The Variable Insertional Anatomy of the Abductor Pollicis Longus: Functional Relevance and Relationship to Adjacent Thumb Extensors
BACKGROUND:The abductor pollicis longus (APL) is classically described as inserting on the base of the first metacarpal. This study analyzed APL insertional anatomy and quantified the size of various elements of the extensor side of the thumb to determine associations with size and function. METHODS:Twenty-four formalin-preserved upper limbs were dissected. The insertional anatomy of the APL, extensor pollicis brevis, and extensor pollicis longus were characterized, and the capacity of APL tendon slips to perform palmar abduction of the first digit was quantified based on slip size and insertion. RESULTS:The mean number of APL tendon slips observed was 2.3. Abductor pollicis longus insertion sites included the base of the first metacarpal, trapezium, abductor pollicis brevis, and opponens pollicis. Only 4 specimens had a solitary metacarpal slip, while 83% of specimens had insertions onto at least 1 thenar muscle. A total of 62.5% of APL tendons exhibited some form of branching that we categorized into "Y" and "Z" patterns. In assessing palmar abduction capacity, we found that APL tendon slips inserting into the base of the first metacarpal were larger in cross-sectional area than nonmetacarpal slips and reproduced complete palmar abduction of the digit in the absence of nonmetacarpal slips. The abduction capacity of APL tendon slips was not correlated to the cross-sectional area. CONCLUSIONS:There is significant variability in APL tendon slips, branching patterns, and insertional anatomy. These findings provide further understanding of the function of the APL and its surgical implications.
Musculoskeletal Ultrasonography of the Extremities: Clinical and Ultrasonographic Correlation
Ultrasonography as a diagnostic and therapeutic tool has become a resource for musculoskeletal injuries. It can be a useful imaging modality for clinical correlation of physical examination findings as well as an aid for image-guided procedures. Understanding the settings in which it is a helpful adjunct will have implications on efficiency and cost utility. The objectives of this chapter are to provide a background of ultrasonography as a musculoskeletal imaging modality, provide clinical correlation for ultrasonographic findings for common upper extremity pathology, review the diagnostic efficacy of ultrasonography for image-guided procedures, and provide insight into the cost utility of ultrasonography guidance for therapeutic injections.
Patient and Surgeon Satisfaction with Telehealth During the COVID-19 Pandemic
BACKGROUND:Until recently, telehealth represented a small fraction of orthopedic surgery patient interactions. The COVID-19 pandemic necessitated a swift adoption of telehealth to avoid patient and provider exposure. This study analyzed patient and surgeon satisfaction with telehealth within the department of orthopedic surgery during the height of the COVID-19 pandemic. METHODS:All orthopedic surgery patients who partici-pated in telehealth from March 30 to April 30, 2020, were sent a 14-question survey via e-mail. Orthopedic surgeons who used telehealth were sent a separate 14-question survey at the end of the study period. Factors influencing patient satisfaction were determined using univariate proportional odds and multivariate partial proportional odds models. RESULTS:Three hundred and eighty-two patients and 33 surgeons completed the surveys. On average, patients were "satisfied" with telehealth (4.25/5.00 Â± 0.96), and 37.0% preferred future visits to be conducted using telehealth. Multivariate partial proportional odds modeling determined that patients who found it easiest to arrange the telehealth visit had greater satisfaction (5.00/5.00 vs. 1.00-3.00/5.00: OR = 3.058; 95% CI = 1.621 to 5.768, p < 0.001), as did patients who believed they were able to communicate most effectively (5.00/5.00 vs. 1.00-4.00/5.00: OR = 20.268; 95% CI = 5.033 to 81.631, p < 0.001). Surgeons were similarly "satisfied" with telehealth (3.94/5.00 Â± 0.86), and while their physical examinations were only "moderately effec-tive" (2.64/5.00 Â± 0.99), they were "fairly confident" in their diagnoses (4.03/5.00 Â± 0.64). Lastly, 36.7% Â± 24.7% of surgeons believed that their telehealth patients required an in-person visit, and 93.9% of surgeons will continue using telehealth in the future. CONCLUSIONS:Telehealth emerged as a valuable tool for the delivery of health care during the COVID-19 pandemic. While both patients and surgeons were satisfied with its use, this study identifies areas that can improve the patient and surgeon experience. The effectiveness and satisfaction with telehealth should inform regulatory and reimbursement policy.
Proximal Row Carpectomy Versus 4-Corner Fusion: Incidence, Conversion to Fusion, and Cost
PURPOSE/OBJECTIVE:The primary objective of this study was to compare incidence, demographic trends, and rates of subsequent fusion between proximal row carpectomy (PRC) and 4-corner fusion (4CF) among patients in the United States. METHODS:A total of 3,636 patients who underwent PRC and 5,047 who underwent 4CF were identified from the years 2005 through 2014 among enrollees in the PearlDiver database. Regional distribution, demographic characteristics, annual incidence, comorbidities, and subsequent wrist fusion were compared between the 2 groups. Of the patients identified, 3,512 from each group were age- and sex-matched and subsequently compared for rates of converted fusion, 30- and 90-day readmission rates, and average direct cost. RESULTS:Patients undergoing 4CF and PRC did not have statistically significant differences in comorbidities. The incidence of the procedures among all subscribers increased for both PRC (1.8 per 10,000 to 2.6 per 10,000) and 4CF (1.2 per 10,000 to 2.0 per 10,000) from 2005 to 2014. Comparing the matched cohorts, patients who underwent 4CF had a higher rate of subsequent fusion than those who underwent PRC (2.67% vs 1.79%). Readmission rates were not significantly different at 30 or 90 days. Average direct cost was significantly greater for 4CF than for PRC. CONCLUSIONS:Both PRC and 4CF have been utilized at increasing rates in the past decade. Wrist fusion rates and average costs are higher in the 4CF group without a significant difference in readmission rates. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Therapeutic III.
The Declining Use of Wrist-Spanning External Fixators
Background: External fixation has been traditionally used to treat comminuted or open distal radius fractures that are not amenable to open reduction internal fixation. This procedure is associated with a relatively high complication rate and has been used with decreasing frequency in recent years. However, trends in external fixation utilization for the treatment of distal radius fractures have not been described. Methods: Using the Nationwide Inpatient Sample, patients with a distal radius fracture treated with external fixation from 2003 to 2014 were identified. The annual incidence was reported, and hospital and demographic variables associated with external fixation use were determined. Results: During the study period, 593 929 patients with a distal radius fracture were identified, of which 51 766 (8.7%) were treated with a wrist-spanning external fixator. Wrist external fixation for the treatment of distal radius fractures declined steadily from 2003 to 2014. In 2003, external fixation use was highest, accounting for 17.4% of distal radius fractures. By 2014, only 4.9% of distal radius fracture were treated with external fixation. During this period, the incidence of distal radius fractures declined by 6.9% while external fixator utilization decreased by 73.7%. Patients receiving an external fixator were more likely to be male, low-income, and treated in a rural, nonteaching, privately owned hospital. Conclusions: External fixator use for the treatment of distal radius fractures steadily declined during the study period. Males and those with lower incomes treated in rural, nonteaching, and privately owned hospitals are more likely to receive external fixation.
Single-stage bilateral reverse total shoulder arthroplasty for bilateral posterior shoulder fracture-dislocation following seizure: A case report [Case Report]
INTRODUCTION/BACKGROUND:Posterior shoulder dislocations comprise a small percentage of shoulder dislocations. Even more uncommon are posterior shoulder fracture-dislocations, which are commonly associated with trauma, seizures, and electrical shock. PRESENTATION OF CASE/METHODS:We present the case of a 64-year-old right-hand dominant male who sustained bilateral shoulder posterior fracture-dislocations after a hypoglycemia-induced seizure. The patient was treated with bilateral reverse total shoulder arthroplasties in a single-stage. He recovered well and continues to have excellent function and range of motion at 4-year follow-up. DISCUSSION/CONCLUSIONS:Treatment options for proximal humerus fracture-dislocations include open reduction internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder arthroplasty (RTSA). The indications for reverse total shoulder arthroplasty continue to expand. CONCLUSION/CONCLUSIONS:This is a rare case of bilateral posterior shoulder fracture-dislocations. In similar cases, simultaneous reverse total shoulder arthroplasties can be considered as a viable treatment option.
Wrist-Spanning Fixation of Radiocarpal Dislocation: A Cadaveric Assessment of Ulnar Translation
Background: Radiocarpal dislocations represent a high-energy wrist injury that can occur with or without concomitant fractures about the wrist. Poor outcomes are often due to radiocarpal instability and secondary ulnar translation. The purpose of this cadaveric study is to determine if there is any difference in the radiographic parameters in a wrist dislocation model given the different location of distal fixation. Methods: Ten paired fresh cadaver upper extremities were fluoroscopically evaluated with posterior-anterior (PA) and lateral views. We created a radiocarpal dislocation model and applied a dorsal bridge plate to either the second or third metacarpal. Repeat PA and lateral fluoroscopic views were obtained for evaluation of radial inclination, radial height, volar tilt, ulnar variance, radiolunate angle, radioscaphoid angle, scapholunate angle, radial rotation index, and four indices for ulnar translation (Taleisnik, Gilula, McMurtry, and Chamay). Results: Bridge plate application to the second metacarpal resulted in a significantly greater incidence of ulnar translation compared to the third metacarpal. Application to either metacarpal resulted in extension of the carpus relative to the radius. Conclusions: A more anatomic radiocarpal relationship was restored more often when distal fixation of the dorsal wrist-spanning bridge plate was applied to the third metacarpal. Further investigation is warranted to determine clinical relevance of these findings in conjunction with clinical and radiographic outcomes.
Epidemiological and Treatment Trends of Distal Radius Fractures across Multiple Age Groups
Background â€ƒThe purpose of this study is to assess the epidemiology, population-specific treatment trends, and complications of distal radius fractures in the United States. Methods â€ƒThe PearlDiver database (Humana [2007-2014], Medicare [2005-2014]) was used to access US inpatient and outpatient data for all patients who had undergone operative and nonoperative treatment for a distal radius fracture in the United States. Epidemiologic analysis was performed followed by age-based stratification, to assess prevalence, treatment trends, and rates of complications. Results â€ƒA total of 1,124,060 distal radius treatment claims were captured. The incidence of distal radius fractures follows a bimodal distribution with distinct peaks in the pediatric and elderly population. Fractures in the pediatric population occurred predominately in males, whereas fractures in the elderly population occurred more frequently in females. The most commonly used modality of treatment was nonoperative; however, the use of internal fixation increased significantly during the study period, from 8.75 to 20.02%, with a corresponding decrease in percutaneous fixation. The overall complication rate was 8.3%, with mechanical symptoms most frequently reported. Conclusions â€ƒThe last decade has seen a significant increase in the use of internal fixation as treatment modality for distal radius fractures. The impetus for this change is likely multifactorial and partly related to recent innovations including volar locking plates and an increasingly active elderly population. The implicated financial cost must be weighed against the productivity cost of maintaining independent living to determine the true burden to the healthcare system.
Carpal Translocation Following Dorsal Bridge Plate Fixation of Distal Radius Fractures: A Cadaveric Study
Background â€ƒDorsal bridge plate fixation is an effective technique for stabilization of highly comminuted, complex distal radius fractures. However, it is unknown whether fixation to the second or third metacarpal is optimal. Given dorsal bridge plating spans the radiocarpal joint, it is unclear if the dorsal spanning plate affects carpal position. This study investigates differences in carpal translocation resulting from bridge plate distal fixation to either the second or third metacarpal. Methods â€ƒTen paired cadaveric upper extremities without evidence of gross deformity or prior surgery distal to the elbow were evaluated with three-view wrist fluoroscopic images for baseline radiographic measurements. An unstable distal radius fracture model was created via a volar approach using a 1-cm osteotomy. Following fracture creation, a dorsal bridge plate was applied with random to the second metacarpal on one limb, and the third metacarpal on the contralateral limb. Laterality for distal fixation was chosen randomly. Fluoroscopic images were repeated and radial inclination, radial height, radiocarpal angle, volar tilt, ulnar variance, radiolunate angle, radioscaphoid angle, radial rotation index, and carpal translocation were measured. Results â€ƒRadial inclination, radial height, radiocarpal angle, volar tilt, ulnar variance, radiolunate angle, and radioscaphoid angle were not statistically different before and after fixation, or when comparing the second or third metacarpal fixation. Additionally, there was no difference in Taleisnik's ulnar translocation index, Chamay's ulnar translation index, or McMurtry's carpal translation index based on which metacarpal was used for distal fixation. Conclusions â€ƒDorsal bridge plate fixation of distal radius fractures restores preoperative physiologic measures of the radius, ulna, and carpus. Carpal translocation was similar when comparing distal fixation to the second or third metacarpal in distal radius fractures stabilized with a bridge plate. Level of Evidence â€ƒThis is a Level V, therapeutic study.
Safety of skeletal traction through the distal femur, proximal tibia, and calcaneus