Accessory Extensor Pollicis Longus Tendon Incidentally Discovered During Dorsal Distal Radius Plating.

Anatomical variations of the extensor pollicis longus (EPL) tendon are rare. Variations are typically asymptomatic, yet knowledge of these variations poses significance in the setting of dorsal approaches to wrist surgery. We present a case of an accessory EPL tendon that was discovered intraoperatively in the fourth dorsal compartment during open repair of a distal radius fracture with a dorsal spanning plate. If not correctly identified, the accessory EPL could have been entrapped beneath the plate, resulting in limited thumb extension and potentially tendon rupture.

Ulnar Wrist Denervation: Articular Branching Pattern and Selective Blockade of the Dorsal Branch of the Ulnar Nerve.

PURPOSE: Ulnar wrist denervation has been a successful treatment for patients with ulnar-sided wrist pain. The purpose of this study was to characterize the articular branches of the dorsal branch of the ulnar nerve (DBUN) and validate a technique for selective peripheral nerve blockade. METHODS: In cadavers, we performed simulated local anesthetic injections using 0.5 mL of 0.5% methylene into the subcutaneous tissue at a point midway between the palpable borders of the pisiform and ulnar styloid. We then dissected the DBUN, characterized its articular branching pattern, and measured staining intensity of the DBUN and the ulnar nerve relative to a standard. RESULTS: The DBUN branched from the ulnar nerve 7.0 ± 1.2 cm proximal to the ulnar styloid. Among 17 specimens, the DBUN provided an average of 1.2 (range, 0-2) ulnocarpal branches and 1.0 (range, 0-2) carpometacarpal articular branches. A simulated local anesthetic injection successfully stained 100% of the DBUN articular branches at or proximal to their takeoff. There was no staining of the proper ulnar nerves. In all specimens, the DBUN supplied at least one articular branch. CONCLUSIONS: A point midway between the palpable border of the pisiform and ulnar styloid may be an effective location for selectively blocking the DBUN articular afferents. CLINICAL RELEVANCE: In this study, we were able to identify a point halfway between the pisiform and ulnar styloid that has the potential to produce a selective peripheral nerve block of the portion of the DBUN that supplies articular fibers to the ulnocarpal joint and the fifth carpometacarpal joint. This technique may prove useful to surgeons treating ulnar-sided wrist pain.

Outcomes after Anterior Interosseous Nerve to Ulnar Motor Nerve Transfer.

Background Ulnar nerve lesions proximal to the elbow can result in loss of intrinsic muscle function of the hand. The anterior interosseous nerve (AIN) to deep motor branch of the ulnar nerve (DBUN) transfer has been demonstrated to provide intrinsic muscle reinnervation, thereby preventing clawing and improving pinch and grip strength. The purpose of this study was to evaluate the efficacy of the AIN to DBUN transfer in restoring intrinsic muscle function for patients with traumatic ulnar nerve lesions. Methods We performed a prospective, multi-institutional study of outcomes following AIN to DBUN transfer for high ulnar nerve injuries. Twelve patients were identified, nine of which were enrolled in the study. The mean time from injury to surgery was 15 weeks. Results At final follow-up (mean postoperative follow-up 18 months + 15.5), clawing was observed in all nine patients with metacarpophalangeal joint hyperextension of the ring finger averaging 8.9 degrees (+ 10.8) and small finger averaging 14.6 degrees (+ 12.5). Grip strength of the affected hand was 27% of the unaffected extremity. Pinch strength of the affected hand was 29% of the unaffected extremity. None of our patients experienced claw prevention after either end-to-end ( n = 4) or end-to-side ( n = 5) AIN to DBUN transfer. Conclusion We conclude that, in traumatic high ulnar nerve injuries, the AIN to DBUN transfer does not provide adequate intrinsic muscle reinnervation to prevent clawing and normalize grip and pinch strength.

Parent Perspectives for Type B Ulnar Polydactyly Management.

BACKGROUND: Type B ulnar polydactyly is one of the most commonly encountered congenital hand differences and can be treated with ligation or excision. The purpose of this study was to determine what factors families consider in selecting treatment for their child with type B ulnar polydactyly. METHODS: We reviewed treatment outcomes and administered a survey by telephone to parents of children with type B ulnar polydactyly treated at a pediatric hospital between 2015 and 2020. We assessed satisfaction, reasons for choosing treatment, and post-management complications. RESULTS: The families of 70 of the 156 consecutive treated patients were successfully contacted and agreed to participate (45% response rate). The mean follow-up was 27 months. Twenty-eight chose in-office suture ligation and 42 chose excision. Rapid treatment was prioritized by those who opted for in-office ligation (P = .044). The complication rate for suture ligation was significantly higher than excision (P < .0001), with the most common complication being a residual remnant (nubbin or neuroma stump) (64%). Respondents with residual remnant reported significantly less satisfaction with the appearance of their child's hand (P < .001) and with treatment outcomes (P = .028) compared to those without residual remnants. CONCLUSIONS: Factors considered by parents in choosing type of treatment for type B ulnar polydactyly vary and may be significantly influenced by the surgeon. Although the majority of parents remain extremely satisfied with their child's outcome regardless of management type, time to treatment plays a determinative role in parents opting for ligation rather than excision in the operating room.

The Association of Insurance Status and Complications After Carpal Tunnel Release.

BACKGROUND: Carpal tunnel release (CTR) is one of the most commonly performed procedures in hand surgery. Complications from surgery are a rare but significant patient dissatisfier. The purpose of this study was to determine whether insurance status is independently associated with complications after CTR. METHODS: We retrospectively identified all patients undergoing CTR between 2008 and 2018 using the Indiana Network for Patient Care, a state-wide health information exchange, and built a database that included patient demographics and comorbidities. Patients were followed for 90 days to determine whether a postoperative complication occurred. To minimize dropout, only patients with 1 year of encounters after surgery were included. RESULTS: Of the 26 151 patients who met inclusion criteria, 2662 (10.2%) had Medicare, 7027 (26.9%) had Medicaid, and 16 462 (62.9%) had commercial insurance. Compared with Medicare, Medicaid status (P < .001) and commercial insurance status (P < .001) were independently associated with postoperative CTR complications. The overall complication rate was 2.23%, with infection, wound breakdown, and complex regional pain syndrome being the most common complications. Younger age, alcohol use, diabetes mellitus, hypertension, and depression were also independently associated with complications. CONCLUSIONS: The incidence of complications after CTR is low. Insurance status, patient demographics, and medical comorbidities, however, should be evaluated preoperatively to appropriately risk stratify patients. Furthermore, surgeons can use these data to initiate preventive measures such as working to manage current comorbidities and lifestyle choices, and to optimize insurance coverage.

Emergency Department Utilization After Administration of Peripheral Nerve Blocks for Upper Extremity Surgery.

BACKGROUND: The purpose of this study was to determine the impact of upper extremity peripheral nerve blocks on emergency department (ED) utilization after hand and upper extremity surgery. METHODS: We reviewed all outpatient upper extremity surgeries performed in a single Midwestern state between January 2009 and June 2019 using the Indiana Network for Patient Care. These encounters were used to develop a database of patient demographics, comorbidities, concurrent procedures, and postoperative ED visit utilization data. We performed univariate, bivariate, and multivariate logistic regression analyses. RESULTS: Among 108 451 outpatient surgical patients, 9079 (8.4%) received blocks. Within 1 week of surgery, a greater proportion of patients who received peripheral nerve blocks (1.4%) presented to the ED than patients who did not (0.9%) (P < .001). The greatest risk was in the first 2 postoperative days (relative risk, 1.78; P < .001). Pain was the principal reason for ED utilization in the block cohort (53.6%) compared with those who did not undergo a block (35.1%) (P < .001). When controlling for comorbidities and demographics, only peripheral nerve blocks (adjusted odds ratio [OR], 1.71; P = 0.007) and preprocedural opioid use (adjusted OR, 1.43; P = .020) conferred an independently increased risk of ED utilization within the first 2 postoperative days. CONCLUSIONS: Peripheral nerve blocks used for upper extremity surgery are associated with a higher risk of unplanned ED utilization, most likely related to rebound pain. Through proper patient education and pain management, we can minimize this unnecessary resource utilization.

Risk for Persistent Peripheral Neuropathy After Repair of Brachial Artery Injuries.

Background Brachial artery lacerations are limb-threatening injuries requiring emergent repair. Concomitant peripheral nerve symptoms are often only identified postoperatively. This study evaluated the prevalence of peripheral nerve deficits among this population as the indications for early nerve exploration have not been definitively established. Methods We reviewed all patients sustaining a brachial artery injury at one pediatric and two adult Level I Trauma Centers between January 1, 2007, and December 31, 2017. We recorded patient demographics, comorbidities, intoxication status, injury mechanism, concomitant injuries, type of repair, and intraoperative peripheral nerve exploration findings. Pre-and post-operative and long-term peripheral nerve function examination findings were analyzed. Differences between categorical variables were determined with Chi-square and Fisher's exact tests. Results Thirty-four patients sustained traumatic brachial artery lacerations requiring operative repair. Injury mechanisms included tidy (clean cut) laceration (n=11, 32%), gunshot wound (n=9, 26%), blunt trauma (n=8, 24%), and untidy laceration (n=6, 18%). Preoperatively, 15% had a normal peripheral nerve examination, 26% had localizable symptoms, 38% had non-localizable symptoms, and 21% were taken to the operating room without formal nerve assessment. Thirty-two percent underwent formal nerve exploration, and 81% underwent nerve repair. At an average follow-up of 2.5 years, 27% of patients underwent exploration, and 39% did not have localizable peripheral nerve deficits (p=0.705). Conclusions Brachial artery injuries are associated with a clinically significant risk for long-term peripheral nerve symptoms. Early nerve exploration in patients with peripheral nerve symptoms after a brachial artery injury may be warranted, although there is no statistically significant likelihood for improved peripheral neurological outcomes.

The Effects of Postoperative Physician Phone Calls for Hand and Wrist Fractures: A Prospective, Randomized Controlled Trial.

Background In this study, we sought to determine if postoperative physician phone calls following hand and wrist fracture surgery improve patient outcomes, satisfaction, and treatment adherence. Methodology We prospectively enrolled 24 consecutive adult patients who underwent outpatient surgery for isolated hand and wrist fractures at a single, metropolitan, safety-net hospital over one year to receive an additional physician phone call starting on postoperative day one. We measured preoperative and postoperative Brief Michigan Hand Questionnaire (bMHQ) composite score, overall satisfaction on a five-point Likert scale, compliance with treatment recommendations, presence of complications, discharge instructions reading level, and clarity of discharge and follow-up instructions. The surgical team was blinded to the treatment arm. Results The bMHQ score improved 26% after surgery; however, there was no difference in absolute score change between groups (12.2 vs. 6.5, p = 0.69). Most patients were satisfied throughout all stages of care, but postoperative satisfaction did not differ between groups (1.4 vs. 2.5, p = 0.21). There was a stronger correlation between patient hand function and satisfaction starting one month after surgery (R2 = 0.502, p = 0.002) than preoperatively (R2 = 0.252, p = 0.029). Immediately following surgery, most patients stated that discharge instructions were clear, and the average readability was below the average patient education level. Despite this, 13% removed their splint or Kirschner wires, 67% did not follow up within a week of recommendation, 62% did not complete postoperative treatment, and 33% had complications. Conclusions Postoperative phone calls by physicians did not improve compliance with recommendations, patient-rated outcome measures, or clinical outcomes among our hand and wrist fracture patient population.

Long-Term Outcomes After Treatment for Type B Ulnar Polydactyly.

BACKGROUND: Type B ulnar polydactyly is a common congenital hand difference and can be treated with either ligation or surgical excision. There is a paucity of literature, however, evaluating long-term patient reported outcomes of these treatments. The purpose of this study was to compare the long-term outcomes after ligation and excision for the management of type B ulnar polydactyly. METHODS: We created a database of patients who underwent treatment for type B ulnar polydactyly at a single pediatric health system from 2005 to 2014. We administered the Patient Reported Outcomes Measurement Information System (PROMIS) Pediatric Upper Extremity survey to patients through telephone and assessed for their satisfaction. RESULTS: We successfully collected outcomes from 69 of 173 eligible patients treated in infancy (40% response rate). The mean follow-up was 11.1±2.5 years, and the average age of the participant at the time of the survey was 11.7±2.6 years of age. Twenty-four patients were treated with in-office ligation and 45 underwent formal surgical excision. Ten patients who were initially treated with ligation required future treatment with surgery because of symptomatic neuroma stump or persistent polydactyly (42%). Patients who were treated with surgical excision rated significantly higher satisfaction with their treatment than those who underwent ligation (P=0.003). Patients in both cohorts rated similar satisfaction with the esthetic appearance of their hand (P=0.07). There was no significant difference in PROMIS-rated hand function between the ligation and surgical cohort (P=0.765) and treated adolescents PROMIS scores were not statistically different than age-matched controls without polydactyly. CONCLUSION: While ligation and surgical excision result in similar function and esthetics, patient satisfaction is higher after surgery. Furthermore, a significant number of patients fail ligation and ultimately undergo surgery for symptomatic neuroma or persistent polydactyly. Counseling parents of patients with type B ulnar polydactyly should include these considerations to assist them in selecting the best treatment for their child. LEVEL OF EVIDENCE: Level III.

Barriers to Upper Extremity Reconstruction for Patients With Cerebral Palsy.

BACKGROUND: Reconstructive surgery for upper extremity manifestations of cerebral palsy (CP) has been demonstrated to be safe and effective, yet many potential candidates are never evaluated for surgery. The purpose of this study was to determine barriers to upper extremity reconstruction for patients with CP in a cohort of upper extremity surgeons and nonsurgeons. METHODS: We sent a questionnaire to 4167 surgeons and nonsurgeon physicians, aggregated responses, and analyzed for differences in perceptions regarding surgical efficacy, patient candidacy for surgery, compliance with rehabilitation, remuneration, complexity of care, and physician comfort providing care. RESULTS: Surgeons and nonsurgeons did not agree on the literature support of surgical efficacy (73% vs 35% agree or strongly agree, respectively). Both surgeons and nonsurgeons felt that many potential candidates exist, yet there was variability in their confidence in identifying them. Most surgeons (59%) and nonsurgeons (61%) felt comfortable performing surgery and directing the associated rehabilitation, respectively. Neither group reported that patient compliance, access to rehabilitation services, and available financial resources were a major barrier, but surgeons were more likely than nonsurgeons to feel that remuneration for services was inadequate (37% vs 13%). Both groups agreed that surgical treatments are complex and should be performed in the setting of a multidisciplinary team. CONCLUSIONS: Surgeons and nonsurgeons differ in their views regarding upper extremity reconstructive surgery for CP. Barriers to reconstruction may be addressed by performing higher level research, implementing multispecialty educational outreach, developing objective referral criteria, increasing surgical remuneration, improving access to trained upper extremity surgeons, and implementing multidisciplinary CP clinics.

Utilization of Techniques for Upper Extremity Amputation Neuroma Treatment and Prevention.

This study aimed to understand the current utilization of surgical approaches for nerve ending management in upper extremity amputation to prevent and treat nerve-related pain. We administered a survey to 190 of 1270 surgeons contacted by email (15% response rate) and analyzed their demographics, practice patterns, and perceptions regarding techniques for nerve ending management in upper extremity amputees. Although many surgical techniques were employed, most surgeons (54%) performed traction neurectomy during amputation and, alternatively, bury nerve into muscle if a neuroma subsequently develops (52%). Surgeons in practice less than 10 years were more likely to perform targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI) than surgeons in practice greater than 10 years (p<0.001). TMR and RPNI were performed more frequently for proximal amputations than distal amputations, but there is no consensus regarding the optimal timing to utilize these techniques. Surgeons commonly cited improved prosthetic control, pain, and phantom limb symptoms as reasons for performing TMR and RPNI. Increased physician compensation as a consideration was more commonly cited among TMR non-adopter than adopters (31% vs 14%, p=0.008). There is no consensus regarding techniques for the prevention or treatment of nerve ending pain in upper extremity amputees. TMR and RPNI are being utilized with increasing frequency and both patient and surgeon factors affect implementation in clinical practice.

Donor site morbidity after sural nerve grafting: A systematic review.

BACKGROUND: Understanding the morbidity of sural nerve harvest is important when counselling patients regarding nerve grafts. Existing data consist of small studies with varying degrees of follow-up and a wide range of reported donor site outcomes. The objective of this study was to systematically review the literature and pool the current data for postoperative outcomes after sural nerve graft harvest. METHODS: A systematic review of literature was conducted to identify studies that examined donor site outcomes of sural nerve graft harvests. RESULTS: Five-hundred and fourteen studies were identified through a literature search, and nine studies met inclusion criteria. There were 240 patients who underwent sural nerve grafts. The most common methods for sensory evaluation were patient survey (44.4%) and Semmes-Weinstein evaluation (33.3%). Five studies reported surface areas of sensory loss, and this generally decreased over time after sural nerve grafting. Overall, 87.2% of patients (n = 190) reported sensory loss, 25.6% (n = 42) of patients reported pain, 22.2% (n = 28) of patients reported cold sensitivity, and 10% (n = 20) of patients reported functional impairment at follow-up. When the proximal sural nerve was spared during harvest, the extent of sensory loss and pain were less than harvest at the popliteal fossa (87.4% vs 95.7%, p = 0.0407 and 9.1% vs 35.5%, p = 0.0004, respectively). CONCLUSIONS: In this study, we present the extent of sensory loss and rates of pain, cold sensitivity, and functional impairment after sural nerve harvest. These data should be discussed prior to surgery in order for patients and surgeons to make an informed decision.

Side-to-Side Metacarpal Fusion for Reconstruction of Bone Loss in the Radial Carpometacarpal Joints.

We present a unique case of side-to-side metacarpal fusion for reconstruction after an isolated gunshot wound to the right hand of a 19-year-old woman. There was a traumatic segmental loss of the proximal right second metacarpal base with considerable comminution of the trapezium and trapezoid. Reconstructive options were limited because of the destruction of the distal carpus and carpometacarpal (CMC) joint. Digital ray amputation was offered but deferred because of patient preference. The reconstruction was performed via metacarpal fusion of the second metacarpal remnant to the third metacarpal base, bypassing the previously destroyed second CMC joint. The fusion of the second and third metacarpals offers acceptable results when the radial CMC joints are traumatized with extensive bone loss.

Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations.

Background: Many patients with complete nerve lacerations after upper extremity trauma have a documented normal peripheral nerve examination at the time of initial evaluation. The purpose of this study was to determine whether physician-, patient-, and injury-related factors increase the risk of false-negative nerve examinations. Methods: A statewide health information exchange was used to identify complete upper extremity nerve lacerations subsequently confirmed by surgical exploration at 1 pediatric and 2 adult level I trauma centers in a single city from January 2013 to January 2017. Charts were manually reviewed to build a database that included Glasgow Coma Scale score, urine drug screen results, blood alcohol level, presence of concomitant trauma, type of injury, level of injury, laterality, initial provider examination, and initial specialist examination. Bivariate and multivariable analyses were performed to evaluate risk factors for a false-negative examination. Results: Two hundred eighty-eight patients met inclusion criteria. The overall false-negative examination rate was 32.5% at initial encounter, which was higher among emergency medicine physicians compared with extremity subspecialists (P < .001) and among trauma surgeons compared with surgical subspecialists (P = .002). The false-negative rate decreased to 8% at subsequent encounter (P < .001). Risk factors for a false-negative nerve examination included physician specialty, a gunshot wound mechanism of injury, injury at the elbow, and age greater than 71 years. Conclusion: There is a high false-negative rate among upper extremity neurotmesis injuries. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes.

Immediate Lymphatic Reconstruction after Axillary Lymphadenectomy: A Single-Institution Early Experience.

PURPOSE: Lymphedema is progressive arm swelling from lymphatic dysfunction which can occur in 30% patients undergoing axillary dissection/radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed in an attempt decrease the risk of lymphedema in patients undergoing axillary lymph node dissection (ALND). The purpose of this study was to assess the efficacy of ILR in preventing lymphedema rates in ALND patients. METHODS: An institutional review board-approved retrospective review was performed of all patients who underwent ILR from 2017 to 2019. Patient demographics, comorbidities, operative and pathologic findings, number of LVAs, limb measurements, complications, and follow-up were recorded and analyzed. Student's sample t-test, Fisher's exact test, and ANOVA were used to analyze data; significance was set at p < 0.05. RESULTS: Thirty-three patients were included in this analysis. Three patients (9.1%) developed persistent lymphedema, and two patients (6.1%) developed transient arm edema that resolved with compression and massage therapy. A significant effect was found for body mass index and the number of lymph nodes taken on the development of lymphedema (p < 0.01). CONCLUSIONS: The rate of lymphedema in this series was 9.1%, which is an improvement from historical rates of lymphedema. Our findings support ILR as a technique that potentially decreases the incidence of lymphedema after axillary lymphadenectomy. Obesity and number of lymph nodes removed were significant predictive variables for the development of lymphedema following LVA.

Pediatric Fingertip Injuries.

Pediatric fingertip injuries are common and peak at 2 years of age. These injuries most frequently result from a crush mechanism and half sustain an associated fracture. The presence of a physis results in unique injury patterns and management considerations in the growing child. Due to a substantial healing potential in children, an initial conservative approach to management for many soft tissue and nail bed injuries is recommended. This article reviews the evidence and approach for treating pediatric fingertip injuries and amputations.

Rhinophyma: Prevalence, Severity, Impact and Management.

Rhinophyma is an advanced stage of rosacea affecting the nasal soft tissues and resulting in disruption of the nasal architecture, airway obstruction, and disfigurement of the nasal aesthetic units. Rhinophyma presents with hypertrophy of the nasal soft tissues, erythema, telangiectasias, nodules, and lobules with a bulbous appearance. Significant psychosocial morbidity is associated with the disease. Understanding of this disease has improved and multiple treatment options exist. The article is a review of the literature to evaluate the pathophysiology, clinical presentation, and epidemiology of keywords "rhinophyma" and "rosacea" using an OVID Medline and PubMed search along with a systematic review of outcomes pertaining to treatment of rhinophyma with laser therapy, scalpel excision, and the subunit method using an OVID Medline search. The subunit method has the highest complication and revision rates followed by carbon dioxide laser therapy. Outcomes between carbon dioxide laser and scalpel therapy and electrocautery are equivalent. Scalpel excision is a more cost-effective treatment modality with less post-operative complications; however, it risks poor hemostasis intraoperatively. Patient satisfaction is common post-therapy regardless of the treatment method. Over 89% of patients would recommend undergoing treatment for rhinophyma irrespective of treatment type. Treatment options vary, and choice of treatment can be dependent on practitioner and patients' treatment goals.

Unique Complications of Venous Anastomotic Couplers: A Systematic Review of the Literature.

BACKGROUND: Anastomotic couplers expedite venous microvascular anastomoses and have been established as an equivalent alternative to hand-sewn anastomoses. However, complications unique to the coupler such as palpability and extrusion can occur. The purpose of this study was to perform a systematic review of the literature to assess complications distinct to the venous anastomotic coupler. METHODS: A Medline, PubMed, EBSCO host search of articles involving anastomotic venous couplers was performed. Studies involving arterial anastomotic couplers, end-to-side anastomoses, and reviews were excluded. Data points of interest were flap failure, venous thrombosis, hematoma, partial flap necrosis, infection, coupler extrusion, and coupler palpability. RESULTS: The search identified 165 articles; 41 of these met inclusion criteria. A total of 8,246 patients underwent 8,955 venous-coupled anastomoses. Combined reoperation rate was 3.3% and all-cause unsalvageable flap failure was 1.0%. Complications requiring reoperation included venous thrombosis (2.0%), hematoma (0.4%), partial flap necrosis (0.4%), and infection (0.3%). Eight patients had palpable couplers and 11 patients had extrusion of couplers (head/neck, hand, and feet) and required operative management. CONCLUSION: Venous couplers remain an equivalent alternative to conventional hand-sewn anastomosis. However, venous coupler extrusion and palpability in the late postoperative period is a complication unique to anastomotic couplers, particularly in radiated head and neck, feet and hand free flaps. Removing extruded venous couplers is safe after tissue integration 3 weeks postoperatively. Coupler palpability and extrusion should be integrated into preoperative patient counseling and assessed in follow-up examinations.