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Outside of Preiser and Kienbock disease, avascular necrosis (AVN) of the remaining carpal bones is a rare cause of wrist pain and disability with a natural history that is incompletely understood. At present, much of the available clinical information exists in the form of isolated case reports or small case series. Although reported surgical treatment options are numerous, there is a dearth of comparative studies and long-term outcomes data with which to guide management.

Background Markers of bone metabolism (MBM) play an important role in fracture evaluation, and changes have been associated with increased fracture risk. The purpose of the present study was to describe changes in MBM in premenopausal women with distal radial fractures. Methods Premenopausal women with distal radial fractures (n = 34) and without fractures (controls) (n = 39) were recruited. Serum MBM in patients with distal radial fractures were obtained at the time of the initial presentation, 6 weeks, and 3, 6, and 12 months. MBM included 25(OH) vitamin D, PTH, osteocalcin, P1NP, BSAP, CTX, sclerostin, DKK1, periostin, and TRAP5b. Areal bone mineral density (aBMD) was assessed with dual x-ray absorptiometry, and the bone material strength index (BMSi) was assessed with microindentation. Results Most MBM reached peak levels at 6 weeks after the injury, including osteocalcin (+17.7%), sclerostin (+23.5%), and DKK1 (12.6%). Sclerostin was lower (-27.4%) and DKK1 was higher (+22.2%) at 1 year after the fracture. CTX declined below baseline levels at 6 and 12 months, whereas TRAP5b, BSAP, and periostin did not significantly change. At 12 months, sclerostin was lower (p = 0.003) and DKK1 was higher (p = 0.03) in the distal radial fracture group than in the control group. Greater fracture severity was associated with greater increases in P1NP and BSAP. aBMD and BMSi were not associated with fracture. Conclusions Distal radial fractures caused increases in several MBM, which typically peaked at 6 weeks after injury and gradually decreased over 6 months. Sclerostin and DKK1 remained below and above baseline at 1 year, respectively. Increasing fracture severity resulted in larger changes in MBM. aBMD and BMSi did not discriminate between patients with distal radial fractures and controls. Continued efforts to identify markers of skeletal fragility in young women are warranted to mitigate future fracture risk. Level of evidence Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: The objective of this study was to determine whether economic well-being is associated with patient-reported functional outcomes and range of motion 1 year following volar plate fixation of distal radius fracture. Methods: A retrospective study was performed on 200 patients with distal radius fractures treated with volar plate fixation at two Level 1 trauma centres from 2006 to 2017 with 1-year clinical follow-up using a previously published cohort. The economic well-being of patients was assessed using the Distressed Communities Index (DCI). Our outcome variables were patient-reported functional outcomes assessed by QuickDASH score and wrist and forearm range of motion 1 year after surgery. The analysis of variance (ANOVA) test was used to compare outcome variables across pre-established tiers of economic well-being. Results: The mean QuickDASH score at 1 year following distal radius fracture volar plate fixation was 10.8 and ranged from 7.3 to 12.2 across tiers of economic well-being. QuickDASH score and wrist range of motion were not significantly different across all tiers of economic well-being. However, wrist flexion–extension arc at 1 year following surgery was significantly decreased in the economically at-risk group compared with the remaining cohort. Conclusions: Patient-reported functional outcomes 1 year after volar plate fixation of distal radius fracture are similar across tiers of economic well-being. Economically disadvantaged patients are at risk for poorer wrist motion following distal radius fracture surgery, though it is not clear if this difference is clinically significant. Level of Evidence: Level II (Prognostic)

Purpose There is a paucity of literature examining the trajectory of meaningful clinical improvement after distal radius fracture (DRF) fixation. We sought to answer the following questions: (1) When do patients meet the minimum clinically important difference (MCID) in the Quick–Disabilities in Arm, Shoulder, and Hand questionnaire (QuickDASH) score change after DRF fixation? (2) What gains in terms of number of MCIDs achieved (as measured by QuickDASH) do patients make as they recover from DRF fixation? (3) What patient and injury factors are characteristic of patients who meet or do not meet the average recovery trajectory? Methods We performed a retrospective review of an institutional database of DRF patients treated with operative fixation. The change in QuickDASH scores from before surgery to approximate follow-up intervals of 0 to 2 months, 3 to 6 months, and a minimum of 9 of 12 months was assessed, in which a delta of 14 reflected the MCID. The change in QuickDASH score from before surgery to each follow-up interval was divided by 14 to determine the number of MCIDs, representing appreciable clinical improvement. Patient characteristics were compared between those who did and did not reach average levels of clinical improvement. Results The study included 173 patients. Mean QuickDASH score before surgery was 74 (SD, 19; range, 0–100). After surgery, this improved to 50 (SD, 24; range, 0–100) by 0 to 2 months, 22 (SD, 22; range, 0–98) by 3 to 6 months, and 9.8 (SD, 15; range, 0–75) by a minimum of 9 to 12 months. Overall, 96% of patients reached the MCID by 1 year. Mean cumulative number of MCIDs achieved (ie, number of 14-point decreases in QuickDASH score) at each interval was 1.57, 3.64, and 4.43, respectively. Assuming 4.43 represents maximum average improvement at 1 year, patients achieved 35% (1.57 of 4.43) of recovery from 0 to 2 months after surgery and 82% (3.64 of 4.43) of recovery by 3 to 6 months after surgery. There appeared to be no difference in terms of age, sex, or body mass index with respect to these findings. Conclusions Overall, 96% of patients undergoing DRF fixation will achieve one QuickDASH MCID by 1 year after surgery. Patients achieved over 80% of total expected functional improvement by 3 to 6 months after surgery, which appeared to be irrespective of age, sex, or body mass index. Type of study/level of evidence Therapeutic IV.

Purpose The Sauve-Kapandji procedure (SK) combines a distal radioulnar joint (DRUJ) arthrodesis with the creation of an ulnar pseudarthrosis for the salvage of DRUJ instability or arthritis. Despite several published case series, there are limited data on postoperative functional outcomes. This study evaluates patient-reported outcomes of SK using a validated functional outcomes scale. Methods We performed a retrospective review of patients who underwent SK in 2 health care systems over 10 years (2008–2018). Preoperative and postoperative range of motion, Quick–Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, and wrist plain film radiographic measurements were recorded. Preoperative and postoperative outcomes analyses and subgroup comparisons were performed. Results We included 57 patients in the study. Surgical indications included posttraumatic DRUJ arthritis (n = 35), rheumatoid arthritis (n = 10), degenerative DRUJ arthritis (n = 7), Madelung deformity (n = 3), psoriatic arthritis (n = 1), and giant cell tumor of bone (n = 1). During the first postoperative year, QuickDASH scores decreased from a mean of 52 before surgery to 28 at 12 months. The QuickDASH scores at final follow-up demonstrated significant improvement in patients with osteoarthritis and inflammatory arthritis. Supination significantly improved after surgery, from 48° to 74°, whereas wrist flexion, wrist extension, and pronation remained unchanged. Radiographically, significant postoperative decreases were seen in ulnar variance and McMurtry’s translation index. The postoperative complication rate was 21%, including revision osteotomy in 4 patients (7.0%) and hardware removal in 4 patients (7.0%). No DRUJ nonunions were seen. Conclusions The Sauve-Kapandji procedure for DRUJ salvage significantly improved patient-reported outcomes after 1 year and significantly improved supination. Similar functional improvements after SK were seen in both osteoarthritis and inflammatory arthritis. Type of study/level of evidence Therapeutic IV.

Fasciotomy is the standard of care to treat acute compartment syndrome (ACS). Although fasciotomies often prevent serious complications, postoperative complications can be notable. Surgical site infection (SSI) in these patients is as high as 30%. The objective of this study was to determine factors that increase the risk of SSI in patients with ACS.A retrospective review of 142 patients with compartment syndrome over 10 years was done. We collected basic demographics, mechanism of trauma, time to fasciotomy, incidence of SSI, use of prophylactic antibiotics, and type and time to wound closure. Statistical analysis of continuous variables was done using the Student t-test, ANOVA, multivariable regression model, and categorical variables were compared using the chi-square test.Twenty-five patients with ACS (17.6%) developed infection that required additional treatment. In the multivariate regression model, there were significant differences in median time to closure in patients with infection versus those without, odds ratio: 1.06 (Confidence Interval 95% [1.00 to 1.11]), P = 0.036. No differences were observed in infection based on the mechanism of injury, wound management modality, or the presence of associated diagnoses.In patients with ACS, the time to closure after fasciotomy is associated with the incidence of SSI. There seems to be a golden period for closure at 4 to 5 days after fasciotomy. The ability to close is often limited by multiple factors, but the correlation between time to closure and infection in this study suggests that it is worth exploring different closure methods if the wound cannot be closed primarily within the given timeframe.

Purpose The nature and focus of hand surgery fellowships has been shown to vary. Compounding this issue is a paucity of information regarding the educational goals and desires of prospective fellows. The purpose of this study was to understand applicant motivation for pursuing a fellowship and the most important components of these fellowships. Methods We performed an anonymous survey of all the candidates who applied for a hand surgery fellowship during the 2019–2020 academic year to establish general demographic information, preferences regarding fellowship size, and the importance of various educational and logistical components. We also recorded self-reported comfort level in treating pathologies encountered during a hand-focused subspecialty practice. Results The most important motivation cited for pursuing a fellowship in hand surgery was the “complexity and variety of cases” (n = 55, 90%). The 5 most important desired components of a fellowship were the exposure to “bread and butter” hand surgery (n = 35, 57%), ability to take level 1 hand call (n = 26, 43%), exposure to complex wrist reconstruction (n = 26, 43%) or peripheral nerve surgery/transfers (n = 23, 38%), and soft tissue coverage including free flaps (n = 19, 31%). Further analysis revealed that the orthopedic surgery residents frequently rated exposure to level 1 call (n = 20, 45%) as 1 of their 3 most important characteristics, whereas the plastic/general surgery residents frequently ranked exposure to complex wrist reconstruction (n = 16, 38%) as 1 of their 3 most important characteristics. The components of a fellowship that received the fewest selections into an applicant’s top 3 components were exposure to shoulder surgery (n = 1, 1.64%), education regarding practice building/billing (n = 2, 3.2%), and the ability to conduct research (n = 4, 6.5%). Conclusions Most applicants pursue a subspecialty training in hand surgery because of the field’s variety and breadth of cases. The applicants prioritize exposure to “bread and butter” cases in conjunction with both complex soft tissue and microsurgical reconstruction. Clinical relevance Assisting hand fellowships in understanding what is most important to prospective fellows will allow for appropriate recruitment and development of the field of hand surgery in general.

Purpose A paucity of evidence exists regarding the optimal treatment of open fractures of the distal radius. The purpose of this study was to compare short-term complication rates between various treatment options following open fractures of the distal radius. Methods We performed a retrospective review of all open fractures of the distal radius at a single level 1 trauma center over a 10-year period. The primary outcome measure was the number of minor and major complications. Demographic and clinical characteristics of patients across treatment and outcome groups were compared and models were used to describe the relationships between outcome and treatment. Results Ninety patients met the inclusion criteria for evaluation. An even distribution between high-energy (n = 45) and low-energy (n = 45) injuries was seen with 61 fractures Gustilo I (67%), 19 Gustilo II (22%), and 10 Gustilo III (11%). The majority of fractures were intra-articular (n = 48 AO type C vs n = 42 AO type A/B). Fractures were treated with immediate open reduction internal fixation (ORIF) in 67 cases (74%), external fixation in 12 (13%), initial external fixation followed by ORIF at a later time in 8 (9%), or closed reduction and percutaneous pinning in 3 (4%). We observed 33 complications (37%) of which 24 were major and 9 minor. Mechanism of injury and type of treatment were the only variables shown to correlate with an increased rate of complications. Conclusions We conclude that open fractures of the distal radius treated by immediate ORIF at the time of index debridement can result in satisfactory outcomes compared with other forms of treatment. Type of study/level of evidence Therapeutic IV.

Background: The optimal treatment of human bites to the dorsal metacarpophalangeal region (ie, “fight bite”) in the absence of gross purulence is controversial. Few studies have compared the outcomes of operative debridement with expectant wound care and oral antibiotics. Methods: We performed a retrospective chart review of all patients evaluated at a Level 1 trauma center over a 10-year period. We compared demographic and clinical characteristics of patients across treatment and outcome groups using the Fisher exact test. Logistic regression models were used to describe the relationships between the outcome and treatment variables. Results: We identified 115 patients with a mean age of 29 years. The mean follow-up was 51.8 days. Seventy-two (63%) patients were treated with antibiotics only. Thirty-two (28%) patients were treated with irrigation in the emergency department (ED) and expectant wound care. Eleven (9%) patients were treated with irrigation and debridement in the operating room. No demographic variables were found to correlate with the treatment selected. A 12% complication rate (major and minor) was observed. After adjusting for duration of follow-up and days to presentation, neither the treatment rendered nor the antibiotics selected influenced the rate of complications. Time to presentation >24 hours was the only variable associated with higher complication rate ( P = .003). Conclusions: Not all fight bites require operative intervention. Irrigation in the ED with expectant wound care and oral antibiotics can be sufficient for patients presenting within 24 hours of injury in the absence of gross purulence.

We evaluated physician prescribing patterns before and after the implementation of a state-mandated opioid electronic prescribing (ePrescribing) program after 4 common outpatient hand surgeries. Specifically, we aimed to answer the following: (1) is there a change in the number of opioids prescribed after the institution of ePrescribing for carpal tunnel release (CTR), ganglion excision, distal radius fracture (DRF) open reduction internal fixation (ORIF), and carpometacarpal (CMC) arthroplasty and (2) what factors are associated with an increased number of tablets or total morphine milligram equivalents (MMEs) prescribed.We retrospectively reviewed patients who underwent CTR, ganglion excision, DRF ORIF, or CMC arthroplasty and analyzed the number of tablets and MMEs prescribed before and after the policy implementation, as well as which factors were associated with an increased total number of opioid tablets and MMEs prescribed.A total of 428 patients were included. After policy implementation, there was a significant decrease in MMEs prescribed for ganglion excision (68 [SD, 45] vs 50 [SD, 60],The initiation of state-mandated ePrescribing was associated with a decreased number of opioids-both MMEs and tablets-prescribed after surgery by hand surgeons for a variety of common procedures. Furthermore, a greater percentage of patients received no opioid prescriptions after ePrescribing. These findings support the value of ePrescribing as a potential tool to further decrease excess opioid prescriptions.Therapeutic III.

Background Treatment of distal radius fractures (DRFs) in patients aged >65 years is controversial. The purpose of this study was to identify what patient and fracture characteristics may influence the decision to pursue surgical versus nonsurgical treatment in patients aged >65 years sustaining a DRF. Methods We queried our institutional DRF database for patients aged >65 years who presented to a single academic, tertiary center hand clinic over a 5-year period. In all, 164 patients treated operatively were identified, and 162 patients treated nonoperatively during the same time period were selected for comparison (total N = 326). Demographic variables and fracture-specific variables were recorded. Patient and fracture characteristics between the groups were compared to determine which variables were associated with each treatment modality (operative or nonoperative). Results The average age in our cohort was 72 (SD: 11) years, and 274 patients (67%) were women. The average Charlson Comorbidity Index (CCI) was 4.1 (SD: 2.1). The CCI is a validated tool that predicts 1-year mortality based on patient age and a list of 22 weighted comorbidities. Factors associated with operative treatment in our population were largely related to the severity of the injury and included increasing dorsal tilt (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < .001) and AO Classification type C fractures (OR, 5.42; 95% CI, 2.35-11.61; P < .001). Increasing CCI was the only factor independently associated with nonoperative management (OR, 0.84; 95% CI, 0.72-0.997; P = .046). Conclusion Fracture severity is a strong driver in the decision to pursue operative management in patients aged >65 years, whereas increasing CCI predicts nonoperative treatment.

Purpose For fractures requiring operative fixation, the “tripod technique” using headless compression screws has recently been described as a less invasive alternative to open reduction and internal fixation with plate and screws. The purpose of this study was to evaluate the clinical and radiographic outcomes of the tripod technique for the treatment of radial head and neck fractures. Methods We performed a retrospective chart review of all radial head and neck fractures treated with the tripod technique at our institution over a 10-year period. Patients with less than 6 months of follow-up were excluded. Outcomes were evaluated at the latest follow-up using range of motion measurements and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire. Results We evaluated 13 patients with a mean age of 48 years and average follow-up of 72 months (range, 21–153 months). All the patients achieved union by 12 weeks after surgery. The average postoperative Quick Disabilities of the Arm, Shoulder and Hand score was 5.9 (range, 0–23). The mean flexion was 139°, and the mean extension was −8°. There were no major postoperative complications . Five patients had minor complications. No patients required a reoperation . Conclusions The tripod technique is a useful alternative to the traditional method of plate and screw fixation for unstable radial head and neck fractures. Type of study/level of evidence Therapeutic IV.

Orthopaedic surgeons perform a variety of procedures where life-threatening or limb-threatening clinical scenarios or complications are relatively rare. Because these devastating complications and disaster presentations are infrequent, the occurrence can lead to concerns regarding training and preparedness. This chapter will provide a general knowledge base of common intraoperative disasters as well as life-threatening and/or limb-threatening conditions related to the upper extremity, pelvis, and lower extremity. Fundamental clinical and surgical management strategies are explored with respect to these conditions to provide a level of preparedness to help any orthopaedic surgeon control a potentially devastating complication or emergency.

Fractures of the distal radius are increasingly common, resulting in a cost of $170 million to Medicare alone. They represent the most common fracture of the upper extremity and are the second most common fracture overall in women > 60 years of age. With increasing life expectancy in most societies, the incidence of distal radius fractures (DRFs) has been steadily increasing over the past 40 years, particularly in the elderly population (defined as patients > 65 years of age). The lifetime risk of a Caucasian woman > 60 sustaining a DRF is 15% (compared to 2% for men). Thus, the injury burden imposed by fractures of the distal radius on society, particularly the elderly population, looms large. Radiographic parameters for operative vs nonoperative treatment have been well established for patients 65 years of age. As clinical information continues to evolve, identifying evidence-based, cost-conscious practices will be essential for the sustainability of health systems worldwide.

BACKGROUND Few studies have examined whether orthopaedic surgery, including hand surgery, is associated with patients' financial health. We sought to understand the level of financial burden and worry for patients undergoing two common hand procedures-carpal tunnel release and open reduction and internal fixation for a distal radius fracture-as well as to determine factors associated with a higher financial burden and worry. QUESTIONS/PURPOSES In patients undergoing operative treatment for isolated carpal tunnel syndrome with carpal tunnel release or open reduction and internal fixation for a distal radius fracture, we used validated financial burden and worry questionnaires to ask: (1) What percentage of patients report some level of financial burden, and what is the median financial burden composite score? (2) What percentage of patients report some level of financial worry, and what percentage of patients report a high level of financial worry? (3) When accounting for other assessed factors, what patient- and condition-related factors are associated with financial burden? (4) When accounting for other assessed factors, what patient- and condition-related factors are associated with high financial worry? METHODS In this cross-sectional survey study, a hand and upper extremity database at a single tertiary academic medical center was reviewed for patients 18 years or older undergoing operative treatment in our hand and upper extremity division for an isolated distal radius fracture between October 2017 and October 2019. We then selected all patients undergoing carpal tunnel release during the first half of that time period (given the frequency of carpal tunnel syndrome, a 1-year period was sufficient to ensure comparable patient groups). A total of 645 patients were identified (carpal tunnel release: 60% [384 of 645 patients]; open reduction and internal fixation for a distal radius fracture: 40% [261 of 645 patients). Of the patients who underwent carpal tunnel release, 6% (24 of 384) were excluded because of associated injuries. Of the patients undergoing open reduction and internal fixation for a distal radius fracture, 4% (10 of 261) were excluded because of associated injuries. All remaining 611 patients were approached. Thirty-six percent (223 of 611; carpal tunnel release: 36% [128 of 360]; open reduction and internal fixation: 38% [95 of 251]) of patients ultimately completed two validated financial health surveys: the financial burden composite and financial worry questionnaires. Descriptive statistics were calculated to report the percentage of patients who had some level of financial burden and worry. Further, the median financial burden composite score was determined. The percentage of patients who reported a high level of financial worry was calculated. A forward stepwise regression model approach was used; thus, variables with p values < 0.10 in bivariate analysis were included in the final regression analyses to determine which patient- and condition-related factors were associated with financial burden or high financial worry, accounting for all other measured variables. RESULTS The median financial burden composite score was 0 (range 0 [lowest possible financial burden] to 6 [highest possible financial burden]), and 13% of patients (30 of 223) reported a high level of financial worry. After controlling for potentially confounding variables like age, insurance type, and self-reported race, the number of dependents (regression coefficient 0.15 [95% CI 0.008 to 0.29]; p = 0.04) was associated with higher levels of financial burden, while retired employment status (regression coefficient -1.24 [95% CI -1.88 to -0.60]; p < 0.001) was associated with lower levels of financial burden. In addition, the number of dependents (odds ratio 1.77 [95% CI 1.21 to 2.61]; p = 0.004) and unable to work or disabled employment status (OR 3.76 [95% CI 1.25 to 11.28]; p = 0.02) were associated with increased odds of high financial worry. CONCLUSION A notable number of patients undergoing operative hand care for two common conditions reported some degree of financial burden and worry. Patients at higher risk of financial burden and/or worry may benefit from increased resources during their hand care journey, including social work consultation and financial counselors. This is especially true given the association between number of dependents and work status on financial burden and high financial worry. However, future research is needed to determine the return on investment of this resource utilization on patient clinical outcomes, overall quality of life, and well-being. LEVEL OF EVIDENCE Level III, therapeutic study.

Background: Management of distal radius fractures in patients over 65 is a topic of significant study, but there are variations within this group in terms of independence and activity level. This study compares the outcomes of operative distal radius fracture treatment in patients over 75 with those aged 65 to 74, to evaluate the effects of patient demand and advanced age on outcome. Methods: A retrospective review of a single-institution distal radius fracture database was performed. All patients over age 65 were evaluated for inclusion. Patient factors including activity, independence level, and quick disabilities of the arm, shoulder and hand (QuickDASH) score were recorded. Patients were selected for open reduction and internal fixation (ORIF) based on a discussion between the patient and the treating surgeon. Outcome measures including QuickDASH were recorded at 1-year post-injury. Patients aged 65 to 74 and 75 and over were compared to evaluate for demographic, functional, and outcome differences. Results: In all, 75 patients were included in the study. Fifty-one patients were aged 65 to 74, and 24 patients were aged over 75. The majority of patients rated themselves as “completely independent” and “active,” the highest levels of each. There was no difference in QuickDASH scores between those patients who rated themselves as completely partially independent, or active versus moderately active. There was no statistically significant difference in QuickDASH or range of motion parameters at final follow-up. Conclusions: This study demonstrates that, in a group of patients with high levels of independence and activity, outcomes are similar in patients aged 65 to 74 and over 75 at 1 year following distal radius ORIF.

Open distal radius fractures are rare injuries with few studies to guide treatment. Degree of soft tissue injury and contamination may be a primary consideration to dictate timing and operative intervention. Antibiotics should be started as early as possible and include a first-generation cephalosporin. Surgical fixation remains a matter of surgeon preference: although studies support the use of definitive internal fixation, many surgeons address contaminated injuries with external fixation. Although postoperative outcomes are similar to closed injuries for low-grade open distal radius fractures, high-grade injuries with more complex fracture patterns carry a high risk of complications, poor outcomes, and repeat surgical procedures.

Distal radius fractures are common fractures of the upper extremity. Whereas surgical outcomes have been extensively investigated, the impact of risk factors such as body mass index (BMI) and smoking on patient outcomes has not been explored. We hypothesized that obesity and smoking would have a negative impact on the functional and radiographic outcomes of surgically treated patients with distal radius fractures.We performed a retrospective analysis of patients surgically treated for a distal radius fracture between 2006 and 2017 at 2 level 1 trauma centers. Patients were divided into obese (BMI ≥ 30) and nonobese (BMI30) groups according to the World Health Organization BMI Classification. Patients were also divided into current, former, and never smokers based on reported cigarette use. Primary outcomes included patient-reported outcome measures (Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH]), range of motion (ROM) arc (flexion-extension, pronation-supination), radiographic union (Radiographic Union Scoring System [RUSS] score), and change in radiographic alignment (radial height, radial inclination, volar tilt) between first and last follow-up. Multivariable models corrected for age, sex, comorbidities, fracture complexity, osteoporosis, and time to surgery.Two hundred patients were identified, 39 with BMI of 30 or greater and 161 with BMI less than 30. Obese patients had more comorbidities but similar fracture types. At 3-month and 1-year follow-up, both groups achieved acceptable QuickDASH scores, close to those of the general population (21 vs 18, 14 vs 2, respectively). The 2 groups were similar in regard to motion, RUSS score, and alignment. There were 148 never smokers, 32 former smokers, and 20 current smokers. At 3 months, smokers demonstrated higher QuickDASH scores (42 vs 21-24) and a lower percentage of radiographically healed fractures (40% vs 69%-82%). At final follow-up, smokers reported small differences in patient-reported outcomes (QuickDASH 18 vs 9-13) whereas ROM, fracture healing, and complication rates were similar.Both obese and nonobese patients can achieve excellent outcomes following surgical treatment of distal radius fracture with similar self-reported outcomes, motion, RUSS score, and alignment. Despite slower healing in the early postoperative period, smokers had similar QuickDASH scores, ROM, and union rates to past smokers and never smokers at final follow-up, with a similar complication profile.Prognostic IV.

Trichophyton is a species of fungus that commonly infects hedgehogs. As the popularity of keeping hedgehogs as pets increases, there have been reports of Trichophyton species infection in humans. Diagnosis and appropriate treatment of Trichophyton infection can be delayed owing to physicians’ low index of suspicion and unfamiliarity with the physical manifestations. We describe a case of a 27-year-old healthy man who developed tinea manuum after handling a pet hedgehog. Presenting symptoms included a worsening bullous eruption and severe pain. Both fungal and histopathological study confirmed Trichophyton infection. He was treated with oral and topical antifungal medication. All symptoms resolved 2 weeks after initiation of treatment.

Thumb web space contracture following hand trauma can be disabling with numerous reconstructive procedures existing to correct the resultant deformity. Following marked soft tissue injury to the hand we utilized the Stryker Hoffmann II Micro External Fixator System to link the first and second metacarpals by a multiplanar system using 1.6 or 2.0 mm self-drilling half-pins and 3 mm carbon fiber connecting rods. This facilitated placement of the thumb in maximal palmar abduction as well as allowed adjustment of thumb position throughout the postoperative period. This technique was performed on 5 patients. Two patients were treated with a first web space external fixator for table saw injuries to the radial aspect of the hand. An additional 2 patients were treated with a first web space external fixator following metacarpophalangeal joint capsular release in the setting of thermal burns. A fifth patient underwent second ray amputation, trapeziectomy and trapezoidectomy for squamous cell carcinoma with subsequent stabilization with the external fixator. The external fixator was left in place until soft tissues were healed (average 5.5 wk). The patients were allowed to mobilize their hand in as much as the external fixator allowed, and no device-associated complications were noted. Thumb web space was preserved with passive and supple thumb circumduction and web space abduction/adduction in all patients at an average follow-up of 5 months. The average Quick Dash Score was 35±5 and the average Modern Activity Subjective Survey of 2007 was 30±8.

Purpose Great effort has been placed on determining the optimal surgical treatment for trapeziometacarpal joint arthritis (TMA). However, a paucity of literature exists concerning the optimal timing of surgical intervention. We hypothesized that an increased duration of TMA symptoms before operative intervention would negatively affect surgical outcomes. Methods We performed a retrospective review on 109 adult patients with 121 joints with symptomatic TMA treated with trapeziectomy and ligament reconstruction with tendon interposition (LRTI) from 2006 to 2017. Outcome measures included Quick–Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, complication rates, and surgical revision rates. Results Among 109 patients, average QuickDASH score at initial presentation was 41.1 ± 17.9. Patients had symptoms of TMA for an average of 3.2 years (median, 2.1 years) before undergoing operative intervention. Patients were divided into 2 groups: those with symptoms less than 2 years and those with symptoms greater than 2 years. Patients who underwent LRTI after less than 2 years of symptoms achieved a significantly greater degree of improvement in the QuickDASH score compared with patients with symptoms greater than 2 years (26.2 vs 5.3). Conclusions Patients with less than 2 years of symptomatic TMA before LRTI can expect the greatest improvement in patient-reported disability impairment compared with those with more than 2 years of symptoms. This can be used to counsel patients regarding the optimal timing of surgery if nonsurgical treatment has failed to provide durable symptomatic relief. Type of study/level of evidence Therapeutic IV.

Purpose Corticosteroid injections are commonly used to treat thumb carpometacarpal arthritis in adults. We aimed to define the timing of surgery following an initial corticosteroid injection and identify patient-specific factors that influence the likelihood of repeat injection or surgery. Methods We performed a retrospective analysis of all patients who underwent a first-time corticosteroid injection for carpometacarpal arthritis between 2009 and 2017. Demographic information, radiographic classification, additional nonsurgical therapies, complications, and outcomes were collected. Primary outcomes were repeat injection and surgical reconstruction. Kaplan-Meier survival analysis was used to characterize the timing of surgical intervention and Cox regression modeling was used to identify predictors of subsequent intervention. Results Two-hundred thirty-nine patients (average age, 62.9 years) were identified, of which 141 (59.0%) had a repeat injection and 90 (37.6%) underwent surgery. There were no patient-specific characteristics associated with repeat injection. Eaton stage III/IV arthritis at initial presentation, current smoking status, and prior ipsilateral hand surgery were associated with an increased likelihood of surgery. By Kaplan-Meier analyses, 87.7% of patients who presented with Eaton III/IV arthritis did not have surgery within a year and 66.7% of these patients did not have surgery within 5 years. Conclusions In this retrospective observational cohort study with 10-year follow-up from a 4-surgeon practice, advanced radiographic arthritis, current smoking status, and a history of ipsilateral hand surgery were patient-specific factors that predicted progression to surgery following injection. Of patients who presented with advanced radiographic arthritis, one-third underwent surgery within 5 years of initial injection. Although injection efficacy and causality cannot be inferred based on an observational longitudinal analysis, these data identify patient-specific factors that may have an impact on surgical decision-making and a potential timeframe for future intervention. Type of study/level of evidence Prognostic IV.

Purpose To compare patient-reported outcomes, functional outcomes, radiographic alignment, and complications of volar versus dorsal corrective osteotomies as the treatment for symptomatic distal radius malunions. Methods We performed a retrospective review of all patients who underwent a distal radius corrective osteotomy with either a volar or dorsal approach and plating at 1 of 3 institutions between 2005 and 2017. Demographic data, type of surgical treatment, and radiographs were examined. Outcomes were Quick–Disabilities of the Arm, Shoulder, and Hand (QuickDASH) function scores and radius union scoring system as well as major and minor complications. Results We included 53 cases (37 volar osteotomies and 16 dorsal osteotomies). Postoperative follow-up from the time of surgery to last QuickDASH score was 84.6 months (range, 12–169.4 months). Compared with the dorsal osteotomy group, the volar osteotomy group demonstrated a better postoperative flexion-extension arc (94.9° vs 72.9°, respectively), pronation-supination arc (146.2° vs 124.9°, respectively), and last QuickDASH scores (6.65 vs 12.87), respectively. Radiographically, there was no difference noted in radial height, radial inclination, or volar tilt in the immediate postoperative and last radiographs. There was a higher rate of complications in the dorsal osteotomy group (8 cases [50% of patients]) compared with the volar osteotomy group (7 cases [18.9% of patients]), including a higher rate of hardware removal. Conclusions For patients with symptomatic malunions of the distal radius, the volar and dorsal approaches both resulted in improvement in QuickDASH scores and range of motion. Volar plating resulted in slightly better QuickDASH scores and fewer complications compared with dorsal plating. Type of study/level of evidence Therapeutic IV.

Open distal radius fractures are rare injuries with few studies to guide treatment. Degree of soft tissue injury and contamination may be a primary consideration to dictate timing and operative intervention. Antibiotics should be started as early as possible and include a first-generation cephalosporin. Surgical fixation remains a matter of surgeon preference: although studies support the use of definitive internal fixation, many surgeons address contaminated injuries with external fixation. Although postoperative outcomes are similar to closed injuries for low-grade open distal radius fractures, high-grade injuries with more complex fracture patterns carry a high risk of complications, poor outcomes, and repeat surgical procedures.

Purpose Over 50,000 power saw-related injuries occur annually in the United States. Numerous safety measures have been implemented to protect the users of these tools. This study was designed to determine which interventions, if any, have had a positive impact on the safety of the consumer or laborer. Methods We queried the National Electronic Injury Surveillance System database for hand and upper-extremity injuries attributed to power saws from 1997 to 2014. Demographic information including age, sex, date of injury, device, location, body part involved, diagnosis, and disposition was recorded. We performed statistical analysis using interrupted time series analysis to evaluate the incidence of injury with respect to specific safety guidelines as well as temporal trends including patients’ age. Results An 18% increase in power saw–related injuries was noted from 1997 (44,877) to 2005 (75,037). From 2006 to 2015 an annual decrease of 5.8% was observed. This was correlated with regulations for power saw use by the Consumer Safety Product Commission (CPSC) and Underwriters Laboratories. Mean age of injured patients increased from 48.8 to 52.9 years whereas the proportion of subjects aged less than 50 years decreased from 52.8% to 41.9%. These trends were most pronounced after the 2006 CPSC regulations. Conclusions The incidence of power saw injuries increased from 1997 to 2005, with a subsequent decrease from 2006 to 2015. The guidelines for safer operation and improvements in equipment, mandated by the CPSC and Underwriters Laboratories, appeared to have been successful in precipitating a decrease in the incidence of power saw injuries to the upper extremity, particularly in the younger population. Clinical relevance The publication of safety regulations has been noted to have an association with a decreased incidence in power saw injuries. Based on this, clinicians should take an active role in their practice as well as in their professional societies to educate and counsel patients to prevent further injury.

A case of volar forearm pain associated with ulnar nerve paresthesia caused by a reversed palmaris longus muscle is described. The patient, an otherwise healthy 46-year-old male laborer, presented after a previous unsuccessful forearm fasciotomy for complaints of exercise exacerbated pain affecting the volar forearm associated with paresthesia in the ulnar nerve distribution. A second decompressive fasciotomy was performed revealing an anomalous "reversed" palmaris longus, with the muscle belly located distally. Resection of the anomalous muscle was performed with full relief of pain and sensory symptoms.

Purpose: This study investigates factors associated with failure and reoperation after glenoid labrum repair. Methods: We studied a nonconcurrent cohort of consecutive patients undergoing arthroscopic superior labrum repair at a single institution by 2 fellowship-trained surgeons over a 10-year period. Results: There were 348 patients included in this study with a mean age of 33.4 years (95% confidence interval [CI], 32.1 to 35.9) and a mean clinical follow-up of 12.3 months (95% CI, 10.9 to 13.8). The overall reoperation rate was 6.3%, with a revision labrum repair rate of 4.3%. Subsequent surgery and failure after arthroscopic labrum repair were significantly correlated with Workers’ Compensation claims (odds ratio [OR], 4.6; P .001; 95% CI, 1.8 to 11.7), the use of tobacco (OR, 12.0; P .03; 95% CI, 1.2 to 114.9), and the use of absorbable poly-L/D-lactic acid (PLDLA) anchors (100% correlation, P .001). The OR for having repeat surgery was 12.7 (95% CI, 4.9 to 32.9; P .001) with poly-96L/4D-lactic acid (Mini-Revo; Linvatec, Largo, FL) and also increased with the use of poly-70L/30D-lactic acid (Bio-Fastak and Bio-Suturetak; Arthrex, Naples, FL) anchor material (P .04) after removal of the patients exposed to poly-96L/4D-lactic acid anchors. The rates of repeat surgery with PLDLA anchors from Linvatec and PLDLA anchors from Arthrex were 24% and 4%, respectively. None of the patients treated with nonabsorbable suture anchors (polyether ether ketone or metallic) returned to the operating room (P .001). After we controlled for associated factors in a multivariate analysis, the use of absorbable anchors, in particular poly-96L/4D-lactic acid anchors (OR, 14.7; P .001), and having a work-related injury (OR, 8.1; P .001) remained independent factors associated with both repeat surgery and revision superior labrum repair. Conclusions: Bioabsorbable PLDLA anchor material led to significantly more SLAP repair failures and reoperations compared with nonabsorbable suture anchors. Our recommendation is that glenoid labrum repairs be performed with nondegradable material and, specifically, that the use of anchors composed of PLDLA material should be avoided. Level of Evidence: Level III, retrospective comparative study.

Commentary on : Chang SF, Hong CM, Yang RS. The performance of an online osteoporosis detection system a sensitivity and specificity analysis. J Clin Nurs 2014;23:1803–9.[OpenUrl][1][CrossRef][2][PubMed][3] Osteoporosis implications with regard to fragility fracture have been well established, causing a high cost to society and imparting significant morbidity to the patient. This study was conducted in Taiwan where the prevalence of osteoporosis in adults older than 35 years has been estimated at approximately 11%, with the female population having a nearly three times higher prevalence (14.9%) compared to … [1]: {openurl}?query=rft.jtitle%253DJ%2BClin%2BNurs%26rft.volume%253D23%26rft.spage%253D1803%26rft_id%253Dinfo%253Adoi%252F10.1111%252Fjocn.12209%26rft_id%253Dinfo%253Apmid%252F23876185%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1111/jocn.12209&link_type=DOI [3]: /lookup/external-ref?access_num=23876185&link_type=MED&atom=%2Febnurs%2F18%2F4%2F114.atom

Background: Fractures of the distal aspect of the radius are common, yet little is known about this type of fracture among older men. The purpose of this study was to compare fracture characteristics, treatment, and osteoporosis evaluation among men and women who had sustained a distal radial fracture. We hypothesized that the men would have similar patterns of injury and lower rates of evaluation for osteoporosis. Methods: We retrospectively reviewed the medical records of ninety-five men and 344 women over the age of fifty years who were treated for a distal radial fracture at a single institution over a five-year period. We assessed whether the patients had received a dual x-ray absorptiometry (DXA) scan and osteoporosis treatment within six months following the injury. Multivariate analysis identified independent predictors of bone mineral density (BMD) testing and osteoporosis treatment. Results: Men had less severe fractures than women (a Type-C fracture rate of 20% for men compared with 40% for women; p = 0.014). While 184 (53%) of the women had a DXA scan after injury, only seventeen (18%) of the men were evaluated (p < 0.001). Among the patients who underwent DXA scan, nine men (9% of men overall) and sixty-five women (19% of women overall) had a diagnosis of osteoporosis (p = 0.01). Male sex was an independent predictor of failure to undergo BMD testing as well as receive subsequent treatment with calcium and vitamin D or bisphosphonates (p < 0.001). Conclusions: Significantly fewer men received evaluation for osteoporosis following a distal radial fracture, with rates of evaluation unacceptably low according to published guidelines. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The use of animals to augment traditional medical therapies was reported as early as the 9th century but to our knowledge has not been studied in an orthopaedic patient population. The purpose of this study was to evaluate the role of animal-assisted therapy using therapy dogs in the postoperative recovery of patients after THA and TKA.We asked: (1) Do therapy dogs have an effect on patients' perception of pain after total joint arthroplasty as measured by the VAS? (3) Do therapy dogs have an effect on patients' satisfaction with their hospital stay after total joint arthroplasty as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)?A randomized controlled trial of 72 patients undergoing primary unilateral THA or TKA was conducted. Patients were randomized to a 15-minute visitation with a therapy dog before physical therapy or standard postoperative physical therapy regimens. Both groups had similar demographic characteristics. Reduction in pain was assessed using the VAS after each physical therapy session, beginning on postoperative Day 1 and continuing for three consecutive sessions. To ascertain patient satisfaction, the proportion of patients selecting top-category ratings in each subsection of the HCAHPS was compared.Patients in the treatment group had lower VAS scores after each physical therapy session with a final VAS score difference of 2.4 units (animal-assisted therapy VAS, 1.7; SD, 0.97 [95% CI, 1.4-2.0] versus control VAS, 4.1; SD, 0.97 [95% CI, 3.8-4.4], p0.001) after the third physical therapy session. Patients in the treatment group had a higher proportion of top-box HCAHPS scores in the following fields: nursing communication (33 of 36, 92% [95% CI, 78%-98%] versus 69%, 25 of 36 [95% CI, 52%-84%], p=0.035; risk ratio, 1.3 [95% CI of risk ratio, 1.0-1.7]; risk difference, 23% [95% CI of risk difference, 5%-40%]), pain management (34 of 36, 94% [95% CI, 81%-99%], versus 26 of 36, 72% [95% CI, 55%-86%], p=0.024; risk ratio, 1.3 [95% CI of risk ratio, 1.1-1.6]; risk difference, 18% [95% CI of risk difference, 5%-39%]). The overall hospital rating also was greater in the treatment group (0-10 scale) (9.6; SD, 0.7 [95% CI, 9.3-9.8] versus 8.6, SD, 0.9 [95% CI, 8.3-8.9], p0.001).The use of therapy dogs has a positive effect on patients' pain level and satisfaction with hospital stay after total joint replacement. Surgeons are encouraged to inquire about the status of volunteer-based animal-assisted therapy programs in their hospital as this may provide a means to improve the immediate postoperative recovery for a select group of patients having total joint arthroplasty.Level II, randomized controlled study. See Instructions for Authors for a complete description of levels of evidence.

An acute blue finger is an uncommon but potentially serious finding with a heterogeneous etiology. A rare group of patients will present with acute, atraumatic, nonischemic blue fingers. The clinical course of these patients appears to be benign. We describe the presentation of an otherwise healthy 22-year-old woman with an acute idiopathic blue finger. We highlight the differential diagnoses and evaluation of this rare condition.

Controlled-release, injectable polymer microspheres provide a clinically feasible alternative to gene-modification for the local, sustained delivery of cytokines to tumors for cancer immunotherapy. Long-term release kinetics, bioactivity profiles, and stability of interleukin-2 (IL-2), interleukin-12 (IL-12), and granulocyte- macrophage colony-stimulating factor (GM-CSF)-encapsulated microspheres prepared by phase inversion nanoencapsulation (PIN) were evaluated. While all formulations released physiologically relevant quantities of cytokine for up to 30 days, the individual release kinetics were different. Recovery of specific activity after encapsulation was 40%, 60%, and 90%-that of pre-encapsulation levels for IL-2, GM-CSF and IL-12, respectively. Upon storage, the IL-12 microspheres rapidly lost activity, whereas IL-2 and GM-CSF microspheres remained stable for at least 9 weeks. These studies demonstrate that biochemical properties of microsphere formulations vary depending on the cytokine, and rigorous characterization of formulations is a prerequisite to in vivo testing.

Introduction There has been limited data regarding failure after arthroscopic repair of superior glenoid labrum tears. This study investigates factors associated with failure and re-operation in this patient population. Methods This is a non-concurrent cohort of consecutive patients undergoing arthroscopic labrum repair at a single institution by two fellowship-trained surgeons over a ten year period. Results There were 348 patients included in this study with a mean age of 33.4 (95% CI 32.1-35.9) and an average clinical follow-up of 12.3 months (95% CI 10.9-13.8). The overall re-operation rate was 6.3% with a revision labrum repair rate of 4.3%. The interval between the index procedure to the second procedure was approximately 50 weeks. Subsequent surgery and failure after arthroscopic labrum repair were significantly correlated with workers' compensation (OR 4.6, p Conclusion The results of this study strongly support a recommendation against the use of poly-lactic acid suture anchors for glenoid labrum repair surgery.