Published by Springer Verlag
Online ISSN: 1558-9455
Print ISSN: 1558-9447
Thirty minutes after 0.5 cm 3 of 1:1,000 epinephrine injected 
Reports of high-dose epinephrine injections (1:1,000) into fingers.
Accidental finger injections with high-dose (1:1,000) epinephrine is a new and increasing phenomenon. The purpose of this study is to document the incidence of finger necrosis and the treatment for this type of injury. The necessity or type of treatment required for this type of injury has not been established. The literature was reviewed from 1900 to 2005 by hand and by Internet to document all cases of high-dose (1:1,000) finger epinephrine injection. In addition, the authors added five additional cases. There are a total of 59 reported cases of finger injections with high-dose epinephrine, of which, 32 cases were untreated. There were no instances of necrosis or skin loss, but neuropraxia lasting as long as 10 weeks and reperfusion pain were carefully documented. Treatment was not uniform for those who received it, but phentolamine was the most commonly used agent. There is not one case of finger necrosis in all of the 59 reported cases of finger injections with 1:1,000 epinephrine in the world literature. The necessity or type of treatment of high-dose epinephrine injection injuries remains conjecture, but phentolamine is the most commonly used agent in the reported cases, and the rationale and evidence for its use are discussed.
Mean degree of contracture and mean reduction in contracture of MP and PIP joints at baseline and after last injection by primary joints and high or low baseline severity. Individual cords could receive up to three injections; endpoint data are for last injection. MP low severity, ≤50° contracture; MP high severity, >50°; PIP low severity, ≤40°, PIP high severity, >40°. MP metacarpophalangeal joint, PIP proximal interphalangeal joint
Patient satisfaction with CCH compared with placebo. P<0.001 CCH vs placebo for all comparisons. CCH collagenase clostridium histolyticum  
Dupuytren's contracture is a benign fibromatosis of the palmar and digital fascia of the hand of uncertain etiology, resulting in nodules and cords beneath the skin of the palm of the hands that may lead to the development of contractures. Surgical intervention is often considered when metacarpophalangeal (MP) joint contracture is 30° or more, or when there is any degree of proximal interphalangeal (PIP) joint contracture. Collagenase clostridium histolyticum (CCH) is a nonsurgical, minimally invasive enzymatic drug indicated for the treatment of adult patients with Dupuytren's contracture (DC) and palpable cord. CCH has been available for approximately 3.5 years, and postapproval experience indicates that the effectiveness of CCH is equivalent to or better than efficacy observed in clinical trials, as seen by lower injection rates to achieve clinical success. Postapproval experience has shown a risk-benefit profile that favors CCH for patients not indicated for surgery based on current recommendations and shows also that treating earlier-stage vs later-stage joint contracture results in significantly better outcomes on average. Postapproval surveillance reveals a safety profile similar to that observed in clinical trials. Nonserious adverse events are mainly local reactions; tendon rupture, a serious adverse event, is reported rarely in the clinical practice setting and at a lower rate than in clinical trials. Risk Evaluation and Mitigation Strategy (REMS) training is designed to mitigate benefit vs risk to achieve safe and effective use of CCH.
In 1980, William White published a paper "Why I Hate the Index Finger". The National Library of Medicine never indexed it so it has been missing for almost 30 years. It is reprinted here for the benefit of the current generation of hand surgeons.
The average of the change in pinch strength postoperatively for the patients who were treated with each technique. 
The average of the pinch strength as a percentage of the contralateral thumb for each technqiue. 
There are numerous techniques for the surgical management of thumb carpometacarpal (CMC) joint arthritis. The four senior authors of this study employ three such techniques: trapeziectomy with hematoma distraction arthroplasty, hemitrapeziectomy with osteochondral allograft, and ligament reconstruction tendon interposition (LRTI). This study examines the three commonly utilized procedures at a single institution. This study examines the 10-year experience from 1995-2005 with a minimum 3-month follow-up. Disabilities of the arm, shoulder, and hand (DASH) scores, pre-and postoperative pinch strength, and operative time were examined. After approval from the institutional review board of our institution was obtained, all patients treated surgically by three of the senior authors were contacted via mail and phone. Each patient was asked to complete and return a DASH questionnaire. Of the 115 patients treated during that period, 60 participated in this study. Each patient's final postoperative pinch measurement was obtained from occupational therapy and clinic records. This pinch strength was compared to the preoperative pinch and contralateral pinch strength. Lastly, the total operative time for each procedure was obtained from the operative record. The only significant finding in this study was a shorter mean operative time with the trapeziectomy group (76.90 min) and osteochondral allograft group (90.45 min) when compared to the LRTI group (139.00 min; p = 0.001 and p = 0.001, respectively). We found no significant difference between groups in terms of DASH score and pinch strength. There was no difference between the techniques in terms of postoperative pinch strength and patient satisfaction measured by DASH scores. The operative times for trapeziectomy and hematoma interposition as well as the osteochondral allograft were significantly shorter than that of the LRTI. This presents further evidence that potentially, "less is more" in the treatment of thumb CMC arthritis. We used a retrospective study design to evaluate potential differences between the three surgical techniques described above, therapeutic, levels III-IV.
Spiral and comminuted fractures of the metacarpals are rotationally and axially unstable fractures with a tendency to shorten, which in turn causes significant extensor lag and loss of grip strength. We have designed a new, cheap and locally developed method of locked intramedullary nailing of these metacarpal fractures. We are presenting the results of our first 21 patients with 22 fractures treated by closed, fluoroscopically assisted, intramedullary K-wiring with proximal locking done by a specially designed locking pin. This was a retrospective, observational cohort study of all patients with spiral and comminuted fractures of metacarpals with minimum of 1 year of follow-up and average follow-up of 14 months (range, 12 to 26 months). The patients were evaluated clinico-radiologically using range of motion, extensor lag, time to healing, amount of collapse, angulation and rotation and complications. All fractures had healed uneventfully with average time to union being 8 weeks. Average metacarpal shortening was 2.04 ± 0.95 mm, while the average post-operative angulation of the fracture was 4.81° ± 1.7. The metacarpophalangeal range-of-motion recovered almost fully with the average extensor lag being only 5.22° ± 2.42. Other than extensor tendinitis in two patients, there were no other complications. This method is cosmetically appealing, provides stable fixation, avoids periosteal stripping associated with open reduction and is associated with very low complication rate, and thus can be safely and effectively used for the treatment of these difficult fractures.
Seprafilm was initially used successfully as a membrane to reduce abdominal adhesions. Subsequently it was tried in a number of other areas to reduce postoperative scarring. Seprafilm was employed in this study to see if it would reduce postoperative scarring after supraclavicular thoracic outlet decompression for neurogenic thoracic outlet syndrome (NTOS). There were 249 operations for primary NTOS (185) and recurrent NTOS (64). Seprafilm was applied to the nerve roots at the end of each procedure. Diagnosis was established by careful history and extensive physical exam consisting of several provocative maneuvers. Scalene muscle block confirmed the diagnosis. Success rates for primary operations, 1-2 years postoperation were 74% for scalenectomy without first rib resection and 70% for scalenectomy with first rib resection. For reoperations, success rate for scalenectomy and neurolysis after transaxillary rib resection was 78% whereas success rate for neurolysis after supraclavicular scalenectomy was 68%. Seprafilm did not significantly improve overall results compared to our results 15 years ago, although in reoperations there was a trend toward improvement with Seprafilm. Observations in 10 reoperations after use of Seprafilm revealed that there were fewer adhesions between fat pad and nerve roots, making it much easier to find the nerve roots. Recurrence was because of scar formation around individual nerve roots. Seprafilm made reoperations easier by reducing scarring between scalene fat pad and brachial plexus. However, it did not prevent scar tissue forming around the individual nerve roots nor did it significantly lower the failure rate for primary operations. The trend supported the use of Seprafilm in reoperations.
Intensity of immunoperoxidase staining of the arterial wall. Immunoreactivity for nitrotyrosine was marked elevated after 1-and 3-day vibration, compared to non-vibrated, restrained sham groups (sham 1, 3 days). D-4F treatment blocked the increase in nitrotyrosine during vibration (vibration+D-4F). No effect of D-4F was detected on  
Hand-arm vibration syndrome (HAVS) is a debilitating sequela of neurological and vascular injuries caused by prolonged occupational exposure to hand-transmitted vibration. Our previous study demonstrated that short-term exposure to vibration can induce vasoconstriction and endothelial cell damage in the ventral artery of the rat's tail. The present study investigated whether pretreatment with D-4F, an apolipoprotein A-1 mimetic with known anti-oxidant and vasodilatory properties, prevents vibration-induced vasoconstriction, endothelial cell injury, and protein nitration. Rats were injected intraperitoneally with 3 mg/kg D-4F at 1 h before vibration of the tails for 4 h/day at 60 Hz, 49 m/s(2) r.m.s. acceleration for either 1 or 3 days. Vibration-induced endothelial cell damage was examined by light microscopy and nitrotyrosine immunoreactivity (a marker for free radical production). One and 3-day vibration produced vasoconstriction and increased nitrotyrosine. Preemptive treatment with D-4F prevented these negative changes. These findings suggest that D-4F may be useful in the prevention of HAVS.
Although pneumatic tourniquets are widely used in upper extremity surgery, further evidence is needed to support their safe use. Excessive pressure and prolonged ischemic time can cause soft-tissue injury. The purpose of this study was to determine the safety of tourniquet use in a yearlong, consecutive series of patients. A retrospective review of all patients who underwent upper extremity surgery by two board-certified hand surgeons over a 1-year period was performed. Demographic variables, comorbidities, and complications were noted along with tourniquet parameters, including application site, ischemic pressure, and time. A total 505 patients were included in the study because a tourniquet was used during their operation. Patients ranged in age from 3 months to 90 years old (mean 40.1 years). More than half of the population was overweight (mean body mass index (BMI) 27.1), and 77.1 % of adults had at least one cardiac risk factor. No immediate or delayed tourniquet-related injuries were identified. The average operative time was 35.9 min, with an average tourniquet time of 33.1 min. Tourniquet inflation pressure of 250 or 225 mmHg was utilized in 78 and 21 % of adult patients, respectively; no patients had a pressure setting exceeding 275 mmHg. In this series of more than 500 operations, there were no immediate or delayed tourniquet-related events using parameters determined perioperatively by the attending surgeon. Tourniquet pressures of 250 mmHg or less in adult patients with less than 2 h of ischemic time appear to be safe, even in the elderly and patients with multiple medical comorbidities.
Diagram of the modified Brunelli pull-out technique. a The suture is started from the finger pulp. b, c, d The completion of the slipknot. e The suture passes through the distal stump. f The suture is
Modified Brunelli pullout method-technical details. a The uninjured annular pulleys are preserved, but the cruciate pulleys are opened (A2, A4= annular pulleys; the A2 was partial opened) b The suture is started from the finger pulp and then is passed through the proximal stump in a "U" manner at 1-1.5 cm. c The suture is tied over. d The circumferential running suture. e The active mobilization against resistance is started after 48 h
Final result 1 year after surgery: regain of flexion to within less than 3 cm of the distal palmar crease 
FDP disruption of the second digit 2 years postoperative result. a Finger aspect. b , c The degree of functional rehabilitation without flexion/extension deficit 
The reconstruction of the continuity of flexor tendons disruptions in zone II still remains one of the most challenging problems in hand surgery. The ideal repair has to provide sufficient strength and the possibility of early mobilization in the attempt to obtain a functional range of motion. One of the methods which appears to respond to these requests is the pull-out technique described by Brunelli, which moves the tension from the level of the tendon disruption to the finger pulp over the tendon insertion. After using this method, but by doing some modifications of the original technique, our aim was to conduct a retrospective study looking at gap formation, suture strength, rupture rate, efficiency of the two-strand suture repair and of the early active mobilization against resistance in obtaining a good range of flexion rate. We reviewed a series of 71 flexor digitorum profundus disruptions in zone II, in 58 patients admitted in our service between 2000 and 2008, and treated with this method. We achieved a complete range of flexion in 41 fingers (57.7%) and a flexion deficit of 5-10° in eight fingers (11.3%) and of 10-20° in 22 fingers (31%). We had no ruptures, major strength deficit, or bowstringing. Our study demonstrates that, by moving the tension from the level of disruption to the finger pulp, the rehabilitation program can begin very early post surgery. We had 0% ruptures.
Burns to the hand are common in burn victims. These burns often leave complex wounds that require local flaps for coverage. Local flaps are often excluded because they lie within the zone of thermal injury. The purpose of this case report is to report the successful use of a Quaba flap harvested from a previously burned and skin-grafted area. The patient's medical record including pre-operative, intra-operative, and post-operative photographs were reviewed and utilized as sources of data. The patient tolerated the procedure well and was able to return to his previous hand therapy regimen without adverse event and with an acceptable cosmetic result. The Quaba flap can be a safe and effective option for local hand coverage even in previously burned and skin-grafted areas.
Arthrodesis of the distal interphalangeal (DIP) joint is indicated for the treatment of arthritis. While several techniques have been recommended, the use of headless compression screws has grown in popularity. Rates of union reported vary widely, ranging from 80% to 100%, with most studies based on small series. The purpose of this study was to review the outcomes and complications associated with DIP joint arthrodesis using the Herbert headless compression screw in a large case series. The medical charts, surgical reports, and X-rays for patients undergoing DIP joint arthrodesis with a Herbert screw between January 1996 and May 2006 were retrospectively reviewed to determine the frequency and types of complications. All operations were performed by the senior author at a single institution. Of 64 joints in 51 patients that were treated with the Herbert screw, a total of 95% (n = 61) went on to union. Union within 3 months occurred in 89% (n = 57) while delayed union (between 3 and 6 months) occurred in 6% (n = 4). Nonunion requiring subsequent revision arthrodesis occurred in 5% (n = 3). Screw removal for symptomatic hardware was required in 8% (n = 5). Fusion of the DIP joint with the Herbert screw can be achieved at rates that are comparable to other techniques and other headless compressive screws. However, while complications do occur, the Herbert screw provides an acceptable rate of union and ease of operative technique, making it a suitable procedure for DIP joint arthrodesis.
We are reporting our 10-year experience with 68 patients. Sixty-six flaps were of fasciocutaneous type and two were of osteofasciocutaneous type. These flaps were used for volar and dorsal traumatic hand defects, first web space reconstruction, thumb reconstruction, and repair of congenital anomalies. Sixty flaps (88.24%) had complete uneventful take-up. Four flaps developed partial necrosis, whereas four flaps suffered complete necrosis. The single most important factor for flap survival in our experience has been inclusion of at least two perforators to supply the skin pedal. The proximal flap dissection has a learning curve and all of our poor results were in the early part of our experience. We believe that posterior interosseous fasciocutaneous flap (PIF) is a versatile and reliable option for the challenging problems of hand soft-tissue coverage.
Complications in metacarpal fracture treatment increase in proportion to the severity of the initial injury and the invasiveness of the surgical fixation technique. This manuscript evaluates the feasibility of minimizing internal fixation construct size and soft tissue dissection, while preserving the advantages of stable internal fixation in a biomechanical model. We hypothesized that comparable construct stability could be achieved with mini-plates in an orthogonal (90/90) configuration compared with a standard dorsal plating technique. This hypothesis was evaluated in a transverse metacarpal fracture model. Twelve metacarpals were subject to either placement of a 2.0-mm six-hole dorsal plate or two 1.5-mm four-hole mini-plates in a 90/90 configuration. These constructs were tested to failure in a three-point bending apparatus, attaining failure force, displacement, and stiffness. Mean failure force was 353.5 ± 121.1 N for the dorsal plating construct and 358.8 ± 77.1 N for the orthogonal construct. Mean failure displacement was 3.3 ± 1.2 mm for the dorsal plating construct and 4.1 ± 0.9 mm for the orthogonal construct. Mean stiffness was 161.3 ± 50.0 N/mm for the dorsal plating construct and 122.1 ± 46.6 N/mm for the orthogonal construct. Mean failure moment was 3.09 ± 1.06 Nm for the dorsal plating construct and 3.14 ± 0.67 Nm for the orthogonal construct. The dorsal plating group failed via screw pullout, whereas the orthogonal failed either by screw pullout or breakage of the plate. When subject to apex dorsal bending, the orthogonal construct and the standard dorsal plate construct behaved comparably. These data suggest that despite its shorter length, lower profile, and less substantial screws, the orthogonal construct provides sufficient rigidity. This study represents a "proof of concept" regarding the applicability of orthogonal plating in the metacarpal and provides the foundation for minimizing construct size and profile.
The purpose of this study was to evaluate the results of excision of the ulnar slip of the flexor digitorum superficialis tendon, with or without A1 pulley release, for the treatment of trigger finger in diabetic patients. We performed a retrospective review with long-term follow-up examinations. Short-term data was obtained on 18 consecutive patients (37 fingers). Long-term information was collected on 14 of these patients (24 fingers) at an average of 48 months after surgery. Short-term follow-up revealed average proximal interphalangeal joint (PIP) flexion of 81 degrees . One patient had slight residual triggering. At long-term follow-up, 93% of patients were completely or very satisfied with the procedure. Total active finger motion averaged 218 degrees , and PIP extension deficit averaged less than 5 degrees . Pinch strength was equal to the contralateral corresponding finger. There were no significant complications. One finger had minimal residual triggering. In conclusion, this procedure is a safe and effective treatment for the often-difficult problem of stenosing flexor tenosynovitis in the diabetic patient.
Proposed anatomic landmarks for the thumb A1 pulley. DC distal crease, DPC distal-proximal crease, PPC proximal-proximal crease
Exposure of the flexor tendon sheath demonstrating the location of the proximal edge of the A1 pulley. Needles are placed at the various volar creases of the thumb. DC distal crease, DPC distal – proximal crease, PPC proximal – proximal crease 
Dissection of the flexor tendon sheath demonstrates the presence of the variable and oblique pulleys distal to the A1 pulley. A red arrow represents the proximal edge of each pulley, and a black arrow represents the distal edge 
A case demonstrating the percutaneous release of the A1 pulley in a 47-year-old male with intermittent locking of the right thumb. Left the thumb A1 pulley is marked based on the proximal – proximal crease as a 
Triggering of the thumb is a common entity resulting in pain and disability. Operative management requires accurate knowledge of the pulley system for proper release of the A1 pulley. The purpose of this study was to predict the location of the A1 pulley with surface anatomic landmarks while avoiding injury to the neurovascular bundles and the critical oblique pulley. Thirteen fresh cadaveric thumbs were dissected while the volar digital creases of the thumb served as our potential anatomic landmarks for the A1 pulley. These included the distal crease and the two identifiable proximal creases. Measurements from the proximal edge of the A1 pulley to the surface landmarks were obtained. The pulley system was also inspected for variability, and the length of the A1 pulley was measured. Of the three volar creases in the thumb, the proximal-proximal crease (PPC) corresponded anatomically to the A1 pulley and demonstrated minimal variability compared to the other landmarks. It measured 0.10 ± 0.15 cm distal to the proximal edge of the A1 pulley. The average length of the thumb A1 pulley measured 0.61 ± 0.17 cm. Therefore, the distal edge of the A1 pulley is predicted to be located 0.51 cm distal to the PPC. Hand surface landmarks can be used reliably to predict the location of the thumb A1 pulley, thus avoiding injury to adjacent structures such as the critical oblique pulley.
The A2 and A4 pulleys have been shown to be important in finger flexor tendon function. Other authors have suggested either reconstruction or venting of portions of these pulleys in an attempt to preserve finger function in certain clinical situations. This study examines the effects of partial incision of these pulleys on finger flexion kinematics and biomechanics. The index and ring fingers of 16 cadaveric hands were studied. The flexor digitorum profundus tendon was isolated and attached to a computer driven servo-motor. Micro-potentiometers measured flexion angles of the metacarpophalangeal, proximal inter-phalangeal and distal inter-phalangeal joints. Joint inertial torques were calculated making use of this experimental kinematic data. Proximal 50 % incisions of either the A2 or the A4 pulleys resulted in a statistically significant decrease in overall finger motion. This effect was greatest in the proximal inter-phalangeal joint, with a decrease in joint motion, as well as an earlier time to initiation of motion. These changes in finger motion were more pronounced with A2 pulley incision than they were with A4 pulley incision, but the changes were statistically significant in either case. No significant changes in joint inertial torques were shown. Our data provides evidence to the importance of the proximal portions of the A2 and A4 pulleys, and may support partial distal incision of these pulleys in certain clinical situations.
Mechanical properties of A2 pulley.
Mechanical properties of A4 pulley.
Rock climbing has become increasingly more popular in the USA over the past two decades. Accordingly, with increased participation comes an increase in climbing-related injuries. Rooks et al noted that three-quarters of elite and recreational climbers will suffer upper extremity injuries, approximately 60% involving the hand or wrist and 40% divided evenly between the shoulder and elbow. Most of these injures will be strains, microtrauma, and tendonitis; however, 30-50% represent trauma to the proximal interphalangeal region. The purpose of this study was to investigate the biomechanical properties of the A2 and A4 pulley and compare biomechanical properties among gender and digit. A specially designed materials testing machine, shown in the included figure, measured maximum breaking load, displacement and stiffness of the A2 and A4 pulleys of ten cadaveric hands using an S hook to apply a steady force until complete pulley rupture. The A2 and A4 biomechanical properties of breaking load, displacement, and stiffness did not significantly differ among the index, middle, ring, and little fingers. Additionally, there was no significant difference in A2 or A4 pulley biomechanics between male and female specimens. The A2 and A4 pulleys among differing digits and genders have similar biomechanical properties in regards to maximum breaking load, displacement, and stiffness.
Anatomical observations of the extensor apparatus of the fifth digit
The figure shows the anatomical findings. a The most frequent presentation was a bifid EDM and a single EDC V . b In two specimens, the EDC was missing, but a connexus intertendineus was present. The center of the axis of abduction and adduction of the fifth MP joint is marked by a black line. In both cases, the ulnar-most slip of the EDM remained ulnar to the center of the axis of abduction and adduction of the fifth MP joint while the radial-most slip passed over the center of the fifth MP joint  
Functional observations after modification of the extensor apparatus of the small finger
Radialization of the EDM at the level of the fifth MCP joint  
One of several operations to correct abduction deformity of the little finger, (Wartenberg's sign) in ulnar nerve palsy, is a combined procedure that radializes the extensor digiti minimi (EDM) at the level of the fifth metacarpophalangeal (MCP) joint and reroutes it from the fifth to fourth extensor compartment. This cadaveric study was designed to investigate the impact of both elements on adduction. Anatomy of the little finger extensor apparatus was studied in 16 freshly frozen cadaver hands sectioned at mid forearm. We observed little finger motion after different modifications of the EDM. We tested the effect of a rerouting maneuver by pulling on the EDM, as well as radialization of the EDM alone and in combination with rerouting. The EDM was present in all cases. Little finger extensor digitorum communis (EDC(V)) was missing in two cadavers. In no case was adduction created by rerouting the EDM to the fourth compartment. Radialization of the EDM corrected the abduction deformity beyond the axis of abduction/adduction of the fifth MCP joint in 13 cases and only up to it in three cases. In one of the three with limited correction, a rerouting maneuver allowed for further adduction. The key to correct abduction deformity of the little finger is radialization of the EDM, which can be done through a solitary incision at the level of the MCP joint. Rerouting alone does not correct the abduction deformity, and in combination with radialization it does not predictably enhance the correction.
Patient demographic and operative data for the five patients meeting inclusion criteria in the study 
Restoration of shoulder abduction following injury to the brachial plexus is sometimes difficult to achieve in obstetrical brachial plexus palsy and traumatic brachial plexus palsy. Nerve transfers are a recognized treatment option for patients with traumatic brachial plexus injuries [5]. To maximize shoulder function, notably shoulder abduction and external rotation, simultaneous reconstruction of the suprascapular and axillary nerves is often advocated [6, 7]. Nerve transfers permit faster reinnervation of muscle than traditional nerve grafting because the nerve repair can be performed much closer to the neuromuscular junction [9]. Application of nerve transfers in the obstetric brachial plexus palsy-affected population is gaining acceptance and is increasingly practiced along with or in lieu of neuroma resection with autologous nerve grafting [2]. While the triceps branch of the radial nerve to the axillary nerve transfer has been described in the adult patient population, there is a paucity of reports of its effectiveness in restoring shoulder abduction in children. In this report, consecutive cases of triceps to axillary nerve transfer in children performed by a single surgeon are reviewed. These nerve transfers were performed for patients with obstetrical brachial plexus palsy and also for traumatic injuries.
Anatomic variation of the trapeziometacarpal joint stabilizing structures is one of the concepts proposed to explain the pathogenesis of trapeziometacarpal arthritis. We undertook this study to test the hypothesis that septation of the first extensor compartment or variation of the abductor pollicis longus (APL) tendon (supernumerary insertions) are more frequently associated with the progression or severity of trapeziometacarpal arthritis. Septation within the first extensor compartment was significantly associated with trapeziometacarpal arthritis (p = 0.013), whereas supernumerary APL insertions (trapezium or thenar) did not reveal a significant association (p = 0.811 and p = 0.937, respectively). The results of this study do not support a role for variations of APL tendon insertions in trapeziometacarpal arthritis. Yet, the presence of septation within the first extensor compartment may play an important role in the pathogenesis of trapeziometacarpal arthritis.
The presence of aberrant anatomy during a limited-open carpal tunnel release does not require conversion to an open procedure. We describe the occurrence of aberrant anatomy seen during limited-open carpal tunnel release, and suggest the safest way to proceed with carpal tunnel release once aberrant anatomy is encountered. A retrospective chart review was completed for patients who underwent limited-open carpal tunnel release between January 2000 and June 2007. The surgical record was examined to determine if any aberrant anatomy was encountered during the procedure. Of the 1,227 hands operated on, 69 anomalies were identified. Two carpal tunnel releases were converted to open releases after it was determined that the aberrant motor branches precluded safe release with a limited-open technique An understanding of anatomical variations combined with vigilance and careful dissection enhances the chance for safe and effective limited-open carpal tunnel release.
We report two cases resulting in complications following suture ligation treatment for ulnar polydactyly. One case consisted of bilateral, retained gangrene and cellulitis, and a second case consisted of a residual, sensitive skin tag. The case involving gangrene and cellulitis developed after an unsuccessful suture ligation of bilateral pedunculated duplicated digits. The second case developed after suture ligature ablation of a rudimentary digit in the nursery but presented 3 years later with a residual symptomatic nubbin. Both cases were treated by surgical excision of the residual tissue in the operating room. The first case illustrates a morbid complication following unsuccessful ligature while the second case demonstrates the inevitable suboptimal long-term outcome associated with what has traditionally been considered "successful" suture ligation.
a X-ray and photograph of the hands of a child with Ellis-van Creveld syndrome. b Note the polydactyly with an extra small digit on the ulnar side. Several other digits are distorted and the third and fourth metatarsals on the right side are fused. There is also curvature of the fifth metatarsal on the left side
Changes in the nails of the fingers of a patient with nail – patella syndrome. The nails are almost completely absent or markedly ridged and abnormally structured. The skin shows a loss of creases 
Classic changes in the hand of a patient with Marfan ’ s syndrome. The digits are markedly elongated and the digital structure is distorted. The distal radius and ulna region show a V-shaped deformity which leads to the deviation and further limitation of function of the hand 
Almost all forms of the mucopolysaccharidoses show gross distortion of the hand and foot structure. a Shows a child with Hurler syndrome with hepatosplenic enlargement. Note the hand flexion deformities. As noted in the X-ray, the metacarpals and phalanges are 
The hands of children with cartilage-hair hypoplasia show skin and structural alterations consisting principally of short digits often bent. The metacarpals are short, and the carpal bone are poorly structured and calcified
The small bones and soft tissues of the hands and feet can be affected by systemic disorders, and frequently, the findings are quite unique and virtually diagnostic for some genetic or metabolic disorders. Photographs and imaging studies for the hands and feet are available in a digitized system, which has been approved by our hospital institutional review board. Examination of these and their description can establish a relationship with some degree of certainty to a series of highly variable and uncommon clinical disorders. Description of the clinical, physiologic and genetic characteristics, and illustrations of hand and foot abnormalities are provided for an array of diseases, including Ellis-van Creveld syndrome, fibrodysplasia ossificans progressiva, achondroplasia, Kniest dysplasia, pseudo- and pseudo-pseudohypoparathyroidism, acromegaly, nail-patella syndrome, Marfan's disease, cartilage-hair hypoplasia, and several forms of mucopolysaccharidosis. The findings support the concept that many genetic disorders can often be diagnosed by clinical and imaging examination of the patient's hands and feet.
Radiological changes have been described in de Quervain's disease of the wrist. The author analyzed the clinical data of 114 patients who reported to the orthopedic clinic of a Regional Referral Hospital for a period of 4 years [2003 to 2007]. Radiographs of the wrist were available for 39 cases, of which 14 [35.89%] were found abnormal. Two patients with abnormal radiographs [14.28%] required surgery where as 7 out of 25 [28%] with normal radiographs were managed surgically. Radial styloid abnormality was not found statistically significant [p < 0.05], and the outcome of management was irrespective of the changes in the radial styloid.
We report a case of Brodie's abscess of the distal radius that presented 4 years after closed reduction and percutaneous pinning for a closed distal radius fracture. This condition has not been previously reported in the adult distal radius and we detail the clinical features and imaging findings. We also present a new way of management of Brodie's abscess using injectable bone substitute along with adjunctive parenteral antibiotic therapy.
X-ray of right hand and wrist superficial abscess with subcutaneous gas. 
Three looped penrose drains placed to fully drain all extents of abscess. 
Right hand and wrist after removal of penrose loops, with resolution of cellulitis and edema. 
Left long finger felon and paronychia.
Complex superficial abscesses are a common occurrence that traditionally have been treated by making relatively large incisions over the surface of the abscess, in order to ensure drainage and access for packing and dressing changes. The authors outline a minimally invasive technique that can be used for draining complex subcutaneous abscesses that extend over a large surface area. It is a simple technique utilizing multiple small incisions and looped penrose drains. This technique has been found to be very effective in many areas of the body and has multiple advantages over traditional incision, drainage, gauze packing, and dressing changes.
A summary of the variant forms of arthrogryposis.
A 1-year-old boy presented to us with congenital inability to flex his elbow. He had bilaterally absent biceps brachii and brachialis muscles, a rare condition. We performed pedicle latissimus dorsi musculocutaneous flaps to the left and right volar upper arm at 21 and 24 months of age, respectively, to create elbow flexors. By 4 years of age, he had excellent elbow flexion bilaterally with strength grade in excess of 4.5. In addition to discussing our patient's treatment options, we discuss other potential causes of weak elbow flexion when faced with this clinical dilemma.
In this paper, we report a case of a 14-year-old girl with congenital aplasia of the flexor pollicis longus tendon who had no other associated anomalies of thumb hypoplasia and no trauma history. Flexor pollicis longus tendon anomalies are rare; several types of this congenital anomaly have been reported in the literature. The diagnosis should be considered if a patient is unable to flex the interphalangeal joint of the thumb. A hypoplastic thumb or an absent interphalangeal joint crease may be a diagnostic feature in such cases. Besides physical examination, we also used direct radiography and magnetic resonance imaging to diagnose this rare congenital anomaly in our patient.
Reinnervation mechanism of an end-to-side neurotization of the suprascapular nerve to the spinal accessory nerve to restore supra/infraspi- natus function and preserve trapezius function. a In this case, a neuroectomy at the coaptation site of the spinal accessory nerve was created in order to acquire reinnervation by the motor fibers. b In addition, an axonotmetic injury was created proximal to the end-to-side neurotization through a compression to induce reinnervation of the suprascapular nerve. c Wallerian degeneration proceeds distal to the axonotmetic injury following the compression. d Afterwards, axonal regeneration proceeds through the native donor and into the recipient pathway through the end-to-side repair. The LABC graft was measured at 3 cm for this case. 
Restoration of elbow flexion 5.5 years following end-to-end neurotization of the ulnar nerve (flexor carpi ulnaris fascicle) to the brachialis nerve and median nerve (flexor carpi radialis fascicle) to the biceps branch of the musculocutaneous nerve. a Normal flexion on the unoperated left side is observed with a 25-lb weight. b Restoration 
Five years and 6 months following an end-toside neurotization of the suprascapular nerve to the spinal accessory nerve and end-to-end neurotization of the triceps branch to the axillary nerve on the right side. a At rest, the patient does not demonstrate scapular winging on the previously injured right side. b Restoration of the deltoid and supra/ infraspinatus is evident with the ability to abduct the right arm to 180° without weights. In addition, hypertrophy of the lower trapezius is seen on the right side with proper scapular stabilization. c To determine the extent of these functional outcomes, the patient demonstrates proficient abduction to 180° with a 5-lb weight. d Flexion was also examined and the patient was able to flex both arms to their full range of motion of 180° without weights. e With a 5-lb weight, the patient was able to demonstrate proper flexion to 180° on the left side. f In comparison, on the right side with a 5-lb weight, the patient was only able to flex to approximately 120°.
Unlabelled: The use of end-to-side neurrorhaphy remains a controversial topic in peripheral nerve surgery. The authors report the long-term functional outcome following a modified end-to-side motor reinnervation using the spinal accessory to innervate the suprascapular nerve following a C5 to C6 avulsion injury. Additionally, functional outcomes of an end-to-end neurotization of the triceps branch to the axillary nerve and double fascicular transfer of the ulnar and medial nerve to the biceps and brachialis are presented. Excellent functional recoveries are found in respect to shoulder abduction and flexion and elbow flexion. Electronic supplementary material: The online version of this article (doi:10.1007/s11552-009-9242-3) contains supplementary material, which is available to authorized users.
Intraoperative views. a Microsurgical dissection prior to division of XI at its distal bifurcation; b completed repair with fibrin glue. XI spinal accessory nerve; SCM sternocleidomastoid muscle; SS suprascapular nerve; P phrenic nerve; UT upper trunk. 
Miami shoulder classification.
Effect of patient age at time of transfer on clinical and functional outcome.
The purpose of this study is to evaluate the value of distal spinal accessory nerve (SAN) transfer to the suprascapular nerve (SSN) in children with brachial plexus birth injuries in order to better define the application and outcome of this transfer in these infants. Over a 3-year period, 34 infants with brachial plexus injuries underwent transfer of the SAN to the SSN as part of the primary surgical reconstruction. Twenty-five patients (direct repair, n = 20; interposition graft, n = 5) achieved a minimum follow-up of 24 months. Fourteen children underwent plexus reconstruction with SAN-to-SSN transfer at less than 9 months of age, and 11 underwent surgical reconstruction at the age of 9 months or older. Mean age at the time of nerve transfer was 11.6 months (range, 5-30 months). At latest follow-up, active shoulder external rotation was measured in the arm abducted position and confirmed by review of videos. The Gilbert and Miami shoulder classification scores were utilized to report shoulder-specific functional outcomes. The effects of patient age at the time of nerve transfer and the use of interpositional nerve graft were analyzed. Overall mean active external rotation measured 69.6°; mean Gilbert score was 4.1 and the mean Miami score was 7.1, corresponding to overall good shoulder functional outcomes. Similar clinical and shoulder-specific functional outcomes were obtained in patients undergoing early (<9 months of age, n = 14) and late (>9 months of age, n = 11) SAN-to-SSN transfer and primary plexus reconstruction. Nine patients (27%) were lost to follow-up and are not included in the analysis. Optimum results were achieved following direct transfer (n = 20). Results following the use of an interpositional graft (n = 5) were rated satisfactory. No patient required a secondary shoulder procedure during the study period. There were no postoperative complications. Distal SAN-to-SSN (spinoscapular) nerve transfer is a reliable option for shoulder reinnervation in infants with brachial plexus birth injuries. Direct transfer seems to be the optimum method. The age of the patient does not seem to significantly impact on outcome.
The objective of this paper was to biomechanically investigate rotational stability of the thumb after ulnar collateral ligament (UCL) and accessory collateral ligament (ACL) disruption and repair at the metacarpal joint of the thumb. Twelve fresh frozen adult cadaveric thumbs were used. The torsion test was performed under constant rotation of 1/s through 30 arc of metacarpal phalangeal (MCP) joint. The torsional resistance was determined for four categories: first no intervention of the UCL structures (control), next with the proper UCL cut at the distal insertion, then with the additional ACL ligament cut, and lastly with the repair of only the proper UCL. The decrease on the amount of torsional rigidity for each of the last three categories was determined and compared. Each thumb was used as its own control. Significance of the differences in each test categories was statistically determined. After the proper UCL was cut, the torsional rigidity of the MCP joint was reduced 35.18 +/- 17.56% (p < 0.001). When, additionally, the ACL was cut, the torsional rigidity of the MCP joint was further reduced to 49.34 +/- 16.82% (P < 0.001). After repair of only the proper UCL, the torsional rigidity of the MCP joint improved, but still showed a considerable reduction from controls. The amount of reduction was not consistent among specimens and was 13.52 +/- 16.40%. The ACL ligament is a contributor of rotary stability as well as a provider of lateral stability. Leaving the ruptured ACL unrepaired causes some residual rotating instability and that may lead to future rotational instability of the MCP joint.
Anomalous muscles usually do not cause symptoms but are of academic interest mainly discovered during cadaveric dissection. An aberrant muscle belly arising from the index finger flexor digitorum superficialis tendon causing carpal tunnel syndrome is rare. The management of such an anatomical variant is dependent on whether the median nerve compression is associated with a palpable mass. A brief case highlighting important management principles along with a complete literature review is reported.
The consequences following work-related injuries are far reaching, which are in part due to unrecognized and untreated posttraumatic stress disorder (PTSD). Imaginal exposure is a frequently used cognitive behavioral approach for the treatment of PTSD. This study examined the impact of early versus delayed treatment with imaginal exposure on amelioration of PTSD symptomatology in individuals who suffered upper extremity injuries. Sixty individuals who suffered severe work-related injuries received standard, non-randomly assigned psychological treatment for PTSD (e.g., prolonged imaginal exposure) either early (30-60 days) or delayed (greater than 120 days) following severe work-related upper extremity injury. Nine measures of various components of PTSD symptomatology were administered at onset of treatment, end of treatment, and at 6-month follow-up evaluations. Patients showed significant treatment outcomes at all three measurement intervals in both the early and delayed groups demonstrating that Prolonged Imaginal Exposure is an appropriate treatment for persons diagnosed with PTSD. In addition, there was no difference in return to work status between the early and the delayed treatment groups. However, the early treatment group required significantly fewer treatment sessions than the delayed treatment group. Results supported the utility of imaginal exposure and the need for early assessment and referral for those diagnosed with PTSD following upper extremity injuries.
Water-filled sphere, effect of transillumination with penlight
Ink-filled sphere, opaque with penlight
Spheres placed subcutaneously on hand dorsum
The aim of this study was to assess the accuracy and intraobserver reliability of the technique of penlight transillumination of simulated hand tumors as well as the rationale for the technique. Eight observers examined small (9.5 mm) plastic spheres in a fresh frozen cadaveric human hand 3 weeks apart in a blinded manner. The observers were divided into two overall groups based on their level of training. Four spheres simulating hand tumors (two dorsal and two palmar) were placed subcutaneously. The spheres were known to either transilluminate or to be opaque. The observers noted their impression as to whether the spheres either did or did not transilluminate. Accuracy and multi-rater-kappa-statistical analysis were performed. The overall accuracy was 87.5%: 95% for senior group, 81% for junior group (P = .388, not significant). The average kappa of the intraobserver reliability overall was 0.46. The senior group had a kappa value of 0.67 (substantial agreement), the "junior" group: 0.25 (fair agreement). Accuracy at correctly determining whether or not a small hand tumor transilluminated was high. The senior group was more accurate overall in correctly determining transillumination, though not with statistical significance. Intraobserver reliability was high for the senior group and less robust for the junior group.
Hand strength comparison at 18 months follow-up after resection and reconstruction of recurrent first dorsal web space melanoma.
Oncologic defects of the hand can be problematic for the reconstructive surgeon. These defects may require a delay in definitive coverage until clear margins of resection can be obtained, which can result in a prolonged period of painful dressing changes and increased risk of soft-tissue infection. In addition, reconstructive options for oncologic defects are often limited to skin grafting, which can yield functional deficits secondary to contracted healing. Currently, there is no definitive method for preventing skin graft contracture; however, acellular dermis has been proposed as a biomechanical scaffold to enhance subsequent skin graft healing and slow this functionally debilitating process. Here, we present a patient with recurrent melanoma of the first dorsal web space. After re-resection of the melanoma, the 11 cm x 5 cm defect was reconstructed using acellular dermis as temporary coverage to allow ample time for permanent section results. Ten days later, after confirming negative margins of resection, a split-thickness skin graft (STSG) was applied over the vascularized neo-dermis. Follow-up clinical examination and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires were used to assess outcome. At 7 months, the patient had no recurrence of melanoma and a DASH functional reduction of only 6.9%. After approximately 18 months, the patient's wounds had healed with excellent cosmetic and functional results, without any evidence of a web space contracture. These observations suggest that acellular dermis is a useful adjunct for wound coverage of the hand, particularly in areas of functional importance, such as the first dorsal web space.
The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. The authors of the material are military service members. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.
Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause for patients to present to a physician's office or emergency department. We observed increasing numbers of community-acquired MRSA infections in patients admitted to the hand surgery service at our suburban academic center. It is an important issue as unsuspected community-acquired MRSA hand infections can be admitted to the hospital, inadequately treated, and allowed for nosocomial spread. This study was performed to examine the trend in the incidence of community-acquired MRSA infections in patients admitted to the hand surgery service in order to sensitize practitioners to have a high index of suspicion for this entity and promote early recognition and treatment of this organism. A multihospital retrospective chart review was undertaken to compare the total number of community-acquired MRSA infections in our hospital as well as the number in patients admitted to the hand surgery service with community-acquired MRSA from 2000 through 2008. Statistical analysis was provided by linear regression. Two community-acquired hand MRSA infections were treated in 2000, as compared to three in 2001 and 2002, four in 2003, five in 2004, six in 2005, 14 in 2006, 13 in 2007, and ten in 2008. This increase was statistically significant (p = 0.038). This retrospective review documents a rapidly rising number of community-acquired MRSA hand infections in the suburban environment. The hand surgeon must be aware of the increased prevalence of this entity to adequately combat this organism and prevent prolonged hospital stays, expanded morbidity, and inflated treatment costs.
Anteroposterior view of the right shoulder revealed a displaced mid-shaft fracture of the clavicle and a type-V dislocation of the AC joint, according to Rockwood classification 
Rockwood classification of acromioclavicular joint injuries
Reconstruction of the CC ligaments with the TightRope system (Arthrex). The device is composed by two metal buttons, one circular and one oblong, joined by a No 5 fiber-wire continuous loop. As sole fixation device it is recommended only for an acute injury 
Postoperative anteroposterior view of the right shoulder demonstrated union of the fracture and excellent reduction of the CC interval and the AC joint
The AC joint is surrounded by a thin capsule that is reinforced by superior, inferior, anterior, and posterior AC ligaments. AC stability is also reinforced by the CC ligaments (conoid and trapezoid) 
Injuries around the clavicle are quite common. Furthermore, AC joint dislocation combined with fracture of the distal end of the clavicle are quite frequent and well recognized [13]. However, the specific combination of ipsilateral fracture of the mid-shaft clavicle with AC joint dislocation is a rare injury, and there have been only five reports (eight cases) in the literature [6, 8, 22–24]. To our knowledge, there have been no published study in the English literature for the treatment of this unusual ipsilateral shoulder injury with the use of a TightRope fixation system in reconstructing the AC joint dislocation combined with open reduction and internal fixation of the clavicle fracture with a locking plate.
Compartment syndrome is a condition with multiple reported etiologies, and permanent disability may ensue if not treated in a timely fashion. We report the first case, to our knowledge, of acute forearm compartment syndrome caused by intravenous autologous blood reinfusion. The patient underwent forearm fasciotomy, and hematoma was encountered deep to the superficial volar fascia, presumably extravasated from the reinfusion catheter. With the rise in the number of knee and hip arthroplasties, surgeons need a heightened awareness of the possible complications and morbidity associated with a presumed increase in autologous blood reinfusion.
With the tendon end delivered from the wound, a running suture arcade is placed that will be run through the EndoButton and then tied. 
Patient results: range of motion, strength, and outcome scores.
Final construct with tendon fed through a unicortical radial trough ( a ). Anteroposterior ( b ) and lateral ( c ) radiographs demonstrating the EndoButton is anchored outside the far cortex of the radius. 
Statistical analysis of subjective and objective measures between subgroups.
There are many ways to repair distal biceps tendon ruptures with no outcome studies demonstrating superiority of a specific technique. There are few studies reporting on the repair of acute and chronic distal biceps tendon ruptures using the EndoButton via an anterior single-incision approach. We report on 27 patients who underwent distal biceps tendon repair with an EndoButton. The average age was 50.1 years (range, 36-78). There were 17 acute repairs (within 4 weeks of injury), nine chronic repairs (greater than 4 weeks), and one revision of a previous acute repair. All chronic repairs were repaired without the need for graft augmentation. Patients were assessed postoperatively using the ASES elbow outcome instrument and isokinetic flexion and supination strength and endurance testing. Eight control subjects were also tested for comparison. At an average follow-up of 30.9 months, 26 of 27 patients returned to their previous employment and activity level. The average ASES elbow score was 98.2 (range, 81-100). Compared with the contralateral extremity, there was no loss of motion. Average flexion strength recovery was 101% and mean supination strength recovery was 99%. There was no significant difference in function or strength with repair of acute versus chronic ruptures. Using the EndoButton technique, acute and chronic distal biceps tendon ruptures can be repaired safely with excellent clinical results.
Progression of SEQES scores 1988-2008.
Percent of patients achieving union with operative versus non-operative management (based on weighted means). 
The purpose of this review was to assess the current evidence supporting operative fixation versus casting for acute scaphoid fractures through a systematic review and meta-analysis of the literature. Our search yielded 59 articles that met our inclusion criteria with five studies achieving high, 22 moderate, and 32 low Structured Effectiveness Quality Evaluation Scale scores. Pooled results of the four Sackett level 1 evidence studies showed no significant difference between the operative (114/115, 99%) versus non-operative group (106/112, 95%) (p = 0.07) when the definition of nonunion was based on more definitive criterion versus plain radiographs that may be insufficient to assess bony union. Similar results were found for the Sackett level 2 and 4 articles. This systematic review reveals that significant weaknesses exist in the literature with respect to the level of evidence and quality of published studies on this topic. Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures.
Acute calcific tendinitis (ACT) is a relatively uncommon disorder of the hand and wrist. ACT is a well-known condition of the shoulder, but it often goes unrecognized when occurring in the hand or wrist. The overall lack of familiarity along with the non-specific symptoms associated with ACT frequently leads to misdiagnosis or delay in diagnosis. We report a case of acute calcific tendinitis occurring in the carpal tunnel which is a rare presentation.
Exploration of the carpal tunnel revealed fresh blood and blood clot was seen in the carpal tunnel 
Carpal tunnel syndrome is a common compression neuropathy of the median nerve. Acute carpal tunnel syndrome (aCTS) is rare, associated with a variety of conditions. In this case report we present a patient who developed aCTS and volar forearm compartment syndrome after a radial artery line placement, while receiving intravenous heparin. The patient underwent immediate forearm fasciotomy and surgical release for restoration of nerve function, which resulted in improved hand function and mild residual median nerve neuropathy. There is controversy whether to discontinue or not anticoagulation in a patient with aCTS. In our patient, heparin therapy was restarted on the second postoperative day.
A patient with subungual hemorrhage, hemosiderin staining, and mild onycholysis. No acute paronychia is present. 
The left middle finger demonstrates hemosiderin staining, onycholysis, a subungual abscess, and erythema indicative of more invasive infection. 
The volar aspect of the finger demonstrates erythema and a loss of DIP flexion crease because of swelling. 
Patient in Fig. 2 shown 18 months after surgical treatment. Taxane therapy has not been interrupted and spontaneous resolution of the subungual dystrophy has occurred. 
Breast cancer now affects 1 in 8 American women and the taxane agent paclitaxel (Taxol Bristol-Myers Squibb) is a major tool in the treatment of many such patients. Hand surgeons are therefore likely to encounter upper extremity complications related to the use of taxane therapy. We present an unusual case of a felon developing in a breast cancer patient on paclitaxel therapy with no antecedent history of trauma. Whereas onycholysis and subungual hemorrhage are reported complications of taxane therapy (Fig. 1), an acute felon with or without associated paronychia is an unusual and more aggressive manifestation of this drug-related nail dystrophy.
Boston carpal tunnel questionnaire scoring for Group A and Group B 
Acute carpal tunnel syndrome (CTS) is a complication that can develop after distal radius fractures. Our hypothesis tested whether patient-reported outcomes after acute carpal tunnel release (CTR) performed in combination with distal radius fracture open reduction internal fixation (ORIF) are worse than patient-reported outcomes with only elective CTR as measured by the symptom severity and functional status scales of the Boston carpal tunnel questionnaire (BCTQ). A retrospective assessment identified 26 patients treated with acute CTR at the same time as distal radius ORIF, no history of pre-existing CTS or CTR, no other injuries, and >12 months follow-up. Sixteen of these patients (Group A) could be contacted and answered the BCTQ. Group A was age- and sex-matched to control patients (Group B) treated with only elective CTR. A case-control study was performed comparing outcomes of both groups. The average age of patients was 51 ± 15 years, with an average follow-up of Group A at 49 ± 21 months versus Group B at 55 ± 20 months. The mean symptom severity scale score for Group A was 1.4 ± 0.4 and for Group B was 1.4 ± 0.4. The mean functional status scale score for Group A was 1.4 ± 0.5 and for Group B was 1.3 ± 0.4. The mean total BCTQ score for Group A was 26.5 ± 7.5 and for Group B was 24.9 ± 7.5. There were no statistical or clinically significant differences between Group A and Group B for symptom severity, functional status, and total BCTQ scores. Patients with acute CTR performed at the same time with distal radius ORIF do as well in the long-term as those patients with only elective CTR as measured by the BCTQ. Patients should expect similar recovery of subjective nerve function from acute median nerve dysfunction when CTR is performed with distal radius ORIF as patients with only elective CTR.
Anteroposterior (a), oblique (b), and lateral (c) injury radiographs of a comminuted distal radius fracture with a concomitant unstable metaphyseal distal ulna fracture. Note the sigmoid notch and distal radioulnar joint involvement, and the palmar-rotatory displacement of the ulna articular head fragment. One year postoperative anteroposterior (d), oblique (e), and lateral (f) radiographs demonstrate osseous union. There is no evidence of ulnar stump instability, radioulnar impingement, or carpal translocation following the distal ulna resection.
Optimal acute management of the highly comminuted distal ulna head/neck fracture sustained in conjunction with an unstable distal radius fracture requiring operative fixation is not well established. The purpose of the present study was to determine the clinical, radiographic, and functional outcomes following acute primary distal ulna resection for comminuted distal ulna fractures performed in conjunction with the operative fixation of unstable distal radius fractures. Between 2000 and 2007, 11 consecutive patients, mean age 62 years (range, 30-75) were treated for concomitant closed, comminuted, unstable fractures of the distal radius and ulna metaphysis. All 11 patients underwent distal ulna resection through a separate dorsal ulnar incision with ECU tenodesis following surgical fixation of the distal radius fracture. According to the Q modifier of the Comprehensive Classification of Fractures, there were six comminuted fractures of the ulnar neck (Q3) and five fractures of the head/neck (Q5). Operative fixation of the distal radius fracture included volar plate fixation in four patients and spanning external fixation with supplemental percutaneous Kirschner wires in seven patients. At a mean of 42 months (range, 18-61 months) postoperatively, clinical, radiographic, and wrist-specific functional outcome with the modified Gartland and Werley wrist score were evaluated. At latest follow-up, mean wrist range of motion measured 53 degrees flexion (range, 35-60 degrees), 52 degrees extension (range, 30-60 degrees), 81 degrees pronation (range, 75-85 degrees), and 77 degrees supination (range, 70-85 degrees). Mean grip strength measured 90% of the contralateral, uninjured extremity (range, 50-133%). No patient had distal ulna instability. Final radiographic assessment demonstrated restoration of distal radius articular alignment. According to the system of Gartland and Werley as modified by Sarmiento, there were seven excellent and four good results. No patient has required a secondary surgical procedure. Acute primary distal ulna resection yields satisfactory clinical, radiographic, and functional results in appropriately selected patients and represents a reliable alternative to open reduction and internal fixation when anatomic restoration of the distal ulna/sigmoid notch cannot be achieved. Primary distal ulna resection with distal radius fracture fixation may help avoid secondary procedures related to distal ulna fixation or symptomatic post-traumatic distal radioulnar joint arthrosis.
a Lateral and b oblique radiographs of the right hand showing a dislocation of the fourth and fifth CMC joints without any associated fractures
a Lateral and b oblique radiographs of the right hand in a dorsal splint after closed reduction of the fourth and fifth CMC dislocations showing good alignment of the CMC joints
a Lateral and b oblique radiographs of the right hand 8 months after the CMC dislocation. Anatomical alignment has been maintained
PA radiograph of the right hand 8 months after the CMC dislocation showing the focus of the metacarpal cascade lines ( single red lines ) to a common spot in the distal radius and also the intact M- line ( double red line ) through all five CMC joints, indicating an anatomic position of the CMC joints 
PA radiograph of the right hand. The metacarpal cascade lines do not focus to a common point, demonstrating a CMC 4 – 5 dislocation ( single red lines ). The break in the M-line also emphasizes a CMC 4 – 5 dislocation ( double red line ) 
Dislocations of the ulnar carpometacarpal (CMC) joints are uncommon injuries. Initially, the injury is often overlooked or not found as an injury at all. Most cases presented in the literature advocate reduction with operative stabilization to prevent secondary dislocation. We present four cases of acute fourth and fifth CMC dislocations treated conservatively by closed reduction and splint immobilization.
Top-cited authors
Donald H Lalonde
Martin LeBlanc
  • Dalhousie University
Julia K Terzis
  • NYU Langone Medical Center
Neal Chen
  • Philadelphia Hand Center P.C.
Wasim S Khan
  • University of Cambridge