Ideal Length and Diameter for Intramedullary Screw Fixation of Metacarpal Fractures: A Biomechanical Study.

Purpose: This biomechanical study evaluated the effect of intramedullary screw diameter and length relative to 3-point bending force and torsional force when used to stabilize metacarpal shaft fractures. Methods: Transverse osteotomies were made in the proximal metacarpal shaft in 36 middle finger metacarpal fourth-generation composite Sawbones. To compare screw diameters, antegrade intramedullary screws of 30-mm length were placed in 6 metacarpals, which included 4.7-mm Acutrak 2, Standard Acutrak 2 (4.0 mm), and Mini-Acutrak 2 (3.5 mm) screws. To compare screw lengths, metacarpals were fixated with Standard Acutrak 2 screws of 26, 30, or 34 mm in length, with screw tips bypassing the osteotomy by 6, 10, or 14 mm, respectively. A 6 degrees of freedom robot was used for torsional and 3-point bending testing. Results: Increasing screw diameter demonstrated significant differences in both 3-point bending and torsional strengths. Maximum torsional loads were 69 Ncm (4.7-mm Acutrak 2), 45 Ncm (Standard Acutrak 2), and 27 Ncm (Mini-Acutrak 2) (P < .05). Loads to failure in the 3-point bending tests were 916 N (4.7-mm Acutrak 2), 713 N (Standard Acutrak 2), and 284 N (Mini-Acutrak 2) (P < .05). Differing screw lengths demonstrated significant differences with maximum torsional loads when comparing the 26-mm screws (22 Ncm) with 30- and 34-mm screws (45 and 55 Ncm, respectively) (P < .05). The 3-point dorsal bending strengths were significantly different between the 26-mm screws (320 N) and 30- and 34-mm screws (713 N and 702 N, respectively) (P < .05). Conclusions: The results demonstrated significantly higher torsional strength and resistance to 3-point bending with larger intramedullary screw diameters. Further, when selecting the intramedullary screw length, the screw tip should pass at least 10 mm beyond the fracture. Clinical Relevance: This study provided biomechanical evidence to guide surgeons in selecting intramedullary screw diameter and length for treating metacarpal fractures.

Ganglions in the Hand and Wrist: Advances in 2 Decades.

Ganglion cysts represent the most common soft-tissue mass in the hand and wrist. Ganglion cysts are most commonly encountered at the dorsal or volar aspects of the wrist, although cysts may arise from the flexor tendon sheath, interphalangeal joint, and extensor tendons. Intraosseous and intraneural ganglion cysts have also been described. Diagnosis of ganglion cysts relies primarily on history and physical examination. Transillumination and aspiration of masses may be useful adjuncts to diagnosis. Imaging such as radiography and ultrasonography may be indicated to evaluate for associated conditions, such as degenerative joint disease, or to rule out a solid or heterogeneous mass. Advanced imaging such as MRI is generally reserved for patients in whom occult ganglions, intraosseous ganglions, or solid tumors, including sarcoma, remain a concern. Treatment of ganglion cysts includes observation, aspiration or puncture with possible corticosteroid injection, and surgical excision. Nonsurgical management may result in cyst resolution in over 50% of patients. Surgical excision is associated with recurrence rates of 7% to 39%. Advances in surgical techniques have allowed surgeons to conduct arthroscopic ganglion excision, with recurrence rates similar to those of open management. This study highlights the advances in diagnosis, treatment, and outcomes that have taken place over the past 2 decades for this common condition affecting the hand and wrist in the adult population.

Magnetic resonance imaging for elbow pathology: overused by both orthopedic surgeons and primary care providers.

Background: Magnetic resonance imaging (MRI) use by both orthopedic surgeons and primary care providers (PCP) for analysis of elbow pathology is expensive and growing in frequency. In light of this, scrutiny regarding the appropriate utilization of this technology is increasing. Currently, there is no literature investigating the appropriateness of MRI use for complex elbow pathology from either orthopedic surgeons or PCPs. Methods: A retrospective chart review was performed on consecutive elbow MRIs performed at a tertiary care center between January 1, 2012, and December 31, 2015. A total of 225 patients were included. Patients meeting the inclusion criteria were divided into two cohorts, determined by whether the ordering provider was an orthopedic surgeon or a PCP. MRI referrals were made by orthopedic surgeons in 94 patients and by nonorthopedic surgery providers in 131 patients. MRI diagnoses of no pathology, muscle/tendon tear, neuritis/nerve injury, tendinosis, ligament injury/instability, osteoarthritis/degenerative joint disease/decreased range of motion/contracture, or fracture/osteochondral injury were analyzed, as were the interventions of no intervention, nonprocedural treatment (therapy, orthosis, or nonoperative modality), nonsurgical procedure/referral for procedure, referral to surgeon, surgery, additional imaging/electrodiagnostic nerve testing, or other. Results: 1. Orthopedic surgeons are more accurate in their diagnoses after MRI, while PCPs order more MRI scans for 'routine' diagnoses typically made without MRI. 2. When the MRI did not validate an orthopedic surgeon's preimaging diagnosis, rates of surgery decreased. The same discrepancy in diagnosis leads to an increase in orthopedic surgeon referrals within the PCP cohort. 3. An MRI was ordered for "pain" by orthopedic surgeons and PCPs in approximately 30% of the patients in both groups with a similarly low rate of pathology discovery. Conclusions: The unexpected result of this study is that there is still a large quantity of MRI exams being conducted by orthopedic surgeons for the preMRI diagnosis of "pain." In both groups, there was a similar rate of negative imaging. We expected orthopedic surgeons who have advanced knowledge in musculoskeletal pathology would be less likely to order an MRI for pain and would also less likely order an MRI that resulted in no pathology. This places an increased and unnecessary burden on the financial aspect of the health care system.

Review of human supraspinatus tendon mechanics. Part I: fatigue damage accumulation and failure.

Repetitive stress injuries to the rotator cuff, and particularly the supraspinatus tendon (SST), are highly prevalent and debilitating. These injuries typically occur through the application of cyclic load below the threshold necessary to cause acute tears, leading to accumulation of incremental damage that exceeds the body's ability to heal, resulting in decreased mechanical strength and increased risk of frank rupture at lower loads. Consistent progression of fatigue damage across multiple model systems suggests a generalized tendon response to overuse. This finding may allow for interventions before gross injury of the SST occurs. Further research into the human SST response to fatigue loading is necessary to characterize the fatigue life of the tendon, which will help determine the frequency, duration, and magnitude of load spectra the SST may experience before injury. Future studies may allow in vivo SST strain analysis during specific activities, generation of a human SST stress-cycle curve, and characterization of damage and repair related to repetitive tasks.

Review of human supraspinatus tendon mechanics. Part II: tendon healing response and characterization of tendon health.

Overuse injuries of the rotator cuff, particularly of the supraspinatus tendon (SST), are highly prevalent and debilitating in work, sport, and daily activities. Despite the clinical significance of these injuries, there remains a large degree of uncertainty regarding the pathophysiology of injury, optimal methods of nonoperative and operative repair, and how to adequately assess tendon injury and healing. The tendon response to fatigue damage resulting from overuse is different from that of acute rupture and results in either an adaptive (healing) or a maladaptive (degenerative) response. Factors associated with the degenerative response include increasing age, smoking, hypercholesterolemia, biological sex (variable by tendon), diabetes mellitus, and excessive load post fatigue damage. After injury, the average healing rate of tendon is approximately 1% per day and may be significantly influenced by biologic sex (females have lower collagen synthesis rates) and excessive load after damage. Although magnetic resonance imaging (MRI) is considered the gold standard in assessing acute tears as well as tendinopathic change in the SST, ultrasonography has proven to be a valuable tool to measure tendinopathic change in real time. Ultrasonography can determine multiple mechanical and structural parameters of the SST that are altered in fatigue loading. Thus, ultrasonography may be utilized to understand how these parameters change in response to SST overuse, and may aid in determining the activity level that places the SST at greater risk of rupture.

Using Telehealth Rehabilitation Therapy to Treat a Finger Flexor Tendon Repair During COVID-19.

Telehealth-assisted finger rehabilitation therapy demonstrated good functional results following repair of a zone 2 flexor tendon laceration.

The Effect of Forearm Shortening on Forearm Range of Motion.

PURPOSE: Osseous shortening of the forearm is performed during forearm replantation; however, no large clinical reviews have discussed its effects on patient outcomes. A recent cadaver study demonstrated the progressive loss of forearm pronation/supination ranges of motion with increased shortening lengths using external fixation. Our study aimed to quantify the effects of shortening on passive forearm motion using internal fixation after 2, 4, and 6 cm of mid-forearm shortening. METHODS: A volar Henry approach and direct approach to the ulna were used on 8 cadaveric specimens. The forearms were sequentially shortened by 2, 4, and 6 cm. Fixation was performed on the volar surfaces of the radius and ulna. Pronation and supination of the forearms were tested by applying 1 Nm of torque at baseline and after the fixation of both the radius and ulna using osteotomy. Radiographs and measurements were obtained at each phase to determine the maximum radial bow and radioulnar gap. Data were analyzed using a linear mixed-effects model. RESULTS: Greater shortening of the radius and ulna led to progressively greater reductions in both pronation and supination range of motion. Larger differences were seen in supination at 2-4 cm of shortening and in pronation at 4-6 cm of shortening. Changes in supination were found to be associated with the radial bow and radioulnar gap; changes in pronation were found to be associated with the radial bow and radial bow's location. CONCLUSIONS: This study demonstrates that quantifiable effects on passive forearm motion occur after osseous shortening of the forearm. CLINICAL RELEVANCE: This information may improve surgeons' and patients' understanding of the changes in forearm motion expected after shortening in the setting of replantation or tumor resection or in the setting of limb salvage of a mangled extremity.

Risk factors for failure of limb salvage among veterans with foot ulcers.

BACKGROUND: There is limited available information to guide early discussions involving limb salvage for patients with non-traumatic foot ulcers. We hypothesized patient, wound and treatment factors identifiable at initial operative treatment would be associated with failure of attempted limb salvage. METHODS: We retrospectively assessed United States military veterans treated operatively for non-traumatic foot ulcers at a Veteran's Administration (VA) hospital from 2008 to 2018. Cox proportional hazard analysis assessed for independent associations with eventual above ankle amputation. RESULTS: Limb salvage failed for 52 of 461 patients (11.0%). Univariable associations included initial wound area ≥1 cm (p < .001), immediate TMA (p < .001), diagnosis of PVD (p < .001) or diabetes (p = .005), nonpalpable pulse (p = .006), CKD (p = .023), creatine ≥ 1.5 (p = .004), and HgA1c ≥ 6.2 (p < .001). Independent associations consisted of initial wound area ≥1 cm (HR 6.0, 95% CI 1.4-25.1, p = .014), immediate TMA (HR 3.5, 95% CI 1.9-6.4, p < .001), and PVD (HR 3.5, 95% CI 1.6-7.5, p = .001). When <2 risk factors were present, 99.1% and 96.8% retained their hindfoot at 5 and 10 years, respectively. However, this decreased to 87.3% and 80.1% with two risk factors and fell to 63.3% and 43.3% with three risk factors. CONCLUSION: Failure of limb salvage was increasingly likely as the number of identified independent risk factors increased. These results may assist in prognostication and shared decision making between patients and providers. LEVEL OF EVIDENCE: Prognostic, Level III.

Treatment Options for Distal Radioulnar Joint Arthritis: Balancing Functional Demand and Bony Resection.

The distal radioulnar joint is a complex anatomic structure that allows for a combination of rotation and translation with extrinsic and intrinsic stabilizers that maintain stability through a delicate equilibrium. Traumatic, congenital, inflammatory, and degenerative processes can disturb this sensitive balance, resulting in distal radioulnar joint arthritis. We discuss the joint's anatomy and biomechanics and the clinical approach to the patient. We review the surgical treatment options, expected outcomes, and their shortcomings. Selecting the best surgical intervention often means choosing the procedure with the set of complications and limitations best suited for the specific patient.

Dupuytren Contractures: An Update of Recent Literature.

Dupuytren disease is a fibroproliferative disorder that affects the palmar fascia of the hand and results in varying degrees of nodule and cord formation. Over time, patients may develop progressive contractures, impairing their ability to type, to perform with fine instruments, or to participate in social activities such as shaking hands. Treatment options for Dupuytren contractures include needle aponeurotomy (NA), injection of collagenase Clostridium histolyticum (CCH) with manipulation of the digits, and surgical fasciectomy. Over the past decade, the use of CCH has increased. Recent studies have provided additional data regarding the pathophysiology, indications, outcomes, and costs associated with the treatment for Dupuytren contractures, and this review highlights these advances.

Pyogenic Extensor Tenosynovitis of the Wrist-A Cause of Spontaneous Extensor Tendon Rupture: A Report of 2 Cases.

CASES: We present 2 cases of spontaneous extensor tendon rupture in the setting of pyogenic extensor tenosynovitis of the wrist caused by penetrating wounds-a cat bite and injection drug use in patients 1 and 2, respectively. Patient 1 underwent reconstruction of the extensor digitorum communis tendons with palmaris longus autograft. Patient 2 declined surgical reconstruction. CONCLUSIONS: These cases highlight a rare but severe complication of dorsal hand/wrist infection. Early surgical intervention should be considered to prevent this complication, which may have permanent functional consequences and requires complex reconstructive and rehabilitative efforts.

Anomalous Forearm Muscles and Their Clinical Relevance.

Despite their relatively low prevalence in the population, anomalous muscles of the forearm may be encountered by nearly all hand and wrist surgeons over the course of their careers. We discuss 6 of the more common anomalous muscles encountered by hand surgeons: the aberrant palmaris longus, anconeus epitrochlearis, palmaris profundus, flexor carpi radialis brevis, accessory head of the flexor pollicis longus, and the anomalous radial wrist extensors. We describe the epidemiology, anatomy, presentation, diagnosis, and treatment of patients presenting with an anomalous muscle. Each muscle often has multiple variations or subtypes. The presence of most anomalous muscles is difficult to diagnose based on patient history and examination alone, given that symptoms may overlap with more common pathologies. Definitive diagnosis typically requires soft tissue imaging or surgical exploration. When an anomalous muscle is present and symptomatic, it often requires surgical excision for symptom resolution.

Fixation of Regan-Morrey Type II Coronoid Fractures: A Comparison of Screws and Suture Lasso Technique for Resistance to Displacement.

PURPOSE: The aim of this study was to compare the load to failure and stiffness achieved in coronoid fractures treated with a posterior-to-anterior screw versus a suture lasso technique. METHODS: We performed a biomechanical study using 10 pairs of fresh-frozen cadaveric elbows. A transverse osteotomy at the midpoint of the coronoid height was created to simulate a Regan-Morrey type II coronoid fracture. The specimens were randomized to screw fixation or suture lasso fixation. The load to failure and stiffness were then measured using a materials testing machine. RESULTS: Screw fixation provided greater strength and stiffness than suture lasso fixation. Mean load to failure was 405 N in the screw fixation group compared with a load to failure of 207 N for suture fixation. Screw fixation resulted in a mean stiffness of 284 kPa/mm compared with 119 kPa/mm after suture fixation. CONCLUSIONS: Screw fixation was biomechanically superior to fixation using a suture lasso technique. For coronoid fractures in which screw or suture fixation is feasible, screw fixation may provide greater resistance to displacement of the coronoid compared with a suture lasso technique. CLINICAL RELEVANCE: Clinical studies have reported a higher rate of failure after screw fixation compared with suture lasso fixation; however, this study demonstrated a greater stiffness and load to failure after screw fixation of type II coronoid fractures. Screw fixation may provide a stronger fixation construct for fractures of adequate size to support a screw. Further studies may be warranted to assess the importance of securing the anterior capsule to the coronoid tip when using a suture lasso construct because this may affect the stability of the elbow after fixation.

Acute Arterial Thrombosis of the Hand.

Arterial thrombosis of the hand occurs infrequently but may result in considerable morbidity and compromise of hand function. The hand surgeon may be called upon to direct management in cases of acute arterial thrombosis of the hand and should have an understanding of the available diagnostic tools and treatment modalities. This article discusses the vascular anatomy of the hand and clinical manifestations of arterial thrombosis. Differences between isolated thrombosis and diffuse intravascular injury are detailed, and treatment options for these conditions are described. Appropriate care often requires coordination with interventional radiologists or vascular surgeons. Outcomes after treatment of arterial thrombosis of the hand are variable, and prognosis may be related to whether isolated thrombosis or diffuse intravascular injury is present.

Excision and advancement in the treatment of comminuted olecranon fractures.

Comminuted fractures of the olecranon (Mayo type IIB) present a unique challenge to the surgeon as it can be difficult or impossible to entirely preserve the olecranon's normal articulation with the trochlea of the humerus. In this article, we describe a modification of a previously described technique for reconstructing these fractures when a stable anatomic reduction and fixation is not possible. In this method, the comminuted fragments are excised and the proximal olecranon fragment is advanced past the resulting defect and fixed to the distal ulna. Clinical follow-ups from 2 cases are presented; satisfactory preservation of range of motion and elbow stability were achieved in each case.