Faculty Bibliography

Lymphedema may be primary (because of congenital lymphatic abnormalities) or secondary (commonly caused by cancer treatments). It progresses from pitting edema to fibrotic, nonpitting swelling. Diagnosis involves limb measurements and imaging like lymphoscintigraphy, indocyanine green lymphography, and magnetic resonance imaging lymphangiography. Treatment begins with complete decongestive therapy, and unresponsive cases may undergo microsurgical procedures such as lymphaticovenous shunts or vascularized lymph node transfer. Historically clinicians advised against procedures like needle sticks or tourniquet use in lymphedema-affected limbs. However, recent evidence disproves these concerns. Surveys show hand surgeons are more open to operating on lymphedema patients than other specialists. Several small studies report no considerable worsening of lymphedema after surgery, although transient flare-ups and minor infections have been noted. No studies confirmed deep infections, and most erythema-related cases resolved with oral antibiotics. Patients with prior breast cancer surgery, especially those who underwent axillary lymph node dissection, were previously thought to be at high risk. However, multiple studies show that hand surgery does not increase the risk of developing lymphedema in this group. Tourniquet use and avoiding routine prophylactic antibiotics are generally considered safe. Hand surgery appears safe for patients with or at risk of lymphedema; however, caution is warranted given the lack of consensus guidelines and recommendations. There is a lack of standardized guidelines, and surgeon practices vary widely. Further interdisciplinary research is needed to establish clear protocols and ensure optimal outcomes for these vulnerable patients.

The ulnar nerve has a long and often misunderstood history with eponym usage. We describe the history of eponym usage in the anatomy of the ulnar nerve-who, when, what, where, and how. The relevant anatomy is investigated from proximal to distal, from the Arcade of Struthers to Osborne's band, to forearm ulnar nerve to median nerve connections, to Guyon's canal. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to ulnar nerve anatomy.

Endoscopic carpal tunnel release (ECTR) continues to rise in popularity as a treatment option for carpal tunnel syndrome. Numerous variations in technique and instrumentation currently exist, broadly classified into two-portal and single-portal techniques with antegrade and retrograde designs. ECTR is equally effective as open carpal tunnel release for alleviating symptoms of carpal tunnel syndrome with no differences in long-term outcomes. ECTR has an increased risk of transient nerve injury, whereas open carpal tunnel release has an increased risk of wound and scar complications. ECTR has higher direct costs but is associated with earlier return to work. ECTR is a safe and effective approach to carpal tunnel release in the hands of experienced surgeons.

Tumoral calcinosis is a rare and benign subtype of calcinosis cutis, a group of disorders involving soft tissue calcium deposition. Only 250 cases have been described since 1898; hand involvement is exceedingly rare. We report a case of extensive calcinosis within the flexor sheath of the little finger. Presentation included a painful mass over the volar aspect of the little finger, restricted digit motion, and skin compromise at the site of the mass. Surgical debulking was performed resulting in restoration of finger function.

PURPOSE/OBJECTIVE:Wide-awake local anesthesia no tourniquet (WALANT) is an increasingly popular surgical technique. However, owing to surgeon preference, patient factors, or hospital guidelines, it may not be feasible to inject patients with solutions containing epinephrine the recommended 25 minutes prior to incision. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis. METHODS:Ninety-six consecutive patients undergoing short hand procedures using only local anesthesia and a tourniquet (LA-T) were assessed before and after surgery. A high arm pneumatic tourniquet was used in 73 patients and a forearm pneumatic tourniquet was used in 23. All patients received a local, unbuffered plain lidocaine injection. No patients received sedation. Pain related to local anesthesia, pneumatic tourniquet, and the procedure was assessed using a visual analog scale (VAS). Patient experience was assessed using a study-specific questionnaire based on previous WALANT studies. Tourniquet times were recorded. RESULTS:Mean pain related to anesthetic injection was rated 3.9 out of 10. Mean tourniquet related pain was 2.9 out of 10 for high arm pneumatic tourniquets and 2.3 out of 10 for forearm pneumatic tourniquets. Patients rated their experience with LA-T favorably and 95 of 96 patients (99%) reported that they would choose LA-T again for an equivalent procedure. Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times less than 10 minutes were associated with less pain than tourniquet times greater than 10 minutes (P < .05); however, both groups reported the tourniquet to be on average less painful than the local anesthetic injection. CONCLUSION/CONCLUSIONS:Short wide-awake procedures using a tourniquet are feasible and well accepted. Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. Tourniquets for short wide-awake procedures can be used in settings in which preprocedure epinephrine injections are logistically difficult or based on surgeon preference. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Therapeutic IV.

The Essex-Lopresti injury is caused by a high energy mechanism and consists of a characteristic triad: a comminuted radial head fracture, disruption of the distal radioulnar joint, and tearing of the interosseous membrane. These injuries are often difficult to diagnosis on initial evaluation, and the majority are missed acutely. Chronic Essex-Lopresti injuries lead to radioulnar longitudinal instability, proximal radius migration, ulnocarpal impaction, and chronic elbow pain. These injuries present a challenging problem for the treating surgeon.

A Stener lesion is a complete tear of the ulnar collateral ligament (UCL) from the thumb proximal phalanx at the level of the metacarpophalangeal (MCP) joint that is displaced superficial to the adductor pollicis aponeurosis, leading to interposition of the aponeurosis between the UCL and the MCP joint. The interposition of the adductor aponeurosis distinguishes the Stener lesion from other UCL injuries and impedes healing, thereby necessitating surgery. A thorough clinical examination, including valgus stress testing of the MCP joint, is crucial to the diagnosis. In cases where the clinical evaluation is equivocal, imaging studies including ultrasound or magnetic resonance can be performed. Acute Stener lesions can be treated with repair of the UCL primarily through direct suture, suture anchor, or pull-out suture techniques. Chronic injuries are treated with dynamic (via tendon transfer) or static (via grafting) reconstruction methods, while MCP arthrodesis or arthroplasty can be reserved for cases where MCP joint osteoarthritis is present. Overall, patient outcomes are generally good with operative treatment of Stener lesions. This article reviews the relevant anatomy and pathogenesis, clinical evaluation, diagnostic studies, management, outcomes, complications, and an illustrative case of Stener lesions and complete UCL injuries of the thumb.

CONTEXT/BACKGROUND:Major League Baseball (MLB) players are at risk of hook of hamate fractures. There is a paucity of data assessing the effect of a hook of hamate fracture on MLB players' future athletic performance. OBJECTIVE:To determine if MLB players who sustain hook of hamate fractures demonstrate decreased performance upon return to competition when compared with their performance before injury and that of their control-matched peers. DESIGN/METHODS:Retrospective Case-Control Design. SETTING/METHODS:Retrospective Database Study. PARTICIPANTS/METHODS:18 MLB players who sustained hook of hamate fractures. METHODS:Data for 18 MLB players with hook of hamate fractures incurred over 26 seasons (1989 to 2014) were obtained from injury reports, press releases, and player profiles ( www.mlb.com and www.baseballreference.com ). Player age, position, number of years in the league, mechanism of injury and treatment were recorded. Individual season statistics for the two seasons immediately prior to injury and the two seasons after injury for the main performance variable - wins above replacement (WAR) were obtained. Eighteen controls matched by player position, age, and performance statistics were identified. A performance comparison of the cohorts was performed. MAIN OUTCOME MEASURES/METHODS:Post-injury performance compared to pre-injury performance and matched-controls. RESULTS:Mean age at the time of injury was 25.1 years with a mean of 4.4 seasons of MLB experience prior to injury. All injuries were sustained to their nondominant batting hand. All players underwent operative intervention. There was no significant change in WAR or ISO when pre-injury and post-injury performance was compared. When compared with matched-controls, no significant decline in performance in WAR the first season and second season after injury was found. CONCLUSION/CONCLUSIONS:MLB players sustaining hook of hamate fractures can reasonably expect to return to their pre-injury performance levels following operative treatment.

Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.