Carpal tunnel syndrome costs the United States billions of dollars each year. The majority of patients are industrial workers, females, and the elderly who first present to their primary care physicians. Therefore, it is essential that the primary care physician understand this syndrome in order to diagnose and direct treatment. Here we present a review of the anatomy, pathophysiology, diagnosis, and current treatment of carpal tunnel syndrome that is relevant for the treating primary care physician. In addition, we discuss the role of the primary care physician in the diagnosis, management, and treatment of carpal tunnel syndrome. The aim of this review is to improve the integrated care of those patients suffering from carpal tunnel syndrome.

Infection is a rare but serious complication of shoulder arthroplasty. The most prevalent cause of patient infections is Cutibacterium acnes (formerly Proprionibacterium acnes), a commensal skin bacterial species. Its presentation is often non-specific and can occur long after shoulder arthroplasty, leading to delay in diagnosis. This bacterium is difficult to culture, typically taking 14 to 17 days for a positive culture and often does not exhibit abnormal results on a standard laboratory workup for infection (eg, ESR, CRP, and synovial WBC count). Male patients are at particularly high-risk due to having a greater number of sebaceous follicles than females. While it is difficult to diagnose, early diagnosis can lead to decreased morbidity, appropriate treatment, and improved clinical outcomes. Current options for treatment include antibiotics, one stage implant exchange, or two stage implant exchange, although success rates of each are not currently well described. A better understanding of the prevention, diagnosis, and treatment of C. acnes infection could lead to better patient outcomes from shoulder arthroplasty.

Hip fractures are a common cause of acute pain in elderly patients. However, pain may be undertreated due medical comorbidities. Strong evidence supports the use of regional nerve blocks to reduce preoperative pain after hip fracture. Despite recommendations for their use, regional nerve blocks may not be in widespread practice in the United States. To help promote the addition of regional nerve blocks into hip fracture protocols, this paper will provide an overview of two commonly used regional nerve blocks for hip fracture (fascia iliaca compartment block and femoral nerve block), review the regional nerve block protocols presented in 12 studies, and present the detailed protocol currently in use at The Queen's Medical Center in Honolulu, HI.

Background: Rupture of the distal biceps tendon remains an uncommon injury that is ideally treated by operative repair. Single-incision anterior approach with suture anchor repair is one such method. The purpose of this study was to describe the outcomes in patients who underwent repair of the distal biceps tendon with single anterior incision and suture anchor repair. Methods: One hundred and nineteen patients (120 repairs) with distal biceps tendon repairs between January 1, 2002 and December 31, 2012 were identified and their charts retrospectively reviewed. Twenty-five of these patients participated in additional collection of outcome data including range of motion, strength, pain, satisfaction, and clinical outcome. Results: In the retrospective analysis, the population was 93% male. Average age was 47.3 yr; however, females had a significantly higher mean age (62.5). Most of the patients (69.8%) returned to full or partial work. The additional data collection cohort reported high satisfaction, little-to-no pain on visual analog scale (VAS) and average Disability of the Arm Shoulder and Hand (DASH) scores. Patients with workers’ compensation claims reported significantly higher pain and worse DASH scores. There was small but significant loss of pronation, and a small loss of grip strength that approached significance. Conclusions: Single anterior incision with suture anchor repair may be utilized for repair of ruptures of the distal biceps tendon with good clinical and functional outcomes and minimal loss of range of motion and strength. Females tend to be older at presentation than males with this condition. As in other studies, workers’ compensation claims were associated with poorer clinical outcomes. Level of Evidence: Therapeutic, level IV, case series study.

Use of mobile tablet computers (MTCs) in residency education has grown. The objective of this study was to investigate the impact of MTCs on multiple specialties' residency training and identify MTC adoption impediments. To our knowledge, this current project is one of the first multispecialty studies of MTC implementation. A prospective cohort study was formulated. In June 2012 iPad2s were issued to all residents after completion of privacy/confidentiality agreements and a mandatory hard-copy pre-survey regarding four domains of usage (general, self-directed learning, clinical duties, and patient education). Residents who received iPads previously were excluded. A voluntary post-survey was conducted online in June 2013. One-hundred eighty-five subjects completed pre-survey and 107 completed post-survey (58% overall response rate). Eighty-six pre- and post-surveys were linked (response rate of 46%). There was a significant increase in residents accessing patient information/records and charting electronically (26.9% to 79.1%; P<.001), but a significant decrease in looking up drug and treatment reference material (97.0% to 82.1%; P=.0039). There was a significant increase in MTC use as a primary means of charting when conducting rounds (4.9% to 39.5%; P<.001) and a significant decrease in using paper charts (30.1% to 15.7%; P=.0073). There was also a significant increase in MTC use as a primary means for explaining a diagnosis (7.7% to 57.7%; P<.001). The use of MTC has an impact on how residents approach medical education, clinical practice, and patient education. The survey tool may be useful in collecting data on MTC use by other graduate medical education programs.

Background:As mobile computing technology continues to improve and grow in popularity, such devices are becoming more prevalent in modern medical practice and education. The purpose of this study was to quantify resident perceptions, usage patterns, and the utility of an iPad/mobile tablet computer in orthopaedic surgery residency training.Methods:A total of nine residents were included in the pilot study. A mixed methods approach (i. e. quantitative and qualitative methods) was utilized, given the relatively small sample size. Each resident participated in a baseline survey and post survey for the study period of 1 academic year. The surveys attempted to quantify the usage patterns in three main areas: (1) resident education, (2) clinical practice, and (3) patient education. In addition, a qualitative component (i. e. focus group) was conducted to develop themes related to usage patterns. To determine quantitative effect, resident percentile score changes on in-training examination were compared before and after implementation of the pilot study with paired t-testing. A Student t-test was used to compare change in mean program percentile rank on in-training examination before and after implementationResults:An overall increase in usage of portable computing (the iPad) as a way for residents to study as well as perform administrative and clinical duties was observed. There was a trend towards increased overall study time and study time "on-the-go'' as participants indicated increased study time in "hospital work areas.'' There were also observed increases in professional activities such as referencing treatment options and ordering lab tests. Conversely, few participants reported using the iPad for accessing radiographic studies or demonstrating conditions to patients. The focus group discussion emphasized improved efficiency gained by having quick and easy access to reference and study material. However, the lack of informational technology support and infrastructure for integration with the electronic medical records (EMRs) and Picture Archiving and Communication System (PACS) hindered clinical and patient educational usage. Mean annual increase in in-training examination scores increased from 3.4 to 8.1 percentile points, similarly the mean annual program percentile rank based on scores increased from the 72nd to the 85th percentile.Conclusions:Mobile computers such as the iPad can be useful for residents in orthopaedic surgery by improving their access to educational resources and allowing more study time "on-the-go'' which may lead to more time studying in general and improvement in test scores. Patient education and clinical usage is possible but information technology support is needed for these devices to be used to their fullest potential.

The supracondylar process is a congenital bone projection on the distal anteromedial humerus often associated with a ligament of Struthers, a fibrous connection between the process and medial epicondyle. It is largely asymptomatic and only on rare occasions presents with neurovascular compression resulting in a supracondylar process syndrome. This case report describes a 28-year-old woman with supracondylar process syndrome, and our management. The topic is further explored with a literature review of 43 reported cases. Analysis of the case reports indicates that isolated median nerve injuries are the most common. Other presentations such as fractures, vascular compromise, and ulnar nerve involvement are less frequent. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved.

These gates (Fig. 1) race the University of Pennsylvania campus in Philadelphia and link the campus to the Charles Addams Hall, the center for fine arts at Penn. The gates design captures the quirky spirit of artist Charles Addams, for whom the fine arts building is named. The gates were designed by Mark Lueders, an alumnus and sculptor on Penn's Fine Arts faculty. His animated design incorporates bronze sculptures of hands using tools that relate to the making of paintings, drawings, sculpture, and clay. There are a total of 56 hands from 46 different people with their respective fine arts tools. The creation and installation of the gates were made possible through the generosity of the Kelly Family Foundation and Penn Trustee Paul K. Kelly, his wife Nancy, and their daughter Brooke. The official dedication of the gates took place on May 8, 2003.

A curved longitudinal incision is made over the medial side of the elbow beginning 8 cm proximal to the medial epicondyle and extending distally posterior to the medial epicondyle, and then along the anterior surface of the forearm in line with the course of the pronator teres muscle. The medial antebrachial cutaneous nerve in the distal portion of the incision is identified and protected. The ulnar nerve is isolated and retracted posteriorly. The median nerve and its branches to pronator teres and flexor digitorum superficialis are identified. The median nerve and brachial artery are retracted laterally. Common origins are defined of the pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris at the medial epicondyle. The cortex of the medial epicondyle is drilled with a 2.0 mm drill bit. The epicondyle is then osteotomized, fashioning a 1.2 cm diameter, 1 cm deep, bone “plug” that is to be fixed subsequently to the anterior surface of the humerus. The flexor pronator muscles are freed distally for 5 to 6 cm taking care to preserve the median nerve branches to the pronator teres and flexor digitorum superficialis muscles and the ulnar nerve branches to flexor carpi ulnaris (Fig. 1, A). The brachialis muscle is split and the anterior surface of the humerus is exposed 5 to 7 cm proximal to the medial epicondyle. The mobility of the flexor pronator group is checked with the elbow in flexion to assure their proximal transfer without un-