Search

Background: Metacarpal shaft fractures are common and can be treated nonoperatively. Shortening, angulation, and rotational deformity are indications for surgical treatment. Various forms of treatment with advantages and disadvantages have been documented. The purpose of the study was to determine the stability of fracture fixation with intramedullary headless compression screws in two types of metacarpal shaft fractures and compare them to other common forms of rigid fixation: dorsal plating and lag screw fixation. It was hypothesized that headless compression screws would demonstrate a biomechanical stronger construct., Methods: Five matched paired hands (age 60.9 ± 4.6 years), utilizing non-thumb metacarpals, were used for comparative fixation in two fracture types created by an osteotomy. In transverse diaphyseal fractures, fixation by headless compression screws (n = 7) and plating (n = 8) were compared. In long oblique diaphyseal fractures, headless compression screws (n = 8) were compared with plating (n = 8) and lag screws (n = 7). Testing was performed using an MTS frame producing an apex dorsal, three point bending force. Peak load to failure and stiffness were calculated from the load-displacement curve generated., Results: For transverse fractures, headless compression screws had a significantly higher stiffness and peak load to failure, means 249.4 N/mm and 584.8 N, than plates, means 129.02 N/mm and 303.9 N (both p < 0.001). For long oblique fractures, stiffness and peak load to failure for headless compression screws were means 209 N/mm and 758.4 N, for plates 258.7 N/mm and 518.5 N, and for lag screws 172.18 N/mm and 234.11 N. There was significance in peak load to failure for headless compression screws vs plates (p = 0.023), headless compression screws vs lag screws (p < 0.001), and plates vs lag screws (p = 0.009). There was no significant difference in stiffness between groups., Conclusion: Intramedullary fixation of diaphyseal metacarpal fractures with a headless compression screw provides excellent biomechanical stability. Coupled with lower risks for adverse effects, headless compression screws may be a preferable option for those requiring rapid return to sport or work., Level of Evidence: Basic Science Study, Biomechanics.

Purpose: To evaluate the clinical success rate, along with risk factors for failure, in patients undergoing latissimus dorsi transfer for the treatment of massive, irreparable, previously failed rotator cuff tears., Methods: We performed a retrospective chart review of prospectively collected data from an institutional shoulder outcome registry. All patients who underwent latissimus dorsi transfer for previously failed rotator cuff repair between 2006 and 2013 with a minimum follow-up period of 1 year were included in the study. The indications for inclusion were large (≥2 tendons), retracted, chronic rotator cuff tears with fatty infiltration or atrophy for which prior surgical repair had failed. Preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores were collected, along with postoperative Single Assessment Numerical Evaluation scores. Complications and clinical failures (Δ in ASES score <17) were recorded. Patient demographic and tear characteristics were evaluated as potential risk factors for failure., Results: A total of 22 patients (mean age, 53 ± 6 years) were included in the study, with a mean follow-up time of 3.4 ± 1.1 years. Over 63% of patients (n = 14) reported undergoing 2 or more prior failed rotator cuff repairs. Patients undergoing latissimus dorsi transfer showed significant improvements in ASES scores (from 35.2 ± 21.9 preoperatively to 55.8 ± 22.9 postoperatively, P = .001), Simple Shoulder Test scores (from 3.5 ± 3.1 preoperatively to 5.2 ± 3.4 postoperatively, P = .002), and pain scores (from 5.9 ± 2.8 preoperatively to 4.6 ± 4.3 postoperatively, P = .002) at final follow-up. The complication rate after latissimus transfer was 27%. The rate of revision to reverse total shoulder arthroplasty was 13.6% (n = 3) after a mean of 2.7 years, and the clinical failure rate was 41% (n = 9) at final follow-up. An acromiohumeral interval of less than 7 mm (P = .04) and high-grade fatty infiltration (grade 3 or greater, P = .004) were significant preoperative risk factors for clinical failure., Conclusions: Latissimus dorsi tendon transfer resulted in a clinical failure rate of 41% and complication rate of 27%, with an acromiohumeral interval of less than 7 mm and high-grade fatty infiltration being associated with postoperative failure., Level of Evidence: Level IV., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to determine the biomechanical stability of headless compression screws in the fixation of metacarpal neck fractures and to compare them with another common, less invasive form of fixation, K-wires. The hypothesis was that headless compression screws would show higher stiffness and peak load to failure than K-wire fixation., Methods: Eight matched-paired hands (n = 31), using the ring and little finger metacarpals, had metacarpal fractures simulated at the physeal scar. Each group was stabilized with either a 3.5-mm headless compression screw or 2 0.045-in (1.1-mm) K-wires. Nineteen metacarpals were tested in 3-point bending and 12 in axial loading. Peak load to failure and stiffness were calculated from the load displacement curve. Bone mineral density was recorded for each specimen., Results: Bone mineral density was similar in the 2 groups tested for 3-point bending and axial loading. Stiffness was not significantly different in 3-point bending for headless compression screws and K-wires (means, 141.3 vs 194.5 N/mm) but it was significant in axial loading (means, 178.0 vs 111.6 N/mm). Peak load to failure was significantly higher in headless compression screws in 3-point bending (means, 401.2 vs 205.3 N) and axial loading (means, 467.5 vs 198.3 N)., Conclusions: Compared with K-wires, headless compression screws for metacarpal neck fractures are biomechanically superior in load to failure, 3-point bending, and axial loading., Clinical Relevance: Headless compression screws demonstrate excellent biomechanical stability in metacarpal neck fractures. In conjunction with promising clinical studies, these data suggest that headless compression screws may be an option for treating metacarpal neck fractures., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: The purpose of this review is to identify current principles in the diagnosis and treatment of collateral ligament injuries of the thumb in the athlete., Recent Findings: Cadaver studies have clearly identified the ulnar and radial collateral ligaments origin and insertion footprints for repair or reconstruction. Ulnar and radial collateral ligament injuries are common in athletics. History and physical examination are paramount in determining partial versus complete tear. When surgical treatment is indicated, placing the repair/reconstruction in the anatomic footprint restores stability while maintaining motion. The senior author's preferred techniques are reported.

Background: Hand and wrist injuries are common during athletics and can have a significant impact especially if initially disregarded. Due to their high level of physical demand, athletes represent a unique subset of the population., Main Body: The following is an overview of hand and wrist injuries commonly seen in athletics. Information regarding evaluation, diagnosis, conservative measures, and surgical treatment are provided., Conclusion: Knowledge of these entities and special consideration for the athlete can help the team physician effectively treat these players and help them achieve their goals.

Purpose: To determine the effect of local-only anesthesia on nonsurgical time compared with monitored anesthesia care (MAC)/local and general anesthesia. Our hypothesis was that local-only anesthesia cases would have lower nonsurgical times compared with MAC/local and general anesthesia., Methods: We retrospectively reviewed the surgical records of 1,179 patients undergoing elective hand surgery. For each case, we recorded the type of anesthesia used (general, MAC/local, or local-only anesthesia) and in-room presurgical time, in-room postsurgical time, and, if relevant, room turnover time. We did not record room turnover times for the first case of the day or for cases after procedures that did not meet inclusion criteria. We also recorded the presence of any anesthesia providers (anesthesiologist vs anesthesia-assistant [certified registered nurse anesthetist])., Results: A total of 566 cases performed on 501 patients met inclusion criteria. Room turnover times were not calculated for 304 cases. The choice of anesthesia had a significant effect on nonsurgical operating room time. Local anesthesia cases had significantly less nonsurgical time compared with general anesthesia and MAC/local. Cases performed under MAC/local anesthesia also had significantly reduced nonsurgical time compared with general anesthesia. The presence of a certified anesthesia assistant had no effect on any time metrics recorded., Conclusions: Choice of local anesthesia, when appropriate, may facilitate rapid operating room turnover and improve overall facility efficiency with lower costs., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Injuries to the thumb ulnar collateral ligament (UCL) are common. Failure to address the ensuing laxity of the metacarpophalangeal joint can lead to compromised grip and pinch, pain, and ultimately osteoarthritis. Instability to valgus stress with the lack of a firm end point is a strong indicator of complete rupture of the UCL. Nonoperative treatment is reserved for incomplete ruptures of the thumb UCL. Operative intervention is typically performed for complete ruptures. Repair of acute ruptures and reconstruction for chronic injuries yield excellent results. Complications are rare and most patients show preservation of motion, key pinch, and grip strength., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: The objective of the current study was to compare surgeon-rated visualization in shoulder arthroscopy using irrigation fluid with and without epinephrine., Methods: Eighty-three patients were randomized to receive irrigation fluid with (44 patients) or without (39 patients) epinephrine during their arthroscopic shoulder procedures. After each procedure, the blinded senior author (G.F.C.) evaluated visualization based on a visual analog scale (VAS), and all clinically important procedure variables were recorded., Results: Eighty-three arthroscopic shoulder procedures were included in the study. Fifty-four of these procedures were arthroscopic rotator cuff repairs, allowing a subset analysis of this specific procedure. There was a significant difference, with improved visualization in the epinephrine group versus the group without epinephrine when comparing all procedures (P < .0001) and when comparing only rotator cuff repairs (P < .0001). However, there was no statistical difference in other clinically important variables, including operative time and amount of irrigation fluid used., Conclusions: The addition of epinephrine to irrigation fluid significantly improves surgeon-rated visualization in shoulder arthroscopy. Without an observed significant difference in operative time or volume of irrigation fluid used, the clinical significance of this improved visualization is unclear, and the use of irrigation fluid without epinephrine remains a viable option in the hands of an experienced surgeon., Level of Evidence: Level I, high-quality randomized controlled trial with statistically significant difference., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Pectoralis major ruptures have been increasing in incidence over the past decade, most likely attributable to physical activities, such as sports and weight training. Men account for the vast majority of cases with elderly women making up the remaining small percentage. In this case report, we describe a pectoralis major rupture in a middle-aged woman that has never been documented and provide a brief review of the literature.

Background: Distal radial fracture characterization with standard radiographs has been consistently poor, leading to a widespread use of computed tomography (CT) with this injury. Traction radiographs have recently been shown to improve interobserver reliability for fracture characterization and treatment. Our goal was to compare five traction radiographs and CT images to evaluate the interobserver and intraobserver reliability of individual fracture fragment identification, the correct identification of fracture fragments on CT imaging compared with traction images, and the consistency of treatment recommendations., Methods: Eleven observers were asked to evaluate two blinded presentations of either traction images or CT images displaying seventeen different intra-articular distal radial fractures. Each observer was then asked to identify the presence or absence of six specific fracture fragments (radial column, dorsal wall, dorsal ulnar corner, volar ulnar corner, volar rim, and central impaction) and recommend treatment (nonoperative, open reduction and internal fixation, and external fixation or distraction plating). Analyses were conducted to evaluate the interobserver reliability of traction images and CT images for fracture fragment identification, the intraobserver variability of fracture fragment identification, the correct fracture fragment identification with traction radiographs compared with a gold standard CT scan, and the consistency in treatment selection., Results: Interobserver reliability for traction images and CT images were both fair to poor. Intraobserver variability for fragment identification was similar for each fragment, without significance. Treatment recommendations based on traction radiographs agreed in 80.9% of the cases for open reduction and internal fixation and in 67.9% for external fixation compared with CT images., Conclusions: Traction radiographic images are a suitable alternative to CT imaging for identifying and assessing distal radial fractures.

Purpose: To evaluate the effect of orthopedic and nonorthopedic operating room (OR) staff on the efficiency of turnover time in a hand surgery practice., Methods: A total of 621 sequential hand surgery cases were retrospectively reviewed. Turnover times for sequential cases were calculated and analyzed with regard to the characteristics of the OR staff being primarily orthopedic or nonorthopedic., Results: A total of 227 turnover times were analyzed. The average turnover time with all nonorthopedic staff was 31 minutes, for having only an orthopedic surgical technician was 32 minutes, for having only an orthopedic circulator was 25 minutes, and for having both an orthopedic surgical technician and a circulator was 20 minutes. Statistical significance was seen when comparing only an orthopedic surgical technician versus both an orthopedic circulator and a surgical technician and when comparing both nonorthopedic staff versus both an orthopedic circulator and a surgical technician., Conclusions: OR efficiency is being increasingly evaluated for its effect on hospital revenue and OR staff costs. Reducing turnover time is one aspect of a multifaceted solution in increasing efficiency. Our study showed that, for hand surgery, orthopedic-specific staff can reduce turnover time., Type of Study/level of Evidence: Economic/Decision Analysis III., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Traumatic hip dislocation is a rare but potentially devastating injury in a child. Although most hip dislocations are posterior, other variants have been described. An anterior dislocation in the pediatric population is uncommon and, to our knowledge, this is the first case of anterior-inferior (obturator) dislocation (ie, the femoral head lies in the obturator foramen), to be reported in the English-language literature. In this article, we describe the case of a young boy with a traumatic obturator hip dislocation treated conservatively with closed reduction and followed closely for 1 year. The patient did not develop any sequelae throughout the follow-up year. This case report, along with a review of the literature, will help guide clinicians in the care of patients with this rare injury.