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Appreciation and knowledge of anatomy as it relates to surgical approaches is critical for planning treatment of traumatic wrist injuries. This article discusses the pertinent anatomy and some of the more commonly used approaches to wrist trauma.

Hemiarthroplasty is a common form of treatment for rotator cuff tear arthropathy. Clinical outcomes of the bone-sparing Copeland Extended Articular Surface (EAS) hemi-resurfacing arthroplasty for rotator cuff tear arthropathy have not been reported in the literature. This article presents the authors' preliminary results in this study. Six patients treated with this prosthesis were retrospectively reviewed and the preoperative and postoperative scores for range of motion and outcomes as assessed by the disabilities of the arm, shoulder, and hand (DASH) questionnaire and visual analog scale for pain were compared. Significant improvements were found in function, with DASH scores decreasing from an average of 55 to 22, pain improving from 8.83 to 4.5, and external rotation improving from 49; to 67;. Five of the six patients were satisfied with the outcome of the procedure. This level IV therapeutic study concluded that the bone-sparing Copeland EAS hemi-resurfacing arthroplasty is a viable alternative to stemmed hemiarthroplasty for the treatment of rotator cuff tear arthropathy in younger, more active patients in whom future revision is a likely possibility.

Open or unstable metacarpal fractures frequently require open reduction and internal fixation. Locking plate technology has improved fixation of unstable fractures in certain settings. In this study, we hypothesized that there would be a difference in strength of fixation using double-row locking plates compared with single- and double-row non-locking plates in comminuted metacarpal fractures.We tested our hypothesis in a gap metacarpal fracture model simulating comminution using fourth-generation, biomechanical testing-grade composite sawbones. The metacarpals were divided into 6 groups of 15 bones each. Groups 1 and 4 were plated with a standard 6-hole, 2.3-mm plate in AO fashion. Groups 2 and 5 were plated with a 6-hole double-row 3-dimensional non-locking plate with bicortical screws aimed for convergence. Groups 3 and 6 were plated with a 6-hole double-row 3-dimensional locking plate with unicortical screws. The plated metacarpals were then tested to failure against cantilever apex dorsal bending (groups 1-3) and torsion (groups 4-6).The loads to failure in groups 1 to 3 were 198 +/- 18, 223 +/- 29, and 203 +/- 19 N, respectively. The torques to failure in groups 4 to 6 were 2,033 +/- 155, 3,190 +/- 235, and 3,161 +/- 268 N mm, respectively. Group 2 had the highest load to failure, whereas groups 5 and 6 shared the highest torques to failure (p.05). Locking and non-locking double-row plates had equivalent bending and torsional stiffness, significantly higher than observed for the single-row non-locking plate. No other statistical differences were noted between groups.When subjected to the physiologically relevant forces of apex dorsal bending and torsion in a comminuted metacarpal fracture model, double-row 3-dimensional non-locking plates provided superior stability in bending and equivalent stability in torsion compared with double-row 3-dimensional locking plates, whereas single-row non-locking plates provided the least stability.

An experimental model for the study of canine flexor tendon adhesions was designed using a standardized crush-abrasion injury, meticulous sheath closure, and three-week limb immobilization. Ten animals in the experimental protocol were evaluated for visible adhesion formation. With use of a flexor tendon adhesion rating scale, consistent adhesion formation was documented with an average score of 10.4 +/- 2.1 (range, 0 to 12). Five additional animals had biomechanical testing. Applying an increasing load to the proximally divided profundus tendon (0 to 10 Newtons), it was found that the angle of distal interphalangeal joint motion and the displacement of the toe were significantly decreased, and the work generated significantly increased in the experimental versus control digits (p less than 0.05). The consistent production of visible adhesions thus correlates with biomechanical impairments in toe motion and work. The study of agents aimed at diminishing flexor tendon adhesions will thus be facilitated by this reliable model. Systemic or intrasheath administration of agents will be possible.

Two hundred open fractures distal to the carpus in one hundred twenty-one patients were studied retrospectively. One hundred seventy-three fractures were followed-up to complete bony union, which occurred at a median period of seven weeks. Ninety-seven total complications included nine wound infections in seven patients, eighteen malunions, seventeen delayed or nonunions, twenty-three fixation problems, and two late amputations. Infection rate increased in the presence of wound contamination, delay in treatment greater than twenty-four hours, or systemic illness. It was not increased by presence of internal fixation, immediate wound closure, large wound size, tendon/nerve/vascular injury, or high-energy mechanism. We suggest a classification predictive of infection: type I: Clean wound and no systemic illness; type II: Contaminated wound, delay in treatment greater than twenty-four hours, or significant systemic illness. We recommend choosing fracture stabilization on the basis of the mechanical needs of the fracture, regardless of wound size, injury energy, or contamination. Immediate wound closure is appropriate for type I injuries and delayed closure should be reserved for type II wounds.

The left carotid artery of 12 Sprague-Dawley rats was sectioned and anastomoses immediately performed utilizing a new technique termed coupled suturing. Patency and constriction were assessed immediately postoperatively and at 1, 2, and 3 weeks. Specimens were also evaluated by light microscopy and scanning electron microscopy. Vessels healed well with excellent patency and edge eversion. With the development of a specialized needle, coupled suture could prove to be a reasonable alternative to current methods of anastomosis. Its main advantage is better intimal eversion, which decreases the risk of thrombosis.

The flexor digitorum profundus tendon of the second medial toe of the hind foot was completely divided and repaired in zone II in 30 New Zealand white rabbits. Half of the animals received indomethacin solution (1 mg/kg/day) injected subcutaneously 2 hours before operation and daily for 4 weeks. The remaining 15 animals received daily injection of the same volume of saline solution. At 4 weeks the animals were killed and measurements were made of the angular motion of the distal interphalangeal joint and the excursion of the tendon. The animals treated with indomethacin had a greater tendon excursion and angular rotation of the joint than the control animals, implying a suppression of adhesions.

Purpose Most metacarpal fractures are stable and can be treated with nonsurgical stabilization. However, some metacarpal fractures are treated with open reduction and internal fixation because of an open fracture, instability, or multiple fractures. Newer plate designs have emerged that allow a shorter plate and screw construct. We sought to determine the relative strength of 3 different methods of metacarpal plating for unstable fractures. Methods We tested our hypothesis in a transverse metacarpal fracture model using fourth-generation, biomechanical testing grade composite sawbones (Sawbones; Pacific Research Laboratories, Vashon, WA). The metacarpals were divided into 3 groups of 15 bones. Group 1 was plated with a standard 6-hole, 2.3-mm plate with 6 nonlocking bicortical screws in standard AO fashion. Group 2 was plated with a 6-hole, double-row, 3-dimensional (3D) plate with 3 nonlocking screws on either side of the fracture aiming for convergence of the screws. Group 3 was plated with a 2.4-mm plate using 6 nonlocking screws and standard AO technique. The metacarpals were then tested to failure in cantilever bending mode. Results All constructs broke through the bone. No plate failure or screw pullout was seen. Group 1 had a load to failure of 264 N ± 14. Group 2 had a load to failure of 302 N ± 17. Group 3 had a load to failure of 274 N ± 20. The load to failure was highest in group 2 (3D plate). All differences were statistically significant. Conclusions All 3 methods produced a strong construct. The load to failure was highest in group 2 (3D plate). Double-row plates with converging screws provide adequate or superior strength of fixation when compared with standard plate constructs.

Successful treatment of cubital tunnel syndrome requires obtaining a history of the physical and environmental factors involved for each patient, conducting a thorough physical examination, and staging and implementing an individually tailored treatment plan. Rest and avoiding pressure on the nerve by activity modification might be sufficient. If symptoms persist, splint immobilization of the elbow is warranted. Keep in mind that the natural history of untreated cubital tunnel syndrome includes spontaneous improvement in approximately half of patients.

The distal radioulnar joint is inherently unstable. Pathologic instability can be acute or chronic; it can be dorsal, palmar, or multidirectional; and it can result primarily from soft-tissue injury or osseous malunion. Recognition of the type and cause of instability is fundamental to provide effective treatment.

Despite improved understanding of carpal mechanics, increased awareness of intercarpal ligament injuries, and improved techniques for treating carpal instability, post-traumatic intercarpal osteoarthrosis remains a common problem. Osteoarthritis of the carpal bones, including scapholunate advance collapse wrist, scaphotrapeziotrapezoid arthritis, lunotriquetral arthritis, triquetrohamate arthritis, and pisotriquetral arthritis, follows specific unique patterns, but in each, the final common pathway leads to degenerative change. Injury or deformity leads to instability and altered kinematics, producing abnormal joint contact pressures. Cartilage injury and eventual degeneration of the join follow. The etiology, prevalence, and current evaluation and treatment of these conditions are of importance to hand surgeons.

Malignant tumors of the proximal humerus are challenging to treat. Reconstruction with a metallic implant or allograft is the most common method, but each has known risks and frequent complications. Allograft-prosthesis composite reconstruction has not been widely used and may avoid problems posed by metal prostheses or allografts used alone. Six patients with malignant tumors of the proximal humerus were treated with allograft-prosthesis composite reconstruction after excision of the intra-articular tumor. Outcomes were assessed by use of the Disabilities of the Arm, Shoulder and Hand questionnaire; the Short Form 36 (SF-36) Health Survey; and the American Shoulder and Elbow Surgeons Shoulder Assessment Form. Preoperative and postoperative scores at a mean of 55 months were compared. Disability increased after surgery based on the Disabilities of the Arm, Shoulder and Hand questionnaire and SF-36, although disability appeared to decrease with time. The mean mental component score on the SF-36 showed continued improvement with time after surgery. One asymptomatic nonunion was repaired, and painful loosening developed in one patient, requiring revision at 45 months. Allograft-prosthesis composite reconstruction is a safe method for treating some malignant tumors of the proximal humerus, providing stable reconstruction and preserving function of the shoulder joint.

To determine causation in work-related upper extremity disorders, one must appreciate the philosophical constructs used in establishing causation and have clear definitions of the disorder in question. The preponderance of evidence does not support repetition as a major risk factor for physical injury. Terms such as "repetitive stress," "repetitive strain," and "cumulative trauma" should be abandoned, and we should educate our patients as to the multiple risk factors for upper extremity pain.

Purpose Multiple options have been reported for reconstruction of Campanacci grade 3 giant-cell tumor of the distal radius after resection. In 1990, the senior author described an allograft reconstruction combined with a Sauve-Kapandji procedure after distal radius resection and reported preliminary results in 3 patients. The purpose of this study was to assess with validated patient outcome surveys the intermediate to long-term outcomes of all patients treated with this surgery and to analyze their functional results and document tumor control. Methods All cases of distal radius osteoarticular allograft combined with the Sauve-Kapandji reconstruction for Campanacci grade 3 giant-cell tumors performed from 1986 to 2000 by a single surgeon were evaluated by clinical and radiologic examinations; the Disabilities of the Arm, Shoulder, and Hand questionnaire; the Short Form–36; and Mayo Wrist scores. Results Nine consecutive patients (7 women, 2 men) with an average age at follow-up evaluation of 42 years and with a Campanacci grade 3 giant-cell tumor of the distal radius formed the study population. Clinical follow-up time after reconstruction averaged 7 years. Examination showed an average of 51° of extension and 19° of flexion of the wrist and 63° of supination and 79° of pronation of the forearm. Grip strength measured in 5 patients averaged 23 kg. The Disabilities of the Arm, Shoulder, and Hand questionnaire; the Short Form–36; and the Mayo Wrist scores averaged 15, 72, and 73, respectively. These scores indicate modest functional impact. No patient had tumor recurrence, metastases, nonunion, or proximal ulna instability. Conclusions En bloc resection of a Campanacci grade 3 giant-cell tumor of the distal radius followed by reconstruction with an osteoarticular allograft and a Sauve-Kapandji procedure with autogenous bone graft results in a reasonable functional outcome at intermediate to long-term follow-up evaluation. Type of study/level of evidence Therapeutic IV.

Poisson regression model is widely used in software quality modeling. When the response variable of a data set includes a large number of zeros, Poisson regression model will underestimate the probability of zeros. A zero-inflated model changes the mean structure of the pure Poisson model. The predictive quality is therefore improved. In this paper, we examine a full-scale industrial software system and develop two models, Poisson regression and zero-inflated Poisson regression. To our knowledge, this is the first study that introduces the zero-inflated Poisson regression model in software reliability. Comparing the predictive qualities of the two competing models, we conclude that for this system, the zero-inflated Poisson regression model is more appropriate in theory and practice.

Pediatric fractures sometimes are complicated by growth disturbances. Most reported growth disturbances are in the lower extremity and can entail growth arrest or overgrowth. We report a case of overgrowth and angular deformity after an extraphyseal distal radius fracture that resulted in clinically significant pain and functional impairment because of palmar instability of the distal ulna. A dome osteotomy was successful in treating the patient's wrist pain, distal radioulnar instability, and multiplanar deformity of the distal radius.

The radial artery has gained widespread acceptance as a conduit for coronary artery bypass. Advantages include minimal donor site discomfort, ease of handling, excellent early patency rates, and the possibility of freedom from late conduit atherosclerosis. Although most series describe minimal morbidity, a significant incidence of radial sensory neuropathy and isolated instances of hand claudication and ischemia have been reported. We performed an outcome study utilizing the Short Form-36, the Upper Limb-Disabilities of Arm, Shoulder and Hand, and a modified self-administered hand diagram to compare 288 patients undergoing coronary artery bypass utilizing the radial artery with a control group of 174 patients undergoing coronary artery bypass without the radial artery. The data were analyzed by the t test for continuous variables and the chi-square test for categorical variables, and subsequently a multivariate regression model was constructed. No patients developed hand claudication or ischemia. Although there was an incidence of radial sensory neuropathy of 9.9% associated with radial artery harvest, it was not significantly higher than the incidence in the control group (5.2%, p=.16). Intrinsic patient factors such as obesity, age, diabetes, and peripheral vascular disease were the principal determinants of overall health and quality of life issues.

We reviewed 38 fractures of the humeral shaft which had been treated non-operatively to identify factors prognostic of nonunion. Of these, 23 healed uneventfully and 15 progressed to nonunion. Factors prognostic of nonunion included long oblique fracture pattern, alcohol abuse, and obesity. In patients with these risk factors, lack of clinical and radiographic evidence of healing 8 to 10 weeks post-injury suggests an impending nonunion, and operative intervention should be considered.

A prospective randomized study was undertaken of 50 consecutive patients undergoing surgery for idiopathic carpal tunnel syndrome to determine the value of splintage of the wrist following open carpal tunnel release. Patients were randomized to either be splinted for 2 weeks following surgery or to begin range-of-motion exercises on the first post-operative day. Subjects were evaluated at 2 weeks, 1 month, 3 months, and 6 months after surgery by motor and sensory testing, physical examination, and a questionnaire. Variables assessed included date of return to activities of daily living, dates of return to work at light duty and at full duty, pain level, grip strength, key pinch strength, and occurrence of complications. Patients who were splinted had significant delays in return to activities of daily living, return to work at light and full duty, and in recovery of grip and key pinch strength. Patients with splinted wrists experienced increased pain and scar tenderness in the first month after surgery; otherwise there was no difference between the groups in the incidence of complications. We conclude that splinting the wrist following open release of the flexor retinaculum is largely detrimental, although it may have a role in preventing the rare but significant complications of bowstringing of the tendons or entrapment of the median nerve in scar tissue. We recommend a home physiotherapy programme in which the wrist and fingers are exercised separately to avoid simultaneous finger and wrist flexion, which is the position most prone to cause bowstringing.

The application of statistical modeling techniques has been an intensely pursued area of research in the field of software engineering. The goal has been to model software quality and use that information to better understand the software development process. Neural network modeling methods have been applied to this field. The results reported indicate that neural network models have better predictive quality than some statistical models when predicting reliability and the number of faults. In this paper, we will explore the application of principal components analysis to neural network modeling as a way of improving the predictive quality of neural network quality models. We trained two neural nets with data collected from a large commercial software system, one with raw data, and one with principal components. Then, we compare the predictive quality of the two competing neural net models. >

The purpose of this study was to review and report the results of using a new procedure, the dorsal intercarpal ligament capsulodesis (DILC), to treat a group of patients with chronic flexible scapholunate dissociation. This was a prospective study of 21 patients (22 wrists), ranging in age from 16 to 62 years followed up for 1 to 4 years. For this study all patients returned to complete a questionnaire and have a physical examination performed by physicians and therapists independent of the treating surgeons and to obtain standardized radiographs of the wrists. Patient demographics, mechanism of injury, range of motion, and grip strength were recorded. Patients completed the Mayo wrist, Short-Form (SF)-12, and Disabilities of Arm, Shoulder and Hand (DASH) questionnaires. Results showed there were significant improvements in scapholunate angle and scapholunate gap at final follow-up examination, with minor loss of range of motion and grip strength. Patients were satisfied with the outcomes, showing an average score of 17 on the DASH and 83 on the SF-12. The DILC procedure is a reasonable option for treating chronic scapholunate dissociation. The procedure has conceptual advantages to recommend it: it avoids a tether between radius and scaphoid and keeps the proximal carpal row linked as a functional unit. It reduces the scapholunate angle and gap. Overall the results to date are quite encouraging.

A survey, to which 401 hand therapists responded, was conducted to establish research priorities in the field of hand therapy and to investigate barriers to hand therapy research. Results indicated that reimbursement issues, particularly those generated by managed care, were reported to have adversely affected quality of patient care, job satisfaction, job security, and ability to conduct research. Research priorities were defined in this study, and the need for clinical trials to determine the effectiveness of hand therapy interventions was found to be urgent. Research questions identified by respondents reflected both the traditional disorders treated by hand therapists, such as tendon repairs, and a greater concern with issues concerning cumulative trauma. Barriers to research were reported by respondents, and ways in which professional organizations could meet clinicians' needs in conducting and utilizing research were highlighted. J HAND THER. 2002;15:3-15.

Hand surgeons currently are challenged with the task of measuring and establishing the connection between the diagnosis and treatment of health-related quality-of-life problems. Although true quality of life cannot be measured directly, instruments in the form of questionnaires have been developed that use self-reporting to account for functional performance, health status, and health-related quality of life. Instruments must be reliable, valid, responsive, and appropriate. Misunderstanding these properties often hinders interpreting the recent stream of outcome studies in the literature. Most physicians are not sure what if any outcome information should be collected routinely or if any outcome instrument is diagnostically useful. Currently there is no convincing evidence to support the routine use of patient-based outcome measures in hand surgeons' practices. Those hand surgeons who would like to carry out an outcome study should consider seeking help from others with expertise in outcomes design and analysis.

An unusually large chondrosarcoma arising in the hand of a young patient with multiple hereditary exostoses is presented.

This textbook is coauthored by two hand surgeons who individually have made relevant and unique contributions to the understanding of hand surgery anatomy during their careers. Their collaboration has produced a convenient stand-alone comprehensive reference resource consisting of a collection of material from multiple texts and journals. The textbook is organized into two main sections. The first, entitled “Systems Anatomy,” consists of four chapters that separate the anatomy into skeletal, muscle, nerve, and vascular systems. The chapter on muscle anatomy includes a wonderful appendix that summarizes the origin, insertion, action, and innervations of all of the muscles of the upper extremity. These four pages will probably be cherished and carried around by every hand fellow for years to come. The chapter on vascular systems includes a brief description of vascularized bone grafts; however, illustrations are omitted and there is no description of the intercompartmental supraretinacular arterial supply, which one would expect to find here. The second section, entitled “Regional Anatomy,” consists of six chapters that divide …

We determined the direct relationships between wrist position and displacement of the median nerve during active contraction of the flexor tendons at the wrist with an intact, transected transverse carpal ligament (TCL). Nine fresh cadavers were mounted in an apparatus to allow variable wrist position. Excursions of the tendons and displacement of the median nerve were measured by tracking markers with a video camera. Each limb was tested at 0 degree, 30 degrees, and 60 degrees of wrist extension before and after release of the TCL. Excursion of the flexor tendons required for full finger flexion ranged from 2.3 to 3.1 cm (mean, 3 cm). Median nerve displacement ranged from 0.9 to 1.4 cm (mean, 1 cm). The relationship between median nerve and flexor tendon excursion was consistently linear. Finger motion alone allows for median nerve displacement after surgery in the carpal tunnel.

The patient with compression neuropathies of the median and ulnar nerves at the wrist commonly presents with pain, paresthesias, and weakness in the hand and digits. Diagnosis of these conditions is becoming more widespread with the increased attention given to “cumulative trauma disorders” during the past decade. Successful management requires a thorough understanding of the pathophysiology of compression neuropathy and how it relates to the various diagnostic tests available today. The authors review the epidemiology, etiology, and evaluation of compression neuropathy and discuss common clinical presentations, treatment recommendations, and controversies surrounding carpal and ulnar tunnel syndromes. J Am Acad Orthop Surg 1994;2:115-123

A case is reported in which the median nerves bifurcated bilaterally, with the radial segment of each nerve passing through an accessory ligamentons compartment within the carpal tunnel.

Our experience with the Sauve-Kapandji procedure for reconstruction of the rheumatoid distal radioulnar joint is reported. Twenty-one wrists in 17 patients were followed for an average of 39 months postoperatively. Average range of motion at follow-up evaluation was pronation to 78 degrees and supination to 86 degrees. X-ray films demonstrated that significant ulnarward and palmarward translocation of the carpus was prevented. The Sauve-Kapandji procedure provides a stable ulnar side support in the rheumatoid wrist with distal radioulnar degeneration.

Repetitive cyclic loading of a nerve has been proposed as a pathogenic factor in the development of occupational compression neuropathies. Little is known about the basic response of peripheral nerve to cyclic compression. We investigated the hypothesis that cyclic compression is more detrimental to nerve function than constant compression. We measured the amplitudes and velocities of distally evoked action potentials in the presence of constant or cyclic compression of the tibial nerve in rats. Seven groups were subjected to constant or cyclic compression for 6 h by a computer controlled, hydraulically activated compression chamber. Nerves were compressed with 0 (control group), 30, 60, or 90 mm Hg of constant pressure or 0-30, 20-50, or 30-60 mm Hg of cyclic compression for approximately 20,000 compression cycles. Action potentials were recorded every 15 min. The effects of cyclic compression on nerve conduction were equivalent to the effects of constant compression at the average applied pressure. Cyclic loading itself does not appear to be an important pathogenic factor in the development of nerve conduction block.

We report the outcome of ulnar lengthening with the Ilizarov technique in five adults with radial hemimelia and previous wrist centralization. The indications for ulnar lengthening in these patients were either a functional deficit due to the short ulna or poor appearance that caused the patient significant unhappiness. All patients had a successful lengthening of the ulna, with a gain in length from 4 to 13 cm; however, the procedures were prolonged (7 to 25 months), and all patients experienced complications. At the time of follow-up examination no patient had residual pain or paresthesias. In four of five patients, although ulnar lengthening resulted in somewhat stiffer digits, it improved function of the extremity as a whole. When asked if they would repeat the lengthening, knowing what they know now, all five replied that they would. The technical difficulties encountered in these cases suggest a cautious approach to ulnar lengthening. This is a long, arduous, painful process that requires a psychologically robust patient. If the ulna is very short preoperatively, lengthening can enhance the volume of space accessible to the hand and in that way improve function.

A 10-center randomized prospective multicenter study of endoscopic release of the carpal tunnel was carried out. Surgery was performed with a new device for transecting the transverse carpal ligament while control hands were treated with conventional open surgery. There were 122 patients in the study; 25 had carpal tunnel surgery on both hands and 97 had surgery on one hand. Of the surgical procedures, 65 were in the control group and 82 were in the device group. The endoscopic device was coupled to a fiberoptic light and a video camera. A trigger-activated blade was used to incise the transverse carpal ligament. After surgery, the best predictors of return to work and to activities of daily living were strength and tenderness variables. For patients in the device group with one affected hand, the median time for return to work was 21 1/2 days less than that for the control group. Two patients treated with the endoscopic device required reoperation by open surgical decompression; only one of these had incomplete release with the device. Two patients in the device group experienced transient ulnar neurapraxia.

Twelve patients with the histologic diagnosis of soft-tissue hemangioma of the extremities (nine intramuscular, two subcutaneous, and one synovial) were evaluated in a retrospective study using plain film radiography (n = 12), angiography (n = 8), computed tomography (CT; n = 4), magnetic resonance imaging (MRI; n = 3), and ultrasonography (US; n = 2). In eight of nine intramuscular lesions, the plain film demonstration of phleboliths suggested the diagnosis, while the plain radiographs were normal in three. Angiograms showed the pathognomonic features of soft-tissue hemangioma in six patients. MRI was characteristic in all three patients: The lesion demonstrated intermediate signal intensity on T1-weighted spin echo images and extremely bright signal on T2-weighting. US showed a hypoechoic soft-tissue mass in one case and a mixed echo pattern in the other. In one case, a central echogenic focus with acoustic shadowing consistent with a calcified phlebolith was identified, and one lesion exhibited increased color flow and low resistance arterial Doppler signal. CT showed a nonspecific mass in one of four cases and a mass with phleboliths in three. If a deep hemangioma is suspected, we recommend initial imaging with plain radiography followed by MRI. US may be useful in confirming the presence of a mass in doubtful cases or if MRI is unavailable. CT offers no distinct advantage over the combined use of plain radiography and MRI. Although angiography demonstrated the pathognomonic features in all six deeply situated lesions, because of its invasiveness it should be reserved chiefly for those patients undergoing surgical resection.

Condensing osteitis of the clavicle is a benign, often painful disorder, marked by bony sclerosis at the sternal end of the clavicle. It can be mistaken for other abnormalities such as Friedrich disease, bone island, osteoid osteoma, sternoclavicular osteoarthritis, and even a metastasis and osteosarcoma. Clinical, radiologic, scintigraphic, and histologic features of this condition are discussed and a brief overview of the treatment is provided. Three histologically proved cases are added to the 13 previously reported in the literature. Recognition of condensing osteitis of the clavicle may avoid the occasional unnecessarily aggressive diagnostic approach taken to search for a malignant tumor.