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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.

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.

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.

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.

To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE).Prospective cohort followed for 1 year.Clinics.Patients diagnosed with UNE (N=55).All subjects had simple decompression surgery.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.Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with3 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).Subjects with3 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.

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.

Despite encouraging results from small case series, correction of distal radius malunion remains a challenging procedure with uncertain outcomes. The most appropriate treatment for a distal radius malunion is prevention. If a symptomatic malunion is discovered, correction should be undertaken as early as possible. It is recommended that action be taken within six months of the primary injury to decrease the negative impact of soft-tissue contracture on the eventual reconstruction. Although some patients complain about residual problems after malunion surgery, corrective surgery has been shown to improve both radiographic and functional outcomes, and may prevent future secondary problems.

The Internet has changed the way in which we gather and interpret information. Although books were once the exclusive bearers of data, knowledge is now only a keystroke away. The Internet has also facilitated the synthesis of new knowledge. Specifically, it has become a tool through which medical research is conducted. A review of the literature reveals that in the past year, over 100 medical publications have been based on Web-based survey data alone. Because of emerging Internet technologies, Web-based surveys can now be launched with little computer knowledge. They may also be self-administered, eliminating personnel requirements. Ultimately, an investigator may build, implement, and analyze survey results with speed and efficiency, obviating the need for mass mailings and data processing. All of these qualities have rendered telephone and mail-based surveys virtually obsolete. Despite these capabilities, Web-based survey techniques are not without their limitations, namely, recall and response biases. When used properly, however, Web-based surveys can greatly simplify the research process. This article discusses the implications of Web-based surveys and provides guidelines for their effective design and distribution.

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

Although reconstruction is often the primary choice of surgeons after an open tibial fracture, there is no evidence to support the long-term effectiveness of flap reconstruction over below-knee amputation. The aim of this study was to perform a decision analysis to evaluate treatment preferences for type IIIB and IIIC tibial fractures. Reconstructive microsurgeons, physical medicine physicians, and patients with lower extremity trauma completed a Web-based standard gamble utility survey to generate quality-adjusted life years (QALYs). Physicians assigned quite high utility values, and there was a slight preference for reconstruction over amputation, with a gain of only 0.55 QALY. Patients assigned significantly lower utility values and also favored reconstruction over amputation, but with a larger gain of 5.54 QALYs. The disparate utilities assigned by the physicians and the patients highlight the necessity of realistic discussion of outcomes, regardless of the management methods.

Purpose Type I lunates have a single distal facet for articulation with the capitate; type II lunates have an additional (medial) hamate facet on the distal articular surface. We retrospectively reviewed a series of patients with scaphoid nonunions to determine if there was an association between lunate morphology and the degree of carpal instability observed. Association between lunate morphology and the location of the scaphoid fracture (proximal or waist) was also investigated. Methods Radiographs were evaluated for 45 patients with established scaphoid nonunions. Lunate morphology, scaphoid fracture location, and radiolunate angle were determined. Results Type I lunates were present in 21 patients. Of these, 15 were found to have a dorsal intercalated segment instability pattern (radiolunate angle greater than 15°). By contrast, only 4 of the patients with type II lunates exhibited this pattern of instability. No significant association was found between lunate morphology and the scaphoid fracture location. Conclusions Type II lunate morphology is associated with significantly decreased incidence of dorsal intercalated segment instability (DISI) deformity in cases of established scaphoid nonunion (p = .0002). Lunate morphology, however, was not significantly associated with the location of the scaphoid fracture in these cases (p = .19). Type of study/level of evidence Prognostic IV.

Primary repair of a high ulnar nerve injury results in a uniformly poor outcome as a result of the great distance between the site of injury and the innervated muscles. In this study the authors present two cases of high ulnar nerve injuries in adults. Reconstruction was performed using the distal branch of the anterior interosseous nerve, which was transferred to the distal motor branch of the ulnar nerve. This resulted in timely return of function to the ulnar-innervated intrinsic muscles of the hand, which was documented further by electromyography. For high ulnar nerve injuries, this type of nerve transfer is a much better approach than the traditional primary neurorrhaphy.