both Bluetooth and Wi-Fi and can function tethered through a smartphone). GoPro is mainly a hardware unit that can record in various settings (it is popular with athletes who want to capture and broadcast their participation in action sports). Newer GoPro Hero versions offer Wi-Fi, which allows streaming of video content to a smartphone or tablet through an app. Having clearly defined goals for a device—‌‌as they pertain to use outside the operating room, such as outdoor activities and underwater recording—‌may help the surgeon decide which product is more suitable. Last, it is important to consider limitations. Google Glass resolution is 720p (1280×720) for video and 5 MP for still images, and GoPro resolution can reach 1080p (1920×1080) for video and 5 MP for stills.

Both devices require purchase of accessories. An external USB battery pack is useful for both devices, as is a password-encrypted hard drive for media storage. Lenswear does not come with the base version of Google Glass and is purchased separately from the company. GoPro users buy micro SD cards (~$50 per 64-GB high-speed transfer card) for storage on the device and may buy lithium-ion batteries as an alternative to the external USB battery pack.

Author Update

In January 2015, Google announced that it was temporarily suspending its “Explorer” program, which allowed individual users to buy and test the device for personal use. However, Google is continuing its development of Glass with health care technology, among other areas of growth and development.^2,3

2. Recording a successful surgical video

Unlike a camcorder, which typically is set on a tripod for conventional video recording of surgery, Google Glass and GoPro are intricately linked to the operator. Surgeons must be constantly aware of where they are during surgery and try not to let anything obstruct the camera’s view.

 

Before starting a case, the surgeon using either device must ensure that its battery is fully charged, as a full charge typically supports 1 hour of continuous recording (the Google Glass battery is a lithium-ion 670-mAh internal unit). A full charge should be enough to capture a short case. Newer GoPro models, with a battery listed at 1050 mAh, provide 1 to 2 hours of recording. When more than 1 hour is needed, an external USB battery pack can be used. This pack allows the device to remain plugged in throughout the case (the pack is kept in the surgeon’s back pocket). We recommend having an external battery pack that is at least 10,000 mAh (~$30 online retail), which easily provides 3+ hours of recording. Unfortunately, this arrangement can be cumbersome. Alternatively, with GoPro, additional batteries may be purchased, but the user needs to dismount the device in order to swap them in (may be difficult during surgery). With both units, partitioning a video into shorter segments conserves battery power and minimizes the risk of file corruption, which may occur if the battery dies or the device overheats.

Google Glass users can bypass manual operation of the device by giving it voice commands (eg, start video, take still image). The exception is for recording video for more than 10 seconds (current default setting). Unfortunately, the surgeon must touch the device to start this recording, which means using extra gloves to preserve operating field sterility. Still images can be made through a combination of voice and head gestures and without manual intervention (Figure 2). Last, users must ensure that the device is not actively connected through Bluetooth to a mobile phone, as incoming calls, text messages, and e-mails may disrupt active recording and become a distraction. The connection can be deactivated by disabling Bluetooth on the host smartphone or by placing the phone into airplane mode and turning off Wi-Fi.

Google Glass users can see what is being recorded through the viewfinder prism, whereas GoPro requires precise framing of the video before recording. Framing is done by grossly aiming the device in the desired direction. However, there is no way to ensure exact aim during recording. If at any point during a case there is slight repositioning of the GoPro, there is a risk of recording the case out of the center of view. An important advantage to newer GoPro versions is the ability to control the device through a wireless remote that can be placed under the surgeon’s gown. The remote can be used to pause and resume recording, without changing gloves, as is done with Google Glass. Last, because the minimum viewing distance from the surgical field is usually 18 inches or more, typically there is no loss of focus or blurring of the image from short-distance recording on either device.

3. File management and playback

Before using wearable technology in the operating room, surgeons must become aware of its limitations with respect to file storage and playback. Google Glass has a usable memory of about 12 GB (1 hour of video may require 1.5-2.0 GB). Conversely, GoPro’s capacity is defined by the micro SD card used. Therefore, the Google Glass hard drive must be regularly maintained well before being brought into the operating room, whereas recording can be extended (with respect to memory) for the GoPro if the media card is large enough.

Both devices allow for wired file transfer, which may be done with Windows Explorer (PC) or iPhoto (Macintosh). However, Google Glass also allows for wireless transfer, through portable storage supported by Google. Although this type of file transfer may be convenient for short, everyday clips made outside the operating room, it is prohibitive for surgical media, mainly because of patient privacy concerns. With wireless transfer to a nonsecure cloud platform, there is a risk of breach of patient confidentiality. We therefore recommend against using wireless upload when producing surgical multimedia, as patient identifiers are likely to be included in the recorded audio or video contents. Conversely, with GoPro, the micro SD card can be used as a portable hard drive to transfer files to a laptop or media reader, obviating the need for wired or wireless transmission. Last, when using traditional wire transfer or memory card to upload to a hard drive, users must ensure that the drive complies with patient privacy laws and regulations.

 4. Privacy and patient consent

As mentioned, great care must be taken to ensure that patient privacy laws are followed. This is especially relevant with content uploaded to online cloud storage, as with Google Glass. The upload may occur automatically if the unit is connected to a Wi-Fi hotspot. In addition, when using surgical media for a real-time webcast for education or demonstration purposes, surgeons must ensure that no protected health information is broadcast and that the patient and the surgical team are aware of the webcast and its purposes.

 

Before using wearable technology during patient care, patient consent must be obtained. Surgeons should ask the patient to consent to video recording of surgery or an encounter (eg, clinic visit) for education purposes. Our institution’s consent form includes a section for this particular type of consent. If an institution’s form lacks such a section, surgeons should consult their risk management department to ensure there is a proper avenue for obtaining patient consent to record the procedure or encounter. A separate, dedicated media consent form may be required. Last, whoever operates a wearable device should be careful to use the device only during encounters that have received explicit recording consent—as opposed to wearing the device in the hallways or elsewhere in the hospital, where protected health information might be inadvertently recorded.⁴

 5. Putting it all to use

After successful recording of surgery, an effort should be made to produce a high-quality video for education or demonstration purposes. Unfortunately, there is no built-in optical zooming with Google Glass or GoPro, and recording segments in which surgeons focus on detailed anatomy (with high-quality zoom) may prove difficult. Online descriptions of do-it-yourself modifications to place zoom capability on GoPro devices may be useful in surgical video recording, particularly for small surgical fields (hand or foot surgery). In addition, footage may be zoomed in on during postprocessing (Figure 3), though some resolution will be lost in the editing.

There is no practical way to incorporate Google Glass or GoPro while using surgical loupes or a surgical microscope. As a result, videos recorded with wearable technology may not reach the minimum resolution needed for useful surgical technique videos, as these traditionally are produced on high-definition camcorders with optical zoom, allowing detailed viewing of anatomical structures without resolution loss through digital zoom or postprocessing editing.

There has been tremendous benefit in incorporating wearable technology into our practice. Videos made with Google Glass and GoPro have been successfully used for surgical preparation and training, allowing orthopedic surgical residents to rehearse surgery before participating in it. Alternatively, having used Google Glass or GoPro to record a case, residents have then been able to review each surgical step on video—thereby reinforcing their knowledge of the steps, techniques, pearls, and pitfalls before performing the surgery again. Footage from surgeries recorded with Google Glass and GoPro has also been shown at weekly technique-focused conferences, allowing surgeons to analyze particular steps and highlight applicable learning points. Last, attending surgeons in our practice have used wearable technology in “coaching” mode, either reviewing case footage to identify areas for improvement or sharing footage with senior surgeons in order to elicit feedback and suggestions for possible improvement.

As new iterations of wearable video technology come to market, with advancements in both hardware and software, surgeons may be able to enhance education and teaching through seamless recording of surgical procedures. Use of wearable technology may also begin to extend beyond the operating room—to outpatient settings, such as preoperative and postoperative physical examinations. The latest versions of Google Glass and GoPro Hero allow surgeons to record surgical procedures with relative ease, without the personnel, equipment, and coordination required for traditional surgical videography.

Video 1. Coracoid harvest for transfer during Latarjet procedure performed and filmed by Dr. Jobin using GoPro Hero 3.

Video 2. Distal biceps repair performed by Dr. Makhni and Dr. Jobin, filmed by Dr. Makhni using Google Glass.

Safe and efficient advanced surgical skill training is of tremendous importance. With the recent increase in Internet use for medical education, there has been a concomitant increase in video recording of surgical procedures and techniques. Surgical recordings have been used in a variety of ways—as live webcasts for remote participants, as “coaching” opportunities for surgeons evaluating their own performance in the operating room, and even as informational resources for patients about to undergo the same surgery.

Surgical multimedia is being delivered through several different outlets. Many academic conferences and meetings showcase videos of different procedures, and several subspecialty societies (eg, Arthroscopy Association of North America) house archives of technical videos for viewing by members. In addition, the VuMedi website offers videos and allows members to comment on them and interact with the videographers. Surgeons are even posting technique videos on YouTube and other public websites.

A large proportion of surgical multimedia is recorded with conventional high-definition video cameras.¹ Besides being able to experience a case at any time and from outside the operating room, the audience can watch from numerous vantage points, angles, and zoom levels. Also, surgeons’ narration can be valuable in helping the audience follow along with the case.

Recording surgical multimedia historically required tight coordination and precise planning by surgeon and videographer. However, innovations in wearable technology now allow surgeons to literally wear video cameras and record procedures as they perform them, in real time—to act as both surgeon and videographer.

Two such products are Google Glass (Google, Mountain View, California) and GoPro Hero (GoPro, San Mateo, California), both of which allow surgeons to record exactly what they see during procedures (Figure 1). Using a wearable technology for surgical multimedia creation requires a deep familiarity with its capabilities and limitations. In this article, we summarize these products’ similarities and differences and provide a technical overview for using wearable technologies in surgical multimedia creation.

1. Choosing a device

When purchasing either wearable device, several factors must be considered, including budget, possible uses outside the operating room, and possible limitations of the technology (Table 1). At this time, Google Glass is significantly more expensive than GoPro Hero. The Google Glass base unit costs $1500, and the GoPro Hero 3 model costs approximately $200 (higher-priced Hero models are available). Both devices require accessories (eg, portable battery unit, dedicated hard drive).

Device capabilities must also be considered (Table 2). Google Glass consists of both hardware and software. Users can record what is seen and heard through the lens and then use apps to create text and e-mail portals to online gaming, social media, and even golf-course GPS. The app market for Google Glass is nascent but undoubtedly will increase in volume and scope as more users adopt the technology (Google Glass comes with both Bluetooth and Wi-Fi and can function tethered through a smartphone). GoPro is mainly a hardware unit that can record in various settings (it is popular with athletes who want to capture and broadcast their participation in action sports). Newer GoPro Hero versions offer Wi-Fi, which allows streaming of video content to a smartphone or tablet through an app. Having clearly defined goals for a device—‌‌as they pertain to use outside the operating room, such as outdoor activities and underwater recording—‌may help the surgeon decide which product is more suitable. Last, it is important to consider limitations. Google Glass resolution is 720p (1280×720) for video and 5 MP for still images, and GoPro resolution can reach 1080p (1920×1080) for video and 5 MP for stills.

Both devices require purchase of accessories. An external USB battery pack is useful for both devices, as is a password-encrypted hard drive for media storage. Lenswear does not come with the base version of Google Glass and is purchased separately from the company. GoPro users buy micro SD cards (~$50 per 64-GB high-speed transfer card) for storage on the device and may buy lithium-ion batteries as an alternative to the external USB battery pack.

Author Update

In January 2015, Google announced that it was temporarily suspending its “Explorer” program, which allowed individual users to buy and test the device for personal use. However, Google is continuing its development of Glass with health care technology, among other areas of growth and development.^2,3

2. Recording a successful surgical video

Unlike a camcorder, which typically is set on a tripod for conventional video recording of surgery, Google Glass and GoPro are intricately linked to the operator. Surgeons must be constantly aware of where they are during surgery and try not to let anything obstruct the camera’s view.

 

Before starting a case, the surgeon using either device must ensure that its battery is fully charged, as a full charge typically supports 1 hour of continuous recording (the Google Glass battery is a lithium-ion 670-mAh internal unit). A full charge should be enough to capture a short case. Newer GoPro models, with a battery listed at 1050 mAh, provide 1 to 2 hours of recording. When more than 1 hour is needed, an external USB battery pack can be used. This pack allows the device to remain plugged in throughout the case (the pack is kept in the surgeon’s back pocket). We recommend having an external battery pack that is at least 10,000 mAh (~$30 online retail), which easily provides 3+ hours of recording. Unfortunately, this arrangement can be cumbersome. Alternatively, with GoPro, additional batteries may be purchased, but the user needs to dismount the device in order to swap them in (may be difficult during surgery). With both units, partitioning a video into shorter segments conserves battery power and minimizes the risk of file corruption, which may occur if the battery dies or the device overheats.

Google Glass users can bypass manual operation of the device by giving it voice commands (eg, start video, take still image). The exception is for recording video for more than 10 seconds (current default setting). Unfortunately, the surgeon must touch the device to start this recording, which means using extra gloves to preserve operating field sterility. Still images can be made through a combination of voice and head gestures and without manual intervention (Figure 2). Last, users must ensure that the device is not actively connected through Bluetooth to a mobile phone, as incoming calls, text messages, and e-mails may disrupt active recording and become a distraction. The connection can be deactivated by disabling Bluetooth on the host smartphone or by placing the phone into airplane mode and turning off Wi-Fi.

Google Glass users can see what is being recorded through the viewfinder prism, whereas GoPro requires precise framing of the video before recording. Framing is done by grossly aiming the device in the desired direction. However, there is no way to ensure exact aim during recording. If at any point during a case there is slight repositioning of the GoPro, there is a risk of recording the case out of the center of view. An important advantage to newer GoPro versions is the ability to control the device through a wireless remote that can be placed under the surgeon’s gown. The remote can be used to pause and resume recording, without changing gloves, as is done with Google Glass. Last, because the minimum viewing distance from the surgical field is usually 18 inches or more, typically there is no loss of focus or blurring of the image from short-distance recording on either device.

3. File management and playback

Before using wearable technology in the operating room, surgeons must become aware of its limitations with respect to file storage and playback. Google Glass has a usable memory of about 12 GB (1 hour of video may require 1.5-2.0 GB). Conversely, GoPro’s capacity is defined by the micro SD card used. Therefore, the Google Glass hard drive must be regularly maintained well before being brought into the operating room, whereas recording can be extended (with respect to memory) for the GoPro if the media card is large enough.

Both devices allow for wired file transfer, which may be done with Windows Explorer (PC) or iPhoto (Macintosh). However, Google Glass also allows for wireless transfer, through portable storage supported by Google. Although this type of file transfer may be convenient for short, everyday clips made outside the operating room, it is prohibitive for surgical media, mainly because of patient privacy concerns. With wireless transfer to a nonsecure cloud platform, there is a risk of breach of patient confidentiality. We therefore recommend against using wireless upload when producing surgical multimedia, as patient identifiers are likely to be included in the recorded audio or video contents. Conversely, with GoPro, the micro SD card can be used as a portable hard drive to transfer files to a laptop or media reader, obviating the need for wired or wireless transmission. Last, when using traditional wire transfer or memory card to upload to a hard drive, users must ensure that the drive complies with patient privacy laws and regulations.

 4. Privacy and patient consent

As mentioned, great care must be taken to ensure that patient privacy laws are followed. This is especially relevant with content uploaded to online cloud storage, as with Google Glass. The upload may occur automatically if the unit is connected to a Wi-Fi hotspot. In addition, when using surgical media for a real-time webcast for education or demonstration purposes, surgeons must ensure that no protected health information is broadcast and that the patient and the surgical team are aware of the webcast and its purposes.

 

Before using wearable technology during patient care, patient consent must be obtained. Surgeons should ask the patient to consent to video recording of surgery or an encounter (eg, clinic visit) for education purposes. Our institution’s consent form includes a section for this particular type of consent. If an institution’s form lacks such a section, surgeons should consult their risk management department to ensure there is a proper avenue for obtaining patient consent to record the procedure or encounter. A separate, dedicated media consent form may be required. Last, whoever operates a wearable device should be careful to use the device only during encounters that have received explicit recording consent—as opposed to wearing the device in the hallways or elsewhere in the hospital, where protected health information might be inadvertently recorded.⁴

 5. Putting it all to use

After successful recording of surgery, an effort should be made to produce a high-quality video for education or demonstration purposes. Unfortunately, there is no built-in optical zooming with Google Glass or GoPro, and recording segments in which surgeons focus on detailed anatomy (with high-quality zoom) may prove difficult. Online descriptions of do-it-yourself modifications to place zoom capability on GoPro devices may be useful in surgical video recording, particularly for small surgical fields (hand or foot surgery). In addition, footage may be zoomed in on during postprocessing (Figure 3), though some resolution will be lost in the editing.

There is no practical way to incorporate Google Glass or GoPro while using surgical loupes or a surgical microscope. As a result, videos recorded with wearable technology may not reach the minimum resolution needed for useful surgical technique videos, as these traditionally are produced on high-definition camcorders with optical zoom, allowing detailed viewing of anatomical structures without resolution loss through digital zoom or postprocessing editing.

There has been tremendous benefit in incorporating wearable technology into our practice. Videos made with Google Glass and GoPro have been successfully used for surgical preparation and training, allowing orthopedic surgical residents to rehearse surgery before participating in it. Alternatively, having used Google Glass or GoPro to record a case, residents have then been able to review each surgical step on video—thereby reinforcing their knowledge of the steps, techniques, pearls, and pitfalls before performing the surgery again. Footage from surgeries recorded with Google Glass and GoPro has also been shown at weekly technique-focused conferences, allowing surgeons to analyze particular steps and highlight applicable learning points. Last, attending surgeons in our practice have used wearable technology in “coaching” mode, either reviewing case footage to identify areas for improvement or sharing footage with senior surgeons in order to elicit feedback and suggestions for possible improvement.

As new iterations of wearable video technology come to market, with advancements in both hardware and software, surgeons may be able to enhance education and teaching through seamless recording of surgical procedures. Use of wearable technology may also begin to extend beyond the operating room—to outpatient settings, such as preoperative and postoperative physical examinations. The latest versions of Google Glass and GoPro Hero allow surgeons to record surgical procedures with relative ease, without the personnel, equipment, and coordination required for traditional surgical videography.

Video 1. Coracoid harvest for transfer during Latarjet procedure performed and filmed by Dr. Jobin using GoPro Hero 3.

Video 2. Distal biceps repair performed by Dr. Makhni and Dr. Jobin, filmed by Dr. Makhni using Google Glass.

Distal radius fractures are among the most common upper extremity injuries. A Swedish study noted that 75% of forearm fractures involve the distal radius.¹ Extensor pollicis longus (EPL) ruptures are a well-documented complication (0.3% incidence²) of distal radius fractures.

The first description of EPL ruptures is attributed to Duplay in 1876 and was termed drummer boy’s palsy.³ Spontaneous EPL ruptures are often described in the setting of acute or chronic tenosynovitis.^4,5 Beginning in the early 1930s, multiple case reports began to connect distal radius fractures with EPL ruptures.⁶ Although EPL ruptures are rare, their consequences are substantial and typically necessitate reconstructive procedures. Extensor indicis proprius (EIP)-to-EPL tendon transfer has become a common surgical treatment for this complication. Increasing our knowledge of several characteristics associated with this complication may help clinically in preventing EPL ruptures.

Multiple studies have indicated that EPL ruptures occur more often in nondisplaced fractures and often occur between 6 and 8 weeks after injury.^2,5,7,8 Several factors are implicated in the etiology of EPL ruptures in distal radius fractures. The classic 1979 study by Engkvist and Lundborg⁹ showed that the EPL tendon has an area of poor vascularity around the Lister tubercle. Explorations of nondisplaced distal radius fractures have shown an intact extensor retinaculum that allows the tendon to continue to travel through an enclosed space.^4,5,7 In the setting of distal radius fracture, hematoma may contribute to tendon ruptures secondary to increased pressure within an intact third dorsal compartment, which further compromises vascularity in this region of the EPL tendon.

Recognition and prevention of an impending EPL rupture may help avoid the significant consequences of this complication. Decompression and release of the third dorsal compartment have been described as constituting a prophylactic surgical option.^10,11 Early thumb range of motion is also advocated to help prevent EPL rupture.⁹ However, results reported in the literature are inconclusive as to the effectiveness of these or indeed any preventive procedures. Dr. Lourie uses a novel technique that involves aspiration of the third dorsal compartment in patients with clinical symptoms associated with impending EPL rupture. Needle decompression, a less invasive option, can be quickly performed in an office, and it is hypothesized that removal of the hematoma may prevent EPL ruptures.

In the present study, we retrospectively reviewed Dr. Lourie’s records of patients with EPL ruptures in association with distal radius fractures to help delineate which radiographic and clinical characteristics identify patients at risk for these ruptures. A cadaveric model of a nondisplaced distal radius fracture was then created in order to simulate a change in third compartment pressures before and after needle decompression. We present preliminary outcomes on a case series of 4 patients who underwent aspiration of the third compartment and who were thought to be at risk for EPL rupture.

Materials and Methods

Institutional review board approval was obtained for this study. From Dr. Lourie’s records, 19 patients treated between 1998 and 2009 were identified as having confirmed or clinically impending EPL ruptures in association with nonoperative treatment of distal radius fractures. Prodromal symptoms that were used to diagnose impending EPL ruptures included pain with resisted active EPL extension, pain with passive flexion of the thumb interphalangeal joint, and localized swelling over the third dorsal compartment of the wrist.^5,7,10,12 Eleven patients had complete radiographs, which were reviewed for radiographic characteristics. Posteroanterior (PA) and lateral radiographs of the injured wrist were reviewed. On the PA radiographs, fraction location was measured from the tip of the radial styloid using a line perpendicular to the radial shaft. Fractures were also evaluated for displacement and intra-articular involvement.

A cadaveric model was developed to evaluate compartment pressures in the EPL sheath in a simulated distal radius fracture. Six fresh-frozen cadaveric forearms were used after being thawed at room temperature. The cadavers were radiographically evaluated to determine that there was no evidence of prior fracture. A Stryker compartment pressure monitoring system (Stryker, Kalamazoo, Michigan) was used to take initial pressure readings in the third dorsal compartment slightly ulnar to the Lister tubercle (preinjection readings). A limited volar approach was then created. Under fluoroscopy, a half-inch osteotome was used to make an extra-articular fracture line in the distal radius, in the region of the Lister tubercle. The osteotomy was a mean of 1.2 cm from the distal aspect of the radius. The osteotomy site was then injected from the volar aspect with 5 mL of radiopaque (Hypaque) dye (Figure 1). Fluid extravasation into the third dorsal compartment was visualized under fluoroscopy (Figures 2–4). The monitor was then reinserted into the EPL sheath, and once again pressures were measured (postinjection readings). An 18-gauge needle was then used to aspirate the compartment just ulnar to the Lister tubercle. Compartment pressures were measured a final time (postaspiration readings). For all readings, 3 pressure measurements were recorded and then averaged. Pressure measurements were compared using t test.

 

In the office, the third dorsal compartment was aspirated after skin preparation with povidone-iodine. The Lister tubercle is typically palpable along the dorsal distal radius and is aligned with the cleft between the index and long fingers. Aspiration with an 18-gauge needle is performed just ulnar to the Lister tubercle in the EPL sheath, and hematoma is evacuated. The patient is then placed back into a long-arm cast or splint per the clinical situation.

Results

Patient age ranged from 17 to 81 years. Eight (1 male, 7 female) patients sustained an EPL rupture a mean of 46 days after initial trauma (range, 21-118 days). Two patients were treated with a prophylactic EPL transposition secondary to clinically apparent impending rupture, and 4 were treated with prophylactic needle decompression of the third compartment. Ruptures were treated with EIP-to-EPL transfers.

As in other studies, each patient’s radiographs showed a nondisplaced fracture and a transverse fracture line. Six patients also had a longitudinal, intra-articular fracture line that exited in a common spot between the scaphoid and the lunate facet.

Results in our cadaveric model were consistent with those in in vitro decompression of the third dorsal compartment (Table 1). In the cadaver model, mean (SD) initial third dorsal compartment pressure was 0.77 (0.88) mm Hg. Mean (SD) pressure after osteotomy and Hypaque injection was 25.5 (11.11) mm Hg. After simulated therapeutic aspiration, mean (SD) pressure decreased to 1.61 (1.40) mm Hg. Mean change in pressure from after injection to after aspiration was 23.89 mm Hg (P = .000388) (Table 2).

Information from other studies and from Dr. Lourie’s experience was used to identify patients at significant risk for EPL ruptures in association with distal radius fractures. Four patients in Dr. Lourie’s practice between 2004 and 2009 had characteristic findings, including a nondisplaced distal radius fracture, localized swelling over the third dorsal compartment, and pain with resisted active EPL extension. Prophylactic aspiration and hematoma evacuation were performed in this series, yielding a mean hematoma amount of 2 mL (Table 3).

For all 4 patients, aspirations were performed within 2 weeks of injury. Subjectively, these patients described almost immediate pain relief and less discomfort with EPL motion after aspiration. Three of the 4 reported sustained pain relief on close follow-up 7 and 14 days after aspiration. The fourth patient continued to have pain over the third dorsal compartment, though she described it as significantly improved. Her initial fracture contained about 50% dorsal comminution, and she began to have a significant callus response. After 2 months of continued symptoms, and out of concern about consequences of an impending rupture, open decompression and transposition of the EPL were performed. In follow-up over 29 months, this patient continued to do well and had full EPL function. The 3 patients treated with aspiration alone have not had an EPL rupture (range of follow-up, 29-89 months).

Discussion

Distal radius fractures are very common injuries, and treating physicians must attempt to prevent possible complications. EPL tendon ruptures continue to be rare events (incidence, <1%) in association with distal radius fractures. Although statistics vary, studies have found a higher incidence in nondisplaced (vs displaced) distal radius fractures.^5,7,10 Ruptures in nondisplaced fractures occur within 2 weeks to 3 years after injury but typically an average of 6 weeks after injury.^2,4,7-9 Prodromal symptoms often include tenderness and swelling around the dorsal distal radius region around the Lister tubercle.^7,11,12 Patients may complain of pain with active thumb extension or passive thumb range of motion.¹¹ Rupture is indicated by an inability to actively extend the thumb.

Studies have shown that the tendon rupture site is around the Lister tubercle.⁷ No single cause for EPL ruptures has been confirmed, and the etiology is likely a mix of factors in relation to the clinical situation. Two theories have been espoused for the relation between EPL ruptures and distal radius fractures. The mechanical theory involves a prominent spicule of bone abrading the tendon and subsequently causing rupture.^5,9 This seems less likely for nondisplaced fractures. The vascular theory centers on a watershed region of the EPL tendon around the Lister tubercle. Studies have found microangiographic evidence of a 5-mm portion of tendon around the Lister tubercle that has no mesotenon and poor vascularity.^7,9 The tendon in this section may be reliant on synovial diffusion for nutrition,⁷ but hematoma may displace synovial fluid, interfering with tendon nutrition.

Researchers have studied the third dorsal compartment in patients with impending or established ruptures. In a series by Hirasawa and colleagues,⁷ 11 patients with a nondisplaced fracture and a tendon rupture had an intact retinaculum and smooth bony surfaces on the dorsal radius. Periosteal hypertrophy and narrowing of the third compartment were noted. In another series, Helal and colleagues⁵ reported on 16 patients (nondisplaced and displaced fractures) who had possible EPL ruptures over a 4-year period. In all cases, the extensor retinaculum was intact. Likewise, the 7 patients with EPL ruptures in a series by Bonatz and colleagues⁴ had an intact extensor retinaculum. On exploration, Bunata¹⁰ noted fluid collections, including hematomas, within the sheath, as well as a lack of bony prominences. Simpson¹² explored 2 cases of blunt trauma, no fracture, and subsequent EPL rupture. Clinically these 2 patients had swelling in the region of the Lister tubercle, and surgically they were found to have a distended, blood-filled sheath. These ruptures may correlate with nondisplaced distal radius fractures and provide further evidence supporting the vascular theory of ruptures. The combination of intact compartment and volume overload presents a situation akin to compartment syndrome. Acute compartment decompression with needle evacuation would theoretically relieve the vascular insult.

 

In the study by Helal and colleagues,⁵ Hypaque injections were given to patients with nondisplaced distal radius fractures. The dye remained in the third dorsal compartment, which implies an intact closed space. That study used a cadaveric model as well, with distal radius osteotomies performed to simulate a nondisplaced distal radius fracture. The authors noted an intact extensor retinaculum in their model. Our cadaver model is similar, except we measured pressures in the third compartment; our model indicated increased compartment pressures within the EPL sheath. Subsequent aspiration in our cadaveric study led to lower pressures in the third dorsal compartment. This cadaveric model implies that needle decompression of the third dorsal compartment may be beneficial in the setting of nondisplaced distal radius fractures and symptoms indicating a compromised EPL.

Splinting is an important factor that may help prevent EPL tendon ruptures after distal radius fractures. Synovial diffusion may be the primary mechanism for delivering nutrition to the EPL tendon.⁷ A splint that allows thumb metacarpophalangeal and interphalangeal flexion may provide the EPL motion needed for effective synovial nutritional pathways.⁹ Prodromal symptoms of tendon rupture should then be carefully monitored.

Conclusion

Results of our retrospective review are consistent with previous results elucidating the risk factors for EPL ruptures in association with distal radius fractures. In our patients who sustained EPL ruptures, findings included nondisplaced fractures, about 50% with an intra-articular component. Clinical findings included localized swelling over the third dorsal compartment, pain with resisted active EPL extension, and pain with passive flexion of the thumb interphalangeal joint. The cadaveric portion of this study indicated a significant change in pressure in the third dorsal compartment after aspiration. Preliminary outcomes in this 4-patient series are no EPL ruptures after prophylactic aspiration. Hematoma evacuation after nondisplaced distal radius fractures may become a useful addition to the surgeon’s armamentarium. Studies are needed to determine if needle aspiration of the third dorsal compartment can become an office-based procedure with value in preventing EPL ruptures in the appropriate clinical situation.

Distal radius fractures are among the most common upper extremity injuries. A Swedish study noted that 75% of forearm fractures involve the distal radius.¹ Extensor pollicis longus (EPL) ruptures are a well-documented complication (0.3% incidence²) of distal radius fractures.

The first description of EPL ruptures is attributed to Duplay in 1876 and was termed drummer boy’s palsy.³ Spontaneous EPL ruptures are often described in the setting of acute or chronic tenosynovitis.^4,5 Beginning in the early 1930s, multiple case reports began to connect distal radius fractures with EPL ruptures.⁶ Although EPL ruptures are rare, their consequences are substantial and typically necessitate reconstructive procedures. Extensor indicis proprius (EIP)-to-EPL tendon transfer has become a common surgical treatment for this complication. Increasing our knowledge of several characteristics associated with this complication may help clinically in preventing EPL ruptures.

Multiple studies have indicated that EPL ruptures occur more often in nondisplaced fractures and often occur between 6 and 8 weeks after injury.^2,5,7,8 Several factors are implicated in the etiology of EPL ruptures in distal radius fractures. The classic 1979 study by Engkvist and Lundborg⁹ showed that the EPL tendon has an area of poor vascularity around the Lister tubercle. Explorations of nondisplaced distal radius fractures have shown an intact extensor retinaculum that allows the tendon to continue to travel through an enclosed space.^4,5,7 In the setting of distal radius fracture, hematoma may contribute to tendon ruptures secondary to increased pressure within an intact third dorsal compartment, which further compromises vascularity in this region of the EPL tendon.

Recognition and prevention of an impending EPL rupture may help avoid the significant consequences of this complication. Decompression and release of the third dorsal compartment have been described as constituting a prophylactic surgical option.^10,11 Early thumb range of motion is also advocated to help prevent EPL rupture.⁹ However, results reported in the literature are inconclusive as to the effectiveness of these or indeed any preventive procedures. Dr. Lourie uses a novel technique that involves aspiration of the third dorsal compartment in patients with clinical symptoms associated with impending EPL rupture. Needle decompression, a less invasive option, can be quickly performed in an office, and it is hypothesized that removal of the hematoma may prevent EPL ruptures.

In the present study, we retrospectively reviewed Dr. Lourie’s records of patients with EPL ruptures in association with distal radius fractures to help delineate which radiographic and clinical characteristics identify patients at risk for these ruptures. A cadaveric model of a nondisplaced distal radius fracture was then created in order to simulate a change in third compartment pressures before and after needle decompression. We present preliminary outcomes on a case series of 4 patients who underwent aspiration of the third compartment and who were thought to be at risk for EPL rupture.

Materials and Methods

Institutional review board approval was obtained for this study. From Dr. Lourie’s records, 19 patients treated between 1998 and 2009 were identified as having confirmed or clinically impending EPL ruptures in association with nonoperative treatment of distal radius fractures. Prodromal symptoms that were used to diagnose impending EPL ruptures included pain with resisted active EPL extension, pain with passive flexion of the thumb interphalangeal joint, and localized swelling over the third dorsal compartment of the wrist.^5,7,10,12 Eleven patients had complete radiographs, which were reviewed for radiographic characteristics. Posteroanterior (PA) and lateral radiographs of the injured wrist were reviewed. On the PA radiographs, fraction location was measured from the tip of the radial styloid using a line perpendicular to the radial shaft. Fractures were also evaluated for displacement and intra-articular involvement.

A cadaveric model was developed to evaluate compartment pressures in the EPL sheath in a simulated distal radius fracture. Six fresh-frozen cadaveric forearms were used after being thawed at room temperature. The cadavers were radiographically evaluated to determine that there was no evidence of prior fracture. A Stryker compartment pressure monitoring system (Stryker, Kalamazoo, Michigan) was used to take initial pressure readings in the third dorsal compartment slightly ulnar to the Lister tubercle (preinjection readings). A limited volar approach was then created. Under fluoroscopy, a half-inch osteotome was used to make an extra-articular fracture line in the distal radius, in the region of the Lister tubercle. The osteotomy was a mean of 1.2 cm from the distal aspect of the radius. The osteotomy site was then injected from the volar aspect with 5 mL of radiopaque (Hypaque) dye (Figure 1). Fluid extravasation into the third dorsal compartment was visualized under fluoroscopy (Figures 2–4). The monitor was then reinserted into the EPL sheath, and once again pressures were measured (postinjection readings). An 18-gauge needle was then used to aspirate the compartment just ulnar to the Lister tubercle. Compartment pressures were measured a final time (postaspiration readings). For all readings, 3 pressure measurements were recorded and then averaged. Pressure measurements were compared using t test.

 

In the office, the third dorsal compartment was aspirated after skin preparation with povidone-iodine. The Lister tubercle is typically palpable along the dorsal distal radius and is aligned with the cleft between the index and long fingers. Aspiration with an 18-gauge needle is performed just ulnar to the Lister tubercle in the EPL sheath, and hematoma is evacuated. The patient is then placed back into a long-arm cast or splint per the clinical situation.

Results

Patient age ranged from 17 to 81 years. Eight (1 male, 7 female) patients sustained an EPL rupture a mean of 46 days after initial trauma (range, 21-118 days). Two patients were treated with a prophylactic EPL transposition secondary to clinically apparent impending rupture, and 4 were treated with prophylactic needle decompression of the third compartment. Ruptures were treated with EIP-to-EPL transfers.

As in other studies, each patient’s radiographs showed a nondisplaced fracture and a transverse fracture line. Six patients also had a longitudinal, intra-articular fracture line that exited in a common spot between the scaphoid and the lunate facet.

Results in our cadaveric model were consistent with those in in vitro decompression of the third dorsal compartment (Table 1). In the cadaver model, mean (SD) initial third dorsal compartment pressure was 0.77 (0.88) mm Hg. Mean (SD) pressure after osteotomy and Hypaque injection was 25.5 (11.11) mm Hg. After simulated therapeutic aspiration, mean (SD) pressure decreased to 1.61 (1.40) mm Hg. Mean change in pressure from after injection to after aspiration was 23.89 mm Hg (P = .000388) (Table 2).

Information from other studies and from Dr. Lourie’s experience was used to identify patients at significant risk for EPL ruptures in association with distal radius fractures. Four patients in Dr. Lourie’s practice between 2004 and 2009 had characteristic findings, including a nondisplaced distal radius fracture, localized swelling over the third dorsal compartment, and pain with resisted active EPL extension. Prophylactic aspiration and hematoma evacuation were performed in this series, yielding a mean hematoma amount of 2 mL (Table 3).

For all 4 patients, aspirations were performed within 2 weeks of injury. Subjectively, these patients described almost immediate pain relief and less discomfort with EPL motion after aspiration. Three of the 4 reported sustained pain relief on close follow-up 7 and 14 days after aspiration. The fourth patient continued to have pain over the third dorsal compartment, though she described it as significantly improved. Her initial fracture contained about 50% dorsal comminution, and she began to have a significant callus response. After 2 months of continued symptoms, and out of concern about consequences of an impending rupture, open decompression and transposition of the EPL were performed. In follow-up over 29 months, this patient continued to do well and had full EPL function. The 3 patients treated with aspiration alone have not had an EPL rupture (range of follow-up, 29-89 months).

Discussion

Distal radius fractures are very common injuries, and treating physicians must attempt to prevent possible complications. EPL tendon ruptures continue to be rare events (incidence, <1%) in association with distal radius fractures. Although statistics vary, studies have found a higher incidence in nondisplaced (vs displaced) distal radius fractures.^5,7,10 Ruptures in nondisplaced fractures occur within 2 weeks to 3 years after injury but typically an average of 6 weeks after injury.^2,4,7-9 Prodromal symptoms often include tenderness and swelling around the dorsal distal radius region around the Lister tubercle.^7,11,12 Patients may complain of pain with active thumb extension or passive thumb range of motion.¹¹ Rupture is indicated by an inability to actively extend the thumb.

Studies have shown that the tendon rupture site is around the Lister tubercle.⁷ No single cause for EPL ruptures has been confirmed, and the etiology is likely a mix of factors in relation to the clinical situation. Two theories have been espoused for the relation between EPL ruptures and distal radius fractures. The mechanical theory involves a prominent spicule of bone abrading the tendon and subsequently causing rupture.^5,9 This seems less likely for nondisplaced fractures. The vascular theory centers on a watershed region of the EPL tendon around the Lister tubercle. Studies have found microangiographic evidence of a 5-mm portion of tendon around the Lister tubercle that has no mesotenon and poor vascularity.^7,9 The tendon in this section may be reliant on synovial diffusion for nutrition,⁷ but hematoma may displace synovial fluid, interfering with tendon nutrition.

Researchers have studied the third dorsal compartment in patients with impending or established ruptures. In a series by Hirasawa and colleagues,⁷ 11 patients with a nondisplaced fracture and a tendon rupture had an intact retinaculum and smooth bony surfaces on the dorsal radius. Periosteal hypertrophy and narrowing of the third compartment were noted. In another series, Helal and colleagues⁵ reported on 16 patients (nondisplaced and displaced fractures) who had possible EPL ruptures over a 4-year period. In all cases, the extensor retinaculum was intact. Likewise, the 7 patients with EPL ruptures in a series by Bonatz and colleagues⁴ had an intact extensor retinaculum. On exploration, Bunata¹⁰ noted fluid collections, including hematomas, within the sheath, as well as a lack of bony prominences. Simpson¹² explored 2 cases of blunt trauma, no fracture, and subsequent EPL rupture. Clinically these 2 patients had swelling in the region of the Lister tubercle, and surgically they were found to have a distended, blood-filled sheath. These ruptures may correlate with nondisplaced distal radius fractures and provide further evidence supporting the vascular theory of ruptures. The combination of intact compartment and volume overload presents a situation akin to compartment syndrome. Acute compartment decompression with needle evacuation would theoretically relieve the vascular insult.

 

In the study by Helal and colleagues,⁵ Hypaque injections were given to patients with nondisplaced distal radius fractures. The dye remained in the third dorsal compartment, which implies an intact closed space. That study used a cadaveric model as well, with distal radius osteotomies performed to simulate a nondisplaced distal radius fracture. The authors noted an intact extensor retinaculum in their model. Our cadaver model is similar, except we measured pressures in the third compartment; our model indicated increased compartment pressures within the EPL sheath. Subsequent aspiration in our cadaveric study led to lower pressures in the third dorsal compartment. This cadaveric model implies that needle decompression of the third dorsal compartment may be beneficial in the setting of nondisplaced distal radius fractures and symptoms indicating a compromised EPL.

Splinting is an important factor that may help prevent EPL tendon ruptures after distal radius fractures. Synovial diffusion may be the primary mechanism for delivering nutrition to the EPL tendon.⁷ A splint that allows thumb metacarpophalangeal and interphalangeal flexion may provide the EPL motion needed for effective synovial nutritional pathways.⁹ Prodromal symptoms of tendon rupture should then be carefully monitored.

Conclusion

Results of our retrospective review are consistent with previous results elucidating the risk factors for EPL ruptures in association with distal radius fractures. In our patients who sustained EPL ruptures, findings included nondisplaced fractures, about 50% with an intra-articular component. Clinical findings included localized swelling over the third dorsal compartment, pain with resisted active EPL extension, and pain with passive flexion of the thumb interphalangeal joint. The cadaveric portion of this study indicated a significant change in pressure in the third dorsal compartment after aspiration. Preliminary outcomes in this 4-patient series are no EPL ruptures after prophylactic aspiration. Hematoma evacuation after nondisplaced distal radius fractures may become a useful addition to the surgeon’s armamentarium. Studies are needed to determine if needle aspiration of the third dorsal compartment can become an office-based procedure with value in preventing EPL ruptures in the appropriate clinical situation.

Distal radius fractures are among the most common upper extremity injuries. A Swedish study noted that 75% of forearm fractures involve the distal radius.¹ Extensor pollicis longus (EPL) ruptures are a well-documented complication (0.3% incidence²) of distal radius fractures.

The first description of EPL ruptures is attributed to Duplay in 1876 and was termed drummer boy’s palsy.³ Spontaneous EPL ruptures are often described in the setting of acute or chronic tenosynovitis.^4,5 Beginning in the early 1930s, multiple case reports began to connect distal radius fractures with EPL ruptures.⁶ Although EPL ruptures are rare, their consequences are substantial and typically necessitate reconstructive procedures. Extensor indicis proprius (EIP)-to-EPL tendon transfer has become a common surgical treatment for this complication. Increasing our knowledge of several characteristics associated with this complication may help clinically in preventing EPL ruptures.

Multiple studies have indicated that EPL ruptures occur more often in nondisplaced fractures and often occur between 6 and 8 weeks after injury.^2,5,7,8 Several factors are implicated in the etiology of EPL ruptures in distal radius fractures. The classic 1979 study by Engkvist and Lundborg⁹ showed that the EPL tendon has an area of poor vascularity around the Lister tubercle. Explorations of nondisplaced distal radius fractures have shown an intact extensor retinaculum that allows the tendon to continue to travel through an enclosed space.^4,5,7 In the setting of distal radius fracture, hematoma may contribute to tendon ruptures secondary to increased pressure within an intact third dorsal compartment, which further compromises vascularity in this region of the EPL tendon.

Recognition and prevention of an impending EPL rupture may help avoid the significant consequences of this complication. Decompression and release of the third dorsal compartment have been described as constituting a prophylactic surgical option.^10,11 Early thumb range of motion is also advocated to help prevent EPL rupture.⁹ However, results reported in the literature are inconclusive as to the effectiveness of these or indeed any preventive procedures. Dr. Lourie uses a novel technique that involves aspiration of the third dorsal compartment in patients with clinical symptoms associated with impending EPL rupture. Needle decompression, a less invasive option, can be quickly performed in an office, and it is hypothesized that removal of the hematoma may prevent EPL ruptures.

In the present study, we retrospectively reviewed Dr. Lourie’s records of patients with EPL ruptures in association with distal radius fractures to help delineate which radiographic and clinical characteristics identify patients at risk for these ruptures. A cadaveric model of a nondisplaced distal radius fracture was then created in order to simulate a change in third compartment pressures before and after needle decompression. We present preliminary outcomes on a case series of 4 patients who underwent aspiration of the third compartment and who were thought to be at risk for EPL rupture.

Materials and Methods

Institutional review board approval was obtained for this study. From Dr. Lourie’s records, 19 patients treated between 1998 and 2009 were identified as having confirmed or clinically impending EPL ruptures in association with nonoperative treatment of distal radius fractures. Prodromal symptoms that were used to diagnose impending EPL ruptures included pain with resisted active EPL extension, pain with passive flexion of the thumb interphalangeal joint, and localized swelling over the third dorsal compartment of the wrist.^5,7,10,12 Eleven patients had complete radiographs, which were reviewed for radiographic characteristics. Posteroanterior (PA) and lateral radiographs of the injured wrist were reviewed. On the PA radiographs, fraction location was measured from the tip of the radial styloid using a line perpendicular to the radial shaft. Fractures were also evaluated for displacement and intra-articular involvement.

A cadaveric model was developed to evaluate compartment pressures in the EPL sheath in a simulated distal radius fracture. Six fresh-frozen cadaveric forearms were used after being thawed at room temperature. The cadavers were radiographically evaluated to determine that there was no evidence of prior fracture. A Stryker compartment pressure monitoring system (Stryker, Kalamazoo, Michigan) was used to take initial pressure readings in the third dorsal compartment slightly ulnar to the Lister tubercle (preinjection readings). A limited volar approach was then created. Under fluoroscopy, a half-inch osteotome was used to make an extra-articular fracture line in the distal radius, in the region of the Lister tubercle. The osteotomy was a mean of 1.2 cm from the distal aspect of the radius. The osteotomy site was then injected from the volar aspect with 5 mL of radiopaque (Hypaque) dye (Figure 1). Fluid extravasation into the third dorsal compartment was visualized under fluoroscopy (Figures 2–4). The monitor was then reinserted into the EPL sheath, and once again pressures were measured (postinjection readings). An 18-gauge needle was then used to aspirate the compartment just ulnar to the Lister tubercle. Compartment pressures were measured a final time (postaspiration readings). For all readings, 3 pressure measurements were recorded and then averaged. Pressure measurements were compared using t test.

 

In the office, the third dorsal compartment was aspirated after skin preparation with povidone-iodine. The Lister tubercle is typically palpable along the dorsal distal radius and is aligned with the cleft between the index and long fingers. Aspiration with an 18-gauge needle is performed just ulnar to the Lister tubercle in the EPL sheath, and hematoma is evacuated. The patient is then placed back into a long-arm cast or splint per the clinical situation.

Results

Patient age ranged from 17 to 81 years. Eight (1 male, 7 female) patients sustained an EPL rupture a mean of 46 days after initial trauma (range, 21-118 days). Two patients were treated with a prophylactic EPL transposition secondary to clinically apparent impending rupture, and 4 were treated with prophylactic needle decompression of the third compartment. Ruptures were treated with EIP-to-EPL transfers.

As in other studies, each patient’s radiographs showed a nondisplaced fracture and a transverse fracture line. Six patients also had a longitudinal, intra-articular fracture line that exited in a common spot between the scaphoid and the lunate facet.

Results in our cadaveric model were consistent with those in in vitro decompression of the third dorsal compartment (Table 1). In the cadaver model, mean (SD) initial third dorsal compartment pressure was 0.77 (0.88) mm Hg. Mean (SD) pressure after osteotomy and Hypaque injection was 25.5 (11.11) mm Hg. After simulated therapeutic aspiration, mean (SD) pressure decreased to 1.61 (1.40) mm Hg. Mean change in pressure from after injection to after aspiration was 23.89 mm Hg (P = .000388) (Table 2).

Information from other studies and from Dr. Lourie’s experience was used to identify patients at significant risk for EPL ruptures in association with distal radius fractures. Four patients in Dr. Lourie’s practice between 2004 and 2009 had characteristic findings, including a nondisplaced distal radius fracture, localized swelling over the third dorsal compartment, and pain with resisted active EPL extension. Prophylactic aspiration and hematoma evacuation were performed in this series, yielding a mean hematoma amount of 2 mL (Table 3).

For all 4 patients, aspirations were performed within 2 weeks of injury. Subjectively, these patients described almost immediate pain relief and less discomfort with EPL motion after aspiration. Three of the 4 reported sustained pain relief on close follow-up 7 and 14 days after aspiration. The fourth patient continued to have pain over the third dorsal compartment, though she described it as significantly improved. Her initial fracture contained about 50% dorsal comminution, and she began to have a significant callus response. After 2 months of continued symptoms, and out of concern about consequences of an impending rupture, open decompression and transposition of the EPL were performed. In follow-up over 29 months, this patient continued to do well and had full EPL function. The 3 patients treated with aspiration alone have not had an EPL rupture (range of follow-up, 29-89 months).

Discussion

Distal radius fractures are very common injuries, and treating physicians must attempt to prevent possible complications. EPL tendon ruptures continue to be rare events (incidence, <1%) in association with distal radius fractures. Although statistics vary, studies have found a higher incidence in nondisplaced (vs displaced) distal radius fractures.^5,7,10 Ruptures in nondisplaced fractures occur within 2 weeks to 3 years after injury but typically an average of 6 weeks after injury.^2,4,7-9 Prodromal symptoms often include tenderness and swelling around the dorsal distal radius region around the Lister tubercle.^7,11,12 Patients may complain of pain with active thumb extension or passive thumb range of motion.¹¹ Rupture is indicated by an inability to actively extend the thumb.

Studies have shown that the tendon rupture site is around the Lister tubercle.⁷ No single cause for EPL ruptures has been confirmed, and the etiology is likely a mix of factors in relation to the clinical situation. Two theories have been espoused for the relation between EPL ruptures and distal radius fractures. The mechanical theory involves a prominent spicule of bone abrading the tendon and subsequently causing rupture.^5,9 This seems less likely for nondisplaced fractures. The vascular theory centers on a watershed region of the EPL tendon around the Lister tubercle. Studies have found microangiographic evidence of a 5-mm portion of tendon around the Lister tubercle that has no mesotenon and poor vascularity.^7,9 The tendon in this section may be reliant on synovial diffusion for nutrition,⁷ but hematoma may displace synovial fluid, interfering with tendon nutrition.

Researchers have studied the third dorsal compartment in patients with impending or established ruptures. In a series by Hirasawa and colleagues,⁷ 11 patients with a nondisplaced fracture and a tendon rupture had an intact retinaculum and smooth bony surfaces on the dorsal radius. Periosteal hypertrophy and narrowing of the third compartment were noted. In another series, Helal and colleagues⁵ reported on 16 patients (nondisplaced and displaced fractures) who had possible EPL ruptures over a 4-year period. In all cases, the extensor retinaculum was intact. Likewise, the 7 patients with EPL ruptures in a series by Bonatz and colleagues⁴ had an intact extensor retinaculum. On exploration, Bunata¹⁰ noted fluid collections, including hematomas, within the sheath, as well as a lack of bony prominences. Simpson¹² explored 2 cases of blunt trauma, no fracture, and subsequent EPL rupture. Clinically these 2 patients had swelling in the region of the Lister tubercle, and surgically they were found to have a distended, blood-filled sheath. These ruptures may correlate with nondisplaced distal radius fractures and provide further evidence supporting the vascular theory of ruptures. The combination of intact compartment and volume overload presents a situation akin to compartment syndrome. Acute compartment decompression with needle evacuation would theoretically relieve the vascular insult.

 

In the study by Helal and colleagues,⁵ Hypaque injections were given to patients with nondisplaced distal radius fractures. The dye remained in the third dorsal compartment, which implies an intact closed space. That study used a cadaveric model as well, with distal radius osteotomies performed to simulate a nondisplaced distal radius fracture. The authors noted an intact extensor retinaculum in their model. Our cadaver model is similar, except we measured pressures in the third compartment; our model indicated increased compartment pressures within the EPL sheath. Subsequent aspiration in our cadaveric study led to lower pressures in the third dorsal compartment. This cadaveric model implies that needle decompression of the third dorsal compartment may be beneficial in the setting of nondisplaced distal radius fractures and symptoms indicating a compromised EPL.

Splinting is an important factor that may help prevent EPL tendon ruptures after distal radius fractures. Synovial diffusion may be the primary mechanism for delivering nutrition to the EPL tendon.⁷ A splint that allows thumb metacarpophalangeal and interphalangeal flexion may provide the EPL motion needed for effective synovial nutritional pathways.⁹ Prodromal symptoms of tendon rupture should then be carefully monitored.

Conclusion

Results of our retrospective review are consistent with previous results elucidating the risk factors for EPL ruptures in association with distal radius fractures. In our patients who sustained EPL ruptures, findings included nondisplaced fractures, about 50% with an intra-articular component. Clinical findings included localized swelling over the third dorsal compartment, pain with resisted active EPL extension, and pain with passive flexion of the thumb interphalangeal joint. The cadaveric portion of this study indicated a significant change in pressure in the third dorsal compartment after aspiration. Preliminary outcomes in this 4-patient series are no EPL ruptures after prophylactic aspiration. Hematoma evacuation after nondisplaced distal radius fractures may become a useful addition to the surgeon’s armamentarium. Studies are needed to determine if needle aspiration of the third dorsal compartment can become an office-based procedure with value in preventing EPL ruptures in the appropriate clinical situation.