Faculty Bibliography

Radial head arthroplasty was introduced in 1941 and the literature supports satisfactory overall midterm patient outcomes and acceptable complication profiles with several models. There are several previously described mechanisms by which radial head complications typically occur. We present the case of a rarely described mechanism of radial head implant failure: elbow synovitis and pain from partial dissociation and metallosis in an adjustably aligned, modular, monopolar, mixed metal, press-fit radial head arthroplasty.

BACKGROUND:No study exists on preparatory time-from patient's entrance into the operating room to skin incision-and its role in hand surgery operating room inefficiency. The purpose of this study was to investigate the length and variability of preparatory time and assess the relationship between several variables and preparatory time. METHODS:Consecutive upper extremity cases performed for a period of 1 month by hand surgeons were reviewed at 3 surgical sites. Preparatory time was compared across locations. Cases at one location were further analyzed to assess the relationship between preparatory time and several variables. Both traditional statistical methods and Shewhart control charts, a quality control tool, were used for data analysis. RESULTS:A total of 288 cases were performed. The mean preparatory times at the 3 sites were 25.1, 25.7, and 20.7 minutes, respectivley. Aggregated preparatory time averaged 24.4 (range 7-61) minutes, was 75% the length of the surgical time, and accounted for 34% of total operating room time. Control charts confirmed substantial variability at all locations, signifying a poorly defined process. At a single site, where 189 cases were performed by 14 different surgeons, there was no difference in preparatory time by case type, American Society of Anesthesiologists status, or case start time. Preparatory time varied by surgeon and anesthesia type. CONCLUSIONS:Preparatory time was found to be a source of inefficiency, independent of the surgical site. Control charts reinforced large variations, signifying a poorly designed process. Surgeon seemingly plays an important, albeit likely indirect, role. Efforts to improve operating room workflow should include preparatory time.

BACKGROUND:The purpose of this study was to prospectively document the incidence of variations in the course of palmar cutaneous branch of the median nerve (PCBMN) that may increase the risk of injury to the nerve during the flexor carpi radialis (FCR) approach. We hypothesize that the incidence of anomalous branching of the PCBMN around the FCR sheath will be approximately 5%. METHODS:All cases that met inclusion criteria between November 2013 and March 2018 were included. The operating surgeon made the final decision for operative intervention using the FCR approach. Each surgeon performed the standard FCR approach to the distal radius. The branching location from the median nerve, the relationship to the FCR sheath, and the course of the PCBMN were recorded. RESULTS:In total, 101 distal radius fractures were included. The average branching point of PCBMN was 5.2 cm from the distal wrist crease (range = 3.3-9.0). There were 26 anomalous branching patterns of PCBMN. Nineteen (18.8%) crossed volar, dorsal, or ran within the FCR sheath. Six PCBMN were found within the FCR sheath, 1 penetrated the FCR sheath, 6 crossed volar to the FCR sheath, and 6 were dorsal to the FCR tendon sheath. When comparing the branching patterns of the PCBMN from the median nerve, 4 branched from the volar aspect, 2 branched from the dorsal aspect, and 1 branched from the ulnar aspect of the median nerve. CONCLUSIONS:Variation in the course of the PCBMN relative to the FCR sheath is more than previously thought and can be expected in approximately 18.8% of patients.

BACKGROUND:A cadaveric study was performed to evaluate the accuracy and reliability of radiographic estimation of the volar lip fragment size in proximal interphalangeal joint fracture-dislocations. METHODS:Middle phalangeal base volar lip fractures of varying size and morphology were simulated in 18 digits. Radiographs and digital photographs of the middle phalangeal joint surface were obtained pre- and postinjury. Ten orthopedic surgeons of varying levels of training estimated the fracture size based on radiographs. The estimated joint involvement on radiograph was compared with the digitally measured joint involvement. RESULTS:Radiographic estimation underestimated the volar lip fragment size by 9.02%. Estimations possessed high intraobserver (0.76-0.98) and interobserver (0.88-0.97) reliabilities. No differences were detected between levels of surgeon training. CONCLUSIONS:The significant underestimation of the volar lip fragment size demonstrates the lack of radiographic estimation accuracy and suggests that surgeons should be mindful of these results when making treatment plans.

PURPOSE: To correlate the physical examination finding of distal radial metaphyseal tenderness with plain radiographic and magnetic resonance imaging after acute wrist injury to diagnose occult distal radius fractures. We hypothesized that persistent distal radial metaphyseal tenderness 2 weeks after acute injuries is predictive of an occult fracture. METHODS: Twenty-nine adult patients presented, after acute trauma, with distal radial metaphyseal tenderness and initial plain radiographs and/or fluoroscopic images that did not show a distal radius fracture. Patients were reevaluated clinically and radiographically at approximately 2 weeks after initial presentation. Patients with persistent distal radial tenderness and negative radiographs underwent magnetic resonance imaging to definitively diagnose an occult distal radius fracture. We calculated the sensitivity and positive predictive value for persistent distal radial metaphyseal tenderness using a 95% confidence interval and standard formulas. Both radiographs and magnetic resonance imaging were used as our endpoint diagnosis for a distal radius fracture. RESULTS: We diagnosed 28 occult distal radius fractures, 8 by follow-up radiograph and 20 by magnetic resonance imaging. The positive predictive value for patients who completed the protocol was 96%. One patient who did not have an occult distal radius fracture had a fracture of the ulnar styloid. CONCLUSIONS: Tenderness of the distal radial metaphysis after wrist injury is strongly suggestive of a distal radius fracture despite both normal plain radiographs and fluoroscopic images. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

BACKGROUND:The purpose of this study is to evaluate the role of radiographic and clinical exams in predicting screw penetration into the proximal radioulnar joint and ulnohumeral joint during open reduction and internal fixation of the radial head and proximal ulna. METHODS:Olecranon and radial head plates were applied to 15 cadaveric elbows. Screws were assessed for intra-articular joint penetration using both clinical exam and radiographic evaluation. Clinical exam consisted of evaluation for crepitus. Radiographs demonstrating screws positioned near the joint surface were evaluated for penetration by 3 fellowship trained hand surgeons. Elbows were disarticulated and screw prominence was determined and recorded using standardized calipers. The ability of clinical and radiographic exams to correctly predict a breach in the articular surface was determined by calculating sensitivity, specificity, and predictive values. Consideration was given to screw position. RESULTS:The sensitivity of crepitus was 81.1% for screws in the radial head plate and 72.6% for screws in the olecranon plate. The sensitivity of radiographs was 72.4% for the screws in the radial head plate and 55.0% for screws in the olecranon plate. Correct radiographic assessment of penetration varied but position o-2 on the olecranon plate consistently resulted in the lowest sensitivity of 30.3%. CONCLUSIONS:The study evaluates sensitivity and specificity of clinical and radiographic means when assessing for articular penetration of screws during olecranon and radial head locking plate fixation. Certain screw locations are more difficult to evaluate than others and may go undetected by standard means of assessment used in a surgical setting.

Thumb ligament injuries are common, particularly those involving the metacarpophalangeal joint. Our understanding and treatment of these injuries continues to evolve. This article provides a comprehensive review of recent literature with updates pertaining to the anatomy, function, diagnosis, and treatment of thumb ligament injuries.

PURPOSE: Distal radius fractures comprise the majority of hand- and wrist-related malpractice claims. We hypothesized that a majority of lawsuits would be for malunions resulting from nonsurgical treatment. Additional goals of this study were to quantify costs associated with claims, determine independent risk factors for making an indemnity payment, and illustrate trends over time. METHODS: Seventy closed malpractice claims filed for alleged negligent treatment of distal radius fractures by orthopedic surgeons insured by the largest medical professional liability insurer in New York State (NYS) from 1981 to 2005 were reviewed. We separately reviewed defendants' personal closed malpractice claim histories from 1975 to 2011. Overall incidence of malpractice claims among distal radius fractures treated in NYS was calculated using the NYS Statewide Planning and Research Cooperative System database and the 2008 American Academy of Orthopedic Surgeons census data. RESULTS: The overall incidence of malpractice claims for distal radius fracture management was low. Malunion was the most common complaint across claims regardless of treatment type. Claims for surgically treated fractures increased over time. A majority of claims documented poor doctor-patient relationships. Male plaintiffs in this group were significantly older than males treated for distal radius fractures in NYS. Most defendants had a history of multiple malpractice suits, all were male, and only a small percentage were fellowship-trained in hand surgery. Defendants lacking American Board of Orthopedic Surgery certification were significantly more likely to make indemnity payments. Thirty-eight of 70 cases resulted in an indemnity payment. CONCLUSIONS: Malunion and poor doctor-patient relationships are the major features of malpractice litigation involving distal radius fracture management. Older defendant age and lack of American Board of Orthopedic Surgery certification increase the likelihood of making an indemnity payment. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analyses II.

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.