HAND

Background: The use of tissue plasminogen activator (tPA) for the treatment of frostbite has been reported and advocated, but its efficacy has not been well established. We conducted a systematic review to guide physicians on the role of tPA in the treatment of frostbite. Our hypothesis was that the use of tPA improves clinical outcomes, as measured by amputation rate. Methods: We searched MEDLINE (PubMed) and EMBASE for primary research articles on the use of tPA for the treatment of extremity frostbite. Information related to study design, outcomes, and complications was extracted. A total of 204 citations were screened, and then 35 abstracts and 24 reports were reviewed. Fifteen studies met the standard for final review. Results: One randomized, prospective study; 3 cohort studies; 8 case series; and 3 case reports were found. A total of 208 patients were treated. Differences in protocols, inclusion criteria, and outcomes measures prevented combining the study results. In all the studies, the authors reported that the use of tPA was or may have been useful in reducing amputation rates or increasing tissue salvage. Complication rates ranged from 0% to 100%, with a combined rate of 13%. The quality of the evidence was low. Conclusions: Due to the low scientific quality of the studies, the efficacy of tPA in reducing amputation rates cannot currently be established. Randomized, prospective trials or well-controlled cohort studies are needed to better assess the role of tPA. Consideration should be given to limiting its use to research protocols.

Background: Despite the proven efficacy and advantages of absorbable implants, their use for metacarpal shaft fixation has been limited. This is likely due to the high reported complication rates in early studies with polyglycolic acid (PGA) implants, notably high rates of noninfectious inflammatory reaction (5%-25%), occurring up to 30 weeks after fixation. The objective of this study was to assess the clinical outcomes of newer absorbable plates and screws in the treatment of metacarpal shaft fractures. Methods: The authors performed a systematic search of the PubMed, Ovid MEDLINE, and EMBASE databases dating from 1946 to 2017. Primary outcome measures were the development of noninfectious inflammatory reaction and implant failure. Results: A total of 42 metacarpal shaft fractures in 35 patients were included. The average follow-up time was 20.4 months (n = 24; range: 3.6-61 months). Only 1 case (2.4%) of noninfectious inflammatory reaction was reported with polylactic acid (PLA) plates and PLA/PGA compounds. Noninfectious inflammatory reaction was observed in 4 out of the 9 patients (44.4%) with a trimethylene carbonate/PLA compound. Symptoms appeared after an average time of 15.8 months (range: 12-19 months) post-fixation. Painless prolonged inflammation that resolved spontaneously within 6 months was reported in 7.1% of cases (n = 3). Implant failure with loss of fracture reduction was reported in 9.5% of cases (n = 4). Conclusions: Newer absorbable materials appear to have significantly lower rates of noninfectious inflammatory reaction than previously reported. When compared with metallic fixation of the metacarpal shaft, absorbable fixation appears to have comparable complication rates and biomechanical properties.

Background: Metacarpal shaft fractures that necessitate surgery are frequently fixated with either intramedullary pins or plates and screws. This study compared outcome measurements of these two techniques. Methods: Patients operated on for closed shaft fractures of metacarpals 2-5 were examined at least 1 year after injury. All fractures were fixated by pinning between years 2013 and 2015 and by locking plates and screws between 2016 and 2017. Evaluation included range of motion measurements for all fingers compared with the contralateral hand; comparison of grip strength; finger alignment and rotation; Disabilities of the Arm, Shoulder and Hand (DASH) score; and radiographic measurements of fracture reduction and healing. Results: Thirty patients with 39 fractured metacarpals treated by pinning were compared with 29 patients with 35 fractured metacarpals treated by locking plate and screws. Both groups had similar characteristics and preoperative fracture patterns on radiograph. Patients in the plate group were found to have significantly improved outcomes in total range of motion of the operated digits (loss of 4° extension, 10° flexion, and 14° total vs 10° extension, 19° flexion, and 29° total), grip strength (93% vs 83% of contralateral hand), rotational deformity (5 digits, 1° vs 15 digits, 6°), and DASH score (10.5 vs 15.6). Radiographic bone healing time (59 vs 50 days) and operative time (58 vs 41 minutes) were both significantly longer in fractures fixated by plates. Conclusions: Fixation with locking plates allows earlier mobilization without need for splinting. Our study supports the use of this method over intramedullary pinning for metacarpal shaft fractures.

Background: Birth brachial plexus injury usually affects the upper trunks of the brachial plexus and can cause substantial loss of active shoulder external rotation and abduction. Due to the unbalanced rotational forces acting at the glenohumeral joint, the natural history of the condition involves progressive glenohumeral joint dysplasia with associated upper limb dysfunction. Surgical reconstruction methods have been described previously by Sever and L’Episcopo, and modified by Hoffer and Roper to release the adduction contracture and to restore external rotation and shoulder abduction. Methods: The authors describe their preferred technique for contracture release and tendon transfer to improve external rotation and shoulder abduction. Pertinent anatomy and highlights of surgical exposure are reviewed. Results: The senior author has utilized this technique with consistent clinical outcomes to improve shoulder function for patients with persisting nerve palsy associated with birth brachial plexus injury. A review of the literature supports utilization of this technique. Conclusions: Transfer of the latissimus dorsi and teres major to the posterior rotator cuff for reanimation of shoulder abduction and external rotation deficits associated with birth brachial plexus injury is a safe and reliable technique. Careful patient selection and attention to surgical detail are critical for optimal outcomes.

Background: Managing postoperative pain is important for patients and surgeons. However, there is concern over opioid dependency. Cubital tunnel decompression is among the most common upper extremity surgeries. Our study aimed to analyze opioid use after cubital tunnel decompression to guide postoperative opioid prescribing. Methods: We prospectively collected opioid consumption for 16 consecutive months (February 2016 to June 2017) for cubital tunnel decompression patients. Data on demographics, insurance type, surgery performed, functional questionnaires (Quick Disabilities of the Arm, Shoulder and Hand [QuickDASH]), and electrodiagnostics (electromyography) were collected. Opioid consumption was reported at first postoperative visits. Results: One hundred patients consumed a mean of 50 morphine equivalent units (MEUs) (range, 0-300), or 7 oxycodone 5-mg pills, postoperatively. Cubital tunnel release (CuTR) patients consumed fewer than ulnar nerve transposition (UNT) patients (40.4 vs 62.5 MEUs or 5.4 vs 8.3 pills, P = .08). Patients undergoing submuscular UNT consumed more than CuTR (115.0 vs 40.4 MEUs or 15.3 vs 5.4 pills, p = 0.003) and more than subcutaneous UNT patients (37.8 MEU or 5.0 pills, p = 0.03). Medicare patients consumed less than privately insured (42.7 vs 54.1 MEUs, 5.7 vs 7.2 pills, P = .02) and less than workers’ compensation patients (76.8 MEU or 10.2 pills, P = .04). Older patients consumed fewer than younger patients (P = .03). Postoperative QuickDASH score was positively related to opioid intake (P = .009). Conclusions: Patients consumed 7 oxycodone 5-mg pills after cubital tunnel decompression. Younger, privately insured, and workers’ compensation patients, and those with worse functional scores and those undergoing UNT (specifically the submuscular technique) consumed more opioids.

Background: We tested how different applications of casts and splints affect underlying below-dressing pressures and how these dressings respond to swelling. Methods: A 3-in polyvinyl chloride pipe with an attached 100 mL saline bag to the outer surface was used to simulate a human forearm. A pressure transducer was attached to the bag and connected to a monitor providing continuous pressure measurements. Either a circumferential fiberglass cast or single-sided plaster splint was applied around the bag. To simulate the dressing’s compliance to soft tissue swelling, change in pressure was measured after 25 mL of saline was injected into the bag. Compliance was determined by calculating change in volume over change in pressure as volume was added. Results: In our 150 mL model, cast bivalving reduced pressure up to 28%, and splitting the cotton padding of a splint reduced pressures up to 33%. The mean compliance (ability to accommodate swelling) across all volume intervals was 182% greater in a bivalved cast versus a cast and 21% greater in a cotton-split splint versus a splint. Below-dressing pressure of a tightly wrapped elastic bandage was up to 2.76× greater than a medium tension bandage and up to 6.44× greater than a loosely applied bandage. A splint with real cotton padding had a 28% greater pressure than a splint with synthetic soft-roll padding. Conclusions: Splitting a dressing, utilizing synthetic cotton padding, and applying an elastic bandage cautiously can help reduce surface pressures and allow the construct to be more accommodating to soft tissue swelling.

Background:Carpal tunnel syndrome (CTS) is the most common peripheral mononeuropathy and thus is frequently encountered by general practitioners (GPs). The aim of this study is to investigate the referral pattern of GPs with regard to electrodiagnostic (EDX) testing for suspected CTS prior to hand surgery consultation, as well as to investigate the results of EDX testing for suspected CTS when requested by GPs prior to evaluation by a hand surgeon. Methods: We retrospectively reviewed patients referred to our hand surgery clinic over a consecutive 2-year period for suspected CTS. Results: A total of 403 patients were referred to our hand surgery clinic from January 1, 2016, to December 31, 2017. Of the 403, 295 (73.2%) were referred by GPs. GPs obtained prereferral EDX testing in 198 (67.1%) of these patients. EDX testing confirmed their diagnosis in 177 patients (89.4%). There were 21 patients (10.6%) identified with normal EDX testing and a more likely diagnosis reached based on clinical examination. Conclusions: GPs make up the majority of our referrals for CTS, and they obtain EDX testing prior to consultation in two-thirds of referrals. GPs appear to accurately utilize EDX testing to confirm their diagnosis prior to referral and have a low rate of normal testing where symptoms are more readily explained by an alternative diagnosis.

Background: Trapeziometacarpal prostheses have been used for more than 50 years in the treatment of first carpometacarpal joint arthritis. Even though this technique is more expensive than trapeziectomy, it has many advantages such as faster convalescence with better patient comfort and improved strength and range of motion. The aim of this study was to report the early functional results of a patient cohort treated with a dual mobility thumb carpometacarpal joint prosthesis. Methods: A retrospective study was performed to assess the functional results of 25 patients treated for trapeziometacarpal advanced osteoarthritis (Eaton and Littler stage III) with 28 MOOVIS prostheses. Preoperative and postoperative assessments included pain, range of motion, and pinch and grip strength. The average follow-up time was 27.5 months. Results: The mean pain score measured by a visual analog scale was 8 preoperatively and 1 postoperatively. The mean preoperative Kapandji opposition score was 7 and counter-opposition score was 1; postoperative scores were 10 and 4, respectively. The grip strength improved after the surgery and the results were compared separately between dominant and nondominant sides. Final functional results were good: the mean Quick Disabilities of the Arm, Shoulder and Hand Questionnaire score was 12, and the mean Michigan Hand Outcomes score was 87%. Conclusions: Total joint arthroplasty with a dual mobility prosthesis appears to be a satisfactory solution in our series. The absence of prosthesis instability encourages us to recommend this technique for the treatment of advanced trapeziometacarpal osteoarthritis for people having an activity without too many manual constraints.

Background: We sought to compare the functional outcomes, radiographic outcomes, and complications of trapeziectomy and flexor carpi radialis (FCR) to abductor pollicis longus (APL) side-to-side tendon transfer with or without suture-button suspensionplasty for thumb basilar joint arthritis. Methods: Patients treated with and without suture-button suspensionplasty were compared over a 6-year period. Data were reviewed for complications and functional outcomes, including grip and pinch strength, range of motion, and visual analog scale (VAS) pain scores. Plain radiographs were independently reviewed at initial presentation and at final follow-up, including proximal phalanx length, trapezial space height, and trapezial height ratio. Results: Seventy thumb arthroplasties were performed in 70 patients. Trapeziectomy with FCR-APL side-to-side tendon transfer was performed in 39 patients, and trapeziectomy with FCR-APL side-to-side tendon transfer with suture-button suspensionplasty was performed in 31 patients. Mean length of follow-up was 28.4 ± 3.9 and 23.8 ± 2.6 months, respectively. Postoperative grip, oppositional and appositional pinch strength, and VAS pain scores improved compared with preoperative values, but were not significantly different based on suture-button suspensionplasty. Percentage decline in trapezial space ratio was significantly different between groups at 36.7% and 20.4% for procedures with and without suture-button suspensionplasty, respectively indicating that the trapezial space was better maintained within the suture suspension cohort. The incidence of postoperative complications, including surgical site infection, paresthesias, reoperation, complex regional pain syndrome, and symptomatic subsidence, was not significantly different between groups. Conclusions: Trapeziectomy with FCR to APL side-to-side tendon transfer with and without suture-button suspensionplasty results in comparable improvement in pain, grip strength, and functional parameters. Suture-button suspensionplasty results in significantly greater preservation of trapezial space.

Background: Scaphoid fractures are a common injury, and a known complication is nonunion. One option to treat this nonunion is with the Matti-Russe technique, which takes a corticocancellous graft and fits it into the defect without internal fixation. The advent of modern methods of fixation has led the classic Matti-Russe technique to fall out of favor. In this study, we describe the classic technique and evaluate the results of the Matti-Russe method for treatment of scaphoid nonunions specifically for the pediatric population. Our purpose was to evaluate the long-term clinical and radiologic outcomes after surgery for scaphoid nonunion using the Matti-Russe technique in the pediatric population. Methods: A retrospective review was performed of patients less than 17 years of age, with a scaphoid nonunion that was treated with the Matti-Russe technique. This technique consisted of open reduction with intercalated bone graft and no internal fixation with hardware. Union was determined by radiographic evaluation. Computed tomography was obtained in 7 of 10 patients in this series and showed bony bridging in more than 50% of the scaphoid width in 3 different views. Intrascaphoid, scapholunate, and radiolunate angles were calculated. We reviewed wrist range of motion and complications. We obtained postoperative Mayo and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: There were 10 patients who underwent the Matti-Russe technique. The average age was 14.7 years old (±1.34, range: 13-17). All 10 of these patients had a scaphoid waist nonunion. There were 9 males and 1 female with an average follow-up of 13 months. The average amount of time to surgery from the date of injury was 12.3 months. All 10 patients went on to radiographic union at or before 6 months from surgery. Preoperative intrascaphoid, scapholunate, and radiolunate angles were 29° (±5.38), 62° (±18.28), and 20° (±9.22). Postoperative intrascaphoid, scapholunate, and radiolunate angles improved to 16° (±6.89), 38° (±8.50), and 10° (±4.69), which was significant. Seven out of 10 patients completed postoperative outcomes measures. The average postoperative Mayo wrist score was 87.9 (±14.10, range: 60-100). The average postoperative DASH score was 1.9 (±2.03, range: 0-4.5). There were no associated complications nor reoperations. Conclusion: The Matti-Russe technique is a safe and effective treatment for scaphoid nonunion in the pediatric population. It facilitates scaphoid union without the need for screw fixation and avoiding potential complications with hardware.

Background: The anatomy of the scapholunate interosseous ligament (SLIL) has been described qualitatively in great detail, with recognition of the dorsal component’s importance for carpal stability. The purpose of this study was to define the quantitative anatomy of the dorsal SLIL and to assess the use of high-frequency ultrasound to image the dorsal SLIL. Methods: We used high-frequency ultrasound imaging to evaluate 40 wrists in 20 volunteers and recorded the radial-ulnar (length) and dorsal-volar (thickness) dimensions of the dorsal SLIL and the dimensions of the scapholunate interval. We assessed the use of high-frequency ultrasound by comparing the length and thickness of the dorsal SLIL on ultrasound evaluation and open dissection of 12 cadaveric wrists. Student’s t test was used to assess the relationship between measurements obtained on cadaver ultrasound and open dissection. Results: In the volunteer wrists, the mean dorsal SLIL length was 7.5 ± 1.4 mm and thickness was 1.8 ± 0.4 mm; the mean scapholunate interval was 5.0 mm dorsally and 2.5 mm centrally. In the cadaver wrists, there was no difference in dorsal SLIL length or thickness between ultrasound and open dissection. Conclusions: The dorsal SLIL is approximately 7.5 mm long and 1.8 mm thick. These parameters may be useful in treatment of SLIL injuries to restore the native anatomy. High-frequency ultrasound is a useful imaging technique to assess the dorsal SLIL, although further study is needed to assess the use of high-frequency ultrasound in detection of SLIL pathology.

Background: Repair of the flexor pollicis longus (FPL) tendon by tendon retriever can be challenging because of uncertainty of the optimal direction. This study aims to describe the FPL tendon path in the thenar eminence. Methods: In 18 hands of 9 cadavers, the angle of the FPL tendon was, after dissection, measured in relation to the axis formed between the metacarpophalangeal (MCP) joint of the thumb and the dorsal carpometacarpal joint (MC1-axis) and the axis formed between the second MCP joint and the distal edge of the trapezium (MC2-axis). Results: The FPL does not follow the angle of the thumb metacarpal. The FPL runs ulnarly from the MC1-axis at a median of 32.5° in abduction and 30.6° in adduction. In relation to the MC2-axis, it runs at a median of 47.5° in abduction and 25° in adduction. Conclusions: The FPL tendon path can be preoperatively marked using: (1) the MC1-axis from which it runs ulnarly approximately at an angle of 30° in both abduction and adduction; or (2) the MC2-axis from which it runs radially at an angle of 47.5° in abduction and at an angle of 25° in adduction. We conclude that the FPL tendon path can be preoperatively marked using these axes and does not parallel the metacarpal axes of the thumb.

Background: The use of barbed sutures in wound closure and tendon repair has been previously been studied with improved results over traditional suture material. We examine the use of barbed suture in muscle belly repair in a custom configuration, comparing it with traditional configurations and a control. Methods: Twenty-five matched porcine psoas muscles were assigned to 5 different test groups: Mason-Allen with #1 Ethibond, Figure of Eight Allen with #1 Ethibond, Modified Kessler with #1 Ethibond, Custom Configuration with #2 Barbed PDS, Custom Configuration with #1 Ethibond. Repair was performed on the cut edge of muscle, with the free end of the suture anchored to a fixed base, forming a single-sided repair. An Instron 8874 tensiometer was used to linearly distract the repair to failure at 1 mm/s after 1 N preload. Five samples of each group were run, comparing load to failure and distraction at 10 N. Results: Repair with barbed suture in custom configuration had statistically significantly greater load to failure than all other methods. It also showed statistically significant less displacement at 10 N of force than all other methods of repair except the Mason-Allen repair with #1 Ethibond. Mode of failure for traditional techniques was suture pull-through with tissue loss. Failure with barbed suture was through suture pullout without tissue loss. Conclusions: Custom configuration with a barbed suture increases the load to failure and decreases displacement of the repair site at 10 N of force. In addition, when the suture does pull out, it does so with minimal tissue loss.

Background: Workers’ compensation is intended for injuries that occur at work and is expected to be mostly for trauma and mostly nondiscretionary conditions. We tested the null hypothesis that there is no difference in the ratio of likely discretionary to likely nondiscretionary surgery between patients treated under workers’ compensation compared with commercial insurance controlling for age, sex, and anatomical site for either traumatic or nontraumatic diagnoses. Methods: Using claims data from the Texas workers’ compensation database and Truven Health commercial claims we classified International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedure codes as likely discretionary or likely nondiscretionary, and as traumatic or nontraumatic. Ratios of likely discretionary to likely nondiscretionary surgery were calculated and compared. Results: Among patients treated under workers’ compensation, the ratio of likely discretionary to likely nondiscretionary surgery was significantly higher for traumatic diagnoses (0.57 [95% confidence interval, CI, = 0.56-0.61] vs 0.38 [95% CI = 0.37-0.40], P < .05) and significantly lower for nontraumatic diagnoses (9.4 [95% CI = 9.20-9.42] vs 13.2 [95% CI = 12.9-13.3], P < .05) compared with commercial insurance. Conclusions: Workers’ compensation often covers likely discretionary musculoskeletal surgery, and insurance type may influence treatment.

Background: Distal radius fracture (DRF) is a common fracture of the upper extremity. The role of concurrent injuries in patients treated for DRFs is poorly elucidated. The authors sought to determine whether remote injuries were associated with worse outcomes after management of DRFs. Methods: A retrospective cohort study including all consecutively seen patients by a university hospital hand service between 2010 and 2015. Preoperative radiographs were analyzed, and patients were managed by surgeon preference and evaluated postoperatively using pain scores. Remote injury was defined as any other injury sustained at the time of fracture not localized to affected extremity. Univariate analysis was performed to identify factors associated with risk of complication. A multivariate logistic regression analysis was performed, controlling for confounding factors. Results: A total of 181 DRFs in 176 patients were treated over the 5-year period of the study. Forty-eight (26.5%) of the fractures were managed nonoperatively with casting, 12 (6.6%) with closed reduction and pinning, and 119 (65.7%) with open reduction and plating. The mean follow-up was 5.2 months. The complication rate was 18.2%. The most common complication was persistent pain in 5 patients, followed by median neuropathy, loss of reduction, arthritis, and distal radioulnar joint instability. After controlling for age, body mass index, hand surgeon, and other confounders, remote injury was associated with a significantly increased risk of complications (P = .04, odds ratio: 6.03, 95% confidence interval: 1.05-34.70). Conclusions: Patients with remote injuries have a 6-fold increased risk of complications after DRF treatment. The additional risk in these patients should be considered during patient/family counseling and clinical decision-making in DRF management.

Background: Surgical thoracic outlet syndrome (TOS) management involves decompression of the neurovascular structures by releasing the anterior and/or middle scalene muscles, resection of the first and/or cervical ribs, or a combination. Various surgical approaches (transaxillary, supraclavicular, infraclavicular, and transthoracic) have been used with varying rates of complications. The purpose of this study was to evaluate early postoperative outcomes following surgical decompression for TOS. We hypothesized that first and/or cervical rib resection would be associated with increased 30-day complications and health care utilization. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all TOS cases of brachial plexus surgical decompression in the region of the thoracic inlet from 2005 to 2013. Results: There were 225 patients (68% females; mean age: 36.4 years ± 12.1; 26% body mass index [BMI] ⩾ 30). There were 205 (91%) patients who underwent first and/or cervical rib resection (±scalenectomy), and 20 (9%) underwent rib-sparing scalenectomy. Compared with rib-sparing scalenectomy, rib resection was associated with longer operative time and hospital stays (P < .001). In the 30 days postoperatively, 8 patients developed complications (rib-scalenectomy, n = 7). Only patients with rib resection returned to the operating room (n = 10) or were readmitted (n = 9). Conclusions: Early postoperative complications are infrequent after TOS decompression. Rib resection is associated with longer surgical times and hospital stays. Future studies are needed to assess the association between early and long-term outcomes, surgical procedure, and health care utilization to determine the cost-effectiveness of the various surgical interventions for TOS.

Background: Obesity is a known risk factor for wound complications; however, unlike elective upper extremity procedures, where obesity can be modified preoperatively, excision of soft tissue sarcomas (STSs) is not elective, and as such, obesity cannot be modified. There is a paucity of data concerning the impact of obesity on wound healing in upper extremity sarcoma surgery. Methods: A total of 261 (159 males and 102 females) patients with a STS of the upper extremity from 2006-2014 were reviewed. The mean age and body mass index (BMI) were 56 (18-97) years and 26.6 (15.4-40.8) kg/m², respectively. Sixty-nine patients (26%) were classified as obese (BMI ⩾30 kg/m²): class I (obese, BMI = 30-34.9 kg/m²; n = 48, 18%), class II (severely obese, BMI = 35.0-39.9 kg/m²; n = 16, 6%), and class III (morbidly obese, BMI ≥ 40 kg/m²; n = 5, 2%). Functional outcomes were also compared between obese and nonobese patients using the Musculoskeletal Tumor Society (MSTS) 1993 rating system and Toronto Extremity Salvage Scores (TESS). Results: Forty-nine patients (19%) sustained a wound dehiscence, delayed healing, or infection. Class III obesity increased the risk of wound complications (hazard ratio [HR] = 8.19, 95% confidence interval [CI] = 1.96-22.96, P < .001) and infection (HR = 10.09, 95% CI = 1.60-34.83, P = .01). There was no difference in the mean TESS (93 vs 90, P = .13) or MSTS93 (95 vs 93, P = .39) between obese and nonobese patients. Conclusions: The results of this study indicate morbid obesity significantly increased the risk of a postoperative wound complication and infection. However, following upper extremity limb salvage surgery, obese patients should expect to have excellent functional outcome.

Background: Proximally based, pedicled flexor carpi ulnaris (FCU) muscle flap has been described previously for soft tissue coverage of the proximal forearm and elbow. No studies have been done on the distal muscular perforators and its use as a distally based flap. Methods: Ten fresh-frozen cadaveric dissections were done. Specimens were injected with latex to facilitate identification of the perforators. Distal muscular perforators were dissected and distances of the pedicles from the distal wrist crease and ulnar styloid were measured and recorded. A clinical case is also presented where a distally based FCU muscle flap was used for coverage in a patient with median nerve neuroma. Results: A distal muscular perforator and a second more proximal perforator were identified in all specimens. The average distance from the most distal muscular perforator to the ulnar styloid was 3.0 cm. The average distance to the wrist crease was 4.6 cm. The more proximal perforators had an average distance to the ulnar styloid and wrist crease of 7.3 cm and 8.8 cm, respectively. At 7 months post-op, the patient who underwent median nerve neurolysis and coverage with pedicled FCU flap had much improved sensation, with complete resolution of pain and tingling, and without any functional deficits. Conclusions: The use of a distally based FCU muscle flap is a good option for soft tissue coverage of the distal forearm, wrist, and hand. The distal muscular perforators from the ulnar artery exhibit a relatively consistent anatomy.

Background: Physician extenders, such as physician assistants (PAs) and nurse practitioners (NPs), have been incorporated into health systems in response to the rising demand for care. There is a paucity of literature regarding patient perspectives toward physician extenders in hand surgery. Methods: We anonymously surveyed 939 consecutive new patients before their clinic visit. Our questionnaire assessed patient perspectives toward physician extenders, including optimal scope of practice, the effect of the extender when choosing a hand surgeon, and pay equity for the same clinical services. Results: Of 939 patients, 784 (84%) responded: 54% were male and 46% were female with a mean age of 44.1 years. Most (65%) patients consider the extender’s training background when choosing a hand surgeon, with 31% of all patients considering PAs to have higher training than NPs and 17% the reverse. Patients responded that certain services should be physician-provided, including determining the need for advanced imaging (eg, magnetic resonance imaging), follow-up for abnormal diagnostics, and new patient visits. Patients were amenable to services being extender-provided, including minor in-office procedures, preoperative teaching, and postoperative clinic visits. Patients lacked a consensus toward reimbursement equity for hand surgeons and physician extenders providing the same clinical services. Conclusions: Our data suggest that patients presenting to a hand surgeon are comfortable receiving direct care from a physician extender in many, but not all, circumstances. Hand surgeons can use these data when deciding how to use extenders to optimize patient satisfaction and practice efficiency as health care systems become increasingly consumer-focused and value-based.

Background: Various techniques have been described for removal of a tight constricting ring from a finger. A novel procedure is described in this article. Methods: The method is a modification of the string wrap or winding technique. A 1-inch Coban wrap, lubricant, and pickups are all that is required. Results: The author has used this method to remove constricting rings from swollen and arthritic fingers in 5 patients. The technique has been successful in all cases, and no complications occurred. Conclusions: The Coban method is a quick, easy, and inexpensive technique for ring removal from a finger. The technique should be taught to and known by every clinician who treats hand problems.