Racial Disparities in Surgical Versus Nonsurgical Management of Distal Radius Fractures in a Medicare Population.

BACKGROUND: As racial/ethnic disparities in management of distal radius fractures (DRFs) have not been well elucidated in the literature, this study sought to evaluate the correlation of race/ethnicity on surgical versus nonsurgical management of DRFs in a Medicare population. METHODS: The PearlDiver Standard Analytical Files Medicare claims database was used to identify patients ≥65 years old with isolated DRF. Patients with polytrauma or surgery performed for upper extremity neoplasm were excluded. Surgical versus nonsurgical management was compared based on demographics, comorbidity (Elixhauser Comorbidity Index, ECI), race/ethnicity, and whether the fracture was open or closed. Univariate and multivariable analyses were used to assess for independent predictors. RESULTS: Of 54 564 isolated DRFs identified, surgery was performed for 20 663 (37.9%). On multivariable analysis, patients were independently less likely to receive surgical management if they were: older (relative to 65- to 69-year-olds, incrementally decreasing by age bracket up to >85 years where odds ratio [OR] was 0.27, P < .001), higher ECI (per 2 increase OR: 0.96, P < .001), and closed fractures (OR: 0.35, P < .001). For race/ethnicity: black (OR: 0.64, P < .001), Hispanic (OR: 0.71, P < .001), and Asian (OR: 0.60, P < .001) patients were less likely to undergo surgery. CONCLUSIONS: While age, comorbidities, and fracture type are known to affect surgical decision-making for DRF, race/ethnicity has not previously been reported, and its independent prediction of nonsurgical management for several groups points to a disparity in surgical decision-making/access to care. This highlights the need for increased attention to initiatives that seek to provide equitable care to all patients. LEVEL OF EVIDENCE: Level III-Retrospective review of national database.

Tumors of the brachial plexus region: A 15-year experience with emphasis on motor and pain outcomes and literature review.

Background: Brachial plexus region tumors are rare. In this study, we reviewed our experience with resection of tumors involving or adjacent to the brachial plexus to identify patterns in presentation and outcome. Methods: We report a retrospective case series of brachial plexus tumors operated on by a single surgeon at a single institution over 15 years. Outcome data were recorded from the most recent follow-up office visit. Findings were compared to a prior internal series and comparable series in the literature. Results: From 2001 to 2016, 103 consecutive brachial plexus tumors in 98 patients met inclusion criteria. Ninety percent of patients presented with a palpable mass, and 81% had deficits in sensation, motor function, or both. Mean follow-up time was 10 months. Serious complications were infrequent. For patients with a preoperative motor deficit, the rate of postoperative motor decline was 10%. For patients without a preoperative motor deficit, the rate of postoperative motor decline was 35%, which decreased to 27% at 6 months. There were no differences in motor outcome based on extent of resection, tumor pathology, or age. Conclusion: We present one of the largest recent series of tumors of the brachial plexus region. Although the rate of worsened postoperative motor function was higher in those without preoperative weakness, the motor deficit improves over time and is no worse than antigravity strength in the majority of cases. Our findings help guide patient counseling in regard to postoperative motor function.

Comparing Race/Ethnicity and Zip Code Socioeconomic Status for Surgical versus Nonsurgical Management of Proximal Humerus Fractures in a Medicare Population.

BACKGROUND: This study evaluated the effect of race/ethnicity and socioeconomic status (SES) on surgical utilization after proximal humerus fractures in a large Medicare cohort. METHODS: The PearlDiver Medicare claims database was used to identify patients aged 65years and older with isolated, closed proximal humerus fractures, for whom race/ethnicity data were available (65.5% of identified fractures). Patients with polytrauma or neoplasm were excluded. Patient demographic, race/ethnicity, comorbidity, and median household income were compared for surgical versus nonsurgical management. Univariate and multivariable logistic regressions were used to determine disparities of surgical utilization based on the abovementioned factors. RESULTS: Of 133,218 patients with proximal humerus fracture identified, surgery was conducted for 4446 (3.3%). Those less likely to receive surgery were older (incrementally by increasing age bracket up to 85 years and older odds ratio [OR], 0.16, P < 0.001), male (OR, 0.79, P < 0.001), Black (OR, 0.51, P < 0.001) or Hispanic (0.61, P = 0.005), higher Elixhauser Comorbidity Index (per 2 increase OR, 0.86, P < 0.001), and low median household income (OR, 0.79, P < 0.001). CONCLUSIONS: The independent significance of race/ethnicity and SES point to disparities in surgical decision making/access to care. These findings highlight the need for increased attention on initiatives and policies that seek to eliminate racial disparities and improve health equity independent of SES.

Acute forearm compartment syndrome in the setting of acquired hemophilia A.

Patients with acquired or congenital hemophilia are at risk for Acute Compartment Syndrome (ACS) and pose a diagnostic challenge and a treatment risk with post-fasciotomy hemostasis of critical importance. We present the case of a woman with ACS of the forearm in the setting of newly diagnosed acquired hemophilia A.

Modification and application of the proximal humerus ossification system to adolescent idiopathic scoliosis patients.

PURPOSE: We have previously demonstrated that proximal humeral ossification patterns are reliable for assessing peak height velocity in growing patients. Here, we sought to modify the system by including medial physeal closure and evaluate whether this system combined with the Cobb angle correlates with progression to surgery in patients with adolescent idiopathic scoliosis. METHODS: We reviewed 616 radiographs from 79 children in a historical collection to integrate closure of the medial physis into novel stages 3A and 3B. We then analyzed radiographs from the initial presentation of 202 patients with adolescent idiopathic scoliosis who had either undergone surgery or completed monitoring at skeletal maturity. Summary statistics for the percentage of patients who progressed to the surgical range were calculated for each category of humerus and Cobb angle. RESULTS: The intra-observer and inter-observer ICC for assessment of the medial physis was 0.6 and 0.8, respectively. Only 3.4% of radiographs were unable to be assessed for medial humerus closure. The medial humerus physis begins to close about 1 year prior to the lateral physis and patients with a closing medial physis, but an open lateral physis were found to be the closest to PHV (0.7 years). Stratifying patients by Cobb angle and modified humerus stage yield categories with low and high risks of progression to the surgical range. CONCLUSION: The medial humerus can be accurately evaluated and integrated into a new modified proximal humerus ossification system. Patients with humerus stage 3A or below have a higher rate of progression to the surgical range than those with humerus stage 3B or above.

White matter changes linked to visual recovery after nerve decompression.

The relationship between the integrity of white matter tracts and cortical function in the human brain remains poorly understood. We investigate reversible white matter injury, in this case patients with compression of the optic chiasm by pituitary gland tumors, to study the structural and functional changes that attend spontaneous recovery of cortical function and visual abilities after surgical removal of the tumor and subsequent decompression of the nerves. We show that compression of the optic chiasm led to demyelination of the optic tracts, which reversed as quickly as 4 weeks after nerve decompression. Furthermore, variability across patients in the severity of demyelination in the optic tracts predicted visual ability and functional activity in early cortical visual areas. Preoperative measurements of myelination in the optic tracts predicted the magnitude of visual recovery after surgery. These data indicate that rapid regeneration of myelin in the human brain is a component of the normalization of cortical activity, and ultimately the recovery of sensory and cognitive function, after nerve decompression. More generally, our findings demonstrate the use of diffusion tensor imaging as an in vivo measure of myelination in the human brain.