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Background Telemedicine consultation can increase patients’ access to subspecialty care and decrease the number of unnecessary hospital transfers. In 2014, the Arkansas Hand Trauma Telemedicine Program (AHTTP) was established to extend specialized hand care throughout Arkansas. The purpose of this study is to assess whether transfers are affected when consultation with a hand specialist is performed by phone compared with using a live audiovisual consultation. Methods We reviewed data from the first year of the AHTTP. Data collection included type of consultation (telephone only or live audiovisual), need for transfer, and type of transfer (general orthopedic or hand specialist). Results In 2014, the first year of AHTTP there were 331 hand injuries identified; of those, 298 used the AHTTP with 195 (65%) using telemedicine and 103 (35%) using phone consultation only. The use of video when compared with phone consultation did not significantly affect the decision to transfer ( P = .42) or alter the rate of transfer for general orthopedic or hand specialist care ( P = .25). Conclusions The assessment of both phone and telemedicine modalities showed that there was no significant difference in transfer rates for either consultation, highlighting that communication with a hand surgeon was the key to accurate assessment of the need for transfer.

Background Nitinol memory compression staples have been proposed as an effective alternative to compression screws for capitolunate arthrodesis (CLA) for scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrist. The purpose of this study was to compare the clinical outcomes of CLA for SNAC or SLAC wrist treatment using either compression screws or nitinol staples. Methods In all, 47 patients with CLA for SLAC or SNAC wrist with screws or nitinol staples were retrospectively identified. Primary outcome was fusion on radiographs and/or computed tomography. Secondary outcomes were hardware-related complications (HWCs) and other complications, range of motion, grip strength, and patient-reported outcome measures (PROMs), including Visual Analogue Pain scale; Disabilities of the Arm, Shoulder, and Hand score; and patient-rated wrist evaluation. Results Of the 47 eligible patients, 40 (85%) were included: 31 patients in the staple group and 9 patients in the screw group. The average age was 49 (17-80) years. There was an 89% union rate for the screw group and a 97% union rate for the staple group. Two patients had screw backout: one who went onto union after screw removal and the other who went onto nonunion after hardware removal. There were 2 (6.5%) HWCs in the staple group. One patient had staple loosening requiring revision and the other dorsal impingement requiring staple removal after radiographic union. In all subsequent cases, the staples were countersunk with no impingement. No significant differences existed between any additional outcomes. Conclusions We found no differences between nitinol staples and screws for CLA regarding HWCs or PROMs. Nitinol staples may offer additional benefits as a safe and effective alternative to compression screws for wrist fusions.

Background: Telemedicine is an evolving tool to increase patients’ access to subspecialty care. Since 2014, Arkansas has been utilizing telemedicine in the evaluation of patients with hand injuries. The purpose of this study is to assess the effect of this novel telemedicine system for the management of hand trauma on patient transfer. Methods: We reviewed data from the first year of the telemedicine program (2014) and compared it to data from the year prior (2013). Data collection from both years included number of hand consults and need for transfer. From the 2014 data, we also recorded the use of telemedicine, type of transfer, distance of transfer, and time to disposition. Results: During 2013 (pre-telemedicine), there were 263 hand traumas identified. In all, 191 (73%) injuries required transfer to a higher level of care, while 72 (23%) were managed locally. In the first year of the telemedicine program (2014), a total of 331 hand injuries were identified. A total of 298 (90%) resulted in telemedicine consultation with 65% (195) utilizing video encounters. After telemedicine consultation, local management was recommended for 164 injuries (55%) while transfer was recommended for 134 (45%). Using telemedicine, there was a significant decrease in the percentage of transfer for hand injuries ( P < .001). Conclusions: The telemedicine program was well utilized and provided patients throughout the state with continuous access to fellowship trained hand surgeons including regions where hand subspecialty care is not available. The program resulted in a significant decrease in the number of hospital transfers for the management of acute hand trauma.

Purpose: The Arkansas Hand Trauma Telemedicine Program (AHTTP) is a novel telemedicine system that was developed in 2014 within a rural state to address the growing need of access to hand trauma care with one trauma center that cares for mangling hand injuries. The purpose is to compare transfers for hand injuries prior to and after the implementation of this system. Methods: The hospital institutional database was queried for all transfers to a level 1 medical center in the state from 2012 to 2015, allowing the comparison of data prior to and after the institution of the AHTTP. Patient disposition from the emergency department was categorized to evaluate the impact of AHTTP. Distance, mode of transport, and transport cost were assessed. Findings: There were 202 transfers for the treatment of isolated hand trauma (92 from 2012 to 2013 and 110 from 2014 to 2015). Prior to the institution of AHTTP, transfer patients were admitted 47.8% of the time compared with 68.2% of the time after the development of the program ( P = .02). The approximate cost of transport for patients who were discharged home directly from the emergency department was 38.5% (US $47,233) of the total costs for the 2012-2013 period and was 21.4% (US $34,017) of the costs for the 2014-2015 period ( P < .0001). Conclusions: There was a statistically significant decrease in the number of unnecessary transfers and transportation costs after the telemedicine program was started. The implementation of AHTTP in a rural state reduced health care costs and improved the efficiency of hand specialty care.

The posterior approach is a commonly employed exposure of the elbow that provides excellent visualization and efficacy for various orthopedic procedures, including total elbow arthroplasty (TEA) and fracture care. The posterior approach to the elbow has been associated with an increased rate of wound complications, including infection, skin necrosis, and wound dehiscence. Despite an association between these complications and decreased elbow perfusion, data regarding the intrinsic anatomic etiology for preferential complications in this area has been scarcely reported in the literature. This study characterizes the subdermal and cutaneous vascular perfusion about the elbow by describing the predominant direction of circulation, subdermal anastomoses, and volume of perfusion through cadaveric modeling using computed tomography angiography (CTA). Fifteen upper extremity cadaver specimens were prepared with injection of radiographic contrast directly into the axillary artery immediately preceding CTA imaging of each specimen. Sectra IDS7 software for Windows was used for analysis of all images to produce superimposed axial and 3-D reconstructions of each CTA series. From these images it was discerned that the predominant direction of flow in the posterior elbow integument is anterior medial to posterior lateral. Both the posterior medial and posterior lateral subdermal vascular networks emanate from proximally derived medial arterial sources with few anastomoses and minimal collateral perfusion from the anterolateral location. Consequently, it is important to preserve medial subdermal vascular structures to prevent ischemic wound complications. This is especially true in previously incised elbow integuments. Clin. Anat. 32:509-514, 2019. © 2019 Wiley Periodicals, Inc.

Control of independent digital flexion and extension has remained an elusive goal in myoelectric prosthetics for upper extremity amputees. We first performed a cadaver study to determine the feasibility of transferring the interossei muscles for each digit to the dorsum of the hand without damaging the neurovascular pedicles. Once this capability was ensured, a clinical case was performed transferring the interossei of the middle and ring fingers to the dorsum of the hand where they could serve as a myoelectric signal for a partial hand amputee to allow individual digital control with a myoelectric prosthesis. Before surgery, it was impossible to detect an independent signal for each interossei; however, after the surgery, signals were reliably detected, which allowed these muscles to serve as myosites for finger flexion using a myoelectric prosthesis and move each digit independently. This concept of salvaging innervated and perfused muscles from an amputated part and transferring them into the more proximal and superficial portion of a salvaged limb has broad applications for improved myoelectric prosthetic control.

Nondisplaced scaphoid fractures can be effectively treated nonoperatively, with union rates approaching or, in some series, exceeding the rates attained with operative intervention. The evidence supports equal outcomes when using a short arm or long arm cast for the closed treatment of nondisplaced scaphoid fractures. Also, equivalent outcomes have been demonstrated with or without a thumb spica component to the cast. Operative intervention is the recommended treatment for displaced scaphoid fractures. Advanced imaging should be obtained if clinical suspicion is present for a scaphoid fracture with negative radiographs more than 2 weeks after the injury. In some settings, it may even be more cost-effective to obtain advanced imaging sooner.

The purpose of this study was to determine the publication rate of manuscripts presented at the Southern Orthopaedic Association's (SOA) annual meetings. An extensive literature search was performed using Google Scholar and PubMed search engines and all accepted abstracts (posters or podium presentations) presented at an SOA annual meeting from 2005 to 2011 were evaluated. A total of 568 abstracts were presented at SOA meetings between 2005 and 2011. Of these, 234 (41%) were published in the peer-reviewed literature. The publication rate was 66% in 2005 and 28% in 2010. The average time from presentation to peer-reviewed publication was 1.6 ± 0.24 years (range, 2 years in 2006 to 1 year in 2011). The SOA publication rate was comparable with other major orthopaedic conference publication rates, yet more than half of all abstracts remain unpublished. SOA attendees should be aware that approximately 40% of all accepted presentations will go unpublished.

Of 904 patients who underwent primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) at the same hospital, 802 participated in a preoperative education day called "Joint Academy" (JA). The length of stay of JA participants was 2.12 days (49.5%) less than patients who did not attend a JA (p.01). JA attendees were 62% more likely to be discharged to home (p.01) and had an average internal hospital cost $1,493 (18.9%) lower than the non-JA group (p.01). Total costs incurred by JA attendees averaged $4,016 (27.2%) less than total costs for those patients who did not participate in a JA (p.01). Patient participation in a preoperative education program may significantly reduce overall costs for primary TKA and THA procedures.

Summary: Congenital melanocytic nevus of the hand in the pediatric population is an uncommon diagnosis. These lesions have malignant potential and can cause psychosocial effects from cosmetic deformity. Early surgical intervention is recommended in these cases. The literature suggests that full-thickness skin grafting is to be performed in the hand to maintain functionality and avoid contracture and scarring. This creates a large donor-site defect and increased risk of graft loss due to slow revascularization from graft thickness. In addition, for large defects, the full-thickness skin graft donor site would require a split-thickness graft. However, split-thickness skin grafting is avoided in the hand due to increased scarring and contracture and decreased range of motion despite decreased donor-site morbidity and better revascularization. We describe a novel reconstructive technique that uses a dermal regenerative template (Integra) with split-thickness grafting. Having performed in 2 pediatric patients, we demonstrate that aesthetic and functional outcomes are equivalent to full-thickness grafting while creating a superficial donor site and allowing for improved revascularization from decreased graft thickness.

Perseverance, Agnew‐Wiluna Belt, Western Australia, is the largest stratabound komatiitic dunite‐hosted Ni–Cu–(PGE) deposit on Earth. Perseverance is often reported as containing demonstrable evidence for thermal erosion (e.g. truncation of footwall stratigraphy), an essential component in prevailing ore genesis models. Perseverance is a highly strained and strongly altered deposit. The strong alteration and structural overprint have resulted in a metakomatiite unit with no primary volcanological or magmatic contacts with surrounding rocks. Strain is strongly partitioned around the komatiitic dunitic core and the surrounding rocks are largely mylonitic, annealed mylonitic gneisses or schists. The protolith of the surrounding rocks is difficult to assess because of alteration and strain. Previous work suggested that the surrounding stratigraphy was very complicated. The felsic units were described as felsic lapilli tuffs and were interpreted as subaqueous welded ignimbrites. Our reassessment of the footwal...

It has become a common practice to obtain weight-bearing radiographs for the assessment of early-stage osteoarthritis of the knee, and weight bearing with the knee in full extension has been the most common method. Other methods for evaluating knee joint space using weight-bearing radiography include the Rosenberg and 20/10 views. Eighty consecutive patients with knee pain were evaluated with standing Rosenberg and standing 20/10 views as part of their radiographic evaluation. The joint space for the right and left knee of each patient was measured. There was no statistically significant difference between the measurements for the 20/10 or Rosenberg views in left or right knees. We found no indication to additionally include 20/10 views in routine examinations of osteoarthritic knees when Rosenberg views had been obtained.

Kimberlites are volatile-rich magmas from mantle depths of ≥ 150 km and are the primary source of diamonds. Kimberlite volcanism involves the formation of diverging pipes or diatremes, which are the locus of high-intensity explosive eruptions. A conspicuous and previously enigmatic feature of diatreme fills are 'pelletal lapilli'--well-rounded clasts consisting of an inner 'seed' particle with a complex rim, thought to represent quenched juvenile melt. Here we show that these coincide with a transition from magmatic to pyroclastic behaviour, thus offering fundamental insights into eruption dynamics and constraints on vent conditions. We propose that pelletal lapilli are formed when fluid melts intrude into earlier volcaniclastic infill close to the diatreme root zone. Intensive degassing produces a gas jet in which locally scavenged particles are simultaneously fluidised and coated by a spray of low-viscosity melt. A similar origin may apply to pelletal lapilli in other alkaline volcanic rocks, including carbonatites, kamafugites and melilitites.

A thick sequence of bedded pyroclastic deposits, comprised largely of crystal poor, partially flow-banded perlite fragments defines the remains of a tuff ring around the eastern margin of the Miocene Ramadas Volcanic Centre (RVC), Central Andes, NW Argentina. In numerous quarry exposures, planar bed-forms dominate, but low-angle cross-stratification, lensoidal truncations and lateral pinching and swelling of cm–dm scale bed-forms occur, consistent with pyroclastic surge as the dominant transport and depositional mechanism. Intercalated are mantling, very fine grained, well-sorted, mm–cm scale planar ash layers that represent deposition from pyroclastic fall out and are most likely the products of co-surge ash clouds. Also observed are thick m-scale, laterally continuous, poorly-sorted horizons that are interpreted as pyroclastic flow deposits. Grainsize variations within the > 70 m thick succession range from fine ash to coarse lapilli, with occasional large blocks reaching 20 cm. Clast vesicularities are typically very low. The sequence constitutes a rhyolitic tuff ring around the proximal margins of the RVC. Stratigraphic relationships indicate that the tuff ring was developed following cessation of the major plinian eruption phase of the RVC. A series of pyroclastic density currents and associated ash clouds is inferred to have resulted in the construction of the rhyolitic tuff ring, with deposition focussed on the eastern and southern margins of the central vent. The fine-grained nature of the deposits and low clast vesicularity are consistent with some degree of magma:water interaction during fragmentation. Pervasive perlitic fracturing of clasts found within the tuff deposits also indicates hydration and an extended, post-depositional hydration of the pyroclastic sequence, due to the influence of meteoric water, is likely to have occurred, with deposit permeability, clast specific surface and climate influential in facilitating additional textural modification of pyroclasts.