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Context: Major League Baseball (MLB) players are at risk of hook of hamate fractures. There is a paucity of data assessing the effect of a hook of hamate fracture on MLB players' future athletic performance., Objective: To determine if MLB players who sustain hook of hamate fractures demonstrate decreased performance upon return to competition when compared with their performance before injury and that of their control-matched peers., Design: Retrospective case-control design., Setting: Retrospective database study., Participants: 18 MLB players who sustained hook of hamate fractures., Methods: Data for 18 MLB players with hook of hamate fractures incurred over 26 seasons (1989-2014) were obtained from injury reports, press releases, and player profiles ( www.mlb.com and www.baseballreference.com ). Player age, position, number of years in the league, mechanism of injury, and treatment were recorded. Individual season statistics for the 2 seasons immediately prior to injury and the 2 seasons after injury for the main performance variable-Wins Above Replacement-were obtained. Eighteen controls matched by player position, age, and performance statistics were identified. A performance comparison of the cohorts was performed., Main Outcome Measures: Postinjury performance compared with preinjury performance and matched-controls., Results: Mean age at the time of injury was 25.1 years with a mean of 4.4 seasons of MLB experience prior to injury. All injuries were sustained to their nondominant batting hand. All players underwent operative intervention. There was no significant change in Wins Above Replacement or isolated power when preinjury and postinjury performance were compared. When compared with matched-controls, no significant decline in performance in Wins Above Replacement the first season and second season after injury was found., Conclusion: MLB players sustaining hook of hamate fractures can reasonably expect to return to their preinjury performance levels following operative treatment.

Background: Intramedullary headless screw (IMHS) has shown promise as an alternative to other fixation devices for metacarpal neck fractures. The purpose of this study was to assess the biomechanical performance of IMHS versus the commonly-used crossed K-wire technique. We hypothesized that IMHS fixation provides superior stability to K-wires., Methods: A metacarpal neck fracture model in 23 human cadaveric metacarpals was created. The specimens were divided into two groups based upon fixation method: Group 1, 3 mm intramedullary headless screw; and Group 2, 0.045 inch crossed K-wires. A cantilever bending model was used to assess load-to-failure (LTF), maximum displacement, energy absorption, and stiffness., Results: The mean LTF was 70.6 ± 30.1 N for IMHS and 97.5 ± 34.7 N for crossed K-wires. Mean stiffness was 11.3 ± 3.4 N/mm and 17.7 ± 7.8 N/mm for IMHS and crossed K-wires, respectively. The mean maximum displacement was 20.2 ± 4.6 mm for IMHS and 24.1 ± 3.7 mm for crossed K-wires. Moreover, mean energy absorption was 778.3 ± 528.9 Nmm and 1095.9 ± 454.4 Nmm, respectively, for IMHS and crossed K-wires. Crossed K-wires demonstrated significantly higher stiffness and maximum displacement than IMHS (p < 0.05)., Conclusions: IMHS fixation of unstable metacarpal neck fractures offers less stability compared to crossed K-wires when loaded in bending., Clinical Relevance: Crossed K-wires offer superior stability for the treatment of metacarpal neck fractures. These results reveal that IMHS fixation is less favorable biomechanically and should be cautiously selected with regards to fracture stability., Competing Interests: The authors did not receive any funding for this study/ manuscript. Additionally, the authors have no relevant disclosures or conflicts of interest to declare. Also, there are no acknowledgements.

Background: Whether percutaneous pinning or plate fixation is more appropriate for metacarpal fractures is still open to debate. Our study purpose was to review the current literature in an attempt to determine the optimal treatment modality for metacarpal fractures on the basis of functional outcomes, radiographic outcome and rates of complications., Methods: We selected Pubmed, Cochrane library, EMBASE and the relevant English orthopedic journals and pooled data from eligible trials including four comparative studies and one retrospective review. Overall, the studies contained 222 patients with 231 fractures, 143 treated with pinning and 88 treated with plates and screws. Mean follow up was 7.5 months (4-12 months). Data were analyzed and the fixed effects are assumed for meta-analysis., Results: Patients undergoing pinning for metacarpal fractures have higher motion scores when compared to open reduction and internal fixation with plate and screws. Functional scores, grip strength, radiographic parameters, time to union and complications were found not to be significantly different between the two groups., Conclusions: There is evidence to support the use of pins over ORIF with plates and screws in the treatment of metacarpal fractures. This may have practical advantages, including minimal dissection, easier insertion and availability of the pins. The limitations of this study include the small number of eligible studies, lack of reporting of standard deviation value, and the lack of DASH score assessments at follow up. Further randomized controlled trials that include a larger patient numbers with longer follow up are needed to substantiate the superiority of one fixation method over another.

Background: Recently, intramedullary headless screw (IMHS) has shown promise as an alternative to dorsal plate fixation of metacarpal fractures. The purpose of this study was to assess the biomechanical performance of IMHS versus plating. We hypothesized that IMHS fixation provides inferior stability to plating. Methods: Metacarpal fracture model with 3-mm of volar gapping in forty-four human cadaveric metacarpals was created. The specimens were divided into 5 groups: Group 1, 1.5-mm non-locking plate; Group 2, 1.5-mm locking plate; Group 3, 2.0-mm non-locking plate; Group 4, 2.0-mm locking plate; and Group 5, 2.4-mm short cannulated IMHS. A 4-point bending model was used to assess load-to failure (LTF) and stiffness. Results: Mean LTF was 364 ± 130 N for 1.5-mm non-locking plates, 218 ± 94 N for 1.5-mm locking plates, 421 ± 86 N for 2.0-mm non-locking plates, 351 ± 71 N for 2.0-mm locking plates, and 75 ± 20 N for IMHS. Mean stiffness was 91 ± 12 N/mm for 1.5-mm non-locking plates, 110 ± 77 N/mm for 1.5-mm locking plates, 94 ± 20 N/mm for 2.0-mm non-locking plates, 135 ± 16 N/mm for 2.0-mm locking plates, and 55 ± 15 N/mm for IMHS. IMHS demonstrated significantly lower LTF and stiffness than plates. Conclusions: IMHS fixation of unstable metacarpal shaft fractures offers less stability compared to plating when loaded in bending. The LTF and stiffness of IMHS versus plating of metacarpal shaft fractures has not been previously quantified. Our results reveal that IMHS fixation is less favorable biomechanically and should be carefully chosen in regards to fracture stability., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.T.C. is on the Speakers Bureau for Integra Life Sciences and is a consultant for Wright Medical Technology.

Background: The aim was to determine whether players in the National Basketball Association (NBA) who sustain metacarpal fractures demonstrate decreased performance upon return to competition when compared with their performance before injury and that of their control-matched peers. Methods: Data for 32 NBA players with metacarpal fractures incurred over 11 seasons (2002-2003 to 2012-2013) were obtained from injury reports, press releases, and player profiles (www.nba.com and www.basketballreference.com). Player age, body mass index (BMI), position, shooting hand, number of years in the league, and treatment (surgical vs nonsurgical) were recorded. Individual season statistics for the 2 seasons immediately prior to injury and the 2 seasons after injury, including player efficiency rating (PER), were obtained. Thirty-two controls matched by player position, age, and performance statistics were identified. A performance comparison of the cohorts was performed. Results: Mean age at the time of injury was 27 years with an average player BMI of 24. Players had a mean 5.6 seasons of NBA experience prior to injury. There was no significant change in PER when preinjury and postinjury performances were compared. Neither injury to their shooting hand nor operative management of the fracture led to a decrease in performance during the 2 seasons after injury. When compared with matched controls, no significant decline in performance in PER the first season and second season after injury was found. Conclusion: NBA players sustaining metacarpal fractures can reasonably expect to return to their preinjury performance levels following appropriate treatment., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The objectives of this investigation were to report temporal trends in resident performed upper extremity fracture procedures and analyze case volume variability., Methods: Orthopaedic resident case logs from the Accreditation Council for Graduate Medical Education were reviewed for graduating years 2007 to 2014. The mean number of wrist, forearm, elbow, humerus, and shoulder fracture-dislocation procedures performed by residents was analyzed. The median number of procedures reported by the top 30% and bottom 30% of residents (by case volume) was also recorded. Linear regression modeling was used to assess temporal trends., Results: The mean number of wrist and forearm fracture cases performed per resident fell from 55.3 in 2007 to 46.7 in 2014 (p = 0.325) while the number of elbow and humerus fracture procedures remained relatively constant (45.6 to 45.4; p = 0.224). The mean number of shoulder fracture cases increased significantly (14.7 to 22.5; p < 0.001). Over the 8-year period, residents in the 70th percentile of caseload performed significantly more wrist and forearm (62.6 versus 39.5; p < 0.001), elbow and humerus (55 versus 34.9; p < 0.001), and shoulder (23 versus 12.9; p < 0.001) fracture procedures than residents in the 30th percentile., Conclusion: Resident case volume for wrist, forearm, elbow, and humerus fractures is constant or falling. However, shoulder fracture caseloads are increasing. Regardless, there is substantial disparity in upper extremity fracture case volume among residents. Further investigation is needed to assess possible educational effects of resident caseload disparity.

Perilunate dislocations and fracture dislocations are the result of an axial load with hyperextension and ulnar deviation of the wrist, combined with intercarpal supination. Prompt treatment injuries is essential. There is a high rate of missed or incorrect diagnosis. In the past, closed management was recommended. These methods proved to be ineffective. Current research and data show better results with anatomic restoration of carpal alignment and direct ligament repair. A combined dorsal and volar approach is preferred. This article reviews the current literature and discusses the surgical techniques to restore carpal alignment and repair the scapholunate interosseous ligament., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Fractures of the digits and the metacarpals are common injuries in athletes. The majority of these can be treated nonoperatively with careful attention to alignment, rotation, and shortening. Those requiring operative fixation are usually amenable to either K-wire, interfragmentary screw, or plate fixation. Whichever treatment pathway is chosen, the goal should be to provide adequate stability for healing while attempting to maintain mobility of the joints and digits. Dedicated rehabilitation is essential to optimizing functional outcomes, patient satisfaction, and return to sport.

Background and Purpose: Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase (COX) activity, which is the rate-limiting enzyme in the synthesis of prostaglandins. Previous studies have indicated that NSAID therapy, and in particular NSAIDs that specifically target the inflammatory cyclooxygenase (COX-2), impair bone healing. We compared the effects of ibuprofen and rofecoxib on fibula osteotomy healing in rabbits to determine whether nominal, continuous inhibition of COX-2 with rofecoxib would differentially affect fracture healing more than cyclical inhibition of COX-2 using ibuprofen, which inhibits COX-1 and COX-2 and has a short half-life in vivo., Methods: Bilateral fibula osteotomies were done in 67 skeletally mature male New Zealand white rabbits. The rabbits were treated with placebo, rofecoxib (12.5 mg once a day), or ibuprofen (50 mg 3 times a day) for 28 days after surgery. Plasma ibuprofen levels were measured by HPLC analysis. Bone healing was assessed by histomorphometry at 3 and 6 weeks after osteotomy, and at 6 and 12 weeks by torsional mechanical testing., Results: Plasma ibuprofen levels peaked and declined between successive doses. Fracture callus morphology was abnormal in the rofecoxib-treated rabbits and torsional mechanical testing showed that fracture healing was impaired. Ibuprofen treatment caused persistence of cartilage within the fracture callus and reduced peak torque at 6 weeks after osteotomy as compared to the fibulas from the placebo-treated rabbits. In the specimens allowed to progress to possible healing, non-union was seen in 5 of the 26 fibulas from the rofecoxib-treated animals as compared to 1 of 24 in the placebo group and 1 of 30 in the ibuprofen treatment group., Interpretation: Continuous COX-2 inhibition as modeled by rofecoxib treatment appears to be more deleterious to fracture repair than cyclical cyclooxygenase inhibition as modeled by ibuprofen treatment. Ibuprofen treatment appeared to delay bone healing based upon the persistence of cartilage within the fracture callus and diminished shear modulus. Despite the ibuprofen-induced delay, rofecoxib treatment produced worse fracture (osteotomy) healing than ibuprofen treatment.

Osteochondral injuries in the hand are common. The small size of the joints and associated articular surfaces make repair of these injuries difficult. Osteochondral autografting has been described in the knee for some time and has recently been reported for hand injuries. We describe the use of an osteochondral graft taken from the dorsal nonarticular portion of the metacarpal head for a defect in the metacarpophalangeal joint surface.

Purpose: Proximal interphalangeal (PIP) joint fracture-dislocations are complex injuries, and successful surgical treatment can be challenging. The hamate appears to be an appropriate graft based on its general shape and dimensions. The purpose of this study was to evaluate the rationale and suitability of the hamate as an autograft for proximal interphalangeal joint fracture-dislocations and to determine the inherent stability of the donor site after graft harvesting., Methods: Fresh-frozen cadaveric hand specimens were used to evaluate the hamate as a suitable graft source for defects of the middle phalanx based on macroscopic, radiographic, and biomechanical properties. Radiographic measurements were made of the articular contours of the hamate and the base of middle phalanx of digits 2 through 5. Hemicondylar hamate replacement arthroplasty (HHRA) was performed in cadavers for defects created in the middle phalanges. Biomechanical stability testing of the hamate-metacarpal joint was then assessed in additional specimens before and after HHRA. Fluoroscopic examination with a 22.2-N load applied in a 45 degrees dorsal-proximal direction was used to assess stability of the carpometacarpal joints. A servohydraulic testing machine was then used to determine the amount of translation induced with a similarly directed force before and after harvesting of the hamate graft., Results: The cadaveric HHRA reconstructions restored joint stability with no tendency to subluxate. Radiographic measurement showed that the hamate has a central ridge and bicondylar facet with articular contours that are similar to the base of the middle phalanx. The removal of a central portion of the hamate did not induce dislocation or create obvious clinical instability of the carpometacarpal joint., Conclusions: The HHRA technique is used for treatment of fracture-dislocations of the proximal interphalangeal joint. This study demonstrated the suitability of using the dorsal portion of the hamate as an osteochondral autograft for middle phalangeal base fractures; the technique creates minimal donor site morbidity.

The high demands placed on the upper extremity in sporting activities subject the competitive athlete to common injuries of the hand. Treatment options are based on the fracture configuration, associated extremity injuries, and status of the surrounding soft tissue. Metacarpal and phalangeal fractures may usually be treated by closed, nonoperative methods, and most athletes may quickly return to play with a protective orthosis. Supplemental methods of fixation, such as percutaneous pins and tension-band wires, may be used for unstable fractures. When required, open reduction and internal fixation can provide optimum stability to the fracture, which allows immediate range-of-motion and early return to play.