The Impact of Social Determinants of Health on the Treatment of Distal Radius Fracture.

BACKGROUND: Disparities in social determinants of health (SDH) have been shown to play an increasingly important role in the equitable delivery of health care. Distal radius fractures (DRFs) are among the most common upper-extremity injuries encountered. This study aims to examine the influence of economic, educational, social, environmental, and healthcare disparities on management of these injuries. METHODS: PearlDiver Mariner insurance claims database was analyzed for treatment patterns of DRF in patients aged 18 to 65 years based on the presence or absence of social determinants of health disparities (SDHDs). Outcome variables included the primary mode of management of DRF, including operative versus non-operative, as well as concomitant procedures. Multivariate logistic regression was used to compare fracture management modality in patients with and without SDHDs. RESULTS: Of 161 704 patients identified with DRF, 38.3% had at least 1 reported SDHD. The majority of SDHDs were economic. Patients identified with 1 or more SDHDs had a higher medical comorbidity index. Patients with environmental SDHD were more likely to receive non-operative management. Within any SDHD and economic subgroups, odds of operative management were higher. No relationship was identified between SDHD and concomitant procedures. CONCLUSIONS: The presence of environmental disparities in SDH may predispose patients disproportionately to non-operative management. The presence of SDHDs may influence medical decision-making in favor of open reduction and internal fixation in patients with DRF treated operatively. In treating at-risk populations, providers should be aware of the potential for implicit bias associated with SDHDs and prioritize shared decision-making between patients and physicians.

Regional Anesthesia for Wrist Fractures and Dislocations: Are We Really Blocking Opioid Prescribing?

BACKGROUND: The aim of this study was to evaluate the impact of regional anesthesia for the treatment of wrist fractures or dislocation on opioid prescription-filling patterns. METHODS: Patients undergoing surgery for hand and wrist fractures or dislocations from 2010 to 2018 were identified by using a national insurance claims database. Patients were stratified by procedures conducted with and without regional anesthesia. Preoperative opioids were defined by a filled opioid prescription within 1 month prior to surgery, postoperative within 1 month following the surgery, and prolonged postoperative 3 to 6 months following surgery. Patients' demographic data, comorbidities, additional medications, 30-day emergency department (ED) visits, and hospital readmissions were analyzed. RESULTS: A total of 24 598 patients treated with and 115 199 patients treated without a regional nerve block for wrist fractures and dislocations were identified. Regional anesthesia was associated with greater postoperative opioid prescription but fewer prolonged postoperative prescriptions. There was an increased odds of all-cause 30-day ED visits but a decreased odds of 30-day hospital readmissions when patients received a regional nerve block prior to surgery. CONCLUSIONS: In this study, receiving regional anesthesia prior to surgical intervention for wrist fractures or dislocations was associated with increased filling of postoperative opioid prescriptions, but not prolonged postoperative opioid prescriptions. Additional investigation is needed to identify and implement nonnarcotic multimodal analgesia regimens that may help decrease usage of narcotic medications surrounding these procedures. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Mechanism of Cannabichromene and Cannabidiol Alone Versus in Combination in the Alleviation of Arthritis-Related Inflammation.

BACKGROUND: Patients suffering from arthritis have limited treatment options for nonoperative management. In search of pain relief, patients have been taking over-the-counter cannabinoids. Cannabidiol (CBD) and cannabichromene (CBC) are minor cannabinoids with reported analgesic and anti-inflammatory properties and have been implicated as potential therapeutics for arthritis-related pain. To this end, we utilized a murine model to investigate the effectiveness of and mechanism by which CBC alone, CBD alone, or CBD and CBC in combination may provide a reduction in arthritis-associated inflammation. METHODS: Forty-eight mice were included in the study, which were separated into 4 groups: control group (n = 12), treatment with CBD alone (n = 12), treatment with CBC alone (n = 12), and treatment with CBD + CBC (n = 12). We induced inflammation in each mouse utilizing the collagen-induced arthritis model. At scheduled timepoints, mice were clinically assessed for weight gain, swelling, and arthritis severity. In addition, inflammation-associated serum cytokine levels were analyzed for each animal. RESULTS: Thirty-five of 48 mice survived the duration of the study resulting in the following group numbers: control group (n = 8), treatment with CBD alone (n = 9), treatment with CBC alone (n = 9), and treatment with CBD + CBC (n = 9). Animals treated with CBC and CBD + CBC showed significant weight gain between 3 and 5 weeks. Irrespective of treatment, regression analysis comparing all cytokine measurement and physical outcomes found a significant positive correlation between levels of 5 individual cytokines and both arthritis scores and swelling. Animals treated with CBD + CBC showed a significant decrease in swelling between 3 and 5 weeks compared with the control group. Cannabinoid treatment selectively affected the gene expression of eotaxin and lipopolysaccharide-induced CXC chemokine with combined treatment of CBC + CBD. CONCLUSION: Treatment with cannabinoids resulted in decreased clinical markers of inflammation. Further, the anti-inflammatory effect of CBC and CBD in conjunction was associated with a greater anti-inflammatory effect than either minor cannabinoid alone. Future work will elucidate the possibility of synergistic or entourage effects of minor cannabinoids used in combination for the treatment of arthritis-related pain and inflammation.

Use of Rectus Femoris Muscle Flap in Patients With Absent Profunda Femoris Vascular Flow.

Background: The rectus femoris (RF) muscle flap is an excellent choice for soft tissue coverage of complex wounds of the groin because of its reliable vascular anatomy and sufficient bulk allowing coverage of vascular anastomoses. The muscle receives its blood supply from the descending branch of the lateral femoral circumflex artery (dLFCA), which originates from the profunda femoris artery (PFA) in the proximal thigh. This case series reports 3 patients on whom pedicled RF muscle flaps were performed successfully despite known occlusion of the PFA preoperatively. Methods: All 3 patients had a history of peripheral vascular disease (PVD) and underwent femoral-popliteal bypass. This was complicated by pseudoaneurysm in 2 patients and exposure of the polytetrafluorethylene graft in the third patient. Computed tomography angiography (CTA) or traditional angiography was obtained for each patient, showing occlusion of the PFA. After adequate debridement and confirming flow through the pedicle, vascular graft coverage at the groin was performed using a pedicled RF muscle flap, followed by split thickness skin grafting (n = 2) or primary skin closure (n = 1). Results: The 3 patients included in this report had successful coverage of exposed vascular bypass grafts in the groin utilizing pedicled RF muscle flaps despite known occlusion of the PFA preoperatively. Follow-up at 3 months postoperatively showed healthy flaps with well-healed overlying skin graft or closure for all patients. Conclusions: The pedicled RF muscle flap may be successfully used for coverage of complex groin wounds in patients with occlusion of the PFA. This flap is useful in complex groin wounds related to vascular interventions, particularly when other local options have been exhausted. This case report presents 3 successful cases of groin wound coverage using pedicled RF muscle flap despite known preoperative occlusion of the PFA.