Search

To compare the Disabilities of the Arm, Shoulder, and Hand (DASH) patient-reported outcome measure as administered by tablet computer to the traditional paper format.In a prospective, randomized study design, 223 consecutive adult patients who presented to the clinic of a single hand surgeon at a tertiary medical center were randomized by visit time to receive the DASH by either paper or tablet computer. Test completeness, time to completion, DASH score, and diagnostic and demographic data were collected and compared between the two cohorts. In total, 120 participants took the DASH using the tablet and 103 using paper.43% of the paper surveys had at least one question that was omitted, compared with 13% in the tablet group; 14% of the paper surveys were not scoreable ( 27 questions answered) compared with 4% of the tablet surveys. The mean time to complete was 3.1 minutes for the paper version of the DASH and 4.3 minutes for the tablet version. Among our study population, there was no influence of age, sex, or diagnosis category on the time required to complete either version of the test. The mean DASH score was 45 for the paper version and 32 for the tablet version.The use of digital data entry methods in the arena of health care outcomes research is increasing. Administration of the DASH via a tablet computer resulted in more complete data, slightly increased responder burden, and a lower DASH score. This finding may have important implications for the use of this metric in an electronic format in future research endeavors.Diagnostic II.

Throughout the development of hand surgery as a specialty thousands of papers have been published. This paper identifies the classic papers in 13 categories covering the field of hand surgery. To be named a classic paper, it must meet three criteria: (1) it must establish or refine a technique or concept; (2) the technique must survive the passage of time; and (3) it must change the course of treatment. (J Hand Surg 2000;25A:14–18. Copyright © 2000 by the American Society for Surgery of the Hand.)

Publication of research results in peer-reviewed journals represents the consummation of the scientific method. In order to determine the rate of publication of oral presentations at the annual meeting of the American Society for Surgery of the Hand, every presentation (n = 397) from the 1990, 1991, and 1992 annual meetings was subjected to a Medline Plus computer search in January 1995. Meeting abstracts were grouped by program designation to scientific session, research session, and residents and fellows conference categories, and a Kaplan-Meier survivorship curve was formulated for each category. We determined an ultimate publication rate of 52% at 53 months. Subanalysis by year of presentation showed rates of 32%, 48%, and 51% for the respective years 1992, 1991, and 1990, with publication for most research occurring within 3 years of presentation. No statistically significant difference existed between the three categories, although a distinct trend toward higher ultimate publication rate (74%) was found for research abstracts. The ultimate publication rate for hand surgery presentations is comparable to that reported for other disciplines.

Positive Froment's paper sign and Jeanne's sign are an indication of ulnas nerve palsy. However, these signs are not always present in ulnas nerve palsy. Described below is a case in which both of these signs were present secondary to a shortened thumb metacarpal in the absence of an ulnas palsy. Other causes of these signs are also reported.

PURPOSE: To better understand the manner in which outcomes are reported after brachial plexus reconstruction, we conducted a systematic review of the scientific literature. METHODS: We included English-language articles describing treatment of brachial plexus injuries to restore motor function of the shoulder, elbow, forearm, and/or wrist with nerve repair, nerve graft, and/or nerve transfer. We recorded the anatomic location of injury, the treatment used, and the manner in which motor function, active and passive range of motion, pain, quality of life, function or disability, patient satisfaction, and psychosocial health were reported. RESULTS: In reviewing 88 papers with outcomes for 5,189 patients, 83 (94%) of the papers reported postoperative motor function. Of these, 49 (59%) did not include any other measures of patient outcome. Active range of motion was reported in 24 (27%) studies, pain was reported in 15 (17%) studies, quality of life was reported in 4 (5%) studies, function or disability was reported in 5 (6%) studies, patient satisfaction in 3 (3%) studies, and psychosocial health was reported in 1 study. DISCUSSION: To date, outcome reporting for brachial plexus surgery has largely centered on motor recovery and typically has not included measures of function or non-musculoskeletal recovery. Incorporating currently-used measures of physical recovery with patient-derived outcomes measures such as quality of life, function, pain, and satisfaction will likely help provide a more comprehensive understanding of the effect of brachial plexus reconstruction surgery. LEVEL OF EVIDENCE: Diagnostic Level III (Systematic Review of Diagnostic Level III studies)

Purpose We conducted a systematic review to document ethical concerns regarding human upper extremity (UE) allotransplantation and how these concerns have changed over time. Methods We performed a systematic review of 5 databases to find manuscripts addressing ethical concerns related to UE allotransplantation. Inclusion criteria were papers that were on the topic of UE allotransplantation, and related ethical concerns, written in English. We extracted and categorized ethical themes under the 4 principles of bioethics: Autonomy, Beneficence, Nonmaleficence, and Justice. We assessed theme frequency by publication year using Joinpoint regression, analyzing temporal trends, and estimating annual percent change. Results We identified 474 citations; 49 articles were included in the final analysis. Publication years were 1998 to 2015 (mean, 3 publications/y; range, 0–7 publications/y). Nonmaleficence was most often addressed (46 of 49 papers; 94%) followed by autonomy (36 of 49; 74%), beneficence (35 of 49; 71%), and justice (31 of 49; 63%). Of the 14 most common themes, only "Need for More Research/Data" (nonmaleficence) demonstrated a significant increase from 1998 to 2002. Conclusions Upper extremity transplantation is an appealing reconstructive option for patients and physicians. Its life-enhancing (vs life-saving) nature and requirement for long-term immunosuppression have generated much ethical debate. Availability of human data has influenced ethical concerns over time. Our results indicate that discussion of ethical issues in the literature increased following publication of UE transplants and outcomes as well as after meetings of national societies and policy decisions by regulatory agencies. Clinical relevance Because UE transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.

Purpose To evaluate control group selection in nonrandomized studies published in the Journal of Hand Surgery American (JHS). Methods We reviewed all papers published in JHS in 2013 to identify studies that used nonrandomized control groups. Data collected included type of study design and control group characteristics. We then appraised studies to determine whether authors discussed confounding and selection bias and how they controlled for confounding. Results Thirty-seven nonrandomized studies were published in JHS in 2013. The source of control was either the same institution as the study group, a different institution, a database, or not provided in the manuscript. Twenty-nine (78%) studies statistically compared key characteristics between control and study group. Confounding was controlled with matching, exclusion criteria, or regression analysis. Twenty-two (59%) papers explicitly discussed the threat of confounding and 18 (49%) identified sources of selection bias. Conclusions In our review of nonrandomized studies published in JHS, papers had well-defined controls that were similar to the study group, allowing for reasonable comparisons. However, we identified substantial confounding and bias that were not addressed as explicit limitations, which might lead the reader to overestimate the scientific validity of the data. Clinical relevance Incorporating a brief discussion of control group selection in scientific manuscripts should help readers interpret the study more appropriately. Authors, reviewers, and editors should strive to address this component of clinical importance.

Patients with the hypermobility type of Ehlers-Danlos (EDS-HT) often complain of wrist pain, usually originating from subluxations. As a result of the laxity, wrist function in these patients can be highly limited. This paper presents a surgical technique that stabilizes the lunocapitate joint with the use of an extensor carpi radialis brevis strip. Five patients with confirmed EDS-HT were treated with an extensor carpi radialis brevis tenodesis for their midcarpal instability. Two patients presented with complications following surgery, one major and one minor. This paper presents a potentially satisfactory surgical solution to recurrent midcarpal instability in EDS-HT patients and demonstrates that the use of an autologous tendon might be feasible in spite of a background of abnormal collagen metabolism. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved.

This report describes a technique for recording range of motion of digital joints. The technique involves tracing digital outlines with an angled marker on a sheet of paper attached to a special interray pad. A complete dorsal silhouette of the entire ray can be obtained by mounting the pad and the paper astride the palm parallel to the ray of the digit being evaluated. Fabrication and use of the equipment is described. This silhouetting system could be an alternative to wire tracing in visualizing tendencies of dynamics of digital range of motion.

Purpose To assess whether there was a difference in score between paper and telephone administration of disability and psychological questionnaires relevant to patients with an upper extremity illness. Methods The short version of the Disabilities of the Arm, Shoulder, and Hand score, the 5-question version of the Short Health Anxiety Inventory, the 4-question version of the Pain Catastrophizing Scale, the Patient Health Questionnaire-2, and an ordinal pain scale were completed by 135 patients both in the office and the next day over the phone. We compared scores with repeated measures analysis of variance and Pearson correlation. We used intraclass correlation coefficients to test the level of agreement. Results There were small but significant differences between paper and phone administration of the short version of the Disabilities of the Arm, Shoulder, and Hand scores and pain scores, but not the Patient Health Questionnaire-2, Short Health Anxiety Inventory-5, and Pain Catastrophizing Scale-4. There was a large Pearson correlation and excellent intraclass correlation coefficient agreement, as well. Conclusions Shorter questionnaires can be used to assess disability and psychological factors by phone. Phone administration of measures of disability and psychological factors can replace paper administration in studies that do not require in-person examination. (Copyright (C) 2013 by the American Society for Surgery of the Hand. All rights reserved.)

Purpose To determine whether electronic self-administration of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire using a tablet computer increased completion rate compared with paper self-administration. Methods We gave the DASH in self-administered paper form to 222 new patients in a single hand surgeon's practice. After a washout period of 5 weeks, we gave the DASH in self-administered tablet computer form to 264 new patients. A maximum of 3 questions could be omitted before the questionnaire was considered unscorable. We reviewed the submitted surveys to determine the number of scorable questionnaires and the number of omitted questions in each survey. We completed univariate analysis and regression modeling to determine the influence of survey administration type on respondent error while controlling for patient age and sex. Results Of the 486 total surveys, 60 (12%) were not scorable. A significantly higher proportion of the paper surveys (24%) were unscorable compared with electronic surveys (2%), with significantly more questions omitted in each paper survey (2.6 ± 4.4 questions) than in each electronic survey (0.1 ± 0.8 questions). Logistic regression analysis revealed survey administration mode to be significantly associated with DASH scorability while controlling for age and sex, with electronic survey administration being 14 times more likely than paper administration to yield a scorable DASH. Conclusions In our retrospective series, electronic self-administration of the DASH decreased the number of omitted questions and yielded a higher number of scorable questionnaires. Prospective, randomized evaluation is needed to better delineate the effect of survey administration on respondent error. Clinical relevance Administration of the DASH with a tablet computer may be beneficial for both clinical and research endeavors to increase completion rate and to gain other benefits from electronic data capture.

This article presents the history of the discovery of compression of the median nerve in the carpal tunnel without an identifiable cause as a distinct clinical entity. By analyzing primary sources, we show that, at the beginning of the twentieth century, physicians described patients with paresthesias and numbness in the hands, most prominent at night, accompanied by bilateral symmetrical atrophy along the radial side of thenar eminence. At the time, the 2 most influential hypotheses regarding etiology were, first, compression of the lower trunk of the brachial plexus by a cervical or first rib, and second, compression of the thenar branch of the median nerve as it passes beneath the anterior annular ligament of the wrist. The condition was named syndrome of partial thenar atrophy and was considered a distinct clinical entity. In 1946, after extensive analysis, neurologist Walter Russell Brain concluded that both sensory and motor symptoms of the syndrome were caused by "compression neuritis" of the median nerve in the carpal tunnel. At his suggestion, surgeon Arthur Dickson Wright performed decompression of the nerve by "an incision of the carpal ligament," with excellent results. Brain presented this work at the Royal Society of Medicine in London in 1946 and published his landmark paper in Lancet the following year. In so doing, he established the basis for the disease we know today as idiopathic carpal tunnel syndrome. Unfortunately, in 1947, Brain did not realize that another "condition" with the same clinical picture but without atrophy of the thenar muscles, known as acroparesthesia at the time, was actually the same disease as syndrome of partial thenar atrophy, but of lesser severity. As a result of Brain's influence, 7 other papers were published by 1950. Between 1946 and 1950, there were at least 10 papers that presented, in total, 31 patients (26 women) who exhibited symptoms of compression of the median nerve without an identifiable cause and underwent section of the transverse carpal ligament.

This Landscape review represents our summary of what makes a great collaboration between a surgeon and a scientist. At first, with no perspective, such a collaboration seems easy and natural. But as time goes on, with more perspective, you realize how special it is. Now, in our 60s, with ~35 years of collaboration and 75 coauthored papers (most of them in The Journal of Hand Surgery), we are both thankful and humbled for this tremendously fruitful and, importantly, very fun collaboration. We are not so foolish to think that we made this great collaboration—it was a gift. However, we now recognize many of the characteristics that make it great and have developed the following ten tips.

Purpose The first carpometacarpal (CMC) joint is a frequent location of osteoarthritis in the hand. The denervation of the first CMC joint has gained traction as a viable treatment for CMC arthritis. This study reviewed literature on CMC denervation for first CMC arthritis. Methods A systematic review of papers and abstracts was conducted. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Articles including the results of CMC denervation were included. We compiled data on patient demographics, preoperative testing , intraoperative technique, and postoperative outcomes. Anatomic literature was also reviewed to assess agreement on the innervation of the first CMC joint. Results Six anatomic studies and 9 clinical studies were included in this systematic review. Pinch strength, grip strength, and Kapandji scores increased on average in patients. Pain relief was noted on average in patients in 5 studies that reported pain outcomes. In studies that reported postoperative complications , the most frequent complications were radial paresthesias, hypoesthesia dorsal and/or distal to the surgical site, and wound infection. Conclusions The innervation of the CMC joint is controversial. This is reflected in clinical practice, wherein varied surgical approaches are used. Carpometacarpal denervation shows promise as an option to treat patients with CMC arthritis without joint instability , but its results vary. Additional clinical studies with longer-term follow-up and control groups are necessary to better determine its longevity and efficacy. Type of study/level of evidence Therapeutic V.

Nontraumatic neuropathies of the upper limb are rare in children. In this paper, we present the latest updates in this field and also critically review the diagnosis and treatment of nerve compression syndromes in children. This review describes the most common manifestations including idiopathic carpal tunnel syndrome (CTS), CTS occurring as a component of lysosomal storage diseases (mucopolysaccharidosis) and hereditary neuropathies, ulnar nerve neuropathy, and atraumatic radial nerve neuropathies.

Tendon injuries are encountered after major and minor hand trauma. Despite meticulous repair technique, adhesion formation can occur, limiting recovery. Although a great deal of progress has been made toward understanding the mechanism of tendon healing and adhesions, clinically applicable solutions to prevent adhesions remain elusive. The goal of this paper is to review the most recent literature relating to the tendon healing and adhesion prevention.

Purpose Wrist fusion provides a solution to the painful, arthritic wrist, and can be concomitantly performed with or without a proximal row carpectomy (PRC). The benefits of combining a PRC with fusion include a large amount of local bone graft for fusion and a lower number of joints needed to fuse. We hypothesized that wrist fusion combined with PRC will have a higher fusion rate than wrist fusion performed without PRC. Methods A systematic review was performed to identify all papers involving wrist arthrodesis using the following databases: PubMed, Ovid, Scopus, Web of Science, and COCHRANE. A literature search was performed using the phrases “wrist” OR “radiocarpal” and “fusion” OR “arthrodesis”. Inclusion criteria included complete radiocarpal fusion performed for rheumatoid, posttraumatic, or primary arthritis; union rates available; English-language study. Studies were excluded if case reports; diagnoses other than the ones listed previously; inability to abstract the data. Data collected included wrist fusions with PRC or without PRC, union rate, patient age, underlying diagnosis, and method of fixation. Results A total of 50 studies were included in the analysis. There were 41 studies with no PRC, 8 studies with PRC, and 1 study with and without PRC. There were 347 patients with a PRC and 339 patients had a successfully fused wrist (97.7%). There were 1,355 patients who had a wrist fusion with no PRC, and1,303 patients had successful wrist fusion (96.2%). The difference in fusion rate between the 2 groups, 97.7% versus 96.2%, was not statistically significant. Conclusions There is no statistically significant difference with regards to union rate in wrist fusion with a PRC versus wrist fusion without a PRC. Type of study/level of evidence Therapeutic IV.

© 2021 American Society for Surgery of the Hand Purpose: Whereas the goal of distal radius fracture treatment is anatomical restoration, controversy exists as to whether it is the severity of the disruption of joint alignment at the time of fracture or residual malalignment after healing that determines outcome. The objective of this study was to compare joint contact mechanics bilaterally a minimum of 3 years following a distal radius fracture. Our hypothesis was that 3-dimensional joint space would be reduced in individuals following wrist fracture and that these changes in joint load lead to the development of degenerative arthritis. To test the hypothesis, an interbone spacing algorithm was used to determine whether 3-dimensional joint space and contact mechanics were altered in the distal radioulnar (DRUJ) and radiocarpal joints following a wrist fracture. Methods: In 16 subjects with previous unilateral wrist fractures, 3-dimensional interbone distance (joint space), a measure of joint congruency and 3-dimensional alignment, was quantified from reconstructed computed tomography bone models of the distal radius, ulna, scaphoid, and lunate. Results: At an average of 8 years following fracture, joint interbone spacing area was reduced in the radiolunate joint of the injured wrist in comparison with the uninjured wrist. The joint interbone spacing area was decreased in the DRUJ and radioscaphoid joint of the injured wrist compared with the uninjured wrist but this difference was not statistically significant. Conclusions: This study demonstrates the use of a noninvasive tool that can be used to examine joint loading and suggests that further investigation into the association between altered joint loading and the development of posttraumatic arthritis is needed, especially in the radiocarpal joints. Clinical relevance: This paper provides a noninvasive image-based framework that can be used to examine joint contact area over time and provides preliminary data examining the effect of a distal radius fracture on the joint congruency of the DRUJ and radiocarpal joints.

Double crush syndrome (DCS), as it is classically defined, is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The traditional definition of DCS is narrow in scope because many systemic pathologic processes, such as diabetes mellitus, drug-induced neuropathy, vascular disease and autoimmune neuronal damage, can have deleterious effects on nerve function. Multifocal neuropathy is a more appropriate term describing the multiple etiologies (including compressive lesions) that may synergistically contribute to nerve dysfunction and clinical symptoms. This paper examines the history of DCS and multifocal neuropathy, including the epidemiology and pathophysiology in addition to principles of evaluation and management.

The currently available phalangeal external fixators are either commercial and not universally available or made of Kirschner wires and a linkage mechanism such as rubber bands and cement. They are difficult to assemble and difficult to adjust after application. This paper presents an external fixator made of Kirschner wires and locking balls (better known by their commercial name: Jurgan Balls) that is easily assembled on demand in the operating room. The fixator can be applied statically as well as dynamically allowing motion across the interphalangeal joint. I have applied this fixator in a variety of fracture patterns in a total of 14 patients: 11 phalangeal fractures and 3 metacarpal fractures. The fixator was solid and maintained reduction in all phalangeal fractures. Two thumb metacarpal fractures were adequately fixed. One fourth metacarpal fracture failed fixation during surgery and required a different method of fixation. There was no loss or reduction of any of the fractures in the postoperative period. There were no nonunions and no need for second-stage surgeries. All fixators were removed in the clinic without anesthesia. The described external fixator is made of components that are readily available in most operating rooms. It does not require the use of cement or rubber bands. It allows adjustment during surgery and maintains the reduction throughout the postoperative period. It may be a useful tool for open and/or highly comminuted fractures and fracture subluxations of the proximal and middle phalanges as well as the thumb metacarpal.

Radial head and neck fractures are one of the most common elbow fractures, comprising 2% to 5% of all fractures, and 30% of elbow fractures. Although uncomplicated Mason type I fractures can be managed nonsurgically, Mason type II–IV fractures require additional intervention. Mason type II–III fractures with 3 or fewer fragments are typically treated with open reduction and internal fixation using 2 to 3 lag screws. Transverse radial neck involvement or axial instability with screw-only fixation has historically required the additional use of a mini fragment T-plate or locking proximal radius plate. More recently, less invasive techniques such as the cross-screw and tripod techniques have been proposed. The purpose of this paper is to detail and demonstrate the proper implementation of the tripod technique using headless compression screws.

Current strategies for promoting faster and more effective peripheral nerve healing have utilized a wide variety of techniques and approaches. Nerve grafts, conduits, and stem cell therapy all have their respective advantages. However, there are still some difficulties in attaining complete functional recovery with a single treatment modality. The utilization of adjuvant treatments, in combination with current standard-of-care methods, offers the potential to improve patient outcomes. This paper highlights the current landscape of adjuvant treatments for enhancing peripheral nerve repair and regeneration.

Cervical spondylotic amyotrophy is characterized by severe, proximal upper extremity weakness including an inability to abduct the shoulder and flex the elbow. Treatment using both medical and surgical decompression approaches has produced variable results. This paper reports the use of nerve transfers (spinal accessory to suprascapular, flexor carpi ulnaris fascicle of ulnar to biceps motor branch, radial nerve branch to triceps to axillary) to restore shoulder and elbow function in a case of unilateral cervical spondylotic amyotrophy involving C5 and C6 myotomes. Evidence of regeneration was observed on electromyography as well as clinically at 5 months postoperatively. At 3 years after surgery, recovery of elbow flexion and shoulder abduction was Medical Research Council grade 4/5 with improved external rotation and considerably improved patient-rated Disabilities of the Arm, Shoulder and Hand scores. We propose that nerve transfers be considered along with other reconstruction modalities in the treatment of cervical spondylotic amyotrophy.

High-quality medical photography plays an important role in teaching and demonstrating the functional capacity of the hands, as well as in medicolegal documentation. Obtaining standardized, high-quality photographs is now an essential component of many surgery practices. The importance of standardized photography in facial and cosmetic surgery has been well documented in previous studies, but no studies have thoroughly addressed the details of photography for hand surgery. In this paper, we will provide a set of guidelines and basic camera concepts for different scenarios to help hand surgeons obtain appropriate and informative high quality photographs. A camera used for medical photography should come equipped with a large sensor size and an optical zoom lens with a focal length ranging anywhere from 14-75mm. In a clinic or office setting, we recommend six standardized views of the hand and four views for the wrist, and additional views should be taken for tendon ruptures, nerve injuries, or other deformities of the hand. For intra-operative pictures, the camera operator should understand the procedure and pertinent anatomy in order to properly obtain high-quality photographs. When digital radiographs are not available, and radiographic film must be photographed, it is recommended to reduce the exposure and change the color mode to black and white to obtain the best possible pictures. The goal of medical photography is to present the subject in an accurate and precise fashion.

The classic donor motor units for opponensplasty are the flexor digitorum superficialis, the extensor indicis proprius, the palmaris longus, and the abductor digiti minimi. Occasionally, all classic donor motor units are not available for the opponensplasty; a review of the literature revealed that the flexor carpi ulnaris opponensplasty has not been previously described. The surgical technique of the split flexor carpi ulnaris opponensplasty is described in the current paper along with a clinical example. The result in our patient was satisfactory with the ability to oppose the thumb tip to reach the tip of the ring finger with the wrist in neutral position.

The field of hand surgery is constantly evolving to meet the challenges of repairing intricate anatomical structures with limited availability of donor tissue. The past 10 years have seen an exponential growth in tissue engineering, which has broadened the perspectives of tackling these age-old problems. Various fabrication techniques such as melt electrospinning and fused deposition modelling have been employed to synthesize 3-dimensional bioscaffolds that can be used to replace lost tissue. These bioscaffolds with strategic biomimicry have been shown to allow for integrative and functional repair of tissue injuries. This review article summarizes the most current advances in tissue engineering and its applications in the field of hand surgery. It outlines the current tissue engineering techniques commonly used for tackling musculoskeletal problems and highlights the most promising approaches according to clinical evidence. In particular, the paper explores regenerative medicine concepts applied to specific tissues including nerve, bone, cartilage, tendon, ligament, and vessels. In the face of innovative and pioneering research, tissue engineering will undoubtedly play a key role in reconstructive hand surgery in the not too distant future.

Enthesopathy of the extensor carpi radialis brevis, often referred to as "tennis elbow," is common and responds to nonsurgical treatment in 80% to 90% of patients within 1 year. For those who proceed with surgery, much remains unclear regarding the ideal treatment. This paper discusses controversies in surgical management of extensor carpi radialis brevis enthesopathy including clinical outcomes of open versus arthroscopic techniques, the relevance of concomitant pathology addressed arthroscopically, and avenues for assessing comparative cost data.

Reported outcomes of trapeziometacarpal (TM) arthrodesis have been contradictory. The purpose of this paper is to review the long-term results of TM arthrodesis for arthritis with respect to clinical outcomes, union, development of adjacent joint arthritis, and complications.A retrospective review of TM arthrodeses performed between 1970 and 2003 was undertaken. Among a total of 241 arthrodeses performed, 126 thumbs in 114 patients (79 women, 35 men) treated for osteoarthritis were available for follow-up evaluation. Pre- and postoperative clinical and radiographic data were reviewed. The average age was 57 years (range 32-77). The dominant hand was involved in 76 cases. Supplemental bone graft was used in 90 thumbs. Preoperative appositional (key) pinch, oppositional (tip) pinch, and grip strengths were 3.0 kg, 2.7 kg, and 14 kg, respectively. The average pain score on a scale of 0-10 was 6.6 (range 4-10). The average follow-up was 11.2 years (range 3-28 years).There were 17 nonunions. No correlation existed between the incidence of nonunion and the use of supplemental bone graft. Nine of 17 thumbs had re-operation, including revision arthrodesis (6) and interposition or suspensionplasty (3). The appositional pinch, oppositional pinch, and grip strengths improved to 5.9 kg, 5.4 kg, and 23 kg, respectively (p.01). The average pain score improved to 0.4 (p.01). Radiographic progression of scaphotrapeziotrapezoid arthritis occurred in 39 cases; however, only 8 of these were symptomatic. Development of metacarpophalangeal arthritis was noted in 16 thumbs; none have been clinically relevant.For most patients TM arthrodesis reduces pain, improves function and results in excellent patient satisfaction. Despite the development of metacarpophalangeal and scaphotrapeziotrapezoid joint arthritis, intervention for these joints was rarely warranted.Therapeutic IV.

Evaluation of vascular disorders of the upper extremity requires an anatomic and functional approach. The combination of a good history and physical examination, laboratory testing, and specialized vascular laboratory studies will help detect any underlying collagen vascular disease or coagulopathy and provide physiologic-specific and patient-oriented management. This paper reviews the currently available noninvasive modalities for the evaluation of upper-extremity perfusion.

Mangled upper extremity, as a result of trauma, is a life-altering event requiring a multidisciplinary approach for a successful outcome. All attempts are made to salvage the extremity and preserve function, which may require multiple complex procedures. This paper discusses the importance of a systematic reconstructive sequence and provides a review of commonly utilized techniques, supported with illustrative cases.

Nonunions of the upper extremity are a source of significant morbidity and can be difficult to treat. This paper describes a sliding bone graft technique that offers several significant advantages over other techniques for nonunions.

The fingertip is the most commonly injured part of the hand. When replantation of a fingertip amputation is not possible, flap reconstruction may be necessary for a functional and aesthetically pleasing outcome. This paper reviews commonly utilized reconstruction techniques with a focus on technical tricks and potential complications and how to avoid them, with illustrative cases.

Purpose To determine whether vibratory stimulation would decrease pain experienced by patients during corticosteroid injection for trigger finger. Methods A total of 90 trigger finger injections were randomized to 1 of 3 cohorts. With the injection, patients received no vibration (control group), ultrasound vibration (sham control group), or vibration (experimental group). We used a commercial handheld massaging device to provide a vibratory stimulus for the experimental group. We obtained visual analog scale (VAS) pain scores before and after injection to assess anticipated pain and actual pain experienced. Results Anticipated pain and actual pain did not differ significantly among groups. Anticipated VAS pain scores were 45, 48, and 50 and actual VAS pain scores were 56, 56, and 63 for the vibration, control, and sham control groups, respectively. When normalized using anchoring VAS pain scores for "stubbing a toe" or "paper cut," no between-group differences remained in injection pain scores. Conclusions Concomitant vibratory stimulation does not reduce pain experienced during corticosteroid injections for trigger finger. Type of study/level of evidence Therapeutic I.

We describe a new principle for artificial sensibility of the hand based on sense substitution, using hearing as substitution for loss of sensation. The experiments were performed on 3 patients who had recently undergone isolated median nerve repair, 1 patient with replantation of an amputated forearm, 1 patient using a myoelectric prosthesis, and 4 patients using cosmetic prostheses. Small condenser microphones were mounted dorsally on the distal phalanges of multiple fingers of the nonsensate hands or prostheses. The friction sound, reflecting the vibrotactile stimuli generated by the moving touch of the objects, was picked up by the microphones and processed in a stereo amplifier that separated signals from individual fingers into different channels. The signals were transmitted to earphones, making possible a spatial resolution that enabled identification of each finger by the generated acoustic stimuli. Since the friction sound is characteristic of specific surfaces and textures, the corresponding acoustic stimuli made possible identification of different textures, such as glass, metal, wood, and paper, without using vision. We conclude that sense substitution using specifically processed acoustic stimuli as a substitute for sensation may represent a useful principle for generation of artificial sensibility in prostheses or hands lacking sensibility due to lesions in the peripheral or central nervous system or because of neurologic disease.

In this systematic review, we examined the available evidence regarding compartment syndrome of the forearm. Applying our inclusion criteria, we found 12 articles for a total of 84 cases using the MEDLINE (Ovid) database. All were retrospective studies (level IV evidence). In this study, papers were analyzed for causes, diagnosis, treatment, methods of wound closure, functional outcome, and complications. The most common cause of compartment syndrome of the forearm in children was a supracondylar fracture, while in adults the most common cause was a fracture of the distal radius. The diagnostic criterion used was clinical assessment alone in 48%, and in 52%, a combination of measurement of intracompartmental pressure and clinical assessment was used. The intracompartmental pressure was measured using various techniques including a wick catheter, slit catheter, the Whitesides technique, and the Stryker compartment pressure measuring device. Fasciotomy was the preferred method of treatment (73%). In cases reporting wound management, postfasciotomy skin grafting was needed in 61% of the cases, whereas secondary closure was performed in 39% of the cases. Neurological deficit was the most common complication (21%).

The correction of type II and III typical cleft hands can be complicated because each hand can contain a variation of congenital problems including syndactyly, camptodactyly, thumb hypoplasia, deficiency of the first web space, abnormal phalanges, maligned joints, and abnormal intrinsic muscles and extrinsic tendons. The most difficult problem is the index ray, which lies in a "no man's land" between the central cleft and the mobile thumb. Presented in this paper is a technique for correction and transposition of the index ray through a simple incision, which separates the glabrous from the dorsal skin surfaces. Skeletal alignment must be precise. Preservation of the adductor pollicis muscle, if present, is crucial to a functional pinch. Long-term problems such as persistent radial deviation of the index finger and unyielding flexion contractures can be avoided.

Purpose The purpose of this study was to evaluate the long-term clinical results of a proximal row carpectomy with an average 15-year follow-up for the primary treatment of advanced-stage (Lichtman IIIA and IIIB) Kienbock's disease. This study is a follow-up to a paper by the senior author in a similar cohort of patients where the clinical results of a proximal row carpectomy were evaluated for the treatment of advanced-stage Kienbock's disease at an average 3-year follow-up. Methods Seventeen patients with a minimum of 10 years of follow-up were identified who met criteria for inclusion. Thirteen of these patients were located and agreed to participate. Patients were seen, examined, and queried regarding their wrists. Range of motion, grip strength, and subjective patient satisfaction were all obtained and quantified using a clinical outcomes scale. Results Twelve of 13 patients demonstrated excellent or good results based on the clinical outcomes scale used (5 excellent, 7 good, 1 fair, and none poor). Total arc of motion averaged 73% of the uninvolved side. Grip strength averaged 92% of the uninvolved side. Compared with preoperative values, range of motion improved an average of 16% and grip strength improved an average of 129%, an overall average improvement of 12° and 18 kg, respectively. At the most recent follow-up, all patients remained employed. Seven patients held manual labor positions, 2 were nurses, and 4 were employed in sedentary vocations. All patients demonstrated some degree of degenerative changes, usually localized to the radiocapitate articulation in the lunate fossa. Clinical results did not correlate with radiographic degeneration. Conclusions This study demonstrates proximal row carpectomy to be a reliable motion-preserving procedure with good clinical results maintained out to an average of 15 years postoperatively. Type of study/level of evidence Therapeutic IV.

Purpose This was an intraoperative anatomical study to identify the prevalence of variations in the motor branch of median nerve and to correlate these with the presence of a transverse carpal ligament (TCL) with superficial or interposed muscle. Methods Over a period of 12 years in 1400 consecutive patients in whom the carpal tunnel was opened for any reason, observations were made in each hand to (1) determine the presence or absence of muscle fibers lying superficial to or within the TCL and (2) identify the anatomic branching patterns of the motor branch of median nerve. The primary objective was to ascertain whether the appearance of the TCL could be used to predict the anatomy of the motor branch. Results A normal motor branch arising beneath a purely ligamentous TCL was found in 1011 hands (72%). The focus of this paper is on the remaining 386 hands (28%), in which muscle fibers were found lying superficial to or within the TCL; in this group, only 29 hands (8%) had a normal motor branch. An anomalous motor branch was found in 93% of hands with a TCL with superficial or interposed muscle fibers and in less than 1% of hands with a purely ligamentous TCL. Conclusions In exposing the carpal tunnel, special care should be taken by the surgeon to identify and protect the motor branch when muscle fibers are encountered superficial to or within the TCL.

Hand signs (called mudras in Sanskrit) play an important role in Buddhist art. They represent specific events from the life of Sidharta Gautama, the founder of Buddhism. These events symbolize moral principles important to the discipline. There are six important hand signs: (1) dhyana mudra, (2) varada mudra, (3) abhaya mudra, (4) vitarka mudra, (5) dharmachakra mudra, and (6) bhumispara mudra. The use of these hand signs was popularized by Buddhist universities in India around the 4th or 5th century ad. This paper will examine the symbolism behind the six main hand signs and reveal their message, which will be valuable for modern society.

Indications for small joint arthroscopy in the hand remain poorly understood. This is due to a paucity of papers discussing this technique in the literature, as well as inadequate hands on training in the pearls and pitfalls regarding this application within the commonly used "scope" of arthroscopy. Despite the fact that small joint arthroscopes have been available for over a decade, hand surgeons have been slow to adopt this technique within their treatment armamentarium for the treatment of both traumatic and degenerative conditions involving the thumb and the digital metacarpophalangeal joints. A proposed arthroscopic classification for basal joint osteoarthritis provides additional clinical information and can direct further treatment depending on the stage of disease. This chapter will also review the brief history of trapeziometacarpal arthroscopy and provide insight as to how this technique can be incorporated into a treatment algorithm in managing this common affliction. Metacarpophalangeal joint arthroscopy is even less commonly used, while traumatic and overuse injuries are frequently seen in the thumb, and present an ideal indication in certain scenarios. Painful conditions affecting the metacarpophalangeal joints of the fingers are less commonly seen, yet the small joint arthroscope presents a much clearer picture of the present pathology compared to other imaging techniques or even open, and potentially deleterious, surgery. The application of this technology to the smaller joints will soon make the treating surgeon realize that a myriad of pathologies are readily visible and can augment treatment, as well as diagnosis. Similar to the wrist, small joint arthroscopy may one day supplant imaging techniques such as MRI or CT in establishing an accurate diagnosis.

Purpose The real utility of needle electromyography (EMG) for evaluation of infants with obstetric brachial plexopathy remains controversial. The objective of this paper is to evaluate how EMG correlates with clinical evaluation of these patients. Methods We performed EMG in 41 infants (42 arms) with severe obstetric brachial plexopathy who were from 3 to 12 months of age. We correlated the EMG interference pattern with the clinical assessment of infraspinatus, deltoid, biceps, triceps, and extensor digitorum communis muscles. Results Motor unit potentials were always present, and abnormal spontaneous activity was not common in proximal muscles. The correlation between EMG interference pattern and clinical assessment was not good, except for extensor digitorum communis. EMG showed higher scores than clinical evaluation for infraspinatus, deltoid, and biceps muscles. Respiratory synkinesis was present in 19 patients, or 45% of the affected arms, and it could involve any muscle innervated from C5 to T1. Conclusions Needle EMG fails to estimate or overestimates clinical recovery in proximal muscles in this age group. Type of study/level of evidence Prognostic III.

This paper is a brief history of The Journal of Hand Surgery from its founding in July 1976 through the third issue published in July 1999. An analysis of the 3,713 scientific articles published is done relative to type, content, and country of origin. The persons responsible for the journal are named and other features of the Journal are discussed. (J Hand Surg 2000;25A:5–13. Copyright © 2000 by the American Society for Surgery of the Hand.)

When a study concludes that there is no difference between 2 treatments ("negative studies"), it is essential to determine whether the study has sufficient power to find a clinically significant difference. Insufficient power precludes an adequate assessment of therapeutic efficacy and may result in a type II error, an erroneous conclusion that the null hypothesis is correct. In evaluating 39 studies that highlighted negative findings in The Journal of Hand Surgery, we found that 32 (82%) papers had a power of less than .80 to detect a 25% treatment effect and, when the treatment effect was increased to 50%, more than one half of the studies still had a power of 0.80. These "negative studies" frequently have inadequate statistical power to support their conclusions. These findings have important implications for researchers, editors, and readers.

This paper stresses the importance of central slip attenuation in the management of Dupuytren's contracture. Such attenuation occurs in patients who have had prolonged proximal interphalangeal joint contractures and is a common problem when the flexion contracture exceeds 60°. The diagnosis can be made at the time of surgical correction by a tenodesis test. If central slip attenuation is confirmed, the postoperative regime described here will give a better correction of what at first might appear to be an intractable proximal interphalangeal joint flexion deformity.

The mixed connective tissue disease syndrome has been described in the medical literature. The clinical and serological characteristics of the syndrome are defined in this paper. The hands of these patients differ from the hands of patients with systemic lupus, rheumatoid arthritis, or systemic sclerosis. In 10 patients there were no erosive changes on radiological examination and all 10 patients had Raynaud's phenomenon. The most striking finding was tightness in the flexors. Mild cases of flexor tightness improved with systemic steroids. One patient with severe flexor tightness required surgical release of adhesions from a chronic inflammatory process of fascia, muscle, and tenosynovium. Biochemical studies showed an abnormal collagen pattern that may be distinct for mixed connective tissue disease.

If a dorsal rotational flap is chosen for reconstructive resurfacing of a moderate thumb-index flexion-adduction web contracture release, the design advised in this paper is advocated as the most physiologic use of skin with least torsion on the pedicle base. The key to the procedure is designing the pedicle to cross the axis of motion of the pedicle tip on one side, preferably the thumb, and the pedicle base on the opposite side.

This paper discusses the potential roles of work pace and work pressure as risk factors in the development of cumulative trauma disorders. Specifically, electromyographic (EMG) data were collected from the forearm flexor muscles of workers performing a highly repetitive task. This task had previously been identified as one that involved a high incidence of cumulative trauma disorders. Workers were asked to increase and decrease their work pace for short periods of time. The EMG data indicated that faster work paces were accompanied by higher forces. However, it was also noted that unsuccessful attempts to speedup or slowdown produced similar increases and decreases in EMG activity, indicating that speed of movement was not the only factor contributing to the changes in muscular activity. The results are discussed in relation to the stress and tension associated with work pressure caused by machine pacing, production standards, and incentive systems.

The use of electrophysiological techniques as an adjunct in the surgical repair of peripheral nerve injuries can improve the quality of the repair and thus the degree of functional recovery. These techniques provide objective information needed to assess the degree of injury and can assist the surgeon in making proper decisions regarding treatment of peripheral nerve lesions. The purposes of this paper are to review: (1) the current theories of the functions of peripheral nerves and their and organs, (2) the development of electrophysiological techniques, (3) the principles involved in their use, and (4) the present and possible future applications of these techniques in peripheral nerve surgery and to outline them.

Surgical excision of a ganglion on the dorsum of the wrist is usually a benign procedure. The most frequent complications are transient postoperative stiffness and recurrence of the ganglion. This paper reports the development of a rotatory subluxation of the scaphoid after the manipulation of the wrist of a patient who had developed postoperative stiffness after the surgical excision of a dorsal wrist ganglion. This unusual complication was successfully treated by closed pinning under radiographic control followed by immobilization in palmar flexion. Manipulation of the wrist for the management of postoperative stiffness is rarely, if ever, indicated. Limitation of motion of a wrist without underlying structural changes is best managed by gentle, gradual splinting, both static and dynamic. It is suggested that preoperative x-rays should be obtained as part of the routine workup for a dorsal wrist ganglion.

ThiS paper reports our experience in the case of a malignant hemangioendothelioma in the subcutaneous tissues surrounding the radial neurovascular bundle at the base of the index finger in a 16-year-old Caucasian girl. The diagnosis was made after operation from the biopsy material. Index-ray amputation was performed and the patient was alive and well without local recurrence or distal metastasis 4 years after the operation.