A Comparison of Patient Characteristics and Outcomes Between Patients Receiving Flexor Digitorum Superficialis Slip Excision or Isolated A1 Pulley Release for Trigger Finger.

PURPOSE: Resection of the radial or ulnar slip of the flexor digitorum superficialis (FDS) tendon is a known treatment option for persistent trigger finger. Risk factors for undergoing FDS slip excision are unclear. We hypothesized that patients who underwent A1 pulley release with FDS slip excision secondary to persistent triggering would have a higher comorbidity burden compared to those receiving A1 pulley release alone. METHODS: We identified all adult patients who underwent A1 pulley release with FDS slip excision because of persistent triggering either intraoperatively or postoperatively from 2018 to 2023. We selected a 3:1 age- and sex-matched control group who underwent isolated A1 pulley release. Charts were retrospectively reviewed for demographics, selected comorbidities, trigger finger history, and postoperative course. We performed multivariable logistic regression to assess the probability of FDS slip excision after adjusting for several variables that were significant in bivariate comparisons. RESULTS: We identified 48 patients who underwent A1 pulley release with FDS slip excision and 144 controls. Our multivariable model showed that patients with additional trigger fingers and a preoperative proximal interphalangeal (PIP) joint contracture were significantly more likely to undergo FDS slip excision. CONCLUSIONS: Patients who underwent A1 pulley release with FDS slip excision were significantly more likely to have multiple trigger fingers or a preoperative PIP joint contracture. Clinicians should counsel patients with these risk factors regarding the potential for FDS slip excision in addition to A1 pulley release to alleviate triggering of the affected digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Interpreting Electrodiagnostic Studies for the Management of Nerve Injury.

Nerve injuries are common after trauma and can be life-altering for patients. Electrodiagnostic studies are the gold standard for diagnosing and prognosticating nerve injuries. However, most surgeons are not trained in the interpretation of these studies; rather, they rely on the interpretation provided by the electrodiagnostician, who in turn is unlikely to be trained in nerve reconstruction. This discrepancy between the interpretation of these studies and the management of nerve injuries can lead to suboptimal surgical planning and patient outcomes. This review aims to provide a framework for surgeons to take a more active role in collaborating with their colleagues in electrodiagnostic medicine in the interpretation of these studies, with an ultimate goal of improved patient care. The basics of nerve conduction studies, electromyography, and relevant terminology are reviewed. The relationship between the concepts of demyelination, axon loss, Wallerian degeneration, nerve regeneration, collateral sprouting, and clinical function are explained within the framework of the Seddon and Sunderland nerve injury classification system. The natural evolution of each degree of nerve injury over time is illustrated, and management strategies are suggested.

Accuracy in Screw Selection in a Cadaveric, Small-Bone Fracture Model.

PURPOSE: Using a cadaveric model simulating clinical situations experienced during open reduction and internal fixation of proximal phalangeal fractures, the aim of this study was to evaluate the relationship between level of training and the rates of short, long, and ideal screw length selection based on depth gauge use without fluoroscopy assistance. METHODS: A dorsal approach to the proximal phalanx was performed on the index, middle, and ring fingers of 4 cadaveric specimens, and 3 drill holes were placed in each phalanx. Volunteers at different levels of training then measured the drill holes with a depth gauge and selected appropriate screw sizes. The rates of short, long, and ideal screw selection were compared between groups based on level of training. Ideal screws were defined as a screw that reached the volar cortex but did not protrude more than 1 mm beyond it. RESULTS: Eighteen participants including 3 hand fellowship-trained attending physicians participated for a total of 648 selected screws. The overall rate of ideal screw selection was lower than expected at 49.2%. There was not a statistically significant relationship between rate of ideal screw selection and higher levels of training. Attending surgeons were less likely to place short screws and screws protruding 2 mm or more beyond the volar cortex CONCLUSIONS: Overall, the rate of ideal screw selection was lower than expected. The most experienced surgeons were less likely to place short and excessively long screws. CLINICAL RELEVANCE: Based on the low rate of ideal screws, the authors recommend against overreliance on depth gauging alone when placing screws during surgery. The low-rate ideal screw length selection highlights the potential for future research and development of more accurate technologies to be used in screw selection.

Pediatric Scaphoid Proximal Pole Nonunion With Avascular Necrosis.

A 13-year-old, right hand-dominant, otherwise healthy boy presented with left wrist pain 19 months after a nonmotorized scooter injury. Radiographs and magnetic resonance imaging at presentation demonstrated proximal pole scaphoid nonunion with avascular necrosis of the proximal fragment. Operative and nonsurgical treatment options were discussed and the family elected for an attempt at nonsurgical management. The patient was placed in a short-arm thumb spica cast, with a window for a bone stimulator, for 14 weeks. At the conclusion of the treatment, the pain had resolved and x-ray and computed tomography scan demonstrated bony union. The authors recommend considering an initial trial of nonsurgical management for treatment of all pediatric scaphoid nonunions.

Submuscular Versus Subcutaneous Ulnar Nerve Transposition: A Cadaveric Model Evaluating Their Role in Primary Ulnar Nerve Repair at the Elbow.

PURPOSE: To investigate the length gained from subcutaneous and submuscular transposition of the ulnar nerve at the elbow. Specifically, the study aimed to define an expected nerve gap able to be overcome, and to determine if a difference between transposition techniques exists. METHODS: Eleven cadaveric specimens from the scapula to fingertip were procured. In situ decompression and mobilization of the ulnar nerve at the elbow followed by simulated laceration of the nerve was performed. Nerves were marked 5 mm from the laceration site to facilitate overlap measurement and to simulate nerve end preparation to viable fascicles before primary coaptation. Nerve ends were attached to spring gauges set at 100 g of tension (strain ≤ 10%). Measurements of nerve overlap were obtained in varying degrees of wrist (0°, 30°, 60°) and elbow (0°, 15°, 30°, 45°, 60°, 90°) flexion. Measurements were performed after in situ decompression and mobilization, and then repeated after both subcutaneous and submuscular transposition. RESULTS: Ulnar nerve transposition was found to increase nerve overlap at an elbow flexion of 30° or greater. No difference was seen between subcutaneous and submuscular transpositions at all wrist and elbow positions. In situ decompression and mobilization alone provided an average of 3.5 cm of length gain with the elbow extended. Transposition in conjunction with clinically feasible wrist and elbow flexion (30° and 60°, respectively) provided 5.2 cm of length gain. Controlling for mobilization, a statistically significant increase in overlap of approximately 2 cm was gained from transposition. CONCLUSIONS: Although mobilization combined with wrist and elbow flexion may afford substantial gap reduction and should be used initially when approaching proximal ulnar nerve lacerations, transposition should be considered when faced with a large nerve gap greater than 3 cm at the elbow. No difference was seen between submuscular and subcutaneous transposition techniques. CLINICAL RELEVANCE: This study defines the extent an ulnar nerve gap at the elbow can be overcome by in situ mobilization, joint positioning, and transposition. It additionally compares the efficacy of submuscular and subcutaneous transposition techniques in closing this gap.

Effects of Hand Fellowship Training on Rates of Endoscopic and Open Carpal Tunnel Release.

PURPOSE: To investigate rates, trends, and complications for carpal tunnel release (CTR) related to fellowship training using the American Board of Orthopaedic Surgery Part II Database. METHODS: We searched the American Board of Orthopaedic Surgery database for patients with carpal tunnel syndrome who underwent either open carpal tunnel release (OCTR) or endoscopic (ECTR) from 2003 to 2013. Cases with multiple treatment codes were excluded. Data were gathered on geographic location, fellowship, and surgical outcomes. Data were then divided into 2 cohorts: hand fellowship trained versus non-hand fellowship trained. We performed analysis with chi-square tests of independence and for trend. RESULTS: Overall, 12.4% of all CTRs were done endoscopically. Hand fellowship-trained orthopedists performed about 4.5 times the number of ECTR than did non-hand fellowship-trained surgeons. An increasing trend over time of ECTR was seen only among the hand fellowship cohort. The northwest region of the United States had the highest incidence (23.1%) of ECTR, and the Southwest the lowest incidence (5.9%). The complication incidence associated with CTR overall was 3.6%, without a significant difference between ECTR and OCTR. Within the hand fellowship cohort the complication incidence for ECTR was significantly less than for OCTR. There was no difference in overall complication rates with ECTR and OCTR between the 2 cohorts. Wound complications were higher with OCTR (1.2% vs 0.25%) and nerve palsy with ECTR (0.66% vs 0.27%); with postoperative pain equivalent between techniques independent of fellowship training. CONCLUSIONS: Within the United States from 2003 to 2013, the rate of ECTR increased, as did complications. However, complication rates remained low in the first 2 years of practice. Hand fellowship-trained surgeons performed more ECTR than did non-hand fellowship-trained orthopedic surgeons, and both groups had similar complication rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bicolumnar intercarpal arthrodesis: minimum 2-year follow-up.

PURPOSE: To determine greater than 2-year outcomes for combined lunate-capitate and triquetrum-hamate arthrodeses. METHODS: We identified 16 patients who underwent scaphoid excision and combined arthrodeses of the lunate-capitate and triquetrum-hamate joints (bicolumnar arthrodesis) from 2007 to 2010. Eleven patients returned for follow-up evaluation, which included measurement of operative and contralateral control wrist flexion, extension, and grip strength, and completion of a patient-reported outcomes questionnaire, visual analog scale pain assessment, and Disabilities of the Arm, Shoulder, and Hand questionnaire. Radiographs of each patient were reviewed for evidence of union. Complications including nonunion and hardware migration were recorded. RESULTS: Wrist flexion-extension in the operative wrist was 68% of the contralateral control wrist. Grip strength of the operative wrist was 97% of the contralateral wrist. All 11 patients had radiographic bicolumnar union; 8 patients had spontaneous radiographic fusion of the capitohamate joint. One patient required capitolunate screw removal for migration despite having evidence of union. CONCLUSIONS: Results from scaphoid excision and bicolumnar intercarpal arthrodesis are comparable to those reported for traditional scaphoid excision and 4-corner arthrodesis, with a similar loss of wrist range of motion and with possible preservation of better grip strength in the operative wrist. Advantages of this modification include preservation of the normal lunate-triquetrum and capitate-hamate anatomic relationships and simplification of operative technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The influence of patient insurance status on access to outpatient orthopedic care for flexor tendon lacerations.

PURPOSE: To determine the effect of patient insurance status on access to outpatient orthopedic care for acute flexor tendon lacerations. METHODS: The research team contacted 100 randomly chosen orthopedic surgery practices in North Carolina by phone on 2 different occasions separated by 3 weeks. The research team attempted to obtain an appointment for a fictitious 28-year-old man with an acute flexor tendon laceration. Insurance status was presented as Medicaid in 1 call and private insurance in the other call. Ability of an office to schedule an appointment was recorded. RESULTS: Of the 100 practices, 13 were excluded because they did not perform hand surgery, which left 87 practices. The patient in the scenario with Medicaid was offered an appointment significantly less often (67%) than the patient in the scenario with private insurance (82%). The odds of the patient with private insurance obtaining an appointment were 2.2 times greater than the odds of the Medicaid patient obtaining an appointment. The Medicaid patient was more likely not to be offered an appointment owing to the lack of a hand surgeon at a practice (28% of appointment denials) than privately insured patients (13% of appointment denials). CONCLUSIONS: For patients with acute flexor tendon lacerations, insurance status has an important role in the ability to obtain an orthopedic clinic appointment. We found that patients with Medicaid have more barriers to accessing care for a flexor tendon laceration than patients with private insurance. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Outcomes Following Surgical Fixation of Distal Radius Fractures in Patients With Chronic Kidney Disease.

Purpose: Moderate-to-severe chronic kidney disease (CKD, stages III-IV) and end-stage renal disease (ESRD or CKD stage V) are known to be independent risk factors for fragility fracture. Altered bone and mineral metabolism contributes to greater complications and mortality rates in the setting of fractures, although most existing literature is limited to hip fractures. We hypothesized that patients with moderate-to-severe CKD or ESRD would have greater complication rates after surgical treatment of distal radius fractures compared with those without CKD. Methods: We retrospectively identified all patients at a level 1 trauma center between 2008 and 2018 who had a diagnosis of stage III-IV CKD or ESRD at the time of operative fixation of a distal radius fracture. We recorded demographic data, comorbidities, and surgical complications. Data for readmissions within 90 days and 1-year mortality were collected. A 2:1 sex-matched control group without CKD who underwent distal radius fixation was selected for comparison, with age-adjusted analysis. Results: A total of 32 patients with CKD (78.1% CKD stage III/IV, 21.9% ESRD) and 62 without CKD were identified. The mean age was 67 ± 12 years in the CKD group and 55 ± 15 years in the control group. The CKD group had a higher Charlson Comorbidity Index (5.7 vs 2.0). Surgical complication rate in the CKD group was 12.5% (12.0% CKD III/IV; 14.3% ESRD). Neither early nor late surgical complication rates were statistically different from those in patients without CKD. Reoperation rate as well as 30- and 90-day readmission rates were similar between groups. Overall, 1-year mortality was greater in the CKD group (9.4% vs 0%). Conclusions: Surgical complications and readmission rates are similar in patients with and without CKD after distal radius fracture fixation. However, 1-year mortality rate is significantly higher after distal radius fixation in patients with moderate-to-severe CKD or ESRD. Type of study/level of evidence: Prognostic IIIa.

Outcomes Following Surgical Fixation of Upper Extremity Fractures in Patients with Chronic Kidney Disease.

Purpose: Moderate to severe (stage III-IV) chronic kidney disease (CKD) and end stage renal disease (ESRD) have been shown to be independent risk factors for sustaining a fragility fracture. High rates of complications and mortality are associated with fracture fixation in patients with CKD, but existing literature is limited. It is unknown how CKD stage III-IV or ESRD affects outcomes in upper-extremity fractures. We hypothesize that patients with CKD stage III-IV or ESRD will have high complication rates after surgical fixation of upper extremity fractures. Methods: We identified all patients between 2008 and 2018 who underwent operative fixation of an upper extremity fracture proximal to the distal radius with a diagnosis of CKD stage III-IV or ESRD at the time of injury. Those with an acute kidney injury at the time of injury or a history of a kidney transplant were excluded. Demographics, medical complications, and surgical complications were collected retrospectively. Data on readmissions within 90 days and mortality within 1 year were also collected. Results: Thirty-five patients were identified. Three patients had ESRD. Fractures included two clavicle, twelve proximal humerus, one humeral shaft, ten distal humerus, five olecranon, two ulnar shaft, one radial shaft, and two both-bone forearm fractures. In total, 91.4% of fractures were closed injuries. Surgical complications occurred in 40% of patients. The reoperation rate was 11.4%, and all cases of reoperation involved hardware removal. The all-cause 90-day readmission rate was 34.3%. The 1-year mortality rate was 8.6%. Conclusions: Surgical complications occurred in 40% of patients with CKD stage III-IV or ESRD who underwent fixation for an upper extremity fracture. It is important to counsel these patients regarding their high risk for complications. Further research is needed to investigate and identify how to mitigate risk. Type of study/level of evidence: Prognostic IV.

Routine Postoperative Radiographs Do Not Affect Decision Making Following Carpometacarpal Arthroplasty.

Purpose: Arthritis of the first carpometacarpal (CMC) joint affects up to 15% of the population aged over 30 years and 40% of the population aged over 50 years. Arthroplasty of the first CMC joint is a widely accepted treatment option for these patients, with most patients doing well long term despite radiographic evidence of subsidence. Postoperative treatment protocols vary with no defined gold standard, and the need for routine postoperative radiographs has not been defined. The purpose of this study was to evaluate the use of routine postoperative radiographs following CMC arthroplasty. Methods: A retrospective review of patients who underwent CMC arthroplasty from 2014 to 2019 at our institution was performed. Patients receiving a concomitant trapezoid resection or metacarpophalangeal capsulodesis/arthrodesis were excluded. Demographic data, as well as the frequency and timing of postoperative radiographs, were collected. Radiographs were included if taken up to 6 months from the date of surgery. The primary outcome was a repeated operative intervention. Descriptive statistics were used for the analysis. Results: A total of 155 CMC joints from 129 patients were included in the study. Sixty-one (39.4%) patients had no postoperative radiographs, 76 (49.0%) patients had one postoperative radiographic series, 18 (11.6%) had two, 8 (5.2%) had three, and 1 (0.6%) patient had four postoperative series of radiographs. A radiographic series is defined as multiple views taken at a single time point. Four of 155 (2.6%) patients underwent additional operative intervention. There were no patients who underwent revision CMC arthroplasty. Two had wound infections that underwent irrigation and debridement. Two developed metacarpophalangeal arthritis and underwent arthrodesis. There were no cases where repeat operative intervention was driven by postoperative radiographic findings. Conclusions: Routine postoperative radiographs following CMC arthroplasty do not lead to changes in patient management, specifically further surgery. These data may support forgoing routine radiographs in the postoperative period following CMC arthroplasty. Type of study/level of evidence: Therapeutic IV.

What is Operative? Conceptualizing Neuralgia: Neuroma, Compression Neuropathy, Painful Hyperalgesia, and Phantom Nerve Pain.

Neuralgia, or nerve pain, is a common presenting complaint for the hand surgeon. When the nerve at play is easily localized, and the cause of the pain is clear (eg, carpal tunnel syndrome), the patient may be easily treated with excellent results. However, in more complex cases, the underlying pathophysiology and cause of neuralgia can be more difficult to interpret; if incorrectly managed, this leads to frustration for both the patient and surgeon. Here we offer a way to conceptualize neuralgia into 4 categories-compression neuropathy, neuroma, painful hyperalgesia, and phantom nerve pain-and offer an illustrative clinical vignette and strategies for optimal management of each. Further, we delineate the reasons why compression neuropathy and neuroma are amenable to surgery, while painful hyperalgesia and phantom nerve pain are not.

Following a Surgical Paradigm Shift Through the Adoption of Nerve Transfers Among Board-Eligible and Practicing Plastic Surgeons.

BACKGROUND: Nerve transfers represent a new paradigm in the treatment of nerve injuries. Their current level of adoption among surgeons is unknown. This study evaluates the incidence of nerve transfers on case logs of board-eligible plastic surgeons over the past 14 years and surveys practicing nerve surgeons regarding their use of this technique. METHODS: We queried the American Board of Plastic Surgery case log database for all nerve reconstruction Current Procedural Terminology codes from 2008 to 2021 and assessed trends and relationships between geographic region, examination year, and nerve transfer use. We surveyed nerve surgery professional societies to assess trends in practice, compared with a 2017 survey. RESULTS: A total of 1959 nerve reconstruction cases were logged by 738 candidates from 2008 to 2021. Twelve percent of cases included nerve transfers. The proportion of nerve transfer codes (Z = -11.57; P < .0001) and the proportion of candidates performing nerve transfers (Z = -9.21, P < .0001) increased over the study period. Nerve transfers were associated with geographic region (χ2 = 25.826, P = .0002), with most cases performed in the Midwest (26.4%). A higher proportion of practicing nerve surgeons reported performing nerve transfers in this survey than in our 2017 survey (χ2 = 16.7, P < .001). CONCLUSIONS: There has been an increase in nerve transfers logged in the past 14 years by board-eligible plastic surgeons, as well as increased use among currently practicing nerve surgeons. Although nerve transfer use is increasing among both plastic and orthopedic surgeons, a greater proportion of nerve reconstructions include nerve transfers in the plastic surgery cohort.

Calling on Sponsorship: Analysis of Speaker Gender Representation at Hand Society Meetings.

BACKGROUND: The paucity of leadership diversity in surgical specialties is well documented. Unequal opportunities for participation at scientific meetings may impact future promotions within academic infrastructures. This study evaluated gender representation of surgeon speakers at hand surgery meetings. METHODS: Data were retrieved from the 2010 and 2020 meetings of the American Association for Hand Surgery (AAHS) and American Society for Surgery of the Hand (ASSH). Programs were evaluated for invited and peer-reviewed speakers excluding keynote speakers and poster presentations. Gender was determined from publicly available sources. Bibliometric data (Hirsch index) for invited speakers were analyzed. RESULTS: In 2010 at the AAHS ( n = 142) and ASSH meetings ( n = 180), female surgeons represented 4% of the invited speakers and in 2020 increased to 15% at AAHS ( n = 193) and 19% at ASSH ( n = 439). From 2010 to 2020, female surgeon invited speakers had a 3.75-fold increase at AAHS and 4.75-fold increase at ASSH. Representation of female surgeon peer-reviewed presenters at these meetings was similar (2010 AAHS, 26%; and 2010 ASSH, 22%; 2020 AAHS, 23%; 2020 ASSH, 22%). The academic rank of women speakers was significantly lower ( P < 0.001) than for male speakers. At the assistant professor level, the mean Hirsch index was significantly lower ( P < 0.05) for female invited speakers. CONCLUSIONS: Although there was a significant improvement in gender diversity in invited speakers at the 2020 meetings compared with 2010, female surgeons remain underrepresented. Gender diversity is lacking at national hand surgery meetings, and continued effort and sponsorship of speaker diversity is imperative to curate an inclusive hand society experience.

Beyond the Cubital Tunnel: Use of Adjunctive Procedures in the Management of Cubital Tunnel Syndrome.

BACKGROUND: Our management of cubital tunnel syndrome has expanded to involve multiple adjunctive procedures, including supercharged end-to-side anterior interosseous to ulnar nerve transfer, cross-palm nerve grafts from the median to ulnar nerve, and profundus tenodesis. We also perform intraoperative brief electrical stimulation in patients with severe disease. The aims of this study were to evaluate the impact of adjunctive procedures and electrical stimulation on patient outcomes. METHODS: We performed a retrospective review of 136 patients with cubital tunnel syndrome who underwent operative management from 2013 to 2018. A total of 38 patients underwent adjunctive procedure(s), and 33 received electrical stimulation. A historical cohort of patients who underwent cubital tunnel surgery from 2009 to 2011 (n = 87) was used to evaluate the impact of adjunctive procedures. Study outcomes were postoperative improvements in Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores, pinch strength, and patient-reported pain and quality of life. RESULTS: In propensity score-matched samples, patients who underwent adjunctive procedures had an 11.3-point greater improvement in DASH scores than their matched controls (P = .0342). In addition, patients who received electrical stimulation had significantly improved DASH scores relative to baseline (11.7-point improvement, P < .0001), whereas their control group did not. However, when compared between treatment arms, there were no significant differences for any study outcome. CONCLUSIONS: Patients who underwent adjunctive procedures experienced greater improvement in postoperative DASH scores than their matched pairs. Additional studies are needed to evaluate the effects of brief electrical stimulation in compression neuropathy.

Decompression with Brachioradialis Tenotomy Improves Pain and Quality of Life in Patients with Radial Sensory Nerve Compression.

BACKGROUND: Decompression of the superficial sensory branch of the radial nerve (SBRN) with complete brachioradialis tenotomy may treat pain in both simple and complex cases of SBRN compression neuropathy. METHODS: A retrospective chart review was performed of consecutive patients undergoing this procedure between 2008 and 2020 including postoperative outcomes within 90 days. Data were collected and analyzed, including patient and injury demographics, pain descriptors, and patient-reported pain questionnaire, including reported pain severity and impact on quality of life using visual analogue scale (VAS) instruments. Within-group presurgical and postsurgical analyses and between-group statistical analyses were performed. RESULTS: Thirty-three of 58 patients met inclusion criteria. Median time from symptom onset to surgery was 300 days, and median postoperative follow-up time was 37 days. Twenty-five percent of patients ( n = 8) underwent isolated SBRN decompression. The remainder had concomitant decompression of another radial [ n = 16 (48%) or peripheral [ n = 12 (36%)] entrapment point. Ten of 33 patients (30%) had resolution of pain at final follow-up ( P = 0.004). Median change in worst pain over the previous week was -4 ( P < 0.001), and average pain over the last month was -2.75 ( P < 0.001) on the VAS. The impact of pain on quality of life showed a median change of -3 ( P < 0.001) on the VAS. CONCLUSION: Decompression of the sensory branch of the radial nerve including a complete brachioradialis tenotomy improves pain and quality-of-life VAS scores in patients with both simple compression neuropathy syndrome and complex nerve compression syndrome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Elbow radiographic anatomy: measurement techniques and normative data.

BACKGROUND: An increase in elbow pathology in adolescents has paralleled an increase in sports participation. Evaluation and classification of these injuries is challenging because of limited information regarding normal anatomy. The purpose of this study was to evaluate normal radiographic anatomy in adolescents to establish parameters for diagnosing abnormal development. Established and new measurements were evaluated for reliability and variance based on age and sex. METHODS: Three orthopaedic surgeons independently, and in a standardized fashion, evaluated the normal anteroposterior and lateral elbow radiographs of 178 adolescent and young adult subjects. Fourteen measurements were performed including radial neck-shaft angle, articular surface angle, articular surface morphologic assessment (subjective and objective evaluation of the patterns of ridges and sulci), among others. We performed a statistical analysis by age and sex for each measure and assessed for inter- and intraobserver reliability. RESULTS: The distal humerus articular surface was relatively flat in adolescence and became more contoured with age, as objectively demonstrated by increasing depth of the trochlear and trochleocapitellar sulci, and decreasing trochlear notch angle. Overall measurements were similar between males and females, with an increased carrying angle in females. There were several statistically significant differences based on age and sex; but these were small and unlikely to be clinically significant. Inter and intraobserver reliability were variable; some commonly utilized tools had poor reliability. CONCLUSION: Most commonly utilized radiographic measures were consistent between sexes, across the adolescent age group, and between adolescents and young adults. Several commonly used assessment tools show poor reliability.

Classifying the Severity of Cubital Tunnel Syndrome: A Preoperative Grading System Incorporating Electrodiagnostic Parameters.

BACKGROUND: Current classifications for cubital tunnel syndrome have not been shown to reliably predict postoperative outcomes. In this article, the authors introduce a new classification that incorporates clinical and electrodiagnostic parameters, including compound muscle action potential amplitude, to classify the preoperative severity of cubital tunnel syndrome. The authors compare this to established classifications and evaluate its association with patient-rated improvement. METHODS: The authors reviewed 44 patients who were treated surgically for cubital tunnel syndrome. Patients were retrospectively classified using their proposed classification and the Akahori, McGowan-Goldberg, Dellon, and Gu classifications. Correlation of grades was assessed by Spearman coefficients and agreement was assessed by weighted kappa coefficients. Patient-reported impairment was assessed using the Disabilities of the Arm, Shoulder, and Hand questionnaire before and after surgery. RESULTS: The classifications tended to grade patients in a similar way, with Spearman coefficients of 0.60 to 0.85 ( p < 0.0001) and weighted kappa coefficients of 0.46 to 0.71 ( p < 0.0001). Preoperative Disabilities of the Arm, Shoulder, and Hand scores increased with severity grade for most classifications. In multivariable analysis, the authors' classification predicted postoperative Disabilities of the Arm, Shoulder, and Hand score improvement, whereas established classifications did not. CONCLUSIONS: Established classifications are imperfect indicators of preoperative severity. The authors introduce a preoperative classification for cubital tunnel syndrome that incorporates electrodiagnostic findings in addition to classic signs and symptoms. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, III.

Radial Nerve Palsy: Nerve Transfer Versus Tendon Transfer to Restore Function.

BACKGROUND: Radial nerve injuries cause profound disability, and a variety of reconstruction options exist. This study aimed to compare outcomes of tendon transfers versus nerve transfers for the management of isolated radial nerve injuries. METHODS: A retrospective chart review of 30 patients with isolated radial nerve injuries treated with tendon transfers and 16 patients managed with nerve transfers was performed. Fifteen of the 16 patients treated with nerve transfer had concomitant pronator teres to extensor carpi radialis brevis tendon transfer for wrist extension. Preoperative and postoperative strength data, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and quality-of-life (QOL) scores were compared before and after surgery and compared between groups. RESULTS: For the nerve transfer group, patients were significantly younger, time from injury to surgery was significantly shorter, and follow-up time was significantly longer. Both groups demonstrated significant improvements in grip and pinch strength after surgery. Postoperative grip strength was significantly higher in the nerve transfer group. Postoperative pinch strength did not differ between groups. Similarly, both groups showed an improvement in DASH and QOL scores after surgery with no significant differences between the 2 groups. CONCLUSIONS: The nerve transfer group demonstrated greater grip strength, but both groups had improved pain, function, and satisfaction postoperatively. Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. Both tendon transfers and nerve transfers are good options for patients with radial nerve palsy.

Posterior Interosseous Nerve Compression in the Forearm, AKA Radial Tunnel Syndrome: A Clinical Diagnosis.

BACKGROUND: Posterior interosseous nerve (PIN) compression in the forearm without motor paralysis is a challenging clinical diagnosis. This retrospective study evaluated the clinical assessment, diagnostic studies, and outcomes following surgical decompression of the PIN in the forearm. METHODS: This study reviewed 182 patients' medical charts following PIN decompression between 2000 and 2020 by a single surgeon. After exclusion of combined nerve entrapments, polyneuropathy, motor palsy, or lateral epicondylitis, the study included 14 patients. Data collected included: clinical presentation and pain drawings, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. RESULTS: There were 15 PIN decompressions (14 patients, mean follow-up = 11.9 months). Clinical presentation included pain (n = 14) (proximal dorsal forearm, n = 14; distal forearm over radial sensory nerve, n = 3) and positive clinical tests (sensory collapse test over the radial tunnel, n = 8; pain with forearm pronation and compression over the radial tunnel, n = 10; Tinel sign, n = 5). Postoperatively, there were significant improvements in Visual Analog Scale pain scores (6.7 to 3.3, P = .0006), quality-of-life scores (74.7 to 32.7, P = .0001), and DASH scores (46.3 to 33.6, P = .02). CONCLUSIONS: The PIN compression in the forearm without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent, therapy-resistant dorsal forearm pain should be evaluated for PIN compression. Surgical decompression provides statistically significant quantifiable improvement in pain and quality of life.