Scientific Abstract Presentations: Hand Session 2 Thursday, September 26 Thu, Sep 26 3:00-4:00 p.m. PDT

Aim: Irrigation and Debridement (I&D) are crucial steps in the management of open fractures serving to mitigate the risk of infection and promote optimal wound healing. Currently, there are no established guidelines for managing open fractures of the distal phalanx. The timing of I&D in the context of open distal phalanx fractures remains a subject of debate, with variability in clinical practice and a lack of standardized protocols.This systematic review aims to highlight the temporal application of surgical I&D in open distal phalanx fractures and its impact on complication rates.

Method: A systematic review was completed following the 2020 PRISMA guidelines using Medline, Embase and Cochrane. The title and abstract as well as the full-texts were screened in duplicate. Data was extracted by two independent reviewers, while conflicts were resolved through consensus with a third reviewer. Primary outcomes focused on fractures utilizing surgical debridement and irrigation. Additionally, patient characteristics, administration of antibiotics, functional outcomes and complications were analyzed as means of central tendency.

Results: Seventeen articles were included in the systematic review, yielding a total of 798 patients accounting for 703 debridement procedures . The average age was 9.2 years old, and men were predominant (61%). The majority of patients underwent immediate (<24 hour) I&D 86.7% (567/654 patients), while the average follow-up time following treatment was 9.2 months (n =12 studies). Amongst the patients subject to debridement, an infection rate of 5.22% was recorded (26/498 patients). Additional complications included mal-union and misalignments in 2.76%, physeal closure disturbances in 16.1%, and nail bed deformities in 19.2%. Additionally, complications based on timing of I&D revealed a 0% (0/220 patients) rate under 8 hours, a rate of 5.76% (20/347 patients) between 8-24 hours and a 72.4% (21/29 patients) rate of complications above 24 hours.

Conclusions: Surgical debridement and irrigation of open distal phalanx fractures yield favorable outcomes with low rates of infection and mal-union. In addition to reducing the risk of complications, this modality demonstrates favorable results in terms of range of motion and patient satisfaction with minimal adverse effects. Most notably, this review emphasizes the importance of timely and thorough debridement and irrigation in the management of open fractures of the distal phalanx. By providing clinicians with evidence-based recommendations, this review aims to inform clinical practice and optimize patient outcomes in this challenging clinical scenario.

Introduction: The Americans with Disability Act (ADA) safeguards individuals with disabilities, including those related to upper extremity mobility, from discrimination. The purpose of this study was to investigate the nature of ADA complaints initiated by individuals with upper extremity prosthetic devices. In doing so, the aim was to provide hand and upper extremity surgeons with valuable insights into the ADA and its relationship with patient care.

Methods: The Westlaw Campus Research legal database was searched for all cases involving clients with finger, hand, and arm prosthetics. Cases were included if at least one plaintiff with an upper extremity prosthetic initiated an ADA complaint related to their prosthetic. No limitation was placed on whether the prosthetic was functional or for cosmetic purposes. Characteristics of each case were collected, including the location where the case was initiated, the type of ADA complaint, plaintiff and defendant demographics, and case outcomes.

Results: After removal of duplicates, 557 cases were identified, of which 16 cases met inclusion criteria. Cases were initiated throughout the United States; the majority of states had one case except New Jersey and Florida which each had two cases. The majority of prosthetic-wearers were male (N=13, 81.3%) and only one case involved a pediatric client. The alleged discrimination most commonly took place in the workplace (N=12, 75%), followed by correctional facilities (N=2, 12.5%), an amusement park (N=1, 6.3%), and a housing authority (N=1, 6.3%). The location of discrimination was reflected in the frequency of ADA Title involvement; Title I: Employment, Title II (Public Services) and Title III (Public Accommodations) were noted in 12 (75%), 3 (18.8%) and 1 (6.3%) of the cases, respectively. Physician evaluations were mentioned in 10 (62.5%) of the cases.

Conclusion: Hand and upper extremity surgeons may benefit from ADA-related education that would enable them to better understand patient experiences and improve counseling on the legal challenges surrounding the use of upper extremity prosthetics. This study underscores the need for advocacy initiatives aimed at improving patient awareness of their workplace rights.

Purpose: To investigate if early surgical intervention for osteochondromas in or around the proximal interphalangeal joint (PIPJ) in pediatric patients will result in improved functional outcomes and decreased angular deformities.

Methods and Materials: A retrospective chart review was performed from 2014 to 2023 to identify patients with osteochondroma within-or in close proximity-to the PIPJ. Eight patients were identified with osteochondromas affecting the PIPJ. Surgery was recommended for patients with angular deformities or restricted range of motion. Radiographic imaging, treatment and outcomes were reviewed. We classified the osteochondromas into three types based on radiographic locations as originally described by Ohnishi et al., 2011. A goniometer was utilized to measure passive range of motion of the affected digits. Radiographs and clinical imaging were used to measure digit angulation. A 1-tailed t-test (P < 0.05) was performed for statistical analysis with Excel.

Results: Eight patients with osteochondroma affecting the PIPJ were identified; three of these patients carry a diagnosis of multiple hereditary exostosis (MHE). All patients underwent surgical excision of the osteochondroma. The average age at surgery was 6.25 years. Seven tumors presented dorsally, and one presented on the volar aspect of the digit. Two tumors blocked flexion; three tumors blocked extension; all tumors caused an angular deformity. Pre-operative and post-operative angulation improved from an average of 14.4° to 5.4°, it was significantly improved (P < 0.05). Operative intervention was performed on all patients. No serious complications were encountered.

Conclusion: Osteochondroma affecting the PIPJ in pediatric patients can lead to functional deficits and deformity, necessitating early surgical intervention. Our retrospective study demonstrates that excision of osteochondromas in/around the interphalangeal joints leads to improvements in angulation and range of motion. We recommend tumor excision when tumors lead to clinodactyly and/or if they affect any part of the joint surface.

Abstract

Purpose: According to the United States Consumer Product Safety Commission, an estimated 10,200 emergency department visits occurred in 2022 because of firework-related injuries (1). The hand, wrist, and fingers are the most affected by firework explosions, representing 29% of documented injuries (1). Though a small percentage of firework-related hand injuries require surgery, these patients often sustained devastating injuries resulting in significant life-long impairment (2). Firework blast trauma most commonly affects the hands and occurs along a spectrum of severity ranging from minor burns to mangling injuries. The thumb accounts for 40% of hand function (3). Proper thumb function depends on several factors: length, sensation without chronic pain, a functional CMC joint and thenar muscle, and a supple first web space. There is a paucity in the literature focusing on reconstruction of thumb injuries resulting from firework explosions. Based on a retrospective chart review of our institution's trauma l center with frequent exposure to these high-energy blast injuries, a detailed treatment algorithm is proposed.

Methods: Patients who underwent operative management for firework-related hand injuries at a level one trauma center between January 2009 and December 2023 were retrospectively reviewed for demography, injury pattern and treatment. General descriptive statistics were performed.

Results: Seventy-four patients who sustained severe firework blast injuries to the hand were reviewed. Thumb injuries were treated in 59 patients (80%). A majority of these, 52 patients, involved both the thumb and the first web space (88%). A wide range of surgical treatments were employed, and often several different techniques were used for the case. Amputation (60%) was performed most frequently, followed by skin grafting (36%) and primary closure (32%). Local and free flaps were performed in 35% of the cases.

Conclusions: In this study, we summarized patient demographic, injury pattern, and treatment for operative firework blast hand injuries at a large metropolitan level 1 trauma center. A majority of operative firework injuries to the hand involve the thumb and first web space. It's paramount to preserve or restore length, sensation, mobility of the thumb and a supple first web space. Proximal thumb injuries tend to require more aggressive treatment of the first web space. In case of devastating proximal injuries involving the CMC joint, creating a stable and well-positioned sensate post is acceptable. Given the predominant involvement of the thumb and the first web space in these injuries and the paramount importance of the thumb in normal hand function, we focused on treatment of the thumb. To this end, we propose a treatment algorithm to guide surgical management of thumb and first web space blast injuries.

References

1. U.S Consumer Product Safety Commission. Fireworks annual report 2022. Accessed January 21, 2023, https://www.cpsc.gov/s3fs-public/2022-Fireworks-Annual-Report.pdf
2. Sandvall BK, Keys KA, Friedrich JB. Severe Hand Injuries From Fireworks: Injury Patterns, Outcomes, and Fireworks Types. The Journal of Hand Surgery. 2017;42(5):385.e1-385.e8. doi:10.1016/j.jhsa.2017.01.028
3. Dickey RM, Meade AE, Agnew SP, Zhang AY. Treatment of Nonreplantable Total Thumb Amputation at the CMC Level Using Index Finger Pollicization. Hand (N Y). Nov 2022;17(6):1154-1162. doi:10.1177/1558944720988074

Purpose Given the increasing incidence of brachial plexus injuries and costs of brachial plexus surgery in the US, $66 million in 2006, maximizing outcomes and preventing complications is the best approach to providing high-value care (1). However, there is still a lack of knowledge pertaining to the influence of laboratory values in patients undergoing brachial plexus surgery. This study aims to elucidate the effect of preoperative hematocrit, albumin, and creatinine values on complication rates after brachial plexus surgery.

Materials and Methods The ACS NSQIP database was queried for occurrences of brachial plexus neurolysis from 2011-2020. CPT 64713 as well as concurrent ICD-9 codes (353.0, 953.4) and/or concurrent ICD-10 codes (G54.0, S14.3XXA, S14.3XXD, S14.3XXS) were used to define the cohort. For each patient, the latest serum hematocrit, creatinine, and albumin within 90 preoperative days of surgery was selected. Additional covariates spanned demographics, medical history, and operative characteristics. Outcome variables of interest were tracked to 30 days postoperatively and included aggregate medical complications, wound complications, non-home discharge, return to OR and extended length of stay (eLOS), defined as the 75th percentile of each analysis cohort.

Within each cohort, an independent two-tailed t test was initially performed to assess for difference in lab values between patients that had an outcome of interest versus those who did not. For any lab value-outcome pairs that demonstrated significance, multivariate logistic regression controlling for covariates was conducted to assess the independent predictive ability of the serum lab value. If significance was again achieved, an area-under-the-receiver-operating-characteristic-curve (AUC) estimate was generated. From this curve, an optimal lab value cutoff point was determined using the Youden's Index.

Results A total of 272 patients with serum albumin, 899 patients with serum hematocrit, and 793 patients with creatinine were included in the study cohort. Multivariate analysis revealed that increases in hematocrit decreased the odds of wound complications (aOR: 0.713; 95% CI: 0.572 – 0.889; p=0.003). In males, AUC analysis found a predictive hematocrit cutoff of ≤ 42.7% for wound complications (AUC: 0.81±0.258, p=0.033). In females, AUC analysis found a predictive hematocrit cutoff of ≤ 39.0% for wound complications (AUC: 0.82±0.207, p=0.007). Bivariate analysis showed lower creatinine levels in patients experiencing an eLOS (0.81 mg/dL vs. 0.88 mg/dL, p = 0.005). Multivariate analysis found that increases in creatinine decreased the odds of eLOS (aOR: 0.124; 95% CI: 0.028 – 0.552; p=0.006).

Conclusions Increased hematocrit was independently associated with decreased odds of short-term wound complications in this brachial plexus surgery cohort. In addition, predictive cutoff values were identified that can be used to identify patients at risk of complications. Equipped with this knowledge, surgical teams can make informed risk-stratification decisions in the preoperative setting to prevent undesirable outcomes. Future studies are needed to assess the efficacy of interventions that aim to optimize laboratory values before surgery.

1. Dy CJ, Peacock K, Olsen MA, Ray WZ, Brogan DM. Incidence of Surgically Treated Brachial Plexus Injury in Privately Insured Adults under 65 Years of Age in the USA. HSS J. 2020;16(2_suppl):339-343. doi:10.1007/s11420-019-09741-8

Background: Obstetric brachial plexus palsy (OBPP) can lead to lifelong disability, resulting in significant social, psychological, and economic consequences for patients and their families. Coordinated care of infants with OBPP requires specialized follow-up with a multidisciplinary care team, including plastic surgeons and occupational therapists, over the course of many years. Due to the complex coordination required for establishing consistent care, a patient's socioeconomic and geographic context may impact the level of care they are able to receive. This study aims to assess the role that socioeconomic context has on the clinical and surgical outcomes of infants with OBPP by means of the Area of Deprivation Index (ADI) and geographic locality.

Methods: A retrospective study was performed of infants with OBPP who presented to the brachial plexus clinic of Children's Hospital of Pittsburgh from 2008 to 2020. ADI and urban-rural locale were determined based on address and zip code. Outcomes of interest included complete recovery, defined as Active Movement Scale (AMS) score equal to 105, surgical intervention, and follow-up duration. Multivariate regression analysis was performed to assess for variables associated with outcomes for OBPP.

Results: A total of 195 patients met inclusion criteria. Seventy-three (37.4%) patients underwent surgical intervention for exploration or nerve grafting, at an average age of 1.3 ± 2.2 years. Median ADI was 76 (range 3-100). Thirty-two percent (31.8%) of patients were from a rural locale. Twenty-three percent (23.3%) of patients were from a non-white background. On multivariable regression analysis, rural location was significantly associated with a decreased incidence of surgical intervention (OR 0.5, CI 0.256-0.982, p=.04). Higher ADI was significantly correlated with lower AMS scores at 9 months and at most recent follow-up (R2 = -0.31, p=.004; R2=-0.136, p=.04, respectively). Patients of non-white racial backgrounds were significantly associated with lower birth weights compared to white patients (p=.04), lower AMS scores at 3 months (p=.004), lower AMS scores at 6 months (p = .009), 9 months (p<.001), post-operatively (p=.01), and at most recent follow-up (p =<.001). The proportion of patients achieving full-recovery was not significantly different between groups based on race, ADI quartiles, and Urban-Rural geography. There was no difference between groups based on ADI, race, and rural locale for average age at referral, age at surgery, and duration of follow-up.

Conclusion: Socioeconomic status is an intricate relationship between multiple factors. This study demonstrates that geographic location and race may impact functional movement outcomes and surgical intervention for OBPP. Additionally, our findings highlight the importance of regular follow-up for patients with OBPP as well as the reevaluation of resources available for those with socioeconomic hardship. At an initial visit and regular follow-up visits, providers should screen patients for barriers to accessing routine care, such as transportation or scheduling conflicts, and attempt to alleviate these barriers.

Introduction

Underserved populations are disproportionately affected by trauma and include patients from racial minorities, low-income, and rural residence. This study describes pediatric hand injuries in these groups and assesses their risk of injury.

Methods

This was a retrospective cohort of pediatric patients referred to our hand clinic from 2010-2020. Patients were stratified by race, median household income, and geography. Population and socioeconomic data were obtained from the United States Census Bureau. Area Deprivation Index (ADI) was calculated and stratified by the top 50% (most disadvantaged neighborhoods) and bottom 50% (least disadvantaged neighborhoods). Charts were abstracted, summary statistics were calculated, and relative risks (RR) were computed via binomial regression. Significance was assessed at alpha=0.05.

Results

1,311 patients were referred for hand trauma. The median age was 11.2 years. 465 patients (35.5%) were female, 388 (29.6%) were a minority race, 107 (8.2%) lived in rural locations, and 158 (12.1%) had a median annual household income < $43,000. 969 patients (73.9%) lived in neighborhoods with the top 50% ADI. Compared to urban children, rural children were more likely to have fingertip injuries (14% vs 1.6%, RR 8.48, CI 4.46-16.14, p<0.001). Compared to Caucasians, minority-race children were more likely to have violent (10.6% vs 2.9%, RR 3.63, CI 2.27-5.81, p<0.001) or self-inflicted mechanisms of injury (4.9% vs 2.3%, RR 2.16, CI 1.18-3.98, p=0.01), but less likely to have fingertip injuries (11.3% vs 19.5%, RR 0.61, CI 0.45-0.82, p<0.001), index finger injuries (10.6% vs 15.5%, RR 0.69, CI 0.50-0.96, p=0.02), and open fractures (10.1% vs 15.0%, RR 0.63, CI 0.46-0.88, p=0.005). Compared to children from less disadvantaged neighborhoods, children from the top 50% ADI neighborhoods were more likely to have violent mechanisms of injury (6.0% vs 2.9%, RR 2.08, CI 1.08-4.03, p=0.02), and less likely to have vascular injuries (1.2% vs 2.6%, RR 0.44, CI 0.21-0.96, p=0.04). No significant differences were found when comparing children from different income levels.

Conclusions

The greater prevalence of fingertip injuries in rural children relative to urban children highlights the ongoing need for rural hand specialists. Children from minority races and disadvantaged backgrounds were more likely to suffer from hand trauma due to violence compared to their Caucasian and less disadvantaged counterparts. These findings may represent the impacts of the social determinants of health.

Introduction: Brachial plexus birth injury (BPBI) results from upper limb traction during delivery. While the incidence of BPBI has decreased in high-income countries (HICs), low- and middle-income countries (LMICs) still face a high prevalence, e.g., 27.2% in one African nation.1 Timely surgical intervention is crucial for functional recovery in infants without spontaneous resolution of BPBI, including nerve grafting and/or transfers prior to one year of age. Although safe and essential surgery as a public health approach is gaining traction, microsurgical BPBI interventions have historically not been utilized in short term global outreach in LMICs who face a greater burden of BPBI.2 This study assessed the feasibility of microsurgical BPBI interventions in a resource-limited setting (RLS). Methods: Surgicorps International collaborated with Beit-CURE Children's Hospital Lusaka to evaluate LMIC pediatric BPBI patients without access to care outside of physiotherapy programs. A visiting HIC plastic surgeon, along with additional staff, assessed patients for operative or non-operative treatment. BPBI surgeries were performed by the visiting HIC plastic surgeon with repeat evaluation performed at a one-year post-operative visit. Interventions were limited by lack of pediatric anesthesiologist and pediatric ICU specialists, necessitating surgeries <3hrs, excluding high-risk infants, and ruling out nerve grafting due to post-operative care limitations. LMIC hospital facilities provided necessary equipment including well-equipped modern operating rooms and anesthesia equipment, while specialized equipment was donated, including microsurgical instruments, high power loupe magnification, and nerve stimulators. Results: During a one-week period, twelve LMIC patients (5 months to 12 years) were evaluated, and two aged 11 and 15 months underwent nerve transfers (double fascicular transfer for elbow flexion and spinal accessory to suprascapular nerve transfer for external rotation and abduction). At one-year post-operative follow-up, both showed improved function with Active Movement Scale (AMS) of 6 and 7 respectively for anti-gravity elbow flexion and 6 and 6 respectively for shoulder abduction. Another patient (21 months) underwent tendon transfers (pectoralis major lengthening, subscapular release, latissimus dorsi and teres major transfer to infraspinatus), showing significant increased range of motion in external rotation and abduction. Three patients were recommended non-operative interventions. No acute surgical complications occurred. Conclusion: While nerve grafting is standard in HICs for BPBI, this study provides proof of concept for safe and effective microsurgical BPBI intervention in a LMIC with a formerly unmet surgical need. Challenges in staff and equipment availability were addressed, emphasizing the potential for positive surgical outcomes with minimal risk in a RLS. Future efforts should continue to explore non-operative interventions, telehealth follow-up, and the development of formal microsurgical training programs for Zambian surgeons to enhance sustainable care. References: [1] Hamzat TK, Carsamer S, Wiredu EK. Prevalence of newborn brachial plexus palsy in Accra, Ghana. Journal of Pediatric Neurology. 2008;6:133-138. doi:10.1055/s-0035-1557453 [2] Meara JG, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet Commissions. Lancet 2015; 386: 569-624

Background/Purpose: Wide-awake and office-based hand surgeries are increasingly common. The association of these techniques with postoperative pain and pain control has garnered recent attention. A prior study demonstrated that office-based trigger finger release (TFR) were associated with decreased perioperative opioid prescriptions compared to those performed in the operating room (1). The current study provides an in-depth analysis of the association between surgical setting and perioperative opioid prescriptions for wide-awake TFR.

Methods: Patients undergoing TFR between 2010 and 2021 were identified in PearlDiver, a national administrative claims database. Exclusion criteria were age <18 years, <6 months of preoperative data, <1 month of postoperative data, bilateral TFR and concomitant hand surgery. To identify wide-awake cases, patients with procedural codes for general anesthesia, monitored anesthesia care, sedation and regional blocks were excluded. Patients were stratified by surgical setting (office or operating room), then matched based on age, sex, Elixhauser Comorbidity Index score and geographic region. Patients with prior opioid prescriptions, opioid dependence, opioid abuse, substance use disorder, chronic back/neck pain, generalized anxiety and major depression were identified. Perioperative opioid prescriptions (those filled within 7 days before or 30 days after surgery) were characterized. Logistic regression and linear regression were used for multivariate analysis of filled prescriptions and MME of prescriptions.

Results: There were 16,604 matched wide-awake TFR patients in each cohort. In the cohort of office-based patients, 4,993 (30%) filled a prescription for perioperative opioids, in contrast to 8,763 (53%) patients who underwent surgery in the operating room. This disparity was statistically significant in both univariate and multivariate analyses (odds ratio 0.37; 95CI 0.35–0.39; p<0.001). Univariate analysis indicated that office-based surgeries were linked to lower morphine milligram equivalents (MME) in opioid prescriptions than those performed in operating rooms (median of 140 vs 150, respectively). However, multivariate analysis demonstrated that opioid prescriptions for office-based surgeries were actually associated with greater MME (p=0.009).

Conclusions: Patients undergoing office-based TFR were less likely to fill perioperative opioid prescriptions but were prescribed opioids with greater MME. In wide-awake TFR, it appears that a disparity may exist in patient and provider beliefs about postoperative pain control. Future patient- and provider-level investigations may produce insights into perceptions of postoperative pain and pain control, which may be useful for reducing opioid prescriptions across surgical settings.

References 1. Mookerjee VG, Kammien AJ, Prsic A, Grauer JN, Colen DL. Wide Awake Trigger Finger Releases Performed in the United States: Trends in Volume, Operative Setting, and Reimbursement. Ann Plast Surg. 2023;91(2):220-224.

Purpose:
ATV-related upper extremity injuries are commonly seen and treated in the emergency room. Despite existing research on patterns of injuries in ATV-related trauma, there has not been a comprehensive study on patterns of upper-extremity injuries from ATV use. The aim of this study was to examine the incidence, patterns, trends, and characteristics of ATV-related distal upper extremity injuries across the United States using the US Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) database to better understand these injury trends and outcomes.

Methods:
In this study, the NEISS database was utilized to investigate distal upper extremity injuries specifically related to the use and operation of ATVs during a 10-year period from 2013 to 2022. The queried injuries encompassed the lower arm, wrist, hand, and fingers. The query was conducted using NEISS product codes for different types of ATVs, including three-wheeled ATVs, four-wheeled ATVs, ATVs with more than four wheels, and ATVs with an unspecified number of wheels. Demographic factors such as age, sex, race, and incident location were also examined in the analyzed dataset. The injuries were further assessed to include diagnosis, involved body parts, and disposition. The injuries were also categorized based on their locations and further subcategorization was done for forearm injuries to include ulna, radius, both, and unspecified. 

Results:
Since 2013, there has been a steady decline in the national estimate of total ATV-related injuries from 111,155 to 81,831 in 2022. There has been a gradual uptrend in the amount of distal upper extremity ATV injuries, with a peak of 19,973 in 2020. The number of male patients reported was approximately twice the number of female patients (68.87%, 2,268/3,292 vs. 31.13%, 1025/3,292). Adolescents between the ages of 10 to 19 experienced the highest incidence of ATV-associated distal extremity injuries (41.1% of reported, 37.3% of national estimate), followed by patients between the ages of 20 to 29 (19% of reported, 19.5% of national estimate). The most commonly reported location of incidents were sports fields (18.9%, 625) followed by home (557, 16.9%). Of the reported cases, most were examined, treated, and discharged (2833, 86%) and another 10% (327) were admitted. 

Among all the injuries listed, fractures were the most common reported injury across all body parts, occurring in 49.1% of all distal upper extremity injuries (1,740/3,541).  Of the 883 reported forearm fractures, 40.5% involved the radius, 7.6% involved the ulna, 17% involved both bones, and 34.9% were unspecified. 

Conclusion:
This study demonstrated a predominance of injuries in males and the 10-19 age group and fractures as the most reported associated distal upper extremity injury type. Given that the rate of ATV-related upper extremity injuries has not followed the declining trend of overall ATV-related injuries, more attention should be focused on the effectiveness of upper extremity injury prevention such as rider education and the utilization of safety equipment in the form of arm restraints that keep the upper extremities in the vehicle, especially during rollovers.