Adam B. Shafritz

Epidemiology and Risk Factors of Humerus Fractures Among Skiers and Snowboarders

Background The incidence of humerus fractures while participating in snowboarding and skiing is undefined. Very little is known about the risk factors associated with these fractures. Hypothesis Snowboarders are at increased risk for sustaining humerus fractures when compared with skiers. In addition, the types of fractures, laterality, and risk factors differ between the 2 groups. Study Design Case-control study; Level of evidence, 3. Methods At a major ski area clinic, 318 humerus fractures were evaluated over 34 seasons. Radiographs were classified according to the AO and Neer systems. Patient data were analyzed and compared with that of a control population of uninjured skiers and snowboarders to determine incidence and risk factors. Results The incidence of humerus fractures among snowboarders (0.062 per 1000 snowboarder days) was significantly higher than that of skiers (0.041 per 1000, P < .05). Skiers were more likely to sustain proximal fractures, and snowboarders were relatively more likely to sustain diaphyseal and distal fractures (P < .05). Of glenohumeral dislocations, 6.56% were associated with proximal humerus fractures among skiers (1.7% among snowboarders). Snowboarders who lead with their left foot were more likely to fracture their left humerus (P = .023). Helmet use and gender were not risk factors for humerus fractures among either skiers or snowboarders. Jumping was involved in 28.3% of humerus fractures among snowboarders and in 5.4% among skiers. Skiers with humerus fractures were more skilled, older, and fell less frequently than controls. Snowboarders were less skilled, younger, and fell at a similar rate compared with controls. Conclusion Snowboarders are at significantly higher risk of sustaining humerus fractures than skiers. In skiers, humerus fractures show no laterality and most often involve the proximal humerus. In contrast, snowboarders more often fracture the left humerus at the diaphysis.

Long-term clinical outcomes, motion, strength, and function after total claviculectomy

BACKGROUND Total excision of the clavicle is rarely performed. No previous study has documented long-term outcomes with objective measurements of strength, motion, and patient-centered outcomes. We present the long-term consequences of total claviculectomy on shoulder girdle function, global upper extremity function, and overall general health. METHODS Five total claviculectomy patients were evaluated at 2 time points (2005 and 2010, mean 4.8 and 9.4 years postoperatively) by use of the DASH, SF-36, Simple Shoulder Test, ASES, UCLA, HSS, and Constant shoulder scores. Isokinetic strength, clinical range of motion, and kinematic analysis were performed on each limb pair. RESULTS All clinical scores allowing side-to-side comparison were poorer for the aclaviculate side, with significance reached for 2005 ASES scores and 2010 ASES, UCLA, HSS, and Constant scores. DASH scores and SF-36 scores were not significantly inferior to age- and sex-matched population norms. Deficits in strength were present in the aclaviculate limbs, with significance reached for adduction in 2005 and for forward flexion and external rotation in 2010. Kinematic and clinical range of motion analysis revealed scapular dyskinesis and significant deficits in external rotation in the aclaviculate limb. CONCLUSIONS We found that the clavicle contributes to the strength, coordinated scapulohumeral rhythm, and overall range of motion of the shoulder girdle. Patients compensate for loss of the clavicle with minimal functional deficit. With time, patients gradually lose some compensatory ability as evidenced by deteriorating limb-specific, patient-centered outcome measures, diminished strength in certain planes of shoulder motion, and scapular dyskinesis at long-term follow-up. Despite objective deficits, these patients continue to have normal self-perceptions of overall health and global upper extremity function.

Chemotherapy Extravasation Injuries

NJURY FROM EXTRAVASATION of intravenous chemotherapeutic drugs can lead to severe disability and morbidity. Although the annual incidence of extravasation injury is only 0.1% to 0.7%, it is 4.7% in the chemotherapy patient population and ranges from 11% to 58% in children. 1 These high-risk populations— neutropenic cancer patients and neonates in the intensive care unit— cannot physiologically afford such an injury. Peripheral intravenous devices placed in the upper extremity and used for chemotherapy put the dorsum of the hand and the antecubital fossa at substantial risk for injury. Although intravenous extravasation prevention is paramount, swift treatment in the event of an accident is critical in avoiding morbidity. Appropriate treatment requires knowledge of the nature of the toxic agent extravasated as well as an understanding of the medical and surgical treatment options available.

Negative-pressure wound therapy.

EVIDENCE DEFINITIONS  Class I: Prospective randomized controlled trial.  Class II: Prospective clinical study or retrospective analysis of reliable data. Includes observational, cohort, prevalence, or case control studies.  Class III: Retrospective study. Includes database or registry reviews, large series of case reports, expert opinion.  Technology assessment: A technology study which does not lend itself to classification in the above-mentioned format. Devices are evaluated in terms of their accuracy, reliability, therapeutic potential, or cost effectiveness.

Scapholunate and perilunate injuries in the athlete

Purpose of the reviewScapholunate and perilunate injuries can be difficult to diagnose and treat in the athlete. In this review article, we present the mechanism of injury, evaluation, management, and outcomes of treatment for these injuries.Recent findingsAcute repair of dynamic scapholunate ligament injuries remains the gold standard, but judicious use of a wrist splint can be considered for the elite athlete who is in season. The treatment of static scapholunate ligament injury remains controversial. Newer SL reconstructive techniques that aim to restore scapholunate function without compromising wrist mobility as much as tenodesis procedures show promise in athlete patients.SummaryAcute injuries to the scapholunate ligament are best treated aggressively in order to prevent the sequelae of wrist arthritis associated with long-standing ligamentous injury. Acute repair is favored. Reconstructive surgical procedures to manage chronic scapholunate injury remain inferior to acute repair. The treatment of lunotriquetral ligament injuries is not well defined.

Reverse total shoulder arthroplasty: early results of forty-one cases and a review of the literature.

Reverse total shoulder arthroplasty was officially approved for use in the United States in 2003. The procedure is proving to be one of the most exciting advances in upper extremity surgery in the past quarter-century. The prosthesis is used to salvage the arthritic, unstable, rotator cuff-deficient shoulder and allow patients to obtain nearly pain-free overhead motion of the upper limb. This article reviews the previous literature and the results of 41 reverse shoulder arthroplasties implanted in 39 patients by a single orthopedically trained hand and upper extremity surgeon at a single institution from November 2004 until July 2011.

Analyzing glenohumeral torque–rotation response in vivo

BACKGROUND Because the human shoulder has many degrees of freedom that allow redundant means of producing the same net humerothoracic motion, there are many impediments to objective, repeatable assessment of shoulder function in vivo. Devices designed to date have suffered from poor reliability. In this study we introduce a new device and methods to evaluate human shoulder kinematics and evaluate its reproducibility from subject to subject and from day to day. METHODS This was a controlled laboratory study. Using electromagnetic motion sensors to record the position and orientation of the thorax, scapula, and humerus, we quantified the kinematic response of twenty four normal shoulders in response to known internal-external torque application. A four-parameter logistic function was selected to characterize the strident features of the torque-rotation relationship. FINDINGS Our analysis in conjunction with the measurement technique described herein, allowed the passive glenohumeral internal-external range of motion to be differentiated from other motion components and was determined to within 9.6% of full scale over three repeated trials. Range of motion was the most reliable biomechanical outcome, more so than computed indices of glenohumeral flexibility and hysteresis. The exact profile of the torque-rotation response, and therefore the repeatability of the calculated outcomes, was unique from shoulder to shoulder. INTERPRETATION The development of the capacity for precise, non-invasive measurement of shoulder biomechanics over time is a requisite step towards optimizing treatment of shoulder injury and disease. Our current methods are superior to previous attempts at trying to non-invasively evaluate the biomechanics of the glenohumeral joint.

Lift-off Test Results After Lesser Tuberosity Osteotomy Versus Subscapularis Peel in Primary Total Shoulder Arthroplasty

Background: The ideal method for management of the subscapularis tendon during anatomic total shoulder arthroplasty (TSA) remains controversial. Methods: In a retrospective cohort study, primary anatomic TSA procedures performed with either a subscapularis peel or a lesser tuberosity osteotomy from 2002 to 2010 were reviewed at a minimum 1-year follow-up. The primary outcome measure was the performance of a normal lift-off test postoperatively. Multivariate logistic regression analysis was performed to determine if other covariates besides surgical technique correlated with an abnormal lift-off test result. Results: Ninety TSA procedures were evaluated. Forty-six procedures were performed with subscapularis peel, and 44 were performed with lesser tuberosity osteotomy. Mean follow-up was 4 years. In the subscapularis peel group, 32 of 46 shoulders (69.6%) had a normal lift-off test, compared with 40 of 44 shoulders (90.9%) in the lesser tuberosity osteotomy group (P = 0.01). The results of multivariate logistic regression suggested that lesser tuberosity osteotomy was associated with a normal postoperative lift-off test 4.5 times more often than was subscapularis peel. Conclusions: Our study suggests that the use of lesser tuberosity osteotomy as the surgical approach for anatomic TSA is a reliable option that provides the patient with a better chance of maintaining subscapularis function postoperatively than the subscapularis peel does. Level of Evidence: Level III retrospective cohort study

The Krukenberg Procedure

HERE ARE FEW THINGS more devastating to one’s functional independence than the loss of a hand. Reconstruction after hand amputation is generally limited to prosthetic use, although recently hand transplantation has shown early promise. The seldom-used Krukenberg procedure serves as an alternative to these costly and often limited alternatives. Designed in 1917 by German army surgeon Hermann Krukenberg, this intriguing procedure provides dexterity and tactile sensation by converting the radius and ulna into a clawlike pincer. 1 Patients maintain voluntary control over grasping and releasing objects (Figs. 1, 2), allowing them to perform most activities of daily living. This procedure has traditionally been reserved for blind bilateral arm amputees, 2 although successful results have been published when used for congenital malformations 3,4 and sighted unilateral amputees. 3,5 Many cultures reject the Krukenberg procedure because of the unfavorable cosmetic appearance of the Krukenberg pincer. 3 This is unfortunate because many of these same cultures also lack access to the other alternatives to manage limb loss. INDICATIONS AND PATIENT SELECTION The Krukenberg procedure is best suited for blind bilateral upper extremity amputees, because they have lost the visual input necessary to operate prosthetic devices effectively, as there is no tactile feedback relayed from a prosthesis. Patients being considered for the procedure must have a forearm stump at least 8 to

Team Approach: Repair and Rehabilitation Following Flexor Tendon Lacerations

Flexor tendon lacerations are uncommon, with a reported prevalence of 6 per 100,000 acute hand injuries[1][1]. Sterling Bunnell, the founder of hand surgery specialization[2][2], recognized the challenges of flexor tendon repair and recommended against primary flexor tendon repair in what he termed