Publications by authors named "David E Ruchelsman"

51 Publications

Excision of Hook of Hamate Fractures in Elite Baseball Players: Surgical Technique and Return to Play.

Orthop J Sports Med 2022 Mar 30;10(3):23259671211038028. Epub 2022 Mar 30.

Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, Massachusetts, USA.

Background: Hook of hamate fractures are relatively common in baseball players, but the proper diagnosis and surgical technique can be challenging. Outcomes after surgical excision, as well as optimal surgical technique, in elite baseball players have not been clearly established.

Hypothesis: Excision of hook of hamate fractures with a technique tailored to elite professional and collegiate baseball players will lead to high rates of return to play within a short time.

Study Design: Case series; Level of evidence, 4.

Methods: We reviewed the cases of 42 elite athletes who underwent surgical excision of 42 hook of hamate fractures at a single academic hand surgery practice from 2006 to 2020. The athletes competed at the professional (n = 20) or varsity collegiate (n = 22) baseball levels and were treated using the same surgical technique tailored toward the elite athlete. The clinical history, timing of surgery, complications, and time to return to play were recorded for each patient.

Results: All 42 patients underwent an excision of their hook of hamate fracture at a mean of 7.2 weeks (range, 0.5-52 weeks) from the onset of symptoms. All but one patient were able to return to full preinjury level of baseball participation within 6 weeks from the date of surgery, with a mean return to sport of 5.4 weeks (range, 3-8 weeks). Two patients returned to the operating room-1 for scar tissue formation causing ulnar nerve compression and 1 for residual bone fragment causing pain and ulnar nerve compression.

Conclusion: Surgical excision of hook of hamate fractures in elite baseball players showed a very high rate of return to play within 6 weeks. Meticulous adherence to the described surgical technique tailored to athletes optimizes clinical outcomes and avoids complications.
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http://dx.doi.org/10.1177/23259671211038028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8972935PMC
March 2022

Deep Penetrating Kerosene Exposure in the Hand Mimicking Deep Space Infection.

J Hand Microsurg 2020 Aug 22;12(2):125-127. Epub 2019 Nov 22.

Department of Hand Surgery, PC, Newton-Wellesley Hospital, Tufts University School of Medicine, Boston, Massachusetts, United States.

In this case report, we review the clinical course of an adolescent who sustained a low-velocity, low-pressure, penetrating wound to the midpalmar aspect of the hand with a kerosene containing thermometer. The exposure led to a clinical picture of an acute midpalmar abscess within 24 hours. Despite irrigation and debridement of frank purulent material, cultures and pathology remained negative for infection. This case highlights that kerosene exposure, although rare, can mimic an acute infection with intraoperative findings consistent with sterile purulence. Hand surgeons must be aware of the effects of deep soft tissue exposure with hydrocarbons, such as kerosene and petrol, and should have a low threshold to take the patient to the operating room for thorough irrigation and debridement of the offending substance.
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http://dx.doi.org/10.1055/s-0039-1697062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410801PMC
August 2020

Low Rate of Complications Following Intramedullary Headless Compression Screw Fixation of Metacarpal Fractures.

Hand (N Y) 2020 11 20;15(6):798-804. Epub 2019 Mar 20.

Thomas Jefferson University, Philadelphia, PA, USA.

There has been a recent increase in the use of headless compression screws for fixation of metacarpal neck and shaft fractures as they offer several advantages, and minimal complications have been reported. This study aimed to evaluate the clinical complications and their solutions following retrograde intramedullary headless compression screw fixation of metacarpal fractures. We describe complications and the approach to their management. We performed a multicenter case series through retrospective review of all patients treated with intramedullary headless screw fixation of metacarpal fractures by 3 fellowship-trained hand surgeons. Patient demographics, implant used, type of complication, pre- and postoperative radiographs, operative reports, and sequelae were reviewed for each case. We defined complications as infection, loss of fixation, hardware failure, malrotation, nonunion, malunion, metal allergy, and any repeat surgical intervention. Four complications (2.5%) were identified through the review of 160 total metacarpal fractures. One complication was a nickel allergy, one was a broken screw after repeat trauma, and 2 patients had bent intramedullary screws. Screw removal in 3 patients was simple and without complications or persistent limitations. One bent screw with a refracture was left in place. No serious complications were seen. Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed.
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http://dx.doi.org/10.1177/1558944719836214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850257PMC
November 2020

Clinical Outcomes of Limited Open Intramedullary Headless Screw Fixation of Metacarpal Fractures in 91 Consecutive Patients.

Hand (N Y) 2020 11 17;15(6):793-797. Epub 2019 Mar 17.

Newton-Wellesley Hospital, MA, USA.

The objective of the study is to evaluate clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless screw (IMHS) fixation for metacarpal neck and shaft fractures. Retrospective review of 91 consecutive patients (79 men; 12 women), mean age 28 (range =15-69) years, treated with IMHS fixation for acute displaced metacarpal neck (N = 56) and shaft (N = 35) fractures at a single institution. Mean follow-up was 10 (range = 1-71, median = 3) months. Preoperative mean magnitude of metacarpal neck angulation was 48° (range = 0°-90°), and mean shaft angulation was 42° (range = 0°-70°). Active motion was initiated within 5 days postoperatively. Clinical outcomes were assessed with digital goniometry, grip strength, and return to full activity. The time to radiographic union and radiographic arthrosis was assessed. All 91 patients achieved full functional arc of metacarpophalangeal (MCP) motion, and all achieved full active MCP extension or hyperextension. At mean follow-up of 10 months, postoperative mean MCP joint flexion-extension arc was 88° (range = 55°-110°). Grip strength was available for 52 patients and measured 104.1% of the contralateral hand (range = 58%-230%). Radiographic union data were available for 86 patients. Seventy-six percent (65/86) achieved radiographic union by the end of week 6 (range = 2-10 weeks). Early arthrosis was noted in 1 patient at the MCP. There were 3 cases of shaft refracture after recurrent blunt trauma, following prior evidence of full osseous union. The IMHS fixation is safe, reliable, and durable for metacarpal neck/subcapital, axially stable shaft fractures, and select delayed unions or malunions. It allows for early postoperative motion without affecting union rates and obviates immobilization. This technique offers distinct advantages over formal open reduction and percutaneous Kirschner wire techniques.
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http://dx.doi.org/10.1177/1558944719836235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850249PMC
November 2020

Ulnar Nerve Complications After Ulnar Collateral Ligament Reconstruction of the Elbow: A Systematic Review.

Am J Sports Med 2019 04 23;47(5):1263-1269. Epub 2018 Apr 23.

Newton-Wellesley Hospital, Newton, Massachussetts, USA.

Background: While ulnar collateral ligament reconstruction (UCLR) of the elbow is an increasingly commonly performed procedure with excellent results reported in the published literature, less attention has been paid to specifically on the characterization of postoperative ulnar nerve complications, and it is unclear what operative strategies may influence the likelihood of these complications.

Purpose: The purpose of this study is to examine the prevalence and type of ulnar nerve complications after UCLR of the elbow based on the entirety of previously published outcomes in the English literature. In addition, this study examined how the rate of ulnar nerve complications varied as a function of surgical exposures, graft fixation techniques, and ulnar nerve management strategies.

Study Design: Systematic review and meta-analysis.

Methods: A systematic review of the literature was completed using the MEDLINE, PubMed, and Ovid databases. UCLR case series that contained complications data were included. Ulnar neuropathy was defined as any symptoms or objective sensory and/or motor deficit(s) after surgery, including resolved transient symptoms. Meta-analysis of the pooled data was completed.

Results: Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. The mean prevalence of postoperative ulnar neuropathy was 12.0% overall after any UCLR procedure at a mean follow-up of 3.3 years, and 0.8% of cases required reoperation to address ulnar neuropathy. There were no cases of intraoperative ulnar nerve injury reported. The surgical approach associated with the highest rate of neuropathy was detachment of flexor pronator mass (FPM) (21.9%) versus muscle retraction (15.9%) and muscle splitting (3.9%). The fixation technique associated with the highest rate of neuropathy was the modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%), interference screw (5.0%), docking technique (3.3%), hybrid suture anchor-bone tunnel (2.9%), and modified docking (2.5%). Concomitant ulnar nerve transposition was associated with a higher neuropathy rate (16.1%) compared with no handling of the ulnar nerve (3.9%). Among cases with concomitant transposition performed, submuscular transposition resulted in a higher rate of reoperation for ulnar neuropathy (12.7%) compared with subcutaneous transposition (0.0%).

Conclusion: Despite a perception that UCLR has minimal morbidity, a review of all published literature revealed that 12.0% of UCLR surgeries result in postoperative ulnar nerve complications. UCLR techniques associated with the highest rates of neuropathy were detachment of the FPM, modified Jobe fixation, and concomitant ulnar nerve transposition, although it remains unclear whether there is a causal relationship between these factors and subsequent development of postoperative ulnar neuropathy due to limitations in the current body of published literature.
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http://dx.doi.org/10.1177/0363546518765139DOI Listing
April 2019

Chronic Exertional Compartment Syndrome in Athletes.

J Hand Surg Am 2017 Nov;42(11):917-923

Tufts University School of Medicine, Tufts Medical Center, Boston, MA; Department of Hand and Upper Extremity Surgery, Newton-Wellesley Hospital, Newton, MA; Hand Surgery Research and Education Foundation, Newton, MA. Electronic address:

Chronic exertional compartment syndrome (CECS) refers to exercise-induced, reversible increases in pressure within well-defined inelastic fascial compartments leading to compromised tissue perfusion followed by functional loss, ischemic pain, and neurologic symptoms. Symptoms typically resolve when the activity ceases and there are usually no permanent sequelae. In the upper extremity, this condition most commonly affects athletes during sports requiring repetitive and vigorous gripping, such as rowers. In addition to clinical history and examination, a number of methods aid diagnosis, including compartment pressure measurements, magnetic resonance imaging, and near infrared spectroscopy. When symptoms persist despite conservative treatment, multiple operative techniques have been described to treat CECS including open, mini-open, and endoscopic release of involved compartments. We review the pathophysiology, diagnostic modalities, treatment strategies, and outcomes data for CECS of the upper extremity while highlighting areas of residual controversy.
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http://dx.doi.org/10.1016/j.jhsa.2017.09.009DOI Listing
November 2017

Extensor Carpi Ulnaris Subsheath Reconstruction.

J Hand Surg Am 2016 Nov 18;41(11):e433-e439. Epub 2016 Sep 18.

Orthopaedic & Neurosurgery Specialists, ONS Foundation for Clinical Research and Education, Greenwich, CT.

Acute extensor carpi ulnaris (ECU) subsheath injury and chronic subsheath insufficiency may result in symptomatic ECU instability at the level of the distal ulna osseous sulcus. Associated ulnocarpal (ie, triangular fibrocartilage complex) and ECU intrinsic tendinopathic changes may accompany subsheath pathologies and require concomitant treatment. Surgical treatment is indicated in refractory cases despite nonoperative treatment and may consist of repair of the torn edge of the ECU subsheath or, more frequently, reconstruction utilizing a radially based extensor retinacular sling. An ECU subsheath reconstructive technique is detailed.
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http://dx.doi.org/10.1016/j.jhsa.2016.08.009DOI Listing
November 2016

Collagenase enzymatic fasciotomy for Dupuytren contracture in patients on chronic immunosuppression.

Am J Orthop (Belle Mead NJ) 2015 Nov;44(11):518-21

Royal Adelaide Hospital, Adelaide, South Australia, Australia.

Collagenase enzymatic fasciotomy is an accepted nonsurgical treatment for disabling hand contractures caused by Dupuytren disease. We conducted a study to investigate use of collagenase in an immunosuppressed population. We retrospectively reviewed data from 2 academic hand surgical practices. Eight patients on chronic immunosuppressive therapies were treated with collagenase for digital contractures between 2010 and 2011. Thirteen collagenase enzymatic fasciotomies were performed in these 8 patients. Mean preinjection contracture was 53.0°. At mean follow-up of 6.7 months, mean magnitude of contracture improved to 12.9°. Mean metacarpophalangeal joint contracture improved from 42.0° to 4.2°. Mean proximal interphalangeal joint contracture improved from 65.8° to 21.7°. Three of the enzymatic fasciotomies were complicated by skin tears. There were no infections. As more patients seek nonsurgical treatment for Dupuytren disease, its safety and efficacy in select cohorts of patients should continue to be evaluated prospectively.
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November 2015

Open carpal tunnel release with use of a nasal turbinate speculum.

Am J Orthop (Belle Mead NJ) 2015 Nov;44(11):495-8

Hand Surgery PC, Newton-Wellesley Hospital, Tufts University School of Medicine, Newton, MA; and Department of Orthopaedic Surgery, Masachusetts General Hospital/Harvard Medical School, Boston, MA.

Incomplete release of the transverse carpal ligament (TCL) and median nerve injury are complications of carpal tunnel release (CTR). In this article, we describe a modified mini-open release using a fine nasal turbinate speculum to aid in the proximal release with direct visualization of the proximal limb of the TCL and the distal volar forearm fascia (DVFF). The technique begins with a 2.5-cm palmar longitudinal incision, and standard distal release of the TCL is completed. A fine nasal turbinate speculum is inserted into the plane above the proximal limb of the TCL and the DVFF. A long-handle scalpel is used to incise the TCL and the DVFF under direct visualization. We retrospectively analyzed a cohort of 101 consecutive CTR cases (63 right, 38 left). Carpal tunnel syndrome symptoms were relieved in all patients with a high degree of satisfaction. This modified mini-open technique provides surgeons with a reproducible and inexpensive method to ensure a safe proximal release of the TCL.
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November 2015

Clinical outcomes following collagenase injections compared to fasciectomy in the treatment of Dupuytren's contracture.

Hand (N Y) 2015 Jun;10(2):260-5

Hand Surgery, P.C., Newton-Wellesley Hospital, Tufts University School of Medicine, Boston, MA USA ; Division of Hand Surgery, Newton-Wellesley Hospital, Newton, MA USA ; Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA USA.

Introduction: The aim of this study is to compare the efficacy of collagenase injections with that of fasciectomy in the treatment of Dupuytren's contracture.

Methods: This is a case-control retrospective study. We reviewed the electronic medical records from January 2009 through January 2013, identifying 142 consecutive patients who underwent either fasciectomy or collagenase injection. Exclusion criteria for both groups were age <18 years, pregnant women, and arthroplasty or arthrodesis of the treated joint. Follow-up data beyond 1-year duration was available for 117 of the patients: 44 patients who had undergone fasciectomy, and 73 patients who had received collagenase injection. The primary outcome measure in this study was resolution of joint contracture to 0-5° deficit of full extension. Data was analyzed using two-sample t tests for continuous data and chi-square test for categorical data. A significant P value was set at <0.05.

Results: At the latest follow-up, significantly more joints treated with fasciectomy met the primary outcome measure. Metacarpophalangeal (MP) joints responded better than the proximal interphalangeal (PIP) joints for both treatments. At the latest follow-up (14.2 months for collagenase, 16.3 months for fasciectomy), 46 % of MP joints treated with collagenase and 68 % of MP joints treated with fasciectomy maintained resolution of joint contracture. Sub-analysis of the affected joints based on the severity of initial contracture demonstrated that MP and PIP joints with contractures <45° responded better than more severely contracted joints (>45°).

Conclusions: Fasciectomy yields a greater mean magnitude of correction for digital contractures at the latest follow-up when compared to collagenase. Both treatments were more effective for treatment of MP joint contracture compared to PIP joint contracture.

Level Of Evidence: Level III, therapeutic.
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http://dx.doi.org/10.1007/s11552-014-9704-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4447679PMC
June 2015

Perilunate dislocations.

J Hand Surg Am 2015 Feb 15;40(2):358-62; quiz 362. Epub 2014 Nov 15.

ONS Foundation for Clinical Research and Education, Greenwich; Greenwich Hospital, Yale-New Haven Health, New Haven, CT; Newton-Wellesley Hospital, Newton; Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA. Electronic address:

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http://dx.doi.org/10.1016/j.jhsa.2014.10.006DOI Listing
February 2015

Ultrasound guidance of steroid injections.

J Hand Surg Am 2014 Dec 23;39(12):2498-501. Epub 2014 Oct 23.

Hand Surgery, P.C., Newton-Wellesley Hospital/Tufts University School of Medicine, Boston, MA; Division of Hand Surgery, Newton-Wellesley Hospital, Boston, MA. Electronic address:

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http://dx.doi.org/10.1016/j.jhsa.2014.09.027DOI Listing
December 2014

Clinical outcomes of limited-open retrograde intramedullary headless screw fixation of metacarpal fractures.

J Hand Surg Am 2014 Dec 18;39(12):2390-5. Epub 2014 Sep 18.

Hand Surgery, P.C., Newton, MA; Newton-Wellesley Hospital/Tufts University School of Medicine, Boston, MA.

Purpose: To evaluate clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless compression screw (IMHS) fixation for metacarpal neck and shaft fractures.

Methods: Retrospective review of prospectively collected data on a consecutive series of 39 patients (34 men; 5 women), mean age 28 years (range, 16-66 y) treated with IMHS fixation for acute displaced metacarpal neck/subcapital (N = 26) and shaft (N = 13) fractures at a single academic practice between 2010 and 2014. Preoperative magnitude of metacarpal neck angulation averaged 54° (range, 15° to 70°), and shaft angulation averaged 38° (range, 0° to 55°). Patients used a hand-based orthosis until suture removal and began active motion within the first week. Clinical outcomes were assessed with digital goniometry, pad-to-distal palmar crease distance, and grip strength. Time to union and radiographic arthrosis was assessed. Twenty patients reached minimum 3-month follow-up, with a mean of 13 months (range, 3-33 mo).

Results: All 20 patients with minimum 3 months of follow-up achieved full composite flexion, and extensor lag resolved by 3-week follow-up. All patients demonstrated full active metacarpophalangeal joint extension or hyperextension. Grip strength measured 105% (range, 58% to 230%) of the contralateral hand. No secondary surgeries were performed. There were 2 cases of shaft re-fracture from blunt trauma following prior evidence of full osseous union with the screw in place. All patients achieved radiographic union by 6 weeks. There was no radiographic arthrosis at latest follow-up. One patient reported occasional clicking with metacarpophalangeal joint motion not requiring further treatment.

Conclusions: Limited open retrograde IMHS fixation proved to be safe and reliable for metacarpal neck/subcapital and axially stable shaft fractures, allowed for early postoperative motion without affecting union rates, and obviated immobilization. This technique offers distinct advantages in select patients.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2014.08.016DOI Listing
December 2014

Informed shared decision-making and patient satisfaction.

Psychosomatics 2014 Nov-Dec;55(6):586-94. Epub 2014 Jan 3.

Department of Behavioral Medicine, Benson Henry Mind Body Institute, Massachusetts General Hospital; Harvard Medical School, Boston, MA.

Background: Evidence suggests that when patients have a role in medical decisions they are more satisfied with their health care.

Objective: To assess predictors of patient satisfaction, ratings of the provider's informed shared decision-making (ISDM), and disability among patients with orthopedic pain complaints.

Research Design: A total of 130 patients with nontraumatic painful conditions of the upper extremity were enrolled. Medical encounters were audio recorded and coded by 2 independent coders. Eight ISDM elements and a total ISDM score were evaluated. Bivariate and multivariable analyses were used to answer the study questions.

Measures: Participants completed the Princess Margaret Hospital Patient Satisfaction with their Doctor Questionnaire to measure satisfaction; the Disabilities of Arm, Shoulder and Hand questionnaire; the Patient Health Questionnaire-9 to measure depression; the Whiteley Index to assess heightened illness concerns; and the pain catastrophizing scale to assess coping strategies in response to pain.

Results: Less health anxiety, female gender, the ISDM element Identify choice, and any specific diagnosis determined 22% of the variation in satisfaction. Less health anxiety and unemployed unable to work compared with full-time working status were associated with a better rating of shared decision-making on the ISDM. Catastrophic thinking, female gender, symptoms of depression, and any specific diagnosis were associated with greater disability. Catastrophic thinking and symptoms of depression were the greatest contributors to the variation in disability.

Conclusions: Psychologic factors are the strongest determinants of patient satisfaction, ratings of shared decision-making on the ISDM, and upper-extremity disability. Health anxiety is the most important factor in ratings of patient satisfaction and ISDM, whereas depression and catastrophizing are salient predictors of disability.

Level Of Evidence: Prognostic level I.
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http://dx.doi.org/10.1016/j.psym.2013.12.013DOI Listing
October 2016

Headless bone screw fixation for combined volar lunate facet distal radius fracture and capitate fracture: case report.

J Hand Surg Am 2014 Aug 10;39(8):1489-93. Epub 2014 May 10.

Department of Orthopaedic Surgery, Newton-Wellesley Hospital and Tufts University School of Medicine, Newton, MA.

We report a case of concomitant fractures of the volar lunate facet of the distal radius and capitate body. Surgical fixation was achieved with open reduction internal fixation using headless compression screws for both fractures. Because of the nature of complications seen after both operative and nonsurgical management, these fractures warrant particular attention.
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http://dx.doi.org/10.1016/j.jhsa.2014.03.034DOI Listing
August 2014

Adductor pollicis jamming injuries in the professional baseball player: 2 case reports.

J Hand Surg Am 2013 Jun;38(6):1181-4

Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA02462, USA.

We characterize a mechanism of injury, injury pattern, and treatment algorithm for adductor pollicis myotendinous injuries in 2 professional baseball players. Similar to myotendinous eccentric injuries in other anatomical areas, the adductor pollicis sustains a sudden forceful eccentric load during a jammed swing, resulting in intramuscular strain or tendon rupture. Based on the reported injury mechanism, and magnetic resonance imaging features of these myotendinous injuries, the thumb of the top hand during a jammed swing was suddenly and forcefully eccentrically abducted from a contracted and adducted position, resulting in injury patterns.
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http://dx.doi.org/10.1016/j.jhsa.2013.03.042DOI Listing
June 2013

Outcomes of digital zone IV and V and thumb zone TI to TIV extensor tendon repairs using a running interlocking horizontal mattress technique.

J Hand Surg Am 2013 Jun;38(6):1079-83

Division of Hand and Upper Extremity Surgery, Tufts Medical Center and Newton-Wellesley Hospital/Tufts University School of Medicine, Boston, MA02462, USA.

Purpose: Biomechanical evidence has demonstrated that the running interlocking horizontal mattress (RIHM) repair for extensor tendon lacerations is significantly stronger, with higher ultimate load to failure and less tendon shortening compared with other techniques. We investigated the efficacy and safety of primary extensor tendon repair using the RIHM repair technique in the fingers followed by the immediate controlled active motion protocol, and in the thumb followed by a dynamic extension protocol.

Methods: We conducted a retrospective review of all patients undergoing extensor tendon repair from August 2009 to April 2012 by single surgeon in an academic hand surgery practice. The inclusion criteria were simple extensor tendon lacerations in digital zones IV and V and thumb zones TI to TIV and primary repair performed using the RIHM technique. We included 8 consecutive patients with 9 tendon lacerations (3 in the thumb). One patient underwent a concomitant dorsal hand rotation flap for soft tissue coverage. We used a 3-0 nonabsorbable braided suture to perform a running simple suture in 1 direction to obtain a tension-free tenorrhaphy, followed by an RIHM corset-type suture using the same continuous strand in the opposite direction. Average time to surgery was 10 days (range, 3-33 d). Mean follow-up was 15 weeks (range, 10-26 wk). We applied the immediate controlled active motion protocol to all injuries except those in the thumb, where we used a dynamic extension protocol instead.

Results: Using the criteria of Miller, all 9 tendon repairs achieved excellent or good results. There were no tendon ruptures or extensor lags. No patients required secondary surgery for tenolysis or joint release. No wound complications occurred.

Conclusions: The RIHM technique for primary extensor tendon repairs in zone IV and V and T1 to TIV is safe, allows for immediate controlled active motion in the fingers and an immediate dynamic extension protocol in the thumb, and achieves good to excellent functional outcomes. These clinical outcomes support prior biomechanical data.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2013.03.031DOI Listing
June 2013

Fractures of the radial head and neck.

J Bone Joint Surg Am 2013 Mar;95(5):469-78

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA.

The majority of simple fractures of the radial head are stable, even when displaced 2 mm. Articular fragmentation and comminution can be seen in stable fracture patterns and are not absolute indications for operative treatment. Preservation and/or restoration of radiocapitellar contact is critical to coronal plane and longitudinal stability of the elbow and forearm. Partial and complete articular fractures of the radial head should be differentiated. Important fracture characteristics impacting treatment include fragment number, fragment size (percentage of articular disc), fragment comminution, fragment stability, displacement and corresponding block to motion, osteopenia, articular impaction, radiocapitellar malalignment, and radial neck and metaphyseal comminution and/or bone loss. Open reduction and internal fixation of displaced radial head fractures should only be attempted when anatomic reduction, restoration of articular congruity, and initiation of early motion can be achieved. If these goals are not obtainable, open reduction and internal fixation may lead to early fixation failure, nonunion, and loss of elbow and forearm motion and stability. Radial head replacement is preferred for displaced radial head fractures with more than three fragments, unstable partial articular fractures in which stable fixation cannot be achieved, and fractures occurring in association with complex elbow injury patterns if stable fixation cannot be ensured.
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http://dx.doi.org/10.2106/JBJS.J.01989DOI Listing
March 2013

Quantitative 3-dimensional CT analyses of intramedullary headless screw fixation for metacarpal neck fractures.

J Hand Surg Am 2013 Feb 28;38(2):322-330.e2. Epub 2012 Nov 28.

Hand and Upper Extremity Surgery Service, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.

Purpose: Fixation countersunk beneath the articular surface is well accepted for periarticular fractures. Limited open intramedullary headless compression screw (HCS) fixation offers clinical advantages over Kirschner wire and open techniques. We used quantitative 3-dimensional computed tomography to assess the articular starting point, surface area, and subchondral volumes used during HCS fixation of metacarpal neck fractures.

Methods: We simulated retrograde intramedullary insertion of 2.4- and 3.0-mm HCS and 1.1-mm Kirschner wires for metacarpal neck fracture fixation in 3-dimensional models from 16 adults. We used metacarpal head articular surface area (mm(2)) and subchondral volumes (mm(3)) and coronal and sagittal plane arcs of motion, during which we analyzed the center and rim of the articular base of the proximal phalanx engaging the countersunk entry site.

Results: Mean metacarpal head surface area mated to the proximal phalangeal base in neutral position was 93 mm(2); through the coronal plane arc (45°) was 129 mm(2), and through the sagittal plane arc (120°) was 265 mm(2). The mean articular surface area used by countersunk HCS threads was 12%, 8%, and 4%, respectively, in each of these arcs. The 1.1-mm Kirschner wire occupied 1.2%, 0.9%, and 0.4%, respectively. Mean metacarpal head volume was 927 mm(3). Mean subchondral volume occupied by the countersunk portion was 4%. The phalangeal base did not overlap the dorsally located countersunk entry site through most of the sagittal plane arc. During coronal plane motion in neutral extension, the center of the base never engaged the dorsally located countersunk entry site.

Conclusions: Metacarpal head surface area and subchondral head volume occupied by HCS were minimal. Articular surface area violation was least during the more clinically relevant sagittal plane arc of motion.

Clinical Relevance: The dorsal articular starting point was in line with the medullary canal and avoided engaging the center of the articular base through most of the sagittal plane arc. Three-dimensional computed tomography data support the use of an articular starting point for these extra-articular fractures.
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http://dx.doi.org/10.1016/j.jhsa.2012.09.029DOI Listing
February 2013

Symptomatic neural loop causing hemidigital anesthesia: case report.

J Hand Surg Am 2012 Oct 31;37(10):1994-6. Epub 2012 Aug 31.

Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA, USA.

Digital neural loops were identified over a century ago and are common findings in cadaveric studies of palmar and digital anatomy. Symptomatic digital neural loops are rare. We report a case of hemidigital anesthesia resulting from a proper digital nerve neural loop penetrated by its common digital artery in the palm. After neurolysis of the median nerve and the common and proper digital nerves to the third webspace, we transected the common digital artery, transposed it out of the neural loop, and repaired it. The patient's sensory symptoms fully resolved over 6 weeks. The differential diagnosis, diagnostic workup, and surgical treatment are reviewed.
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http://dx.doi.org/10.1016/j.jhsa.2012.07.012DOI Listing
October 2012

Scaphoid fracture in the elite athlete.

Hand Clin 2012 Aug;28(3):269-78, vii

Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Tufts University School of Medicine, Newton, MA 02462, USA.

Scaphoid fracture remains a common, potentially devastating, injury that can impair upper extremity function. Early recognition with proper imaging and treatment provides the best opportunity to heal and return to a normal activity level. Surgical treatment offers the patient a quicker return to the rehabilitation of the extremity and therefore an earlier return to elite play. There is evidence that healing occurs faster if the fractured scaphoid is fixed with internal fixation. Absolute compliance by the athlete and the training program that surrounds the athlete is critical to protect the wrist while maintaining the necessary conditioning of an elite athlete.
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http://dx.doi.org/10.1016/j.hcl.2012.05.005DOI Listing
August 2012

Treatment of symptomatic distal interphalangeal joint arthritis with percutaneous arthrodesis: a novel technique in select patients.

Hand (N Y) 2010 Dec 27;5(4):434-9. Epub 2010 Mar 27.

Arthrodesis of the distal interphalangeal (DIP) joint is a reliable means of achieving pain relief in a symptomatic DIP joint afflicted by a variety of degenerative, inflammatory, or posttraumatic conditions. Successful arthrodesis is more reproducible when rigid compression of the joint is achieved. The emergence of an increasing number of commercially available headless or variable pitch compression screws reflects the growing trend among hand surgeons to utilize rigid stabilization of the DIP joint so that motion at more proximal levels can be initiated immediately without affecting arthrodesis rates. Successful closed percutaneous DIP arthrodesis can be achieved in a patient with hypertrophic osteoarthropathy, passively correctable deformity, and patients at increased risk for perioperative soft tissue complications associated with open arthrodesis. We present a novel percutaneous DIP fusion technique utilizing a cannulated headless compression screw in a select group of patients. The sagittal plane diameters of the distal and middle phalanges are templated. Cannulated headless compression screws, 2.4 and 3.0 mm, with short or long terminal threads at the leading end of the screw are selected based upon patient-specific anatomic considerations. Pain-free status and radiographic fusion were achieved in both patients (gout arthropathy, n = 1; posttraumatic arthritis, n = 1) at an average of 6 weeks postoperatively. Our current indications, along with pearls and pitfalls with this technique, are reviewed. In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques.
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http://dx.doi.org/10.1007/s11552-010-9265-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988121PMC
December 2010

Sensory restoration by lateral antebrachial cutaneous to ulnar nerve transfer in children with global brachial plexus injuries.

Hand (N Y) 2010 Dec 12;5(4):370-3. Epub 2010 Jun 12.

Selective peripheral nerve transfers represent an emerging reconstructive strategy in the management of both pediatric and adult brachial plexus and peripheral nerve injuries. Transfer of the lateral antebrachial cutaneous nerve of the forearm into the distal ulnar nerve is a useful means to restore sensibility to the ulnar side of the hand when indicated. This technique is particularly valuable in the management of global brachial plexus birth injuries in children for which its application has not been previously reported. Four children ages 4 to 9 years who sustained brachial plexus birth injury with persistent absent sensibility on the unlar aspect of the hand underwent transfer of the lateral antebrachial cutaneous nerve to the distal ulnar nerve. In three patients, a direct transfer with a distal end-to-side repair through a deep longitudinal neurotomy was performed. In a single patient, an interposition nerve graft was required. Restoration of sensibility was evaluated by the "wrinkle test."
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http://dx.doi.org/10.1007/s11552-010-9284-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988122PMC
December 2010

Outcome after tendon transfers to restore wrist extension in children with brachial plexus birth injuries.

J Pediatr Orthop 2011 Jun;31(4):455-7

Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA.

Children with brachial plexus birth injuries often require tendon transfer to restore active wrist extension and maximize hand function. The purpose of this study is to assess the clinical results in children with brachial plexus birth injuries after tendon transfer to reconstruct active wrist extension. Over a 10-year period, 21 children (11 male, 10 female) underwent tendon transfer to reconstruct active wrist extension by a single surgeon. Eight patients had C5/C6/C7 injury and 13 patients had global palsy (C5-T1). The average age at surgery was 5.5 years (range, 3 to 8 y). Restoration of wrist extension was measured according to the functional scale of Duclos and Gilbert. The mean duration of follow-up was 36 months (minimum follow-up of 1 y). At latest follow-up, 14 (66%) children (C5/C6/C7, n=8; global, n=6) demonstrated active wrist extension ≥ 30 degrees. Within the global injury subcohort, 3 patients demonstrated static extension of the wrist. Four failures occurred in the global palsy group. Children with absent active wrist extension after a brachial plexus birth injury can benefit from a tendon transfer. The more severe global palsy cases have a worse outcome.
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http://dx.doi.org/10.1097/BPO.0b013e31821adcc0DOI Listing
June 2011

Avulsion injuries of the flexor digitorum profundus tendon.

J Am Acad Orthop Surg 2011 Mar;19(3):152-62

Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.

Avulsions of the flexor digitorum profundus tendon may involve tendon retraction into the palm and fractures of the distal phalanx. Although various repair techniques have been described, none has emerged as superior to others. Review of the literature does provide evidence-based premises for treatment: multi-strand repairs perform better, gapping may be seen with pullout suture-dorsal button repairs, and failure because of bone pullout remains a concern with suture anchor methods. Clinical prognostic factors include the extent of proximal tendon retraction, chronicity of the avulsion, and the presence and size of associated osseous fragments. Patients must be counseled appropriately regarding anticipated outcomes, the importance of postoperative rehabilitation, and potential complications. Treatment alternatives for the chronic avulsion injury remain patient-specific and include nonsurgical management, distal interphalangeal joint arthrodesis, and staged reconstruction.
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http://dx.doi.org/10.5435/00124635-201103000-00004DOI Listing
March 2011

Glenohumeral deformity in children with brachial plexus birth injuries.

Bull NYU Hosp Jt Dis 2011 ;69(1):36-43

NYU Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York, USA.

Shoulder deformity remains the most common musculo-skeletal sequela following a brachial plexus birth injury. The natural history of untreated glenohumeral deformity is one of progression in this unique patient population. In infants and young children with persistent neurological deficits, shoulder dysfunction becomes a major source of morbidity, as these children have extreme difficulty placing the hand in space. The functional limitations due to muscle denervation and the resultant periarticular soft tissue contractures and progressive osseous deformities have been well-characterized. Increasing attention is being given to the glenohumeral dysplasia (GHD) and the associated prevalence of early posterior dislocation of the shoulder in infants with brachial plexus birth injuries. GHD represents a spectrum of findings, including glenoid and humeral head articular incongruities and dysplasia, subluxation, and frank dislocation. This article presents our comprehensive, temporally-based management strategies for the glenohumeral joint deformities in these children utilizing soft tissue and bony reconstructive procedures.
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June 2011

Primary subcutaneous Alternaria alternata infection of the hand in an immunocompromised host.

Med Mycol 2011 Jul 7;49(5):543-7. Epub 2011 Feb 7.

Harvard Combined Plastic Surgery Residency Training Program, Department of Plastic and Reconstructive Surgery, Brigham & Women's Hospital, Boston, Massachusetts, USA.

We describe a case of a progressive subcutaneous Alternaria alternata infection in the hand of a patient with chronic lymphocytic leukemia (CLL). The diagnosis was based upon the examination of tissue biopsy and isolation of the etiologic agent in culture. The identity of the isolate was determined by phenotypic characteristics and by sequencing the ITS and D1/D2 regions of the rDNA. Despite combination therapy with voriconazole and micafungin, the lesion continued to progress. Posaconazole therapy, along with surgical excision of the infected tissue, resulted in the eradication of infection. The limitations of the clinical management of invasive Alternaria infections are discussed.
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http://dx.doi.org/10.3109/13693786.2011.555848DOI Listing
July 2011

Osteochondritis dissecans of the capitellum: current concepts.

J Am Acad Orthop Surg 2010 Sep;18(9):557-67

Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Osteochondritis dissecans (OCD) of the capitellum is an uncommon disorder seen primarily in the adolescent overhead athlete. Unlike Panner disease, a self-limiting condition of the immature capitellum, OCD is multifactorial and likely results from microtrauma in the setting of cartilage mismatch and vascular susceptibility. The natural history of OCD is poorly understood, and degenerative joint disease may develop over time. Multiple modalities aid in diagnosis, including radiography, MRI, and magnetic resonance arthrography. Lesion size, location, and grade determine management, which should attempt to address subchondral bone loss and articular cartilage damage. Early, stable lesions are managed with rest. Surgery should be considered for unstable lesions. Most investigators advocate arthroscopic débridement with marrow stimulation. Fragment fixation and bone grafting also have provided good short-term results, but concerns persist regarding the healing potential of advanced lesions. Osteochondral autograft transplantation appears to be promising and should be reserved for larger, higher grade lesions. Clinical outcomes and return to sport are variable. Longer-term follow-up studies are necessary to fully assess surgical management, and patients must be counseled appropriately.
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http://dx.doi.org/10.5435/00124635-201009000-00007DOI Listing
September 2010

The role of locking technology in the hand.

Hand Clin 2010 Aug 11;26(3):307-19; v. Epub 2010 Jun 11.

Hand and Upper Extremity Service, Yawkey Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Suite 2100, MA 02114, USA.

Locked fixed-angle plating in the hand and wrist helps to optimize outcomes following surgical fixation of select acute fractures and complex reconstructions. Select indications include unstable distal ulna head/neck fractures, periarticular metacarpal and phalangeal fractures, comminuted/multifragmentary diaphyseal fractures with bone loss (ie, combined injuries of the hand), osteopenic/pathologic fractures, nonunions and corrective osteotomy fixation, and small joint arthrodesis. Locked plating techniques in the hand should not be seen as a panacea for wrist and digital acute trauma and delayed reconstructions. An understanding of the biomechanics of fixed-angle plating and proper technical application of locking constructs will optimize outcomes and minimize complications. As clinical experience with locking technology in hand trauma broadens, new indications and applications will emerge. Currently, several systems are available. The specific implants share common features in their protocols for insertion, but unique differences in their design (ie, individual locking mechanisms, uniaxial vs polyaxial locking capability, metallurgy, and plate profiles) must be appreciated and considered preoperatively.
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http://dx.doi.org/10.1016/j.hcl.2010.04.001DOI Listing
August 2010

Digital intraosseous epidermoid inclusion cyst of the distal phalanx.

J Hand Microsurg 2010 Jun 11;2(1):24-7. Epub 2010 Aug 11.

Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, USA.

Epidermoid inclusion cysts (EIC) of the bone are exceedingly rare. We present a case of an atypical EIC originating at the base of the distal phalanx of the index finger following a remote history of crush injury to the finger. The differential diagnosis of expansile, lytic lesions of the phalanges remains broad, and definitive diagnosis requires tissue histopathological analysis. At latest follow-up, the patient was pain-free and obtained an excellent clinical and radiographic outcome following intra-lesional curettage and bone grafting. Differentiation of EIC from other radiolucent digital lesions remains challenging, especially when classic radiographic findings are not seen. We review the clinical, radiographic, and pathologic diagnostic features of this lesion, as well as our current treatment algorithm.
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http://dx.doi.org/10.1007/s12593-010-0001-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3452980PMC
June 2010
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