Complex Elbow Fracture-Dislocations: An Algorithmic Approach to Treatment.

Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.

Radiocapitellar and Ulnotrochlear Pressures Increase in a Radial Head Fracture Model: A Cadaveric Biomechanical Analysis.

BACKGROUND: Changes in intra-articular pressure have not been previously described in relation to the management of radial head fractures. We hypothesized that pressure within the radiocapitellar and ulnotrochlear joints would increase with progressive radial head resection, mimicking a displaced radial head fracture, in a cadaveric model. METHODS: Ten cadaveric specimens were tested. Intra-articular pressure sensors were used to measure pressure within the radiocapitellar and ulnotrochlear joints with the forearm in full supination. The elbow was loaded to 100 N in extension, 45° of flexion, and 90° of flexion under the following conditions: (1) intact radial head, (2) 20% radial head resection, (3) 40% radial head resection, and (4) 100% radial head resection. RESULTS: The distribution of pressure between the radiocapitellar and ulnotrochlear joints did not change with sequential, partial resection of the radial head (radiocapitellar joint, between 48.92% and 53.79%; ulnotrochlear joint, between 46.21% and 51.08%). After 20% resection, radiocapitellar peak contact pressure (PCP) increased by 22% (from 1,410 to 1,721.5 kPa) and ulnotrochlear PCP increased by 36% (from 1,319 to 1,797.5 kPa). After 40% resection, radiocapitellar PCP increased by 123% (from 1,410 to 3,145 kPa; p = 0.0003) and ulnotrochlear PCP increased by 105% (from 1,319 to 2,702 kPa; p = 0.007). Ulnotrochlear PCP increased by a total of 159% after complete radial head resection (from 1,319 to 3,415.5 kPa; p = 0.003). CONCLUSIONS: Pressures in the radiocapitellar and ulnotrochlear joints were equally distributed with an intact radial head and after partial resection. Radiocapitellar and ulnotrochlear pressures increased with increasing radial head resection, significantly exceeding 100% of normal after radial head resection of 40% of the anterolateral diameter. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Osteolysis Following the Use of Polyetheretherketone Suture Anchors in Hand and Wrist Surgery: A Preliminary Study.

PURPOSE: The objective of this study was to investigate and describe the presence of osteolysis after implantation of polyetheretherketone (PEEK) suture anchors in the hand and wrist. METHODS: Patients who underwent hand or wrist surgery using PEEK suture anchor(s) at a large academic institution from January 2019 to January 2021 were identified. Patients without accessible intraoperative fluoroscopic imaging were excluded. Patient demographics, type of procedure, and suture anchor material were recorded. The suture anchor tunnel size was measured on sequential radiographs and recorded as percentage change. Descriptive statistics were used to summarize findings. RESULTS: A total of 26 PEEK suture anchors in 14 patients were included, with an average follow-up of 12.0 months (range, 1.5-24.1 months). Twenty-seven percent of the anchors (7/26) demonstrated osteolysis at final follow-up, as defined by enlargement of tunnel size by >30%. In all anchors, the tunnel size increased by 19.1% on average (range, -7.7% to 56.1%) by final follow-up. CONCLUSIONS: Polyetheretherketone suture anchors may be associated with the development of osteolysis in hand and wrist surgery. The clinical implications of osteolysis in the smaller bones of the hand and wrist remain unclear. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Posterolateral Rotatory Instability Develops Following the Modified Kocher Approach and Does Not Resolve Following Interval Repair.

BACKGROUND: The modified Kocher and extensor digitorum communis (EDC)-splitting intervals are commonly utilized to approach the lateral elbow. Iatrogenic injury to the lateral ulnar collateral ligament may result in posterolateral rotatory instability (PLRI). in the present cadaveric study, we (1) evaluated lateral elbow stability following the use of these approaches and (2) assessed the accuracy of static lateral elbow radiographs as a diagnostic tool for PLRI. METHODS: Ten matched-pair cadaveric upper-extremity specimens (n = 20) were randomly assigned to Kocher or EDC-splitting approaches. Specimens underwent evaluation pre-dissection, post-dissection, and following repair of the surgical interval. Clinical evaluation of lateral elbow stability was performed with the lateral pivot-shift maneuver. Radiographic radiocapitellar displacement was evaluated with the fully extended hanging arm test and on lateral elbow 30° flexion radiographs. Paired Wilcoxon signed-rank tests with Bonferroni correction were utilized to compare groups. RESULTS: All Kocher group specimens (10 of 10) developed PLRI on the pivot-shift maneuver following dissection. No EDC-splitting group specimens (0 of 10) developed instability with pivot-shift testing. The fully extended hanging arm test showed no difference in radiocapitellar displacement between groups (p > 0.008). Lateral elbow 30° flexion radiographs in the Kocher group showed an increased radiocapitellar displacement difference (mean, 8.46 mm) following dissection compared with the pre-dissection baseline (p < 0.008). Following repair of the Kocher interval, the radiocapitellar displacement (mean, 6.43 mm) remained greater than pre-dissection (mean, 2.26 mm; p < 0.008). In the EDC-splitting group, no differences were detected in radiocapitellar displacement on lateral elbow radiographs with either the fully extended hanging arm or lateral elbow 30° flexion positions. CONCLUSIONS: The Kocher approach produced PLRI that did not return to baseline conditions following repair of the surgical interval. The EDC-splitting approach did not cause elbow instability clinically or radiographically. The hanging arm test was not reliable for the detection of PLRI. CLINICAL RELEVANCE: The Kocher interval for lateral elbow exposure results in iatrogenic PLRI that is not detectable on the hanging arm test and that does not return to baseline stability following repair of the surgical interval.

Metacarpal Neck Osteochondroma: An Atypical Cause of "Trigger Finger".

"Locking" of the digits is a relatively common patient complaint in hand surgery. Typically, this phenomenon arises from either triggering of tendons at the A1 pulley or subluxation of tendons around the metacarpal head. Although trigger digit and sagittal band injury comprise most diagnoses, clinicians must be aware of rarer entities that alter the underlying osseous anatomy and predispose the digits to "locking." Here, we present a case of metacarpal neck osteochondroma causing subluxation of the index metacarpophalangeal joint radial collateral ligament.

Proximal Hamate Reconstruction of Proximal Pole Scaphoid Nonunion: A Case Series and Analysis of Clinical Outcomes.

BACKGROUND: Small proximal pole scaphoid nonunions present a clinical challenge influenced by fragment size, vascular compromise, deforming forces exerted through the scapholunate interosseous ligament (SLIL), and potential articular fragmentation. Osteochondral autograft options for proximal pole reconstruction include the medial femoral trochlea, costochondral rib, or proximal hamate. This study reports the clinical outcomes of patients treated with proximal hamate osteochondral autograft reconstruction. METHODS: A retrospective review identified patients treated with this surgery from 2 institutions with a minimum 6-month follow-up. Clinical outcomes included the Visual Analog Dcale pain score, 12-item Short-Form survey, abbreviated Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist and forearm range of motion (ROM), radiographic assessment, and complications. We reviewed and compared these outcomes with those of the current published literature. RESULTS: Four patients (mean age: 24 years, 75% men) with a 12.8-month average follow-up (range: 6-20 months) were included. Radiographic union was identified in all cases by 12 weeks (range, 10-12). The average wrist ROM was 67.5% flexion/extension and 100% pronation/supination compared with the contralateral side at the final follow-up. The mean QuickDASH score was 17.6 (SD, 13). No complications were identified. CONCLUSIONS: Proximal pole scaphoid nonunion reconstruction using autologous proximal hamate osteochondral graft demonstrated encouraging clinical and radiographic outcomes. Proximal hamate harvest involves minimal donor site morbidity without a distant operative site, uses an osteochondral graft with similar morphology to the proximal scaphoid, requires no microsurgical technique, and permits reconstruction of the SLIL using the volar capitohamate ligament.

Carpometacarpal Arthroplasty What's the Rule of Thumb?

Carpometacarpal (CMC) arthritis of the thumb is one of the most common pathologies encountered in clinical hand and orthopedic surgery practices. Anatomy of the CMC joint and its biomechanics are theorized to predispose the articulation to laxity and subsequent degenerative changes. Diagnosis of CMC arthritis is primarily based on history, physical examination, and imaging findings, all of which coalesce to guide treatment. There are a multitude of treatment options for CMC arthritis, each with its own set of pearls and pitfalls with treatment decision making shared by surgeon and patient. Continued research and longitudinal data on outcome measures will assist in determining the ultimate "rule of thumb" for the treatment of CMC arthritis.

Demographics of Common Compressive Neuropathies in the Upper Extremity.

BACKGROUND: The purpose of this study was to compare the demographic differences of the most common peripheral nerve compressions in the upper extremity-carpal tunnel syndrome (CTS), ulnar nerve compression (UNC) at the elbow, combined CTS and UNC, radial tunnel syndrome (RTS), and posterior interosseous nerve syndrome (PINS)-as a means to better understand the etiologies of each. METHODS: A retrospective chart review was performed of all patients over the age of 18 years seen at our institution in the 2018 calendar year. International Classification of Diseases, Tenth Revision codes were used to identify patients with diagnoses of upper extremity peripheral nerve compressions. Demographic details and relevant comorbidities were recorded for each patient and compared with controls, who were seen the same calendar year with no neuropathies. χ2 analyses, independent-samples t tests, and multivariate logistic regressions were performed (P < .05). RESULTS: A total of 7448 patients were identified. Those with CTS were mainly women, former smokers, and diabetic (all P < .001) and with a greater average body mass index (BMI) (P = .006) than controls. Patients with UNC were more often men and younger when compared with controls (both P < .001). A history of smoking, diabetes, and average BMI were similar between patients with UNC and controls (all P > .05). Those patients with combined CTS/UNC were mainly men, former smokers, and diabetic (all P < .001) when compared with controls. Patients with RTS/PINS were also mostly men (P = .007), diabetic (P = .042), and were more often current smokers (P < .001). CONCLUSIONS: The demographics of patients with various compressive neuropathies were not homogeneous, suggesting different etiologies.

A Brief History of Tendon Transfer and, Specifically, the Opposition Tendon Transfer.

The development of tendon transfers is it relatively recent evolution in orthopedic surgery. Drobnik performed the first upper extremity tendon transfer in 1894 for a patient with radial nerve palsy, which marks the beginning of a field that developed rapidly. By 1918, Steindler had performed his now famous "opponensplasty" in which he rerouted the flexor pollicis longus tendon to the radial base of the proximal pha- lanx. In the subsequent decades, numerous surgeons offered alternative methods to restore thumb opposition. Names now synonymous with hand surgery, such as Huber, Littler, Howell, Camitz, Royle, Bunnell, and Burkhalter, would all leave a mark on the history of opposition transfers. In this review we discuss the history of tendon surgery and trans- fers, focusing on the procedure of thumb opposition transfer.

The First Successful Combined Full Face and Bilateral Hand Transplant.

BACKGROUND: Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, the authors present the first successful combined full face and bilateral hand transplant. METHODS: A 21-year-old man presented for evaluation with sequelae of an 80 percent total body surface area burn injury sustained after a motor vehicle accident. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined face and bilateral hand transplantation. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. RESULTS: Combined full face (i.e., eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (i.e., forearm level) was performed over 23 hours on August 12 to 13, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At 8 months, the patient was approaching functional independence and remained free of acute rejection. He had significantly improved range of motion, motor power, and sensation of the face and hand allografts. CONCLUSIONS: Combined face and bilateral hand transplantation is feasible. This was the most comprehensive vascularized composite allotransplantation procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.

Penlight versus Smartphone: Diagnostic Efficacy of Transillumination.

Background: The purpose of this study was to compare the diagnostic accuracy of a smartphone flashlight to a conventional penlight with regards to transillumination of simulated soft tissue masses of the hand and wrist. Methods: Eight participants performed transillumination assessments in a fresh frozen cadaver upper extremity model. Spheres measuring 9.5 mm were used to simulate fluid-filled or solid soft tissue masses. Two spheres were placed on the volar aspect and two on the dorsal aspect of the wrist. These were then evaluated with either a smartphone flashlight or penlight. Participants noted whether each sphere did or did not transilluminate. Each participant performed two evaluations at an interval of 3 weeks. Results: The overall sensitivity, specificity and accuracy of the smartphone were 100%, 44% and 72%, respectively. The overall sensitivity, specificity and accuracy of the penlight were 100%, 75% and 88%, respectively. The difference in accuracy between the smartphone group and penlight group was statistically significant (p = 0.029). The kappa value, indicating intra-observer agreement, for the smartphone group and penlight group was 0.76 and 0.76, respectively. Conclusion: In conclusion, transillumination with a penlight is a viable adjunct to the examination of soft tissue masses of the hand and wrist. The use of a smartphone flashlight, while convenient, is less accurate than a penlight and can lead the examiners to misinterpret the composition of soft tissue masses. Level of Evidence: Level IV (Diagnostic).

Updates on Distal Radius Fractures Past, Present, and Complications.

Before the 1900s, distal radius fractures were misdiagnosed as radiocarpal dislocations and most were treated nonoperatively. Between the 1900s and 1920s there were several anesthesia and antiseptic advancements that led to the advancement of surgical interventions. Then after the continued use and implementation of radiographs in orthopedics, radiographic parameters allowed for a critical analysis of treatment and patient outcomes that led to the further advancement of distal radius fracture treatment. This review will detail the historical content that led us to current practices. Additionally, current methods are critiqued, and common complications are reviewed in order to allow orthopedic surgeons to avoid these complications today.

Understanding Acute Distal Radioulnar Joint Instability.

Acute instability of the distal radioulnar joint (DRUJ) is often underestimated but can cause devastating loss of forearm and wrist form and function. These traumatic injuries can be caused by disruption of the triangular fibrocartilage complex, the interosseous membrane, or fractures of the radius or ulna, and a comprehensive understanding of the anatomy involved is paramount to the adequate treatment of these injuries. While stable DRUJ instability can be treated with immobilization, often surgical intervention is required and is based on the anatomical restraints to the DRUJ that are disrupted.

Evaluation and Management of Carpal Fractures Other Than the Scaphoid.

Fractures of the carpus can be debilitating injuries and often lead to chronic pain and dysfunction when not properly treated. Although scaphoid fractures are more common, fractures of the other carpal bones account for nearly half of all injuries of the carpus. Often missed on initial presentation, a focused physical examination with imaging tailored to the suspected injury is needed to identify these fractures. In addition to plain radiographs, advanced imaging such as CT and MRI are helpful in diagnosis and management. Treatment of carpal fractures is based on the degree of displacement, stability of the fracture, and associated injuries. Those that require surgical fixation often affect the congruency of the articular surfaces, are unstable, are at risk for symptomatic nonunion, are associated with notable ligamentous injury, or are causing nerve or tendon entrapment. Surgical strategies involve percutaneous Kirschner wires, external fixation, screws and/or plates, excision, or fusion for salvage. Owing to the intimate articulations in the hand, small size of the carpal bones, and complex vascular supply, carpal fracture complications include symptomatic nonunion, osteonecrosis, and posttraumatic arthritis.

Anomalous Courses of the Palmar Cutaneous Branch of the Median Nerve in Relation to the Flexor Carpi Radialis Tendon for ORIF of Distal Radius Fractures.

Background: The purpose of this study was to prospectively document the incidence of variations in the course of palmar cutaneous branch of the median nerve (PCBMN) that may increase the risk of injury to the nerve during the flexor carpi radialis (FCR) approach. We hypothesize that the incidence of anomalous branching of the PCBMN around the FCR sheath will be approximately 5%. Methods: All cases that met inclusion criteria between November 2013 and March 2018 were included. The operating surgeon made the final decision for operative intervention using the FCR approach. Each surgeon performed the standard FCR approach to the distal radius. The branching location from the median nerve, the relationship to the FCR sheath, and the course of the PCBMN were recorded. Results: In total, 101 distal radius fractures were included. The average branching point of PCBMN was 5.2 cm from the distal wrist crease (range = 3.3-9.0). There were 26 anomalous branching patterns of PCBMN. Nineteen (18.8%) crossed volar, dorsal, or ran within the FCR sheath. Six PCBMN were found within the FCR sheath, 1 penetrated the FCR sheath, 6 crossed volar to the FCR sheath, and 6 were dorsal to the FCR tendon sheath. When comparing the branching patterns of the PCBMN from the median nerve, 4 branched from the volar aspect, 2 branched from the dorsal aspect, and 1 branched from the ulnar aspect of the median nerve. Conclusions: Variation in the course of the PCBMN relative to the FCR sheath is more than previously thought and can be expected in approximately 18.8% of patients.

Preparatory Time-Related Hand Surgery Operating Room Inefficiency: A Systems Analysis.

Background: No study exists on preparatory time-from patient's entrance into the operating room to skin incision-and its role in hand surgery operating room inefficiency. The purpose of this study was to investigate the length and variability of preparatory time and assess the relationship between several variables and preparatory time. Methods: Consecutive upper extremity cases performed for a period of 1 month by hand surgeons were reviewed at 3 surgical sites. Preparatory time was compared across locations. Cases at one location were further analyzed to assess the relationship between preparatory time and several variables. Both traditional statistical methods and Shewhart control charts, a quality control tool, were used for data analysis. Results: A total of 288 cases were performed. The mean preparatory times at the 3 sites were 25.1, 25.7, and 20.7 minutes, respectivley. Aggregated preparatory time averaged 24.4 (range 7-61) minutes, was 75% the length of the surgical time, and accounted for 34% of total operating room time. Control charts confirmed substantial variability at all locations, signifying a poorly defined process. At a single site, where 189 cases were performed by 14 different surgeons, there was no difference in preparatory time by case type, American Society of Anesthesiologists status, or case start time. Preparatory time varied by surgeon and anesthesia type. Conclusions: Preparatory time was found to be a source of inefficiency, independent of the surgical site. Control charts reinforced large variations, signifying a poorly designed process. Surgeon seemingly plays an important, albeit likely indirect, role. Efforts to improve operating room workflow should include preparatory time.

Surgical Management of Scaphotrapeziotrapezoid Arthritis.

Scaphotrapeziotrapezoid (STT) arthritis occurs commonly with basal joint arthritis, but can also occur in isolation or in conjunction with other patterns of wrist arthritis, such as scapholunate advanced collapse. Surgical options depend on the specific clinical scenario encountered. Isolated STT arthritis was classically managed with arthrodesis, but is now often addressed with distal scaphoid resection (open or arthroscopic), trapeziectomy (partial or complete) and partial trapezoid resection, or implant arthroplasty. Development of postoperative dorsal intercalary segment instability is a notable concern with any of these techniques. STT arthritis in conjunction with basal joint arthritis can be managed effectively with trapeziectomy and either partial trapezoid excision or distal scaphoid excision. STT arthritis with scapholunate advanced collapse is uncommon, but can be managed with proximal row carpectomy or scaphoidectomy and four-corner fusion. If basal joint arthritis is also present, trapeziectomy can additionally be performed, but grip strength is likely to be substantially diminished.

Surgical Site Infection After Open Upper Extremity Fracture and the Effect of Urgent Operative Intervention.

OBJECTIVES: To identify which factors are predictive of surgical site infection in upper extremity fractures, and to assess whether the timing of operative debridement influences infection risk. DESIGN: Retrospective database review. SETTING: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. PATIENTS: Patients in the NSQIP database with fractures involving the upper extremity. INTERVENTION: Surgical management of upper extremity fracture, including operative debridement for open injuries. MAIN OUTCOME MEASUREMENTS: Surgical site infection, including both superficial and deep infections. RESULTS: A total of 22,578 patients were identified, including 1298 patients with open injuries (5.7% of total). The overall wound infection rate was 0.79%. Patients with open injuries were found to have a higher incidence of infection compared with those with closed injuries (1.7% vs. 0.7%, P < 0.001). Independent risk factors for 30-day infection included open fracture diagnosis, obesity, smoking, and American Society of Anesthesiolgists class >2 (all P < 0.05). Of patients with open fractures, 79.7% were taken expediently to the operating room. The rate of infection did not differ based on whether surgery was performed expediently or not (1.8% vs. 1.1%, P = 0.431). CONCLUSIONS: Based on an analysis of the NSQIP database, the overall risk of surgical site infection following intervention for open or closed upper extremity fractures remains low. Risk factors for infection include open injury, obesity, and cigarette smoking. There was no difference in the infection rate based on the urgency of operative debridement. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Open and Closed Hand Fractures and the Effect of Urgent Operative Intervention.

PURPOSE: To establish and compare the incidence of 30-day postoperative infection in surgically managed open and closed metacarpal and phalangeal fractures, and to determine whether open fractures treated urgently had a lower incidence of postoperative infection. METHODS: We conducted a retrospective analysis of patient demographics, comorbidities, and 30-day infection rates of patients undergoing operative fixation of metacarpal, proximal, or middle phalanx fractures from 2008 to 2015 using the American College of Surgeons' National Surgical Quality Improvement Program database. A total of 3,506 patients were identified and patient variables and infection incidence were compared between open and closed injuries, as well as open injuries managed within 1 day of admission and those treated on an elective basis or treated more than 1 day after admission. Bivariate analysis was used to determine independent risk factors for postoperative infection. RESULTS: Although 34.2% of open hand fractures were taken urgently to the operating room, the diagnosis of open fractures along with nonurgent surgical treatment for open fractures was associated with a low incidence of postoperative infection. In addition, smoking was a risk factor for postoperative infection although anatomic location (phalanx vs metacarpal) was not. CONCLUSIONS: Patients undergoing surgery for metacarpal or proximal/middle phalangeal fractures are not at greater risk for infection based on the diagnosis of open fracture alone. In addition, patients with open fractures who are taken to the operating room more than 1 day from presentation did not have a higher incidence of infection. Smoking is associated with increased 30-day infection rates after surgery, and surgeons should identify these patients for preoperative risk stratification, counseling, and postoperative wound monitoring. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.