Misdiagnosis in Amyotrophic Lateral Sclerosis.

The symptoms of amyotrophic lateral sclerosis (ALS) can mimic those of compressive neuropathies, such as carpal and cubital tunnel syndromes, especially early in a patient's clinical course. We surveyed members of the American Society for Surgery of the Hand and found that 11% of active and retired members have performed nerve decompression surgeries on patients later diagnosed with ALS. Hand surgeons are commonly the first providers to evaluate patients with undiagnosed ALS. As such, it is important to be aware of the history, signs, and symptoms of ALS to provide an accurate diagnosis and prevent unnecessary morbidities, such as nerve decompression surgery, which invariably results in poor outcomes. The major "red flag" symptoms warranting further work-up include weakness without sensory symptoms, profound weakness and atrophy in multiple nerve distributions, progressively bilateral and global symptoms, presence of bulbar symptoms (such as tongue fasciculations and speech/swallowing difficulties), and, if surgery is performed, failure to improve. If any of these red flags are present, we recommend neurodiagnostic testing and prompt referral to a neurologist for further work-up and treatment.

Scapholunate Ligament Injury: Management Strategies From Occult Injury to Arthritis.

This chapter will explore scapholunate ligament injuries with a focus on injury recognition, diagnosis, the natural history, and options for treatment. Treatment is based upon injury factors, patient factors, and surgeon preference. The classification systems in common use will be discussed, and treatment options will be explored, including nonsurgical, arthroscopic, repair, reconstruction, pain relieving measures, and salvage procedures.

Hand and Upper Extremity Infections in Intravenous Drug Users: Epidemiology and Predictors of Outcomes.

PURPOSE: Injectable drug use (IDU) is a national epidemic, public health problem, and common cause of hand and upper extremity (UE) infections. This study assesses the epidemiology of the IDU patient population presenting to a Midwestern academic medical center emergency department (ED) and examines predictors influencing morbidity and outcomes. METHODS: A retrospective review was performed using International Classification of Diseases, Ninth Revision (ICD-9) codes to identify all adult patients presenting to the ED with hand/UE infections, with and without concurrent IDU diagnoses, over a period of 2.5 years. Demographics and clinical factors were examined utilizing bivariate and multivariable analyses to identify predictors of outcomes, including not completing outpatient follow-up and leaving against medical advice (AMA). RESULTS: A total of 1,482 patients with 1,754 ED visits for hand/UE infections were identified, including 308 patients with IDU-acquired infections (396 visits) and 1,174 patients with non-IDU infections (1,358 visits). Psychiatric comorbidities and hepatitis C were common in the IDU group (51% and 39%, respectively), and 31% of IDU patients were uninsured. Heroin use was identified in 96% of visits. The IDU infections were more likely to have surgical intervention than those in non-IDU patients (16% vs 6%), and a longer mean length hospital stay (2.4 vs 0.9 days). The IDU patients were more likely than non-IDU patients to leave AMA. In multivariable analysis, IDU, psychiatric comorbidity, and insurance status were independent predictors (P < .05) for leaving AMA. CONCLUSIONS: In the setting of a national epidemic, hand/UE infections due to IDU are a common problem seen by hand surgeons. This study characterizes the growing IDU patient population at an urban academic medical center, examining the largest cohort of these patients to date. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Anatomy of the Posterior Antebrachial Cutaneous Nerve, Revisited.

PURPOSE: To describe the branching pattern of the posterior antebrachial cutaneous nerve (PABCN) and to corroborate measurements and observations reported by previous authors. METHODS: Using 28 fresh-frozen cadaver specimens, we dissected the PABCN from its origin from the radial nerve to its terminal arborization in the distal forearm. Measurements relative to the lateral humeral epicondyle were recorded. The course of the nerve over the muscles of the mobile wad and its branching pattern in the proximal forearm were noted. RESULTS: The PABCN originated from the radial nerve at a mean of 14.2 cm proximal to the lateral epicondyle. The fascial hiatus through which the PABCN emerged to become superficial was a mean of 8.2 cm proximal to the lateral epicondyle. All specimens had at least 1 longitudinal branch that passed a mean of 2.8 cm anterior to the lateral epicondyle. Thirty-two percent of specimens had a lesser proximal branch in the distal third of the lateral arm; 86% had an epicondylar branch to the lateral epicondyle; and 21% had a second longitudinal branch. Ninety-three percent had a longitudinal branch coursing over the interval between the brachioradialis and the extensor carpi radialis longus in the proximal forearm. CONCLUSIONS: After becoming superficial in the distal brachium, the PABCN typically gives off a discrete epicondylar branch and then continues distally in the forearm as 1 or 2 longitudinal branches. In addition, in the proximal third of the forearm, a consistent longitudinal branch of the PABCN courses over the interval between the brachioradialis and the extensor carpi radialis longus. This review confirms previous observations of the PABCN. CLINICAL RELEVANCE: Knowledge of the course of the PABCN will assist surgeons in identifying and avoiding injury in clinical situations such as plating the proximal radius or releasing the radial tunnel.

The Effectiveness of Mini-C-Arm Fluoroscopy for the Closed Reduction of Distal Radius Fractures in Adults: A Randomized Controlled Trial.

PURPOSE: Most distal radius (DR) fractures are initially managed with closed reduction and orthosis application. Mini-C-arm fluoroscopy provides assessment of reduction quality in real time. Our null hypothesis was that there would be no difference in the reduction quality of DR fractures in the emergency department when using mini-C-arm fluoroscopy during reduction compared with standard reduction techniques (evaluating reduction quality with orthogonal radiographs taken in an orthosis). METHODS: Sixty-three consecutive patients with closed DR fractures requiring reduction between April 2015 and April 2017 were prospectively randomized to standard versus fluoroscopically aided reductions. Reductions were performed by orthopedic surgery residents. The primary outcome measurement was reduction quality (radial height, radial inclination, ulnar variance, and volar tilt) as measured on postreduction radiographs. RESULTS: Standard reductions were performed in 34 patients and fluoroscopically aided reductions in 29 patients. The 2 groups were similar in regards to all potential confounders that were analyzed. No differences in postreduction radial height, radial inclination, ulnar variance, or volar tilt were noted. Overall reduction attempts and subjective difficulty of fracture reduction were increased when using fluoroscopy. The rate of initial operative management did not differ between groups. CONCLUSIONS: The use of mini-C-arm fluoroscopy during the initial closed reduction of adult DR fractures results in equivalent postreduction radiographic parameters when compared with conventional reduction techniques. Additional research regarding time spent in the emergency department and overall cost could elucidate potential benefits of fluoroscopically aided DR fracture reduction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Use and Effectiveness of Ethyl Chloride for Hand Injections.

PURPOSE: Limited literature supports using ethyl chloride topical spray as an anesthetic for hand injections whereas documented risks include frostbite, skin irritation, and inhalation toxicity. We hypothesize that ethyl chloride spray imparts no benefit to patients' perception of pain or anxiety for routine hand injections. METHODS: We first surveyed all members of the American Society for Surgery of the Hand to discern the prevalence of ethyl chloride use during routine injections. We then performed a prospective, randomized, study at 2 institutions evaluating the efficacy of ethyl chloride spray compared with "routine injection" (no topical spray) in patients indicated for a hand injection. All patients completed a pre- and postinjection 11-point questionnaire that inquired about various components of pain and anxiety. RESULTS: A total of 2,083 (73% response rate) American Society for Surgery of the Hand members responded to the survey and revealed that 59% of hand surgeons always or often use ethyl chloride, and 24% never use it. There were no differences for region or practice setting, but experienced surgeons were less likely to routinely use ethyl chloride (35%) compared with younger surgeons (66%). Among 151 patients participating in the clinical study (75 with ethyl chloride), there were no differences for any outcome measure assessed. Injection pain in the spray and no-spray groups, pain after 1 minute, and overall anxiety were equivalent. Subgroup analysis demonstrated no effect of sex, anticipated anxiety, or pain threshold. CONCLUSIONS: Ethyl chloride is widely used among hand surgeons but imparts no benefit for routine hand injections in the clinical setting. The potential risks and costs of ethyl chloride use may outweigh its benefits. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Modified Long Toe Extensor Tendon Harvest for Use as Intercalary Graft in Upper Extremity Reconstruction.

Autograft tendon harvested from the long toe extensors are of great utility as intercalary grafts in upper extremity reconstruction. However, standard full-length harvest is complicated by the presence of extensor retinacula and multiple juncturae between adjacent extensors, which often necessitate extensive dissection, increasing the potential for morbidity. We describe a modified technique for partial harvest of the long toe extensors, which is performed entirely proximal to the superior extensor retinaculum. This technique requires a single incision and provides adequate length of graft for the majority of forearm to fingertip reconstructions. The technique is described in the context of our preliminary cadaver findings, with a case example provided to further illustrate the utility of this technique.

Volar Anatomy of the Proximal Phalanx: Implications for Screw Length Selection for Fixation of Shaft Fractures.

PURPOSE: To investigate the anatomy of the volar surface of the proximal phalanx of the hand, specifically the longitudinal groove running along the volar phalangeal shaft. METHODS: We measured skeletonized proximal phalanges from 10 embalmed human cadaver hands at 5 equidistant points along the shaft. The difference between the maximum dorsal-palmar thickness of the shaft and thickness measured from the center of the volar groove to the most dorsal aspect of the phalanx indicated the depth of the groove at each point. These specimens underwent microtomography to characterize their osseous morphology further. Screws placed dorsal to palmar into the specimens and viewed fluoroscopically simulated the appearance of screw protrusion into the volar groove under intraoperative imaging. Similarly, screws placed into a fresh-frozen cadaveric hand illustrated possible screw impingement on soft tissue in vivo. RESULTS: The volar groove was most pronounced at the proximal and distal ends of the phalangeal shaft, becoming shallower along the midportion of the bone. The average difference between total bone thickness and thickness measured from the depth of the groove was significant at each of the 5 points of measurement along the phalangeal shaft for each of the 5 digits of the hand, including the thumb. Average groove depths ranged from 4% to 14% of total bone thickness, with a maximum individual measurement of 22%. Average depth of the groove at each of these positions ranged from 0.19 to 1.64 mm, reaching a maximum of 2.31 mm. CONCLUSIONS: We demonstrated that there is a longitudinal groove running the length of the phalangeal shaft. CLINICAL RELEVANCE: Viewed laterally, the cupped edges of the groove obscure its depth. Dorsally placed bicortical screws could protrude into the groove, remaining unnoticed on intraoperative imaging. The resulting impingement on the flexor tendon could lead to postsurgical stiffness or flexor tendon attritional rupture.

Contemporary management of dupuytren contracture.

Dupuytren contracture is a condition that affects the palmar fascia. It most commonly affects men of northern European ancestry and initially presents at middle age. The diseased fascia may form cords that extend into the digits, resulting in limited motion and function. Treatment is aimed at either releasing or removing the diseased cord so that the finger can extend fully. Common interventions include surgery, needle aponeurotomy, and collagenase injection. Surgery remains the gold standard in treatment and most commonly includes a limited fasciectomy. Although often successful, surgery carries inherent risks and may involve a lengthy recovery with extensive therapy. Needle aponeurotomy and collagenase injections are office-based alternatives that aim to weaken the cord and release the contracture. Needle aponeurotomy involves repeated needling along the cord in intervals and collagenase injections to dissolve a portion of the cord. Despite being less invasive, problems such as nerve and/or tendon injury, skin tears, and autoimmune reactions have been reported. Regardless of treatment, recurrence remains a concern.

Complications of common hand and wrist surgery procedures: flexor and extensor tendon surgery.

Orthopaedic and hand surgeons frequently treat disorders of the flexor and extensor tendon systems. Common conditions, such as trigger finger, de Quervain tenosynovitis, extensor tendon injury, and zone II flexor tendon injury, can be challenging to treat. Complications that limit normal hand function still occur despite advances in surgical techniques and therapy protocols. It is helpful to be aware of the complications related to the treatment of these hand disorders and understand surgical techniques to minimize their frequency.

Iatrogenic nerve injuries in common upper extremity procedures.

Iatrogenic nerve injuries frequently occur during procedures around the hand and wrist, although they are not always recognized at the time of injury or in the immediate postoperative period. Because preventing injuries is of paramount importance, extensive knowledge of the anatomy of the at-risk nerves is critical. Best results occur after immediate repair because a substantial delay before secondary surgery diminishes the chances for recovery from motor or sensory nerve dysfunction and relief from pain. It is helpful to review iatrogenic nerve injuries associated with common hand surgical procedures.

Complications of distal radial and scaphoid fracture treatment.

Fractures of the distal radius and the scaphoid are common injuries in adults. In recent years, surgical fixation of these types of fractures has increased in response to improved patient outcomes and evolving fixation techniques. Potential soft-tissue, neurovascular, or osseous complications, including tendon injuries, carpal tunnel syndrome, loss of fracture reduction, and osteonecrosis, can increase the time the patient requires immobilization and can lead to poor patient outcomes. Prompt recognition and diagnosis of these complications may improve patient outcomes and satisfaction.

Complications following dislocations of the proximal interphalangeal joint.

Dorsal fracture-dislocations of the proximal interphalangeal joint are challenging injuries to treat and are associated with many complications. The determination of stability is crucial to appropriate management. Stable injuries can usually be treated nonsurgically, whereas unstable injuries typically require surgical stabilization. Many surgical techniques have been used, including extension block pinning, volar plate arthroplasty, open reduction and internal fixation, external fixation, and hemihamate autografting. Because stiffness and flexion contracture are frequent complications, every effort should be made to initiate early motion while maintaining concentric reduction. Other complications include redislocation, chronic swelling, swan neck and coronal plane deformities, and pin tract infections. Assessing injury characteristics, including chronicity, the percentage of articular surface fractured, and the degree of comminution, and understanding complications will help in determining the most appropriate treatment. Chronic dislocations and those injuries in which painful arthritis develops can be successfully treated with salvage procedures, including arthroplasty and arthrodesis.

How do you educate someone to have the skills of an orthopaedic surgeon?

The landscape of orthopaedic surgical education is changing because of many factors, including advances in surgical procedures and musculoskeletal basic science along with an increased focus on ethics and patient education. Over the course of 5 years, a training program must navigate resident physicians through many rotations and effectively teach trainees to become competent orthopaedic surgeons. Each rotation must best balance service requirements and educational experiences to optimize resident education and patient outcomes. Factors such as the 80-hour work week and the current medicolegal climate limit the ability of residents to learn basic surgical skills in the operating room. The benefits of performing simulator-based surgical procedures in cadavers and using simulation for other procedures are becoming increasingly important to teach basic psychomotor skills to residents. Allowing a technically incompetent resident to graduate is a disservice to the medical profession, society, patients, and (ultimately) to the resident. Dealing with such a resident is challenging but necessary to ensure that residency programs continue to graduate competent medical professionals.

Reduction and association of the scaphoid and lunate procedure: short-term clinical and radiographic outcomes.

PURPOSE: To evaluate the success of reduction and association of the scaphoid and lunate with a fibrous union in an effort to evaluate the technique's validity and reproducibility. METHODS: A retrospective review was performed on 7 patients (8 wrists) with an average follow-up of 38 months. Static and grip radiographs were examined in the preoperative, immediate postoperative, and final follow-up settings to evaluate scapholunate (SL) diastasis, SL angle, hardware position, and complications. At final follow-up, grip strength and wrist range of motion were recorded, and patients completed the Disabilities of the Arm, Shoulder, and Hand and the Patient-Rated Wrist Evaluation outcome questionnaires. RESULTS: Radiographic success, defined by maintenance of corrected SL diastasis, absence of dorsal intercalated segmental instability, and no progression of SL advanced collapse was achieved in 3 of the 8 wrists. One wrist developed radioscaphoid arthritis. No patients required a salvage procedure. Despite the loss of reduction that occurred in all patients, the patients' disability remained minimal as detected by the scores on the outcome measures. CONCLUSIONS: The procedure was ineffective in providing stability about the SL interval. With a majority of patients experiencing early radiographic failure of the procedure in the short term, our experience suggests that the reduction and association of the scaphoid and lunate procedure should be abandoned despite the relatively low outcomes measures scores, which may be reflective of the short follow-up duration for this series. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Long-term results of Swanson silicone arthroplasty for proximal interphalangeal joint osteoarthritis.

PURPOSE: To review the long-term outcome of the Swanson silicone arthroplasty in the osteoarthritic proximal interphalangeal (PIP) joint at a single institution. METHODS: We identified 51 patients who had undergone PIP joint Swanson silicone arthroplasty for osteoarthritis and included in the study only those 22 patients (38 joints) who responded and could follow up. These patients returned for follow-up evaluation at an average of 10 years (range, 2-24 y). Subjective outcomes were assessed using the Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire, visual analog pain scale, and Likert questionnaire scores. Clinical and radiographic objective data were collected by measuring range of motion and coronal plane deformation and assessing final radiographs. RESULTS: Silicone arthroplasty at the PIP joint consistently provided pain relief in patients who returned for follow-up. The average Quick-Disabilities of the Arm, Shoulder, and Hand score was 17 and the average pain visual analog scale score was 0.4. The Likert questionnaire revealed that on average, patients agreed or strongly agreed that they would have surgery again, would recommend surgery to another patient, and were satisfied at an average of 10 years after surgery. Patients had neutral responses when they rated appearance, functional improvement, and range of motion. Objectively, range of motion (flexion arc of 50°) did not significantly change from the preoperative flexion arc (55°). Radiographically, 31 implants had deformation, including 21 with implant fracture. There were 3 revisions for symptomatic implant fractures and 1 implant was removed for infection. There was no correlation between radiographs and satisfaction. CONCLUSIONS: Despite unchanged range of motion and considerable radiographic implant deformation or fracture, patients obtained consistent pain relief and satisfaction. With an implant survivorship of 90% at average of 10 years postoperatively, silicone implant arthroplasty remains our treatment of choice for the symptomatic osteoarthritic PIP joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Thirty-Three-Year Follow-up Following Silicone Scaphoid Arthroplasty: A Case Report.

CASE: A 64-year-old man presented with a 3-year history of right wrist pain and swelling 33 years after a silicone scaphoid arthroplasty for chronic scaphoid nonunion. Radiographs demonstrated a deformed scaphoid implant, carpal and distal radius cysts, and mild carpal collapse. He elected to undergo a wrist arthrodesis with a dorsal fusion plate after failing conservative management. CONCLUSION: Although carpal bone silicone implant arthroplasties of the wrist have long been abandoned, our patient was pain free and fully functional for 3 decades. He was pleased to undergo serial examinations with radiographs for 30 years without any therapeutic intervention.

Characterization of Major Complications of Bridge Plating of Distal Radius Fractures at a Level I Trauma Center.

BACKGROUND: Comminuted, markedly displaced distal radius fractures can cause instability requiring advanced stabilization with dorsal bridge plating. However, published complication rates of bridge plating widely vary. We hypothesize that complications of bridge plating of distal radius fractures are more prevalent than published rates. METHODS: A retrospective review was performed on all patients at an academic level I trauma center treated with a bridge plate for a distal radius fracture from 2014 to 2022. RESULTS: Sixty-five wrists were included in the final analysis: average age 53 years, male 51%, average plate retention 4 months, and average follow-up 6 months. Carpal tunnel release (CTR) was performed at time of primary procedure in 7 (10%) cases. Radial height, radial inclination, dorsal tilt, and ulnar variance were all significantly improved (P < .001). Grip strength, flexion, extension, and supination were significantly limited (P < .03). Twenty-one patients (32%) developed 35 major complications requiring unplanned reoperation, including mechanical hardware-related complication (15%), deep infection (11%), nonunion/delayed union (9%), adhesions (6%), median neuropathy (6%), symptomatic arthritis (5%), and tendon rupture (2%). Plate breakage occurred in 3 patients (5%) and was always localized over the central drill holes of the bridge plate. CONCLUSIONS: Major complications for bridge plating of distal radius fractures were higher at our institution than previously published. Plate breakage should prompt reconsideration of plate design to avoid drill holes over the wrist joint. Signs and symptoms of carpal tunnel syndrome should be carefully assessed at initial presentation, and consideration for concomitant CTR should be strongly considered.

Clinical and radiographic outcomes of metacarpophalangeal joint pyrolytic carbon arthroplasty for osteoarthritis.

PURPOSE: To determine the effectiveness of pyrolytic carbon arthroplasty for the management of primary osteoarthritis of the metacarpophalangeal joint. METHODS: A retrospective review of 11 pyrolytic carbon arthroplasties for osteoarthritis of the metacarpophalangeal joint, performed by a single surgeon, was conducted. All patients returned for clinical assessment at a minimum of 2 years after surgery. Evaluation included range of motion, pain and functional scores, and patient satisfaction. Validated outcome measures included the Michigan Hand Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand. Radiographs were assessed for implant failure, loosening, migration, and subsidence. RESULTS: The average follow-up was 4 years (minimum 2 y). The arc of motion significantly improved from 62° before surgery to 76° after surgery. Grip strength decreased slightly compared to the contralateral side (average, 3 kg). The average pain score was 1 on a 10-point visual analog scale. All but 1 patient were fully satisfied at final follow-up. All patients who were working before surgery returned to work after surgery. The Michigan Hand Questionnaire average score was 80, and the Quick Disabilities of the Arm, Shoulder, and Hand average score was 22. Two patients experienced persistent, asymptomatic squeaking and clicking, and 1 patient reported extensor tendon subluxation. One joint had conversion to arthrodesis for continued, unexplained pain. All surviving implants had a surrounding lucency on radiographs. The average subsidence was 3 mm; there was no implant migration, fracture, or dislocation. CONCLUSIONS: Pyrolytic carbon arthroplasties of the metacarpophalangeal joint resulted in satisfactory outcomes at average 4-year follow-up, with improved joint motion, good pain relief and satisfaction, and few complications. Radiographic outcomes revealed a consistent, asymptomatic surrounding lucency with no evidence of implant failure or migration.

Proximal row carpectomy: minimum 20-year follow-up.

PURPOSE: Proximal row carpectomy (PRC) is a motion-sparing procedure for degenerative disorders of the proximal carpal row. Reported results at a minimum 10-year follow-up consistently show maintenance of strength, motion, and satisfaction with an average conversion rate to radiocarpal arthrodesis of 12%. We hypothesized that PRC would continue to provide a high level of satisfaction and function at a minimum of 20 years. METHODS: Seventeen wrists in 16 patients, including 7 laborers, underwent PRC for symptomatic degenerative disorders of the proximal carpal row at an average age of 36 years. Patients returned for radiographic and clinical evaluation, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire and Patient-Related Wrist Evaluation were used for subjective assessment. Follow-up was a minimum of 20 years (average, 24 y). RESULTS: Eleven wrists (65%) underwent no further surgery at a minimum 20-year follow-up. The average time to failure of PRC, defined as the time from PRC to radiocarpal arthrodesis, was 11 years (range, 8 mo to 20 y). Ten of 11 patients who did not undergo radiocarpal arthrodesis continued to be satisfied, with minimal decrease in motion and grip strength compared with the uninvolved side. Average score for QuickDASH was 16 and for Patient-Related Wrist Evaluation was 26. The flexion-extension arc was 68°, and grip strength was 72% of the contralateral side. All patients returned to their original employment. There was no correlation between degenerative radiographic changes and satisfaction level. The predicted probability of failure revealed a higher risk in patients who underwent PRC at a younger age, which leveled off at age 40 years. CONCLUSIONS: PRC provides satisfaction at a minimum of 20 years with a survival rate of 65%. Whereas we recommend a minimum age for PRC between 35 and 40 years, young patients should not be excluded as PRC candidates; these patients should undergo appropriate preoperative counseling of their increased failure risk secondary to their young age. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.