HAND

Background: Hybrid Russe technique for the treatment of scaphoid nonunion with humpback deformity has been described with a reported 100% union rate. We sought to evaluate the reproducibility of this technique. Methods: We completed a retrospective chart review of patients with a scaphoid waist nonunion and humpback deformity treated with the hybrid Russe technique from 2015 to 2019 with a minimum of 3-month follow-up. Twenty patients with 21 nonunions were included (mean follow-up: 7.0 months). Scapholunate angle was the primary outcome measure. Secondary outcomes included: intrascaphoid angle, radiolunate angle, pain on the visual analog scale (VAS), and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Other variables included: time to computed tomography (CT) union, range of motion, and complications. Descriptive statistics were presented. Pre- and postoperative angles, VAS, and QuickDASH scores were evaluated with Wilcoxon signed rank tests. Results: The mean scapholunate angle improved −17.6° ± 6.4°. The mean intrascaphoid angle improved 28.2° ± 6.3°. The mean radiolunate angle improved 12.8° ± 8.8°. Of the 21 scaphoids, 20 (95%) demonstrated union on a CT scan. One patient was diagnosed with a nonunion. In total, 90% of patients noted symmetric range of motion compared with the contralateral side. The mean VAS pain score improved 6 ± 3 points. The mean QuickDASH score improved 10 ± 8 points. Complications (aside from nonunion) included 1 patient with persistent wrist pain that resolved with removal of hardware. Conclusions: The hybrid Russe technique for the treatment of scaphoid nonunions with humpback deformity demonstrates a 95% union rate. This technique is effective, reproducible, and may serve as an alternative to techniques that include structural grafts from distant sites.

Background: A common symptom associated with carpal tunnel syndrome (CTS) is nighttime awakening (NTA), which typically resolves quickly following carpal tunnel release (CTR). The early improvement in those who do not wake-up at night is less clear. This study investigates outcomes following CTR in patients with preoperative NTA symptoms compared to those without at 6 weeks and 3 months. Methods: Patients diagnosed with CTS who proceeded with CTR and agreed to participate in a prospective study completed the Boston Carpal Tunnel Questionnaire (BCTQ) and Michigan Hand Outcome Questionnaire (MHQ) at their preoperative appointment and 6-week and 3-month follow-ups. We compared outcomes between time points for improvement. Results: Of 45 patients, 37 patients with NTA had BCTQ scores of 3.09, 1.86, and 1.50 at preoperative, 6-week, and 3-month follow-up, respectively, and MHQ scores of 56.68, 74.91, and 81.01. NTA patients had improvement of both BCTQ and MHQ at 6 weeks and 3 months. Nonawakening patients had BCTQ scores of 2.58, 2.15, and 1.86 and MHQ scores of 57.94, 62.71, and 72.16, respectively. This cohort did not have significant improvement of MHQ at 6 weeks, but did at 3 months. The BCTQ severity scores in the nonawakening patients had significant improvement at both 6 weeks and 3 months, but did not at either time point for the BCTQ functionality scores. At 6 weeks, 2/37 patients continued to have NTA and no patients had NTA at 3 months. Conclusion: Patients with CTS and NTA symptoms had significant improvements in BCTQ and MHQ at 6 weeks and 3 months. Patients who did not awaken at night did not have significant improvements when evaluating BCTQ functional results, although they did improve when analyzing for BCTQ for symptom severity and MHQ, but not to the same level as those that do awaken and improvement was slower based on MHQ scores.

Background: Routine preoperative screening tests before low-risk surgery cannot be justified if the risks to patients are not outweighed by benefits. Several studies and professional guidelines suggest avoiding screening tests prior to minor operations. We aimed to assess the prevalence and patient characteristics associated with low-value preoperative tests (LVTs) prior to carpal tunnel release (CTR) at an academic medical center. Methods: From electronic medical records, we identified patients aged ≥18 who underwent CTR from 2015 to 2017. We determined the occurrence of 9 common LVTs, such as complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (ECG), in the 30 days prior to CTR. Multivariable logistic and Poisson regression were used to identify factors associated with receiving any LVT and the number of LVTs, respectively. Results: Among 572 patients, 248 (43.4%) had at least 1 LVT. The most common tests were ECG (31.3% of CTRs), CBC (27.3% of CTRs), and BMP (23.6% of CTRs). Patient factors associated with higher odds of receiving LVT included older age, higher Elixhauser comorbidity score, and general or regional anesthesia (vs monitored anesthesia care). Conclusions: Low-value preoperative tests were frequently received by patients undergoing CTR and were associated with anesthesia type, age, and number of comorbidities. Although our study focused on CTR, these results likely have implications for other commonly performed low-risk procedures. These findings can help guide efforts to improve the quality and value of surgery for carpal tunnel syndrome and facilitate the development of strategies to reduce LVT, such as audit feedback and provider education.

Background: This cadaveric study defines the interval distance between the proximal insertion of the volar wrist ligaments and the distal edge of the pronator quadratus on the distal radius. It is important to be aware of this distance during surgical dissection for placement of volar locking plates for wrist fractures. Disruption of the volar wrist ligament insertion may have adverse biomechanical consequences such as carpal instability, which can lead to pain and eventually wrist arthritis. Methods: Thirteen cadaveric wrists were dissected using the trans-flexor carpi radialis volar approach to identify relevant anatomy. The distance between the distal border of the pronator quadratus and the most proximal insertion of the volar wrist ligaments was measured. Results: The average distance between the pronator quadratus and the proximal insertion of the volar wrist ligaments was 5 mm, with a standard deviation of 2 mm. Conclusions: The volar wrist ligaments insert quite near the distal end of the pronator quadratus. Surgeons should be cognizant of the proximity of the volar wrist ligaments and be judicious with subperiosteal stripping of the distal fragment during volar plating procedures.

Background: Digital nerves will experience tension under normal daily activities, and understanding the amount of tension experienced in these nerves relates directly to the necessary strength in nerve repairs. To begin quantification of tension, the tension borne by the median and digital nerves in cadaveric hands was quantified under conditions of finger hyperextension, nerve distraction, and finger flexion. Methods: Five cadaveric hands were mounted in a special fixture that allowed finger hyperextension and flexion and could apply known distractions while the tension borne by each digital nerve was measured. Sequential dissection exposed the digital nerves so that measurements of tension in the median, common, and proper digital nerves were conducted with finger hyperextension, nerve distraction, and finger flexion. Results: Metacarpophalangeal (MCP) hyperextension of 30° created mean nerve tensions up to 0.64 N, 5 mm of nerve distraction created mean nerve tensions up to 1.23 N, and 90° of MCP flexion relieved up to a mean of 1.18 N of nerve tension. Conclusions: In situ tension is present in the median and digital nerves with digital motion. Finger hyperextension and nerve distraction produce tension, whereas finger flexion reduces tension. Existing nerve repairs are strong enough to withstand in situ nerve tensions produced by reasonable digital motion if the original nerve length is present.

Background: Although the diagnosis of thoracic outlet syndrome (TOS) is often missed, outcomes from surgical intervention significantly improve patient satisfaction. This article seeks to highlight patient characteristics, intraoperative findings, and both short and long-term outcomes of thoracic outlet decompression in the adolescent population. Methods: A retrospective chart review of patients between the ages of 13 and 21 years with a clinical diagnosis of neurogenic thoracic outlet syndrome (NTOS) who were treated surgically between 2000 and 2015 was performed. Data points including preoperative patient characteristics and intraoperative findings were collected. In addition, patient-reported outcome scores, including Visual Analog Scale (VAS), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, Cervical Brachial Symptom Questionnaire (CBSQ), and NTOS index, were obtained for a cohort of patients with follow-up ranging from 2 to 15 years. Results: The study population consisted of 54 patients involving 61 extremities. The most common procedures included neurolysis of the supraclavicular brachial plexus (60, 98.4%), anterior scalenectomy (59, 96.7%), and middle scalenectomy (54, 88.5%). First rib resection (FRR) was performed in 28 patients (45.9%). Long-term outcomes were collected for 24 (44%) of 54 patients with an average follow-up of 69.5 months (range, 24-180 months). The average VAS improved from 7.5 preoperatively to 1.8 postoperatively. The average SANE increased from 28.9 preoperatively to 85.4 postoperatively. The average postoperative scores were 11.4 for the QuickDASH, 27.4 for the CBSQ, and 17.2 for the NTOS index. Subgroup analysis of patients having FRR (28, 45.9%) demonstrated no difference in clinical outcome measures compared with patients who did not have FRR. Conclusion: Surgical treatment of NTOS in adolescent patients has favorable intermediate and long-term outcomes.

Background: The objective of this work was to perform a critical review of the 2-dimensional and 3-dimensional anatomy of the adult brachial plexus divisions and cords. Methods: Twelve adult brachial plexuses from fresh cadavers were dissected. All were male and aged between 30 and 50 years. Only corpses without brachial plexus injuries were selected. The purpose of the dissections was to identify the origin of the anterior and posterior divisions of the adult brachial plexus in their respective trunks, as well as the positioning of the posterior, lateral, and medial cords. Results: The posterior division of all trunks had a cranial and dorsal origin, while the anterior division of all trunks had a caudal and ventral origin. The posterior cord was the most cranial of all, the lateral cord was central, and the medial cord was the most caudal of all cords. The posterior division of the superior trunk was always between the suprascapular nerve and the anterior division. Conclusions: Brachial plexus diagrams in most textbooks and papers are different from what was found in our dissections. Contrary to the known diagram, the posterior divisions always had a cranial origin in the superior, middle, and inferior trunks.

Background: Tendon transfers are commonly performed in patients with brachial plexus birth palsy (BPBP) to improve function. Transferring 2 tendons in patients with C5-7 injury has the potential complication of loss of midline function. The purpose of this study was to investigate whether a single tendon transfer (1TT) as opposed to the traditional double tendon transfer (2TT) resulted in any differences in functional outcomes in patients with C5-7 BPBP. Methods: A retrospective review of all patients with C5-7 BPBP who underwent tendon transfers to improve shoulder external rotation over a 5-year period was performed at 2 institutions. Outcomes were assessed using the modified Mallet (MM) classification scores. Results: Twenty-two C5-7 patients had complete records of preoperative and postoperative MM scores, including 11 sex-matched patients in both the 1TT and 2TT groups. When comparing preoperative and postoperative MM categories, there were significant improvements in both the 1TT and 2TT groups for global abduction (P < .05 and P < .01, respectively) and external rotation (P < .00001 for both). Modified Mallet (MM) hand to neck scores were significantly improved in the 2TT group (P < .05) but not in the 1TT group (P = .053). Internal rotation scores significantly decreased in both groups (P < .001). Both groups demonstrated significant increases in total scores from the preoperative MM scores (P < .01). Conclusion: The 1TT and 2TT procedures result in substantial gains in upper extremity functions for patients with C5-7 BPBP as measured by the MM score, specifically within the global abduction and external rotation subcategories. However, a significant loss occurs in internal rotation for both groups.

Background: Treatment decisions regarding volar base fractures of the middle phalanx depend on whether the proximal interphalangeal (PIP) joint is reduced. Our aim was to study the agreement among hand surgeons in determining whether the PIP joint fractures are subluxated and to study the factors associated with subluxation of these fractures. Methods: In this retrospective chart review, 413 volar base fractures of the middle phalanx were included. Demographic and injury-related factors were gathered from medical records and radiographs. Using a Web-based survey, interobserver agreement was determined among 105 hand surgeons on the assessment of PIP joint subluxation of a series of 26 cases. Using the cohort of 413 fractures, a threshold for percent articular involvement and relative fracture displacement that corresponds with subluxation of the PIP joint was analyzed. Results: We found moderate to substantial agreement between hand surgeons on subluxation (κ = 0.59, P < .0001) and an overall percent agreement of 85%. Percent articular involvement and relative fracture displacement were independently associated with subluxation of the PIP joint (P < .001). Percent articular involvement of 35% had a specificity of 90% and a negative predicting value (NPV) of 92% for joint subluxation. Relative fracture displacement of 35% had a specificity of 92% and an NPV of 94% for joint subluxation. Conclusions: Surgeons generally agree on whether a PIP joint is subluxated. Percent articular involvement and relative fragment displacement are objective measurements that can help characterize joint stability and assist with decision-making.

Background: Current recommendations for osteoarthritis of the metacarpophalangeal joint (MCPJ) are confined to implant arthroplasty to preserve joint motion and provide pain relief. This study documents the median 2-year results of a novel soft tissue arthroplasty technique that interposes the dorsal capsule. Methods: A retrospective review of 10 MCPJ dorsal capsule interposition arthroplasties in 8 patients was conducted. Physical evaluation assessed MCPJ range of motion (ROM), grip strength, and pain. Outcome tests used were the Michigan Hand Outcome Score, Visual Analog Scale (VAS), and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH). Kellgren and Lawrence Classification assessed severity of MCPJ osteoarthritis on preoperative radiographs. Results: The mean follow-up was 29 months from surgery. Average VAS was 2/10 postoperatively and average postoperative ROM improved 7 degrees. Average postoperative grip strength of the surgical hand was 30 kg. The QuickDASH average score was 24. Average Michigan Hand Questionnaire final score was 70. Patients with Kellgren Grades 2 or 3 osteoarthritis had the best QuickDASH and Michigan Hand Outcome scores. All patients working before surgery returned to work. No patient required a second surgery. Conclusion: This technique of dorsal capsule interposition arthroplasty provides a viable surgical option for isolated degenerative or traumatic arthritis of the MCPJ at an average follow-up of 2 years. Pain relief was most reliably provided in patients with less severe radiograph findings. The advantages of this procedure include preservation of bony anatomy, collateral ligaments, and volar plate to not preclude later implant arthroplasty.

Background: There is poor understanding regarding functional limitation of thumb strength and dexterity following thumb metacarpophalangeal (MCP) and interphalangeal (IP) arthrodesis. The purpose of this investigation was to quantitatively evaluate the functional limitations of MCP and IP joint fusion using an orthosis to simulate fusion. Methods: Thirty-two healthy volunteers underwent simulated MCP and IP thumb arthrodesis using custom-molded orthoses. Each volunteer was independently assessed for hand and thumb function using the Jebsen-Taylor Hand Function test, lateral pinch strength, tip pinch strength, and Grooved Pegboard test. Comparisons between the 3 groups in all functional tests were carried out. Results: The mean lateral pinch strength was significantly greater in the unsplinted group (8.3 kg) compared with the MCP- (6.3 kg) and IP-splinted (5.7 kg) groups. Mean tip pinch strength was also significantly higher in the unsplinted group than in MCP- and IP-splinted thumbs (4.6 kg vs 4.1 and 3.9 kg). There was no difference in the Jebsen-Taylor or Grooved Pegboard test between the 3 groups. Conclusion: Our study suggests that with a fused MCP joint the lateral and tip pinch strength will decrease by 24% and 10%, respectively, compared with a healthy nonsplinted thumb. A fused IP joint will decrease lateral and tip pinch by 31% and 16%, respectively. This information does not take into account an arthritic thumb. We found that the Jebsen-Taylor test and Grooved Pegboard test were not affected by simulated thumb MCP and IP fusion.

Background: Surgical treatment of basal joint arthritis commonly consists of trapeziectomy followed by various suspensionplasty techniques to provide stability to the thumb ray. Our study goal was to assess the motion and stability of the thumb ray after trapeziectomy and placement of a suture button (Mini TightRope®, Arthrex, Naples, Florida) in a high- or low-angle trajectory. We hypothesized that a low-angle trajectory would yield the greatest stability while providing maximal motion of the thumb. Methods: Eleven fresh-frozen cadaver arms were imaged fluoroscopically in anterior-posterior and lateral views before and after trapeziectomy, and after placement of low- and high-angle suture buttons. The intermetacarpal angle between the thumb and index metacarpals was measured after application of a standard force. Radial abduction, opposition, subsidence, palmar abduction, adduction, and subsidence were measured. Results: Compared to posttrapeziectomy constructs, low- and high-angle TightRope constructs demonstrated less subsidence, low-angle TightRopes had less palmar abduction, and high-angle TightRope constructs had less radial abduction and adduction. High-angle TightRopes allowed more palmar abduction than low-angle constructs. The high-angle TightRopes trended toward more subsidence than low-angle constructs, although it was not significant. Conclusions: Both TightRope constructs provided improved axial stability after trapeziectomy while not excessively limiting any one motion of the thumb. Compared to the high-angle trajectory, the low-angle TightRope placement provided a more stable construct with respect to subsidence and angular motion. Given the concern for excessive motion of the first metacarpal base with the high-angle construct, we recommend a low-angle trajectory TightRope placement.

Background: Multiple surgical techniques are described for basal joint osteoarthritis. This study compares clinical outcomes and patient satisfaction with trapeziectomy and abductor pollicis longus (APL) suspensionplasty compared to trapeziectomy with ligament reconstruction and tendon interposition (LRTI) when performed by 2 fellowship-trained hand surgeons. Methods: A retrospective review of 51 consecutive patients undergoing APL suspensionplasty (53 hands) was performed. With this technique, a distally based APL slip is brought through and sewn to the flexor carpi radialis (FCR). The remaining APL is placed in the trapeziectomy void. This technique was compared to 151 patients (166 hands) who underwent LRTI using the FCR tendon. Outcomes assessed included postoperative pain relief, grip and pinch strength, complications, and need for reoperation. Two-tailed, Fisher’s exact test was used for data analysis. Results: APL suspensionplasty resulted in postoperative pain relief in 92.5% (n = 49) compared to 94.0% (n = 156) with LRTI (P = .758). Mean postoperative grip and pinch strengths with APL suspensionplasty were 41.2 and 10.4 kg, respectively. With LRTI, average grip strength was 42.0 kg, and pinch was 10.1 kg. Both techniques were well tolerated with minimal complications. In the APL group, 1 patient had a postoperative infection requiring drainage. Among the LRTI cases, 1 wound dehiscence required closure, and 2 minor postoperative wound infections resolved with oral antibiotics. Mean follow-up time among APL suspensionplasty patients was 3.3 months compared to 8.4 months following LRTI. Conclusions: APL suspensionplasty is a safe, effective procedure which provides similar pain relief and functional outcomes compared to LRTI.

Background: The frequency, pattern, and treatment of pediatric hand fractures are rarely reported. We sought to review our institution’s experience in the management of pediatric hand fractures. Methods: A retrospective review of children and adolescents (younger than 18 years) treated for hand fractures between January 1990 and June 2017 was preformed. Fractures were categorized into metacarpal, proximal/middle phalanx, distal phalanx, or intra-articular metacarpophalangeal (MCP)/proximal interphalangeal (PIP)/distal interphalangeal (DIP) fractures. Patients were categorized into 3 age groups (0-5, 6-11, and 12-17 years). Results: A total of 4356 patients were treated for hand fractures at a mean ± SD age of 12.2 ± 3.5 years. Most fractures occurred in patients aged 12 to 17 years (n = 2775, 64%), followed by patients aged 6 to 11 years (n = 1347, 31%). Only 234 (5%) fractures occurred in children younger than 5 years. Most fractures occurred in the proximal/middle phalanx (48%), followed by metacarpal (33%), distal phalangeal (12%), and intra-articular MCP/PIP/DIP joints (7%). Proximal/middle phalangeal fractures were the most common in all age groups. About 58% of intra-articular MCP/PIP/DIP fractures in patients aged between 0 and 5 years required open reduction ± fixation, and the remaining 42% fractures were amenable to closed reduction. In patients older than 5 years, about 70% of these fractures were amenable to closed reduction. All age groups included, most metacarpal (93%), proximal/middle phalangeal (92%), and distal phalangeal (86%) fractures were amenable to closed reduction alone. Conclusions: The frequency, pattern, and treatment of hand fractures vary among different age groups. Understanding the pattern of these fractures helps making the right diagnosis and guides choosing the appropriate treatment.

Background: Multiple flexor tendon repair techniques have been developed over the last years. Despite all this, there is no standard technique that has proven to be superior to others, leading to great variability in the use of techniques in surgical practice. We describe a novel tendon repair technique and compare its biomechanical characteristics with 2 conventional techniques. Methods: Comparative experimental biomechanical study in ex vivo animal models. In all, 66 deep flexor tendons of the pig’s front legs were taken and it’s repair was performed by 1 of 3 techniques (helical 6-strand cruciate tendon repair, Adelaide tendon repair, or modified Kessler). These repairs were subjected to biomechanical study, measuring, and registering the ultimate tensile strength, load to 2-mm gap force, and stiffness. Results: The helical 6-strand cruciate tenorrhaphy compared with the Adelaide and modified Kessler techniques carries statistically significant greater ultimate tensile strength before failure (65.5, 46, and 36 N, respectively, P < .001). It also required a greater load to 2-mm gap force and is less stiff, allowing greater strain before failure. This technique does not generate significant changes in the dimensions of the tendons compared to the others, and there was no significant difference in the strength of repair between surgeons. Conclusions: The helical 6-strand cruciate tenorrhaphy is a novel technique, useful for the repair of flexor tendons in the hand that holds up the necessary forces to initiate early mobilization in the postoperative period and has better biomechanical properties than 2 standard techniques.

Isolated third toe-to-thumb transfers have been rarely reported and none in the pediatric population. We describe a third toe-to-thumb transfer for reconstruction of a congenital hypoplastic thumb with excellent functional results and no morbidity in the donor foot.

Urgent surgical intervention for amniotic band sequence (ABS) is currently indicated for concerns of vascular compromise and progressive lymphedema. Peripheral motor nerve palsies are rare, and reports of surgical intervention in these cases describe persistent motor dysfunction. We report band release and ulnar, median, and radial nerve decompression in a 1-week-old with a severe upper extremity constriction band and signs of ulnar nerve motor dysfunction. A literature review on nerve exploration and outcomes of patients with motor nerve palsy from ABS was performed. Early evidence of ulnar motor function was observed at 5.5-month follow-up. Previous reports of nerve decompression for upper extremity constriction bands with motor nerve palsy document poor recovery after interventions beginning at 3 months of age. In this case, band release and nerve decompression were undertaken at 7 days of age, and we observed early motor recovery. This finding suggests that very early surgical intervention in the neonate may facilitate nerve recovery in appropriate candidates.

Background: Vascularized fibula graft (VFG) transfer is an established method of repairing large skeletal defects resulting from trauma, tumor resection, or infection. It obviates the process of creeping substitution that conventional bone grafts undergo and therefore exhibits better healing and improved strength. The aim of this study is to evaluate hypertrophy in VFG. Methods: We retrospectively reviewed patients undergoing VFG and studied immediate and late postoperative radiographs. Orthogonal views were measured for width of graft cortex and intramedullary canal, as well as adjacent recipient bone. Changes were measured for total cross sectional area, cortical area, intramedullary area, and graft width. Results: Thirty patients were included in the analysis, with recipient sites including 3 forearm, 4 humerus, 12 tibia, and 11 femur. Mean follow-up was 7.6 years (0.5-24.9 years). Patients’ mean age was 31 (16-59 years). Average hypertrophy was 254% in early postoperative period and 340% in the late postoperative period. There was rapid graft hypertrophy in early postoperative period that plateaued with time. The width of the graft increased over time but didn’t exceed the width of the adjacent recipient bone. In the later postoperative period, the size of graft intramedullary canal increased. Upper and lower extremity grafts showed similar hypertrophy. Conclusions: Using VFG to treat large skeletal defects is an attractive option in part due to the graft’s ability to hypertrophy. We describe an early period of periosteal hypertrophy, followed by endosteal hypertrophy. These processes have relevance to function, mechanical strength, and surgical decision-making.

Background: Total wrist arthroplasty (TWA) is a treatment option for many debilitating wrist conditions. With recent improvements in implant design, indications for TWA have broadened. However, despite these improvements, there are still complications associated with TWA, such as unplanned reoperation and eventual implant removal. The goal of this study was to identify risk factors for an unplanned reoperation or implant revision after a TWA at 2 academic medical centers between 2002 and 2015. Methods: In this retrospective study, 24 consecutive TWAs were identified using CPT codes. Medical records were manually reviewed to identify demographic, patient- or disease-related, and surgery-related risk factors for reoperation and implant removal after a primary TWA. Results: Forty-six percent of wrists (11 of 24 TWAs performed) had a reoperation after a median of 3.4 years, while 29% (7 of 24) underwent implant revision after a median of 5 years. Two patients had wrist surgery prior to their TWA, both eventually had their implant removed (P = .08). There were no risk factors associated with reoperation or implant removal. Conclusion: Unplanned reoperation and implant removal after a primary TWA are common. Approximately 1 in 3 wrists are likely to undergo revision surgery. We found no factors associated with reoperation or implant removal; however, prior wrist surgery showed a trend toward risk of implant removal after TWA.

Background: The optimal treatment for a distal radius fracture (DRF) remains an ongoing discussion. This study observed whether early activity postinjury can lead to the prevention of type 1 complex regional pain syndrome (CRPS-1). Method: Patients who underwent nonoperative treatment for a DRF were invited to participate in this study. Patients followed an exercise program with progressive loading exercises at home immediately after cast removal. After a minimum of 3 months, patients were interviewed by telephone to determine the presence of disproportionate pain. If present, the patients were seen during a clinical consultation to determine whether they had CRPS-1, using the Budapest Diagnostic Criteria. Results: Of the 129 patients included in this study, 12 reported disproportionate pain, and none were diagnosed with CRPS-1. The incidence of CRPS-1 was zero in this study. Conclusion: A more active treatment approach seems to lower the incidence of CRPS-1. A larger randomized study is necessary to strengthen the evidence.

Background: Management of distal radius fractures in patients over 65 is a topic of significant study, but there are variations within this group in terms of independence and activity level. This study compares the outcomes of operative distal radius fracture treatment in patients over 75 with those aged 65 to 74, to evaluate the effects of patient demand and advanced age on outcome. Methods: A retrospective review of a single-institution distal radius fracture database was performed. All patients over age 65 were evaluated for inclusion. Patient factors including activity, independence level, and quick disabilities of the arm, shoulder and hand (QuickDASH) score were recorded. Patients were selected for open reduction and internal fixation (ORIF) based on a discussion between the patient and the treating surgeon. Outcome measures including QuickDASH were recorded at 1-year post-injury. Patients aged 65 to 74 and 75 and over were compared to evaluate for demographic, functional, and outcome differences. Results: In all, 75 patients were included in the study. Fifty-one patients were aged 65 to 74, and 24 patients were aged over 75. The majority of patients rated themselves as “completely independent” and “active,” the highest levels of each. There was no difference in QuickDASH scores between those patients who rated themselves as completely partially independent, or active versus moderately active. There was no statistically significant difference in QuickDASH or range of motion parameters at final follow-up. Conclusions: This study demonstrates that, in a group of patients with high levels of independence and activity, outcomes are similar in patients aged 65 to 74 and over 75 at 1 year following distal radius ORIF.

Background: Percutaneous guide wire insertion for scaphoid screw fixation can be challenging and often requires multiple attempts with significant radiation exposure to the surgical team. A 3-dimensional (3D) printed targeting device has the potential to reduce procedure time and intraoperative radiation exposure. Methods: Our targeting device protocol included a preprocedure computed tomography (CT) scan of a casted cadaver wrist, followed by 3D printing of a customized targeting guide. In a comparison trial, seven orthopedic surgery residents performed percutaneous scaphoid guide wire insertion on different cadaver specimens by both freehand technique and using our targeting device. Radiation exposure and procedure times were compared. All specimens underwent postprocedure CT to assess Kirschner wire (K-wire) accuracy, determined by central third placement. Pre- and postprocedure CT scans from the targeting device group were co-registered to compare planned and actual K-wire trajectories. Results: Using the freehand technique, mean fluoroscopy time was 120 seconds (standard deviation: ±53 seconds) generating 2.45 milligray of radiation. Average procedure time was 21 minutes with a mean of 6.4 (range: 3-9) insertion attempts. A single insertion attempt was made using the targeting device with an average procedure time of 30 seconds and no fluoroscopy exposure. Four K-wires were placed within the central scaphoid in both groups. Using the targeting device, average linear deviation from the planned trajectory was 2.1 mm, while the maximum linear deviation was 3.75 mm. Conclusion: When compared to freehand scaphoid guide wire insertion, our targeting device provides similar accuracy while significantly reducing intraoperative radiation exposure and procedure time.

Background: The internet is becoming a common source of health information for hand surgery patients. This study evaluates the quality of web-based resources on ganglion cysts of the hand. Methods: We completed a search for “ganglion cyst” on 3 search engines (Google, Dogpile, and Yippy). The quality of the top-100 patient education websites was assessed using a validated internet rating tool. Websites were evaluated based on affiliation, accountability, currency, interactivity, website organization, readability, coverage, and accuracy. Results: Of the 100 websites, the majority (74%) had commercial affiliations. Only 34% of websites identified an author, and even fewer identified the authors’ credentials (27%) or affiliations (26%). A third of the websites cited references, and less than half provided an update date. The average readability based on Flesch-Kincaid grade level was 9.2, and only 3% could be read at or below 6th grade reading level. Prevention was the most poorly covered topic at 13% due to omission. In all, 66% of the websites were completely accurate in terms of global accuracy. Websites were most likely to present inaccurate information on treatment, often failing to mention conservative treatment (watch-and-wait approach) or promoting the use of natural health products. We also found 5% of websites presented closed rupture of the ganglion cyst as a legitimate home remedy. Conclusions: The overall quality of online information on ganglion cysts is highly variable and may occasionally be harmful for patients. It is increasingly important for physicians to prompt patients about their internet use.

Background: Although intravenous (IV) infiltration is relatively common, data regarding complications and outcomes of this problem remain limited. In addition, there is wide variation in institutional protocols for the management of IV infiltrations. Through retrospective review, we aim to delineate complications and outcomes, and propose an algorithm for the management of these injuries. Methods: We performed a retrospective review of all patients who had an IV infiltration at a tertiary care center’s inpatient and outpatient facilities between January 1, 2016, and December 31, 2018. Results: In all, 479 patients with 495 infiltrations were included, with a mean age of 36.7 years. The upper extremity was involved in 89.6% of events. Of all the events, 8.6% led to a superficial soft tissue infection, 3.2% led to necrosis or eschar formation, and 1.9% led to ulceration or full-thickness wound formation. There were zero cases of compartment syndrome. Only 5.1% resulted in any long-term defects; none resulted in a functional defect of the extremity. Patients with vascular disease did not experience worse outcomes compared with healthy individuals. Plastic or orthopedic surgery was consulted in 25.3% of events. No emergent surgical intervention was required, 7 (1.4%) required bedside procedures, and 7 (1.4%) patients underwent nonacute operations. Conclusions: A specialist was consulted in about one-quarter of IV infiltrations, yet none were surgical emergencies. Instead, most complications could be monitored and managed by a primary team. Therefore, we propose algorithms involving nursing staff, wound care teams, and primary physicians with limited specialist consultation to manage these injuries.

Background: Congenital insensitivity to pain is a rare autosomal recessive condition characterized by insensitivity to painful stimuli due to absence of sensory and sympathetic post ganglionic neurons in the skin and skeletal system leading to lack of protective sensation and altered joint propioception. This study was performed to assess hand and wrist manifestations of patients with congenital insensitivity to pain in the Maltese Islands. Methods: Records of public and private hospitals were reviewed to identify patients suffering from this condition. A review of notes, patients, and imaging was performed. A Disabilities of the Arm, Shoulder, and Hand score was obtained to assess level of function. Results: Nine patients were identified. Mean age of diagnosis was 8.9 years. Interphalangeal joints were most commonly affected. Multiple spontaneous or posttraumatic fingertip ulceration occurred in 5 patients. Anhidrosis resulted in more protracted ulcers and infections, requiring amputation of distal and middle phalanges due to osteomyelitis. The wrist joint was less commonly involved and showed more complex joint involvement. Conclusion: The hand and wrist are involved in different ways, with fingertip ulceration leading to potential infection and osteomyelitis in the hand, whereas the wrist joint is involved in cases of increased axial loading and load transfer, such as following prolonged use of walking and mobility aids. The latter should be borne in mind during management of lower limb conditions. Hand care and hygiene is important in all patients, especially in cases of anhidrosis due to the increased rate of ulceration and osteomyelitis requiring surgical intervention. Despite the severity of the condition, patients report good overall function.

Background: The purpose of this study was to investigate the relationship between insurance status and patient-reported pain both before and after upper extremity surgical procedures. We hypothesized that patients with Medicaid payer status would report higher levels of pre- and postoperative pain and report less postoperative pain relief. Methods: In all, 376 patients who underwent upper extremity procedures by a single surgeon at an academic ambulatory surgery center were identified. Patient information, including insurance status and Visual Analog Scale pain score (VAS-pain) at baseline, 2 weeks, and 1, 3, and 6 months, were collected. VAS-pain scores were compared with t-tests and linear regression. Results: Preoperatively and at 2-week, 1-month, and 3-month follow-up, Medicaid patients reported statistically significant higher pain levels than patients with Private insurance, finding a mean adjusted increase of 0.51 preoperatively, 0.39 at 1 month, and 0.79 at 3 months. Preoperatively and at 3-month follow-up, Medicaid patients reported statistically significant higher pain than patients with Medicare, finding increases in VAS-pain of 0.99 preoperatively and 0.94 at 3 months. There was no difference in pain improvement between any insurance types at any time point (all P values > .05). Conclusions: Patients with Medicaid report higher levels of preoperative pain and early postoperative pain, but reported the same improvement in pain as patients with other types of insurance. As healthcare systems are becoming increasingly dependent on patient-reported outcomes, including pain, it is important to consider that differences may exist in subjective pain depending on insurance status.