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Health care systems, including operating rooms, are a considerable contributor to environmental waste. Given ongoing concerns regarding water scarcity in the United States and worldwide, action to reduce water utilization should be taken. Traditional water-based hand scrubbing wastes an estimated 11 L of water per scrub. Waterless hand rubbing with an alcohol-based solution has been shown to be as effective as traditional water-based hand scrubbing in surgical hand antisepsis and in preventing surgical site infections. Furthermore, alcohol-based rubbing results in less waste and reduced costs when compared with water-based hand scrubbing. The hand surgery operating room, including minor procedure rooms, serves as an opportunity to decrease water use and reduce the environmental impact of our field. Waterless alcohol-based hand rubbing for antisepsis may also be an opportunity to save money and provide value-based care to our patients., Competing Interests: Conflicts of Interest Dr R. Glenn Gaston has Biomet IP royalties, is paid consultant for Hanger Clinic, Integra, Restor3d, Stryker, Checkpoint Surgical, Enovis and is also a Board/committee member of American Association for Hand Surgery and American Society for Surgery of the Hand. No benefits in any form have been received or will be received by other authors related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Wrist arthroscopy is considered the gold standard for diagnosis of intra-articular wrist conditions including triangular fibrocartilage complex (TFCC) tears; however, the ability to reliably diagnose TFCC pathology during wrist arthroscopy is unclear. The purpose of this study was to assess the reliability of the diagnosis of TFCC tears on wrist arthroscopy videos., Methods: Five hand surgeons reviewed 43 cases on a secure web-based platform at two time points separated by 4-6 weeks. Each case included a deidentified clinical vignette and wrist radiographs with ulnar variance measurements and an arthroscopy video of ulnar wrist pathology, averaging 42 seconds. Surgeons were queried on the presence of TFCC tear and Palmer and Atzei classifications. Interobserver/intraobserver reliabilities were determined using kappa coefficients., Results: The interobserver reliability regarding the presence/absence of TFCC tear was fair-good, with kappa coefficients of 0.596 in the first round of case review and 0.708 in the second round. The overall intraobserver reliability for the presence/absence of TFCC tear was also fair-good, with a kappa coefficient of 0.567. For cases with central TFCC tears, the interobserver reliability regarding the presence of TFCC tear was perfect, with a kappa coefficient of 1.0. When central tears were excluded, the kappa coefficients decreased to 0.322 and 0.368 in each round. The interobserver reliability for the Palmer and Atzei classifications was low, with kappa coefficients of 0.220 and 0.121 in the first round and 0.222 and 0.123 in the second round., Conclusions: Experienced wrist arthroscopy surgeons demonstrated fair-good interobserver reliability for the diagnosis of TFCC tear on wrist arthroscopy. However, when central TFCC tears were excluded, interobserver reliability was poor. These findings demonstrate a need for a focus on education for wrist arthroscopy anatomy., Clinical Relevance: This investigation demonstrated poor agreement in surgeon identification and classification of TFCC tears, aside from central TFCC tears. The low reliability has a direct bearing on treatment considerations for TFCC tears., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Conventional teaching in the management of partial hand amputations prioritizes residual limb length, often through local, regional, or distant flaps. While multiple options exist to provide durable soft tissue coverage, only a few flaps are thin and pliable enough to match that of the dorsal hand skin. Despite debulking, excessive soft tissues from previous flap reconstructions can interfere with residual limb function, prosthesis fit, and surface electrode recording for myoelectric prostheses. With rapid advances in prosthetic technology and nerve transfer techniques, patients can achieve very high levels of function following prosthetic rehabilitation that rival, or even outpace, traditional soft tissue reconstruction. Therefore, our reconstruction algorithm for partial hand amputations has evolved to the thinnest coverage possible, providing adequate durability. This evolution has provided our patients with faster and more secure prosthesis fitting with better surface electrode detection, enabling earlier and improved use of simple and advanced partial hand prostheses., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: This study investigated metacarpal fracture occurrences, characteristics, treatments, and return-to-play times for National Football League (NFL) athletes., Methods: NFL players who sustained metacarpal fractures during the 2012 to 2018 seasons were reviewed. All players on the 32 NFL team active rosters with metacarpal fractures recorded through the NFL Injury Database were included. Player age, time in the league, player position, injury setting, injury mechanism, fractured ray, management, and return-to-play were recorded., Results: There were 208 injury occurrences resulting in 1 or more metacarpal fractures, identified in 205 players. Of these, 81 (39%) injuries were operated. Return-to-play data were available for 173 (83%) injured players. The median return-to-play time for all athletes was 15 days (interquartile range, 1-55 days). Of the injured players, 130 (71%) missed time but returned the same season. Within this 130-player subset, 69 (53%) were treated nonsurgically and 61 (47%) operatively with median return-to-play times of 16 days (interquartile range, 6-30 days) and 20 days (interquartile range, 16-42 days) respectively. Eighteen individuals in this 130-player subgroup sustained a thumb metacarpal fracture. The return-to-play time was slower for patients sustaining thumb metacarpal fractures compared to other metacarpal fractures, and was significantly longer (median, 55 days) following nonsurgical treatment of thumb fractures compared with operative intervention (median, 24 days). A regression analysis revealed no trend or difference in return to football with respect to player age, time in the league, injury setting (practice vs game), injury mechanism, articular involvement, multiple concomitant injuries, or player position., Conclusions: Most NFL players who sustain metacarpal fractures miss less than 3 weeks and return to play the same season. The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The ideal method of central slip reconstruction is difficult to determine due to the multitude of techniques, nonstandardized outcome reporting, and small patient series in the literature. Although most boutonniere deformities may be treated with nonsurgical measures, chronic, subacute, or open injuries may require operative intervention. To aid surgeons in the choice of the ideal central slip reconstruction method, this biomechanical study compared the 3 most common methods performed at our institution: direct repair, lateral band centralization, and distally-based flexor digitorum superficialis (FDS) slip repair., Methods: A boutonniere deformity was induced in 35 fresh-frozen cadaver digits. The central slip was repaired in 9 digits using a primary suture repair, in 9 digits using a lateral band centralization technique, and in 9 digits using a distally-based FDS slip reconstruction. A control group without injury was tested in 8 digits. Following repair or reconstruction, each digit was tested for load to failure, strain, and stiffness at the repair., Results: The average load to failure after central slip reconstruction was significantly greater for a distally based FDS slip method at 82.1 ± 14.6 N (95% CI, 62.2-101.9 N) than all other repair types. Although the FDS slip reconstruction was not as strong as the intact state (82.1 N vs 156.2 N, respectively), it was 2.6 times stronger than the lateral band centralization (82.1 N vs 31.6 N, respectively) and 3 times stronger than a primary repair (82.1 N vs 27.6 N, respectively)., Conclusions: Reconstruction of the central slip using a distally-based FDS slip provided the greatest biomechanical strength compared with the direct repair or lateral band centralization., Clinical Relevance: The use of a distally based reconstruction using FDS may allow for safer early motion., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Multiple techniques are described for repair of zone I flexor tendon injuries, many of which are fraught with complications. This study evaluated the clinical complications after a transosseous repair technique., Methods: A retrospective review of a single institutional database identified all zone I flexor digitorum profundus (FDP) injuries repaired using a transosseous technique. In this technique, 2 nonabsorbable sutures were passed from volar to dorsal through transosseous tunnels and tied dorsally over the distal phalanx proximal to the germinal matrix. Demographics, injury characteristics, operative details, and complications were reviewed., Results: Eight patients met the inclusion criteria. Average age was 31 years (range, 15-66 years) and all patients were male. Eight fingers were included: ring (4), small (3), and middle (1). Seven injuries were closed and one was open. Average time between injury and surgery was 13 days (range, 4-34 days). Five patients experienced complications, including osteomyelitis, chronic draining granuloma, and abnormal nail growth. Three patients required an additional operative procedure for management of complications., Conclusions: Transosseous repair of zone I flexor digitorum profundus injuries with a buried dorsal suture is associated with a high rate of clinical complications., Type of Study/level of Evidence: Therapeutic V., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Health care is an important contributor to environmental waste. In 2013, the health care sector was responsible for substantial fractions of national air pollution emissions and impacts, including acid rain (12%), greenhouse gas emissions (10%), smog formation (10%), air pollutants (9%), stratospheric ozone depletion (1%), and carcinogenic and noncarcinogenic air toxins (1% to 2%). Operating rooms produce between 20% and 70% of total hospital waste. Hand surgery, with short, high-volume cases, is a notable contributor to this environmental and subsequent financial burden. This article aims to highlight the Lean and Green initiative proposed by the American Association for Hand Surgery along with the American Society for Surgery of the Hand, the American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery in 2015, to reduce the amount of waste generated by hand surgery. We have reviewed the literature to propose multiple ways to reduce both material and nonmaterial waste-energy consumption, sterilization techniques, reprocessing of devices, patient transportation, production of surgical supply, anesthesia, and sanitation in hand surgery., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Targeted muscle reinnervation (TMR) is a surgical technique that improves modern myoelectric prosthesis functionality and plays an important role in the prevention and treatment of painful postamputation neuromas. Originally described for transhumeral amputations and shoulder disarticulations, the technique is being adapted for treatment of transtibial, transfemoral, transradial, and partial hand amputees. We describe a new technique for forearm TMR following transradial amputation with an emphasis on selecting nerve transfer patterns, managing sensory nerves, improving terminal soft tissue coverage, and employing pattern recognition technology., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Nitinol memory compression staples are a recent addition to carpal bone fixation. Compared with traditional staples, they have been shown to have superior compression at the far cortex relative to standard and traditional compression staples. The purpose of this study was to (1) determine the effective leg length of different nitinol staples, (2) confirm the effect of 1 versus 2 staples on biomechanical compression, and (3) determine the effect of troughing (countersinking the staple into bone) the bone on staple biomechanical properties., Methods: Three commonly used nitinol staples of various bridge and leg lengths were used in a bicortical sawbones block construct. There were 3 separate constructs tested, which included single staple, double staple, and troughed. We measured compression force, stiffness, and bending strength for each construct before and after cyclical 4-point bending. Compression mapping was used to determine the effective leg length of each staple, which included the distance that compression extended beyond the tips of the staple legs., Results: Effective leg length for each staple construct extended 2 mm distal to the tip of the shortest staple leg. Two staple constructs more than doubled compressive force and increased bending strength by greater than 90% in all staple types. There was no loss of compressive force before or after loading for single, double, or troughed constructs with any staple type., Conclusions: This study supports that nitinol staples do not have to be placed bicortically to achieve adequate compression; placing staples 2 mm short of the far cortex has the same compression as bicortical placement; and troughing of the bone will not significantly diminish the biomechanical properties of the construct., Clinical Relevance: Better understanding of the effective leg length of nitinol staples provides support that bicortical placement is not necessary for adequate compression. This study supports troughing bone to minimize implant prominence., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Control of independent digital flexion and extension has remained an elusive goal in myoelectric prosthetics for upper extremity amputees. We first performed a cadaver study to determine the feasibility of transferring the interossei muscles for each digit to the dorsum of the hand without damaging the neurovascular pedicles. Once this capability was ensured, a clinical case was performed transferring the interossei of the middle and ring fingers to the dorsum of the hand where they could serve as a myoelectric signal for a partial hand amputee to allow individual digital control with a myoelectric prosthesis. Before surgery, it was impossible to detect an independent signal for each interossei; however, after the surgery, signals were reliably detected, which allowed these muscles to serve as myosites for finger flexion using a myoelectric prosthesis and move each digit independently. This concept of salvaging innervated and perfused muscles from an amputated part and transferring them into the more proximal and superficial portion of a salvaged limb has broad applications for improved myoelectric prosthetic control., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Advances in motor vehicle safety, trauma care, combat body armor, and cancer treatment have enhanced the life expectancy and functional expectations of patients with upper-extremity amputations. Upper-extremity surgeons have multiple surgical options to optimize the potential of emerging prosthetic technologies for this diverse patient group. Targeted muscle reinnervation is an evolving technique that improves control of myoelectric prostheses and can prevent or treat symptomatic neuromas. This review addresses current strategies for the care of patients with amputations proximal to the wrist with an emphasis on recent advancements in surgical techniques and prostheses., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: In an effort to improve fracture healing and decrease the need for autologous bone graft, products such as recombinant human bone morphogenetic protein (rhBMP-2) have been developed and used in both spine and nonspine surgery. There is a paucity of literature regarding the use of rhBMP-2 in scaphoid nonunion surgery with very little reporting on the complications associated with its use. The objective of this study was to retrospectively review the complications documented for a case series of patients treated with revision fixation, bone graft, and rhBMP-2 in revision scaphoid nonunion surgery., Methods: We retrospectively reviewed 6 cases of scaphoid nonunion revision surgery comprising open reduction and internal fixation (ORIF). All cases were performed for persistent nonunion after a previous scaphoid ORIF. All patients were treated with revision screw fixation, bone graft, and rhBMP-2. Union was determined by computed tomography in all cases. Complications of nonunion, heterotopic bone formation, delayed wound healing, functional loss of motion, and need for revision surgery are reported., Results: Between 2011 and 2014, 6 cases in which rhBMP-2 was used in revision scaphoid nonunion surgery were identified. All patients had failed an initial attempt at ORIF after delayed union or nonunion. The time from injury to index ORIF ranged from 3 months to 4 years (mean, 24 months). Revision surgery with rhBMP-2 was performed at an average of 6 months from the index ORIF. Of the 6 cases, 2 had resultant persistent nonunion. Both underwent scaphoid excision and midcarpal arthrodesis. Four cases developed notable heterotopic ossification (one of which required revision surgery). One patient had a loss of functional motion after the revision surgery. There were no cases of delayed wound healing. Only one of the 6 patients healed without complications., Conclusions: In this case series, the use of rhBMP-2 in scaphoid nonunions was associated with a higher complication rate than reported in previous studies. Surgeons performing off-label use of rhBMP-2 should be aware of the potential for complications including heterotopic ossification., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate efficacy and safety of concurrent administration of 2 collagenase clostridium histolyticum (CCH) injections to treat 2 joints in the same hand with Dupuytren fixed flexion contractures (FFCs)., Methods: Patients with 2 or more contractures in the same hand caused by palpable cords participated in a 60-day, multicenter, open-label, phase 3b study. Two 0.58 mg CCH doses were injected into 1 or 2 cords in the same hand (1 injection per affected joint) during the same visit. Finger extension was performed approximately 24, 48, or 72 or more hours later. Changes in FFC and range of motion, incidence of clinical success (FFC ≤ 5°), and adverse events (AEs) were summarized., Results: The study enrolled 715 patients (725 treated joint pairs), and 714 patients (724 joint pairs) were analyzed for efficacy. At day 31, mean total FFC (sum of 2 treated joints) decreased 74%, from 98° to 27°. Mean total range of motion increased from 90° to 156°. The incidence of clinical success was 65% in metacarpophalangeal joints and 29% in proximal interphalangeal joints. Most treatment-related AEs were mild to moderate, resolving without intervention; the most common were swelling of treated extremity, contusion, and pain in extremity. The incidence of skin lacerations was 22% (160 of 715). Efficacy and safety were similar regardless of time to finger extension., Conclusions: Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint, with the exception of skin laceration. The incidence of clinical success in this study after 1 injection per joint was comparable to phase 3 study results after 3 or more injections per joint. Two concurrent CCH injections may allow more rapid overall treatment of multiple affected joints, and the ability to vary the time between CCH injection and finger extension may allow physicians and patients greater flexibility with scheduling treatment., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

This article provides a philosophic overview of the management of athletes at all levels from high school to professional. It further reviews sports-specific injury patterns and position-specific injury patterns. This aspect is crucial, as many injuries may be relatively common for specific sports but rare in the general population, so recognition of these injuries requires a high degree of suspicion. The guiding principles of management are also discussed., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To investigate whether inclusion of the volar plate in repair of flexor digitorum profundus avulsions increases the strength of the repair and resists gapping., Methods: Cadaveric fingers (n = 18) were divided into 3 equal groups. The first technique involved 2 micro-suture anchors only (A). The second used only volar plate repair (VP). The third group was a hybrid, combining a micro-suture anchor with volar plate augmentation (AVP). Specimens were loaded cyclically to simulate passive motion rehabilitation before being loaded to failure. Clinical failure was defined as 3 mm of gapping, and physical failure as the highest load associated with hardware failure, suture breakage, anchor pullout, or volar plate avulsion., Results: Gapping throughout cycling was significantly greater for the A group than VP and AVP with no difference detected between VP and AVP groups. Gapping exceeded 3 mm during cycling of 3 A specimens, but in none of the VP or AVP specimens. Load at clinical and physical failure for A was significantly lower than for VP and AVP, whereas no difference was detected between VP and AVP., Conclusions: In this cadaveric model, incorporating the volar plate conferred a significant advantage in strength, increasing the mean load to physical failure by approximately 100 N., Clinical Relevance: According to previous biomechanical studies, current reconstructive strategies for flexor digitorum profundus zone I avulsions are not strong enough to withstand active motion rehabilitation. We demonstrated the potential use of volar plate augmentation and the prospective advantageous increase in strength in this cadaveric model. In vivo performance and effects on digital motion are not known., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Ulnar impaction syndrome is abutment of the ulna on the lunate and triquetrum that increases stress and load, causing ulnar-sided wrist pain. Typically, ulnar-positive or -neutral variance is seen on a posteroanterior radiograph of the wrist. The management of ulnar impaction syndrome varies from conservative, symptomatic treatment to open procedures to shorten the ulna. Arthroscopic management has become increasingly popular for management of ulnar impaction with ulnar-positive variance of less than 3 mm and concomitant central triangular fibrocartilage complex tears. This method avoids complications associated with open procedures, such as nonunion and symptomatic hardware. The arthroscopic wafer procedure involves debridement of the central triangular fibrocartilage complex tear, along with debridement of the distal pole of the ulna causing the impaction. Debridement of the ulna arthroscopically is taken down to a level at which the patient is ulnar neutral or slightly ulnar negative. Previous studies have shown good results with relief of patient symptoms while avoiding complications seen with open procedures.

We present 3 cases of sesamoid fractures involving the index, ring, and little finger metacarpophalangeal joints. These injuries present similar to more common sprains of the finger metacarpophalangeal joint and may be difficult at times to appreciate on standard posteroanterior and lateral x-rays. Oblique images can aid in making the diagnosis at times. Whereas we still recommend immobilization as the initial treatment for these injuries, all 3 of our cases failed nonoperative management and eventually required sesamoid excision., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Distal condylar phalangeal (DCP) fractures in children are uncommon, but their periarticular location makes them problematic. Malunions are particularly difficult to treat. These fractures are generally thought to have a poor remodeling potential because their location is far from the phalangeal physis. We present 8 cases of DCP malunion in children with a mean 5-year follow-up demonstrating consistent remodeling., Methods: In this study, DCP fractures were defined as those occurring at or distal to the collateral ligament recess of the proximal or middle phalanx in skeletally immature patients. Radiographic parameters examined at the time of established malunion and at final follow-up included coronal and sagittal plane deformity and translational malalignment of the distal fragment in relation to the proximal shaft. Range of motion was measured, and a brief questionnaire was implemented to establish patient satisfaction., Results: We examined 8 patients with a minimum 1-year follow-up (mean, 5.3 y). Average age at injury was 8.8 years (range, 2-14 y). In the sagittal plane, fractures remodeled from an initial mean deformity of 30.9° to 0.0°; in the coronal plane, from 10.5° to 3.9°. Fracture translation in the sagittal plane corrected, as well, from a mean 57.5% at injury to 0.0% at final follow-up. There was no functionally limiting loss of motion of the digit in any patient. Subjectively, only 2 patients complained of cosmetic deformity, both of which were coronal plane deformities of the small finger., Conclusions: In this case series, DCP malunions in children remodeled significantly and completely in the sagittal plane, and all patients had good final range of motion. Furthermore, patients were satisfied with nonsurgical treatment at long-term follow-up. This series describes the remodeling potential of DCP fractures in children, lending support to the previously reported cases. These findings support treating late-presenting pediatric DCP malunions nonsurgically., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the clinical outcomes of scaphoid and triquetral excision combined with capitolunate arthrodesis versus 4-corner (capitate, hamate, lunate, triquetrum) intercarpal arthrodesis., Methods: We retrospectively identified 50 patients with scapholunate advanced collapse wrist changes who had 4-corner arthrodesis. Thirty-four patients were able to return and complete all follow-up evaluations. Patient demographics were similar between the 2 groups. Follow-up evaluation included radiographs, wrist range of motion (flexion-extension, radial-ulnar deviation, and pronation-supination); grip strength; visual analog scale (VAS); and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Complications of nonunion, hardware migration, conversion to wrist arthrodesis or arthroplasty, and pisotriquetral arthritis were recorded., Results: Sixteen patients had capitolunate arthrodesis, and 18 patients had a 4-corner arthrodesis. There was no statistical difference in radial-ulnar deviation, pronation-supination, grip strength, VAS, or DASH scores between groups. There was a slight increase in flexion-extension in the 4-corner group. There were 2 nonunions in the 4-corner group and none in the capitolunate group. Five patients in the capitolunate group required screw removal secondary to migration. Three patients in the 4-corner group required a subsequent pisiform excision., Conclusions: Capitolunate arthrodesis compares favorably to 4-corner arthrodesis at an average 3-year follow-up in this series with respect to range of motion, grip strength, DASH scores, and VAS. Advantages of capitolunate arthrodesis include a lessened need for bone graft harvesting while maintaining a similarly low nonunion rate, easier reduction of the lunate following triquetral excision, and avoiding subsequent symptomatic pisotriquetral arthritis. Screw migration, however, remains a concern with this technique., Type of Study/level of Evidence: Therapeutic III.

Purpose: We report a series of pisotriquetral arthritis cases following wrist and intercarpal arthrodesis, offer an anatomic and biomechanical rationale, and introduce intraoperative considerations to avoid this potential complication., Methods: Nine patients with pisotriquetral arthritis requiring pisiform excision following wrist and intercarpal arthrodesis were retrospectively evaluated at 2 institutions. Five paired cadaver wrists were tested for alterations in pressure and kinematics of the pisotriquetral joint following four-corner and total wrist fusions., Results: Nine patients were successfully treated with pisiform excision for pisotriquetral arthritis following wrist and intercarpal fusions. Biomechanical cadaver testing demonstrated profound alterations in pisotriquetral kinematics and pressure changes in measured degrees of wrist position following wrist and intercarpal fusions., Conclusions: Patients undergoing four-corner and/or wrist arthrodesis should be assessed for pisotriquetral discomfort before surgery, including a physical examination and a 30 degrees supinated radiograph to look for degenerative changes. Attempts should be made intraoperatively to ensure that the proximal row is not fused in an extended position. After surgery, if discomfort develops and conservative treatment fails, then pisiform excision can successfully alleviate the pain.

Purpose: To present the results of various treatment modalities based on injury grade of radial collateral ligament (RCL) injuries to the index metacarpophalangeal (MP) joint., Methods: Fourteen patients were evaluated (4 male, 10 female) with RCL injuries to the index MP joint. We defined injuries as Grade 1 (tenderness over RCL, no instability), grade 2 (laxity compared to the contralateral digit with a definite endpoint), or grade 3 (laxity without endpoint). Early presentation is defined as less than four weeks and late greater than four weeks., Results: The average follow up was 24 months. Grade I-II injuries seen early (4 patients) treated with 4-6 weeks splinting had excellent results (normal ROM, stable pinch, pain free). There were no Grade I-II injuries seen late. Of Grade III injuries seen early (2 patients), attempted treatment in a removable splint was unsuccessful secondary to patient noncompliance; subsequently requiring primary repair of the collateral ligament which resulted in good outcomes. No Grade III injury seen early had attempted treatment in a cast. Eight patients presented late with Grade III injuries (4 elected for surgical intervention, 4 for nonsurgical management) and all had fair or poor outcomes., Conclusions: The significance of this injury remains underestimated and requires a high index of suspicion. Stable injuries seen early should be treated with prompt immobilization. Casting may be more effective than a removable splint. Grade III injuries seen early could possibly be treated with cast immobilization though close follow up is mandatory as surgical repair may be necessary in the high demand hand. All Grade III injuries treated late yielded fair to poor results requiring tendon reconstruction or fusion with significant alteration in hand function.