Hand Surgeon Posture: An Evaluation and Factors That Affect It.

Objective: Approximately 68% of orthopaedic surgeons report occupational related musculoskeletal pain, with back pain being the most common. Poor posture while operating has been proven to contribute to these high rates of musculoskeletal pain. There is little research regarding intraoperative surgeon posture within the field of hand and upper extremity surgery. This prospective study aims to investigate and analyze hand surgeon posture in the operating room. Methods: Posture of three hand surgeons was recorded using the UPRIGHT GO posture tracking device while performing a prospective series of 223 hand and upper extremity surgeries. This device reports posture in terms of overall percentage of time spent slouched versus upright. For this cohort of 223 cases, data were collected including surgical procedure, whether the surgery was performed in a seated or standing position, whether or not loupes were worn during the procedure, and if the surgeon was the primary or assistant surgeon. These data were then analyzed to look for any contributing factors to poor posture. Results: The three hand surgeons in this study spent an average of 40.3% of their time slouched while operating. The average percentage of time slouched was significantly greater with the use of loupes versus no loupes. Additionally, mean time slouching was slightly increased when the surgeon was seated and also when the surgeon was acting as the assistant surgeon. Conclusion: The three orthopaedic hand surgeons in our study spent a significant portion of their operative time slouched. The main variable associated with a significant risk of poor surgical posture was wearing loupes. Slight increases in slouching were seen with operating while seated and as the assistant surgeon. Surgeon awareness of these variables, as well as techniques to improve surgeon posture, should be developed in order to help contribute to better surgeon posture within the field of hand surgery.

Failure factors for carpal tunnel syndrome surgical treatment: When and how to perform a revision carpal tunnel decompression surgery.

Despite being a procedure widely used all over the world with high rates of symptom remission, surgical treatment of carpal tunnel syndrome may present unsatisfactory outcomes. Such outcomes may be manifested clinically by non-remission of symptoms, remission of symptoms with recurrence a time after surgery or appearance of different symptoms after surgery. Different factors are related to this unsuccessful surgical treatment of carpal tunnel syndrome. Prevention can be achieved through a thorough preoperative clinical evaluation of the patient. As such, the surgeon will be able to make differential or concomitant diagnoses, as well as determine factors related to patient dissatisfaction. Perioperative factors include the correct identification of anatomical structures for complete median nerve decompression. Numerous procedures have been described for managing postoperative factors. Among them, the most common is adhesion around the median nerve, which has been treated with relative success using different vascularized flaps or autologous or homologous tissue coverage. The approach to cases with unsuccessful surgical treatment of carpal tunnel syndrome is discussed in more detail in the text.

Failure factors for carpal tunnel syndrome surgical treatment: When and how to perform a revision carpal tunnel decompression surgery / Fatores de insucesso do tratamento cirúrgico da síndrome do túnel do carpo: Quando e como revisar a cirurgia de descompressão do túnel do carpo

Abstract Despite being a procedure widely used all over the world with high rates of symptom remission, surgical treatment of carpal tunnel syndrome may present unsatisfactory outcomes. Such outcomes may be manifested clinically by non-remission of symptoms, remission of symptoms with recurrence a time after surgery or appearance of different symptoms after surgery. Different factors are related to this unsuccessful surgical treatment of carpal tunnel syndrome. Prevention can be achieved through a thorough preoperative clinical evaluation of the patient. As such, the surgeon will be able to make differential or concomitant diagnoses, as well as determine factors related to patient dissatisfaction. Perioperative factors include the correct identification of anatomical structures for complete median nerve decompression. Numerous procedures have been described for managing postoperative factors. Among them, the most common is adhesion around the median nerve, which has been treated with relative success using different vascularized flaps or autologous or homologous tissue coverage. The approach to cases with unsuccessful surgical treatment of carpal tunnel syndrome is discussed in more detail in the text.

Resumo Apesar de ser um procedimento amplamente utilizado em todo o mundo e com elevadas taxas de remissão dos sintomas, o tratamento cirúrgico da síndrome do túnel do carpo pode apresentar resultados não satisfatórios ao paciente. Esse resultado não satisfatório pode se manifestar clinicamente pela não remissão dos sintomas, remissão dos sintomas mas recorrência desses após um período de tempo da cirurgia ou aparecimento de diferentes sintomas após a cirurgia. Diferentes fatores estão relacionados a esse insucesso do tratamento cirúrgico da síndrome do túnel do carpo (ITCSTC). A prevenção pode ser conseguida por meio de minuciosa avaliação clínica do paciente no período pré-operatório. Dessa forma o cirurgião poderá fazer diagnósticos diferenciais ou diagnósticos concomitantes, assim como identificar fatores ligados a insatisfação do paciente. Os fatores per-operatórios incluem a correta identificação das estruturas anatômicas para completa descompressão do nervo mediano. Inúmeros procedimentos têm sido descritos para o tratamento dos fatores que ocorrem no período pós-operatório. Desses o mais comum, a formação de aderências em torno do nervo mediano, tem sido tratado com relativo sucesso utilizando diferentes retalhos vascularizados ou cobertura com o uso de tecido autólogo ou homólogo. Descreveremos a abordagem do ITCSTC com maiores detalhes no texto.

Inter-relationships of Metacarpals 1 to 5, Regarding Their Length, Metaphyseal Midshaft Width, Articular Surface Area of Head and Base, Age, and Sex: A Cadaveric Study.

Background: Metacarpal factures are common, comprising up to 50% of hand fractures. More work is needed to further our understanding of metacarpal anatomy to improve fixation techniques and reduce postoperative complications following surgical implants. The purpose of this anatomic study was to evaluate the length, midshaft metaphyseal width, and area of the articular surface of the head (AH) and base (AB) of metacarpals 1 to 5. Methods: This prospective study assessed measures from 17 cadavers at 1 institution's anatomy lab. The anatomic dimensions of the metacarpals in both the right and left hands were measured. Epidemiological data including sex and age at death were also collected. Results: In all, 29 hands were dissected for metacarpal anatomic measurements, for a total of 145 metacarpals. The second metacarpal was longest, at 69.58 mm. Multivariate analysis of variance revealed a significant effect of sex overall, with greater metacarpal dimensions in men. Increasing age was associated with decreasing dimensions, except for AH of metacarpal 1 (F = 3.43, P = .02) and AB of metacarpal 1 (F = 11.54, P < .001) and 4 (F = 4.21, P = .01). Multiple metacarpal dimensions were also significantly correlated with each other. Conclusion: Our data reveal further information regarding metacarpal dimensions of length, midshaft width, and AH and AB. The results allow for potential to improve surgical management through improving metacarpal implants, developing an optimal plate and screw design, techniques to better accommodate anatomical differences based on age and sex, reducing postoperative complications and improving the standard of care.

Myoelectric prosthesis: a potential emerging therapeutic in restoring function post-arm amputation complicated by necrotizing fasciitis.

A literature search confirmed no previous cases of an arm amputation secondary to necrotizing fasciitis (NF) being successfully treated with a myoelectric prosthesis. This report explores a case of a 55-year-old right-handed male with flexor tenosynovitis infection of the hand after a small laceration. Following infectious disease consult of the infection, a diagnosis of NF was made. Broad-spectrum antibiotics were initiated but the infection worsened after 12 hours. Two debridements with wound vacuum were undertaken in the next 48 hours. After further patient deterioration, a distal left forearm amputation was undertaken. The patient fully recovered and then underwent occupational therapy training with a myoelectric prosthesis to restore hand function. The patient was seen for follow-up 3, 6, 12 and 24 months after amputation. At 2-year follow-up, the patient was continuing rehabilitation with an occupational therapist to acclimate to the prosthesis with some gain of function in gross movement.

Crush Injury-induced Finger Compartment Syndrome: A Case Report and Literature Review.

Isolated finger compartment syndrome is an uncommon condition and is not well-documented. It is usually associated with pain, decreased sensation, and intra-compartmental swelling. We present the case of a finger fracture after a crush injury that developed compartment syndrome, which responded well after surgical fixation and midline skin incision for digital decompression. A 20-year-old male with a history of a 200 lb crush-injury to the left index finger 24 hours prior presented to the emergency department with decreased sensation and range of motion, deformity, increasing pallor, and severe pain. Radiographs demonstrated a middle phalanx fracture of the index finger. Digital decompression of the index finger through a radial approach, along the middle line, and open reduction internal fixation of the middle phalanx improved perfusion almost immediately. The patient continued to improve at his one-week, 12-week, and six-month follow-up appointments, with a normal neurovascular exam, a capillary refill of less than two seconds, and, ultimately, he was able to make a full composite fist. Though finger compartment syndrome is uncommon, it should be suspected in cases where the patient demonstrates hallmark clinical signs and symptoms. Compartment syndrome is a clinical diagnosis that requires urgent diagnosis and intervention and must be suspected regardless of the anatomic location of the injury.

Morphometric analysis of the second through fifth metacarpal through posteroanterior X-Rays.

Over the past 10 years, metacarpal fractures have had an annual incidence of 13.6 per 10,000 individuals. Literature has not reviewed anatomical variations through radiographic imaging, which may play a role in reducing postoperative complications. The purpose of this study was to use radiographic imaging to provide a detailed anatomy of the second through fifth metacarpals. This retrospective study measured length, neck width, narrowest body width, and narrowest medullary canal width of the second through fifth metacarpals through the use of posteroanterior X-rays. Patients who were ≥18 years and received hand radiographs from January 2015 to July 2019 were included in this study. Those with acute injury or fracture of the metacarpal were excluded. Five hundred and seventy-two metacarpals were included in this study, with 143 metacarpals measured each for the second through fifth metacarpal. The second metacarpal had the largest measured length, neck width, and narrowest body width at 68.72, 12.34, and 8.74 mm, respectively. The fifth metacarpal had the greatest average medullary canal width at 4.15 mm. This is the largest study in literature to comprehensively examine the anatomical variation of the second through fifth metacarpals. The second metacarpal had greatest dimensions except for canal width, which was the fifth metacarpal. Men almost consistently had greater metacarpal size when compared to women, and age was associated with second and third metacarpal canal width. The increased knowledge of metacarpal anatomy may potentially lay the foundation of further improvement of metacarpal implants and potentially reduce postoperative complications. Clin. Anat., 33:1014-1018, 2020. © 2019 Wiley Periodicals, Inc.

A Potentially Inexpensive Diagnostic Method for A2 Pulley Ruptures.

Injuries to the flexor pulley system of the hand, while uncommon, can be problematic and debilitating for patients. Current standards of diagnosis for A2 pulley disruptions often include costly imaging studies and inaccurate clinical testing. We present the case of a patient with an isolated complete A2 pulley avulsion that was diagnosed by employing a simple technique using a silicone wedding ring. A silicone wedding band was applied over the region of a suspected A2 pulley rupture, resulting in the immediate restoration of full range of motion as well as complete resolution of the injury after three months, without any need for surgical intervention. The usage of this ring confirmed an A2 pulley avulsion that was visualized on magnetic resonance imaging (MRI). The proposed "Wedding Band Test" is potentially an accurate and inexpensive diagnostic tool for clinical evaluation of A2 pulley ruptures.

Repair of Forearm Muscle Herniation Using Local Fascial Flap: A Case Report.

Forearm muscle herniation is a rare but known cause of symptomatic pain in the upper extremity caused by compression or strangulation of the muscle belly through a defect in the overlying fascia. Because of the rarity of this condition, optimal treatment is still widely unknown and debated. To date, there are various treatment methods published, including rest, physiotherapy, primary repair, fasciotomy, fascia lata inlay, onlay or wrap-around, mesh graft, and acellular porcine collagen matrix. In this study, a 61-year old man underwent an ulnar nerve transposition to correct cubital tunnel syndrome, resulting in subsequent symptoms of muscle herniation on the volar aspect of the forearm. Prominent muscle herniation was visible a few weeks after the onset of symptoms and surgical correction of the fascial defect was performed using a local fascial flap. Postoperatively, the patient's herniation symptoms resolved without signs of ulnar nerve entrapment. The rationale for this treatment option is discussed.

An unusual presentation of metacarpophalangeal joint instability of the thumb.

Thumb injuries are not as common as those occurring in the fingers. The authors present the case of a patient who had an isolated avulsion of the extensor pollicis brevis that resulted in metacarpophalangeal joint instability, with intact radial and ulnar collateral ligament.

Lesões no polegar não são tão comuns como aquelas nos dedos. Os autores um caso em que a paciente sofreu uma avulsão isolada do extensor curto do polegar que resultou em instabilidade da articulação metacarpofalângica do polegar, com ligamento colateral ulnar e radial intacto.

Intraoperative Tips for Hand Surgery: A Focus on Reducing Postoperative Scarring and Tendon Rupture.

This article is a collection of intraoperative techniques performed by a single hand surgeon with literature support for these techniques for the purpose of circumventing potential limitations intraoperatively. These techniques include the use of a Beaver Blade handle (Beaver, Beaver-Visitec, Waltham, MA, US) to be used as a rasp to smooth intraosseous tunnels during tendon transfers, a Stryker (Stryker, Stryker Corporation, Kalamazoo, MI, US) or Synthes (Deputy Synthes, Johnson & Johnson, West Palm Beach, FL, US) drill as a motorized file for plate deburring, and Insorb forceps (Insorb, Incisive Surgical, Plymouth, MN, US) for skin closure. These tips serve as methods to minimize scarring and circumvent unfortunate obstacles, such as tendon rupture, and the consequential weakened repair that can occur post-operatively. These have not been previously reported in the literature but have been performed by the senior author with no resulting complications. Additionally, the common availability of the equipment allows for a potential economic benefit.

Sensitivity and Specificity of Skyline and Carpal Shoot-Through Fluoroscopic Views of Volar Plate Fixation of the Distal Radius: A Cadaveric Investigation of Dorsal Cortex Screw Penetration.

BACKGROUND: Volar plate fixation of distal radius fractures can result in soft tissue injuries. Abnormal contour of the dorsal cortex of the distal radius provides difficulties in discerning screw penetration on standard radiographs. The skyline and carpal shoot-through views are additional views to improve dorsal cortex visibility. We report on the sensitivity and specificity of determining screw protrusion with these views. METHODS: Seven fresh frozen cadavers were instrumented with a distal radius volar locking plate. Initial screw length was determined by depth gauge measurement. A dorsal dissection of the wrist was performed to detect screw penetration. Protruding screws were documented and replaced with screws of the appropriate length and deemed as baseline. Screws were then sequentially lengthened by 2 and 4 mm. Skyline and carpal shoot-through views were obtained at baseline, 2 mm, and 4 mm. The images were randomized and compiled into an untimed survey asking orthopedic surgeons to determine whether screws were penetrating through the dorsal cortex. RESULTS: Based on depth gauge measurements, 4 out of 44 (9.1%) volar plate locking screws penetrated the dorsal cortex, as confirmed with dorsal dissection. Sensitivities for the skyline and carpal shoot-through views were 75% and 86% ( P ≤ .001), respectively, for 2-mm protrusions, and 76% and 89% ( P ≤ .001), respectively, for 4-mm screw protrusions. Specificities were 85% and 84% for the skyline and shoot-through views, respectively. CONCLUSIONS: We believe that the carpal shoot-through view has utility and can be implemented to augment standard intraoperative views, and may decrease the incidence of screw protrusion resulting in soft tissue injuries.