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Introduction: Vision loss is a symptom found frequently in patients presenting to the emergency department (ED). Central retinal artery occlusion (CRAO) is an uncommon yet time-sensitive and critical cause of painless vision loss in which delayed diagnosis can lead to significant morbidity. Emergency medicine literature documents the ability to diagnose a CRAO using ultrasound by identifying the hyperechoic thrombus coined the retrobulbar spot sign.Case Report: We present the case of a patient presenting with painless monocular vision loss for which CRAO was diagnosed in the ED using point-of-care ultrasound enhanced by the utilization of serial Doppler examinations as well as calculation of the central retinal artery resistive index.Conclusion: Despite the pre-existing literature on point-of-care ultrasound investigation of central retinal artery occlusion, there are no emergency medicine case reports describing serial examination of the central retinal artery by spectral Doppler or calculation of arterial resistive index to improve this evaluation and monitor progression of the pathology. [2024;7(5)1–5.]

Introduction: Carotid artery dissection is a rare but serious condition manifesting with signs and symptoms that closely overlap with other more benign medical diagnoses. This vascular injury, however, can result in debilitating sequelae, including thromboembolic cerebrovascular accidents.Case Report: We describe the atypical presentation of a healthy eight-year-old male who presented to the emergency department (ED) with generalized abdominal pain and non-bloody, non-bilious emesis. These symptoms occurred nine days after he sustained blunt head trauma after a non-syncopal fall from standing while playing hockey. He was initially diagnosed with gastroesophageal reflux disease and constipation and was discharged home. The following day he developed an acute headache followed shortly by gait ataxia, prompting a return visit to the ED. Imaging of the head and neck revealed a left internal carotid artery dissection. The patient was started on intravenous unfractionated heparin and admitted to the hospital. He was later discharged symptom-free on therapeutic enoxaparin for eight weeks, followed by daily aspirin therapy.Conclusion: Pediatric trauma patients, especially those sustaining insult to the head and cervical spine, are at risk for craniocervical arterial injuries. This rare but dangerous pathology often manifests in a non-specific, delayed fashion making it a challenging diagnosis for physicians to make on the initial medical encounter.1,2 Maintaining a high clinical suspicion for carotid artery dissection is required to make this diagnosis and should guide a thorough history, physical examination, and appropriate imaging in orderto improve patient morbidity and mortality. This case emphasizes key clinical features and risk factors of this disease that may help emergency clinicians promptly recognize and treat this entity.

Explant analysis can provide important understanding of how artificial joints perform in the human body. The articulating surfaces of the metacarpal head and the radius cup from a chromium nitride coated metal-on-metal Motec wrist implant were analysed. Due to bone resorption and aseptic loosening, the implant was removed after 6 years in the patient, and metallosis was observed during removal. Visually, some areas of the articulating surfaces appeared polished, others were dulled. A chemical composition analysis of the metacarpal head showed that the polished surfaces were chromium rich, implying this surface was the original chromium nitride coating, whereas the dulled surfaces were cobalt rich, indicating the underlying cobalt chromium substrate. In addition, the underlying cobalt chromium substrate was an order of magnitude rougher than the polished surface, indicating the scale of damage to it. It is speculated that the loss of the coating, and the subsequent damage to the underlying substrate due to a third-body wear process, led to osteolysis and the metallosis seen at revision surgery. [ABSTRACT FROM AUTHOR]

The aim of this study was to analyse the short- and medium-term complications of the Motec total wrist arthroplasty (TWA). Identifying exact modes of failure and their causes should allow surgeons to avoid or mitigate these risks in the future. Retrospective analysis of prospectively collected data from six hand surgeons at five international centres provided details of 171 Motec TWAs. The mean follow-up was 5.8 years (range 18 months to 12 years). There were 33 (19%) complications within our cohort, with a revision rate of 8.2% (14 revisions). There was no difference in complication rates between metal-on-metal and metal-on-polymer articulations. Failure of osseointegration was the most common complication. Problems with soft tissue balancing, implant impingement related osteolysis, bony impingement and metacarpal fracture were found to be other preventable causes of failure in this series. Elimination of these preventable complications will improve survival rates for this implant. Level of evidence: IV [ABSTRACT FROM AUTHOR]

We examined the learning curve of Motec total wrist arthroplasty (TWA) of six experienced surgeons in their first 30 cases. Three times more complications/revisions were encountered in the first half of the study compared with the second half. Motec TWA surgery should be concentrated in a smaller number of centres performing higher volumes. [ABSTRACT FROM AUTHOR]

Background: In 2012, our unit published our experience with a pyrocarbon proximal interphalangeal joint (PIPJ) implant. Due to high subsidence rates, a decision was made to change to a cemented surface replacement proximal interphalangeal joint (SR-PIPJ) implant. The purpose of this study was to assess whether the change to a cemented implant would improve the subsidence rates. Methods : Retrospective review of all patients who had a cemented SR-PIPJ arthroplasty performed from 2011 to 2013 with at least 12 months follow-up. Results: A total of 43 joints were included with an average follow-up of 26.5 months. There was a significant (P =.02) improvement in arc of motion with an average satisfaction score of 3.3 (satisfied patient). Subsidence was noted in 26% of joints with a significant difference in range of motion (P =.003) and patient satisfaction (P =.001) between the group with and without subsidence. Conclusions : The change to a cemented implant resulted in satisfied patients with an improvement in range of motion. The rate of subsidence improved but remains unacceptably high. [ABSTRACT FROM AUTHOR]

We report outcomes of reconstruction of zone 1 or 2 flexor tendon injuries using a heterodigital hemi-tendon transfer of the flexor digitorum profundus in 23 fingers of 23 patients. At mean follow-up of 57 months, the mean total active motion of the three finger joints including the metacarpophalangeal joint was 128 degrees preoperatively and 229 degrees at final follow up. According to Strickland criteria, the function was excellent for 14 fingers, good for seven fingers and poor for two fingers. The subgroup analysis showed that the results were better in cases of primary surgery, children, and for the index and little fingers. Complications included stiffness of three fingers, and rupture in one finger that was converted to a two-stage tendon reconstruction. We conclude that this technique restores good function in most patients with zone 1 and 2 flexor tendon injuries, in which primary tendon repair has not been performed or was unsuccessful, and where pulley reconstruction is not required.Level of evidence: IV [ABSTRACT FROM AUTHOR]

Dear Editor, Delayed presentation and an immunocompromised status from diabetes mellitus, HIV infection and intravenous drug usage are known to increase the risk of hand infections and give a more complex clinical course ([2]). We excluded patients with hand infections that did not require surgical intervention, surgical site infections and patients under the age of 13, who were treated elsewhere. Patients with severe sepsis and diabetic patients with hand sepsis were admitted to hospital for intravenous antibiotics and were seen by the attending surgeon regularly. [Extracted from the article]

We present a rare case of wrist Charcot neuroarthropathy secondary to post-tuberculosis syringomyelia. Level of evidence: V.

The aim of this study was to analyse the short- and medium-term complications of the Motec total wrist arthroplasty (TWA). Identifying exact modes of failure and their causes should allow surgeons to avoid or mitigate these risks in the future. Retrospective analysis of prospectively collected data from six hand surgeons at five international centres provided details of 171 Motec TWAs. The mean follow-up was 5.8 years (range 18 months to 12 years). There were 33 (19%) complications within our cohort, with a revision rate of 8.2% (14 revisions). There was no difference in complication rates between metal-on-metal and metal-on-polymer articulations. Failure of osseointegration was the most common complication. Problems with soft tissue balancing, implant impingement related osteolysis, bony impingement and metacarpal fracture were found to be other preventable causes of failure in this series. Elimination of these preventable complications will improve survival rates for this implant. Level of evidence: IV., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: DB, SF, MS and TT are consultants for Swemac Innovation AB (Linkoping, Sweden).

We report outcomes of reconstruction of zone 1 or 2 flexor tendon injuries using a heterodigital hemi-tendon transfer of the flexor digitorum profundus in 23 fingers of 23 patients. At mean follow-up of 57 months, the mean total active motion of the three finger joints including the metacarpophalangeal joint was 128 degrees preoperatively and 229 degrees at final follow up. According to Strickland criteria, the function was excellent for 14 fingers, good for seven fingers and poor for two fingers. The subgroup analysis showed that the results were better in cases of primary surgery, children, and for the index and little fingers. Complications included stiffness of three fingers, and rupture in one finger that was converted to a two-stage tendon reconstruction. We conclude that this technique restores good function in most patients with zone 1 and 2 flexor tendon injuries, in which primary tendon repair has not been performed or was unsuccessful, and where pulley reconstruction is not required., Level of Evidence: IV.