miR-206 enforces a slow muscle phenotype.

Striated muscle is a highly specialized collection of tissues with contractile properties that vary according to functional needs. Although muscle fiber types are established postnatally, lifelong plasticity facilitates stimulus-dependent adaptation. Functional adaptation requires molecular adaptation, which is partially provided by miRNA-mediated post-transcriptional regulation. miR-206 is a muscle-specific miRNA enriched in slow muscles. We investigated whether miR-206 drives the slow muscle phenotype or is merely an outcome. We found that miR-206 expression increases in both physiological (including female sex and endurance exercise) and pathological conditions (muscular dystrophy and adrenergic agonism) that promote a slow phenotype. Consistent with that observation, the slow soleus muscle of male miR-206-knockout mice displays a faster phenotype than wild-type mice. Moreover, left ventricles of male miR-206 knockout mice have a faster myosin profile, accompanied by dilation and systolic dysfunction. Thus, miR-206 appears to be necessary to enforce a slow skeletal and cardiac muscle phenotype and to play a key role in muscle sexual dimorphisms.

Post-operative Immobilization in Total Elbow Arthroplasty for Rheumatoid Arthritis: A Systematic Review of Outcomes.

The purpose of this analysis is to determine the effect of length of immobilization following total elbow arthroplasty (TEA) for rheumatoid arthritis on the outcomes, complications, and survival of the implant. A review of TEA literature was performed. Post-operative motion was categorized into three groups: no post-operative immobilization (group 1), short-term 2-5 days immobilization (group 2), and extended 7-14 days immobilization (group 3). Thirty-six articles reporting on 43 studies involving 2,346 elbows in 2015 patients were included. Total complication rates were 23% at 8.9 years for group 1, 31% at 6.8 years for group 2, and 31% at 6.9 years for group 3. Survival rates were 79% at 15.3 years, 75% at 10.4 years, and 92% at 9.1 years for each group, respectively. Total complication rates were lowest in elbows without post-operative immobilization. However, survival rates were greatest in elbows with extended post-operative immobilization. (Journal of Surgical Orthopaedic Advances 31(4):209-217, 2022).

The Association of H-index and Academic Rank Among Full-time Academic Foot and Ankle Surgeons Affiliated with Fellowship Programs.

The purpose of this study is to investigate the association between Hirsch index (h-index) and academic rank among foot and ankle surgeons affiliated with American Orthopaedic Foot and Ankle Society (AOFAS) fellowship programs. The total number of publications, academic rank, years in practice, fellowship training pedigree, and h-indices of 176 foot and ankle surgeons from 48 AOFAS fellowship programs were recorded, and statistical analysis was performed. We found a strong association between total number of publications and h-index. Number of publications, h-index and training program affiliation were associated with higher academic rank, except at the chair/director position. Overall, h-index is a stronger predictor of academic rank than number of publications. The results of this study suggest that h-index and total number of publications are associated with a higher academic rank for full-time foot and ankle fellowship affiliated surgeons. (Journal of Surgical Orthopaedic Advances 31(4):263-267, 2022).

Dorsal Bridge Plate for Distal Radius Fractures: A Systematic Review.

PURPOSE: This study presents patient demographics, injury characteristics, outcomes, and complications associated with dorsal bridge plating (DBP) in the treatment of distal radius fractures. METHODS: A literature search performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines identified 206 articles, 12 of which met inclusion criteria, accounting for 310 patients. Included articles contained the results of DBP for treatment of distal radius fractures with reported outcomes between 1988 and 2018. Data were pooled and analyzed focusing on patient demographics, as well as 3 primary outcomes of complications, range of motion (ROM), and Disabilities of the Arm, Shoulder, and Hand (DASH) and QuickDASH scores. RESULTS: Average age was 55 years, median follow-up was 24 months, and the most common use was in comminuted (92%) intra-articular (92%) distal radius fracture caused by fall (58%), or motor vehicle collision or motorcycle collision (27%). A minority of patients had open fractures (16%) and most were cases of polytrauma (65%). Median time from placement to DBP removal was 17 weeks (mean, 119 days). At final follow-up, mean wrist ROM was 45° flexion, 50° extension, 75° pronation, and 73° supination. Mean DASH score was 26.1, and mean QuickDASH score was 19.8. The overall rate for any complication was 13%; the most common was hardware failure (3%) followed by symptomatic malunion or nonunion (3%), and persistent pain after hardware removal (2%). CONCLUSIONS: Dorsal bridge plating was found to be used most commonly in intra-articular, comminuted distal radius fractures with overall functional wrist ROM, moderate patient-reported disability, and a 13% complication rate at follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Variation in state and federal reimbursement in the United States in the treatment of upper extremity fractures.

BACKGROUND: Medicare and Medicaid are 2 of the largest government-run health care programs in the United States. Although Medicare reimbursement is determined at the federal level by the Centers for Medicare & Medicaid Services, Medicaid reimbursement rates are set by each individual state. The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement rates for 12 orthopedic procedures performed to treat common fractures of the upper extremity. METHODS: Twelve orthopedic procedures were selected and their Medicare reimbursement rates were collected from the 2020 Medicare Physician Fee Schedule. Medicaid reimbursement rates were obtained from each state's physician fee schedule. Reimbursement rates were then compared by assessing the ratio of Medicaid to Medicare, the dollar difference in Medicaid to Medicare reimbursement, and the difference per relative value unit. The range of variation in Medicaid reimbursement and Medicare wage index-adjusted Medicaid reimbursement was calculated. Comparisons in reimbursement were calculated using coefficient of variation and Student t tests to evaluate the differences between the mean Medicaid and Medicare reimbursements. Two-sample coefficient of variation testing was used to determine whether dispersion in Medicare and Medicaid reimbursement rates differed significantly. RESULTS: There was significant difference in reimbursement rates between Medicare and Medicaid for all 12 procedures, with Medicare reimbursing on average 46.5% more than Medicaid. In 40 states, Medicaid reimbursed less than Medicare for all 12 procedures. Regarding the dollar difference per relative value unit, Medicaid reimbursed on average $18.03 less per relative value unit than Medicare. The coefficient of variation for Medicaid reimbursement rates ranged from 0.26-0.33. This is in stark contrast with the significantly lower variability observed in Medicare reimbursement, which ranged from 0.06-0.07. CONCLUSION: Our findings highlight the variation in reimbursement that exists among state Medicaid programs for 12 orthopedic procedures commonly used to treat fractures of the upper extremity. Furthermore, average Medicaid reimbursement rates were significantly lower than Medicare rates for all 12 procedures. Such discrepancies in reimbursement may act as a barrier, impeding many Medicaid patients from accessing timely orthopedic care.

Primary and Revision Circumferential Labral Reconstruction for Femoroacetabular Impingement in Athletes: Return to Sport and Technique.

PURPOSE: To determine return-to-play rates and hip-specific outcomes in athlete hips with femoroacetabular impingement syndrome treated with circumferential labral reconstruction (CLR). METHODS: All consecutive patients who underwent CLR from January through December 2016 performed by the senior surgeon with complete 2-year outcome scores were identified. The hips of 57 non-athletes who underwent CLR were excluded from analysis, as were 165 patients who underwent labral repair and 4 patients who underwent labral debridement. Outcome measures were completed by patients within 1 week prior to surgery and between 22 and 26 months postoperatively. Thirty patients met the inclusion criteria for this study. All 30 participated in regular, competitive athletic events and had magnetic resonance arthrogram-confirmed labral tears, and nonsurgical measures had failed. Of the 30 patients, 5 (16.7%) participated in cutting sports; 5 (16.7%), asymmetrical or overhead sports; 4 (13.3%), contact sports; 13 (43.3%), endurance sports; and 3 (10.0%), flexibility sports. Moreover, 25 of 30 (83.3%) were high-level athletes. Both primary (n = 23) and revision (n = 7) procedures were included. RESULTS: As determined by the International Hip Outcome Tool 12 score, 28 of 30 patients (93.3%) met the patient acceptable symptomatic state whereas 30 of 30 (100%) achieved substantial clinical benefit and exceeded the minimal clinically important difference for their operative hip. In addition, 23 of 30 patients (76.6%) met the patient acceptable symptomatic state whereas 30 of 30 (100%) achieved substantial clinical benefit and exceeded the minimal clinically important difference for the operative hip as determined by the visual analog scale pain score. Of 30 patients, 26 (86.7%) were able to return to play. The mean time to return to play was 6.6 months (standard deviation, 2.4 months). CONCLUSIONS: Two-year outcomes in this population of athletes undergoing CLR for femoroacetabular impingement syndrome show a statistically and clinically significant improvement in patient-reported outcomes, a statistically and clinically significant decrease in pain, and an overall return-to-play rate of 86.7%. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Capitolunate Arthrodesis: A Systematic Review.

PURPOSE: To compile and review the indications, outcomes, and complications of capitolunate arthrodesis (CLA). METHODS: We performed a literature search identifying 33 articles, 6 of which met inclusion criteria, including 80 patients. Included publications contained the results of CLA with minimum 12-month follow-up between 2000 and 2018. Data were pooled and analyzed focusing on the primary outcomes of union and complications. RESULTS: Average age of patients was 48 years (range, 22-86 years), median follow-up was 34 months (range, 12-198 months), and most common indication was scaphoid nonunion advanced collapse (59%). Nearly half underwent a concomitant triquetrum excision (49%). Most patients were pain-free (78%) and returned to work (92%). Grip strength and visual analog pain scale both improved after CLA. Whereas 96% fused within a reported 42 to 210 days (median, 70 days), 11% of patients had complications including nonunion (3.8%) and loose hardware (6.3%). The reoperation rate was 14%, including wrist arthrodeses and wrist arthroplasty. CONCLUSIONS: Capitolunate arthrodesis is a feasible option for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists with complications similar to those encountered in 4-corner arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Spine Injuries Sustained After Falls While Crossing the U.S.-Mexico Border.

This study is to report the demographics, incidence, and patterns of spinal injuries associated with border crossings resulting from a fall from a significant height. A retrospective cohort study was performed at a Level I trauma center from January 2016 to December 2021 to identify all patients who fell from a significant height while traversing the U.S.-Mexico border and were subsequently admitted. A total of 448 patients were identified. Of the 448 patients, 117 (26.2%) had spine injuries and 39 (33.3%) underwent operative fixation. Females had a significantly higher incidence of spine injuries (60% vs. 40%; p < 0.00330). Patients with a spine fracture fell from a higher median fall height (6.1 vs. 4.6 m; p < 0.001), which resulted in longer median length of stay (LOS; 12 vs. 7 days; p < 0.001), greater median Injury Severity Score (ISS; 20 vs. 9; p < 0.001), and greater relative risk (RR) of ISS >15 (RR = 3.2; p < 0.001). Patients with operative spine injuries had significantly longer median intensive care unit (ICU) LOS than patients with non-operative spine injuries (4 vs. 2 days; p < 0.001). Patients with spinal cord injuries and ISS >15 sustained falls from a higher distance (median 6.1 vs. 5.5 m) and had a longer length of ICU stay (median 3 vs. 0 days). All patients with operative spine injuries had an ISS >15 relative to 50% of patients with non-operative spine injuries (median ISS 20 vs. 15; p < 0.001). Patients with spine trauma requiring surgery had a higher incidence of head (RR = 3.5; p 0.0353) and chest injuries (RR = 6.0; p = 0.0238), but a lower incidence of lower extremity injuries (RR = 0.5; p < 0.001). Thoracolumbar injuries occurred in 68.4% of all patients with spine injuries. Patients with operative spine injuries had a higher incidence of burst fracture (RR = 15.5; p < 0.001) and flexion-distraction injury (RR = 25.7; p = 0.0257). All patients with non-operative spine injuries had American Spinal Injury Association (ASIA) D or E presentations, and patients with operative spine injuries had a higher incidence of spinal cord injury: ASIA D or lower at time of presentation (RR = 6.3; p < 0.001). Falls from walls in border crossings result in significant injuries to the head, spine, long bones, and body, resulting in polytrauma casualties. Falls from higher height were associated with a higher frequency and severity of spinal injuries, greater ISS, and longer ICU length of stay. Operative spine injuries, compared with non-operative spine injuries, had longer ICU length of stay, greater ISS, and different fracture morphology. Spine surgeons and neurocritical care teams should be prepared to care for injuries associated with falls from height in this unique population.

Primary Repair versus Reverse End-to-Side Coaptation by Anterior Interosseous Nerve Transfer in Proximal Ulnar Nerve Injuries.

BACKGROUND: Proximal ulnar nerve lacerations are challenging to treat because of the complex integration of sensory and motor function in the hand. The purpose of this study was to compare primary repair and primary repair plus anterior interosseous nerve (AIN) reverse end-to-side (RETS) coaptation in the setting of proximal ulnar nerve injuries. METHODS: A prospective cohort study was performed of all patients at a single, academic, level I trauma center from 2014 to 2018 presenting with isolated complete ulnar nerve lacerations. Patients underwent either primary repair (PR) only or primary repair and AIN RETS (PR + RETS). Data collected included demographic information; quick Disabilities of the Arm, Shoulder and Hand questionnaire score; Medical Research Council score; grip and pinch strength; and visual analogue scale pain scores at 6 and 12 months postoperatively. RESULTS: Sixty patients were included in the study: 28 in the PR group and 32 in the RETS + PR group. There was no difference in demographic variables or location of injury between the two groups. Average quick Disabilities of the Arm, Shoulder and Hand questionnaire scores for the PR and PR + RETS groups were 65 ± 6 and 36 ± 4 at 6 months and 46 ± 4 and 24 ± 3 at 12 months postoperatively, respectively, and were significantly lower in the PR + RETS group at both points. Average grip and pinch strength were significantly greater for the PR + RETS group at 6 and 12 months. CONCLUSION: This study demonstrated that primary repair of proximal ulnar nerve injuries plus AIN RETS coaptation yielded superior strength and improved upper extremity function when compared with PR alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Correction of Cubitus Varus Using Computer-Assisted Hexapod Multiplanar External Fixators: A Report of 3 Cases.

CASE: Three male patients, 8-, 13-, and 18-year-old, all developed posttraumatic cubitus varus elbow deformity after distal humerus supracondylar fractures. Each underwent a distal humerus osteotomy with application of a hexapod external fixator to gradually correct the deformity. CONCLUSION: In patients with cubitus varus malunion, the stability of the hexapod external fixation, percutaneous nature of the osteotomy, and availability of running a residual computer-assisted program provides a consistent technique for deformity correction.

Common Finger Injuries: Treatment Guidelines for Emergency and Primary Care Providers.

INTRODUCTION: Finger and hand injuries are among the most common musculoskeletal conditions presenting to emergency departments and primary care providers. Many rural and community hospitals may not have immediate access to an orthopedic surgeon on-site. Furthermore, military treatment facilities, both within the continental United States and in austere deployment environments, face similar challenges. Therefore, knowing how to treat basic finger and hand injuries is paramount for patient care. MATERIALS AND METHODS: The Armed Forces Health Surveillance Branch operates the Defense Medical Surveillance System, a database that serves as the central repository of medical surveillance data for the armed forces. The Defense Medical Surveillance System was queried for ICD-10 codes associated with finger injuries from 2015 to 2019 among active duty service members across the major branches of the military. RESULTS: The most commonly reported finger injuries were open wounds to fingers without damage to nails, metacarpal fractures, phalanx fractures, and finger subluxation/dislocation. Emergency departments were the most commonly reported treatment facility type accounting for 35% of initial finger injuries, followed by 32.2% at orthopedic surgery clinics, 22.2% at family medicine clinics, and 10.8% at urgent care centers. CONCLUSIONS: Finger injuries are common in the military setting and presenting directly to an orthopedic surgeon does not appear the norm. Fingertip injuries, fractures within the hand, and finger dislocations can often be managed without the need for a subspecialist. By following simple guidelines with attention to "red flags," primary care providers can manage most of these injuries with short-term follow-up with orthopedics.

Injuries Sustained With Falls From Height in Crossing the United States-Mexico Border at a Level I Trauma Center: A Prospective Cohort Study.

INTRODUCTION: The US Department of Homeland Security has reported increases in encounters and apprehensions at the US Southwest border for the past several years. The purposes of this study were to assess the demographics, patterns of injuries, and surgical interventions, associated with falls from height along the US-Mexico border. METHODS: A prospective cohort study was conducted at a Level I trauma center from January 2016 through December 2021 of all patients who fell from height crossing the US-Mexico border and presented with injuries requiring admission. RESULTS: A total of 448 patients were admitted with a median age of 30 years (interquartile range [IQR] 16, range 6 to 65). Monthly frequency of admissions increased markedly with a median of 18.5 (IQR 5.3) in 2021. Patients presented with limited health data, and comorbidities were identified in 111 patients (24.7%). Median height fallen was 5.5 m (18 ft). Patients sustaining a fall from ≥ 5.5 m were markedly more likely to have an Injury Severity Score (ISS) of > 15. Median length of stay was 9 days (IQR 11). There were a total of 1,066 injuries with 723 extremity and pelvic; 236 spine; and 107 head or neck, face, thorax, or abdominal injuries. Median ISS was 9.0 (IQR 7, range 1 to 75, 33% > 15). Tibial plafond fracture and spine injury were markedly associated with longer lengths of stay and ISS > 15. All injuries resulted in 635 separate surgical events and 930 procedures. Clinical follow-up occurred in 55 patients (12.2%), with median duration of 28 days (range 6 days to 8 months). DISCUSSION: Injuries associated with border crossings and falls from height were serious and increased in frequency. As the US policy on border security evolves, surgeons in these regions should be prepared to handle the associated injuries and sequelae. Prevention of these serious and debilitating injuries should be undertaken to decrease the burden of disease.

Acromial Morphology Does Not Correlate with Age at Time of Rotator Cuff Tear: A Cross-Sectional Study.

Background: The purpose of this study was to determine if scapular anatomy differs between younger and older patients with atraumatic full-thickness supraspinatus tears. Methods: The critical shoulder angle, acromial index and lateral acromial angle were measured on standardized radiographs of two groups of patients who underwent arthroscopic repair of full-thickness degenerative supraspinatus tears. Group 1 included 61 patients under the age of 50 years while Group 2 included 45 patients over the age of 70 years. The mean critical shoulder angle, acromial index, and lateral acromial angle were then compared. Results: There was no significant difference between groups for the critical shoulder angle (p = .433), acromial index (p = .881) or lateral acromial angle (p = .263). Interobserver reliability for critical shoulder angle, acromial index, and lateral acromial angle was nearly perfect (interclass correlation coefficient 0.996, 0.996, 0.998, respectively). No significant correlation existed between age and critical shoulder angle (p = .309), acromial index (p = .484) or lateral acromial angle (p = .685). Discussion: While the critical shoulder angle and acromial index were found to be high and in the typical range for patients with rotator cuff tears in both groups, there were no significant differences in acromial morphology between Groups 1 and 2.

Traumatic Finger Amputation in the U.S. Military.

INTRODUCTION: Finger amputations can lead to loss of work time and suboptimal function, particularly in the active duty military. There is a paucity of epidemiologic and outcome data for these injuries. The purposes of this study are to define key demographic data pertaining to transphalangeal finger amputations in the U.S. Military and to assess epidemiological data to define risk factors for medical readiness following finger injuries. MATERIALS AND METHODS: This was a retrospective review of the military electronic medical record of encounters between 2016 and 2019 with traumatic transphalangeal amputation ICD 10 codes S68.5 (thumb) and S68.6 (finger). Primary outcomes included median military occupational activity limitation length, ability to return to duty, and medical separation from the military. RESULTS: A total of 235 patients were included in the final dataset. 221 (94.0%) of these service members were able to return to full duty, although 14 (6.0%) underwent medical separation from the military because of their finger injuries. The median limited duty timeline was 6 weeks. Significant risk factors identified that led to increased rates of medical separation were the use of tobacco (odds ratio [OR] of 5.53, 95% CI 1.21-25.29), junior enlisted status (OR of 5.51, 95% CI 1.67-18.17), and thumb or index finger involvement (OR of 3.50, 95% CI 1.13-10.83). CONCLUSIONS: Within a physically high-demand population, traumatic finger amputation can limit duties and may lead to medical separation from service. Traumatic finger amputations are common and often require 6 weeks of restricted short-term disability, particularly in a tobacco-using, young, physically active cohort.

Pharmacologic Treatments in Upper Extremity Complex Regional Pain Syndrome: A Review and Analysis of Quality of Evidence.

BACKGROUND: The purpose of this study was to assess the quality of evidence informing on common pharmacologic modalities used in upper extremity complex regional pain syndrome (CRPS). METHODS: A literature search was performed for primary prospective trials that reported on the pharmacologic treatment of CRPS type I and II specific to the upper extremity. Thirty-one trials were included and evaluated by 2 independent reviewers according to the Oxford Levels of Evidence (LOE), modified Coleman Methodology Score, and the revised Consolidated Standards of Reporting Trials (CONSORT) score. Cohen's kappa coefficient was calculated to measure interrater reliability. RESULTS: Twenty-two Oxford LOE I and 9 level II trials met the inclusion criteria. Overall, there was high interrater reliability in the Oxford LOE (100% agreement), modified Coleman Methodology Score (87% agreement), and CONSORT score (94% agreement). The pharmacologic interventions with the highest quality of evidence supporting use in treatment of upper extremity CRPS were bisphosphonates and ketamine. Interventions that lack high-quality evidence are tricyclic antidepressants (TCAs) and topical dimethyl sulfoxide (DMSO). Pharmacologic agents that remain inconclusive are calcitonin, gabapentin, mycophenolate, probiotics, steroids, nonsteroidal anti-inflammatory drugs, vitamin C, and N-acetylcysteine. Agents with limited benefit are mannitol, isosorbide dinitrate, guanethidine, and morphine. CONCLUSIONS: Based on the evidence evaluated in this study, bisphosphonates should be considered as a first-line medication in the treatment of CRPS. In patients presenting with chronic or refractory CRPS, strong consideration should be given for the use of ketamine. Adjunct treatment in the acute setting should include TCAs and/or topical DMSO.

Ten-Year Trends in Level of Evidence in Hand Surgery.

BACKGROUND: The purposes of this study were to analyze the trends in Oxford level of evidence (LOE), LOE of most-cited articles, and association between LOE and journal impact factor (IF) and SCImago Journal Rank (SJR) over a 10-year period (2009-2018) in 3 prominent hand surgery journals, specifically HAND, Journal of Hand Surgery (American Volume) (JHS), and Journal of Hand Surgery (European Volume) (JHSE). METHODS: All articles published from 2009 to 2018 in HAND, JHS, and JHSE were reviewed for assigned or available LOE. Data were pooled and analyzed for trends in LOE; relationship among IF, SJR, and LOE; and citation density. RESULTS: A total of 3921 total publications were tabulated from 2009 to 2018, with the majority of studies being level V (1700, 43%) and fewer studies being level I (146, 4%). Over the 10-year study period, there was no significant change in frequency of level I studies for any journal. HAND trended significantly toward higher LOE, JHS trended toward higher LOE, and JHSE trended toward decreased LOE without significance. Among all journals, the annual number of articles and the average LOE were independent significant predictors of IF and SJR. Statistically significant correlations were found between citation density and LOE for JHS and HAND. CONCLUSIONS: Higher quality evidence is becoming more prevalent in the hand surgery literature over the past 10 years. Annual articles, average LOE, and level I and II and level IV articles were significant predictors of increasing IF and SJR.

Qualitative analysis of randomized controlled trials informing recommendations for venous thromboembolism prophylaxis after distal lower extremity injuries.

Purpose: The purpose of this study is to assess the quality of evidence to stratify recommendations for chemoprophylaxis following distal lower extremity trauma. Methods: Literature review identified primary studies investigating venous thromboembolism (VTE) chemoprophylaxis following traumatic injury distal to the knee. Inclusion criteria were randomized controlled trials in adult patients treated with and without operative intervention. Each primary study was assessed by the Consolidated Standards of Reporting Trials 2010 checklist and Modified Coleman methodology score. Results: Literature review resulted in 462 studies, of which 9 met inclusion and exclusion criteria. All studies included low molecular weight heparin as a treatment group with 2 (22%) also including a treatment group with a direct factor Xa inhibitor. Five studies (56%) used placebo as a control group. The mean Modified Coleman Methodology score was 63% (range 51%-72%), a categorical rating of Fair. The mean Consolidated Standards of Reporting Trials score was 78% (range 56%-97%). Most studies (89%) screened all asymptomatic subjects for deep venous thrombosis. Statistical significance in VTE incidence among prophylactic treatment groups was not achieved in 78%. Conclusions: Development of consensus for VTE prophylaxis recommendations following traumatic injury distal to the knee is complicated by heterogenous study populations, low incidence of VTE in study populations, and inconsistent definitions of clinically important VTE. Low molecular weight heparin is not consistently superior for preventing VTE. Chemoprophylaxis should be considered on an individual basis in the presence of additional risk factors, although an externally validated, evidence-based risk assessment tool does not currently exist.Level of Evidence: IV, therapeutic.

Bone Morphogenetic Protein in Scaphoid Nonunion: A Systematic Review.

Background Scaphoid nonunion can lead to carpal collapse and osteoarthritis, a painfully debilitating problem. Bone morphogenetic protein (BMP) has been successfully implemented to augment bone healing in other circumstances, but its use in scaphoid nonunion has yielded conflicting results. Case Description The purpose of this study is to assess the outcomes and complications of scaphoid nonunion treated surgically with BMP. Literature Review A literature review of all available journal articles citing the use of BMP in scaphoid nonunion surgery from 2002 to 2019 was conducted. We included studies that used BMP as an adjunct to surgical treatment for scaphoid nonunions in both the primary and revision settings with computed tomography determination of union. Demographic information, dose of BMP, tobacco use, outcomes, and complications were recorded. A total of 21 cases were included from four different studies meeting inclusion criteria. Clinical Relevance The union rates were 90.5% overall, 100% for primary surgeries, and 77.8% for revision surgeries. Five patients (24%) experienced 11 complications, including four cases (19%) of heterotrophic ossification. Use of BMP in scaphoid nonunion surgery resulted in a 90.5% overall union rate but was also associated with complications such as heterotopic ossification. All included studies used BMP to augment bone graft, screw or wire fixation, or a combination of methods. The efficacy of BMP in scaphoid nonunion is unclear, and a sufficiently powered, randomized controlled trial is needed to determine optimal fixation methods, dosing, and morbidity of the use of BMP. Level of Evidence This is a Level IC, therapeutic interventional study.

Hypothenar Hammer Syndrome in an Elderly Caucasian Female: A Case Report.

Hypothenar hammer syndrome (HHS) is a vascular disorder characterized by ulnar artery thrombosis or aneurysmal formation. It is most commonly reported in middle-aged males who suffer from repetitive trauma to the palm secondary to occupational or recreational activities. Most cases of HHS can be managed conservatively; however, surgical management is typically indicated for persistent symptoms following conservative measures, imminent vascular compromise, those who fail conservative treatment, or those in imminent danger of rupture. Here we present the case of a right-handed 74-year-old female with HHS who presented with a three-week history of a mass in the hypothenar eminence of the left hand. Reportedly, the mass had appeared slowly and had no associated pain, ischemia of the distal hand, numbness, paresthesia, or changes in the overlying skin. She denied any history of a blunt or penetrating hand injury. The patient was treated surgically by removing a 2.0-cm thrombosed pseudoaneurysm of a collateral branch of the ulnar artery within the left hypothenar eminence. On follow-ups at 1, 2, and 12 weeks postoperatively, the patient's pain was found to be well-controlled. Her normal range of motion was restored, and her digits remained neurovascularly intact. This was an atypical presentation of HHS, and our review of the disorder emphasizes the importance of diagnostic reasoning in rare conditions with unusual presentations of HHS.

Bilateral Congenital Absence of Small Finger Flexor Digitorum Superficialis Tendons in a Trauma Patient.

The flexor digitorum superficialis (FDS) is the only muscle in the intermediate layer of the flexor compartment of the forearm. Its main function is flexion of the proximal interphalangeal (IP) joint. Variations of the FDS are common, and knowledge of these variations is necessary for hand surgeons because the little finger tendon of the FDS is commonly used in hand reconstruction surgery. Here we present a case of bilateral absence of the little finger tendon of the FDS in an 11-year-old Hispanic female trauma patient presenting to the Emergency Department with multiple traumatic injuries including bilateral hand lacerations sustained in a motor vehicle accident. On physical examination, flexion of the IP joint of the thumb, and metacarpal phalangeal, proximal IP, and distal IP joints of the little finger were absent bilaterally. In the operating theater, the lacerations were extended to evaluate the status of the tendons of the FDS and flexor digitorum profundus (FDP). On the right, a complete transection of the FDP tendons to the ring and little fingers were found and repaired. Upon further exploration, the FDS tendon to the ring finger was identified and repaired, whereas the little finger tendon was found to be absent. On the left, the FPL tendon was identified and repaired along with the FDP tendon to the little finger. The FDS was subsequently identified and found to be lacking the tendon to the little finger. Clinically, the absence of the FDS could lead to problems in hand reconstruction surgery and functional testing of the hand.