HAND

Background: Pyrocarbon implants represent an increasingly popular method to treat proximal interphalangeal joint dysfunction. To this point, no association has been shown between pyrocarbon biomaterials and fibromatosis. We present a potentially serious and destructive complication associated with pyrocarbon arthroplasty. Methods: We demonstrate a clinical case involving pyrocarbon arthroplasty and subsequent fibromatosis development in an otherwise healthy 23-year-old female. To present this association, we illustrate the diagnostic workup involved in a rapidly expanding soft tissue mass of the hand and explain the appropriate treatment. Results: Pyrocarbon arthroplasty was associated with development of locally destructive fibromatosis confirmed by histopathological examination. Treatment involved wide resection with preservation of local structures. Conclusion: We describe the first association between fibromatosis and pyrocarbon biomaterial. Due to fibromatosis destructive effects, clinicians should be aware of potential complications associated with these materials and know how to accurately diagnose and treat these lesions.

Background: The etiology of multifocal osteonecrosis is not definitively known; however, hypercoagulable state is a very plausible cause. Methods: We present an unusual case of a 12-year-old boy with a history of Legg-Calve-Perthes disease presenting with right wrist pain who was subsequently diagnosed with Kienbock’s disease. The finding of multifocal osteonecrosis prompted testing for a hypercoagulable state that was positive for Factor V Leiden thrombophilia. A thorough literature review using Medline database was conducted to investigate associations between inherited hypercoagulable states and multifocal osteonecrosis. Results: Our literature review identified 2 similar cases of multifocal osteonecrosis associated with a hypercoagulable disorder in adult patients. There were no reports among the pediatric patient population. Meta-analysis has demonstrated a potential link between Legg-Calve-Perthes disease and Factor V Leiden thrombophilia. Conclusions: This study offers further evidence to support the theory that multifocal osteonecrosis may be linked to a hypercoagulable state. Patients presenting with multifocal osteonecrosis should undergo screening for hypercoagulable states. Further investigation is needed to ascertain the potential benefit of prophylactic anticoagulation in patients with a known hypercoagulable state and multifocal osteonecrosis.

Background: Background: Pleomorphic hyalinizing angiectatic tumors (PHATs) are extremely rare, non-metastasizing tumors of uncertain origin that are typically seen in the lower extremities. To date, it is estimated that less than 100 cases have been reported worldwide since first described in 1996. Methods: The case of a 35-year-old male with a several-year history of a dorsal hand mass is presented. Although the patient was initially asymptomatic, in the months prior to presentation, the patient complained of pain with power grasp and direct pressure over the mass. The patient underwent uncomplicated surgical excision, during which the mass was noted to be adherent to the underlying extensor tendons. Results: Immunopathology confirmed the mass to be PHAT. We believe this is the first documented case of this rare tumor occurring in the hand. Conclusions: History and epidemiology of PHAT are reviewed. Then, in the context of the presented case, pre-operative evaluation, surgical management, pathologic findings and post-operative follow-up are all discussed.

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy found in clinical practice. Recent studies evaluated which external factors could be involved in the CTS symptoms, including prolonged exposure to vibration, especially in the upper limb. This study investigated signs and symptoms in patients with CTS after using urban transport on (1) both upper limbs, (2) how long before these symptoms appear, and (3) the hands position or body reaction during the act of pressing the safety bars. Methods: The study was conducted from July 2012 to April 2013. A total of 205 (178 women and 27 men) patients were evaluated. CTS was diagnosed in 285 hands. All participants answered a questionnaire formulated by the authors. The questionnaire was applied by researchers who were single-blinded and not involved in the research. Results: Most of the participants (87%) were women, but there was no statistical significance in age between groups (women = 51.24 ± 8.47 years, men = 51.10 ± 6.52 years, P > .05). The symptoms appeared significantly in the first 15 minutes after boarding when compared with patients who had no symptoms during the journey. There was no difference between hands position along the journey and the onset of symptoms. Conclusions: The onset of symptoms in patients with CTS using urban public transportation most commonly occurred in the first 15 minutes after boarding. Public transport vibration seems to be, at least in part, directly related to the development of symptoms. Questionnaires for the assessment of paresthesia symptoms during the use of public transport may be useful for CTS diagnosis.

Background: Symbrachydactyly is a unilateral congenital hand malformation characterized by failure of formation of fingers and the presence of rudimentary digit nubbins. The management is variable and are investigated in this review. Methods: A detailed review of the literature was compiled into succinct clinically relevant categories. Results: Etiology, classification, non-surgical management, surgical intervention, and patient oriented outcomes are discussed. Conclusions: All interventions should prioritize realistic, evidence-supported appearance and functional gains. Studies of the baseline function and quality of life of children with symbrachydactyly would allow surgeons to better understand functional changes associated with various interventions and would help surgeons and parents to make the best treatment decisions.

Background: Carpal coalition and metacarpal synostosis are uncommon congenital anomalies of the carpus and hand. Methods: A comprehensive review of the literature was performed to help guide surgical and non-surgical treatment of carpal coalition and metacarpal synostosis. Results: The embryology, epidemiology, medical and surgical management, and associated outcomes are detailed. Conclusions: Most patients with these disorders will likely benefit from conservative measures. Surgery should be considered in patients with pain and limitations in wrist and hand function.

Background: Volar plate fixation with locked screws has become the preferred treatment of displaced distal radius fractures that cannot be managed nonoperatively. This treatment, however, is not without complication. The purpose of this study was to determine what percentage of hand surgeons, over a 12-month period, have experienced a tendon complication when using volar plates for the treatment of distal radius fractures. Methods: A total of 3022 hand surgeons were e-mailed a link to an online questionnaire regarding their observation and treatment of tendon injuries associated with volar plating of distal radius fractures. Responses were reported using descriptive statistics. Results: Of the 596 (20%) respondents, 199 (33%) surgeons reported encountering at least one flexor tendon injury after distal radius volar plating over the past year of practice. The flexor pollicis longus was the most commonly reported tendon injury (254, 75%). Palmaris longus grafting (118, 37%) and tendon transfer (114, 36%) were the most often reported treatments following this complication. A total of 216 respondents (36%) also encountered 324 cases of extensor tendon rupture after volar plating of distal radius fractures, with tendon transfer (88%) being the preferred treatment option. Conclusions: Both flexor and extensor tendon ruptures can be seen after volar plating of distal radius fractures. Surgeons should be aware of these complications. Critical assessment of hardware position at the time of index procedure is recommended to avoid complications. Long-term studies are needed to standardize approaches to managing tendon rupture following volar plating of distal radius fractures.

Background: Glomus tumors are uncommon vascular tumors of the hand. Malignant glomus tumors, known as glomangiosarcomas, are very rare and offer management challenges. Methods: A review of the diagnosis and treatment of malignant glomus tumors is presented in along with a report of the largest malignant glomus tumor of the hand to date. Results: The review illustrates the management of glomangiosarcomas. Only 6 previous such cases have been reported. Conclusion: The rare nature of malignant glomus tumors mandates case presentation and longitudinal analysis to help guide surgical management an optimize outcomes.

Background: The incidence of carpal tunnel syndrome (CTS) is 48 million patients in the United States. The purpose of this longitudinal study was to determine whether Dynasplint stretching (immediately after diagnosis) had an effect on a patient’s decision to seek surgical treatment for CTS. Methods: Fifty patients (10 men, 40 women, mean age 51.2 ± 12 years) were recruited for this randomized, controlled, longitudinal trial. Patients were diagnosed with CTS by physical examination and nerve conduction studies. The intervention used was Dynasplint stretching that delivered a prolonged duration of low load stretching. Patients who were randomly chosen for the Experimental category wore the device for two 30-minute sessions per day with regular increases in splint tension for 60 days. Control patients received nonsteroidal anti-inflammatory medication plus instructions on daily home stretching. Results: The final, longitudinal outcome showed a 72% reduction in surgery chosen by the experimental group (n = 25), compared with 38% reduction for control patients (n = 25). Conclusions: Immediate treatment with Dynasplint stretching showed a 2 to 1 reduction in surgery, with abundant financial savings.

Background: Variation in pain intensity and magnitude of disability among patients with musculoskeletal illness is largely accounted for by variations in symptoms of depression, catastrophic thinking, and heightened illness concern. It is possible that patients with greater stress, distress, and less effective coping strategies might be more likely to seek the use of Complementary Health Approaches (CHA). This study addressed the primary null hypothesis that there are no demographic, illness-related, or psychological factors associated with CHA use among patients with upper extremity illness. Methods: A cohort of 170 patients completed a web-based Complementary and Alternative Medicine (CAM) questionnaire the Patient Reported Outcomes Measurement Information System (PROMIS) Depression and Pain Interference questionnaires. We evaluated differences between patients who sought CAM treatment regarding the PROMIS Pain Interference and PROMIS Depression scores. Ninety-four patients (56%) use or plan to use CAM treatment. A CAM provider was consulted by 61 patients (37%): most commonly a massage therapist (30/61), chiropractor (26/61), or acupuncturist (14/61). Results: In bivariate analysis patients who sought CAM reported greater average PROMIS Pain Interference than those who did not. In multivariable logistic regression, CAM use was associated with a higher Pain Interference Score and the specific surgeon. Conclusion: In conclusion, CHA use is prevalent amongst orthopaedic patients and associated with less effective coping strategies. Orthopaedic surgeons might consider asking patients about CHA use and determining whether those patients are interested in cognitive behavioral therapy.

Background: The purpose of this study is to evaluate long-term outcomes of ligamentous repair rather than reconstruction for chronic thumb ulnar collateral ligament (UCL) injuries. Methods: Patients at least 15-years status-post repair of a chronic (greater than 6 weeks) UCL tear were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale (VAS) pain scale, and study-specific questions. Twelve of 21 (57%) living patients were available for long-term, greater than 15-year follow-up (average 24.5 years, range 16.9-35.6). Results: Eighty-eight percent of patients had some degree of osteoarthritis. Increased age at the time of injury and higher DASH scores were correlated with increased grades of the thumb metacarpophalangeal osteoarthritis. Delay to treatment and VAS pain scores had no correlation with radiographic findings. Conclusions: Repair of a chronic UCL injury with available local tissue appears to be a reasonable alternative to ligament reconstruction, resulting in durable long-term outcomes despite the majority of patients progressing to osteoarthritis.

Background: The aim was to test the null hypothesis that splint material, thickness, or longitudinal ridging does not affect the strength of a wrist splint. Methods: Ten splints were made according to each of 7 different splint designs (resulting in 7 groups of 10 splints each). All splints were the same length and were molded to approximate the contour of the volar hand, wrist, and forearm with the wrist in neutral. Three groups consisted of plaster splints of different thicknesses (8, 10, and 12 ply). Three additional groups included splints of the same thicknesses but with a longitudinal ridge. A single group was constructed from prefabricated fiberglass splinting material and did not involve a longitudinal ridge. Five splints in each group were subjected to 3-point bending mimicking flexion of the wrist and 5 were subjected to a 3-point bend mimicking wrist extension. Splints were loaded to failure using a servohydraulic load frame. Analysis of variance was used to compare splints. Results: Among the plaster splints, more layers of material and longitudinal ridging increased splint strength. Ridged 8-ply plaster splints exceeded the strength of nonridged 10-ply plaster splints. Ridged 8-ply plaster splints were similar in strength to fiberglass splints. Conclusions: The 8-ply ridged plaster splints may be a lighter, effective, and cheaper alternative to more common splint designs.

Background: American Academy of Orthopaedic Surgeons (AAOS) distal radius fracture (DRF) clinical practice guidelines (CPG) are readily available to clinicians, patients, and policymakers. International Classification of Functioning, Disability, and Health (ICF) provides a framework for describing the impact of health conditions. The International Classification of Diseases–10th Revision (ICD-10) is a classification system to classify health conditions as specific disease or disorders. The aim of this study is to analyze and describe the scope and focus of the AAOS DRF CPG using the ICF and ICD-10 as a basis for content analysis, and to compare the content of the CPG with the ICF hand core sets as the reference standard. Methods: Established linking rules were used by 2 independent raters to analyze the 29 recommendations of the AAOS DRF CPG. ICD-10 codes were assigned in the same process. Summary linkage statistics were used to describe the results for ICF and the hand core sets. Results: Among the 29 recommendations of the AAOS DRF CPG, 5 meaningful concepts were linked to the ICF codes. Of these, 5 codes appeared on the comprehensive ICF core set and only 3 codes appeared in the brief ICF core set, and 7 conditions were covered in ICD-10 codes. Conclusions: The AAOS DRF CPG focuses on surgical interventions and has minimal linkage to the constructs of the ICD-10 and ICF. It does not address activity or participation (disability), and is not well linked to key concepts relevant to hand conditions.

Background: The repair of a segmental peripheral nerve injury is a clinical challenge. Several studies have been performed to determine superior methods for overcoming nerve gaps. The purpose of this study was to investigate if the inside-out slided epineurium of the distal segment of an injured nerve can serve as a conduit to bridge a short nerve defect (10 mm). Methods: Nineteen sciatic nerves in Sprague–Dawley rats were transected, and a 10-mm gap was left between the ends. A section of distal epineurium was pulled inside out to bridge the gap. Walking track analysis was performed, and the sciatic function index (SFI) was calculated. Wet muscle mass and withdrawal reflex were measured. The density of axon fibers at different levels of repaired nerves was determined, and histological analysis was performed at 16 weeks. Results: The mean SFI improved from −81.0 at 4 weeks to 36.3 at 16 weeks. The axon densities showed regeneration through the epineural tube, and 5 of the rats demonstrated a withdrawal reflex. The weight of the tibialis anterior muscle of the injured limb at 16 weeks was 59% that of the uninjured side. Conclusions: The distal epineural sheath tube provided a size-matched conduit between the nerve stumps, with no histological donor-site morbidity. Histologically, regeneration occurred through the epineural tube without neuroma formation, and functional recovery was comparable to that of previous studies of nerve repair techniques. Technique may be an addition to the armamentarium of tools used to treat segmental nerve defects.

Background: Approximately 33% of Americans have inadequate health literacy, which is associated with infrequent use of preventative services, increased hospitalization and use of emergency care, and worse control of chronic diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients undergoing carpal tunnel release (CTR), as these individuals may be at increased risk of inferior outcomes. Methods: This cross-sectional study included individuals older than or equal to 18 years of age who were scheduled for elective CTR. Participants completed a demographic survey and the LiMP questionnaire during their preoperative office visit. The prevalence of limited health literacy was determined, with chi-square analysis used to determine the influence of demographic parameters. Results: The mean LiMP score was 6 ± 1.40. Limited musculoskeletal literacy was seen in 34% of participants (22/65). Analysis identified race (Caucasian), gender (female), higher education levels (≥college), current or prior employment in a health care field, and a prior physician visit for a non–carpal tunnel musculoskeletal complaint as being associated with higher literacy rates. Conclusions: Approximately one-third of patients scheduled for elective CTR have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning, as CTR is performed in the United States on roughly 500 000 individuals annually, at an estimated cost of 2 billion dollars. The identification of those most at risk is thus crucial, and will facilitate the development of education campaigns and interventions geared toward those who are most vulnerable.

Background: The most frequent deformity of the hand occurring in patients with RA affects the metacarpophalangeal (MCP) joint and it is characterized by a volar subluxation of the proximal phalanges and ulnar drift of the fingers. Methods: The Extensor Indicis Proprius (EIP) tenodesis for correction of ulnar deviation of fingers (II to V) was performed in 10 hands (40 fingers and 5 patients). Results: There was complete correction of the subluxation or dislocation and almost complete correction of the ulnar drift of the metacarpophalangeal joints at the initial postoperative evaluation (three to four months after surgery). However, at final evaluation (eight to twelve months after the operation), all of the digits had some recurrence of ulnar deviation. Conclusion: The EIP tenodesis provides a correct forces vector to maintain the fingers in proper alignment following correction of ulnar deviation.

Background: Posttraumatic finger stiffness can occur as a result of hand fractures. The purpose was to assess and quantify the improvement in range of motion (ROM) after surgical management of the stiff finger in patients who developed loss of motion following treatment for a metacarpal or phalangeal fracture. In addition, an aim was to identify possible risk factors for suboptimal improvement in ROM postoperatively. Methods: A retrospective review was performed on 18 patients who underwent surgery to improve finger stiffness following metacarpal or phalangeal fracture. Demographic data including age, initial diagnosis and treatment, health history, and worker’s compensation status were collected. We determined the number of specific procedures performed at the time of surgery, the number of days between surgical release and initiation of therapy, and the total active motion (TAM) prior to surgical release and at the patient’s last follow-up. Results: Mean TAM improved from 150° preoperatively (range 60°-241°) to 191° postoperatively (range 61°-271°). Most patients required multiple anatomic structures released concomitantly, with an average of 3.1. Patients who started physical therapy within 7 days of the release improved by 59°, whereas those who started physical therapy after 7 days (average 11.5 days) lost 19° of motion. Patients who had filed a worker’s compensation claim improved an average of 9°, whereas nonworker’s compensation patients improved an average of 58°. Degree of TAM improvement had a weak correlation with patient age or preoperative TAM. Conclusions: Surgical release for stiff fingers following hand fractures can offer modest improvements in ROM in some patients. Although the overall increase in motion as a result of these operations is generally limited, functional improvement can be obtained. Delay in initiating physical therapy is a risk factor for persistent or worsened stiffness. Patients involved in worker’s compensation claims demonstrated significantly lower TAM improvement after surgical intervention.

Background: The purpose of this study was to investigate how American Society for Surgery of the Hand (ASSH) members’ Medicare reimbursement depends on their geographical location and number of years in practice. Methods: Demographic data for surgeons who were active members of the ASSH in 2012 were obtained using information publicly available through the US Centers for Medicare and Medicaid Services (CMS). “Hand-surgeons-per-capita” and average reimbursement per surgeon were calculated for each state. Regression analysis was performed to determine a relationship between (1) each state’s average reimbursement versus the number of ASSH members in that state, (2) average reimbursement versus number of hand surgeons per capita, and (3) total reimbursement from Medicare versus number of years in practice. Analysis of variance (ANOVA) was used to detect a difference in reimbursement based on categorical range of years as an ASSH member. Results: A total of 1667 ASSH members satisfied inclusion in this study. Although there was significant variation among states’ average reimbursement, reimbursement was not significantly correlated with the state’s hand surgeons per capita or total number of hand surgeons in that given state. Correlation between years as an ASSH member and average reimbursement was significant but non-linear; the highest reimbursements were seen in surgeons who had been ASSH members from 8 to 20 years. Conclusions: Peak reimbursement from Medicare for ASSH members appears to be related to the time of surgeons’ peak operative volume, rather than any age-based bias for or against treating Medicare beneficiaries. In addition, though geographic variation in reimbursement does exist, this does not appear to correlate with density or availability of hand surgeons.

Background: Previous studies using ultrasound for diagnosis of carpal tunnel syndrome have reported on relatively small series of patients, leading to large standard deviations and/or confidence intervals for the mean cross-sectional area of the median nerve. The purpose of this study is to define the CSA of the median nerve in a large cohort of patients. Methods: Patients (n = 175) without history of carpal tunnel release were recruited. All participants were evaluated using the Carpal Tunnel Syndrome-6 questionnaire, a validated clinical diagnostic tool, with a score of 12 or greater considered positive for CTS. Ultrasound examination was performed on both wrists of all participants using a 13-6 MHz linear array transducer. Results: The mean median nerve CSA was significantly larger (P < .001) for patients with a positive (mean = 11.16, SD = 2.51) versus negative CTS-6 result (mean = 6.91, SD = 2.06). There was a significant correlation (.527, P < .001, n = 349) between CSA and CTS-6 score. Logistic regression analysis determined that a CSA of 10 mm2 optimized sensitivity and specificity at 80% and 88%, respectively. Accuracy was 87.9%. Conclusions: A significant difference in mean CSA was found between patients with and without CTS. Median nerve CSA showed a statistically significant positive correlation with CTS-6. Similar to prior studies, a CSA of 10 mm2 was determined to be the optimal cutoff. In this large series of patients, ultrasound was a sensitive, specific, and accurate test for confirmation of a clinical diagnosis of CTS.

Background: A widely discussed subject, albeit with few associated studies and publications, centers on whether sacrifice of the radial artery to perform the radial forearm flap (RFF) is deleterious to the patient. The objective of this study was to assess, by questionnaire, the complications reported at the donor site, particularly those related to sacrifice of the radial artery. Methods: During the 2014 Symposium of the Brazilian Society of Reconstructive Microsurgery, surgeons were asked to answer a questionnaire on RFF cases and complications. Results: Results were collected from hand and plastic surgeons. Regarding the opinion of respondents on the deleteriousness of sacrificing the radial artery, most answered negatively, that is, no deleterious effects reported. No statistically significant difference was found between the level of experience and opinion on whether sacrificing the radial artery was deleterious. Conclusions: Beyond performing some procedures and following evolution within a specific service, it was decided to broaden the range of opinions and enlarge the casuistic by assessing the opinions of many specialists from the fields of hand surgery and plastic surgery. Data collected using the questionnaire were compared to determine the sequelae at the donor site and particularly whether sacrifice of the radial artery in RFF was deleterious to the patient. Although complaints at the donor site were frequently cited, no objective reports on morbidity following the sacrifice of the radial artery in RFF were provided.

Background: Finger flexion is a composite movement involving both long flexors and intrinsic hand muscles. Previous studies have characterized this but have not investigated differences within the normal population. Were discrete finger motion patterns identified, this could guide rehabilitation programs following flexor tendon surgery. Methods: Twelve volunteers repeatedly flexed and extended at a comfortable speed, resting their hand on a horizontal surface. Video was recorded perpendicular to the little finger flexion plane, and the little finger tip position was identified frame by frame to create a composite curve. Its highest point was noted, and the horizontal distance was measured from this point to the palmar digital crease (ΔX^H). Results: In addition, 2 investigators independently reviewed frame-by-frame images and allocated subjects into groups based on the motion pattern. ΔX^H demonstrated 2 clusters within our study population, and there was a statistically significant (P < .036) difference between groups. Conclusions: This study demonstrated that qualitative and quantitative differences exist in flexion curves between individuals.

Background: In recent years the use of biodegradable suture anchors for treating tendon and ligament pathology in hand surgery became popular. These materials are biocompatible, radiolucent, and load sharing, as they incrementally transfer load to surrounding bone during the resorption process. Despite these numerous advantages, polyglycolic (PGA) and poly-L-lactic acid (PLLA) have become a problem because of the potential risk for foreign body reactions. Methods: This article presents a case of an intraosseous foreign body reaction and massive osteolysis of the proximal carpal after dorsal lunate dislocation repair with bioabsorbable suture anchors. Results: Because of the persistent pain and the decreased strength, a proximal row carpectomy was performed 12-months after the initial trauma. Conclusions: Hand surgeons should be aware of the possibility of a late foreign body reaction, that could be especially severe in carpal bones.