13 research outputs found
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Can You Go the Distance: Collagenase Clostridium histolyticum Manipulation at 1 Month after Injection.
Collagenase Clostridium histolyticum is a popular treatment in Dupuytren contracture. Current guidelines are for manipulation 24 hours to 7 days after injection. We present a case of successful manipulation 28 days after injection
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Approach to the Treatment of Expansile Metacarpal Aneurysmal Bone Cysts: A Report of Two Cases.
The two cases presented demonstrate the management of aneurysmal bone cysts of the metacarpal, which destroyed the normal bone architecture. Treatment of both cases included wide resection and metacarpal reconstruction with an intercalary fibular allograft. Denosumab use contrasts these two cases and is helpful in reestablishment of a cortical rim for fixation in the absence of a 1-cm margin proximally or distally to preserve the native carpometacarpal and metacarpophalangeal joints. Surgical resection and allograft reconstruction is a viable treatment for expansile metacarpal aneurysmal bone cysts, and neoadjuvant denosumab has utility in creating an ossified margin for fixation
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Variation in practice habits in the treatment of pediatric distal radius fractures.
Distal radius fractures are widespread in the pediatric population. Standardized treatment protocols have not been well defined. We sought to examine the diversity of current practice patterns in the treatment of these fractures by surveying hand, pediatric, and general orthopedic surgeons. Hand, pediatric, and general orthopedic surgeons were surveyed using an internet-based questionnaire on the management of pediatric distal radius fractures. Each surgeon was asked to select a criterion from among choices of 'acceptable' alignment criteria at the onset of the survey. Ten cases were then provided to represent a broad spectrum of injuries from minimally angulated torus fractures to complete, displaced fractures. In addition to the variation in injury pattern, the patients in the survey differed in age at the time of injury (3-15 years of age). For each case, surgeons were asked to select a preferred treatment, first on the basis of injury films, and then again after reviewing 1-week follow-up radiographs. A total of 781 surgeons completed the survey. In patients younger than 9 years of age, a residual sagittal angulation of 20° or less, coronal angulation of 10° or less, and 1 cm or less of bayonet apposition was deemed 'acceptable' by 88, 90, and 69% of respondents, respectively. In older patients, these percentages were 58, 64, and 29%, respectively. When specific cases were reviewed, 20.3% of surgeons recommended treatment different from their own theoretical 'acceptable' criteria. When subspecialty training was analyzed, hand surgeons and general orthopedic surgeons were 2.9 and 1.6 times more likely to recommend surgery, respectively, as compared with pediatric surgeons after viewing the initial radiograph. Private practice surgeons were 1.5 times more likely to recommend surgery compared with academic surgeons based on the initial injury radiographs. Our survey highlights the discordance between theoretical acceptable criteria of surgeons and their practice habits, as well as the substantial disparities in treatment recommendations based on subspecialty training. Further study is warranted to determine whether these variations in treatment affect patient outcomes. This survey is a level IV observational study
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Variation in practice habits in the treatment of pediatric distal radius fractures.
Distal radius fractures are widespread in the pediatric population. Standardized treatment protocols have not been well defined. We sought to examine the diversity of current practice patterns in the treatment of these fractures by surveying hand, pediatric, and general orthopedic surgeons. Hand, pediatric, and general orthopedic surgeons were surveyed using an internet-based questionnaire on the management of pediatric distal radius fractures. Each surgeon was asked to select a criterion from among choices of 'acceptable' alignment criteria at the onset of the survey. Ten cases were then provided to represent a broad spectrum of injuries from minimally angulated torus fractures to complete, displaced fractures. In addition to the variation in injury pattern, the patients in the survey differed in age at the time of injury (3-15 years of age). For each case, surgeons were asked to select a preferred treatment, first on the basis of injury films, and then again after reviewing 1-week follow-up radiographs. A total of 781 surgeons completed the survey. In patients younger than 9 years of age, a residual sagittal angulation of 20° or less, coronal angulation of 10° or less, and 1 cm or less of bayonet apposition was deemed 'acceptable' by 88, 90, and 69% of respondents, respectively. In older patients, these percentages were 58, 64, and 29%, respectively. When specific cases were reviewed, 20.3% of surgeons recommended treatment different from their own theoretical 'acceptable' criteria. When subspecialty training was analyzed, hand surgeons and general orthopedic surgeons were 2.9 and 1.6 times more likely to recommend surgery, respectively, as compared with pediatric surgeons after viewing the initial radiograph. Private practice surgeons were 1.5 times more likely to recommend surgery compared with academic surgeons based on the initial injury radiographs. Our survey highlights the discordance between theoretical acceptable criteria of surgeons and their practice habits, as well as the substantial disparities in treatment recommendations based on subspecialty training. Further study is warranted to determine whether these variations in treatment affect patient outcomes. This survey is a level IV observational study
A Clinical Scoring System for Distinguishing Patients With Coincident Cubital Tunnel Syndrome Among Patients With Carpal Tunnel Syndrome
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Range of motion measurements in hand surgery: should they be used for assessing outcomes?
PurposeThe purpose of the study was to assess how context influences range of motion measurements in hand surgery.MethodsOne hundred seventy-five consecutive patients presenting to a hand surgery clinic were evaluated over 7 sessions. Passive and active motion were measured with a goniometer and by visual estimation. The affected joint was measured by 3 different examiners-one hand surgeon and 2 research assistants (RAs). Measurements by the RAs were performed under the pretense of imaginary project titles and purposes.ResultsRange of motion measurements were easily influenced. As the invented project's purpose became more specific and dependent on physician intervention, the bias became more pronounced. Measurements performed under construed project titles that promoted surgical intervention garnered outcomes that supported surgery (P < 0.01). Conversely, when the manufactured study's intent was to find support in conservative treatment, this outcome could also be generated (P < 0.01).DiscussionRange of motion measurements can easily be influenced by the context of the study, even in seemingly blinded examiners. Reliable range of motion measurements can only be made when the examiner has no knowledge of the study's intent
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Does the gatekeeper model work in hand surgery?
BackgroundMost managed care plans use a physician "gatekeeper" to control referrals to hand surgeons. The appropriateness of this model for upper extremity complaints has never been challenged. The purpose of this study was to evaluate the prior management of patients with elective hand disorders who present to a hand surgery clinic.MethodsAll patients presenting to a tertiary, academic medical center for a new-patient hand surgery evaluation from February 3, 2011, to June 15, 2011, were prospectively enrolled. Patients were evaluated for prior provider, diagnosis, treatment, and complications. Actual diagnosis, recommended workup, and appropriate treatment were determined independently by two experienced hand examiners. Traumatic injuries and surgeon disagreements in diagnosis and treatment were excluded, leaving 125 patients.ResultsNinety-eight percent of patients had been evaluated by a primary care provider. Overall, the correct diagnosis was established 34 percent of the time. Nerve compression syndromes were diagnosed with the greatest accuracy (64 percent), whereas stenosing tenosynovitis was diagnosed correctly only 15 percent of the time. Before presentation, 74 percent of patients had undergone a study or intervention. On review, 70 percent of studies/interventions were deemed unnecessary. Advanced imaging was unwarranted in 90 percent of patients who received it. Seventeen percent of patients experienced a complication. Most (67 percent) were caused by a delay in diagnosis, whereas 33 percent resulted from an intervention.ConclusionsHealth care providers less familiar with an examination of the hand often misdiagnose and mistreat common problems. A referral system may not be the most efficient means of delivering care to patients with elective hand maladies