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Purpose: Distal radius fractures may include difficult-to-treat fractures of the volar ulnar corner, colloquially termed as the "critical corner." These fragments are problematic because they are often missed, and their fixation is difficult. We aimed to compare the distal extent of the exposure of the volar surface of the distal radius between the classic Henry approach and the extended flexor carpi radialis (EFCR) approach., Methods: Thirteen matched-pair specimens were randomized to receive either the Henry approach or the EFCR approach to the volar distal radius. A mini Hohmann retractor provided retraction at the level of the critical corner. The force needed to attain a standardized angle of retraction at 60° was measured. A 0.062-inch Kirschner wire was placed at the most distal and most ulnar point that was visible from a position directly above the incision. Each distal radius was removed from the specimens. A digital caliper was used to measure the distance from the pin hole to the articular margin of the lunate fossa, along a line parallel to the long axis of the radius., Results: The pin was significantly closer to the articular margin in the EFCR approach (mean, 2.94 ± 1.69 mm) than in the Henry approach (mean, 9.70 ± 2.70 mm)., Conclusions: Our results demonstrated significantly more distal visualization of the volar distal radius in the EFCR approach compared to the Henry approach., Clinical Relevance: Adequate exposure of the volar surface of the distal radius is crucial for assessment and fixation of the volar ulnar corner. Complete visualization of the volar ulnar corner improves surgeons' ability to detect a volar marginal fragment and adequately fix this fragment., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: O'Driscoll popularized the principle of linked column fixation for distal humerus fractures. Despite the linked column concept being widely accepted, there are few reported techniques to accomplish this goal. A novel device was designed based on the principles of linked columns. An interlocking beam is used to connect the medial and lateral plates, creating a unified fixed angle construct. Our primary objective was to report clinical outcomes across multiple institutions for a linking beam used in distal humerus fracture fixation., Methods: A retrospective series was collected from 5 institutions for the TiBeam (Skeletal Dynamics) with a minimum follow-up of 6 months. Acute and chronic treatment of distal humerus fracture patterns and all plate configurations were included for analysis., Results: A total of 36 cases were collected at a mean age of 52 years and a mean follow-up of 19.3 months. AO C-type fractures were 56% of the series. The median Mayo Elbow Performance Score was 85 (interquartile range [IQR] 76.3-90), the median DASH was 21.4 (IQR 15.9-30), and the median score on the visual analog scale for pain during activities of daily living was 3.5 (IQR 2-5). An olecranon osteotomy was used in 86% of cases, and an anatomic plate was used for fixation of the osteotomy in 94% of those cases. There were 3 cases of olecranon plate removal for a rate across the series of 13.7%., Discussion: Our short-term results demonstrate satisfactory clinical outcomes with low rates of revision for distal humerus fracture fixed with a linking beam. Further, the rate of removal for the olecranon osteotomy plate was lower than historical reports for aggregate methods of osteotomy fixation., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Summary: Longitudinal forearm instability is a consequence of interosseous ligament complex disruption. Radiographic identifiers should alert the surgeon to the disrupted structures. Understanding the injury pattern can simplify the treatment process. The clinical presentation will vary based on the involved interosseous ligament components. The surgeon should aim to restore the anatomic radioulnar relationship and then address the remaining pathology as needed. The central band is the foundational structure that maintains this relationship and should be addressed in each injury pattern when disrupted. In this study, we describe rare forms of longitudinal forearm instability., Competing Interests: D. M. Mercer discloses speaker's bureau relationships with Skeletal Dynamics and Axogen. J. J. Heifner declares no conflicts of interest related to this study., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The incidence of radial head fractures is increasing, and radial head arthroplasty (RHA) is being more frequently used as treatment for irreparable fractures. Our objective was to compare radiocapitellar pressure between the native joint and 2 radial head prosthesis conditions: (1) a prosthetic head that was aligned to the forearm axis of rotation and (2) the same prosthesis with an axisymmetric nonaligned head., Methods: Ten cadaveric specimens received a pressfit radial head prosthesis (Align; Skeletal Dynamics) for both prosthetic testing conditions. Anatomic alignment (AL) was defined as the prosthetic head aligned to the forearm axis of rotation. Axisymmetric alignment (AX) was defined as the prosthetic radial head aligned to the axis of the prosthetic stem. Axial load was applied with the elbow in extension and the forearm pronated. Data were collected using a Tekscan 4000 sensor., Results: The mean pressure in the AL and AX groups were significantly higher than the mean pressure in the native joint. Compared with the native joint, the mean pressure was 19% higher in the AL group and 56% higher in the AX group. Peak pressure beyond 5 MPa occurred in 0 specimens in the native joint group, in 1 specimen (10%) in the AL group, and in 5 specimens (50%) in the AX group., Discussion: Our results demonstrated that a pressfit radial head prosthesis aligned with the forearm axis of rotation yields capitellar pressures that were more similar to the native condition than a nonaligned pressfit prosthesis. These findings suggest that anatomic alignment may optimize capitellar wear properties, improving the long-term durability of radial head arthroplasty., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Revision of radial head arthroplasty (RHA) may be indicated in cases of prosthesis loosening and malposition. Inherent difficulties in revision surgery include poor bone stock and disrupted soft tissue envelope. Although cases of RHA used for revision of failed RHA are rare, there is reasonable expectation for increasing frequency of these cases due to the increasing incidence of primary RHA. Furthermore, there is an increasing demand for postoperative recovery of function; thus, surgeons may consider revising a failed RHA to a new RHA. We report on series of failed RHA which were revised to a new radial head prosthesis., Methods: A retrospective review was performed at multiple institutions for a single radial head prosthesis used for revision of a failed radial head prosthesis. Clinical and radiographic outcomes were collected with a minimum of 1 year of follow-up., Results: Across 11 patients at a mean follow-up of 45.1 months, the mean Mayo Elbow Performance Score was 81.7; mean Disabilities of the Arm, Shoulder, and Hand scores were 24.4; and mean Visual Analog Scale for pain was 0.6. Radiographic analysis yielded no evidence of capitellar wear or stem loosening., Conclusion: A radial head prosthesis can produce satisfactory results when used for revision of a failed prosthesis. Inherent difficulties in revision surgery include the potential for reduced bone stock and a disrupted soft tissue envelope. Elements of prosthesis design which may contribute to effectively managing revision surgery include a long stem with in-growth surface and prosthetic head alignment to the axis of forearm rotation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: G.P.K. declares consulting relationship with Axogen, Trice Medical, and OrthoCircle and is a shareholder in Oxos Medical. D.M.M. declares speakers bureau relationship with Skeletal Dynamics and Axogen. J.J.H., L.E.B., P.A.S., and G.A.G. have nothing to declare.

Case: A 34-year-old man was acutely treated with radial head arthroplasty and central band repair following Essex-Lopresti injury. A 38-year-old man presented with chronic longitudinal instability following failed radial head arthroplasty, which was performed for failed fixation. Treatment with revision radial head arthroplasty and central band reconstruction restored longitudinal stability., Conclusion: We have a low threshold to repair the central band in acute Essex-Lopresti injury with sufficient evidence of disruption. Nearly all chronic cases require central band reconstruction to restore longitudinal stability. We do not temporarily pin the DRUJ, and distal ulnar shortening is rarely indicated., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C363)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: The distal radioulnar joint (DRUJ) is supported by an array of dynamic and static stabilizers, of which the triangular fibrocartilage complex (TFCC) is the most important, and the distal interosseous ligament is next in importance. The distal oblique band (DOB) is an identifiable component of the distal interosseous ligament, found in a subset of the population. Our objective was to determine the contribution of the DOB to DRUJ stability in the presence of a disrupted TFCC., Methods: Twenty-three above-elbow specimens were prepared by removing the TFCC and the DRUJ joint capsule, preserving the distal interosseous ligament and the pronator quadratus. Cadavers were stratified into two groups-those with, and those without a DOB. A bone plate and screws were attached to the ulna; then, a transverse load was applied to failure, creating a diastasis between the radius and ulna., Results: The group with a DOB had a mean load at failure of 160.7 ± 46.5 N. The group without a DOB had a mean load at failure of 148.0 ± 26.3 N. Stiffness prior to failure was 16.9 N/mm in the group with a DOB and 12.4 N/mm in the group without a DOB., Conclusions: The current results indicate that the DOB may not substantially contribute to DRUJ stability in the presence of a disrupted TFCC., Clinical Relevance: Stability of the DRUJ after TFCC injury may not be substantially improved by the presence of a DOB. Thus, the clinical importance of DOB reconstruction remains unclear., Competing Interests: Conflicts of Interest Drs Orbay and Mercer report financial involvement with Skeletal Dynamics. No benefits in any form have been received or will be received by the other authors related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

We present two cases of complex metacarpal fractures treated with an intramedullary locking nail. This is an emerging fixation method that minimizes tissue insult, provides sufficient stability, and allows early mobilization. Locking nails accommodate the capture of fractured fragments in complex unstable patterns and provide longitudinal and rotational stability. The described intrafocal technique is intended to improve coaxial placement of the wire into the medullary canal., Competing Interests: Dr Mercer has association/financial involvement with Skeletal Dynamics (speaker’s bureau) and Axogen (speaker’s bureau). No benefits in any form have been received or will be received by the other authors related directly to this article., (© 2024 The Authors.)

We describe a medial approach to the coronoid where the flexor-pronator mass is released from its humeral origin by creating a proximally based tendinous flap. This technique facilitates access to the coronoid, preservation of the medial collateral ligament origin, and repair of the flexor-pronator mass. This approach has utility for all coronoid fracture variations but especially the O'Driscoll anteromedial subtype 3, which includes fractures of the sublime tubercle, the anteromedial facet, and the coronoid tip., Competing Interests: Conflicts of Interest and Source of Funding: J.L.O. discloses patents 8506606 and 8608741 issued to Skeletal Dynamics. Irrevocable trusts of which J.L.O. and his family members are the beneficiaries and own stock in Skeletal Dynamics, and Skeletal Dynamics reimburses expenses when J.L.O. speaks or presents on the company’s behalf. F.R., R.R.L.G., N.A.H., and D.M.M. disclose a relationship with Skeletal Dynamics that includes consulting and speaker’s bureau. D.M.M. discloses a relationship with Axogen that includes the speaker’s bureau. For the remaining author none were declared., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: The goal of surgical management for unstable elbow injuries is the restoration of joint concentricity and stability. After internal fixation, concerns may exist regarding instability or durability of the fixation construct. Historically, these scenarios were treated with options such as transarticular pinning or external fixation. Recently, an internal joint stabilizer (IJS) that allows postoperative mobilization was introduced. Our objective was to systematically review the literature to aggregate the clinical and biomechanical evidence for the IJS of the elbow., Methods: A systematic review of the PubMed and Google Scholar databases was performed, following the PRISMA guidelines. The search results were narrowed from 2015 through 2023 to coincide with the inception of the device being reviewed., Results: A total of nine retrospective reports on the IJS ( N  = 171) cases at a mean follow-up of 10.8 months were included. The pooled rate of implant failure was 4.4%, and recurrent instability was 4.1%. Additionally, the we included seven case reports and two biomechanical reports., Conclusions: The aggregate literature describes satisfactory clinical outcomes with low rates of recurrent instability and device failure for the IJS of the elbow. The limited biomechanical investigations conclude efficacy for stability profiles., Clinical Relevance: Across a spectrum of unstable elbow cases, the IJS prevented recurrent instability during the early postoperative period. Notably, the device requires an additional procedure for removal, and the long-term impact of the retained devices is currently unclear., (© 2023 The Authors.)

Introduction: Concerning rates of nonunion in articular distal humerus fractures indicate an unsolved problem. The fixation principles of O'Driscoll describe linking the fractured articular segment to the distal humerus columns with compression screws which creates a stable fixed angle construct. A novel device has been introduced which utilizes an interlocking beam through the articular segment to connect the distal aspect of the medial and lateral plates, creating a linked construct. We sought to evaluate the stability of this linked construct using an articular model of distal humerus fracture., Materials and Methods: Ten matched pair specimens of 65 years of age or older were randomized to the use (LB group) or non-use (NLB group) of an interlocking beam to link the medial and lateral locking plates in fixation of an AO Type C3 fracture model. Outside of the linking beam, fixation between the matched pairs was consistent using 2.7 mm locking screws distally with fixed trajectories and +/- 2 mm lengths., Results: Mean stiffness was 273 Newtons/mm in the LB group and 225 Newtons/mm in the NLB group (p = 0.001). Mean maximum displacement was 0.28 in the LB group and 0.93 mm in the NLB group (p = 0.006). Mean load to failure was 277 pounds in the LB group and 280 pounds in the NLB group (p = 0.94)., Discussion: Our results indicate that an interlocking beam which links the medial and lateral plates provides greater stability compared to a similar construct without an interlocking beam. We attribute this finding to the beam's double supported design which resists cantilever bending and provides robust compression of the fractured fragments., Competing Interests: Declaration of Competing Interest RG and NH disclose royalties and speaker's bureau with Skeletal Dynamics. DM discloses speaker's bureau with Skeletal Dynamics and Axogen. JH, GL, TD have nothing to disclose., (Copyright © 2023. Published by Elsevier Ltd.)

Recent advancements in surgical treatment have improved clinical results in complex traumatic elbow injury. There is increasing recognition that conservative treatment and inadequate surgical fixation carry high risk of substantial morbidity in many of these cases. Recent literature displays improved outcomes in complex elbow instability, in part, because of a more complete comprehension of the injury patterns and fixation methods. Prompt surgical management with stable internal fixation, which permits immediate postoperative mobilization, has been a consistent variable across the reports leading to more satisfactory outcomes. This applies to both acute and chronic cases., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Metacarpal fractures are common and can be functionally disabling. The majority are managed non-operatively. When surgical intervention is indicated, various methods of fixation are available with the utility of each being based on injury pattern, patient function and surgeon preference. Early mobilization, especially in case of open reduction and internal fixation, is a critical component of treatment to prevent stiffness and restore function. When possible, a fixation construct that can withstand the applied forces of early postoperative motion is chosen. We provide an updated description for diagnosis, treatment options and operative fixation for metacarpal fractures.

Purpose: Kienböck's disease consists of intrinsic and extrinsic characteristics that coalesce into a pathology with multifactorial etiology. Mechanical, morphological, and vascular factors have been identified as contributory. Radial osteotomy is one of the most commonly used surgical treatment for late-stage Kienböck's disease. Despite its frequent use and reported value, the specifics of radial osteotomy have not been described in aggregate. Our objective was to review the recent literature for descriptions of the radial osteotomy techniques used for treatment of Kienböck's disease., Methods: The inclusion criteria for the systematic review were as follows: (1) patients aged >18 years, (2) a publication date no older than 2012, and (3) a complete description of the distal radius osteotomy technique, including verbiage that specified numeric dimensions of bony resection or verbiage that detailed a goal in terms of a radiographic parameter that would guide the bony resection., Results: The studies were grouped according to the stated description of radial osteotomy. This process yielded the following three main groups: (1) studies that used radial shortening, (2) studies that used lateral closing wedge osteotomy or combined lateral closing wedge with radial shortening, and (3) novel osteotomy descriptions., Conclusions: The Kienböck's disease literature predominantly describes an osteotomy to shorten the radius by 2-3 mm. In some studies, the degree of radial shortening corresponded to the value necessary to achieve near-neutral ulnar variance. The common goal in using lateral closing wedge osteotomy was to achieve a radial inclination of 5° to 15°. Unique wedge resections, some with multiplanar corrections, have been recently described with each purporting specific advantages., Clinical Relevance: Our findings support the premise of mechanical and biologic efficacy for radial osteotomy, with satisfactory results being reported across a wide spectrum of osteotomy techniques., (© 2023 The Authors.)

We describe the development of an innovative baccalaureate nursing education strategy for public health nursing. Virtual simulation pedagogy is known to be effective for acute care nursing practice while less known for public health nursing. Three Canadian nursing schools, the Canadian Association of Schools of Nursing (CASN), and the Canadian Alliance of Nurse Educators using Simulation (CAN-Sim) partnered to develop three public health nursing virtual simulation games. Learners work through unfolding population health scenarios, simulating public health nursing practice focused on entry level public health nursing competencies. Each game fosters clinical reasoning and collaborative, community decision-making to respond to population health issues during community assessment, evidence-informed health promotion planning, and evaluation processes. A companion guide was developed to support best practices in implementing virtual simulation and promote optimum student learning using the public health nursing games., (© 2023 Wiley Periodicals LLC.)

It is challenging to restore the clinically acceptable alignment of the distal radius after an acute on chronic fracture or after a secondary fracture occurring after malunion of a primary distal radius fracture. In cases of insignificant primary deformity, restoration to the primary deformity may suffice to obtain a successful clinical result. A borderline acceptable primary radial deformity can be unacceptable after the second injury, resulting in functional disability. If surgery is indicated, the surgeon must contend with both primary and secondary deformities to restore proper distal radius anatomy. We present our technique to correct both primary and secondary distal radius deformities through the new or secondary fracture plane., Competing Interests: Conflicts of Interest and Source of Funding: Irrevocable trusts of which J.L.O. and family members are the beneficiaries own stock in Skeletal Dynamics, and the company reimburses expenses when he speaks or presents on the company’s behalf. D.M.M. discloses speaker’s bureau for Skeletal Dynamics and Axogen. For the remaining authors none were declared., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

A variety of fixation options exist for treatment of unstable proximal phalanx fractures. Variables which require consideration include the strength of fixation, the invasiveness of the technique and the postoperative rehabilitation protocol. Here we present a minimally invasive technique for dual headless compression screw fixation of proximal phalanx fractures which reduces extensor tendon violation and allows early motion in the immediate postoperative period., Competing Interests: Conflicts of Interest and Source of Funding: F.R., R.R.L.G., N.A.H., and D.M.M. disclose a relationship with Skeletal Dynamics that includes consulting and speaking. J.J.H. reports no conflicts of interest and no source of funding., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Student engagement with the community is a cornerstone of undergraduate nursing education in Canada. Working with community from perspectives of social justice, health equity, advocacy, and political action are essential for workforce readiness. We suggest that the erosion of public health theory and clinical courses in baccalaureate nursing programs undermines the potential capability of nurses to address the intersectionality of the social determinants of health. The impact of the COVID-19 pandemic on populations further demonstrates inequities, particularly among marginalized populations. Public health nursing education supports students' understanding about the health impacts of social injustice, how systemic racism is embedded in colonial and Eurocentric structures, and practices of superiority and privileges.We, as a national group of public health nursing educators, set out to investigate how existing guidelines and competencies support public health in undergraduate education across Canada. Results from a national questionnaire of educators, and of PHN leaders on new graduate practice readiness are presented. Questionnaire responses confirm an erosion of PHN theory and practice in baccalaureate nursing education (BNE) curricula. The results of the questionnaires combined with evidence of PHN since the global pandemic provide educators and practitioners more insight to inform future directions to respond to workforce readiness., (© 2022 Wiley Periodicals LLC.)

Background: Patient age may play a role in the surgeon's decision between radial head arthroplasty (RHA) and open reduction internal fixation in radial head fracture treatment. Though large sample reports have detailed outcomes of radial head replacement for a mean age younger than 50 years, the age ranges are widely distributed . Patient outcomes are not uniform across a broad age distribution. Therefore, treatment decisions should be evaluated within the confines of a narrower age bracket. An understanding of clinical outcomes for radial head replacement in younger adults will provide value for guiding treatment decisions. We performed a systematic review comparing the clinical outcomes for radial head replacement in patients younger and older than 50 years of age. Further analysis compared outcomes between RHA performed as a primary procedure and as a secondary procedure in patients younger and older than 50 years of age., Methods: PubMed was queried for articles which delineated individual patient data for age, surgical treatment, and appropriate outcome metrics. Articles were grouped based on patient age of under 50 and over 50 years and within those age groups, based on the arthroplasty being performed as a primary or as a secondary procedure., Results: There were no significant differences between the under 50 and the over 50 groups for Mayo Elbow Performance Score ( P  = .79) and for implant revision/removal ( P  = .32). In the under 50 group, RHA done as a primary procedure had significantly higher ( P  = .001) mean Mayo Elbow Performance Score than RHA done as a secondary procedure. In the over 50 group, relative risk was 2.39 (95% confidence interval, 2.12-2.69) for implant revision/removal ( P  = .11) when comparing primary and secondary procedures., Discussion: At a mean follow-up of 48 months, RHA in patients under the age of 50 years had satisfactory outcomes which were comparable to outcomes in patients over the age of 50 years. Across both age groups, arthroplasty performed as a primary procedure demonstrated superior outcomes compared to arthroplasty performed as a secondary procedure. Our findings provide guidance to surgeons who face a multifaceted decision when encountering younger adult patients with radial head fracture patterns that may not be amenable to fixation. Awareness of the age-specific performance of radial head implants is an important component of the decision for surgical treatment., (© 2022 The Author(s).)

Background: Distal radius fractures often present with a 3-part articular fragmentation pattern, with separation of the dorsal and volar lunate fossa. The column concept of distal radius fixation addresses the importance of stabilizing both the scaphoid fossa lateral column and the lunate fossa intermediate column. Recent evidence strengthens the value of immediate postoperative mobilization. Satisfactory outcomes following these protocols are predicated on volar locking plates (VLPs) providing adequate stability to the fracture repair. We hypothesize that a VLP which individually supports both lateral and intermediate distal radius columns may provide comparable stability between articular and non-articular cadaveric fracture models under parameters meant to simulate postoperative loading., Methods: Eleven cadaveric matched pair specimens were randomized to receive a simulated AO Type A2 non-articular distal radius fracture on one side with an AO Type C3 articular fracture on the contralateral side. Stiffness during cyclic loading was compared between fracture groups. A matched-paired Student t-test was used to determine statistical significance ( P = .05)., Results: There were no significant differences ( P = .35) in stiffness between the articular models (mean 370.0 N/mm, +/-93.5) and the non-articular models (360.4 N/mm, +/-60.0) of distal radius fracture., Conclusion: A VLP that individually supports the scaphoid and lunate fossa with fixed angle subchondral support may provide comparable fixation strength with resistance to displacement between articular and non-articular fracture patterns. The current results suggest that fossa-specific VLP fixation in articular fractures can maintain construct stability during postoperative loading.

Purpose: Distal radius fractures are the most common fractures in adults. Because of the prevalence of these injuries, patients may present with a repeat distal radius fracture on the same wrist through the site of a malunion. We clinically refer to this as an acute on chronic distal radius fracture. In this setting, the restoration of acceptable alignment can be challenging. There is little guidance in the literature for the management of these fractures. We report our experience with acute on chronic distal radius fractures. The secondary fracture plane was used to correct the prior deformity, and the construct was fixated with a fixed angle volar locking plate., Methods: Records of patients with malunion of the distal radius who experienced an acute fracture of the ipsilateral distal radius were reviewed. Inclusion required treatment with open reduction internal fixation using a distal fragment first technique and a volar locking plate through the extended flexor carpi radialis approach. Clinical outcomes and complications were collected., Results: Across 13 patients, the mean follow-up term was 13 months (range, 6-40 months). Radiographic union was noted in all patients. The mean visual analog scale score for pain was 1.8, and the mean Quick Disabilities of the Arm, Shoulder, and Hand score was 21.9. There were no recorded complications., Conclusion: Our results and described technique provide reproducible guidance for the management of acute on chronic distal radius fractures. These cases can be managed using the secondary fracture plane, a distal fragment first technique, and a volar locking plate to correct the preexisting deformity., Type of Study/level of Evidence: Therapeutic IV., (© 2022 The Authors.)

Common indications for surgical procedures of the wrist and hand include acute fractures or fracture-dislocations; nonunited fractures; posttraumatic, degenerative, and inflammatory arthritides and tendinopathies; injuries to tendons, ligaments, and the triangular fibrocartilage complex; and entrapment neuropathies. Soft tissue or osseous infections or masses may also need surgical treatment. Several of these procedures require surgical hardware placement, and most entail clinical follow-up with periodic imaging. Radiography should be the first imaging modality in the evaluation of the postoperative wrist and hand. Computed tomography, magnetic resonance imaging, diagnostic ultrasonography, and occasionally nuclear medicine studies may be performed to diagnose or better characterize suspected postoperative complications. To provide adequate evaluation of postoperative imaging of the wrist and hand, the interpreting radiologist must be familiar with the basic principles of these surgical procedures and both the imaging appearance of normal postoperative findings as well as the potential complications., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables., Questions/purposes: (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians?, Methods: This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized β coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics., Results: We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did., Conclusion: Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases., Clinical Relevance: The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic., Competing Interests: This study received funding from NCATS/NIH (award number UL1TR000445). Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Abstract: Events causing acute stress to the health care system, such as the COVID-19 pandemic, place clinical decisions under increased scrutiny. The priority and timing of surgical procedures are critically evaluated under these conditions, yet the optimal timing of procedures is a key consideration in any clinical setting. There is currently no single article consolidating a large body of current evidence on timing of nerve surgery. MEDLINE and EMBASE databases were systematically reviewed for clinical data on nerve repair and reconstruction to define the current understanding of timing and other factors affecting outcomes. Special attention was given to sensory, mixed/motor, nerve compression syndromes, and nerve pain. The data presented in this review may assist surgeons in making sound, evidence-based clinical decisions regarding timing of nerve surgery., Competing Interests: Conflicts of interest and sources of funding: Although this review was not directly funded by any grant, Texas Tech University Department of Orthopaedics does receive funding and grant awards to participate in the nationwide RANGER nerve allograft trial as well as investigating uses of AVIVE (human umbilical membrane) sponsored by Axogen. The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Treatment of isolated complete tear of the scapholunate ligament is challenging. The purpose of this study was to determine (1) whether delayed repair of only scapholunate ligament is an option without other reconstruction procedures and (2) whether functional outcomes are possible despite radiographic presence of arthritis. This study included patients who had complete ligament tear at exploration and underwent only scapholunate ligament repair without capsulodesis or tenodesis. Fifteen patients returned for clinical and radiographic examinations. Preoperatively, mean scapholunate gap was 2.9 mm and 4.58 mm on posteroanterior and tangential posteroanterior views, respectively. Postoperatively, the final mean gap was 2.5 mm and 3.9 mm on the posteroanterior and tangential posteroanterior views, respectively. The mean preoperative and final scapholunate angles were 74° and 72.6°, respectively. Seven patients had radiographic arthritis at final follow-up. Delayed scapholunate repair is possible after complete ligament tear. At long-term follow-up, clinical functional outcomes may not correlate with radiographic presence of degenerative arthritis. [ Orthopedics . 2021;44(3):e446-e453.].

Background: Although experiences in the operating room can help surgeons to learn simple bone-drilling techniques, outside training may be better suited for complex procedures. We adapted a rotary handpiece to evaluate the bone-drilling skills of orthopaedic resident physicians during the 2017 Southwest Orthopaedic Trauma Association (SWOTA) motor skills course., Methods: Twenty-five postgraduate year (PGY)-1 orthopaedic residents from 7 institutions were asked to perform a bicortical drilling task 3 times both before and after attending a motor skills course. Kinetic and kinematic data were collected using force, acceleration, and visual sensors., Results: Sixteen parameters were measured. The interdependence of these parameters (taken separately for precourse and postcourse performance) is presented. Evidence for motor skill acquisition across a short time scale is elucidated. Noteworthy correlations include overpenetration with force (0.65 mm), palmar-dorsal (P-D) toggle (0.65°), vibration in the P-D direction (0.53 m/s), time (-0.41 sec), and RPM (revolutions per minute; -0.36); time with both RPM (0.38) and P-D toggle (-0.40°); and force with both RPM (-0.41) and P-D toggle (0.32°). Differences in performance before and after the motor skills course include reduction in overpenetration (28.8 to 18.2 mm), reduction in skiving (22% to 6%), and reduction in preparation time (27.3 to 9.65 sec). Additionally, there were several differences in performance by institution that were significant (overpenetration, toggle in the P-D and radial-ulnar [R-U] directions, and both drilling force and drilling time)., Conclusions: Understanding how performance and outcome parameters are correlated provides powerful insight into how surgical procedures can be best performed. In particular, we hope that these findings will inform new training paradigms. Variations in resident training from 1 institution to another are evidenced in surgical performance. Similarly, the methods used here to quantify changes in performance across the 3-day SWOTA training course allow a unique vehicle for optimization of these types of training opportunities outside of the operating room.

The purpose of this study was to describe long-term outcomes of partial trapeziectomy with capsular interposition (PTCI) arthroplasty for patients with osteoarthritis of the basal joint of the thumb. A total of 27 patients (20 women, 7 men; 32 thumbs) with a mean age of 61 years (range, 47-74 years) agreed to return for follow-up and were included in the study. Mean postoperative follow-up was 64.3 months (range, 28-112 months). Evaluation included tests for grip and pinch strength; range of motion of the metacarpophalangeal joint; measurement of the first web space; completion of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; visual analog scale (VAS) measurements; and radiographic examination of the hand. A paired, 2-tailed t test was used to determine statistical significance (P<.05) of pre- and postoperative values. Postoperative values for grip strength were significantly increased from preoperative values. No significant loss of pinch strength was noted. Excessive hyperextension of the metacarpophalangeal joint did not occur, and the first web space was maintained. The mean DASH questionnaire and VAS scores were 5.06 (range, 0-26.5) and 0.32, respectively. Use of PTCI arthroplasty resulted in minimal loss in thumb height (7%) and significantly reduced thumb metacarpal subluxation (13%). There were no reported complications. The low DASH questionnaire and VAS scores compare well with other studies and indicate good functional outcomes. In treating thumb basal joint osteoarthritis, use of PTCI arthroplasty may result in improved thumb stability and grip strength, minimal subsidence of the thumb metacarpal, and reduced joint subluxation. [Orthopedics. 2018; 41(2):e228-e233.]., (Copyright 2018, SLACK Incorporated.)

Background: In a cadaveric model, we evaluated thumb metacarpal subsidence, indicated by a decreased metacarpal-to-scaphoid distance, after 2 surgical procedures used to treat thumb carpometacarpal (CMC) osteoarthritis (OA): partial trapeziectomy with capsular interposition (PTCI), which involves removal of 2 mm of both the distal trapezium and base of the metacarpal; and total trapeziectomy with capsular interposition (TTCI). Methods: Nine matched pairs of cadaveric hands were randomly assigned to undergo either PTCI or TTCI. Preoperatively, physiologic forces were applied across the thumb CMC joint by loading 6 tendons, simulating lateral pinch. Anteroposterior radiographs were obtained, and the metacarpal-to-scaphoid distance on each image was estimated independently by 3 separate readers using customized software. A hand surgeon then performed the PTCI and TTCI procedures, and the measurements under loading were repeated. The results were assessed for interrater reliability. Mean values for metacarpal-to-scaphoid distance before and after the surgical procedures were compared. Results: Preoperatively, the metacarpal-to-scaphoid distance in the PTCI and TTCI groups was not significantly different. Postoperatively, metacarpal subsidence was significantly less in the PTCI group (17% compared with 34% for TTCI; P = .05). Conclusions: Metacarpal subsidence occurred after both PTCI and TTCI, but significantly less subsidence was observed after PTCI; thus, thumb length was better preserved. Previous research has shown an inverse correlation between maintenance of thumb length and overall Disabilities of the Arm, Shoulder, and Hand (DASH) score. A procedure for treating thumb CMC OA that preserves thumb length and minimizes disruption of stabilizing joint tissue may provide enhanced maintenance of thumb stability and improved patient outcomes., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The field of conservation genetics, when properly implemented, is a constant juggling act integrating molecular genetics, ecology, and demography with applied aspects concerning managing declining species or implementing conservation laws and policies. This young field has grown substantially since the 1980s following the development of polymerase chain reaction and now into the genomics era. Our laboratory has 'grown up' with the field, having worked on these issues for over three decades. Our multidisciplinary approach entails understanding the behavior and ecology of species as well as the underlying processes that contribute to genetic viability. Taking this holistic approach provides a comprehensive understanding of factors that influence species persistence and evolutionary potential while considering annual challenges that occur throughout their life cycle. As a federal laboratory, we are often addressing the needs of the U.S. Fish and Wildlife Service in their efforts to list, de-list, or recover species. Nevertheless, there remains an overall communication gap between research geneticists and biologists who are charged with implementing their results. Therefore, we outline the need for a National Center for Small Population Biology to ameliorate this problem and provide organizations charged with making status decisions firmer ground from which to make their critical decisions.

Introduction: Osteoarthritis of the thumb trapeziometacarpal (basal) joint is a very common problem facing the hand and upper extremity surgeon. Many surgical procedures have been described with varied results. We present the surgical technique--partial trapeziectomy with capsular interposition arthroplasty--used by the senior author over the last 10 years. The essential steps of the procedure are: bony resection of the base of the first metacarpal and the distal trapezium; interposition of a proximally based joint capsule flap; and reefing of periosteal flaps elevated from the first metacarpal and including the abductor pollicis longus tendon. This procedure utilizes capsular tissue as an interposition without ligament reconstruction, eliminating the need for tendon harvest and the morbidity associated with the harvest. The postoperative rehabilitation is simple and can be done at home. An illustrative case is presented., Level of Evidence: Level V.

Previous studies have examined possible incentives for pursuing orthopedic fellowship training, but we are unaware of previously published studies reporting the trends in the orthopedic job market since the acceptance of certain criteria for fellowship programs by the Accreditation Council for Graduate Medical Education (ACGME) in 1985. We hypothesized that, since the initiation of accredited postresidency fellowship programs, job opportunities for fellowship-trained orthopedic surgeons have increased and job opportunities for nonfellowship-trained orthopedic surgeons have decreased. We reviewed the job advertisements printed in the Journal of Bone and Joint Surgery, American Volume, for the years 1984, 1994, 2004, and 2009. We categorized the job opportunities as available for either a general (nonfellowship-trained) orthopedic surgeon or a fellowship-trained orthopedic surgeon. Based on the advertisements posted in the Journal of Bone and Joint Surgery, American Volume, a trend exists in the orthopedic job market toward seeking fellowship-trained orthopedic surgeons. In the years 1984, 1994, 2004, and 2009, the percentage of job opportunities seeking fellowship-trained orthopedic surgeons was 16.7% (95% confidence interval [CI], 13.1%-20.3%), 40.6% (95% CI, 38.1%-43.1%), 52.2% (95% CI, 48.5%-55.9%), and 68.2% (95% CI, 65.0%-71.4%), respectively. These differences were statistically significant (analysis of variance, P<.05). Fellowship training is thus a worthwhile endeavor., (Copyright 2012, SLACK Incorporated.)

Background: Glenohumeral arthritis in younger individuals is challenging because of the complex pathology, need for extended durability, and high expectations of the patients. Humeral hemiarthroplasty combined with concentric glenoid reaming is a surgical option for the management of glenohumeral arthritis that avoids the risks of glenoid component failure and avoids the challenges of tissue interposition. The results of this procedure in young patients have not been previously reported., Methods: Sixty-five shoulders in patients who were 55 years old or less at the time of surgery underwent humeral hemiarthroplasty combined with concentric glenoid reaming and were followed for a minimum of 2 years or until the time of revision surgery. Patient self-assessments of shoulder comfort and function were compared before and after surgery. For 22 of these shoulders, standardized radiographs were available for follow-up evaluation., Results: Nine shoulders required revision surgery. These shoulders had 3 ± 3 prior surgeries, in comparison to 1 ± 1 prior surgeries for the unrevised group. For the 56 unrevised shoulders, the number of Simple Shoulder Test functions that could be performed improved from a mean of 4.1 before surgery to a mean of 9.5 at an average follow-up of 43 months (range, 24-85) (P < .001). For the 22 shoulders with radiographic follow-up, medial glenoid erosion averaged 1.1 mm (range, 0.0-6.3 mm) at an average of 44 months after the procedure., Conclusion: In selected patients 55 years or younger with glenohumeral arthritis, this procedure can provide significant improvement in self-assessed shoulder comfort and function., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Hypothesis: Glenoid erosion and medial migration of the humeral head prosthesis have been observed after most types of shoulder arthroplasty. A method of measuring the change in humeral head position with time after shoulder prosthetic arthroplasty was applied it to 14 shoulders that underwent humeral hemiarthroplasty with concentric glenoid reaming. We hypothesized that the measurement technique would be reproducible and that the rate of wear would be small in the series of shoulders studied., Materials and Methods: Standardized anteroposterior and axillary radiographs were obtained after surgery. Two examiners measured the position of the humeral head center in relation to scapular reference coordinates for the anteroposterior and axillary projections and plotted these values against time after surgery. The change in position was characterized as the slope of this plot. Shoulders were included if there were at least 3 sets of postoperative films, the last being at least 2 years after surgery., Results: The slopes measured by the 2 examiners agreed within 0.5 mm/y for the anteroposterior and the axillary projections. For the series of shoulder arthroplasties, the rate of movement of the head center toward the scapula was less than 0.4 mm/y for either examiner in either projection., Discussion: Medial migration is a concern after any type of shoulder arthroplasty, whether a hemiarthroplasty, a biological interpositional arthroplasty, or a total shoulder arthroplasty. Quantifying the rate of medial migration over time after shoulder arthroplasty is an important element of clinical follow-up., Conclusions: This is an inexpensive, practical, and reproducible method that can be used to determine the rate of medial migration of the humeral head on plain radiographs after shoulder arthroplasty. The average rate of medial migration in the shoulders in this study was small., (Copyright © 2011. Published by Mosby, Inc.)

Background: Reverse shoulder arthroplasty changes the center of rotation (COR) of the glenohumeral joint and in doing so affects the resting tension in the deltoid and residual cuff muscles, as well as their respective moment arms. The purpose of this study was to assess the change in COR from the preoperative to postoperative state in a group of patients undergoing reverse shoulder arthroplasty., Materials and Methods: The position of the COR in relation to a scapular coordinate system was determined for the anteroposterior and axillary radiographs before and after reverse total shoulder arthroplasty for 68 shoulders (63 patients) receiving either a Delta prosthesis or an Encore Reverse Shoulder Prosthesis., Results: Preoperatively, the COR was superiorly displaced a mean of 9 ± 7 mm from the origin of the coordinate system. For all shoulders, the postoperative COR was inferiorly displaced by 12 mm to a position 3 ± 3 mm below the coordinate origin (P < .001) and medially displaced by 27 ± 4 mm from the coordinate origin (P < .001) in the anteroposterior projection. For the shoulders receiving the Delta prosthesis, the COR was inferiorly displaced by 2 ± 3 mm from the coordinate origin, whereas it was inferiorly displaced by 7 ± 3 mm with the Encore prosthesis (P < .001). The COR was medially displaced by 28 ± 4 mm with the Delta prosthesis and by 19 ± 3 mm with the Encore prosthesis (P < .001)., Conclusions: The position of the COR relative to the scapula is significantly altered by reverse shoulder arthroplasty and is significantly different for 2 different implant designs., (Copyright © 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: The reported outcomes of shoulder arthroplasty in patients under the age of fifty years are worse than those in patients over fifty. While there are several possible explanations for this finding, we explored the possibility that patients who had a primary shoulder arthroplasty when they were under fifty years of age differed from those who had the procedure when they were over fifty with respect to their pre-arthroplasty self-assessed comfort and function, sex distribution, and specific type of arthritis., Methods: The study group consisted of patients with glenohumeral arthritis who were treated with a primary shoulder arthroplasty by the same surgeon between 1990 and 2008. For each decade of age, the sex distribution, the pre-arthroplasty self-assessed shoulder comfort and function, and the prevalence of twelve different diagnoses were documented. We reviewed the series for three potential causes of worse outcomes in patients under fifty years of age as compared with those over fifty years of age: (1) a higher percentage of women, (2) a lower score for pre-arthroplasty self-assessed comfort and function, and (3) more complex pathological conditions., Results: Patients under the age of fifty years were not more likely than those over fifty to be female or to have a lower pre-arthroplasty self-assessed comfort and function score, but they did have more complex pathological conditions, such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic arthritis. Only 21% of the younger patients had primary degenerative joint disease, whereas 66% of the older patients had that diagnosis. This difference was significant (p < 0.000000001)., Conclusions: Surgeons performing shoulder arthroplasty in individuals under the age of fifty should be prepared to encounter pathological conditions such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic arthritis rather than primary osteoarthritis, which is more common in individuals older than fifty. The pathoanatomy in these younger patients may complicate the surgery, the rehabilitation, and the outcome of the shoulder arthroplasty.

Background: Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period., Methods: Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects., Results: Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources., Conclusions: The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.

This study provides population representative data on live births occurring in Niamey, Niger during the period 1980 to 1985. A total of 5097 live births were systematically sampled from maternity registers over the study period. Due to legislation and incentives to register all live births, between 90 and 95 per cent of all live births are represented in this study. The data here suggest that low birth weight (LBW) prevalence may be lower in this urban area than it is in the region as a whole; and that the demographic risk factors are similar to those found in other developing countries. Finally, in many developing countries, maternity coverage of attended births may be quite high, suggesting that record or prospective studies examining trends in LBW and risk factors for perinatal outcomes might be convenient and implemented at very low cost.

A patient with an amelanotic lentigo malignant melanoma is presented which manifested itself initially as an erythematous flare with the subsequent development of nodules. The diagnosis was only made histologically. A computer search of the literature revealed 6 previous cases, and a review of these rare tumours is presented.

Web neck deformity has been recognised for over 100 years and during that time there has been a large amount of literature devoted to it. There has been surprisingly little information published on the exact nature of the deformity, particularly the exact site and composition of the web and the presence or absence of any other soft tissue anomalies in the head and neck, which could modify a surgical approach. Our paper will describe the "simple" webbing found in four cases of Turner's syndrome and one case of Klippel-Feil syndrome, and discuss some of the associated features seen in these syndromes. We also review the major methods of surgical treatment and examine the role of tissue expanders in the surgical correction of this anomaly.

A characteristic 'crow's foot' pattern is seen around the eye in many flash burns. The protective blink reflex underlies this, and the injury is due to convected rather than radiant energy.