Toward the use of MRI measurements of bound and pore water in fracture risk assessment.

The current clinical assessment of fracture risk lacks information about the inherent quality of a person's bone tissue. Working toward an imaging-based approach to quantify both a bone tissue quality marker (tissue hydration as water bound to the matrix) and a bone microstructure marker (porosity as water in pores), we hypothesized that the concentrations of bound water (Cbw) are lower and concentrations of pore water (Cpw) are higher in patients with osteoporosis (OP) than in age- and sex-matched adults without the disease. Using recent developments in ultrashort echo time (UTE) magnetic resonance imaging (MRI), maps of Cbw and Cpw were acquired from the uninjured distal third radius (Study 1) of 20 patients who experienced a fragility fracture of the distal radius (Fx) and 20 healthy controls (Non-Fx) and from the tibia mid-diaphysis (Study 2) of 30 women with clinical OP (low T-scores) and 15 women without OP (normal T-scores). In Study 1, Cbw was significantly lower (p = 0.0018) and Cpw was higher (p = 0.0022) in the Fx than in the Non-Fx group. In forward stepwise, logistic regression models using Bayesian Information Criterion for selecting the best set of predictors (from imaging parameters, age, BMI, and DXA scanner type), the area-under-the-receiver operator characteristics-curve (AUC with 95 % confidence intervals) was 0.73 (0.56, 0.86) for hip aBMD (best predictors without MRI) and 0.86 (0.70, 0.95) for the combination of Cbw and Cpw (best predictors overall). In Study 2, Cbw was significantly lower (p = 0.0005) in women with OP (23.8 ± 4.3 1H mol/L) than in women without OP (29.9 ± 6.4 1H mol/L); Cpw was significantly higher by estimate of 2.9 1H mol/L (p = 0.0298) with clinical OP, but only when accounting for the type of UTE-MRI scan with 3D providing higher values than 2D (p < 0.0001). Lastly, Cbw, but not Cpw, was sensitive to bone forming osteoporosis medications over 12-months. UTE-MRI-derived measurements of bound and pore water concentrations are potential, aBMD-independent predictors of fracture risk.

The Influence of Psychosocial Factors on Disability and Expected Improvement Before Surgery for Adult Traumatic Brachial Plexus Injury.

PURPOSE: Psychosocial factors influence pain and recovery after extremity trauma and may be targets for early intervention. This may be of particular interest for patients with adult traumatic brachial plexus injury (BPI), given the broad and devastating impact of the injury. We hypothesized that there would be an association between depressive symptoms, anxiety, and pain interference with preoperative disability and expectations for improvement after BPI surgery. METHODS: We enrolled 34 patients into a prospective multicenter cohort study for those undergoing surgery for adult traumatic BPI. Before surgery, participants completed Patient-Reported Outcome Measurement Information System scales for pain interference, anxiety, and depressive symptoms, and a validated BPI-specific measure of disability and expected improvement. We performed Pearson correlation analysis between pain interference, anxiety symptoms, and depressive symptoms with (A) disability and (B) expected improvement. We created separate linear regression models for (A) disability and (B) expected improvement including adjustment for severity of plexus injury, age, sex, and race. RESULTS: Among 34 patients, there was a moderate, statistically significant, correlation between preoperative depressive symptoms and higher disability. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. There was no association between severity of plexus injury and disability. Depressive symptoms also were moderately, but significantly, correlated with higher expected improvement. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. CONCLUSIONS: Depressive symptoms are associated with greater disability and higher expected improvement before BPI surgery. Screening for depressive symptoms can help BPI teams identify patients who would benefit from early referral to mental health specialists and tailor appropriate expectations counseling for functional recovery. We did not find an association between severity of BPI and patient-reported disability, suggesting either that the scale may lack validity or that the sample is biased. LEVEL OF EVIDENCE: Prognostic II.

Nerves in Continuity Following Hand Trauma: A Descriptive Report.

BACKGROUND: Understanding the clinical presentation of nontransected nerve injuries in acute hand trauma/wrist trauma will help in early intervention, which is vital for maximizing return of function in patients. This retrospective study evaluated patients who experienced traumatic hand injuries with nerve in continuity within the zone of injury. METHODS: This was a single-center retrospective chart review of 20 patients with hand or wrist trauma resulting in damage to bone, tendon, or soft tissues within Zones II to V. Patients were 18 to 70 years of age and had documented visualization of at least one nerve within the zone of injury at the time of surgery but no documented full or partial nerve transection. The cohort was characterized using descriptive statistics including mechanism of injury, extent of strength and sensation deficits, and outcomes. Resolution of symptoms was defined as full, partial, or none. RESULTS: Of the 20 patients included in the study, 15 patients (75%) showed symptoms of impaired nerve function either prior to surgery or at the first post-surgical follow-up visit. Without direct nerve treatment, only 23% (3/13) of patients experienced full recovery based on qualitative sensory assessment. However, patients reporting pain after surgery (57%; 8/14) showed full recovery from pain despite no direct nerve treatment. CONCLUSIONS: In our retrospective cohort of patients with hand/wrist trauma that presented with an intact nerve in continuity, we found that a majority showed symptoms of nerve injury. Further, these patients showed slow recovery over time with a minority achieving partial or full recovery or improvement in pain.

Sterility of Miniature C-arm Fluoroscopy in Hand and Upper Extremity Surgery.

Previous studies have demonstrated that sterile equipment is frequently contaminated intraoperatively, yet the incidence of miniature c-arm (MCA) contamination in hand and upper extremity surgery is unclear. To examine this incidence, a prospective study of MCA sterility in hand and upper extremity cases was performed in a hospital main operating room (MOR) ( n = 13) or an ambulatory surgery center operating room (AOR) ( n = 16) at a single tertiary care center. Case length, MCA usage parameters, and sterility of the MCA through the case were examined. We found that MOR surgical times trended toward significance ( p = 0.055) and that MOR MCAs had significantly more contamination prior to draping than AOR MCAs ( p < 0.001). In MORs and AORs, 46.2 and 37.5% of MCAs respectively were contaminated intraoperatively. In MORs and AORs, 85.7 and 80% of noncontaminated cases, respectively, used the above hand- table technique, while 50 and 83.3% of contaminated MOR and AOR cases, respectively, used a below hand-table technique. Similar CPT codes were noted in both settings. Thus, a high-rate of MCA intraoperative contamination occurs in both settings. MCA placement below the hand-table may impact intraoperative contamination, even to distant MCA areas. Regular sterilization of equipment and awareness of these possible risk factors could lower bacterial burden.

Intraoperative use of impact microindentation to assess distal radius bone quality.

Impact microindentation is a new technique that measures the resistance of a patient's bone to micro-indentation but has not yet been implemented in an intraoperative setting. To assess the technique's safety and utility, we acquired microindentation measurements of bone material strength index (BMSi) using the OsteoProbe prior to distal radius fixation with a volar locking plate. Subsequently, the patients received a dual-energy x-ray absorptiometry scan to measure the areal bone mineral density of the proximal femur, lumbar spine, and contralateral distal radius. By assigning the patients to low-energy, fragility fracture (n = 17) and high-energy fracture (n = 11) groups based on clinical history, we investigated whether intraoperative BMSi was sensitive to osteoporosis. Impact microindentation added a maximum of 10 min of operative time and did not result in any intraoperative or postoperative complications. There were, however, no significant differences in BMSi at the radius between these two groups. This study demonstrates the feasibility of performing intraoperative impact microindentation to directly assess a patient's bone quality, but additional research is necessary to establish whether intraoperative microindentation can identify patients with inferior bone matrix quality.

Avoiding Ring Avulsion Injuries With Silicone Rings: A Biomechanical Study.

PURPOSE: Finger avulsion injuries account for 5% of upper extremity injuries requiring evaluation in an emergency room. They are devastating injuries that require microvascular reconstruction or amputation. As public awareness rises, there is a growing market for silicone rings, with limited data on their ability to prevent ring avulsion injuries. METHODS: Five cadaver forearms were attached to a custom fixture, allowing for ring avulsion simulations. Specifically designed silicone or metal rings of varying sizes (#4-#11) were assigned to one of five fingers on each forearm, based on fit. The contralateral corresponding finger was tested using a ring of the same size in the other material. A preload of 2 N was applied to each ring, and ultimate failure force was determined by applying an upward force at a loading rate of 500 mm/sec until failure. Additionally, a fifth cadaver forearm was used to determine the ultimate failure force of silicone rings in a clenched fist position. RESULTS: The average ultimate failure force for silicone rings of all sizes was 53.0 N, compared to 495.2 N for metal rings of all sizes. The average ultimate failure force of silicone rings in the clenched fist position was increased across rings of all sizes, with an average of 99.9 N. There were no degloving injuries in the silicone ring avulsion group. CONCLUSIONS: Biomechanically, silicone rings have a significantly lower failure force than metal rings and may help prevent ring avulsion injuries. CLINICAL RELEVANCE: The use of silicone rings should be encouraged in professions where ring avulsion injuries are more likely, such as heavy labor.

Acute-Phase Reactants in Operatively Treated Upper Extremity Infections: A Retrospective Review.

Background: There are limited data on the use of acute-phase markers in the diagnosis of upper extremity infections. The goal of this study was to determine the percentage of patients with elevated white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) in the setting of an upper extremity infection requiring operative debridement. Methods: In a retrospective review over 12 years, 61 patients who met the inclusion criteria were identified. Results: C-reactive protein was the most sensitive test in the detection of culture-positive infection compared with ESR and WBC (P < .001, P < .0001, respectively). Ninety percent of patients (55 of 61) presented with an abnormal CRP value. The WBC count and ESR were abnormal in 54% and 67% of our cohort, respectively. Conclusions: C-reactive protein is the most sensitive laboratory test when evaluating upper extremity infections that necessitate debridement. The WBC count and ESR should be interpreted with caution and can be normal even in the presence of an infection.

A Survey of Burnout Among Members of the American Society for Surgery of the Hand.

PURPOSE: Physician burnout affects approximately half of US physicians, significantly higher than the general working population. The aims of this study were to determine the prevalence of burnout specifically among hand surgeons and to identify factors unique to the practice of hand surgery that may contribute to burnout. METHODS: A Web-based survey, developed in conjunction with the American Medical Association, was administered to all active and lifetime members of the American Society for Surgery of the Hand using the Mini Z Burnout assessment tool. Additional data were collected regarding physician demographics and practice characteristics. RESULTS: The final cohort included 595 US hand surgeons (American Society for Surgery of the Hand [ASSH] members) and demonstrated that 77% of respondents were satisfied with their job, although 49% regarded themselves as having burnout. Lower burnout rates were correlated with physicians aged older than 65, those who practice in an outpatient setting, practice hand surgery only, visit one facility per week, having a lower commute time, those who performed 10 or fewer surgeries per month, and being considered grandfathered for Maintenance of Certification. It was shown that sex, the use of physician extenders, compensation level, and travel club involvement had no impact on burnout rates. CONCLUSIONS: The survey demonstrated that nearly half of US hand surgeons experience burnout even though most are satisfied with their jobs. There is a need to increase awareness and promote targeted interventions to reduce burnout, such as creating a strong team culture, improving resiliency, and enhancing leadership. CLINICAL RELEVANCE: Burnout has been shown to affect physicians, their families, patient care, and the health care system as a whole negatively. The findings should promote awareness among hand surgeons and inform future quality improvement efforts targeted at reducing burnout for hand surgeons.

Factors Influencing Infection Rates after Open Hand Fractures.

Introduction Open hand fractures are anecdotally reported to have lower infection rates than open long bone fractures. Although a 3-hour rule for antibiotic administration and a 6-hour rule for operative debridement have historically been upheld as ideal management for open fractures, other factors may be more influential in the development of infection. The purpose of this study was to investigate factors associated with open hand fracture infections. Materials and Methods We retrospectively reviewed 67 patients with 107 open hand fractures between 2012 and 2017. Time from injury to antibiotic administration and operative debridement, modified Gustilo-Anderson classification, and patient characteristics including age, smoking status, and presence of chronic disease were examined for each patient. Outcome parameters were the development of infection and fracture union. Results The overall rate of infection was 9% (6 of 67 patients). No type 1 or type 2 fractures developed infection in contrast to 12.2% of type 3 fractures. Patients who received antibiotics in less than 3 hours and underwent debridement in less than 6 hours did not have lower infection or nonunion rates than those who did not. The association between the modified Gustilo-Anderson classification and the development of infection or nonunion was statistically significant. Conclusion Factors including time to antibiotics, time to operative debridement, smoking status, and chronic disease comorbidities were not predictive of either infection or nonunion in open hand fractures. Fracture type as defined by a modified Gustilo-Anderson classification was the factor most strongly related to the development of infection or nonunion in these fractures.

Peripheral nerve repair throughout the body with processed nerve allografts: Results from a large multicenter study.

BACKGROUND: Peripheral nerve damage resulting in pain, loss of sensation, or motor function may necessitate a reconstruction with a bridging material. The RANGER® Registry was designed to evaluate outcomes following nerve repair with processed nerve allograft (Avance® Nerve Graft; Axogen; Alachua, FL). Here we report on the results from the largest peripheral nerve registry to-date. METHODS: This multicenter IRB-approved registry study collected data from patients repaired with processed nerve allograft (PNA). Sites followed their own standard of care for patient treatment and follow-up. Data were assessed for meaningful recovery, defined as ≥S3/M3 to remain consistent with previously published results, and comparisons were made to reference literature. RESULTS: The study included 385 subjects and 624 nerve repairs. Overall, 82% meaningful recovery (MR) was achieved across sensory, mixed, and motor nerve repairs up to gaps of 70 mm. No related adverse events were reported. There were no significant differences in MR across the nerve type, age, time-to-repair, and smoking status subgroups in the upper extremity (p > .05). Significant differences were noted by the mechanism of injury subgroups between complex injures (74%) as compared to lacerations (85%) or neuroma resections (94%) (p = .03) and by gap length between the <15 mm and 50-70 mm gap subgroups, 91 and 69% MR, respectively (p = .01). Results were comparable to historical literature for nerve autograft and exceed that of conduit. CONCLUSIONS: These findings provide clinical evidence to support the continued use of PNA up to 70 mm in sensory, mixed and motor nerve repair throughout the body and across a broad patient population.

Prevalence and Clinical Manifestations of the Anconeus Epitrochlearis and Cubital Tunnel Syndrome.

Background: The true prevalence of the anconeus epitrochlearis (AE) and the natural history of cubital tunnel syndrome associated with this anomalous muscle are unknown. The purpose of this study was to evaluate the prevalence of AE and to characterize the preoperative and postoperative features of cubital tunnel syndrome caused by compression from an AE. Methods: All elbow magnetic resonance imaging (MRI) scans and all patients undergoing cubital tunnel surgery during a 20-year period were identified and retrospectively reviewed for the presence of an AE. All patients with an AE identified intra-operatively were matched to patients with no AE identified at surgery based on age, sex, concomitant procedures, and year of surgery. Preoperative and postoperative physical exam findings, electrodiagnostic study results, time to improvement, and reoperations were compared between the groups. Results: A total of 199 patients had an elbow MRI, and 27 (13.6%) patients were noted to have an AE present. Average time to improvement after surgical release was 23.0 days for patients with an AE and 33.2 days for patients with no AE. Twenty-seven patients with an AE noted improvement at the first postoperative visit (68%) compared to 15 patients without an AE (33%). No patients with an AE underwent reoperation for recurrent symptoms (0%) compared with four patients (10%) without an AE. Conclusions: The prevalence of AE in our study is 13.6%. These patients experience quicker and more reliable symptom improvement after surgical release than those without the anomalous muscle.

Symptomatic Radial Neck Nonunion Following Traumatic Impacted Radial Neck Fracture.

PURPOSE: Minimally displaced or impacted radial neck fractures are commonly sustained after elbow trauma, although few require surgical treatment or result in lasting complications. Whereas they are rare, radial neck nonunion after this injury can have adverse implications for patient function and quality of life. The current study presents a case series of 8 radial neck nonunions after minimally displaced or impacted radial neck fractures. METHODS: Using our institution's electronic medical record database, referred to as the Synthetic Derivative database, we performed a retrospective review of all radial neck fractures that presented to our institution over 15 years. RESULTS: Of 472 minimally displaced or impacted radial neck fractures, 8 progressed to symptomatic nonunion. Average age of these patients was 54 ± 9.3 years. One patient presented with bilateral radial neck nonunions. CONCLUSIONS: Nonunion after an impacted radial neck fracture is a rare yet frustrating outcome for patients and providers alike. Our results estimate the rate of symptomatic radial neck nonunion after minimally displaced or impacted radial neck fractures to be 1.7%. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Failed Extensor Tendon Repairs: Extensor Tenolysis and Reconstruction.

Extensor tendon injuries are common and require a complex treatment strategy to appropriately manage them, including initial repair, revision/reconstruction options, and postoperative protocols. Intrinsic and extrinsic components of the extensor mechanism contribute to a complex anatomic apparatus but also allow for numerous reconstructive options. Tenolysis, tendon grafting, and local tissue reconstruction are all options that can be used to treat complex extensor tendon injuries, but the type of repair is dependent on which of the eight extensor zones and accompanying structures are injured. To adequately assess and treat these injuries, a working knowledge of the anatomy, reconstructive techniques, and rehabilitation is imperative.

Electrical Injuries of the Hand and Upper Extremity.

High-voltage electrical injuries are relatively rare injuries that pose unique challenges to the treating physician, yet the initial management follows well-established life-saving, trauma- and burn-related principles. The upper extremities are involved in most electrical injuries because they are typically the contact points to the voltage source. The amount of current that passes through a specific tissue is inversely proportional to the tissue's intrinsic resistance with electricity predominantly affecting the skeletal muscle secondary to its large volume in the upper extremity. Therefore, cutaneous burns often underestimate the true extent of the injury because most current is through the deep tissues. Emergent surgical exploration is reserved for patients with compartment syndrome; otherwise, initial débridement can be delayed for 24 to 48 hours to allow tissue demarcation. Early rehabilitation, wound coverage, and delayed deformity reconstruction are important concepts in treating electrical injuries.

Critical ischemia and myonecrotic sepsis following scapulothoracic dissociation in the setting of apparent hand perfusion: A case report.

Scapulothoracic dissociation is a rare and devastating injury to the shoulder girdle. It is often caused by traction or severe blunt trauma injury to the upper extremity and is associated with both neurologic and vascular injuries. Scapulothoracic dissociation is a highly morbid and rare injury pattern that is often seen in conjunction with other traumatic injuries. The authors describe a case of scapulothoracic dissociation with associated complete brachial plexus injury and subclavian artery injury that was complicated by hypoperfusion, myonecrosis, and subsequent polymicrobial infection of the affected limb in the setting of a warm hand with brisk capillary refill. While capillary refill and hand warmth in the setting of a pulseless extremity have been used in previous cases of scapulothoracic dissociation as an indication for limb perfusion and nonoperative management, these markers cannot reliably be used to evaluate collateral circulation as exemplified in this case report. This case highlights multiple important aspects of the evaluation and management of scapulothoracic dissociation that orthopaedic surgeons and vascular surgeons should be familiar with and utilize when dealing with these challenging injuries. Level of Evidence: V.

Biomechanical Strength of Scaphoid Partial Unions.

Background It remains unknown how much force a partially united scaphoid can sustain without refracturing. This is critical in determining when to discontinue immobilization in active individuals. Purpose The purpose of this study was to test the biomechanical strength of simulated partially united scaphoids. We hypothesized that no difference would exist in load-to-failure or failure mechanism in scaphoids with 50% or more bone at the waist versus intact scaphoids. Materials and Methods Forty-one cadaver scaphoids were divided into four groups, three experimental osteotomy groups (25, 50, and 75% of the scaphoid waist) and one control group. Each was subjected to a physiologic cantilever force of 80 to 120 N for 4,000 cycles, followed by load to failure. Permanent deformation during physiologic testing and stiffness, max force, work-to-failure, and failure mechanism during load to failure were recorded. Results All scaphoids survived subfailure conditioning with no significant difference in permanent deformation. Intact scaphoids endured an average maximum load to failure of 334 versus 321, 297, and 342 N for 25, 50, and 75% groups, respectively, with no significant variance. There were no significant differences in stiffness or work to failure between intact, 25, 50, and 75% groups. One specimen from each osteotomy group failed by fracturing through the osteotomy; all others failed near the distal pole loading site. Conclusion All groups behaved similarly under physiologic and load-to-failure testing, suggesting that inherent stability is maintained with at least 25% of the scaphoid waist intact. Clinical Relevance The data provide valuable information regarding partial scaphoid union and supports mobilization once 25% union is achieved.

Novel preclinical murine model of trauma-induced elbow stiffness.

BACKGROUND: Peri-articular injury may result in functional deficits and pain. In particular, post-traumatic elbow stiffness is a debilitating condition, precluding patients from performing activities of daily living. As such, clinicians and basic scientists alike, aim to develop novel therapeutic interventions to prevent and treat elbow stiffness; thereby reducing patient morbidity. Yet, there is a paucity of pre-clinical models of peri-articular stiffness, especially of the upper extremity, necessary to develop and test the efficacy of therapeutics. We set out to develop a pre-clinical murine model of elbow stiffness, resulting from soft tissue injury, with features characteristic of pathology observed in these patients. METHODS: A soft tissue peri-elbow injury was inflicted in mice using cardiotoxin. Pathologic tissue repair was induced by creating an investigator-imposed deficiency of plasminogen, a protease essential for musculoskeletal tissue repair. Functional testing was conducted through analysis of grip strength and gait. Radiography, microcomputed tomography, and histological analyses were employed to quantify development of heterotopic ossification. RESULTS: Animals with peri-elbow soft tissues injury in conjunction with an investigator-imposed plasminogen deficiency, developed a significant loss of elbow function measured by grip strength (2.387 ± 0.136 N vs 1.921 ± 0.157 N, ****, p < 0.0001) and gait analysis (35.05 ± 2.775 mm vs 29.87 ± 2.075 mm, ***, p < 0.0002). Additionally, plasminogen deficient animals developed capsule thickening, delayed skeletal muscle repair, fibrosis, chronic inflammation, and heterotopic ossification; all features characteristic of pathology observed in patients with trauma-induced elbow stiffness. CONCLUSION: A soft tissue injury to the peri-elbow soft tissue with a concomitant deficiency in plasminogen, instigates elbow stiffness and pathologic features similar to those observed in humans. This pre-clinical model is valuable for translational studies designed to investigate the contributions of pathologic features to elbow stiffness or as a high-throughput model for testing therapeutic strategies designed to prevent and treat trauma-induced elbow stiffness.

A Helping Hand: The Case for Volunteerism.

Medical professionals are often regarded as influential community figures, yet their actual civic engagement may not match these expectations. Physicians certainly have a commitment to their own patients, but principles of medical ethics and professionalism suggest that physicians are also responsible for treating patients who lack access to care. Physician volunteerism is beneficial for entire communities, but can be particularly transformative for uninsured, underinsured, or geographically isolated patients. Volunteerism also yields countless benefits for physicians themselves, including professional development, skill building, and reduction of burnout. Despite evidence for the positive results of volunteerism, some physicians are discouraged by the time commitments, working conditions, and ethical controversies. Yet for interested physicians, diverse opportunities exist in medical and nonmedical activities and domestic and international areas.

Opioid Use After Upper Extremity Surgery.

Ever since the institution of pain as the fifth vital sign, there has been a rising opioid epidemic in the United States, with Americans now consuming 80% of the global opioid supply while representing only 5% of the world's population. Surgeons are tasked with the duty of both managing patients' pain in the perioperative period and following responsible prescribing behaviors. Several articles have been published with the goal of evaluating opioid use after upper extremity surgery, risk factors for opioid misuse/abuse, the impact of anesthetic type, and the role of multimodal pain management regimens. These studies have found that, on average, surgeons prescribe 2 to 5 times more opioids than patients consume. Multimodal pain management strategies are effective for decreasing postoperative opioid consumption. Risk factors for prolonged opioid use and/or misuse are younger age, history of substance abuse, psychological disorders, and previous pain diagnoses. Use of regional blockade anesthesia, particularly with long-acting agents or indwelling catheters, can be helpful in the management of postoperative pain. This review article summarizes the available literature regarding opioid use after upper extremity surgery to provide the surgeon with additional information to make informed decisions regarding postoperative opioid prescription.