Increasing Severity of Radial Longitudinal Deficiency Correlates With the Degree of Proximal Ulnar Hypoplasia.

PURPOSE: Classification systems and treatment for children with radial longitudinal deficiency are classically focused on the hand and wrist. However, the elbow can affect the function of these patients secondary to stiffness or instability. The objective of this study was to determine if a correlation exists between severity of radial longitudinal deficiency (RLD) and degree of proximal ulnar hypoplasia. METHODS: A single-institution retrospective review was performed at a pediatric hospital. One hundred elbows were identified in 72 patients who met the inclusion criteria. Measurements such as the coronoid height, olecranon coronoid angle (OCA), and the anterior coverage index were obtained from lateral radiographs of children with RLD. Ten elbows had posterior subluxation of the ulnohumeral joint radiographically. Eleven patients had thrombocytopenia absent radius (TAR) syndrome. RESULTS: There was a significant mean difference for OCA between RLD types. Type 4 RLD (mean [M] = 17.9; standard deviation [SD] = 11.3) had a significantly lower OCA than type 0 (M = 26.4; SD = 5.9) and type 1 (M = 31.0; SD = 5.0). A subanalysis of the 58 elbows with type 4 RLD demonstrated that those with TAR (n = 11) had significantly higher anterior coverage index total scores (M = 1.7; SD = 0.3) than those with type 4 without TAR (M = 1.5; SD = 0.2). CONCLUSIONS: The degree of proximal ulnar hypoplasia is correlated with increasing severity of RLD, with significantly lower OCA and coronoid height observed in the elbow radiographs of patients with type 4 RLD compared with type 0 and type 1. Children with TAR have less proximal ulnar dysplasia and higher anterior coverage index than children with type 4 RLD without associated TAR. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Surgical Trends in the Treatment of Supracondylar Humerus Fractures in Early Career Practice: An American Board of Orthopaedic Surgery (ABOS) Part-II Database Study.

BACKGROUND: Pediatric supracondylar humerus fractures are the most common elbow injury in children, accounting for 12% to 17% of all childhood fractures. A lack of information exists regarding complication rates on the basis of fellowship status and geography. METHODS: The American Board of Orthopaedic Surgery (ABOS) Part-II database was used to identify candidates who performed either percutaneous or open treatment of humeral supracondylar or transcondylar fractures between 2002 and 2016 on patients aged 0 to 12 years. Candidates were categorized by fellowship training experience. Information analyzed included fellowship status, surgical procedure, complications, and geographic location of treatment. Data were analyzed utilizing the χ and Fischer exact tests and were considered significant if P≤0.05. RESULTS: A total of 9169 cases (mean, 5.36+2.27 y; range, 0 to 12) were identified between 2002 and 2016, 8615 of which were treated with closed reduction and percutaneous pinning, whereas 554 were treated with an open procedure. The 5 most common fellowships treating these fractures were listed as pediatrics (4106), sports medicine (1004), none (912), trauma (732), and hand/upper extremity (543). Pediatrics performed the highest number of open reduction and internal fixation (ORIF), however, reported the statistically lowest percentage of ORIF. A statistically significant difference was identified between surgical complication rates and fellowship specialties, with pediatrics having the lowest complication rate (7.0%), followed by no fellowship (8.2%), trauma (9.0%), sports medicine (9.8%), and hand/upper extremity (11.2%) (P<0.001). This significant difference was also present when analyzing closed reduction and percutaneous pinning alone (P=0.002), however, not with the analysis of ORIF. CONCLUSIONS: Early career pediatric fellowship-trained orthopaedic surgeons are more likely to treat pediatric supracondylar humerus fractures. Overall, although they treat more patients with ORIF than any other group, their percentage treated with ORIF is statistically the lowest. A significant difference in reported complication rates was found to be associated with specific fellowship training, with pediatric fellowship-trained surgeons having the fewest complications and foot/ankle fellowship-trained surgeons associated with the highest rate of reported surgical complications. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes.

BACKGROUND: Triangular fibrocartilage complex (TFCC) tears have been treated with increasing frequency in pediatric and adolescent patients over the past decade. There is little information on these injuries in young athletes and a scarcity of data regarding their ability to return to preinjury levels of athletic participation. The purpose of this study was to review the outcomes of pediatric and adolescent athletes with operatively treated TFCC tears with or without a concurrent ulnar shortening osteotomy and to determine their ability to return to their preoperative level of activity. METHODS: A retrospective chart review was performed for all patients who underwent operative treatment of TFCC tears between 2006 and 2012 within one Upper Extremity practice. Patients were included if they were high-level athletes, unable to participate in their sport secondary to wrist pain and desired to return to their sport. All operative patients had imaging studies and clinical findings consistent with TFCC injury as the primary source of their activity-limiting pain and had failed nonoperative management prior to surgery. Patients without at least 3 months of documented postoperative follow up were excluded. RESULTS: In total, 22 patients were included in the chart review with 20 patients willing to participate in a telephone survey and PODCI. Eighty percent of patients returned to their sport following operative treatment of their injury at an average of 4.8 months. Seven of the 22 patients underwent a concurrent ulnar shortening osteotomy for ulnar positive variance. All 20 patients reported satisfaction with the outcomes of their surgery and treatment. CONCLUSIONS: Operative treatment of TFCC injuries in adolescent and pediatric athletes after failure of conservative treatment allowed return to sport at the previous level of participation. Concurrent ulnar shortening osteotomy in the setting of ulnar positive variance did not prohibit return to high-level athletic participation. LEVEL OF EVIDENCE: Level IV.

The Limited Utility of Routine Pathologic Examination of Ganglion Cyst Excision From the Hand and Digits.

BACKGROUND: It is routine practice at many institutions to send surgically excised ganglion cysts for pathologic analysis. This adds significant cost to the procedure with questionable benefit. The purpose of this study was to determine the necessity of routine pathologic examination of ganglion cysts excised from the hand. METHODS: We conducted a retrospective review of 443 patients who underwent ganglion excision from the hand with routine pathologic examination between 2012 and 2022. The final pathologic diagnosis was compared with the treating surgeon's clinical diagnosis, and the rates of concordant, discrepant, and discordant diagnoses were identified. Discrepant diagnoses were defined as differing clinical and pathologic diagnoses that did not change clinical management. Discordant diagnoses were defined as differing clinical and pathologic diagnoses that altered the treatment plan. RESULTS: The prevalence of a concordant diagnosis was 96.2% (426 of 443; 95% confidence interval, 94.4%-98.0%). The prevalence of a discrepant diagnosis was 3.8% (17 of 443; 95% confidence interval, 2.1%-5.6%), and the prevalence of a discordant diagnosis was 0. The odds ratio was 0.04 for a discrepant diagnosis and 0 for a discordant diagnosis. CONCLUSIONS: Our study suggests abandoning routine pathologic analysis in patients undergoing ganglion cyst excision from the hand will not compromise quality of care when the surgeon is able to make a confident diagnosis. Discrepant diagnoses were rare and discordant diagnoses that did not occur. We recommend pathologic evaluation only when there is uncertainty in the clinical diagnosis.

Describing the women of orthopaedic surgery.

Aims: The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery. Methods: An electronic survey was conducted of practising female orthopaedic surgeons based in the USA through both the Ruth Jackson Society and the online Facebook group "Women of Orthopaedics". Results: The majority of surveyed female orthopaedic surgeons reported being married (76.4%; 285/373) and having children (67.6%; 252/373). In all, 66.5% (247/373) were collegiate athletes; 82.0% (306/373) reported having no female orthopaedic surgeon mentors in undergraduate and medical school. Their mean height is 65.8 inches and average weight is 147.3 lbs. Conclusion: The majority of female orthopaedic surgeons did not have female mentorship during their training. Additionally, biometrically, their build is similar to that of the average American woman.

Challenges for Women in Hand Surgery: Our Perspective.

Over recent decades, the prevalence of women in surgical subspecialties has increased. There has been a significant rise in the percentage of women entering integrated plastic surgery programs and an increase, albeit smaller, in women entering orthopedic surgery training programs. Although female membership in the American Society for Surgery of the Hand has steadily increased, women remain in the vast minority within this professional society and many others within the field of hand surgery. In addition to underrepresentation in positions of leadership, women face challenges such as imposter syndrome, bullying, unfavorable work structure for work-family balance, macro and micro-aggressions, and lack of mentors at a higher rate than their male colleagues. As awareness rises of the additional challenges that women in hand surgery face, we must directly address them to improve equity within our subspecialty.

Treatment Trends in Pediatric Trigger Thumb Among Hand Surgeons, Pediatric Orthopedic Surgeons, and Pediatric Hand Surgeons.

BACKGROUND: The appropriate initial management of pediatric trigger thumb (PTT) remains controversial. Some providers advocate for prolonged nonoperative management, whereas others may offer surgical release to provide a reliable and expedient resolution. The goal of this study was to elucidate the practice patterns of surgeons with different fellowship training who treat patients with PTT. We hypothesized that an association between surgeon specialty training and treatment algorithm would be identified. METHODS: A cross-sectional survey was sent to mailing lists of 3 professional organizations whose members represent most providers caring for pediatric hand patients. Respondents were asked their training background and treatment recommendations for several clinical scenarios. Responses were compared across subspecialties. RESULTS: Of the respondents, 444 completed a fellowship in hand surgery, 167 completed a pediatric orthopedic fellowship, and 155 completed an additional congenital hand fellowship. Providers with hand fellowship training were more likely to offer surgical intervention as a first-line treatment for a 3-year-old patient with a flexible trigger thumb than those who completed a pediatric orthopedic fellowship (P = .001), and more likely to offer surgical intervention to a 3-year-old patient with an intermittent (P = .007), painful (P = .015), or locked (P = .012) trigger thumb than those providers who completed additional training in congenital hand surgery. No statistically significant differences in practice patterns were appreciated for children aged 6 and 18 months. CONCLUSION: Variability was appreciated in practice patterns for initial treatment recommendation for a patient presenting with PTT. Subspecialty training does appear to affect treatment recommendations for clinical scenarios involving a 3-year-old patient with PTT, although this trend is not observed when treating younger patients.

Vascularized pedicle bone grafting for nonunions of the tarsal navicular.

BACKGROUND: Osteonecrosis and nonunions of the tarsal navicular remain a challenging clinical problem. This article presents a series of patients treated with local vascularized pedicle bone grafting to the navicular. The purpose of this study was to determine the early clinical and radiographic outcomes of this technique. METHODS: Patients who underwent local vascularized pedicle bone grafting for osteonecrosis of the navicular from 2002 to 2007 were included in this study. The Ankle Osteoarthritis Scale (AOS), the Revised Foot Function Index (FFI-R), and the Short-Form 36 (SF-36) outcomes questionnaires were administered at most recent followup. Postoperative imaging was reviewed for evidence of healing. Eight patients with a mean age of 47.5 (range, 18 to 68) years were included in this study. The mean followup time was 61 (range, 32 to 72) months. RESULTS: Two patients underwent concomitant talonavicular arthrodesis. Two patients underwent additional procedures to address continued nonunion of the navicular. Neither patient elected to complete the outcomes questionnaires. The mean postoperative FFI score was 35.2 (range, 16.6 to 59). SF-36 subscales were as follows: bodily pain, 53; general health, 55; mental health, 75; physical function, 56; role emotional, 61; role physical, 37.5; social function, 71; and vitality, 56. The mean postoperative AOS pain score was 27.9 (range, 0 to 46.2) and the average disability score was 31.4 (range, 0 to 78.2). Postoperative imaging revealed consolidation and full healing in six of eight patients. CONCLUSION: Vascularized pedicle bone grafting is a treatment option for patients with chronic nonunion or osteonecrosis of the navicular. Additionally, it may serve as an adjunct procedure to provide increased vascularity to talonavicular arthrodesis in cases of navicular osteonecrosis and talonavicular arthritis.

Extremity Pressure in Splints Wrapped With an Elastic Bandage Versus Bias Cut Stockinette: An Experimental Model.

BACKGROUND: Many variables affect the pressure caused by splinting or casting. The purpose of this study was to compare pressure underlying a splint wrapped with either an elastic bandage or a bias cut stockinette. METHODS: Thirty-two plaster volar resting splints were applied to a simulated extremity with a saline bag secured to it. A pressure transducer was connected to the saline bag to monitor changes in pressure once splints were applied, and 15 mL increments of saline were added to the bag to simulate swelling. Each dressing type was tested with normal application and tight application. RESULTS: Normal application splints wrapped with either bias cut stockinette or an elastic bandage demonstrated similar initial splint pressures (P = .81). With simulated swelling, splints wrapped with bias cut stockinette demonstrated a 15 mmHg (95% confidence interval [CI], 1.5-28.5) higher average pressure than those wrapped with an elastic bandage (P = .035). Tight application splints with an elastic bandage wrap demonstrated a 46 mmHg (95% CI, 16-77) higher initial splint pressure than those wrapped with bias cut stockinette (P = .009). CONCLUSIONS: Splints wrapped using either an elastic bandage or bias cut stockinette appear to have a similar safety profile, although in cases of excessive swelling, an elastic bandage may provide additional compliance. Tight splint application appears to be more hazardous with the use of an elastic bandage compared with a bias cut stockinette. Further study of the use of elastic bandages and bias cut stockinettes in the clinical setting may be warranted.

Management of Monteggia Injuries in the Pediatric Patient.

Monteggia fracture-dislocations in the pediatric population have unique patterns of injury that require distinct considerations in diagnosis and management. When appropriately diagnosed and treated early, acute pediatric Monteggia injuries have favorable outcomes. Missed or inadequately treated injuries result in chronic Monteggia lesions that require more complex surgical reconstructions and are associated with less predictable outcomes. This article reviews the classification, diagnosis, and treatment of acute and chronic pediatric Monteggia injuries as well as the controversies there in.

Surgical treatment of upper extremity contractures in Emery-Dreifuss muscular dystrophy.

Emery-Dreifuss muscular dystrophy is a rare form of muscular dystrophy. In the present study we present two patients with Emery-Dreifuss muscular dystrophy and severe upper extremity contractures treated successfully with contracture release and musculotendinous lengthenings. For each of these patients a chart review was carried out and surgical technique reviewed. Patient 1 demonstrated elbow flexion contractures of 65° (right) and 60° (left) preoperatively and ∼45° (right) and 20° (left) postoperatively. Patient 2 demonstrated flexion contractures of 75° bilaterally preoperatively and 45° bilaterally postoperatively. For more severe elbow contractures, surgical treatment resulted in improved range of motion without a significant sacrifice of strength, allowing these patients to remain independent.