A Case of Superficial Acral Fibromyxoma of the Index Finger.

Superficial acral fibromyxoma (SAFM) is a rare, slow-growing benign soft tissue tumor that is typically asymptomatic in nature and usually affects the acral regions of the hands and feet. The majority of these lesions are subungual. Excisional biopsy is the primary treatment modality. Despite the distinct clinical and histopathological features, misidentification of this slow-growing tumor persists. This case report contributes to the existing literature by delineating the clinicopathologic features, radiographic and MRI findings, and treatment strategies of SAFM.

A quality and readability comparison of artificial intelligence and popular health website education materials for common hand surgery procedures.

INTRODUCTION: ChatGPT and its application in producing patient education materials for orthopedic hand disorders has not been extensively studied. This study evaluated the quality and readability of educational information pertaining to common hand surgeries from patient education websites and information produced by ChatGPT. METHODS: Patient education information for four hand surgeries (carpal tunnel release, trigger finger release, Dupuytren's contracture, and ganglion cyst surgery) was extracted from ChatGPT (at a scientific and fourth-grade reading level), WebMD, and Mayo Clinic. In a blinded and randomized fashion, five fellowship-trained orthopaedic hand surgeons evaluated the quality of information using a modified DISCERN criteria. Readability and reading grade level were assessed using Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) equations. RESULTS: The Mayo Clinic website scored higher in terms of quality for carpal tunnel release information (p = 0.004). WebMD scored higher for Dupuytren's contracture release (p < 0.001), ganglion cyst surgery (p = 0.003), and overall quality (p < 0.001). ChatGPT - 4th Grade Reading Level, ChatGPT - Scientific Reading Level, WebMD, and Mayo Clinic written materials on average exceeded recommended reading grade levels (4th-6th grade) by at least four grade levels (10th, 14th, 13th, and 11th grade, respectively). CONCLUSIONS: ChatGPT provides inferior education materials compared to patient-friendly websites. When prompted to provide more easily read materials, ChatGPT generates less robust information compared to patient-friendly websites and does not adequately simplify the educational information. ChatGPT has potential to improve the quality and readability of patient education materials but currently, patient-friendly websites provide superior quality at similar reading comprehension levels.

Screw Position Following Percutaneous Versus Mini-Open Intramedullary Retrograde Screw Fixation of Metacarpal Fractures.

BACKGROUND: Metacarpal fracture fixation using the retrograde intramedullary screw technique can be performed through two different approaches. The mini-open approach requires greater soft tissue dissection but allows for direct visualization of the metacarpal head compared with the percutaneous approach. Our aim was to determine which approach resulted in optimal screw position. METHODS: Eighty-one consecutive patients that underwent intramedullary screw fixation for metacarpal fractures from 2016 to 2021 were identified. Patients were treated by 4 fellowship-trained orthopedic hand surgeons who employed the mini-open or percutaneous approach. Postoperative radiographs were reviewed for screw position. RESULTS: A total of 81 patients (41 mini-open, 40 percutaneous) were included in this study. There were no significant differences between the two groups in age, sex, hand dominance, or affected digit. Postoperative screw position at first postoperative visit was not significantly different between the two groups on anteroposterior or lateral radiographs. CONCLUSION: Postoperative screw position is not significantly different between the mini-open and percutaneous approaches for intramedullary screw fixation of metacarpal fractures. LEVEL OF EVIDENCE: Level III, therapeutic.

Metacarpal Shortening with Intramedullary Screw Fixation: A Cadaveric Study.

Background Intramedullary screw fixation is a commonly used technique for the management of metacarpal fractures. However, compression across the fracture site can lead to unintentional shortening of the metacarpal. Questions/Purposes Our aim was to evaluate the risk of overshortening with differing intramedullary device designs for fixation of metacarpals. Methods The small finger metacarpal of nine fresh-frozen cadavers were included. A metacarpal neck fracture was simulated with a 5-mm osteotomy. Three different intramedullary screw designs were compared. Each screw was placed in a retrograde fashion into the intramedullary canal and the amount of shortening measured. Screws were reversed and the number of reverse turns with the screwdriver needed to release overshortening were measured. Results The average shortening at the osteotomy site was 2.5 mm. The mean shortening was 80%, 58%, and 12% for the partially threaded screw, fully threaded screw, and threaded nail, respectively. The mean differences of the distance shortened were statistically significant for the threaded nail compared with the partially and fully threaded screws. The partially threaded screw had the most shortening, while the threaded nail provided the least amount of shortening. When the screws were reversed, the screws did not disengage until the screw was fully removed from the osteotomy site. Conclusion The fully threaded nail demonstrates less shortening and possibly minimizes overshortening of fractures compared with partially threaded and fully threaded screw designs. Overshortening cannot be corrected by unscrewing the screw unless completely removed from the distal fragment. Clinical Relevance Orthopaedic surgeons may select intermedullary screws based on the design that is suited for the particular metacarpal fracture pattern.

Use of Telemedicine Among Hand Surgeons and Their Patients.

PURPOSE: Initially designed to address geographic obstacles to patient care, reliance on telemedicine rapidly increased during the coronavirus pandemic. The purpose of this study was to analyze the proficiency of computer and mobile device usage among a cohort of surgeons and their patients who either used telemedicine or had in-person visits. METHODS: We retrospectively identified patients who had an outpatient telemedicine visit (T group), or in-person visit (NT group) with a hand and wrist orthopedic surgeon, between March 2020 and July 2020. These patients and their surgeons were sent the Computer Proficiency Questionnaire (CPQ-12) and the Mobile Device Questionnaire (MDPQ-16) via email. A total of 602 survey responses were collected, 279 of which belonged to patients in the T group and 323 to patients in the NT group. RESULTS: The two groups were similar in demographics, including age and sex. Scores on the CPQ-12 and MDPQ-16 did not significantly differ between the two groups. In the patient sample, there was no correlation between CPQ-12 and MDPQ-16 scores and the proportion of telehealth visits. The orthopedic surgeon group also had no observed correlation between the CPQ-12 and MDPQ-16 scores and number or proportion of telemedicine visits. CONCLUSIONS: Overall proficiency with computer and mobile devices was not correlated with the likelihood of patients or orthopedic surgeons using telemedicine visits. Patient selection appears to be driven by other factors, which could include limitations in transportation, convenience, and time constraints. CLINICAL RELEVANCE: Orthopedic surgeons should continue to offer telehealth visits to their patients regardless of estimated capabilities with electronic devices of both the patient and the surgeon.

Evaluating the Efficacy of a Thermoresponsive Hydrogel for Delivering Anti-Collagen Antibodies to Reduce Posttraumatic Scarring in Orthopedic Tissues.

Excessive posttraumatic scarring in orthopedic tissues, such as joint capsules, ligaments, tendons, muscles, and peripheral nerves, presents a significant medical problem, resulting in pain, restricted joint mobility, and impaired musculoskeletal function. Current treatments for excessive scarring are often ineffective and require the surgical removal of fibrotic tissue, which can aggravate the problem. The primary component of orthopedic scars is collagen I-rich fibrils. Our research team has developed a monoclonal anti-collagen antibody (ACA) that alleviates posttraumatic scarring by inhibiting collagen fibril formation. We previously established the safety and efficacy of ACA in a rabbit-based arthrofibrosis model. In this study, we evaluate the utility of a well-characterized thermoresponsive hydrogel (THG) as a delivery vehicle for ACA to injury sites. Crucial components of the hydrogel included N-isopropylacrylamide, poly(ethylene glycol) diacrylate, and hyaluronic acid. Our investigation focused on in vitro ACA release kinetics, stability, and activity. Additionally, we examined the antigen-binding characteristics of ACA post-release from the THG in an in vivo context. Our preliminary findings suggest that the THG construct exhibits promise as a delivery platform for antibody-based therapeutics to reduce excessive scarring in orthopedic tissues.

Technique for Minimally Invasive, Arthroscopic-assisted Distal Radius Fracture Fixation.

Distal radius fractures are common injuries that often require surgical intervention. Commonly, these fractures are fixed using open reduction internal fixation with plating and screws. This often requires a more extensive soft tissue dissection and exposure. In contrast for certain cases, percutaneous headless compression screws may be appropriate. We present a technique for minimally invasive arthroscopic-assisted reduction and percutaneous screw fixation with an extremity traction device. A case is provided to demonstrate the technique as a viable option for the treatment of intra-articular distal radius fractures.

The Effect of Percutaneous Retrograde Metacarpal Intramedullary Screw Insertion on the Extensor Tendon.

PURPOSE: Both limited-open and percutaneous techniques have been described for retrograde insertion of intramedullary metacarpal screws. The percutaneous approach does not allow direct visualization of the starting point at the metacarpal head. However, it limits soft tissue dissection and expedites the procedure. The purpose of our study was to determine whether percutaneous, retrograde intramedullary screw fixation causes substantial iatrogenic damage to the extensor tendon. We also investigated whether larger sized screws would cause greater tendon injury compared to smaller screws. METHODS: Eight fresh frozen cadaver hands were used for percutaneous, retrograde intramedullary screw insertion of the index, long, ring, and small finger metacarpals of each specimen. Three different types of headless compression screws were used: a small fully threaded screw, a large fully threaded screw, and a Herbert-style partially threaded screw. After insertion, dissection was carried down to the screw entry site. Extensor tendon damage was evaluated, including tendon defect size and any irregularities noted in the tendon. RESULTS: There was no statistical difference with respect to how frequently a screw perforated the extensor tendons between all four finger metacarpals. Overall, the defect width caused by the screw was minimal, ranging from 0.66 mm to 1.89 mm for all finger and screw types. The large style screw did cause the greatest mean defect width, however, this was not statistically significant. When normalized to total tendon width, the defect was less than 28% of the total tendon width, with an average of 20% for all finger and screw types. Upon gross inspection, there was no fraying or irregularity noted at the screw-tendon insertion site, and it was often difficult to identify the screw entry site through the tendon by direct visualization alone. No tendon ruptures were noted. CONCLUSIONS: This study found that percutaneous insertion of a retrograde, intramedullary metacarpal screw causes minimal extensor tendon injury. In contrast to the limited-open approach, the percutaneous technique requires less soft tissue dissection and the possibility of reduced swelling, scarring, and risk of adhesions. Moreover, it has the potential to allow for early functional rehabilitation and reduced operative time. Interestingly, none of the tendons demonstrated fraying or rupture, as one might expect to occur with blind passage of a drill and screw through a tendon. Overall, the percutaneous, retrograde intramedullary screw technique appears to cause minimal iatrogenic injury to the extensor tendon.

Proximity of the Ulnar Neurovascular Structures in Endoscopic Carpal Tunnel Release Surgery: A Cadaveric Study.

PURPOSE: To evaluate the proximity of the ulnar neurovascular structures to the endoscopic blade during endoscopic carpal tunnel release (CTR). METHODS: Ten fresh-frozen cadaver hands were used to perform endoscopic CTR using devices from two manufacturers. The skin was excised from the palm, and the endoscopic carpal tunnel blade was deployed at the distal edge of the transverse carpal ligament (TCL). The blade's proximity to the ulnar neurovascular bundle, deep ulnar motor branch, superficial palmar arch, and median nerve was recorded. Following release of the TCL, the device was turned ulnar to the maximal extent to determine if direct injury to the ulnar neurovascular bundle was possible. RESULTS: The average longitudinal distance from the end of the TCL to the superficial palmar arch was 13.3 mm (range, 8.4-20.9) and to the ulnar motor branch was 10.8 mm (range, 4.0-15.0). The average transverse distance from the end of the TCL to the ulnar neurovascular bundle was 5.9 mm (range, 3.1-7.8) and to the median nerve was 3.3 mm (range, 0-6.5). In two of our specimens, the median nerve subluxated volarly over the cutting device. When placing the blade at the distal edge of the TCL, injury to the deep motor branch of the ulnar nerve, ulnar neurovascular bundle, or superficial palmar arch was not possible in any specimens using the tested devices, even when turning the blade directly toward these structures. CONCLUSIONS: There is a low likelihood of direct injury to the ulnar neurovascular bundle during endoscopic CTR. CLINICAL RELEVANCE: These results suggest that injury to the ulnar neurovascular bundle is unlikely during endoscopic CTR if the distal aspect of the transverse carpal ligament can be clearly identified prior to release. Control of the median nerve is also important to prevent subluxation over the cutting device.

Anatomic Relationship of Hand Intrinsic Tendons at the Metacarpal Head as It Relates to the Diagnosis of Saddle Syndrome: A Cadaveric Study.

PURPOSE: The purpose of this cadaveric study was to investigate the intrinsic anatomy surrounding the metacarpal head and the relationship between the interosseous-lumbrical junction (ILJ) and transverse metacarpal ligament (TML) as it pertains to saddle deformity-posttraumatic adhesions at the ILJ that cause impingement during intrinsic activation. METHODS: Ten fresh frozen cadaveric arms underwent dissections, identifying the intrinsic musculature within the second through fourth webspaces. The TML and ILJ, or "true tendon," were identified. A separate area of nontendinous fibrous tissue identified proximal to the ILJ was referred to as "pseudotendon." Measurements were made within each webspace to identify distances between these structures in full finger extension and intrinsic plus position to assess for changes during simulated motion. RESULTS: The true tendon to TML distance progressively decreased toward the ulnar digits. In the intrinsic plus position, the pseudotendon to TML distance was 0 mm at all webspaces for each specimen. When moving from neutral to intrinsic plus, the true tendon to TML distance decreased the most in the third and fourth webspaces compared with the second, consistent with the trend toward a smaller ILJ to TML gap in the ulnar digits. CONCLUSIONS: There is a fibrous pseudotendinous region proximal to the ILJ that abuts the TML in the intrinsic plus position, which may cause impingement when inflamed in the setting of saddle syndrome. Furthermore, a decreased ILJ to TML gap in the ulnar digits may be related to an increased predilection for saddle deformity in those areas. CLINICAL RELEVANCE: These results suggest that there is a fibrous region present proximal to the ILJ that may be implicated in the pathology of saddle deformity. Furthermore, decreased distances found between the ILJ and TML in vivo may be an explanation for increased occurrence of saddle syndrome in the third and fourth webspaces in clinical practice.

Perioperative Management of Oral Anticoagulants and Antiplatelet Therapy in Hand and Wrist Surgery.

There is wide variability in the management of patients on antithrombotic therapy requiring surgery of the hand and wrist. There are no specific guidelines regarding whether to temporarily cease or continue oral anticoagulants and antiplatelet agents. Discontinuation of these medications before surgery can lead to perioperative thromboembolic or ischemic events. On the other hand, continuation can lead to intraoperative or postoperative bleeding complications. This review discusses various anticoagulants and antiplatelet agents with special considerations for their management, analyzes the current literature, summarizes current recommendations, and provides direction for additional research.

Appropriateness of Self-Scheduled Office Visits in Outpatient Hand Surgery.

PURPOSE: Our practice recently implemented a system that enables patients to self-schedule outpatient visits through an online portal. The purpose of this study was to evaluate the appropriateness of self-scheduled appointments in the Hand and Wrist Surgery Division of our practice. METHODS: Outpatient visit notes from 128 new patient visits among 18 fellowship-trained hand and upper extremity surgeons were collected; 64 visits were self-scheduled online, and 64 were scheduled using the traditional call center system. The notes were deidentified and divided among 10 hand and upper extremity surgeons, such that each note was reviewed by two different reviewers. The surgeons scored each visit on a scale of 1-10, with 1 representing a completely inappropriate visit for a hand surgeon and 10 representing a completely appropriate visit. Primary diagnoses and treatment plans were recorded, including whether surgery was planned during the visit. The final score for each visit resulted from the average of the two separate scores. The average appropriateness score for all self-scheduled visits was compared with the average score for all traditionally scheduled visits with a two-sample t test. RESULTS: The average appropriateness score for self-scheduled visits was 8.4 of 10, with seven visits resulting in a planned surgery (10.9%). Traditionally scheduled visits had an average appropriateness score of 8.4 of 10, with eight visits resulting in a planned surgery (12.5%). The average difference in the scores between reviewers for all visits was 1.7. CONCLUSIONS: In our practice, the appropriateness of visits that are self-scheduled is nearly identical to the appropriateness of traditionally scheduled visits. CLINICAL RELEVANCE: Implementation of self-scheduling systems may allow for greater patient autonomy and access to care and reduce administrative burden on office staff.

Extracellular Targets to Reduce Excessive Scarring in Response to Tissue Injury.

Excessive scar formation is a hallmark of localized and systemic fibrotic disorders. Despite extensive studies to define valid anti-fibrotic targets and develop effective therapeutics, progressive fibrosis remains a significant medical problem. Regardless of the injury type or location of wounded tissue, excessive production and accumulation of collagen-rich extracellular matrix is the common denominator of all fibrotic disorders. A long-standing dogma was that anti-fibrotic approaches should focus on overall intracellular processes that drive fibrotic scarring. Because of the poor outcomes of these approaches, scientific efforts now focus on regulating the extracellular components of fibrotic tissues. Crucial extracellular players include cellular receptors of matrix components, macromolecules that form the matrix architecture, auxiliary proteins that facilitate the formation of stiff scar tissue, matricellular proteins, and extracellular vesicles that modulate matrix homeostasis. This review summarizes studies targeting the extracellular aspects of fibrotic tissue synthesis, presents the rationale for these studies, and discusses the progress and limitations of current extracellular approaches to limit fibrotic healing.

Swelling, Stiffness, and Dysfunction Following Proximal Interphalangeal Joint Sprains.

PURPOSE: Proximal interphalangeal (PIP) joint sprains are common injuries that often result in prolonged swelling, stiffness, and dysfunction; however, the duration of these sequelae is unknown. The purpose of this study was to determine the duration of time that patients experience finger swelling, stiffness, and dysfunction following a PIP joint sprain. METHODS: This was a prospective, longitudinal, survey-based study. To identify patients with PIP joint sprains, the electronic medical record was queried monthly using International Classification of Disease, Tenth Revision, codes for PIP joint sprain. A five-question survey was emailed monthly for 1 year or until their response indicated resolution of swelling, whichever occurred sooner. Two cohorts were established: patients with (resolution cohort) and patients without (no-resolution cohort) self-reported resolution of swelling of the involved finger within 1 year of a PIP joint sprain injury. The measured outcomes included self-reported resolution of swelling, self-reported limitations to range of motion, limitations to activities of daily living, Visual Analog Scale (VAS) pain score, and return to normalcy. RESULTS: Of 93 patients, 59 (63%) had complete resolution of swelling within 1 year of a PIP joint sprain. Of the patients in the resolution cohort, 42% reported return to subjective normalcy, with 47% having self-reported limitations in range of motion and 41% having limitations in activities of daily living. At the time of resolution of swelling, the average VAS pain score was 0.8 out of 10. In contrast, only 15% of patients in the no-resolution cohort reported return to subjective normalcy, with 82% having self-reported limitations in range of motion and 65% having limitations in activities of daily living. For this cohort, the average VAS pain score at 1 year was 2.6 out of 10. CONCLUSIONS: It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Remote fit wrist braces through artificial intelligence.

INTRODUCTION: Physical boundaries to access skilled orthotist or hand therapy care may be hindered by multiple factors, such as geography, or availability. This study evaluated the accuracy of fitting a prefabricated wrist splint using an app on a smart device. We hypothesize that remote brace fitting by artificial intelligence (AI) can accurately determine the brace size the patient needs without in-person fitting. METHODS: Healthy volunteers were recruited to fit wrist braces. Using 2 standardized calibrated images captured by the smart device, each subject's image was loaded into the machine learning software (AI). Later, hand features were extracted, calibrated, and measured the application, calculated the correct splint size, and compared with the splint chosen by our subjects to improve its own accuracy. As a control (control 1), the subjects independently selected the best brace fit from an array of available splints. Subject selection was recorded and compared with the AI fit splint. As the second method of fitting (control 2), we compared the manufacturer recommended brace size (based on measured wrist circumference and provided sizing chart/insert brochure) with the AI fit splint. RESULTS: A total of 54 volunteers were included. Thirty-two splints predicted by the algorithm matched the exact size chosen by each subject yielding 70% accuracy with a standard deviation of 10% ( p < 0.001). The accuracy increased to 90% with 5% standard deviation if the splints were predicted within the next size category. Fit by manufacturer sizing chart was only 33% in agreement with participant selection. CONCLUSION: Remote brace fitting using AI prediction model may be an acceptable alternative to current standards because it can accurately predict wrist splint size. As more subjects were analyzed, the AI algorithm became more accurate predicting proper brace fit. In addition, AI fit braces are more than twice as accurate as relying on the manufacturer sizing chart.

Extensor carpi ulnaris tendon pathology and ulnar styloid bone marrow edema as diagnostic markers of peripheral triangular fibrocartilage complex tears on wrist MRI: a case-control study.

OBJECTIVES: To evaluate extensor carpi ulnaris (ECU) tendon pathology and ulnar styloid process bone marrow edema (BME) as diagnostic MRI markers for peripheral triangular fibrocartilage complex (TFCC) tears. METHODS: One hundred thirty-three patients (age range 21-75, 68 females) with wrist 1.5-T MRI and arthroscopy were included in this retrospective case-control study. The presence of TFCC tears (no tear, central perforation, or peripheral tear), ECU pathology (tenosynovitis, tendinosis, tear or subluxation), and BME at the ulnar styloid process were determined on MRI and correlated with arthroscopy. Cross-tabulation with chi-square tests, binary logistic regression with odds ratios (OR), and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to describe diagnostic efficacy. RESULTS: On arthroscopy, 46 cases with no TFCC tear, 34 cases with central perforations, and 53 cases with peripheral TFCC tears were identified. ECU pathology was seen in 19.6% (9/46) of patients with no TFCC tears, in 11.8% (4/34) with central perforations and in 84.9% (45/53) with peripheral TFCC tears (p < 0.001); the respective numbers for BME were 21.7% (10/46), 23.5% (8/34), and 88.7% (47/53) (p < 0.001). Binary regression analysis showed additional value from ECU pathology and BME in predicting peripheral TFCC tears. The combined approach with direct MRI evaluation and both ECU pathology and BME yielded a 100% positive predictive value for peripheral TFCC tear as compared to 89% with direct evaluation alone. CONCLUSIONS: ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to diagnose tears. KEY POINTS: • ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to confirm the presence of TFCC tears. • If there is a peripheral TFCC tear on direct MRI evaluation and in addition both ECU pathology and BME on MRI, the positive predictive value is 100% that there will be a tear on arthroscopy compared to 89% with direct evaluation alone. • If there is no peripheral TFCC tear on direct evaluation and neither ECU pathology nor BME on MRI, the negative predictive value is 98% that there will be no tear on arthroscopy compared to 94% with direct evaluation alone.

Functional Outcomes of Cubital Tunnel Release in Patients with Negative Electrodiagnostic Studies.

BACKGROUND: Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper extremity. Electrodiagnostic studies (EDSs) are often used to confirm diagnosis. However, negative EDSs can present a difficult clinical challenge. The purpose of this study was to determine the functional outcomes and symptom improvement for patients with a clinical diagnosis of CuTS, but with negative EDSs, who are treated surgically. METHODS: Patients who had EDSs before ulnar nerve surgery were identified by means of database search. Chart review was performed on 867 cases to identify those with negative EDSs. Twenty-five ulnar nerve operations in 23 patients were included in analysis. Chart review was performed to record preoperative and postoperative symptoms, physical examination findings, and outcome measures (ie, Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Ulnar Nerve Evaluation). RESULTS: At a mean follow-up period of 20.7 ± 14.9 months, 15 of 25 cases (60.0%) had complete resolution of all preoperative symptoms. All 10 patients who had residual symptoms endorsed improvement in their preoperative complaints. The median preoperative Disabilities of the Arm, Shoulder and Hand score was 40.0 [interquartile range (IQR), 23.9 to 58.0], which significantly decreased to a median of 6.8 (IQR, 0 to 22.7) at final follow-up ( P < 0.01). The median postoperative Patient-Rated Ulnar Nerve Evaluation score was 9.5 (IQR, 1.5 to 19.5). CONCLUSIONS: Patients with CuTS and normal EDSs treated surgically can be expected to have favorable outcomes with respect to symptoms and improvement in functional outcome scores. After ruling out confounding diagnoses, the authors continue to offer surgical intervention for these patients when nonoperative treatment has failed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Efficacy of Waterproof Cast Protectors and Their Ability to Keep Casts Dry.

PURPOSE: The purpose of the study was to compare the efficacy of 6 different commercially available waterproof cast protectors in their ability to maintain a dry environment and evaluate whether cast protectors perform better than a plastic bag secured with tape in keeping casts dry. METHODS: We enrolled 23 adult participants to test 6 different commercially available cast protectors and a plastic bag. Participants trialed all cast protectors twice, with and without motion, by fully submerging each cast protector in water with a paper towel held between their index and middle fingers. Moisture accumulation within the cast protectors was estimated by the change in weight of paper towel. An analysis of variance test was performed to compare differences between cast protectors in their ability to maintain a dry internal environment. RESULTS: The plastic bag showed an average moisture accumulation of 5.50 g without motion compared with all other cast protectors, which had 0.0 g of moisture accumulation. One cast protector and the plastic bag had an average moisture accumulation of 0.46 g and 4.51 g with motion compared to all other cast protectors. The plastic bag was ranked the worst by 100% of participants. CONCLUSIONS: Cast protectors appear to offer superior protection from moisture compared with a plastic bag. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.