Outcomes of Pediatric Proximal Phalanx Base Fractures.

INTRODUCTION: Extra-articular juxtaphyseal fractures of the proximal phalanx are among the most common finger fractures in children. Immobilization of the digit for 3 to 4 weeks after reduction of the fracture is the current standard of care. The purpose of this retrospective study was to evaluate outcomes after intervention among pediatric proximal phalanx base fractures and establish radiographic criteria to guide management. METHODS: A multi-institutional retrospective review of skeletally immature patients treated for proximal phalanx juxtaphyseal fractures between 2002 and 2019 was conducted. Variables collected included Salter-Harris classification; initial, postreduction, early follow-up, and final angulation and displacement on the posterior-anterior and lateral radiographs; clinical rotational deformity at final follow-up; and method of treatment. Exclusion criteria included less than 3 weeks of follow-up; Salter-Harris III, IV, and V fractures; inadequate medical record details; and missing radiographs. RESULTS: Six hundred thirty-four fractures meeting the inclusion criteria were categorized into no reduction, closed reduction (CR), and surgical (OP) groups. Only CR and OP groups saw large decreases in angulation by 11.8° CR (95% confidence interval, 10.1 to 13.6) and 19.0° OP (95% confidence interval, 8.7 to 29.3). Closed reduction patients had a mean coronal angulation value of 6.1° at post-reduction, which was maintained with immobilization to 5.8° at final follow-up. At final follow-up, scissoring was noted, three in the no reduction and three in the CR group for an overall 0.93% rotational malalignment rate. DISCUSSION: Extra-articular proximal phalanx juxtaphyseal fractures rarely require surgical management and can typically be treated with or without CR, based on the degree of deformity, in the emergency department or clinical setting. Low rates of documented sequelae after nonsurgical management were seen in this cohort, allowing for establishment of treatment parameters that can result in clinically insignificant angular and rotational deformity. LEVEL OF EVIDENCE: Therapeutic IV.

Shared Decision-Making Tool for Opioid Prescribing After Ambulatory Orthopedic Surgery in Veterans: A Randomized Controlled Clinical Trial.

Purpose: We examined whether an educational, shared-decision-making tool designed to empower patients, individualize pain management, and maximize use of nonopioid, over-the-counter analgesics reduces opioid use and waste while maintaining adequate pain relief. Methods: We developed an educational, shared-decision-making tool regarding postoperative pain medication for outpatient hand surgery. Patients randomized to groups with and without the tool were surveyed for 4 weeks after surgery. Survey variables included Patient-Reported Outcomes Measurement Information System pain intensity and pain interference scores, as well as the number of oxycodone or over-the-counter pills taken. Results were compared using chi-squared, Wilcoxon rank-sum, and Welch's t tests. Results: Fifty-three patients participated: 25 in the shared-tool group and 28 in the no-tool group. The mean age was 60 years, with more women in the no-tool group than the shared-tool group (n =17 versus 11, respectively). The shared-tool group averaged 6.4 prescribed oxycodone pills, versus 10 for the no-tool group (P < .01). The median numbers of oxycodone pills taken the first week after surgery were 2 (interquartile range, 6) for the shared-tool group and 3 (interquartile range, 6) for the no-tool group (P = .97). Patient-reported outcome measures for pain intensity and pain interference were not significantly different for weeks 1, 3, and 4 after surgery. Pain interference was significantly lower in week 2 in the shared-tool group (difference, -4.4; 95% confidence interval, -8.57 to -0.30; P = .04). Conclusions: The shared-tool group had equivalent or better pain control and were prescribed a lower number of opioid pain pills than the no-tool group. Both groups used nonopioid medications, with no difference in the types of over-the-counter medications used. Shared decision-making strategies could be applied to other outpatient orthopedic surgical settings, and may reduce the amount of opioids prescribed without compromising pain control. Type of study/level of evidence: Therapeutic II.

Outcomes of Orthopedic Hand Surgeries in Minor Procedure Rooms at a Veterans Affairs Medical Center.

Purpose: There is a high demand for minor hand surgeries within the veteran population. The objective of this study was to compare clinical outcomes and resource use at a Veterans Affairs Medical Center (VAMC) of hand surgeries performed in minor procedure rooms (MPR) and operating rooms using local anesthesia with or without monitored anesthesia care. Methods: We retrospectively evaluated all patients undergoing carpal tunnel release, de Quervain's release, foreign body removal, soft tissue mass excision, or A1 pulley release at a VAMC over a 5-year period. Data collected included demographic information, mental health comorbidities, presence of preoperative and postoperative pain, complications after surgery, time to surgery, number of personnel in surgery, turnover time between cases, and time spent in the postanesthesia care unit. Statistical analysis included Fisher exact or chi-square analysis to compare MPR versus operating room groups and Student t test or Mann-Whitney test to compare continuous variables. Results: In this cohort of 331 cases, 123 and 208 patients underwent surgery in MPRs and operating rooms, respectively. Preoperative and postoperative pain were similar between the MPR and operating room groups. Complications were slightly lower in the MPR group versus the operating room group (0% MPR vs 2.9% operating room). Median time from surgical consult to surgery was 6 days less for MPR patients (15 vs 21). The MPR cases also used fewer personnel during surgery, averaging 4.76 versus 4.99 people. The MPR patients spent 9 minutes less in the postanesthesia care unit (median, 36 vs 45 minutes) and turnover time between cases was nearly 8 minutes faster in MPRs than in operating rooms (median, 20 vs 28 minutes). Conclusions: Minor procedure rooms at a VAMC allow more veteran patients to be scheduled for minor hand surgeries within a shorter time frame, utilize less staff and postoperative monitoring, and maintain excellent outcomes with limited complications. Clinical relevance: Minor hand surgeries in MPRs have outcomes equivalent to those of operating rooms with improved time savings and resource use.