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We performed a cadaver study using seven fresh-frozen adult upper limbs to assess the impact of increasingly larger distal radial deformity in the sagittal plane on the range of motion in pronation/supination. Three palmar (20°, 30° and 40° angulations) and three dorsal (10°, 20° and 30° angulations) tilt deformities, without any radial shortening, were simulated by performing a radial osteotomy and using custom-made three-dimensional-printed anterior plates. We measured the maximum unconstrained pronation and supination before the osteotomy and after each induced deformation. There was a decrease in the median pronation and supination values for all palmar and dorsal tilt deformities. The pronation range was more impaired than the supination range, and dorsal tilt deformities caused the greatest loss in forearm rotation. Our results suggest that forearm rotation in both pronation and supination is reduced as soon as 10° to 20° distal radial deformity occurs in the palmar or dorsal direction.

Background: Fracture dislocations of the proximal interphalangeal joint (PIPJ) are challenging injuries and a dynamic external fixator frame is often used. We devised a dynamic external fixator device called the Gexfinger® that allows greater control of the degree of traction. The aim of this study is to report the mid-term outcomes of this device. Methods: This is a retrospective study of patients with fracture dislocation of the PIPJ who were treated with the Gexfinger® over a 3-year period. Clinical data with regard to the patient, the injury, treatment and period of follow-up were recorded. The outcome measures included time to return to work, arc of motion at the interphalangeal joints, grip strength, visual analogue score (VAS) for pain, patient satisfaction and complications. Results: We studied 26 patients (17 men and 9 women) with an average age of 38 years. The average articular surface involvement was 56%. The mean period between injury and surgery was 6 days and the frames were maintained for 5.5 weeks on average. The mean follow-up period was 8.5 weeks. All patients returned to work at an average of 7 weeks. The mean arc of motion at the PIPJ and distal interphalangeal joint (DIPJ) were 82° and 65°, respectively and the mean grip strength was 83% of the contralateral side. 22 patients reported no pain at the final follow-up. Fifteen patients were very satisfied, 8 satisfied and 3 unsatisfied. Two patients had stiffness of the PIPJ. Conclusions: The mid-term outcomes of the Gexfinger® are similar to other methods of dynamic traction described in literature. It is modular, easy to assemble and allows a greater control of the degree of traction. In combination with additional screws and/or K-wires, it has allowed us to treat a wide spectrum of PIPJ fracture dislocations with good outcomes. Level of Evidence: Level IV (Therapeutic)

We performed a retrospective review of standard anteroposterior and lateral radiographs of the thumb in 80 patients, to compare two radiographic landmarks, in terms of mediolateral bone support, for centering the trapezial component in total joint arthroplasty. On anteroposterior view, we identified the distal articular surface of the trapezium and trapezium width, and defined the two midpoints as radiographic landmarks for positioning a 9-mm trapezial cup. Mean trapezium width was significantly greater than the distal articular surface of the trapezium, and the midpoints did not match. Thus, after positioning simulated 9-mm prosthetic cups centered on each landmark, the residual radial bone distance was significantly greater using the landmark based on trapezium width. The mean value was 33% greater with this landmark, and the minimum value was 2.1 mm, compared to 0.2 mm using the landmark based on the distal articular surface. Our study thus suggested that the midpoint of the trapezium width is the more relevant radiographic landmark for centering the trapezial prosthetic cup in total joint arthroplasty, by preserving better bone stock on the radial side without depleting the ulnar side. On an intraoperative anteroposterior fluoroscopic view, this landmark could be used to check cup positioning. Nous avons effectué une revue rétrospective de radiographies standards de face et de profil du pouce chez 80 patients, afin de comparer deux repères radiographiques et d'identifier la solution la plus cohérente, d'un point de vue du support osseux médio-latéral, pour le centrage la cupule trapézienne dans l'arthroplastie totale trapézo-métacarpienne. Sur les radiographies de face, nous avons identifié la surface articulaire distale du trapèze et la largeur du trapèze. Ensuite, nous avons défini deux repères radiographiques au milieu de ces longueurs pour le positionnement d'une cupule trapézienne de 9 mm. La largeur du trapèze avait une valeur moyenne significativement plus élevée que la surface articulaire distale du trapèze, et leurs milieux ne correspondaient pas. Ainsi, après positionnement des cupules prothétiques simulées avec un diamètre de 9 mm centré sur chaque repère, la distance osseuse résiduelle radiale était significativement plus élevée en utilisant le repère basé sur la largeur du trapèze. La valeur moyenne était 33% plus élevée avec ce repère radiographique et sa valeur minimale était de 2.1 mm alors qu'elle était de 0.2 mm en utilisant le repère basé sur la surface articulaire distale. Notre étude suggère que le milieu de la largeur du trapèze est le repère radiographique le plus cohérent pour centrer la cupule prothétique trapézienne dans l'arthroplastie totale trapézo-métacarpienne, en préservant un meilleur stock osseux du côté radial sans épuiser le côté ulnaire. En effectuant une vue peropératoire de face avec la fluoroscopie, ce repère pourrait être utilisé pour vérifier le bon positionnement de la cupule.

We performed a cadaver study using 18 fresh-frozen adult forearms and hands to compare the tendon loads required to generate progressively greater key pinch (0.5 kg to 2 kg) after three different surgical procedures to treat trapeziometacarpal osteoarthritis: isolated trapeziectomy, trapeziectomy followed by ligament reconstruction with tendon interposition and total joint arthroplasty using a Touch® implant. Thumb pinch was simulated by loading the main actuator tendons involved in the key pinch. Six specimens were randomly assigned to each of the three surgical procedure groups. Measurements were made before and after the joint surgery. Specimens that underwent trapeziectomy with or without ligament reconstruction with tendon interposition required significantly higher tendon loads than those with the implant to achieve the same pinch force. There was no significant difference between the isolated trapeziectomy and ligament reconstruction groups. Using the implant resulted in similar median tendon loads compared with those of the intact sample. Total joint arthroplasty with a Touch® prosthesis may yield a superior biomechanical profile in which the tendon loads needed to achieve a certain key pinch force are lower and better distributed between the actuator muscles compared with trapeziectomy with or without ligament reconstruction.

Purpose This study describes the anatomy and analyzes the variations of the midsectional morphology of the sigmoid notch. Methods The wrists of 50 patients with suspected scaphoid fracture were evaluated by magnetic resonance imaging (MRI). Sigmoid notch length, volar and dorsal rim heights, insertion length of the volar radioulnar ligament, and Tolat morphology classification were measured on T1-weighted axial plane MRI. Ulnar variance and distal radioulnar joint (DRUJ) inclination were assessed on anteroposterior radiographs. Results The most common sigmoid notch shapes were types C (C-shaped, 60%) and B (ski-slope, 30%), followed by types D (S-shaped, 6%) and A (flat, 4%). Types A and B had a flat dorsal rim (mean 0.77 ± 1.09 mm, range 0.0–1.54 mm, and mean 0.22 ± 0.3 mm, range 0.0–0.76 mm, respectively). Types C and D had more prominent dorsal rims (means 1.47 ± 0.59 mm, range 0.66–2.57 mm, and mean 1.6 ± 0.97 mm, range 0.8–2.68 mm, respectively). The average volar lip length was 1.60 ± 1.11 mm (range, 0.0–4.10). The dorsovolar length of the radius was 18.4 ± 2.01 mm; the length of the sigmoid notch was 14.3 ± 1.73 mm. The type of sigmoid notch according to Tolat was significantly associated with volar lip length (p = 0.005). The type of sigmoid notch was not associated with ulnar variance or DRUJ inclination. The length of the sigmoid notch was significantly associated with the type of sigmoid notch (p = 0.005). The analysis demonstrated a negative association between the sigmoid notch length and the volar insertion of the radioulnar ligament (p = 0.019). Conclusions The transversal morphology of the sigmoid notch was either flat with the least congruence (similar to type A of Tolat), with volar congruence only (similar to type B), or with volar and dorsal congruence (similar to types C and D). A shorter sigmoid notch may be compensated by a broader insertion of the volar radioulnar ligament. Clinical Relevance The measurements and correlations demonstrated in this study can be a guide when considering reconstructive procedures or dealing with the instability of the DRUJ.

Ultrasound (US) assessment of the wrist is frequently used for the evaluation of carpal tunnel due to high frequency of local compression of the median nerve (MN), but the ulnar–palmar wrist region (UPWR) has received limited attention in the medical literature. The possibilities of US in the assessment of UPWR are therefore likely underestimated by sonologists. This review article is focused on the US assessment of the normal anatomy and anatomic variations of the UPWR. The anatomy of this region of the wrist is complex and less studied than the radial side. In an effort to simplify it and to present it didactically, we have divided this region in three parts on the basis of osseous landmarks. Our review indicates sonography is effective in identifying the UPWR and related disorders, and is thus a valuable tool for ensuring appropriate management of a variety of disorders.

Early detection of local complications (venipuncture complications, nerve lesions, infections, arthritis, and tenosynovitis, tendon adhesions and re-tears, complications related to orthopaedic hardware) after hand surgery is required for prompt treatment. Ultrasound has proven to be a valuable imaging modality for detecting and assessing a variety of disorders of the wrist and hand. The purpose of this pictorial essay is to present a wide range of complications after wrist and hand surgery assessed by ultrasound.

Conventional radiography is the first modality to investigate the radio-ulno-carpal joint in the event of trauma or instability. This study sought to determine the reliability of cone beam computer tomography (CBCT) and scout of view in evaluating carpal alignment compared with conventional radiographs in order to assess the influence of wrist kinematics on usual measurements.We prospectively recruited 305 patients who successively underwent plain radiography and CBCT. 51 patients with prior acute unilateral wrist trauma were eligible for entry into the study (mean age of 39 years). Three blinded readers performed the measurements separately. The axial method and bony axial lines defined previously in the literature were applied, with three categories of measurements performed, consisting of distal radio-ulnar, radiocarpal, and radio/carpometacarpal measurements. Intraclass correlation coefficients (ICCs) for paired t-test were calculated to assess inter- and intra-observer agreements.Inter-observer agreement was very high (0.94) for all modalities. Intra-observer reliability between scout view and CBCT was almost perfect for all measurements. Intra-observer reliability between radiograph and scout view/CBCT was perfect for distal radio-ulnar measurements, substantial for radio-carpal, and moderate for radio/carpometacarpal measurements.In the absence of a strict position control between two imaging acquisitions, only distal radio-ulnar measurements were shown perfectly reliable when using these two imaging methods, which is suggestive of a minor relevance of ulnar/radial deviation. Excepting for some angles, the radio-carpal and radio-carpometacarpal measurements were shown to differ according to wrist position, being thus more sensitive to flexion/extension of the wrist.

Although the nail is a small anatomical structure, it can be affected by various tumors and tumor-like conditions. Because of the distinctive nail anatomy, the clinical presentation of tumors is modified, thus rendering the diagnosis challenging. As nail biopsy and surgery are painful procedures associated with an increased risk of permanent onychodystrophy, pre-operative diagnosis is desirable. Although conventional radiographs are still the first-line radiologic examination for the assessment of bony structures beneath the nail matrix, they do not allow detailed evaluation of the phalangeal soft tissues. High resolution MRI allows accurate detection and mapping of nail lesions and can suggest a specific diagnosis. This review focuses on high resolution MRI of nail tumors and tumor-like lesions. We review the nail anatomy and the optimal MRI protocol. We then discuss a variety of tumors and tumor-like lesions in relation to the clinical presentation, anatomic location, histological features and imaging characteristics. We herewith describe common benign tumors (glomus tumor, onychomatricoma, keratoakanthoma, fibroma, subungual exostosis, hemangioma, chondroma, pyogenic granuloma), malignant tumors (subungual melanoma, subungual squamous cell carcinoma), as well as tumor mimics (mucoid cyst, epidermoid cyst). Although not entirely specific, MRI is a valuable tool in treatment planning of these tumors.

The wrist is a joint structure particularly exposed during sports practice to trauma or overuse. Ligament trauma is particularly common as well as tendinopathies. A rigorous clinical examination is the key to the management of the sports patient. The additional examinations will confirm the diagnosis and help guide the management. The purpose of the treatment in the athlete will depend on his sports activity, his age, the sport, the time between the accident and the sports season.Le poignet est une structure articulaire particulièrement exposée au traumatisme ou à la surutilisation lors de la pratique sportive. Les traumatismes ligamentaires sont très fréquents ainsi que les tendinopathies. Un examen clinique rigoureux est la clé de la prise en charge du patient sportif. Les examens complémentaires vont confirmer le diagnostic et permettre d’orienter la prise en charge. Le but du traitement chez le sportif va dépendre de son activité sportive, de son âge, du sport, du délai entre l’accident et de la saison de sport en question.

Cadaveric joint simulators are commonly used to explore native and pathological joint function as well as to test medical devices. Recently, robotic manipulators have been proposed as a new gold standard for in vitro biomechanical testing as they offer higher possibilities than Universal Testing Machines in terms of degrees of freedom (DOF). However, current protocols remain conducted in extra-corporal conditions by fixing one segment of a diarthrodial joint while mobilising the other segment. Moreover, induced motions are commonly not specimen-specific and do not respect related joint kinematic constraints and physiologic boundaries. In this study, using a 7 DOF redundant robotic manipulator, an intra-corporal condition protocol was defined. This protocol allows 1) the analysis of the shoulder girdle full kinematic chain, 2) the replication of specimen-specific humerus motions initially induced by an operator. On the 10 shoulders tested, the robotic manipulator was able to perform requested end-effector motions with a reliability of 0.28 ± 0.57 mm and 0.15 ± 0.25°, and a fidelity of 0.27 ± 0.56 mm and 0.22 ± 0.28°. This protocol will be used in the future to explore joint function as well as to test medical devices, on the shoulder girdle and potentially other joints.

We performed a biomechanical study using 60 Sawbones® rigid foam blocks of two simulated densities (osteoporotic, n = 30 and non-osteoporotic, n = 30) and 10 cadaveric trapezium bones from fresh-frozen, unembalmed adult cadaver hands to assess the trapezial prosthetic cup migration with progressively greater compression loads (10–40 kg). Two cups from the Touch® prosthesis were compared: 9-mm conical cup and 9-mm spherical cup. Uniaxial compression tests were carried out using an MTS Criterion® Series 40 Electromechanical Testing System. Cup migration was measured in millimeters (mm) at 10, 20, and 40 kg of compression load. Median cup migration values were similar in the cadaveric trapezium bones and Sawbones® non-osteoporotic blocks, and higher in the Sawbones® osteoporotic blocks. In the cadaveric trapezium bones and the Sawbones® non-osteoporotic blocks, migration values were less than or equal to 0.1 mm for 10 and 20 kg loads; it was 0.2 mm for 40 kg load. In the Sawbones® osteoporotic blocks, migration values were less than or equal to 0.3 mm for 10 and 20 kg loads; it was 0.4–0.5 mm for 40 kg load. There was no significant difference between the two cup shapes in both cadaveric trapezium bones and Sawbones® non-osteoporotic blocks. In Sawbones® osteoporotic blocks, the largest difference between the two cup shapes was 0.1 mm for loads up to 40 kg, which corresponded to our measurement accuracy. Our findings indicate that the trapezial component of total trapeziometacarpal joint arthroplasty undergoes very weak migration for axial compression loads up to 40 kg, presumably below the threshold of clinical relevance. The cup shape did not have an obvious influence; however, low bone mineral density may result in greater cup migration. Nous avons réalisé une étude biomécanique utilisant 60 blocs de mousse rigide Sawbones® de deux densités simulées (ostéoporotiques, n = 30 et non ostéoporotiques, n = 30) et 10 trapèzes cadavériques provenant de spécimens adultes frais, pour évaluer la migration de la cupule prothétique trapézienne pour des charges de compression de plus en plus importantes (10 à 40 kg). Deux cupules de la prothèse Touch® ont été comparées: conique 9 mm et sphérique 9 mm. Des tests de compression uniaxiale ont été effectués à l'aide d'un banc d'essai électromécanique MTS Criterion® série 40. La migration de la cupule a été mesurée en millimètres (mm) à 10, 20 et 40 kg de charge de compression. Les valeurs médianes de migration de la cupule étaient similaires pour les trapèzes cadavériques et les Sawbones® non ostéoporotiques, alors qu'elles étaient plus élevées pour les Sawbones® ostéoporotiques. Pour les trapèzes cadavériques et les Sawbones® non ostéoporotiques, les valeurs de migration étaient inférieures ou égales à 0,1 mm pour les charges de 10 et 20 kg; elles étaient de 0,2 mm pour les charges de 40 kg. Dans les Sawbones® ostéoporotiques, les valeurs de migration étaient inférieures ou égales à 0,3 mm pour les charges de 10 et 20 kg; elles étaient de 0,4 à 0,5 mm pour les charges de 40 kg. Il n'y avait pas de différence significative entre les deux formes de cupules dans les trapèzes cadavériques et les Sawbones® non ostéoporotiques. Pour les Sawbones® ostéoporotiques, la plus grande différence entre les deux formes de cupule était de 0,1 mm pour des charges allant jusqu'à 40 kg, ce qui correspondait à notre précision de mesure. Nos résultats indiquent que la composante trapézien de l'arthroplastie totale de l'articulation trapézo-métacarpienne subit une très faible migration pour des charges de compression axiale allant jusqu'à 40 kg, vraisemblablement en dessous du seuil de pertinence clinique. La forme de la cupule n'a pas eu d'influence évidente; cependant, une faible densité minérale osseuse peut entraîner une plus grande migration de la cupule.

The elbow joint is highly congruent and subject to less stress than other joints. This contributes to a rather low incidence of pathologies in the general population. However, in athletes who perform repeated movements with supraphysiological forces, diverse pathologies may appear. The objective of this article is to develop an anatomopathological approach to elbow pain in order to identify its origin. A rapid and precise diagnosis allows initiating an adequate treatment and minimizing time of sporting activity arrest.L’articulation du coude est soumise à des contraintes mécaniques moindres que d’autres articulations et présente une importante congruence. Ces éléments contribuent à la faible incidence des pathologies qui l’affectent dans l’ensemble de la population. Toutefois, chez le sportif qui effectue des mouvements répétés et avec des forces supraphysiologiques, de multiples lésions peuvent survenir. L’objectif de cet article est de développer une démarche anatomopathologique pour le diagnostic des douleurs de coude. Un diagnostic rapide et précis permet la mise en place d’un traitement adéquat ainsi que de minimiser le temps d’arrêt de l’activité sportive.

The management of many traumatic conditions of the hand and wrist can be done or at least initiated by the primary care physician, often the first actor of the scenario. To do so, he must first have performed a correct reading of X-rays made with specific incidences to the suspected pathology. This article reviews the radiological diagnosis of the most common pathologies in hand and wrist traumatology to facilitate interpretation by general practitioners.La prise en charge de nombreuses pathologies traumatiques de la main et du poignet peut s’effectuer ou tout du moins être initiée par les médecins de premier recours (MPR), bien souvent premiers acteurs du scénario. Pour ce faire, le MPR doit au préalable avoir effectué une lecture correcte des radiographies standards réalisées avec des incidences spécifiques à la pathologie suspectée. Cet article rappelle comment interpréter une radiographie standard du poignet et de la main. Les pathologies parmi les plus fréquentes en traumatologie de la main et du poignet sont abordées afin d’en faciliter l’interprétation.

Trapeziometacarpal dislocation is a rare traumatic lesion, especially in the pediatric population. Various treatments have been described for acute cases. We report the case of a 15-year-old boy who was admitted in the emergency department with chronic post-traumatic trapeziometacarpal dislocation due to an untreated first metacarpal base fracture (Bennett), with complete articular destruction. The patient was treated by open reduction, interposition of a costal cartilage graft, and intermetacarpal K-wire fixation. Follow-up at 2 years after the surgery showed excellent clinical and radiological results. This surgical technique had not been described previously in the pediatric population.

The aim of this study was to assess distal radioulnar joint stability after unipolar ulnar head replacement for post-Darrach instability. All the patients who underwent ulnar head replacement between1999 and 2015 for post-Darrach procedure instability at our clinic were reviewed. Seven Hebert-type and two uHead (SBI/Stryker) prostheses were implanted. None of the implants were cemented. We assessed stability, pain, range of motion and strength pre- and postoperatively. The changes in the radiographic appearance between immediate postoperative and the last follow-up were determined. All patients (8 patients and 9 joint replacements) had a stable distal ulnar stump at the mean follow-up of 69 months. No complications occurred and no revisions were needed. Pain on a visual analog scale (VAS) was 0 at rest and 6 during maximum effort at the last follow-up; it was 1.5 at rest and 8.5 during effort preoperatively. Wrist flexion and extension, supination and grip strength were unchanged. Pronation increased from 45° to 70°. An area of bone resorption proximal to the ulnar head implant was found in 5 cases but no secondary displacement of the implant or increased pain was reported. Ulnar head replacement stabilizes the ulnar stump. The implant acts as a spacer to place the soft tissues under tension. Distal ulnar stump instability after the Darrach procedure can be solved by a unipolar ulnar head replacement procedure.

We report the selection in a 15-year-old boy of a multidrug-resistant, extended-spectrum β-lactamase (ESBL)-producing Aeromonas salmonicida after medicinal leech therapy that required an antibiotic prophylaxis based on piperacillin/tazobactam and cotrimoxazole. Whole genome sequencing of the strain indeed revealed 13 antibiotic resistance genes, including the ESBL CTX-M-3 and the unusual β-lactamase SCO-1. Keywords: Aeromonas salmonicida, medicinal leech therapy, multidrug resistance, whole genome sequencing

Background Variations in morphology of the carpal bones have been described. Their implication in wrist disease and specific kinematic features has been recognized, and a better knowledge of these variations is essential. Questions/Purpose To radiographically determine any association between the morphological variations of the distal radioulnar joint (DRUJ) and the lunate bone. Materials and Methods Radiographs of 100 wrists of patients presenting to the emergency department with wrist pain and referred to our outpatient clinic were retrospectively reviewed for DRUJ inclination, ulnar variance, and radiocarpal and midcarpal morphology of the lunate. Results There were 51 females and 49 males, mean age 51.2 years (range: 21–94). There was a statistically significant association between the DRUJ inclination and the morphology of the radiocarpal side of the lunate (p Conclusion This study demonstrated a statistically significant association at the radiocarpal level between the DRUJ inclination, ulnar variance, and the morphology of the lunate. No association was found with the morphology of the midcarpal side of the lunate. Accordingly, a classification of these carpal associations is proposed, highlighting seven main wrist configurations. Clinical Relevance These associations can guide future studies of wrist kinematics.

Objectives: In a series of 9 cases with radio-carpal arthritis from trauma that benefitted from a radioscapholunate arthrodesis with excision of the distal scaphoid pole, we desired to measure the perioperative range of motion to see if mobility was preserved after the operation. We also sought to describe our graft technique with a bone cover coming from the cortical distal radius. Methods: We retrospectively collected data from nine patients that benefitted from this surgical technique and we documented the clinical and radiological information. Results: With a mean follow-up of three years, we had the following perioperative results: flexion 44°, extension 41°, ulnar deviation 24° and radial deviation 17°. This range of motion was depressed at postoperative follow-up. We did not observe any pseudoarthrosis. We did find a high complication rate with three cases of mediocarpal arthritis, one tendon rupture and one radiotriquetral conflict. During the postoperative period, the pain was 0/10. Conclusions: Radioscapholunate arthrodesis in the case of radiocarpal arthritis with the use of a bone graft coming from the distal radius demonstrated robust results in terms of pain. The perioperative benefit on mobility was not found during postoperative period. A bone graft using a cortical cover from the distal radius yielded favorable results with regards to bone healing. [Hand Microsurg 2017; 6(2.000): 62-67]

Highlights • Scaphoid union is controversial regarding diagnosis of healing. • XR is the most used modality with poor reliability and reproducibility. • CBCT allows with higher confidence diagnosis of consolidation avoiding longer immobilisation. • Evaluation for translation is better with CBCT than XR at un early follow up. • Six weeks is a reasonable delay to perform the first imaging follows up in waist scaphoid fracture., Purpose To assess the accuracy and reliability of using cone beam computed tomography (CBCT) compared to X-ray six weeks after injury for predicting scaphoid union. Materials and methods Overall; 52 patients with scaphoid fractures between April 2018 and March 2019 were prospectively included in this study. The mean age was 34.52 (13–88) years, and the gender ratio male/female 43/9. Of the fractures, 26 had occurred on the right side, and 26 on the left side. In total, 28 % of patients were manual workers. All patients underwent X-ray and CBCT six weeks after injury. Four readers, two radiologists, and two hand surgeons analyzed the findings using double-blinded X-ray and CBCT and categorized fractures as consolidated based on a 50 % visibility threshold concerning trabecular bridges. Proximal pole sclerosis, communition, cyst formation, and humpback deformity were similarly analyzed for all cases. Agreement between readers was calculated using Kappa, and sensitivity, specificity, and accuracy using RStudio software. The gold standard was the radiologic and clinical follow-up for all patients at two months. Results Inter-reader agreement between the four readers was moderate concerning X-ray (0.543) but substantial concerning CBCT (0.641). It was almost perfect between seniors regarding CBCT (Kappa = 0.862). Sensitivity, specificity, and accuracy were 0.75–0.78, 0.4, and 0.61–0.64, respectively, for two readers regarding CBCT. The X-ray values were 0.65–0.71, 0.35–0.4, and 0.53–0.59, respectively. Conclusion CBCT proves more accurate and reliable than X-ray for diagnosing scaphoid union at an early follow-up and prevents longer immobilization and interruption of activity or work.

Purpose Scaphoid nonunion remains a major problem in hand surgery. The 1,2 intercompartmental supraretinacular artery flap (1,2 ICSRA), as first described by Zaidemberg et al, is widely used with reported union rates of approximately 80%. However, its use is limited in the case of associated carpal collapse as in dorsal intercalated segmental instability (DISI) and humpback deformity. In this study, we present a novel approach to this flap enabling the correction of associated carpal collapse. Methods Between 2006 and 2015, 9 patients with scaphoid nonunion or delayed union with carpal collapse were treated with a vascularized bone flap based on the 1,2 ICSRA using a combined volar and dorsal approach. Immobilization in a short-arm cast was applied for 8 weeks. Union rates, correction of DISI and humpback deformity, as well as clinical end points were noted. In addition, scapholunate (SL) angles were measured using 2 accepted radiological techniques, employing either the scaphoid midline axis or its proximal radiological landmarks as a reference. Results All cases united and a median time to bone consolidation of 4 months (range, 2–5 months) was observed. Preoperative DISI deformities (n = 4) were corrected in all patients. Humpback deformities (n = 5) were also corrected. Two patients had repeat surgery: one for K-wire removal after bony consolidation and the other for neuropathic pain. Conclusions The 1,2 ICSRA bone flap is a reliable treatment for scaphoid nonunion associated with carpal collapse. This combined volar and dorsal approach permits the correction of DISI and humpback deformity without compromising the scaphoid vascular supply, which eliminates the need to use free bone flaps from other sites. In this series, we observed a 100% union rate. Two patients required reoperation for symptomatic hardware and dorsal wrist pain linked to superficial neuritis. Type of study/level of evidence Therapeutic IV.

ObjectiveThe optimal duration of postsurgical antibiotic therapy for adult native joint bacterial arthritis remains unknown.MethodsWe conducted a prospective, unblinded, randomised, non-inferiority study comparing either 2 or 4 weeks of antibiotic therapy after surgical drainage of native joint bacterial arthritis in adults. Excluded were implant-related infections, episodes without surgical lavage and episodes with a follow-up of less than 2 months.ResultsWe enrolled 154 cases: 77 in the 4-week arm and 77 in the 2-week arm. Median length of intravenous antibiotic treatment was 1 and 2 days, respectively. The median number of surgical lavages was 1 in both arms. Recurrence of infection was noted in three patients (2%): 1 in the 2-week arm (99% cure rate) and 2 in the 4-week arm (97% cure rate). There was no difference in the number of adverse events or sequelae between the study arms. Of the overall 154 arthritis cases, 99 concerned the hand and wrist, for which an additional subgroup analysis was performed. In this per-protocol subanalysis, we noted three recurrences: one in the 2-week arm (97 % cure); two in the 4-week arm (96 % cure) and witnessed sequelae in 50% in the 2-week arm versus 55% in the 4-week arm, of which five (13%) and six (13%) needed further interventions.ConclusionsAfter initial surgical lavage for septic arthritis, 2 weeks of targeted antibiotic therapy is not inferior to 4 weeks regarding cure rate, adverse events or sequelae and leads to a significantly shorter hospital stay, at least for hand and wrist arthritis.Trial registration numberNCT03615781.

Denosumab has shown promising results in the management of giant cell tumor of bone, a primary bone tumor with locally aggressive behaviour. We report a case of premature denosumab interruption due to radiological and clinical tumor expansion of a giant cell tumor of the distal ulna. Although denosumab is known to induce tumor regression, with progressive ossification and loss of the characteristic morphology of giant cell tumor of bone, the ulnar tumor specimen showed a moderately to highly cellular proliferation of short spindle-shaped cells, and no osteoclast-like giant cells. There were no abnormal mitotic figures. We considered the surgical specimen as a giant cell tumor of bone with partial regression after prematurely interrupted denosumab treatment. This case illustrates the diagnostic issues of an initially unfavourable evolution raising concern for malignancy, and the difficulties in histological assessment of a partially treated giant cell tumor of bone, that may mimic osteosarcoma.

Treatment of septic hand tenosynovitis is complex, and often requires multiple débridements and prolonged antibiotic therapy. The authors undertook this study to identify factors that might be associated with the need for subsequent débridement (after the initial one) because of persistence or secondary worsening of infection.In this retrospective single-center study, the authors included all adult patients who presented to their emergency department from 2007 to 2010 with septic tenosynovitis of the hand.The authors identified 126 adult patients (55 men; median age, 45 years), nine of whom were immunosuppressed. All had community-acquired infection; 34 (27 percent) had a subcutaneous abscess and eight (6 percent) were febrile. All underwent at least one surgical débridement and had concomitant antibiotic therapy (median, 15 days; range, 7 to 82 days). At least one additional surgical intervention was required in 18 cases (median, 1.13 interventions; range, one to five interventions). All but four episodes (97 percent) were cured of infection on the first attempt after a median follow-up of 27 months. By multivariate analysis, only two factors were significantly associated with the outcome "subsequent surgical débridement": abscess (OR, 4.6; 95 percent CI, 1.5 to 14.0) and longer duration of antibiotic therapy (OR, 1.2; 95 percent CI, 1.1 to 1.2).In septic tenosynovitis of the hand, the only presenting factor that was statistically predictive of an increased risk of needing a second débridement was the presence of a subcutaneous abscess.Risk, III.

Necrotizing fasciitis is a rare condition. Due to the agressivity of the infection and the amputation rate, it is very important to be aware of this diagnostic and do a proper surgical debridement. We describe a clinical case of a patient with a necrotizing fasciitis that needed two fingers amputation. After the antibiotic treatment and a second surgical debridement we performed a skin graft. The follow up at 6 months show a good function of the hand.

Hand aneurysms are a rare entity only described as case reports in the literature. The aim of our study was to describe a series of four cases and the surgical technique using an arterial bypass. We also wanted to define an algorithm for the imaging of this pathology. We have operated on four patients with hand aneurysms in the past decade or so. One patient had an aneurysm in the thumb proper palmar digital artery, one in the superficial palmar arch and the two others in the ulnar artery. All patients had an excision surgery with direct arterial bypass; no patient had a venous graft. All patients were seen a few years after the surgery and underwent an ultrasonography to check the anastomosis permeability. All anastomoses were permeable 2 to 8 years after surgery. Through a review of the literature we discuss the best algorithm for imaging a hand aneurysm. Direct arterial suture by proximal and distal mobilization allows for long-term permeability. If a graft is necessary, a graft of arterial origin should be preferred. The additional first-line examination is ultrasonography, followed by arteriography if acute ischemia is present; otherwise, CT angiography or MR angiography is performed.

The optimal duration of postsurgical antibiotic therapy for native hand and finger joint septic arthritis is unknown. We conducted a three-year (May 2015–May 2018), prospective, unblended, single-center, interventional study of adult patients agreeing to a randomization (1–1) to either 2 or 4 weeks of systemic and targeted antibiotic therapy after surgical drainage for native joint infection of the hand or wrist. It was a non-inferiority trial with a lower margin of 10% and two major outcomes—cure of infection and persistent (mechanical) sequelae at the last control visit. We excluded patients with implant-related infections while the implant was still in place, patients without surgical lavage, and patients with short follow-ups (

L’hemi-arthroplastie du radius distal est une alternative chirurgicale encore peu repandue dans le cadre de la prise en charge des fractures comminutive du radius distal du sujet âge. Dans ce contexte, l’osteosynthese est a risque de complications et de deplacement secondaire notamment de par la mauvaise qualite osseuse. Le but de cette etude etait de rapporter les resultats a court et moyen terme des hemi-arthroplasties du radius distal dans le traitement des fractures type C3 selon l’AO du sujet âge. De juillet 2016 a novembre 2018, 12 patients âges en moyenne de 79 ans (68–89) ont beneficie de la mise en place d’une hemi-arthroplastie radiale cimentee. Tous les patients ont ete evalues sur le plan clinique, fonctionnel et radiographique. Les complications per- et postoperatoires ont ete recherchees. Dans 11 cas, il s’agissait de la prothese REMOTION (SBI) et dans un cas de la prothese SOPHIATM (Biotech). Une resection de la tete ulnaire de type DARRACH a ete realisee conjointement chez 9 patients. Le recul moyen etait de 8 mois (3–24). Les mobilites moyennes etaient de 33° (20–60) en flexion et 48° (30–70) en extension. L’arc de mobilite en prono-supination etait en moyenne de 160° (140–180). La force de serrage moyenne etait de 11 kgf (5–20) au Jamar. Huit patients etaient strictement indolores au dernier recul. Trois reprises chirurgicales ont eu lieu durant le suivi. Un cas d’infection precoce (2 semaines) a necessite un lavage avec conservation de l’implant et antibiotherapie durant 3 mois. Un patient a ete repris pour une arthropathie radio-ulnaire distale avec realisation d’un DARRACH. Enfin, une instabilite radio-carpienne est survenue a 6 semaines postoperatoire avec luxation radio-carpienne anterieure pour laquelle une reprise chirurgicale a ete realisee. Les radiographies au dernier recul n’ont pas mis en evidence de descellement de l’implant ni de translation ulnaire du carpe. L’hemi-arthroplastie du radius distal permet de restaurer rapidement une mobilite et une autonomie satisfaisante chez les sujets âges. Malgre un taux de reprise a 25 %, cette option therapeutique nous parait preferable a une osteosynthese chez les sujets âges, autonomes, presentant des fractures type C3 selon l’AO du radius distal. Un suivi a long terme voire une etude comparative apparait indispensable afin de pouvoir valider de facon consensuelle cette prise en charge.

The PI2® spacer is designed for treatment of trapeziometacarpal (TM) osteoarthritis. However, the shape of this implant has raised concerns about its stability. We retrospectively investigated 45 implants in 41 patients treated for trapeziometacarpal osteoarthritis in our hospital between 2004 and 2009 who underwent trapeziectomy and insertion of a PI2® spacer. Outcome parameters included revision rates and clinical outcomes correlated with implant position and scaphometacarpal distance, assessed using standard radiographs. A total of 12 implants (27%) were removed at a median time of 10 months (interquartile range (IQR), 7–22 months). These included five dislocations and one early infection. Additionally, a further six patients underwent revision due to persistent pain. Three of these had scapho-trapezoid osteoarthritis, two had developed subluxation of the implant, and one did not show any radiographic abnormalities. A review of patient records revealed that 33 implants remained in place at a median time of 29 months (IQR, 20–57). However, of those, only 21 implants (64%) in 17 patients were available for clinical evaluation at a median follow-up of 29 months (IQR, 19–62 months). No significant differences in clinical outcomes including functional results were observed between in-place ( n = 8) and subluxated ( n = 13) implants. Due to the high revision rate (12/45), consistent with other reports in the literature, we have abandoned the use of the PI2® spacer. We recommend the establishment of a registry for evaluation of future implants. Type of study/level of evidence: Case-series study/level IV

In this paper we illustrate the principal extraspinal pathologies causing sciatica and new approaches for the study of structures such as the lumbosacral plexus (LSP). Visualisation of the LSP in its entirety is difficult with conventional two-dimensional MRI sequences owing to its oblique orientation. In our institution, we have found that the utilisation of three-dimensional short tau inversion-recovery sampling perfection with application-optimised contrasts using different flip angle evolutions sequence is helpful, allowing multiplanar and maximum intensity projection reconstructions in the coronal oblique plane and curvilinear reformats through the plexus. Diffusion tensor imaging enables the observation of microstructural changes and can be useful in surgical planning. The normal anatomy of the LSP, its different extraspinal pathologies and differential diagnoses are thoroughly presented.

Trapezometacarpal dislocation is an uncommon traumatic lesion, especially in pediatric population, accounting for less than 1% of hand traumas. The lesion is usually due to an axial force, transmitted on a partially flexed thumb, causing the metacarpal bone to dislocate dorsally. When acute, various treatments have been described — closed reduction and cast, open or closed reduction with temporary K-Wire fixation, dorsal capsule and ligament reconstruction. In this abstract, we report a case of a 15-year-old boy who was admitted in the emergency department with a chronic post-traumatic trapeziometacarpal dislocation. The history reveals that he suffered from an thumb traumatism, by falling of a motorcycle seven months before, left untreated. By the time of the admission, he was suffering from thumb pain following a minor trauma that happened one week before. The X-rays and the preoperative CT scan showed a trapeziometacarpal dislocation, due to an untreated first metacarpal base fracture, with complete articular destruction. He underwent surgery, which consisted of an open reduction, a interposition graft of costal cartilage (9th rib) and ligament reconstruction (intermetacarpal, anterior oblique, posterior capsule). A temporary K-wire between first and second metacarpal was made followed by a cast immobilization for one month. The follow-up of the surgery showed a complete recuperation of the articular mobility and an absence of pain. Finally the X-rays revealed a reduction of the luxation.

Imaging plays an essential role for the detection and analysis of pathologic conditions of the brachial plexus. Currently, several new techniques are used in addition to conventional 2D MR sequences to study the brachial plexus: the 3D STIR SPACE sequence, 3D heavily T2w MR myelography sequences (balanced SSFP=CISS 3D, True FISP 3D, bFFE and FIESTA), and the diffusion-weighted (DW) neurography sequence with fiber tracking reconstruction (tractography). The 3D STIR sequence offers complete anatomical coverage of the brachial plexus and the ability to slice through the volume helps to analyze fiber course modification and structure alteration. It allows precise assessment of distortion, compression and interruption of postganglionic nerve fibers thanks to the capability of performing maximum intensity projections (MIP) and multiplanar reconstructions (MPRs). The CISS 3D, b-SSFP sequences allow good visualization of nerve roots within the spinal canal and may be used for MR myelography in traumatic plexus injuries. The DW neurography sequence with tractography is still a work in progress, able to demonstrate nerves tracts, their structure alteration or deformation due to pathologic processes surrounding or located along the postganglionic brachial plexus. It may become a precious tool for the understanding of the underlying molecular pathophysiologic mechanisms in diseases affecting the brachial plexus and may play a role for surgical planning procedures in the near future.

OBJECTIVE. The aim of this article is to present the sonographic appearance of the most common masses of the wrist and hand and to discuss the role of sonography in their diagnosis.CONCLUSION. Sonography is a readily available imaging technique that can detect and assess masses of the wrist and hand. Together with standard radiography, sonography can be used as a first-line radiologic technique in this field.

Resume Objectifs La prise en charge des lesions traumatiques du plexus du brachial depend essentiellement de la localisation pre- (avulsion radiculaire) ou postganglionnaire (atteinte des troncs et faisceaux) des lesions. L'objectif de cette etude etait de determiner la valeur diagnostique et pronostique de l'IRM dans le bilan lesionnel du plexus brachial traumatique et de correler les resultats de l'imagerie aux donnees cliniques et electroneuromyographiques (ENMG) precoces et tardives. Materiel et methode Neuf patients presentant des lesions traumatiques du plexus brachial ont ete explores par IRM et ENMG a la phase aigue. Un controle a distance a egalement ete realise chez cinq patients. Le protocole IRM comprenait des sequences en FSE T2 et STIR. Les images ont ete interpretees independamment par deux radiologues seniors. Les resultats ont ensuite ete valides en concertation pluridisciplinaire entre chirurgiens, radiologues et neurologues afin de determiner la localisation exacte des lesions ainsi que le mecanisme en cause. L'apport et les limites de chaque technique ont egalement ete precises. Resultats Parmi les neuf patients, l'IRM etait jugee normale chez trois patients alors que l'ENMG montrait des lesions distales chez deux d'entre eux. Chez trois patients, les sequences STIR retrouvaient des hypersignaux etendus de C5 a T1 des troncs et des faisceaux avec persistance des anomalies de signal a trois mois chez un patient et regression partielle des anomalies chez les deux autres. Chez les trois derniers patients, les sequences 3DT2 montraient la presence d'avulsions radiculaires, en concordance avec les donnees de l'ENMG initiale. Conclusion L'IRM est l'examen de choix pour detecter les avulsions radiculaires. En revanche, l'IRM ne permet pas d'apprecier et de localiser les lesions tres distales du plexus contrairement a l'ENMG. La differenciation entre œdeme (atteinte reversible) et demyelinisation (atteinte irreversible) des lesions postganglionnaires necessite une IRM tardive ou des examens complementaires type ENMG.

The majority of fifth metacarpal neck fractures (boxers fracture) are treated conservatively without surgery. The purpose of this prospective, randomized, multicenter trial was to determine if the outcomes of soft wrap and buddy taping (SW) was noninferior to reduction and cast (RC) in boxer's fracture with palmar angulation ≤70° and no rotational deformity.Sixty-eight patients with similar characteristics were prospectively enrolled and randomized at four institutions. Our primary outcome was measured by the shortened Disabilities of the Arm, Shoulder and Hand (quickDASH) questionnaire at 4 months. Noninferiority was claimed if there was no more than +10 points difference in the quickDASH. Other secondary radiographic and clinical outcomes were measured.At 4 months, mean difference in the quickDASH between the two groups was -10.4 (95 % confidence interval, -27.0; +6.2) which was under the pre-specified margin. There was no significant difference between both groups' secondary outcomes of pain, satisfaction with the esthetic appearance, mobility of the metacarpophalangeal-joint at flexion and extension, or power grip. Increased fracture angulation, as measured on follow-up radiographs, was not significantly different between both groups. The degree of palmar fracture angulation was not related to work leave or profession. Duration of time off from work was 11 days shorter in SW compared to RC (P = 0.03).This study supports the use of soft wrap and buddy taping for treatment of boxer's fracture with palmar angulation ≤70° and no rotational deformity. Although there was no statistical difference in satisfaction with the esthetic appearance, the patient must be willing to accept the loss of the "knuckle" with this treatment method.

To the Editor, Skin and soft tissue infections are most frequently caused by methicillin-sensitive Staphylococcus aureus (MSSA) and Streptococcus pyogenes. Although all infections are potentially s...

Les revisions chirurgicales apres neurolyses ouvertes ou endoscopiques primaires du nerf median au niveau du tunnel carpien sont necessaires en cas de recidive ou persistance des symptomes. Soltani et al. (2013) demontrent par une meta-analyse que les revisions chirurgicales avec interposition d’un lambeau vascularise ont un taux de succes superieur (86 %) aux revisions chirurgicales sans lambeau (75 %). Nous presentons les resultats cliniques d’une etude retrospective incluant 20 revisions chirurgicales par neurolyse a ciel ouvert du nerf median et lambeau synovial selon Wulle au niveau du tunnel carpien effectuees entre janvier 2012 et decembre 2016. Un total de 20 interventions dont 17 patients (moyenne d’âge ± EC : 53,9 ± 14,8) ont beneficie d’une neurolyse a ciel ouvert associee a un lambeau synovial comme traitement chirurgical en cas de recidive du syndrome de tunnel carpien. Seuls les cas avec recidive du tunnel carpien presentant une cicatrisation du retinaculum des flechisseurs ou presentant un nerf median avec une fibrose peri-neurale a l’imagerie par resonances magnetique, a l’ultrason et ou par constatation directe peroperatoire ont ete inclus dans l’analyse. Les resultats de la chirurgie ont ete repartis en 4 categories en fonction du dernier suivi postoperatoire. Un resultat excellent est defini comme la disparition complete des plaintes, un bon resultat comme une diminution notable des symptomes, un resultat nul definit une faible amelioration ou l’absence d’amelioration et un mauvais resultat etant une aggravation des symptomes. Les analyses descriptives demontrent que 75 % des patients presentent une evolution favorable, dont 20 % un resultat excellent et 55 % un bon resultat, alors que 10 % presentent une evolution nulle et 15 % une evolution defavorable. Le recul est situe entre 46 jours et 1280 jours postoperatoires avec un recul median de 348 jours (recul moyen ± EC : 371j ± 367). Les resultats de notre etude demontrent que 75 % des patients presentent une evolution favorable apres revision du canal carpien par neurolyse a ciel ouvert et lambeau synovial de recouvrement. Cette option chirurgicale peu invasive est interessante et devrait faire partie de l’arsenal therapeutique des syndromes de tunnel carpiens recidivants.

Les TCG sont des tumeurs rares dans la main. Lorsque l’atteinte est osseuse, il faut, pour eviter les recidives, realiser une resection large. Cela implique une perte de substance osseuse qu’il faut par la suite reconstruire. Nous decrivons 2 cas de reconstruction osseuse dans ce contexte tumoral avec la technique de la membrane induite selon Masquelet (un premier metacarpien et une phalange). Description des cas Cas 1 : il s’agit d’une jeune patiente de 24 ans qui presente une TCG de l’interphalangienne distale du 3e doigt de la main droite. Le bilan par imagerie montre un envahissement articulaire et dans ce contexte une resection de l’articulation et de la partie distale de P2 est planifiee. La patiente beneficie d’un premier temps de Masquelet avec resection tumorale, mise en place de ciment et stabilisation par une broche. Deux mois plus tard, elle beneficie du deuxieme temps de Masquelet avec greffe osseuse spongieuse prise au depend du radius distal et stabilisation avec une vis de compression. Le suivi radiologique montre une consolidation. Cas 2 : il s’agit d’une patiente de 67 ans qui presente une TCG du premier metacarpien avec extension dans la base de P1. Le bilan par imagerie confirme l’atteinte articulaire. Une chirurgie est planifiee pour resection de la tumeur et arthrodese metacarpo-phalangienne. Un premier temps de Masquelet est realise avec stabilisation par plaque. Deux mois plus tard, la patiente beneficie du deuxieme temps de Masquelet avec prise de greffe cortico-spongieuse prise au depend de la crete iliaque. Le suivi radiologique montre une consolidation acquise a 2 mois post deuxieme temps de Masquelet. La technique de la membrane induite, grâce a ses facteurs d’osteoinductions, permet de reconstruire des pertes de substance osseuse dans les resections larges necessaires a la chirurgie des TCG. Le delai entre les 2 chirurgies nous permet d’avoir les resultats de la pathologie et de s’assurer des marges saines de resection. Le suivi de nos 2 cas montre une consolidation et une absence de recidive. Un suivi au long cours est necessaire.

The treatment of impacted distal radius fractures is complex. Internal fixation by a dorsal approach with arthrotomy should be considered, particularly when the fractures are dorsally comminuted. This was a retrospective, observational study of 26 patients operated between 2008 and 2012 who were reviewed in September 2013. In the surgical procedure, a single dorsal incision was made over the distal radius and arthrotomy performed; the fracture site was stabilized with two 2.4mm locking plates. The average follow-up was 39months. All fractures were type 23C in the AO classification. All patients were assessed with the QuickDASH and Mayo Wrist scores. Total range of motion was 82% of the contralateral side. Grip strength was 30kg in average. The mean radial sagittal tilt was +6° postoperatively. No plate movement or intra-articular screws were present. Four patients developed symptomatic early osteoarthritis. Thirteen patients had the plate removed due to discomfort. No tendon ruptures were observed. The dorsal approach remains a treatment option for specific intra-articular fractures. It offers direct intra-articular congruency control, along with a stable buttress and locking fixation for early mobilization. Our results are comparable to those using other surgical techniques for this type of high-energy fracture.

Non-tuberculous mycobacterial infections of the hand are difficult to treat and require a long time before remission. But how long should we wait to see an improvement? To answer this question, the published scientific literature was reviewed in English, French and German. Tuberculosis, arthritis and osteomyelitis cases were excluded. A total of 241 non-tuberculous mycobacterial hand infections in 38 scientific publications were retrieved. Most were case reports or series. The median age of the patients was 58 years and one third was female. Patients were immunocompromised in 17 episodes. The most common species were Mycobacterium marinum in 198 episodes (82%), followed by M. chelonae in 13 cases (5%). There were no cases of mixed infection. Most infections were aquatic in origin and community-acquired, and were treated with a combination of surgical debridement and long-duration systemic combination antibiotic therapy (14 different regimens; no local antibiotics) for a median duration of 6 months. The median number of surgical procedures was 2.5 (range 1–5). Clinical success was not immediate: a median period of 3 months (range 2–6) was necessary before the first signs of improvement were observed. The majority (173 cases; 76%) remained entirely cured after a median follow-up time of 1.7 years (range, 1–6). Only two microbiological recurrences occurred (1%). However, 49 patients (21%) had long-term sequelae such as pain, stiffness and swelling. The approach of long-duration antibiotic treatment in combination with repeated surgery for mycobacterial soft tissue infections of the hand leads to few recurrences. However, clinical success is not immediate and may take up to 3 months. Type of study Therapeutic study: systematic review of level III studies. Level of evidence III.