Biomechanical Factors in Stability of the Forearm
In the forearm, ligaments and joints act in unison to facilitate placement of the hand in 3-dimensional space and transmit loads across the upper extremity. Intricate, effective forearm stabilizers facilitate physiologic motions and restrict abnormal ones. The proximal radioulnar joint, interosseous ligament complex, and distal radioulnar joint work together to ensure the forearm is stable. Each ligament and joint is designed to leverage its biomechanical advantages. Damage destabilizes the synergy of the forearm and results in debilitating injury patterns. Physicians need to understand how all these structures work togeth...
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Authors: Jorge L. Orbay, Richard A. Cambo Source Type: research

Galeazzi Injuries
Fractures of the radial shaft associated with disruption of the distal radioulnar joint (DRUJ) are termed Galeazzi fractures. These fractures are unstable injuries requiring open reduction and internal fixation of the fracture to achieve optimal outcomes. DRUJ stability should be carefully assessed intraoperatively and addressed accordingly. (Source: Hand Clinics)
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Authors: Rohit Garg, Chaitanya Mudgal Source Type: research

The One Bone Forearm
This article presents experience with creating a one bone forearm in patients using synostosis procedures. (Source: Hand Clinics)
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Authors: Brett Schiffman, Douglas Hanel Source Type: research

Solutions for the Unstable and Arthritic Distal Radioulnar Joint
An unstable and osteoarthritic distal radioulnar joint presents with considerable functional impairment, pain, and weakness in gripping manipulation of objects. A wide variety of surgical alternatives have been described to address these concerns. Resection arthroplasties include different types of distal ulna resection and soft tissue procedures; good overall results have been described for these types of procedures, although they have shown limitations in achieving and maintaining pain relief and stability, especially in more active patients. Since the late 1980s, partial and total joint arthroplasties have emerged as go...
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Authors: Juan Manuel Breyer, Pamela Vergara Source Type: research

Solutions for the Unstable and Arthritic Elbow Joint
An unstable, arthritic elbow presents a therapeutic challenge. Patients may have painful, limited range of motion, often due to trauma or progressive joint destruction from rheumatologic disease. The options for management may be particularly challenging when treating young, active patients. While elbow arthroplasty usually provides predictable pain relief and joint range of motion, concerns exist regarding postoperative activity limitations and implant survival. Therefore, these procedures are limited to select subsets of patients, typically low-demand, elderly patients. Interposition arthroplasty is an option for the you...
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Authors: Danil A. Rybalko, Michael R. Hausman Source Type: research

Problems of Eponymous Proportions
Three predictable patterns of forearm fracture-dislocation —Essex-Lopresti, Monteggia, and Galeazzi—can occur and are eponymously labeled for the investigators who appreciated their unique characteristics and offered a framework by which to understand them. Recognition of these injuries and subsequent investigation and increased understanding of these l esions have resulted in improved understanding about forearm anatomy and stability. Management of the component of instability differs based on the type of fracture-dislocation, the timing of intervention, and surgeon preference. Despite advances in understandin...
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Authors: Anthony L. Logli, Nicholas Pulos Source Type: research

Elbow Fracture-Dislocations
This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur. (Source: Hand Clinics)
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Authors: Timothy J. Luchetti, Emily E. Abbott, Mark E. Baratz Source Type: research

Elbow Instability
Acute elbow dislocations are commonly seen in clinical practice, and attention to management principles and strategies can help facilitate improved outcomes. Patients may present with simple elbow dislocation, in which nonoperative treatment is highly successful. Alternatively, fracture dislocations can be sometimes easily managed but frequently are associated with the need for surgical intervention and operative and postoperative challenges. (Source: Hand Clinics)
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Authors: Julie E. Adams Source Type: research

Title
(Source: Hand Clinics)
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Source Type: research

Copyright
ELSEVIER (Source: Hand Clinics)
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Source Type: research

Contributors
KEVIN C. CHUNG, MD, MS (Source: Hand Clinics)
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Source Type: research

Contents
Julie E. Adams (Source: Hand Clinics)
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Source Type: research

Forthcoming Issues
Treatment of Fingertip Injuries and Nail Deformities (Source: Hand Clinics)
Source: Hand Clinics - October 9, 2020 Category: Orthopaedics Source Type: research

Instability in the Setting of Distal Radius Fractures
Distal radius fractures with severe displacement or concomitant triangular fibrocartilage complex tears may be accompanied by distal radioulnar joint instability. Clinicians should examine the distal radioulnar joint closely when managing wrist fractures and treat coexisting instability appropriately. Chronic instability from distal radius malunion may require osteotomy or radioulnar ligament reconstruction. With proper management, most patients recover forearm stability and rotational motion after distal radius fracture. (Source: Hand Clinics)
Source: Hand Clinics - September 1, 2020 Category: Orthopaedics Authors: Phillip R. Ross, Kevin C. Chung Source Type: research

Management of Monteggia Injuries in the Pediatric Patient
This article reviews the classification, diagnosis, and treatment of acute and chronic pediatric Monteggia injuries as well as the controversies there in. (Source: Hand Clinics)
Source: Hand Clinics - September 1, 2020 Category: Orthopaedics Authors: Tyler C. Miller, Felicity G. Fishman Source Type: research

Management of Monteggia Injuries in the Adult
Monteggia fracture-dislocation of the elbow is a fracture of the proximal ulna with associated dislocation of the radial head or radial neck fracture. In adults, this injury is managed with open reduction and internal fixation of the ulna fracture. Care should be taken to ensure anatomic reduction of the proximal ulna. If radial head dislocation or subluxation persists, reduction of the ulna should be reassessed. Rarely, interposed soft tissue may block radial head reduction, and requires removal. Complications include hardware prominence, stiffness, infection, heterotopic ossification, nerve injury, malunion or nonunion o...
Source: Hand Clinics - September 1, 2020 Category: Orthopaedics Authors: Midhat Patel, Niloofar Dehghan Source Type: research

Rehabilitation of Elbow Instability
This article reviews key concepts that enable the clinician to apply an evidence-informed approach when managing elbow instability. (Source: Hand Clinics)
Source: Hand Clinics - September 1, 2020 Category: Orthopaedics Authors: Joey G. Pipicelli, Graham J.W. King Source Type: research

Chronic Distal Radioulnar Joint Instability
The distal radioulnar joint is inherently unstable, relying primarily on ligaments for stability. Disruption of the joint-stabilizing structures can occur in isolation or concomitantly with osseous trauma. Instability can result from dislocations, fractures, ligament injuries, or malunions. Untreated instability alters wrist and forearm kinematics, leading to pain, weakness, and possibly arthritis. In chronic instability, the native ligaments may not be reparable, necessitating a reconstructive procedure. (Source: Hand Clinics)
Source: Hand Clinics - September 1, 2020 Category: Orthopaedics Authors: Logan W. Carr, Brian Adams Source Type: research

Acute Distal Radioulnar Joint Instability
This article reviews the anatomy and mechanics of pronation and supination (axial rotation) of the forearm through the distal radioulnar joint (DRUJ), and the proximal radioulnar joint (PRUJ). Injuries to the bones and/or ligaments of the forearm, wrist, or elbow can result in instability, pain, and limited rotation. Acute dislocations of the DRUJ commonly occur along with a fracture to the distal radius, radial metadiaphysis, or radial head. These injuries are all caused by high-energy trauma. Outcomes are predicated on anatomic reduction and restoration of stability to the DRUJ and PRUJ with or without ligamentous repair...
Source: Hand Clinics - September 1, 2020 Category: Orthopaedics Authors: Louis H. Poppler, Steven L. Moran Source Type: research

The Essex-Lopresti Injury:
This article describes evaluation and treatment considerations for Essex-Lopresti injuries. Specific information about pattern recognition and treatment options is provided. (Source: Hand Clinics)
Source: Hand Clinics - September 1, 2020 Category: Orthopaedics Authors: Julie E. Adams, A. Lee Osterman Source Type: research

Preface
In the year 2020, the year of this issue ’s publication, we have faced unprecedented challenges to our society, to our patients, and to us as surgeons and health care workers providing musculoskeletal health. The pandemic of COVID-19 has altered all our lives, perhaps for a few months or perhaps permanently. (Source: Hand Clinics)
Source: Hand Clinics - September 1, 2020 Category: Orthopaedics Authors: Julie E. Adams Source Type: research

Introduction
In this issue, experienced and expert authors share their insights on the problems of instability of the forearm. (Source: Hand Clinics)
Source: Hand Clinics - September 1, 2020 Category: Orthopaedics Authors: Julie E. Adams Source Type: research

Hand Infections
Upper extremity infections are common. Most infections can be effectively treated with minor surgical procedures and/or oral antibiotics; however, inappropriate or delayed care can result in significant, long-term morbidity. The basic principles of treating hand infections were described more than a century ago and most remain relevant today. Immunosuppressant medications, chronic health conditions such as diabetes and human immunodeficiency virus, and public health problems like intravenous drug use, have changed the landscape of hand infections and provide new challenges in treatment. (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Ben K. Gundlach, Sarah E. Sasor, Kevin C. Chung Source Type: research

Imaging and Laboratory Workup for Hand Infections
Hand infections can lead to significant morbidity if not treated promptly. Most of these infections, such as abscesses, tenosynovitis, cellulitis, and necrotizing fasciitis, can be diagnosed clinically. Laboratory values, such as white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and recently, procalcitonin and interleukin-6, are helpful in supporting the diagnosis and trending disease progression. Radiographs should be obtained in all cases of infection. Ultrasound is a dynamic study that can provide quick evaluation of deeper structures but is operator dependent. Computed tomographic and MRI stud...
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Colin M. Whitaker, Sara Low, Tetyana Gorbachova, James S. Raphael, Chris Williamson Source Type: research

Antibiotic Management and Antibiotic Resistance in Hand Infections
This article discusses the history, prevalence, and treatment of both community-acquired and health care –associated methicillin-resistant Staphylococcus aureus in regard to hand infections. (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Jessica M. Intravia, Meredith N. Osterman, Rick Tosti Source Type: research

Fingertip Infections
The fingertip is the most common site of infections in the hand, which frequently are encountered by surgeons, dermatologists, and emergency and primary providers. Their mismanagement may have serious consequences. This review discusses the unique anatomy of the volar fingertip pulp and perionychium and reviews pathophysiology and treatment of acute and chronic paronychia, including the decision for surgical versus medical management, choice of antibiotics, incisional techniques, and postincisional care. Felons and the evidence regarding their management are reviewed. Several infectious, rheumatologic, and oncologic condit...
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: James Barger, Rohit Garg, Frederick Wang, Neal Chen Source Type: research

Pyogenic Flexor Tenosynovitis: Evaluation and Management
Pyogenic flexor tenosynovitis is a closed-space infection that can lead to a devastating loss of finger and hand function. It can spread rapidly into the palm, distal forearm, other digits, and nearby joints. Healthy individuals may present with no signs of systemic illness and often deny any penetrating trauma or inoculation. Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function. Many treatment options have been described, although all share 2 common principles: evacuation of the infection and tailored postoperative antibiotic treatment with close monitorin...
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Kanu Goyal, Amy L. Speeckaert Source Type: research

Septic Joints
Infections in the joints of the hand and wrist carry the risk of significant morbidity. Common presenting symptoms include joint redness, swelling, and pseudoparalysis that occurs several days following a penetrating trauma. Diagnostic workup should be expedited, including a laboratory evaluation and arthrocentesis. Imaging, including radiographs, ultrasound, computed tomography, and/or MRI, are helpful tools in diagnosis. Once infection is identified, prompt surgical debridement and antibiotics are required. Once the infection has been managed, hand therapy is initiated to decrease the risk of stiffness. Stiffness is the ...
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Brian Chenoweth Source Type: research

Necrotizing Soft Tissue Infections of the Upper Extremity
Necrotizing soft tissue infections of the upper extremity have varying microbiologies and etiologies. Risk factors for development include diabetes mellitus, intravenous drug use, peripheral arterial disease, smoking, alcohol abuse, and immunocompromised state. Although clinical examination is the mainstay of diagnosis, laboratory tests and imaging can aid in diagnosis. Surgical d ébridements usually are needed for treatment, with resultant defects that often require reconstruction. Rates of amputation are reported as 22% to 37.5% and mortality from necrotizing soft tissue infections of the upper extremity from 22% ...
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Atlee Melillo, Kamal Addagatla, Nicole J. Jarrett Source Type: research

Hand Infections Associated with Systemic Conditions
This article reviews the most common presentation of hand infections for these patients and summarizes current approaches to the management of hand infections for patients with common immunocompromising conditions. (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Zachary J. Finley, Gleb Medvedev Source Type: research

Fungal Infections of the Hand
Clinically significant fungal infections of the upper extremity are uncommon but increasing They are classified based on anatomic location and epidemiology. The anatomic categories that affect the hand include cutaneous, subcutaneous, and deep. Cutaneous infections are caused by organisms that metabolize keratin and can cause serious morbidity but are rarely fatal. Subcutaneous infections are similar to the cutaneous infections and are produced by low virulence organisms. Cutaneous and subcutaneous infections are most common and can be treated by primary care physicians and dermatologists. Deep infections are less common b...
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Mary Patricia Fox, Sidney M. Jacoby Source Type: research

Complications of Hand Infections
Although most hand infections can be eradicated by appropriate management with return to normal function, complications are frequently encountered. Common complications include stiffness, osteomyelitis, and large soft tissue defects that require complex wound management. Risk factors for hand infections include an immunocompromised host state, as is the case in patients with diabetes mellitus or human immunodeficiency virus/AIDS, as well as those on immunosuppressive medications for autoimmune disorders or following organ transplantation. Patients at risk for complications secondary to hand infections should be monitored c...
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Joshua Luginbuhl, Mark K. Solarz Source Type: research

Soft Tissue Coverage for Severe Infections
Coverage of soft tissue defects in the upper extremity caused by infection and debridement of infected tissue is a challenging problem. Treatment starts with prompt identification and eradication of infection, including antibiotics and extensive debridement. Optimizing the patient ’s medical and nutritional status can facilitate eradication of infection and wound healing. Coverage of soft tissue defects caused by infection and debridement demands consideration of many factors. Options include healing by primary or secondary intention, skin grafts, local flaps, and distant f laps. Negative pressure wound therapy and a...
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Vanessa Prokuski, Adam Strohl Source Type: research

Pediatric Hand Infections
Infections are an important source of morbidity in pediatric hands that come from frequent exposure to mouths and other dangers while exploring the world. Although Staphylococcus aureus is still the most common organism in pediatric hand infections, it is less common than in adults because pediatric patients are more likely to develop mixed aerobic/anaerobic infections or group A Streptococcus pyogenes infection. Pediatric patients with open physes potentially may sustain Seymour fractures of the distal phalanges that may become infected and sources for osteomyelitis if not recognized early. (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Joseph F. Styron Source Type: research

Mycobacterial Infections in the Hand and Wrist
Mycobacterial hand infections are uncommon. These infections have an indolent course and are marked by variable and nonspecific presentations, often leading to diagnostic and treatment delays. The pathogens involved in mycobacterial hand infections include Mycobacterium tuberculosis complex, atypical mycobacteria, and M leprae. Initial treatment involves a combination of long-term antibiotics and surgical d ébridement to cure the infection. Reconstructive procedures aid in restoring hand function lost secondary to the disease. (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Abdo Bachoura, David S. Zelouf Source Type: research

Hand Abscesses
This article describes surgical approaches for closed-space infections. Drainage, debridement, and intraoperative irrigation are initial steps along with the decision for continuous postoperative irrigation based on intraoperative findings. Focused and thorough postoperative evaluation and antibiotics lead to successful management of these soft tissue deep abscesses. An experienced hand therapist should be involved early in recovery process to guide wound care along with passive assisted and active range of motion exercises of the wrist and digits. (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Mark S. Rekant, Ryan Tarr Source Type: research

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Prior to the discovery of the penicillin, infectious disease was a leading cause of death in the young and old and in both developed and underdeveloped countries. Since the Great Wars, medical science has evolved treatments that have greatly reduced the burden on humanity and have made it possible to cure many infections. However, as our treatments have evolved, so have microorganisms. Whereas once methicillin-resistant Staphylococcus aureus was confined to rare case reports, community-acquired infections with multidrug resistance have become the most commonly encountered pathogens in some regions and present a new challen...
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: Rick Tosti, John R. Fowler Tags: Preface Source Type: research

Hand Infections
HAND CLINICS (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Authors: John R. Fowler, Rick Tosti Source Type: research

Copyright
ELSEVIER (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Source Type: research

Contributors
KEVIN C. CHUNG, MD, MS (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Source Type: research

Contents
Rick Tosti and John R. Fowler (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Source Type: research

Hand Clinics
Managing Axial Instability of the Forearm (Source: Hand Clinics)
Source: Hand Clinics - June 23, 2020 Category: Orthopaedics Source Type: research

Using Evidence for Hand Surgery
Each step of the evidence-based practice process is critical and requires clear understanding for accurate application. To practice evidence-based care, providers must acquire a specific skillset that facilitates translation of a patient problem into an answerable research question. Additional requirements are understanding of electronic databases, critical appraisal of the available evidence, and integration of the findings to generate a specific, individualized treatment plan. Although this process is demanding, evidence-based practice is essential in the delivery of optimal patient care. (Source: Hand Clinics)
Source: Hand Clinics - April 17, 2020 Category: Orthopaedics Authors: Kristine A. Huynh, Kevin C. Chung Source Type: research

Physician Reimbursement
In 1992, the use of relative value units to link a particular payments with specific services was initiated to replace traditional fee for service. The system incentivizes volume rather than quality. In 1997, initiatives were formalized to emphasize quality measures. Physicians must participate in the Merit-based Incentive Payment System (MIPS). Physicians can opt out of MIPS if they participate in an Alternative Payment Model such as Bundled Payments. Reimbursement based on an episode of care reduces perceived incentive to increase volumes, but may result in difficulty with access to care for patients with complex medical...
Source: Hand Clinics - April 17, 2020 Category: Orthopaedics Authors: Anne J. Miller-Breslow, Noah M. Raizman Source Type: research

Navigating the Intersection of Evidence and Policy in Hand Surgery Practice
Collaboration with organizations beyond the clinical setting is necessary to identify safety hazards that contribute to the high incidence and severity of hand conditions. Hand surgeons are acutely aware of obstacles patients face while navigating the health care system. Advocacy efforts encourage the development of equitable insurance policies and improve health resource allocation so that hand surgeons can treat a larger patient population. Participation in quality initiatives supports the development of evidence-based clinical guidelines. Further evidence must be generated to ensure that surgeons remain proficient in th...
Source: Hand Clinics - April 17, 2020 Category: Orthopaedics Authors: Natalie B. Baxter, Kevin C. Chung Source Type: research

Translating Hand Surgery Evidence to Policy and Practice
Hand surgery researchers should focus on developing high-quality evidence to support the development of health policies affecting surgical care. Policy-makers and leaders of national hand societies can help reduce the variation of care for patients receiving hand surgery by incorporating evidence into guidelines and policies. Comprehensive guidelines for perioperative care help encourage the translation of evidence into practice. Moreover, the identification of institutional-level barriers and facilitators of integration ensures the successful implementation of hand surgery –specific programs. The development of robu...
Source: Hand Clinics - April 17, 2020 Category: Orthopaedics Authors: Jacob S. Nasser, Kevin C. Chung Source Type: research

The Influence of the United States Health Care Environment and Reform on Academic Medical Centers
Academic medical centers (AMC) provide care for most of the underinsured populations of the United States. Their large size and the high acuity of cases make AMCs vulnerable to changes in health care policy. They also are the primary centers for health care research and education and are therefore heavily dependent on federal programs and funding. Since the passage of the Affordable Care Act, AMCs have seen a decrease in the number of patients without insurance. They have also participated in the implementation of alternative payment models, including accountable care organizations, with mixed success. (Source: Hand Clinics)
Source: Hand Clinics - April 17, 2020 Category: Orthopaedics Authors: Lars Matkin, David Ring Source Type: research

How a Nationalized Health Care System Influences Hand Surgery Practice
The United Kingdom ’s health care is provided free at the point of delivery by the National Health Service (NHS). The NHS uses an internal market model to fund health care, as opposed to using a provider-purchaser partnership model. Hand surgery is provided by plastic surgeons and trauma and orthopaedic surgeons. Th e nationalized system has disadvantages and benefits. This environment is heavily cost controlled, with some restrictions on individual practice and associated long waiting times. The advantages include a large population base for research in hand surgery and careful monitoring systems for problems with d...
Source: Hand Clinics - April 17, 2020 Category: Orthopaedics Authors: Daniel Cadoux- Hudson, David Warwick Source Type: research

Evidence-Based Hand Therapy and Its Impact on Health Care Policy
The unique and collaborative relationship between hand therapists and surgeons is invaluable in meeting the unique functional needs of clients with upper extremity conditions and injuries. Current legislative issues and research items that directly affect hand therapy and hand surgery practice include the opioid epidemic, the importance of optimizing function, value-based care, and the expansion of evidence-based medicine to support clinical decisions. This calls for the need for hand therapists to develop and use evidence that can drive policy change and optimize outcomes for clients with upper extremity conditions and in...
Source: Hand Clinics - April 17, 2020 Category: Orthopaedics Authors: Lesley Khan-Farooqi, Ekta Pathare Source Type: research

Access to Hand Therapy Following Surgery in the United States
This article presents views on certain aspects of health care that aide in and those that impede access to hand therapy for patients in the United States, and concludes with a brief glimpse into some ongoing efforts t o improve access for patients. (Source: Hand Clinics)
Source: Hand Clinics - April 17, 2020 Category: Orthopaedics Authors: Jasmine Krishnan, Kevin C. Chung Source Type: research