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Background: Spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer can restore function to the rotator cuff following brachial plexus injuries. The traditional anterior approach using the lateral branch of the SAN causes denervation of the lateral trapezius limiting shoulder elevation. Suprascapular nerve pathology at the suprascapular notch may be missed resulting in poor reinnervation of the rotator cuff. The posterior approach uses the medial SAN and allows decompression and visualization of the SSN at the notch and nerve transfer coaptation closer to the target muscles with a shorter reinnervation distance.

Methods: This is a review of 28 patients from 2014 to February 2020 who underwent SAN to SSN nerve transfer via a posterior approach. Patients were evaluated for SSN pathology, external rotation power, and range of motion. Data were evaluated for high-energy trauma (HET) and low-energy trauma/nontraumatic etiology subsets.

Results: A total of 8 HET (40%) patients had pathology identified at the suprascapular notch during the posterior approach, including SSN scarring, ruptures, neuromata-in-continuity, and ossification of ligaments. British Medical Research Council grade greater than or equal to 4 shoulder external rotation was achieved in 75% patients with median range of motion 137.5°.

Conclusions: Spinal accessory nerve to SSN transfer using a posterior approach allows visualization of pathology involving the SSN and coaptation of a medial SAN transfer close to the target muscles. Following HET, 8 cases (40%) had posterior pathology identified. Spinal accessory nerve to SSN transfer through a posterior approach shows improved external rotation power and range of motion.

Background: Proximal phalanx fractures are common, with surgical fixation indicated for unstable fractures. Traditionally, closed reduction percutaneous pinning (CRPP) resulted in decreased stiffness and tendon irritation compared to open reduction internal fixation (ORIF). We hypothesized that more recent studies would have more similar outcomes to CRPP. The purpose of this study was to compare CRPP and ORIF in terms of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and complications.

Methods: Four electronic databases were queried from 2010 to present. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two independent reviewers performed a two-step review process to identify relevant articles. Patient demographics, total active motion (TAM), DASH, and complications were extracted. The methodological quality of each study included was assessed independently. Meta-analysis was performed for comparative trials.

Results: Fourteen studies met inclusion criteria including four comparative studies: Thirteen studies included TAM. The weighted average TAM was 228 ± 34° for CRPP and 223 ± 32° for ORIF (P = .07 with 95% confidence interval (CI), -0.5 to 10.5). Seven studies evaluated DASH scores; weighted average was 8.2 ± 8.9 for CRPP and 11.7 ± 6.5 for ORIF (P < .01 with 95% CI, 1.8-5.2). Two studies directly compared CRPP to ORIF, favoring ORIF for both TAM with d = 1.07 and DASH with d = 0.23. Rates of tenolysis or hardware removal were higher for ORIF (P < .01).

Conclusions: New literature suggests more equipoise with regard to treatment of proximal phalanx fracture with CRPP versus ORIF.

Type of study/level of evidence: Meta-analysis, Level II.

Background: There is increased interest in ultrasound (US) for the diagnosis of cubital tunnel syndrome (CuTS). We hypothesize that ulnar nerve cross-sectional area (CSA) correlates with disease severity and electrodiagnostic studies (EDX).

Methods: ARetrospective review was performed at a tertiary medical center. One hundred seventeen patients (166 ulnar nerves) were evaluated. Maximum CSA at 3 points around the elbow (proximal, groove, and distal) and EDX results (American Board of Electrodiagnostic Medicine-certified physiatrist's interpretations) were collected.

Results: US was positive (CSA > 0.1 cm²) in 95/117 cases (81.20%) versus 84/117 (71.79%) positive for EDX. CuTS patients treated surgically had significantly greater (0.13 cm², standard deviation [SD] 0.038) preoperative CSA than non-operative patients (0.10 cm², SD 0.033) (p = .003). CSA increased as EDX increased in severity; mild (0.116 cm², SD 0.031), moderate (0.121 cm², SD 0.035), and severe (0.163 cm², SD 0.047) with a significant difference between the mild and severe groups (P = .001) and between the moderate and severe groups (p = .01). Significant differences were seen between patients with positive US and EDX studies compared to those with negative US and EDX in the average physical function scores (57.26, SD 8.57 versus 43.18, SD 7.70; p < .001); average sleep scores (50.14, SD 9.53 versus 56.62, SD 7.31; p = .02); average physical function scores (43.04, SD 8.68 versus 57.08, SD 6.34; p < .001) and average depression scores (49.10, SD 10.88 versus 45.043, SD 7.06; p = .02).

Conclusions: US is a reliable tool for diagnosis and surgical decision-making for CuTS.

Type of study/level of evidence: Diagnostic/III.

Background: Kirschner wire (K-wire) insertion during surgery for distal radius fractures carries a risk of damaging the radial nerve's superficial branch. In this prospective study, we investigated the relationship between the radial nerve's superficial branch and the radius using ultrasound to minimize risk.

Methods: We collected data from 101 healthy volunteers (202 limbs; 51 men; mean age: 40.6 years). We ultrasonographically assessed the courses of the radial nerve's dorsal and superficial palmar branches at 0, 1, 2, and 3 cm proximal to the radial styloid process tip. The positional relationship between the radial nerve's superficial branch and the radius was determined by splitting the radius's ultrasound map into 4 sections (R1-R4) from the palmar side. The section containing the dorsal and palmar branch midpoints was determined for each height.

Results: In many limbs, the dorsal branch tended to wrap from the proximal palmar to the distal dorsal side at 1 to 2 cm proximal to the radial styloid process tip. In approximately 90% of limbs, the palmar branch ran along the radius's palmar side rather than the radial surface.

Conclusions: A small incision enabling direct view may be the best approach for avoiding nerve damage when the superficial branch is less than or equal to 2 cm proximal to the tip of the radial styloid process. Inserting the K-wire from the dorsal side of the radius may be safer for more proximal locations. We recommend a preoperative ultrasound examination to determine the course of the superficial branches of the radial nerve in each patient.

Background: Ultrasound (US) has emerged as a promising supplement to electrodiagnostic studies (EDX) in the diagnosis of cubital tunnel syndrome (CuTS) and has potential to be performed by novice operators. Our objective is to understand the discrepancies in assessment between the two modalities and to assess the utility of US in CuTS diagnosis by a novice operator.

Methods: Patients who presented to a single tertiary academic medical center and clinically diagnosed with CuTS were prospectively enrolled. Electrodiagnostic studies were performed along with US measurements of the cross-sectional area (CSA) of the ulnar nerve by both a board-certified physiatrist and novice operator. Electrodiagnostic study and US outcomes were compared among four diagnostic impression groups: EDX-/US-, EDX+/US-, EDX-/US+, and EDX+/US+.

Results: Sixteen patients were classified as abnormal by both EDX and US, 14 were classified abnormal by US only, 3 were classified abnormal by EDX only, and 6 were classified normal by both EDX and US (P = .008, K = 0.14). The EDX+/US+ group had a significantly reduced sensory amplitude compared with the EDX-/US+ (P = .04) group. Diagnostic classifications between a board-certified physiatrist and novice operator were in moderate agreement (K = 0.58, P = .08).

Conclusions: Ultrasound detected a greater proportion of patients as abnormal than EDX. A subset of patients with clinical diagnoses of CuTS had normal sensory amplitudes but increased maximum nerve CSAs. Competency in US may be easily acquired with minimal training, suggesting its potential to be extended for use by other members of the health care team.

Background: Arthroplasty is commonly performed in the management of osteoarthrosis of the hand and wrist by orthopedic or plastic surgeons with a fellowship in hand. The differences between operative outcomes between the 2 groups have not been described. Therefore, we analyzed a national database to determine acute outcomes between orthopedic and plastic surgery when performing arthroplasty for osteoarthrosis of the hand and wrist.

Methods: A retrospective cross-sectional analysis was performed by including patients with osteoarthrosis of the hand and wrist by International Classification of Diseases codes. Demographic, operative, and outcome variables were collected. Pearson χ² and Fischer exact tests were used for categorical variables, while a Mann-Whitney U test was performed for continuous variables. Multivariate regression analysis was performed to determine strength of predictors.

Results: There were 3721 patients who received arthroplasty for osteoarthrosis of the hand and wrist from 2007 to 2020. Most cases were performed by orthopedic surgeons (82.7%); however, there were an increasing number of surgeries performed by plastic surgeons. Most cases were performed on the intercarpal or carpometacarpal joints (81.7%). The incidence of acute complications was low (1.9%) with superficial surgical site infections (SSIs) being the most common complication. Univariate analysis found that plastic surgery may result in higher chances of superficial SSIs, but multivariate analysis indicated that there were no significant differences between the 2 groups.

Conclusion: There were no significant differences on multivariate regression analysis between plastic and orthopedic surgeons, suggesting that both can perform arthroplasty of the hand and wrist without safety concerns.

Background: The use of online search engines for health information is becoming common practice. We analyzed Google search queries to identify the most frequently asked topics and questions related to lateral epicondylitis ("tennis elbow") and the Web sites provided to address these questions.

Methods: Four search terms for lateral epicondylitis were entered into Google Web Search. A list of the most frequently asked questions along with their associated Web sites was extracted and categorized by 2 independent reviewers.

Results: A total of 400 questions were extracted with 168 associated Web sites. The most popular question topics were related to indications/management (39.0%), risks/complications (19.5%), and the ability to perform specific activities (18.8%). Frequently asked questions had to do with the duration of symptoms, self-management strategies (eg, brace use and self-massage), and the indications for surgery. The most common Web sites provided to address these questions were social media (27.5%), commercial (24.5%), academic (16.5%), and medical practice (16.3%).

Conclusion: The most frequently asked questions about lateral epicondylitis on Google centered around symptom duration and management, with most information originating from social media and commercial Web sites. Our data can be used to anticipate patient concerns and set expectations regarding the prognosis and management of lateral epicondylitis.

Background: The aim of this study was to evaluate the impact of regional anesthesia for the treatment of wrist fractures or dislocation on opioid prescription-filling patterns.

Methods: Patients undergoing surgery for hand and wrist fractures or dislocations from 2010 to 2018 were identified by using a national insurance claims database. Patients were stratified by procedures conducted with and without regional anesthesia. Preoperative opioids were defined by a filled opioid prescription within 1 month prior to surgery, postoperative within 1 month following the surgery, and prolonged postoperative 3 to 6 months following surgery. Patients' demographic data, comorbidities, additional medications, 30-day emergency department (ED) visits, and hospital readmissions were analyzed.

Results: A total of 24 598 patients treated with and 115 199 patients treated without a regional nerve block for wrist fractures and dislocations were identified. Regional anesthesia was associated with greater postoperative opioid prescription but fewer prolonged postoperative prescriptions. There was an increased odds of all-cause 30-day ED visits but a decreased odds of 30-day hospital readmissions when patients received a regional nerve block prior to surgery.

Conclusions: In this study, receiving regional anesthesia prior to surgical intervention for wrist fractures or dislocations was associated with increased filling of postoperative opioid prescriptions, but not prolonged postoperative opioid prescriptions. Additional investigation is needed to identify and implement nonnarcotic multimodal analgesia regimens that may help decrease usage of narcotic medications surrounding these procedures.

Level of evidence: Level III, retrospective cohort study.

Ulnar-sided wrist pain can be attributed to various bony and ligamentous structures. The purpose of this review is to compare outcomes following surgical interventions for isolated lunotriquetral (LT) interosseous ligament injuries in adults. We assessed 202 procedures from 9 retrospective case series studies of low to moderate quality based on the Structured Effectiveness Quality Evaluation Scale. The comparative outcomes (ie, range of motion, pain, strength, quality of life, complications, return to work, and patient satisfaction) were aggregated and categorized under arthrodesis, capsulodesis, ligament repairs and reconstruction, and ulna shortening osteotomy procedures. Although the comparison of outcomes was largely inconclusive due to the heterogeneity and the omission of preoperative characteristic data, we did observe higher complications and reoperation rates post LT arthrodesis. It is recommended that all outcomes be standardized and presented uniformly with best practices developed to better characterize the injury's severity and integrity in future studies.