Evaluation of Patient Expectations and Outcomes after Distal Radius Fractures.

BACKGROUND: Patient expectations influence patient-reported outcomes after musculoskeletal injuries. The goal of this study is to determine how pretreatment expectations correlate with outcomes in patients with distal radius fractures. METHODS: Seventy-five patients with an isolated distal radius fracture were prospectively enrolled into nonoperative and operative cohorts. The Trauma Expectation Factor-Trauma Outcome Measure (TEF-TOM) score was the primary outcome measure. Trauma Expectation Factor scores were recorded at the time of enrollment, and TOM scores were recorded at 3, 6, and 12 months. Quick Disabilities of the Arm, Shoulder, and Hand (qDASH) and Patient-Rated Wrist Evaluation (PRWE) scores were also recorded. RESULTS: Trauma Outcome Measure scores at all time points were worse than expected (P < .01). Expectations were higher for patients younger than 65 years than for the 65+ group (P = .02). In patients aged 65+ years, mean TOM at 3 months was not significantly different than expected (P = .11) but decreased by 6 (P = .04) and 12 months (P < .01). Baseline TEF and TEF-TOM scores were not significantly different between operative and nonoperative groups (P = .37). Quick Disabilities of the Arm, Shoulder, and Hand and PRWE scores were not significantly different between age or treatment groups at the final follow-up. CONCLUSIONS: The overall treatment of distal radial injuries in our study did not meet patient expectations. Patients aged 65 years or older had lower expectations but were not able to predict their outcomes better than patients aged <65 years. There were no differences in TEF or TOM by treatment method. Patients demonstrated improved functional outcomes (qDASH/PRWE) at all time points regardless of age and treatment method.

Understanding Variations in the Management of Displaced Distal Radius Fractures With Satisfactory Reduction.

BACKGROUND: The American Academy of Orthopaedic Surgeons has set forth Clinical Practice Guidelines (CPGs) to help guide management of closed, displaced distal radius fractures (DRFs). There still exists variation in practice regarding operative vs nonoperative decision-making. This study aims to identify which factors influence the decision to treat DRFs not indicated for surgery by the CPGs after initial closed reduction. METHODS: Fifteen sets of DRFs and clinical vignettes were distributed via email to over 75 orthopedic residency programs, Orthopaedic Trauma Association, and New York Society for Surgery of the Hand membership. A Qualtrics survey collected respondent demographics, choice of treatment, and rationale. RESULTS: Responses were received from 106 surgeons and resident trainees. The odds of selecting operative management for fractures with 5 or more radiographic instability signs versus 3 or 4 was 3.11 (P < .05). Age over 65, higher patient activity level, and dominant-hand injury were associated with greater odds of operative management (3.4, 30.28, and 2.54, respectively). In addition, surgeons with more years in practice and high-volume surgeons had greater odds of selecting operative management (2.43 and 2.11, respectively). CONCLUSIONS: Assessment of instability at the time of injury, patient age and activity level, as well as surgeon volume and time in practice independently affect the decision to manage well-reduced DRF with surgical or nonsurgical treatment. The source of heterogeneity in the treatment of these fractures is borne at least in part from a lack of formal direction on the importance of prereduction instability from the CPGs.

The "Bag of Bones" Treatment of Comminuted Intra-articular Distal Humerus Fractures in the Elderly.

BACKGROUND: Extensively comminuted intra-articular distal humerus fractures in the elderly present a challenging therapeutic dilemma. The purpose of this study was to investigate the results of nonoperative treatment of these fractures in a select subset of patients. METHODS: Patients treated with nonoperative management for a comminuted intra-articular distal humerus fracture between 2007 and 2018 were reviewed. Patients were administered 3 elbow-specific functional outcomes instruments. RESULTS: A total of 8 patients (2 men, 6 women) were treated with brief immobilization followed by early range of motion. All had fractures with extensive comminution of the articular surface such that open reduction and internal fixation was not feasible. Average age was 70 years. At an average of 33 months postinjury, average flexion was 124°, and extension was -27°, with full forearm rotation. No patients required pain medications at the latest follow-up. At 33 months of follow-up, the average Mayo Elbow Performance Score was 92/100 (100 optimal), Oxford Elbow Score was 43/48 (48 optimal), and Quick Disabilities of the Arm, Shoulder, and Hand Score was 10/100 (0 optimal). All patients were satisfied with the nonsurgical treatment that they received. CONCLUSIONS: Nonoperative treatment for comminuted intra-articular distal humerus fractures results in acceptable functional outcome in elderly patients and should be considered when the fracture is not amenable to internal fixation and in lower-demand patients with higher surgical risk.

Management of Isolated Ulnar Shaft Fractures.

¼ Most isolated ulnar shaft fractures are stable and heal without complication regardless of treatment protocol.¼ Casting above the elbow may create unwanted stiffness without enhancing union rates.¼ Defining unstable fractures and determining which injuries would benefit from operative management remain a challenge.¼ Recent development of intramedullary devices has shown promise in preliminary studies, but more vigorous investigation is needed to determine their role.

Distal Intersection Syndrome Between Second and Third Dorsal Compartments of the Wrist.

Distal intersection syndrome (DIS) is a rare form of tenosynovitis affecting the second and third dorsal extensor compartments of the wrist, which is rarer and more distal than the classically described intersection syndrome between the first and second compartments. In this report, we present three cases of DIS, their inciting activities, and ensuing treatment courses. Diagnosis of DIS was confirmed via MRI in all cases. Treatment modalities consisted of non-steroidal anti-inflammatory medications and varying durations of immobilization in all three patients, initially. One patient ultimately underwent surgical debridement and partial tenosynovectomy. At the end of follow-up, all patients saw a reduction in symptomatology with a return to baseline activity levels. This case report provides an overview of the possible clinical courses of DIS, as well as treatment strategies that can be implemented. Providers must maintain a high index of suspicion for this condition and treat patients with a great deal of caution, as extensor tendon rupture is possible.

Reduction Techniques in Volar Locking Plate Fixation of Distal Radius Fractures.

Distal radius fractures are the most common upper extremity fracture and volar locking plate fixation has become a common modality for operative management of these injuries over the last 2 decades. However, despite the widespread use of volar locking plates, there remains no comprehensive guide detailing the available reduction techniques using these systems. This review aims to consolidate the reduction techniques from the literature along with the authors' experiences into a blueprint for distal radius fracture reduction when using a volar plate. Techniques described include those with and without use of the plate and with supplementary means of fixation for both extra-articular and intra-articular fracture patterns.

A Novel Method of Patient Positioning Using Shoulder Arthroscopy Equipment for Elbow Arthroscopy.

Indications for elbow arthroscopy are expanding; however, it is uncommon compared with shoulder arthroscopy. Elbow arthroscopy can be complicated by positioning, including the need to obtain specific arm holders required by most operating rooms. Surgery can be performed in the supine, prone, or lateral position. Arm traction allows for distraction of the joint space, full insufflation, and therefore visualization of intra-articular anatomy. This article outlines a new technique using previously available shoulder arthroscopy equipment to avoid increased cost incurred by procuring new, elbow-specific equipment. This technique is performed in the supine position using a hydraulic system and a shoulder 3-point distractor. [Orthopedics. 2018; 41(1):e158-e160.].

Radial head arthroplasty.

Radial head arthroplasty remains an encouraging treatment option for comminuted radial head fractures in an unstable elbow or forearm. This article discusses the surgical considerations related to radial head arthroplasty, including anatomy, indications, and surgical technique. Radial head arthroplasty outcomes literature and a review of current implant options are also discussed.

Correlation of radiographic muscle cross-sectional area with glenohumeral deformity in children with brachial plexus birth palsy.

BACKGROUND: Muscle imbalance about the shoulder in children with persistent brachial plexus birth palsy is thought to contribute to glenohumeral joint deformity. We quantified cross-sectional areas of the internal and external rotator muscles in the shoulder by magnetic resonance imaging in patients with chronic brachial plexopathy and the correlation between these muscle cross-sectional area ratios and glenohumeral deformity. The purposes of this investigation were to evaluate differences in the ratios between affected and unaffected shoulders in the same individual and to assess whether an increased internal to external rotator muscle cross-sectional area correlated with greater glenohumeral deformity. METHODS: This cohort study consisted of magnetic resonance imaging of seventy-four patients with chronic neuropathic changes about the shoulder from brachial plexus birth palsy. There were at least nine patients with scans available for each of the five classified subtypes of glenohumeral deformity: type I (fifteen patients), type II (seventeen), type III (seventeen), type IV (sixteen), and type V (nine). Cross-sectional areas of the pectoralis major, teres minor-infraspinatus (external rotators), and subscapularis muscles were measured. The supraspinatus muscle cross-sectional area could not be reliably measured. The ratio of subscapularis to external rotators, the ratio of pectoralis major to external rotators, and the compound ratio of subscapularis and pectoralis major to external rotators were compared with the severity of the glenohumeral deformity. Passive range of motion, Mallet and Toronto clinical scores, and Narakas type were also compared with the severity of the glenohumeral deformity and the muscle cross-sectional area measurements. RESULTS: Muscle cross-sectional area ratios were significantly correlated with glenohumeral deformity type. The mean ratio of pectoralis major to external rotators for affected shoulders over all deformity types compared with that for unaffected shoulders was significantly increased by 30% (p < 0.001); the mean ratio for subscapularis and pectoralis major to external rotators, by 19% (p = 0.015), and the mean ratio for subscapularis to external rotators, by 10% (p = 0.008). There was a significant increase in the ratio of pectoralis major to external rotators in affected shoulders within each type of deformity. Analysis of variance indicated higher ratios of pectoralis major to external rotator muscle cross-sectional areas in more severe deformity types (p < 0.001). There were significant differences in external rotation measurements with the shoulder at 90 degrees of abduction only among glenohumeral deformity types I, II, and III (p < 0.05). CONCLUSIONS: The degree of muscle imbalance between internal and external rotators about the shoulder is measurable by magnetic resonance imaging in children with persistent brachial plexopathy, and the imbalance correlates with the degree of glenohumeral deformity. Our results may provide useful information to guide the timing and the choice of operative intervention in these children.

Long-term follow-up of basal joint resection arthroplasty of the thumb with transfer of the abductor pollicis brevis origin to the flexor carpi radialis tendon.

PURPOSE: To investigate the long-term functional and clinical outcomes of a tendon transfer during basal joint interposition arthroplasty for osteoarthritis of the basal joint of the thumb, in which the origin of the abductor pollicis brevis (APB) and opponens pollicis is transferred to the flexor carpi radialis tendon, in order to increase the abduction moment arm of the thumb and provide dynamic stabilization of the base of the first metacarpal. METHODS: We observed 22 patients, who received basal joint interposition arthroplasty with APB and opponens pollicis tendon transfer, over an average of 9 years (range, 3-20 years). Subjective outcome measures included patient satisfaction scores, visual analog scale scores for pain, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Clinical evaluations included thumb range of motion, grip strength, and pinch strength. RESULTS: At an average follow-up of 9 years, 95% of patients (21 out of 22) subjectively scored the procedure as good or excellent and reported improvement in activities of daily living. Mean visual analog scale pain score was 4.4 at rest and 7.8 with activity (out of 100), and mean DASH score was 13.3 (out of 100). Average grip strength of the operated hand was equal to that of the contralateral hand, and lateral and tip pinch strengths were 79% and 93%, respectively, of the contralateral hand. No intraoperative or early postoperative complications were reported, although 1 patient whose procedure was performed as treatment for failed silastic arthroplasty reported metacarpal instability at 9-year follow-up (DASH score of 22). CONCLUSIONS: Basal joint arthroplasty with APB and opponens pollicis tendon transfers provides excellent long-term results for carpometacarpal thumb osteoarthritis. The procedure is safe, with a low complication rate. Its success has long-term durability as measured by patient satisfaction, functional outcome measures, range of motion, and strength. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Radial nerve palsy in the newborn: a report of four cases and literature review.

BACKGROUND: Radial nerve palsy in the neonate is a rare clinical entity but must be distinguished from the more common brachial plexus birth palsy which occurs during the perinatal period. Although longer term upper-limb function following brachial plexus birth palsy is highly variable depending on the extent of neurological involvement, sparse reports of neonates with radial nerve palsy have nearly universal spontaneous recovery with normal upper-limb function. METHODS: We report 4 cases of patients born with findings consistent with radial nerve palsy. RESULTS: All 4 cases of neonatal radial nerve palsy supported a common etiology of intrauterine compression and resulted in spontaneous recovery of radial nerve function. CONCLUSION: Neonatal radial nerve palsy should be suspected in newborns presenting with absent wrist and digital extension but intact deltoid, biceps, and triceps function with wrist and digital flexor function. The presence of ecchymosis and/or fat necrosis along the posterolateral brachium may support the notion that neonatal radial nerve palsy is caused by a compression injury during or before labor. Complete spontaneous recovery of radial nerve function may be anticipated if there is no associated infectious or constriction band pathology.