Characterization of Major Complications of Bridge Plating of Distal Radius Fractures at a Level I Trauma Center.

BACKGROUND: Comminuted, markedly displaced distal radius fractures can cause instability requiring advanced stabilization with dorsal bridge plating. However, published complication rates of bridge plating widely vary. We hypothesize that complications of bridge plating of distal radius fractures are more prevalent than published rates. METHODS: A retrospective review was performed on all patients at an academic level I trauma center treated with a bridge plate for a distal radius fracture from 2014 to 2022. RESULTS: Sixty-five wrists were included in the final analysis: average age 53 years, male 51%, average plate retention 4 months, and average follow-up 6 months. Carpal tunnel release (CTR) was performed at time of primary procedure in 7 (10%) cases. Radial height, radial inclination, dorsal tilt, and ulnar variance were all significantly improved (P < .001). Grip strength, flexion, extension, and supination were significantly limited (P < .03). Twenty-one patients (32%) developed 35 major complications requiring unplanned reoperation, including mechanical hardware-related complication (15%), deep infection (11%), nonunion/delayed union (9%), adhesions (6%), median neuropathy (6%), symptomatic arthritis (5%), and tendon rupture (2%). Plate breakage occurred in 3 patients (5%) and was always localized over the central drill holes of the bridge plate. CONCLUSIONS: Major complications for bridge plating of distal radius fractures were higher at our institution than previously published. Plate breakage should prompt reconsideration of plate design to avoid drill holes over the wrist joint. Signs and symptoms of carpal tunnel syndrome should be carefully assessed at initial presentation, and consideration for concomitant CTR should be strongly considered.

Not Just Another Trigger Finger.

BACKGROUND: Open A1 pulley release for trigger finger has generally been considered a minor procedure with infrequent complications. Most reported complications are minor, including scar pain and tenderness, mild extension lag, and recurrence of triggering. Rates of major complications, such as bowstringing, neurovascular bundle injury, and infection requiring reoperation, are less than 1% to 4%. We aimed to describe the potentially devastating sequelae of these major complications and the subsequent consequences. METHODS: Three patients underwent open trigger finger release, which were all complicated by severe postoperative surgical site infection requiring multiple subsequent procedures. We review our initial management, subsequent reconstructive options, and outcomes with up to 19 years follow-up. RESULTS: All 3 adult patients who underwent open A1 pulley release for trigger finger developed a surgical site infection, leading to flexor tenosynovitis requiring urgent operative debridement and multiple subsequent procedures. Two patients were poorly controlled diabetics, and the third patient was otherwise healthy. Each patient ultimately developed distinct consequences from their postoperative course-finger stiffness and contracture, disabling bowstringing requiring the use of a pulley ring, and flexor tendon rupture requiring staged tendon reconstruction, respectively. All 3 patients at final follow-up had a permanent functional deficit. CONCLUSIONS: Major complications after trigger finger release are infrequent. However, if left untreated, particularly in diabetic patients, there can be disastrous consequences, resulting in permanent loss of function. This case series highlights the importance of accurate diagnosis of postoperative infections and expedient treatment thereafter.

Misdiagnosis in Amyotrophic Lateral Sclerosis.

The symptoms of amyotrophic lateral sclerosis (ALS) can mimic those of compressive neuropathies, such as carpal and cubital tunnel syndromes, especially early in a patient's clinical course. We surveyed members of the American Society for Surgery of the Hand and found that 11% of active and retired members have performed nerve decompression surgeries on patients later diagnosed with ALS. Hand surgeons are commonly the first providers to evaluate patients with undiagnosed ALS. As such, it is important to be aware of the history, signs, and symptoms of ALS to provide an accurate diagnosis and prevent unnecessary morbidities, such as nerve decompression surgery, which invariably results in poor outcomes. The major "red flag" symptoms warranting further work-up include weakness without sensory symptoms, profound weakness and atrophy in multiple nerve distributions, progressively bilateral and global symptoms, presence of bulbar symptoms (such as tongue fasciculations and speech/swallowing difficulties), and, if surgery is performed, failure to improve. If any of these red flags are present, we recommend neurodiagnostic testing and prompt referral to a neurologist for further work-up and treatment.

Carpometacarpal Arthrodesis: Indications and Techniques.

Trapeziometacarpal arthrodesis is a beneficial surgery for young and higher-demand patients who have trapeziometacarpal arthritis. Surgical techniques can vary, but certain aspects of the surgery are critical, including bony preparation and positioning of the thumb in space. Reported outcomes are generally favorable, although the quality of evidence is poor. There are no comparison studies assessing different arthrodesis techniques, and only a few comparing arthrodesis to the trapeziometacarpal arthroplasty procedures. Most published results are case series with retrospectively collected data.

Nonunion and Reoperation Following Proximal Interphalangeal Joint Arthrodesis and Associated Patient Factors.

BACKGROUND: Proximal interphalangeal joint (PIPJ) arthrodesis can provide reliable pain relief and restore hand function in patients with PIPJ arthritis. However, there is a paucity of literature on patient-specific preoperative risk factors that are associated with adverse outcomes after PIPJ arthrodeses. Therefore, the primary purpose of this study was to assess preoperative predictors of nonunion and reoperation after PIPJ arthrodesis. METHODS: This study identified all patients who underwent PIPJ arthrodesis at a single community practice between 1987 and 2013. The final analysis included 415 PIPJs treated with arthrodesis. The mean follow-up was 1.3 years. Data on preoperative diagnosis, demographics, comorbidities, and operative techniques were recorded, as well as the occurrence of nonunions and reoperations. Logistic regression models were used to identify independent risk factors of nonunion and reoperation. RESULTS: There were 40 nonunions (10%) and 62 reoperations (15%). Of the reoperations, there were 39 incidences of isolated hardware removal, 9 irrigation and debridement, 8 amputations, 5 revision arthrodeses, and 1 corrective osteotomy. The highest number of nonunions occurred in the traumatic diagnosis group (37%), followed by the rheumatoid group (23%) and the scleroderma group (15%). The highest number of reoperations occurred within the traumatic joint disorder group (40%), followed by the rheumatoid group (24%) and the scleroderma group (11%). Multivariate analysis revealed that male sex (P < .01) and hepatic disease (P = .03) were significant risk factors of nonunion. Male sex was also significantly associated with increased reoperation risk (P < .01). CONCLUSION: Risks of nonunions and reoperations after PIPJ arthrodeses are low; however, these findings may guide clinicians and patients in the preoperative decision-making process and help with targeted postoperative surveillance to mitigate these risks.

Treatment Modality of Distal Ulnar Head and Neck Fractures Associated With Operatively Treated Distal Radius Fractures Does Not Affect Outcomes.

Background: This study compares the functional outcomes and complications between operatively and nonoperatively treated distal ulnar head and neck fractures associated with internal fixation of concomitant distal radius fractures. Methods: A 7-year retrospective chart review was performed to identify patients with operatively treated distal radius fractures associated with distal ulnar head and neck fractures. Ulnar styloid fractures were excluded. Fifty-eight patients who had a minimum of 6 months of follow-up were identified. Patients were divided into 3 treatment groups: nonoperative, open reduction internal fixation (ORIF), and distal ulna resection. Reviewed data included demographics, injury and treatment details, complications, and patient-reported outcome measures. Outcomes measures included Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Patient-Rated Wrist Evaluation (PRWE) surveys. Due to inadequate power, 5 patients treated with distal ulna resection were excluded from statistical analysis. Results: The average patient age was 56 years, with an average follow-up of 27 months. All patients underwent ORIF of the distal radius fracture. Distal ulna fractures were treated nonoperatively in 25 patients, with ORIF in 28 patients, and with distal ulna resection in 5 patients. There were no statistically significant differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores between ORIF and nonoperative treatment. Conclusion: No differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores were observed between ORIF and nonoperative treatment of distal ulnar head and neck fractures associated with operatively treated distal radius fractures.

Automated Reporting of Patient Outcomes in Hand Surgery: A Pilot Study.

BACKGROUND: Obtaining patient-reported outcomes (PROs) is becoming a standard component of patient care. For nonacademic practices, this can be challenging. From this perspective, we designed a nearly autonomous patient outcomes reporting system. We then conducted a prospective, cohort pilot study to assess the efficacy of the system. METHODS: We created an automated system to gather PROs. All operative patients for 4 surgeons in an upper-extremity private practice were asked to participate. These patients completed the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaires preoperatively and received follow-up e-mails requesting patients to complete additional QuickDASH questionnaires at 3, 6, and 12 weeks postoperatively and to complete a 13-week postoperative satisfaction survey. Response rates and satisfaction levels are reported with descriptive statistics. RESULTS: Sixty-two percent of participants completed the 3-week assessment, 55% completed the 6-week assessment, and 43% completed the 12-week assessment. Overall, 35% of patients completed all questionnaires, and 73% completed at least 1 postoperative assessment. The collection of follow-up questionnaires required no additional time from the clinical staff, surgeon, or a research associate. CONCLUSIONS: Automated e-mail assessments can collect reliable clinical data, with minimal surgeon or staff intervention required to administer and collect data, minimizing the financial cost. For nonacademic practices, without access to additional research resources, such a system is feasible. Further improvements in communication with patients could increase response rates.

A Failed 4-Corner Arthrodesis Using a Polyether-Ether-Ketone Implant: A Case Report.

CASE: A 59-year-old man underwent scaphoidectomy and 4-corner arthrodesis with a polyether-ether-ketone (PEEK) circular plate for scapholunate advanced collapse of the wrist. Five years later, he presented with a symptomatic nonunion and radiocarpal arthritis. Total wrist arthrodesis with a dorsal plate was performed. During revision surgery, considerable synovitis was encountered. Histological evaluation revealed a foreign body response likely secondary to PEEK particles. CONCLUSION: Use of PEEK implants can result in an adverse local tissue reaction if particles are generated. This is a rare biomaterial-related complication, and surgeons should be aware of this adverse tissue response when using this or other PEEK implants.

Hand and Upper Extremity Infections in Intravenous Drug Users: Epidemiology and Predictors of Outcomes.

PURPOSE: Injectable drug use (IDU) is a national epidemic, public health problem, and common cause of hand and upper extremity (UE) infections. This study assesses the epidemiology of the IDU patient population presenting to a Midwestern academic medical center emergency department (ED) and examines predictors influencing morbidity and outcomes. METHODS: A retrospective review was performed using International Classification of Diseases, Ninth Revision (ICD-9) codes to identify all adult patients presenting to the ED with hand/UE infections, with and without concurrent IDU diagnoses, over a period of 2.5 years. Demographics and clinical factors were examined utilizing bivariate and multivariable analyses to identify predictors of outcomes, including not completing outpatient follow-up and leaving against medical advice (AMA). RESULTS: A total of 1,482 patients with 1,754 ED visits for hand/UE infections were identified, including 308 patients with IDU-acquired infections (396 visits) and 1,174 patients with non-IDU infections (1,358 visits). Psychiatric comorbidities and hepatitis C were common in the IDU group (51% and 39%, respectively), and 31% of IDU patients were uninsured. Heroin use was identified in 96% of visits. The IDU infections were more likely to have surgical intervention than those in non-IDU patients (16% vs 6%), and a longer mean length hospital stay (2.4 vs 0.9 days). The IDU patients were more likely than non-IDU patients to leave AMA. In multivariable analysis, IDU, psychiatric comorbidity, and insurance status were independent predictors (P < .05) for leaving AMA. CONCLUSIONS: In the setting of a national epidemic, hand/UE infections due to IDU are a common problem seen by hand surgeons. This study characterizes the growing IDU patient population at an urban academic medical center, examining the largest cohort of these patients to date. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Scapholunate Ligament Injury: Management Strategies From Occult Injury to Arthritis.

This chapter will explore scapholunate ligament injuries with a focus on injury recognition, diagnosis, the natural history, and options for treatment. Treatment is based upon injury factors, patient factors, and surgeon preference. The classification systems in common use will be discussed, and treatment options will be explored, including nonsurgical, arthroscopic, repair, reconstruction, pain relieving measures, and salvage procedures.

Anatomy of the Posterior Antebrachial Cutaneous Nerve, Revisited.

PURPOSE: To describe the branching pattern of the posterior antebrachial cutaneous nerve (PABCN) and to corroborate measurements and observations reported by previous authors. METHODS: Using 28 fresh-frozen cadaver specimens, we dissected the PABCN from its origin from the radial nerve to its terminal arborization in the distal forearm. Measurements relative to the lateral humeral epicondyle were recorded. The course of the nerve over the muscles of the mobile wad and its branching pattern in the proximal forearm were noted. RESULTS: The PABCN originated from the radial nerve at a mean of 14.2 cm proximal to the lateral epicondyle. The fascial hiatus through which the PABCN emerged to become superficial was a mean of 8.2 cm proximal to the lateral epicondyle. All specimens had at least 1 longitudinal branch that passed a mean of 2.8 cm anterior to the lateral epicondyle. Thirty-two percent of specimens had a lesser proximal branch in the distal third of the lateral arm; 86% had an epicondylar branch to the lateral epicondyle; and 21% had a second longitudinal branch. Ninety-three percent had a longitudinal branch coursing over the interval between the brachioradialis and the extensor carpi radialis longus in the proximal forearm. CONCLUSIONS: After becoming superficial in the distal brachium, the PABCN typically gives off a discrete epicondylar branch and then continues distally in the forearm as 1 or 2 longitudinal branches. In addition, in the proximal third of the forearm, a consistent longitudinal branch of the PABCN courses over the interval between the brachioradialis and the extensor carpi radialis longus. This review confirms previous observations of the PABCN. CLINICAL RELEVANCE: Knowledge of the course of the PABCN will assist surgeons in identifying and avoiding injury in clinical situations such as plating the proximal radius or releasing the radial tunnel.

Inflammatory Reactions to Xenogenic Nerve Wraps: A Report of Three Cases.

CASE: Recurrent carpal tunnel syndrome is a challenging problem. Nerve wraps have been introduced as a barrier to prevent scar traction neuritis for use during revision carpal tunnel surgery. We present 3 cases of inflammatory responses to bovine collagen and porcine subintestinal mucosal nerve wraps in patients undergoing revision carpal tunnel surgery. No patient had evidence of infection, and pathology revealed acute and chronic inflammation. All 3 patients responded favorably following wrap removal. CONCLUSIONS: We recommend caution with the routine use of nerve wraps in the setting of revision carpal tunnel surgery.

Atypical Mycobacterial Infections of the Upper Extremity.

Atypical mycobacterial infections of upper extremity synovial-lined structures are often misdiagnosed and unrecognized. Despite an increasing incidence, lack of physician awareness of these pathogens may result in considerable delay in diagnosis and management, potentially leading to permanent disability. The authors conducted a literature review and analyzed 31 cases of penetrating atypical mycobacterial infection to better understand the clinical characteristics and to evaluate their posttreatment complication rate compared with available literature. Medical records for culture-positive cases of tenosynovial or intra-articular atypical mycobacterial infections of the upper extremity that were treated were retrospectively reviewed. Treatment outcomes were analyzed against published case reviews and case series. Thirty-one cases of penetrating atypical mycobacterial infection were identified. Mycobacterium marinum (n=11) was the most common organism and was associated with aquatic exposure. Twenty-eight cases received empiric treatment, 17 of which received contraindicated treatment. Patients saw an average of 5 physicians prior to receiving an accurate diagnosis, and the mean time to diagnosis was 10 months. All cases received antibiotic treatment in addition to surgical management. Twenty cases (68%) failed treatment outcomes. Delay in diagnosis and inappropriate management of atypical mycobacterial infections may lead to a treatment failure rate that is higher than what has been reported in the literature. Mycobacterium avium and M fortuitum had significantly higher failure rates than other organisms. A high index of suspicion is required to make a diagnosis and prevent residual disability. [Orthopedics. 2018; 41(3):e383-e388.].

The Effectiveness of Mini-C-Arm Fluoroscopy for the Closed Reduction of Distal Radius Fractures in Adults: A Randomized Controlled Trial.

PURPOSE: Most distal radius (DR) fractures are initially managed with closed reduction and orthosis application. Mini-C-arm fluoroscopy provides assessment of reduction quality in real time. Our null hypothesis was that there would be no difference in the reduction quality of DR fractures in the emergency department when using mini-C-arm fluoroscopy during reduction compared with standard reduction techniques (evaluating reduction quality with orthogonal radiographs taken in an orthosis). METHODS: Sixty-three consecutive patients with closed DR fractures requiring reduction between April 2015 and April 2017 were prospectively randomized to standard versus fluoroscopically aided reductions. Reductions were performed by orthopedic surgery residents. The primary outcome measurement was reduction quality (radial height, radial inclination, ulnar variance, and volar tilt) as measured on postreduction radiographs. RESULTS: Standard reductions were performed in 34 patients and fluoroscopically aided reductions in 29 patients. The 2 groups were similar in regards to all potential confounders that were analyzed. No differences in postreduction radial height, radial inclination, ulnar variance, or volar tilt were noted. Overall reduction attempts and subjective difficulty of fracture reduction were increased when using fluoroscopy. The rate of initial operative management did not differ between groups. CONCLUSIONS: The use of mini-C-arm fluoroscopy during the initial closed reduction of adult DR fractures results in equivalent postreduction radiographic parameters when compared with conventional reduction techniques. Additional research regarding time spent in the emergency department and overall cost could elucidate potential benefits of fluoroscopically aided DR fracture reduction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

The Accuracy of Common Hand Injections With and Without Ultrasound: An Anatomical Study.

BACKGROUND: The aim of the study is to determine the accuracy of hand injections with and without the aid of ultrasound (U/S) into the carpal tunnel, thumb carpometacarpal (CMC) joint, first dorsal compartment (DC) and the radiocarpal (RC) joint. METHODS: Four participants of various level of experience injected the carpal tunnel, thumb CMC, first DC, and RC joint into 40 fresh frozen cadaver specimens with blue dye and radiographic contrast. Participants 1 and 2 were injected without U/S guidance, and participants 3 and 4 were injected with U/S guidance. A successful injection was determined by both fluoroscopy and dissection/direct observation. Additional information was recorded for each injection such as median nerve infiltration and evidence of thumb CMC arthrosis. RESULTS: The overall accuracy for carpal tunnel, thumb CMC, first DC, and RC injections were 95%, 63%, 90%, and 90%, respectively. Success was compared with and without U/S guidance. Success rates were similar for each injection site, except the thumb CMC joint, where U/S participants had 25% higher accuracy. In the setting of thumb CMC arthrosis, the incidence of success was 38% for participants with no U/S aid and 72% for participants with U/S aid. There was a significant difference between participants who used U/S with the participant with more U/S experience being more successful. CONCLUSION: Carpal tunnel, first DC, and RC injections had an accuracy of greater than 90%. Thumb CMC injections have a lower accuracy (63%) and one can improve accuracy with U/S. The accuracy of U/S-guided injections is dependent on the user and their experience.

Use and Effectiveness of Ethyl Chloride for Hand Injections.

PURPOSE: Limited literature supports using ethyl chloride topical spray as an anesthetic for hand injections whereas documented risks include frostbite, skin irritation, and inhalation toxicity. We hypothesize that ethyl chloride spray imparts no benefit to patients' perception of pain or anxiety for routine hand injections. METHODS: We first surveyed all members of the American Society for Surgery of the Hand to discern the prevalence of ethyl chloride use during routine injections. We then performed a prospective, randomized, study at 2 institutions evaluating the efficacy of ethyl chloride spray compared with "routine injection" (no topical spray) in patients indicated for a hand injection. All patients completed a pre- and postinjection 11-point questionnaire that inquired about various components of pain and anxiety. RESULTS: A total of 2,083 (73% response rate) American Society for Surgery of the Hand members responded to the survey and revealed that 59% of hand surgeons always or often use ethyl chloride, and 24% never use it. There were no differences for region or practice setting, but experienced surgeons were less likely to routinely use ethyl chloride (35%) compared with younger surgeons (66%). Among 151 patients participating in the clinical study (75 with ethyl chloride), there were no differences for any outcome measure assessed. Injection pain in the spray and no-spray groups, pain after 1 minute, and overall anxiety were equivalent. Subgroup analysis demonstrated no effect of sex, anticipated anxiety, or pain threshold. CONCLUSIONS: Ethyl chloride is widely used among hand surgeons but imparts no benefit for routine hand injections in the clinical setting. The potential risks and costs of ethyl chloride use may outweigh its benefits. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Volar Anatomy of the Proximal Phalanx: Implications for Screw Length Selection for Fixation of Shaft Fractures.

PURPOSE: To investigate the anatomy of the volar surface of the proximal phalanx of the hand, specifically the longitudinal groove running along the volar phalangeal shaft. METHODS: We measured skeletonized proximal phalanges from 10 embalmed human cadaver hands at 5 equidistant points along the shaft. The difference between the maximum dorsal-palmar thickness of the shaft and thickness measured from the center of the volar groove to the most dorsal aspect of the phalanx indicated the depth of the groove at each point. These specimens underwent microtomography to characterize their osseous morphology further. Screws placed dorsal to palmar into the specimens and viewed fluoroscopically simulated the appearance of screw protrusion into the volar groove under intraoperative imaging. Similarly, screws placed into a fresh-frozen cadaveric hand illustrated possible screw impingement on soft tissue in vivo. RESULTS: The volar groove was most pronounced at the proximal and distal ends of the phalangeal shaft, becoming shallower along the midportion of the bone. The average difference between total bone thickness and thickness measured from the depth of the groove was significant at each of the 5 points of measurement along the phalangeal shaft for each of the 5 digits of the hand, including the thumb. Average groove depths ranged from 4% to 14% of total bone thickness, with a maximum individual measurement of 22%. Average depth of the groove at each of these positions ranged from 0.19 to 1.64 mm, reaching a maximum of 2.31 mm. CONCLUSIONS: We demonstrated that there is a longitudinal groove running the length of the phalangeal shaft. CLINICAL RELEVANCE: Viewed laterally, the cupped edges of the groove obscure its depth. Dorsally placed bicortical screws could protrude into the groove, remaining unnoticed on intraoperative imaging. The resulting impingement on the flexor tendon could lead to postsurgical stiffness or flexor tendon attritional rupture.

Modified Long Toe Extensor Tendon Harvest for Use as Intercalary Graft in Upper Extremity Reconstruction.

Autograft tendon harvested from the long toe extensors are of great utility as intercalary grafts in upper extremity reconstruction. However, standard full-length harvest is complicated by the presence of extensor retinacula and multiple juncturae between adjacent extensors, which often necessitate extensive dissection, increasing the potential for morbidity. We describe a modified technique for partial harvest of the long toe extensors, which is performed entirely proximal to the superior extensor retinaculum. This technique requires a single incision and provides adequate length of graft for the majority of forearm to fingertip reconstructions. The technique is described in the context of our preliminary cadaver findings, with a case example provided to further illustrate the utility of this technique.

Hardware-related complications following radiocarpal arthrodesis using a dorsal plate.

Background Hardware-related complications more than 6 months after total wrist arthrodesis are rarely reported, and controversy remains around the inclusion of the middle finger carpometacarpal joint (CMCJ) in the fusion mass. Purpose To determine the frequency of hardware-related complications including plate fractures, screw fractures, and symptomatic plate/screw loosening, and to investigate whether failure to fuse the middle finger CMCJ contributed to these hardware complications. Patients and Methods A retrospective chart review was designed to identify long-term hardware-related complications following 122 wrist arthrodeses using plate fixation. Patients with at least 6 months of follow-up were reviewed to determine the number of complications, the involvement of the middle finger CMCJ, and the procedures required to address these complications. Results At a median of 2.5 years following arthrodesis (range, 6 months-19 years), 20 (16%) hardware-related complications occurred and included screw fracture (n = 12), plate loosening (n = 5), and plate fracture (n = 3). Thirteen (65%) of the hardware complications occurred after the CMCJ was not fused during the procedure. The CMCJ did not fuse after attempted arthrodesis in 6 additional wrists. Conclusions Persistent middle finger CMCJ micromotion was likely present in 19/20 wrists (95%) that experienced symptomatic hardware complications. Given the occurrence of hardware failures centering on this joint, it is our recommendation that, unless one plans for routine plate removal within a given timeframe, the middle finger CMCJ must be included in the fusion mass. Level 4 Therapeutic Case Series.