Return to Play in Youth Athletes: Role of the Radiologist with Focus on the Upper Extremity.

Increase in youth sports participation, longer duration of play, and earlier starting points have increased the prevalence of acute and repetitive overuse musculoskeletal injuries. This rise in injury rates has led to increased efforts to better understand the susceptible sites of injury that are unique to the growing immature skeleton. Upper extremity injuries are currently the best studied, particularly those that occur among pediatric baseball players and gymnasts. The weak link in skeletally immature athletes is the growth plate complex that includes those injuries located at the epiphyseal and apophyseal primary physes and the peripherally located secondary physes. This article reviews the anatomy and function of these growth plate complexes, followed by a discussion of the pathophysiologic mechanisms, spectrum of imaging findings, and existing evidence-based guidelines for injury prevention and return to play.

Physeal Fractures of the Distal Ulna: Incidence and Risk Factors for Premature Growth Arrest.

BACKGROUND: The aim of this study is to assess the rate of distal ulnar growth arrest following physeal fracture and to identify specific risk factors for premature physeal closure. METHODS: A retrospective review of patients with a distal ulnar physeal fracture was performed at a single United States children's hospital. Patients without 6-month follow-up were excluded. Patient demographics, injury characteristics, treatment, and outcomes were abstracted. Fractures were classified by the Salter-Harris (SH) system. All follow-up radiographs were reviewed for changes in ulnar variance or signs of premature physeal arrest. RESULTS: Fifty-six children with distal ulnar physeal fracture at a mean age of 10.7±3.3 years were included with a mean follow-up of 1.9 years. The most common fracture pattern was a SH II (52.7%), versus SH I (29.1%), SH III (9.1%), and SH IV (9.1%). Of displaced fractures (41.1%), the mean translation was 40.2±38.3% the and mean angulation was 24.8±20.9 degrees. Eleven fractures (19.6%) demonstrated radiographic signs of growth disturbance, including 3 patients (5.4%) with growth disturbance but continued longitudinal growth and 8 patients (14.3%) with complete growth arrest. The average ulnar variance was -3.4 mm. Three patients underwent subsequent surgical reconstruction including ulnar lengthening with an external fixator, distal ulna completion epiphysiodesis with distal radius epiphysiodesis, and ulnar corrective osteotomy. Patients with displaced fractures and SH III/IV fractures were more likely to develop a growth disturbance (34.8% vs. 3.2%, P =0.003; 50.0% vs. 11.1%, P =0.012, respectively). Children with less than 2 years of skeletal growth remaining at the time of injury had a higher risk of growth disturbance (46.2% vs. 9.5%, P =0.007). CONCLUSIONS: SH III and IV fractures are more common injury patterns in the distal ulna compared with the distal radius. Growth disturbance or growth arrest occurs in ~20% of distal ulnar physeal fractures. Displaced fractures, intra-articular fractures, fractures requiring open reduction, and older children are at increased risk of distal ulnar growth arrest and should be followed more closely. LEVEL OF EVIDENCE: Level IV--case series.

An Evolution of the Surgical Management of Synpolydactyly: A Case Series of 21 Hands.

INTRODUCTION: Synpolydactyly is a rare congenital anomaly characterized by syndactyly and polydactyly in the central hand. Limited treatment guidelines exist for this complex condition. METHODS: A retrospective review of synpolydactyly patients was conducted at a large, tertiary pediatric referral center to describe our surgical experience and evolution of management. The Wall classification system was used to categorize cases. RESULTS: Eleven patients (21 hands) with synpolydactyly were identified. Most of the patients were White and had at least one first-degree relative who also had synpolydactyly. The Wall classification yielded the following results: 7 type 1A hands, 4 type 2B hands, 6 type 3 hands, and 4 uncategorizable hands. Each patient had an average of 2.6 surgeries and an average follow-up time of 5.2 years. The rates of postoperative angulation and flexion deformities were 24% and 38%, respectively, with many of these cases also demonstrating preoperative alignment abnormalities. These cases often required additional surgeries including osteotomies, capsulectomies, and/or soft tissue releases. The rate of web creep was 14% with 2 of these patients requiring revision surgery. Despite these findings, at the time of final follow-up, most patients had favorable functional outcomes, were able to engage in bimanual tasks, and were able to perform activities of daily living independently. CONCLUSIONS: Synpolydactyly is a rare congenital hand anomaly with a significant degree of variability in clinical presentation. The rates of angulation and flexion deformities as well as web creep are not insignificant. We have learned to prioritize correcting contractures, angulation deformities, and skin fusion, over simply trying to delete the "extra" number of bones as this may destabilize the digit(s).

Prevention of Venous Thromboembolism in Microvascular Surgery Patients Using Weight-Based Unfractionated Heparin Infusions.

BACKGROUND: Unfractionated heparin infusions are commonly used in microvascular surgery to prevent microvascular thrombosis. Previously, fixed-dose heparin infusions were believed to provide sufficient venous thromboembolism (VTE) prophylaxis; however, we now know that this practice is inadequate for the majority of patients. Anti-factor Xa (aFXa) level is a measure of unfractionated heparin efficacy and safety. This study evaluated the pharmacodynamics of weight-based dose heparin infusions and the impacts of real-time aFXa-guided heparin dose adjustments. METHODS: This prospective clinical trial enrolled adult microvascular surgery patients who received a weight-based heparin dose following a microsurgical procedure. Steady-state aFXa levels were monitored, and patients with out-of-range levels received dose adjustments. The study outcomes assessed were aFXa levels at a dose of heparin 10 units/kg/hour, time to adequate aFXa level, number of dose adjustments required to reach in-range aFXa levels, and clinically relevant bleeding and VTE at 90 days. RESULTS: Twenty-one patients were prospectively recruited, and usable data were available for twenty patients. Four of twenty patients (20%) had adequate prophylaxis at a heparin dose of 10 units/kg/hour. Among patients who received dose adjustments and achieved in-range aFXa levels, the median number of dose adjustments was 2 and the median weight-based dose was 11 units/kg/hour. The percentage of patients with in-range levels was significantly increased (65 vs. 15%, p = 0.0002) as a result of real-time dose adjustments. The rate of VTE at 90 days was 0%, and clinically relevant bleeding rate at 90 days was 15%. CONCLUSION: Weight-based heparin infusions at a rate of 10 units/kg/hour provide a detectable level of anticoagulation for some patients following microsurgical procedures, but most patients require dose adjustment to ensure adequate VTE prophylaxis.

Measuring Functional Outcomes After Bilateral Vascularized Composite Hand Allotransplantation: A Report of 3 Cases.

PURPOSE: Currently, numerous assessment tools are available to measure functional outcomes after bilateral hand transplantation. The purpose of this article is to present our experience utilizing quantitative assessment tools for functional evaluation and to describe our results after bilateral hand transplantation. METHODS: A single surgeon's experience with bilateral hand transplantation from 2011 to 2016 was retrospectively reviewed. Three bilateral hand transplantations were performed in 2 adults and 1 child. A minimum 2-year follow-up evaluation was available. For the adult patients, postoperative outcome measures included patient-reported pain and disability scores, return of sensation, muscle strength, range of motion, and return to work/activities of daily living, the Hand Transplant Scoring System (HTSS), the Sollerman hand function test, and complications. For our pediatric patient, postoperative outcome measures included the Functional Independence Measure for children (WeeFIM) scale, a functional independence measure for children, the 9-Hole Peg Test, the Box and Block test, and complications. RESULTS: Our 2 adult patients were age 28 and our pediatric patient was age 8 at transplantation. Follow-up ranged from 2 to 7 years. The functional assessments were performed over a period from 11 to 48 months after transplantation. Both adult patients achieved functional independence and the HTSS, Short Form-36 Health Score (SF-36), DASH, and Sollerman tests demonstrated sequential improvement compared with pretransplantation scores assessed with the use of prostheses. Our pediatric patient demonstrated improvement in his Box and Block test score for each hand at sequential visits after transplantation. His 9-Hole Peg Test demonstrated improvement, and his WeeFIM assessment at 20 months indicated a greater level of independence. CONCLUSIONS: Patient-reported outcomes and the Sollerman test when used in addition to the HTSS appear to reflect functional improvement in adult patients after bilateral hand transplantation. Although children pose a unique challenge with functional assessment, we found the WeeFIM assessment, 9-Hole Peg Test, and the Box and Block test helpful in evaluating functional outcomes in our pediatric patient. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Pediatric vascularized composite allotransplantation: What is the landscape for obtaining appropriate donors in the United States?

Listing the world's first pediatric bilateral hand transplant patient for a donor posed many challenges including matching the appropriate donor age, bone size, skin tone, and growth potential in an already limited donor population. This study describes the prevalence and distribution of potential pediatric VCA donors in the United States. We assessed the UNOS database from 2008 to 2015 to identify the prevalence of potential pediatric VCA donors. Standard VCA inclusion and exclusion criteria were applied to the dataset for all pediatric solid organ donors. Frequency analyses were performed of characteristics important for VCA matching. The dataset began with 57 300 brain-dead donors and after applying the inclusion and exclusion criteria including age <18, decreased to 4663 (8.1%). The number of pediatric potential VCA donors per UNOS region ranged from 11 to 112/year. The majority of pediatric potential VCA donors were blood type O Whites, with the least common profile being blood type AB of "other" ethnicity. The present study confirmed that pediatric VCA donors are rare and may require longer travel times for procurement and listing at multiple centers in order to find a suitable donor. This will be a limiting factor for the expansion of pediatric VCA.

A Review on the Orthoplastic Approach to Lower Limb Reconstruction.

Just as in the craft of carpentry, a stable foundation and framework are absolutely essential to the final function of a building, but no more important than the drywall, trim, and paint that make the building functional, durable, and livable. Reconstruction of the lower extremity is similar; the orthopaedic surgeon must obtain stable fixation of the damaged or diseased bone once a thorough debridement of nonviable bone is performed, while the plastic or orthopaedic soft tissue surgeon must provide vascularized, stable coverage. These two components are complementary and both contribute to the success or failure of functional limb restoration. The stability of bone repair will predict the ultimate functional status, while the vascularized envelope will enhance the biology of bone and soft tissue healing. When both components are properly attended to, the result is often a functional limb with an acceptable appearance. While a single surgeon need not perform both of these tasks (although some may choose to do so), the orthopaedic and plastic surgeon involved in this care must have a clear understanding of each other's role and their importance for a good outcome. This is what we call the orthoplastic approach to reconstructive surgery of the extremities, that is, the application of principles and practice of both specialties applied simultaneously to optimize the outcomes in limb reconstruction. In this review article, we discuss the history of orthoplastic surgery, the key elements of orthoplastic surgery, and thoughts on factors that lead to good outcomes through select cases.

Defining the Salvage Time Window for the Use of Ischemic Postconditioning in Skeletal Muscle Ischemia Reperfusion Injury.

BACKGROUND: The aim of this study was to determine the optimal salvage time window within which ischemic postconditioning can be used to ameliorate ischemia/reperfusion (I/R) injury in skeletal muscle. METHODS: A total of 48 Sprague-Dawley rats were divided into two groups: I/R only (control) and I/R with postconditioning. Subgroups were divided by duration of ischemia (2, 4, 6, and 8 hours). A pedicled gracilis muscle model was used. The postconditioning protocol consisted of six cycles of 15 seconds of reperfusion followed by 15 seconds of ischemia (total time = 3 minutes). Muscles were harvested 24 hours after I/R injury to examine tissue viability, histology, myeloperoxidase activity, and protective gene expression. RESULTS: Postconditioning groups showed improved muscle viability after 4 and 6 hours of ischemia time as compared with controls (p < 0.05). Higher expression of mitochondrial complexes I, II, III, endothelial nitric oxide synthase, inducible nitric oxide synthase, and Bcl-2 were observed in the postconditioning group after 4 and 6 hours of ischemia (p < 0.05). Lower expression of tumor necrosis factor-α and caspase 3 was observed in the postconditioning group at 4 hours (p < 0.05). Myeloperoxidase activity was similar in both groups at all-time points except 8 hours ischemia, where the control group had higher activity (p < 0.05). CONCLUSION: Results of this study demonstrate that the effective time window within which postconditioning is most effective for the salvage of skeletal muscle is between 4 and 6 hours of ischemia. Postconditioning offered improved mitochondrial and vascular function with decreased inflammation and cell death. This may be clinically useful as a postinjury salvage technique to attenuate I/R injury after 4 to 6 hours of ischemia.

Side-to-side nerve bridges reduce muscle atrophy after peripheral nerve injury in a rodent model.

BACKGROUND: Peripheral nerve injury can result in muscle atrophy and long-term disability. We hypothesize that creating a side-to-side bridge to link an injured nerve with a healthy nerve will reduce muscle atrophy and improve muscle function. METHODS: Sprague-Dawley rats were divided into four groups (n = 7 per group). Group 1: transection only--a 10-mm gap was created in the proximal tibial nerve; group 2: transected plus repaired--the transected tibial nerve was repaired; group 3: transected plus repaired plus nerve bridge--transected nerve repaired with a distal nerve bridge between the tibial and peroneal nerves via epineurial windows; and group 4: transected plus nerve bridge--transected tibial nerve left unrepaired and distal bridge added. Gait was assessed every 2 wk. At 90 d the following measures were determined: gastrocnemius mass, muscle and nerve nuclear density, and axonal infiltration into the nerve bridge. RESULTS: Groups 3 and 4 had greater improvements in walking track recovery than groups 1 and 2. Group 3's gastrocnemius muscles exhibited the least amount of atrophy. Groups 1, 2, and 4 exhibited greater histologic appearance of muscle breakdown compared with group 3 and control muscle. Finally, most bridges in groups 3 and 4 had neuronal sprouting via the epineurial windows. CONCLUSIONS: Our study demonstrated reduced muscle atrophy with a side-to-side nerve bridge in the setting of peripheral nerve injury. These results support the application of novel side-to-side bridges in combination with traditional end-to-end neurorrhaphy to preserve muscle viability after peripheral nerve injuries.

Medical student perceptions of plastic surgeons as hand surgery specialists.

PURPOSE: Plastic surgeons are often not perceived as hand surgery specialists. Better educating medical students about the plastic surgeon's role in hand surgery may improve the understanding of the field for future referring physicians. The purposes of this study were to assess medical students' understanding of hand surgery specialists and to analyze the impact of prior plastic, orthopedic, and general surgery clinical exposure on this understanding. METHODS: An online survey including 8 hand-related clinical scenarios was administered to students at a large academic medical center. After indicating training level and prior clinical exposure to plastic surgery or other surgical subspecialties, students selected one or more appropriate surgical subspecialists for management of surgical hand conditions. RESULTS: A response rate of 56.4% was achieved. Prior clinical exposure to plastic, orthopedic, and general surgery was reported by 29%, 43%, and 90% of fourth year students, respectively. Students generally chose at least 1 acceptable specialty for management of hand conditions with improvement over the course of their training (P = 0.008). Overall, students perceived orthopedic surgeons as hand specialists more so than plastic and general surgeons. Clinical exposure to plastic surgery increased the selection of this specialty for nearly all scenarios (22%-46%, P = 0.025). Exposure to orthopedic and general surgery was associated with a decrease in selection of plastic surgery for treatment of carpal tunnel and hand burns, respectively. CONCLUSIONS: Medical students have a poor understanding of the plastic surgeon's role in hand surgery. If plastic surgeons want to continue to be recognized as hand surgeons, they should better educate medical students about their role in hand surgery. This can be achieved by providing a basic overview of plastic surgery to all medical students with emphasis placed on hand and peripheral nerve surgery.

Improving Skin Paddle Reliability and Muscle Gliding in Free Functional Gracilis Transfers.

Free functional muscle transfer is an attractive option within reconstructive surgery when seeking to restore critical muscle function. The gracilis muscle has long been utilized for this purpose due to its expendability and consistent anatomy. Historically, survival of the skin overlying the distal one-third of the myocutaneous gracilis flap has been unpredictable. To address this, the myofasciocutaneous technique was developed, with prior studies demonstrating improved distal skin paddle viability with this approach; however, the mechanism is poorly defined. This study aimed to understand what factors contribute to survival benefit in myofasciocutaneous gracilis flaps. Using cadaveric dissections followed by latex dye injections, we discuss the creation of a deep fascial sheath that contains a rich vascular network and permits adhesion-free excursion at the recipient site. This study advances our understanding of the myofasciocutaneous gracilis flap and provides wider clinical applicability in free functional muscle transfer.

Outcomes of Biodegradable Temporizing Matrix for Soft Tissue Reconstruction of the Hand and Extremities.

Background: NovoSorb biodegradable temporizing matrix (BTM) is a novel, bilayer, synthetic skin substitute made of biodegradable polyurethane foam covered with a sealing membrane. BTM has demonstrated excellent outcomes in burn literature; however, few studies have been published for hand and extremity soft tissue reconstruction. Methods: All patients who underwent extremity reconstruction with BTM from 2018 to 2023 were reviewed. Demographics, presentations, and clinical outcomes were recorded. Results: A total of 86 cases from 54 patients (53.7% pediatric; age range: 0-81 years) were included. Common indications included trauma (36%), infection (18.6%), and malignancy (11.6%). BTM was placed over exposed tendon (38.4%), bone (19%), joints (12.8%), nerves (8.1%), and/or blood vessels (7%). BTM served as temporary wound coverage in 26 cases. Complications included hematoma (8.1%), infection (4.7%), and spontaneous delamination (4.7%). Wound closure was successfully obtained without flap use in 93.3%. Poor BTM take was associated with peripheral vascular disease, hypertension, immunosuppression, and BTM hematoma and infection (<0.05). Conclusion: This study contributes to the growing body of evidence favoring BTM use in challenging reconstructive cases. Although prospective comparative studies are forthcoming, BTM likely has broad applications in reconstructive surgery.

Medical student perceptions of the scope of plastic and reconstructive surgery.

BACKGROUND: The scope of plastic surgery is not well understood by people outside the field. Better educating medical students about plastic surgery may improve understanding of the field, establish appropriate referral patterns early on, and assist with career decision-making. The purpose of this study was to assess medical student understanding of plastic surgery and to analyze the impact of prior plastic surgery clinical exposure on this understanding. METHODS: An online survey consisting of 24 clinical scenarios was administered to medical students of the University of Utah. After indicating their level of training and whether they had prior clinical exposure to plastic surgery or other surgical subspecialties, students selected one or more appropriate surgical subspecialties to manage each scenario. RESULTS: Of 408 students, 230 (56.4%) responded to the survey. Prior clinical exposure to plastic surgery was reported by 15.8% to 29.4% of students (first to fourth year). Overall, 92% of students chose at least one acceptable surgical specialty for referral. Plastic surgery was selected by only 54% of students for all conditions, and this did not improve throughout medical school. Senior students (third and fourth years) with prior plastic surgery exposure chose plastic surgery more often than those without prior exposure (71% vs. 51%, P < 0.0001). Plastic surgery was chosen most frequently for rhinoplasty and breast reconstruction and less frequently for hand/peripheral nerve surgery and wound surgery. CONCLUSIONS: Improved medical student education about the scope of plastic surgery is needed, especially in the areas of hand/peripheral nerve surgery and general reconstructive surgery.

Wrist Level Tendon Repairs Utilizing a Novel Tendon Stapler Device: An Efficiency and Biomechanical Study.

BACKGROUND: A novel tendon stapler device (TSD) was recently developed and FDA-approved to improve the strength and consistency of primary tendon repairs. We hypothesized this TSD would demonstrate faster and superior biomechanical properties compared to a standard suture coaptation. We also hypothesized that the TSD biomechanical properties would be consistent across participants with differing tendon repair experience. METHODS: Participants included a novice, intermediate, and expert in tendon repairs. Timed comparisons were performed in flexor zones IV-V and extensor zones VI-VII on human cadaver arms. Suture repairs were performed with a modified Kessler with a horizontal mattress. TSD repairs were performed on the matched donor arms. Biomechanical testing included 2-mm gap force, ultimate failure load, and mode of failure. RESULTS: In total, 228 tendon coaptations from 12 donor arms were performed and analyzed. TSD coaptations were three times faster and withstood nearly 50% higher forces on the 2-mm gap testing and roughly 30% higher forces on ultimate failure testing. These findings did not change when the repair times were analyzed by individual participants. The suture coaptations failed from suture pull-through, suture breakage, and knot failure. The TSD coaptation failures only occurred from device pull-through. CONCLUSION: The TSD produces significantly faster and stronger primary tendon coaptations compared to a standard 4-strand core suture repair in human donor arms. These findings also demonstrated minimal variability among participants with differing tendon repair experience. Although further investigation is needed, this device has potential to revolutionize tendon repairs.

Alternative Tendon Coaptations to the Pulvertaft Weave Technique: A Systematic Review and Meta-Analysis of Biomechanical Studies.

BACKGROUND: The Pulvertaft weave technique (PT) is frequently used during tendon repairs and transfers. However, this technique is associated with limitations. In this systematic review and meta-analysis, quantitative and qualitative analyses were performed on in vitro, biomechanical studies that compared the PT with alternative techniques. METHODS: Articles included for qualitative and/or qualitative analysis were identified following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies included in the meta-analysis were analyzed either as continuous data with inverse variance and random effects or as dichotomous data using a Mantel-Haenszel analysis assuming random effects to calculate an odds ratio. RESULTS: A comprehensive electronic search yielded 8 studies meeting inclusion criteria for meta-analysis. Two studies with a total of 65 tendon coaptations demonstrated no significant difference in strength between the PT and traditional side-to-side (STS) techniques (P = .92). Two studies with a total of 43 tendon coaptations showed that the STS with 1 weave has a higher yield strength than the PT (P = .03). Two studies with a total of 62 tendon repairs demonstrated no significant difference in strength between the PT and the step-cut (SC) techniques (P = .70). The final 2 studies included 46 tendon repairs and demonstrated that the wrap around (WA) technique has a higher yield strength than the PT (P < .001). CONCLUSIONS: The STS, SC, and WA techniques are preferred for improving tendon form. The STS and WA techniques have superior yield strengths than the PT, and the SC technique withstands similar stress to failure as the PT.

The BREASTrial Stage III: Acellular Dermal Matrix Breast Reconstruction Outcomes from 3 Months to 2 Years Postoperatively.

BACKGROUND: The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial (BREASTrial) is a blinded, randomized trial comparing the outcomes of tissue expander breast reconstruction using AlloDerm or DermaMatrix. In this final stage of the trial, outcomes 3 months to 2 years after definitive reconstruction are reported along with patient satisfaction data. METHODS: A randomized trial was conducted to compare complication rates between groups of patients who underwent reconstruction with AlloDerm and DermaMatrix. Regression models were used to analyze the impact of matrix type, age, chemotherapy, radiation therapy, and reconstructive type on complication rates. Premastectomy and postmastectomy questionnaires were used to assess patient satisfaction and were also analyzed using regression models. RESULTS: Of the 128 patients (199 breasts) who were randomized in the trial, 108 patients (167 breasts) were available for analysis in stage III. There was no difference in the overall complication rates between the AlloDerm and DermaMatrix groups (6% versus 13.2%; P = 0.3) or the severity of those complications ( P = 0.7). Obesity was a positive predictor for complications, regardless of reconstruction group ( P = 0.02). Patient satisfaction was positive overall and did not grossly vary between AlloDerm and DermaMatrix groups. CONCLUSIONS: Findings from the BREASTrial conclude that AlloDerm and DermaMatrix exhibit similar histologic and clinical outcomes. Patient satisfaction is also similar between matrices. Obesity is a predictor of complications, and acellular dermal matrices should be used with caution in these patients. As the largest head-to-head trial comparing two acellular dermal matrices, the BREASTrial contributes to the fund of knowledge regarding acellular dermal matrix supplementation in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Recent Advancements in the Diagnosis and Treatment of Congenital Hand Differences.

Congenital hand and upper limb differences include a wide spectrum of structural abnormalities that affect functional, appearance, and psychosocial domains of affected children. Ongoing advances in the understanding and treatment of these differences continue to shape management. Over the past 10 years, new developments have been made in areas of molecular genetics, noninvasive treatments, surgical techniques, and outcome measures in several commonly seen congenital hand differences. Applying these advances in knowledge and management of congenital hand differences will enable surgeons to achieve the best outcomes possible for these children.

Clinical and operative risk factors for complications after Apert hand syndactyly reconstruction.

This study evaluated how Apert hand syndactyly presentations and reconstructive techniques influence reconstruction outcomes. All cases at a major paediatric hospital between 2007 and 2022 were analysed, including 98 web space reconstructions in 17 patients. Overall, 62% of hands developed complications and 15% required revision surgery. Upton hand type was significantly associated with postoperative complication incidence, specifically including range-of-motion deficits, flexion contracture, web creep and revision surgery. More severe syndactylies may benefit from additional measures to reduce complications. Rectangular commissural flaps showed 1.9 times greater complication risk than interdigitating triangular flaps, including 11.2 times greater risk of web creep. Zigzag volar finger flaps showed 1.8 times greater complication risk than straight-line incisions, including 3.8 times greater risk of web creep. Our study showed that interdigitating triangular commissural flaps and straight-line volar finger incisions are preferable to rectangular commissural and zigzag finger flaps in most cases of Apert hand syndactyly to minimize complications. LEVEL OF EVIDENCE: III.

Hand Surgeons' Understanding of Partial Hand Prostheses: Results of a National Survey Study.

PURPOSE: Partial hand amputations are devastating injuries that often negatively affect individuals and communities. Partial hand prostheses can mitigate the burdens of living with an amputation, especially when reconstruction alone cannot restore form or function. However, hand surgeons may be unfamiliar with these newer devices because the prosthetic field is rapidly progressing. METHODS: An electronic survey was distributed to hand surgeon members of the American Association for Hand Surgery with the intent of assessing surgeons' familiarity with partial hand prosthetic devices and their clinical applications. Survey items used Likert 5-point scales, rank order, multiple-choice, and yes/no question formats. Responses were compared by training background (orthopedic or plastic surgery) and by years of experience (≤10 years in practice or >10 years in practice). RESULTS: Overall, hand surgeons are unfamiliar with modern partial hand prosthetic devices. Most of the cohort denied working within a multidisciplinary hand team (76.2%) or consulting with a prosthetist prior to revisional surgeries (71.4%). Restoring gross motor function and reducing pain were important outcomes to the cohort (4.42 and 4.17, respectively). Plastic trained hand surgeons were more likely to list toe-to-hand transfers as treatment options for multilevel digital amputations (P = .03) and transmetacarpal amputations (P = .02). Senior hand surgeons were more likely to suggest no treatment for partial thumb amputations (P = .02). CONCLUSIONS: Expanding surgeon knowledge and encouraging collaboration within a multidisciplinary team may enhance amputee care.

A New Source of Mutilating Hand Injuries: The Side-by-Side Utility Terrain Vehicle.

BACKGROUND: Rates of mutilating hand injuries are increasing from accidents caused by all-terrain vehicles (ATVs) and the recently popularized side-by-side utility terrain vehicles (UTVs). Increasing surgeon familiarity with upper extremity (UE) injury patterns, severity, and outcomes following ATV and UTV accidents may improve patient care and advocacy. METHODS: Retrospective comparisons of UE injury patterns, severity, hospital and intensive care unit (ICU) admission lengths, and number of operations were made between ATVs and UTVs. Findings were analyzed with Fisher exact tests, multivariate analysis of variance, analyses of variance with post hoc analyses, and multiple linear regressions. RESULTS: A total of 154 cases were identified for inclusion (ATV, n = 87; UTV, n = 67). Patient ages ranged from 4 to 89 years. The UTV group contained significantly more hand and finger injuries, and more of the fractures were open ( P = 0.005, P < 0.001, and P < 0.001, respectively). Riders of UTVs had nearly three times as many mutilating hand injuries and a nearly ninefold increase in amputations compared with ATV riders ( P < 0.001 and P < 0.001, respectively). On average, the UTV group spent 2.5 additional days in the hospital, 0.91 additional days in an ICU, and had 1.3 additional operations ( P = 0.001, P = 0.007, and P < 0.001, respectively). Vehicle type was the only variable significantly correlated with days in the hospital, ICU, and number of UE operations ( P = 0.002, P = 0.008, and P < 0.001, respectively). CONCLUSIONS: Hand surgeons are in a unique position to serve as forerunners for increasing public awareness of off-road vehicle risks and promoting rider safety. Collaborating with manufacturers and emergency care providers and directing teaching initiatives may improve patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.