Establishing the Role of Inflammatory Markers in the Diagnosis and Treatment of Acute Hand Infections in the Pediatric Population.

INTRODUCTION: Distinguishing the severity of the diagnosis and an appropriate treatment plan in pediatric hand infections can be complex due to the variable amount of information available at the presentation. Inflammatory blood markers, including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are reported to aid in determining the severity of infection and response to treatment in adult hand infections. The purpose of this study was to identify the relevance of inflammatory marker levels in pediatric patients with hand and wrist infections and to determine their utility in diagnosis and treatment. METHODS: This multicenter, retrospective, cohort study included patients aged 0 to 18 who received treatment for an acute hand or wrist infection between 2009 and 2020. Data collected included demographics, time to presentation, diagnosis, inflammatory markers, culture results, antibiotic treatment, and surgical treatment. Infections were categorized as deep (osteomyelitis, tenosynovitis, abscess) and superficial (paronychia, felon, cellulitis). Exclusion criteria included: patients above 18 years of age, chronic infection, open fractures, and absence of any documented inflammatory markers. Statistically, t tests were used to compare mean differences in inflammatory markers between patients who did and did not receive pretreatment antibiotics and between patients who had superficial versus deep hand infections. RESULTS: A total of 123 patients met the inclusion criteria. Pretreatment with antibiotics before definitive management was not significantly associated with differences in laboratory markers compared with patients not pretreated with antibiotics. Deep hand infections had inflammatory markers similar to superficial infections. Patients with deep hand infections required a bedside or operative procedure 78.9% of the time compared with superficial infections (21.2%) ( P <0.001). Patients with an isolated methicillin-resistant Staphylococcus aureus infection had inflammatory marker values that were not significantly different from patients infected with all other microbes. CONCLUSIONS: Inflammatory markers were not significantly different between patients who received pretreatment with antibiotics and those who did not. While deep infections were often treated with bedside or surgical procedures, the inflammatory marker values were similar to those of superficial infections. The same held true for patients infected with culture-positive, isolated methicillin-resistant Staphylococcus aureus bacteria. Consequently, inflammatory markers may be useful to identify the presence of infection and monitor the response to treatment, they did not aid in determining the specific type of infection or selection of a treatment plan. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Ulnar Epiphysiodesis: Success of the Index Procedure.

INTRODUCTION: Premature radial physeal closure is a relatively rare occurrence in children. When isolated growth arrest of the radius with continued ulnar growth occurs, the resulting ulnar positive deformity leads to altered wrist mechanics and pain. Timely epiphysiodesis of the distal ulna with and without ulnar shortening osteotomy can address these issues, but continued ulnar overgrowth is a possible complication. We seek to evaluate the success rate of the primary epiphysiodesis of the ulna and associated clinical outcomes. METHODS: A chart review was conducted at 2 children's hospitals from 2008 to 2019. Patients between the ages of 6 and 18 years old, with premature distal radius physeal closure, with or without positive ulnar variance, and >2 months follow-up were included. We evaluated the following characteristics for each patient: demographics, initial cause of premature radial physeal closure, ulnar variance, additional procedures performed during epiphysiodesis, preoperative and postoperative pain, range of motion, instability. Summary statistics were conducted and expressed as proportions, medians and means. A paired t test evaluated change in ulnar variance for those who had an ulnar shortening osteotomy performed. RESULTS: Thirty-one wrists among 30 patients were identified, and the median age at the time of surgery was 12.2 years (interquartile range: 3.4). Ulnar shortening osteotomies were performed in 53.1% of cases and distal radius osteotomy in 15.6%. Bone graft was utilized in 25.8% of the epiphysiodesis procedures. There were 2 failures of primary epiphysiodesis indicating an index success rate of 93.7%. The average ulnar variance correction was 3.1 mm (95% confidence interval: 1.9, 4.4). The mean physeal time to closure was 134 days. Preoperative symptoms were resolved for 90.6% cases at final follow-up. CONCLUSION: Ulnar epiphysiodesis successfully terminates ulnar physeal growth in 93.7% of cases. Preoperative symptoms were completely resolved with a median physeal closure of just over 4 months. Ulnar variance was corrected on average by 4.1 mm when a radial or ulnar shortening osteotomy was performed at the time of epiphysiodesis. LEVEL OF EVIDENCE: Level IV-case series.

Seymour Fractures: A Retrospective Review of Infection Rates, Treatment and Timing of Antibiotic Administration.

BACKGROUND: Seymour fractures are important to recognize and treat promptly because injuries may result in growth disturbance, nail deformity, or infection. We hypothesize that the administration of antibiotics within 24 hours of injury will be associated with a decreased rate of infection. METHODS: Patients younger than 18 years were included if clinical examination and radiographs demonstrated a Seymour fracture. The timing of antibiotic administration and treatment details were reviewed. The presence of superficial infections or radiographic evidence of osteomyelitis was recorded. RESULTS: A total of 52 patients with 54 fracture that had greater than 30 days of follow-up and were included in data analysis. The average age at the time of injury was 10.2 years. Thirty-four (63%) of 54 patients were most commonly injured secondary to a crush type mechanism. The overall infection rate was 27.3% (15/54 fractures). Among the 29 fractures that received antibiotics within 24 hours of injury, 2 infections (6.9%) were noted at final follow-up. Delayed administration of antibiotics beyond 24 hours postinjury was observed in 17 fractures and was associated with an increased infection rate of 76.5% (13/17, P = 0.000). CONCLUSIONS: Early administration of antibiotics within 24 hours of injury is associated with a reduction in the development of infections. Patients with delayed antibiotic administration may be at high risk for early superficial infection or osteomyelitis. This study highlights the importance of early identification and appropriate treatment of Seymour fractures including the prompt administration of antibiotics following injury.

A comparison of sugar-tong and volar-dorsal splints for provisional immobilization of distal radius fractures in the adult population.

INTRODUCTION: Distal radius fractures are extremely common injuries affecting a wide range of patient demographics. The purpose of this study was to evaluate the outcomes of distal radius fractures managed initially with closed reduction and immobilization in either a below elbow volar-dorsal splint versus sugar-tong splint prior to conversion into a short arm cast. METHODS: We performed a retrospective study of patients with distal radius fractures placed in a sugar-tong (n = 45) and volar-dorsal splint (n = 36). Anteroposterior and lateral radiographs were evaluated immediately after closed reduction and placement into either a sugar-tong or volar-dorsal splint. The radial inclination, radial length, volar tilt, and intra-articular displacement were measured. RESULTS: The average age was not significantly different between groups (Diff: 1.1 years, P = 0.8766). Initial clinic follow-up radiographs illustrated significantly lower radial inclination in the sugar-tong group than volar-dorsal group (17.1 vs. 19, P = 0.0443). Follow-up mean radial length was not significantly lower in the sugar-tong than volar-dorsal group (8.4 vs. 9.2, P = 0.0858). Palmar tilt and articular step-off was not significantly different between splint types. The loss of reduction was 28.8% for the sugar-tong and 25.0% for the volar-dorsal group (P = 0.696). CONCLUSION: Our results did not demonstrate a significant difference in loss of reduction rates between the two splint groups. There was no significant difference between the sugar-tong and volar-dorsal groups in terms of loss of radial length and volar tilt. Loss of reduction was similar between groups suggesting no advantage of a volar-dorsal splint compared to a sugar-tong splint. LEVEL OF EVIDENCE: Therapeutic level III.

Brachial Plexus Birth Injury: Epidemiology and Birth Weight Impact on Risk Factors.

BACKGROUND: Brachial plexus birth injury (BPBI) is a condition in which the brachial plexus is thought to be damaged during the birth process. Studies have cited a varying incidence rate ranging from 0.5 to 4.0 per 1000 live births. The purpose of this study is to evaluate birth claims data over a 15-year period to identify risk and protective factors for BPBI in the state of Colorado. METHODS: A data request was made to the state hospital association for birth claims data. We requested all birth claims from the years 2000 to 2014. ICD9 codes for variables of interest included: BPBI, shoulder dystocia, heavy-for-dates, macrosomia, breech delivery, instrumented birth, birth hypoxia, and gestational diabetes. A multivariable logistic regression model quantified both risk and protective factors for the development of BPBI as odds ratios (ORs) with 95% confidence intervals (CI). RESULTS: There were 966,447 birth records received from State Hospital Association. The BPBI incidence was 0.63/1000 live births. The mean (SD) birth weight was 3187 (572) g for the total population and 3808 (643) g for the BPBI births. Later admission year indicated a decrease in BPBI births (OR, 0.94; 95% CI: 0.92, 0.96/y). Asian, black, and Hispanic infants were more likely to have a BPBI than white infants. Shoulder dystocia (OR, 60.37; 95% CI: 47.90, 76.13) was the highest risk factor for BPBI followed by instrumented forceps birth (OR, 21.04; 95% CI: 12.22, 36.21), breech delivery (OR, 15.38; 95% CI: 5.60, 42.25), and gestational diabetes (OR, 4.46; 95% CI: 3.29, 6.57). Cesarean single births had the lowest risk for BPBI (0.27; 95% CI: 0.20, 0.37), whereas cesarean multiple births (2.33; 95% CI: 1.10, 4.94) and natural multiple births (3.20; 95% CI: 1.36, 7.55) were at higher risk when compared with natural single births and all were statistically significant at P<0.027. Colorado births had a decreased risk of BPBI compared with the United States each year from 2000 (0.82/1000 births vs. 1.6/1000 live births, P<0.001) to 2012 (0.56/1000 live births vs. 0.9/1000 live births, P=0.003). CONCLUSIONS: BPBI has decreased from 2000 to 2014. Historically Colorado has had a lower BPBI incidence than the United States. Shoulder dystocia, instrumented forceps birth, gestational diabetes, and breech delivery are the biggest predictors for BPBI. Increased awareness of shoulder dystocia and instrumented birth are hypothesized to have reduced these incidences. Nonwhites and Medicaid patients seem to be at higher risk for BPBI. LEVEL OF EVIDENCE: Level II-Prognostic.

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.

Playing Surface and Sport Contact Status Modulate Time to Lower Extremity Musculoskeletal Injury at a Greater Level than Concussion History Among Collegiate Student-Athletes.

OBJECTIVES: While previous investigations have demonstrated a positive correlation between previous concussion and risk of subsequent lower extremity musculoskeletal injury (LEMSKI), the effect of sport- and patient-specific factors on time to injury has not been thoroughly described. This study's main objective was to evaluate the relationship between prior concussion and time to LEMSKI among a population of collegiate student-athletes. Secondary objectives were to evaluate the relationship between playing surface, sport contact status, and biologic sex on time to LEMSKI. We hypothesized that those with previous concussion, those competing on synthetic surfaces, and those competing in collision sports would experience decreased latency to LEMSKI overall. METHODS: A retrospective observational analysis of National Collegiate Athletic Association (NCAA) Division I student-athletes was conducted utilizing a mixed linear model analysis with contrasts. Inclusion criteria included participation in the Pac-12 Health Analytics Program with a documented LEMSKI between 2017 and 2020. Exclusion criteria included concurrent concussion and LEMSKI, injury resulting in serious morbidity or mortality, and incomplete medical record. Participants were classified by whether they sustained a concussion prior to LEMSKI in each athletic season. RESULTS: Of 1179 athletes included, 1140 had no previous concussion and 37 had a previous concussion. There was no observed effect of previous concussion (F=0.038; p=0.846) on time to LEMSKI overall. Student-athletes competing on constructed surfaces sustained a subsequent LEMSKI 14.5 days sooner (SE=5.255; p=0.045), and those competing on organic surfaces sustained a subsequent LEMSKI 23.5 days sooner (SE=4.018; p<0.001) in the season than those competing on synthetic surfaces. Contact sport student-athletes sustained a subsequent LEMSKI 52.1 days sooner than collision sport student-athletes (SE=5.248; p<0.001), and limited contact sport student-athletes sustained a subsequent LEMSKI 42.29 days sooner than collision sport student-athletes (SE=4.463; p<0.001). There was no observed effect of biologic sex (F=0.602; p=0.438) on time to LEMSKI overall. CONCLUSION: There was no observed impact of concussion on time to LEMSKI overall in this collegiate athletic population. Contact sports were associated with decreased time to LEMSK, while synthetic surfaces were associated with increased time to LEMSKI in this population. There was no observed impact of biologic sex on time to LEMSKI. LEVEL OF EVIDENCE: Case-control, level of evidence III.

Is the Repair of Acute Scapholunate Injuries Associated With Distal Radius Fractures Necessary at the Time of Osteosynthesis? A Systematic Review and Meta-Analysis.

BACKGROUND: Acute scapholunate ligament injuries (SLIs) can occur in distal radial fractures (DRFs). This systematic review compares patient-reported outcomes and range of motion (ROM) between operative and nonoperative treatment of acute SLIs in association with surgical fixation of DRFs. We hypothesize that there is no clinical difference. METHODS: A meta-analysis was used to evaluate the effectiveness of SLI repair versus no repair occurring with DRF with Disabilities of the Arm, Shoulder, and Hand (DASH) scores. We identified 154 articles of which 14 were eligible for review. Only 7 studies reported sufficient radiographic or clinical outcomes data and were included: 3 for meta-analysis and 4 underwent narrative analysis due to lack of homogeneity. We analyzed the patients in 2 groups: operative SLI (O-SLI) versus nonoperative SLI (NO-SLI). The primary outcomes were ROM and DASH scores with 1-year follow-up, where a pooled effect size was generated to determine a difference between groups. RESULTS: A total of 128 patients were included (71 O-SLI and 57 NO-SLI), with a mean follow-up of 70.2 months (SD: 23.5). The overall effect size for ROM for flexion was 1.74 (95% confidence interval [CI], -3.48 to 6.95; P = .51) and for extension was 0.79 (95% CI, -3.41 to 4.99; P = .71), while the overall effect size for DASH scores was -0.28 (95% CI, -0.66 to 0.10; P = .14). Although NO-SLI led to better ROM and O-SLI led to lower DASH scores, these were not significantly different. CONCLUSION: The acute surgical intervention of a scapholunate interosseous ligament injury is no different from conservative management in the setting of acute DRFs undergoing osteosynthesis. But the sample size for pooed analyses was small, hence the evidence to date is low to recommend either way.

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.

Depression and Anxiety among Patients with Atraumatic Lateral Epicondylitis and Ulnar-Sided Wrist Pain.

Background Ulnar-sided wrist pain (UWP) and lateral epicondylitis (LE) are common disorders that can be difficult to treat. Depression and anxiety have been shown to modify patient symptoms, disability and pain. Questions/Purposes The purpose of our study was to quantify the prevalence of depression and anxiety among patients with LE or UWP. A secondary aim was to determine if these patients report higher levels of pain upon presentation and if they are more likely to require occupational therapy. Patients and Methods A retrospective chart review was conducted, and patients included those with LE or UWP, atraumatic in origin, ages 18 and over, and ongoing use of noninvasive treatment of LE or UWP. Results Our final analysis included 97 patients of which 57 had LE, 34 had UWP, and 6 had both. The prevalence of a mood disorder was 34.0%. Anxiety and/or depression was more prevalent in patients with LE compared to UWP. The most common medication was alprazolam. Pain scores averaged 1.2 points higher in subjects with a history of a mental health disorder. After adjusting for age and sex, there was no significant association between prevalence of depression and/or anxiety and utilization of physical or occupational therapy. Conclusions Patients with either LE, UWP or both along with depression and/or anxiety may be less likely to improve with traditional treatments. Future investigations are warranted focusing on the value of a multidisciplinary team consisting of a hand surgeon, behavioral therapist, or psychologist to optimize treatment response. Level of Evidence This is a Level IV, case series study.