Search

BACKGROUND The purpose of this study was to identify the utilization rate and most common reasons for presentation to the emergency department (ED) after elective outpatient hand surgery and to determine preoperative risk factors for these ED visits. METHODS Patients who underwent elective hand surgery at an ambulatory surgery center between 2014 and 2015 were retrospectively evaluated using the New York and Florida State Databases. The primary outcome was all-cause 7- and 30-day ED utilization rates. Reasons for presentation to the ED were recorded and manually stratified. Bivariate and multivariate analyses were performed to identify independent predictors of ED utilization. RESULTS From 2014 to 2015, 212,506 procedures were identified; the 7- and 30-day ED visit rates were 1.8% and 4.4%, respectively. Postoperative pain was the most common cause of an ED visit after outpatient hand surgery at 7 days (25.4%) and 30 days (16.1%) postoperatively. Overall, 98% of patients presenting to the ED for postoperative pain were subsequently discharged home. After controlling for confounding, comorbid congestive heart failure, chronic lung disease, diabetes, renal failure, schizophrenia, and depression were independent risk factors for an ED visit at up to 30 days postoperatively. Those with Medicare insurance were 94% more likely to present to the ED within 30 days than those with private health insurance, whereas those with Medicaid were more than three times as likely to present to the ED as those with private insurance. DISCUSSION ED utilization after outpatient hand surgery is low, with postoperative pain being the most common cause of an ED visit at all time points. Nearly 98% of patients presenting to the ED for postoperative pain are subsequently discharged home. LEVEL OF EVIDENCE Level III, Retrospective Cohort.

Background: The aim of this study is to determine whether the American Academy of Orthopaedic Surgeons’ (AAOS) Appropriate Use Criteria (AUC) for distal radius fractures correlates with actual treatment by orthopedic hand surgeons at a level I trauma center. Methods: ICD-9 codes were used to retrospectively identify patients who presented with wrist fractures over 1 year. Patients with isolated distal radius fractures were evaluated using the AAOS AUC application for distal radius fractures. Actual treatment was then compared with treatment recommended by the AUC. Results: Of the 112 patients, 64 (57%) received treatment that matched the AAOS AUC recommendation as an “appropriate treatment.” Actual management matched the AUC recommendation 100%, 7%, and 50% of the time, for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type A, B, and C fractures, respectively. Surgery was performed for type A, B, and C fractures 30%, 7%, and 50% of the time, respectively. For type B fractures, only the 2 cases that were managed operatively were in agreement with the AUC. For type C fractures, increased patient age (57 years and older) was significantly associated with nonoperative treatment decisions. Surgeon decisions for nonoperative treatment were in agreement with the AUC recommendations 40% of the time, whereas surgeon decisions for surgery matched the AUC recommendations 97% of the time. Conclusions: We found low agreement between actual treatment decisions and the AUC-recommended “appropriate” treatments, especially for the type B and C fractures that were managed nonoperatively. The AUC favors surgery for all intra-articular fractures, while we emphasized age and fracture displacement in our decision-making process.

The skeletal anatomy of the hand is composed of phalanges, metacarpal bones, and carpal bones. Its function is a product of the complex interactions between the power provided by the intrinsic and extrinsic musculature, the stability provided by the ligaments, and the structure provided by the bones, which serve as insertion and attachment sites for the muscles and ligaments. This article provides a detailed description of the skeletal anatomy of the human hand.

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.

Background: Evaluating rotation during open reduction and internal fixation of a forearm fracture is of paramount importance. In challenging cases, surgeons may utilize radiographic relationships between proximal and distal radial and ulnar landmarks to assess rotational position. However, to our knowledge, limited anatomic data are available to confirm these relationships. Methods: Six hundred cadaveric radii and ulnae were obtained. Digital representations of the bicipital tuberosity, the radial styloid, the coronoid process, and the ulnar styloid were acquired, and the rotational profiles between respective landmarks were calculated. In order to validate the results and investigate the ability to differentiate rotated osseous positions, each bone was imaged in increments of 10° of rotation and the profile of each landmark was measured. Results: The radial styloid was at a mean of 158° ± 14° of supination relative to the bicipital tuberosity. The ulnar styloid was at a mean of 185° ± 14° of supination relative to the coronoid process. Imaging of the bones in increments of 10° of rotation supported the relationships above. It was also found that a 1-mm difference in profile size corresponded to up to 60° of rotation for the average ulna, compared with 10° for the average radius. Conclusions: Our findings suggest that using the bicipital tuberosity and the radial styloid to assess intraoperative rotation of the radius on anteroposterior radiographs may be of limited value; the landmarks were not generally 180° apart. Although the rotational positions of the coronoid process and the ulnar styloid were, on average, closer to 180°, surgeons should be aware of the wide range of normal anatomy as well as the inability to judge rotation by as much as 60°, even for an “ideal” ulna. Clinical Relevance: This study, to our knowledge, represents the first anatomic investigation of the rotational profiles between the osseous landmarks used to assess forearm rotation after fracture. We recommend that surgeons first image the bicipital tuberosity at its largest profile, supinate the arm 20°, and confirm that the radial styloid is at its largest profile. The ulna can then be assessed to support the lack of rotational deformity in the forearm.

Both operative and nonoperative treatment of hand fractures can result in numerous complications, including stiffness, malunion, nonunion, arthritis, infection, and complex regional pain syndrome. These complications are frequently encountered and are often challenging to treat. This article systematically outlines the diagnosis and treatment of each of these complications to achieve the best possible outcome for the patient's overall hand function.

Purpose To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved

To our knowledge, no report has been published of a flexor tendon rupture as a result of a closed phalangeal fracture. A 58-year-old woman with multiple medical comorbidities presented with a closed, apex volar fracture of her long finger proximal phalynx with clinically intact flexor digitorum profundus and superficialis tendons in zone 2 of the flexor tendon sheath. After 5 weeks of nonoperative treatment, the patient reported hearing a pop in her finger, and clinical findings suggested rupture of the flexor digitorum profundus and superficialis tendons. Intraoperatively, the nonreparable attritional rupture was underneath the A2 pulley. A bony prominence in the tendon sheath floor from the healed phalynx fracture made rerupture a concern with a tendon graft. A Hunter Active Tendon Implant (Wright Medical Technology, Inc, Arlington, Tennessee) was used to reconstruct the flexor digitorum profundus tendon to avoid a second procedure. The patient progressed well and had regained a functional arc of active finger range of motion by 2 months postoperatively. The Hunter Active Tendon Implant provided a suitable alternative to a 2-staged procedure, with the added benefit that a good tendon bed was developed in the event that a second procedure was needed.

The purpose of this retrospective cohort comparison study was to determine the effect of ulnar collateral ligament reconstruction on postoperative range of motion (ROM) in patients undergoing posttraumatic elbow contracture release. Twenty-four consecutive patients underwent elbow arthrolysis. Six patients also underwent simultaneous collateral ligament excision and reconstruction, and 18 did not require ligament excision. All patients followed the same postoperative rehabilitation program. Minimum follow-up was 12 months. Final flexion/extension ROMs were similar in both groups. No subjective reports of postoperative elbow instability occurred in either group. Ligament reconstruction and early postoperative motion can be safely performed in the setting of posttraumatic elbow capsulectomy without sacrificing ROM gain or compromising stability provided by the ligament reconstruction.

Lateral epicondylitis is a common condition affecting 1% to 3% of the population. Although the exact cause is still unknown, numerous theories have been put forth. One theory suggests a hypovascular zone at the origin of the common extensor mass. This study examines the microvascular supply of the lateral epicondyle and the common extensor mass, with the use of India ink injection and the Spalteholz tissue-clearing technique. Six fresh-frozen cadaveric arms underwent serial sectioning (coronal plane in five and axial plane in one) after vascular injection with India ink. Sections were cleared via a modified Spalteholz technique. Photographs were taken before and after the clearing procedure, and the microvascular pattern of the common extensor mass and lateral epicondyle was described. Two hypovascular zones were identified in the region of the lateral epicondyle. The first was noted at the proximal lateral epicondyle just distal to the supracondylar ridge and the second 2 to 3 cm distal to the lateral epicondyle on the deep surface of the common extensor tendon. Two regions of hypovascularity were noted at the lateral epicondyle and within the common extensor origin. These hypovascular regions may preclude the normal inflammatory cascade and healing response to microtearing in this region. Thus, these zones may play a role in the etiology of lateral epicondylitis.

Purpose To report our experience using a fixed-angle volar plate in conjunction with a corrective osteotomy and cancellous bone graft for the treatment of distal radius malunions with dorsal angulation in 4 patients. Methods Four consecutive patients had a volarly based opening wedge osteotomy with a fixed angle volar plate and cancellous bone grafting for the treatment of a dorsally angulated distal radius malunion. Data collected retrospectively included a visual analog pain scale, grip strength, range of motion, radiographic parameters, and each patient’s subjective functional outcomes as measured by the Disabilities of the Arm, Shoulder, and Hand questionnaire. Motion, strength, and radiographic values were compared with the contralateral arm for each patient. Results The average time from initial fracture to corrective osteotomy was 346 days. The average length of follow-up evaluation was 13.5 months. The flexion–extension arc of motion increased an average of 21° to a value of 84% of the contralateral side; the pronation–supination arc of motion increased an average of 20° to a value of 98% of the contralateral side. The average tilt of the radius improved from 26° extension to 2° extension; the average radial inclination improved from 22° to 24°; the average ulnar variance excluding the 1 patient who had a distal ulna resection improved from 5 mm to 1 mm. The average retrospective Disabilities of the Arm, Shoulder, and Hand score improved from 30 to 7; the average retrospective visual analog pain scale score improved from 4.5 to 1. The average grip strength increased from 20 to 29 kg, which corresponded to 73% of the contralateral extremity. Conclusions The rigid characteristics of fixed angle volar plates can provide an alternative to the traditional techniques of distal radius osteotomy including structural bone grafting and dorsal plate fixation or external fixation. In addition these plates are strong enough to allow for early postoperative motion. Type of study/level of evidence Therapeutic, Level IV.

Purpose To test the null hypothesis that there are no differences in the priorities and preferences of patients with idiopathic trigger finger (TF) and hand surgeons. Methods One hundred five hand surgeons of the Science of Variation Group and 84 patients with TF completed a survey about their priorities and preferences in decision making regarding the management of TF. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid. Results Patients desired orthotics more and surgery less than physicians. Patients and physicians disagreed on the main advantage of several treatment options for TFs and on disadvantages of the treatment options. Patients preferred to decide for themselves after receiving advice, whereas physicians preferred a shared decision. Patients preferred booklets, and physicians opted for Internet and video decision aids. Conclusions Comparing patients and hand surgeons, there were some differences in treatment preferences and perceived advantages and disadvantages regarding idiopathic TF—differences that might be addressed by a decision aid. Clinical relevance Information that helps inform patients of their options based on current best evidence might help them understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.