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The opposable thumb provides both stability and mobility and is needed to accomplish different prehensile tasks. The trapezium is a complex bone, with a distal articular surface that is convex in the sagittal plane of the thumb and concave in the coronal plane of the thumb. The numerous additional articulations with the carpus and the oblique orientation to the main plane of the hand makes it difficult to evaluate the trapeziometacarpal joint using standard hand or wrist radiographic views. This review gives an overview of the different radiological views that have been described for the thumb with an emphasis on their historical origin and positioning during radiography. We also describe different measurements and classifications that can be obtained using different thumb radiographs.

Background The effect of obliquity of tendon laceration on repair strength is not well studied. The overwhelming majority of biomechanical studies assess repair strength following a laceration that is perpendicular to the long axis of the tendon. The aim of this study was to investigate whether the angle of tendon laceration affects the core suture strength. Methods In all, 110 fresh human cadaveric flexor tendons were cut at varying angles of 15°, 30°, 45°, and 60° and the control group at 90°. All tendons were repaired with 6-strand modified Tang technique. The repair strength was tested using a custom-made tensioning machine, and the initial static gap force and the ultimate breaking force were measured. Results The mean gap force and 95% confidence interval (CI) for the 15°, 30°, 45°, 60°, and 90° groups were 15.2 N (11.4-19.0 N), 15.8 N (13.6-18.1 N), 15.6 N (13.1-18.4 N), 16.6 N (13.7-19.5 N), and 22.3 N (16.6-27.9 N), respectively. In the same respective order, the break force and 95% CI were 25.9 N (21.9-29.8 N), 26.5 N (23.2-29.7 N), 31.1 N (26.1-36.1 N), 35.6 N (28.2-43.1 N), and 51.8 N (62.5-41.0), respectively. The Fisher least significant difference demonstrated significant differences between the control group and all experimental groups for both gap force and break force. Conclusions Obliquity of tendon laceration affects the core suture strength when compared with a transverse cut. Flexor tendons cut at 90° demonstrated a higher overall gap force and breaking strength that were statistically significant when compared with all obliquely cut groups. These findings should be considered when repairing and starting postoperative therapy for obliquely cut tendons.

A 35 year-old right-handed female presented with persistent wrist pain lasting two years. Imaging disclosed an accessory tendon-shaped structure, identified as a Flexor Carpi Radialis Brevis, strangling the Flexor Carpi Radialis tendon at the wrist during effort. Surgical exploration found the insertion of the Flexor Carpi Radialis Brevis to be bifid. Resection of the stenosing branch and the fibrotic tendon sheath restored strength in the right wrist and painless symmetrical motion compared to the left wrist ten weeks postoperatively.

We assess the distribution of trapezial inclination in a young population in order to propose a threshold for trapezial dysplasia. One hundred peritrapezial views were reconstructed from wrist computed tomography scan datasets to measure trapezial inclination. Seventy peritrapezial views were constructed from 10 datasets to assess the influence of radiograph rotation. Mean trapezial inclination in our population was 8° (range 0.2–17.9). Fifteen degrees of radiographic pronation or supination did not alter trapezial inclination significantly. Intra-rater consistency and absolute agreement had an interclass correlation (ICC) of 0.95. Inter-rater consistency and absolute agreement had an ICC of 0.88. Trapezial inclination is a reliable measurement for trapezial dysplasia with an excellent intra-rater and good inter-rater reliability and does not change significantly with 15° of radiographic pronation or supination. These normal values can be used to propose a threshold for trapezial dysplasia in the management of trapeziometacarpal joint instability in the younger population. Level of evidence: IV

Background Although outcome of volar plating is generally good, care should be taken to avoid specific iatrogenic and preventable complications, with an incidence reporting averaging 15%. Flexor tendon rupture due to a prominent plate, extensor tendon rupture due to a dorsal protruding screw tips, cartilage lesions due to intra-articular screw placement, loss of reduction due to insufficient stability, and persisting ulnar pain with distal radioulnar joint instability due to unstable triangular fibrocartilaginous complex lesions or unstable ulnar styloid base fractures all have been described. Purpose We believe that a majority of these complications can be prevented by meticulous assessment of several intraoperative parameters during volar plating. Therefore, we introduce the WRIST protocol, a stepwise easy-to-remember manual that combines multiple fluoroscopic measurements to guide intraoperative decision making. Conclusion Large prospective studies of the “WRIST” protocol are needed for validation. But we believe that it may help surgeons to optimize surgical technique, functional and radiographic outcome, and prevent complications when treating distal radial fractures.

Background: The Pulvertaft weave was described more than 50 years ago and is still used in tendon transfers. The aim of this study was to evaluate the strength of a modified core suture Pulvertaft weave technique and compare it to the original Pulvertaft weave traditionally used in tendon transfer surgery. Methods: 12 extensor pollicis longus tendons and extensor indices proprius tendons were harvested from fresh frozen cadavers. Six Pulvertaft weaves were performed using FiberWire 4.0 and six core suture tendon weave were performed using FiberLoop 4.0. Biomechanical analysis was performed and stifness, first failure load and ultimate failure load were measured for both set of repairs. Results: The stiffness of the core suture tendon repair (9.5 N/mm) was greater than that of the Pulvertaft repair (2.5 N/mm) The first failure load of the core suture tendon repairs (68.9 N) was greater than the Pulvertaft repairs (19.2 N) and the ultimate failure load of the core suture tendon repairs (101.8 N) was greater than the Pulvertaft repairs (21.9 N). All of these differences were statistically significant. Conclusions: The core suture Pulvertaft weave is a modification to the Pulvertaft weave used in tendon transfers. The results of this cadaveric study suggest it is 5 times stronger than the traditional Pulvertaft repair, potentially allowing it to be used with early active motion protocols after tendon transfers.

Background Several volar plating techniques exist to treat distal radial fractures. Question We investigated minimally invasive plate osteosynthesis (MIPO) with pronator quadratus (PQ) sparing versus conventional flexor carpi radialis approach for volar plating with PQ repair after distal radial fractures during the first postoperative year. Patients and Methods Prospective data of two consecutive cohorts were compared: 62 patients in MIPO group with an average age of 61.2 years and 66 patients in PQ repair group with an average age of 61.4 years completed the entire follow-up period. Results Range of motion was not significantly different, except flexion–extension that was significantly higher in the MIPO group. Quick Disabilities of the Arm, Shoulder and Hand was significantly lower in the MIPO group. Pain visual analogue scale was only significantly lower at 6 weeks. Grip strength measurements and patient satisfaction were not significantly different. Conclusions MIPO volar plating with PQ sparing is a surgical technique that can be chosen according to surgeon's preference and expertise, resulting in a better flexion–extension mobility and function score according to our study. Level of evidence This is a Level 3 study.

BACKGROUND: Distal phalanx fractures are frequently encountered in our daily practice. They are often caused by crush injuries and are the most frequent work-related hand fractures. Different types of fixation have been proposed for displaced fractures. METHODS: A retrospective study was performed on two fixation types. Twenty-four distal phalanx fractures were treated with k-wire fixation with fluoroscopic control in a main operating room setting. Twenty-five distal phalanx fractures were treated with hypodermic needle fixation without fluoroscopic control in an emergency treatment room setting. Clinical and radiological data were collected on fracture type, fracture healing and complications. The cost of both types of surgery was assessed. RESULTS: No significant difference in healing time, union, delayed union and non-union was found between the two groups. Loosening was significantly more frequent in the hypodermic needle group, without affecting clinical or radiographic outcome. No infections were encountered in both groups. Surgery performed in the emergency treatment room reduced the cost with 9000 dollars when compared to surgery performed the main operating room. CONCLUSION: Treatment of displaced distal phalanx fractures with hypodermic needle fixation yields good results. Performing this procedure in a treatment room is safe and might reduce operative time, institutional costs and radiation exposure for both surgeon and patients.

Background: Since the Sauvé-Kapandji procedure was introduced in 1936, many modifications were created using dynamic stabilizer, such as the ECU (extensor carpi ulnaris), the FCU (flexor carpi ulnaris), pronator teres to solve proximal ulnar stump pain. We believe that this modification is also another option for distal ulnar stump instability. Methods: From January 1998 to February 2017, there were 13 patients received the Sauvé-Kapandji (S-K) procedure with tenodesis of the ECU to the carpus and interosseous membrane. The average age at operation was 52 years (range, 28 to 63 years). Four had traumatic arthritis (two from distal radial fracture malunion, two had instability of distal radioulnar joint from Essex-Lopresti injury), four had primary osteoarthritis of the distal radio-ulnar joint, two had rheumatoid arthritis, one had gouty arthritis, two had madelung deformity. The average follow-up was 30 months (range, 15 to 72 months). Results: Postoperative pronation/supination of the forearm had significantly improved with the exception of the wrist flexion/extension. After surgery, the mean radioulnar distance was narrowed from 11 mm to 9 mm, but no significant difference in 12 patients. All patients had improved in wrist pain, 10 patients had no pain and 3 patients with mild pain over the distal ulnar stump. The mean grip strength had significantly improved from 51% of the contralateral side to 75%. The lateral and stress X-ray films showed no instability of the distal ulnar stump after surgery. Conclusions: In conclusion, the modified S-K procedure using the tenodesis of ECU provides a multi-directional stability and is a reliable surgical procedure for distal radioulnar disorders.

This is a 39-year-old male, fell from a bike, left wrist with trans-styloid perilunate fracture dislocation that underwent open reduction internal fixation, 20 months after surgery the patient developed avascular necrosis of the lunate, final wrist fusion was performed secondary to the arthritic changes on the wrist. Anatomic dissection was performed and vascularity of the lunate was identified, its origin is from the volar palmar arch, when dislocated palmarly and more than 90 degrees the vessel is still intact. More than 512 patients with perilunate dislocation and perilunate fracture dislocation are included we identified in the literature transient avascular necrosis of the lunate in nine and seventeen of pure avascular necrosis of the lunate. Concluding that avascular necrosis of the lunate after perilunate dislocation or perilunate fracture dislocation is an infrequent finding especially when the volar ligaments are intact.

Bennett's fractures are the most common fractures around the trapeziometacarpal joint but require specialized radiographs to be correctly diagnosed. If a fracture is missed at initial presentation, it may heal with an intra-articular gap, leading to joint incongruency and a painful trapeziometacarpal joint. We present a new technique to correct the intra-articular gap and restore joint congruency in the event of a symptomatic Bennett malunion with a gap of at least 2 mm. The joint is exposed through an anterolateral approach, and the malunion is marked with K-wires under fluoroscopic control. A closing wedge osteotomy with excision of the malunion site is then performed to restore joint congruency. The osteotomy is fixed with 3 interfragmentary screws, and the joint is immobilized for 2 weeks before passive mobilization is initiated. Hardware can be removed between 3 and 6 months postoperatively after consolidation of the osteotomy. We recommend this technique in active patients without trapeziometacarpal osteoarthritis who present with a painful Bennett malunion. Restoration of the joint congruency reduces pain and may prevent the development of posttraumatic osteoarthritis.

Carpal stability depends on the integrity of both intra-articular and intracapsular carpal ligaments. In this review, the role of the radial-sided and ulnar-sided extrinsic and intrinsic ligaments is described, as well as their advanced imaging using magnetic resonance arthrography (MRA) and contrast-enhanced magnetic resonance imaging (MRI) with three-dimensional (3D) scapholunate complex sequences and thin slices. In the last decade, the new concept of a so-called “scapholunate complex” has emerged among hand surgeons, just as the triangular ligament became known as the triangular fibrocartilage complex (TFCC).The scapholunate ligament complex comprises the intrinsic scapholunate (SL), the extrinsic palmar radiocarpal: radioscaphocapitate (RSC), long radiolunate (LRL), short radiolunate (SRL) ligaments, the extrinsic dorsal radiocarpal (DRC) ligament, the dorsal intercarpal (DIC) ligament, as well as the dorsal capsular scapholunate septum (DCSS), a more recently described anatomical structure, and the intrinsic palmar midcarpal scaphotrapeziotrapezoid (STT) ligament complex. The scapholunate (SL) ligament complex is one of the most involved in wrist injuries. Its stability depends on primary (SL ligament) and secondary (RSC, DRC, DIC, STT ligaments) stabilizers.The gold standard for carpal ligament assessment is still diagnostic arthroscopy for many hand surgeons. To avoid surgery as a diagnostic procedure, advanced MRI is needed to detect associated lesions (sprains, midsubstance tears, avulsions and chronic fibrous infiltrations) of the extrinsic, midcarpal and intrinsic wrist ligaments, which are demonstrated in this article using 3D and two-dimensional sequences with thin slices (0.4 and 2 mm thick, respectively).

Background: Trapeziometacarpal arthroplasties are designed to restore an adequate level of mobility, stability, and grip strength. In this article, pain and functional and radiographic outcome of Ivory arthroplasty in male patients are investigated. Methods: Between 2005 and 2012, the Ivory arthroplasty was inserted in 21 male patients with degenerative trapeziometacarpal osteoarthritis, of which 14 patients were found eligible for inclusion. Mobility, grip strength, patient self-assessment (pain; Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH]), and radiographic outcome were measured. Twenty-two female patients who received an Ivory arthroplasty between 2005 and 2007 were included and underwent the same evaluation. Age at primary surgery, survival rate of the implant, and clinical outcome were compared between the 2 groups. Results: In both groups, QuickDASH score and mean pain sensation improved significantly. The improvement in mobility obtained significance in the female group. In the male group, 7 arthroplasties failed (mean follow-up of 65 months). In the female group, 3 of the 24 arthroplasties failed (mean follow-up of 123 months). Kaplan-Meier survival analysis demonstrated a significant lower implant survival in the male group. Conclusions: Decrease in muscle mass and decline in grip strength that postmenopausal women tend to experience might explain the significant difference in implant survival between sexes. In 4 of the 7 failed arthroplasties in the male group, no surgical revision was required. Trapeziometacarpal arthroplasty, even after radiographic failure, still served as a spacer, avoiding collapse of the thumb base. Nevertheless, the failure rate of the Ivory arthroplasty in male patients is high, and an alternative treatment should be considered.

Mallet fingers are injuries to the extensor tendon at the distal interphalangeal (DIP) joint and can present as a bony avulsion or as a soft tissue injury. Nonbony mallet fingers are frequently splinted in extension between 6 and 8 weeks. If splinted correctly, most results are good with a mean DIP joint extension lag between 5 and 10 degrees. However, decreased swelling, hygienic considerations and patient compliance can lead to splint removal and a less favorable outcome. We present a percutaneous tenodermodesis using only a digital block and a 4.0 nylon suture. This office-based procedure provides joint reduction and prevents joint movement during the immobilization period. The suture can be removed after 8 weeks, allowing active mobilization of the DIP joint. We present the results of 8 patients with a mean follow-up of 3 months and mean initial extension lag of 32 degrees, resulting in a mean final extension lag of 2 degrees and excellent outcomes using the Crawford criteria.

Closed reduction and fixation with elastic intramedullary nails is a popular technique to treat displaced pediatric forearm fractures and has yielded good functional results. Postoperative neurological symptoms can be due to neuropraxia and expectative treatment has been advised for 3 months until further investigation is necessary. We present a case of an 11-year-old boy that presented with median nerve palsy 2 months after a displaced forearm fracture treated with elastic intramedullary nails. Ultrasound and nerve conduction study confirmed the presence of a median nerve entrapped in the callus of the radial fracture. Surgical exploration demonstrated that the nerve was twisted around the intramedullary device. After neurolysis and surgical repair the patient finally recovered 2 years after the operation. This case highlights the possibility of median nerve entrapment after reduction with elastic intramedullary nails. Symptoms should be recognized early, and urgent surgical exploration is needed to prevent irreversible damage.

BACKGROUND: Surgical reinsertion of the distal biceps tendon for acute and chronic tears is a widely accepted procedure, but little is known about surgical treatment of distal biceps tendinopathy. METHODS: Twenty patients underwent a surgical procedure for distal biceps tendinopathy after failure of conservative treatment. The surgery was performed through a single incision. The biceps tendon was detached, debrided and reinserted using a ToggleLoc (Zimmer Biomet) device. Clinical and radiologic evaluation was performed after a minimum follow-up of 1 year. Quick-Dash score, Liverpool Elbow Score, Mayo Elbow Performance Index, Broberg and Morrey Score and Short HSS Scoring System were used, and isokinetic testing was performed. RESULTS: The outcome of these five clinical elbow scores showed no clinically relevant differences between the affected and non-affected side. Isokinetic testing of peak torque in flexion and supination showed equal strength between both sides. These results indicate good functional outcome and recovery of flexion and supination, compared to the non-operated side and the normal population. CONCLUSION: This study demonstrates that distal biceps tendon debridement and reinsertion is a safe and valid option for patients with distal biceps tendinopathy after failure of conservative treatment. LEVEL OF EVIDENCE: Level 3 retrospective cohort study.

Background Proximal migration of the first metacarpal can be seen after total trapeziectomy and various techniques have been described to prevent this subsidence. Purpose We hypothesized the insertion of a poly-L/D-lactide spacer to prevent proximal migration of the first metacarpal without the need of an additional ligament reconstruction, allowing early mobilization and less demanding rehabilitation. Patients and Methods Ten thumbs were treated with a total trapeziectomy and insertion of a poly-L/D-lactide scaffold. Clinical and radiological evaluation was performed after 6 months and 1 year. Patient satisfaction, pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, mobility of the thumb, and strength were assessed. Results Pain according to the visual analog scale decreased (p = 0.01) and QuickDASH score decreased (p = 0.02) significantly after 1 year. Radiological evaluation after 12 months showed a collapse of the scaphometacarpal distance of 45% (p = 0.01). Osteolysis of the distal scaphoid pole and/or proximal metacarpal was seen in 6 out of 10 cases. Because of the osteolysis, the use of the poly-L/D-lactide scaffold was discontinued in our practice. Conclusion In this limited series, total trapeziectomy with the use of the poly-L/D-lactide scaffold provides significant pain reduction and improvement of overall function. Radiographic evaluation shows significant collapse of the scaphometacarpal distance after 1 year and frequent signs of osteolysis. We do not encourage the use of the poly-L/D-lactide scaffold with total trapeziectomy before long-term clinical and radiological follow-ups of the osteolysis are available.

Introduction: Accurate quantification of hip stem migration allows early detection of inferior implants and helps to diagnose stem loosening. Radiostereometric analysis (RSA) is accurate but requires bone markers and expensive stereo-radiographic equipment. Objectives: We developed and validated a marker-free automated Computer Tomography based Spatial Analysis tool (CTSA) to quantify stem-bone migration in consecutive CT scans. Methods: We first segmented bone and stem within both three-dimensional images, then we pairwise registered these elements. By comparing the rigid transformations of stem and bone, we calculated stem migration compared to the bone and transferred the translation and rotation parameters to an anatomic coordinate system. Accuracy was assessed in a stembone model by calculating the difference between imposed and measured rotations and translations in 39 cases. Precision, defined as stem migration calculated in a zero-migration model, was assessed 8 experimental cases and in 5 patients. Results: The in-vitro accuracy of CTSA was below 0.20 mm for translations and 0.19° for rotations in all cases (95% tolerance interval (95% TI) below 0.22 mm and 0.20°, largest standard deviation of the signed error (SDSE) 0.081 mm and 0.057°). The in-vitro precision was below 0.05 mm and 0.08° in all cases (95% TI below 0.06 mm and 0.08°, largest SDSE 0.012 mm and 0.020°). The precision in five patients was below 0.48 mm and 0.37° (95% TI below 0.59 mm and 0.61°, largest SDSE 0.202 mm and 0.279°). However, this could be largely improved by optimizing scanning conditions. Conclusions: Our marker-free automated CT-based spatial analysis can detect hip stem migration with an accuracy and precision comparable to that of radiostereometric analysis (RSA), but without the burden of bone markers and the cost of stereo-radiographic equipment. As such, it could become a new standard to quantify of hip stem migration in an experimental setting but also in clinical practice.