Search

Background Surgical procedure selection for carpal arthritis depends on which articular surfaces are affected, but there is no consensus on how to preoperatively evaluate cartilage surfaces. Despite advances in cross-sectional imaging, the utility of advanced imaging for preoperative decision-making has not been well established. Objectives Our objective was to assess if there is an added value to presurgical advanced imaging or diagnostic procedures in planning for carpal arthrodesis or carpectomy and to determine what imaging or diagnostic procedures influence surgical treatment options. Methods A seven-question survey was sent to 2,400 hand surgeons. Questions assessed which articular surfaces surgeons consider important for decision-making, which imaging modalities surgeons employ, and how often surgeons utilize diagnostic arthroscopy before performing carpectomy or arthrodesis procedures. Results A total of 337 (14%) surveys were analyzed. The capitolunate articulation (alone or in combination) was most frequently reported to impact surgical decision-making (48.1%). Most surgeons (86.6%) reported that standard plain radiographs are usually sufficient. Few surgeons reported always obtaining magnetic resonance imaging (MRI) or computed tomography (CT), with 44.2% of surgeons believing that MRI is never useful and 38.4% believing that CT is never useful. Most surgeons (68.2%) reported that they never perform wrist arthroscopy as part of their decision-making process. Conclusions This study provides information on the decision-making process in the surgical management of carpal arthritis. Given advances in cross-sectional imaging, further studies are needed to determine the utility of MRI and CT for the planning of surgical procedures in the treatment of arthritis of the carpus. Level of Evidence: Level 4.

de Quervain’s release, or first dorsal compartment release, is a commonly performed procedure. There are several approaches to surgery including transverse and longitudinal incisions. The wrist is a sensitive area, and patients often report residual pain post-release. We offer a modified technique on wound closure in de Quervain’s release to facilitate a smoother postoperative experience by taking in account the patient experience from the finish of release until the time of suture removal. Prolene™ sutures that require removal are preferred over absorbable sutures due to skin reactions that occur with absorbable sutures that may cause more scarring, pain, and irritation to the radial sensory nerve. Additionally, the placement of Steri-Strips beneath the knot and cut end of suture, as well as one on top of the construct, ensures that there is minimal opportunity for prominent, stiff knots or sharp ends of suture to bother the patient. Altogether, from suture choice to purposeful Steri-Strip placement, our simple and quick modifications place high value in patient comfort and cosmesis, leading to improved patient satisfaction.

Objectives The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. Methods Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of ‘0’, ‘5’ and ‘10’ reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of ‘8’ or higher for 80% or more of the panellists. Results Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. Conclusions Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. Key Points • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Purpose Selecting treatment for scapholunate (SL) instability is notoriously difficult. Many methods of reconstruction have been described, but no procedure demonstrates clear superiority. New methods proposed use internal bracing (IB) with suture anchors and flat braided suture (FBS), alone or as an augmentation with tendon autograft for SL ligament injuries . Our goal was to use computed tomography (CT) to analyze alignment of the SL joint after 3 different modes of fixation of SL instability: after reconstruction with IB incorporating either tendon autograft or the dorsal intercarpal ligament (DICL), or DICL capsulodesis without FBS. Methods Ten fresh-frozen, matched-pair, forearm-to-hand specimens were used. Serial sectioning of the SL stabilizing ligaments was performed and the SL interval was measured with CT. We reconstructed the SL ligament with DICL capsulodesis alone (DICL) or with IB augmented with either tendon autograft (IB plus T) or DICL (DICL plus IB). The SL interval was measured with CT. Specimens underwent 500 weighted cycles on a jig and were reimaged. Differences in SL interval after repair and cycling were compared. Results Dorsal intercarpal ligament capsulodesis augmented with IB best maintained the SL interval before and after cycling. Dorsal intercarpal ligament capsulodesis alone was inferior to DICL plus IB and IB plus T both before and after cycling. Conclusions Dorsal intercarpal ligament capsulodesis augmented with IB appears to maintain better SL joint reduction than IB with tendon autograft. Clinical relevance This work serves as a necessary step for further study of the biomechanical strength and clinical application of FBS technology in the reconstruction of SL instability. Flat braided suture augmentation of DICL capsulodesis may provide another option to consider for reconstruction of SL instability.

Purpose To determine the effect of simulated radioscapholunate fusion with distal scaphoid excision (RSLF+DSE), 4-corner fusion with scaphoidectomy (4-CF), and proximal row carpectomy (PRC) on the wrist’s range of motion (ROM), contact pressure, and contact force in a cadaveric model. Methods Ten freshly frozen cadaveric wrists were tested under 4 sequential conditions: native wrist, RSLF+DSE, 4-CF, and PRC. The simulated fusions were performed using two 1.6-mm Kirschner wires . The ROM in the flexion-extension and radioulnar deviation planes was evaluated. Contact area, contact pressure, and contact force were measured at the scaphocapitolunate joint for the RSLF+DSE simulation and radiocarpal joint for the 4-CF and PRC simulations. Mechanical testing was performed using a 35-N uniaxial load and pressure-sensitive film. Results The RSLF+DSE and 4-CF groups had a decreased wrist arc ROM compared with the native wrist. The PRC group had a greater wrist arc ROM compared with the RSLF+DSE and 4-CF groups, but compared to the native wrist, it demonstrated a mildly decreased wrist arc ROM. The carpal pressure and contact force were significantly increased in the RSLF+DSE, 4-CF, and PRC groups compared with those in the native wrist. The RSLF+DSE group had the smallest increase in the carpal pressure and contact force, whereas the PRC group had the greatest increase. Conclusions Our study validates previous findings that PRC is motion-conserving but has the greatest contact force, whereas RSLF-DSE and 4-CF may cause a decrease in the ROM but have lower contact forces. Clinical relevance Understanding the underlying native wrist biomechanics and alterations following different surgical treatments may assist hand surgeons in their clinical decision making for the treatment of stage II scapholunate advanced collapse.

Our institution saw four hamate fractures in the 2011 baseball season, the first season following implementation of new batting standards in collegiate baseball. The purpose of this paper was to identify whether the incidence of hamate fractures increased with the introduction of the new batting standard. Surveys sent to Division 1 collegiate baseball athletic trainers reported the number, mechanism, treatment and return to play of hamate fractures from 2008-2010 (old batting standards) and for the 2011 season. This study shows that there was more than a 200% increased risk of hamate fracture with implementation of the 2011 collegiate baseball batting standards. The most common injury mechanism was batting with the down hand (79%). We suggest that a national injury database be considered for collegiate athletics so that injury rates, risk factors and results of interventions could be studied to improve the health of our nations' athletes. (Journal of Surgical Orthopaedic Advances 28(4):285-289, 2019).

The helicopter, as a means of transport, has facilitated a significant decrease in intervention time at the site of request, increasing the chances of survival of the critical patient. Since 2003, SMURD has managed to form a fleet composed of nine helicopters and two airplanes. From an operational and strategic point of view, the SMURD intervention unit, set up seven Aeromedical Operational Bases (A.O.B.) equipped with helicopters and materials necessary for their operation. There is a dynamic increase in the number of air rescue missions in Romania, with most missions being carried out by the air rescue bases in Târgu Mureş and Bucharest. Specialty literature has clearly demonstrated the positive impact on the survival of critical patients assisted by airborne crews, so it is necessary for the Romanian air rescue system to grow up. It is necessary to increase the number of air bases, purchase new helicopters and to continue the training programs of both pilots and medical personnel.

© 2016, The Association of Bone and Joint Surgeons®. Background: Voluntary knuckle cracking is a common habit, with a reported prevalence of 25% to 45%. Habitual knuckle cracking also is a frequent source of questions for physicians, and the largest study to date reported an association with functional hand impairments. Questions/purposes: (1) When compared with subjects who are not habitual knuckle crackers, do habitual knuckle crackers have greater QuickDASH scores, swelling, weakness, joint laxity, or ROM? (2) In subjects who crack their knuckles, does cracking immediately increase ROM? (3) What are the characteristic sonographic findings in joints that crack? Methods: A prospective, institutional review board-approved study was performed on 400 metacarpophalangeal joints (MPJs) in 40 asymptomatic adult subjects. Of those, 30 subjects had a history of habitual knuckle cracking (defined as daily voluntary popping of MPJs). Clinical history provided by all subjects included a standardized QuickDASH questionnaire. Physical examination was performed by two orthopaedic surgeons (blinded to subjects’ knuckle-cracking history and sonographic outcomes). The physical examination included evaluation for swelling, grip strength, and ROM before and after attempted knuckle cracking. Sonographic examination was conducted by one sonographer, with static and real-time cine images recorded before, during, and after MPJ distraction was performed by the subjects. Two musculoskeletal radiologists (blinded to subjects’ knuckle-cracking history) interpreted the images for a definite hyperechoic focus during and after MPJ distraction; this was compared against the reference standard of an audible “crack” during joint distraction. Results: Comparing subjects with knuckle cracking with those who did not crack their knuckles, there was no differences in QuickDASH scores (knuckle crackers, 3.7 ± 5.2; nonknuckle crackers, 3.2 ± 6.3; mean difference, 0.6; 95% CI, −3.5 to 4.6; p = 0.786), laxity (knuckle crackers, 2.0 ± 1.8; nonknuckle crackers, 0.3 ± 0.7; mean difference, 1.7; 95% CI, 0.5–2.9; p = 0.191), and grip strength (preultrasound, right hand, p = 0.499, left hand p = 0.575; postultrasound, right hand p = 0.777, left hand p = 0.424); ROM comparisons between subjects with a history of habitual knuckle cracking versus subjects without such a history only yielded increased ROM in joints that cracked during manipulation (knuckle cracking, 143.8° ± 26.5°; nonknuckle cracking, 134.9° ± 28.6°; mean difference, 9.0°; 95% CI, 2.9°–15.1°; p = 0.004). Swelling was not observed in any subjects, including when comparing MPJs before versus after distraction maneuvers that resulted in audible cracks. Immediately after a documented crack, there were greater ranges of motion with active flexion (preultrasound, 85.7° ± 12.4°; postultrasound, 88.6° ± 11.6°; mean difference, −2.9°; 95% CI, −5.1° to −0.8°; p = 0.009), passive flexion (preultrasound, 96.1° ± 12.4°; postultrasound, 100.3° ± 10.4°; mean difference, −4.3°; 95% CI, −6.2° to −2.3°; p < 0.001), passive extension (preultrasound, 41.8° ± 18.1°; postultrasound, 45.2° ± 17.6°; mean difference, −3.5°; 95% CI, −6.9° to −0.1°; p = 0.046), and passive total ROM (preultrasound, 137.8° ± 24.8°; postultrasound, 145.6° ± 23.1°; mean difference, −7.7°; 95% CI, −11.7° to −3.8°; p < 0.001). The characteristic sonographic finding observed during cracking events is an echogenic focus that appears de novo dynamically in the joint during distraction. Conclusions: We found no evidence of immediate adverse physical examination findings after knuckle cracking. However, we did find a small increase in ROM among joints that cracked compared with those that did not. Future studies should examine if there are any long-term beneficial and adverse clinical outcomes associated with habitual knuckle cracking. Level of Evidence: Level I, prognostic study.

Case A 33-year-old woman presented with a six-month history of spontaneous radial nerve palsy and no identified lesion on imaging. She underwent operative exploration where an hourglass deformity was seen and resected. Pathology returned as a rare tumor, a myofibroma. The patient regained full radial nerve function. Conclusions A trial of observation is often indicated in the cases of isolated nerve palsy where anatomic lesions have been eliminated. This case highlights that imaging studies can miss a tumor involving nerve and that painless, spontaneous nerve palsy may be a time where early surgical intervention offers a better chance of recovery.

OBJECTIVE: To describe the normal motion pattern at the midcarpal compartment during active radial-ulnar deviation of the wrist using dynamic MRI and to determine the observer performance for measurements obtained in asymptomatic volunteers. METHODS: Dynamic MRI of 35 wrists in 19 asymptomatic volunteers (age mean 30.4 yrs, sd 8.6) was performed during active radial-ulnar deviation using a fast gradient-echo pulse sequence with 315 ms temporal resolution (acquisition time, 19 sec). Two independent readers measured the transverse translation of the trapezium at the scaphotrapezium joint (STJ) and the capitate-to-triquetrum distance (CTD). Relationships between these measurements and laterality, sex, lunate type, and wrist kinematic pattern were evaluated. RESULTS: At the STJ, the trapezium moved most in radial deviation, with an overall translation of 2.3mm between ulnar and radial deviation. Mean CTD measurements were the greatest in ulnar deviation and varied 2.4mm between ulnar and radial deviation. Mean CTD was greater in men than women in the neutral position (p=0.019), as well as in wrists with type II lunate morphology during radial and ulnar deviation (p=0.001, p=0.014). There were no significant differences in trapezium translation or CTD with wrist laterality and kinematic pattern. Intraobserver and interobserver correlation coefficients were 0.97 and 0.87 for trapezium translation and 0.84 and 0.67 for CTD. CONCLUSION: This study is the first to demonstrate the performance of dynamic MRI to quantify STJ motion and CTD. Dynamic MRI with a short acquisition time may be used as a tool to supplement static MRI in evaluation of the midcarpal compartment.

Background Flexor tendon injury is a rare but serious complication of distal radius volar plating. Purpose This study aims to determine whether the design of distal radius volar plates impacts the amount of force exerted on the flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendons when the plates are placed proximal and distal to the watershed line. Methods Three commercially available plates were applied to 10 fresh, matched-pair upper extremity specimens. Cyclical loading was applied to the tendons, and the force generated between tendon and plate was measured. Linear mixed effect models were used to evaluate differences in maximum and mean forces by plate position, plate design, and the interaction between position and design. Results Forces on the tendons differed significantly by position but not plate design. For the FPL tendon, the average maximum force with a plate in Soong's grade 2 was 4.50 (95% confidence interval [CI]: 2.8–7.3) times higher than when the plate was in a Soong's grade 0 placement, and 4.63 (95% CI: 2.82–7.61) times higher for the FDP tendon. While not statistically significant, lower observed force values with thinner plates when plates were placed distal to the watershed line suggest that that plate thickness could also be a critical plate characteristic for distally placed plates. Conclusion Despite differences in plate design, the main determinant of plate prominence and therefore flexor tendon injury potential is placement in relation to the watershed line. Clinical Relevance This study may help to guide surgeon implant selection and volar plate design.

Author(s): Shaw, Calvin B; Foster, Brent H; Borgese, Marissa; Boutin, Robert D; Bateni, Cyrus; Boonsri, Pattira; Bayne, Christopher O; Szabo, Robert M; Nayak, Krishna S; Chaudhari, Abhijit J | Abstract: BackgroundCarpal instability is defined as a condition where wrist motion and/or loading creates mechanical dysfunction, resulting in weakness, pain and decreased function. When conventional methods do not identify the instability patterns, yet clinical signs of instability exist, the diagnosis of dynamic instability is often suggested to describe carpal derangement manifested only during the wrist's active motion or stress. We addressed the question: can advanced MRI techniques provide quantitative means to evaluate dynamic carpal instability and supplement standard static MRI acquisition? Our objectives were to (i) develop a real-time, three-dimensional MRI method to image the carpal joints during their active, uninterrupted motion; and (ii) demonstrate feasibility of the method for assessing metrics relevant to dynamic carpal instability, thus overcoming limitations of standard MRI.MethodsTwenty wrists (bilateral wrists of ten healthy participants) were scanned during radial-ulnar deviation and clenched-fist maneuvers. Images resulting from two real-time MRI pulse sequences, four sparse data-acquisition schemes, and three constrained image reconstruction techniques were compared. Image quality was assessed via blinded scoring by three radiologists and quantitative imaging metrics.ResultsReal-time MRI data-acquisition employing sparse radial sampling with a gradient-recalled-echo acquisition and constrained iterative reconstruction appeared to provide a practical tradeoff between imaging speed (temporal resolution up to 135 ms per slice) and image quality. The method effectively reduced streaking artifacts arising from data undersampling and enabled the derivation of quantitative measures pertinent to evaluating dynamic carpal instability.ConclusionThis study demonstrates that real-time, three-dimensional MRI of the moving wrist is feasible and may be useful for the evaluation of dynamic carpal instability.

We present a method for the statistical modeling of the displacements of wrist bones during the performance of coordinated maneuvers, such as radial-ulnar deviation (RUD). In our approach, we decompose bone displacement via a set of basis functions, identified via principal component analysis (PCA). We utilized MRI wrist scans acquired at multiple static positions for deriving these basis functions. We then utilized these basis functions to compare the displacements undergone by the bones of the left versus right wrist in the same individual, and between bones of the wrists of men and women, during the performance of the coordinated RUD maneuver. Our results show that the complex displacements of the wrist bones during RUD can be modeled with high reliability with just 5 basis functions, that captured over 91% of variation across individuals. The basis functions were able to predict intermediate wrist bone poses with an overall high accuracy (mean error of 0.26 mm). Our proposed approach found statistically significant differences between bone displacement trajectories in women versus men, however, did not find significant differences in those of the left versus right wrist in the same individual. Our proposed method has the potential to enable detailed analysis of wrist kinematics for each sex, and provide a robust framework for characterizing the normal and pathologic displacement of the wrist bones, such as in the context of wrist instability.

Carpal instability is defined as a condition where wrist motion or loading creates mechanical dysfunction, resulting in weakness, pain and decreased function. Often the diagnosis is made late when malalignment is visualized on static radiography, CT, or MRI. When conventional imaging methods do not identify the instability patterns, yet clinical signs associated with instability exist, the diagnosis of dynamic instability is often suggested to describe carpal derangement manifested only during the wrist’s active motion or stress. We addressed the question: can advanced MRI techniques provide quantitative measures for evaluating dynamic carpal instability and supplement standard static MRI acquisition? Our objectives were to [1] develop a real-time, three-dimensional MRI method to image the carpal joints during their active, uninterrupted motion; and [2] demonstrate feasibility of the method for assessing metrics relevant to dynamic carpal instability, thus overcoming limitations of conventional MRI. Twenty wrists (bilateral wrists of ten healthy participants) were scanned during radial-ulnar deviation and clenched-fist maneuvers. Images resulting from two real-time MRI pulse sequences, four sparse data acquisition schemes, and three constrained image reconstruction priors were compared. Image quality was assessed via blinded scoring by two radiologists and quantitative imaging metrics. Data acquisition employing sparse radial sampling with a gradient-recalled-echo acquisition and constrained iterative reconstruction (temporal resolution up to 135 ms per slice) appeared to provide a reasonable tradeoff between imaging speed and quality. This real-time MRI method effectively reduced streaking artifacts arising from data undersampling and enabled the derivation of quantitative measures pertinent to evaluating dynamic carpal instability.

Several methods of describing patterns of carpal kinematics from radiographs have emerged due to their potential use in developing personalized treatments for wrist pathologies. Such radiography-derived metrics have been used to infer associations between patterns of scaphoid kinematics and other clinically relevant factors such as sex, but the simultaneous effects of sex and wrist position on scaphoid kinematic metrics has yet to be considered. We sought to investigate the relationship between wrist position in the coronal plane and radiographic measurements of the scaphoid for each sex independently, then identify sex-specific differences in scaphoid measurements and calculated metrics. We retrospectively identified 38 subjects with posteroanterior radial and ulnar deviation radiographs. Radiographic scaphoid measurements were collected and used to calculate five scaphoid kinematic metrics per participant. We used Pearson correlation coefficients to explore the relationships between the degrees of wrist deviation in the coronal plane and radiographic scaphoid measurements for men and women independently. We used the non-parametric Wilcoxon signed-rank test to compare values between sexes. The correlations between degrees of coronal wrist deviation and radiographic measurements of scaphoid inclination were significant only for men. Men also had significantly greater values for all radiographic scaphoid measurements. Our study demonstrated sex-specific differences in the relationship between the degrees of radial and ulnar wrist deviation and scaphoid positioning.Clinical RelevanceOur findings show the importance of stratifying by sex in studies of carpal kinematics, such as scaphoid kinematics, and that investigation of strategies to restore normal carpal function should incorporate sex as a biological variable.

Purpose The aims of this study were (1) to assess the utility of the Quality of Life in Neurological Disorder (Neuro-QoL) questionnaire in patients with carpal tunnel syndrome by comparing the validated patient-reported outcome (PRO) measure Neuro-QoL to the validated Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) before and following carpal tunnel release, (2) to compare the measurements of the median nerve cross-sectional area (CSA) using high-resolution ultrasound (HRUS) before and after surgery, and (3) to determine a correlation between HRUS and PRO. Methods Individuals diagnosed with carpal tunnel syndrome were evaluated using the CTSAQ, Neuro-QoL, and HRUS before surgery and at 3 months after surgery. Results Twenty patients completed the study. Overwhelmingly, there was an improvement in symptoms and function assessed by patients on both the Neuro-QoL and the CTSAQ at 3 months after surgery. The Neuro-QoL Physical Function and Upper Extremity scores had strong correlation with the CTSAQ activity score but had low to moderate correlation with the CTSAQ symptoms score, before and after surgery. The HRUS measurements of the median nerve at the carpal tunnel inlet demonstrated a decrease in CSA whereas no noticeable changes were observed at mid tunnel and at the outlet (hook of hamate). The correlations between the ultrasound findings and PRO measures ranged from weak to strong. Conclusions Patients had resolution of symptoms and higher physical function following carpal tunnel release measured by both the CTSAQ and the Neuro-QoL scores. The Neuro-QoL self-assessment questionnaire, a measurement of quality of life, correlated well with the CTSAQ. Therefore, it could be used as a self-assessment outcomes tool in patients undergoing carpal tunnel release. At 3 months after surgery, HRUS measurements of the median nerve CSA showed a noticeable decrease of CSA only at the inlet of carpal tunnel. This objective improvement correlated with the improvement in CTSAQ and Neuro-QoL scores. Type of study/level of evidence Diagnosis II.

ObjectiveRadiologic presentation of carpal instability at the radial side of the carpus, e.g. scapholunate diastasis following scapholunate interosseous ligament injury, has been studied extensively. By comparison, presentation at the ulnar-sided carpus has not. The purpose of this study was to assess the effects of lunate morphology, sex, and lunotriquetral interosseous ligament (LTIL) status on the radiologic measurement of the capitate-triquetrum joint (C-T distance). Further, we sought to evaluate the diagnostic accuracy of C-T distance for assessing LTIL injuries.Materials and methodsWe retrospectively identified 223 wrists with wrist radiographs and MR arthrograms with contrast injection. Data collected included sex, lunate morphology and LTIL status from MR arthrography, and C-T distance from radiography. The effects of lunate morphology, sex, and LTIL injury status on C-T distance were evaluated using generalized linear models. Diagnostic performance of C-T distance was assessed by the area under receiver-operator characteristic curve (AUROC).Results and conclusionLunate morphology, sex, and LTIL injury status all had significant effects on C-T distance; wrists with type II lunates, men, and wrists with LTIL injuries had greater C-T distances than wrists with type I lunates, women, and wrists without LTIL injuries, respectively (p&nbsp

Flexor pulley injuries are most commonly seen in avid rock climbers; however, reports of pulley ruptures in nonclimbers are increasing. In addition to traumatic disruption, corticosteroid-induced pulley rupture has been reported as a complication of treating stenosing tenosynovitis. Over the last decade, there have been 2 new developments in the way hand surgeons think about the flexor pulley system. First, the thumb pulley system has been shown to have 4 component constituents, in contrast to the classic teaching of 3 pulleys. Second, in cases of zone II flexor tendon injury, the intentional partial A2 and/or A4 pulley excision or venting is emerging as a component for successful treatment. This is challenging the once-held dogma that preserving the integrity of the entire A2 and A4 pulleys is indispensable for normal digit function.

Background: Ultrasonography-assessed hyomental distance (HMD) ratio has been found to discriminate between obese patients with Cormack-Lehane grades 1 or 2 vs. those with grades 3 or 4. The aim of our study is to evaluate the performance of the HMD evaluated ultrasonographically in neutral, ramped, and maximum hyperextended positions, as well as for the ratios obtained by dividing the HMD in the ramped position to that in the neutral position (HMDR1) and by dividing the HMD in maximum hyperextension to that in the neutral position (HMDR2), in order to predict the occurrence of Cormack-Lehane grades 3 or 4 during direct laryngoscopy. Methods: Ultrasound measurements were performed preoperatively in 25 patients with morbid obesity, measuring the HMD in the neutral, ramped, and maximum hyperextended positions. Pre-epyglotic soft tissue thickness, Mallampati and upper lip bite test scores were recorded. Cormack-Lehane grading was considered as an outcome variable in the Receiver Operating Characteristics curve analysis. Results: HMD in the neutral, ramped and maximum hyperextended positions presented similar sensitivities, 100% [39.8–100.0]. For HMD, specificity was 42.86% [21.8–66.0] in the neutral position, 61.9% [38.4–81.9] in the ramped postion, and 71.4% [47.8–88.7] in the maximum hyperextended position. For HMDR1, the cut-off value was 1.12. This threshold provides 75% [19.4–99.4] sensitivity and 76.2% [52.8–91.8] specificity. For HMDR2, a cut-off value of 1.23 provides 100% [39.8–100.0] sensitivity and 90.5% [69.6–98.8] specificity. Conclusion: HMDR2 seems to have superior diagnostic accuracy in predicting difficult laryngoscopy in the obese population compared to HMDR1, as well as compared to the HMD in the neutral, ramped, and maximum hyperextended positions.

Introduction Peyronie's disease (PD) and Dupuytren contractures (DC) are often comorbid and are believed to have a similar underlying pathophysiologic mechanism. Aim To investigate the prevalence of PD-like symptoms (PDLS) in men with DC. Methods From October 2013 to December 2016, men who were seen and evaluated for DC were offered the opportunity to participate in an anonymous survey. The survey assessed several basic demographic and sexual health factors and included items from the International Index of Erectile Function and the Erection Hardness Scale. Men who reported PDLS were asked a series of questions derived from the Peyronie's Disease Questionnaire and for their opinions on theoretical treatment modalities for sexual problems and penile deformity. Main Outcome Measure Prevalence of PDLS in men with DC. Results One hundred forty men with DC were invited to participate; 85 surveys were returned (response rate = 61%). Twenty-two respondents (26%, 95% confidence interval = 17–35) reported PDLS. Approximately one fourth of all respondents had an Erection Hardness Scale score lower than 3. The most common specific PDLS concerns were penile curvature (91%), length loss (55%), narrowing (36%), and hinging (32%). In men with PDLS, 73% felt at least a little bothered by the symptoms when attempting sexual activity and 40% reported having sex less frequently because of the symptoms. Just 27% of men with PDLS had ever used a treatment for a sexual concern. In terms of treatments for penile deformities, 64% of men with PDLS expressed an interest in treatment administered in the form of an in-office procedure; 41% were potentially amenable to a surgical procedure. Conclusion The prevalence of PDLS in men with DC is similar to the prevalence of DC in men diagnosed with PD. A substantial number of these men have distress and would consider standard-of-care treatments for PD. Shindel AW, Sweet G, Thieu W, et al. Prevalence of Peyronie's Disease-Like Symptoms in Men Presenting With Dupuytren Contractures. Sex Med 2017;5:e135–e141.

The purpose of this article is to illustrate MRI examples of acute triangular fibrocartilage complex (TFCC) injuries following the Palmer classification, including subtypes of the acute traumatic injuries originally described. In the discussion of these athletic TFCC injuries, recent studies and references are discussed with regard to implications in diagnosis and treatment. The article also reviews the role of ulnar abutment in degenerative injury to the TFCC and surgical approaches to correction. Recent findings regarding the role of the TFCC in distal radioulnar joint stability (DRUJ) and the importance of MRI in preoperative planning of the wrist are reviewed. New studies emphasizing the importance of repair of partial tears of the foveal attachment of the TFCC, the association of TFCC tears with distal radius fractures, and wafer procedures are also discussed. Injuries of the triangular fibrocartilage complex (TFCC) are commonplace in athletes across multiple sports. The TFCC acts to cushion forces transmitted from the ulnar side of the wrist to the upper extremity. Athletic activities tend to deliver an increased axial load and greater twisting motion upon the wrist. The Palmer classification system for TFCC injuries was first introduced in 1989, but is still used for both acute traumatic and degenerative injuries of the TFCC. MRI plays a pivotal role in diagnosing and classifying athletic injuries of the TFCC, helping guide orthopedists and hand surgeons in caring for patients with ulnar-sided wrist pain.

Evidence-based medicine empowers physicians to systematically analyze published data so as to quickly formulate treatment plans that deliver safe, robust, and cost-effective patient care. In this article, we sample some areas in hand and upper extremity surgery where the evidence base is strong enough that it has or should have unified treatment strategies; we identify some problems where good evidence has failed to unify treatment, and discuss problems for which evidence is still lacking but needed because treatment remains controversial. We also discuss circumstances in which level 4 evidence is more likely than randomized trials to guide treatment.

This chapter details the steps in surgical release of the carpel tunnel. From the palmar side, the transverse carpal ligament is reached, and it is slowly released until full opening of the carpal tunnel. Indications, essential steps, postoperative care, and sample operative dictation are included.

This chapter details the steps in performing a ligament reconstruction and tendon interposition. A subperiosteal longitudinal capsulotomy between the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons is made over the carpometarcarpal and scaphotrapezial joint. The trapezium is dissected and osteophytic bone between base of thumb and index metacarpal is removed. A bone tunnel is created through the first metacarpal. The ulnar half of the flexor carpi radialis (FCR) tendon is transected at the musculotendinous junction and is then passed through the bone tunnel. The tendon is tied and sutured onto itself using Krackow style technique. Remaining tendon is rolled and secured into the arthroplasty space. Indications, essential steps, postoperative care, and sample operative dictation are included.

This chapter details the steps in performing an open approach to cubital tunnel in situ decompression. Decompression is achieved by ulnar nerve dissection and fascia release for minimal compression and traction of the ulnar nerve. Indications, essential steps, postoperative care, and sample operative dictation are included.

This chapter details the steps in performing the Sauve–Kapandji Procedure. The distal radioulnar joint (DRUJ) is exposed and a segment of the ulnar shaft is resected. Kirschner wires are placed through the ulnar head and the arthrodesis site is packed with autologous bone grafts and fixed with two cannulated screws. Indications, essential steps, postoperative care, and sample operative dictation are included.

Purpose To determine the effects of motion-increasing modifications to radioscapholunate (RSL) arthrodesis on capitolunate contact pressure in cadaveric wrist specimens. Methods Ten fresh-frozen cadaveric wrists were dissected of all superficial soft tissue, potted in polymethyl-methacrylate, and the carpus exposed via a ligament-sparing capsulotomy. An RSL arthrodesis was simulated using 2 2.4-mm distal radius plates with locking screws. The distal scaphoid pole and triquetrum were removed with an osteotome and rongeur, respectively. Contact area, pressure, and force were measured in the capitolunate joint during the application of a 35-N uniaxial load using pressure-sensitive film. Measurements were obtained before and after simulated RSL fusion, following distal scaphoidectomy and after triquetrectomy. Results The combination of RSL fusion with distal scaphoid excision (DSE) increased contact forces in the capitolunate joint by 50% over controls. An RSL fusion, and RSL fusion with DSE and triquetrum excision (TE), exhibited intermediate levels of contact force between controls and RSL fusion with DSE. Capitolunate contact pressures were similar between all experimental groups. Contact area in the capitolunate joint increased by 43% after RSL fusion with DSE over intact specimen controls. Lastly, contact area in wrists with RSL fusion, and RSL fusion with DSE and TE, were elevated, but not significantly different from intact controls. Conclusions A DSE performed at the time of RSL fusion results in increased midcarpal joint contact force and area, with resultant contact pressures unchanged. Triquetrectomy, which has been previously shown to improve range of motion, did not increase contact forces in the capitolunate joint. Clinical relevance If a surgeon is contemplating performing an RSL arthrodesis with DSE, we recommend adding a triquetrectomy to improve motion because this does not add to the potentially deleterious effects of increased midcarpal contact force.

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.

The most common procedures to treat Kienbock’s disease involve osteotomies of the radius or ulna and are frequently referred to as joint-leveling procedures. The theory for these osteotomies, first proposed by Hulten in 1928, comes from the belief that abnormal association between the lunate and radius leads to altered mechanics at the radiocarpal joint which predispose those individuals to developing Kienbock’s disease. Various osteotomies of the radius and ulna can be categorized into three main groups: radial shortening, radial wedge, and ulnar lengthening. New long-term outcome data for radial shortening and wedge osteotomies have been promising despite radiographic progression of disease and have thus widened indications for such procedures. While biomechanical data has lent support to each group, ulnar-lengthening procedures have largely fallen out of favor secondary to increased complication rates relative to other options. Despite these complications, ulnar-lengthening osteotomy along with radial-sided osteotomies offer the added benefit of staying extra-articular should further intra-articular salvage procedures be required in the future.

Purpose To investigate the changes, trends, and implications of carpal tunnel release (CTR) surgery within an ambulatory setting over the past decade in the United States. Methods We undertook an analysis of ambulatory surgery center CTR cases using data from the National Survey of Ambulatory Surgery. The Centers for Disease Control and Prevention carried out this survey in 1996, and again in 2006. We searched the cases with the procedure codes indicative of CTR. Results The number of CTR procedures increased by 38% (from 360,000 to 577,000) between 1996 and 2006. In 1996, 16% of all ambulatory CTRs were performed in freestanding ambulatory surgery centers (hospital-based centers were 84%), and the proportion increased to 49% in 2006. By 2006, greater than 99% of CTRs were performed in an ambulatory setting. There was a significant increase in women aged 50 to 59 years of age undergoing CTR. Conclusions The minimal invasiveness of CTR combined with the advent of ambulatory care facilities has made CTR a predominantly outpatient procedure. In contrast to other reports, our study demonstrated a higher incidence of CTR within the United States in 2006 compared with 1996. Elderly women, in particular, with CTS were 3 times more likely to be treated surgically than other age groups. Further study is needed to better define factors influencing CTR indications. Type of study/level of evidence Prognostic II.

Objective To evaluate the recent epidemiology of hip fractures in the US. Methods We identified hip fracture cases from the 2008 Nationwide Emergency Department Sample, which contains more than 28 million emergency department (ED) records. Results In 2008, approximately 341,000 (95% confidence interval 323,000-358,000) patients visited EDs with hip fractures. Of those, 90% were age >60 years. Between ages 60-85 years, the risk of fracture doubled for every 5- to 6-year increase in age. However, the hip fracture risk increased slowly after age 85 years. The overall trochanteric-to-cervical fracture ratio was nearly 2:1. The risk of trochanteric fracture increased faster with age compared with the risk of cervical fracture. At age 85 years, the rates of trochanteric and cervical fractures (per 100,000) were 1,300 and 700, respectively, among women and 800 and 500, respectively, among men. Conclusion The slowed growth of hip fracture risk after age 85 years suggests that the eldest old group may have a distinct hip fracture risk. Our study showed that trochanteric fractures were twice as common as cervical fractures. Because trochanteric fractures are more closely related to severe and generalized bone loss than cervical fractures, we hypothesize that the high incidence rate of trochanteric fractures in the US suggests that osteoporosis is a health problem that is linked to hip fracture. In addition to improved safety measures to reduce falls, rigorous preventive treatments of osteoporosis may be needed.

Background: The number of total shoulder arthroplasties performed in the United States increased slightly between 1990 and 2000. However, the incidence of shoulder arthroplasty in recent years has not been well described. The purpose of the present study was to examine recent trends in shoulder hemiarthroplasty and total shoulder arthroplasty along with the common reasons for these surgical procedures in the United States. Methods: We modeled the incidence of shoulder arthroplasty from 1993 to 2008 with use of the Nationwide Inpatient Sample. On the basis of hemiarthroplasty and total shoulder arthroplasty cases that were identified with use of surgical procedure codes, we conducted a design-based analysis to calculate national estimates. Results: While the annual number of hemiarthroplasties grew steadily, the number of total shoulder arthroplasties showed a discontinuous jump (p < 0.01) in 2004 and increased with a steeper linear slope (p < 0.01) since then. As a result, more total shoulder arthroplasties than hemiarthroplasties have been performed annually since 2006. Approximately 27,000 total shoulder arthroplasties and 20,000 hemiarthroplasties were performed in 2008. More than two-thirds of total shoulder arthroplasties were performed in adults with an age of sixty-five years or more. Osteoarthritis was the primary diagnosis for 43% of hemiarthroplasties and 77% of total shoulder arthroplasties in 2008, with fracture of the humerus as the next most common primary diagnosis leading to hemiarthroplasty. Conclusions: The number of shoulder arthroplasties, particularly total shoulder arthroplasties, is growing faster than ever. The use of reverse total arthroplasty, which was approved by the United States Food and Drug Administration in November 2003, may be part of the reason for the greater increase in the number of total shoulder arthroplasties. A long-term follow-up study is warranted to evaluate total shoulder arthroplasty in terms of patient outcomes, safety, and implant longevity.

Purpose To present intermediate-term follow-up for pediatric patients following correction of forearm deformity with the use of distraction osteogenesis after distal radius physeal arrest in the setting of trauma. Methods Retrospective review of a single surgeon's experience using a circular external fixator to correct forearm deformity in four patients whose average age at time of application was 13.8 years. All patients were evaluated clinically with radiographs, physical examination, and functional outcome assessments including the Short-Form 12, Disabilities of the Arm, Shoulder and Hand, and Mayo Wrist score. Results At the time of intermediate-term follow-up, at a mean of 112 months, all patients were nearly pain free (average visual analog scale of 1). All were willing to undergo the same treatment again. Wrist flexion increased 11°, extension decreased 2°, radial deviation decreased 14°, ulnar deviation increased 7°, and pronation and supination both decreased 5° on average. The radius was lengthened an average of 7 mm, with an average preoperative ulnar variance of +7 mm and an average postoperative ulnar variance of +1 mm. Mean outcome scores were as follows: Short-Form 12 was 82, Disabilities of the Arm, Shoulder and Hand was 11, and Mayo Wrist was 76. Three of four patients experienced treatment-related complications, whereas two of four required unplanned returns to the operating room. Conclusions The use of distraction osteogenesis is a reasonable alternative to osteotomy, bone grafting, and internal fixation in pediatric patients with severe forearm deformity and dysfunction after physeal arrest in the setting of trauma. This procedure is burdened with complications and requires a committed patient and surgeon. It provides good correction of deformity and relief of pain, and maintains functional range of motion while avoiding the use of permanent orthopedic implants. Type of study/level of evidence Therapeutic IV.

N p s t ( s a n HE PATIENT 52-year-old woman, a former pediatrician, presents or treatment of lateral elbow pain of 3 months’ duraion. No longer working, she has filled her spare time ith playing tennis 3 times a week and mountain biking n weekends. She is extremely frustrated because both f these activities exacerbate the pain. Recently the pain ad occurred with holding a coffee cup and brushing er teeth. She has taken over-the-counter nonsteroidal nti-inflammatory medications and has worn a forearm race without relief. Examination reveals exquisite oint tenderness over the lateral epicondyle. The pain is ncreased with wrist extension against resistance and ith passive wrist flexion. Provocative signs for radial unnel syndrome are all negative. Radiographs of the lbow including anteroposterior, lateral, and radiocapiellar views are normal. You confirm her self-diagnosis f lateral epicondylitis. She comes to your office asking our opinion about steroid injection and other potenially disease-modifying nonsurgical treatments.