Incidence and reasons for hardware removal following operative fixation of distal radius fractures.

PURPOSE: To determine the incidence and reasons for hardware removal after operative fixation of distal radius fractures. METHODS: We retrospectively reviewed 33 patients who underwent removal of a volar distal radius plate from 2007 to 2013. We recorded the primary reason for plate removal, patient sex, body mass index, AO fracture type, and plate manufacturer. The total number of both distal radius plating procedures and implant removals was analyzed. RESULTS: Of the 33 patients who underwent implant removal, the most common reasons for removal were pain (30%), tenosynovitis (27%), malunion (24%), infection (12%), nonunion (6%), and tendon rupture (3%). The most common AO fracture types requiring plate removal were A2, C2, and C3 (7 each). A total of 517 distal radius fractures received plate fixation at our institution from 2007 to 2009, a number that rose to 610 from 2010 to 2012. The number of distal radius plate removals over that same time was relatively constant at 17 and 16, respectively. CONCLUSIONS: We advise continued review of reasons for implant removal to limit future hardware complications related to volar plating of distal radius fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Factors influencing infection rates after open fractures of the radius and/or ulna.

PURPOSE: To investigate factors associated with the development of deep infection in patients with open fractures of the radius and/or ulna. METHODS: We retrospectively reviewed 296 open fractures of the radius and/or ulna. Of these patients, 200 had at least 6-month follow-up and were included in this study. The following variables were examined for each patient: time from injury to antibiotic administration, time from injury to operative debridement, Gustilo-Anderson classification, type of antibiotic received, and host characteristics such as age, diabetes, and tobacco use. Outcome parameters included the presence of deep infection and fracture union. RESULTS: The overall rate of deep infection was 5% (10 of 200). No type 1 fractures (of 41) developed deep infection. In contrast, 4% (2 of 48) of type 2 and 7% (8 of 110) of type 3 fractures developed infection. Of 200 patients, 28 received antibiotics in less than 3 hours and underwent debridement in less than 6 hours from the time of injury; however, they did not have lower rates of infection. Similar findings were noted when nonunion was used as the outcome, and the association between Gustilo-Anderson classification and the development of nonunion was statistically significant. CONCLUSIONS: Factors such as time to antibiotics and time to operative debridement were not predictors for either rate of deep infection or nonunion in open fractures of the radius and/or ulna. The type of fracture as outlined by the Gustilo-Anderson classification was the factor most strongly associated with the development of deep infection and nonunion in these fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Medical malpractice in hand surgery.

The rise in medical malpractice claims over the past few decades has altered physicians' practice patterns and has had a considerable financial impact on the medical community as a whole. While numerous studies have analyzed the content and effect of these claims, only a handful of articles have addressed specifically the issue of medical malpractice in hand surgery. This article outlines the available literature on malpractice in hand surgery, offers guidance to hand surgeons on managing medical malpractice claims, and discusses preventative measures they might take to limit such claims from being filed in the future. We conclude that the key measures one can take to protecting oneself legally are knowing and abiding by the standard of care, keeping patients informed and developing good relationships with them, and meticulously documenting. Although some malpractice claims are unavoidable, we believe that one can limit his or her exposure to them by incorporating these measures into their respective practices.

The most cited articles in hand surgery over the past 20-plus years: a modern-day reading list.

PURPOSE: To create a current reading list of the hand surgery articles most commonly cited in the last 20-plus years. METHODS: Using the Web of Science Citation Index Search, we searched "hand" and "wrist" in the orthopedic, surgery, and sport sciences research areas. We then reviewed the articles and chose the 50 most commonly cited articles related to hand surgery. Articles were categorized as clinical or basic science. Clinical articles were subcategorized as either therapeutic, prognostic, diagnostic, or economic/decision analysis and assigned a level of evidence rating. We calculated the number of citations per year (citation density). RESULTS: The total number of citations for the top 50 articles ranged from 92 to 317. Citation density ranged from 4 to 24 (average, 9.7). Of the 50 articles, 39 were clinical (78%), whereas the remainder were basic science. Clinical articles were most commonly therapeutic (25 of 39; 64%), followed by diagnostic (11 of 39; 28%) and prognostic (3 of 39; 8%). There were no economic/decision analysis-type articles. The most common level of evidence was level IV, which made up 38% of the list (19 of 50 articles). The second most common was level I, which represented 20% of the list (10 of 50 articles). A total of 70% of the articles (35 of 50) were published between 1990 and 1999, and the remainder of the articles were published after 1999. Fifty percent of the articles appeared in the Journal of Hand Surgery, American volume. CONCLUSIONS: Many of the articles found on our list have shaped the way we practice hand surgery today. We hope that this report and the articles it names can help residents and fellows study current hand surgery and its evolution over the past 20 years. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analyses IV.

Prevalence of labral tears in the elderly.

BACKGROUND: The prevalence of SLAP (superior labrum antero-posterior) tears in the general population is not well known. The purpose of this study is to determine the prevalence of SLAP tears in the elderly using a cadaveric population. METHODS: One hundred two embalmed cadaveric shoulders were dissected by a single, experienced orthopaedic shoulder surgeon (D.H.L.). The average age of the cadavers was 80.6 years (range, 57-96). There were 40 female and 62 male shoulders. For each shoulder dissection, the labrum, rotator cuff, and glenohumeral articular cartilage were inspected. RESULTS: SLAP tears were found in 10 out of 102 shoulders (9.8%), 9 (8.8%) of which were classified as type I and 1 (0.98%) as type II. Twenty-one shoulders (20.6%) were found to have an anterior sublabral foramen, which had an average length of 7 mm (range, 3-11). Seven shoulders (6.9%) had a Buford complex. CONCLUSION: The prevalence of SLAP tears in the elderly is very low. However, there are a significant number of normal anatomic labral variants (eg, sublabral foramina, Buford complexes), which can resemble SLAP tears. These findings add to our knowledge of the prevalence of SLAP tears and will assist future researchers in determining both why the incidence of SLAP repair is increasing and whether it is justified.

Sporotrichosis of the upper extremity.

This article presents a case of a chronic, nonhealing thumb wound in a patient with diabetes mellitus. A 67-year-old right-hand-dominant man presented with progressive erythema and swelling of the right thumb several months after sustaining a paper cut along the eponychium. The patient had already completed an extensive laboratory evaluation, including bacterial and fungal cultures, as well as a punch biopsy that was inconclusive. In addition, the patient underwent several rounds of empiric antibiotic therapy without resolution of his symptoms. Despite these measures, the patient's thumb wound persisted and new lesions began to appear proximally along the forearm. Excisional biopsy of the lesions was ultimately required to obtain additional tissue for a pathologic analysis. Culture of the specimen on Saboraud dextrose agar revealed a definitive diagnosis of infection with Sporothrix schenkii. A subsequent course of oral antifungal therapy with itraconazole was well tolerated and resulted in disease regression. Early diagnosis of sporotrichosis is essential to prevent complications including septic arthritis, systemic infection, and death. This case illustrates the importance of maintaining a high index of suspicion for atypical infectious agents in patients with poor immune function.