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A Munster thumb-spica cast may play a role in the conservative treatment of non-displaced scaphoid fractures by allowing some elbow motion during the long immobilization period. [ABSTRACT FROM AUTHOR]

Background: There is a lack of data regarding the baseline hemodynamic blood flow parameters of the wrist and digits. Therefore, we aimed to quantify the digital and radial artery blood flow parameters using ultrasound and assess the influence of patient characteristics on hemodynamics., Methods: We analyzed ultrasonographic data from 25 patients (50 hands) between October 2019 and December 2021. Variables of interest included dimensions of the radial artery and index finger (IF) ulnar and radial digital arteries at the palmodigital crease and their corresponding flow parameters. We compared variables among men and women and patients with and without diabetes using Wilcoxon Rank Sum test., Results: Our cohort consisted of 18 women (36 hands) and three participants with diabetes (six hands). The mean diameter of the IF radial digital artery was 7 mm, and that of the ulnar digital artery was 10 mm. The average peak systolic velocity for the radial digital artery was 21.31 cm/sec, and for the ulnar digital artery, it was 30.03 cm/sec. Comparing men and women, the only significant difference found was in the time-averaged mean velocity for the ulnar digital artery (men:5.66 cm/sec vs. women:9.68 cm/sec, P = 0.02) and volume of flow for the ulnar digital artery (men:10.87cc/min vs. women:18.58cc/min, P = 0.03). We found no differences in blood flow parameters comparing participants with and without diabetes., Conclusion: These data provide a baseline measurement of digital flow hemodynamics that can be used in future studies to model vascular flow after replantation., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Although total hip and knee arthroplasty have largely moved to the outpatient setting, total elbow arthroplasty (TEA) remains a predominantly inpatient procedure. Currently, evidence on the safety and potential cost savings of outpatient TEA is limited. Therefore, we aimed to compare the costs and complications associated with performing TEA in the inpatient versus outpatient setting., Methods: We identified patients who received elective TEA using the Truven Health MarketScan database. Outcomes of interest were 90-day complication rate, readmission rate, and procedure costs in the inpatient and outpatient settings. We used propensity score matching and logistic regression analysis to assess how patient comorbidities and surgical setting influenced complications and readmission rates. The median cost per patient was compared using the Mann-Whitney U test., Results: We identified 307 outpatient and 414 inpatient TEA procedures over a 9-year period. Elixhauser comorbidity scores were higher for the inpatient cohort. The incidence of surgical complications was significantly higher in the inpatient than the outpatient cohort (27% vs 9%). The odds of 90-day readmissions were similar in the 2 groups (37% vs 25%). In terms of cost, the median inpatient TEA was more expensive than outpatient TEA ($26 817 vs $18 412). However, the median cost for occupational therapy within 90 days of surgery was higher for outpatient TEA patients ($687 vs $571)., Conclusions: The results of this study demonstrate that surgeons can consider a transition toward outpatient TEA for patients without significant comorbidities, as this will substantially reduce health care costs.

CD13, an ectoenzyme on myeloid and stromal cells, also circulates as a shed, soluble protein (sCD13) with powerful chemoattractant, angiogenic, and arthritogenic properties, which require engagement of a G protein-coupled receptor (GPCR). Here we identify the GPCR that mediates sCD13 arthritogenic actions as the bradykinin receptor B1 (B1R). Immunofluorescence and immunoblotting verified high expression of B1R in rheumatoid arthritis (RA) synovial tissue and fibroblast-like synoviocytes (FLSs), and demonstrated binding of sCD13 to B1R. Chemotaxis, and phosphorylation of Erk1/2, induced by sCD13, were inhibited by B1R antagonists. In ex vivo RA synovial tissue organ cultures, a B1R antagonist reduced secretion of inflammatory cytokines. Several mouse arthritis models, including serum transfer, antigen-induced, and local innate immune stimulation arthritis models, were attenuated in Cd13-/- and B1R-/- mice and were alleviated by B1R antagonism. These results establish a CD13/B1R axis in the pathogenesis of inflammatory arthritis and identify B1R as a compelling therapeutic target in RA and potentially other inflammatory diseases.

Purpose: To evaluate the association of diabetes and perioperative hemoglobin A1C (HgA1C) value with postoperative wound healing complications following carpal tunnel release (CTR) and trigger finger release (TFR)., Methods: A retrospective review of diabetic patients who underwent CTR and/or TFR between 2014 and 2018 was performed. Hemoglobin A1C value within 90 days of surgery was recorded for all diabetic patients. A nondiabetic comparison group was selected from within the same study period in an approximately 1:1 procedural ratio, although direct matching was not performed. A chart review was used to examine postoperative wound healing complications, such as wound infection, wound dehiscence, or delayed wound healing., Results: Two hundred sixty-two diabetic patients and 259 nondiabetic patients underwent 335 and 337 CTR and/or TFR procedures, respectively. There were 36 wound complications in the diabetic group and 9 complications in the nondiabetic group. Logistic regression analysis demonstrated an increased association of wound healing complications with diabetic patients compared to nondiabetic patients. Additionally, an increased association was demonstrated among diabetic patients with an HgA1C value above 6.5% compared with those with an HgA1C value below 6.5%., Conclusions: Compared with nondiabetic controls, diabetic patients have increased associated risk of postoperative wound healing complications following CTR and/or TFR. This increased association was further demonstrated among diabetic patients with elevated perioperative HgA1C values., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2021 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: To explore the intrinsic role of inhibitor of DNA binding 1 (ID-1) in rheumatoid arthritis (RA) fibroblast-like synoviocytes (FLS) and to investigate whether ID-1 is citrullinated and autoantigenic in RA., Methods: RA patient serum ID-1 levels were measured before and after infliximab treatment. RA FLS were transfected with a clustered regularly interspaced short palindromic repeat (CRISPR)/CRISPR-associated protein 9 construct targeting ID-1 to examine the effects of ID-1 deletion. RA synovial fluid (SF) and homogenized synovial tissue (ST) were immunoprecipitated for ID-1 and measured for citrullinated residues using an enzyme-linked immunosorbent assay and Western blotting. Liquid chromatography tandem mass spectrometry (LC-MS/MS) was performed on in vitro-citrullinated recombinant human ID-1 (cit-ID-1) to localize the sites of citrullination. Normal and RA sera and SF were analyzed by immunodot blotting for anti-citrullinated protein antibodies (ACPAs) to cit-ID-1., Results: RA patient serum ID-1 levels positively correlated with several disease parameters and were reduced after infliximab treatment. RA FLS displayed reduced growth and a robust increase in interleukin-6 (IL-6) and IL-8 production upon deletion of ID-1. ID-1 immunodepletion significantly reduced the levels of citrullinated residues in RA SF, and citrullinated ID-1 was detected in homogenized RA ST (n = 5 samples; P < 0.05). Immunodot blot analyses revealed ACPAs to cit-ID-1 but not to native ID-1, in RA peripheral blood (PB) sera (n = 30 samples; P < 0.001) and SF (n = 18 samples; P < 0.05) but not in normal PB sera. Following analyses of LC-MS/MS results for citrullination sites and corresponding reactivity in immunodot assays, we determined the critical arginines in ID-1 for autoantigenicity: R33, R52, and R121., Conclusion: Novel roles of ID-1 in RA include regulation of FLS proliferation and cytokine secretion as well as autoantigenicity following citrullination., (© 2019 The Authors. Arthritis & Rheumatology published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.)

Aminopeptidase N/CD13 is expressed by fibroblast-like synoviocytes (FLS) and monocytes (MNs) in inflamed human synovial tissue (ST). This study examined the role of soluble CD13 (sCD13) in angiogenesis, MN migration, phosphorylation of signaling molecules, and induction of arthritis. The contribution of sCD13 was examined in angiogenesis and MN migration using sCD13 and CD13-depleted rheumatoid arthritis (RA) synovial fluids (SFs). An enzymatically inactive mutant CD13 and intact wild-type (WT) CD13 were used to determine whether its enzymatic activity contributes to the arthritis-related functions. CD13-induced phosphorylation of signaling molecules was determined by Western blotting. The effect of sCD13 on cytokine secretion from RA ST and RA FLS was evaluated. sCD13 was injected into C57BL/6 mouse knees to assess its arthritogenicity. sCD13 induced angiogenesis and was a potent chemoattractant for MNs and U937 cells. Inhibitors of Erk1/2, Src, NF-κB, Jnk, and pertussis toxin, a G protein-coupled receptor inhibitor, decreased sCD13-stimulated chemotaxis. CD13-depleted RA SF induced significantly less MN migration than sham-depleted SF, and addition of mutant or WT CD13 to CD13-depleted RA SF equally restored MN migration. sCD13 and recombinant WT or mutant CD13 had similar effects on signaling molecule phosphorylation, indicating that the enzymatic activity of CD13 had no role in these functions. CD13 increased the expression of proinflammatory cytokines by RA FLS, and a CD13 neutralizing Ab inhibited cytokine secretion from RA ST organ culture. Mouse knee joints injected with CD13 exhibited increased circumference and proinflammatory mediator expression. These data support the concept that sCD13 plays a pivotal role in RA and acute inflammatory arthritis., (Copyright © 2019 by The American Association of Immunologists, Inc.)

Purpose: Wear of polyethylene bearings represents a limiting factor in the long-term success of total elbow prostheses. Bearing stress is 1 factor contributing to accelerated wear. Physiological loading of total elbow prostheses and implant design influence upon bearing stresses have not been well described. This study evaluates bearing stresses in 3 commercially available implant designs under loads associated with daily living., Methods: Motion tracking from a healthy volunteer helped establish a musculoskeletal model to simulate flexor and extensor muscle activation at 0°, 45°, and 90° of shoulder abduction with a 2.3-kg weight in hand-forces and moments were measured at the elbow. Resulting physiological joint reaction forces and moments were applied to finite element models of 3 total elbow bearing designs (Coonrad/Morrey, Nexel, and Discovery) to evaluate contact area and polyethylene stresses., Results: Increasing shoulder abduction resulted in minimal changes to the elbow joint reaction force but greater joint moments. All implants showed greater peak stresses with increasing shoulder abduction-elbow varus. Discovery and Nexel achieved greater contact area (23% vs > 100%) and demonstrated up to 39% lower peak polyethylene stresses compared with the Coonrad/Morrey design., Conclusions: Shoulder abduction results in a varus moment at the elbow. Newer bearing designs (Nexel and Discovery) provide a combination of higher contact area, improved load sharing, reduced edge loading, and lower stresses through elbow range of motion when compared with a cylindrical hinge-bearing design (Coonrad/Morrey)., Clinical Relevance: Although the Coonrad/Morrey is a clinically successful prosthesis, our physiological loading model shows that Discovery and Nexel provide greater contact area, better load sharing and lower peak stresses. This may lead to a decrease in polyethylene wear rates and the eventual risks of osteolysis and aseptic loosening. Further studies are needed to determine how these findings translate clinically., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To review the incidence of union of patients with proximal pole scaphoid fracture nonunions treated using a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) vascularized graft and a small compression screw., Methods: This is a retrospective case series of 12 patients. Calculations of the size of the proximal pole fragment relative to the total scaphoid were performed using posteroanterior view scaphoid radiographs with the wrist in ulnar deviation and flat on the cassette. Analyses were repeated 3 times per subject, and the average ratio of proximal pole fragment relative to the entire scaphoid was calculated. We reviewed medical records, radiographs, and computed tomography (CT) scans of these 12 patients. The CT scans that were performed after an average of 12 weeks were ultimately used to confirm union of the scaphoid fractures. One patient was unable to have a CT so was excluded from the final calculation., Results: All 11 (100%) scaphoid fractures that were assessed by CT were found to be healed at the 12-week assessment point. The mean proximal pole fragment size was 18% (range, 7%-27%) of the entire scaphoid., Conclusions: The 1,2 ICSRA vascularized graft and compression screw was an effective treatment for patients with proximal pole scaphoid fractures., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background  Forearm rotation results in change in ulnar variance. Axial loading of the wrist is required to maintain daily activities. Change in ulnar variance during axial loading has not been investigated previously. Purpose  To measure the change in ulnar variance on axially loaded wrists. Patients and Methods  We examined 21 asymptomatic individuals and 24 patients with unilateral ulnar-sided wrist pain. All patients underwent standard neutral posteroanterior wrist radiographs without load and under axial loading on bilateral wrists. Axial loading was standardized at 18.1 kgf using an analog weight scale. A magnetic resonance (MR) arthrogram was obtained only in patients with ulnar-sided wrist pain. Beighton flexibility score was recorded on healthy volunteers. Change in ulnar variance between 0 and 18.1 kgf was compared for each wrist among all subjects. A correlation was sought between the change in ulnar variance, MR arthrogram findings, and physical examination. Results  In individuals without wrist pain, on average, 0.4 mm increase in ulnar variance was measured between 0 and 18.1 kgf. There was no difference between the dominant and nondominant side. No correlation was found with increasing age. In contrast, patients with ulnar-sided wrist pain displayed an average increase of 0.8 mm in ulnar variance. Compared with the contralateral wrist, more than 1 mm increase in ulnar variance was correlated with intra-articular pathologies including dorsoulnar ligament disruption, central triangular fibrocartilage complex (TFCC) perforation, and foveal detachment. Conclusion  Compared with contralateral side, more than 1 mm increase in ulnar variance is suggestive of longitudinal instability or TFCC pathology. Level of Evidence  Level II, diagnostic.

Background: A fracture through the proximal radius is a theoretical concern after cortical button distal biceps fixation in an active patient. The permanent, nonossified cortical defect and medullary tunnel is at risk during a fall eliciting rotational and compressive forces. We hypothesized that during simulated torsion and compression, in comparison with unaltered specimens, the cortical button distal biceps repair model would have decreased torsional and compressive strength and would fracture in the vicinity of the bicipital tuberosity bone tunnel., Methods: Sixteen fourth-generation composite radius Sawbones models were used in this controlled laboratory study. A bone tunnel was created through the bicipital tuberosity to mimic the exact bone tunnel, 8 mm near cortex and 3.2 mm far cortex, made for the BicepsButton distal biceps tendon repair. The radius was then prepared and mounted on either a torsional or compression testing device and compared with undrilled control specimens., Results: Compression tests resulted in average failure loads of 9015.2 N in controls versus 8253.25 N in drilled specimens ( P = .074). Torsional testing resulted in an average failure torque of 27.3 Nm in controls and 19.3 Nm in drilled specimens ( P = .024). Average fracture angle was 35.1° in controls versus 21.1° in drilled. Gross fracture patterns were similar in compression testing; however, in torsional testing all fractures occurred through the bone tunnel in the drilled group., Conclusion: There are weaknesses in the vicinity of the bone tunnel in the proximal radius during biomechanical stress testing which may not be clinically relevant in nature., Clinical Relevance: In cortical button fixation, distal biceps repairs creates a permanent, nonossified cortical defect with tendon interposed in the bone tunnel, which can alter the biomechanical properties of the proximal radius during compressive and torsional loading.

Purpose: To determine the rate of return to play and to identify lesion or osteochondral graft characteristics that may influence the return to competitive athletics after osteochondral autograft transplantation (OAT) for symptomatic osteochondritis dissecans (OCD) lesions., Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A duplicate search of PubMed, Embase, Scopus, Web of Science, and CENTRAL databases was performed, beginning from the database inception dates through July 2016, for all articles evaluating the return to play after OAT for OCD lesions of the capitellum. A methodological quality assessment was completed for all included studies. Patient demographics, osteochondral lesion and graft characteristics, the number of patients, and timing of return to competitive activity were collected and evaluated. Association between graft size/number, the time to osseous healing, and return to sport was evaluated., Results: Seven articles met the inclusion criteria. All included studies were case series of moderate quality with a mean Methodological Index for Non-Randomized Studies score of 12/16. Overall, 94% (119/126) of patients undergoing OAT for OCD lesions of the capitellum successfully returned to competitive sports. The mean reported time for unrestricted return to athletic competition after OAT was 5.6 months (range, 3-14 months)., Conclusions: Current best evidence suggests that OAT is successful in treating advanced OCD lesions of the capitellum and returning athletes to high-level competition. Evidence supporting the association between the size and number of grafts used and the time to osseous healing and return to sport is currently limited. Our assessment of the time to return to athletic competition was limited because of variable surgical technique, postoperative rehabilitation protocols, and outcome assessment., Level of Evidence: Level IV, systematic review of Level IV studies., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: Metacarpal fractures are commonly treated by a variety of means including casting or open reduction internal fixation when unacceptable alignment is present following attempted closed reduction. Dorsal plating with either single-row 2-dimensional or double-row 3-dimensional plates has been proposed. This study's purpose was to determine if there are any differences in fixation construct stability under cyclic loading and subsequent load to failure between the lower profile 3-dimensional and the larger 2-dimensional plates in a metacarpal fracture gap sawbone model., Methods: Thirty metacarpal cortico-cancellous synthetic bones were cut with a 1.75-mm gap between the 2 fragments simulating mid-diaphyseal fracture comminution. Half of the metacarpals were plated with 2.0-mm locking 2-dimensional plates and half with 1.5-mm locking 3-dimensional plates. The plated metacarpals were mounted into a materials testing apparatus and cyclically loaded under cantilever bending for 2,000 cycles at 70 N, then 2,000 cycles at 120 N, and finally monotonically loaded to failure. Throughout testing, fracture gap sizes were measured, failure modes were recorded, and construct strength and stiffness values were calculated., Results: All 3-dimensional constructs survived both cyclic loading conditions. Ten (67%) 2-dimensional constructs survived both loading conditions, whereas 5 (33%) failed the 120-N loading at 1377 ± 363 cycles. When loaded to failure, the 3-dimensional constructs failed at 265 N ± 21 N, whereas the 2-dimensional constructs surviving cyclic loading failed at 190 N ± 17 N., Conclusions: The shorter, thinner 3-dimensional metacarpal plates demonstrated increased resistance to failure in a cyclic loading model and increased load to failure compared with the relatively longer, thicker 2-dimensional metacarpal plates., Clinical Relevance: The lower-profile 3-dimensional metacarpal plate fixation demonstrated greater stability for early postoperative resistance than the thicker 2-dimensional fixation, whereas the smaller size and lower profile of the 3-dimensional plates potentially reduces soft tissue stripping, implant prominence, and risk of extensor tendon irritation., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Although rare, biceps and triceps tendon ruptures constitute significant injuries that can lead to profound disability if left untreated, especially in the athletic population. Biceps rupture is more common than triceps rupture, with both resulting from a forceful eccentric load. Surgical repair is the treatment method of choice for tendinous ruptures in athletes. Nonoperative management is rarely indicated in this population and is typically reserved for individuals with partial ruptures that quickly regain strength and function. Surgical anatomy, evaluation, diagnosis, and surgical management of these injuries are covered in this article., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Osteochondritis dissecans (OCD) of the capitellum is a painful condition, which often affects young throwing athletes. Our current understanding regarding the etiology, risks factors, diagnosis, and efficacy of the available treatment options has expanded over recent years, however remains suboptimal. Recent data on patient-reported outcomes following osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the capitellum have been promising but limited. This review seeks to critically analyze and summarize the available literature on the etiology, diagnosis, and reported outcomes associated with OCD of the capitellum and the use of OAT for its treatment. Methods: A comprehensive literature search was conducted. Unique and customized search strategies were formulated in PubMed, Embase, Scopus, Web of Science, and CENTRAL. Combinations of keywords and controlled vocabulary terms were utilized in order to cast a broad net. Relevant clinical, biomechanical, anatomic and imaging studies were reviewed along with recent review articles, and case series. Results: Forty-three articles from our initial literature search were found to be relevant for this review. The majority of these articles were either review articles, clinical studies, anatomic or imaging studies or biomechanical studies. Conclusions: Current evidence suggests that OAT may lead to better and more consistent outcomes than previously described methods for treating large OCD lesions of the capitellum., Competing Interests: Regarding financial relationships unrelated to the study, A.B. reports consulting for Arthrex, Inc., and stock/stock options with A3 Surgical; and J.N.L. reports consulting for Innomed and research funding from Synthes Paoli, PA.

Background: The aim of this study was to compare postoperative immobilization techniques of the thumb metacarpophalangeal (MP) ulnar collateral ligament (UCL) in a cadaver model of a noncompliant patient., Methods: A cadaveric model with fresh-frozen forearms was used to simulate pinch under two immobilization conditions: (1) forearm-based thumb spica splint alone and (2) forearm-based thumb spica splint with supplemental transarticular MP Kirschner wire fixation. Pinch was simulated by thumb valgus loading and flexor pollicis longus (FPL) loading. Ulnar collateral ligament displacements were measured and strain values calculated. Statistical analysis was performed using a repeated measures analysis of variance model., Results: With valgus thumb loading, we noted a significantly lower UCL strain in the splint and pin group compared to splint immobilization alone. Increased load was associated with a statistically significant increase in UCL strain within each immobilization condition. FPL loading resulted in negative displacement, or paradoxical shortening, of the UCL in both immobilization groups., Conclusions: While immobilized, valgus thumb force, as opposed to MP flexion, is a likely contributor to UCL strain during simulated pinch representing noncompliance during the postoperative period. Supplemental thumb MP pin fixation more effectively protects the UCL from valgus strain. UCL shortening with FPL loading likely represents paradoxical MP extension due to flexion of the distal phalanx against the distal splint, suggesting attempted thumb flexion with splint immobilization alone does not jeopardize UCL repair., Clinical Relevance: This study provides a foundation to aid clinical decision-making after UCL repair. It reinforces the practice of surgeons who routinely pin their MP joints, but also brings to attention that the use of temporary MP pin fixation may be considered in difficult cases, such as those with potential noncompliance or tenuous repair.

Forearm fractures may be complicated by the disruption of the distal radioulnar, proximal radioulnar, or radiocapitellar joints. The key principles in treating this unique subset of fractures include early recognition and management of the injury and restoration and maintenance of the anatomic alignment. This articles addresses radial diaphyseal fractures with distal radioulnar joint disruption, proximal ulnar fractures with radiocapitellar disruption, and disruption of the forearm longitudinal axis and how to properly recognize and manage these forearm fracture-dislocations., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To report the branching patterns, vessel diameters, and location of the valves in the arcus venosus dorsalis pedis (AVDP) as a graft option for use in superficial palmar arch reconstruction after mutilating hand injuries., Methods: We dissected 10 cadaveric feet and measured vessel diameters, recorded number of branches, and located valves within the tibial, middle, and fibular thirds of the system. We used retrograde india ink injection to locate valves., Results: The AVDP branching pattern was grossly different from side to side in the 4 cadavers with bilateral feet available. Mean flat diameters were 4.7, 2.9, and 2.1 mm in the tibial, middle, and fibular thirds of the arch, respectively. There was a mean of 1.7 valves (range, 1-4 valves) in the tibial third, 1.5 valves (range 0-4 valves) in the middle third, and 0 valves in the fibular third. There was an average of 3.4 branches off the middle third with a mean branch diameter of 2.1 mm. In 65% of these branches, valves were within 1 cm distal to the main arch. The direction of flow within the middle third was from fibular to tibial., Conclusions: Valves were commonly found within the middle and tibial thirds of the AVDP and within branches just distal to bifurcations. By contrast, the fibular third of the AVDP contained no valves. Valvular anatomy suggests that the direction of flow within the middle third was from fibular to tibial direction., Clinical Relevance: The AVDP is morphologically similar to the palmar arch. When rendering valves within the AVDP incompetent, attention should be paid not just to the main arch itself, but also to branches off the AVDP. The fibular and middle thirds of the AVDP can safely be used for palmar arch reconstruction without blockage of flow owing to valves. The branches off the middle third must be used within a few millimeters of their takeoff to avoid valves., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE)., Design: Prospective cohort followed for 1 year., Setting: Clinics., Participants: Patients diagnosed with UNE (N=55)., Intervention: All subjects had simple decompression surgery., Main Outcome Measures: The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow., Results: Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9-23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9-24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, -0.38; 95% CI, -.67 to -.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, -.40; 95% CI, -.79 to -.01)., Conclusions: Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Fractures of the hand are common injuries and in particular, fractures involving the articular surfaces can present difficulties to the orthopedic surgeon in practice. Although the treatment of these fractures needs to be individualized based on fracture pattern and location, the goals for these fractures are to restore the alignment, stability, and congruity and to allow for early motion to prevent stiffness and traumatic arthritis. This article classifies the various types of intra-articular hand fractures as well as the workup and management of these injuries., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE)., Objective: We measured patient outcomes following ulnar nerve decompression to (1) identify the most appropriate outcomes tools for UNE and (2) to describe outcomes following ulnar nerve decompression., Methods: Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament, and 2-point discrimination were measured. Construct validity was calculated by using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means., Results: Key-pinch (P = .008) and Semmes-Weinstein monofilament testing of the ulnar ring (P < .001) and small finger (radial: P = .004; ulnar: P < .001) improved following decompression. Two-point discrimination improved significantly across the radial (P = .009) and ulnar (P = .007) small finger. Improved symptoms and function were noted by the CTQ (preoperative CTQ symptom score 2.73 vs 1.90 postoperatively, P < .001), DASH (P < .001), and MHQ: function (P < .001), activities of daily living (P = .003), work (P = .006), pain (P < .001), and satisfaction (P < .001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness., Conclusion: Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.

Background: Although numerous studies have investigated long-term outcomes after surgical treatment of ulnar neuropathy at the elbow with simple decompression, no study has evaluated the trend of postoperative recovery. The authors assessed timing of recovery after simple decompression for ulnar neuropathy at the elbow., Methods: The five-center Surgery of the Ulnar Nerve Study Group prospectively recruited 58 consecutive subjects with ulnar neuropathy at the elbow and treated them with simple decompression. Patients were evaluated preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patient-rated outcomes questionnaires included the Michigan Hand Questionnaire; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the Carpal Tunnel Questionnaire. Functional tests used were grip strength, key pinch strength, two-point discrimination, and Semmes-Weinstein monofilament testing. Postoperative improvement was assessed at each time point to establish the trend of recovery in reaching a plateau., Results: Significant patient-reported symptomatic and functional recovery occurred over the first 6 weeks postoperatively as represented by improvements in questionnaire scores. Symptomatic recovery occurred earlier than functional recovery as measured by sensory and strength testing and the work domain of the Michigan Hand Questionnaire. Improvement in patient-reported outcomes continued and reached a plateau at 3 months, whereas measured strength and sensory recovery continued over 12 months., Conclusion: The greatest clinical improvement after simple decompression for ulnar neuropathy at the elbow, according to questionnaire scores, occurs in the first 6 weeks postoperatively and reaches a plateau by 3 months.

Management of coronal shear fractures of the distal humerus has evolved considerably over the past 3 decades, with an increased appreciation of the complexity of these fractures, improvements in internal fixation techniques, and the use of more extensile exposures. Nearly all of these fractures are displaced, given the paucity of soft tissue attachments and correspondingly, nonsurgical management is fraught with complications including chronic pain, mechanical symptoms, and instability and is not recommended. Good to excellent outcomes can be achieved in the majority of patients with open reduction internal fixation, particularly when the fracture is limited to the radiocapitellar joint. Outcomes are worst for those with considerable medial extension or comminution. Computed tomography is highly recommended to guide surgical planning. The presence of posterior comminution or extension to the medial column might require more extensile exposures and supplemental fixation for adequate stability. Arthroscopic reduction and fixation techniques have been described for the simple fracture. Those not amenable to fixation might do better with total elbow arthroplasty in a select population. Long-term data demonstrate the durability of these elbows following open reduction internal fixation. Complications other than stiffness are rare. Radiographic avascular necrosis does not appear to affect outcome. Radiographic mild to moderate arthritis was observed in half of patients at 17-year follow-up., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate and compare the biomechanical properties of 8 different locked fixed-angle volar distal radius plates under conditions designed to reflect forces seen in early fracture healing and postoperative rehabilitation., Methods: We evaluated the Acumed Acu-Loc (Acumed, Hillsboro, OR), Hand Innovations DVR (Hand Innovations, Miami, FL), SBi SCS volar distal radial plate (Small Bone Innovations, Morrisville, PA), Synthes volar distal radius plate and EA extra-articular volar distal radius plate (Synthes, Paoli, PA), Stryker Matrix-SmartLock (Stryker Leibinger, Kalamazoo, MI), Wright Medical Technology Locon VLS (Wright Medical Technology, Arlington, TN), and Zimmer periarticular distal radius locking plate (Zimmer, Warsaw, IN). After affixing each plate to a synthetic corticocancellous radius, we created a standardized dorsal wedge osteotomy. Each construct had cyclic loading of 100 N, 200 N, and 300 N for a total of 6000 cycles. Outcomes, including load deformation curves, displacement, and ultimate yield strengths, were collected for each construct., Results: The Wright plate was significantly stiffer at the 100 N load than the Zimmer plate and was stiffer at the 300 N load than 4 other plates. The Zimmer and Hand Innovations plates had the highest yield strengths and significantly higher yield strengths than the Wright, SBi, Stryker, and Synthes EA plates., Conclusions: Given the biomechanical properties of the plates tested, in light of the loads transmitted across the native wrist, all plate constructs met the anticipated demands. It seems clear that fracture configuration, screw placement, cost, and surgeon familiarity with instrumentation should take priority in selecting a plating system for distal radius fracture treatment., Clinical Relevance: This study provides further information to surgeons regarding the relative strengths of different plate options for the treatment of distal radius fractures., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Heterotopic ossification (HO) about the elbow has been described after surgery, trauma, and burns. Even limited deposits can lead to significant functional deficits. Little data exist regarding outcomes of patients treated with radiation therapy (RT) after elbow surgery. We report here the Cleveland Clinic experience with single-fraction radiation following surgery to the elbow. The primary endpoint was the rate of new HO after RT. Secondary endpoints were range of motion, functional compromise, and toxicity., Methods and Materials: From May 1993 to July 2006, 36 patients underwent elbow surgery followed by single-fraction RT. Range of motion data were collected before and during surgery and at last follow-up. Radiographs were reviewed for persistent or new HO. Patient and treatment factors were analyzed for correlation with development of HO or functional compromise., Results: Median follow-up was 8.7 months, median age was 42 years, and 75% of patients were male. Twenty-six (72%) patients had HO prior to surgery. All patients had significant limitations in flexion/extension or pronation/supination at baseline. Thirty-one (86%) patients had prior elbow trauma, and 26 (72%) patients had prior surgery. RT was administered a median of 1 day postoperatively (range, 1-4 days). Thirty-four patients received 700 cGy, and 2 patients received 600 cGy. Three (8%) patients developed new HO after RT. All patients had improvement in range of motion from baseline. No patient or treatment factors were significantly associated with the development of HO or functional compromise., Conclusions: Single-fraction RT after surgery to the elbow is associated with favorable functional and radiographic outcomes., (Copyright 2010 Elsevier Inc. All rights reserved.)

Elbow motion is essential for upper extremity function to position the hand in space. Unfortunately, the elbow joint is prone to stiffness following a multitude of traumatic and atraumatic etiologies. Elbow stiffness can be diagnosed with a complete history and physical exam, supplemented with appropriate imaging studies. The stiff elbow is challenging to treat, and thus, its prevention is of paramount importance. When this approach fails, non-operative followed by operative treatment modalities should be pursued. Upon initial presentation in those who have minimal contractures of 6-month duration or less, static and dynamic splinting, serial casting, continuous passive motion, occupational/physical therapy, and manipulation are non-operative treatment modalities that may be attempted. A stiff elbow that is refractory to non-operative management can be treated surgically, either arthroscopically or open, to eliminate soft tissue or bony blocks to motion. In the future, efforts to prevent and treat elbow stiffness may target the basic science mechanisms involved. Our purpose was to review the etiologies, classification, evaluation, prevention, operative, and non-operative treatment of the stiff elbow.

Open fractures are often classified according to a system described by Gustilo and Anderson. However, this system was applied to open long bone fractures, which may not predict the incidence of infection in open metaphyseal fractures of the upper extremity. Other studies have found that wound contamination and systemic illness were the best predictors of infections in open hand fractures. Our study assessed infection in open distal radius fractures and identifies factors that are associated with these infections. We hypothesize that contamination, rather than absolute wound size, is the best predictor of infection associated with open distal radius fractures. A review by CPT code yielded 42 patients with open distal radius fractures between 1997 and 2002 treated at a level one trauma center. Medical records and radiographic follow-up were reviewed to assess the time to irrigation and debridement, the number of debridements in initial treatment period, the method of operative stabilization, the Gustilo and Anderson type of fracture, the Swanson type of fracture, and description of wound contamination. Forty-two patients were followed up for an average of 15 months (range 4 to 68 months). Twenty-four fractures were classified as Gustilo and Anderson type I, ten were type II, and eight were type III, 30 were Swanson type I, and 12 were Swanson type II. Five of the 42 fractures were considered contaminated. Two were exposed to fecal contamination. The others were contaminated with tar, dirt/grass, and gravel, respectively. Three of 42 (7%) fractures developed infections. All three infected cases received a single irrigation and debridement. Two of five contaminated fractures (40%) developed a polymicrobial infection. Both were exposed to fecal contamination and, therefore, considered Swanson type II fractures. They were classified as Gustilo and Anderson type II and IIIB based solely upon the size of the wound. Both required multiple debridements and eventually wrist fusions. The third infection occurred in a Gustilo and Anderson type II and Swanson type I open fracture treated with one debridement and plate fixation. Hardware removal, debridement, and antibiotics resolved the infection. Three contaminated fractures that healed uneventfully received two debridements. Statistical analysis revealed a correlation with infection and contamination (p = 0.0331). The number of initial debridements played a role in infection, but was not statistically significant. No relationship between infection and time to initial irrigation and debridement, method of fixation, Gustilo and Anderson type, or Swanson type was found. We propose that open distal radius fractures behave differently than open long bone fractures. Infection developed in 7% of the distal radius fractures in our study and was significantly associated with wound contamination. We recommend that contamination be included as factor for prognosis in open distal radius fractures. Contaminated fractures should be treated with multiple debridements as part of the initial plan not based upon subsequent development of an infection.

The elbow is as prone to stiffness as it is essential for upper-extremity function. The elbow is a highly constrained synovial hinge joint that frequently becomes stiff after injury. Elbow contracture is challenging to treat, and therefore prevention is of paramount importance. When this approach fails, nonoperative followed by operative treatment modalities can be pursued. In the future, efforts to prevent and treat elbow stiffness may target the basic science mechanisms involved.

Distal biceps tendon ruptures typically occur with biceps contraction against resistance with the elbow flexed at 90 degrees. Anatomic repair is the gold standard in active patients. Numerous surgical techniques are available; however, the Endobutton might offer several advantages. We describe a novel technique for chronic distal biceps reconstruction using a modification of the Endobutton technique with an anterior cruciate ligament (ACL) drill guide as well as tendoachilles allograft. The Endobutton technique might offer several advantages, including direct tendon-to-bone healing, less bony debris to limit heterotopic ossification, less heating of the bone, ease of use, a biomechanical superiority, and excellent clinical outcomes.

The metacarpophalangeal (MP) joint is resistant to injury due to its strong capsuloligamentous structures, which include the volar plate and deep transverse metacarpal and collateral ligaments. Complex MP joint dislocations are, by definition, irreducible by closed means and require open reduction, as the volar plate becomes entrapped between the metacarpal head and proximal phalanx. The dorsal approach may offer the following advantages: 1) reduced risk to palmarly displaced neurovascular structures, 2) facilitated management of osteochondral fractures, and 3) full exposure of the volar plate. However, the dorsal approach requires splitting of the volar plate for adequate reduction, which may delay recovery.

Introduction: Extensor tendon irritation and attritional tendon ruptures are potentially serious complications after open reduction and internal fixation of distal radius fractures. These complications are well recognized after dorsal plating of distal radii; and these are now being reported after errant screw placement during volar fixed-angle plating. Intraoperative detection of improper screw placement is critical, as corrective action can be taken before completion of the operative procedure. The purpose of this study was to define the extensor tendon compartments at risk secondary to dorsal screw penetration and to compare pronation and supination fluoroscopic images with standard lateral images in demonstrating dorsal screw prominence during volar locked plating., Methods: Eight fresh-frozen human cadaveric upper extremities underwent fixation with a volar, fixed-angle distal radius locked plate (Wright Medical Technology, Arlington, TN). Three fluoroscopic views (lateral, supinated, and pronated) followed by dorsal wrist dissections were compared to determine accuracy in detecting dorsal screw prominence and extensor tendon compartment violation. Subsequently, screws measuring 2, 4, 6, 8, and 10(mm longer than the measured depths were sequentially inserted into each distal locking screw, with each image deemed either "in" (completely inside the bone) or "out" (prominent screw tip dorsally-would typically be exchanged for a shorter screw intraoperatively)., Results: The radial most distal locking screw (position 1) violated either the first (25%) or second (75%) extensor tendon compartments. The average screw prominence required for radiographic detection was: 6.5(mm for lateral views and 2(mm for supinated views. Pronated views did not identify prominent screws. Screws occupying plate position 2 consistently entered Lister's tubercle, with 5/8 exiting the apex and 3/8 exiting the radial base. The average screw prominences for radiographic detection were: 2.75(mm-lateral views and 3.0(mm-supinated views. Although the screws entered the second dorsal compartment, they did not encroach upon either of the tendons. Screws occupying plate position 3 violated the third extensor tendon compartment in 7/8 specimens with 1/8 exiting the Ulan base of Lister's tubercle. The average screw prominences for radiographic detection were: 3.5(mm-lateral views and 2.5(mm-pronated views. Supinated views did not identify prominent hardware. Screws occupying plate position 4 all violated the IV dorsal extensor compartment-2/8 screws were noted to tent the posterior interosseous nerve. The average screw prominences required for radiographic detection were: 4.0(mm-lateral views and 2.5(mm-pronated views. The supinated views did not identify prominent screws., Conclusions: Volar fixed-angle plating has shown great promise in the advancement of distal radius fracture management. We have seen in our referral practices and in the literature an increase in the number of extensor tendon complications arising from unrecognized dorsally prominent screws, pegs, or tines. Standard PA and lateral radiographs cannot adequately visualize screw position and length secondary to the complex geometry of the dorsal cortex. We believe this study supports the routine application of intraoperative, oblique pronosupination fluoroscopic imaging for enhanced confirmation of distal locking screw position and length.

The relationship of the posterior interosseous nerve (PIN) to the radius was studied to determine the change in position associated with forearm motion because of the risk of injury during surgical exposure of the lateral elbow. The distance from the PIN to the radiocapitellar joint (RCJ) was measured in 24 cadaveric specimens in pronation, neutral rotation, and supination. The mean distance from the PIN to the RCJ was 4.6 +/- 0.5 cm, 5.3 +/- 0.6 cm, and 5.7 +/- 0.7 cm in supination, neutral rotation, and pronation, respectively. In pronation, there was substantial variation of this distance, with a minimum distance of 4.3 cm. In supination, the minimum distance was 4.0 cm. On the basis of limited PIN distal translation, noted with pronation, as well as the variation between individuals, we recommend limiting dissection to 4.0 cm from the RCJ during a lateral approach without formal identification of the PIN. This safe zone is recommended regardless of forearm rotation, in contrast to the recommendation of prior authors, as pronation does not reliably increase the distance of the PIN to the RCJ.

A radial nerve injury associated with a humeral shaft fracture is an important injury pattern among trauma patients. It is the most common peripheral nerve injury associated with this fracture. Although treatment for this injury pattern is a controversial subject among upper-extremity surgeons, certain principles of management need to be applied in all cases. As our understanding of the pathoanatomy of the humerus and surrounding neurovascular structures has evolved, surgeons have adapted their strategies to improve outcome and avoid long-term morbidity. The principles of management and the clinical outcomes of various treatment strategies, defined in the literature, are reviewed in this article.

Ulnar-sided injuries of the wrist have received more attention recently for their potential negative impact on the outcome of distal radius fractures. Radiographs and medical records were retrospectively reviewed for 166 distal radius fractures treated during a 1-year interval. Distal radius fractures were classified according to the AO system, and accompanying ulnar styloid fractures were evaluated for both size and displacement. Each distal radius fracture was also evaluated for radiographic and clinical evidence of distal radioulnar joint instability. The distribution of ulnar styloid fractures was not random; greater than one third involved the base. All distal radius fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture. A fracture at the ulnar styloid's base and significant displacement of an ulnar styloid fracture were found to increase the risk of distal radioulnar joint instability.

A key parameter in the mechanical environment created in distraction osteogenesis is the axial stiffness of the external fixator. Mechanical testing of the frames with wire and half pins has been used to estimate the stiffness contributions of wires based on the span length and of half pins based on the offset length. A summation of the wire and half pin contributions appears to represent a suitable estimate for the axial stiffness of frames composed of a mixture of wires and half pins. Using this estimate, clinicians can make informed decisions regarding frame construction, and it may be possible to investigate the rate of bone formation relative to axial frame stiffness in the clinical setting.