A Comparison of Patient Characteristics and Outcomes Between Patients Receiving Flexor Digitorum Superficialis Slip Excision or Isolated A1 Pulley Release for Trigger Finger

PURPOSE

Resection of the radial or ulnar slip of the flexor digitorum superficialis (FDS) tendon is a known treatment option for persistent trigger finger. Risk factors for undergoing FDS slip excision are unclear. We hypothesized that patients who underwent A1 pulley release with FDS slip excision secondary to persistent triggering would have a higher comorbidity burden compared to those receiving A1 pulley release alone.

METHODS

We identified all adult patients who underwent A1 pulley release with FDS slip excision because of persistent triggering either intraoperatively or postoperatively from 2018 to 2023. We selected a 3:1 age- and sex-matched control group who underwent isolated A1 pulley release. Charts were retrospectively reviewed for demographics, selected comorbidities, trigger finger history, and postoperative course. We performed multivariable logistic regression to assess the probability of FDS slip excision after adjusting for several variables that were significant in bivariate comparisons.

RESULTS

We identified 48 patients who underwent A1 pulley release with FDS slip excision and 144 controls. Our multivariable model showed that patients with additional trigger fingers and a preoperative proximal interphalangeal (PIP) joint contracture were significantly more likely to undergo FDS slip excision.

CONCLUSIONS

Patients who underwent A1 pulley release with FDS slip excision were significantly more likely to have multiple trigger fingers or a preoperative PIP joint contracture. Clinicians should counsel patients with these risk factors regarding the potential for FDS slip excision in addition to A1 pulley release to alleviate triggering of the affected digit.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Posterior Interosseous Nerve Compression in the Forearm, AKA Radial Tunnel Syndrome: A Clinical Diagnosis

BACKGROUND

Posterior interosseous nerve (PIN) compression in the forearm without motor paralysis is a challenging clinical diagnosis. This retrospective study evaluated the clinical assessment, diagnostic studies, and outcomes following surgical decompression of the PIN in the forearm.

METHODS

This study reviewed 182 patients' medical charts following PIN decompression between 2000 and 2020 by a single surgeon. After exclusion of combined nerve entrapments, polyneuropathy, motor palsy, or lateral epicondylitis, the study included 14 patients. Data collected included: clinical presentation and pain drawings, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores.

RESULTS

There were 15 PIN decompressions (14 patients, mean follow-up = 11.9 months). Clinical presentation included pain (n = 14) (proximal dorsal forearm, n = 14; distal forearm over radial sensory nerve, n = 3) and positive clinical tests (sensory collapse test over the radial tunnel, n = 8; pain with forearm pronation and compression over the radial tunnel, n = 10; Tinel sign, n = 5). Postoperatively, there were significant improvements in Visual Analog Scale pain scores (6.7 to 3.3, P = .0006), quality-of-life scores (74.7 to 32.7, P = .0001), and DASH scores (46.3 to 33.6, P = .02).

CONCLUSIONS

The PIN compression in the forearm without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent, therapy-resistant dorsal forearm pain should be evaluated for PIN compression. Surgical decompression provides statistically significant quantifiable improvement in pain and quality of life.

Calling on Sponsorship: Analysis of Speaker Gender Representation at Hand Society Meetings

BACKGROUND

The paucity of leadership diversity in surgical specialties is well documented. Unequal opportunities for participation at scientific meetings may impact future promotions within academic infrastructures. This study evaluated gender representation of surgeon speakers at hand surgery meetings.

METHODS

Data were retrieved from the 2010 and 2020 meetings of the American Association for Hand Surgery (AAHS) and American Society for Surgery of the Hand (ASSH). Programs were evaluated for invited and peer-reviewed speakers excluding keynote speakers and poster presentations. Gender was determined from publicly available sources. Bibliometric data (Hirsch index) for invited speakers were analyzed.

RESULTS

In 2010 at the AAHS ( n = 142) and ASSH meetings ( n = 180), female surgeons represented 4% of the invited speakers and in 2020 increased to 15% at AAHS ( n = 193) and 19% at ASSH ( n = 439). From 2010 to 2020, female surgeon invited speakers had a 3.75-fold increase at AAHS and 4.75-fold increase at ASSH. Representation of female surgeon peer-reviewed presenters at these meetings was similar (2010 AAHS, 26%; and 2010 ASSH, 22%; 2020 AAHS, 23%; 2020 ASSH, 22%). The academic rank of women speakers was significantly lower ( P < 0.001) than for male speakers. At the assistant professor level, the mean Hirsch index was significantly lower ( P < 0.05) for female invited speakers.

CONCLUSIONS

Although there was a significant improvement in gender diversity in invited speakers at the 2020 meetings compared with 2010, female surgeons remain underrepresented. Gender diversity is lacking at national hand surgery meetings, and continued effort and sponsorship of speaker diversity is imperative to curate an inclusive hand society experience.

Following a Surgical Paradigm Shift Through the Adoption of Nerve Transfers Among Board-Eligible and Practicing Plastic Surgeons

BACKGROUND

Nerve transfers represent a new paradigm in the treatment of nerve injuries. Their current level of adoption among surgeons is unknown. This study evaluates the incidence of nerve transfers on case logs of board-eligible plastic surgeons over the past 14 years and surveys practicing nerve surgeons regarding their use of this technique.

METHODS

We queried the American Board of Plastic Surgery case log database for all nerve reconstruction Current Procedural Terminology codes from 2008 to 2021 and assessed trends and relationships between geographic region, examination year, and nerve transfer use. We surveyed nerve surgery professional societies to assess trends in practice, compared with a 2017 survey.

RESULTS

A total of 1959 nerve reconstruction cases were logged by 738 candidates from 2008 to 2021. Twelve percent of cases included nerve transfers. The proportion of nerve transfer codes (Z = -11.57; P < .0001) and the proportion of candidates performing nerve transfers (Z = -9.21, P < .0001) increased over the study period. Nerve transfers were associated with geographic region (χ² = 25.826, P = .0002), with most cases performed in the Midwest (26.4%). A higher proportion of practicing nerve surgeons reported performing nerve transfers in this survey than in our 2017 survey (χ² = 16.7, P < .001).

CONCLUSIONS

There has been an increase in nerve transfers logged in the past 14 years by board-eligible plastic surgeons, as well as increased use among currently practicing nerve surgeons. Although nerve transfer use is increasing among both plastic and orthopedic surgeons, a greater proportion of nerve reconstructions include nerve transfers in the plastic surgery cohort.

Beyond the Cubital Tunnel: Use of Adjunctive Procedures in the Management of Cubital Tunnel Syndrome

BACKGROUND

Our management of cubital tunnel syndrome has expanded to involve multiple adjunctive procedures, including supercharged end-to-side anterior interosseous to ulnar nerve transfer, cross-palm nerve grafts from the median to ulnar nerve, and profundus tenodesis. We also perform intraoperative brief electrical stimulation in patients with severe disease. The aims of this study were to evaluate the impact of adjunctive procedures and electrical stimulation on patient outcomes.

METHODS

We performed a retrospective review of 136 patients with cubital tunnel syndrome who underwent operative management from 2013 to 2018. A total of 38 patients underwent adjunctive procedure(s), and 33 received electrical stimulation. A historical cohort of patients who underwent cubital tunnel surgery from 2009 to 2011 (n = 87) was used to evaluate the impact of adjunctive procedures. Study outcomes were postoperative improvements in Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores, pinch strength, and patient-reported pain and quality of life.

RESULTS

In propensity score-matched samples, patients who underwent adjunctive procedures had an 11.3-point greater improvement in DASH scores than their matched controls (P = .0342). In addition, patients who received electrical stimulation had significantly improved DASH scores relative to baseline (11.7-point improvement, P < .0001), whereas their control group did not. However, when compared between treatment arms, there were no significant differences for any study outcome.

CONCLUSIONS

Patients who underwent adjunctive procedures experienced greater improvement in postoperative DASH scores than their matched pairs. Additional studies are needed to evaluate the effects of brief electrical stimulation in compression neuropathy.

Radial Nerve Palsy: Nerve Transfer Versus Tendon Transfer to Restore Function

BACKGROUND

Radial nerve injuries cause profound disability, and a variety of reconstruction options exist. This study aimed to compare outcomes of tendon transfers versus nerve transfers for the management of isolated radial nerve injuries.

METHODS

A retrospective chart review of 30 patients with isolated radial nerve injuries treated with tendon transfers and 16 patients managed with nerve transfers was performed. Fifteen of the 16 patients treated with nerve transfer had concomitant pronator teres to extensor carpi radialis brevis tendon transfer for wrist extension. Preoperative and postoperative strength data, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and quality-of-life (QOL) scores were compared before and after surgery and compared between groups.

RESULTS

For the nerve transfer group, patients were significantly younger, time from injury to surgery was significantly shorter, and follow-up time was significantly longer. Both groups demonstrated significant improvements in grip and pinch strength after surgery. Postoperative grip strength was significantly higher in the nerve transfer group. Postoperative pinch strength did not differ between groups. Similarly, both groups showed an improvement in DASH and QOL scores after surgery with no significant differences between the 2 groups.

CONCLUSIONS

The nerve transfer group demonstrated greater grip strength, but both groups had improved pain, function, and satisfaction postoperatively. Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. Both tendon transfers and nerve transfers are good options for patients with radial nerve palsy.

Interpreting Electrodiagnostic Studies for the Management of Nerve Injury

Nerve injuries are common after trauma and can be life-altering for patients. Electrodiagnostic studies are the gold standard for diagnosing and prognosticating nerve injuries. However, most surgeons are not trained in the interpretation of these studies; rather, they rely on the interpretation provided by the electrodiagnostician, who in turn is unlikely to be trained in nerve reconstruction. This discrepancy between the interpretation of these studies and the management of nerve injuries can lead to suboptimal surgical planning and patient outcomes. This review aims to provide a framework for surgeons to take a more active role in collaborating with their colleagues in electrodiagnostic medicine in the interpretation of these studies, with an ultimate goal of improved patient care. The basics of nerve conduction studies, electromyography, and relevant terminology are reviewed. The relationship between the concepts of demyelination, axon loss, Wallerian degeneration, nerve regeneration, collateral sprouting, and clinical function are explained within the framework of the Seddon and Sunderland nerve injury classification system. The natural evolution of each degree of nerve injury over time is illustrated, and management strategies are suggested.

What is Operative? Conceptualizing Neuralgia: Neuroma, Compression Neuropathy, Painful Hyperalgesia, and Phantom Nerve Pain

Neuralgia, or nerve pain, is a common presenting complaint for the hand surgeon. When the nerve at play is easily localized, and the cause of the pain is clear (eg, carpal tunnel syndrome), the patient may be easily treated with excellent results. However, in more complex cases, the underlying pathophysiology and cause of neuralgia can be more difficult to interpret; if incorrectly managed, this leads to frustration for both the patient and surgeon. Here we offer a way to conceptualize neuralgia into 4 categories-compression neuropathy, neuroma, painful hyperalgesia, and phantom nerve pain-and offer an illustrative clinical vignette and strategies for optimal management of each. Further, we delineate the reasons why compression neuropathy and neuroma are amenable to surgery, while painful hyperalgesia and phantom nerve pain are not.

Median Nerve Compression in the Forearm: A Clinical Diagnosis

Background: Median nerve entrapment in the forearm (MNEF) without motor paralysis is a challenging diagnosis. This retrospective study evaluated the clinical presentation, diagnostic studies, and outcomes following surgical decompression of MNEF. Methods: The study reviewed 147 patient medical charts following MNEF surgical decompression. With exclusion of patients with combined nerve entrapments (radial and ulnar), polyneuropathy, neurotmetic nerve injury, or median nerve motor palsy, the study sample included 27 patients. Data collected include: clinical presentation and pain, strength, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 27 patients (mean follow-up = 7 months), and 13 patients had previous carpal tunnel release (CTR). Clinical presentation included pain (n = 27) (forearm, n = 22; median nerve innervated digits, n = 21; and palm, n = 21) and positive clinical tests (forearm scratch collapse test, n = 27; pain with compression over the flexor digitorum superficialis arch/pronator, n = 24; Tinel sign, n = 11). Positive electrodiagnostic studies were found for MNEF (n = 2) and carpal tunnel syndrome (n = 11). Primary CTR was performed in 10 patients and revision CTR in 7 patients. Postoperatively, there were significant (P < .05) improvements in strength, pain, quality of life, and DASH scores. Conclusions: The MNEF without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent forearm pain and median nerve symptoms (especially after CTR) should be evaluated for MNEF. Surgical decompression provides satisfactory outcomes.

The Effect of Intraoperative Glove Choice on Carpal Tunnel Pressure

Introduction The aim of this study was to quantify the effect of surgical gown and glove wear on carpal tunnel pressure. The authors hypothesized that gowning and gloving is associated with an increase in carpal tunnel pressure in cadaveric specimens wearing appropriately sized gloves. Furthermore, they hypothesized that increased glove thickness, double gloving, and smaller-than-appropriately sized gloves would all serve to increase carpal tunnel pressure.

Materials and Methods Baseline carpal tunnel pressure measurements were obtained in 11 cadaveric specimens. Each specimen was subsequently gowned and gloved. Carpal tunnel pressures were obtained for each specimen fitted with four different types of gloves in four scenarios: (1) appropriately sized gloves, (2) one full-size smaller, (3) one full-size larger, and (4) double gloved.

Results Mean carpal tunnel baseline value was 3.5 mm Hg. Appropriately sized single-glove wear more than doubled baseline carpal tunnel pressure. Double gloving and smaller-than-appropriately sized glove wear more than tripled baseline values. Among the single-glove subgroup, the thickest gloves (ortho) were associated with the highest increase in pressure from baseline values.

Conclusion Glove selection can have repercussions related to carpal tunnel pressure. Susceptible surgeons should consider these factors when making decisions regarding intraoperative glove wear.

Gender Preferences of Patients When Selecting Orthopaedic Providers

BACKGROUND

Orthopaedic surgery is a male-dominated specialty associated with many stereotypes, despite the increased representation of females compared to 30 years ago. Numerous studies have examined medical student and resident perceptions regarding females in orthopaedic surgery to explain the disparity, but there are few studies that analyze whether patients have a gender preference in their orthopaedic surgeon. Our study sought to determine whether patients have a preference for the gender of their orthopaedic surgeon, and what traits in orthopaedic surgeons are important to their patients.

METHODS

A total of 191 new patients seen in the emergency department and orthopaedic urgent care clinic were administered a 22-question survey regarding preferences in their orthopaedic provider. Patients were asked questions regarding preferred gender of their provider, as well as preferences in characteristics exhibited.

RESULTS

The majority of patients did not have a preference for the gender of their orthopaedist (83.9%); however, 14.5% of patients preferred a female surgeon and 1.6% of patients preferred a male surgeon. Female patients had a preference for the same gender compared to male patients and preferred females (p=0.04). Of the patients that had a preference, 90% preferred a female provider. There were trends towards preference for gender that varied depending on subspecialty. There was a statistically insignificant trend towards preference for male providers in total joint replacements and spine surgery, and conversely a preference for female providers in hand surgery and pediatric orthopaedics. 48.6% of patients cited the single most important trait to be board certification, followed by years in practice (27.1%), then reputation or prestige (16.7%). Over one-third of patients found physical appearance, gender, racial background and age to be important traits.

CONCLUSIONS

The majority of patients did not have a preference for the gender of their orthopaedic surgeon. 16.1% of patients had a preference, and the majority of these patients preferred female surgeons. Preferences for a specific gender were seen that varied based on the subspecialty. Efforts at increasing gender diversity in orthopaedics should continue to be a major goal.Level of Evidence: III.

Accuracy in Screw Selection in a Cadaveric, Small-Bone Fracture Model

PURPOSE

Using a cadaveric model simulating clinical situations experienced during open reduction and internal fixation of proximal phalangeal fractures, the aim of this study was to evaluate the relationship between level of training and the rates of short, long, and ideal screw length selection based on depth gauge use without fluoroscopy assistance.

METHODS

A dorsal approach to the proximal phalanx was performed on the index, middle, and ring fingers of 4 cadaveric specimens, and 3 drill holes were placed in each phalanx. Volunteers at different levels of training then measured the drill holes with a depth gauge and selected appropriate screw sizes. The rates of short, long, and ideal screw selection were compared between groups based on level of training. Ideal screws were defined as a screw that reached the volar cortex but did not protrude more than 1 mm beyond it.

RESULTS

Eighteen participants including 3 hand fellowship-trained attending physicians participated for a total of 648 selected screws. The overall rate of ideal screw selection was lower than expected at 49.2%. There was not a statistically significant relationship between rate of ideal screw selection and higher levels of training. Attending surgeons were less likely to place short screws and screws protruding 2 mm or more beyond the volar cortex CONCLUSIONS: Overall, the rate of ideal screw selection was lower than expected. The most experienced surgeons were less likely to place short and excessively long screws.

CLINICAL RELEVANCE

Based on the low rate of ideal screws, the authors recommend against overreliance on depth gauging alone when placing screws during surgery. The low-rate ideal screw length selection highlights the potential for future research and development of more accurate technologies to be used in screw selection.

The Effect of Intraoperative Glove Choice on Carpal Tunnel Pressure

Introduction The aim of this study was to quantify the effect of surgical gown and glove wear on carpal tunnel pressure. The authors hypothesized that gowning and gloving is associated with an increase in carpal tunnel pressure in cadaveric specimens wearing appropriately sized gloves. Furthermore, they hypothesized that increased glove thickness, double gloving, and smaller-than-appropriately sized gloves would all serve to increase carpal tunnel pressure.

Materials and Methods Baseline carpal tunnel pressure measurements were obtained in 11 cadaveric specimens. Each specimen was subsequently gowned and gloved. Carpal tunnel pressures were obtained for each specimen fitted with four different types of gloves in four scenarios: (1) appropriately sized gloves, (2) one full-size smaller, (3) one full-size larger, and (4) double gloved.

Results Mean carpal tunnel baseline value was 3.5 mm Hg. Appropriately sized single-glove wear more than doubled baseline carpal tunnel pressure. Double gloving and smaller-than-appropriately sized glove wear more than tripled baseline values. Among the single-glove subgroup, the thickest gloves (ortho) were associated with the highest increase in pressure from baseline values.

Conclusion Glove selection can have repercussions related to carpal tunnel pressure. Susceptible surgeons should consider these factors when making decisions regarding intraoperative glove wear.

Simplified Cable Nerve Grafting with Nerve-Cutting Guides and Fibrin Glue

Cable nerve grafting is the recommended surgical treatment for large peripheral nerve defects. Traditionally, this is performed by bridging a gap in the nerve with multiple autologous nerve cables, repairing the epineurium of each cable to the perineurium of a fascicle of the injured nerve that is similar in size to the graft. The authors present a new technique in which they used nerve-cutting guides to aid in the placement of fibrin glue to secure the sides of the cabled nerve graft together to facilitate handling of the cabled nerve graft and to expedite repair. Freshening the graft nerve ends after the application of fibrin glue using appropriately sized nerve-cutting guides allows for donor-recipient size match and epineurium-to-epineurium repair of the cabled graft to injured nerve. Though further follow-up is needed to determine long-term outcomes following this technique, early results are promising with clinical improvement seen in a similar timeframe to traditional grafting.

Pediatric Scaphoid Proximal Pole Nonunion With Avascular Necrosis

A 13-year-old, right hand-dominant, otherwise healthy boy presented with left wrist pain 19 months after a nonmotorized scooter injury. Radiographs and magnetic resonance imaging at presentation demonstrated proximal pole scaphoid nonunion with avascular necrosis of the proximal fragment. Operative and nonsurgical treatment options were discussed and the family elected for an attempt at nonsurgical management. The patient was placed in a short-arm thumb spica cast, with a window for a bone stimulator, for 14 weeks. At the conclusion of the treatment, the pain had resolved and x-ray and computed tomography scan demonstrated bony union. The authors recommend considering an initial trial of nonsurgical management for treatment of all pediatric scaphoid nonunions.

Effects of Hand Fellowship Training on Rates of Endoscopic and Open Carpal Tunnel Release

PURPOSE

To investigate rates, trends, and complications for carpal tunnel release (CTR) related to fellowship training using the American Board of Orthopaedic Surgery Part II Database.

METHODS

We searched the American Board of Orthopaedic Surgery database for patients with carpal tunnel syndrome who underwent either open carpal tunnel release (OCTR) or endoscopic (ECTR) from 2003 to 2013. Cases with multiple treatment codes were excluded. Data were gathered on geographic location, fellowship, and surgical outcomes. Data were then divided into 2 cohorts: hand fellowship trained versus non-hand fellowship trained. We performed analysis with chi-square tests of independence and for trend.

RESULTS

Overall, 12.4% of all CTRs were done endoscopically. Hand fellowship-trained orthopedists performed about 4.5 times the number of ECTR than did non-hand fellowship-trained surgeons. An increasing trend over time of ECTR was seen only among the hand fellowship cohort. The northwest region of the United States had the highest incidence (23.1%) of ECTR, and the Southwest the lowest incidence (5.9%). The complication incidence associated with CTR overall was 3.6%, without a significant difference between ECTR and OCTR. Within the hand fellowship cohort the complication incidence for ECTR was significantly less than for OCTR. There was no difference in overall complication rates with ECTR and OCTR between the 2 cohorts. Wound complications were higher with OCTR (1.2% vs 0.25%) and nerve palsy with ECTR (0.66% vs 0.27%); with postoperative pain equivalent between techniques independent of fellowship training.

CONCLUSIONS

Within the United States from 2003 to 2013, the rate of ECTR increased, as did complications. However, complication rates remained low in the first 2 years of practice. Hand fellowship-trained surgeons performed more ECTR than did non-hand fellowship-trained orthopedic surgeons, and both groups had similar complication rates.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The influence of patient insurance status on access to outpatient orthopedic care for flexor tendon lacerations

PURPOSE

To determine the effect of patient insurance status on access to outpatient orthopedic care for acute flexor tendon lacerations.

METHODS

The research team contacted 100 randomly chosen orthopedic surgery practices in North Carolina by phone on 2 different occasions separated by 3 weeks. The research team attempted to obtain an appointment for a fictitious 28-year-old man with an acute flexor tendon laceration. Insurance status was presented as Medicaid in 1 call and private insurance in the other call. Ability of an office to schedule an appointment was recorded.

RESULTS

Of the 100 practices, 13 were excluded because they did not perform hand surgery, which left 87 practices. The patient in the scenario with Medicaid was offered an appointment significantly less often (67%) than the patient in the scenario with private insurance (82%). The odds of the patient with private insurance obtaining an appointment were 2.2 times greater than the odds of the Medicaid patient obtaining an appointment. The Medicaid patient was more likely not to be offered an appointment owing to the lack of a hand surgeon at a practice (28% of appointment denials) than privately insured patients (13% of appointment denials).

CONCLUSIONS

For patients with acute flexor tendon lacerations, insurance status has an important role in the ability to obtain an orthopedic clinic appointment. We found that patients with Medicaid have more barriers to accessing care for a flexor tendon laceration than patients with private insurance.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

The radial nerve in the brachium: an anatomic study in human cadavers

PURPOSE

To explore the course of the radial nerve in the brachium and to identify practical anatomic landmarks that can be used to avoid iatrogenic injury during humerus fracture fixation.

METHODS

Data were collected from 27 adult cadaveric specimens, including 18 embalmed cadavers and 9 fresh-frozen limbs. Measurements were taken using osseous landmarks to define the relationship of the radial nerve and the posterior and lateral humerus. The extremities were studied further to determine the association of the radial nerve and anatomic landmarks on both longitudinal and cross-sectioned specimens.

RESULTS

A 6.3 cm +/- 1.7 segment of radial nerve was found to be in direct contact with the posterior humerus from 17.1 cm +/- 1.6 to 10.9 cm +/- 1.5 proximal to the central aspect of the lateral epicondyle, centered within 0.1 cm +/- 0.2 of the level of the most distal aspect of the deltoid tuberosity. The radial nerve lay in direct contact with the periosteum in all specimens, without evidence of a structural groove in the humerus in any specimen. On entering the anterior compartment, the radial nerve had very little mobility as it was interposed between the obliquely oriented lateral intermuscular septum and the lateral aspect of the humerus. As it extended distally, the nerve coursed anterior to the humerus and became protected by brachialis muscle at the level of the proximal aspect of the lateral metaphyseal flare.

CONCLUSIONS

The radial nerve is at risk of injury with fractures of the humerus and with subsequent operative fixation in 2 areas. The first is along the posterior midshaft region for a distance of 6.3 cm +/- 1.7 centered at the distal aspect of the deltoid tuberosity. The second is along the lateral aspect of the humerus in its distal third from 10.9 cm +/- 1.5 proximal to the lateral epicondyle to the level of the proximal aspect of the metaphyseal flare. The deltoid tuberosity is a consistent and practical anatomic landmark that can be used to determine the level of the radial nerve along the posterior aspect of the humerus during operative fixation from an anterior approach.

Ulnar and median nerve palsy in long-distance cyclists. A prospective study

BACKGROUND

Although case reports have identified the presence of distal ulnar nerve sensory and motor dysfunction in long-distance cyclists, the actual incidence of this condition, referred to as "cyclist's palsy," is unknown.

PURPOSE

To determine the incidence of distal ulnar nerve compression in cyclists.

STUDY DESIGN

Prospective study.

METHODS

Twenty-five road or mountain bike riders responded to a questionnaire and were then physically examined and interviewed before and after a 600-km bicycle ride.

RESULTS

Twenty-three of the 25 cyclists experienced either motor or sensory symptoms, or both. Motor symptoms alone occurred in 36% of the hands (11 cyclists) tested; no significant difference in the incidence of motor symptoms was found among cyclists of various experience levels or based on handlebar types (mountain bike versus road bike). Sensory symptoms alone occurred in 10% of hands (four cyclists) tested, with the majority of these being in the ulnar distribution. A significantly higher proportion of mountain bike riders had sensory deficits compared with road bike riders; however, there was no significant difference in the occurrence of sensory deficits based on level of experience. A total of 24% of the hands (eight cyclists) tested experienced a combination of motor and sensory symptoms. These motor and sensory symptoms were equally distributed between road bike riders and mountain bike riders and riders of various experience levels.

CONCLUSIONS

Cyclist's palsy occurs at high rates in both experienced and inexperienced cylists. Steps may be taken to decrease the incidence of cyclist's palsy; these include wearing cycling gloves, ensuring proper bicycle fit, and frequently changing hand position.

Needlestick injuries among medical students

BACKGROUND

Concern about occupational exposure to bloodborne pathogens exists, and medical students, who lack in experience in patient care and surgical technique, may be at an increased exposure risk.

METHODS

This prospective cohort study evaluated needlestick injuries and practices regarding the use of protective strategies against bloodborne pathogens in medical students. A questionnaire was developed and sent to 224 medical students.

RESULTS

Of 224 students, 146 students (64%) returned questionnaires. Forty-three students (30%) reported needlestick injuries that most commonly occurred in the operating room; 86% of students reported always using double gloves in the operating room; 90% reported always wearing eye protection, and all but one student had been vaccinated against hepatitis B. A concern about contracting a bloodborne pathogen through work was noted in 125 students, although they usually reported that this concern only slightly influenced their decision regarding a career subspecialty.

CONCLUSION

Medical students have a high risk for needlestick injuries, and attention should be directed to protection strategies against bloodborne pathogens.