Faculty Bibliography

A survey regarding upper-extremity steroid injection practices was distributed to all active members of the American Society for Surgery of the Hand (ASSH) and American Shoulder and Elbow Surgeons (ASES) using SurveyMonkey. Response rates for the ASSH and ASES were 26% and 24%, respectively. The potency-adjusted dose of steroid injected for common hand and wrist injections ranged from 0.375 to 133.33 mg and for shoulder injections ranged from 0.375 to 250 mg. These ranges span 356-fold and 667-fold differences, respectively. Potency-adjusted doses differed significantly between steroid types for all injections evaluated in this study. American Society for Surgery of the Hand members gave significantly smaller doses of steroid for the glenohumeral and acromioclavicular joints than ASES members. Only 9% of respondents based injection practice on a scientific reference. Sixteen percent of ASSH and 31% of ASES respondents reported no specific rationale for their steroid injection practice; 78% of ASSH and 52% of ASES respondents attributed their rationale to some kind of instruction from their mentors or colleagues. Upper-extremity surgeons demonstrate substantial variability in their practice of steroid injections, with up to a 667-fold range in steroid dose. Experienced clinical opinion is the principal rationale for these injection practices; little rationale is based on formal scientific evidence.

The treatment of patients with distal radius fractures can be challenging and requires a thorough understanding of the condition. Many treatment options are available. The choice of treatment is based on patient factors, such as age and activity level, along with the characteristics of the fracture. It is helpful to use a case-based format to review the anatomy, the radiographic evaluation, and the initial and definitive treatment options for patients with distal radius fractures.

Although there are many surgical options to treat thumb carpometacarpal (CMC) arthritis, a precise etiology for this common disorder remains obscure. To better understand the physiology of the thumb CMC joint and treat pathology, it is helpful to examine the biomechanics, hormonal influences, and available surgical treatment options, along with the evolutionary roots of the thumb; its form and function, its functional demands; and the role of supporting ligaments based on their location, stability, and ultrastructure. It is important to appreciate the micromotion of a saddle joint and the role that sex, age, and reproductive hormones play in influencing laxity and joint disease. Minimally invasive surgery is now challenging prevailing treatment principles of ligament reconstruction and plays a role in thumb CMC joint procedures.

Locally administered corticosteroids are a common therapy in many hand and wrist disorders. Corticosteroids pose a theoretical risk to patients with diabetes mellitus by potentially raising blood glucose to hyperglycemic levels. Although oral corticosteroids are known to have an effect on blood glucose control, limited data exist on extra-articular administration. The purpose of this study was to examine the systemic impact of extra-articularly administered corticosteroids in the hand and wrist on serum glucose concentration in patients with diabetes mellitus.Twenty-three patients with diabetes mellitus received a 1-mL triamcinolone acetonide injection for de Quervain's tenosynovitis, trigger finger, flexor carpi ulnaris tendonitis, or carpal tunnel syndrome. Patients recorded their daily morning blood glucose levels for 1 week before injection and for 4 weeks after injection. Average blood glucose levels increased slightly from baseline after injection, reaching statistical significance 1, 5, and 6 days after injection, but were not clinically significant (average increase, 14.2, 9.7, and 32.7 mg/dL, respectively). Isolated increases more than 2 times the standard deviation of preinjection values occurred at least once in the majority of patients. The frequency of hyperglycemic episodes increased after injection, but the proportions of patients with at least 1 hyperglycemic episode before and after injection were not significantly different.These results suggest that local corticosteroid injections are a clinically safe treatment option for inflammatory processes of the hand and wrist in patients with diabetes mellitus. On average, patients experienced slight increases in blood glucose after receiving an injection. Most experienced isolated increases substantially beyond baseline and isolated hyperglycemic effects, but these did not pose an apparent clinical risk.

PURPOSE: Displaced olecranon fractures are often amenable to treatment with open reduction and tension-band wiring. The purpose of this study is to examine the relationships of the tips of K-wires used in a tension-band construct to volar neurovascular structures in the proximal forearm and the proximal radioulnar joint. METHODS: We performed simulated percutaneous pinnings of the proximal ulna under fluoroscopic guidance on 15 cadavers with intact proximal ulnas. The K-wires were drilled obliquely through the tip of the olecranon process and directed to engage the anterior ulnar cortex, distal to the coronoid. Using calipers, we measured the distance from the tip of each pin to the anterior interosseous nerve (AIN), ulnar artery, proximal radioulnar joint (PRUJ), and volar cortex of the ulna, as well as the distance from the volar cortex of the ulna to the AIN and ulnar artery. The angle created by the K-wires and the longitudinal axis of the ulna was measured on both anteroposterior and lateral radiographs. RESULTS: The distance from pin tip to the AIN and ulnar artery measured a mean of 16 mm with a standard deviation of 6 mm and 14 mm with a standard deviation of 5 mm, respectively, with 1 pin abutting the artery. The shortest distance from both the AIN (11 +/- 5 mm) and the ulnar artery (8 +/- 6 mm) was measured with the shallowest angle of insertion, ranging from 10 degrees to 14.9 degrees on lateral radiographs. The mean distance between the pin tip and the PRUJ measured 7 mm with a standard deviation of 4 mm, with 3 pins penetrating the PRUJ. CONCLUSIONS: The impaction of K-wires under the triceps is often approximately 1 cm, which is similar to the distance of the K-wire tips to the AIN and ulnar artery. Our findings suggest that larger insertion angles might help avoid neurovascular injury when the insertion point of the K-wires is at or just proximal to the tip of the olecranon. In this study, the safe zone for pin insertion on the anteroposterior view is 0 degrees to 10 degrees , and on the lateral view it is 20 degrees to 30 degrees . CLINICAL RELEVANCE: This anatomic study was done to diminish the chance of complications resulting from K-wire placement during tension-band wiring for olecranon fractures.

PURPOSE: The extensor digitorum communis (EDC) splitting approach is a direct lateral approach that can provide greater visualization of the proximal radius than the posterolateral approach to the elbow. The purposes of this study were to identify the anatomic relationships of the posterior interosseous nerve (PIN) during the EDC splitting approach to the proximal radius and to determine its safe zone. METHODS: A fellowship-trained attending hand surgeon performed the EDC splitting approach on 15 cadaveric arms, exposing the EDC origin from the lateral epicondyle and dissecting distally to expose the supinator muscle. Calipers were used to measure the distance from the PIN to the radiocapitellar joint and to the lateral epicondyle in neutral position, full supination, and full pronation. The depth of the nerve from the most superficial aspect of the EDC was recorded for each cadaver. RESULTS: The average distances from the radiocapitellar joint to the PIN in neutral, supination, and pronation were 44.5 +/- 7.9, 40.8 +/- 8.1, and 48.2 +/- 7.9 mm, respectively. The average distances from the lateral epicondyle to the PIN in neutral, supination, and pronation were 61.7 +/- 10.9, 57.6 +/- 9.1, and 64.7 +/- 11.5 mm, respectively. The shortest distance measured from the radiocapitellar joint to the PIN in pronation was 29 mm; the shortest distance measured from the lateral epicondyle to the nerve was 42 mm. The average depth of the nerve from the most superficial aspect of the EDC was 10.2 +/- 2.4 mm. CONCLUSIONS: The PIN is generally safe when dissecting up to 29 mm from the radiocapitellar joint and up to 42 mm from the lateral epicondyle with the forearm in pronation.

PURPOSE: Closed reduction and percutaneous pinning is a reliable technique for treating 2- and 3-part distal radius fractures. There are currently no data that demonstrate the proximity of at-risk nerves and tendons during percutaneous placement of 5 commonly used K-wires. Whereas the previous literature notes the risk of superficial radial nerve injury with K-wire insertion into the radial styloid, the current study provides specific distances, not only to the superficial radial nerve (SRN) but also to the tendons of the first through fifth extensor compartments during K-wire insertion. METHODS: K-wires (1.5 mm or 0.059 in) were placed percutaneously into the distal radius of 15 cadaver specimens, simulating fixation of a distal radius fracture. After dissection, the distance from the K-wires to the extensor tendons and branches of the SRN were measured and tabulated. RESULTS: The volar radial styloid K-wire was an average distance of 1.47 mm +/- 1.7 from the closest branch of the SRN. One penetrated a branch of the SRN. The dorsal radial styloid K-wire was an average distance of 0.35 mm +/- 0.64 from the closest branch of the SRN. No tendons in the first compartment were found penetrated by or touching the K-wires. The transverse radial K-wire was an average distance of 1.07 mm +/- 1.57 from the branches or trunk of the SRN. One K-wire was found piercing the volar branch of the SRN, and 1 K-wire was found piercing the abductor pollicis longus. The dorsal rim K-wire was an average of 2.94 mm +/- 2.11 from the ulnar aspect of the extensor pollicis longus and an average of 1.44 mm +/- 1.65 from the radial aspect of the extensor digitorum communis. The dorsoulnar K-wire was an average distance of 1.88 mm +/- 1.6 ulnar or radial to the extensor digiti quinti proprius and penetrated it in three specimens. CONCLUSIONS: The volar radial styloid, transverse radial, and dorsoulnar K-wires all penetrated either tendons or nerves. It is therefore prudent to make a small incision to identify and protect the underlying structures prior to placement of K-wires used for the fixation of distal radius fractures. Also, care must be taken not to place the dorsal K-wires more than 5 mm ulnar to Lister's tubercle to avoid extensor digitorum communis injury.

PURPOSE: Steroid injections are commonly performed by hand surgeons for relief of symptoms associated with carpal tunnel syndrome. The purpose of this study is to examine the relationship of the needle to the median nerve within the carpal tunnel and to the palmar cutaneous branch, using 2 injection techniques. METHODS: Simulated carpal tunnel injections were performed on 15 cadaveric arms using 2 methods. The first injection used a widely accepted approach in which the needle is inserted at the wrist crease, just ulnar to the palmaris longus, and directed at a 30 degrees angle to the horizontal. In the second method, the needle is positioned just ulnar to the palpable ulnar border of flexor carpi radialis and angled 30 degrees to the horizontal. Specimens were dissected using an open carpal tunnel release. Calipers measured the distance from each needle to the median nerve within the carpal tunnel and to the palmar cutaneous branch. RESULTS: Using the first injection method, the needle pierced the median nerve in 4 specimens, and its mean distance from the nerve measured 1.34 mm +/- 1.83 mm. With the second injection method, the median nerve was pierced in 1 specimen, and the needle averaged a distance of 4.79 mm +/- 3.96 mm from the nerve. In the first approach, the needle averaged 9.47 mm +/- 4.11 mm from the palmar cutaneous branch, compared to 1.74 mm +/- 1.59 mm with the second technique. CONCLUSIONS: Physicians must exercise caution when performing carpal tunnel injections to avoid intraneural injection. The needle was a statistically significant shorter distance to the median nerve with the traditional injection method; however, the alterative method risks injury to the palmar cutaneous branch of the median nerve.