The Journal Of Hand Surgery

Published by WB Saunders
Online ISSN: 0363-5023
Publications
Article
A 41-year-old, right-handed woman presented with thumb pulp swelling of 48 hours duration and increasing pain. The swelling had begun 1 day after she punctured the ungloved right thumb pulp with a thorn as she was trimming roses. Physical examination showed a firmly swollen, red, tender, and warm thumb pulp. Thumb interphalangeal joint flexion was slightly limited by pain but no pain was present over the flexor sheath. X-ray films showed soft tissue swelling but no foreign body or bone changes. The patient was treated for felon by incision and drainage, oral cephalosporin, and soaks. Cultures grew Staphylococcus aureus; a fungal stain was negative. The wound remained inflamed, and a retained thorn was suspected. A computed tomography (CT) scan was contemplated, but ultrasound examination was chosen to rule out a thorn in the thumb pulp. A 10-MH linear array transducer was used (Acoustic Imaging, Phoenix, AZ). Ultrasound examination revealed a .5 mm object anterior to the distal phalanx in the depths of the thumb pulp radially (Fig. 1). The patient was taken to the operating room where the thorn was located using the ultrasound probe placed in a sterile plastic bag. A linear incision down to the distal phalanx palmar radial cortex was made under 3.5-1oupe magnification. Small amounts of inflamed and hem
 
Article
Autogenous interpositional microarterial grafting of 140 saphenous branches of albino rat femoral arteries with an external diameter of 0.3 to 0.5 mm (mean 0.45 +/- 0.06 mm) resulted in an immediate patency rate of 100%. The patency rate observed at 72 hours was 64.3%. The late patency rate was related to blade tip pressure of the double approximator clip used in the microanastomosis. The patency rate with a clip with a blade tip pressure of 22 gm was 52.7% and that with a clip with a blade tip pressure of 2 gm was 77.3%. When arterial occlusion lasted less than 30 minutes, the late patency rate was 76.9% to 78.3%. If arterial occlusion lasted for as long as 1 hour, the late patency rate of vessels occluded by a clip with a blade tip pressure of 22 gm dropped to 27.8%. These results demonstrate that an interpositional microarterial graft as small as 0.5 mm in external diameter is clinically feasible.
 
Preprocedure photographs of hand with Dupuytren contracture affecting the index PIP joint and ring finger MP and PIP joints. Patient is attempting full active extension of fingers.  
After needle aponeurotomy photographs of hand: index and ring fingers released.  
Fasciotomy Recurrence Rates
Fasciectomy Recurrence Rates
Article
To critically review the efficacy, recurrence rate, and complications of needle aponeurotomy (NA) for the treatment of Dupuytren contracture. This was a retrospective study of the results of NA for the treatment of Dupuytren contracture. We included in the study all patients who had NA performed for metacarpophalangeal (MP) or proximal interphalangeal (PIP) joint contracture of 20° or greater between March 2005 and May 2008. There were 474 patients with 1,013 fingers treated. The average age was 62 years (range, 33-92 y). Pre-procedure MP joint contracture averaged 35° (range, 15° to 95°), and PIP joint 50° (range, 15° to 110°). Immediately postprocedure and at least 3 years after treatment (range, 3.0-6.2 y), we measured MP and PIP joint contractures and reviewed records for complications. MP joint contractures were corrected an average of 99% and PIP contractures an average of 89% immediately postprocedure. At final follow-up, 72% of the correction was maintained for MP joints and 31% for PIP joints. The difference between the final corrections for MP versus PIP joints was statistically significant. When we compared the final results of patients age 55 years and older versus under 55 years, we found a statistically significant difference at both MP and PIP joints, with greater correction maintained in the older group. Gender differences were not statistically significant. Needle aponeurotomy provided successful correction to 5° or less contracture immediately postprocedure in 98% (791) of MP joints and 67% (350) of PIP joints. There was recurrence of 20° or less over the original postprocedure corrected level in 80% (646) of MP joints and 35% (183) of PIP joints. Complications were rare except for skin tears, which occurred in 3.4% (34) of digits. This study shows that NA is a safe procedure that can be performed in an outpatient setting. The complication rate was low, but recurrences were frequent in younger patients and for PIP contractures. Therapeutic IV.
 
Article
A review of 1,000 radial artery cannulations performed over a 2-year period showed that, with careful selection of patients, by means of the Allen test and Doppler studies, and with the apparatus used, only two serious complications were encountered; embolectomy was necessary in one and arterial reconstruction in another. Twenty-four percent of patients had evidence of diminution of flow, but in none did it persist for more than 2 weeks. Critical factors in reducing complications were a short period of cannulation, use of a Teflon catheter, and a continuous arterial line flush system.
 
Article
To describe the configuration of the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), including the location of the perforators, and to discuss the clinical use of the 1,2 ICSRA for vascularized bone grafting of scaphoid nonunions. Thirteen fresh-frozen cadaveric forearms were used to evaluate the variations in the anatomy of the 1,2 ICSRA. After injection of red latex, the 1,2 ICSRA and its perforators were characterized and measured. Pedicle length and distal reach of the transposed 1,2 ICSRA pedicle was evaluated. We noted the relationship of the 1,2 ICSRA to the dorsal scaphoid branch of the radial artery. Another 10 specimens were injected, frozen, and sectioned to evaluate vascular penetration into the dorsal distal radius. The 1,2 ICSRA branched from the radial artery 1.9 mm proximal to the tip of the radial styloid (range -6.3-3.2 mm), on average. The average pedicle length was 22.5 mm (range 15-31 mm), which permits its application for both dorsal and volar scaphoid. The relationship between the origin of the 1,2 ICSRA and the dorsal scaphoid branch was categorized into 3 types, including--separate, combined, and shared. The average number of perforating vessels arising from the pedicle was 5.5 (range 3-7), with an average of 2.75 (range 1-7) perforators overlying a 1 by 0.5 cm block of the distal radius bone graft. A graft located between 8-18 mm proximal to the articular surface of distal radius would incorporate the greatest numbers of perforators. The most notable vascular penetration of the distal radius was demonstrated at 10.0 mm proximal to the radial styloid. The detailed anatomy of the 1,2 ICSRA presented in this study may guide in planning and dissection to maximize the vascularity of a pedicled bone graft based on this vessel for the management of scaphoid nonunions.
 
Article
Fourteen patients with established scaphoid nonunion were treated with vascularized pedicle bone grafting. All nonunions healed at a mean of 11.1 weeks (range, 8-16 weeks). Wrist motion was minimally affected by surgery. Intercarpal and scaphoid angles were improved after surgery, particularly in patients with preoperative humpback deformity who had previous interposition grafting. Outcome, based on a self-assessment questionnaire administered at a mean 30 months of follow-up (range, 19-53 months), showed 2 excellent, 7 good, 4 fair, and 1 poor result. Three patients showed progressive radioscaphoid arthrosis. Vascularized bone grafts are indicated in proximal pole fracture nonunions, in the presence of avascular necrosis, and after conventional grafts. Radiocarpal arthritis, if present before surgery, is a poor prognostic sign.
 
Article
Over the past decade vascularized bone grafts that use a 1,2-intercompartmental supraretinacular artery (1,2-ICSRA) pedicle have gained popularity in the treatment of scaphoid nonunions. The purpose of this study was to evaluate critically the outcome, complications, and failures of 1,2-ICSRA-based vascularized bone grafting at our institution to understand better the appropriate indications, methods, and possible contraindications. From January 1994 through July 2003, 50 scaphoid nonunions in 49 patients were treated with 1,2-ICSRA-based vascularized bone grafts. A retrospective review of the clinical and radiographic information was performed. Two patients were lost to follow-up study. Nine female and 38 male patients averaging 24 years of age were followed-up for an average of 7.8 months. Thirty-four scaphoid nonunions went on to union at an average of 15.6 weeks after surgery. Complications occurred in 8 patients and consisted of graft extrusion, superficial infection, deep infection, and failure of fixation. Univariate risk factors for failure included older age, proximal pole avascular necrosis, preoperative humpback deformity, nonscrew fixation, tobacco use, and female gender. Although previous researchers have concluded that vascularized bone grafts based on the 1,2-ICSRA are efficacious in the treatment of scaphoid nonunions, we determined that a successful outcome is not universal and depends on careful patient and fracture selection and appropriate surgical techniques. Therapeutic, Level IV.
 
Article
To evaluate the clinical outcome of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft for scaphoid nonunion (SN). A retrospective study was performed to evaluate patients with SN and treated with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft between 1997 and 2010. Functional measures, quality of life by Short Form SF-36 questionnaire, and analysis of risk factors were included. Out of 39 patients who were eligible for the study, 11 were lost to follow-up. Out of the remaining 28 patients, union was achieved in 21 (75%). The mean length of follow-up was 63 ± 45 months. In hands with scaphoid union, the grip strength and the radioulnar active range of motion were less than the contralateral side but greater compared with patients with nonunion. Active extension-flexion was less compared with the noninjured hand but similar to patients with nonunion. Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 58 to 23 in dominant hands and from 46 to 13 in nondominant hands. Smoking was found to be a risk factor for nonunion. Patients with scaphoid union tended to higher scores in 8 domains of SF-36-Item Health Survey quality of life without significant difference. Surgical treatment of SN with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft provided a union rate comparable with other vascularized bone graft techniques. Previous scaphoid reconstruction with standard iliac crest bone graft was not associated with higher risk for secondary nonunion. There was an upward tendency seen in DASH score and quality of life after scaphoid union. Therapeutic IV.
 
Article
The diagnostic sensitivity, specificity, and accuracy of 1.5 Tesla (T) and of 3.0T magnetic resonance imaging (MRI) are correlated with wrist arthroscopy findings in patients presenting with ulnar-sided wrist pain. The records and diagnostic MRI scans of 102 patients who presented between 1997 and 2006 with ulnar-sided wrist pain were evaluated. Preoperative MRI scans at 1.5T (n = 70) and 3.0T (n = 32) were evaluated by 2 experienced musculoskeletal radiologists with different levels of experience who were blinded to the arthroscopic findings. Preoperative MRI findings for the triangular fibrocartilage complex (TFCC), scapholunate, ulnotriquetral, and lunotriquetral ligaments were recorded and compared with findings at diagnostic arthroscopy. The sensitivity, specificity, and accuracy were calculated for both the 1.5T and 3.0T preoperative MRI scans. Statistical comparisons were made using chi-square test and JMP 6.0 software. A tear of the TFCC was identified retrospectively on 1.5T images in 49 of 58 patients and on 3.0T images in 15 of 16 patients. Compared with the gold standard of arthroscopy, 1.5T wrist MRI in this patient population had a sensitivity of 85%, a specificity of 75%, and an accuracy of 83% for reader 1 for the detection of a tear of the TFCC. In the same patient population, 3.0T wrist MRI had a sensitivity of 94%, a specificity of 88%, and an accuracy of 91% for reader 1. For reader 2, the improvement in sensitivity for the lunotriquetral ligament between the 1.5T and 3.0T images was statistically significant. The sensitivity, specificity, and accuracy of 3.0T wrist MRI for the TFCC is consistently higher compared with those of 1.5T wrist MRI. The trend suggests that 3.0T wrist MRI provides improved capability for detection of TFCC injuries. Given the available sample size, however, the confidence intervals around the point estimates are wide and overlapping. Further studies are needed to confirm or refute our results of the estimated sensitivity, specificity, and accuracy parameters.
 
Article
To assess objective and subjective outcomes of distal interphalangeal joint arthrodesis with a headless compression screw for degenerative osteoarthritis. We retrospectively analyzed 102 cases of distal interphalangeal joint arthrodesis performed with headless compression screws on 59 patients. We included only primary cases of degenerative osteoarthritis with a minimum follow-up of 7 months. We identified appropriate bone coaptation and hardware positioning on postoperative radiographs in all digits. The mean follow-up period was 26 months (range, 7-67 mo). In 89 of 102 cases, patients were fully satisfied; in 9 cases, they were satisfied. Four complications occurred: 2 cases of prominent hardware, 1 complex regional pain syndrome type 1, and 1 symptomatic bony callus on the fused joint. Secondary surgery was required in each of these 4 cases. No nonunion, malunion, nail dystrophy, pseudarthrosis, or infection occurred. All arthrodeses healed. Distal interphalangeal joint arthrodesis with headless compression screws was shown to be safe and effective in cases of degenerative osteoarthritis, with a low complication rate.
 
Article
This study was undertaken to determine the presence or absence of tenosynovitis in persons with idiopathic carpal tunnel syndrome. Eight hundred thirty-five consecutive operations for carpal tunnel syndrome were retrospectively reviewed, and 625 cases of idiopathic carpal tunnel syndrome were identified. Of these 96% (601) had a synovial tissue histologic diagnosis of benign fibrous tissue without inflammation, 4% (23) showed chronic inflammation, and 0.2% (1) revealed evidence of acute inflammation. We believe that tenosynovitis is not a part of the pathophysiologic process in chronic idiopathic carpal tunnel syndrome. Further histologic analysis of the flexor synovium for pathologic changes other than inflammation is needed.
 
Article
We report a population-based, 29-year review of 108 adult patients with soft tissue sarcoma of the upper extremity who had a minimum follow-up period of 3 years. Fifty tumors were localized in the upper arm, 8 in the elbow, 40 in the forearm, and 10 in the hand. Thirty-four tumors were subcutaneous and 74 were deep-seated. The median tumor size was 6 cm. Malignant fibrous histiocytoma was the most common histotype (n = 43), and grade IV (on a 4-grade scale) was the most common malignancy grade (n = 54). All but 6 patients underwent surgery; limb-sparing surgery of the primary tumor was performed in 89 patients. Twenty-four patients were given adjuvant radiotherapy; 11 received adjuvant chemotherapy. Inadequate local treatment was more common in patients treated outside the tumor center. Local recurrence occurred in 15 of 28 with inadequate local treatment and in 16 of 74 patients with adequate local treatment (20 of the 39 patients treated outside the center and 11 of the 63 patients treated at the center). At the latest follow-up visit, 32 patients had developed metastases, giving a 5-year metastasis-free survival rate of 0.72. In a multivariate analysis, tumor size larger than 5 cm and vascular invasion emerged as independent prognostic factors. Patients without these 2 factors had excellent survival. When compared with soft tissue sarcoma of the lower extremity or trunk wall, tumors in the upper extremity were smaller at the time of diagnosis and had a higher 5-year metastasis-free survival rate.
 
Article
Dupuytren's disease is not as commonly reported in women as in men. Our literature search yielded only two such studies. The purpose of this study was to further examine the presentation and surgical outcome of Dupuytren's disease in women, including complications and to compare these outcomes to a similar cohort of men and to previous studies of Dupuytren's disease in women. A retrospective case series review was undertaken, and we identified all women who were admitted for surgical correction of Dupuytren's disease since 1990. Comparison was made with men operated during the same period. Pre- and postoperative measurements for lack of extension at the metacarpophalangeal joint (MCPJ), proximal interphalangeal (PIP) joint, and distal interphalangeal (DIP) joint were made by the senior author. SPSS (Statistical Package for the Social Sciences, SPSS Inc., Chicago, Il) was used for statistical analysis. The t test was used to compare the two groups. One hundred nine women were identified, with 119 operated hands, out of a total of 657 patients operated. Comparisons were made with 548 men. The average age at presentation was 63 years in women, and there was no significant difference between the two groups. One hundred five of the patients had digital involvement. The little and ring fingers were involved most frequently. Thirty-four had involvement of the MCPJ. Mean preoperative contracture was 35 degrees . Mean postoperative contracture was 1 degrees . Proximal interphalangeal joint involvement was seen in 66 patients. Mean preoperative contracture was 42 degrees . Mean postoperative contracture was 7 degrees . Distal joint involvement was identified in only 4 digits. There was no statistical difference with the men as regards digital involvement and joint involvement; however, correction at the PIP joint was significantly lower. Fasciectomy was performed in 107 cases (90%), fasciectomy and local flap in 7 cases (6%), and dermafasciectomy in 5 cases (4%). The most common complication was digital nerve/artery injury (6 patients), and disease recurrence rate was 22%. These were statistically similar to the men. Dupuytren's disease is less prevalent in women but its symptomatic presentation is similar to that in men, with more severe involvement of the PIP joint and a similar recurrence rate. The surgical outcomes, however, were equivalent with regard to final contracture correction, recurrence, and complication rates.
 
Article
Since 1977 we have operated on 13 of 15 triphalangeal thumbs in nine children (five boys, four girls). Follow-up ranged from 22 to 134 months (mean, 65 months). Total active motion averaged 63 degrees at the interphalangeal joint and 79 degrees at the metacarpophalangeal joint. There was no evidence of instability or laxity of ligaments. Reduction osteotomy was insufficient to shorten grossly long thumbs of two patients, and it was necessary to shorten the metacarpal. Premature closure of the phalangeal physis occurred in two thumbs but did not result in inadequate length; one postoperative pin-tract infection resulted in nonunion that required reoperation. This long-term experience supports reduction osteotomy for triphalangeal thumbs because it addresses the deformities and preserves both motion and stability.
 
Article
Traumatic dislocation of the thumb carpometacarpal joint has been rarely reported in children. An 11-year-old boy presented with a traumatic dislocation of the trapeziometacarpal joint. He was successfully treated surgically with ligament reconstruction as previously described.
 
Article
Trapezoid fractures are rare. Mostly single cases reports appear in the literature. The purpose of this study was to review 11 patients treated for trapezoid fractures at our center. We reviewed all trapezoid fractures that presented over the past 10 years at our institution. We reviewed case notes regarding mechanism of injury, fracture pattern, mode of diagnosis, and time to diagnosis and treatment. We treated 11 patients for trapezoid fractures over the 10-year period. A correct diagnosis was made in 5 cases on initial evaluation. Most trapezoid fractures were diagnosed on computed tomographic scan. The fracture plane was predominantly sagittal. Coronal fractures could not be diagnosed on plain radiographs. Fractures of the trapezoid should be suspected from the mechanism of injury, in particular, axial force, and from local tenderness. These fractures may be underdiagnosed. We recommend computed tomography rather than plain radiography alone in case of clinical suspicion. Diagnostic IV.
 
Article
To virtually assess nonunions of the scaphoid waist using 3-dimensional computed tomography (CT) reconstruction for the amount of displacement of the distal fragment and the postfracture reduction position using the intact opposite scaphoid for reference. We generated 3-dimensional reconstructions for 11 nonunions of the scaphoid waist and the contralateral intact scaphoids based on CT. The mean age of the patients was 25 years and the time from injury to the CT scan was 2.4 years. We used the mirrored 3-dimensional model of the healthy scaphoid to guide virtual reduction of the nonunion and calculated the amount of displacement of the distal pole fragment from prereduction to postreduction. We compared the results with the intrascaphoid angles calculated using single CT slices. The scaphoid nonunions showed a mean flexion deformity of 23°, an ulnar deviation of 5°, and a pronation deformity of 10°. Mean translation was 0.9 mm volarward, 0.2 mm radialward, and 3.3 mm distalward. After reduction, all scaphoids showed a bony overlap on the dorsoradial side; the mean volume of this region was 3% of total bone volume. There was no correlation between the degree of displacement and the intrascaphoid angle measurements. Preoperative planning for scaphoid reconstruction is usually performed using conventional radiographs and single CT slices. However, by synthesizing the information from the CT into a 3-dimensional reconstruction, an exact analysis is possible. This method also allows quantification of prosupination displacement. The postreduction area of dorsal bone overlap may be due to appositional callus formation. Simple volar opening of the scaphoid allows correction of angulation deformities but results in lengthening of the scaphoid. Correct reduction of the scaphoid fragments is often only possible if the dorsal appositional callus is resected.
 
Article
In 1984 we initiated a study of factors associated with carpal tunnel syndrome (CTS) in industrial workers by using a case definition based on both symptoms and electrophysiologic findings. Medical history, lifestyle factors, and symptoms were assessed by interview, and electrodiagnostic studies were used to measure median nerve function. Job tasks were classified by both interview and direct observation of work activities. Follow-up evaluations were conducted in 1989 and 1994-1995. The analytic sample consisted of 111 women and 145 men free of CTS in 1984 who were examined at both subsequent contact points. In logistic regression analyses, greater age, female gender, relative overweight, cigarette smoking, and vibrations associated with job tasks were found to significantly increase risk for dominant-hand CTS, whereas presence of an endocrine disorder was marginally related to reduced risk for CTS. These findings were generally similar when analyzed separately for men and women. Similar to other chronic noninfectious diseases, personal factors may play an important role in determining risk for CTS.
 
Article
One hundred fifteen cases of localized nodular synovitis (giant cell tumor of the tendon sheath) were reviewed. The optimal treatment for these lesions is unknown, and a high recurrence rate exists. Growths arose from most of the synovial sites of the hand, including joints, capsular ligaments, and tendon sheaths. Deformation of the bone surface was commonly seen; however, bone invasion was uncommon. The histologic features may vary, but the lesions are always benign and do not metastasize. Treatment consisted of thorough local excision and adjacent joint exploration when appropriate. Recurrence occurred in 10 cases (9%) with one to five additional surgical procedures needed to eradicate the lesion.
 
Article
Currently described sources of bone graft, such as iliac crest and distal radius, for supplemental fixation of scaphoid fractures are suboptimal. In our experience, olecranon bone has the advantage of providing a convenient source of corticocancellous block graft that can be harvested within the same sterile operative field used for fixation of the scaphoid fracture, and it also causes less postoperative pain compared to that obtained from iliac crest. Here, we describe our surgical technique for harvest and use of olecranon bone graft for fixation of scaphoid fractures.
 
Article
Different surgical techniques have been proposed to treat traumatic scapholunate instability. Deciding which treatment is best for each individual case is not easy. In this article we report an algorithm of treatment based on a number of prognostic factors that may help in this matter. We also report on the promising results obtained using a new technique, the 3-ligament tenodesis, for the treatment of nonrepairable complete scapholunate ligament rupture, causing a reducible carpal malalignment without secondary osteoarthritis. This technique incorporates features from 3 previously described techniques.
 
Article
Thirteen patients with 15 intraosseous carpal ganglia (6 scaphoid and 9 lunate cases) are reported. Eleven cases had cortical defects communicating the bone cysts either with the joint space or a coexisting soft tissue ganglion. Nine cysts were primary or idiopathic; soft tissue ganglia were found in 6 secondary cases and anatomic continuity of the intraosseous and extraosseous components through cortical defects was present. Treatment consisted of curettage of the cyst wall and cancellous bone grafting. Approaching lunate cysts through a small opening in the scapholunate interosseous ligament is described. Results were analyzed in 12 cases with at least 1 year of follow-up; the average follow-up period in these cases was 47 months (range, 12-119 months). Results were very good in all but 1 patient, who suffered a partial lunate collapse, which resulted in mild lunocapitate osteoarthritis. No graft reabsorption or recurrence was seen in the control radiographs obtained throughout the follow-up period.
 
Patient and Fracture Data in the Original Cohort (N [ 51) 
The Objective Outcome at 13e15 Years (N [ 38) Related to the Initial Arthroscopic SL Diagnosis 
Radiographic Findings After 13e15 Years Follow-Up of Arthroscopically Diagnosed SL Ligament Tears 
Article
To evaluate the natural history of untreated complete or partial scapholunate (SL) ligament tears associated with displaced distal radius fractures. Between 1995 and 1997, 51 consecutive patients aged < 60 years with displaced distal radius fractures were examined arthroscopically to assess for concomitant soft tissue injuries. Thirty-two of 51 patients had an SL ligament tear, 10 had a complete tear (Lindau grade 3), and 22 had a partial tear (Lindau grades 1 and 2). Thirty-two patients had AO type-C fractures, 3 had type-B fractures, and 16 had type-A fractures. In 2010, 47 of the 51 patients were still alive, and they were invited for an interview, clinical examination, and radiography. Thirty-eight of the 51 original patients participated in the long-term follow-up. Mean grip strength was 83% relative to the contralateral hand in patients with a complete tear, as compared with 92% in patients with partial or no SL tears (nonsignificant). Median Disabilities of the Arm, Shoulder, and Hand questionnaire score was 2 (range, 0‒55) for complete SL tears, compared with 9 (range, 0‒70) for the others (nonsignificant). No differences were found regarding visual analog scale pain or wrist motion/forearm rotation. None of the patients developed a static SL dissociation or a SL advanced collapse wrist. No major differences were found in the subjective, objective, or radiographic outcome after a complete (grade 3) or partial (grade 1 or 2) SL untreated tear associated with displaced distal radius fracture. It should be noted that none of the patients had a grade 4 SL tear, which may have a different outcome. Prognostic II. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
 
Article
We present a 13-year-old gymnast with a stress fracture of the scaphoid. Treatment was successful with immobilization for 8 weeks in a long arm spica cast followed by 4 weeks in a short arm splint.
 
Article
To evaluate the long-term results of a prospective, longitudinal case series of untreated, traumatic triangular fibrocartilage complex (TFCC) tears found in displaced distal radial fractures. Between 1995 and 1997, 51 patients (24 men, 27 women; age, 20-57 y) with a displaced distal radius fracture had wrist arthroscopy to identify associated injuries. Forty-three patients had complete or partial tears of the TFCC, which were not treated. All patients were contacted in 2010, 13-15 years after the injury. One patient had had a TFCC reattachment due to painful distal radioulnar joint instability and was excluded. Thirty-eight patients returned for a radiographic and clinical follow-up that recorded strength, distal radioulnar joint laxity, range of motion, pain scale score, and subjective and objective outcome scores. After 13-15 years, 17/38 patients were lax in the distal radioulnar joint. The mean grip strength was worse in the patients with a lax distal radioulnar joint (83%, SD 15 of the contralateral side vs 103%, SD 33). The median Gartland and Werley score was 5 (good; range, 0-15) in the lax group compared to 1 (excellent; range, 0-9) in the non-lax group, and the median Disabilities of the Arm, Shoulder, and Hand scores were 14 (range, 0-59) and 5 (range, 0-70) respectively. In this 13-15 year, prospective, longitudinal outcome study of the natural course of TFCC tears associated with distal radius fracture, only 1 patient had been operated on for painful instability since the injury. The subjective and objective results did not provide evidence that a TFCC injury would influence the long-term outcome. However, trends were found and, by speculation, the low number of patients in the series and the risk for a type II error could be the cause of absent statistically significance. Larger, preferably prospective, randomized studies are needed to find out whether a more aggressive treatment is beneficial. Diagnostic I.
 
Article
This study evaluated the reliability and morbidity rate of carpal tunnel release with the Indiana Tome technique via a small palmar incision when used by experienced hand surgeons. A retrospective review was performed of 1332 carpal tunnel releases using the Indiana Tome performed by 2 fellowship-trained hand surgeons at university hospitals from July 1993 to August 2006. Chart review focused on complications with this technique. All patients returned to preoperative activities, in employment or otherwise. Nonmanual laborers resumed regular job tasks between 2 days and 3 weeks. The 2 surgeons experienced 11 complications in 1332 cases, for an overall complication rate of 0.83%. The most common complication, in 8 cases, was numbness and hypersensitivity in the third common digital nerve distribution; 2 of these 8 patients had normal 2-point discrimination and the other 6 had persistently 2-point discrimination greater than 10 mm despite resolution of preoperative paresthesia symptoms. In the latter group, 3 patients had repeat exploration, with findings of fascicular injury and scarring in 2 patients and normal nerve in the third (who ultimately had normalized 2-point discrimination by 6 weeks after surgery). The 3 patients without re-exploration had their 2-point discrimination returned to normal by 11 months after surgery. Ultimately, only 2 patients (0.15%) had persistently increased 2-point discrimination. The remaining complications (3 cases) were transient neuropraxia of the entire median nerve (1 patient), an incomplete release (1 patient) requiring repeat surgery, and a recurrence of carpal tunnel syndrome (1 patient) with perineural scar noted at 8 months after surgery, treated successfully with a hypothenar fat pad flap. This is the largest retrospective review of the Indiana Tome technique to date. This technique can be used by experienced hand surgeons and offers early resumption of preoperative activities and a low complication rate. The most common complication was neurapraxia in the third common digital nerve distribution. The overall complication rate was 0.83% (11 in 1332). Therapeutic IV.
 
Article
To evaluate the results of a single surgeon's treatment of mucoid cysts, comparing outcomes between injection and surgery. One hundred thirty-four cysts were treated, with a minimum 2-year follow-up period. Thirty-one patients had nail ridging or deformity at presentation. Eighty patients had multiple soft-tissue punctures into the cyst with a 25-gauge needle and injection with local anesthetic and steroid. Fifty-four patients had surgical excision and joint debridement. In the injection group, complete resolution of the cyst occurred in 48 cases (60%). Among the 32 that recurred, repeat injections were performed in 8 cases; 3 resolved. No recurrences were noted in the surgery group. Nail ridging resolved after surgery in 25 digits; the remaining 6 digits had partial improvement or persistent ridging. Five infections occurred and were treated successfully with antibiotics (4) or debridement (1), or both. Aspiration and injection was convenient but had a 40% recurrence rate. Surgery provided definitive treatment with no major long-term problems.
 
Article
Kienböck's disease is rare in children and there are few reports and therapeutic recommendations in the literature about this condition. We report a case of a 14-year-old female gymnast for whom nonsurgical treatment was followed by complete healing within 12 months. Repeated computed tomography scans provided a sequential coronal, sagittal, and transverse illustration of the progressive healing of the lunate.
 
Article
The spinal accessory nerve (SAN) is conventionally transferred to the suprascapular nerve (SSN) through an incision in the supraclavicular region (the anterior approach) to improve shoulder function in brachial plexus injuries. This approach carries a risk of partial denervation of upper trapezius muscle. Here we describe how dorsal nerve transfer through an incision placed directly over the scapular spine preserves the proximal branches to the upper trapezius muscle and allows nerve transfer close to target muscles. We report our experience with the dorsal approach in 14 cases managed between February 2007 and January 2008. Results were compared with 21 control cases treated by the anterior approach. In addition, we submitted proximal cut ends of the SAN in 10 cases from the experimental group for histomorphometry. A total of 11 patients had C5 and C6 injuries, whereas 3 had associated C7 injuries. The denervation period ranged between 3 and 10 months. In all cases, the distal SAN could be transferred to the SSN without a graft. Histomorphometry revealed an average of 1,671 myelinated axons. Shoulder abduction and external rotation were restored in 13 and 9 cases, respectively, compared with 16 and 12, respectively, in the control group. Electromyography revealed the first sign of reinnervation of infraspinatus muscle at 23 ± 4 weeks, compared with 30 ± 4 weeks in the control group. Initial evidence of shoulder abduction appeared earlier in the study population (28 ± 4 vs 34 ± 4 weeks). Shoulder abduction and external rotation in the study group ranged between 70° and 170° and 30° and 80°, compared with 65° and 160° and 22° and 55° in the control group. Using the Medical Research Council (MRC) grading system, at 6 months postreconstruction, 13 patients had M4 power in the trapezius muscle, whereas 1 had M3, compared with 5 in the control group who displayed grade 3 weakness. A dorsal approach for transfer of the distal SAN into the SSN is an alternative and effective technique in restoring shoulder function in upper brachial plexus injuries. Therapeutic III.
 
Article
Fourteen failed cases of 325 patients who had undergone the operation of toe-to-hand transfer to reconstruct the thumb and/or the finger are reported. Five key factors were related to the survival of the transferred toe: two sets of arterial blood supply in the case of an arterial anomaly, the resection of diseased vascular segments, the observation of capillary blood refill for the judgment of circulatory crisis, and the prevention and treatment of a hypercoagulable state.
 
Article
To evaluate the mid- to long-term outcome of distal radioulnar interposition arthroplasty using an Achilles allograft for salvage of painful instability after distal ulnar resection. Twenty-six patients with an average age of 43 years were treated with Achilles tendon allograft interposition for failed distal ulnar resection. The average follow-up period was 79 months (range, 25-174 mo). Patients had an average of 2 previous procedures. All patients were evaluated clinically and radiographically. At the final follow-up, pain level, satisfaction, forearm rotation, grip strength, and Mayo Modified Wrist Score were assessed. All clinical parameters demonstrated statistically significant improvement at the final follow-up. Mean patient pain scores improved from 8.1 to 1.3, and patient satisfaction scores improved by an average of 6.8 points. Preoperative and postoperative forearm rotation and grip strength measurements improved by an average of 28° in pronation, 41° in supination, and 72% in grip strength. The mean Mayo Modified Wrist Score improved from 42 to 85. Postoperative radiographs showed preservation of an adequate space between the distal radius and the resected distal ulna. No postoperative infections and no foreign body reactions relating to the allograft were observed. Interposition arthroplasty with an Achilles allograft was an effective salvage procedure for the treatment of failed distal ulnar resection, preventing impingement of the ulnar stump on the radius. This procedure potentially provides a safe and reliable treatment, especially for patients who may not be candidates for implant arthroplasty. Therapeutic IV.
 
Article
One hundred fifty patients with suspected wrist ligamentous injuries were studied with both triple injection wrist arthrography and arthroscopy. The diagnoses obtained by these two techniques were compared to determine the differences between these two modalities. All the patients in this study had both the clinical diagnosis of ligamentous injuries of the wrist and normal findings on x-ray films. Intercarpal abnormalities were found in 106 patients (71%) at wrist arthrography and in 136 patients (91%) at arthroscopy. There was only 42% agreement (63 patients) between the arthrographic and arthroscopic diagnoses. Eighty-seven patients (58%) had alterations of their arthrographic diagnoses following arthroscopy. For patients with normal arthrographic findings (44 patients), 88% underwent arthroscopy because there was insufficient correlation between the physical examination findings and the arthroscopic findings. Out of the 44 patients with normal arthrographic findings, 35 patients (80% of the subgroup) had injuries found at arthroscopy. Over half of the patients had alterations in their arthrographic diagnoses following arthroscopy. In a patient with suspected ligamentous injury of the wrist, wrist arthroscopy may be the most efficient method in arriving at a definitive diagnosis.
 
Article
A skillfully applied thenar flap is an excellent method of restoring major distal soft tissue losses of fingers. It not only provides full-thickness skin of near perfect tissue match but also is the only local flap with sufficient subcutaneous tissues to restore adequately the lost finger pulp. Its recovery of sensibility yields good function, it does not hyperpigment, and the donor site is on the less exposed palmar surface of the hand. Age is not a contraindication for its use. The thenar flap must not be confused with the palmar flap, whose bad reputation is well deserved and whose use if probably never indicated. The cardinal technical principles that must be observed for the thenar flap are (1) design the flap out on the thumb near the MP joint crease, (2) fully flex the MP joint and, when possible, the distal IP joint of the recipient finger to minimize proximal IP joint flexion, and (3) sever the pedicle of the flap after 10 to 14 days and immediately start active exercises. Experience bears out that the thenar flap applied with observance of the stated principles usually offers the best solution for treatment of major distal phalangeal soft tissue losses for all age groups.
 
Article
Arthritis of the joints at the base of the thumb can be painful and severely disabling, interfering with normal functional activity. The trapezium implant, which acts as a replacement for the removed pathologic bone, must have certain features if it is to be tolerated by the host tissue and be stable and durable. Implant resection arthroplasty of the trapezium, with careful correction of other associated deformities, has resulted in long-term, excellent functional and cosmetic results in this group of cases.
 
Article
Multicentric giant cell tumor is rare and accounts for less than 1% of all giant cell tumors of bone. We describe a case in which all the lesions occurred in the upper extremities. The 13-year-old boy's first tumor was in the left index metacarpal. Over 16 years, giant cell tumors occurred in 8 sites: right distal radius, left lunate, left middle metacarpal, left distal radius, right ring finger proximal phalanx, right radial head, left distal humerus, and left proximal humerus. Intralesional curettage of the lesions located in the hand and carpals was associated with a high incidence of local recurrence, whereas lesions in the proximal radius and in the humerus have not recurred.
 
Article
The anatomic accuracy of Rembrandt's The Anatomy Lesson of Dr. Nicolaes Tulp (1632) has been debated in the literature for many years. The white cord that courses along the ulnar aspect of the carpus and small finger of the cadaver in Dr. Tulp's dissection conforms to no normal anatomic structure and is believed to represent an anomalous branch of the ulnar nerve, an artistic error, or a combination of both. After the discovery of an accessory abductor digiti minimi (AADM) during a routine dissection of a late-middle-aged male cadaver, we noted that the course of its tendon over the hypothenar eminence resembled the white cord in the painting. After conducting a detailed literature search and anatomic interpretation of the painting, we established 4 criteria for identifying the white cord. Using these criteria, we evaluated the plausibility of an AADM being represented in the painting. We conclude that an AADM should be considered as a possible explanation for the white cord.
 
Article
Rembrandt's The Anatomy Lesson of Dr. Nicolaes Tulp (1632) is considered a masterpiece and is a group portrait of the Amsterdam Guild of Surgeons in the form of an anatomy lesson. Dr. Nicolaes Tulp, Doctor of Medicine and Praelector Anatomiae to the Amsterdam Guild of Surgeons, showed an anatomic dissection of a forearm on the corpse of an executed criminal. The anatomic accuracy in Rembrandt's famous painting has been discussed in the literature for decades without any general consensus. In 2006, on the 400th anniversary of Rembrandt's birth, a forearm dissection of a cadaver and a comparison with the anatomy in the painting are presented to analyze the anatomic accuracy of Rembrandt's famous painting.
 
Article
Axillary lymphadenopathy developed in a patient with rheumatoid arthritis 17 years after the placing of Swanson implants in the hand. Foreign material in the lymph nodes was identified as silicone by energy-dispersive x-ray microanalysis. This emphasizes the long latent period that may be associated with this clinical phenomenon which may mimic other, more serious, diseases.
 
Article
A case with closed sequentional rupture of all flexor tendons of the fingers, 17 years after a Colles fracture is described. The repair with free tendon grafts resulted in a fair result.
 
Article
The zigzag incision with Y-V closure has unique advantages for the treatment of Dupuytren's disease. Much skin can be mobilized to the longitudinal finger axis. There is rarely a need for skin grafting in spite of full correction of the deformity. This approach, combined with properly applied tamponade bulk dressing, allows for early use of the hand with minimal morbidity.
 
Article
To evaluate the treatment of carpal collapse using a four-corner arthrodesis concentrator of nickel-titanium memory alloy. From August 2006 to August 2010, 18 patients with carpal collapse had scaphoid excision and four-corner (capitate, lunate, triquetrum, and hamate) arthrodesis using a nickel-titanium memory alloy four-corner arthrodesis concentrator. The mean follow-up time was 30 months (range, 12-48). Various wrist parameters, including grip strength, wrist motion, and degree of pain were recorded and compared before and after surgery. The average fusion time was 2.3 months (range, 2-4). Neither nonunion nor wound infection was found in any of the patients. At one year follow-up, the grip strength had reached 80% of that of the healthy side, whereas the range of motion was greater than 50% of the contralateral side. After the surgery, the mean pain scores were improved. Four-corner arthrodesis using a nickel-titanium memory alloy four-corner arthrodesis concentrator effectively treated carpal collapse and preserved most wrist function. Therapeutic IV.
 
Article
To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improve the outcome of trapezial excision for the treatment of basal joint arthritis after a minimum follow-up of 5 years. We randomized 174 thumbs with trapeziometacarpal osteoarthritis into 3 groups to undergo simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void and retained for 4 weeks, and a thumb spica was used for 6 weeks in all 3 groups. We reviewed 153 thumbs after a minimum of 5 years (median, 6 y; range, 5-18 y) after surgery with subjective and objective assessments of thumb pain, function, and strength. There was no difference in the pain relief achieved in the 3 treatment groups, with good results in 120 (78%) patients. Grip strength and key and tip pinch strengths did not differ among the 3 groups and range of movement of the thumb was similar. Few complications persisted after 5 years, and these were distributed evenly among the 3 groups. Compared with the results at 1 year in the same group of patients, the good pain relief achieved was maintained in the longer term, irrespective of the type of surgery. While improvements in grip strength achieved at 1 year after surgery were preserved, the key and tip pinch strengths deteriorated with time, but the type of surgery did not influence this. The outcomes of these 3 variations of trapeziectomy were similar after a minimum follow-up of 5 years. There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term.
 
Article
A case of successful staged tendon reconstruction for treatment of a zone II flexor tendon injury with a delay of 18 years between Hunter rod placement and secondary tendon grafting is presented. In this case, the prolonged interval was not detrimental to a successful outcome.
 
Article
Fritz de Quervain was the first surgeon to describe and treat chronic stenosing tendovaginitis at the radial styloid process. The current management of this condition differs little from his initial description and as a result the condition now bears his name. He and his mentor, Nobel Prize winner Theodor Kocher, advanced the understanding and treatment of thyroid disease, especially subacute nonsuppurative thyroiditis, another condition to which his name is attached. He was a pioneer of surgical technology and author of books and articles read worldwide and is largely responsible for the introduction of iodized table salt.
 
Top-cited authors
William P. Cooney
  • Mayo Foundation for Medical Education and Research
Kai-Nan An
  • Mayo Clinic - Rochester
Andrew K Palmer
  • State University of New York Upstate Medical University
Frederick Werner
  • State University of New York Upstate Medical University
Peter Amadio
  • Mayo Clinic - Rochester