Faculty Bibliography

Medial and lateral elbow pain are often due to degenerative tendinosis and less commonly due to trauma. The involved structures include the flexor-pronator tendon origin in medial-sided pain and the extensor tendon origin in lateral-sided pain. Multimodality imaging is often obtained to verify the clinically suspected diagnosis, evaluate the extent of injury, and guide treatment decisions. Image-guided procedures can provide symptom relief to support physical therapy and also induce tendon healing. Surgical debridement and repair are typically performed in refractory cases, resulting in good to excellent outcomes in most cases. In this article, we review and illustrate pertinent anatomical structures of the distal humerus, emphasizing the structure and contributions of the flexor-pronator and extensor tendon origins in acute and chronic tendon abnormalities. We also discuss approaches to image-guided treatment and surgical management of medial and lateral epicondylitis.

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.

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.

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 ± 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 ± 0.86), and while their physical examinations were only "moderately effec-tive" (2.64/5.00 ± 0.99), they were "fairly confident" in their diagnoses (4.03/5.00 ± 0.64). Lastly, 36.7% ± 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.

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.

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.

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.