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Digital mucous cysts are benign synovial fluid collections that typically involve the lateral or dorsal surfaces of the distal interphalangeal joints (DIPJs) or beneath the proximal nail fold. They are typically found in the setting of arthritic degeneration of the underlying joint and occur most frequently between the fifth and seventh decades. 1 Many treatment options for digital mucous cysts have been described, ranging from conservative/minimally invasive to complete surgical excision, with no consensus on best technique. Here, a surgical approach is presented which allows access to address the cyst pedicle as well as any underlying osteophyte while preserving the overlying skin with good outcomes even with compromised or involved dermis and epidermis. This is a reproducible, readily adaptable technique. The surgical technique is presented and reviewed in detail., Competing Interests: The authors have no conflicts of interest or sources of funding to disclose., (© 2024 Society for Indian Hand Surgery and Micro Surgeons. Published by Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Distal radius fractures are among the most common fractures treated globally. Consideration of the mechanism of injury and careful radiographic assessment contributes to appropriate management of these injuries in isolation or jointly with other fractures or injuries affecting the wrist joint. Treatment options can range from non-operative management to a variety of fixation techniques. Interest in the distal radius fractures was renewed as open reduction and monoblock volar locking plate fixation became the preferred contemporary treatment in the last few decades. Isolated volar lunate facet (VLF) fractures are uncommon. However, the stability of the entire carpus may be compromised with fractures of the volar marginal rim. Inadequately or improperly treated fractures of the VLF can lead to significant long-term complications. A critical approach to this unique fracture pattern's evaluation, management, and surgical fixation is paramount for successful and reproducible outcomes in stability and durability., Competing Interests: The authors do not have any relevant financial disclosures., (© 2024 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.)

Background: Extensively comminuted intra-articular distal humerus fractures in the elderly present a challenging therapeutic dilemma. The purpose of this study was to investigate the results of nonoperative treatment of these fractures in a select subset of patients., Methods: Patients treated with nonoperative management for a comminuted intra-articular distal humerus fracture between 2007 and 2018 were reviewed. Patients were administered 3 elbow-specific functional outcomes instruments., Results: A total of 8 patients (2 men, 6 women) were treated with brief immobilization followed by early range of motion. All had fractures with extensive comminution of the articular surface such that open reduction and internal fixation was not feasible. Average age was 70 years. At an average of 33 months postinjury, average flexion was 124°, and extension was -27°, with full forearm rotation. No patients required pain medications at the latest follow-up. At 33 months of follow-up, the average Mayo Elbow Performance Score was 92/100 (100 optimal), Oxford Elbow Score was 43/48 (48 optimal), and Quick Disabilities of the Arm, Shoulder, and Hand Score was 10/100 (0 optimal). All patients were satisfied with the nonsurgical treatment that they received., Conclusions: Nonoperative treatment for comminuted intra-articular distal humerus fractures results in acceptable functional outcome in elderly patients and should be considered when the fracture is not amenable to internal fixation and in lower-demand patients with higher surgical risk., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Treatment of muscle belly lacerations remains a problem for surgeons. Inadequate repair of lacerations can cause functional disability. To date, there is no consensus on the method of repair for these injuries. We have previously described a technique of repairing mid-substance muscle belly lacerations. The aim of this study was to determine the ultimate strength of an intact muscle belly and to compare the anchor suture (AS) technique with the modified Kessler (MK) technique. Methods: Fifteen fresh frozen hind-legs from adolescent pigs were divided into three groups and used for the testing. Each group consisted of five specimens. Group one was the intact control group, group two was repaired with the MK technique and group three was repaired with the AS technique. Following repair, the muscles were secured in a custom-made fixation apparatus and underwent linear tensioning at a rate of 25 mm/min, generating a load-displacement curve for each specimen. The data regarding ultimate strength, modes of failure and number of intact suture/anchor constructs (for groups 2 and 3) was calculated. Results: The ultimate strength of the intact muscle group of was found to be 608.1 ± 107.9  N. This was significantly ( p  < 0.05) higher than the pull-out strength of the MK and AS groups. The pull-out strength of the AS group was 143.1 ± 36.7 N, nearly twice that of the MK group 69.8 ± 16.4 N ( p  = 0.11). Suture pull-out was the most common mode of failure. Conclusions: The AS technique was found to have both higher strain and nearly twice the ultimate pull-out strength compared to the MK repair group. We suggest the AS technique as a viable technique for mid-substance muscle belly repairs.

Osteonecrosis affecting the carpal bones is rare and is mostly seen in the lunate (Kienböck's disease). Osteonecrosis of the scaphoid (Preiser disease) is even rarer. There are only four individual case reports published on patients presenting with trapezium necrosis, none with previous history of corticosteroid injection. This case report is the first presentation of isolated trapezial necrosis in the setting of prior corticosteroid injection for thumb basilar arthritis. Level of Evidence: Level V (Therapeutic).

Objective: This study aimed to explore the clinical application of preoperative precise design for 3D printing and thumb reconstruction, which could help manage the patients with thumb defect and achieve better function and appearance., Methods: This was a retrospective study of 20 patients who underwent the surgery of harvesting toe transplant and thumb reconstruction between January 2015 and December 2016. The 3D model of the thumb defect was created and printed. The dimensions of skin and bones from donor site were precisely designed as reference for surgical operation. The surgery was performed according to the model., Results: Perfect repair of defects was achieved with satisfying appearance and function. The reconstructed thumbs all survived (survival rate of 100%). Follow-up was 3-9 months. The maximum dorsiflexion was 8-30° and the maximum flexion was 38-58°. The two-point sensory discrimination was 9-11 mm. In total, 17 patients reposted "Excellent" satisfaction and three "Good", each for the reconstructed thumb and hand function, respectively. The satisfaction rate was 85%., Conclusion: Preoperative digital design and 3D printing according to the donor and recipient sites allowed a tailored operation. The operation was more precise, the appearance of the reconstructed thumb was good. Level of Evidence II, Retrospective Study ., Competing Interests: All authors declare no potential conflict of interest related to this article.

Background: Volar Barton fractures involve the volar articular margin of the distal radius with proximal and volar subluxation of the carpus. Although traditionally conceptualized as partial articular, some volar Barton fractures are complete articular injuries due to a dorsal cortical break in the distal radial metaphysis. While dorsal cortical breaks can affect surgical strategy, they may be difficult to identify on plain radiographs and their epidemiology remains poorly characterized. Some authors have hypothesized an association with osteoporosis; however, this hypothesis remains untested. To better characterize volar Barton fractures, we analyzed fracture geometry on pre-operative computed tomography (CT) scans to: (1) determine the frequency of a dorsal cortical break; and (2) test the null hypothesis that a dorsal cortical break is not associated with age or gender. Methods: We retrospectively reviewed adults with a volar Barton distal radius fracture and an available pre-operative CT who underwent surgical fixation. Using multivariable logistic regression, we assessed whether age or gender was an independent predictor of a dorsal cortical break. Results: Forty patients (mean age 52 years, 57% female) were identified. Including the shaft as a fragment, 32 (80%) had 3 or more discrete fracture fragments. Thirty patients (75%) had a dorsal cortical break. Dorsal cortical breaks were not associated with either age or gender ( P > 0.05). Conclusions: Most (75%) patients with volar Barton distal radius fractures had a dorsal cortical break. Dorsal cortical breaks were not statistically associated with age or gender, suggesting these fracture patterns may not be associated with osteoporosis as previously hypothesized.

Tension band wiring is a simple, inexpensive, and effective technique to treat many upper extremity fractures. When tension forces result in a mechanical failure of bone, tension band wiring provides stability and promotes early mobilization by converting tensile forces across a fracture into compressive forces. The tension band principle has distinct advantages of reducing periosteal stripping, technical ease, and cost effectiveness when compared with other operative strategies. This technique can be implemented in a variety of fractures and avulsions about the upper extremity as well as small bone arthrodeses.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19., Competing Interests: NoteConflict of Interest The views expressed in this article are those of the authors and do not represent the official policy of the any country. None declared., (Society of Indian Hand & Microsurgeons. This article is published by Thieme.)

Background: There has been a recent increase in the use of headless compression screws for fixation of metacarpal neck and shaft fractures as they offer several advantages, and minimal complications have been reported. This study aimed to evaluate the clinical complications and their solutions following retrograde intramedullary headless compression screw fixation of metacarpal fractures. We describe complications and the approach to their management. Methods: We performed a multicenter case series through retrospective review of all patients treated with intramedullary headless screw fixation of metacarpal fractures by 3 fellowship-trained hand surgeons. Patient demographics, implant used, type of complication, pre- and postoperative radiographs, operative reports, and sequelae were reviewed for each case. We defined complications as infection, loss of fixation, hardware failure, malrotation, nonunion, malunion, metal allergy, and any repeat surgical intervention. Results: Four complications (2.5%) were identified through the review of 160 total metacarpal fractures. One complication was a nickel allergy, one was a broken screw after repeat trauma, and 2 patients had bent intramedullary screws. Screw removal in 3 patients was simple and without complications or persistent limitations. One bent screw with a refracture was left in place. No serious complications were seen. Conclusion: Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed.

We conducted a retrospective review of six patients with carpometacarpal (CMC) ⅘ fracture-dislocations managed with ORIF by a single surgeon between October 2006 and August 2017. An open, dorsal approach to the hamate was used with a combination of interfragmentary screw fixation and Kirschner wire reduction in the CMC joints. At a mean of 96 days follow-up (range: 31-265), all patients had recovered wrist motion, excellent grip strength, and complete resolution of pain. There were no complications or reoperations during the postoperative period. Radiographic review showed restoration of anatomy and well-maintained congruity of the CMC joints. Our study has shown favorable outcomes after open reduction and internal fixation of the hamate body fracture with interfragmentary screws, when combined with stabilization of the CMC dislocation with percutaneous Kirschner wires. Fracture morphology does not appear to guide choice for specific hardware (size screw, headed/headless) or use of a washer. This is a level IV, therapeutic study., Competing Interests: Ethical ApprovalConflict of Interest The institutional review board of our institution approved this study under protocol #2017P000694. None declared.

Objectives  Our understanding of distal radius fractures with concomitant scapholunate (SL) diastasis primarily comes from plain radiographs and arthroscopy. The clinical implications of SL diastasis are not clear. The aim of this study is to describe fracture characteristics of distal radius fractures on computed tomography (CT) scans in patients with distal radius fractures and static SL diastasis. Methods  We queried our institutional databases to identify patients who were treated for a distal radius fracture, had a CT scan with a wrist-protocol, and static SL diastasis on their CT scan. Our final cohort consisted of 26 patients. We then collected data on their demographics, injury, treatment, evaluated injury patterns, and measured radiographic SL characteristics. Our study cohort consisted of 11 men (42%) and almost half of our cohort ( n  = 12; 46%) had a high-energy mechanism of injury. The majority of the patients ( n  = 20; 77%) had operative treatment for their distal radius fracture and two patients (7.7%) had operative treatment of their SL injury. Results  The mean SL distance was 3.5 ± 1.1 mm. Twenty patients (77%) had an intra-articular fracture. In these patients, we observed three patterns: (1) scaphoid facet impaction; (2) lunate facet impaction; and (3) no relative impaction. We observed other injury elements including rotation of the radial styloid relative to the lunate facet and partial carpal subluxations. Conclusion  Static SL dissociation in the setting of distal radius fractures may be an indication of a complex injury of the distal radius, which may not be directly apparent on plain radiography. If these radiographs do not demonstrate impaction of the lunate or scaphoid facet, a CT scan may be warranted to have a more detailed view of the articular surface. Level of Evidence  This is a Level III, diagnostic study., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

A volar approach is commonly used for fixation of distal radius fractures with a volar locking plate. There are certain fracture patterns for which volar locked plating is not suitable. This case based review outlines such case examples., (© 2020 Delhi Orthopedic Association. All rights reserved.)

Background  Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial. Objectives  To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius. Patients and Methods  After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of "proximal pole scaphoid fractures" who underwent surgical fixation by a single surgeon over an 11-year period (2006-2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft. Results  The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm 3 and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm 3 . Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8-16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications. Conclusions  Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure. Level of Evidence  This is a Level IV, case series study., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Introduction  Die punch (DP) fragments are among the most common fracture fragments to lose reduction after volar locked plating of articular distal radius fractures (DRFs). We aimed to report the number of patients in our institution who had a computed tomography (CT)-confirmed DP fragment and who had open reduction and internal fixation (ORIF) through a dorsal approach; to report the length of the radioulnar portion of the DP fragment relative to the total distal radioulnar joint (DRUJ) length; and to identify if an association exists between this length and the choice for a volar versus a dorsal operative approach to the DP fragment. Materials and Methods  We performed measurements on the preoperative CT scans of 94 skeletally mature patients with a DP fragment. We also collected data related to their demographics, injury, and treatment. Of the 94 patients in this study, 84 (89%) had AO type C fractures. Results  Thirteen out of 94 patients (14%) who had ORIF of their DRF with a DP fragment had a separate dorsal incision. The mean proportion of the DP fragment length relative to the total DRUJ length was 0.51 ± 0.19. There was no association between the length of the DP fragment and volar versus dorsal approach. Conclusion  DP fragment size is not an indicator of the need for or use of a dorsal approach in DRF fixation. Level of Evidence  This is a Level IV,-retrospective study., Competing Interests: Conflict of Interest None declared. Authors’ Contributions This study represents a great deal of effort, resources, and dedication on the part of the authors in reviewing and reconstructing all cases, reviewing the literature and performing statistical analyses. All authors have participated in a material way to the elements below: Study design: S.Ö., S.V., S.J., C.M. Gathered data: S.Ö., S.V., S.J. Analyzed data: S.Ö., C.M. Initial draft: S.Ö., S.V., C.M. Ensured accuracy of data: S.Ö., S.V., S.J. Note This work was performed at the Hand and Upper Extremity Service, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States. Ethical Approval The Institutional Review Board approved this study under protocol MGH/2009P001019., (Society of Indian Hand Surgery & Microsurgeons. All rights reserved.)

Objectives  A lack of conclusive evidence on the treatment of acute median neuropathy (AMN) in patients with distal radius fractures has led to inconsistent surgical guidelines and recommendations regarding AMN in distal radius fractures. There is a wide variation in surgical decision-making. We aimed to evaluate international differences between surgical considerations and practices related to carpal tunnel release (CTR) in the setting of distal radius fractures. Methods  We approached surgeons who were a member of the Orthopaedic Trauma Association (United States) or of the Dutch Trauma Society (the Netherlands) and asked them to provide sociodemographic information and information on their surgical practice regarding CTR in the setting of distal radius fractures. After applying our exclusion criteria, our final cohort consisted of 127 respondents. Results  Compared with Dutch surgeons, surgeons from the United States are more of the opinion that displaced distal radius fractures are at risk of developing acute carpal tunnel syndrome (ACTS), consider persistent paresthesia in the median nerve distribution after closed reduction to be a surgical emergency less often, and are more likely to perform a CTR if there are signs of ACTS in the setting of a distal radius fracture. Conclusion  A lack of conclusive evidence has led to international differences in surgical practice regarding the treatment of ACTS in the setting of distal radius fractures. Future research should guide surgeons in making appropriate evidence-based decisions when performing CTR in the setting of distal radius fractures. Level of Evidence  This is a Level V study., (© Thieme Medical Publishers.)

Background: The characteristic clinical presentation of glomus tumors and the low negative predictive value of the magnetic resonance imaging (MRI) raise the question whether MRI improves their management. Therefore, this study aimed to investigate whether MRI improved the management of glomus tumors., Methods: In total, 87 patients with a histologically confirmed glomus tumor were treated over a 25-year period and analyzed retrospectively. Multivariable logistic regression analysis was used to evaluate the independent predictors of an MRI request during the management of glomus tumors., Results: ccording to the results, the patients who were treated by orthopaedic surgeons were more likely to have an MRI during the management of a glomus tumor., Conclusion: The role of an MRI during the management of a glomus tumor is unclear. Orthopaedic surgeons are more likely to request an MRI. Furthermore, visible lesions with characteristic symptoms probably do not benefit from MRI. However, it may help to be sure that the highest-quality MRI is used with the best possible coil for the finger., Competing Interests: Dr. C.A. Bargon has nothing to disclose. Dr. A. Mohamadi has nothing to disclose. Dr. M. Talaei-Khoei has nothing to disclose. Dr. D.C. Ring reports grants from Skeletal Dynamics, other from Wright Medical, personal fees from Biomet, personal fees from Acumed, other from Illuminos, personal fees from Deputy Editor for Journal of Hand Surgery, personal fees from Deputy Editor for Clinical Orthopaedics and Related Research, personal fees from Universities and Hospitals, personal fees from Lawyers, outside the submitted work Dr. C.S. Mudgal has nothing to disclose., (© BY THE ARCHIVES OF BONE AND JOINT SURGERY.)

Objective Closed reduction and percutaneous pinning (CRPP) is losing popularity as a treatment modality for distal radius fractures. However, in select cases, CRPP may have advantages relative to open reduction and internal reduction. We aimed to retrospectively assess the outcomes after CRPP for the treatment of distal radius fractures. Study Design This is a retrospective cohort study. Methods We used billing records to identify all skeletally mature patients with a distal radius fracture who were treated with CRPP by a single surgeon at a level I trauma center in an urban city in the United States. We assessed the medical charts and recorded demographics, trauma and treatment characteristics, radiographic characteristics, and outcomes. Results All patients had a good or excellent range of motion regarding forearm rotation, and almost 80% had good or excellent range of motion regarding flexion or extension of their wrist. One patient had a concern for pin tract infection, and one had subcutaneous migration of a pin, which were both treated by pin removal. Conclusion CRPP is a good option in patients with few and sizeable fracture fragments in patients with a distal radius fracture, and it should be considered as an effective tool to restore radiographic parameters and functional outcomes.

Computed tomography (CT) is increasingly used not just to diagnose union but also to estimate the percentage of the fracture gap that is bridged by healing bone. This study tested the primary null hypothesis that there is no agreement between observers on the extent of union of a scaphoid waist fracture on CT. CT scans of 13 nondisplaced scaphoid waist fractures treated nonoperatively were rated by 145 observers. CT scans were done 10 to 12 weeks after injury. Observers were asked to "eyeball" measure percentage of union. We found that there was a moderate agreement on the categorical degree of partial union of a scaphoid waist fracture on CT (k = 0.34). Agreement on the location of bony bridging was slight (k = 0.31). We concluded that there is limited reliability of diagnosis of partial union of a scaphoid waist fracture on CT and that this should be taken into account in both patient care and research. This is a Level III, diagnostic study.

Purpose: To report on 4 cases of avascular necrosis of the metacarpal head., Methods: We retrospectively reviewed 4 patients who received a diagnosis of avascular necrosis of the metacarpal head and were treated from 2000 to 2016., Results: All patients were males with involvement of the dominant hand. Three patients had a history of trauma and/or fractures in another finger and one had a history of fracture in the same finger. The diagnosis was confirmed on regular x-rays and magnetic resonance imaging. Nonsurgical management was offered to all patients (rest, placement of an orthosis, and nonsteroidal anti-inflammatory drugs) for 3 to 6 months. Two patients responded well to nonsurgical management and improved in their symptoms. One patient refused surgical intervention and continued to have persistent pain. The other patient was treated with curettage and bone graft and had total resolution of pain symptoms with full active range of motion., Conclusions: A high index of suspicion is required to diagnose and treat avascular necrosis of the metacarpal head correctly. Treatment options are numerous and require further studies to investigate their effectiveness in the treatment of this rare disease., Type of Study/level of Evidence: Therapeutic V., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: This study assessed nighttime splinting for 6 weeks as treatment for recent onset idiopathic trigger fingers., Methods: Patients over 18 years with a Quinnell grade 1 or 2, idiopathic trigger finger or thumb causing symptoms for less than 3 months were eligible for a custom-made hand-based orthoplast night orthotic. Improvement of symptoms and/or resolution of triggering were recorded. Patients also completed the short version of the Disabilities of the Arm, Shoulder and Hand and a numerical rating scale for pain at the initial visit, after 6 to 8 weeks, and after 3 months., Results: Thirty-four patients wore a night orthotic for at least 6 weeks. At final evaluation, there was a substantial reduction in disability and pain. Symptoms of triggering resolved completely in 18 patients (55%). Sixteen patients did not resolve their triggering after splinting and therefore underwent a steroid injection., Conclusion: Night splinting is a noninvasive treatment option for idiopathic trigger fingers/thumb with symptoms for less than 3 months.

Background  Radiographic diagnosis of scapholunate ligament injury (SLI) in the setting of distal radius fractures (DRFs) is challenging. It remains unclear to what extent radiographic diagnosis of SLI by a radiologist influences surgical decision-making regarding treatment of SLI. Purpose  We aimed to (1) identify the number of times that concerns for the possibility of concurrent SLI in the setting of a DRF had been raised by the radiologists, (2) identify how often the radiologist's diagnosis was confirmed by the treating surgeon, and (3) how many of the patients with a radiographic concern for SLI by the radiologist received operative treatment for the SLI. Patients and Methods  Based on Current Procedural Terminology codes, we identified 2,923 patients that were operatively treated for their DRF in 1 of 3 participating institutions in an urban city in the United States. We reviewed the medical charts of 654 patients who had a mention of scapholunate ligament (SL) distance in their radiography, surgery, or clinical notes. We then measured the SL distance and recorded patient, diagnosis, and treatment characteristics of all these patients. Results  A total of 200 out of 2,923 patients (6.8%) received a radiological diagnosis of SLI. In seven of these patients (3.5%), the surgeon confirmed the diagnosis of the radiologist. Four patients (2%) had operative repair of their SLI. Conclusion  Radiologists demonstrate a low threshold to identify SLI in the setting of DRFs, while the number of SLIs identified by the treating surgeon is a remarkably smaller number. Level of Evidence  Level II, prognostic study.

Dupuytren contracture is a progressive disease involving collagen within the palmar fascia. When the contracture progresses to meet specific parameters, intervention is considered and includes collagenase injection, percutaneous or open fasciotomy, or palmar fasciectomy. Complications after treatment include contracture recurrence, digital nerve injury or postoperative neurapraxia, flexor tendon injury/rupture, delayed wound healing or skin necrosis, dysvascular digit/arterial injury, hematoma, and infection. Patients with severe or recurrent Dupuytren contracture are more likely to experience complications. Patient education is paramount; one must consider the patient's goals for treatment, functional requirements, time frame for recovery, and tolerance for complications when deciding about treatment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Accurate identification of surface anatomy is critical to identify the location of the A1 pulley. The intercrease line (ICL) describes a transverse line between the radial edge of the proximal palmar crease and the ulnar edge of the distal palmar crease. We hypothesize that this easily identifiable surface landmark approximates the location of the A1 pulley., Methods: The ICL was marked on 7 cadaver hands. We marked a point proximal to the proximal digital crease (PDC) equal to the distance between each digit's proximal interphalangeal crease (PIC) and PDC (the PIC/PDC point). We calculated the distance between PIC/PDC points and proximal edge of the A1 pulleys., Results: The ICL was proximal to A1 in all digits. The PIC/PDC point was distal to A1 in the ring finger, and proximal to A1 in the index, middle, and small fingers. The PIC/PDC point was closer to the A1 pulley than the ICL in the middle and ring fingers., Conclusions: Despite less accuracy than the PIC/PDC point at approximating the location of the A1 pulley, the ICL is reliably proximal to the A1 pulley.

Introduction  The purpose of this study is to examine the clinical results of retrograde intramedullary headless screw (IMHS) fixation for metacarpal fractures. Methods  A retrospective review was performed on 16 patients with 18 metacarpal fractures who underwent IMHS fixation at a single institution. The average age was 32 years. The indications for surgery included rotational malalignment (five patients), multiple metacarpal fractures (five patients), angular deformity (four patients), and shortening greater than 5 mm (two patients). The average length of follow-up was 19.4 weeks (median 10.2 weeks). Results  Functional outcome was considered excellent in all patients with total active motion in excess of 240 degrees. Active motion was initiated within 1 week of surgery. No secondary surgeries were performed related to a complication of IMHS fixation. Conclusion  IMHS fixation of metacarpal fractures is an efficacious treatment modality for patients with comminution, multiple fractures, malrotation, and those who require rapid mobilization. It obviates the need for immobilization or more extensive plate and screw fixation techniques with excellent clinical results.

Background  Conventional angiography is an invasive technique. Submillimeter computed tomography angiography (CTA) has been shown to be an effective alternative for peripheral artery branches. This study aimed to assess the use of CTA to guide the choice and design of foot donor area for finger or thumb reconstruction. Methods  This was a retrospective study of 79 patients who underwent finger or thumb reconstruction between January, 2011 and March, 2014. All these patients underwent preoperative CTA to determine the exact blood supply at the donor site. Preoperative imaging and intraoperative findings at the donor site were compared. Results  Among the 79 patients (158 feet), 474 artery segments (dorsalis pedis artery [DPA], first dorsal metatarsal artery [FDMA], and toe web artery [TWA]) were evaluated using CTA. Image satisfaction rates of the vessels were 100.0 ± 0.0%, 89.2 ± 3.2%, and 60.1 ± 5.0% for DPA, FDMA, and TWA, respectively. Among the 158 feet, 90 were Gilbert type I (57.0%), 52 were Gilbert type II (32.9%), 13 were Gilbert type III (8.2%), and 3 were with poor visibility and could not be classified (1.9%). In all 79 patients, the CTA image of the FDMA was consistent with the intraoperative observations. All reconstructed fingers survived. Follow-up was available for 69 patients. After a 6- to 18-month follow-up, the reconstructed fingers and donor area recovered well, and the reconstructed fingers had strong holding power, without pain. Conclusion  CTA can produce three-dimensional images for extremity arteries, allowing the preoperative assessment of blood supply and planning of donor site., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Coronal (or frontal plane) fractures of the scaphoid are distinctly uncommon. There are few published reports of coronal fractures of the scaphoid. This fracture is often missed on the initial X-ray films. A high index of suspicion should exist when there is a double contour of the proximal scaphoid pole on the anteroposterior X-ray view. A computed tomography scan is integral in making the diagnosis. Early recognition is key in salvaging the scaphoid fracture and in preventing articular damage. Level of Evidence IV. Retrospective case series.

Background: Radial head compression against the capitellum may cause concomitant fracture of the capitellum. The purpose of this study was to investigate if radial head fracture type is associated with a concomitant fracture of the capitellum., Patients and Methods: Data were identified from five area hospitals. We retrieved records of patients older than 18 years of age who underwent treatment for concomitant capitellum fracture and radial head fracture between January 2002 and January 2013. Patients with olecranon fractures or trochlea fractures were excluded., Results: A total of 10 patients with a radial head fracture and a concomitant capitellum fracture were included. Based on the operative reports, nine radial head fractures were classified as Hotchkiss modification of the Mason classification type II, and one was classified as type I. Based on the available radiographs and computed tomography, three capitellum fractures were type I, and seven were type II according to the Grantham classification., Conclusion: Surgeons have to be alert to capitellar damage in case of a Hotchkiss type II radial head fracture., Level of Evidence: This is a level IV, therapeutic, retrospective study.

Background: As part of the process of developing a decision aid for carpal tunnel syndrome (CTS) according to the Ottawa Decision Support Framework, we were interested in the level of 'decisional conflict' of hand surgeons and patients with CTS. This study addresses the null hypothesis that there is no difference between surgeon and patient decisional conflict with respect to test and treatment options for CTS. Secondary analyses assess the impact of patient and physician demographics and the strength of the patient-physician relationship on decisional conflict., Methods: One-hundred-twenty-three observers of the Science of Variation Group (SOVG) and 84 patients with carpal tunnel syndrome completed a survey regarding the Decisional Conflict Scale. Patients also filled out the Pain Self-efficacy Questionnaire (PSEQ) and the Patient Doctor Relationship Questionnaire (PDRQ-9)., Results: On average, patients had significantly greater decision conflict and scored higher on most subscales of the decisional conflict scale than hand surgeons. Factors associated with greater decision conflict were specific hand surgeon, less self-efficacy (confidence that one can achieve one's goals in spite of pain), and higher PDRQ (relationship between patient and doctor). Surgeons from Europe have--on average--significantly more decision conflict than surgeons in the United States of America., Conclusions: Patients with CTS have more decision conflict than hand surgeons. Decision aids might help narrow this gap in decisional conflict.

Purpose: To determine whether patient perception of time spent with a hand surgeon relates to patient satisfaction after a single new-patient office visit., Methods: Prior to each visit, 112 consecutive new patients predicted how much time they expected to spend with the surgeon. Following the visit, patients were asked to estimate the time spent with the surgeon, indicate whether the surgeon appeared rushed, and rate their overall satisfaction with the surgeon. Wait time and actual visit duration were measured. Patients also completed a sociodemographic survey, the Consultation and Relational Empathy Measure, the Newest Vital Sign Health Literacy test, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper Extremity Function, Pain Interference, and Depression. Multivariable logistic and linear regression models were used to determine predictors of patient satisfaction, patient-perceived surgeon rush, and high previsit expectations of visit duration., Results: Patient satisfaction was not associated with perceived visit duration but did correlate strongly with patient-rated surgeon empathy and symptoms of depression. Neither visit duration nor previsit expectations of visit length were determinants of patient-perceived surgeon rush. Only surgeon empathy was associated. Less-educated patients anticipated needing more time with the surgeon., Conclusions: Patient satisfaction with the surgeon and with the time spent during the office visit was primarily linked to surgeon empathy rather than to visit duration or previsit expectation of visit length. Efforts to make hand surgery office visits more patient-centered should focus on improving dialogue quality, and not necessarily on making visits longer., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the prevalence of an estimated diagnosis of major depression in patients with upper extremity conditions and factors that help identify patients who might benefit from psychological treatment., Methods: In this observational cross-sectional study, 190 patients completed questionnaires measuring symptoms of depression with the Patient Health Questionnaire, upper extremity disability with the Patient-Reported Outcomes Measurement Information System Upper Extremity, pain interference with the Patient-Reported Outcomes Measurement Information System Pain Interference, and health anxiety with the Short Health Anxiety Inventory., Results: The estimated prevalence of an estimated diagnosis of major depression (Patient Health Questionnaire 9 ≥ 10) among this group of patients was 12%. Having multiple pain conditions, a history of depression, and greater limitation from pain for daily activities were independently associated with an estimated diagnosis of major depression., Conclusions: The finding that 1 in 8 patients presenting to a hand surgeon have untreated or undertreated symptoms of depression sufficient to qualify for an estimated diagnosis of major depression emphasizes the importance of assessing for depression at all levels of care., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Little is known about factors related to patient satisfaction with treatment for trigger digits. This study tested the null hypothesis that there are no factors associated with treatment satisfaction 2 months after completion of treatment (absence of triggering) or 4 months after the last visit for patients with a trigger thumb or finger. Secondary null hypotheses were: 1) There are no factors associated with a change in patients' preferred treatment before and after consultation with a hand surgeon; and 2) Initial treatment provided is not different from final received treatment. In an observational study, 63 English-speaking adult patients were enrolled after being diagnosed with one or more new idiopathic trigger digits by one of two hand surgeons, but before the hand surgeon discussed treatment options. Patients were asked to fill out questionnaires at enrollment. Final evaluation was by phone. Satisfaction with treatment was not related to the initial treatment or other patient or disease factors. Twenty-three patients (37 %) had a different preference for treatment after talking with a hand surgeon. Involvement of the long and ring fingers were the only factors associated with staying with pre-visit treatment preferences. There was a significant difference in proportions of the various treatments provided at enrollment and final treatment recorded at the final phone evaluation, 14 patients (22 %) had a subsequent alternative form of treatment. Patients' preferences for trigger finger treatment often change after consulting with a hand surgeon and during treatment, but these choices do not affect treatment satisfaction.

Osteosynthesis and tendon repair are essential in upper extremity transplantation to optimally restore function. Transplant surgeons should be aware of all technical issues involved in osteosynthesis, tendon balancing, and tension setting as well as repair in an effort to optimize the function of the transplanted hand. Preoperative planning is vital to achieve good functional results. We present a case of successful osteosynthesis and side-to-side tendon repair, which led to a desirable functional outcome in hand transplantation.

Purpose: To examine the relationship between patient-rated physician empathy and patient satisfaction after a single new hand surgery office visit., Methods: Directly after the office visit, 112 consecutive new patients rated their overall satisfaction with the provider and completed the Consultation and Relational Empathy Measure, the Newest Vital Sign health literacy test, a sociodemographic survey, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Pain Interference, Upper-Extremity Function, and Depression. We also measured the waiting time in the office to see the physician, the duration of the visit, and the time from booking until appointment. Multivariable logistic and linear regression models were used to identify factors independently associated with patient satisfaction., Results: Patient-rated physician empathy correlated strongly with the degree of overall satisfaction with the provider. After controlling for confounding effects, greater empathy was independently associated with patient satisfaction, and it alone accounted for 65% of the variation in satisfaction scores. Older patient age was also associated with satisfaction. There were no differences between satisfied and dissatisfied patients with regard to waiting time in the office, duration of the appointment, time from booking until appointment, and health literacy., Conclusions: Physician empathy was the strongest driver of patient satisfaction in the hand surgery office setting. As patient satisfaction plays a growing role in reimbursement, targeted educational programs to enhance empathic communication skills in hand surgeons merit consideration., Type of Study/level of Evidence: Prognostic II., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

We investigated the functional and radiographic outcome of wrist arthrodesis in 11 adults with spastic wrist deformities, carried out by one surgeon between 2003 and 2012. The underlying cause of spasticity was a cerebrovascular insult in five, traumatic brain injury in four, and cerebral palsy in two patients. A dorsal plate and local bone graft was used in all patients. The mean radiographic flexion deformity significantly improved from 67° pre-operatively to 4° of dorsal angulation post-operatively. Thumb-in-palm deformity was more pronounced in three patients after the operation. The functional House score improved in all patients an average of two levels (range 1-3)., (© The Author(s) 2014.)

Background: Although upper-extremity disability has been shown to correlate highly with various psychosocial aspects of illness (e.g., self-efficacy, depression, kinesiophobia, and pain catastrophizing), the role of language in musculoskeletal health status is less certain. In an English-speaking outpatient hand surgery office setting, we sought to determine (1) whether a patient's primary native language (English or Spanish) is an independent predictor of upper-extremity disability and (2) whether there are any differences in the contribution of measures of psychological distress to disability between native English- and Spanish-speaking patients., Methods: A total of 122 patients (61 native English speakers and 61 Spanish speakers) presenting to an orthopaedic hand clinic completed sociodemographic information and three Patient-Reported Outcomes Measurement Information System (PROMIS)-based computerized adaptive testing questionnaires: PROMIS Pain Interference, PROMIS Depression, and PROMIS Upper-Extremity Physical Function. Bivariate and multivariable linear regression modeling were performed., Results: Spanish-speaking patients reported greater upper-extremity disability, pain interference, and symptoms of depression than English-speaking patients. After adjusting for sociodemographic covariates and measures of psychological distress using multivariable regression modeling, the patient's primary language was not retained as an independent predictor of disability. PROMIS Depression showed a medium correlation (r = -0.35; p < 0.001) with disability in English-speaking patients, while the correlation was large (r = -0.52; p < 0.001) in Spanish-speaking patients. PROMIS Pain Interference had a large correlation with disability in both patient cohorts (Spanish-speaking: r = -0.66; p < 0.001; English-speaking: r = -0.77; p < 0.001). The length of time since immigration to the USA did not correlate with disability among Spanish speakers., Conclusion: Primary language has less influence on symptom intensity and magnitude of disability than psychological distress and ineffective coping strategies. Interventions to optimize mood and to reduce pain interference should be considered in patients of all nationalities., Type of Study/level of Evidence: Prognostic II.

Background: The purpose of this study was to report the preoperative complaints and postoperative outcome of patients after removal of the radial head prosthesis., Methods: This is a retrospective review of 14 adult patients (6 females and 8 males) from 2007 to 2011, who underwent radial head prosthesis removal by three surgeons. The average time between implantation and removal was 23 months (range from 2 weeks to 12 years, median 12 months)., Results: The leading reported complaints before removal were restricted mobility of the elbow (active range of motion of less than 100 degrees) in 6, pain in 3, and pain together with restricted mobility in 4 patients. The objective findings before removal were restricted mobility of the elbow in 10 (71%), capitellar cartilage wear, loose implants, and heterotopic ossification each in 8 (57%), subluxation of the radio-capitellar joint or malpositioning of the stem in 5 (36%), and chronic infection in 2 (14%) patients. All patients with pain had wear of the capitellar cartilage on radiographs. The ulnar nerve was decompressed in four patients at the time of removal. Four patients underwent a subsequent operation for postoperative ulnar nerve symptoms 5 to 21 months after removal. Four patients were still complaining about persistent pain at the last follow-up visit. Except two patients, the total range of motion improved with a mean of 34 degrees (range 5 to 70) after a mean follow-up of 11 months., Conclusions: Removal of radial head prosthesis improved function and lessened pain in our case series. The reoperation rate was yet nearly 30% due to ulnar neuritis. Selective ulnar nerve decompression at the time of removal must be evaluated, especially in patients with expected large gain in range of motion after removal.

Purpose: To determine the prevalence of and factors associated with limited health literacy among outpatients presenting to an urban academic hospital-based hand surgeon., Methods: A cohort of 200 English- and Spanish-speaking patients completed the Newest Vital Sign (NVS) health literacy assessment tool, a sociodemographic survey, and 2 Patient-Reported Outcomes Measurement Information System-based computerized adaptive testing questionnaires: Patient-Reported Outcomes Measurement Information System Pain Interference and Upper-Extremity Function. The NVS scores were divided into limited (0-3) and adequate (4-6) health literacy. Multivariable regression modeling was used to identify independent predictors of limited health literacy., Results: A total of 86 patients (43%) had limited health literacy (English-speaking: 33%; Spanish-speaking: 100%). Factors associated with limited health literacy were advanced age, lower income, and being publicly insured or uninsured. Increasing years of education was a protective factor. Primary language was not included in the logistic regression model because all Spanish-speaking patients had limited health literacy. When evaluating health literacy on a continuum, primary language was the factor that most influenced the NVS scores, accounting for 14% of the variability., Conclusions: Limited health literacy was commonplace among patients seeing a hand surgeon, more so in elderly and disadvantaged individuals. We hope our study raises awareness of this issue among hand surgeons and encourages providers to simplify messages and improve communication strategies., Type of Study/level of Evidence: Prognostic II., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)