Severe Carpal Tunnel Syndrome in a Pediatric Patient With a History of Congenital Adrenal Hyperplasia.

The patient is a 17-year-old right-hand-dominant girl with a history of virilizing congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase enzyme deficiency. Her CAH had been managed with supplemental exogenous steroids, but unfortunately, she had been noncompliant for many years. She subsequently presented with severe progressive numbness and tingling in the bilateral upper extremities that were refractory to conservative management. Electromyography/nerve conduction studies confirmed bilateral carpal tunnel syndrome (CTS) with the right being more severe than the left, and she underwent uncomplicated carpal tunnel releases that relieved her symptoms immediately and completely. Carpal tunnel syndrome secondary to CAH may be associated with the effects of elevated sex hormones within the CTS, leading to inflammation and median nerve entrapment. Moreover, hyperandrogenism is associated with elevated acute phase reactants and inflammatory cytokines, contributing to progressive median neuropathy. To the author's knowledge, there have been no reported cases of severe pediatric CTS with associated hyperandrogenism from CAH.

Collagenase Treatment for Dupuytren Contracture of the Metacarpophalangeal Joint After Arthrodesis of the Proximal Interphalangeal Joint.

Successful collagenase (Xiaflex) treatment of Dupuytren's contracture in the metacarpophalangeal joint is possible in the presence of previous arthrodesis of the proximal interphalangeal joint.

Location of distal pronator quadratus repair in distal radius fractures: A cadaveric biomechanical study.

BACKGROUND: We aimed to biomechanically evaluate the distal pronator quadratus and compare two locations of distal transection on the strength of the subsequent repair. METHODS: Eighteen fresh-frozen cadaveric specimens were dissected to the pronator quadratus muscle. Specimens were randomly allocated for transection of the pronator quadratus at the myotendinous junction (red group) or parallel to the myotendinous junction at the midsection of the distal tendinous zone (white group). For both groups, repair of the muscle was performed using two figure-of-8 sutures. The radius and ulna were positioned in 90° of wrist extension. The proximal muscular pronator quadratus was fixed in a cryo-clamp. Load-to-failure testing of the repair was performed at 1 mm/s with maximum amount of force applied to the pronator quadratus recorded for each specimen. FINDINGS: The pronator quadratus had a mean width, height, and area of 31.41 ± 5.74 mm, 53.79 ± 7.46 mm, and 1604.27 ± 429.20 mm2 respectively. The pronator quadratus distal tendinous zone had a mean width, height, and area of 29.71 ± 5.83 mm, 12.22 ± 2.79 mm, 282.94 ± 148.30 mm2 respectively. There was no significant difference between the two groups for pronator quadratus height, width, total area, or tendinous zone height, width, or total area. The average load to failure for the white group was significantly higher than that of the red group (29.46 ± 4.24 N vs. 13.78 N ± 6.66 N). INTERPRETATION: Incision and repair of the pronator quadratus in the distal tendinous region is stronger than incision and repair at the red myotendinous junction of the distal PQ.

Suture Tape Augmentation for the Repair of Index Finger Radial Collateral Ligament Injury: A Biomechanical Study.

PURPOSE: Despite their clinical importance in maintaining the stability of the pinch mechanism, injuries of the radial collateral ligament (RCL) of the index finger may be underrecognized and underreported. The purpose of this biomechanical study was to compare the repair of index finger RCL tears with either a standard suture anchor or suture tape augmentation. METHODS: The index fingers from 24 fresh-frozen human cadavers underwent repair of torn RCLs using either a standard suture anchor or suture tape augmentation. Following the repairs, the initial displacement of the repair with a 3-N ulnar deviating load was evaluated. Next, the change in displacement (cyclic deformation) of the repair after 1,000 cycles of 3 N of ulnar deviating force was calculated (displacement of the 1000th cycle - displacement of the first cycle). Finally, the amount of force required to cause clinical failure (30° ulnar deviation) of the repair was determined. RESULTS: Suture tape augmentation repairs displayed significantly less cyclic deformation (0.8 ± 0.5 mm) after cyclic loading than suture anchor repairs (1.8 ± 0.7 mm). There was no significant difference in the force required to cause the clinical failure of the repairs between the suture tape (35.1 ± 18.1 N) and suture anchor (24.5 ± 9.2 N) repairs. CONCLUSIONS: Index finger RCL repair with suture tape augmentation results in decreased deformation with repetitive motion compared with RCL repair alone. CLINICAL RELEVANCE: Suture tape augmentation may allow for early mobilization following index finger RCL repair by acting as a brace that protects the repaired ligament from deforming forces.

Metacarpal shaft fixation: a biomechanical comparison of dorsal plating, lag screws, and headless compression screws.

BACKGROUND: Metacarpal shaft fractures are common and can be treated nonoperatively. Shortening, angulation, and rotational deformity are indications for surgical treatment. Various forms of treatment with advantages and disadvantages have been documented. The purpose of the study was to determine the stability of fracture fixation with intramedullary headless compression screws in two types of metacarpal shaft fractures and compare them to other common forms of rigid fixation: dorsal plating and lag screw fixation. It was hypothesized that headless compression screws would demonstrate a biomechanical stronger construct. METHODS: Five matched paired hands (age 60.9 ± 4.6 years), utilizing non-thumb metacarpals, were used for comparative fixation in two fracture types created by an osteotomy. In transverse diaphyseal fractures, fixation by headless compression screws (n = 7) and plating (n = 8) were compared. In long oblique diaphyseal fractures, headless compression screws (n = 8) were compared with plating (n = 8) and lag screws (n = 7). Testing was performed using an MTS frame producing an apex dorsal, three point bending force. Peak load to failure and stiffness were calculated from the load-displacement curve generated. RESULTS: For transverse fractures, headless compression screws had a significantly higher stiffness and peak load to failure, means 249.4 N/mm and 584.8 N, than plates, means 129.02 N/mm and 303.9 N (both p < 0.001). For long oblique fractures, stiffness and peak load to failure for headless compression screws were means 209 N/mm and 758.4 N, for plates 258.7 N/mm and 518.5 N, and for lag screws 172.18 N/mm and 234.11 N. There was significance in peak load to failure for headless compression screws vs plates (p = 0.023), headless compression screws vs lag screws (p < 0.001), and plates vs lag screws (p = 0.009). There was no significant difference in stiffness between groups. CONCLUSION: Intramedullary fixation of diaphyseal metacarpal fractures with a headless compression screw provides excellent biomechanical stability. Coupled with lower risks for adverse effects, headless compression screws may be a preferable option for those requiring rapid return to sport or work. LEVEL OF EVIDENCE: Basic Science Study, Biomechanics.

Associations Between Insurance Type and the Presentation of Cubital Tunnel Syndrome.

PURPOSE: In the setting of cubital tunnel syndrome (CuTS), delays in diagnosis can have permanent effects including sensory loss, muscle weakness, and atrophy of intrinsic hand muscles. This study sought to evaluate the association of insurance type on the severity of CuTS. We hypothesized that publicly insured patients will have delayed presentation to the orthopedics office and more significant condition severity. METHODS: A retrospective chart review was conducted for all patients evaluated for CuTS between December 2013 and January 2018 by a fellowship-trained orthopedic hand and upper extremity surgeon at our tertiary referral center. Insurance type, demographics, and measures of CuTS severity were compared. RESULTS: Patients presenting with CuTS of severity greater than or equal to McGowan stage 2A had 4.4-fold greater odds of being publicly insured than privately. Motor and sensory velocities across the elbow were diminished at 42.2 ± 13.9m/s and 33.0 ± 20.8m/s in publicly insured patients compared with 47.5 ± 11.3 m/s and 47.0 ± 16.4m/s for privately insured patients. The same trend was present for motor and sensory amplitudes at 6.6 ± 3.8 µV and 16.9 ± 17.8 µV in publicly insured patients compared with 8.5 ± 3.2 µV and 26.0 ± 18.9 µV in privately insured patients. Patients with public insurance were symptomatic for longer prior to their initial visit, on average 82.8 ± 86.5 weeks, compared with 42.4 ± 58.9 weeks for patients with private insurance. CONCLUSIONS: Publicly insured patients were significantly delayed in seeing an orthopedic surgeon for evaluation and treatment of CuTS and presented with more severe clinical and electrodiagnostic findings compared with privately insured patients. These findings suggest that insurance type, among other socioeconomic factors, may be a barrier to CuTS care. TYPE OF STUDY/LEVEL OF EVIDENCE: Prevalence IV.

Biomechanical Comparison of Fifth Carpometacarpal Fusion Methods: Kirschner Wires Versus Plate and Screws.

BACKGROUND: Fractures and dislocations of the base of the fifth metacarpal can lead to arthritis of the fifth carpometacarpal (CMC) joint. For patients who are symptomatic and fail conservative management, arthrodesis of the fifth CMC joint can be offered. The fusion can be performed using Kirschner wires (K-wires), but can lead to complications such as pin tract infection and pin migration. A low-profile locking plate may represent an attractive alternative. The purpose of this study was to compare the biomechanical stability of these 2 fusion techniques. METHODS: Twelve fresh frozen cadaver hands were divided into 2 groups. The first group underwent fixation of the fifth CMC joint using 2 1.6 mm (0.062 inches) diameter K-wires in a cross-pin configuration. The second group underwent fixation using a 2.0 mm locking plate with 2 locking screws in the hamate and 3 nonlocking screws in the fifth metacarpal shaft. The specimens were then loaded in extension until failure. RESULTS: The stiffness was 15.0±7.2 N/mm for the K-wire group and 14.7±6.0 N/mm (mean±SD) for the plate group (P=0.9366). The peak loads were 62.5±40.0 N and 64.6±24.8 N for K-wire and plate groups, respectively (P=0.9181). The energy to peak load was 294±281 N mm for the K-wire group and 418±190 N mm for the plate group (P=0.3904). CONCLUSIONS: Fifth CMC fusion using either K-wires or plate and screws showed no significant difference in stiffness, peak load, and energy to peak load. These results suggest the 2 methods provide similar biomechanical stability.

Sports-related wrist and hand injuries: a review.

BACKGROUND: Hand and wrist injuries are common during athletics and can have a significant impact especially if initially disregarded. Due to their high level of physical demand, athletes represent a unique subset of the population. MAIN BODY: The following is an overview of hand and wrist injuries commonly seen in athletics. Information regarding evaluation, diagnosis, conservative measures, and surgical treatment are provided. CONCLUSION: Knowledge of these entities and special consideration for the athlete can help the team physician effectively treat these players and help them achieve their goals.

Radiographic prevalence of scaphotrapeziotrapezoid osteoarthrosis.

PURPOSE: To define the radiographic prevalence of scaphotrapeziotrapezoid (STT) osteoarthrosis (OA) in a cohort of patients presenting to a hand surgeon for any complaint. The secondary purpose was to evaluate coexisting thumb carpometacarpal (CMC) joint OA. METHODS: Seven hundred radiographs were evaluated for presence and degree of STT and thumb CMC arthritic changes in consecutive patients presenting to a hand clinic for any chief complaint over the study period. RESULTS: OA was noted at the STT joint in 111 of the 700 (16%) radiographs reviewed. Increased age, female sex, presence of a scapholunate (SL) ligament gap greater than 3 mm, and presence of radiographic thumb CMC joint OA were all significantly correlated with presence of STT joint OA. However, logistical regression analysis demonstrated that only increasing age, presence of an SL ligament gap greater than 3 mm, and presence of thumb CMC joint OA were strong predictors of STT joint OA. CONCLUSIONS: STT joint OA is a common finding on hand radiographs of patients presenting to a hand clinic. Its prevalence increases with age, the presence of an SL ligament gap greater than 3 mm, and with the presence of CMC joint OA. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Pronator syndrome and anterior interosseous nerve syndrome.

Dysfunction of the median nerve at the elbow or proximal forearm can characterize two distinct clinical entities: pronator syndrome (PS) or anterior interosseous nerve (AIN) syndrome. PS is characterized by vague volar forearm pain, with median nerve paresthesias and minimal motor findings. AIN syndrome is a pure motor palsy of any or all of the muscles innervated by that nerve: the flexor pollicis longus, the flexor digitorum profundus of the index and middle fingers, and the pronator quadratus. The sites of anatomic compression are essentially the same for both disorders. Typically, the findings of electrodiagnostic studies are normal in patients with PS and abnormal in those with AIN syndrome. PS is a controversial diagnosis and is typically treated nonsurgically. AIN syndrome is increasingly thought to be neuritis and it often resolves spontaneously following prolonged observation. Surgical indications for nerve decompression include persistent symptoms for >6 months in patients with PS or for a minimum of 12 months with no signs of motor improvement in those with AIN syndrome.

Fibroblast growth factor-2 and bone morphogenetic protein-2 have a synergistic stimulatory effect on bone formation in cell cultures from elderly mouse and human bone.

Combined regimens of fibroblast growth factor-2 (FGF-2) and bone morphogenetic protein-2 (BMP-2) were investigated to stimulate osteogenic differentiation. In young mouse calvaria-derived cells, FGF-2 (0.16ng/mL) in combination with BMP-2 (50ng/mL) did not enhance mineralization, but in old mouse cells it resulted in more mineralization than BMP-2 alone. In young long bone mouse cultures, FGF-2 enhanced mineralization relative to BMP-2 alone, but in old cultures, lower dose of FGF-2 (0.016ng/mL) was necessary. In neonatal mouse calvarial cells, sequential delivery of low-dose FGF-2 and low-dose BMP-2 (5ng/mL) was more stimulatory than co-delivery. In young human cultures, 0.016ng/mL of FGF-2 did not enhance mineralization, in combination with 5ng/mL of BMP-2, but in older cultures, codelivery of FGF-2 and BMP-2 was superior to BMP-2 alone. In conclusion, BMP-2 treatment alone was sufficient for maximal mineralization in young osteoblast cultures. However, coadministration of FGF-2 and BMP-2 increases mineralization more than BMP-2 alone in cultures from old and young mouse long bones and old humans but not in young mouse calvarial cultures.

A biomechanical analysis of treatment options for enchondromas of the hand.

PURPOSE: Enchondromas are the most common benign bone tumor affecting the hand. Standard treatment has consisted of curettage with bone grafting. It has become increasingly common for surgeons to use biologic cement in these cases. The purpose of this study was to evaluate different treatment options used to fill voids after curettage of hand enchondromas to determine if any provide more rigid fixation. METHODS: A cadaveric model of hand enchondromas was designed by making a standardized size corticotomy (0.6 × 1.0 cm) in 60 cadaver metacarpals. Resultant voids were then filled with either no material, bovine demineralized bone matrix (Synthes Paoli, PA, USA), or one of two different calcium phosphate bone cements: a carbonated apatite (Synthes Norian SRS Skeletal Repair System) and a hydroxyapatite (Stryker HydroSet) calcium phosphate. An apex dorsal three-point bend was applied to the metacarpals through an MTS machine, and load to failure and stiffness were recorded. RESULTS: Biomechanically, load to failure for intact metacarpals was significantly superior to those in which a corticotomy was created (p = 0.04). There was a significant increase in load to failure between the metacarpals treated with the calcium phosphate bone cement and the negative controls (p = 0). CONCLUSIONS: In a biomechanical analysis of a cadaveric model of hand enchondromas, calcium phosphate bone cement provided significantly increased strength as compared to curettage alone and approximated the strength of intact metacarpals. It is unknown whether the use of biologic cements in this clinical setting leads to less postoperative immobilization, earlier digital motion, a quicker return to work, or increased patient satisfaction.

Physical examination and radiographic interpretation of carpal anatomy in orthopedic residents and emergency medicine physicians.

The purpose of this study was to evaluate carpal anatomy proficiency in orthopedic residents as well as emergency medicine physicians. Orthopedic surgery residents and emergency medicine physicians were tested on their understanding of normal carpal anatomy using a Wrist Anatomy Assessment (WAA) score, which consists of both palpation of carpal bony landmarks and radiographic interpretation of the carpal bones. There were 89 participants in this study. Cohorts of orthopedic residents (n = 20), emergency medicine residents (n = 21), emergency medicine attending physicians (n = 26), and 4th-year medical students (22) were used. Group size was based on 100% orthopedic resident involvement. Total WAA scores (score of 17 = 100% correct) ranged from 2 to 16, with a mean of 8.6. Carpal palpation and radiographic interpretation means were both significantly better in the orthopedic resident cohort (total WAA score, 13.8), compared with either of the emergency medicine groups (resident total WAA score, 7.5; attending total WAA score, 7.2). Orthopedic residents have a better understanding of the clinical and radiographic anatomy of the carpal bones than emergency medicine residents and attending physicians. Future research to test educational interventions to improve carpal anatomy education is warranted.

Duration of postoperative dressing after mini-open carpal tunnel release: a prospective, randomized trial.

PURPOSE: In this prospective, randomized, controlled study, we hypothesized that there would be no difference in short-term functional, subjective, and blinded wound outcome measures between patients treated after mini-open carpal tunnel release (CTR) with a postoperative bulky dressing for 2 weeks and those with dressing removal and placement of an adhesive strip after 48 to 72 hours. METHODS: A total of 94 consecutive patients underwent mini-open CTR and placement of a bulky dressing and were randomized to either bandage removal at 48 to 72 hours with placement of an adhesive strip or continuation of the postoperative dressing until initial follow-up at approximately 2 weeks. We evaluated patient demographics, Levine-Katz scores, range of motion, strength, and a blinded assessment of wound healing at approximately 2 weeks and between 6 and 12 weeks. We conducted paired and independent sample t-tests to evaluate for statistical significance. RESULTS: There was no significant difference in Levine-Katz scores between groups at either the first follow-up or final visit. One patient with a longer dressing duration had evidence of a wound dehiscence. CONCLUSIONS: Removal of a bulky dressing after mini-open CTR and replacement with an adhesive strip at 48 to 72 hours causes no wound complications and results in equal short-term clinical and subjective outcome measures compared with using a bulky dressing for 2 weeks. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Ulnar collateral ligament injury of the thumb metacarpophalangeal joint.

Injury to the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal (MCP) joint is a common entity encountered by the sports physician and orthopedic surgeon. The term "gamekeeper's thumb," which is sometimes used incorrectly to mean any injury to this ligament, refers to a chronic injury to the UCL in which it becomes attenuated through repetitive stress. In contrast, the term "skier's thumb" refers to an acute ligament injury as seen in skiers who fall on an abducted thumb or athletes who sustain a valgus force on an abducted thumb. If the patient allows a clinical examination, valgus stress testing can diagnose a complete UCL rupture when there is no solid endpoint with the thumb held in 30 degrees of MCP flexion and with the thumb held in extension. In cases with complete UCL tears, operative treatment has been shown to produce excellent results and is recommended. If there is a firm endpoint to valgus stress testing, a partial UCL tear is diagnosed and nonoperative treatment usually favored.