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The treatment of ganglion cysts of the wrist remains understudied in the pediatric population, with the literature showing variable recurrence rates following different interventions. This study sought to determine whether surgical and nonsurgical management of pediatric ganglion cysts was associated with improved resolution rates when compared to observation alone.We identified 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012 and 2017. The mean age at presentation was 11.6 ± 5.2 years. Of the patients, 315 had2 years (mean, 50.0 months) of follow-up, either via chart review or telephone callbacks. There were 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable orthosis, and (4) surgical excision.For patients followed2 years, the cyst resolved in 44% (72/163) of those observed. Only 18% (9/49) of those treated with aspiration resolved, and 55% (12/22) of those treated with an orthosis resolved. Surgical excision was associated with resolution of the cyst in 73% (59/81) of patients. Observation had higher rates of resolution compared to aspiration. Orthosis fabrication and observation had similar rates of cyst resolution. Surgery had the highest rates of resolution when compared to observation and aspiration. Patients older than 10 years were less likely to have the cyst resolve with observation (35%; 28/80) than those younger than 10 years (53%; 44/83) at2 years of follow-up.This study did not find evidence that nonsurgical treatments were associated with improved rates of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall highest rate of resolution. Despite the costs and increased clinic time of orthosis fabrication and aspiration, these treatments were not associated with improved rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence compared to observation.Therapeutic IV.

Purpose Shoulder dystocia is the strongest known risk factor for brachial plexus birth palsy (BPBP). Fractures of the clavicle are known to occur in the setting of shoulder dystocia. It remains unknown whether a clavicle fracture that occurs during a birth delivery with shoulder dystocia increases the risk of BPBP or, alternatively, is protective. The purpose of this study was to use a large, national database to determine whether a clavicle fracture in the setting of shoulder dystocia is associated with an increased or decreased risk of BPBP. Materials and methods The 1997 to 2012 Kids’ Inpatient Database (KID) was analyzed for this study. International Classification of Diseases , Ninth Revision (ICD-9) codes were used to identify newborns diagnosed with shoulder dystocia and BPBP as well as a concurrent fracture of the clavicle. Newborns with shoulder dystocia were stratified into 2 groups: dystocia without a clavicle fracture and dystocia with a clavicle fracture. Multivariable logistic regression was used to quantify the risk for BPBP among shoulder dystocia subgroups. Results The dataset included 5,564,628 sample births extrapolated to 23,385,597 population births over the 16-year study period. A BPBP occurred at a rate of 1.2 per 1,000 births. Shoulder dystocia complicated 18.8% of births with a BPBP. A total of 7.84% of newborns with a BPBP also sustained a clavicle fracture. Births with shoulder dystocia and a clavicle fracture incurred BPBP at a rate similar to that for newborns with shoulder dystocia and no fracture (9.82% vs 11.77%). Shoulder dystocia without a concurrent clavicle fracture was an independent risk factor for BPBP (odds ratio, 112.1; 95% confidence interval, 103.5–121.4). Those with shoulder dystocia and clavicle fracture had a risk for BPBP comparable with those with shoulder dystocia but no fracture (odds ratio, 126.7 vs 112.1). Conclusions This population-level investigation suggests that, among newborns with shoulder dystocia, clavicle fracture is not associated with a significant change in the risk of BPBP. Type of study/level of evidence Prognostic II.

Purpose Ganglion cysts of the hand/wrist are frequently managed without surgery but can be treated with surgical excision if there is pain or dysfunction. No studies have examined the specific factors predictive of surgical treatment for pediatric patients. Methods This was a study of pediatric patients (≤18 years) with ganglion cysts of the hand/wrist seen between 2017 and 2019 at 2 institutions. Baseline demographic data were collected in addition to cyst characteristics, Wong-Baker pain scores, and Patient-Reported Outcomes Measurement Information System scores (pain, depression, upper extremity function, anxiety). Multivariable regression was used to determine the factors predictive of surgical intervention at ≥6 months of eligible follow-up. Results A total of 167 patients with a mean age of 10.1 ± 5.3 years were included for analysis. Forty-three (25.7%) underwent surgical excision of their ganglion cyst at means of 2.3 months after the initial visit and 12.6 months after cyst appearance. Sex and cyst location were similar between cohorts. Surgical patients were older (12.1 vs 9.4 years, respectively) and presented to the clinic later after an appearance (10.9 vs 6.5 months, respectively) compared to nonsurgical patients. Surgical patients also had higher pain scores at presentation (median, 3 vs 0, respectively). Cysts receiving surgery were larger than those without surgery (81.4% vs 55.3% >1 cm, respectively). Pain interference Patient-Reported Outcomes Measurement Information System scores were higher in the surgical than the nonsurgical group (45.2 vs 39.6, respectively). In a multivariable analysis, pain scores ≥4 (odds ratio, 3.4) were predictive of surgery for patients ≥3 years, whereas older age (odds ratio, 1.1) and a cyst size >1 cm (odds ratio, 3.3) predicted surgery across all patients. Conclusions Pediatric patients with ganglion cysts who initially present at older ages with moderate/severe pain scores and larger cysts are more likely to ultimately choose surgical excision. Surgeons may observe a preference for earlier surgery in this subset of patients. Type of study/level of evidence Prognostic II.

Purpose Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort. Methods A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores. Results A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores. Conclusions Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function. Type of study/level of evidence Diagnostic II.

Purpose In order to effectively improve value in health care delivery , providers must thoroughly understand cost drivers. Time-driven activity-based costing (TDABC) is a novel accounting technique that may allow for precise characterization of procedural costs. The purpose of the present study was to use TDABC to characterize costs in a high-volume, low-complexity ambulatory procedure (endoscopic vs open carpal tunnel release [CTR]), identify cost drivers, and inform opportunities for clinical improvement. Methods The costs of endoscopic and open CTR were calculated in a matched cohort investigation using TDABC. Detailed process maps including time stamps were created accounting for all clinical and administrative activities for both the endoscopic and the open treatment pathways on the day of ambulatory surgery . Personnel cost rates were calculated accounting for capacity, salary, and fringe benefits. Costs for direct consumable supplies were based on purchase price. Total costs were calculated by aggregating individual resource utilization and time data and were compared between the 2 surgical techniques. Results Total procedural cost for the endoscopic CTR was 43.9% greater than the open technique ($2,759.70 vs $1,918.06). This cost difference was primarily driven by the disposable endoscopic blade assembly ($217), direct operating room costs related to procedural duration (44.8 vs 40.5 minutes), and physician labor. Conclusions Endoscopic CTR is 44% more expensive than open CTR compared with a TDABC methodology at an academic medical center employing resident trainees. Granular cost data may be particularly valuable when comparing these 2 procedures, given the clinical equipoise of the surgical techniques. The identification of specific cost drivers with TDABC allows for targeted interventions to optimize value delivery. Type of study/level of evidence Economic Analysis II.

Purpose The purpose of the study was to determine the long-term results of preaxial polydactyly reconstruction through evaluating strength, range of motion, pain, arthritis, and functional outcomes. Methods Patients having preaxial polydactyly reconstruction 15 to 60 years ago completed the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT). Aggregate scores were compared with those of the general population. Patients completed a clinical evaluation comprising grip strength, pinch strength, side pinch strength, and range of motion. Mean strength and range of motion were compared with the contralateral extremity. Patients had radiographs of the reconstructed thumb to evaluate for arthritis. Results Twenty-five patients, comprising 27 surgical reconstructions, completed patient-reported outcomes questionnaires, and 13 reconstructions underwent clinical and radiographic evaluation. The median follow-up was 36 years. The most common Flatt-Wassel classification was type IV. The mean DASH score was 3.7, similar to the general population mean of 10.1 (SD, 14.5). The mean PROMIS UE CAT score was 51.5, similar to the general population mean of 50 (SD, 10.0). The mean pinch strength, side pinch strength, and grip strength did not differ significantly from the contralateral extremity. There was significantly decreased range of motion at the interphalangeal joint. No patient had pain in the thumb or hand on clinical evaluation. A minority of patients developed radiographic evidence of interphalangeal joint arthritis (15.4%). Nearly half of patients, 46.2%, had angular deformity. Conclusions Preaxial polydactyly reconstruction patients have functional outcomes similar to the general population, despite decreased range of motion at the interphalangeal joint. Patients have maintained pinch strength, side pinch strength, and grip strength. Radiographic findings of arthritis were seen in 15% of patients at follow-up but none of these patients had associated pain. Late angular deformity developed in nearly half of patients, and this highlights the importance of close follow-up until skeletal maturity. Type of study/level of evidence Therapeutic IV.

Purpose To characterize the clinical presentation, common pathogens, antimicrobial susceptibility, and treatment methods associated with pyogenic flexor tenosynovitis (PFT) in pediatric patients. Methods Patients who underwent surgical treatment for PFT at a large tertiary-care children's hospital between 2001 and 2015 were identified. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, culture results, treatment strategies, and early complications. Results Thirty-two patients (71.9% male) with a mean age of 9.5 ± 5.5 years (range, 0.8–19 years) were included. At least 3 Kanavel signs were present on presentation in 62% of the cohort, with all 4 signs identified in 34%. Three children (9%) presented with 0 to 1 Kanavel signs, with semiflexed posturing of the digit as the least commonly (41%) manifested sign. The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (MRSA) (38%), methicillin-sensitive S. aureus (22%), and Pasteurella multocida (13%). Multiple organisms were cultured in 19% of cases. Intravenous antibiotics were administered for a median duration of 4 days (range, 1–16 days) in all cases. Organisms were sensitive to the initial antibiotic regimen in 81% of cases. All methicillin-resistant S. aureus infections were sensitive to vancomycin and trimethroprim-sulfamethoxazole, and 83% were sensitive to clindamycin. Incision and drainage (I&D) was performed in all cases, with 18% of patients requiring repeat I&D. Surgical approaches included limited incision (80%), midaxial incision (13%), and Bruner incision (7%). The average length of hospitalization was 5.1 days. Infection resolved in all cases without readmission. No neurovascular complications were identified. Conclusions The presence of Kanavel signs at presentation are a meaningful indicator of PFT, but are not uniformly present on examination in children and adolescents. Owing to the prevalence of antimicrobial resistance and polymicrobial infection, empirical antibiotic therapy using broad-spectrum agents with MRSA coverage is essential. In our cohort of pediatric patients with PFT of sufficient severity to warrant surgical management, prompt I&D along with culture-guided antibiotics predictably resolves infection. Type of study/level of evidence Therapeutic IV.

Purpose Some patients report a transient increase in pain the day after a corticosteroid injection. We investigated factors associated with greater pain during and the day after a corticosteroid injection for idiopathic trigger finger. Methods A total of 100 patients with trigger finger completed questionnaires measuring heightened illness concern, catastrophic thinking, depression, perceived health, expected pain, pain with injection, and pain the day after injection. We performed bivariate analysis to determine variables associated with pain with injection, next-day pain, and next-day pain greater than 4 points on an 11-point ordinal scale. We entered variables with a significant correlation into multivariable linear regression models. Results The average pain with injection and the day after injection were 4.3 (SD 2.8) and 1.8 (SD 2.0), respectively. Expected pain, heightened illness concern, catastrophic thinking, depression, physician, and gender correlated with pain with injection. A multivariable regression model conducted in backward stepwise fashion demonstrated that physician, depression, expected pain, and female gender explained 28% of the variance in pain with injection. Pain with injection was the only significant predictor of next-day pain and pain greater than 4 points the day after injection. Conclusions Our data suggest that psychosocial factors are the strongest correlates of pain with corticosteroid injection, but a large portion of the variability remains unexplained. Future research will investigate cognitive/behavioral methods for decreasing pain with injection. Type of study/level of evidence Prognostic I.

Purpose To identify the incidence and risk factors for 30-day postoperative morbidity and mortality following operative treatment of distal radius fractures in a multicenter cohort. Methods We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005–2011 for cases of closed distal radius fractures treated operatively with internal fixation. Patient demographics, comorbidities, and operative characteristics were analyzed. Thirty-day postoperative complications were identified and separated into categories of major morbidity or mortality, minor morbidity, and any complication. Risk factors were identified using univariate and multivariate analyses. Results We identified 1,673 cases of closed distal radius fractures managed with internal fixation. The overall incidence of having any early complication was 3%. Major morbidity was 2.1%, which included 4 patient deaths, and minor morbidity was 1%. The most common major morbidity was a return to the operating room (16 patients). The most common minor morbidity was urinary tract infection (6 patients). The multivariate analysis demonstrated ASA class III or IV, dependent functional status, hypertension, and myocardial infarction/congestive heart failure to be significant risk factors for any early complication. There was a 10.0% complication rate in the inpatient group and a 1.3% complication rate in the outpatient group. Conclusions The incidence of early complications following internal fixation for closed distal radius fractures was low, especially in the outpatient group. In the setting of an isolated injury to the distal radius, the data presented here can provide prognostic information for patients during informed consent for what is considered to be an elective procedure. Surgeons should consider risk of morbidity and mortality when considering surgery for patients with noteworthy cardiopulmonary disease, increased ASA class, or poor functional status. Type of study/level of evidence Prognostic II.

Background Congenital radioulnar synostosis (CRUS) refers to an abnormal connection between the radius and ulna due to embryological failure of separation. Derotational osteotomy has been advocated for children with functional limitations, although historically this procedure has been associated with a 36% complication rate including compartment syndrome and loss of correction. Methods A retrospective evaluation of consecutive patients who underwent derotational osteotomy for CRUS at a single institution was performed. Children with functional limitations secondary to excessive pronation were indicated for surgery with a goal of correction to 10 to 20 degrees of pronation. All patients were treated with a standardized surgical technique including careful subperiosteal elevation, rotational osteotomy at the level of the synostosis, control of the osteotomy fragments, appropriate pinning techniques, and prophylactic forearm fasciotomies. Electronic medical records, preoperative radiographs, and postoperative radiographs were reviewed. Results Derotational osteotomy was performed in 31 forearms in 26 children (13 bilateral, 13 unilateral) with a mean age of 6.8 years (range, 3.0 to 18.8 y). The mean clinical follow-up was 46 months (range, 6 to 148 mo). The mean preoperative pronation deformity was 85 degrees (range, 60 to 100 degrees). The mean correction achieved was 77 degrees (range, 40 to 95 degrees), resulting in a mean final position of 8 degrees of pronation (range, 0 to 30 degrees). All patients successfully achieved union by 8 weeks postoperatively. There were no cases of compartment syndrome, vascular compromise, or loss of fixation. The overall complication rate was 12% (2 transient anterior interosseous nerve palsies, 1 transient radial nerve palsy, 1 symptomatic muscle herniation). Both transient anterior interosseous nerve palsies occurred in patients with rotational corrections exceeding 80 degrees. Conclusions Derotational osteotomy can be safely and effectively performed in children with CRUS. Meticulous surgical technique, including control of the osteotomy, judicious pin fixation, and prophylactic fasiotomies, may diminish the risk of neurovascular compromise and loss of correction. Transient anterior interosseous nerve palsies occurred, and may be related to large rotational corrections.

a I c i w n a In B ri ef HE ASSOCIATION BETWEEN radial nerve injury and humeral shaft fracture was described by Berkeley surgeons Holstein and Lewis, who oberved radial nerve palsy in the setting of spiral fracures of the distal third of the humeral shaft wherein the distal bone fragment is always displaced proxially with its proximal end deviated radialward” and hat “the radial nerve is caught in the fracture site.” ubsequent reports have described cases of radial nerve alsy following fractures of the middle third of the shaft f the humerus as well. A recently published anaomical study by Carlan et al. emphasizes that the radial erve is at risk of injury in these 2 regions: (1) along the osterior mid-aspect of the humerus where the nerve ies in direct contact with the periosteum and (2) along he distal lateral humerus where the nerve pierces the ateral intermuscular septum. A recent epidemiological study documented a 9% ncidence of radial nerve injury following humeral shaft racture, whereas a systematic review of the literature oted a 12% incidence. Radial nerve palsy may be ither partial or complete; complete motor loss occurs n approximately 50% of cases. Radial nerve palsy in he setting of humeral shaft fracture can be further lassified as primary or secondary. In primary nerve alsy, loss of function occurs at the time of injury. In econdary nerve palsy, loss of function occurs during he course of treatment. Because prospective randomzed clinical trials have not evaluated treatment of this njury, our clinical decision making has to be based on he empiric evidence garnered from retrospective case eries. In complete primary radial nerve palsy associated