Jeffrey N Lawton

Concordia University–Ann Arbor, Ann Arbor, Michigan, United States

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Publications (28)50.58 Total impact

  • Albert V. George · Jeffrey N. Lawton ·
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    ABSTRACT: Forearm fractures may be complicated by the disruption of the distal radioulnar, proximal radioulnar, or radiocapitellar joints. The key principles in treating this unique subset of fractures include early recognition and management of the injury and restoration and maintenance of the anatomic alignment. This articles addresses radial diaphyseal fractures with distal radioulnar joint disruption, proximal ulnar fractures with radiocapitellar disruption, and disruption of the forearm longitudinal axis and how to properly recognize and manage these forearm fracture-dislocations. Copyright © 2015 Elsevier Inc. All rights reserved.
    Hand clinics 02/2015; 31(2). DOI:10.1016/j.hcl.2015.01.010 · 1.26 Impact Factor
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    ABSTRACT: Background The aim of this study was to compare postoperative immobilization techniques of the thumb metacarpophalangeal (MP) ulnar collateral ligament (UCL) in a cadaver model of a noncompliant patient. Methods A cadaveric model with fresh-frozen forearms was used to simulate pinch under two immobilization conditions: (1) forearm-based thumb spica splint alone and (2) forearm-based thumb spica splint with supplemental transarticular MP Kirschner wire fixation. Pinch was simulated by thumb valgus loading and flexor pollicis longus (FPL) loading. Ulnar collateral ligament displacements were measured and strain values calculated. Statistical analysis was performed using a repeated measures analysis of variance model. Results With valgus thumb loading, we noted a significantly lower UCL strain in the splint and pin group compared to splint immobilization alone. Increased load was associated with a statistically significant increase in UCL strain within each immobilization condition. FPL loading resulted in negative displacement, or paradoxical shortening, of the UCL in both immobilization groups. Conclusions While immobilized, valgus thumb force, as opposed to MP flexion, is a likely contributor to UCL strain during simulated pinch representing noncompliance during the postoperative period. Supplemental thumb MP pin fixation more effectively protects the UCL from valgus strain. UCL shortening with FPL loading likely represents paradoxical MP extension due to flexion of the distal phalanx against the distal splint, suggesting attempted thumb flexion with splint immobilization alone does not jeopardize UCL repair. Clinical Relevance This study provides a foundation to aid clinical decision-making after UCL repair. It reinforces the practice of surgeons who routinely pin their MP joints, but also brings to attention that the use of temporary MP pin fixation may be considered in difficult cases, such as those with potential noncompliance or tenuous repair.
    Hand 02/2015; 10(4). DOI:10.1007/s11552-015-9747-x
  • John J Lee · David J Ruta · John R Lien · Alex Brunfeldt · Jeffrey N Lawton · Kagan Ozer ·
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    ABSTRACT: Purpose To report the branching patterns, vessel diameters, and location of the valves in the arcus venosus dorsalis pedis (AVDP) as a graft option for use in superficial palmar arch reconstruction after mutilating hand injuries. Methods We dissected 10 cadaveric feet and measured vessel diameters, recorded number of branches, and located valves within the tibial, middle, and fibular thirds of the system. We used retrograde india ink injection to locate valves. Results The AVDP branching pattern was grossly different from side to side in the 4 cadavers with bilateral feet available. Mean flat diameters were 4.7, 2.9, and 2.1 mm in the tibial, middle, and fibular thirds of the arch, respectively. There was a mean of 1.7 valves (range, 1-4 valves) in the tibial third, 1.5 valves (range 0-4 valves) in the middle third, and 0 valves in the fibular third. There was an average of 3.4 branches off the middle third with a mean branch diameter of 2.1 mm. In 65% of these branches, valves were within 1 cm distal to the main arch. The direction of flow within the middle third was from fibular to tibial. Conclusions Valves were commonly found within the middle and tibial thirds of the AVDP and within branches just distal to bifurcations. By contrast, the fibular third of the AVDP contained no valves. Valvular anatomy suggests that the direction of flow within the middle third was from fibular to tibial direction. Copyright
    The Journal Of Hand Surgery 09/2014; 39(11). DOI:10.1016/j.jhsa.2014.08.020 · 1.67 Impact Factor
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    ABSTRACT: To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE). Prospective cohort followed for 1 year. Clinics at five study sites. Patients diagnosed with UNE (N=55). All subjects had simple decompression surgery. The primary outcome measure was patient-reported outcomes such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow. Multiple regression models with the change in the overall MHQ score as the dependent variable showed that at 3 months post-operative time, patients with less than 3 months duration of symptoms showed 12 points (95% CI = 0.9, 23.5) greater improvement in MHQ scores than those with 3 months or longer symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI = 2.9, 24.0) greater improvement in MHQ scores at 6 months post-op, but it was no longer associated with better outcomes at 12 months. Worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coeff=-0.38, 95% CI = -0.67, -0.09), and baseline MHQ score was the only significant predictor of 12-month MHQ scores (coeff=-0.40, 95% CI=-0.79, -0.01). Subjects with less than 3 months of symptoms and worse baseline MHQ scores, showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.
    Archives of physical medicine and rehabilitation 11/2013; 95(4). DOI:10.1016/j.apmr.2013.10.028 · 2.57 Impact Factor
  • Nikhil Oak · Jeffrey N Lawton ·
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    ABSTRACT: Fractures of the hand are common injuries and in particular, fractures involving the articular surfaces can present difficulties to the orthopedic surgeon in practice. Although the treatment of these fractures needs to be individualized based on fracture pattern and location, the goals for these fractures are to restore the alignment, stability, and congruity and to allow for early motion to prevent stiffness and traumatic arthritis. This article classifies the various types of intra-articular hand fractures as well as the workup and management of these injuries.
    Hand clinics 11/2013; 29(4):535-49. DOI:10.1016/j.hcl.2013.08.007 · 1.26 Impact Factor
  • Article: Preface.
    Jeffrey N Lawton ·

    Hand clinics 11/2013; 29(4):xi. DOI:10.1016/j.hcl.2013.09.003 · 1.26 Impact Factor
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    ABSTRACT: The Wrist and Radius Injury Surgery Trial (WRIST) study group is a collaboration of 21 hand surgery centers in the United States, Canada, and Singapore, to showcase the interest and capability of hand surgeons to conduct a multicenter clinical trial. The WRIST study group was formed in response to the seminal systematic review by Margaliot et al and the Cochrane report that indicated marked deficiency in the quality of evidence in the distal radius fracture literature. Since the initial description of this fracture by Cones in 1814, over 2,000 studies have been published on this subject; yet, high-level studies based on the principles of evidence-based medicine are lacking. As we continue to embrace evidence-based medicine to raise the quality of research, the lessons learned during the organization and conduct of WRIST can serve as a template for others contemplating similar efforts. This article traces the course of WRIST by sharing the triumphs and, more important, the struggles faced in the first year of this study. (Copyright (C) 2013 by the American Society for Surgery of the Hand All rights reserved.)
    The Journal Of Hand Surgery 06/2013; 38A(6):1194-1201. DOI:10.1016/j.jhsa.2013.02.027 · 1.67 Impact Factor
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    ABSTRACT: Background: Although numerous studies have investigated long-term outcomes after surgical treatment of ulnar neuropathy at the elbow with simple decompression, no study has evaluated the trend of postoperative recovery. The authors assessed timing of recovery after simple decompression for ulnar neuropathy at the elbow. Methods: The five-center Surgery of the Ulnar Nerve Study Group prospectively recruited 58 consecutive subjects with ulnar neuropathy at the elbow and treated them with simple decompression. Patients were evaluated preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patient-rated outcomes questionnaires included the Michigan Hand Questionnaire; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the Carpal Tunnel Questionnaire. Functional tests used were grip strength, key pinch strength, two-point discrimination, and Semmes-Weinstein monofilament testing. Postoperative improvement was assessed at each time point to establish the trend of recovery in reaching a plateau. Results: Significant patient-reported symptomatic and functional recovery occurred over the first 6 weeks postoperatively as represented by improvements in questionnaire scores. Symptomatic recovery occurred earlier than functional recovery as measured by sensory and strength testing and the work domain of the Michigan Hand Questionnaire. Improvement in patient-reported outcomes continued and reached a plateau at 3 months, whereas measured strength and sensory recovery continued over 12 months. Conclusion: The greatest clinical improvement after simple decompression for ulnar neuropathy at the elbow, according to questionnaire scores, occurs in the first 6 weeks postoperatively and reaches a plateau by 3 months.
    Plastic and Reconstructive Surgery 04/2013; 131(4):563e-573e. DOI:10.1097/PRS.0b013e318282764f · 2.99 Impact Factor
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    ABSTRACT: BACKGROUND:: Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE). OBJECTIVE:: We measured patient outcomes following ulnar nerve decompression to 1) identify the most appropriate outcomes tools for UNE and 2) describe outcomes following ulnar nerve decompression. METHODS:: Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively, 6-weeks, 3-months, 6-months, and 12-months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament (SWM), and 2-point discrimination (2PD) were measured. Construct validity was calculated using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means. RESULTS:: Key pinch (p=0.008) and SWM testing of the ulnar ring (p<0.001) and small finger (radial: p=0.004; ulnar: p<0.001) improved following decompression. 2PD improved significantly across the radial (p=0.009) and ulnar (p=0.007) small finger. Improved symptoms and function were noted by the CTQ (Preoperative CTQ symptom score 2.73 vs. 1.90 postoperatively, p<0.001), DASH (p<0.001), and MHQ: function (p<0.001), activities of daily living (p=0.003), work (p=0.006), pain (p<0.001), and satisfaction (p<0.001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness. CONCLUSION:: Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.
    Neurosurgery 02/2013; 72(6). DOI:10.1227/NEU.0b013e31828ca327 · 3.62 Impact Factor
  • John J Lee · Jeffrey N Lawton ·
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    ABSTRACT: Management of coronal shear fractures of the distal humerus has evolved considerably over the past 3 decades, with an increased appreciation of the complexity of these fractures, improvements in internal fixation techniques, and the use of more extensile exposures. Nearly all of these fractures are displaced, given the paucity of soft tissue attachments and correspondingly, nonsurgical management is fraught with complications including chronic pain, mechanical symptoms, and instability and is not recommended. Good to excellent outcomes can be achieved in the majority of patients with open reduction internal fixation, particularly when the fracture is limited to the radiocapitellar joint. Outcomes are worst for those with considerable medial extension or comminution. Computed tomography is highly recommended to guide surgical planning. The presence of posterior comminution or extension to the medial column might require more extensile exposures and supplemental fixation for adequate stability. Arthroscopic reduction and fixation techniques have been described for the simple fracture. Those not amenable to fixation might do better with total elbow arthroplasty in a select population. Long-term data demonstrate the durability of these elbows following open reduction internal fixation. Complications other than stiffness are rare. Radiographic avascular necrosis does not appear to affect outcome. Radiographic mild to moderate arthritis was observed in half of patients at 17-year follow-up.
    The Journal of hand surgery 11/2012; 37(11):2412-7. DOI:10.1016/j.jhsa.2012.09.001 · 1.67 Impact Factor
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    ABSTRACT: BACKGROUND: The diagnosis of displacement in scaphoid fractures is notorious for poor interobserver reliability. QUESTIONS/PURPOSES: We tested whether training can improve interobserver reliability and sensitivity, specificity, and accuracy for the diagnosis of scaphoid fracture displacement on radiographs and CT scans. METHODS: Sixty-four orthopaedic surgeons rated a set of radiographs and CT scans of 10 displaced and 10 nondisplaced scaphoid fractures for the presence of displacement, using a web-based rating application. Before rating, observers were randomized to a training group (34 observers) and a nontraining group (30 observers). The training group received an online training module before the rating session, and the nontraining group did not. Interobserver reliability for training and nontraining was assessed by Siegel's multirater kappa and the Z-test was used to test for significance. RESULTS: There was a small, but significant difference in the interobserver reliability for displacement ratings in favor of the training group compared with the nontraining group. Ratings of radiographs and CT scans combined resulted in moderate agreement for both groups. The average sensitivity, specificity, and accuracy of diagnosing displacement of scaphoid fractures were, respectively, 83%, 85%, and 84% for the nontraining group and 87%, 86%, and 87% for the training group. Assuming a 5% prevalence of fracture displacement, the positive predictive value was 0.23 in the nontraining group and 0.25 in the training group. The negative predictive value was 0.99 in both groups. CONCLUSIONS: Our results suggest training can improve interobserver reliability and sensitivity, specificity and accuracy for the diagnosis of scaphoid fracture displacement, but the improvements are slight. These findings are encouraging for future research regarding interobserver variation and how to reduce it further.
    Clinical Orthopaedics and Related Research 07/2012; 470(7):2029-34. DOI:10.1007/s11999-012-2260-4. · 2.77 Impact Factor
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    ABSTRACT: To evaluate and compare the biomechanical properties of 8 different locked fixed-angle volar distal radius plates under conditions designed to reflect forces seen in early fracture healing and postoperative rehabilitation. We evaluated the Acumed Acu-Loc (Acumed, Hillsboro, OR), Hand Innovations DVR (Hand Innovations, Miami, FL), SBi SCS volar distal radial plate (Small Bone Innovations, Morrisville, PA), Synthes volar distal radius plate and EA extra-articular volar distal radius plate (Synthes, Paoli, PA), Stryker Matrix-SmartLock (Stryker Leibinger, Kalamazoo, MI), Wright Medical Technology Locon VLS (Wright Medical Technology, Arlington, TN), and Zimmer periarticular distal radius locking plate (Zimmer, Warsaw, IN). After affixing each plate to a synthetic corticocancellous radius, we created a standardized dorsal wedge osteotomy. Each construct had cyclic loading of 100 N, 200 N, and 300 N for a total of 6000 cycles. Outcomes, including load deformation curves, displacement, and ultimate yield strengths, were collected for each construct. The Wright plate was significantly stiffer at the 100 N load than the Zimmer plate and was stiffer at the 300 N load than 4 other plates. The Zimmer and Hand Innovations plates had the highest yield strengths and significantly higher yield strengths than the Wright, SBi, Stryker, and Synthes EA plates. Given the biomechanical properties of the plates tested, in light of the loads transmitted across the native wrist, all plate constructs met the anticipated demands. It seems clear that fracture configuration, screw placement, cost, and surgeon familiarity with instrumentation should take priority in selecting a plating system for distal radius fracture treatment. This study provides further information to surgeons regarding the relative strengths of different plate options for the treatment of distal radius fractures.
    The Journal of hand surgery 04/2012; 37(7):1381-7. DOI:10.1016/j.jhsa.2012.03.021 · 1.67 Impact Factor
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    ABSTRACT: Heterotopic ossification (HO) about the elbow has been described after surgery, trauma, and burns. Even limited deposits can lead to significant functional deficits. Little data exist regarding outcomes of patients treated with radiation therapy (RT) after elbow surgery. We report here the Cleveland Clinic experience with single-fraction radiation following surgery to the elbow. The primary endpoint was the rate of new HO after RT. Secondary endpoints were range of motion, functional compromise, and toxicity. From May 1993 to July 2006, 36 patients underwent elbow surgery followed by single-fraction RT. Range of motion data were collected before and during surgery and at last follow-up. Radiographs were reviewed for persistent or new HO. Patient and treatment factors were analyzed for correlation with development of HO or functional compromise. Median follow-up was 8.7 months, median age was 42 years, and 75% of patients were male. Twenty-six (72%) patients had HO prior to surgery. All patients had significant limitations in flexion/extension or pronation/supination at baseline. Thirty-one (86%) patients had prior elbow trauma, and 26 (72%) patients had prior surgery. RT was administered a median of 1 day postoperatively (range, 1-4 days). Thirty-four patients received 700 cGy, and 2 patients received 600 cGy. Three (8%) patients developed new HO after RT. All patients had improvement in range of motion from baseline. No patient or treatment factors were significantly associated with the development of HO or functional compromise. Single-fraction RT after surgery to the elbow is associated with favorable functional and radiographic outcomes.
    International journal of radiation oncology, biology, physics 08/2010; 77(5):1493-9. DOI:10.1016/j.ijrobp.2009.06.072 · 4.26 Impact Factor
  • Michael Darowish · Jeffrey N Lawton · Peter J Evans ·

    Cleveland Clinic Journal of Medicine 06/2009; 76(5):306-8. DOI:10.3949/ccjm.76a.08090 · 2.71 Impact Factor
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    Sumon Nandi · Steven Maschke · Peter J Evans · Jeffrey N Lawton ·
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    ABSTRACT: Elbow motion is essential for upper extremity function to position the hand in space. Unfortunately, the elbow joint is prone to stiffness following a multitude of traumatic and atraumatic etiologies. Elbow stiffness can be diagnosed with a complete history and physical exam, supplemented with appropriate imaging studies. The stiff elbow is challenging to treat, and thus, its prevention is of paramount importance. When this approach fails, non-operative followed by operative treatment modalities should be pursued. Upon initial presentation in those who have minimal contractures of 6-month duration or less, static and dynamic splinting, serial casting, continuous passive motion, occupational/physical therapy, and manipulation are non-operative treatment modalities that may be attempted. A stiff elbow that is refractory to non-operative management can be treated surgically, either arthroscopically or open, to eliminate soft tissue or bony blocks to motion. In the future, efforts to prevent and treat elbow stiffness may target the basic science mechanisms involved. Our purpose was to review the etiologies, classification, evaluation, prevention, operative, and non-operative treatment of the stiff elbow.
    Hand 05/2009; 4(4):368-79. DOI:10.1007/s11552-009-9181-z
  • Peter J Evans · Sumon Nandi · Steven Maschke · Harry A Hoyen · Jeffrey N Lawton ·
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    ABSTRACT: The elbow is as prone to stiffness as it is essential for upper-extremity function. The elbow is a highly constrained synovial hinge joint that frequently becomes stiff after injury. Elbow contracture is challenging to treat, and therefore prevention is of paramount importance. When this approach fails, nonoperative followed by operative treatment modalities can be pursued. In the future, efforts to prevent and treat elbow stiffness may target the basic science mechanisms involved. (J Hand Surg 2009;34A:769-778. (C) 2009 Published by Elsevier Inc. on. behalf of the American Society for Surgery of the Hand.)
    The Journal of hand surgery 05/2009; 34(4):769-78. DOI:10.1016/j.jhsa.2009.02.020 · 1.67 Impact Factor
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    Ryan W Patterson · Joy Sharma · Jeffrey N Lawton · Peter J Evans ·
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    ABSTRACT: Distal biceps tendon ruptures typically occur with biceps contraction against resistance with the elbow flexed at 90 degrees. Anatomic repair is the gold standard in active patients. Numerous surgical techniques are available; however, the Endobutton might offer several advantages. We describe a novel technique for chronic distal biceps reconstruction using a modification of the Endobutton technique with an anterior cruciate ligament (ACL) drill guide as well as tendoachilles allograft. The Endobutton technique might offer several advantages, including direct tendon-to-bone healing, less bony debris to limit heterotopic ossification, less heating of the bone, ease of use, a biomechanical superiority, and excellent clinical outcomes.
    The Journal of hand surgery 04/2009; 34(3):545-52. DOI:10.1016/j.jhsa.2008.12.019 · 1.67 Impact Factor
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    Dane A Glueck · Constantine P Charoglu · Jeffrey N Lawton ·
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    ABSTRACT: Open fractures are often classified according to a system described by Gustilo and Anderson. However, this system was applied to open long bone fractures, which may not predict the incidence of infection in open metaphyseal fractures of the upper extremity. Other studies have found that wound contamination and systemic illness were the best predictors of infections in open hand fractures. Our study assessed infection in open distal radius fractures and identifies factors that are associated with these infections. We hypothesize that contamination, rather than absolute wound size, is the best predictor of infection associated with open distal radius fractures. A review by CPT code yielded 42 patients with open distal radius fractures between 1997 and 2002 treated at a level one trauma center. Medical records and radiographic follow-up were reviewed to assess the time to irrigation and debridement, the number of debridements in initial treatment period, the method of operative stabilization, the Gustilo and Anderson type of fracture, the Swanson type of fracture, and description of wound contamination. Forty-two patients were followed up for an average of 15 months (range 4 to 68 months). Twenty-four fractures were classified as Gustilo and Anderson type I, ten were type II, and eight were type III, 30 were Swanson type I, and 12 were Swanson type II. Five of the 42 fractures were considered contaminated. Two were exposed to fecal contamination. The others were contaminated with tar, dirt/grass, and gravel, respectively. Three of 42 (7%) fractures developed infections. All three infected cases received a single irrigation and debridement. Two of five contaminated fractures (40%) developed a polymicrobial infection. Both were exposed to fecal contamination and, therefore, considered Swanson type II fractures. They were classified as Gustilo and Anderson type II and IIIB based solely upon the size of the wound. Both required multiple debridements and eventually wrist fusions. The third infection occurred in a Gustilo and Anderson type II and Swanson type I open fracture treated with one debridement and plate fixation. Hardware removal, debridement, and antibiotics resolved the infection. Three contaminated fractures that healed uneventfully received two debridements. Statistical analysis revealed a correlation with infection and contamination (p = 0.0331). The number of initial debridements played a role in infection, but was not statistically significant. No relationship between infection and time to initial irrigation and debridement, method of fixation, Gustilo and Anderson type, or Swanson type was found. We propose that open distal radius fractures behave differently than open long bone fractures. Infection developed in 7% of the distal radius fractures in our study and was significantly associated with wound contamination. We recommend that contamination be included as factor for prognosis in open distal radius fractures. Contaminated fractures should be treated with multiple debridements as part of the initial plan not based upon subsequent development of an infection.
    Hand 03/2009; 4(3):330-4. DOI:10.1007/s11552-009-9173-z
  • Ryan W Patterson · Steven D Maschke · Peter J Evans · Jeffrey N Lawton ·
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    ABSTRACT: The metacarpophalangeal (MP) joint is resistant to injury due to its strong capsuloligamentous structures, which include the volar plate and deep transverse metacarpal and collateral ligaments. Complex MP joint dislocations are, by definition, irreducible by closed means and require open reduction, as the volar plate becomes entrapped between the metacarpal head and proximal phalanx. The dorsal approach may offer the following advantages: 1) reduced risk to palmarly displaced neurovascular structures, 2) facilitated management of osteochondral fractures, and 3) full exposure of the volar plate. However, the dorsal approach requires splitting of the volar plate for adequate reduction, which may delay recovery.
    Orthopedics 12/2008; 31(11):1099. DOI:10.3928/01477447-20081101-22 · 0.96 Impact Factor
  • C. Robinson · J. Lyons · P. Evans · J. Lawton · T. Graham · J. Polster · J. Suh ·

    International Journal of Radiation OncologyBiologyPhysics 11/2007; 69(3). DOI:10.1016/j.ijrobp.2007.07.1794 · 4.26 Impact Factor

Publication Stats

261 Citations
50.58 Total Impact Points


  • 2013-2015
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
    • Drexel University
      Filadelfia, Pennsylvania, United States
  • 2012-2015
    • University of Michigan
      • Department of Orthopaedic Surgery
      Ann Arbor, Michigan, United States
  • 2007-2010
    • Cleveland Clinic
      • Department of Orthopaedic Surgery
      Cleveland, Ohio, United States
  • 2001
    • University of Kentucky
      • Department of Orthopaedic Surgery and Sports Medicine
      Lexington, Kentucky, United States