Search

Golf is unique in this compendium of sports-related hand and wrist injury management. It is the only sport where the ball is stationary and there is no opponent against whom the player is defending. This distinctive sport dates to the 15th century in Scotland and is one of the oldest sports, but it is one where technology has changed many of the fundamental elements-from the "playing field (through advanced in agronomy) and the equipment (club and ball technology).

Among professional combat athletes, excessive and repetitive trauma to the carpometacarpal (CMC) joints may cause instability, arthritis, and the development of traumatic carpal boss. If nonoperative management is unsuccessful, CMC joint arthrodesis with iliac crest bone graft and supplemental Kirschner wire fixation is a reliable surgical option that results in pain-free return to full competition. From 2002 to 2015, 15 professional athletes with 17 symptomatic carpal bosses were treated with CMC joint arthrodesis after unsuccessful nonoperative management. The operative technique included decortication of the articular surface of the CMC joints, insertion of iliac cancellous and corticocancellous slot grafts, and secure Kirschner wire fixation. Patient charts and postoperative imaging were retrospectively reviewed. Outcome measures included grip strength, pain relief, fusion rate, return to competition, and complications. Mean age at the time of surgery was 28.2 years (range, 21–39 years). The radiographic fusion rate was 100% and occurred at a mean of 7.5 weeks. Mean return to competition occurred at 6 months. Grip strength at final follow-up increased 32% from preoperative level and was 90% of the grip strength of the contralateral hand. Postoperatively, 2 patients had sagittal band ruptures, and 1 patient had a fifth metacarpal fracture. No revision procedures were performed. All patients undergoing CMC arthrodesis had successful fusion, without the need for revision surgery and with return to full competition. For professional fighters, CMC arthrodesis with iliac crest autograft is a safe and effective surgical method for treating symptomatic traumatic carpal boss. [ Orthopedics . 2022;45(1):e17–e22.]

The basal joint complex of the thumb provides the framework necessary for function of the human hand. Although its unique saddle articulation allows for a wide range of motion necessary for routine function of the hand, it is rendered inherently unstable because of poor bony congruency and reliance on its capsuloligamentous support. Painful instability of this joint can stem from several causes including traumatic dislocation, various hypermobility conditions, and chronic overuse and microtrauma. A thorough history and examination as well adequate imaging is necessary for proper evaluation of instability. Treatment options range from nonoperative modalities to surgery, which entails closed, percutaneous, or open reduction with numerous ligament repair and reconstruction techniques. Arthroscopy can also serve to be a useful adjunct for assessment of the joint and stabilization of the critical capsuloligamentous structures. This review outlines the critical osseous and soft-tissue anatomy surrounding the thumb carpometacarpal joint, the key points in evaluating patients presenting with acute traumatic and chronic thumb carpometacarpal instability without fracture or arthritis, and reviews both nonoperative and operative treatments of this injury.

Scleroderma is derived from Latin meaning hard skin. It is an uncommon, noninflammatory connective tissue disorder characterized by increased fibrosis of the skin and in certain variants, multiple other organ systems. Scleroderma involves a spectrum of pathologic changes and anatomic involvement. It can be divided into localized and systemic scleroderma. Hand involvement is common and can include calcium deposits within the soft tissues, digital ischemia, and joint contracture. Nonsurgical management consists of lifestyle modifications, biofeedback, therapy for digital stiffness/contracture, and various pharmacologic medications. When nonsurgical measures are unsuccessful, certain surgical options may be indicated, each with their inherent advantages and pitfalls. Patients with scleroderma who are undergoing surgical intervention pose unique difficulties because of their poorly vascularized tissue and deficient soft-tissue envelopes, thus increasing their susceptibility to wound healing complications and infection. Some subgroups of patients are frequently systemically ill, and specific perioperative measures should be considered to reduce their surgical risk. The spectrum of hand manifestations seen in patients with scleroderma will be reviewed with the focus on evaluation and management.

Background: The purpose of this study was to determine the occurrence of patients undergoing primary trigger finger release (TFR) that underwent ulnar superficialis slip resection (USSR) for decompression and to determine which digit was most commonly affected. Methods: A retrospective chart review was conducted of all cases of open TFR performed by a single surgeon. The following data were obtained: age, sex, laterality, affected digit, and consideration for USSR. All patients failed nonoperative treatment of at least 1 steroid injection. The occurrence of patients who underwent TFR and USSR and which digit(s) most commonly underwent USSR were determined. The average patient age that underwent USSR, frequency by sex, and relative occurrence of USSR in each digit were computed. Statistical calculations were conducted using χ2 analysis ( P < .05). Results: A total of 911 primary open TFRs were performed in 631 patients over a 16-year period. A total of 20 TFRs in 20 patients underwent USSR (2.2%). The long finger was the most commonly affected digit (40%) that required simple decompression. Within all USSR cases, the long finger was the most commonly affected digit. The index finger was the second most affected (30%), and there were no cases in the small finger. Conclusions: This study determined the occurrence of primary TFR cases that underwent USSR, with the long finger being the most commonly affected digit. Surgeons may consider this additional procedure to perform a larger decompression than simple A1 pulley release alone.

Background: Night time numbness is a key characteristic of CTS and relief of night time symptoms is one of the outcomes most important to patients. This study tested the null hypothesis that there is no difference between sleep quality and night symptoms before and after carpal tunnel release (CTR). Methods: Forty-four, English-speaking adult patients requesting open CTR for electrodiagnostically confirmed carpal tunnel syndrome completed questionnaires before and after surgery. Average age was 59, 24 patients were men and 20 were women. Patient with a primary or secondary sleep disorder were excluded. Before surgery, patients completed the Pittsburg Sleep Quality index (PSQI). At an average of 3 months after surgery, participants completed PSQI questionnaires. Onset of sleep quality improvement was specifically addressed. Differences between preoperative and postoperative sleep quality were evaluated using the paired t-test. Spearman correlations were used to assess the relationship between continuous variables. Results: Of the 44 patients, 32 (72%) were classified as poor sleepers (PSQI > 5.5) prior to surgery. At 3 months follow up, there was a significant improvement PSQI global scores (7.8 ± 5.1 vs 4 ± 3.5, p < 0.001) as well as subdivisions. Daytime dysfunction (0.2 ± 0.4, p < 0.001) and medication use (1.0 ± 1.2 vs 0.9 ± 1.2, p < 0.045) secondary to sleep disturbance and was improved as well. In all patients, onset of improvement was within 24 hours of surgery. Conclusions: CTR is associated with improvement in sleep quality at 3 months follow-up. CTR improves daytime dysfunction related to the sleep disturbance. The onset of sleep improvement is 24 hours after surgery in most cases.

The purpose of this study is to more accurately determine distal radius articular step-off in the posteroanterior (PA) view. A cadaveric forearm was osteotomized with varying amounts of articular displacement. A second osteotomy was made through the distal radius metaphysis to create four positions of tilt in the lateral plane (5° and 15° dorsal tilt; 5° and 15° volar tilt). Using fluoroscopy, the beam was positioned in the lateral plane from 25° volar to 20° dorsal, separated by 5° increments, obtaining modified PA images of the distal radius in its various configurations. The images were randomly evaluated for step-off by three hand surgeons in a blinded fashion. Statistical analysis was performed to determine the accuracy between estimated and actual step-off and was demonstrated to be greater when the PA view was parallel to the distal radius tilt in the lateral plane, for all four configurations of distal radius tilt. Data pertaining to the distal radius with 0 mm of step-off did not demonstrate the PA view, parallel to the distal radius tilt, to be superior than the PA views not parallel to the tilt; reaffirming that with anatomic reduction, any fluoroscopic image exhibits good alignment. This study confirms that the most accurate method of accessing PA step-off is to first determine the tilt of the radius on a lateral film and then align the beam in the PA plane to match this tilt.

Purpose To determine whether simplification of the Eaton-Glickel (E-G) classification of trapeziometacarpal (TMC) joint arthrosis (eliminating evaluation of the scaphotrapezial [ST] joint) and information about the patient's symptoms and examination influence interobserver reliability. We also tested the null hypotheses that no patient and/or surgeon factors affect radiographic rating of TMC joint arthrosis and that no surgeon factors affect the radiographic rating of ST joint arthrosis.Methods In an on-line survey, 92 hand surgeons rated TMC joint arthrosis and ST joint arthrosis separately on 30 radiographs (Robert, true lateral, and oblique views) according to the (modified) E-G classification. We randomly assigned 42 observers to review radiographs alone and also informed 50 of the patient's symptoms and examination. Information about symptoms and examination was randomized. Interobserver reliability was determined with the s* statistic. Because of the hierarchical data structure, cross-classified ordinal multilevel regression analyses were performed to identify factors associated with the severity of arthrosis.Results Shortening the E-G classification to the first 3 stages significantly improved the interobserver reliability, which approached substantial agreement. Providing clinical information to observers marginally improved interobserver reliability. Factors associated with a lower E-G stage for TMC joint arthrosis, among observers who rated the severity of TMC joint arthrosis based on radiographs and clinical information, included female surgeon, practice setting, supervising surgical trainees in the operating room, self-reported number of patients with TMC joint arthrosis typically treated annually, male patient, higher patient age, pain limiting daily activities, and shoulder sign. A self-reported larger number of patients with TMC joint arthrosis treated annually was the only variable associated with a higher modified E-G classification to rate ST joint arthrosis.Conclusions Our findings suggest that simpler classifications that focus on a single anatomical area are reliable and that surgeon and patient factors can bias interpretation of objective pathophysiology such as radiographic findings. Copyright (C) 2016 by the American Society for Surgery of the Hand. All rights reserved.

Primary repair of a nerve is preferable over nerve grafting when a tension-free environment can be achieved. The purpose of this cadaveric study was to evaluate the facility of nerve-gap closure gained by removing the hamate hook, eliminating the circuitous path of the motor branch of the ulnar nerve in the hand. Six cadaveric specimens were dissected and the length of the motor branch coursing through Guyon’s canal before and after hamate hook excision and nerve transposition was recorded. Average length was significantly shorter in specimens after transposition, with a mean 21% reduction relative to the nerve’s original course. This knowledge may help guide surgeons on whether excision of the hamate hook will allow for primary repair of the nerve when a segmental defect or retraction and scarring of the nerve stumps is encountered.

Loss of contact between radial head fracture fragments is strongly associated with other elbow or forearm injuries. If this finding has adequate interobserver reliability, it could help examiners identify and treat associated ligament injuries and fractures (eg, forearm interosseous ligament injury or elbow dislocation). (1) What is the interobserver agreement on radiographic loss of contact between radial head fracture fragments? (2) Are there factors associated with the observer such as location of practice or subspecialization that increase interobserver reliability? Fully trained practicing orthopaedic and trauma surgeons from around the world evaluated 27 anteroposterior and lateral radiographs of radial head fractures on a web-based platform for the following characteristics: (1) loss of contact between at least one radial head fracture fragment and the remaining radial head and neck; (2) a gap between fragments of 2 mm or greater; (3) anticipated fracture instability (mobility) on operative exposure; (4) anticipated associated ligament injuries; and (5) recommendation for treatment. Agreement among observers was measured using the multirater kappa measure. Kappas for various observer characteristics were compared using 95% confidence intervals. The overall interobserver agreement was moderate (range, 0.49-0.55) for each question except associated ligament injury, which was fair (0.33). Shoulder and elbow surgeons had substantial agreement (range, 0.51-0.61) in many areas, but kappas were generally in the moderate range (0.41-0.59) based on number of years in practice, radial head fractures treated per year, and trainee supervision. Radiographic signs of radial head fracture instability such as loss of contact have moderate reliability. This characteristic seems clinically useful, because loss of contact between at least one radial head fracture fragment and the remaining radial head and neck is strongly associated with associated ligament injury or other fractures. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence

Purpose It is our impression that there is substantial, unexplained variation in hand surgeon recommendations for treatment of peripheral mononeuropathy. We tested the null hypothesis that specific patient and provider factors do not influence recommendations for surgery. Methods Using a web-based survey, hand surgeons recommended surgical or nonsurgical treatment for patients in 2 different scenarios. Six elements of the first scenario (symptoms, circumstances, mindset, diagnosis, objective testing, and expectations) had 2 possibilities that were each independently and randomly assigned to each rater. For the second scenario, 2 different scenarios were randomly assigned to each rater. Multivariable logistic regression sought factors associated with a recommendation for surgery. Results A total of 186 surgeons of the Science of Variation Group completed a survey regarding recommendation of surgery for 2 different patients based on clinical scenarios. Recommendations for surgery did not vary significantly according to provider characteristics. For the various elements in scenario 1, recommendation for surgery was more likely for patients who were self-employed and continued to work and who had objective electrodiagnostic abnormalities. For the 2 vignettes used in scenario 2, a recommendation for surgery was associated with abnormal electrophysiology. Conclusions The findings of this study suggest that—at least in a survey setting—surgeons prefer to offer peripheral nerve decompression to patients with abnormal electrophysiology, particularly those with effective coping strategies. Clinical relevance The role of objective verification of pathophysiology is debated, but it is an influential factor in recommendations for hand surgery.

Metacarpophalangeal arthrodesis and interphalangeal arthrodesis are excellent tools in the surgeon's armamentarium to restore function of the disabled hand. Typical indications for these procedures are pain, deformity, and/or stiffness. Arthrodesis is generally considered a salvage procedure to be used when other reconstructive procedures, such as arthroplasty, are not possible or would be associated with a high rate of complication or failure. To determine the most functional position for arthrodesis in each patient, the surgeon should preoperatively evaluate the compromised joint in the context of the disease process, determine the initial cause of the joint pathology, and assess the condition of the surrounding joints. Current methods of achieving fusion of metacarpophalangeal and interphalangeal joints include options for incisions, bone preparation techniques, and surgical implants; each has advantages and associated risks.

In the authors' experience scapholunate interosseous ligament (SLIL) disruption with resultant scapholunate dissociation (SLD) is the most frequent disabling carpal injury among professional basketball players. Prompt diagnosis, precision surgical repair, and intensive sport-specific rehabilitation are requisites for optimal recovery. This article reports the techniques and results of a consistent surgical protocol comprising accurate carpal reduction, direct SLIL repair, and dorsal intercarpal ligament augmentation for 25 professional basketball players with disabling SLD. Follow-up assessment supports the contention that early surgery, prior to scar contracture, facilitates treatment and enhances outcome.

This article describes the treatment of the two most debilitating hand-related boxing injuries: boxer's knuckle and traumatic carpal boss. Recognition of the normal anatomy as well as the predictable pathology facilitates an accurate diagnosis and precision surgery. For boxer's knuckle, direct repair of the disrupted extensor hood, without the need for tendon augmentation, has been consistently employed; for traumatic carpal boss, arthrodesis of the destabilized carpometacarpal joints has been the preferred method of treatment. Precisely executed operative treatment of both injuries has resulted in a favorable outcome, as in the vast majority of cases the boxers have experienced relief of pain, restoration of function, and an unrestricted return to competition.

Although bilateral osteonecrosis of the femoral head and bilateral stress fracture of the femoral neck are well-documented conditions, the occurrence of both conditions in the same patient has not been reported, to our knowledge. We present the case of a patient with both entities who was managed with internal fixation of both hips, which provided stabilization of the stress fractures as well as treatment of the osteonecrosis with core decompression. Two years after treatment, the stress fractures had healed and there was no evidence of progression of the osteonecrosis. The patient granted permission for the publication of data concerning the case. Aforty-six-year-old woman presented to us with a six-month history of bilateral groin pain. The right hip was more painful than the left. There was no history of trauma. The medical history included interstitial nephritis, diagnosed on the basis of a renal biopsy performed five years earlier, and osteopenia, diagnosed on the basis of a bone mineral densitometry value that was -1.25 standard deviations below the mean for age and sex-matched controls. The nephritis was treated with a three-month course of prednisone at the time of the initial diagnosis. The serum creatinine level remained elevated at 2.0 to 3.2 mg/dL (176.8 to 282.9 μmol/L), but that level had remained stable since the diagnosis of interstitial nephritis five years earlier. The patient had not received medical treatment for the osteopenia although it was recommended to her at the time that the densitometry was performed. The patient had a history of drug and alcohol abuse more than twenty years previously, but she stated that she had not used drugs or alcohol since that time. There was no history of amenorrhea or an eating disorder. The patient stated that she was an “avid” runner, running >5 mi (>8 km) every morning, prior to …

Background: Tape blisters after hip surgery can be a source of postoperative morbidity and can increase patient discomfort. The purpose of this prospective study was to compare two different types of tape to determine whether the type of tape influences the rate of blister formation. Methods: Ninety-nine patients (100 hips) were enrolled in the study. Patients were randomized into one of two treatment groups: one treated with a nonstretchable silk tape and one treated with a perforated, stretchable cloth tape. After surgery, the assigned tape was applied over the postoperative dressing with care not to produce skin tension. At the first dressing change, the presence or absence of blisters was recorded as were the number, size, location, and type of any blisters. The presence or absence of tape blisters was recorded at the time of each subsequent dressing change. Results: A tape blister developed on twenty-five hips in twenty-five patients. The risk of a blister developing was 41% (twenty of forty-nine patients) when the nonstretchable silk tape was used and 10% (five of fifty patients) when the perforated cloth tape was used (relative risk = 4.08, 95% confidence interval = 1.53 to 10.87, p = 0.005). We found no association between formation of tape blisters and the age or gender of the patient, number of medical comorbidities, smoking history, results of nutritional assessment, or type of surgery. Conclusions: The prevalence of tape blisters was significantly lower when perforated cloth tape was used than it was when nonstretchable silk tape was used. Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

Fingertip injuries are a common problem. There may be pulp loss and exposed bone. Various techniques have been described to reconstruct function as well as aesthetics; yet it is still unclear which treatment options should be chosen for each specific injury. Evidence-based treatment strategies are limited because there are no prospective randomized clinical trials evaluating one method with another. Fingertip injuries are usually variable in their presentation, and therefore treatment decisions are often dictated by the knowledge and expertise of the treating physician combined with the patient's unique injury. With exposed bone and major distal soft tissue loss, many reconstructive techniques have been well-described including local advancement flaps, thenar flaps, and cross-finger flaps. There is scarce literature discussing surgical options when multiple fingers are involved. This report details a novel technique used to reconstruct 2 simultaneously injured fingers using the double thenar flap.

Purpose To evaluate dexterity and grip strength after simulated distal interphalangeal (DIP) joint fusion of the index and middle fingers in varying degrees of flexion. Methods Forty-six right-handed subjects performed grip and dexterity testing using the Grooved Pegboard Test in positions of index finger 20° flexion or full extension, middle finger 20° flexion or full extension, and unrestricted index and middle finger DIP joint motion (control). Simulated fusion was performed with the use of custom-molded thermoplastic orthoses. Results Index finger dexterity scores were improved when the DIP joint was splinted in 20° compared with full extension. There was no significant difference in the middle finger dexterity when comparing 20° flexion with full extension. In either position, dexterity scores were higher (lower performance) for the index finger than for the middle finger, showing a greater interference to dexterity with splinting the index finger DIP joint. Mean grip strength was unaffected by middle finger DIP joint position, whereas splinting of the index finger in full extension resulted in reduced grip strength. Conclusions Because positioning the middle finger DIP joint in either extension or 20° of flexion did not significantly affect grip strength or dexterity, other considerations such as appearance can be given priority. For the index finger, however, positioning the DIP joint in 20° of flexion may improve grip strength and dexterity over positioning it in neutral. Type of study/level of evidence Prognostic I.

Purpose To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved

Purpose This study tested the null hypothesis that there are no differences between the preferences of hand surgeons and those patients with carpal tunnel syndrome (CTS) facing decisions about management of CTS (ie, the preferred content of a decision aid). Methods One hundred three hand surgeons of the Science of Variation Group and 79 patients with CTS completed a survey about their priorities and preferences in decision making regarding the management of CTS. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid. Results Important areas on which patient and hand surgeon interests differed included a preference for nonpainful, nonoperative treatment and confirmation of the diagnosis with electrodiagnostic testing. For patients, the main disadvantage of nonoperative treatment was that it was likely to be only palliative and temporary. Patients preferred, on average, to take the lead in decision making, whereas physicians preferred shared decision making. Patients and physicians agreed on the value of support from family and other physicians in the decision-making process. Conclusions There were some differences between patient and surgeon priorities and preferences regarding decision making for CTS, particularly the risks and benefits of diagnostic and therapeutic procedures. Clinical relevance Information that helps inform patients of their options based on current best evidence might help patients understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.

A laboratory study was performed to compare the stability and ultimate strength of three standard fixation techniques for split-type lateral tibial plateau fractures. The three methods of fixation were (a) three 6.5-mm cancellous lag screws with washers; (b) two 6.5-mm cancellous lag screws with washers and an additional antiglide 4.5-mm cortical screw with washer; and (c) six-hole L-shaped buttress plate. Twelve pairs of embalmed mildly osteopenic lower extremities were used. Simulated split-type lateral tibial plateau fractures were created, reduced, and then instrumented in a matched pair design. The instrumented specimens were axially loaded to determine resistance to displacement, cyclically loaded to 10,000 cycles to determine dynamic stability, and then loaded to failure. There were no statistically significant differences found between the three different treatment groups with respect to initial stability, displacement under cyclic loading, or failure strength either as matched pairs or for the average group values. No significant correlations were found between resistance to displacement or failure strength as a function of either fragment size or sample bone density. On the basis of biomechanical stability, there appears to be no difference between the three fixation techniques tested. The results of this study suggest that use of an antiglide screw or buttress plate does not offer an advantage over lag screw fixation alone for the treatment of split type lateral tibial plateau fractures.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

In the authors' experience scapholunate interosseous ligament (SLIL) disruption with resultant scapholunate dissociation (SLD) is the most frequent disabling carpal injury among professional basketball players. Prompt diagnosis, precision surgical repair, and intensive sport-specific rehabilitation are requisites for optimal recovery. This article reports the techniques and results of a consistent surgical protocol comprising accurate carpal reduction, direct SLIL repair, and dorsal intercarpal ligament augmentation for 25 professional basketball players with disabling SLD. Follow-up assessment supports the contention that early surgery, prior to scar contracture, facilitates treatment and enhances outcome.

Traditionally, flexor digitorum superficialis tenodesis has been recommended for surgical correction of posttraumatic proximal interphalangeal (PIP) joint hyperextension deformity resulting from recurrent volar plate (VP) disruption. In contrast, VP repair has been used sparingly to restore joint stability, because of concerns regarding excessive scarring, insufficient substance, and the often long time between injury and repair. In the study reported here, we critically evaluated the long-term functional outcome of isolated VP repairs for chronic dorsal instability of the PIP joint performed over an 18-year period. Twenty-five patients underwent surgery for hyperextension deformity of the PIP joint. Mean time from injury to repair was 8.2 years. All patients complained of painful locking of the PIP joint in extension. Precise repair of the VP was performed by meticulous scar lysis and advancement to the anatomical site of insertion while avoiding the adjacent nutrient vessels. Follow-up evaluation included completion of the DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire and digital mobility, strength, and radiographic assessment. At a mean follow-up of 8 years, we found consistent alleviation of pain, restoration of joint stability, mean arc of motion ranging from 6 degrees to 92 degrees of flexion, and grip strength returned to within 90% of the contralateral side. All patients returned to unrestricted activities.

The anatomy of the ulnar nerve is described from its origin at the brachial plexus to its termination in the hand and digits. The critical anatomy surrounding the cubital tunnel and Guyon canal is emphasized, and clinically relevant anatomic variations, muscle anomalies, and peripheral nerve anastomoses are described.

We present the unusual case of a flexor carpi radialis tendon that ruptured after extended strenuous physical activity by a patient with paralysis of the opposite limb secondary to poliomyelitis.

The surgical treatment of recurrent posterior shoulder instability via a posterior approach has had a variable degree of success reported in the literature with recurrence rates ranging between 8% and 45%. The purpose of this study was to review the results of posterior capsulorrhaphy in a consecutive series of patients with recurrent posterior instability. Seventeen consecutive patients underwent operative management for posterior glenohumeral instability. The dominant shoulder was involved in ten patients. All patients were male with an average age of 28.1 years (range: 16 to 54 years). Ten patients had sustained a specific injury which precipitated the instability. Six patients reported dislocations requiring formal closed reduction maneuvers; the remainder described episodes of recurrent subluxation with spontaneous reduction. All patients underwent a posterior capsulorrhaphy using an infraspinatus splitting approach. Eight shoulders required repair of a posterior capsulolabral detachment. In addition, one patient required augmentation with a posterior bone block for significant glenoid rim deficiency. Outcome was assessed by personal interview, clinical assessment, and standardized radiographs. At an average follow-up of 3.9 years (range: 1.8 to 10.8 years) patients estimated their overall shoulder function to be 81% of the contralateral unaffected shoulder. The subjective result was excellent for eight patients, good for five patients, fair in two patients, and poor in two patients. One of the poor outcomes was in a patient with glenohumeral degenerative changes at the index procedure which progressed and eventually required a total shoulder arthroplasty. The other poor result was in a patient found to have a full-thickness rotator cuff tear 10.6 years after the index procedure. Two patients (12%) had recurrence of their instability. Both of these patients sustained a significant re-injury which precipitated their symptoms. Five patients complained of occasional night pain at the time of their last follow-up examination. Only one patient (who was re-injured) had to change professions as a result of shoulder symptoms. Posterior capsulorrhaphy for treatment of isolated posterior glenohumeral instability yields satisfactory clinical results. Recurrent instability in this series was associated with a specific re-injury and did not appear to increase with longer follow-up.

During exercise, muscular expansion and swelling occur. Chronic exertional compartment syndrome represents abnormally increased compartment pressures and pain in the involved extremity secondary to a noncompliant musculofascial compartment. Most commonly, it occurs in the lower leg, but has been reported in the thigh, foot, upper extremity, and erector spinae musculature. The diagnosis is obtained through a careful history and physical exam, reproduction of symptoms with exertion, and pre- and post-exercise muscle tissue compartment pressure recordings. It has been postulated that increased compartment pressures lead to transient ischemia and pain in the involved extremity. However; this is not universally accepted. Other than complete cessation of causative activities, nonoperative management of CECS is usually unsuccessful. Surgical release of the involved compartments is recommended for patients who wish to continue to exercise.

A tape blister, a skin excoriation that occurs under the taped portion of surgical bandages, can be a source of postoperative morbidity. Tape blisters are caused by the separation of the epidermis from the dermis at the dermal-epidermal junction. Tape resistant to stretching contributes to blister formation because of the concentration of forces at the ends of the tape. Although tape blisters are a pervasive clinical problem, their incidence after hip surgery has rarely been reported in the orthopedic literature. Therefore, we retrospectively reviewed a consecutive series of patients with hip fractures to determine the incidence of tape blisters at our institution. One hundred three patients were included in the study. Tape-related injuries occurred in 22 patients (21.4%). Patient age, patient sex, number of medical comorbidities, smoking history, nutritional status, and type of surgery were not statistically significantly associated with risk for developing tape blisters.

Tape blisters after hip surgery can be a source of postoperative morbidity and can increase patient discomfort. The purpose of this prospective study was to compare two different types of tape to determine whether the type of tape influences the rate of blister formation.Ninety-nine patients (100 hips) were enrolled in the study. Patients were randomized into one of two treatment groups: one treated with a nonstretchable silk tape and one treated with a perforated, stretchable cloth tape. After surgery, the assigned tape was applied over the postoperative dressing with care not to produce skin tension. At the first dressing change, the presence or absence of blisters was recorded as were the number, size, location, and type of any blisters. The presence or absence of tape blisters was recorded at the time of each subsequent dressing change.A tape blister developed on twenty-five hips in twenty-five patients. The risk of a blister developing was 41% (twenty of forty-nine patients) when the nonstretchable silk tape was used and 10% (five of fifty patients) when the perforated cloth tape was used (relative risk = 4.08, 95% confidence interval = 1.53 to 10.87, p = 0.005). We found no association between formation of tape blisters and the age or gender of the patient, number of medical comorbidities, smoking history, results of nutritional assessment, or type of surgery.The prevalence of tape blisters was significantly lower when perforated cloth tape was used than it was when nonstretchable silk tape was used.

c om The social and economic impact of disabling injury to the elite athlete cannot be ignored. In our sports-oriented society, professional sports has become a highly successful worldwide industry that depends on constant high-quality performance of both the team and individual participants. For the celebrated professional basketball player, scapholunate dissociation (SLD) constitutes a career-threatening injury that is publicly chronicled on a daily basis until treatment is complete. For the surgeon, the notoriety of an initial report of a successful surgery is, at most, a transient achievement, whereas an unrestrictive return to competition is the true measure of quality care. The unique, often distracting circumstances associated with treatment of this group must be recognized as potential pitfalls apt to prejudice outcome. Establishing a genuine credible rapport with the athlete andmaintaining open communication with all involved parties are essential aspects of management that avoid conflicting advice, disruption in continuity of care, compromised recovery, and a premature return to competition. Management of scapholunate interosseous ligament (SLIL) disruption is replete with numerous potential problems that in most cases can be avoided by recognition of the high-energy mechanism and spectrum of scapholunate (SL) injury, the key diagnostic features, and the efficacy of early surgical repair. SLIL is the primary component of

We report the case of an "overhead" athlete (a collegiate tennis player) who developed severe ulnar neuropathy after anterior subcutaneous transposition and placement of a fasciodermal sling. Treatment consisted of opening the sling, excising suture material, releasing all other areas of potential compression, and performing anterior submuscular transposition of the ulnar nerve deep to the flexor muscle group. Two years after surgery, subjective symptoms were significantly improved, though the patient continued to experience mild medial-side elbow discomfort and intermittent paresthesia along the ulnar nerve distribution. Pain relief achieved without full sensory and motor recovery is consistent with results reported elsewhere. In short, extreme care must be taken when creating a fasciodermal sling during anterior subcutaneous transposition of the ulnar nerve.

In this article, we report the case of a healthy young woman who sustained an anterior hip dislocation while participating in a noncontact activity (ballet dancing). The patient's atraumatic dislocation failed closed reduction secondary to interposition of anterior capsule and rectus femoris muscle. Open reduction using a Smith-Petersen approach was concentric and stable. Postinjury femoral nerve neuropraxia resolved within 6 weeks. At 2-year follow-up, the patient was without complications of the injury-including avascular necrosis and posttraumatic arthritis. She returned to dancing and is now asymptomatic.

Objective To determine the relative stability of three fixation methods for displaced capitellum fractures. Design Twelve matched pairs of embalmed humeri were divided into two equal groups and simulated capitellum fractures created. The first group compared cancellous lag screws placed in an anteroposterior direction to screws placed in the posteroanterior direction. The second group compared the Acutrac compression screw, inserted anteroposteriorly, to the more stable construct from the first test group. Methods All specimens were cyclically tested with simulated physiologic loading. Both displacement of the capitellum over a range of cycles and the number of cycles to failure were recorded. Results Fixation with posteroanteriorly directed cancellous lag screws was significantly more stable than anteroposteriorly directed screws at 2000 cycles (p = 0.007); loads to failure were not statistically different. Fixation by the Acutrac screws was significantly more stable than posteroanterior cancellous screws at 2000 cycles (p = 0.03). The Acutrac fixation had a higher failure load; however, this was not statistically significant. Conclusion The headless screws tested in this biomechanical study provided more stable fixation of capitellum fractures in the cadaveric specimens than four-millimeter partially threaded cancellous lag screws and may do so in the clinical setting. When the cancellous lag screws were tested, insertion in the posteroanterior direction provided more stable fixation than the anteroposterior direction and has clinical benefit of not violating the articular surface. Ultimately, the decision of which method to use lies with the attending surgeon and the technique with which he or she feels most comfortable.

Five hundred and sixteen community-dwelling, ambulatory, geriatric hip fracture patients who were independent prior to fracture were followed prospectively to determine which patients regained their prefracture independent living status at 3-, 6-, and 12-month follow-up. At 3-, 6-, and 12-month follow-up, 78, 77, and 76% of the patients, respectively, had regained their prefracture independent living status. Analysis was performed to determine which pre- and postinjury factors were predictive of a patient regaining prefracture independent living status at 3, 6, and 12 months after fracture. Patients who were younger than age 85, independent in activities of daily living prior to fracture, independent in ambulation at hospital discharge, and who had three or more medical comorbidities were more likely to regain their prefracture independent living status.