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Purpose of review We review the outcomes and future challenges associated with pediatric vascularized composite allotransplantation, including follow-up data from our bilateral pediatric hand-forearm transplantation. Recent findings In 2015, the first heterologous pediatric upper extremity hand-forearm transplant was performed at the Children's Hospital of Philadelphia, and in 2019, the first pediatric neck reconstructive transplantation was performed in Poland. The 5-year follow-up of the pediatric upper extremity recipient demonstrates similar growth rates bilaterally, an increase in bone age parallel to chronologic age, and perhaps similar overall growth to nontransplant norms. The pediatric upper extremity recipient continues to make gains in functional independence. He excels academically and participates in various extracurricular activities. Future challenges unique to the pediatric population include ethical issues of informed consent, psychosocial implications, limited donor pool, posttransplant compliance issues, and greater life expectancy and therefore time to inherit the many complications of immunosuppression. Summary Currently, we recommend pediatric vascularized composite allotransplantation (VCA) for bilateral upper extremity amputees, preferably on immunosuppression already, and those patients who would have the most potential gain not available through standard reconstructive techniques while being able to comply with postoperative immunosuppression protocols, surveillance, rehabilitation, and follow-up.

Background The best methods to assess surgical knowledge are still debated. The authors used a non-multiple-choice test as a pre- and post-conference assessment to measure residents' knowledge gains with comparison to a standard summative assessment tool. Methods At one didactic conference, plastic surgery residents at a single institution were given a pre-test of drawing and labeling structures in the extensor mechanism of the finger and within the carpal tunnel. The quiz was followed by a lecture on the same material and a subsequent post-test. Scores were correlated with in-service exam performance. Results Pre-test scores (n = 13) were positively correlated with postgraduate year (PGY) until PGY-3. Performance on labeling structures was higher than performance on the respective drawing prompt. Residents' ability to label structures increased more strongly with PGY than their ability to draw structures. The post-test (n = 8) demonstrated that teaching improves performance on labeling questions (pre-test score = 62%; post-test score = 87%). Improvement was observed across all PGYs. Pretest results were positively correlated with in-service exam performance. Conclusions Our study suggests that a knowledge test focused on drawing and labeling structures given to surgical residents is a valid, nontraditional method for assessing resident knowledge. Such a quiz would offer programs an alternative method for regularly evaluating residents aside from in-service questions, in order to identify residents who may need targeted training for the in-service exam and to inform teaching plans.Additionally, residents could use quiz feedback to guide study efforts and prime conference-related learning.

BACKGROUND Cutaneous mold infections occur infrequently but can be life-threatening in immunocompromised children. The literature regarding its surgical management is limited. This study aims to describe the surgical management and outcomes of cutaneous mold infections in immunocompromised children. METHODS Hospitalized patients receiving a skin biopsy at a single pediatric hospital in 2003 to 2017 were identified. Inclusion criteria were immunocompromised status, younger than 21 years, and surgical excision of a confirmed cutaneous mold infection. Patient information, details of immunosuppression, operative details, and 6-month postoperative and disease outcomes were collected. RESULTS Seventeen patients (21 lesions) were identified with an average age of 6.8 years (range = 0.2-19.5 years). Affected anatomic regions included limb (15, 71%), chest (2, 10%), axilla, back, abdomen, and head (1 or 5% each). Excisions occurred, on average, within 1.7 days of initial biopsy (range = 0-7 days). When specified, margins were 0.5 to 2.0 cm, and surgeons used intraoperative fungal detection techniques in 8 cases (47%). Definitive closure was achieved by secondary intention/dressings changes (9, 43%), skin graft (7, 33%), a skin substitute (2, 10%), immediate primary closure (2, 10%), and delayed primary closure (1, 5%). Overall, 14 patients were alive 6 months after resection (82%). CONCLUSIONS This study is the first to critically evaluate the methodology for surgical resection of cutaneous fungal infections in immunocompromised children. We suggest timely excision once diagnosed with, at minimum, 0.5-cm margins and intraoperative pathologic study when considering surgical treatment for this rare but serious infection.

Background Physician burnout is intimately associated with institutional losses, substance abuse, depression, suicidal ideation, medical errors, and lower patient satisfaction scores. Objectives By directly sampling all US plastic and reconstructive surgery residents, this study examined burnout, medical errors, and program-related factors. Methods Cross-sectional study of data collected from current US plastic and reconstructive surgery residents at Accreditation Council for Graduate Medical Education–accredited programs during the 2018 to 2019 academic year. Previously validated survey instruments included the Stanford Professional Fulfillment and Maslach Burnout Indices. Additional data included demographics, relationship status, program-specific factors, and admission of medical errors. Results A total of 146 subjects responded. Residents from each postgraduate year (PGY) in the first 6 years were well represented. Overall burnout rate was 57.5%, and on average, all residents experienced work exhaustion and interpersonal disengagement. No relation was found between burnout and age, gender, race, relationship status, or PGY. Burnout was significantly associated with respondents who feel they matched into the wrong program, would not recommend their program to students, do not feel involved in program decisions, reported increasing hours worked in the week prior, feel that they take too much call, reported making a major medical error that could have harmed a patient, or reported making a lab error. Conclusions This study directly examined burnout, self-reported medical errors, and program suitability in US plastic and reconstructive residents based on validated scales and suggests that burnout and some medical errors may be related to program-specific, modifiable factors, not limited to, but including, involvement in program-related decisions and call structure.

Background: Upper extremity injuries represent one of the most common pediatric conditions presenting to emergency departments (EDs) in the United States. We aim to describe the epidemiology, trends, and costs of pediatric patients who present to US EDs with upper extremity injuries. Methods: Using the National Emergency Department Sample, we identified all ED encounters by patients aged

Purpose E-learning is rapidly growing in medical education, overcoming physical, geographic, and time-related barriers to students. This article critically evaluates the existing research on e-learning in plastic surgery. Methods A systematic review of e-learning in plastic surgery was conducted using the PubMed/MEDLINE, Scopus, and Embase databases. Studies were limited to those written in English and published after 1995 and excluded short communications, letters to the editor, and articles focused on in-person simulation. Results A total of 23 articles were identified. Represented subspecialties include breast, burns, craniofacial/pediatrics, hand, and microsurgery. Most e-learning resources target surgeons and trainees, but a small number are for patients, parents, and referring physicians. Users reported high levels of satisfaction with e-learning and significant gains in knowledge after completion, although there may be more variable satisfaction with teaching technical skills. Two studies showed no differences in knowledge gains from e-learning compared with traditional learning methods. Subgroup analysis showed greater benefit of e-learning for novice learners when evaluated. Surveys of plastic surgeons and trainees showed high interest in and growing utilization of e-learning. Conclusions Research in plastic surgery e-learning shows high user satisfaction and overall improvements in learning outcomes with knowledge gains equivalent to traditional teaching methods and greater benefit in novice learners. Thus, e-learning can serve an important role in plastic surgery education, especially in the current state of social distancing. Future work should aim to define learner preferences and educational needs and better establish how e-learning can augment plastic surgical education, particularly among other teaching methods.

BACKGROUND In 2015, the first bilateral pediatric hand-forearm transplant was performed in an 8-year-old boy. The growth rate of the transplanted upper extremities was unknown at the time. METHODS Forearm and hand radiographs were obtained annually. Radius and ulna measurements were performed by multiple coauthors and mathematically normalized using a standardized methodology. The Greulich and Pyle atlas was used to estimate hand bone age. RESULTS From July of 2015 to July of 2019, unadjusted bone length (metaphysis to metaphysis) increased 38.8 and 39.6 mm for the left radius and ulna, and 39.5 and 35.8 mm for the right radius and ulna, respectively. Distal physes of the donor limbs increasingly contributed to overall bone length relative to proximal physes. Normalized growth between the two limbs was statistically similar. At each annual follow-up, the bone age increased by 1 year. CONCLUSIONS Successful pediatric hand-forearm transplantation offers the advantage of growth similar to that of nontransplanted pediatric patients. The transplanted distal physes contributes more to the overall growth, paralleling normal pediatric growth patterns. Chronologic age parallels the increase in bone age. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.

Background:. Childhood opioid consumption is potentially deleterious to cognitive development and may predispose children to later addiction. Opioids are frequently prescribed for outpatient surgery but may not be necessary for adequate pain control. We aimed to reduce opioid prescriptions for outpatient pediatric skin and soft tissue lesion excisions using quality improvement (QI) methods. Methods:. A multidisciplinary team identified drivers for opioid prescriptions. Interventions were provider education, improving computer order set defaults, and promoting non-narcotic pain control strategies and patient-family education. Outcomes included percentage of patients receiving opioid prescriptions and patient-satisfaction scores. Data were retrospectively collected for 3 years before the QI project and prospectively tracked over the 8-month QI period and the following 18 months. Results:. The percentage of patients receiving an opioid prescription after outpatient skin or soft tissue excision dropped significantly from 18% before intervention to 6% at the end of the intervention period. Patient-reported satisfaction with pain control improved following the QI intervention. Satisfaction with postoperative pain control was independent of closure size or receipt of a postoperative opioid prescription. Intraoperative use of lidocaine or bupivacaine significantly decreased the incidence of postoperative opioid prescription in both bivariate and multivariate analyses. Results were maintained at 18 months after the conclusion of the QI project. Conclusion:. Raising provider awareness, educating patients on expected postoperative pain management options, and prioritizing non-narcotic medications postoperatively successfully reduced opioid prescription rates in children undergoing skin and soft tissue lesion excisions and simultaneously improved patient-satisfaction scores.

We present a case of a 26-year-old right hand dominant male landscaper with a slow growing right ring finger subungual mass. MRI confirmed a 0.9 × 1.5 × 0.9 cm well circumscribed subungual mass believed to be consistent with a glomus tumor, although size and symptoms were not consistent with that diagnosis. The mass was completely excised and diagnosis of schwannoma was confirmed by H&E histology. A literature search was performed utilizing the term “subungual schwannoma.” Four case reports were found describing this diagnosis in the hand as well as a single case report describing it in the foot. In summary, this is a 26-year-old male who presents with a schwannoma in the unusual subungual location. Although rare, based on our case and the existing literature, subungual schwannomas should be included in the differential diagnosis of a slow growing subungual mass, particularly if symptoms and exam are inconsistent with more common etiologies.

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.

Background In 2017, our institution initiated a cadaver laboratory-based course dedicated to teaching reconstructive microsurgery indications, preoperative planning, and flap dissection. The goals of this study are to describe the demographics and experience of participants/instructors and to evaluate the learning objectives and effectiveness of the course. Methods Penn Flap Course (PFC) participants were sent an anonymous survey at the inaugural PFC 2017. Then, in 2019, both instructors and participants were sent a more comprehensive survey. Surveys included questions regarding demographics, training background, experiences in practice and/or training, and course evaluation. Results At PFC 2017, participant response rate was 25% (12/44), and the primary reason for attending the course was to observe and learn from instructor dissections (66.7%). At PFC 2019, the response rate was 77.3% (17/22) for faculty and 73.0% (35/48) for participants. Both in 2017 and 2019, the vast majority of participants reported perceived improvement in understanding of flap dissection principles across all anatomic domains (94.3%–100%). In 2019, when asked about their background experience, the majority of participants reported comfort performing arterial and venous anastomosis without supervision (71%–77%) and being least comfortable with head and neck (H&N) microsurgery (mean comfort level: 5.2/10). Half of the participants (e.g., residents) find the presence of a microsurgery fellow at their institution useful to their educational experience. Instructors with additional fellowship training in microsurgery reported performing a higher volume of free flaps per week (7 vs. 2.3) and per year (94.2 vs. 27.8; p Conclusion Participants feel least comfortable with H&N microsurgical reconstruction. Surgical faculty with microsurgical fellowship training performs greater volume of microsurgical cases with a trend toward more H&N reconstruction. A cadaver/lecture-based flap course is an effective way to improve participants' perceived confidence and understanding of complex flap and microsurgical reconstructive procedures.

Introduction Mohs surgery and reconstruction has enabled tissue-preserving resection of cutaneous malignancies. The goal of our case series evaluation is to present reconstructive techniques and functional outcomes in patients undergoing digit-sparing treatment for primary melanoma. Materials and Methods A chart review was performed to identify consecutive patients undergoing Mohs surgery and reconstruction for melanoma of the digits. Quality of life (QOL) survey was performed to assess function after the procedure. Results Thirty-two patients (13 hand, 19 foot, Age: 65.03 +/–17.78 years) who were undergoing Mohs surgery were identified. No recurrence was identified with an average follow-up of 16.1 months (1–95 months). The average defect size was 5.79 +/–4.54 cm 2. Reconstruction was performed 0–4 days after resection. The most common techniques included full-thickness skin graft (FTSG) (N = 7), collagen matrix + FTSG (N = 4), and volar advancement flap (N = 7). The reconstructive technique choice appears correlated with defect size (p = 0.0125). Neuro-QOL upper extremity survey results showed a difference that approached statistical significance between patients who underwent digit-sparing treatment (n = 7) versus direct to amputation controls (n = 5) (p = 0.072). No survey differences between digit-sparing treatment (n = 10) and amputation (n = 8) were identified in the lower extremity (p = 0.61). Conclusion Our results show digit-sparing treatment can confirm clear surgical margins and a trend toward improvement in upper extremity function compared with immediate amputation.

Author(s): Diamond, Shawn; Lundy, Jonathan B; Weber, Erin L; Lalezari, Shadi; Rafijah, Gregory; Leis, Amber; Gray, Benjamin L; Lin, Ines C; Gupta, Ranjan | Abstract: PurposeLimited data exist regarding volumetric trends and management of upper-extremity emergencies during periods of social restriction and duress, such as the coronavirus disease 2019 pandemic. We sought to study the effect of shelter-in-place orders on emergent operative upper-extremity surgery.MethodsAll patients undergoing emergent and time-sensitive operations to the finger(s), hand, wrist, and forearm were tracked over an equal number of days before and after shelter-in-place orders at 2 geographically distinct Level I trauma centers. Surgical volume and resources, patient demographics, and injury patterns were compared before and after official shelter-in-place orders.ResultsA total of 58 patients underwent time-sensitive or emergent operations. Mean patient age was 42 years; mean injury severity score was 9 and median American Society of Anesthesiologist score was 2. There was a 40% increase in volume after shelter-in-place orders, averaging 1.4 cases/d. Indications for surgery included high-energy closed fracture (60%), traumatic nerve injury (19%), severe soft tissue infection (15%), and revascularization of the arm, hand, or digit(s) (15%). High-risk behavior, defined as lawlessness, assault, and high-speed auto accidents, was associated with a significantly greater proportion of operations after shelter-in-place orders (40% vs 12.5%; P l .05). Each institution dedicated an average of 3 inpatient beds and one intensive care unit-capable bed to upper-extremity care daily. Resources used included an average of 115 minutes of daily operating room time and 8 operating room staff or personnel per case.ConclusionsHand and upper-extremity operative volume increased after shelter-in-place orders at 2 major Level I trauma centers across the country, demanding considerable hospital resources. The rise in volume was associated with an increase in high-risk behavior.Type of study/level of evidenceTherapeutic IV.

Arthroscopic dorsal wrist ganglionectomy is demonstrably a safe procedure with recurrence rates comparable to open surgery. We present a patient with wrist pain following arthroscopic ganglion excision. MRI and arthroscopic findings showed a large dorsal capsular defect, synovial fistula to the fourth extensor compartment, and dorsal radiocarpal ligament resection. Ligament reconstruction and capsular imbrication resolved her symptoms. We postulate that this complication resulted from a large capsular resection. Because we feel that it can be difficult to judge the size of the debridement through an arthroscope, the need for adequate capsular resection in dorsal wrist ganglionectomy needs to be balanced by consideration of potential complications from more aggressive capsular debridement, and thus we feel that capsular resection should be limited to no more than 1 cm2.

As the field of vascularized composite allotransplantation continues to expand, new upper extremity transplant candidates are being considered. We recently evaluated a bilateral amputee who had a mid-forearm amputation and a contralateral metacarpal hand amputation. In the latter limb, a "partial" hand transplant that preserved the majority of the patient's existing hand, including a partially severed thumb with intact thenar muscle function, was proposed. The feasibility of this partial hand transplant was studied in fresh-frozen cadaver limbs. This report details the proposed approach, the cadaveric dissections, and the lessons learned from these dissections. Issues of osteosynthesis, microvascular planning, and intrinsic muscle recovery are discussed, all of which are critical considerations for partial hand transplant candidates. Ultimately, the partial hand approach was felt to be inferior to a more conventional distal forearm transplant in this particular candidate. Practical, functional, and ethical implications of such decision are presented.

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.

Summary Background Although heterologous vascular composite allotransplantation has become a burgeoning treatment option for adult amputees, there have been no successful cases previously reported in children. Here, we describe the surgical, immunological, and neurorehabilitation details with functional outcomes 18 months after heterologous bilateral hand and forearm transplantation in an 8-year-old child with quadrimembral amputations and a previous kidney transplant. Methods 2 years of extensive preparation by medical and surgical teams preceded the hand–forearm transplantation of this child. The initial immunosuppressive protocol included thymoglobulin, tacrolimus, prednisone, and mycophenolate mofetil. In July, 2015, our vascularised composite allotransplantation team did the first bilateral hand and forearm transplantation in a child, an 8-year-old boy with previous living-related kidney transplantation. The surgery included four teams working simultaneously on the donor and recipient limbs, aided by customised cutting guides that aimed to reduce ischaemia time. Following an extended length of time in hospital, skin biopsies and close monitoring of renal function and drug concentrations occurred weekly for the first 3 months and were slowly tapered to monthly, and then quarterly. Skin biopsies were also done when tissue rejection was suspected. Paediatric-specific rehabilitation techniques were applied to promote patient engagement during rehabilitation. Progress was assessed by monthly sensory and motor function tests during routine clinic visits and with serial functional brain imaging studies, including structural brain MRI, magnetoencephalography and transcranial magnetic stimulation. Findings The surgery lasted 10 h and 40 min. Vascular revision of the ulnar artery was required a few hours postoperatively. There were no further immediate postsurgical complications. Rejection episodes occurred throughout the first year but were reversed. An increase in serum creatinine led to the addition of sirolimus at 3 months after transplantation with concomitant reduction in tacrolimus targets. Sensibility to light touch was present by 6 months after transplantation. Intrinsic hand muscle innervation was present by 7–10 months after transplantation. At 18 months, the child had exceeded his previous adapted abilities. As of 18 months after transplantation surgery he is able to write and feed, toilet, and dress himself more independently and efficiently than he could do before transplantation. He remains on four immunosuppressive medications and functional neuroimaging studies have shown motor and somatosensory cortical reorganisation. Interpretation Hand transplantation in a child can be surgically, medically, and functionally successful under carefully considered circumstances. Long-term data on the functional trajectory, neurological recovery, psychological sequelae, and the potential late effect of immunosuppression are still needed to support broader implementation of paediatric vascular composite allotransplantation. Funding The Children's Hospital of Philadelphia.

Background Efforts to standardize hand surgery training during plastic surgery residency remain challenging. We analyze the variability of operative hand experience at U.S. plastic surgery residency programs. Methods Operative case logs of chief residents in accredited U.S. plastic surgery residency programs were analyzed (2011-2015). Trends in fold differences of hand surgery case volume between the 10th and 90th percentiles of residents were assessed graphically. Percentile data were used to calculate the number of residents achieving case minimums in hand surgery for 2015. Results Case logs from 818 plastic surgery residents were analyzed of which a minority were from integrated (35.7%) versus independent/combined (64.3%) residents. Trend analysis of fold differences in case volume demonstrated decreasing variability among procedure categories over time. By 2015, fold differences for hand reconstruction, tendon cases, nerve cases, arthroplasty/arthrodesis, amputation, arterial repair, Dupuytren release, and neoplasm cases were below 10-fold. Congenital deformity cases among independent/combined residents was the sole category that exceeded 10-fold by 2015. Percentile data suggested that approximately 10% of independent/combined residents did not meet case minimums for arterial repair and congenital deformity in 2015. Conclusions Variable operative experience during plastic surgery residency may limit adequate exposure to hand surgery for certain residents. Future studies should establish empiric case minimums for plastic surgery residents to ensure hand surgery competency upon graduation.

Background: Hand conditions commonly present to the emergency department (ED), yet data are lacking regarding the magnitude of hand-related conditions in the emergency setting. The purpose of this study is to describe the burden and quantify the health care resource utilization of hand conditions seen in EDs across the United States. Methods: Using the National Emergency Department Sample, we identified all ED encounters by patients at least 18 years of age that were associated with a hand condition in 2009 to 2012. The primary outcomes were prevalence, etiology, and associated health care charges for specific categories of hand conditions. Results: The final sample included 34.4 million ED encounters associated with a common hand condition generating $180.4 billion in health care charges. The volume of hand-related presentations varied in a predictable and cyclical manner, peaking in July and waning in December of each year. Trauma was the most common etiology (77.5%) predominantly due to falls (26.2%) and lacerations (19.7%). Over 4 years, the volume of ED encounters rose (5% increase, P < .001) and as did the resulting health care charges (24.6% increase, P < .001). Conclusions: Our study confirms that hand-related conditions contribute significantly to ED volume and consume a growing quantity of health care resources in the United States. The volume of patients presenting to EDs with hand-related conditions fluctuates cyclically throughout the year. Open wounds are the most common cause of presentation and mostly occur in young adults, followed by joint pain, contusions, and fractures.

Background: Unexplained wrist pain is a common presentation in children. To our knowledge, no studies have explored the clinical utility of magnetic resonance imaging (MRI) in the diagnostic workup of pediatric patients. Methods: We retrospectively reviewed 307 consecutive wrist MRIs ordered at a tertiary-care pediatric hospital. Demographic data and the indication for imaging were recorded and grouped into admitting categories. The final impression of each MRI was scored with regard to potential impact on future treatment (0 = normal, 1 = minimal, 2 = moderate, 3 = high). Patients who went on to wrist surgery within 1 year were noted. Results: In our cohort, 27% of all studies were normal, including 34% of those with pain. Although pain was the most common category, MRI was most useful in the delineation of a mass/cyst, evaluating for infection and evaluating arthropathy. Compared with all other categories, patients with pain were 3.6 times more likely to have a normal study and 4.6 times more likely to have a clinical score less than or equal to 1. Given an admitting diagnosis of pain, females were 1.7 times more likely to present for an MRI and 2.4 times more likely to have a normal MRI. The Spearman correlation revealed no linear relationship between age and MRI outcome. In all, 13% of patients went on to have surgery within 1 year of MRI. Conclusions: At our pediatric institution, the majority of wrist MRIs were ordered for wrist pain. Given our data, wrist MRI is not an ideal screening tool in children, particularly in those with wrist pain, and should only be used to exclude or confirm a specific diagnosis.

Hoverboards were recently introduced to the US consumer market and experienced rapid popularity. Given the high frequency of musculoskeletal injury with other wheeled recreation devices, we sought to analyze hoverboard injuries in children. A retrospective review of patients with musculoskeletal injury related to hoverboard use was performed at a tertiary care children’s hospital. From November 2015 to January 2016, 2.3% of all fractures were related to hoverboards. Common injury mechanisms were fall (79%) and finger entrapment between wheel and wheel-well (10%). The most frequently fractured sites included the distal radius (43%) and phalanx (17%). Common surgical procedures were nailbed repair and pinning for Seymour fracture and percutaneous pinning for distal radius fracture. There exists high risk for distal radius fractures from falls and phalanx fractures from finger entrapment between the wheel and wheel-well. Hoverboard safety can be improved with regular use of wrist guards and improved wheel-well design.

Background Direct comparison of nerve autograft, conduit, and allograft outcomes in digital nerve injuries is limited. This study aims to compare the outcomes of nerve autografts, allografts, and conduits relative to primary repair (PR) through a systematic review. Methods A review of literature related to digital nerve gap repairs was conducted using PubMed/MEDLINE. Included articles were human clinical studies on digital nerve injuries repaired with nerve autograft, allograft, bovine collagen conduit, or PR. Patient characteristics, injury details, and complications were collected. Greater than 6-month outcomes included static 2-point discrimination, the British Medical Research Council Scale, or Semmes-Weinstein. Results Four autograft, 4 allograft, 5 conduit, and 7 PR publications were included. Allografts had the most repairs (100%) with static 2-point discrimination less than 15 mm, followed by autografts (88%), conduits (72%), and PR (63%). In British Medical Research Council Scale results, autografts (88%) and allografts (86%) were similar for patients with at least S3+ sensibility, compared to conduit (77%) and PR (39%). For Semmes-Weinstein, autografts demonstrated 93% normal sensation or diminished light touch, compared to allografts (71%), PR (70%), or conduits (46%). Conduits had the highest complication rate (10.9%), followed by autografts (5.7%), allografts (3.0%), and PRs (0.4%). Conclusions Although a randomized clinical trial would provide strongest evidence of superiority, this review presents the highest percentage of patients with normal to near normal sensory recovery in allograft and autograft repairs with low rates of complications. Nerve conduit studies reported a higher rate of incomplete recovery of sensation and complications.

Carpal tunnel syndrome (CTS) is one of the most common problems treated by hand surgeons. As our understanding of the condition has improved and focus on quality and evidence-based care has evolved, management of CTS has shifted as well. Although for many patients the diagnosis and treatment plan are relatively straightforward, understanding how to decide what diagnostics are appropriate, how to avoid complications especially in high-risk patients, and even which surgical option to offer remains a challenge. As CTS research efforts broaden and available evidence grows, understanding the different research findings in order to implement the evidence into practice is critical for all surgeons. In this article, we approach commonly encountered challenges in CTS management and take a methodological viewpoint to guide evidence-based practice.

Background: Recent attention has sought to standardize hand surgery training in the United States. This study analyzes the variability in operative hand experience for orthopedic and general surgery residents. Methods: Case logs for orthopedic and general surgery residency graduates were obtained from the American Council of Graduate Medical Education (2006-2007 to 2014-2015). Plastic surgery case logs were not available for comparison. Hand surgery case volumes were compared between specialties with parametric tests. Intraspecialty variation in orthopedic surgery was assessed between the bottom and top 10th percentiles in procedure categories. Results: Case logs for 9605 general surgery residents and 5911 orthopedic surgery residents were analyzed. Orthopedic surgery residents performed a greater number of hand surgery cases than general surgery residents ( P < .001). Mean total hand experience ranged from 2.5 ± 4 to 2.8 ± 5 procedures for general surgery residents with no reported cases of soft tissue repairs, vascular repairs, and replants. Significant intraspecialty variation existed in orthopedic surgery for all hand procedure categories (range, 3.3-15.0). Conclusions: As the model for hand surgery training evolves, general surgeons may represent an underutilized talent pool to meet the critical demand for hand surgeon specialists. Future research is needed to determine acceptable levels of training variability in hand surgery.

Background Prophylactic mastectomy is more common, with many patients seeking reconstruction. Bilateral free flap reconstructions subject patients to 2 flaps and longer operations, potentially increasing their risk for complications. We hypothesized that bilateral abdomen-based free flap reconstruction patients are a unique patient population with a higher rate of perioperative complications. Methods A retrospective chart review compared all 444 bilateral abdomen-based free flap breast reconstructions (in 222 patients) and 367 unilateral free flap breast reconstructions, performed at a single institution between March 2005 and July 2011. Patient and surgical characteristics and complications were studied. Results Bilateral reconstruction patients were slightly younger and heavier (mean, 49.2 years and 77.7 kg) and more likely to be white. Bilateral reconstructions were more often immediate reconstructions and less likely to have postoperative radiation therapy. These patients had longer surgical times and higher rates of intraoperative arterial thrombosis, but there were no significant differences in postoperative thrombosis or flap loss rates between the groups. The bilateral reconstruction patients, however, did have higher rates of minor surgical and medical complications, including a higher rate of lower extremity deep venous thrombosis (1.8% vs 0.3%, P = 0.045). Conclusions We find that bilateral abdomen-based free flap breast reconstruction patients do not have higher rates of major postsurgical complications such as flap loss or postoperative thrombosis. However, higher rates of minor surgical and postoperative medical complications, including significantly more cases of lower extremity deep venous thrombosis, are seen. These findings are important for patient counseling and perioperative management.

BACKGROUND Orthopedic and plastic surgery residents receive unique training yet often compete for similar hand surgery fellowships. This study compared didactic hand surgery training during orthopedic and plastic surgery residency. METHODS The Plastic Surgery In-Service Training Exam and Orthopaedic In-Training Examination were analyzed for hand content for the years 2009 to 2013. Topics were categorized with the content outline for the Surgery of the Hand Examination. Differences were elucidated by means of Fisher's exact test. RESULTS Relative to the Orthopaedic In-Training Examination, the Plastic Surgery In-Service Training Exam had greater hand representation (20.3 percent versus 8.1 percent; p < 0.001) with more annual hand questions (40 ± 3 versus 24 ± 2; p < 0.001). The Plastic Surgery Exam questions had more words, were less often level I-recall type, and were less often image-based. The questions focused more on finger and hand/palm anatomy, whereas the Orthopaedic examination was more wrist-focused. The Plastic Surgery Exam emphasized wound management and muscle/tendon injuries, but underemphasized fractures/dislocations. References differed, but Journal of Hand Surgery (American Volume) and Green's Operative Hand Surgery were common on both examinations. The Plastic Surgery Exam had a greater publication lag for journal references (10.7 ± 0.5 years versus 9.0 ± 0.6; p = 0.035). CONCLUSIONS Differences in didactic hand surgery training are elucidated for plastic surgery and orthopedic residents. Deficiencies in the Plastic Surgery In-Service Training Exam hand curriculum relative to the Orthopaedic In-Training Examination may underprepare plastic surgeons for the Surgery of the Hand Examination. These data may assist future modifications to hand surgery training in the United States.

Purpose The results of spinal accessory to suprascapular nerve transfers have been less reliable than other nerve transfers in the upper limb, possibly owing to compression of the nerve by the suprascapular ligament. The posterior approach has been advocated to allow for release of the ligament. The purpose of this study was to determine whether a ligament release is possible from the anterior approach. Methods Nine fresh-frozen cadavers were dissected to determine whether the ligament could be approached and released from the anterior approach. Complete ligament release was demonstrated by subluxation of the nerve out of the suprascapular notch. Results Ligament release was achieved in all specimens, although in one, confirmation of complete release required a posterior approach. Conclusions Release of the suprascapular ligament to eliminate a potential source of compression of the suprascapular nerve during spinal accessory to suprascapular nerve transfer is possible through an anterior approach. Clinical relevance Release of the suprascapular ligament through an anterior approach allows this procedure to be performed through the same approach as brachial plexus exploration and spinal accessory nerve to suprascapular nerve transfer. This method could reduce surgical time and patient repositioning and avoid additional incisions.

Background: Index finger (IF) pollicization is the standard treatment for severe congenital thumb hypoplasia. The procedure requires a supple and anatomically normal IF. No guidelines exist for IF pollicization in patients who have concomitantly underdeveloped IF, specifically when the digit has only 2 phalanges and 1 interphalangeal joint. Methods: We present a case of a 20-month-old boy with congenital type IV thumb hypoplasia who also had biphalangeal IF. We proposed an IF pollicization operation that required significant modifications to the traditional procedure. Results: Preoperative planning and intraoperative execution are described. The modifications to the traditional procedure included: (1) removal of proximal third of IF metacarpal; (2) creation of a de novo thumb carpometacarpal (CMC) joint by fibrous union whereby the IF CMC joint cartilaginous components are maintained and the remaining distal IF metacarpal is translocated down and secured to this cartilage (in contrast to the traditional use of IF metacarpophalangeal joint as a de novo thumb CMC joint); (3) preservation of IF joints at their “natural” position and function; (4) maintenance of intrinsic muscles at their original distal insertion sites; and (5) important adjustments to skin incision. Conclusions: Pollicization of biphalangeal IF can be executed in a safe and efficient manner. Early recovery has shown promising signs. Long-term results, including the de novo thumb CMC joint function, remain to be evaluated.

Purpose: Hoverboards were recently introduced in the United States consumer market and have rapidly increased in popularity. Concern regarding the safety of hoverboards has largely focused on the risk of fire, drawing media attention and prompting investigation by the United States Consumer Product Safety Commission (CPSC). At our institution, we noted an increase in musculoskeletal injuries related to hoverboard use. We sought to analyze hoverboard injuries to characterize the frequency of injury, pattern of musculoskeletal injury, and provide families with safety information. Methods: An IRB approved retrospective review of all patients with …

Mobile phone messaging software robots allow clinicians and healthcare systems to communicate with patients without the need for human intervention. The purpose of this study was to (1) describe a method for communicating with patients postoperatively outside of the traditional healthcare setting by utilizing an automated software and mobile phone messaging platform and to (2) evaluate the first week of postoperative pain and opioid use after common ambulatory hand surgery procedures.The investigation was a prospective, multicenter investigation of patient-reported pain and opioid usage after ambulatory hand surgery. Inclusion criteria included any adult with a mobile phone capable of text messaging, who was undergoing a common ambulatory hand surgical procedure at one of three tertiary care institutions. Participants received daily, automated text messages inquiring about their pain level and how many tablets of prescription pain medication they had taken in the past 24 h. Initial 1-week response rate was assessed and compared between different patient demographics. Patient-reported pain and opioid use were also quantified for the first postoperative week. Statistical significance was set as p 0.05.Forty-seven (n = 47) patients were enrolled in this investigation. Total response rate of both pain and opioid medication questions through 7 days was 88.3%. Pain trended down on a daily basis for the first postoperative week, with the highest levels of pain being reported in the first 48 h after surgery. Patients reported an average use of 15.9 ± 14.8 tablets of prescription opioid pain medication.We find that a mobile phone messaging software robot allows for effective data collection of postoperative pain and pain medication use. Patients undergoing common ambulatory hand procedures utilized an average of 16 tablets of opioid medication in the first postoperative week.

BACKGROUND To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans. METHODS Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR. RESULTS In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P

Purpose It is our impression that there is substantial, unexplained variation in hand surgeon recommendations for treatment of peripheral mononeuropathy. We tested the null hypothesis that specific patient and provider factors do not influence recommendations for surgery. Methods Using a web-based survey, hand surgeons recommended surgical or nonsurgical treatment for patients in 2 different scenarios. Six elements of the first scenario (symptoms, circumstances, mindset, diagnosis, objective testing, and expectations) had 2 possibilities that were each independently and randomly assigned to each rater. For the second scenario, 2 different scenarios were randomly assigned to each rater. Multivariable logistic regression sought factors associated with a recommendation for surgery. Results A total of 186 surgeons of the Science of Variation Group completed a survey regarding recommendation of surgery for 2 different patients based on clinical scenarios. Recommendations for surgery did not vary significantly according to provider characteristics. For the various elements in scenario 1, recommendation for surgery was more likely for patients who were self-employed and continued to work and who had objective electrodiagnostic abnormalities. For the 2 vignettes used in scenario 2, a recommendation for surgery was associated with abnormal electrophysiology. Conclusions The findings of this study suggest that—at least in a survey setting—surgeons prefer to offer peripheral nerve decompression to patients with abnormal electrophysiology, particularly those with effective coping strategies. Clinical relevance The role of objective verification of pathophysiology is debated, but it is an influential factor in recommendations for hand surgery.

Radial longitudinal deficiency (RLD) is the most common congenital longitudinal deficiency at birth and represents a wide spectrum of upper extremity anomalies, from mild thumb hypoplasia to absent radius. Radial dysplasia may be isolated or associated with an array of systemic anomalies that should be familiar to pediatric hand surgeons. The management of RLD has evolved greatly since its inception in the late 19th century, largely due to decades of innovation that followed the thalidomide catastrophe of the 1960s. Yet controversy still exists regarding many aspects of RLD. Traditional treatments of radial dysplasia (ie, centralization) are unfortunately wrought with poor outcomes and high rates of recurrence, leading some authors to recommend alternative techniques for this condition. Reconstruction of the hypoplastic thumb, although less controversial, is just starting to see long-term outcomes. This article reviews the etiology, classification, and treatment options for RLD, highlighting recent developments and outcomes.

The purpose of this study was to examine current attitude of hand surgeons toward the Affordable Care Act (ACA). An electronic survey was sent to members of American Society for Surgery of the Hand (ASSH) to examine their attitude toward the Affordable Care Act. 974 ASSH members responded to the survey (33% response rate). The majority of respondents were male (89%), trained in orthopedic surgery (81%), and in private practice (75%). 41% of respondents rated their knowledge of the ACA as average. Respondents disagreed that the ACA would improve healthcare in the United States (median 2, mean 2.06, scale 1-5), while agreeing that the ACA would decrease reimbursements specific to hand surgery (median 4, mean 4.11).

An increasing number of women are entering the medical profession, but plastic surgery remains a male-dominated profession, especially within academia. As academic aspirations and advancement depend largely on research productivity, the authors assessed the number of articles authored by women published in the journal Plastic and Reconstructive Surgery.Original articles in Plastic and Reconstructive Surgery published during the years 1970, 1980, 1990, 2000, 2004, and 2014 were analyzed. First and senior authors with an M.D. degree and U.S. institutional affiliation were categorized by gender. Authorship trends were compared with those from other specialties. Findings were placed in the context of gender trends among plastic surgery residents in the United States.The percentage of female authors in Plastic and Reconstructive Surgery increased from 2.4 percent in 1970 to 13.3 percent in 2014. Over the same time period, the percentage of female plastic surgery residents increased from 2.6 percent to 32.5 percent. By 2014, there were more female first authors (19.1 percent) than senior authors (7.7 percent) (p0.001). As a field, plastic surgery had fewer female authors than other medical specialties including pediatrics, obstetrics and gynecology, general surgery, internal medicine, and radiation oncology (p0.05).The increase in representation of female authors in plastic surgery is encouraging but lags behind advances in other specialties. Understanding reasons for these trends may help improve gender equity in academic plastic surgery.

Background: The purpose of this study was to examine the current attitude of hand surgeons toward the Act (ACA), assess their self-described knowledge of the law, and ascertain projected changes in practice plans. Methods: An electronic survey was sent to members of American Society for Surgery of the Hand (ASSH). Results: A total of 974 ASSH members responded to the survey (33% response rate). The majority of respondents were male (89%), trained in orthopaedic surgery (81%) and in private practice (75%). 41% of respondents rated their knowledge of the ACA as average. 84% reported receiving no education on the law. In general, respondents disagreed that the ACA would improve healthcare in the United States (median 2, mean 2.06, scale 1-5), while agreeing that the ACA would decrease reimbursements specific to hand surgery (median 4, mean 4.11). They also disagreed that the ACA would improve access to emergent (median 2, mean 2.10) and elective hand surgery (median 2, mean 2.30). 37% of respondents believed that implementation of the ACA would cause them to retire earlier than planned. Stratified analysis revealed that private-practice and male respondents had a more negative outlook on the ACA compared to academicpractice and female surgeons. Conclusion: The majority of responding hand surgeons have an unfavorable attitude toward the ACA, particularly private-practice and male members. Only a small percentage of respondents reported sufficient preparation for the coming changes related to the ACA. These findings suggest an opportunity for increased education and advocacy from professional organizations.

BACKGROUND: Infant dura mater plays a critical role in calvarial development. This investigation examines the expression of nitric oxide synthase isoforms in the craniofacial skeleton and the influence of nitric oxide signaling on the growth and differentiation of fetal dural and calvarial bone cells. METHODS: Sections of fetal and adult calvaria were evaluated for endothelial and inducible nitric oxide synthase expression by immunohistochemistry. Primary fetal (E18) murine dural cell and calvarial osteoblast cultures were treated with 1 microM or 10 microM DETA-NONOate, a nitric oxide donor compound, or 1 mM N-monomethyl-l-arginine (l-NMMA), a nitric oxide synthase inhibitor. Controls were left untreated. Cell proliferation was measured at 48 hours, and mRNA transcripts for Runx2, alkaline phosphatase, and osteopontin were measured by reverse transcription and quantitative real-time polymerase chain reaction at 2 to 18 days. Experiments were performed in triplicate. RESULTS: Fetal, but not adult, dural cells express endothelial nitric oxide synthase. DETA-NONOate stimulated osteoblast mitogenesis by 16 percent (p < 0.05) but did not affect proliferation of dural cells. l-NMMA inhibited proliferation of dural cells and calvarial osteoblasts by 35 percent (p < 0.01) and 17 percent (p = 0.05), respectively. Exogenous nitric oxide increased dural cell transcription of Runx2, alkaline phosphatase (p = 0.03), and osteopontin (p = 0.09) and calvarial osteoblast transcription of Runx2 (p = 0.02) and osteopontin (p < 0.01). Fetal calvarial osteoblasts and dural cells treated with l-NMMA demonstrated reduced transcription of Runx2 and alkaline phosphatase (p < 0.05). CONCLUSIONS: Fetal dural cells and calvarial osteoblasts express endothelial nitric oxide synthase. Nitric oxide enhances proliferation and differentiation of fetal dural cells and calvarial osteoblasts. These results suggest that endothelial nitric oxide synthase-derived nitric oxide may play an important role in development of the fetal craniofacial skeleton.