Clinical Practice Guidelines to Support Capacity Building in Orthopaedic Surgical Outreach: An International Consensus Building Approach

BACKGROUND

Surgical outreach to low- and middle-income countries (LMICs) by organizations from high- income countries is on the rise to help address the growing burden of conditions warranting surgery. However, concerns remain about the impact and sustainability of such outreach. Leading organizations (e.g., the World Health Organization) advocate for a capacity-building approach to ensure the safety, quality, and sustainability of the local health-care system. Despite this, to our knowledge, no guidelines exist to inform such efforts. We aimed to develop clinical practice guidelines (CPGs) to support capacity-building in orthopaedic surgical outreach utilizing a multistakeholder and international voting panel.

METHODS

We followed a modified American Academy of Orthopaedic Surgeons (AAOS) CPG development process. We systematically reviewed the existing literature across 7 predefined capacity-building domains (partnership, professional development, governance, community impact, finance, coordination, and culture). A writing panel composed of 6 orthopaedic surgeons with extensive experience in surgical outreach reviewed the existing literature and developed a consensus-based CPG for each domain. We created an international voting panel of orthopaedic surgeons and administrators who have leadership roles in outreach organizations or hospitals with which outreach organizations partner. Members individually reviewed the CPGs and voted to approve or disapprove each guideline. A CPG was considered approved if >80% of panel members voted to approve it.

RESULTS

An international voting panel of 14 surgeons and administrators from 6 countries approved all 7 of the CPGs. Each CPG provides recommendations for capacity-building in a specific domain. For example, in the domain of partnership, the CPG recommends the development of a documented plan for ongoing, bidirectional partnership between the outreach organization and the local team. In the domain of professional development, the CPG recommends the development of a needs-based curriculum focused on both surgical and nonsurgical patient care utilizing didactic and hands-on techniques.

CONCLUSIONS

As orthopaedic surgical outreach grows, best-practice CPGs to inform capacity-building initiatives can help to ensure that resources and efforts are optimized to support the sustainability of care delivery at local sites. These guidelines can be reviewed and updated in the future as evidence that supports capacity-building in LMICs evolves.The global burden of disease warranting surgery is substantial, and morbidity and mortality from otherwise treatable conditions remain disproportionately high in low- and middle-income countries (LMICs)1,2. It is estimated that up to 2 million (about 40%) of injury-related deaths in LMICs could be avoided annually if mortality rates were reduced to the level of those in high-income countries (HICs)3. Despite this, progress toward improved access to safe, timely surgery in resource-poor areas has been slow. Historically, nongovernmental organizations (NGOs) have tried to address unmet surgical needs through short-term outreach trips; however, growing criticism has highlighted the limitations of short-term trips, including limited follow-up, an increased burden on the local workforce, and further depletion of local resources4-6. In light of ongoing concerns, public health priorities have shifted toward models that emphasize long-term capacity-building rather than short-term care delivery. Capacity-building is an approach to health-care development that builds independence through infrastructure development, sustainability, and enhanced problem-solving while taking context into account7,8.

Diversity, Equity, and Inclusion in Orthopaedic Surgery: Local and National Efforts

Orthopaedic surgery has not experienced the same increase in diversity as other surgical subspecialties over time. Professional orthopaedic societies across the nation, including the American Academy of Orthopaedic Surgeons, are now making sincere efforts to improve diversity, equity, and inclusion (DEI) within the field. Several national groups provide funding to support DEI -related research as well as scholarships to national meetings. Others are more focused on mentorship and mitigation of residency attrition amongst underrepresented minorities (URMs). Individual residency programs, including the Department of Orthopaedics at Brown University, are engaging in community outreach to attract more diverse candidates to orthopaedics and providing away rotation scholarship support for medical students that identify as female or URMs. These local and national efforts will hopefully lead to a more inclusive environment for all trainees and practitioners within orthopaedics and ultimately improved orthopaedic care for all patients.

YouTube as a Source of Patient Information for Cubital Tunnel Syndrome: An Analysis of Video Reliability, Quality, and Content

BACKGROUND

This study seeks to examine the reliability, quality, and content of YouTube videos on cubital tunnel syndrome, on which there is presently a paucity of information.

METHODS

The top 50 unique YouTube videos by relevance resulting from the Boolean search term "cubital tunnel + cubital tunnel syndrome" were identified, with video properties for analysis including source, upload date, duration, views, and comments. Content was assessed using the Journal of American Medical Association (JAMA) criteria, the Global Quality Score (GQS), and a "Cubital Tunnel-Specific Score" (CTSS).

RESULTS

The average video saw 72 108 ± 199 362 views, with videos produced by allied (nonphysician) health professionals demonstrating the highest mean views (111 789 ± 294 471 views). Videos demonstrated low mean JAMA scores (2.4/4 ± 0.7), GQS (2.8/5 ± 1.3), and CTSS (7.5/21 ± 4.3), with academic and nonacademic physician videos demonstrating significantly greater mean GQS and CTSS scores when compared with videos by allied health professionals. Positive independent predictors for GQS included academic sources (β = 1.871), nonacademic physician sources (β = 1.651), and video duration (β = 0.102), which were likewise positive predictors for CTSS (β = 4.553, 4.639, 0.374). Content relating to surgical techniques or approaches for cubital tunnel decompression had the greatest CTSS scores (11.2 [4.2]).

CONCLUSIONS

YouTube is a source of highly accessible information on cubital tunnel syndrome, although the average video presents generally poor and inadequate information. Directing patients toward higher quality video resources can be a meaningful component of patient education.

Supplementary Fixation Improves Stability of Intra-Articular Distal Radius Fractures Managed With a Spanning Plate

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.

Delayed Scaphoid Fracture Union in Patients With Comorbid Psychiatric Diagnoses: A Retrospective Analysis of 20 340 Patients

BACKGROUND

Psychiatric comorbidities have been shown to influence outcomes of various orthopedic pathologies. This study aimed to compare rates of delayed scaphoid union and surgical intervention for fractures in patients with and without comorbid psychiatric diagnoses.

METHODS

A matched retrospective cohort study was performed using the PearlDiver database to determine the association of depression, anxiety, bipolar disorder, and schizophrenia with delayed union rates within 3 and 6 months and rates of nonacute surgical intervention (fixation or grafting) within 6 and 12 months of scaphoid fracture. Analyses were completed using multivariate logistic regression.

RESULTS

Among 20 340 patients, a comorbid psychiatric diagnosis was associated with increased rates of delayed scaphoid union at 3 months (odds ratio [OR] = 1.29; 95% confidence interval [CI], 1.14-1.45) and 6 months (OR = 1.23; 95% CI, 1.10-1.38). At 3 months, women with any psychiatric disorder (OR = 1.58; 1.29-1.66), depression (OR = 1.68; 1.31-2.17), and schizophrenia (OR = 5.32; 95% CI, 1.06-26.79) were more likely to experience delayed union, with similar results at 6 months. Men with bipolar disorder experienced increased delayed union rates at 6 months (OR = 1.40; 1.03-1.91). A comorbid psychiatric diagnosis (OR = 1.10; 1.01-1.20) was associated with increased rates of surgical intervention, whereas schizophrenia was associated with decreased rates (OR = 0.58; 0.34-0.99).

CONCLUSION

Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union. These results underscore the importance of understanding factors that may place patients at risk of impaired recovery.

Salter-Harris Type III Fracture of the Distal Phalanx: A Rare Juxtaphyseal Variant

Juxtaphyseal fractures of the distal phalanges of upper extremity digits are most commonly of the Salter-Harris II variety and occur most commonly in the thumb. The diagnosis of this injury is essential as it may present as an open fracture with a nailbed injury ("Seymour fracture"). However, an intra-articular, epiphyseal fracture may also occur and mimic a mallet deformity or Seymour fracture. Prompt diagnosis is essential to rule out an open fracture and obtain anatomical alignment and stability to attempt to reduce complications such as physeal arrest. Here, we present a patient with a displaced Salter-Harris type III fracture of his thumb distal phalanx and review his management and early-term outcome. We present this case to bring attention to this rare and unique injury, review the available literature, and discuss management and outcomes.

Excessive Derotational K-Wire Angulation Decreases Compression by Headless Compression Screw

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.

Characterization of the Epidemiology and Risk Factors for Hand Fractures in Patients Aged 1 to 19 Presenting to United States Emergency Departments: A Retrospective Study of 21,031 Cases

BACKGROUND

Hand fractures are among the most common injuries presenting in pediatric emergency departments (EDs) with incidence reported as high as 624 hand fractures per 100,000 person-years. If gone untreated, these injuries can lead to pain, loss of function, and psychological trauma. The purpose of this study was to identify risk factors and characterize pediatric hand fractures over a 5-year period.

METHODS

The National Electronic Injury Surveillance System (NEISS) was queried for all hand fractures in patients aged 1 to 19 years presenting to US EDs between 2016 and 2020. Incidence was calculated using US census data. Cases were retrospectively analyzed using age, location of the injury, sex, coronavirus disease-2019 (COVID-19) era, and etiology of injury. Bivariate logistic regression was used where appropriate.

RESULTS

A total of 21,031 pediatric hand fractures were identified, representing an estimated 565,833 pediatric hand fractures presenting to EDs between 2016 and 2020. The mean incidence of pediatric hand fractures was 138.3 fractures for 100,000 person-years [95% confidence interval (CI): 136.2-140.4], with a 39.2% decrease in incidence occurring between 2019 and 2020. It was found that 42.2% of the fractures were in patients aged 10 to 14. The incidence of hand fractures for males and females was 97.9 (95% CI: 96.2-99.7) and 40.4 (95% CI: 39.2-41.5), respectively, with the male rate peaking at age 14 and the female rate peaking at age 12. Age, sex, location of the injury, and injury during the COVID-19 pandemic were demonstrated to influence the frequency and etiology of the fracture.

CONCLUSION

This study determined the incidence of pediatric hand fractures presenting to EDs across the United States. In addition, it identified risk factors for common hand fracture etiologies (sports-related, falling, crush, punching) and demonstrated the change in rates of different etiologies of pediatric hand fractures that presented to US EDs during the COVID-19 pandemic.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

A Nationwide Epidemiological Analysis of Finger Infections Presenting to Emergency Departments in the United States From 2012 to 2016

Background: There is a paucity of literature exploring the epidemiology of finger infections presenting to emergency departments (EDs) on a national scale. The purpose of this study was to determine the national incidence of and risk factors for finger infections. Methods: Finger infections presenting to EDs between 2012 and 2016 were identified in the National Electronic Injury Surveillance System database. Finger infections were characterized by mechanism and type, with subanalyses for sex, race, and age. Results: Over this 5-year period, finger infections accounted for 80 519 visits to EDs in the United States. The annual incidence increased significantly from 4.4 per 100 000 person-years in 2012 to 6.2 in 2016. The 3 most common causes of finger infections were nail manicuring tools, knives, and doors. The most common diagnosis was finger cellulitis (46.3%). Significantly more men developed finger infections than women (relative risk of 1.4). The highest overall incidence was observed in 40- to 59-year-old men (7.8 per 100 000 person-years). Tenosynovitis resulted in the largest proportion of admissions (25%). Conclusions: We have demonstrated a rising incidence of finger infections presenting to EDs, with 40- to 59-year-old patients most at risk. The most common mechanism was the use of nail manicuring tools, such as nail clippers. Patient education may decrease finger infection incidence from these activities, and early detection of finger infections may be crucial to minimizing hospital admissions and invasive treatments.

Pediatric Digit Replantation Following Traumatic Amputation: Nationwide Analysis of Patient Selection, Outcomes, and Cost

Background: Indications for replantation following traumatic digit amputations are more liberal in the pediatric population than in adults, but delineation of patient selection within pediatrics and their outcomes have yet to be elucidated. This study uses a national pediatric database to evaluate patient characteristics and injury patterns involved in replantation and their outcomes. Methods: The Healthcare Cost and Utilization Project Kid's Inpatient Database was queried for traumatic amputations of the thumb and finger from 2000 to 2012. Participants were separated into those who underwent replantation and those who underwent amputation. Patients undergoing replantation were further divided into those requiring revision amputation and/or microvascular revision. Patient age, sex, insurance, digit(s) affected, charges, length of stay, and complications were extracted for each patient. Results: Traumatic digit amputations occurred in 3090 patients, with 1950 (63.1%) undergoing revision amputation and 1140 (36.9%) undergoing replantation. Younger patients, those with thumb injuries, females, and those covered under private insurance were significantly more likely to undergo replantation. Cost, length of stay, and in-hospital complications were significantly greater in replantation patients than in those who had undergone amputation. Following replantation, 237 patients (20.8%) underwent revision amputation and 209 (18.3%) underwent vascular revision, after which 58 required revision amputation. Risk of revision following replantation involved older patients, males, and procedures done recently. Conclusions: Pediatric patients who underwent replantation were significantly younger, female, had thumb injuries, and were covered by private insurance. Our findings demonstrate that in addition to injury factors, demographics play a significant role in the decision for finger replantation and its outcomes.

Distal Radioulnar Joint Instability: Assessment of Three Intraoperative Radiographic Stress Tests

Background: The purpose of this study is to describe three radiographic stress tests that could be used to examine for distal radioulnar joint (DRUJ) instability intraoperatively, and to determine their ability to detect DRUJ instability after sequentially sectioning the DRUJ. Methods: Eleven fresh frozen cadaveric upper extremities (mean age 52.6 ± 14.9 years) were obtained. We sequentially sectioned the DRUJ. After each component of the DRUJ was sectioned, we performed three radiographic stress tests-squeeze test, ulnar pull in coronal plane, and simulated DRUJ ballotment test. Results: The squeeze test detected a significant increase in diastasis relative to the intact DRUJ after sectioning of the foveal insertion of the triangular fibrocartilage complex (TFCC; 1.0 mm) and the distal oblique bundle (DOB; 1.2 mm). The ulnar pull test in the coronal plane detected a significant increase in diastasis relative to the intact DRUJ after sectioning of the dorsal and volar radioulnar ligaments (2 mm), the foveal insertion of the TFCC (2.6 mm), and the DOB (4.4 mm). The simulated DRUJ ballotment test detected a significant increase in dorsal translation of the ulna relative to the intact DRUJ with sectioning of the foveal insertion of the TFCC (4.9 mm) and the DOB (5.6 mm). Conclusion: The squeeze test and simulated DRUJ ballotment test detect a significant increase in diastasis after the foveal attachment of the TFCC was sectioned. The ulnar pull test in the coronal plane was the most sensitive test for detecting a significant increase in diastasis relative to the intact DRUJ.

Seasonal Trends in Traumatic Digit Amputations: Experience of a Level І and a Level ІІ Hospital in a Northeastern State

Background: Traumatic digit amputations are common hand injuries in the United States. The primary aim of our study was to describe the relationship between season and mechanisms of amputation. Methods: The Emergency Department and Orthopaedic Surgery Billing Department databases of our level І institution in the Northeast were reviewed to identify patients with a traumatic digit amputation between January 2010 and December 2015. Inclusion criteria were defined as any patient presenting with a partial or complete amputation through Verdan zone I or II. All patient information was entered into a secure database, including date of injury, demographic information, digits amputated, mechanism of injury (crush, laceration, avulsion, bite, blast, saw, snow blower, or lawn mower), and Verdan zones of amputation. In addition to descriptive statistics, Fisher exact and χ² tests were used to compare the incidence of these traumatic digit amputation mechanisms between seasons. Results: For this 6-year period, an average of 24 patients presented each season for treatment of a traumatic digit amputation. Of all seasons, spring had the highest proportion of lawn mower amputations (62.5%; P < .0001), summer had the highest proportion of blast amputations (75.0%; P = .011), and winter had the highest proportion of snow blower amputations (90.9%; P < .0001). All other traumatic digit amputation mechanisms had no significant seasonal variation in incidence (P > .30). Conclusions: Given that certain traumatic digit amputation mechanisms occur predictably during certain seasons, seasonal public education has the potential to prevent these debilitating injuries.

Orthopaedic Surgery Faculty: An Evaluation of Gender and Racial Diversity Compared with Other Specialties

The American Academy of Orthopaedic Surgeons has adopted the strategic goal of evolving its culture and governance to become more strategic, innovative, and diverse. Given the charge to increase diversity, a focus on assessing and increasing diversity at the faculty level may help this cause. However, an analysis of gender and racial diversity among orthopaedic faculty has not been performed. The purpose of this study was to evaluate faculty appointments for underrepresented minority (URM) and female orthopaedic surgeons. We also aim to draw comparisons between orthopaedic surgery and other specialties.

Efficacy of a radial-based thumb metacarpophalangeal-stabilizing orthosis for protecting the thumb metacarpophalangeal joint ulnar collateral ligament

STUDY DESIGN

Basic research (biomechanics).

INTRODUCTION

The high degree of motion that occurs at the thumb metacarpophalangeal (MCP) joint must be taken into account when immobilizing a partially torn or repaired thumb ulnar collateral ligament.

PURPOSE OF THE STUDY

To determine the efficacy of a radial-based thumb MCP-stabilizing orthosis in resisting abduction across the thumb ulnar collateral ligament.

METHODS

Ten fresh cadaveric hands were mounted to a custom board. An anteroposterior radiograph of the thumb was obtained with a 2 N preload valgus force applied to the thumb, and the angle between the Kirschner wires was measured as a baseline. Subsequently, 20, 40, 60, 80, and 100 N valgus forces were applied 15 mm distal to the MCP joint. Anteroposterior radiographs of the thumb were obtained after each force was applied. The angle of displacement between the wires was measured and compared with the baseline angle. The angles were measured with an imaging processing tool. A custom radial-based thumb MCP-stabilizing orthosis was fashioned for each cadaveric thumb by a certified hand therapist. The aforementioned loading protocol was then repeated.

RESULTS

The radial-based thumb MCP-stabilizing orthosis significantly reduced mean abduction angles at each applied load.

DISCUSSION

We found that our orthosis, despite being hand-based and leaving the thumb IP and CMC joints free, significantly reduced mean abduction angles at each applied load.

CONCLUSIONS

This investigation provides objective evidence that our radial-based thumb MCP-stabilizing orthosis effectively reduces the degree of abduction that occurs at the thumb MCP joint up to at least 100 N.

LEVEL OF EVIDENCE

n/a (cadaveric).

Superficial acral fibromyxoma: A case report

There are a wide variety of benign and malignant soft tissue tumors. Digital superficial acral fibromyxoma is a rare, benign, expansive soft tissue growth which often involves the distal aspect of the digit and the nail plate. While it is often asymptomatic in nature, it may cause a great deal of distress due to involvement of the nail and the resultant cosmetic deformity. Unlike wide excision or amputation needed for more aggressive tumor types, local excision is often curative. We review the literature and describe the presentation of this unique pathology to our clinic in an otherwise healthy 33-year-old female.

Flexor Tendon Repair With Looped Suture: 1 Versus 2 Knots

PURPOSE

To assess the strength of flexor tendon repair with looped suture. We hypothesized that, after passing the intact looped suture in the desired repair configuration, splitting the loop and tying 2 independent knots would increase the strength of flexor tendon repair.

METHODS

Thirty-two flexor tendons were harvested and were sharply transected in zone II. The tendons were repaired with a 4-strand core suture repair using 3-0 looped nonabsorbable nylon suture. The harvested tendons were randomly assigned and repaired with either a 1- or a 2-knot construct. The repaired flexor tendons were fixed in a servohydraulic material testing system and were loaded to failure either with uniaxial tension or cyclically.

RESULTS

The average force at failure was 43 N for the 1-knot repair and 28 N for the 2-knot repair. The mode of failure of 15 of the flexor tendon repairs that were cyclically loaded to failure was suture pull-out. The average number of cycles and force in cyclic testing that caused failure of flexor tendon repairs was 134 cycles and 31 N for tendons repaired with looped 3-0 suture tied with 1 knot and 94 cycles and 33 N for tendons repaired with looped 3-0 suture tied with 2 knots.

CONCLUSIONS

Our hypothesis was disproved by the results of this study.

CLINICAL RELEVANCE

This study suggests that, when using looped suture, tying 2 independent knots instead of tying a single knot does not increase the strength of the flexor tendon repair.

Leclercia Adecarboxylata Infection in an Immunocompetent Child

Leclercia adecarboxylata is a motile Gram negative rod that is not often pathogenic in immunocompetent patients. We will present the first case report of a L. adecarboxylata in a pediatric patient with no systemic medical disease and present a detailed literature review.

Pediatric upper extremity conditions: traumatic and congenital

There are a variety of upper extremity conditions both traumatic and congenital that the physician will encounter. Some require emergent treatment; some should be observed. It is important to make the correct diagnosis and refer in a timely fashion.

Complex elbow instability

Complex elbow instability consists of dislocation of the ulnohumeral joint with a concomitant fracture of one or several of the bony stabilizers of the elbow, including the radial head, proximal ulna, coronoid process, or distal humerus. Recurrent instability is not often associated with simple dislocation, but an improperly managed complex dislocation may be a prelude to chronic, recurrent elbow instability. Complex instability is significantly more demanding to manage than simple instability. Radial head, coronoid, and olecranon fracture associated with dislocation each must be assessed and often require surgery. Long-term outcome with surgical management of complex elbow injuries is unknown. A few published series examine combinations of different injury patterns managed with various methods. Recently, however, several well-designed prospective outcome studies have evaluated management of several different individual fracture-dislocation patterns with a unified treatment algorithm. Fixation or replacement of injured bony elements, ligamentous repair, and hinged fixation may be used to successfully manage complex elbow instability.

Fractures of the proximal ulna olecranon and coronoid fractures

Fractures of the proximal ulna present unique challenges to the surgeon because of the complexity of the elbow joint. It is important not to underestimate the potential difficulty of these cases and to give each one thorough preoperative consideration before embarking on a surgical course. The primary principles of treatment are to restore joint congruity and stability while permitting early range of motion. A logical and consistent approach, based on the fracture characteristics and concomitant injuries, should produce predictable results.

Thumb kinematics and their relevance to function

With its sophisticated motion and prehensile ability, the TM joint is essential to hand function. The bony anatomy and the musculotendinous forces across the joint allow this advanced function. The elaborate ligamentous system provides stability. The high forces transmitted during routine pinch and grasp would not be possible without this complex arrangement.

Free tissue transfer in the treatment of linear scleroderma

Linear scleroderma is a subtype of localized scleroderma that most commonly affects children. The disease is rare, and the course is unpredictable. Most cases spontaneously resolve in 3-5 years. A small number, however, slowly progress to involve deeper subcutaneous tissues, muscles, and periosteum. Subsequent joint contractures and gross disturbances are frequent. Little on treatment is recorded in the literature. We report on four children who, in addition to bony procedures and release of joint and ligamentous contractures, had excision of the diseased skin and free soft-tissue transfer for coverage.

Fractures of the wrist and hand

The hands are extremely vulnerable to injury because of their constant use. This chapter features analyses of the evaluation, treatment, rehabilitation, and complications of fractures of the distal radius, carpus, metacarpals, and phalanges.