Diagnostic Value of a Carpal Tunnel Corticosteroid Injection in Patients with Negative Electrodiagnostic Studies.

Introduction There is a known false negative rate when using electrodiagnostic studies (EDS) to diagnose carpal tunnel syndrome (CTS). This can pose a management dilemma for patients with signs and symptoms that correlate with CTS but normal EDS. While corticosteroid injection into the carpal tunnel has been used in this setting for diagnostic purposes, there is little data in the literature supporting this practice. The purpose of this study is to evaluate the prognostic value of a carpal tunnel corticosteroid injection in patients with a normal electrodiagnostic study but exhibiting signs and symptoms suggestive of carpal tunnel, who proceed with a carpal tunnel release. Materials and Methods The group included 34 patients presenting to an academic orthopedic practice over the years 2010 to 2019 who had negative EDS, a carpal tunnel corticosteroid injection, and a carpal tunnel release. One patient (2.9%), where the response to the corticosteroid injection was not documented, was excluded from the study, yielding a study cohort of 33 patients. Three patients had bilateral disease, yielding 36 hands for evaluation. Statistical analysis was performed using Chi-square analysis for nonparametric data. Results Thirty-two hands (88.9%) demonstrated complete or partial relief of neuropathic symptoms after the corticosteroid injection, while four (11.1%) did not experience any improvement. Thirty-one hands (86.1%) had symptom improvement following surgery, compared with five (13.9%) which did not. Of the 32 hands that demonstrated relief following the injection, 29 hands (90.6%) improved after surgery. Of the four hands that did not demonstrate relief after the injection, two (50%) improved after surgery. This difference was statistically significant ( p = 0.03). Conclusion Patients diagnosed with a high index of suspicion for CTS do well with operative intervention despite a normal electrodiagnostic test if they have had a positive response to a preoperative injection. The injection can provide reassurance to both the patient and surgeon before proceeding to surgery. Although patients with a normal electrodiagnostic test and no response to cortisone can still do well with surgical intervention, the surgeon should carefully review both the history and physical examination as surgical success may decrease when both diagnostic tests are negative. Performing a corticosteroid injection is an additional diagnostic tool to consider in the management of patients with CTS and normal electrodiagnostic testing.

Does Undergoing Outpatient Hand Surgery Lead to Prolonged Opioid Use? A Comparison of Surgical and Nonsurgical Patients.

BACKGROUND: Orthopedic surgical patients in general have been found to be at higher risk for developing opioid dependence in the postoperative period. However, there is conflicting evidence in the literature whether opioid exposure after hand surgery leads to prolonged use. In the absence of a nonoperative control group, it is not clear whether prolonged opioid use in hand surgical patients is related to undergoing a surgical intervention. The purpose of our study to compare opioid prescription fulfillment patterns in surgical and nonoperative patients in a hand surgery practice. METHODS: We retrospectively compared 320 patients that underwent elbow, wrist, and hand surgery procedures with 741 nonoperative patients treated by 2 hand surgeons. The Pennsylvania Drug Monitoring Program (PDMP), a mandatory statewide database, was used to evaluate the primary outcomes of filling more than one opioid prescription and filling opioid prescriptions beyond 6 months of the index surgery or clinic visit. Bivariate and multivariable logistic regression analysis was performed using the following variables: surgery, prior benzodiazepine use, and prior opioid use. RESULTS: There was no difference in prior opioid use (15.2% vs 16.9%, P = .51) or prior benzodiazepine (10.4% vs 8.4%, P = .33) use between the nonoperative and operative groups. Patients that underwent surgery had a higher incidence of filling more than one opioid prescription (20.9% vs 8.8%, P < .001). However, continued opioid use was not statistically different between nonoperative and operative patients (2.8% vs 5%, P = .08). Bivariate analysis demonstrated that prior opioids (odds ratio [OR] = 12.94, P < .001) and prior benzodiazepines (OR = 1.95, P < .001) were significant independent risk factors for prolonged opioid use. Multivariable analysis demonstrated prior opioid use to be the only independent risk factor for prolonged opioid use (OR = 12.58, P < .001). CONCLUSION: Undergoing outpatient hand surgery do not appear to be an independent risk factor for filling opioid prescriptions beyond 6 months. Significant risk factors for prolonged opioid use include prior use of controlled substances, particularly prior opioid use.

Variability in Medicaid Reimbursement in Hand Surgery May Lead to Inequality in Access to Patient Care.

BACKGROUND: Medicare (MCR) and Medicaid (MCD) remain the dominant providers of government-funded health insurance in the United States. The purpose of this study was to evaluate the variability between MCR and MCD reimbursements for common hand and wrist surgical procedures. We hypothesized that MCD reimbursement rates would have substantial variation between states, whereas MCR rates would remain relatively constant. METHODS: Using the Medicare Physician Fee Schedule Database, the 2019 reimbursements for 7 common hand and wrist procedures were recorded via the respective Current Procedural Terminology codes. The MCD reimbursement rates were then obtained from each state's physician fee schedule database. Comparisons of reimbursement for these procedures were then calculated between states and between MCD and MCR while adjusting for cost of living using the Medicare Wage Index. Finally, the coefficients of variation were computed to compare the extent of variability between the insurance types. RESULTS: Across all procedures, reimbursement rates for MCD ranged from 30.6% to 240% of the average MCR reimbursement, with the mean reimbursement for MCD valued at 78.3% of MCR. Endoscopic carpal tunnel release (CTR) is valued similarly by MCD compared with open CTR with an average of 77.7% and 78.2% reimbursement of MCR, respectively. The coefficients of variation for MCD reimbursements ranged from 0.25 to 0.45, whereas the value was 0.06 for all MCR procedures. CONCLUSIONS: These findings demonstrate a wide variation in MCD payments between states. When compared with MCR, the lower average state MCD reimbursement questions the sustainability for hand surgeons to accept these patients in practice.

Impending Upper Arm Compartment Syndrome Secondary to Intravenous Fluid Infiltration.

We report the case of an 81-year-old female who developed an upper arm anterior compartment syndrome from the mass effect caused by an infiltrated intravenous access catheter. The patient's anterior compartment became tense and uncompressible, and the patient developed radial nerve palsy. A fasciotomy was performed, resulting in the evacuation of 100 mL of fluid. Over the course of the patient's follow-up, motor and sensory function slowly returned. In atraumatic patients with intravenous access, the development of a tense compartment with developing nerve palsies should warrant workup for possible compartment syndrome due to mass effect. If treated promptly with fasciotomy, the complications of this limb-threatening condition can be minimized or possibly reversed.

Wire Extrusion After Flexor Tendon Repair with a Multifilament Stainless Steel Cable-Crimp Suture System: A Case Report.

CASE: We report the case of a 22-year-old man with a ruptured flexor tendon repair associated with wound drainage. The patient subsequently underwent flexor tendon revision with a multifilament stainless steel cable-crimp suture system. Two years after the revision repair, a blister ruptured over the patient's operative site, exposing the stainless steel wire from the revision repair. The wire was removed, and the patient regained full flexion. CONCLUSIONS: As extrusion of metallic suture material from the skin represents a complication, surgeons should be prepared to recognize this rare complication and to preoperatively counsel patients as to this risk.

An Evaluation of the Source and Content of Kienböck's Disease Information on the Internet.

Introduction The use of the internet for health-related information continues to increase. Because of its decentralized structure, information contained within the World Wide Web is not regulated. The purpose of the present study is to evaluate the type and quality of information on the internet regarding Kienböck's disease. We hypothesized that the information available on the World Wide Web would be of good informational value. Materials and Methods The search phrase "Kienböck's disease" was entered into the five most commonly used internet search engines. The top 49 nonsponsored Web sites identified by each search engine were collected. Each unique Web site was evaluated for authorship and content, and an informational score ranging from 0 to 100 points was assigned. Each site was reviewed by two fellowship-trained hand surgeons. Results The informational mean score for the sites was 45.5 out of a maximum of 100 points. Thirty-one (63%) of the Web sites evaluated were authored by an academic institution or a physician. Twelve (24%) of the sites were commercial sites or sold commercial products. The remaining 6 Web sites (12%) were noninformational, provided unconventional information, or had lay authorship. The average informational score on the academic or physician authored Web sites was 54 out of 100 points, compared with 38 out of 100 for the remainder of the sites. This difference was statistically significant. Conclusion While the majority of the Web sites evaluated were authored by academic institutions or physicians, the informational value contained within is of limited completeness. More than one quarter of the Web sites were commercial in nature. There remains significant room for improvement in the completeness of information available for common hand conditions in the internet.

A Study on the Incidence of Hand or Wrist Injuries in CrossFit Athletes.

Purpose The purpose of this study was to investigate the reported rates and characteristics of injuries among CrossFit athletes with specific attention to the hand and wrist. We further sought to identify trends and associations of these injuries by examining demographic data. Methods A questionnaire was created to capture self-reported information on the incidence of hand or wrist injuries and their associations in CrossFit athletes. It was distributed between April 2020 and July 2020 to athletes training at CrossFit affiliated gyms in the New York and Pennsylvania regions. Bivariate logistic regression analysis was used to identify factors correlated with an injury. Results A total of 270 responses (97.5% response rate) were available for final analysis. The median age of respondents was 34 years and 72.2% had been participating in CrossFit for at least two years. CrossFit athletes reported injury rates of 62.2% while engaged in CrossFit training and 20.4% reported an injury specific to the hand or wrist. The majority of hand or wrist injuries occurred after one year of CrossFit training (65.4%). The majority of reported initial injuries occurred to the wrist (75.4%); subsequently, 29.1% reported reinjuring the same region. While 58.2% reported not yet having healed or taking longer than one month to feel fully healed, 72.8% reported returning to unmodified training within one month. Only 15 respondents reported seeking medical attention from a physician for their injury. Physicians generally recommended a training break of over one month, but only two patients reported taking a break this long. Male sex and length of participation in CrossFit were associated with an increased risk of developing a hand or wrist injury. Discussion Hand and wrist injuries represent a significant proportion of injuries among CrossFit athletes. CrossFit practitioners are potentially returning to unmodified training too early following injury, leaving them susceptible to further injury. Physicians and therapists must consider these findings and address both therapies and preventative measures for these types of injuries with their patients.

Cubital Tunnel Syndrome: Current Concepts.

PURPOSE OF REVIEW: Compressive neuropathy of the ulnar nerve across the elbow is a common diagnosis encountered frequently within a hand and upper extremity clinical practice. Appropriate and timely evaluation, diagnosis, objective testing, and evidence-based decisions regarding treatment options are paramount in the optimal care of the patient with this pathology. An understanding of current literature is critical in determining and understanding best practices. RECENT FINDINGS: A thorough review of the recent literature regarding physical examination, diagnostic testing, and nonoperative versus operative results was performed. Regarding physical examination, the glenohumeral internal rotation test and scratch collapse test are more effective and sensitive than traditional maneuvers such as Tinel's testing and the elbow flexion test. Electrodiagnostic testing, magnetic resonance imaging, and ultrasound evaluation have all been shown to be effective in diagnosing cubital tunnel syndrome. However, no single test has proven itself to be superior. Nonoperative treatment can be successful for mild cases of cubital tunnel syndrome. Surgical release techniques comparing open with endoscopic release are equivocal, and in situ release versus transposition techniques show that transposition should not be performed routinely. The diagnosis and treatment of cubital tunnel syndrome do not have a well-defined algorithm based on current literature. The treating physician must therefore utilize the available information to determine a diagnostic and treatment plan individualized to the patient. More rigorous scientific studies are needed to determine the most effective surgical approaches for cubital tunnel syndrome.

Medial Femoral Condyle Periosteal Free Flap for the Treatment of Talus Avascular Necrosis.

BACKGROUND: In patients with avascular necrosis (AVN) of the talus in the precollapse stage unresponsive to conservative measures, joint preservation should be considered. Good results have previously been reported for vascularized bone grafting. The medial femoral condyle (MFC) free flap has recently been introduced, which consists of corticoperiosteal bone. We present a novel surgical technique using a periosteal-only MFC (pMFC) free flap in the treatment of talus AVN. METHODS: We retrospectively reviewed all pMFC free flaps performed from 2016 to 2018 in the precollapse stage of talus AVN. Surgical management included an ankle arthroscopy, talus core decompression, and ipsilateral pMFC free flap to the talus. Foot and Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and visual analog scale (VAS) pain scores were evaluated, and pre- and postoperative imaging studies were assessed by a musculoskeletal-trained radiologist for all patients. Six pMFC free flaps in 5 patients were included in this case series. AVN etiology included idiopathic, posttraumatic, and sepsis-related treatment. All patients were female with an average age of 44.2 (range, 37-67) years. Average postoperative follow-up was 16.9 (range, 6-28) months. RESULTS: Pre- to postoperative FAAM-ADL, ADL single assessment numeric evaluation, and VAS scores showed statistically significant improvement (P < .039). No reoperations or flap complications were observed. There was 1 minor complication, which included postoperative paresthesias at the pMFC harvest site. Postoperative x-rays showed no subsequent collapse, and magnetic resonance imaging (MRI) illustrated progressive improvement of bone marrow edema, decreased surrounding areas of AVN, and decreased joint effusion when compared to preoperative MRI. CONCLUSION: The pMFC free flap is a novel modification of a previously described technique, which appears to have similar results compared to the traditional MFC free flap. It was safe and effective in the short term with excellent clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Telehealth for Upper Extremity Conditions: Perceptions of the Patient and Provider.

The recent coronavirus pandemic has prompted providers to adopt telehealth as a way to maintain contact with their patients on an unprecedented scale. The purpose of this study was to evaluate the perception of care for both patients and physicians using telehealth visits for the management of upper extremity orthopaedic conditions. This study consisted of the analysis of surveys sent to both physicians and patients immediately after the completion of a telehealth visit for an upper extremity condition. Eighty percent of patients responded as "very satisfied" with their encounter. Satisfaction scores were similar for patients seen for a new issue or an existing issue. The use of a video platform was preferable to patients compared with a telephone call. Physicians would have requested a radiograph or offered a steroid injection during a new patient evaluation in 77% of cases. Physicians were less satisfied with the use of telemedicine, particularly when evaluating a new patient. A large majority of patients and physicians alike felt telehealth visits have a role in patient management, acknowledging they would both choose to incorporate "some" of their visits as telehealth evaluations for any particular issue.

The Importance of Preserving the Radial Tuberosity During Distal Biceps Repair.

BACKGROUND: The radial tuberosity contributes to the biceps supination moment arm and the elbow flexion moment. The purpose of our study was to compare the impact of a cortical bone trough versus an anatomic repair on measurements of the forearm supination moment arm and elbow flexion force efficiency. Our hypothesis was that a trough repair would decrease the tuberosity height, the native biceps supination moment arm, and elbow flexion force efficiency compared with an anatomic repair. METHODS: The isometric supination moment arm and elbow flexion force efficiency were measured in ten matched pairs of cadaveric upper limbs. After testing, the geometry of the proximal aspect of the radius was reconstructed with use of stereophotogrammetry. All of the repair sites were three-dimensionally reconstructed to quantify the disturbance of the trough on native anatomy. The tuberosity distance was defined as the distance between the central axis of the radius and the centroid of the respective repair site. RESULTS: Specimens with a trough repair had a 27% lower supination moment arm at 60° of supination (p = 0.036). There were no differences found for pronation or neutral forearm positioning (p > 0.235). Flexion force efficiency was not significantly different between the trough and anatomic repair groups. The average tuberosity distance was 11.0 ± 2.1 mm for the anatomic repairs and 8.3 ± 1.4 mm for the trough repairs (p = 0.003). The percentage of distance lost due to the trough was 25%. Furthermore, the supination moment arm in the supinated position was significantly correlated with the tuberosity distance. CONCLUSIONS: The trough technique resulted in a significant decrease (p = 0.036) in the moment arm of a 60° supinated forearm and a significant reduction (p = 0.003) in radial tuberosity height. The loss of the supination moment arm was correlated with the decrease in tuberosity height, providing evidence that the radial protuberance acts as a mechanical cam. CLINICAL RELEVANCE: The anterior protuberance of the radial tuberosity functions as a supination cam; therefore, consideration should be given to preserve its topographical anatomy during a distal biceps repair.

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.

Incidence of metacarpal fractures in the US population.

BACKGROUND: There are scarce data regarding the epidemiology of metacarpal fractures within the US population. The purpose of this study is to report the epidemiology of metacarpal fractures in the USA using the National Electronic Injury Surveillance System Database (NEISS). METHODS: The NEISS database represents a national probability sample of approximately 100 hospitals in the USA and its territories. The database was queried for metacarpal fractures during the time period 2002-2006. US census data were used to calculate incidence rate (IR) for various demographic criteria. RESULTS: A total of 4,718 metacarpal fractures were identified, representing approximately 160,790 metacarpal fractures. The calculated IR was 13.6 (95 % CI, 13.6-13.67) per 100,000 person-years. The highest IR occurred in the 10-19 age group (IR 38.8; 95 % CI, 38.6-38.9) followed by those 20-29 years of age (IR 28.4; 95 % CI, 28.3-28.5). Metacarpal fractures were found more commonly in males (IR 23; 95 % CI, 22.9-23.1) than females (IR 4.5; 95 % CI, 4.5-4.5), with an incidence rate ratio of 5.08. The most common mechanisms of injury were contact with a wall or door, and falls. The most common setting was in the home, followed by recreational locations. CONCLUSIONS: The estimated incidence of metacarpal fractures presenting for acute hospital care in the USA is 13.6 per 100,000 person-years. Males in the second and third decades of life sustain this injury most commonly. Metacarpal fractures occur frequently in the home or recreational setting, with contact force as the primary mechanism of injury.