Search

Elbow flexion and tinel tests must be interpreted with caution as they are often positive in normal asymptomatic individuals. [ABSTRACT FROM AUTHOR]

Purpose: Physician and surgeon involvement in industry has received considerable attention in recent decades. In this study, we outline the perspective of the general US population regarding (1) disclosure, (2) ownership, and (3) compensation between physicians/surgeons and industry. We hypothesize that the general population would be largely supportive of the physician/surgeon-industry relationship., Methods: An online, survey-based, descriptive study was conducted through a crowdsourcing platform, Amazon Mechanical Turk. Survey respondents were presented with a seven-item questionnaire inquiring about the physician/surgeon and industry relationship. An "attention check" question was included; those who failed this question were excluded. Descriptive statistics were used to assess the data and a McNemar chi-squared test for paired, dichotomous data., Results: A total of 993 respondents were included. Survey responses are summarized in Table 1. 70.6% of respondents stated that it was "important" or "extremely important" to disclose that the patient be informed whether implants used in surgery had been developed by the operating surgeon. 71.1% of respondents reported that it was "important" or "extremely important" to disclose partial ownership within industry. Seventy-one percent of respondents stated it was "important" or "extremely important" to disclose royalty payments pertaining to surgical implants. 95.6% of respondents suggested that it was acceptable for surgeons to accept free airfare and lodging, and 95.2% of respondents stated that it was acceptable for the surgeon to be compensated for time away from practice to learn about new equipment., Discussion: In our survey of 993 respondents, we found that relationships with industry are considered acceptable if appropriate disclosure is given to patients. We also found that although respondents suggested that physicians and surgeons may be influenced by a free meal, compensation for trips to try new equipment and time spent away from practice is considered appropriate., Level of Evidence: 2c, Ecological studies., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Purpose: Patients who fracture their distal radius are at risk of developing carpal tunnel syndrome (CTS). Carpal tunnel syndrome occurs acutely; other patients may present with signs and symptoms of CTS weeks or months after the distal radius fracture. Because CTS may present in a delayed fashion after a distal radius fracture, some surgeons will perform carpal tunnel release (CTR) in patients who undergo open reduction and internal fixation even in those patients who do not have clinical evidence of CTS-a prophylactic CTR. In the current systematic review, we evaluated the literature regarding prophylactic CTR in the setting of surgical treatment of distal radius fractures., Methods: We conducted our literature review based on the preferred reporting items for systematic reviews and meta-analyses guidelines. The search strategy reflected "prophylactic CTR during treatment of distal radius fractures" and was conducted in February 2024. Included studies are summarized in the Table., Results: Six studies met the inclusion criteria. Publication dates ranged from 2001 to 2018. Five studies investigated clinical symptoms and/or electromyography: three of five studies found worsening or persistent median neuropathy, and two of five studies found improvement or no further development of symptoms in their respective patient cohorts. The sixth study found no difference in patient-reported outcomes between either approach., Conclusions: There were no differences in wrist range of motion, postoperative grip strength, or patient-reported outcomes within each of the study cohorts. Based on the findings from the studies included in this review, we do not believe that there is sufficient evidence supporting prophylactic CTR in the setting of surgical treatment of distal radius fractures., Type of Study/level of Evidence: Therapeutic 2a., Competing Interests: No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)

Background: Knowing the questions and concerns that patients have regarding treatment options for lateral epicondylitis may allow for shared-decision making and potentially superior patient outcomes and satisfaction. In the present study, we aimed to further delineate patient preferences with treatment of lateral epicondylitis., Methods: An online, survey-based, descriptive study was conducted through Amazon Mechanical Turk. Survey participants were presented with a clinical scenario regarding lateral epicondylitis and asked four questions regarding treatment preferences for nonoperative treatment, whether they would consider platelet-rich plasma (PRP) injection, and whether they would consider surgical intervention for recalcitrant symptoms. A Likert scale was used for responses. McNemar chi-square test was used for paired nominal data for statistical analysis., Results: A total of 238 survey responses were included. A majority (63%) of respondents elected to proceed with formal physical therapy. When given additional information regarding corticosteroid injections, 50.8% of respondents reported preferring physical therapy. There were no differences between groups for questions 1 and 2 ( P = 0.90). Of the respondents, 75.2% were "likely" or "extremely likely" to consider PRP injection. When asked about surgical intervention, 74.8% of respondents were "likely" or "extremely likely" to proceed with continued symptoms., Conclusions: It is important to include patient preferences in treatment discussions of lateral epicondylitis. Survey respondents preferred formal physical therapy for initial treatment. A surprising majority of respondents were likely to consider a PRP injection. With prolonged symptoms, respondents were interested in discussions of surgical intervention and thus, it should continue to be offered to patients with recalcitrant symptoms., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Purpose: Patient preferences and expectations following both nonsurgical and operative treatment of de Quervain's tenosynovitis are unclear. In this study, we aim to better delineate patient preferences for initial management of de Quervain's tenosynovitis. For patients considering surgical treatment, we hope to identify which factors of surgical care are most important for patients to receive counseling., Methods: An online crowdsourcing platform, Amazon Mechanical Turk, was used to recruit study participants. Study participants were then led through a clinical scenario pertaining to de Quervain's tenosynovitis. They were then asked a series of questions regarding initial treatment options, important factors to consider during surgery, and postoperative expectations. A Likert scale was used for responses. Descriptive statistics and one-way analysis of variance were used to assess survey responses., Results: In total, 199 survey responses were included, and 84% of respondents chose nonsurgical modalities for initial treatment of de Quervain's tenosynovitis. Survey items asking about the importance of cost, risks of surgery, expected recovery time, and expected pain level following surgery revealed that all factors were considered important to respondents. There were no differences between groups in the one-way analysis of variance., Conclusions: Providers should remain cognizant that patients presenting with de Quervain's tenosynovitis may favor initial nonsurgical management. The vast majority of respondents rated the importance of cost, risks of surgery, expected recovery time, and expected pain level as having some level of importance when considering surgical care. When discussing outcomes of surgery, respondents were nearly divided on what would be considered a successful outcome of surgery. This suggests that treating physicians may benefit from clarifying expected outcomes during surgical discussions., Type of Study/level of Evidence: Diagnostics IIb., Competing Interests: No benefits in any form have been received or will be received related directly to this article., (© 2024 The Authors.)

Carpal tunnel syndrome (CTS) is the most common nerve compression syndrome in the upper extremity and is one of the most common problems treated by hand surgeons. Despite its ubiquity-or perhaps because of it-there is a lack of unanimity regarding how best to treat CTS and what the options for treatment are. This study aimed to explore what patients find important when deciding on treatment of CTS in an effort to improve the physician-patient shared decision-making process., Methods: An online crowdsourcing platform was used to recruit participants for this study. Study participants were first led through a clinical scenario in which the symptoms of CTS were explained. They were then asked a series of questions regarding what was important to them when deciding upon treatment. A Likert scale was used for responses., Results: In total, 268 participant responses were included in the study. A majority of patients responded that all surveyed factors were either very important or important when considering treatment. The risk of surgery was most important, whereas postoperative pain was least important. The risk of surgery was significantly more important to patients than postoperative pain and time out of work. The cost of surgery was significantly more important to patients than postoperative pain., Conclusions: Given the lack of consensus regarding an algorithm for the treatment of CTS, the patient's preference is increasingly important when formulating a treatment plan. The results of this study may better help physicians frame the discussion of treatment options for CTS with their patients., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The most common complaint after open surgical release for trigger finger is of pain and scarring at the surgical site. We hypothesized that use of a new nonpalmar endoscopic approach for release of the A1 pulley through an incision at the proximal digital crease would result in decreased scarring and faster recovery compared to those treated with standard open release., Methods: Patients with trigger finger were prospectively enrolled and treated with a nonpalmar endoscopic versus open surgical technique. Outcome measures included scar assessment based on the Patient and Observer Scar Assessment Scale (POSAS) administered 1 week, 1 month, and 6 months postoperatively, time before return to work, occupational therapy visits, and overall satisfaction. Additional outcomes included pain medication use, operative time, and complication and recurrence rates., Results: POSAS scores were better in the endoscopic treatment group than in the open group at all time points with a statistically significant difference seen at 1 week and 1 month postoperatively. The endoscopic group returned to work sooner, required fewer occupational therapy visits, and had better overall satisfaction compared to the open group, but the differences were not statistically significant. Complication and recurrence rates did not differ significantly between groups., Conclusions: Patients treated for trigger finger with a nonpalmar endoscopic release through an incision at the proximal digital crease demonstrate significantly better scarring in the early postoperative period compared to patients treated with the open surgical approach. Treatment for trigger finger with this technique is as effective as the standard open technique., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.

Standard radiographs of the wrist do not provide adequate visualization of the scaphotrapeziotrapezoid joint. A radiographic technique that provides an improved and more complete visualization of the joint compared with routine views is described. [Orthopedics. 2020; 43(2):e123-e124.]., (Copyright 2019, SLACK Incorporated.)

Fracture of a normal humerus can occur during the act of throwing an object. We present the case of a young woman who sustained a spiral fracture of the distal humeral shaft with concomitant radial nerve palsy while throwing a softball and who, after clinical and radiographic evidence of bony healing, suffered a repeat humerus fracture, also while throwing a softball.

A 13-year-old boy fell and suffered concomitant bilateral fractures of the proximal radius and scaphoid. Ipsilateral fractures of the proximal radius and scaphoid have been reported only once previously in a child, and never bilaterally. This article reviews paediatric proximal radial fractures and scaphoid fractures and their associated injuries. This report underlines the importance of examining for other injuries when a child presents with an apparently isolated upper extremity fracture.

Two hundred sixty-four patients with rheumatoid arthritis were treated with 901 Swanson silastic arthroplasties of the metacarpophalangeal joints. Average followup was 8 years with a minimum of 2 years. Preoperative ulnar deviation averaged 45 degrees and improved to an average of 15 degrees postoperatively. Active flexion arc averaged 40 degrees preoperatively and 50 degrees postoperatively, an increase of 10 degrees. The extensor lag postoperatively improved to 10 degrees from 50 degrees preoperatively, placing the arc of metacarpophalangeal joint motion between 10 degrees and 60 degrees flexion. Complications included dehiscence and delayed wound healing (2%), superficial infection (0.5%), deep infection (3%), and prosthetic fracture (14%). Subjectively, most patients thought that their postoperative function was improved. This was thought to be attributable in part to the correction of the ulnar deviation deformity of the fingers, and the shifting of the arc of motion of the metacarpophalangeal joints to one allowing increased metacarpophalangeal extension, thereby improving the opening capacity of the digits and the overall function of the hand.

Endoscopic release of the transverse carpal ligament is an increasingly popular method of treating carpal tunnel syndrome. Advocates of endoscopic carpal tunnel release claim decreased postoperative morbidity and earlier return to work as an advantage of this technique. Others caution that there is little if any short-term difference between endoscopic and open carpal tunnel release, no long-term difference, and an increased likelihood of significant nerve injury.

Evaluation of wrist pain begins with a review of findings from a thorough medical history, a detailed physical examination, and plain radiographs. If a diagnosis is not forthcoming, additional diagnostic studies may be obtained, including "special" radiographs, bone scans, arthrograms, arthroscopy, and computed tomography and magnetic resonance imaging scans. "Abnormal" findings on these additional studies must be correlated with findings from the medical history and physical examination.

The Allen test was performed by four physician examiners on 200 hands of healthy volunteers. Positive results were found in 5.5% of hands. There was not a single case in which all four observers agreed. Considerable inter-observer disagreement is associated with the Allen test.

Squamous cell carcinoma of the perionychium is a rare, slow-growing tumor which is frequently misdiagnosed. Confusion arises because many problems affecting the soft tissue at the fingertips are clinically similar. Physicians should be aware of the possibility of carcinoma when faced with a chronic inflammatory process unresponsive to treatment. Diagnosis is confirmed by biopsy. Treatment options include amputation of the distal digital segment and Mohs microscopically controlled excision.

Inter-observer and intra-observer reliability for classifying radial head fractures by the system of Mason was analyzed. Twenty-three cases of isolated radial head fractures and twenty-five sets of corresponding AP and lateral radiographs representing these fractures were assembled. The cases were reviewed and assessed independently according to the system of Mason by twenty practicing orthopedic surgeons. On two occasions, the inter-observer and intra-observer variation was analyzed by standard unweighted Kappa statistics. In both observations, complete agreement was seen in only 16% of the cases. Kappa statistic values indicated that 69% of the cases at first observation and 45% of the cases at second observation suggest moderate to poor agreement. Intra-observer agreement between the first and second observation was graded fair to poor in 60% of the cases. Individual observer consistency was, on average, only 78% (range 60% to 92%). The demonstrated wide degree of variation suggests that the Mason classification is unreliable.

In summary, medial epicondylectomy for cubital tunnel syndrome provides relief or improvement of symptoms in most patients, with minimal morbidity. If symptoms persist, an anterior transposition can still be performed.

Osteoarthritis of the trapeziometacarpal joint can cause pain and disability. Surgical procedures for this problem include extra-articular ligamentous reconstruction, arthrodesis of the trapeziometacarpal joint, osteotomy of the thumb metacarpal, total joint arthroplasty, silicone interposition arthroplasty, and partial or complete resection of the trapezium. None of the operations results in a painless, stable thumb with good strength and motion in all cases. Disorders of the thumb metacarpophalangeal joint and the scaphotrapezio-trapezoid joints may accompany osteoarthritis of the trapeziometacarpal joint.

This article is an overview of the management of femoral shaft fractures resulting from gunshot wounds. It deals with the initial patient evaluation, operative techniques of fracture stabilization and wound care, associated complications, and the postoperative rehabilitation of these complex fractures. The recommendations are based upon a large patient experience in an urban trauma center.

Scaphoid nonunion can cause pain, loss of wrist motion, and loss of grip strength. Because initial roentgenograms are not always definitive, patients suspected of having a scaphoid fracture despite negative initial radiographs should undergo bone scan. Treatment of acute nondisplaced fracture of the scaphoid generally nonoperative, involving immobilization in a cast. Treatment of scaphoid nonunion is generally operative, and many procedures and their associated risks are reviewed. There is no consensus about the clinical implications of scaphoid malunion.

Fourteen patients underwent evaluation of the distal radioulnar joint following Galeazzi's fracture. Five of 12 patients who underwent a preoperative magnetic resonance imaging scan of the wrist had evidence of injury to the triangular fibrocartilage complex. These 5 patients also had abnormal intraoperative radiocarpal arthrograms. The amount of radial shortening in the injured forearm was measured prior to surgical treatment. Injury to the distal radioulnar joint appeared to be independent of the amount of radial shortening.

Forty proximal interphalangeal joint silicone elastomer flexible implant arthroplasties in 19 patients with systemic inflammatory arthritis were reviewed. The follow-up period averaged 94 months. Before surgery, the average arc of motion was 26 degrees for the 20 digits with boutonniere deformities and 23 degrees for the 16 digits with swan-neck deformities. Eight digits had moderate (grade 2) pain, and four digits had severe (grade 3) pain. After surgery, the deformity was completely corrected in six digits. Digits with a preoperative boutonniere deformity (20 digits) achieved the same (26 degrees) arc of motion after surgery, whereas those with a preoperative swan-neck deformity (16 digits) actually lost 18 degrees. Six digits had moderate pain and one digit had severe pain at the final follow-up evaluation. Thirteen digits (7 patients) with a boutonniere deformity before surgery and a concurrent or previous silastic metacarpophalangeal arthroplasty had significantly better results than those without. Overall, there were 12 good, 18 fair, and 10 poor results. Based on this study, flexible silicone implant arthroplasty has a limited role in the treatment of proximal interphalangeal joints affected by systemic inflammatory arthritis. When performing the arthroplasty, attention should be directed first toward correction of the deformity at the metacarpophalangeal joint.

Sixteen patients who had undergone hip arthrodesis utilizing an anteriorly placed compression plate were evaluated at an average of 4.5 years after surgery. The technique was designed to facilitate future conversion to a total hip arthroplasty by preserving the abductor musculature. Of the 11 patients who underwent primary fusions, 5 failed to unite (45%). Nonunion occurred in all five (100%) patients undergoing refusion for a failed surgical arthrodesis. The authors conclude that an anterior compression plate alone in patients with limited bone stock does not provide adequate fixation and predisposes the patient to failure of fixation and nonunion.

The thoracic outlet syndrome is a compressive neurovascular condition of the upper extremity. The neurologic, arterial, and venous structures may be affected individually or in combination in any given patient. Multiple surgical and medical subspecialists may be involved in the care of these patients, including orthopedic, vascular, and thoracic surgeons, neurosurgeons, and neurologists. The topic is extremely controversial; some authors believe that this is a very common condition, while others question the existence of the syndrome. There is disagreement concerning the diagnosis, workup, and proper therapeutic management. The purpose of this article is to critically review and analyze the literature on this subject.

Tinel's sign and Phalen's test are two provocative tests used in the diagnosis of carpal tunnel syndrome. A review of the literature reveals a wide range of sensitivity for these tests. Analyzing the historical data and comparing these to the Tinel's sign and Phalen's test results of 100 individuals without carpal tunnel syndrome (200 wrists), we conclude that the Tinel's sign is not useful in the evaluation of patients with carpal tunnel syndrome, whereas Phalen's test, which has a greater sensitivity and specificity, can be of use.

Septic arthritis is a devastating complication of transabdominal gunshot wounds to the hip. Five patients sustained gunshot wounds to the hip which violated the alimentary tract. Diagnosis was established with plain radiographs in three patients, arthrogram in one patient, and a gastrointestinal series in one patient. Three patients had an exploratory laparotomy with diverting colostomy followed by immediate hip arthrotomy within 24 hours and no joint infections occurred. In the other two patients, hip involvement was identified late after septic arthritis occurred. Early diagnosis, diverting colostomy, and immediate arthrotomy are recommended for gunshot wounds to the hip which involve the alimentary tract.

A review of the literature reveals that Kienbock's disease has been treated in many different ways. Excision of the lunate, with or without replacement arthroplasty, and joint-leveling procedures (radial shortening or ulnar lengthening) are the most popular procedures, but other methods of treatment (nonoperative, wrist denervation, lunate revascularization, intercarpal arthrodesis and proximal-row carpectomy) have also been performed. Based on our current understanding of the etiology, a joint-leveling procedure seems to make the most sense when surgery is indicated. However, other procedures have yielded a high success rate as well.

Two patients, each with a history of mental illness, were assessed for embedded rings. Removal of the ring was accomplished without loss of digit or further loss of function in one patient. The other patient refused treatment. Altered mental status is a common finding in patients with embedded ring injuries.

We report a case of late multiple infected metacarpophalangeal silicone implants in a patient who had had replacement arthroplasty for treatment of rheumatoid arthritis. The patient had done well for 10 years after metacarpophalangeal joint arthroplasty when an implant infection developed. Over the next 4 years the remaining three implants on her dominant extremity also became infected necessitating their removal. The origin of the infections is thought to be the result of excessive and improper usage of the hand.

Thirty-seven extraarticular fractures of the forearm resulting from low-velocity gunshot injuries were treated by cast immobilization or open reduction and internal fixation with dynamic compression plates. All patients received 72 h of intravenous antibiotics. There were 14 isolated ulna fractures, 17 isolated radius fractures, and six both-bone (radius and ulna) fractures. Cast immobilization was used in 22 of 23 nondisplaced or minimally displaced fractures and eight of 14 displaced fractures. The remaining seven fractures were treated by open reduction and internal fixation. All fractures united within 16 weeks of injury regardless of the method of treatment. Poor clinical results related to the fracture occurred in six patients, five of whom were treated by cast immobilization. Fourteen patients had nerve palsies; eight resolved spontaneously and six had permanent neurologic deficits. There were two compartment syndromes and one ulnar artery transection. There were no infections. We conclude that displaced fractures of the radius, and both bone fractures, are best treated by open reduction and internal fixation. All patients should be closely monitored for 24 h for compartment syndrome, regardless of the fracture type or pattern. Early dynamic splinting is important when associated nerve injuries are present.