Pearls From My Specialty�Orthopedics�

Blake Sellers, MD

McKay Dee Orthopedics and Sports Medicine

Intermountain Health Layton Parkway Clinic- Orthopedics

Objectives

• Improving cost and patient experience through in-office hand surgery

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• Scaphoid fractures evaluation and treatment

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• Volar plate avulsion injuries

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Office-Based Procedures in Hand surgery

• Large push within hand surgery towards performing office-based procedures
• Advantages:
• Decreased cost to hospital system and more importantly the patient
• Improved access
• Decreased waste
• Avoidance of general anesthesia
• No fasting needed
• No need for patients to find rides

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Office-Based Procedures in Hand surgery

• Patient concerns
• Am I going to feel it?
• How bad does the shot hurt?
• I pass out if I see blood.
• I just want to take a nap.
• What are the cost differences?

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Office-Based Procedures in Hand surgery

• Common procedures performed in the office
• Trigger finger release (percutaneous and open)
• Foreign body removals
• Mass excisions
• Ganglion cyst excisions
• Tendon repairs
• De Quervain’s release
• Treatment of open distal phalanx fractures
• Endoscopic and open carpal tunnel release

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Office-Based Procedures in Hand surgery

Endoscopic carpal tunnel release

• Self pay cost:
• ASC: $3,094.00
• Clinic procedure room: $1282.00

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Although in-office procedures have huge potential advantages to the health care system and patients, few providers in the area are set up to do in-office procedures including endoscopic carpal tunnel releases.

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Initial Evaluation and Treatment of Scaphoid Fractures

Scaphoid fractures

• The scaphoid is the most commonly fractured carpal bone, accounting for approximately 60-70% of carpal bone fractures
• Scaphoid fractures tend to occur in young adult men between the ages of 15 and 40 years old.
• The mechanism of injury is a fall onto a hyperextended and radially deviated wrist. Often the patient feels like they just sprained their wrist.
• While most scaphoid fractures unite, 5% to 12% progress to nonunion despite adequate management.
• Present with tenderness in anatomic snuff box or scaphoid tubercle. Important to recognize that not all patients have tenderness

Anatomy

• The scaphoid forms an important mechanical linkage between the proximal and distal carpal rows.
• More than 80% of the scaphoid is covered with articular cartilage
• Blood supply:
• Dorsal scaphoid branches from the radial artery enter the nonarticular portion of the scaphoid at the dorsal ridge and supply approximately 70-80% of the scaphoid.
• The volar scaphoid branches from either the radial artery or superficial palmar branch enter the distal tubercle supplying the distal 20-30%

Imaging

• Initial wrist radiographs:
• PA
• Lateral
• 45-degree pronated oblique
• 45-degree supinated oblique
• Ulnarly deviated PA (scaphoid view)

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• False negative rate of 2% to 20% on initial radiographs based on several studies

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• What if x-rays are negative but you have a high clinical suspicion?
• Place in splint and repeat x-rays in 2 weeks?
• 75% to 80% of patients treated with clinical suspicion of scaphoid fracture would be immobilized unnecessarily. Dorsay TA. et al
• Delayed radiographs at 2 to 3 weeks are also unreliable. Dias et al

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Imaging

• MRI
• Positive predictive value is .88
• Negative predictive value is 1
• Great for ruling out fracture, but 12% of the time will show fracture when there isn’t one.
• Good for looking at proximal pole vascularity

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• CT
• Useful for looking at displacement, which is difficult to determine on plain radiograph
• Evaluation of scaphoid collapse, humpback deformity, cystic change and DISI.

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Imaging

Risk Factors for Nonunion

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• Displacement > 1 mm
• Comminution
• Proximal pole scaphoid fractures: 34% nonunion rate if treated nonoperatively
• Delayed/missed diagnosis > 4 weeks
• Improper immobilization
• Patients often come to clinic with removable thumb spica braces which they wear “some of the time”

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Treatment options

• Cast immobilization
• <1mm displacement

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• Percutaneous screw fixation
• Acute or chronic nondisplaced fractures

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• Open reduction and screw fixation
• Displaced scaphoid fractures

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• Open reduction with bone graft
• Non-vascularized
• Corticocancellous
• Cancellous
• Vascularized

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Nondisplaced scaphoid waist fractures

• Cast immobilization versus operative management
• 90-95% of nondisplaced scaphoid waist fractures will heal with nonoperative treatment, however prolonged immobility can interfere with work and lifestyle, which raises socioeconomic and compliance issues.
• Dias et al. randomized 88 patients to internal fixation or short arm cast. The 8 and 12 week outcomes were better in the operatively treated patients but there were no major differences greater than 12 weeks after injury.
• McQueen et al. randomized 60 patients to percutaneous fixation or cast immobilization. No difference in union rate and the operative treated group regained grip and pinch strength and ROM more quickly but no difference at 1 year follow-up
• Vinnars et al. Randomized 83 fracture to casting or operative treatment. 10 years from the injury there were no significant differences in symptoms, motion, grip strength, or union. The operatively treated group had higher rates of scaphotrapezial arthritis.

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Nondisplaced scaphoid waist fractures

Vinnars et al. total hospital costs were significantly lower with cast treatment however manual workers treated with casting had substantially longer time off work than those with surgical treatment (100 days versus 61 days).

In a metaanalysis of randomized trials Ibrahim et al. found surgical treatment associated with a statistically significant elevated risk of complication with no statistical difference in ROM, grip strength, OA.

Recommend aggressive conservative management.

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Case #1�

22-year-old female who sustained a nondisplaced scaphoid waist fracture when she fell off a wall

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Case #1

2-month follow-up

Case #2

16-year-old presented after injuring his left wrist playing high school football 7 weeks prior.

He thought it was just a sprain but continued having pain so eventually had x-rays taken. He had not been immobilized during this time.

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Case #2

Case #3

22-year-old female who injured her wrist 2 years ago in a GLF. She did not seek treatment at that time.

She recently reaggravated it in an altercation with her boyfriend.

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Case #3 4-month follow-up

Case #4

63-year-old male with long standing left wrist pain and swelling no longer responding to conservative treatment.

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Case #4

Scaphoid Fracture Learning points

1. Have high clinical suspicion because it often presents with a “wrist sprain” that didn’t fully heal
2. Consider advanced imaging if clinical suspicion is high and initial radiographs are negative
3. Removable wrist brace is not adequate immobilization (patients take them off)
4. Biggest risk factors for nonunion:
• Delay in treatment
• Displacement
• Proximal pole fractures

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Volar Plate Avulsion Injuries

Volar plate avulsion injuries

• Results from a hyperextension injury or axial load of the finger (The Jammed Finger)

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• Presents with pain, swelling, and bruising over the volar PIP joint

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• Volar plate prevents hyperextension of the PIP joint

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Volar plate avulsion injuries: Treatment

If the fracture involves less than 40% of the articular surface and there is no dorsal displacement of the middle phalanx:

• Buddy taping and range of motion as tolerated

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If unstable or large articular fragment:

• Referral to hand surgery

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Volar plate avulsion learning points

1. If patient presents with a “jammed finger,” evaluate lateral x-ray for avulsion fracture
2. If the PIP joint is symmetric and fracture is small, treatment with buddy tape and ROM is appropriate
3. Proper treatment of this injury can speed return to activities and avoid costly therapy.
4. Unstable PIP joints or fractures involving a significant portion of the articular surface should be referred to hand surgery.

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Thank You