Faculty Bibliography

The success of hand surgery relies heavily on post-operative therapy. The ability to identify barriers to patient adherence with therapy may therefore allow for improvement in therapeutic and surgical decisions and results. The purpose of this study was to identify significant barriers to adherence with hand therapy following surgery for distal radius fracture. A questionnaire addressing demographic, social, psychological, occupational and medical factors was administered to 20 subjects undergoing surgery for distal radius fracture. Adherence was evaluated by the therapist and by the number of missed sessions. There were 9 males and 11 females. Average age was 46.2 (19-88). The therapists' evaluation of adherence and number of missed appointments were significantly correlated (R2 = 0.86, p < 0.0001, Spearman's test). Gender, distance from therapy, and driving status were significantly related to adherence. Difficulty in reaching the therapy sessions was negatively related to adherence with hand therapy in our population. Other parameters such as smoking, were borderline significant. Further study is needed to investigate the effect of additional parameters, in a larger population in order to better define barriers to patient postsurgical adherence.

PURPOSE: Scaphoid fractures are classified according to their 2-dimensional radiographic appearance, and transverse waist fractures are considered the most common. Our hypothesis was that most scaphoid fractures are not perpendicular to the longitudinal axis of the scaphoid (ie, not transverse). METHODS: Computerized 3-dimensional analyses were performed on 124 computed tomography scans of acute scaphoid fractures. Thirty of the fractures were displaced and virtually reduced. The angle between the scaphoid's first principal axis (longitudinal axis) and the fracture plane was analyzed for location and displacement. The distal radius articular surface was used to depict the volar-dorsal vector of the wrist. RESULTS: There were 86 fractures of the waist, 13 of the distal third, and 25 of the proximal third. The average angle between the scaphoid longitudinal axis and the fracture plane was 53 degrees for all fractures and 56 degrees for waist fractures, both differing significantly from a 90 degrees , transverse fracture. The majority of fracture planes were found to have a volar distal to dorsal proximal (horizontal oblique) inclination relative to the volar-dorsal vector. CONCLUSIONS: Most waist fractures were horizontal oblique and not transverse. According to these findings, fixation of all fractures along the longitudinal axis of the scaphoid may not be the optimal mode of fixation for most. A different approach may be needed in accordance with the fracture plane. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

OBJECTIVES: Concomitant ligamentous injury in distal radius fractures (DRF) may explain continued pain following surgery. The purpose of this study was to compare radiographic measurements assessing scaphoid translation in DRF after reduction, to measurements performed on normal radiographs. This may allow noninvasive evaluation of radiocarpal ligamentous integrity. METHODS: Fifty postoperative radiographs were evaluated. The distance between the ulnar border of the radial styloid and the radial border of the scaphoid was measured midway between the styloid tip and scaphoid base, and then divided by scaphoid width at the same level. The measured ratios were compared to previously established normal data, established radiographic measurements of fracture reduction, fracture characteristics and fixation methods. RESULTS: Radiographic scaphoid position measurements differed significantly from normals (p = 0.0001). Fracture characteristics, surgical difficulty, and technique were not associated with scaphoid position. CONCLUSIONS: Despite accurate surgical reduction, abnormal positioning of the scaphoid may persist. This may reflect ligamentous injury, which generates suboptimal clinical results. Identifying and addressing ligamentous injury during surgery may prevent the development of instability and improve outcome after DRF.

Introduction Osteoarthritis (OA) in the wrist usually develops in a pattern described as scapholunate advanced collapse (SLAC). We observed an alternative pattern of OA that involves the lunocapitate joint in isolation with minimal involvement of the radioscaphoid articulation. Case Series The series was observed from a series of 100 wrist radiographs that were retrospectively reviewed. In order to characterize the alternative pattern of OA, we compared demographic data, presentation, and physical and radiographic examination characteristics between the patients with lunocapitate OA and SLAC wrists. Fifteen radiographs showed OA, nine had a SLAC pattern, and six had lunocapitate OA. The demographics were similar, but the clinical presentation was different. The patients with lunocapitate OA had less tenderness over the snuffbox (P < 0.03), and a lower percentage of a positive scaphoid shift test (P < 0.005). Isolated lunocapitate OA had a higher association with scaphotrapeziotrapezoidal (STT) arthritis (P < 0.004). The SLAC group had an increased scapholunate gap (P = 0.0003). Discussion The presentation of lunocapitate OA differs from SLAC wrist in a number of ways. Further study is necessary to understand the clinical implications of this pattern. Level IV evidence Case series.

INTRODUCTION: Current guidelines suggest early surgical treatment of open fractures. This rule in open hand fractures is not well supported and may be practically difficult to observe. Furthermore, desirable washout can be obtained in the emergency department (ED). The purpose of this study was to determine the importance of early surgery in our institution. METHODS: Seventy patients with open fractures of the hand were retrospectively reviewed for demographics, fracture characteristics, and complications. Statistical analysis included univariate analysis, Fisher exact test, and Akaike information criterion. RESULTS: Intravenous antibiotics were administered early in 53 (75.7%) patients. Mean (SD) time to surgery was 2.3 (134.9) hours. The infection rate was 11.4%. No significant relationship was found between fracture type, finger involved, hand dominance, comorbidities, and infection. Antibiotic administration was significantly related to infection (P = 0.007), whereas time to surgery was not (P = 0.33). Age was weakly related to infection (P = 0.08). DISCUSSION: Administration of intravenous antibiotics in the ED was the most significant factor in preventing infection, whereas the time to operation was not significant. Because a thorough washout and debridement can be performed on open hand fractures in the ED due to the ability to provide adequate anesthesia, the actual time to surgery may possibly be delayed without increasing the risk of infection. Future prospective studies may allow for better guidelines for the treatment of open hand fractures.

Fractures in ankylosing spondylitis (AS) are often difficult to treat and surgical treatment may be fraught with complications. We describe the use of a robotic-assisted device in the surgical treatment of an unstable L1 fracture in an elderly patient with chronic lymphocytic leukemia and AS. The postoperative course was uneventful and the patient was discharged after 3 days. The use of a robotic-assisted device in spine surgery is particularly indicated in difficult high risk cases.

The human wrist is a composite joint which incorporates multiple smaller joints. The biomechanics of the wrist are dependent on its bony structure but also on the ligamentous constitution of its joints. This increases the complexity of the joint and reduces our ability to understand its anatomy, mechanics and pathology. Therefore, our understanding and treatment of osteoarthritis in the wrist lags behind that of other joints in the body such as the knee. We discuss some of the recent directions in the comprehension and treatment of wrist osteoarthritis.

BACKGROUND: The lack of structural support remains a challenge in the treatment of comminuted distal radius fractures. Calcium phosphate and calcium sulfate bone cement has been used in other fracture locations in addition to fixation and has been shown to allow for retention of reduction in difficult cases. METHODS: A case-control retrospective review of 34 consecutive distal radius fractures treated with surgery was performed with the patients classified by Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification. Complications and postoperative radiographs were evaluated. RESULTS: Cement was used in the most difficult cases. Radial height was retained in both groups. Volar tilt was significantly better in the cement group. There were no significant differences between the case and control groups for any complication. No complications related to the use of the cement were found. CONCLUSIONS: The use of bone cement as an adjunct to fixation of distal radius fractures seems to include minimal risks and may afford a technical advantage in maintaining reduction during surgery for difficult fractures. Since there is an aspect of fracture difficulty that we cannot control for by using radiographic assessment alone, cement may provide an advantage over fixation without cement, despite similar outcomes. Bone cement can be part of the "tool box" for difficult distal radius fractures. Further study is necessary to define the technical advantages and limitations of each particular cement product.

We describe a hand therapy protocol aimed at unloading the wrist and increasing blood supply to the wrist, specifically to the lunate. The protocol was used in a series of patients with clinical radial wrist pain, dysfunction and changes on wrist imaging studies. The patients were not candidates for surgical treatment. Application of the therapy protocol improved objective and subjective parameters such as pain and motion, and may provide a viable treatment option for patients with lunate overload or early Kienbock's disease that are not candidates for surgery.