Proximal Interphalangeal Joint Fractures: Various Approaches to Fixation.

There are numerous operative and nonoperative options for the management of proximal interphalangeal joint fractures and fracture dislocations. The treatment of choice should be guided by the fracture pattern and joint stability. The authors highlight a contemporary option for open reduction and internal fixation techniques, but all the techniques presented are viable options under the right circumstances. It is also important to set patient expectations as most of these patients will note post-injury stiffness and potential functional limitations.

Proximal Interphalangeal Joint Arthroplasty for Fracture.

Proximal interphalangeal joint arthroplasties can be performed in the setting of acute comminuted fracture, chronic fracture presentations, and posttraumatic arthritis. These surgeries provide excellent pain relief and patient satisfaction but patients should be cautioned not to expect an improvement in motion postoperatively. Despite high rates of minor complications and radiographic loosening, these implants have good rates of long-term survival with most revisions occurring in the early postoperative period. They provide viable alternatives to arthrodesis, osteotomy and amputation in the appropriate patient.

Supplementary Fixation Improves Stability of Intra-Articular Distal Radius Fractures Managed With a Spanning Plate.

PURPOSE: Previous studies evaluating weight bearing of distal radius fractures treated through dorsal spanning bridge plates used extra-articular fracture models, and have not evaluated the role of supplementary fixation. We hypothesized that supplementary fixation with a spanning dorsal bridge plate for an intra-articular wrist fracture would decrease the displacement of individual articular pieces with cyclic axial loading and allow for walker or crutch weight bearing. METHODS: Thirty cadaveric forearms were matched into 3 cohorts, controlling for age, sex, and bone mineral density. An intra-articular fracture model was fixed with the following 3 techniques: (1) cohort A with a dorsal bridge plate, (2) cohort B with a dorsal bridge plate and two 1.6-mm k-wires, and (3) cohort C with a dorsal bridge plate and a radial pin plate. Specimens were axially loaded cyclically with escalating weights consistent with walker and crutch weight-bearing with failure defined as 2-mm displacement. RESULTS: No specimens failed at 2- or 5-kg weights, but cohort A had significantly more displacement at these weights compared with cohort B. Cohort A had significantly more failure than cohort C. Both cohort A and cohort B had significantly more displacement at crutch weight bearing compared with cohort C. The supplementary fixation group had significantly lower displacement at crutch weight-bearing compared with cohort A in all gaps. Survival curves demonstrated the fixation cohort to survive higher loads than the nonfixation group. CONCLUSION: There was significantly less displacement and less failure of intra-articular distal radius fractures treated with a spanning dorsal bridge plate and supplementary fixation. Our model showed that either type of fixation was superior to the nonfixation group. CLINICAL SIGNIFICANCE: When considering early weight-bearing for intra-articular distal radius fractures treated with a spanning dorsal bridge plate, supplementary fixation may be considered as an augmentation to prevent fracture displacement.

Radial Sided Triangular Fibrocartilage Complex Tears: A Comprehensive Review.

When evaluating the available literature on the diagnosis and management of triangular fibrocartilage complex tears (TFCC), ulnar tears comprise the major focus of TFCC literature. Radial-sided (Class 1D) tears are seldom researched or discussed. The purpose of this study was to review the methods for identifying and treating radial-sided TFCC lesions, by examining the anatomy of the TFCC, the pathology of its radial portion, diagnostic techniques, and both surgical and nonoperative treatments. The avascular nature of the radial TFCC may influence its healing potential. Magnetic resonance arthrogram is the gold standard for non-invasively diagnosing a radial-sided tear. Non-operative management should be exhausted prior to surgical intervention, which commonly involves an inside-out repair involving radial trans-osseous sutures. Still, the literature is limited by patient sample size and therefore requires a greater population of class 1-D tears to confirm optimal diagnostic and treatment methods.

Social Disparities in the Management of Trigger Finger: An Analysis of 31 411 Cases.

BACKGROUND: Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF. METHODS: Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A P-value < .05 was considered significant. RESULTS: Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988). CONCLUSIONS: There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation.

Cost Drivers in Carpal Tunnel Release Surgery: An Analysis of 8,717 Patients in New York State.

PURPOSE: The annual high volume of carpal tunnel releases (CTRs) has a large financial impact on the health care system. Validating the cost drivers related to CTR in a large, diverse patient population may aid in developing cost reduction strategies to benefit health care systems. METHODS: Adult patients with carpal tunnel syndrome who underwent CTR were identified in the New York Statewide Planning and Research Cooperative System database from 2016 to 2017. The Statewide Planning and Research Cooperative System is a comprehensive all-payer database that collects all inpatient and outpatient preadjudicated claims in New York. A multivariable mixed model regression with random effects was performed for the facility to assess the variables that contributed significantly to the total charge. The variables included were patient age, sex, anesthesia method, whether the surgery took place in an ambulatory surgery center or a hospital outpatient department, operation time in minutes, primary insurance type, race, ethnicity, Charlson Comorbidity Index, and categories for billed procedure codes. RESULTS: During the period of 2016 to 2017, 8,717 claims were included, with a mean charge per claim of $4,865. General anesthesia was associated with higher charges than local anesthesia. A procedure at a hospital outpatient department was associated with an approximately 48.2% increase in the total charge compared with that at an ambulatory surgery center. A 1-minute increase in the operation time was associated with a 0.3% increase in the total charge. Claims with antiemetics, antihistamines, benzodiazepines, intravenous fluids, narcotic agents, or preoperative antibiotics were associated with higher total charges than claims that did not bill for these. Compared with endoscopic procedures, open procedures had a 44.3% decrease in the total charges. CONCLUSIONS: This comprehensive multivariable model has validated that general anesthesia, hospital-based surgery, the use of antibiotics and opioids, longer operative times, and endoscopic CTR significantly increased the cost of surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analyses II.

Weight-Bearing Restrictions With Distal Radius Wrist-Spanning Dorsal Bridge Plates.

PURPOSE: The fixation of comminuted distal radius fractures using wrist-spanning dorsal bridge plates has been shown to have good postoperative results. We hypothesized that using a stiffer bridge plate construct results in less fracture deformation with loads required for immediate crutch weight bearing. METHODS: We created a comminuted, extra-articular fracture in 7 cadaveric radii, which were fixed using dorsal bridge plates. The specimens were positioned to simulate crutch/walker weight bearing and axially loaded to failure. The axial load and mode of failure were measured using 2- and 5-mm osteotomy deformations as cutoffs. Bearing 50% and 22% of the body weight was representative of the force transmitted through crutch and walker weight bearing, respectively. RESULTS: The load to failure at 2-mm deformation was greater than 22% body weight for 2 of 7 specimens and greater than 50% for 1 of 7 specimens. The load to failure at 5-mm deformation was greater than 22% body weight for 6 of 7 specimens and greater than 50% for 4 of 7 specimens. The mean load to failure at 2-mm gap deformation was significantly lower than 50% body weight (110.4 N vs 339.2 N). The mean load to failure at 5-mm deformation was significantly greater than 22% body weight (351.8 N vs 149.2 N). All constructs ultimately failed through plate bending. CONCLUSIONS: All constructs failed by plate bending at forces not significantly greater than the 50% body weight force required for full crutch weight bearing. The bridge plates supported forces significantly greater than the 22% body weight required for walker weight bearing 6 of 7 times when 5 mm of deformation was used as the failure cutoff. CLINICAL RELEVANCE: Elderly, walker-dependent patients may be able to use their walker as tolerated immediately after dorsal bridge plate fixation for extra-articular fractures. However, patients should not be allowed to bear full weight using crutches immediately after bridge plating.

"Stress taper" fixation increases torsional failure strength in a cadaveric femur model.

BACKGROUND: To potentially limit peri-implant fractures our institution commonly implements a "stress-taper" fixation construct in which the screw lengths towards the proximal end of a construct are incrementally decreased, in order to avoid a focal stress-riser when loaded. To assess this construct, we asked: 1) Does the stress taper strategy increase torsional strength than the bicortical locking construct when biomechanically tested in a cadaveric femur model? 2) Does it fail in a less comminuted fracture pattern? METHODS: Seven matched pairs of cadaveric femora were randomly assigned to one of two distal femur fixation groups: plating with stress taper strategy or bicortical fixation. Specimens were first cyclically loaded, then axially rotated to failure under 800 N of compression. Peak torque at failure, degrees of rotation at failure, and energy to failure were calculated and compared using paired t-tests. Fractures were categorized with the assistance of fluoroscopy according to the Orthopedic Trauma Association classification, 32. FINDINGS: There was significantly greater peak torque (110.6 ± 49.7 Nm vs. 80.6 ± 35.2 Nm), rotation at failure (23.8 ± 5.3° vs 18.9 ± 4.5°) and energy to failure (25.3 ± 15.7 J vs. 14.1 ± 8.3 J) in the stress-taper group as compared to the bicortical group (p = 0.0424), (p = 0.0213) and (p = 0.0460), respectively. 6/7 fractures in the stress-taper group were classified 32 A1 with 1/7 classified A2. 5/7 fractures in the bicortical group were classified B1 and 2/7 classified A2. INTERPRETATION: 'Stress taper fixation' in distal femurs may be protective against peri-implant fractures compared to traditional bicortical fixation. The 'stress taper' concept can increase torsional failure strength in an in vitro model.

Rates of and Risk Factors for Trigger Finger after Open Carpal Tunnel Release.

Background We have anecdotally noticed a higher rate of trigger fingers (TFs) developing in patients who have undergone carpal tunnel release (CTR). Questions/Objective Is the rate of TFs after CTR greater compared to the nonoperative hand? Is the thumb more commonly involved postoperatively compared with spontaneous TFs? Do particular associated comorbidities increase this risk? Patients and Methods We queried our institutional database for patients who had undergone open CTR during a 2-year period and recorded the development of an ipsilateral TF after a CTR or a contralateral TF in the nonoperative hand. Patient demographics, comorbidities, concurrent initial procedures, time to diagnosis, and finger involvement were recorded. Results A total of 435 patients underwent 556 CTRs during this period. Furthermore, 46 ipsilateral TFs developed in 38 of 556 cases (6.83%) at an average of 228.1 ± 195.7 days after surgery. The thumb was most commonly involved (37.0%) followed by the ring finger (28.3%). The incidence rate of TF in the nonoperative hand during this period was 2.7%, with the ring finger and middle finger most commonly involved (33.3 and 28.6%, respectively). Only history of prior TF in either hand was found to be a significantly associated on Chi-square analysis and multivariable regression ( p < 0.001). Conclusion In patients with carpal tunnel syndrome, ipsilateral TFs occurred after 6.83% of CTRs, compared with a rate of 2.7% in the nonoperative hand, making it an important possible outcome to discuss with patients. The thumb was more commonly involved in triggering in the surgical hand compared with the nonoperative hand. Patients with a history of prior TFs in either hand were more likely to develop an ipsilateral TF after CTR. Level of Evidence This is a Level III, retrospective study.

Nuances of Radiographic Assessment of Distal Radius Fractures to Avoid Missed Fragments.

Distal radius fractures, like many articular and periarticular fractures, can make it difficult to determine the true number, location, and orientation of fracture fragments. This article should help the reader work through imaging interpretation starting from the initial, often displaced radiographs to postreduction imaging and determination if further 3-dimensional imaging is necessary.

Management of Post-Amputation Pain.

INTRODUCTION: The prevalence of amputation and post-amputation pain (PAP) is rising. There are two main types of PAP: residual limb pain (RLP) and phantom limb pain (PLP), with an estimated 95% of people with amputations experiencing one or both. Medical Management: The majority of chronic PAP is due to phantom limb pain, which is neurogenic in nature. Common medications used include tricyclic antidepressants, gabapentin, and opioids. Newer studies are evaluating alternative drugs such as ketamine and local anesthetics. Rehabilitation Management: Mirror visual feedback and cognitive behavioral therapy are often effective adjunct therapies and have minimal adverse effects. Surgical Management: Neuromodulatory treatment and surgery for neuromas have been found to help select patients with PAP. CONCLUSION: PAP is a complex condition with mechanisms that can be located at the residual limb, spinal cord, and brain - or a combination. This complex pain can be difficult to treat. The mainstays of treatment are largely medical, but several surgical options are also being studied.

Evidence-based update on the surgical treatment of pediatric tibial shaft fractures.

PURPOSE OF REVIEW: To describe surgical treatment options for pediatric tibial shaft fractures which are the third most common pediatric long bone fracture. Management of these injuries is dictated by fracture location, fracture pattern, associated injuries, skeletal maturity, and other patient-specific factors. Although most pediatric tibial shaft fractures can be treated nonoperatively, this review provides an update on surgical treatment options when operative intervention is indicated. RECENT FINDINGS: Advances in surgical implants and techniques affords a wide range of options for the surgical treatment of pediatric tibial shaft fractures. Flexible intramedullary nailing is gaining wide adoption for acute surgical treatment. Recent studies support cross-sectional imaging for further evaluation and scrutiny of fracture patterns suspicious for intraphyseal or intra-articular extension. Grade I open tibial shaft fractures may be safely treated with irrigation and debridement in the emergency department; however, no high-level comparative studies have been performed to make any definitive conclusions regarding the effectiveness of this treatment strategy. SUMMARY: Tibial shaft fractures are common injuries in pediatric patients. Management is dictated by fracture location, fracture pattern, associated injuries, patient age, and other patient-specific factors. Surgical intervention is indicated for fractures that are open, irreducible, have failed nonoperative management, are associated with compartment syndrome, or in the multiply injured patient. Surgical treatment options include flexible intramedullary nailing, plate osteosynthesis, external fixation, and rigid intramedullary nailing. Recent literature has shown increased rates of flexible intramedullary nailing. All operative and nonoperative management options can result in complications including compartment syndrome, infection, delayed union, nonunion, malunion, limb length discrepancy, and symptomatic hardware. Most pediatric patients go on to uneventful union with excellent final outcomes and return to full activities.

Shoulder and elbow injuries in NCAA football players, 2009-2010 through 2013-2014.

Background: Although football is one of the most popular collegiate sports, the epidemiology of and risk factors for shoulder and elbow injuries in this population not been recently described. We aimed to characterize this incidence in National Collegiate Athletic Association (NCAA) football players, determine risk factors, and establish outcomes after injury. Methods: All shoulder and elbow injuries in men's football occurring during the 2009-2010 through 2013-2014 academic years were retrospectively identified in the NCAA Injury Surveillance Program database. The injury incidence per 10,000 athletic exposures (AEs) was calculated overall, and by different risk factors. In addition to descriptive statistics, risk factors were compared using injury risk-ratios, and outcomes were compared using injury proportion ratios. Results: NCAA football players sustained 1,187 shoulder and elbow injuries in 899,225 AEs (incidence: 13.20/10,000 AE), most commonly acromioclavicular separation (29.9%), anterior shoulder subluxation (9.0%), shoulder contusion (9.0%), and rotator cuff tear/sprain (8.0%). Together, shoulder instability comprised 28.1% of injuries. Injuries were split evenly between offense (43.5%) and defense (45.9%), and a tackling mechanism caused 37.7%, with 30.3% coming from blocking. The incidence was eight times higher in competition than practice (62.9/10,000 vs 7.9/10,000AE, p < 0.001). Surgery was performed for 9.9% of injuries, and most commonly for all types of shoulder instability (56.8% of surgeries). Injuries were season-ending in 5.2% of players. The likelihood of an injury being season-ending was 2.9 times greater for recurrent injuries than a new injury (p < 0.001); 86.1% of all injuries were new. Conclusions: Shoulder and elbow injuries to NCAA football players can be severe. Competition had an eight times higher incidence than did practice. Tackling and blocking were the most common mechanisms, while AC separation and shoulder instability were the most common injuries. This epidemiology may help players, coaches, trainers, and governing bodies target injury-prevention programs and assess improvement over time.

Incidence, Timing, and Risk Factors for Secondary Revision After Primary Revision of Traumatic Digit Amputations.

PURPOSE: Primary revision amputation is the most common treatment method for traumatic digit amputations in the United States. Few studies have reported secondary revision rates after primary revision amputation. The primary aim of our study was to identify risk factors for secondary revision within 1 year of the index procedure. Secondarily, we describe the incidence and timing of complications requiring secondary revision. METHODS: Our institution's emergency department (ED) database was reviewed for traumatic digit amputations over a 6-year period. Patients were reviewed for demographic characteristics, comorbidities, site of treatment (ED versus operating room), and complications requiring secondary revision. Conditional Cox Proportional Hazard regression was used to model hazard of revision within 1 year of index procedure relative to site of initial management, mechanism of injury, injury characteristics, and patient demographics. RESULTS: Five hundred and thirty-seven patients with 677 digits were managed with primary revision amputation. Five hundred and eighty-six digits (86.6%) were revised in the ED, and 91 (13.4%) in the operating room. Ninety-one digits required secondary revision, including 83 within 1 year. No increased risk of secondary revision amputation within 1 year of the index procedure was observed for patients treated in the ED compared with the operating room. Relative to crush injuries, bite and sharp laceration amputations had 4.8 times and 2.6 times increased risk of secondary revision, respectively. The index finger had a 5.3-fold increased risk of revision with the thumb as the reference digit. Work-related injuries had a 1.9-fold increased risk of secondary revision compared with non-work-related injuries. CONCLUSIONS: No evidence was found indicating that traumatic digit amputations primarily revised in the ED had an increased risk of secondary revision. Patients may be counseled on the risk of secondary procedures based on the mechanism of injury, injury characteristics and demographics, as well as the timing of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Shoulder and elbow injuries in soccer goalkeepers versus field players in the National Collegiate Athletic Association, 2009-2010 through 2013-2014.

OBJECTIVES: Examination of the incidence of shoulder and elbow injuries in the collegiate soccer player population is limited, as is comparison between goalkeepers and field players. We hypothesized that goalkeepers would have a higher incidence of shoulder and elbow injuries than field players. Furthermore, we sought to determine the incidence of shoulder and elbow injuries among National Collegiate Athletic Association (NCAA) soccer players, and to determine injury risk factors. METHODS: The NCAA Injury Surveillance Program database was analyzed for injuries to NCAA men's and women's soccer players during the 2009-2010 through 2013-2014 academic years. The incidence of injury was calculated per 10,000 athletic exposures (AE) for goalkeepers versus field players, activity, and injury characteristics, and compared using univariate analysis and risk-ratios to determine injury risk factors. RESULTS: While the overall incidence of shoulder and elbow injuries in soccer players was 2.7/10,000AE [95% CI 2.62-2.78], the incidence among goalkeepers was 4.6-fold higher (8.3 vs. 1.8/10,000AE, p < 0.0001). Goalkeepers had significantly higher incidences of injury in practice (21.3-fold) and in the preseason (16.1-fold) than field players. Women goalkeepers were disproportionately affected, with injury incidences 7.7-fold higher than women field players, and 1.9-fold higher than male goalkeepers. Acromioclavicular joint injuries, rotator cuff tears/sprains, and elbow and shoulder instability constituted the majority of the goalkeeper injuries. CONCLUSIONS: Shoulder and elbow injuries in NCAA soccer players are significantly more common in goalkeepers than field players. Incidence varies widely by position and injury, with a number of associated risk factors. Soccer players sustaining these injuries, along with their coaches and medical providers, may benefit from this injury data to best manage expectations and outcomes. Soccer governing bodies may use this to track injury incidence and response to preventative measures.

Ulnar Collateral Ligament Injuries of the Elbow in the Throwing Athlete.

UPDATE: This article was updated on February 26, 2018, because of a previous error. On pages 1 and 7, in the author byline section, the authors' names that had read "Andrew Harris" and "Brett Owens" now reads "Andrew P. Harris" and "Brett D. Owens."

A Review of Brachial Plexus Birth Palsy: Injury and Rehabilitation.

Brachial plexus injuries during the birthing process can leave infants with upper extremity deficits corresponding to the location of the lesion within the complex plexus anatomy. Manifestations can range from mild injuries with complete resolution to severe and permanent disability. Overall, patients have a high rate of spontaneous recovery (66-92%).1,2 Initially, all lesions are managed with passive range motion and observation. Prevention and/or correction of contractures with occupational therapy and serial splinting/casting along with encouraging normal development are the main goals of non-operative treatment. Surgical intervention may be war- ranted, depending on functional recovery. [Full article available at http://rimed.org/rimedicaljournal-2017-11.asp].