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Background: Patients with upper limb dysfunction from a brain injury often have different goals of treatment and expectations following a fracture of the upper extremity. This study retrospectively reviewed outcomes of nonoperative management of acute humerus fractures in patients with severe ipsilateral hemiparesis or hemiplegia., Methods: Patients who had sustained an acute humerus fracture managed nonoperatively, greater than 1 year following an upper motor neuron (UMN) injury resulting in ipsilateral severe hemiparesis or hemiplegia at a single tertiary care center from 1988 to 2019, were reviewed. Fractures were classified using the AO-Müller/Orthopaedic Trauma Association and/or Neer classifications. Primary outcome measures included House classification level of function, pain, achievement of and time to radiographic union, and the need for subsequent surgical procedures., Results: Ten distinct nonoperatively managed humerus fractures-3 proximal (11A23), 5 mid-shaft (12A2b = 1, 12A2c = 2, 12A3a = 1, 12A2b = 1), and 2 distal (13A2 = 1, 13 C1 = 1)-were identified in 8 patients (6 women and 2 men) with ipsilateral hemiparesis or hemiplegia. The median radiographic follow-up was 20 months (range: 78 days to 12 years). The median clinical follow-up was 33.5 months (range: 100 days to 12 years). All patients presented with severe pain that was absent at final follow-up. Radiographic union was achieved in all patients with a mean time to union of 90.9 ± 39.3 days (range: 35-185 days). No patients required operative management., Conclusions: Nonoperative management of humerus fractures in patients with an ipsilateral UMN injury might result in reliable pain relief and union without the need for further surgical intervention. Management of humerus fractures in this patient population should be individualized toward their goals of care.

Background: The coronavirus disease 2019 (COVID-19) surge has enabled the widespread usage of telemedicine (TM) and presents a unique opportunity to determine the hand surgery patients' perception of care using validated patient satisfaction scores., Methods: Electronic surveys were distributed to patients aged 18 years and older who underwent a video TM encounter with a single surgeon at an academic medical center during the initial COVID-19 surge (March 23 to October 22, 2020). The study-specific questions were derived from the Press Ganey (PG) Medical Practice TM Survey and compared with institutional PG Outpatient Medical Practice Survey data. Three cohorts were defined: pre-COVID face-to-face, post-COVID TM, and post-COVID face-to-face., Results: Thirty of 65 TM patients (46.2%) responded. No differences in sex, age, or visit type were identified between cohorts. The TM cohort was more likely to live greater than 300 miles from the institution. Median response for all cohorts for the PG care provider and overall experience responses were "very good," and no differences were identified between cohorts. Patient satisfaction with their TM experience was high with median satisfaction scores for arranging and connecting to a TM visit, talking with the provider over a video connection, and having the provider understand the clinical problem were "very good." Patients in the TM cohort reported no difference in preference for face-to-face or TM visits., Conclusions: Patients are satisfied with TM as a substitute for face-to-face visits suggesting that TM can possibly be used to deliver comparable patient experience for hand surgery encounters.

Background: Little information exists to guide decision-making with regard to distal radius fractures in the setting of ipsilateral hemiparesis or hemiplegia., Methods: Patients who sustained a distal radius fracture in the setting of ipsilateral hemiparesis or hemiplegia secondary to brain injury were evaluated. Investigated variables included perioperative pain, preinjury House functional classification score, length of immobilization, radiographic outcome measurements, and time to union., Results: There were 15 patients with distal radius fractures with a mean age of 65.9 years. The mean clinical and radiographic follow-up was 2.8 and 2.9 years, respectively. Wrists were placed into the nonoperative group (NOG, n = 10) and operative group (OG, n = 5). Pain significantly decreased at final follow-up for both groups. Baseline House functional classification scores averaged 1.3 and 1.6 for the NOG and OG, respectively, and were maintained at final follow-up. Length of immobilization for the NOG was 46 days and OG was 37 days, P = .15. Radiographic outcomes at final follow-up in the NOG and OG, respectively, were a mean radial height of 9.3 versus. 11.6 mm, radial inclination of 18.3° versus 22.3°, 4.2° dorsal tilt versus 5.3° volar tilt, and tear drop angle of 45.6° versus 44.5°. There were no significant differences in these measurements. Time to radiographic union averaged 58 days for the NOG and 67 days for the OG, P = .42. There were no revision surgeries., Conclusions: Based on this small case series, patients with distal radius fracture and ipsilateral hemiparesis or hemiplegia may have similar clinical, functional, and radiographic outcomes, regardless of nonoperative or operative treatment.

Background: Upper motor neuron (UMN) syndrome consists of muscle spasticity, weakness, and dyssynergy due to a brain or spinal cord injury. The purpose of this study is to describe the perioperative adverse events for adult patients undergoing single-event, multilevel upper extremity surgery (SEMLS) due to UMN syndrome., Methods: A retrospective case series was performed for 12 consecutive adult patients who underwent SEMLS to correct upper extremity dysfunction or deformity secondary to UMN syndrome. The evaluation consisted of primary outcome measures to identify readmission rates and classify adverse events that occurred within 30 days after surgery., Results: All 12 patients were functionally dependent with 50% (n = 6) men and 50% (n = 6) women at a mean age of 43.6 years (range: 21-73) with a mean of 5.92 (range: 0-16) comorbid diagnoses at the time of surgery. There were no intraoperative complications, hospital readmissions, or deaths among the 12 patients. Five patients experienced 5 minor postoperative complications that consisted of cast- or orthosis-related skin breakdown remote from the incision (n = 3), incidental surgical site hematoma that required no surveillance or intervention (n = 1), and contact dermatitis attributed to the surgical dressing that resolved with topical corticosteroids (n = 1)., Conclusions: With an appropriate multidisciplinary approach, there is minimal risk for developing perioperative and 30-day postoperative adverse events for adults undergoing SEMLS to correct upper extremity deformities secondary to UMN syndrome., Level of Evidence: Level IV.

Background: The scaphoid-trapezoid-trapezium (STT) articulation stabilizes the scaphoid and links the proximal and distal carpal rows. The purpose of the study was to determine whether trapezium excision in the treatment of trapeziometacarpal (TM) arthritis affects carpal stability. Methods: A retrospective chart and radiographic review was performed on all wrists that underwent trapeziectomy with suspensionplasty or ligament reconstruction, and tendon interposition for TM arthritis between 2004 and 2016. Radiographic outcome measures included the modified carpal height ratio (MCHR) and radioscaphoid (RS), radiolunate (RL), and scapholunate (SL) angles. Degenerative change at the TM and STT joints was classified according to the Eaton-Littler, and Knirk and Jupiter classification systems. Radiographic parameters were compared between preoperative and final follow-up time points. Results: A total of 122 wrists were included in the study with a mean follow-up of 3.5 years (range: 1.0-13.0 years). The mean RL (range: -2.2° ± 11.8° to -10.7° ± 16.5°) and RS angles (range: 52.6° ± 13.8° to 44.4° ± 17.8°) decreased significantly (<.001) without significant change in SL angle, indicating progressive lunate and scaphoid extension after trapeziectomy. The mean MCHR decreased significantly (range: 1.6 ± 0.1 to 1.5 ± 0.1) following trapeziectomy, indicating progressive carpal collapse. Progressive scaphoid-trapezoid arthrosis was observed following trapeziectomy. No other preoperative radiographic factors investigated were associated with significant differences in preoperative and postoperative values for radiographic outcome measures. Conclusions: Trapeziectomy can lead to loss of carpal height, coordinated extension of both the lunate and scaphoid, and progressive scaphotrapezoid arthrosis. As such, in wrists with dynamic or static carpal instability, trapeziectomy should be performed with caution due to the risk of carpal collapse with a nondissociative pattern of dorsal intercalated segment instability.

Background: Trapeziectomy with ligament reconstruction tendon interposition (LRTI) or suspensionplasty is an effective treatment in older patients with end-stage thumb basilar arthritis. However, the survivability of this procedure is unknown in younger patients who may impart more stress on their thumbs. Methods: A retrospective review was performed on all patients who underwent trapeziectomy and LRTI or suspensionplasty at 55 years of age or younger from 1992 to 2008. Objective clinical outcome measures included preoperative to postoperative changes in thumb range of motion, grip and pinch strength, a study-specific thumb function score, and the Buck-Gramcko subjective outcome score. Progressive metacarpal subsidence was evaluated on radiographs. Survivorship free from revision surgery was calculated with a Kaplan-Meier analysis. Results: A total of 57 wrists underwent trapeziectomy and LRTI (n = 18) or suspensionplasty (n = 39). The mean patient age at the time of surgery was 49.6 years (range: 38-55 years). Mean clinical and radiographic follow-up were 10.2 and 6.4 years, respectively. Overall, there were significant improvements in pain and grip strength despite progressive and metacarpal subsidence. Survivorship was 100% and 86% free from revision surgery at 10 and 15 years, respectively (n = 2 failures). Conclusions: Trapeziectomy and LRTI or suspensionplasty in patients less than or equal to 55 years of age can result in considerable improvements in pain and grip strength with a 10-year survivorship free from revision.

Background: Traumatic brachial plexus injury (BPI) in patients with complete spinal cord injury (SCI) such as paraplegia or tetraplegia is a very rare and debilitating combined injury that can occur in high-energy traumas. Management of a BPI should be aimed at regaining strength for self-transfers and activities of daily living to restore independence. However, brachial plexus reconstruction (BPR) in this unique patient population requires considerable planning due to the combined elements of upper and lower motor neuron injuries., Methods: We present 2 cases of traumatic complete SCI with concomitant BPI with mean follow-up of 42 months after BPR. The first patient had a left C5-7 BPI with a T2 complete SCI. The second patient sustained a left C5-8 BPI with complete SCI at C8., Results: The first patient underwent BPR including free functioning muscle, intra- and extraplexal nerve transfers, and tendon transfers resulting in active elbow flexion and active elbow, finger, and thumb extension, but no recovery of shoulder function. While the second patient underwent extra-plexal nerve transfer to restore elbow flexion yet did not recover any function in the left upper extreimty., Conclusions: Because extensive upper and lower motor neuron injuries are present in these combined injuries, treatment strategies are limited. Expectations should be tempered in these patients as traditional methods to reconstruct the brachial plexus may result in less than ideal functional outcomes due to the associated upper motor neuron injury.

Background: "Floating forearm" injuries, perilunate injuries, with an elbow dislocation, are rare and challenging to treat., Methods: We present the case of an unusual variant of a floating forearm injury, trans-scaphoid perilunate fracture dislocation and elbow dislocation, with a concomitant open both-bone forearm fracture after a fall from a ladder. Treatment involved irrigation and debridement of the forearm wound, open reduction and internal fixation of the forearm and perilunate injury, and closed reduction of the elbow., Results: At final follow-up, he had returned to his previous occupation. Radiographs demonstrated fully healing fractures without evidence of osteonecrosis or degeneration., Conclusions: A review of the presentation, evaluation, and management of this rare injury pattern is provided.