*MedStar Health, Curtis National Hand Center, Baltimore, MD †Kettering Health, Orthopedics and Sports Medicine, Dayton, OH Disclosure: The authors declare no conflict of interest. Reprints: Kenneth R. Means, MD, Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 N. Calvert Street, JPB 2nd Floor, Baltimore, MD 21218.

The role of an experienced Hand Surgery Consultant within the complete care matrix for a professional sports organization has evolved in my 3-decade career. Granted, hand injuries may have been demoted in this population where ACL tears, shoulder dislocations, and Lisfranc injuries seem to have much greater visibility, but our experience has told us that Hand injuries often contribute to the most surgeries per team/per season and can result in significant man-game loss of service. In my 30 years as a Consultant, Team Physician and/or Medical Director in all 4 major North American-based Leagues (as well as for "itinerant" independent contractor sports of golf, tennis, and motorsports), we have cared for well over 2000 athletes. This privilege has provided us with unparalleled exposure to the locker rooms, training rooms, and clubhouses for almost every team in professional-level competition and many elite-level collegiate programs. My goal in assembling this volume was to highlight the skilled and experienced colleagues who have contributed so much to the surgical science of caring for the hand and wrist in the professional athlete and furthering the logic of having a Hand Surgeon on "speed dial" for our fellow Team Physicians who want to provide optimal care for their athletes. Regrettably, until recently, the limited number of us who had significant involvement in this cohort probably fell short of engaging in scientific inquiry and publishing our observations or series. I will accept more than my share of that shortcoming, but as these practices have expanded in number and the exposure went from anecdotal to voluminous, our community started to communicate within Hand Surgery ranks, but now we want to share our knowledge with all professional involved in elite athlete care. This collection is not meant to be an exhaustive review of individual pathologies. Fortunately, valued colleagues have done a laudable job of chronicling the common-to-complex pathologies that we see in sports coverage This publication is styled less from the "what" and "how" standpoint, aimed instead at providing Team Physicians with the "when" and "why" of optimizing their player's outcomes through collaboration with their Hand Specialist.

Basketball presents several characteristics that distinguishes it from other contact sports and can influence the manner by which a Team Physician and Hand Surgery Consultant interact. An abbreviated list of pathologies that affect the basketball athlete and the approach to their evaluation and treatment by a Hand Surgeon are described in context of return-to-play.

For the purpose of this article, we will not use individual sports as the primary delineator; however, the two different levels of play: High School and Collegiate. We plan to share insight that we have gained through decades of practice treating High School sports and collegiate athletes. This article offers readers reliable guidance on not only treating the athlete's hand but understanding the person as a whole and the struggles at each level of play.

Kenney, Nick ATC, CSCS*; Stackpole, Chris PT, DPT, SCS, ATC, CSCS†; Salazar, Michael DAT, MAE, CIDN, LAT, ATC‡; Spiro, Steve BS, MSEd§; Waters, Eric BS, MS, MHPS∥; Summers, Matt Med, ATC, LAT¶; VanZant, Piet BS, MS#; Bastin, Kevin BS, MSEd**; Soloff, Lonnie PT, DPT, ATC††; Quinlan, James PT, ATC‡‡; Graham, Thomas J. MD§§ Author Information

PURPOSE:Radiocarpal dislocation damages the radiocarpal ligaments, typically eliminating the possibility for repair. The goals of this study were to create a model for ulnar translation of the carpus and design a soft-tissue reconstruction using the brachioradialis (BR) to prevent ulnar translation of the carpus. We primarily sought to recreate the stabilizing effect of the radioscaphocapitate ligament. METHODS:Eight cadaveric upper limbs were dissected, leaving only the BR tendon. The wrist was loaded perpendicular to the long axis of the forearm, and load-displacement curves for ulnar translation were generated. The radiocarpal ligaments were sectioned. Substantial ulnar translation was seen only after complete release of the palmar and dorsal radiocarpal ligaments. Reconstruction was performed with the BR tendon, maintaining the insertion on the radial styloid. The proximal tendon stump was brought distally through a drill hole in the center of the capitate, palmar to dorsal, and secured to the dorsal rim of the radius with a suture anchor. The specimens were then retested after this reconstruction. Qualitative evaluation of graphs plotted, mini c-arm fluoroscopy, and visual observation was also performed. RESULTS:Comparison of the intact specimens and the specimens after sectioning of the radiocarpal ligaments revealed a significant difference between mean ulnar translation (11.1 mm vs 18.4 mm; p < 0.05). Comparison of the sectioned specimens before and after BR reconstruction demonstrated a statistically significant difference in mean ulnar translation (18.4 mm vs 10.6 mm; p < 0.05). Comparison of the intact specimens and the specimens after sectioning-reconstruction did not demonstrate a significant difference, indicating that the BR reconstruction re-established the stability seen in the intact specimens with regard to ulnar translation (11.1 mm vs 10.6 mm; p > 0.05). CONCLUSIONS:The model consistently produced significant ulnar translation after division of the radiocarpal ligaments. The BR reconstruction was primarily designed to restore the function of the radioscaphocapitate ligament. This biomechanical study demonstrates the ability of this reconstruction to generate a statistically significant restraint to ulnar translation in a cadaver model of radiocarpal dislocation.

PURPOSE:Heterotopic ossification (HO) about the elbow has been described after surgery, trauma, and burns. Even limited deposits can lead to significant functional deficits. Little data exist regarding outcomes of patients treated with radiation therapy (RT) after elbow surgery. We report here the Cleveland Clinic experience with single-fraction radiation following surgery to the elbow. The primary endpoint was the rate of new HO after RT. Secondary endpoints were range of motion, functional compromise, and toxicity. METHODS AND MATERIALS:From May 1993 to July 2006, 36 patients underwent elbow surgery followed by single-fraction RT. Range of motion data were collected before and during surgery and at last follow-up. Radiographs were reviewed for persistent or new HO. Patient and treatment factors were analyzed for correlation with development of HO or functional compromise. RESULTS:Median follow-up was 8.7 months, median age was 42 years, and 75% of patients were male. Twenty-six (72%) patients had HO prior to surgery. All patients had significant limitations in flexion/extension or pronation/supination at baseline. Thirty-one (86%) patients had prior elbow trauma, and 26 (72%) patients had prior surgery. RT was administered a median of 1 day postoperatively (range, 1-4 days). Thirty-four patients received 700 cGy, and 2 patients received 600 cGy. Three (8%) patients developed new HO after RT. All patients had improvement in range of motion from baseline. No patient or treatment factors were significantly associated with the development of HO or functional compromise. CONCLUSIONS:Single-fraction RT after surgery to the elbow is associated with favorable functional and radiographic outcomes.

Purpose/Objective(s)Glomus tumors (GT) are rare low grade tumors originating from the paraganglionic tissue in the skull base. Their treatment by stereotactic radiotherapy demands high accuracy in defining the tumor margins. Despite high contrast enhancement and typical pattern in magnetic resonance imaging (MRI) of GTs, the exact delineation can be challenging. As GTs show high expression levels of somatostatin receptor subtypes, 18F-Octreotate PET is supposedly useful for improving target volume delineation in radiotherapy planning of GTs. Up to now 18F-Octreotate PET is used for diagnostic purposes in a semi quantitative manner only. Aim of this study was the definition of a quantitative segmentation threshold based on phantom measurements and its validation for tumor volume determination in patients with GT.Materials/MethodsTo identify the segmentation threshold, a 20 cm diameter cylindric phantom containing 18F-solution filled spheres of different sizes, was used. Background activity was chosen analogous to the mean values measured in the contralateral petrous portion of examined patients. Phantom measurements were performed in three different tumor to background ratios. 9 Patients with 11 tumors (6 untreated, 5 operated tumors) were examined by 18F-octreotate-PET (Biograph 16 PET/CT Tomograph or ECAT HR + PET Tomograph, Siemens Medical Solutions). After image reconstruction (OSEM with 4 iterations, 8 subsets, attenuation and scatter correction) the tumor volume was determined, using a segmentation algorithm implemented in the TrueD software (Siemens Medical Solutions). Patients were also imaged by MRI including a contrast enhanced 3-D MRI dataset (Philipps ACS Gyroscan, 1.5 T). All images were transferred to the radiotherapy treatment planning software (BrainScan 5.21, BrainLab) and tumor volumes were determined by two independent observers (one radiologist, one radiooncologist) using the contrast enhanced T1-weighted images without knowledge of the PET result. Additional MRI sequences were observed if necessary.ResultsPhantom studies revealed that 32% of SUVmax is the appropriate threshold for the determination of the tumor volume at the given, very low background of 18F-Octreotate-PET in the petrous portion of the temporal bone. Using this threshold the mean tumor volumes determined by PET and MRI were 8,6 ± 9 cm3 and 10 ± 10 cm3. We found a significant correlation of the volumes determined by PET compared to the volumes determined by MRI (r = 0.97, p = 0.0001). Correlation was better for larger tumors than for smaller tumors. In two postoperative cases 18F-Octreotate-PET was positive although a tumor could not be distinguished from normal tissue in MRI.ConclusionsThis study shows that a segmentation threshold determined in phantom studies can be applied for gross tumor volume definition in patients with GTs. 32% of the maximal standardized uptake value (SUVmax) is an appropriate threshold in the described setting (scanner, software, reconstruction algorithm) for target volume delineation of GTs by 18F-Octreotate-PET. In addition we showed, that 18F-Octreotate-PET improves radiation therapy planning especially if an accurate discrimination between tumor and normal tissue by MRI is difficult. Purpose/Objective(s)Glomus tumors (GT) are rare low grade tumors originating from the paraganglionic tissue in the skull base. Their treatment by stereotactic radiotherapy demands high accuracy in defining the tumor margins. Despite high contrast enhancement and typical pattern in magnetic resonance imaging (MRI) of GTs, the exact delineation can be challenging. As GTs show high expression levels of somatostatin receptor subtypes, 18F-Octreotate PET is supposedly useful for improving target volume delineation in radiotherapy planning of GTs. Up to now 18F-Octreotate PET is used for diagnostic purposes in a semi quantitative manner only. Aim of this study was the definition of a quantitative segmentation threshold based on phantom measurements and its validation for tumor volume determination in patients with GT. Glomus tumors (GT) are rare low grade tumors originating from the paraganglionic tissue in the skull base. Their treatment by stereotactic radiotherapy demands high accuracy in defining the tumor margins. Despite high contrast enhancement and typical pattern in magnetic resonance imaging (MRI) of GTs, the exact delineation can be challenging. As GTs show high expression levels of somatostatin receptor subtypes, 18F-Octreotate PET is supposedly useful for improving target volume delineation in radiotherapy planning of GTs. Up to now 18F-Octreotate PET is used for diagnostic purposes in a semi quantitative manner only. Aim of this study was the definition of a quantitative segmentation threshold based on phantom measurements and its validation for tumor volume determination in patients with GT. Materials/MethodsTo identify the segmentation threshold, a 20 cm diameter cylindric phantom containing 18F-solution filled spheres of different sizes, was used. Background activity was chosen analogous to the mean values measured in the contralateral petrous portion of examined patients. Phantom measurements were performed in three different tumor to background ratios. 9 Patients with 11 tumors (6 untreated, 5 operated tumors) were examined by 18F-octreotate-PET (Biograph 16 PET/CT Tomograph or ECAT HR + PET Tomograph, Siemens Medical Solutions). After image reconstruction (OSEM with 4 iterations, 8 subsets, attenuation and scatter correction) the tumor volume was determined, using a segmentation algorithm implemented in the TrueD software (Siemens Medical Solutions). Patients were also imaged by MRI including a contrast enhanced 3-D MRI dataset (Philipps ACS Gyroscan, 1.5 T). All images were transferred to the radiotherapy treatment planning software (BrainScan 5.21, BrainLab) and tumor volumes were determined by two independent observers (one radiologist, one radiooncologist) using the contrast enhanced T1-weighted images without knowledge of the PET result. Additional MRI sequences were observed if necessary. To identify the segmentation threshold, a 20 cm diameter cylindric phantom containing 18F-solution filled spheres of different sizes, was used. Background activity was chosen analogous to the mean values measured in the contralateral petrous portion of examined patients. Phantom measurements were performed in three different tumor to background ratios. 9 Patients with 11 tumors (6 untreated, 5 operated tumors) were examined by 18F-octreotate-PET (Biograph 16 PET/CT Tomograph or ECAT HR + PET Tomograph, Siemens Medical Solutions). After image reconstruction (OSEM with 4 iterations, 8 subsets, attenuation and scatter correction) the tumor volume was determined, using a segmentation algorithm implemented in the TrueD software (Siemens Medical Solutions). Patients were also imaged by MRI including a contrast enhanced 3-D MRI dataset (Philipps ACS Gyroscan, 1.5 T). All images were transferred to the radiotherapy treatment planning software (BrainScan 5.21, BrainLab) and tumor volumes were determined by two independent observers (one radiologist, one radiooncologist) using the contrast enhanced T1-weighted images without knowledge of the PET result. Additional MRI sequences were observed if necessary. ResultsPhantom studies revealed that 32% of SUVmax is the appropriate threshold for the determination of the tumor volume at the given, very low background of 18F-Octreotate-PET in the petrous portion of the temporal bone. Using this threshold the mean tumor volumes determined by PET and MRI were 8,6 ± 9 cm3 and 10 ± 10 cm3. We found a significant correlation of the volumes determined by PET compared to the volumes determined by MRI (r = 0.97, p = 0.0001). Correlation was better for larger tumors than for smaller tumors. In two postoperative cases 18F-Octreotate-PET was positive although a tumor could not be distinguished from normal tissue in MRI. Phantom studies revealed that 32% of SUVmax is the appropriate threshold for the determination of the tumor volume at the given, very low background of 18F-Octreotate-PET in the petrous portion of the temporal bone. Using this threshold the mean tumor volumes determined by PET and MRI were 8,6 ± 9 cm3 and 10 ± 10 cm3. We found a significant correlation of the volumes determined by PET compared to the volumes determined by MRI (r = 0.97, p = 0.0001). Correlation was better for larger tumors than for smaller tumors. In two postoperative cases 18F-Octreotate-PET was positive although a tumor could not be distinguished from normal tissue in MRI. ConclusionsThis study shows that a segmentation threshold determined in phantom studies can be applied for gross tumor volume definition in patients with GTs. 32% of the maximal standardized uptake value (SUVmax) is an appropriate threshold in the described setting (scanner, software, reconstruction algorithm) for target volume delineation of GTs by 18F-Octreotate-PET. In addition we showed, that 18F-Octreotate-PET improves radiation therapy planning especially if an accurate discrimination between tumor and normal tissue by MRI is difficult. This study shows that a segmentation threshold determined in phantom studies can be applied for gross tumor volume definition in patients with GTs. 32% of the maximal standardized uptake value (SUVmax) is an appropriate threshold in the described setting (scanner, software, reconstruction algorithm) for target volume delineation of GTs by 18F-Octreotate-PET. In addition we showed, that 18F-Octreotate-PET improves radiation therapy planning especially if an accurate discrimination between tumor and normal tissue by MRI is difficult.

Severe compressive trauma to the hand presents with multiple soft-tissue and osseous manifestations that often appear unrelated, leading to underrecognition and potential undertreatment of the complex injuries. Approaching the crushed hand wit a logical and systematic diagnostic plan allows surgeons to recognize the location and severity of the injury portfolio and direct comprehensive treatment. Both for emphasis and for the purpose of describing the hydraulic mechanism of tissue failure, the term exploded had syndrome is proposed. The exploded hand connotes the compendium of clinical findings that include skin failure at the webspaces or glabrous border, atypical (usually longitudinal) fracture patterns of the tubular bones, and axial carpal dissociations. These are accompanied by extensive compromise of the interosseous musculature that is extruded or may exhibit evolving compartment syndrome. Understanding the trauma mechanism and patterns of injury in the exploded hand will maximize awareness and guide surgical reconstruction and rehabilitation.

Purpose of review: Replacement of the fractured radial head and neck with metallic implants has experienced a renaissance. Clinically and biomechanically, this form of treatment has been demonstrated to yield acceptable range of motion, stability, and durability. The current status of radial head replacement and the future direction of clinical and scientific development are reviewed to update the student of sophisticated elbow surgery and assist in surgical decision making. Recent findings: An expanding clinical experience with more anatomic, modular implants has now been reported in the literature. Material science and laboratory kinematic analysis of the implants are assisting the surgeon in determining optimal morphology and placement of the prosthesis. Although at times conflicting, recent contributions have begun to better define the roles of resection, fixation, and replacement of the fractured radial head. Advances have been made in both technology and technique in regard to employing radial head implant arthroplasty. Summary: Radial head implant arthroplasty has emerged as not only an acceptable but in some reports a superior alternative to simple resection or even osteosynthesis. Despite greater coverage and scrutiny, questions and challenges face the elbow surgeon when considering whether or how to employ a radial head implant. Outcomes will be maximized by selecting the right implant designs and employing them in the proper circumstances.

Fractures and nonunions of the scaphoid are common and can present specific challenges for both diagnosis and treatment. We review the anatomy, cause, presentation, and various treatment options that may be considered by the surgeon, with a concentration on newer techniques.

Traditionally, complex wrist injuries were identified and characterized on the basis of observation of bony injury and presumption of soft tissue embarrassment, followed by employment of a classification scheme or cumbersome nomenclature. The extent of tissue compromise was often underestimated, leading to undertreatment and inferior results. This paper encourages physicians to think more mechanistically about the pattern of injury by relying on the concept of "transverse" force transmission to identify the global extent of wrist trauma. By employing a basic understanding of the components of the wrist "system" and superimposing the flow of energy through it, one can better grasp these complex topics. The standard "greater arc" and "lesser arc" injuries are explained in this context. Another recognizable injury pattern in the transverse instability spectrum, that of the "inferior arc," is introduced, along with clues for its identification. The large fragment and small fragment fracture variants of the inferior arc injury are emphasized, and their significance is described. Basic evaluation and treatment recommendations for inferior arc injuries are offered.

Purpose/Objective: Heterotopic ossification (HO) is a term used to describe normal osseous tissue deposition at ectopic sites. Often this deposition is adjacent to or spans the elbow joint after traumatic injury, burns, neural axis trauma, and some genetic conditions. The treatment of HO depends on the volume of extra bone, its location, and the resultant limitation in range of motion around the joint. One method of preventing HO after injury or surgery is radiation therapy delivered to the area at risk. We describe the Cleveland Clinic's experience using radiation therapy to prevent heterotopic bone formation around the elbow joint.Materials/Methods: The records of 27 patients (29 elbows) treated with radiation therapy between 1993–1998 were reviewed. Twenty-one patients (23 elbows) had greater than 3 months follow-up available for review and are included in this analysis. All patients were classified using the classification system developed by Hastings and Graham prior to surgery. Pre-operative, intra-operative, and post-operative range of motion were recorded and compared. Radiation therapy dose ranged from 600-700cGy in one fraction delivered post-operatively.Results: The median follow-up was 10.2 months (range: 3.4-62.1 months). When comparing the pre-operative range of motion with the range of motion achieved intra-operatively, the median increase in range of motion achieved in the operating room was 75 degrees (range: 15-160 degrees). In comparing the post-operative range of motion with the pre-operative range of motion, the median increase in mobility was 57.5 degrees (range: 10-145 degrees). No patient experienced a post-operative wound complication.Conclusions: Radiation therapy consisting of 700 cGy in one fraction delivered post-operatively is successful in maintaining intra-operative range of motion gains in the majority of patients. This form of therapy should be considered in patients presenting with Hastings and Graham Class II or III heterotopic bone formation around the elbow joint or in patients with multiple prior surgeries who have exhibited a tendency towards subsequent heterotopic bone formation. Purpose/Objective: Heterotopic ossification (HO) is a term used to describe normal osseous tissue deposition at ectopic sites. Often this deposition is adjacent to or spans the elbow joint after traumatic injury, burns, neural axis trauma, and some genetic conditions. The treatment of HO depends on the volume of extra bone, its location, and the resultant limitation in range of motion around the joint. One method of preventing HO after injury or surgery is radiation therapy delivered to the area at risk. We describe the Cleveland Clinic's experience using radiation therapy to prevent heterotopic bone formation around the elbow joint. Materials/Methods: The records of 27 patients (29 elbows) treated with radiation therapy between 1993–1998 were reviewed. Twenty-one patients (23 elbows) had greater than 3 months follow-up available for review and are included in this analysis. All patients were classified using the classification system developed by Hastings and Graham prior to surgery. Pre-operative, intra-operative, and post-operative range of motion were recorded and compared. Radiation therapy dose ranged from 600-700cGy in one fraction delivered post-operatively. Results: The median follow-up was 10.2 months (range: 3.4-62.1 months). When comparing the pre-operative range of motion with the range of motion achieved intra-operatively, the median increase in range of motion achieved in the operating room was 75 degrees (range: 15-160 degrees). In comparing the post-operative range of motion with the pre-operative range of motion, the median increase in mobility was 57.5 degrees (range: 10-145 degrees). No patient experienced a post-operative wound complication. Conclusions: Radiation therapy consisting of 700 cGy in one fraction delivered post-operatively is successful in maintaining intra-operative range of motion gains in the majority of patients. This form of therapy should be considered in patients presenting with Hastings and Graham Class II or III heterotopic bone formation around the elbow joint or in patients with multiple prior surgeries who have exhibited a tendency towards subsequent heterotopic bone formation.

Posttraumatic limitation of forearm rotation can be the result of pathology at any location along the forearm axis. Scar contracture of the distal radioulnar joint (DRUJ) capsule, independent of the triangular fibrocartilage complex (TFCC), is one of the sources that may influence the pronosupination arc. We dissected the wrists of 8 fresh-frozen cadaver specimens to characterize the precise anatomy, relationships, and dynamic characteristics of the entire DRUJ capsule. Additionally, we performed surgical DRUJ capsulectomy in 9 patients with recalcitrant limited forearm pronosupination that was unattributable to dysfunction at any other anatomic forearm location. We conclude that (1) the DRUJ capsule is a defined entity, separate from the triangular fibrocartilage, that is highly specialized to accommodate the distal ulna in forearm rotation; (2) in patients who have restored osseous anatomy after trauma, but have failed to regain pronosupination after maximal rehabilitation, the DRUJ capsule can be identified as the source of the limitation; and (3) DRUJ capsulectomy can markedly improve the arc of forearm rotation in carefully selected patients.

Polydactyly is one of the most common congenital differences. Duplications of the index finger, central rays, and small digit each have unique characteristics and associations. Complex anomalies such as the mirror hand and pentadactyly represent specialized forms of polydactyly. The goal of reconstructing a functional hand is met by appreciating the anatomic variations and systemic implications, then employing the challenging technical and intellectual concepts described.

The diagnosis and treatment of an atypical hand infection present a distinctive challenge for the hand surgeon. Infections caused by these uncommon organisms occur more often in immunocompromised patients. This article emphasizes the salient features of mycobacterial, nocardial, and fungal infections of the hand. With an accurate and timely diagnosis, appropriate surgical and pharmacologic treatment may eradicate these unusual infections.