HAND

Background: Ulnar polydactyly is frequently encountered in the newborn nursery and is commonly treated with bedside suture ligation. However, growing concern about the complications associated with suture ligation has led some practitioners to advocate for primary surgical excision instead. Thus, we set out to compare outcomes of suture ligation and surgical excision by systematic appraisal of the literature. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was performed to identify studies published between 1950 and 2017 that described outcomes of suture ligation, surgical excision, or both. Baseline characteristics, complications, and study quality were extracted for each included article. Results: A total of 900 articles were reviewed, of which 10 studies (8 case series, 2 comparative analyses) met the inclusion criteria. There was considerable heterogeneity among the studies with respect to patient characteristics and reported outcomes. There were 2 retrospective case series of suture ligation that reported no acute complications and a variable proportion of patients with residual remnants or neuromas. Studies evaluating surgical ligation reported no acute or long-term complications, with only 1 case series reporting a small percentage of residual remnants. However, in the largest cohort analysis, the difference in complication rate was reported to be as high as 23.5% for suture ligation compared with 3% for surgical excision. Conclusions: There is a paucity of literature limiting the comparison of suture ligation and surgical excision for ulnar polydactyly. Further studies are required to determine the optimal treatment.

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. We sought to assess the subjective improvement in preoperative symptoms related to CTS, particularly those affecting sleep, and describe opioid consumption postoperatively. Methods: All patients undergoing primary carpal tunnel release (CTR) for electromyographically proven CTS were studied prospectively. All procedures were performed by hand surgery fellowship–trained adult orthopedic and plastic surgeons in the outpatient setting. Patients underwent either endoscopic or open CTR from June 2017 to December 2017. Outcomes assessed were pre- and postoperative Quick Disabilities of Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), and Pittsburgh Sleep Quality Index (PSQI) scores as well as postoperative pain control. Results: Sixty-one patients were enrolled. At 2 weeks, all showed significant (P < .05) improvement in QuickDASH scores. At 6 weeks, 40 patients were available for follow-up. When compared with preoperative scores, QuickDASH (51 vs 24.5; P < .05), VAS (6.7 vs 2.9; P < .05), and PSQI (10.4 vs 6.4; P < .05) scores continued to improve when compared with preoperative scores. At 2-week follow-up, 39 patients responded to the question, “How soon after your carpal tunnel surgery did you notice an improvement in your sleep?” Seventeen patients (43.6%) reported they had improvement in sleep within 24 hours, 12 patients (30.8%) reported improvement between 2 and 3 days postoperatively, 8 patients (20.5%) reported improvement between 4 and 5 days postoperatively, and 2 patients (5.1%) reported improvement between 6 and 7 days postoperatively. Conclusions: The present study demonstrates rapid and sustained improvement in sleep quality and function following CTR.

Background: The objective of this investigation is to examine the effect of postoperative therapy after routine carpal tunnel release. Our hypothesis was that supervised hand therapy does not improve outcomes after routine carpal tunnel release. Methods: Patients with carpal tunnel syndrome were randomly assigned to one of 3 groups based on the last digit of their medical record numbers to one of 3 groups: standard 6-week postoperative rehabilitation (standard therapy), expedited one-session postoperative rehabilitation group (expedited therapy), and no postoperative rehabilitation group (no therapy). The primary outcome measures were Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and return to work. The outcome questionnaire was completed preoperatively, at the 2-week follow-up visit, and monthly to 6 months after surgery. Results: All 3 treatment groups had similar mean QuickDASH scores preoperatively. At 1- to 6-month follow-up, all 3 groups had similar QuickDASH scores at each visit, and all showed a significant decline from baseline (preoperative) QuickDASH score. Overall, QuickDASH score decreased significantly from a preoperative visit mean of 42.7 to a final postoperative (visit 8) mean of 6.69. There was no significant difference in the mean QuickDASH score among all 3 groups at 6-month follow-up. There was no significance in the time of return to work among the 3 groups (standard therapy, 21.8 days; expedited therapy, 20.9 days; no therapy, 16.6 days). Conclusions: This investigation adds evidence that supervised hand therapy does not improve the outcomes of routine carpal tunnel surgery as measured by QuickDASH and return to work.

Background: Surgical management of carpal tunnel syndrome includes performing an endoscopic (ECTR) or open (OCTR) carpal tunnel release. Several studies have shown less postoperative pain and improvement in grip and pinch strength with the endoscopic technique. The goal of this study was to prospectively examine outcomes, patient satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient. Methods: This was a prospective study in which patients with bilateral carpal tunnel syndrome underwent surgical release with both techniques, with initial operative approach randomized in the more symptomatic hand. Demographic data and functional outcomes were recorded, including the pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength testing, grip strength, carpal tunnel syndrome functional status score, carpal tunnel syndrome symptom severity score, and overall satisfaction. Results: Thirty patients completed the study; there were no significant differences in any measure at any of the postoperative time points. Symptom severity and functional status scores were not significantly different between groups at any evaluation. Subjectively, 24 of 30 patients did state they preferred the ECTR, mostly citing less pain as their primary reason, although pain scores were not significantly different. Differences in overall satisfaction were also not significant. Conclusions: Both techniques are well tolerated with no differences in outcomes. With the added cost and equipment associated with ECTR, and no added benefit, the usefulness of ECTR is questionable.

Background: Impairment of the dominant hand should lead to greater disability than impairment of the nondominant hand, but few studies have tested this directly, especially in the domain of upper-extremity peripheral nerve disorder. The aim of this study was to identify the association between hand dominance and standardized measures of disability and health status after upper-extremity peripheral nerve disorder. Methods: An existing database was reanalyzed to identify the relationship between affected-side (dominant vs nondominant) on individuals with unilateral upper-extremity peripheral nerve disorder (N = 400). Primary measure of disability was the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Results: We found no differences in standardized measures of disability or health status between patients with affected dominant hand and patients with an affected nondominant hand. However, a post hoc exploratory analysis revealed that patients with an affected dominant hand reported substantially reduced ability to perform 2 activities in the DASH questionnaire: “write” and “turn a key.” Conclusions: Following unilateral upper-extremity peripheral nerve disorder, impairment of the dominant hand (compared with impairment of the nondominant hand) is associated with reduced ability to perform specific activities, but this reduced ability is not reflected in standardized measures of disability and health status. To adequately identify disability following unilateral impairment of the dominant hand with the DASH, individual items must be used instead of the total score. New or alternative measures are also recommended.

Background: Many patients treated for ulnar nerve compression at the elbow (UNE) are concomitantly treated for carpal tunnel syndrome (CTS). We sought to investigate the association between the conditions. Methods: The Statewide Planning and Research Cooperative System (SPARCS) database was used to determine the number of patients with UNE concomitantly treated for CTS in New York State from 2003 to 2014. We then retrospectively reviewed each patient who received surgical treatment for UNE (n = 222 patients) or CTS (n = 1063 patients) at our tertiary care institution in 2014 and 2015 to assess concomitant treatment. Results: In the SPARCS database, the percentage of patients surgically treated for concomitant UNE and CTS steadily increased from 23% in 2003 to 45% in 2014. At our institution, 50 of 222 patients (23%) surgically treated for UNE underwent concomitant carpal tunnel releases. For concomitantly treated patients, 94% had examinations consistent with UNE and CTS, 87% of patients had median nerve compression on electrodiagnostic tests, and 72% of patients had UNE on electrodiagnostic tests. Conclusions: Most patients concomitantly treated for UNE and CTS have objective findings of both conditions. At least one-fourth of patients indicated for operative ulnar nerve release also require a carpal tunnel release—far beyond the prevalence of CTS in the general population. A diagnosis of UNE merits a comprehensive workup by the treating surgeon and a high suspicion for concomitant median nerve compression.

Background: Emerging literature introduces radiation therapy for benign hand conditions. However, hand surgeons are wary recommending radiation therapy for nonmalignant conditions. In our practice, we have used radiation therapy for patients who present with infiltrative or recurrent giant cell tumor of the tendon sheath (GCTTS) since 1998. The purpose of this study is to examine the secondary effects of radiation to the hand through the critical lens of a hand surgeon. Methods: A case series of patients who received radiation therapy for GCTTS were reviewed. The Radiation Oncology/Toxicity Grading Late Radiation Morbidity Scoring Schema was used, and patients were questioned about symptoms and examined for physical findings involving their irradiated digits. Results: A total of 8 patients with GCTTS presented for follow-up. The average patient age was 59.1 years, and the average time since radiation therapy was 5.4 years. Patients had an average of 2.3 surgeries on the affected digit prior to receiving radiation therapy. The average Disabilities of the Arm, Shoulder, and Hand score was 8.1. The most common sign of radiation was nail changes. All patients complained of sensibility changes, although only 2 of the 8 patients had abnormal moving 2-point discrimination tests. There were no confirmed recurrences of GCTTS and no skin cancers. Conclusions: Patients who received radiation therapy to the hand report high levels of satisfaction with the therapy. Radiation therapy is tolerated well by these patients and has a low level of morbidity in our population.

Background: The reported prevalence of a subcompartment housing the extensor pollicis brevis (EPB) tendon within the first dorsal compartment varies widely in the literature, especially regarding the rates of occurrence between genders and among those with and without De Quervain. Based on direct intraoperative observation, we hypothesized that the prevalence of a septated compartment is far greater than previously reported, particularly in those with De Quervain disease. Methods: A prospective analysis of consecutive patients who underwent first dorsal compartment release was carried out. Patients were divided into 2 groups: those with De Quervain tenosynovitis (“De Quervain” group) and a control cohort without a primary diagnosis of De Quervain (“non–De Quervain” group). The intraoperative findings of a single compartment or a separate subcompartment were recorded. The prevalence of a septated compartment was calculated and compared between genders and both patient groups. Results: A total of 102 consecutive patients were included, with a female predominance (74.5%). Overall, 79.4% of patients had a separate subcompartment for the EPB. In the De Quervain cohort, 89.1% had 2 compartments, while 71.4% of non–De Quervain patients had a subcompartment. Men and women had a similar rate of double compartments (80% and 82.4%, respectively). Conclusions: The prevalence of a septated first dorsal compartment is considerably higher than previously reported, most notably in patients afflicted with De Quervain tenosynovitis. This higher rate of septation occurs with a similar prevalence in both men and women. Owing to its consistent presence, the dual first dorsal compartment should be regarded as an expectant anatomical component of the normal wrist.

Background: Bier block provides anesthesia of an entire extremity distal to the tourniquet without necessitating direct injection at the surgical site. This avoids obscuring anatomy with local anesthetic and anesthetizes a wide area, allowing for multiple procedures and incisions. We hypothesize that a low-volume Bier block with forearm tourniquet, rather than a traditional brachial tourniquet, is a safe, well-tolerated, and effective anesthesia technique. Methods: All cases in which adult patients underwent hand procedures using Bier block anesthesia by a single surgeon over a 4-year period were reviewed. Data collected included patient demographics, procedure(s) performed, complications, tourniquet time and settings, procedure and in-room time, and supplemental medications administered. Results: In all, 319 patients were included, 103 from a university hospital and 216 from an ambulatory surgery center. The most commonly performed procedures were carpal tunnel release (205 cases) and trigger digit release (83 cases). Most patients received a 125-mg dose of lidocaine for the Bier block; many also received additional sedatives. Twenty-three patients received no additional medications. No patients required conversion to general anesthesia. One complication (0.3%) occurred, with paresthesias and tinnitus that resolved without intervention. The average tourniquet time was 24 minutes (SD = 4.3 minutes). Patients were discharged at a median of 49 minutes postoperatively, and 9.1% of patients received supplemental analgesics prior to discharge. Conclusions: Regional anesthesia achieved with a forearm tourniquet and intravenous local anesthetic provides adequate pain control, permits timely discharge home, and has a low complication rate. It should be considered for use in outpatient hand procedures.

Background: Patient-reported outcomes (PROs) are the gold standard for reporting clinical outcomes in research. A crucial component of interpreting PROs is the minimum clinically important difference (MCID). Patient-Rated Wrist Evaluation (PRWE) is a disease-specific PRO tool developed for use in distal radius fractures. The purpose of this study was to determine the influence of injury characteristics, treatment modality, and calculation methodology on the PRWE MCID in distal radius fractures. We hypothesize the MCID would be significantly influenced by each of these factors. Methods: From 2014 to 2016, 197 patients with a distal radius fracture were treated at a single level I trauma center. Each patient was asked to complete a PRWE survey at preoperative baseline, 6-week postoperative, and 12-week postoperative dates. The MCID was derived utilizing 2 distinct strategies, anchor and distribution. Anchor questions involved overall health anchor and mental and emotional health anchor. Patient variables regarding demographics, injury characteristics, and treatment modality were collected. Results: The MCID was unique between analytical methods at all time points. The distribution MCID presented commonality across assessed variables. However, the anchor MCID was unique by AO/OTA fracture classifications, treatment modality, and time points. Conclusions: Our study found the MCID was heavily influenced by assessment time points, analytical method, treatment modality, and fracture classification. These results suggest that to accurately interpret PRO data in clinical trials, an anchor question should be included so that the MCID can be determined for the specific patient population included in the study.

Background: Fractures of the hook of the hamate are rare. Nonoperative management has historically been immobilization in a short arm cast (SAC) without thumb immobilization with a high reported incidence of nonunion. The high prevalence of nonunion following nonoperative treatment may be secondary to motion at the fracture site. The transverse carpal ligament’s attachment to the hook of the hamate results in movement at the fracture site during thumb motion. Methods: A cadaveric study using 8 fresh frozen cadaver arms amputated at the mid-humeral level was performed. Computed tomography (CT) imaging was used to assess the bony anatomy and assure no preexisting fractures were present. Osteotomy of the hook of the hamate was performed through a skin incision proximal to the hook of the hamate and the transverse carpal ligament. Each arm was then mounted in a jig designed to hold and stabilize the arm and hand in supination. CT scans were performed without cast immobilization with the thumb in extension and abduction, with SAC without thumb carpometacarpal joint immobilization, and SAC with thumb carpometacarpal joint immobilization. Results: Motion of the fractured hook of the hamate was found to occur in all noncasted specimens, greatest with base fractures. SAC without thumb immobilization had little to no effect in eliminating fracture motion. SAC including the thumb reduced fracture motion in all specimens. Conclusions: Previous poor experience with nonoperative management of fractures of the hook of the hamate may be partially due to inability to adequately immobilize the fracture fragment. Fracture motion of the hamate hook occurs during thumb movement, likely from traction on the fracture fragment by the transverse carpal ligament.

Background: The purpose of this study is to determine the effects of proximal hamate transfer for proximal pole scaphoid reconstruction upon carpal kinematics. Methods: Eight fresh-frozen cadaveric wrists underwent evaluation of their radiocarpal and midcarpal motion after proximal hamate osteotomy. A wrist simulator was used to apply cyclical tension to the flexor carpi ulnaris (FCU), flexor carpi radialis (FCR), extensor carpi ulnaris (ECU), and extensor carpi radialis longus and brevis stitched together (ECR). Kinematic motion was captured using Moiré Phase Tracking 3-dimensional motion-tracking sensors (MPT, Metria Innovation, Inc, Milwaukee, Wisconsin) to evaluate the lunocapitate and scapholunate angles for each condition. Results: During wrist flexion-extension and radial-ulnar deviation, there were no statistically significant differences about the lunocapitate or scapholunate axis between the intact and post-hamate osteotomy conditions. Conclusions: The harvest of the proximal hamate for proximal pole scaphoid reconstruction does not appear to adversely affect wrist kinematics.

Background: The objective of this study was to determine interfragmentary compression forces based on screw length and geometry for simulated proximal scaphoid fractures. Methods: Sixty-four foam model simulated fractures were stabilized with screws of various length (10 mm, 18 mm, 20 mm, or 24 mm) and geometry (central threadless or fully threaded) across a proximal fracture. Interfragmentary compression was measured at the simulated fracture site upon fixation. An independent sample t test and 1-way analysis of variance were performed to assess differences in interfragmentary compression. Results: Fixation utilizing a 10-mm screw generated significantly less interfragmentary compression than fixation utilizing a 20-mm or 24-mm screw. When accounting for both screw length and geometry, an 18-mm central threadless screw generated greater interfragmentary compression than a 20-mm and 24-mm fully threaded screw; there was no significant difference in compression between an 18-mm and 24-mm central threadless screw. Conclusions: The design of headless compression screws allows for maximal interfragmentary compression at the screw midpoint; we questioned whether a short screw centered on the fracture site resulted in superior compression to a longer, noncentered screw. Our data suggest that centering a small screw (10 mm) along a proximal fracture generates significantly less interfragmentary compression than a longer, noncentered screw. Our results demonstrate that balance between maximizing screw length and centering the screw on the fracture is vital toward maximizing interfragmentary compression for the fixation of proximal third scaphoid fractures.

Background: Isolated scaphoid fractures (ISFs) are common, whereas transscaphoid fracture-dislocations (TSFDs) are not. Scaphoid fracture location and the extent of comminution are factors that affect treatment and outcome. The purpose of this study is to compare the radiographic characteristics of ISFs with TSFDs associated with greater arc injury. Methods: This study is a retrospective review of all ISFs and TSFDs that presented to our institution during a 5-year period. Fracture location (along the long axis of the scaphoid) was calculated by dividing the distance from the proximal pole to the fracture by the entire length of the scaphoid. The extent of comminution was measured in millimeters along the mid-axis of the scaphoid and divided by the entire length of the scaphoid. Results: One-hundred thirty-eight scaphoid fractures in 137 patients were identified. One-hundred twelve fractures (81%) were ISFs, and 26 (19%) were associated with a TSFD. The mean fracture location was more proximal in TSFDs than in ISFs. However, fractures occurred in the distal third of the scaphoid in 12% of ISFs compared with 0% of TSFDs. Nine percent of ISFs demonstrated comminution as compared with 12% of TSFDs. Extent of comminution was 16% and 28% for ISFs and TSFDs, respectively. Conclusion: Scaphoid fractures associated with greater arc injuries are located more proximally and are more comminuted than ISFs, and distal pole fractures rarely occur in the setting of TSFDs. The increased incidence and extent of comminution in TSFDs may be suggestive of a higher energy injury mechanism.

Background: The objective of this study was to determine the functionality of 3-dimensional (3D) printed orthoses for upper extremity immobilization compared with conventional immobilization. Methods: Twelve healthy volunteers were fitted with a 3D custom printed short arm cast and a short arm fiberglass cast in separate sessions. The Jebsen Hand Function Test (JHFT) was used to test function and dexterity in each cast. All volunteers completed a modified version of the Patient-Rated Wrist Evaluation (PRWE). Skin complications were recorded. Results: There were no significant differences during the JHFT between casts, although one-third of the participants in the 3D cast could perform the tasks in a normal time, which they could not in the fiberglass cast. The average PRWE function score was lower in the 3D cast group than in the fiberglass group (45.5 vs. 80.8). Minor skin irritation was noted in 42% of patients in the fiberglass cast group compared with only 1 patient (8%) in the 3D cast group. One patient in the fiberglass group required a cast change due to inappropriate fit. Conclusions: Both casting techniques demonstrate similar objective function based on the JHFT. Patient satisfaction, comfort, and perceived function are superior in the 3D printed casts.

Background: Due to bone cutting loss from self-tapping screws (STS), progressive destruction of bone can occur with each reinsertion during surgery. When considering the use of jigs that utilize multiple insertions such as those seen in ulnar and radial shortening osteotomy systems, or scenarios where a screw needs to be removed and reinserted due to some technical issue, this can be concerning, as multiple studies examining the effects of multiple reinsertions and the relationship between insertional torque and pullout strength have had mixed results. Methods: Insertional torque and pullout strength were experimentally measured following multiple reinsertions of STS for up to 5 total insertions for various densities and locations along radial sawbone shafts. Results: Torque and pullout strength were significantly greater in middle segments of the radial shaft. Our trials corroborate previous literature regarding a significant reduction in fixation between 1 and 2 insertions; beyond this, there was no significant difference between pullout strength across all segment locations as well as bone densities for 3 to 5 insertions. There was a moderate to high correlation of insertional torque to pullout strength noted across all bone densities and segments (Pearson r = 0.663, P < .001). Conclusion: While reinsertion of STS between 1 and 2 insertions has been shown to significantly differ in pullout strength, beyond this, there does not appear to be a significant difference in up to 5 insertions at any specific region of radial bone across a range of sawbone densities. Further insertions may be considered with caution.

Background: Open surgical release of the A1 pulley is the definitive treatment for the common hand condition of trigger finger, or inflammatory stenosing tenosynovitis. Anecdotal evidence among hand surgeons has questioned whether or not recent steroid injection may be related to complications following open trigger finger release, particularly wound infection, but no studies have primarily studied this connection to date. We aimed to determine whether recent steroid injection was associated with postoperative surgical infections. Methods: We performed a retrospective chart review of 780 adult patients who had undergone open trigger finger release of 999 digits by 6 fellowship-trained hand surgeons at three affiliated hospital settings from January 1, 2014, to January 1, 2016. Data on timing of steroid injections relative to surgery, number of steroid injections, concomitant conditions, use of antibiotics, and postoperative complications including infections were gathered. Results: Steroid injection timing relative to subsequent operative intervention correlated with postoperative surgical site infection in trigger finger release. Older age and decreasing days between steroid injection and surgery correlated with infection rates. Other factors found to be associated with infection rates included smoking, use of preoperative antibiotics, and use of lidocaine with epinephrine. The other factors examined did not correlate with infection rates. Conclusions: Steroid injection, smoking, increasing age, lesser number of days between steroid injection and surgery, and use of lidocaine with epinephrine are risk factors for postoperative trigger surgical infections. We recommend careful preoperative counseling regarding higher wound healing risks for smokers, avoidance of steroid injections immediately prior to an operative date, and scheduling operative dates that tend to be greater than 80 days from the date of last steroid injection. We also recommend avoidance of epinephrine in the local anesthetic solution, as this may minimize surgical site infection risks.

Background: This study aims to describe the long-term patient-reported outcomes after surgery for hypothenar hammer syndrome (HTHS) and to identify factors associated with inferior outcomes. Methods: We retrospectively identified 27 patients who underwent surgical intervention for HTHS from 2002 to 2016. Fifteen patients (56%) completed outcome questionnaires: Quick Disabilities of the Arm, Shoulder, and Hand, Cold Intolerance Symptom Severity (CISS) survey, Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test, and Patient-Reported Outcomes Measurement Information System Pain Interference Computer Adaptive Test. The median questionnaire follow-up was 7.2 years (interquartile range, 3.1-9.9). Outcomes were compared across different surgical techniques, and the influence of patient-related factors on outcomes was also evaluated. Results: Six (40%) patients experienced complete symptom resolution, 6 (40%) had improvement without complete resolution, 1 (7%) had resolution followed by recurrence, and 2 (13%) reported no improvement. The most common symptom after surgical intervention was cold intolerance. Questionnaire scores were similar across ligation, direct repair, and vein graft vascular reconstruction. Patients had better CISS scores if they had surgery on their nondominant hand (13.2 vs 38.6) and did not have a manual labor job (18.1 vs 40.5). Conclusions: Surgery for HTHS leads to moderate long-term improvement in patient-reported outcomes. Different surgical techniques yield similar symptomatic relief. Manual labor and surgery of the dominant hand are associated with worse CISS scores.

Background: The purpose of this study was to analyze the intrarater and interrater reliability of the Soong classification for volar locking plate placement on a randomly selected, consecutive series of radiographs. Our hypothesis was that the classification would be reliable. Methods: Six physicians of differing levels of training (orthopedic surgery intern to fellowship-trained upper extremity staff) were asked to review 40 radiographs in a random order on 2 separate occasions, 4 weeks apart. All observers graded each image (0, 1, or 2) based on the corresponding Soong grade. A weighted κ was used to determine the intrarater agreement. The interrater agreement was determined using an intraclass coefficient: Results: The intrarater reliability using a weighted κ ranged from 0.229 (95% confidence interval [CI]: 0.048-0.411) to 0.946 (95% CI: 0.840-1.051). The interrater intraclass coefficient for Randomization 1 was 0.944 (95% 0.912-0.967) and Randomization 2 was 0.877 (95% CI: 0.797-0.930). Conclusion: The Soong classification is a reliable tool, both interrater and intrarater, for assessing distal radius volar locking plate placement. The classification system remained reliable despite a randomly selected, consecutive series of images and physician observers of varying levels of training.

Background: The purpose of this study was to report outcomes in patients with nonstyloid distal ulna fractures treated in conjunction with open reduction internal fixation (ORIF) of distal radius fractures. Methods: A retrospective review of all patients who had undergone ORIF of a distal radius fracture over a 5-year period at a single institution was performed. Radiographic review was performed to identify patients with a concomitant fracture of the distal ulna. Radiographs were examined to determine whether and how the distal ulna fracture was stabilized and to assess healing of the distal ulna. Range of motion (ROM) was determined by review of the patients’ charts. All skeletally mature patients with distal ulna fractures (not including isolated styloid fractures) undergoing surgical fixation of the distal radius fracture were included. Patients were excluded if follow-up was inadequate. There were 172 fractures of the distal ulna meeting the inclusion criteria. Seven patients were excluded. There were 91 patients treated without ulna fixation (ulna-no) and 74 patients treated with ulna fixation (ulna-yes). Results: Seventy-two (97%) of the ulna-yes patients healed. All patients in the ulna-no group healed. The only significant difference in ROM was in pronation, although the magnitude of this difference was relatively small. Conclusions: Fractures of the distal ulna have high rates of healing and result in equivalent motion regardless of whether the distal ulna is treated operatively. Routine surgical fixation of concomitant distal ulna fractures during distal radius ORIF does not appear to be necessary.

Purpose: The Arkansas Hand Trauma Telemedicine Program (AHTTP) is a novel telemedicine system that was developed in 2014 within a rural state to address the growing need of access to hand trauma care with one trauma center that cares for mangling hand injuries. The purpose is to compare transfers for hand injuries prior to and after the implementation of this system. Methods: The hospital institutional database was queried for all transfers to a level 1 medical center in the state from 2012 to 2015, allowing the comparison of data prior to and after the institution of the AHTTP. Patient disposition from the emergency department was categorized to evaluate the impact of AHTTP. Distance, mode of transport, and transport cost were assessed. Findings: There were 202 transfers for the treatment of isolated hand trauma (92 from 2012 to 2013 and 110 from 2014 to 2015). Prior to the institution of AHTTP, transfer patients were admitted 47.8% of the time compared with 68.2% of the time after the development of the program (P = .02). The approximate cost of transport for patients who were discharged home directly from the emergency department was 38.5% (US $47,233) of the total costs for the 2012-2013 period and was 21.4% (US $34,017) of the costs for the 2014-2015 period (P < .0001). Conclusions: There was a statistically significant decrease in the number of unnecessary transfers and transportation costs after the telemedicine program was started. The implementation of AHTTP in a rural state reduced health care costs and improved the efficiency of hand specialty care.