Background: There is growing evidence that social determinants of health (SDOH) are associated with disparities in access to care and hand and upper extremity health. Quality measures represent an opportunity to evaluate disparities in access and outcomes that can inform improvement interventions. We performed a systematic review of evidence regarding health disparities within hand surgery and aimed to develop suitable quality measures that are clinically important, feasible, usable, and scientifically acceptable. Methods: We performed a systematic review including common hand surgery terms to identify health disparities in hand surgery related to SDOH. Candidate quality measures were constructed based upon evidence from the systematic review. A consortium of 11 US-based hand and upper extremity surgeons completed a modified RAND/UCLA Delphi Appropriateness process to evaluate the importance, feasibility, usability, and scientific acceptability of the candidate quality measures. Panelists rated each measure on a scale of 1 ( definitely not important/feasible/usable/scientifically acceptable ) to 9 ( definitely important/feasible/usable/scientifically acceptable ) in 2 voting rounds separated by a face-to-face discussion. Agreement among panelists and validity were assessed using predetermined criteria. Results: Fourteen candidate quality measures addressing health disparities were identified based on evidence from the systematic review, including time to surgery and emergency department use after hand surgery based on insurance type, clinical outcomes based on social deprivation, among others. All 14 measures were accepted. Conclusions: Fourteen candidate quality measures were identified and accepted based upon consensus to address health disparities in hand surgery, although future investigation will be needed to evaluate their effectiveness.

Liposomal bupivacaine (LB) has gained interest as a long-acting local anesthetic, although its utility in hand and wrist surgery remains unclear. This systematic review and meta-analysis evaluated randomized controlled trials (RCTs) comparing LB with conventional anesthetics in patients undergoing hand or wrist surgeries. Searches were performed in PubMed, Embase, Cochrane Library, Web of Science, Scopus, and Google Scholar through July 2025. Eligible studies reported pain scores and opioid consumption from postoperative day (POD) 0-5, and overall benefit of analgesia scores (OBAS) from POD 1 to 4. Pooled analyses calculated weighted means for pain scores, opioid use, and OBAS, with subgroup analyses for carpometacarpal (CMC) arthroplasty and distal radius open reduction internal fixation (ORIF). Four RCTs involving 211 patients (105 LB, 106 control) were included. Pain scores were not significantly different between groups across POD 0-5. Opioid consumption was marginally reduced on POD 1 with no significant other differences. OBAS scores were lower in the LB group on POD 2 and 3 with no other significant differences. This limited study found that LB use does not significantly reduce postoperative pain and opioid use or enhance analgesia satisfaction compared to standard bupivacaine in hand and wrist surgery. Level of evidence:Therapeutic II.

Purpose Previous studies evaluating weight bearing of distal radius fractures treated through dorsal spanning bridge plates used extra-articular fracture models, and have not evaluated the role of supplementary fixation. We hypothesized that supplementary fixation with a spanning dorsal bridge plate for an intra-articular wrist fracture would decrease the displacement of individual articular pieces with cyclic axial loading and allow for walker or crutch weight bearing. Methods Thirty cadaveric forearms were matched into 3 cohorts, controlling for age, sex, and bone mineral density. An intra-articular fracture model was fixed with the following 3 techniques: (1) cohort A with a dorsal bridge plate, (2) cohort B with a dorsal bridge plate and two 1.6-mm k-wires, and (3) cohort C with a dorsal bridge plate and a radial pin plate. Specimens were axially loaded cyclically with escalating weights consistent with walker and crutch weight-bearing with failure defined as 2-mm displacement. Results No specimens failed at 2- or 5-kg weights, but cohort A had significantly more displacement at these weights compared with cohort B. Cohort A had significantly more failure than cohort C. Both cohort A and cohort B had significantly more displacement at crutch weight bearing compared with cohort C. The supplementary fixation group had significantly lower displacement at crutch weight-bearing compared with cohort A in all gaps. Survival curves demonstrated the fixation cohort to survive higher loads than the nonfixation group. Conclusion There was significantly less displacement and less failure of intra-articular distal radius fractures treated with a spanning dorsal bridge plate and supplementary fixation. Our model showed that either type of fixation was superior to the nonfixation group. Clinical Significance When considering early weight-bearing for intra-articular distal radius fractures treated with a spanning dorsal bridge plate, supplementary fixation may be considered as an augmentation to prevent fracture displacement. (J Hand Surg Am. 2024;49(10):1039.e1e9. Copyright (c) 2024 by the American Society for Surgery of the Hand. All rights reserved.)

Purpose Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome. Methods We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated. Results Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared. Conclusions Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions. Clinical relevance Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical de-cisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making. (J Hand Surg Am. 2023;48(11):1162.e1 -e8. Copyright (c) 2023 by the American Society for Surgery of the Hand. All rights reserved.)

Background: Implants are a significant contributor to health care costs. We hypothesized that extra-articular fracture patterns would have a lower implant charge than intra-articular fractures and aimed to determine risk factors for increased cost. Methods: In total, 163 patients undergoing outpatient distal radius fracture fixation at 2 hospitals were retrospectively reviewed stratified by Current Procedural Terminology codes. Implants and associated charges were noted, as were sex, age, insurance status, surgeon specialty, and location. Bivariate and multivariable regression were used to determine associations. Results: Total implant charges were significantly lower for 25607 (extraarticular, $3,348) than 25608 (2-part intraarticular, $3,859) and 25609 (3+ part intraarticular, $3,991). In addition, intra-articular fractures had higher charges for distal screws/pegs and bone graft. Charge was lower when surgery was performed at a trauma center. There was no charge difference associated with insurance status, age, sex, hand surgery specialty, or fellow status. Substantial intersurgeon variation existed in all fracture types. Conclusion: Distal radius fractures may represent a good model for examining implant costs. Extra-articular fractures had lower implant charges than intra-articular fractures. These data may be used to help construct pricing for distal radius fracture bundles and potential cost savings.

Operations in patients with rheumatoid arthritis are complicated by the fact that most drugs used in medical management have immunosuppressive mechanisms of action, including corticosteroids and conventional synthetic and biologic disease-modifying antirheumatic drugs. In deciding to continue or discontinue these medications perioperatively, surgeons must weigh the relative risk of infection from immunosuppression against the risk of rheumatoid arthritis symptom flares from reduced medical disease control. The objective of this article is to review the existing evidence regarding perioperative management of immunosuppressive rheumatoid arthritis medications, with a specific focus on relevance to hand and upper-extremity procedures.

Background  Scaphoid fracture is the most common carpal bone fracture. Open reduction internal fixation of scaphoid fractures typically undergo stabilization by a single headless compression screw (HCS). During screw insertion, a derotational Kirschner wire (K-wire) is often placed for rotational control of the near and far fragment. Questions/Purposes  The aim of this study was to determine if there is an angle of derotational K-wire placement in relation to the axis of a HCS that compromises the amount of compression generated at a fracture site by the HCS. We hypothesize that increased off-axis angle will lead to decreased compression across the fracture site. Methods  A Cellular Block 20 rigid polyurethane foam (Sawbones, Vashon, WA) scaphoid model was created to eliminate variability in bone mineral density in cadaveric bone. MiniAcutrak HCS screws (Acumed, Hillsboro, OR) were used for testing. Three conditions were tested: (1) HCS with derotational wire inserted parallel to the HCS (zero degrees off-axis); (2) HCS with derotational wire inserted 10 degrees off-axis; and (3) HCS with derotational wire inserted 20 degrees off-axis. Results  A statistically significant difference in the mean compression of the control group (56.9 N) was found between the mean compression with the derotational K-wire placed 20 degrees off-axis (15.2 N) ( p  = 0.001). Conclusions  Compression at the fracture site could be impeded by placing an excessively angulated off-axis derotation wire prior to insertion of the HCS. Clinical Relevance  Our study adds a new detail to the optimal technique of HCS placement in scaphoid fractures to improve compression and fracture union.

Purpose: Despite the importance of collecting patient-reported outcome measures (PROMs), there are few process guidelines for physicians on how to collect and communicate individualized PROMs in patients at the point of care. The purpose of this study was to develop process guidelines on how to routinely collect and communicate individualized PROMs at the point of care in hand surgery. Methods. A consortium of 9 fellowship-trained hand or upper limb surgeons and experts in quality measure development evaluated the importance, feasibility, usability, and scientific acceptability of 12 candidate process guidelines regarding the collection and use of individualized PROMs at the point of care using a modified RAND/University of California Los Angeles Delphi appropriateness method. The panelists evaluated each candidate process guideline in 2 blinded voting rounds with an intervening face-to-face discussion. Predetermined criteria were used to determine panelist agreement or disagreement. Results. The consortium did not reach a consensus on the validity of any of the 12 candidate process guidelines on the routine collection and communication of individualized PROMs at the point of care in hand surgery. The domains of importance and feasibility had greater median scores than those of usability and evidence. Conclusions To effectively collect and use PROMs to improve care for individual patients, process guidelines for when and how PROM scores should be collected and communicated with patients are needed. The expert consortium was unable to reach an agreement on any of the candidate process guidelines, often because of limitations in evidence supporting the use of PROMs at the point of care. Copyright (C) 2021 by the American Society for Surgery of the Hand. All rights reserved.

PurposeThe fixation of comminuted distal radius fractures using wrist-spanning dorsal bridge plates has been shown to have good postoperative results. We hypothesized that using a stiffer bridge plate construct results in less fracture deformation with loads required for immediate crutch weight bearing.MethodsWe created a comminuted, extra-articular fracture in 7 cadaveric radii, which were fixed using dorsal bridge plates. The specimens were positioned to simulate crutch/walker weight bearing and axially loaded to failure. The axial load and mode of failure were measured using 2- and 5-mm osteotomy deformations as cutoffs. Bearing 50% and 22% of the body weight was representative of the force transmitted through crutch and walker weight bearing, respectively.ResultsThe load to failure at 2-mm deformation was greater than 22% body weight for 2 of 7 specimens and greater than 50% for 1 of 7 specimens. The load to failure at 5-mm deformation was greater than 22% body weight for 6 of 7 specimens and greater than 50% for 4 of 7 specimens. The mean load to failure at 2-mm gap deformation was significantly lower than 50% body weight (110.4 N vs 339.2 N). The mean load to failure at 5-mm deformation was significantly greater than 22% body weight (351.8 N vs 149.2 N). All constructs ultimately failed through plate bending.ConclusionsAll constructs failed by plate bending at forces not significantly greater than the 50% body weight force required for full crutch weight bearing. The bridge plates supported forces significantly greater than the 22% body weight required for walker weight bearing 6 of 7 times when 5 mm of deformation was used as the failure cutoff.Clinical relevanceElderly, walker-dependent patients may be able to use their walker as tolerated immediately after dorsal bridge plate fixation for extra-articular fractures. However, patients should not be allowed to bear full weight using crutches immediately after bridge plating.

Distal radius fractures, like many articular and periarticular fractures, can make it difficult to determine the true number, location, and orientation of fracture fragments. This article should help the reader work through imaging interpretation starting from the initial, often displaced radiographs to postreduction imaging and determination if further 3-dimensional imaging is necessary.

Purpose To develop quality measures that are clinically important, feasible, usable, and scientifically acceptable for reducing opioid use after soft tissue procedures of the hand and wrist, and which can be used to evaluate quality in hand surgery. Methods A consortium of 9 fellowship-trained hand/upper-limb surgeons with expertise in quality measure development used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the validity of 2 quality measures for reducing opioid use, based on 4 quality indicators (clinical importance, feasibility, usability, and scientific acceptability). Panelists rated each measure on a scale of 1 (definitely not important/feasible/usable/supported) to 9 (definitely important/feasible/usable/supported) in 2 voting rounds with an intervening face-to-face discussion. Agreement was assessed using predetermined criteria. A measure was considered a valid quality measure if it received a median score of 7 or higher for all 4 indicators with no more than 2 panelists rating outside the range of 7 to 9. Results Panelists achieved agreement on the 4 quality indicators for measuring the proportion of patients undergoing carpal tunnel release, trigger finger release, first dorsal compartment release, or ganglion cyst excision who received structured counseling on opioid use. Panelists also achieved agreement on the 4 quality indicators for measuring the proportion of patients without recent opioid use who did not fill an opioid prescription within 30 days after these procedures. Both candidate quality measures were considered valid. Conclusions Using a validated consensus-building approach, we developed process and outcome quality measures for reducing opioid use after soft tissue hand surgery that were demonstrated to be valid according to 4 quality indicators. Clinical relevance In the era of value-based health care, hand surgeons are assuming increasing responsibility in the prevention of excess opioid prescribing. Quality measures for reducing opioid overprescription can help promote the delivery of evidence-based, high-quality care in hand surgery.

Open pediatric forearm fractures are common injuries that present to emergency departments across the United States. A total of 32% to 80% of all open pediatric fractures involve the forearm. Standard treatment for these injuries includes prompt intravenous antibiotic administration, tetanus prophylaxis, and usually bedside irrigation as a temporizing measure. Gustilo and Anderson type 2 and 3 open pediatric forearm fractures are generally managed with formal irrigation and debridement and fracture stabilization in the operating room. Management of Gustilo and Anderson type 1 open pediatric forearm fractures is not standardized, and level I evidence is currently lacking. Based on the existing data available, early antibiotic administration, bedside irrigation, and fracture stabilization in the emergency department may be a safe and effective initial treatment for these injuries, conferring a low risk for subsequent infection.

PURPOSE:To evaluate, from the surgeon's perspective, the importance, feasibility, and appropriateness of sharing decisions during an episode of care of carpal tunnel syndrome (CTS) or distal radius fracture in patients aged greater than 65 years.METHODS:A consortium of 9 fellowship-trained hand/upper-limb surgeons used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the importance, feasibility, and appropriateness of sharing 27 decisions for CTS and 28 decisions for distal radius fractures in patients aged greater than 65 years. Panelists rated each measure on a scale of 1 (definitely not important/feasible/appropriate) to 9 (definitely important/feasible/appropriate) in 2 voting rounds with an intervening face-to-face discussion. Panelist agreement and disagreement were assessed using predetermined criteria.RESULTS:Panelists achieved agreement on 16 decisions (29%) as important, 43 (78%) as feasible, and 17 (31%) as appropriate for sharing with patients. Twelve decisions met all 3 of these criteria and were therefore considered important, feasible, and appropriate to share with patients. Examples in CTS included decisions to perform extra confirmatory diagnostic testing, to have surgery, and to perform a steroid injection into the carpal tunnel. Examples in distal radius fracture management included the decision to have surgery, type of pain medication prescribed after surgery, and whether to remove the implant. The remaining 43 decisions did not reach consensus on the importance, feasibility, and appropriateness of sharing with patients.CONCLUSIONS:Using a validated consensus-building approach, we identified 12 decisions made during an episode of care for CTS or distal radius fracture that were important, feasible, and appropriate to share with patients from the surgeon's perspective. These decisions merit inclusion in shared decision-making models (eg, preoperative patient preference elicitation tools or decision aids) to align patient preferences with care decisions.CLINICAL RELEVANCE:Understanding which aspects of care are important, feasible, and appropriate to share with patients may improve patient-centered care by aligning patient preferences with care decisions.

Lunate and perilunate dislocations are potentially devastating injuries that are often unrecognized at initial evaluation. Prompt recognition and treatment is necessary to prevent adverse sequelae, including median nerve dysfunction, carpal instability, posttraumatic arthritis, reduced functionality, and avascular necrosis. In patients who are surgical candidates, operative intervention is warranted to restore carpal kinematics and provide optimal outcomes. [Orthopedics. 2019; 42(1):e1-e6.].

Purpose: There are minimal long-term epidemiological data focused on finger amputations in the United States (US). We sought to quantify the incidence and trends in finger amputations over a 20-year period, describe mechanisms of injury by age groups, and examine trends in emergency department (ED) disposition. Methods: The National Electronic Injury Surveillance System was queried over a 20-year period (1997–2016) for finger amputations presenting to US EDs. Using US Census data, national incidence rates were estimated. We evaluated specific mechanisms of injury and ranked common mechanisms for each age group. Trends in hospital admission rates were evaluated and predictors of admission were examined using logistical regression. Results: From 1997 to 2016, a weighted estimate of 464,026 patients sustained finger amputations in the US with an estimated yearly incidence of 7.5/100,000 person-years. A bimodal age distribution was seen, with the greatest incidence in children aged less than 5 years and adults over 65 years. Doors were the most common injury mechanism in children (aged less than 5 years), whereas power saws were most common in teens and adults (aged more than 15 years). Over the study period, there was a significant increase in patients admitted to the hospital; however, this increase was not seen among African Americans. Significant predictors of hospital admission included male gender, age less than 18 years, high-energy mechanisms, non–African American race, and very large hospital size, as defined by the National Electronic Injury Surveillance System. Conclusions: The incidence of finger amputations is bimodal; young children (aged less than 5 years) and the elderly (aged greater than 65 years) are at greatest risk. There is a widening disparity between African Americans and non–African Americans in relation to ED disposition. Doors and power saws are the most common mechanisms of injury; however, these affect different age ranges. This study’s results highlight the need for improved age-specific safety guidelines and device safety features. Type of study/level of evidence: Prognostic IV. Key words: epidemiology, finger amputation, NEISS database

Purpose To identify the relative contributions of the radiocarpal (RC) and midcarpal (MC) joints to dart-thrower's motion (DTM) of the wrist. Methods Six cadaveric upper extremities were fixed to a custom-designed loading jig allowing for pure moment-rotation analysis in 24 different directions of wrist motion. Each specimen was tested in 3 states: intact, simulated radiocarpal fusion (sRCF) and simulated pancarpal fusion (sPCF). Moments of +/- 1.5 Nm were applied at each of 24 directions for each state and the resulting wrist rotation recorded. Data from each specimen were reduced to compute the range of motion (ROM) envelopes and the orientation of the ROM for the 3 different states. Results The ROM was significantly decreased in the sRCF and sPCF groups compared with the intact group in the directions of the pure extension, radial extension, ulnar flexion, and ulnar deviation. No significant difference in ROM was detected between the sRCF and sPCF groups in any direction. The ROM envelopes for the intact, sRCF, and sPCF groups were all oriented obliquely to the axis of pure wrist flexion-extension near a path of ulnar flexioneradial extension, consistent with prior reports on DTM. Conclusions Although both simulated fusion types decreased ROM compared with the intact wrist, the principal direction of wrist motion along the path of DTM was not significantly altered by simulated RCF or PCF. Copyright (C) 2018 by the American Society for Surgery of the Hand. All rights reserved.)

There is a paucity of literature examining the reasons for litigation following carpal tunnel surgery in the United States. The purpose of this retrospective study was to examine a nationwide legal database to describe the most frequent reasons for malpractice litigation following carpal tunnel surgery. All malpractice claims that occurred following carpal tunnel surgery were included. In total, 46 cases met inclusion criteria, representing 15 male and 31 female patients with an average age of 46.4 years (±14.7 years). Four cases (8.7%) resulted in settlement. Of the 42 cases that went to trial, 33.3% ended in a decision in favor of the plaintiff and 66.7% ended in a decision in favor of the physician. The average payment for all lawsuits was $637,140.97. There was no significant difference in the average payment for cases lost in court ($329,690±$233,910) vs cases that ended in settlement ($422,286±$388,973). The 3 most frequent reasons for malpractice litigation after carpal tunnel surgery were nerve injury (n=18, 39.1%), persistent pain and numbness (n=15, 32.6%), and regional sympathetic dystrophy (n=9, 19.6%). Complications of carpal tunnel release should be emphasized during the consent process. [Orthopedics. 2018; 41(4):e569-e571.].

OBJECTIVE:Fishing injuries commonly affect the hands. The goal of this study was to quantify the incidence of fishing-related upper extremity injuries that present to emergency departments in the United States.METHODS:We examined the reported cases of fishing-related upper extremity injuries in the National Electronic Injury Surveillance System database. Analysis was performed based on age, sex and the type of injury reported.RESULTS:The national incidence of fishing-related upper extremity injuries was 119.6 per 1 million person-years in 2014. The most common anatomic site for injury was the finger (63.3%), followed by the hand (20.3%). The most common type of injury in the upper extremity was the presence of a foreign body (70.4%). The incidence of fishing-related upper extremity injuries in males was 200 per 1 million person-years, which was significantly higher than the incidence in females (41 per 1 million person-years).CONCLUSION:The incidence of fishing-related upper extremity injuries that present to the Emergency Department was 120 per 1 million person-years. The incidence was significantly higher in males. With the widespread popularity of the activity, it is important for Emergency Physicians and Hand Surgeons to understand how to properly evaluate and manage these injuries.

Purpose Quality measures are tools used by physicians, health care systems, and payers to evaluate performance, monitor the outcomes of interventions, and inform quality improvement efforts. A paucity of quality measures exist that address hand surgery care. We completed a RAND/UCLA (University of California Los Angeles) Delphi Appropriateness process with the goal of developing and evaluating candidate hand surgery quality measures to be used for national quality measure development efforts. Methods A consortium of 9 academic upper limb surgeons completed a RAND/UCLA Delphi Appropriateness process to evaluate the importance, scientific acceptability, usability, and feasibility of 44 candidate quality measures. These addressed hand problems the panelists felt were most appropriate for quality measure development. Panelists rated themeasures on an ordinal scale between 1 (definitely not valid) and 9 (definitely valid) in 2 rounds (preliminary round and final round) with an intervening face-to-face discussion. Ratings from1 to 3 were considered not valid, 4 to 6 as equivocal or uncertain, and 7 to 9 as valid. If nomore than 2 of the 9 ratings were outside the 3-point range that included the median (1-3, 4-6, or 7-9), the panelists were considered to be in agreement. If 3 or more of the panelists' ratings of a measure were within the 1 to 3 range and 3 or more ratings were in the 7 to 9 range, the panelists were considered to be in disagreement. Results There was agreement on 43% (19) of the measures as important, 27% (12) as scientifically sound, 48% (21) as usable, and 59% (26) as feasible to complete. Ten measures met all 4 of these criteria and were, therefore, considered valid measurements of quality. Quality measures that were developed address outcomes (patient-reported outcomes for assessment and improvement of function) and processes of care (utilization rates of imaging, antibiotics, occupational therapy, ultrasound, and operative treatment). Conclusions The consortium developed 10 measures of hand surgery quality using a validated methodology. These measures merit further development. Copyright (C) 2017 by the American Society for Surgery of the Hand. All rights reserved.