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Shared decision-making for surgery can increase patient engagement, satisfaction, and clinical outcomes. However, the level of involvement that patients desire at each step of the decision-making process is unknown.The authors surveyed patients at an academic hand surgery clinic to examine the preferred role in decision-making using validated questionnaires (i.e., Control Preference Scale, Problem-Solving Decision-Making Scale, and General Self-Efficacy Scale). The Control Preference Scale assesses general treatment preferences, whereas the Problem-Solving Decision-Making Scale distinguishes between problem-solving tasks (e.g., making diagnoses, calculating risks/benefits) and decision-making tasks. Patients' self-beliefs and perceived ability to handle difficult situations were assessed with the General Self-Efficacy Scale. The authors used linear regression models and ordinal logistic regression to examine the relationship between self-efficacy and patients' preferred role in treatment decision-making.Patients overall preferred an equal share of decision-making responsibility with the surgeon (mean Control Preference Scale score, 3.3 ± 0.7). Specifically, for problem-solving tasks, however, 81 percent of patients wanted to "hand over" the responsibility and 19 percent preferred shared decision-making. In contrast, for decision-making tasks, 54 percent of patients preferred shared decision-making. Each point increase in General Self-Efficacy Scale score correlated with 12 percent greater odds of preferring to retain the responsibility (OR, 1.12; 95 percent CI, 1.05 to 1.21; p = 0.001). However, self-efficacy did not show a significant effect for problem-solving tasks.The authors found that patients prefer surgeons to provide expert knowledge for problem-solving tasks but desire equal share of responsibility in decision-making tasks. The authors' findings support the current shift away from the paternalistic model of surgical decision-making, and provide an effective strategy to tailor shared decision-making to align care delivery with patient preferences.

Background Opioids are commonly used following outpatient surgery. However, we understand little about patients' perspectives and how patients decide on postoperative opioid use. This study seeks to investigate aspects of patients' thought processes that most impact their decisions. Methods The authors conducted semistructured interviews with 30 adults undergoing minor elective hand surgery at one tertiary hospital. Narratives were content-coded to arrive at the authors' thematic analysis. The authors incorporated Bandura's concept of self-agency to interpret the data and develop a conceptual framework that best explained the implicit theory within participants' responses. Results The authors found six themes under two domains of self-agency. Participants actively sought out protective mechanisms supporting their decision on opioid use, but sometimes did so unconsciously. They would avoid opioids postoperatively because they were "tough" and wanted to evade the risk of addiction as "good citizens." They conveyed a nuanced safety against addiction because they were "not the kind" to become addicted and because they trusted the surgeons' prescribing. However, participants felt discouraged by the stigma associated with opioids. Both intentionally and unintentionally, participants integrated a strong sense of self in their decision-making processes. Conclusions A robust understanding of how patients choose to take opioids for postoperative pain control is imperative to develop patient-centered strategies to treat the opioid epidemic. Effective opioid-reduction policies should consider patients as active agents who negotiate various internal and external influences in their decision-making processes. Surgeons must incorporate patients' individual goals and perspectives regarding postoperative opioid use to minimize opioid-related harm after surgery.

© 2019 American Society for Surgery of the Hand Purpose: Current evidence on predictors of outcomes after distal radius fracture is often based on retrospective analyses or may be confounded by fracture type. Using data from the Wrist and Radius Injury Surgical Trial (WRIST), a 24-site randomized study of distal radius fracture treatment, in which all fractures are severe enough to warrant surgery, we set out to perform a secondary data analysis to explore predictors of better or worse hand outcomes. Methods: The primary outcome measure was the Michigan Hand Outcomes Questionnaire (MHQ) summary score 12 months after treatment. We used a regression tree analysis with recursive partitioning to identify subgroups of participants who experienced similar outcomes (ie, MHQ score) and to determine which baseline or treatment factors they had in common. Results: Factors most predictive of 12-month MHQ score were pain at enrollment, education, age, and number of comorbidities. Specifically, participants who had a high school education or less and also reported severe pain had the lowest MHQ scores. Conversely, participants with less pain and more education and who were age 87 years or younger with one or no comorbid condition had the highest MHQ scores. Treatment type or radiographic measurements assessed on post-reduction films did not affect 12-month outcomes. Conclusions: These results identified patient characteristics that can be used by surgeons to identify subgroups of patients who may experience similar hand outcomes. Type of study/level of evidence: Prognostic III.

Summary:. Painful neuromas result from traumatic injuries of the hand and digits and cause substantial physical disability, psychological distress, and decreased quality of life among affected patients. The regenerative peripheral nerve interface (RPNI) is a novel surgical technique that involves implanting the divided end of a peripheral nerve into a free muscle graft for the purposes of mitigating neuroma formation and facilitating prosthetic limb control. The RPNI is effective in treating and preventing neuroma pain in major extremity amputations. The purpose of this study was to determine if RPNIs can be used to effectively treat neuroma pain following partial hand and digital amputations. We retrospectively reviewed the use of RPNI to treat symptomatic hand and digital neuromas at our institutions. Between November 2014 and July 2019, we performed 30 therapeutic RPNIs on 14 symptomatic neuroma patients. The average patient follow-up was 37 weeks (6–128 weeks); 85% of patients were pain-free or considerably improved at the last office visit. The RPNI can serve as a safe and effective surgical solution to treat symptomatic neuromas after hand trauma.

Surgeons often prescribe opioid analgesics for pain management after surgery. However, we understand little about how patients perceive opioid prescribing and make decisions to use opioids for postoperative pain management. In this study, we aimed to gain an understanding of patients' decision-making process on postoperative opioid use.We conducted semi-structured interviews with 30 adult patients undergoing elective surgery at our institution. The interviews were content-coded for thematic analysis. We used trust in the medical setting as a conceptual framework to interpret and find the inherent theory in the data.We found that participants based their opioid decisions on their trust or distrust toward various elements of their postoperative pain management. Participants believed that the surgeons "know," thereby, reinforcing their trust in surgeons' postoperative opioid prescribing to be in the participants' best interest. Moreover, the positive reputation of the institution strengthened the participants' trust. However, participants conveyed nuanced trust because of their distrust toward the opioid medications themselves, which were viewed as "suspicious," and the pharmaceutical companies, that were "despised." Despite this distrust, participants had confidence in their inherent ability to protect themselves from opioid use disorders.Understanding how patients perceive and form decisions on postoperative opioid use based on their trust and distrust toward various factors involved in their care highlights the importance of the patient-doctor relationship and building trust to effectively address postoperative pain and reduce opioid-related harms.Through a strengthened therapeutic alliance between patients and surgeons, we can improve our strategies to overcome the ongoing opioid epidemic through patient-centered approaches.

Background Pisiform excision and pisotriquetral arthrodesis are two surgical options for the treatment of pisotriquetral joint pain when conservative methods fail. However, it is unclear which option is best for patients who experience substantial, repetitive loading on their wrists and wish to preserve wrist flexibility and function. Case Description We present a case of bilateral ulnar-sided wrist pain related to the pisotriquetral joint in a 19-year-old collegiate diver. The pain was exacerbated by activities specific to this sport that requires wrist hyperextension, namely full weight-bearing on the hands (handstands), and has an impact on the hands and wrists upon water entry during dives due to direct palmar pressure. There were no radiographic signs of arthritis; however, there were bone marrow changes on magnetic resonance imaging (MRI). Management with rest, splinting, and corticosteroid injection failed to relieve the pain and precluded his ability to return to full-time diving. Treatment consisted of bilateral pisiform excision. Postoperatively, the patient returned to full-time competitive diving with resolution of his painful symptoms. Literature Review Pisiform excision has been shown to have successful outcomes in terms of return to play for lower impact athletes (such as badminton) but has not been reported in athletes who experience a high degree of force repetitively (such as gymnasts or divers). There is one report of pisotriquetral arthrodesis in a young gymnast with suboptimal results. Clinical Relevance This case report demonstrates that pisiform excision is a successful treatment for elite athletes who experience repetitive, palmar force on hyperextended wrists and subsequently develop ulnar-sided wrist pain.

This decision analytical model study uses survey responses to investigate the importance patients gave to attributes of postoperative pain management after hand surgical procedures., Key Points Question Which attributes of pain control are most important to patients after surgical treatment? Findings In this decision analytical model study of survey responses from 321 patients who underwent elective hand surgical procedures, risk of addiction and pain relief were the aspects of postoperative pain control with the highest attribute importance scores. Meaning These findings suggest that a multimodal pain control regimen that is associated with sufficient pain relief and decreased risk of addiction may be ideal for the treatment of postoperative pain., Importance Opioids are often prescribed after elective surgical treatment despite the potential for misuse. Although various pain control regimens exist, patient preferences for acute postoperative pain management are unknown. Objective To describe patient-reported key attributes of postoperative pain management. Design, Setting, and Participants This decision analytical model used responses from a survey based on conjoint analysis to investigate the value patients placed on different aspects of postoperative pain management. Participants were patients aged 18 years or older who underwent elective hand surgical procedures between July 1, 2018, and July 23, 2019, at a single academic center. The survey was completed on a web-based platform and took place between November 2019 and January 2020. Data were analyzed from May through July 2021. Exposures Participants were presented with a series of discrete-choice tasks and asked to select between 2 postoperative medication options that changed from question to question and had varying characteristics. Main Outcomes and Measures Attribute importance scores and part-worth utility values for the queried aspects of pain control were calculated. Results Of 710 individuals invited, 321 (45.2%) completed the survey; there were 212 (66.0%) women and 108 (33.6%) men, and the most common age category was 60 to 69 years (102 participants [31.8%]). Most patients reported previous opioid use (282 individuals [87.9%]). Factors in the decision-making process with the highest attribute importance scores (SDs) were risk of addiction (26.3% [13.0%]) and amount of pain relief (25.6% [14.6%]). Adverse effects 13.9% (7.2%), functional independence 11.8% (7.3%), and level of trust in the prescriber 11.4% (5.8%) had intermediate attribute importance scores (SDs). Cost 7.9% (4.4%) and stigma 3.1% (1.3%) had the lowest attribute importance scores (SDs) in patient decisions. Conclusions and Relevance These findings suggest that multimodal pain control regimens that are associated with optimized pain relief and minimized risk of addiction are preferable to treat acute postoperative pain. The results suggest that identifying procedures for which patients prioritize minimizing risk of addiction over pain relief and incorporating patient preferences into decision-making may be associated with decreased postoperative opioid prescribing.

Modern competitive diving-especially platform diving-applies dramatic stress to the upper extremity. Some stress occurs during handstand-style takeoffs, but more force is delivered to the hand, wrist, elbow, and shoulder during hands-first entry. Hand positions that minimize the amount of splash result in forceful wrist extension. This repetitive impact can lead to chronic upper extremity pain and acute injuries that require operative intervention. Many divers use taping and bracing to prevent or treat this type of injury, but these are only modestly effective. Although minor injuries can improve with conservative management, carpal fractures and ligamentous injuries often require operative intervention.

Diabetic patients are prone to a variety of hand disorders, many of which cause limited motion, pain, and loss of function. In many cases, severity of symptoms and progression of disease are thought to be linked to poor glycemic control. While some of these conditions have straightforward, low-risk solutions—both non-surgical and surgical—others, such as cheiroarthropathy, remain difficult to treat and do not have satisfactory solutions available.

Background: Calcific tendinitis is characterized by calcium hydroxyapatite crystal deposition within tendons and is a common cause of musculoskeletal pain in adults. Its clinical manifestations may be acute, chronic, or asymptomatic. Acute calcific tendinitis is self-resolving condition that is rarely reported in the pediatric population and may be overlooked for more common processes, leading to unnecessary treatment. Methods: A chart reivew was performed of a single case of acute calcific tendonitis of the index finger in a child. Results: We describe a case of calcific tendinitis of the index finger in a 9-year-old boy who was referred to us for a second opinion after surgical exploration of an acutely inflamed digit was recommended based on his initial presentation. The calcifications and symptoms resolved over time without operative management. Conclusions: Although rare in children, acute calcific tendinitis can present similar to an infection. However, appropriate managment is non-operative as the symptoms and radiographic findings resolve over time.

As minimally invasive options for treatment of Dupuytren contractures become increasingly widespread, it is important that the evidence is carefully evaluated and patients are informed of the risks and benefits of the options available. The authors advocate a shared decision-making process, using evidence-based medicine, to guide patients in their treatment choices. In this article, the authors present their thoughtful approach to selecting the appropriate Dupuytren treatment of patients, along with detailed, practical technical tips to avoid complications during the execution of these interventions; both collagenase injection and limited fasciectomy techniques are described in detail.

PURPOSE: We sought to evaluate the use of pre- and post-referral advanced diagnostic testing among patients with three common hand conditions, rates of subsequent tests, and differences in wait time to see a hand surgeon. METHODS: We analyzed a single academic tertiary care center administrative database of encounters from 2006 – 2015 to identify adult patients who were referred to a hand surgeon for three hand conditions (carpal tunnel syndrome [CTS], soft tissue masses [STM], and joint pain [JP]). We recorded patient characteristics, use and timing of diagnostic tests, and wait time for the initial hand surgeon evaluation. RESULTS: Among patients who received advanced diagnostic tests prior to the surgeon evaluation, CTS patients had the highest rate of receiving pre-referral advanced testing (53.4%) compared to 10.6% of JP patients and 5.8% of STM patients. CTS patients had the highest rates of repeat testing (19.5%) compared to patients with JP (1.4%) and STM (0%). Across all three conditions, patients who received pre-referral advanced testing waited an additional 19–94 days to see a surgeon compared to patients who received only post-referral testing or no testing. CONCLUSIONS: The use of pre-referral advanced diagnostic tests is associated with an increased time to see a hand surgeon for common hand conditions. CLINICAL RELEVANCE STATEMENT: Hand surgeons should play a role in identifying patients who do and do not benefit from advanced testing prior to referral to ensure that tests ordered prior to consultation are useful to both patients and treating surgeons.

Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE).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.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.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.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.

Systematic reviews and meta-analyses are important research tools in modern medicine. They serve to condense and clarify large amounts of data into resources that can educate clinicians, enhance patient care, help formulate clinical guidelines, and guide future research endeavors.The existing literature, including recently updated guidelines, on systematic reviews and meta-analysis was reviewed and summarized.A brief background on the origins of systematic reviews is presented, and the advantages and disadvantages of this type of study are discussed. A step-by-step guide to conducting a proper systematic review is outlined, with many illustrative examples. The recently updated reporting guidelines for this type of study are included.Using clinical examples and published guidelines, a framework is presented to help the reader properly conduct a systematic review. These guidelines also help the reader conduct a critical appraisal of systematic reviews published in the scientific literature. Even more importantly, principles regarding application of systematic review results to individual patients are addressed.

Lower extremity trauma is common. Epidemiology studies have shown that open long bone fractures occur at a rate of 11.5 per 100,000 persons per year, and many of these are open tibial shaft fractures1-3. Type III open fractures are the most severe, involving extensive soft tissue trauma and complex fracture patterns4. Many of these injuries can be managed with salvage involving either local muscle flaps or microvascular free tissue transfer for wound coverage. The alternative to reconstruction for such injuries is amputation. Over the past decades, many studies have sought to delineate the advantages and disadvantages of these two principal options for managing severe lower extremity trauma. A recent systematic review of all available literature demonstrated that, despite the abundance of evidence, neither option is superior with respect to clinical outcomes5. Because microvascular reconstruction is technically demanding, time-consuming, and fraught with substantial risk of complications, we must look beyond clinical outcomes to evaluate the costs and utilities afforded to patients by this option. Studies have shown that even with successful limb salvage, many patients are still not ambulatory after two years; persistent pain and disability are not uncommon after this type of injury6, 7. Despite the residual problems with reconstruction, however, some studies suggest that patients with salvaged lower limbs have a better quality of life and impose lower costs on the health care system8-10. As surgeons, we want the best for our patients, but as stewards of modern medicine who work with limited healthcare resources, we are also charged with making evidence-based, fiscally-sound decisions. When dealing with complex operations of uncertain effectiveness, cost-utility analyses can help provide the scientific evidence upon which these decisions can be based. Although costs10 and utilities11 have been measured, a detailed cost-utility analysis with robust sensitivity analysis, which is needed to consider the wide-range of assumptions in clinical decision-making, has not been conducted. This study presents a cost-utility analysis for management of severe open tibial fractures, and will serve to guide surgeons and patients in deciding between the two competing management options.

Leiomyoma is most commonly found in the uterus and lower extremities of middle-aged women. Leiomyoma is uncommonly reported in the hand and is extremely uncommon in children. We present three cases of leiomyoma of the hand, including one case in the hand of a 10-year-old boy.

BACKGROUND: The best treatment for an inadequately reduced fracture of the distal part of the radius is not well established. We collected prospective outcomes data for patients undergoing open reduction and internal fixation of an inadequately reduced distal radial fracture with use of the volar locking plating system. METHODS: Over a two-year period, 161 patients underwent open reduction and internal fixation of an inadequately reduced distal radial fracture with use of the volar locking plating system. Patients were enrolled in the present study three months after the fracture on the basis of strict entry criteria and were evaluated three, six, and twelve months after surgery. Outcome measures included radiographic parameters, grip strength, lateral pinch strength, the Jebsen-Taylor test, wrist range of motion, and the Michigan Hand Outcomes Questionnaire. RESULTS: Eighty-seven patients with a distal radial fracture were enrolled. The mean age at the time of enrollment was 48.9 years. Forty percent (thirty-five) of the eighty-seven fractures were classified as AO type A, 9% (eight) were classified as type B, and 51% (forty-four) were classified as type C. Radiographic assessment showed that the plating system maintained anatomic reduction at the follow-up periods. At the time of the twelve-month follow-up, the mean grip strength on the injured side was worse than that on the contralateral side (18 compared with 21 kg; p < 0.01), the mean pinch strength on the injured side was not significantly different from that on the contralateral side (8.7 compared with 8.9 kg; p = 0.27), and the mean flexion of the wrist on the injured side was 86% of that on the contralateral side. All Michigan Hand Outcomes Questionnaire domains approached normal scores at six months, with small continued improvement to one year. CONCLUSIONS: The volar locking plating system appears to provide effective fixation when used for the treatment of initially inadequately reduced distal radial fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION: “Treatment of Unstable Distal Radial Fractures with the Volar Locking Plating System” (2006;88:2687-94).

Acellular nerve grafts have emerged as a possible alternative for reconstruction of short (

Proximal interphalangeal joint fracture-dislocations are common injuries that require expedient and attentive treatment for the best outcomes. Management can range from protective splinting and early mobilization to complex surgery. In this review, the current concepts surrounding the management of these injuries are reviewed.A literature review was performed of all recent articles pertaining to proximal interphalangeal joint fracture-dislocation, with specific focus on middle phalangeal base fractures. Where appropriate, older articles or articles on closely related injury types were included for completeness. The methodology and outcomes of each study were analyzed.When small avulsion fractures are present, good results are routinely obtained with reduction and early mobilization of stable injuries. Strategies for management of the unstable dorsal fracture-dislocation have evolved over time. To provide early stability, a variety of techniques have evolved, including closed, percutaneous, external, and internal fixation methods. Although each of these techniques can be successful in skilled hands, none has been subjected to rigorous, prospective, comparative trials. Volar dislocations fare less well, with significant loss of motion in many studies. Pilon fractures represent the most complicated injuries, and return of normal motion is not expected.The best outcomes can be achieved by (1) establishing enough stability to allow early motion, (2) restoring gliding joint motion rather than noncongruent motion, and (3) restoring the articular surface congruity when possible. Although the majority of literature on this topic consists of expert opinion and retrospective case series, the consensus appears to favor less invasive techniques whenever possible.

Inferior vena cava (IVC) interruption is being performed with increasing frequency. Indications for this procedure have expanded since the introduction of percutaneous placement techniques. Indications for placement of a second IVC filter are less well defined. It has been reported that a second filter can be placed safely. The purpose of this study was to investigate the intermediate and long-term follow-up of these patients. Five patients underwent placement of a second IVC filter at one institution from 1992 to 1996. During the same period a total of 439 patients underwent IVC filter placement. The five patients, ranging in age from 46 to 67 years, included three men and two women. The indication for the second filter placement was a confirmed or strongly suspected recurrent pulmonary embolus (PE), with thrombus in and above the previously placed IVC interruption device in all patients. Three of the five patients suffered from poorly controlled malignancies. One patient had an ependymoma of the spinal cord that was completely excised. The fifth patient had a documented hypercoagulable state: factor V resistance to activated protein C. The mean time between placement of the first and second filters was 31 weeks (range: 1-65 weeks). Mean follow-up was 94 weeks (range: 0-252 weeks). One patient died within 24 hours of filter placement from profound hypoxemia from a preexistent PE. No fatal PE occurred in any of the four remaining patients. Two patients in this study, following placement of a second IVC filter, had documented pulmonary emboli that were nonfatal. Two patients died as a result of their underlying malignancies. While placement of a second IVC interruption device is an infrequently performed procedure, it appears to be efficacious in preventing death from pulmonary emboli in this extremely high-risk group of patients.

Pathologic fractures occur in bone weakened by a disease process. In the hand, the most common cause of pathologic fracture is a solitary enchondroma, although many other less common causes exist, including bone cysts, benign and malignant tumors, and other rarer entities. Arriving at a correct diagnosis is the key to successful treatment. If the fracture seems the result of a benign process, the fracture can be allowed to heal prior to definitive treatment of the underlying lesion. Fractures associated with aggressive or malignant lesions require more urgent treatment, although the overall prognosis for pathologic fracture due to malignancy is poor.

Ulnar neuropathy at the elbow is the second most prevalent peripheral compressive neuropathy, after carpal tunnel syndrome.1 With an estimated annual incidence of 75,000 cases in the United States, the health care and societal burden of ulnar neuropathy at the elbow continues to grow.2 Similar to carpal tunnel syndrome, various stressors on the ulnar nerve result in pain, numbness, and weakness in ulnar neuropathy at the elbow. Although the biomechanics of the ulnar nerve as it traverses the elbow are different from those on the median nerve in the carpal tunnel, surgical treatments for carpal tunnel syndrome and ulnar neuropathy at the elbow are similar in aiming to relieve nerve compression.3,4 Traditionally, functional outcomes measures used in evaluating treatment for compressive neuropathies have included grip strength and two-point discrimination, among others. Studies using these measures for postoperative evaluation of carpal tunnel syndrome and ulnar neuropathy at the elbow found recovery to take many months, and over 1 year for some.5–8 However, using patient-rated questionnaires, patients report symptomatic improvement far earlier than functional testing indicates. Questionnaires such as the Michigan Hand Questionnaire; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the disease-specific Carpal Tunnel Questionnaire have been validated for carpal tunnel syndrome and ulnar neuropathy at the elbow and are more responsive than the functional tests.9–13 Improvement in these patient-reported outcomes after carpal tunnel surgery occurs in 6 weeks or less.14 Controversy remains as to the optimal surgical treatment for ulnar neuropathy at the elbow; however, numerous prospective trials, systematic reviews, and meta-analyses have shown no difference in outcomes among the various surgical techniques.15–18 These studies advocate simple decompression as the less invasive and less costly procedure, with equivalent outcomes. In all of these trials, long-term outcomes were the main focus. No study has reported the timing of recovery after surgery for ulnar neuropathy at the elbow. Determining how patients recover after surgery is not only critical in understanding the pathophysiology of ulnar neuropathy at the elbow but can guide optimal treatment and management. In addition, it may facilitate establishing appropriate patient and provider expectations, which play a significant role in outcomes. The Surgery of the Ulnar Nerve Study Group, a collaboration of five centers, was established to further investigate this condition. Patients with ulnar neuropathy at the elbow were treated with simple decompression and evaluated at 6 weeks, 3 months, 6 months, and 1 year postoperatively. All three questionnaires—the Michigan Hand Questionnaire; the Carpal Tunnel Questionnaire; and the Disabilities of the Arm, Shoulder and Hand questionnaire—were administered and have been validated for ulnar neuropathy at the elbow by this group.19 Objective measures were also used. The timing of improvement in all of these metrics was evaluated in this cohort. We hypothesized that recovery after surgery for ulnar neuropathy at the elbow would take longer than reported for carpal tunnel syndrome but would occur earlier than previously believed.

To retrospectively characterize the ultrasound appearance of displaced ulnar collateral ligament (UCL) tears that are proven at surgery, and then determine the accuracy of the resulting ultrasound criteria in differentiating displaced from non-displaced UCL tears.After institutional review board approval, 26 patients were identified from the radiology information system over a 10-year period that had ultrasound evaluation of the thumb and surgically proven UCL tear. Retrospective review of the displaced full-thickness tears was carried out to characterize displaced tears and to establish ultrasound criteria for such tears. A repeat retrospective review 4 months later of all UCL tears applied the criteria to determine accuracy of ultrasound in the diagnosis of displaced full-thickness UCL tear.The 26 subjects consisted of 17 displaced full-thickness UCL tears, seven non-displaced full-thickness tears, and two partial-thickness tears at surgery. Retrospective ultrasound review of displaced full-thickness tears identified two criteria present in all cases: non-visualization of the UCL ligament and presence of a heterogeneous mass-like area proximal to the first metacarpophalangeal joint. Applying these criteria at the second retrospective review resulted in 100 % sensitivity, specificity, positive predictive value, negative predictive value, and accuracy.The ultrasound findings of absent UCL fibers and presence of a heterogeneous mass-like abnormality proximal to the first metacarpophalangeal joint achieved 100 % accuracy in differentiating displaced from non-displaced full-thickness UCL tear of the thumb. Displaced full-thickness UCL tears most commonly were located proximal to the adductor aponeurosis.