Faculty Bibliography

BACKGROUND:Morphology may provide the basis for the understanding of wrist mechanics. METHODS:We used classification systems based on cadaver dissection of lunate and capitate types to evaluate a normal database of 70 wrist radiographs in 35 subjects looking for associations between bone shapes. Kappa statistics and a log-linear mixed -effects model with a random intercept were used. RESULTS:There were 39 type-1, 31 type- 2 lunates, 50 spherical, 10 flat and 10 V-shaped capitates. There was a significant difference in lunate and capitate shape between the hands of the same individual p <0.001. This may be due to different loads on the dominant vs. nondominant hands in the same individual. CONCLUSION/CONCLUSIONS:Further study to better understand the development of radiographic parameters of the midcarpal joint may aid in our understanding of the morphology and mechanics of the wrist.

Background: Quality of reduction in distal radius fractures (DRF) is assessed using radiographic parameters, however few studies examine the association between radiographic measurements and functional outcomes. Our purpose was to evaluate the relationship between radiographic measurements and clinical outcome measures following surgery for DRF using detailed testing to demonstrate further associations between post-surgical radiographic measurements and function. Methods: Measurements were performed on postoperative radiographs of 38 patients following ORIF of DRF. Measurements included: radial inclination, radial height, ulnar variance, volar tilt, radiocarpal interval (d2/w2), and the intra-articular step-off. Clinical outcome measures included motion, grip strength, functional dexterity testing, Moberg pick-up test, specific activities of daily living, DASH score, pain scale, manual-assessment questionnaire. Results: Different radiographic parameters correlated with different specific tasks. The parameter correlated with most functional tasks was ulnar-variance. Radial inclination, radial-styloid scaphoid distance, and fracture classification correlated with some functions. Intraarticular step-off, and radial height were not associated with functional testing. Conclusions: Surgical radiographic results may affect post-operative function. Detailed task specific testing may enable a better evaluation of surgical outcomes. Further study and refinement of functional assessment may change our surgical goals in DRF.

Background  Sensorimotor and specifically proprioception sense has been used in rehabilitation to treat neurological and joint injuries. These feedback loops are not well understood or implemented in wrist treatment. We observed a temporary sensorimotor loss, following distal radius fractures (DRF) that should be addressed postsurgery. Purpose  The purpose of this prospective therapeutic study was to compare the outcomes of patients following surgery for DRF treated using a sensorimotor treatment protocol with those patients treated according to the postoperative standard of care. Patients and Methods  Patients following surgery for DRF sent for hand therapy were eligible for the study. Both the evaluation and treatment protocols included a comprehensive sensorimotor panel. Patients were randomized into standard and standard plus sensorimotor postoperative therapy and were evaluated a few days following surgery, at 6 weeks, and 3 months postsurgery. Results  Sixty patients following surgery were randomized into the two treatment regimens. The initial evaluation was similar for both groups and both demonstrated significant sensorimotor deficits, following surgery for DRF. There was documented sensorimotor and functional improvement in both groups with treatment. The clinical results were better in the group treated with the sensorimotor-proprioception protocol mostly in the wrist; however, not all of the differences were significant. Conclusion  Patients after surgery for DRF demonstrate significant sensorimotor deficits which may improve faster when utilizing a comprehensive sensorimotor treatment protocol. However, we did not demonstrate efficacy of the protocol in treating proprioceptive deficits. Further study should include refinement of functional outcome evaluation, studying of the treatment protocol, and establishment of sensorimotor therapeutic guidelines for other conditions. Level of Evidence This is a level II, therapeutic study.

BACKGROUND:Because fragility fractures have an enormous impact on the practice of medicine and global health systems, effective screening is imperative. Currently, dual-energy X-ray absorptiometry (DXA), which has limited ability to predict fractures, is being used. We evaluated the current literature for a method that may constitute a better screening method to predict fragility fractures. A systematic review of the literature was conducted on computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound to evaluate screening methods to predict fragility fractures. We found that ultrasound had sufficient data on fracture prediction to perform meta-analysis; therefore, we analyzed prospective ultrasound cohort studies. Six study populations, consisting of 29,299 individuals (87,296 person-years of observation) and including 992 fractures, were analyzed. MRI was found to be sensitive and specific for osteoporosis, but its use for screening has not been sufficiently evaluated and more research is needed on cost, accessibility, technical challenges, and sensitivity and specificity. CT could predict fracture occurrence; however, it may be problematic for screening due to cost, exposure to radiation, and availability. Ultrasound was found to predict fracture occurrence with an increased risk of 1.45 (95% confidence interval 1.21-1.73) to fracture. Ultrasound has not replaced DXA as a screening tool for osteoporosis, perhaps due to operator-dependency and difficulty in standardization of testing.

BACKGROUND: Anatomical and functional differences between Asian and Caucasian populations have been described and are important in treatment of wrist pathology. The purpose of this study was to establish and compare normal values in an Asian and Caucasian population. We hypothesized that a normal Asian population will have greater wrist ROM and reduced grip- strength when compared to a normal Caucasian population. METHODS: One hundred and-seventy-one normal Asian and 156 normal Caucasian wrists were evaluated. We excluded wrists with current or a history of wrist pathology including past surgery, injury or congenital malformation. We collected demographic information regarding occupation, body mass index (BMI), and previous wrist pathology. The wrist measurements included: wrist extension, flexion, radial, ulnar deviation, and grip strength. Wrists were also evaluated for a mid-carpal clunk, and scaphoid shift test. Mixed models accounted for evaluation of both hands in the same individual and for the relative contribution of different factors to the outcome measures of ROM and grip- strength. RESULTS: The two groups differed in height, BMI and the distribution of occupation. The Asian group had more flexion, less extension and similar radial/ulnar wrist deviation when compared to the Caucasian group. Ethnicity was a significant predictor of wrist joint flexion and extension significantly predicting grip- strength. Age was associated with ROM while occupation, hand side and gender were not significant factors in the mixed model. CONCLUSIONS: We found discrete differences between values in the two populations. More study of anatomical morphological patterns may explain the reason for variations in motion and grip- strength. The differences identified in this study between Asian and Caucasian populations should be taken into account when evaluating outcomes of wrist therapeutic procedures and rehabilitation in different communities.

Surgical arthroplasty of thumb carpometacarpal (CMC) joint osteoarthritis is commonly performed. Postoperative therapeutic protocols aim to improve range of motion and function of the revised thumb. We describe a case in which the thumb CMC joint had been chronically dislocated before surgery, with shortening of the soft-tissue dynamic and static stabilizers of the joint. The postoperative protocol addressed the soft tissues using splinting and exercises aimed at lengthening and strengthening these structures, with good results. It may be beneficial to evaluate soft-tissue tension and the pattern of thumb use after surgery for thumb CMC joint osteoarthritis to improve postoperative functional results.

The literature evaluating external anatomical measurements and carpal tunnel syndrome (CTS) remains inconclusive. The purpose of this study was to compare hand- shape measurements of patients with and without (CTS). A retrospective case - control study of participants with suspected CTS (male/female ratio of 0.69) was performed. Nerve conduction tests (NCT) defined 73 involved hands (CTS) and 65 control hands. The relationship between 3 different hand index ratios (measuring palm length and width) and CTS (defined by NCT) was evaluated using Generalized Estimating Equations model (GEE) with the binary outcome of CTS. Palmar Length/Palmar Width index had the strongest and negative association with CTS with greatest sensitivity and specificity to detect CTS. Hands with more square shape had increased tendency to be diagnosed with CTS. Hand indices that include the shape of the palm may help identify patients with greater likelihood of developing CTS for early screening and prevention.

A retrospective study evaluated a large health maintenance organization for secondary prevention of osteoporosis following fragility fractures of the distal radius. Our population remained undiagnosed and untreated despite the ability of the system to provide adequate care. These patients specifically should be targeted for a comprehensive multidisciplinary effort at prevention. PURPOSE: Osteoporotic wrist fractures carry a high risk for subsequent fragility fractures. Despite therapeutic options and systems that can provide secondary prevention, patients are not always treated appropriately. Our purpose was to evaluate the treatment afforded following a distal radius fragility fracture in our health system. METHODS: A retrospective review of fractures following surgery was performed. Radiographs and mechanism of injury defined fragility fractures. Demographic data, other fractures, and secondary prevention measures were documented. RESULTS: Eighty-two patients were evaluated. The average age was 64 (10.2) years. The follow-up period following the index fracture was 25.2 months (SD = 4.6). Twenty-eight percent of patients had a second fragility fracture. Seven sustained a subsequent fracture within the follow-up period (8.5 %), and 16 (19.5 %) fractured prior to the index fracture. Mean time from primary to index fracture was 50 (42) months. Forty-seven percent of patients with an additional fracture carried the chart diagnosis of osteoporosis or osteopenia while 24.6 % of patients without an additional fracture carried this diagnosis (p = 0.049). No patients were referred for prevention or an endocrinologist at discharge. Twenty-one percent of patients were treated for osteoporosis at any point. CONCLUSIONS: Patients were unlikely to receive appropriate evaluation and treatment for secondary prevention of fragility fractures in our system. A system-based treatment plan for the prevention of osteoporosis should be implemented. Since distal radius fractures occur early in osteoporosis, these fractures should be targeted for secondary prevention.