Shared Decision Making in Hand Surgery.

Shared decision-making (SDM) is a collaborative effort between a physician and a patient to make an informed clinical decision, as defined by each patient's preferences and values. Shared decision-making is particularly used in areas of clinical equipoise or preference-sensitive conditions, which are common in hand surgery. Although there is increased interest in SDM across health care, hand surgeons receive little formal training on SDM. In this review, we explore existing barriers to SDM in hand surgery and provide a framework for participating in SDM discussions.

Anatomical relationships and branching patterns of the dorsal cutaneous branch of the ulnar nerve.

PURPOSE: To describe the variable branching patterns of the dorsal cutaneous branch of the ulnar nerve (DCBUN) relative to identifiable anatomical landmarks on the ulnar side of the wrist. METHODS: We dissected the ulnar nerve in 28 unmatched fresh-frozen cadavers to identify the DCBUN and its branches from its origin to the level of the metacarpophalangeal joints. The number and location of branches of the DCBUN were recorded relative to the distal ulnar articular surface. Relationships to the subcutaneous border of the ulna, the pisotriquetral joint, and the extensor carpi ulnaris tendon were defined in the pronated wrist. RESULTS: On average, 2 branches of the DCBUN were present at the level of the distal ulnar articular surface (range, 1-4). On average, 2.2 branches were present 2 cm distal to the ulnar articular surface (range, 1-4). At least 1 longitudinal branch crossed dorsal to the extensor carpi ulnaris tendon prior to its insertion at the base of the fifth metacarpal in 23 of 28 specimens (82%). In 27 of 28 specimens (96%), all longitudinal branches of the DCBUN coursed between the dorsal-volar midpoint of the subcutaneous border of the ulna and the pisotriquetral joint. In 20 of 28 specimens (71%), a transverse branch of the DCBUN to the distal radioulnar joint was present. CONCLUSIONS: During exposure of the dorsal and ulnar areas of the wrist, identification and protection of just a single branch of the DCBUN are unlikely to ensure safe dissection because multiple branches normally are present. The 6U, 6R, and ulnar midcarpal arthroscopy portals may place these branches at risk. In the pronated forearm, the area between the DCBUN and the pisotriquetral joint contained all longitudinal branches of the DCBUN in 96% of specimens. CLINICAL RELEVANCE: During surgery involving the dorsal and ulnar areas of the wrist, multiple longitudinal branches and a transverse branch of the DCBUN are normally present and must be respected.

Validation of a High-Fidelity Fracture Fixation Model for Skill Acquisition in Orthopedic Surgery Residents.

OBJECTIVE: Simulation has become a widely accepted part of training and credentialing processes due to its ability to supplement technical skill acquisition outside of the operating room (OR). This project explores implementation of a bench-top simulation of open reduction with internal fixation (ORIF) as a cost-effective method for practicing and evaluating surgical skill. DESIGN, SETTING, AND PARTICIPANTS: Participants ranging from intern to attending surgeon performed ORIF using a standard fixation set and a bovine or porcine tibia/radius model. Performance was recorded and scored by blinded reviewers based on a modified global rating scale (GRS), objective structured assessment of technical skills (OSATS) procedure-specific checklist, and critical-mistakes (CM) model. We calculated Fleiss' kappa for inter-rater reliability, Cronbach's alpha for internal consistency of scoring systems, and used univariate analysis to determine the ability of this model to discriminate between training levels. We also performed a normalized performance-versus-cost analysis to characterize perceived value of this simulation compared to other modalities. RESULTS: Twenty subjects completed the fracture fixation exercise. Fleiss' kappa for all scoring systems indicated substantial inter-rater agreement (k = 0.81, 0.80, and 0.74 for GRS, OSATS, and CM, respectively). Internal consistency reliability for GRS and OSATS were high with Cronbach's alpha 0.96(95%CI 0.94-0.97) and 0.94(95%CI 0.91-0.96), respectively. Using a Kuskal-Wallis rank sum test, GRS, OSATS, and CM were found effective for measuring differences between resident levels (p < 0.001, p < 0.001, and p = 0.002, respectively). Qualitative valuation of the exercise indicated similar value for education compared to time spent in the OR and surgical skills labs. CONCLUSIONS: This benchtop surgical simulation provides quantitative measurement of operative skills progression, increases trainee familiarity with ORIF principles, and permits targeted education by senior surgeons with the goal of training safe graduates. Procedure-specific checklist grading tools reliably differentiated between training levels with high internal validity. Implementing this model may decrease training costs and accelerate skill acquisition.

Thumb ulnar collateral and radial collateral ligament injuries.

Thumb metacarpophalangeal ulnar and radial collateral ligament injuries occur frequently in the competitive athlete. Collateral ligament integrity is essential to joint stability, pinch strength, and pain-free motion. Acute rupture of the ulnar collateral ligament is due to a sudden radial deviation force on the abducted thumb and is referred to as skier's thumb. An ulnar-directed force causes injury to the radial collateral ligament. The degree of joint instability on clinical examination allows classification of these injuries and guides management. Surgical repair of acute, complete tears results in good outcomes and allows for return to sporting activity.