Intramedullary Metacarpal Fracture Fixation: A Biomechanical Study of Screw Diameter and Comparison With Intramedullary Wire Stabilization.

PURPOSE: Interest in intramedullary metacarpal fracture fixation (IMFF) with screws is increasing. However, the optimal screw diameter for fracture fixation is not yet established. In theory, larger screws should be more stable, but there is concern about long-term sequelae of larger metacarpal head defects and extensor mechanism injury created during insertion as well as implant cost. Therefore, the purpose of this study was to compare different diameter screws for IMFF to a popular and more cost-effective alternative of intramedullary wiring. METHODS: Thirty-two cadaveric metacarpals were used in a transverse metacarpal shaft fracture model. Treatment groups consisted of IMFF with 3.0 × 60 mm, 3.5 x 60 mm, and 4.5 x 60 mm screws as well as 4 1.1-mm intramedullary wires. Cyclic cantilever bending was performed with the metacarpals mounted at 45° to simulate physiologic loading. Cyclical loading at 10, 20, and 30 N was performed to determine fracture displacement, stiffness, and ultimate force. RESULTS: At 10, 20, and 30 N of cyclical loading, all screw diameters tested provided similar stability as measured by fracture displacement and were superior to the wire group. However, ultimate force under load to failure testing was similar between the 3.5- and 4.5-mm screws and superior to 3.0-mm screws and wires. CONCLUSIONS: For IMFF, 3.0, 3.5, and 4.5-mm diameter screws provide adequate stability for early active motion and are superior to wires. When comparing the different screw diameters, 3.5- and 4.5-mm diameter screws offer similar construct stability and strength superior to the 3.0-mm diameter screw. Therefore, to minimize metacarpal head morbidity, smaller screw diameters may be preferable. CLINICAL RELEVANCE: This study suggests that IMFF with screws is biomechanically superior to wires in cantilever bending strength in the transverse fracture model. However, smaller screws may be sufficient to permit early active motion while minimizing metacarpal head morbidity.

Upper Extremity Crotalid Envenomation: A Review of Incidence and Recent Trends in Management of Snakebites.

PURPOSE: The goal of this study was to evaluate the recent trends in the management of upper extremity Crotalid envenomation in the state of Georgia, United States. METHODS: A retrospective review of the Georgia Poison Center database looking at the reported snakebites to the upper extremity between 2015 and 2020 was performed. Patient demographics, timing and location of injury, severity of envenomation, treatment, including use of antivenin and surgical intervention, and reported complications related to the use of antivenin was extracted. RESULTS: A retrospective review of snakebites between 2015 and 2020 showed 2408 snakebite cases with a mean patient age of 37.4 years. Males incurred 62.8% of all bites. The highest incidence was in summer 52.5%, and between the hours of 5 PM to midnight 57.2%. Overall, 1010 (41.9%) of all bites were categorized as venomous snakebites (55.6% copperhead, 20% rattlesnake, 2.4% cottonmouth, and 22% miscellaneous [including 3 Elapid envenomations] or unidentified. The total number of venomous bites to the upper extremity was 575 (56.9%) and 567 patients received antivenin. Envenomation severity was mild in 29%, moderate in 45%, severe in 10%, and undetermined in 16% of cases. Crotalidae polyvalent immune Fab (Ovine) was the main antivenin used, with overall mean initial therapy dose of 6.2 vials and 59% of patients receiving maintenance therapy. Three patients (0.5%) had a severe anaphylactic reaction to antivenin requiring cessation of therapy. Seven patients had acute compartment syndrome of the upper extremity requiring fasciotomy (3 copperhead, 2 rattlesnake, and 2 unidentified). There was no reported mortality during this period. CONCLUSIONS: Hand surgeons should be familiar with the management of upper extremity Crotalid envenomation. Antivenin remains the main treatment for symptomatic patients. Crotalid snakebites rarely require operative intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Treatment of Fingertip Injuries.

The goal of care when treating fingertip injuries is to minimize the risk of infection while maximizing function, tactile sensation, digit length, pulp padding, and appearance. This outcome can be achieved with careful soft-tissue coverage and, if possible, nail-bed preservation. When replantation for a fingertip amputation is not possible for anatomic or logistical reasons, local or regional flap reconstruction can be a useful alternative to gain early soft-tissue coverage and allow more functional rehabilitation. Reviewing current fingertip soft-tissue coverage procedures and demonstrating key anatomic and technical points with cadaveric dissections provides a foundation for the incorporation of these techniques into practice.

How to Host A Domestic Hand Surgery Outreach Day.

Domestic outreach is an integral yet often overlooked aspect of medical volunteerism. Since 2016, the American Society for Surgery of the Hand's Touching Hands initiative has supported domestic outreach Hand Days in the United States. The purpose of this article is to provide information and guidance to hand surgeons interested in hosting their own domestic hand surgery outreach. Thorough planning is essential to a successful outreach, particularly because each outreach site will have unique considerations. Surgeon team leaders must navigate the infrastructure and legal factors specific to their practice site. Outreach patients should be screened for both financial and surgical eligibility, although there are multiple pathways for the referral and screening process. Patient evaluation also requires coordination of imaging and diagnostic testing for a low-resource population. Multidisciplinary volunteer teams are necessary to provide all perioperative services and are typically recruited from the host practice site. Some potential challenges of domestic outreach include institutional charity care policies, legal concerns, and operative space availability. Because of complex socioeconomic situations, it may be difficult to contact and coordinate care for outreach patients. Despite these potential barriers, domestic outreach offers tremendous benefit for patients who otherwise lack access to surgical care. Even one yearly outreach day can avert years of disability and can have an incredible impact on patients' functional ability and quality of life. Volunteer teams also reap the benefits of outreach by promoting intraorganizational volunteerism, renewing commitment to medical professionalism, and decreasing symptoms of burnout. Hand surgeons have a unique opportunity to provide subspecialized surgical care to underserved patients as the Touching Hands initiative continues to grow and develop. We hope that hand surgeons will consider participating in advancing the Touching Hands mission to provide life-changing surgical care in the world's poorest communities, including our own.

Traumatic Brachial Plexopathy in Athletes: Current Concepts for Diagnosis and Management of Stingers.

Traumatic upper trunk brachial plexopathy, also known as a stinger or burner, is the most common upper extremity neurologic injury among athletes and most commonly involves the upper trunk. Recent studies have shown the incidence of both acute and recurrent injuries to be higher in patients with certain anatomic changes in the cervical spine. In addition, despite modern awareness, tackling techniques, and protective equipment, some think the incidence to be slowly on the rise in contact athletes. The severity of neurologic injury varies widely but usually does not result in significant loss of playing time or permanent neurologic deficits if appropriate management is undertaken. Timely diagnosis allows implementation of means to minimize the risk of recurrent injury. It is important for treating physicians to understand the pathogenesis, evaluation, and acute and long-term management of stingers to improve recovery and minimize chronic sequela.

Differences in Cross-Sectional Intervertebral Foraminal Area From C3 to C7.

STUDY DESIGN: Anatomical comparative study. OBJECTIVES: Few studies have evaluated foraminal areas in the cervical spine without degenerative changes. The purpose of this study was to determine and compare the mean cross-sectional foraminal areas between the C3/4, C4/5, C5/6, and C6/7 levels while also analyzing specimens for differences between sexes and races. METHODS: We performed an anatomic study of the intervertebral foramen at 4 levels (C3/4, C4/5, C5/6, C6/7) in 100 skeletally mature osseous specimens. Specimens were selected to obtain equal number of African American and Caucasian males and females (n = 25/group) aged 20 to 40 years at time of death. Foramina were photographed bilaterally with and without a silicone rubber disc. The maximal vertical height and mid-sagittal width of each foramen were digitally measured and the areas were calculated using an ellipse as a model. RESULTS: The average age at death for all specimens was 30 ± 6 years. The mean cross-sectional area of the C4/5 foramen was significantly smaller compared with the C5/6 (P < .001). C5/6 was significantly narrower than C6/7 (P < .001) foramen with and without disc augmentation. C3/4 was not significantly different from more caudal levels. There was no difference between male and female specimens, while African Americans had smaller foraminal sizes than Caucasians. CONCLUSIONS: This study provides the largest anatomical reference of the cervical intervertebral foramen. In a mature spine without facet joint hypertrophy or osteophytic changes, the C4/5 foramen was narrower than C5/6, which was narrower than C6/7. Understanding the relative foraminal areas in the nonpathological cervical spine is crucial to understanding degenerative changes as well as the anatomical changes in pathologies that affect the intervertebral foramen.

Normal Palmar Anatomy and Variations That Impact Median Nerve Decompression.

Annually, carpal tunnel release is one of the most commonly executed orthopaedic procedures. Despite the frequency of the procedure, complications may occur as a result of anatomic variations. Understanding both normal and variant anatomy, including anomalies in neural, vascular, tendinous, and muscular structures about the carpal tunnel, is fundamental to achieving both safe and efficacious surgery. Reviewing and aggregating this information reveals certain principles that may lead to the safest possible surgical approach. Although it is likely that no true internervous plane or so-called safe zone exists during the approach for carpal tunnel release, the long-ring web space axis does appear to pose the lowest risk to important structures.

Complications of Surgical Release\break of Carpal Tunnel Syndrome: A Systematic Review.

A systematic review of the literature was performed to compare complications of endoscopic and open carpal tunnel release. Techniques were further subdivided into traditional open, limited open, single-portal endoscopic, and two-portal endoscopic. This study also compared incidence of complications in each group based on chronological periods of data collection. The study found that endoscopic release has a higher incidence of transient nerve injury. There was also an increased incidence of superficial palmar arch injuries in the endoscopic group in the 1960-1990 time period as compared with the 1991-2000 and 2001-2012 periods. No difference was found in scar complications between open and endoscopic groups. While vascular injuries have decreased over time, the rate of nerve injuries has not changed since the introduction of endoscopic release. This higher incidence of transient nerve injury and lack of increased skin complications should be weighed when deciding between open and endoscopic techniques.

Medial Elbow Injuries in the Throwing Athlete.

Medial elbow injuries in the throwing athlete are common and increasing in frequency. They occur due to repetitive supraphysiologic forces acting on the elbow during the overhead throw. Overuse and inadequate rest are salient risk factors for injury. Most athletes improve substantially with rest and nonoperative treatment, although some athletes may require surgical intervention to return to play. Because of advances in conservative and surgical treatments, outcomes after medial elbow injury have improved over time. Currently, most athletes are able to return to a high level of play after ulnar collateral ligament reconstruction and experience a low rate of complications.

Radial to Axillary Nerve Transfers: A Combined Case Series.

PURPOSE: Loss of active shoulder abduction after brachial plexus or isolated axillary nerve injury is associated with a severe functional deficit. The purpose of this 2-center study was to retrospectively evaluate restoration of shoulder abduction after transfer of a radial nerve branch to the axillary nerve for patients after brachial plexus or axillary nerve injury. METHODS: Patients who underwent transfer of a radial nerve branch to the anterior branch of the axillary nerve between 2004 and 2014 were reviewed. A total of 27 patients with an average follow-up of 22 months were included. Outcome measures included pre- and postoperative shoulder abduction and triceps strength and active and passive shoulder range of motion. RESULTS: Shoulder abduction strength increased after surgery in 89% of patients. Average preoperative shoulder abduction was 12° compared with 114° after surgery. Twenty-two of 27 patients (81.5%) achieved at least M3 strength, with 17 of 27 patients (62.9%) achieving M4 strength. No differences were observed when subgroup analysis was performed for isolated nerve transfer versus multiple nerve transfer, mechanism of injury, injury level, branch of radial nerve transferred, or time from injury to surgery. A negative correlation was found comparing increasing age and both shoulder abduction strength and active shoulder abduction. No patients lost triceps strength after surgery. There were 4 patients who achieved no significant gain in shoulder abduction or deltoid strength and were deemed failures. No postoperative complications occurred. CONCLUSIONS: Transfer of a branch of the radial nerve to the anterior branch of the axillary nerve was successful in improving shoulder abduction strength and active shoulder motion in the majority of the patients with brachial plexus or isolated axillary nerve injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Severe Brachial Plexus Injuries in American Football.

This article reports a series of severe permanent brachial plexus injuries in American football players. The authors describe the mechanisms of injury and outcomes from a more contemporary treatment approach in the form of nerve transfer tailored to the specific injuries sustained. Three cases of nerve transfer for brachial plexus injury in American football players are discussed in detail. Two of these patients regained functional use of the extremity, but 1 patient with a particularly severe injury did not regain significant function. Brachial plexus injuries are found along a spectrum of brachial plexus stretch or contusion that includes the injuries known as "stingers." Early identification of these severe brachial plexus injuries allows for optimal outcomes with timely treatment. Diagnosis of the place of a given injury along this spectrum is difficult and requires a combination of imaging studies, nerve conduction studies, and close monitoring of physical examination findings over time. Although certain patients may be at higher risk for stingers, there is no evidence to suggest that this correlates with a higher risk of severe brachial plexus injury. Unfortunately, no equipment or strengthening program has been shown to provide a protective effect against these severe injuries. Patients with more severe injuries likely have less likelihood of functional recovery. In these patients, nerve transfer for brachial plexus injury offers the best possibility of meaningful recovery without significant morbidity. [ Orthopedics. 2016; 39(6):e1188-e1192.].

Frequency and complications after operative fixation of clavicular fractures.

BACKGROUND: The purpose of this study was to analyze whether a recent trend in evidence supporting operative treatment of clavicular fractures is matched with an increase in operative fixation and complication rates in the United States. METHODS: The American Board of Orthopaedic Surgery database was reviewed for cases with Current Procedural Terminology (American Medical Association, Chicago, IL, USA) code 23515 (clavicle open reduction internal fixation [ORIF]) from 1999 to 2010. The procedure rate for each year and the number of procedures for each candidate performing clavicle ORIF were calculated to determine if a change had occurred in the frequency of ORIF for clavicular fractures. Complication and outcome data were also reviewed. RESULTS: In 2010 vs, 1999, there were statistically significant increases in the mean number of clavicle ORIF performed among all candidates (0.89 vs. 0.13; P < .0001) and in the mean number of clavicle ORIF per candidate performing clavicle ORIF (2.47 vs. 1.20, P < .0473). The difference in the percentage of part II candidates performing clavicle ORIF from the start to the end of the study (11% vs. 36%) was significant (P < .0001). There was a significant increase in the clavicle ORIF percentage of total cases (0.11% vs. 0.74%, P < .0001). The most common complication was hardware failure (4%). CONCLUSION: The rate of ORIF of clavicular fractures has increased in candidates taking part II of the American Board of Orthopaedic Surgery, with a low complication rate. The increase in operative fixation during this interval may have been influenced by literature suggesting improved outcomes in patients treated with operative stabilization of their clavicular fracture.

Brachial plexus injury: a descriptive study of American football.

A stinger is a common, yet understudied, injury that involves stretching or compression of the brachial plexus, often occurring during contact sports. Five football teams, including high school, collegiate, and professional teams, completed questionnaires. Questions were designed to obtain descriptive information regarding the nature and consequence of this injury and assess effectiveness of current preventive measures. Three hundred and four surveys were returned with 153 players reporting a stinger in their career (50.3%). The prevalence increased with years played and was most common in running backs (69%), defensive linemen (60%), linebackers (55%), and defensive secondary (54%). Current protective equipment and neck-strengthening programs did not provide protective benefits. Players at greatest risk of developing a stinger include those having played 3 or more years and players whose primary position is running back, defensive back, or defensive lineman. Further study is needed to better evaluate the effectiveness of current preventive measures.

Tendon transfers for radial, median, and ulnar nerve palsy.

Tendon transfers are used to restore balance and function to a paralyzed, injured, or absent neuromuscular-motor unit. In general, tendon transfer is indicated for restoration of muscle function after peripheral nerve injury, injury to the brachial plexus or spinal cord, or irreparable injury to tendon or muscle. The goal is to improve the balance of a neurologically impaired hand. In the upper extremity, tendon transfers are most commonly used to restore function following injury to the radial, median, and ulnar nerves. An understanding of the general principles of tendon transfer is important to maximize the outcome.

Flexor tendon repair rehabilitation protocols: a systematic review.

PURPOSE: To systematically review various flexor tendon rehabilitation protocols and to contrast those using early passive versus early active range of motion. METHODS: We searched PubMed and Cochrane Library databases to identify articles involving flexor tendon injury, repair, and rehabilitation protocols. All zones of injury were included. Articles were classified based on the protocol used during early rehabilitation. We analyzed clinical outcomes, focusing on incidence of tendon rupture and postoperative functional range of motion. We also analyzed the chronological incidence of published tendon rupture with respect to the protocol used. RESULTS: We identified 170 articles, and 34 met our criteria, with evidence ranging from level I to level IV. Early passive motion, including both Duran and Kleinert type protocols, results included 57 ruptures (4%) and 149 fingers (9%) with decreased range of motion of 1598 tendon repairs. Early active motion results included 75 ruptures (5%) and 80 fingers (6%) with decreased range of motion of 1412 tendon repairs. Early passive range of motion protocols had a statistically significantly decreased risk for tendon rupture but an increased risk for postoperative decreased range of motion compared to early active motion protocols. When analyzing published articles chronologically, we found a statistically significant trend that overall (passive and active rehabilitation) rupture rates have decreased over time. CONCLUSIONS: Analyzing all flexor tendon zones and literature of all levels of evidence, our data show a higher risk of complication involving decreased postoperative digit range of motion in the passive protocols and a higher risk of rupture in early active motion protocols. However, modern improvements in surgical technique, materials, and rehabilitation may now allow for early active motion rehabilitation that can provide better postoperative motion while maintaining low rupture rates.

Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates.

BACKGROUND: Tears of the superior labrum (superior labrum anterior and posterior [SLAP] lesions) of the shoulder are uncommon injuries; however, the incidence of surgical correction seems to be increasing. PURPOSE: To report the findings of a review of a proprietary descriptive database that catalogs cases for the purpose of board certification on the demographics of SLAP lesion repair. It is the authors' impression that the percentage of cases of SLAP lesion repairs reported by young orthopaedic surgeons is high and that complications associated with this are not insignificant. STUDY DESIGN: Cohort study; level of evidence, 3. METHODS: We searched the American Board of Orthopedic Surgery (ABOS) part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of arthroscopic repair of SLAP lesions. The database was searched for all SLAP lesions (ICD-9 code 840.7) and SLAP repairs (CPT code 29807) for the years 2003 through 2008. Utilization was analyzed by geographic region and was also obtained based on applicant subspecialty declaration. RESULTS: There were 4975 SLAP repairs, representing 9.4% of all applicants' shoulder cases. Mean follow-up was 8.9 weeks because of the time-limited case collection period. There were 78.4% who were men, and 21.6% of patients were women. The percentage of shoulder cases that were SLAP repairs increased over the study period from 9.4% to 10.1% by 2008 (P = .0163). Mean age of male patients was 36.4 ± 13.0 years, with a maximum of 85 years. Mean age of female patients was 40.9 ± 14.0 years, with a maximum of 88 years. Pain was reported as absent in only 26.3% of patients at follow-up and function as normal in only 13.1%. There were 40.1% of applicants who self-reported their patients to have an excellent result. The self-reported complication rate was 4.4%. Declared sports medicine specialists had a higher percentage of SLAP repairs than did general orthopaedic surgeons: 12.4% versus 9.2%. CONCLUSION: The percentage of shoulder cases that are SLAP repairs reported by the candidates is 3 times the published incidence supported by the current literature. The large number of repairs in middle-aged and elderly patients is concerning. Focusing on educating young orthopaedic surgeons to appropriately recognize and treat symptomatic SLAP lesions may bring the rate of SLAP repairs down.

The reliability of measurement of tissue pressure in compartment syndrome.

BACKGROUND: Although there is general agreement as to the pathophysiology and treatment of compartment syndrome and the importance of intramuscular pressure measurements, there are many methods described to obtain these measurements. Variations in experimental measurements using current electronic monitoring, needle, and catheter devices of 18 to 22 mmHg are reported and are enough to cause errors in clinical decision-making that could result in significant clinical consequences. Current unacceptable reliability has been reported with the use of bevel-tipped needles and the clinical Whitesides technique. Because this is contrary to the authors' cumulative clinical and research experience with various methods when properly used (with the small required saline flush to assure a fluid continuum between tissue and the pressure monitor), this study was designed to clarify these problems. Although the two Whitesides techniques (original and clinical) are not in current use where digital methods are available, the clinical method is still used in the Third World. METHODS: To eliminate comparative errors, a laboratory compartment syndrome model was devised to allow simultaneous testing of different devices in the same area of fusiform muscle against increasing intramuscular pressure using the same transducer and monitor. Slit catheters, side-ported bevel-tipped needles, and 18-gauge bevel-tipped needles were compared against each other. The two Whitesides methods using a capillary meniscus and a mercury manometer were compared against a current electronic transducer method using identical 18-gauge bevel-tipped needles and varying diameter capillary tubing. RESULTS: The side-ported needle, slit catheter, and 18-gauge bevel-tipped needle were found to measure equivalent pressure when compared statistically with each other in pairs. The original Whitesides method using a 1.25-mm capillary tube and the digital transducer method using 18-gauge bevel-tipped needles was also found to measure equivalent pressure. The clinical Whitesides method using current plastic intravenous tubing of 3.0-mm internal diameter fails to produce an obvious capillary meniscus, leading to diminished reliability in the measured pressure. CONCLUSIONS: The slit catheter, side-ported bevel-tipped needle, or an 18-gauge needle, when appropriately used with current electronic transducer monitoring, may be used clinically with confidence. When digital methods are not available, the original Whitesides method using 1.25-mm glass capillary tubing is an accurate alternative but requires preplanning. When only 3-mm tubing is available, this method is relatively useful when electronic means are not available by averaging several consecutive measurements.

Compartment syndrome of the upper extremity.

Compartment syndrome involves the sustained elevation of interstitial tissue pressures within an osteofascial envelope to nonphysiologic levels. Tissue injury involves a spectrum from reversible to irreversible damage and, therefore, early recognition and treatment is critical for optimal outcomes. This article reviews the nature of upper extremity compartment syndrome; considers the general classification scheme and potential causes; and discusses the pertinent anatomy, pathophysiology, treatment recommendations, and outcomes for this challenging condition.

Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy.

BACKGROUND: In order to improve digit motion after zone-II flexor tendon repair, rehabilitation programs have promoted either passive motion or active motion therapy. To our knowledge, no prospective randomized trial has compared the two techniques. Our objective was to compare the results of patients treated with an active therapy program and those treated with a passive motion protocol following zone-II flexor tendon repair. METHODS: Between January 1996 and December 2002, 103 patients (119 digits) with zone-II flexor tendon repairs were randomized to either early active motion with place and hold or a passive motion protocol. Range of motion was measured at six, twelve, twenty-six, and fifty-two weeks following repair. Dexterity tests were performed, and the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire and a satisfaction score were completed at fifty-two weeks by ninety-three patients (106 injured digits). RESULTS: At all time points, patients treated with the active motion program had greater interphalangeal joint motion. At the time of the final follow-up, the interphalangeal joint motion in the active place-and-hold group was a mean (and standard deviation) of 156 degrees +/- 25 degrees compared with 128 degrees +/- 22 degrees (p < 0.05) in the passive motion group. The active motion group had both significantly smaller flexion contractures and greater satisfaction scores (p < 0.05). We could identify no difference between the groups in terms of the DASH scores or dexterity tests. When the groups were stratified, those who were smokers or had a concomitant nerve injury or multiple digit injuries had less range of motion, larger flexion contractures, and decreased satisfaction scores compared with patients without these comorbidities. Treatment by a certified hand therapist resulted in better range of motion with smaller flexion contractures. Two digits in each group had tendon ruptures following repair. CONCLUSIONS: Active motion therapy provides greater active finger motion than passive motion therapy after zone-II flexor tendon repair without increasing the risk of tendon rupture. Concomitant nerve injuries, multiple digit injuries, and a history of smoking negatively impact the final outcome of tendon repairs.