Fellowship-trained Hand Surgeons Research Articles

Conservative treatment of lateral epicondylitis: The impact of psychosocial factors on perceived treatment efficacy

BACKGROUND: The relationship of pain, function, and treatment in lateral epicondylitis is not fully understood. Improved understanding of this interrelationship may be required to optimize treatment strategies, particularly with regard to bracing and activity modification. METHODS: A cohort of 36 patients diagnosed by a fellowship-trained hand surgeon over a 25-month period that received treatment in the form of a cock-up wrist splint (CUWS) and recommendations of activity modification was identified. The patients’ function was defined by the QuickDash Outcome measure and pain by the Numeric Pain Rating. Retrospective analysis of prospectively collected pre-treatment data were compared to those obtained following treatment using Wilcoxon signed-rank test. Changes in QuickDash Outcome measures and Numeric Pain Rating following treatment were compared between those individuals that stated the treatment helped and those that stated it did not. RESULTS: Following treatment with a CUWS and activity modification, the median QuickDash score was 8 compared to 40 prior to treatment (95% CI: -32 ~ -20, p-value < 0.0001) indicating statistically significant functional improvement. All 36 of 36 (100%) patients stated that they were able to return to a normal activity level at the time of follow-up. Numeric Pain Rating values improved from 6 to 1 following treatment (95% CI: -6 ~ -4, p-value < 0.0001) The Kendall’s Tau-b correlation coefficient between Numeric Pain Ratings and QuickDash Outcome measure was 0.296 (p-value = 0.018) and 0.473 (p-value = 0.001) before and after treatment, respectively, suggesting a weak to moderate correlation. Patients who stated that the treatment was effective experienced a median change in their QuickDash outcome score of -23 compared to -37 for those whom did not think it was an effective treatment; the estimated difference between the two groups was 14 (CI: 2, 30, p-value 0.019) indicating that patients who thought treatment was not effective actually experienced greater functional improvement. CONCLUSIONS: These results indicate that use of a CUWS and recommendations of activity modification is an effective strategy to help improve patient function and pain levels. However, low to moderate correlation between pain and disability both before and after treatment indicate that other factors such as coping skills and psychosocial influences may effect the disease and treatment course. Furthermore, patients may still make gains in function while questioning the effectiveness of their treatment, which may make assessment of therapeutic response difficult. Future research should be directed at identifying which factors other than pain may influence disability and devising strategies to address them.

Risk factors for complications of open trigger finger release.

Open trigger finger release is generally considered a simple low-risk procedure. Reported complication rates vary widely from 1 to 43%, mostly based on small studies. Our goal was to determine the incidence of complications in a large consecutive series, while also identifying potential risk factors. All open trigger finger releases performed from 2006 to 2009 by four fellowship-trained hand surgeons at a single institution were retrospectively reviewed. There were 795 digits released in 543 patients. Complications were defined as signs or symptoms requiring further treatment and/or considered unresolved by 1month postoperatively. Complications requiring operative intervention were regarded as major. Multivariable analysis was performed to determine possible risk factors for complications. There were 95 documented complications among 795 digits (12%). The most common complications involved persistent pain, stiffness, or swelling, persistent or recurrent triggering, or superficial infection. Most were treated nonoperatively with observation, therapy, steroid injection, or oral antibiotics. There were 19 reoperations (2.4%), mostly including revision release, tenosynovectomy, and irrigation and debridement. Male gender, sedation, and general anesthesia were independently associated with complications, while age, diabetes, hypothyroidism, recent injection, and concurrent procedures were not associated. Open trigger finger release is generally a low-risk procedure, although there is potential for complications, some requiring reoperation. Male gender, sedation, and general anesthesia may be associated with greater risk. Surgeons should be careful to thoroughly discuss the risk of both major and minor complications when counseling patients.

Routine imaging after operatively repaired distal radius and scaphoid fractures: a survey of hand surgeons.

Background There is currently no standard of care for imaging after hand and upper-extremity procedures, and current imaging practices have not been characterized. Questions/Purposes To characterize current imaging practices and to compare those practices to the best available evidence. Patients and Methods A survey was distributed to attending-level surgeons at a regional hand and upper-extremity surgery conference in the United States in 2013. 40 out of 75 surgeons completed the survey (53%). Results All results are presented for distal radius and scaphoid fractures, respectively. There was a high degree of variability between respondents in the number of radiographic series routinely ordered during follow-up of asymptomatic patients, with the number of series ranging from 1-6 and 1-6. On average, respondents did not order an excessive number of follow-up radiographs for asymptomatic patients, with means (± standard deviations) of 2.6 ± 1.0 and 3.3 ± 1.2 radiographic series. Radiographic series were taken at only 74% and 81% of postoperative visits with asymptomatic patients. Only 10% and 8% of respondents felt it was acceptable medical practice to save costs by ordering postoperative radiographs only when patients are symptomatic. Conclusions Among a sample of 40 fellowship-trained hand surgeons, these findings demonstrate a high degree of variability in number of radiographs obtained after operative repair of distal radius and scaphoid fractures. On average, respondents were relatively efficient with respect to total number of postoperative radiographs ordered. Level of Evidence Diagnostic study, level IV.

Blood Glucose Levels in Diabetic Patients Following Corticosteroid Injections Into the Hand and Wrist

To quantify diabetic patients' change in blood glucose levels after corticosteroid injection for common hand diseases and to assess which patient-level risk factors may predict an increase in blood glucose levels. Patients were recruited for this case-crossover study in the clinic of fellowship-trained hand surgeons at a tertiary care center. Patients with diabetes mellitus type 1 or 2, who received a corticosteroid injection, recorded the morning fasting blood glucose levels for 14 days after the injection. Fasting glucose levels on days 1 to 7 after injection qualified as case data; levels on days 10 to 14 provided control data. A mixed model with a priori contrasts was used to compare postinjection blood glucose levels with baseline levels. We used a linear regression model to determine patient predictors of a postinjection rise in blood glucose levels. Of 67 patients recruited for the study returned, 40 (60%) completed blood glucose logs. There was a significant increase in fasting blood glucose levels after injection limited to postinjection days 1 and 2. Among patient risk factors in the linear regression model, type 1 diabetes and use of insulin each predicted a postinjection increase in blood glucose levels from baseline, whereas higher glycated hemoglobin levels did not predict increases. Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients. Patients with type 1 diabetes and insulin-dependent diabetics are more likely to experience this transient rise in blood glucose levels. Therapeutic III.

The Effects of Pronator Quadratus Repair on Outcomes After Volar Plating of Distal Radius Fractures

The purpose of this study was to evaluate forearm rotation after volar plating of the distal radius fractures with and without pronator quadratus repair. This was an institutional review board-approved retrospective review of prospectively collected data. The study was conducted at an Academic Medical Center. Over a 5-year period, 606 patients with distal radius fractures (OTA classifications 23-A through 23-C) were enrolled in an institutional review board-approved, prospectively collected, distal radius database. One hundred and seventy-five patients underwent open reduction and internal fixation with volar plating. Of these, 112 patients had complete 1-year follow-up (6 weeks, 3, 6, and 12 months) and were included in this study. Volar plating of the distal radius was performed with pronator quadratus repair (group A), versus volar plating without pronator quadratus repair (group B). Surgeries in group A were performed by a fellowship trained hand surgeon utilizing volar plates from Depuy Orthopedics (Warsaw, IN), whereas the surgeries in group B were performed by a fellowship trained orthopedic trauma surgeon utilizing volar plates from Stryker (Mahwah, NJ). Primary outcomes include forearm range of motion. Secondary outcomes include grip strength, pain levels, functional outcomes (DASH scores), radiographs, and complications. Baseline and demographic characteristics of the patients were similar between the 2 groups. There was no difference in mean pronation (P = 0.08) at 1 year. Among secondary analyses, radial deviation was significantly different (P = 0.03); however, pain (P = 0.13) and DASH scores (P = 0.14) were not. The only patient that requested plate removal had the pronator repaired (group A). We conclude that there is no advantage in repairing the pronator quadratus during volar plating of distal radius fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of Upper and Lower Extremity Tinel Signs in Diabetics: Crosssectional Study from a United States, Urban Hospital-based Population

Objective: To evaluate the prevalence of the Tinel Sign in the upper and lower extremities of patients with diabetes in an urban community. Methods: An IRB-approved, prospective, cross-sectional, descriptive study was performed on patients with diabetes during their visit to the endocrinologist. Eighty-one consecutive patients (162 sides) were examined by a fellowship-trained Hand Surgeon, experienced in performing the “Tinel Sign”. Mean duration of diabetes was 18.5 years. In the upper extremity known sites of anatomic entrapment were percussed; median nerve at the wrist (carpal tunnel), ulnar nerve at the elbow (cubital tunnel), radial sensory nerve in the forearm, and a negative control site. In the lower extremity, sites were tibial nerve at ankle (tarsal tunnel), proximal tibial nerve (soleal sling), common peroneal nerve at fibular neck (fibular tunnel), superficial peroneal nerve, deep peroneal nerve over dorsum of the foot, and a negative control site. Neuropathy was defined as a score greater than 4 on the Michigan Neuropathy Screening Instrument (MNSI). Statistical evaluation included linear regression, analysis of variance, and Tukey’s post hoc test. Results: 100% of the control sites had absent Tinel Sign. MNSI score and number of positive Tinel Signs were highly correlated ( r=0.94, p=0.001). Upper extremity, prevalence of Tinel Sign in patients with neuropathy (i.e. MNSI >4) ranged from 46.2% to 65% compared to 2.4% to 19.5% without neuropathy (MNSI < 4). Lower extremity prevalence ranges were 23% to 59% with neuropathy and 0% to 17.1% without neuropathy. The chances of having a positive Tinel Sign in the contralateral limb were 38.2%, 42.2%, 44.7% and 48.4% for carpal tunnel, cubital tunnel, fibular tunnel and tarsal tunnel, respectively. Conclusion: Presence of a Tinel sign was highly correlated with presence of neuropathy in diabetics.

Accuracy of Sonographically Guided and Palpation Guided Scaphotrapeziotrapezoid Joint Injections

The purpose of this study was to determine and compare the accuracies of sonographically guided and palpation guided scaphotrapeziotrapezoid (STT) joint injections in a cadaveric model. A clinician with 6 years of experience performing sonographically guided procedures injected 1.0 mL of a diluted latex solution into the STT joints of 20 unembalmed cadaveric wrist specimens using a palmar approach. At a minimum of 24 hours after injection, an experienced clinician specializing in hand care completed palpation guided injections in the same specimens using a dorsal approach and 1 mL of a different-colored latex. A fellowship-trained hand surgeon blinded to the injection technique then dissected each specimen to assess injection accuracy. Injections were graded as accurate if the colored latex was found in the STT joint, whereas inaccurate injections resulted in no latex being found in the joint. All sonographically guided injections were accurate (100%; 95% confidence interval, 81%-100%), whereas only 80% of palpation guided injections were accurate (95% confidence interval, 61%-99%). Sonographically guided injections were significantly more accurate than palpation guided injections, as determined by the ability to deliver latex into the joint (P < .05). Sonographic guidance can be used to inject the STT joint with a high degree of accuracy and is more accurate than palpation guidance within the limits of this study design. Clinicians should consider using sonographic guidance to perform STT joint injections when precise intra-articular placement is desired. Further clinical investigation examining the role of sonographically guided STT joint injections in the treatment of patients with radial wrist pain syndromes is warranted.

Sonographically Guided Distal Radioulnar Joint Injection

Distal radioulnar joint (DRUJ) disorders are uncommon but important causes of ulnar-sided wrist pain and disability. Fluoroscopically guided injections may be performed to diagnose or treat DRUJ-related pain or as part of a diagnostic arthrogram. Sonographic guidance may provide a favorable alternative to fluoroscopic guidance for distal DRUJ injections. This report describes and validates a sonographically guided technique for DRUJ injections in an unembalmed cadaveric model. An experienced clinician used sonographic guidance to inject diluted colored latex into the DRUJs of 10 unembalmed cadaveric specimens. Subsequent dissection by a fellowship-trained hand surgeon confirmed accurate injections in all 10 specimens. Two cases of ulnocarpal flow, indicative of triangular fibrocartilage injury, were noted during injection and subsequently confirmed during dissection. Clinicians should consider using sonographic guidance to perform DRUJ injections when clinically indicated. Further research should explore the efficacy of sonographically guided DRUJ injections to treat patients with painful DRUJ syndromes or to evaluate the triangular fibrocartilage complex in patients with ulnar wrist pain syndromes.

The Rate of Triangular Fibrocartilage Injuries Requiring Surgical Intervention

Triangular fibrocartilage complex injuries are one of the most common causes of ulnar-sided wrist pain. Although pain and discomfort may improve with simple immobilization for a short period of time, a significant number of patients eventually require surgical intervention. The purpose of this study was to investigate the incidence of surgical intervention on patients with a clinical diagnosis of a triangular fibrocartilage complex injury. A retrospective chart review was performed to identify patients with ulnar-sided wrist pain identified with the appropriate ICD-9 code from September 2005 to September 2007. All patients were evaluated and treated by a board-certified, fellowship-trained hand surgeon. Any patients with associated pathology were excluded from the study. All patients were initially treated with a minimum of 4 weeks of either a volar wrist splint worn all the time or a short-arm cast. Magnetic resonance images were obtained on patients without symptomatic relief, and in these cases, surgical arthroscopy was performed. Of the 84 patients identified, 36 patients required surgical intervention. All 36 patients had evidence of triangular fibrocartilage complex injury during arthroscopy. All patients had symptomatic improvement postoperatively. The use of short-arm cast versus a splint did not affect the rate of surgical intervention (P=.38). Among the patients with clinical diagnosis of triangular fibrocartilage complex injury, the rate of surgical intervention required after a minimum 4 weeks of immobilization was 43%. The use of a short-arm cast or volar wrist splint did not affect the rate of surgical intervention.

13-Year Experience of Carpal Tunnel Release Using the Indiana Tome Technique

This study evaluated the reliability and morbidity rate of carpal tunnel release with the Indiana Tome technique via a small palmar incision when used by experienced hand surgeons. A retrospective review was performed of 1332 carpal tunnel releases using the Indiana Tome performed by 2 fellowship-trained hand surgeons at university hospitals from July 1993 to August 2006. Chart review focused on complications with this technique. All patients returned to preoperative activities, in employment or otherwise. Nonmanual laborers resumed regular job tasks between 2 days and 3 weeks. The 2 surgeons experienced 11 complications in 1332 cases, for an overall complication rate of 0.83%. The most common complication, in 8 cases, was numbness and hypersensitivity in the third common digital nerve distribution; 2 of these 8 patients had normal 2-point discrimination and the other 6 had persistently 2-point discrimination greater than 10 mm despite resolution of preoperative paresthesia symptoms. In the latter group, 3 patients had repeat exploration, with findings of fascicular injury and scarring in 2 patients and normal nerve in the third (who ultimately had normalized 2-point discrimination by 6 weeks after surgery). The 3 patients without re-exploration had their 2-point discrimination returned to normal by 11 months after surgery. Ultimately, only 2 patients (0.15%) had persistently increased 2-point discrimination. The remaining complications (3 cases) were transient neuropraxia of the entire median nerve (1 patient), an incomplete release (1 patient) requiring repeat surgery, and a recurrence of carpal tunnel syndrome (1 patient) with perineural scar noted at 8 months after surgery, treated successfully with a hypothenar fat pad flap. This is the largest retrospective review of the Indiana Tome technique to date. This technique can be used by experienced hand surgeons and offers early resumption of preoperative activities and a low complication rate. The most common complication was neurapraxia in the third common digital nerve distribution. The overall complication rate was 0.83% (11 in 1332). Therapeutic IV.

Comparison of Sagittal Computed Tomography and Plain Film Radiography in a Scaphoid Fracture Model

To compare computed tomography (CT) in the sagittal plane and plain film radiography in the diagnosis of scaphoid fracture and displacement. Three groups of scaphoids (no fracture, undisplaced fractures, fractures with displacement > 1 mm) from 11 cadaver wrists were prepared. Each wrist then was imaged by using sagittal plane CT scans in the long axis of the scaphoid and plain film imaging using 6 standard scaphoid views. Eight readers from 3 specialties read each group of images. The sensitivity and specificity for the presence of fracture and fracture displacement were calculated in addition to interobserver and intraobserver reliabilities for each. Both x-ray and CT scans showed a high sensitivity and specificity in detecting the presence of a fracture with no interspecialty differences. The sensitivity for displacement greater than 1 mm was lower for both modalities with no inter-specialty differences. The specificities for x-ray and CT for detecting displacement greater than 1 mm were 84% and 89%, respectively. The poor sensitivity for detecting displacement was explained by the low sensitivity of CT in the diagnosis of radial/ulnar displacement compared with x-ray and the low sensitivity of x-ray in the diagnosis of volar/dorsal displacement compared with CT scans. When fellowship-trained hand surgeons reviewed CT scans and plain films together the sensitivity and specificity for fracture displacement increased significantly. Intraobserver and interobserver reliability for both x-ray and CT scans was excellent except for the reading of CT scans among emergency physicians and for the reading of plain x-rays among senior house staff, representing moderate agreement. Based on these results both CT scans in the sagittal plane and plain films accurately detect fractures with a high degree of interobserver and intraobserver reliability, but they fall short in detecting displacement greater than 1 mm.