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Introduction Osteoarthritis (OA) of the thumb carpometacarpal (CMC) joint is a common disorder that negatively impacts hand function. Denervation of the thumb CMC joint has emerged as a viable treatment option. However, the innervation pattern of the thumb CMC joint is controversial. Therefore, the objective of this study was to identify the articular branches supplying the thumb CMC joint and to document their relationship to anatomical landmarks to provide the foundation for image-guided diagnostic block and denervation procedures. Methods In 10 formalin-embalmed upper limb specimens articular branches supplying the thumb CMC joint were dissected from their origin to termination. A frequency map documenting the number of articular branches was generated. The frequency map enabled visualization and comparison of the relative area of innervation of the thumb CMC joint by each articular branch. Results The thumb CMC joint received innervation from six nerves. These were the deep branch of ulnar nerve (DBUN), dorsal articular nerve (DAN) of the first interosseus space, thenar branch of median nerve (TBMN), palmar cutaneous branch of median nerve (PCBMN), lateral antebrachial cutaneous nerve (LACN) and superficial branch of the radial nerve (SBRN) and/ or their branches. Each nerve was found to innervate different aspects of the joint. The DBUN and DAN were found to innervate the posteromedial aspect of the thumb CMC joint, the TBMN and PCBMN anterior/ anteromedial aspects, LACN posterolateral/lateral/ anterior aspects and SBRN posterolateral/anterolateral aspects. Conclusions The thumb CMC joint was innervated by articular branches originating from the SBRN, DAN, LACN, PCBMN, TBMN and DBUN. The documented anatomical relationships provide the foundation to inform selective diagnostic block and denervation of the thumb CMC joint. Further investigations are needed to assess the clinical implications of the current study. [ABSTRACT FROM AUTHOR]

Open and percutaneous denervation is an emerging technique for joint pain. This study investigated the course and distribution of the articular branches innervating the triangular fibrocartilage complex (TFCC), distal radioulnar joint (DRUJ), and radiocarpal joint (RCJ) relative to bony and soft tissue landmarks to guide wrist denervation procedures. Fourteen formalin-embalmed specimens were serially dissected to expose the origin, course, and distribution of articular branches innervating the TFCC, DRUJ, and RCJ. Bony and soft tissue landmarks to localize each articular branch were documented and visualized on a 3-dimensional reconstruction of the bones of the distal forearm and hand. The TFCC was innervated by articular branches from the posterior interosseus nerve (10 of 14 specimens), dorsal cutaneous branch of the ulnar nerve (14 of 14 specimens), palmar cutaneous branch of the ulnar nerve (12 of 14 specimens), and medial antebrachial cutaneous nerve (9 of 14 specimens). The DRUJ was innervated by the posterior interosseus nerve (9 of 14 specimens) and anterior interosseus nerve (14 of 14 specimens). The RCJ was innervated by the posterior interosseus nerve (14 of 14 specimens), superficial branch of the radial nerve (5 of 14 specimens), lateral antebrachial cutaneous nerve (14 of 14 specimens), and palmar cutaneous branch of the median nerve (10 of 14 specimens). Multiple nerves were found to innervate the TFCC, DRUJ, and RCJ. The relationship of anatomical landmarks to specific articular branches supplying the TFCC, DRUJ, and RCJ can inform selective denervation procedures based on the structural origin of pain. The detailed documentation of the spatial relationship of the nerve supply to the wrist provides clinicians with the anatomical basis to optimize current, and develop new denervation protocols to manage chronic wrist pain. [ABSTRACT FROM AUTHOR]

Purpose Midcarpal instability (MCI) is a cause of chronic wrist pain for which treatment remains controversial. This study’s purpose was to determine the outcome of a treatment algorithm for MCI that included immobilization and surgical interventions. Methods We prospectively enrolled 23 consecutive patients (12 males, average age 27 years) with 27 symptomatic wrists. All had generalized wrist pain with an average duration of 22 months. All had MCI and a catch-up clunk that reproduced the symptoms. Initial treatment was full immobilization for 6 weeks. When necessary, recurrence after immobilization was treated with an anatomically based surgical procedure to plicate the dorsal capsule and extrinsic ligaments to stabilize the midcarpal joint. Failure of surgical plication was followed by 4-corner intercarpal arthrodesis when necessary. Patients were observed for instability, grip strength, wrist motion, and Patient-Rated Wrist Evaluation. Results For 22 wrists there was partial relief of symptoms with full-time cast or orthosis immobilization; however, symptoms quickly returned with mobilization. The other wrists had previously been immobilized and patients refused further nonsurgical care. All patients underwent surgical plication of the dorsum of the wrists. Postoperative follow-up (35 months) showed statistically significant improvements in grip strength and Patient-Rated Wrist Evaluation scores. All patients had improved pain at final follow-up. Most improvement was in female patients aged under 25 years, with hypermobility and without major traumatic or work-related injuries. This contrasted with poorer outcomes in men aged over 25years who had moderate or severe trauma that was mostly work-related. Instability recurred in 2 patients who then had a 4-corner arthrodesis. Conclusions Immobilization was not successful in controlling pain and recurrence of instability in patients with MCI. Surgical midcarpal capsular plication was less effective in men with posttraumatic instability. The capsular plication procedure was successful in young female patients with ligament laxity and a history of only minor or repetitive trauma and no history of major trauma. Type of study/level of evidence Therapeutic IV. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the dynamic anatomy of the ulnar nerve at the elbow. Methods: We studied 11 fresh cadavers. We placed metal clips on the ulnar nerve at three locations: at the medial epicondyle (point A), 3 cm proximal to the epicondyle (point B), and 14 cm proximal to the epicondyle (point C). The distances from the medial epicondyle to points A, B, and C on the ulnar nerve and between each pair of points were measured in full elbow extension and flexion. Results: With full elbow flexion, there was no movement of the ulnar nerve at point A (adjacent to the medial epicondyle). Point A and the adjacent distal ulnar nerve moved as a unit with the forearm around the medial epicondyle. Proximal to the cubital tunnel, there was significant ulnar nerve excursion (P < .01) at points B (0.7 ± 0.3 cm) and C (0.2 ± 0.2 cm). There was differential excursion of the ulnar nerve at points B and C relative to the medial epicondyle. The distances between the markers revealed that the nerve did not stretch to account for the discrepant distances of the 3 points, but a slack region of the nerve proximal to the medial epicondyle was taken up with flexion. Release of the intermuscular septum and the canal of Struthers did not influence movement of the nerve. Conclusions: With elbow flexion, the ulnar nerve did not move appreciably in the distal–proximal direction directly at the cubital tunnel, but maximal excursion was in the fatty region proximal to the elbow. This slack region of the nerve was taken up during flexion, whereas only 2 mm of motion occurred through the canal of Struthers. The slack region might predispose to subluxation of the nerve. Conversely, decreased laxity might result in increased traction of the nerve, contributing to cubital tunnel syndrome. Type of study/level of evidence: Therapeutic II. [ABSTRACT FROM AUTHOR]

Bone substitutes are being increasingly used and may avert the need for autogenous bone graft in orthopedic surgery. Thus it is important to note complications that occur with them to better understand the limitations. We report on early mechanical failure of injectable calcium sulfate leading to implant failure in 2 elderly patients who had corrective osteotomies for malunited distal radius fractures. We hypothesize that these occurred because there was inadequate new bone formation to replace the resorbing bone substitute. We advise caution when using bone substitutes in patients with expected delayed fracture healing. [ABSTRACT FROM AUTHOR]

Purpose: Scaphoid fracture nonunion remains prevalent, and it was our purpose to examine the initial care, fracture site, and patient gender and age to determine factors contributing to fracture nonunion. Methods: The charts of 96 consecutive patients with 99 scaphoid fracture nonunions were reviewed for demographic information, and contact was made with 85 patients (with 88 scaphoid nonunions) to determine the pattern of presentation and initial treatment, if any. Results: Of the 88 scaphoid nonunions, 78 were in men, and 46 were sports injuries; 7 patients had no recollection of an injury. Twenty were proximal pole fractures. For 57 fractures, patients sought care following their injury, but only 42 were diagnosed with scaphoid fractures and received appropriate treatment, although one did not follow up in the clinic. Fifteen patients with nonunions did not receive radiographic investigations or did not have an identifiable fracture on initial x-rays and received no further follow-up or treatment. For 27 nonunions, medical attention was sought but was delayed, with an average time of 57 days between injury and initial assessment. For 31 fractures, medical attention was not sought for the acute injury but presented later following a re-injury (17 nonunions) or with progressive pain or stiffness (13 nonunions). Conclusions: The high rates of delayed presentation and incomplete evaluation and treatment suggest a strong need for better patient and doctor education on the subject of scaphoid injuries and nonunions particularly because the initial injury is, unfortunately, sometimes perceived as trivial. Nonunions do occur despite appropriate immobilization. Proximal pole fractures and fractures that show inadequate progression toward union while being treated in a cast should be considered for surgical intervention based on the high number of such cases identified in this study. Type of study/level of evidence: Prognostic II. [ABSTRACT FROM AUTHOR]

Purpose: Scaphoid fractures have the highest prevalence of nonunion in the human body, but despite this, little is known about the microstructure of the bone. Given that microstructural changes in the bone at the site of nonunion define the nonunion, it was our purpose to characterize the trabecular microarchitecture on both sides of the nonunion and compare these to the normal structure. Methods: Fifteen human scaphoid nonunions (14 men, 1 woman; average age, 29 years; interval between injury and examination ranged from 7 to 156 months) were excised during surgical reconstruction and assessed by high-resolution micro–computed tomography. Results: The bone from the nonunions was clearly different from that of normal scaphoids (obtained from nonreplantable hand amputations or postmortem). Bone on both sides of the nonunions was characterized by higher bone mineral density and an increased number of trabeculae, which were thinner and more tightly packed together compared with the normal scaphoid bones. Further evaluation showed that the bone on the proximal side of the nonunion had higher bone mineral density, higher bone volume fraction, decreased bone surface area, increased trabecular thickness, and increased trabecular number when compared with the distal side. Conclusions: These data demonstrate the differing microstructure of the bone at the scaphoid nonunion, particularly on the proximal side, and indicate that the biology also differs from normal. The data also show that scaphoid nonunions produce new bone at the site, which may have positive implications toward hardware fixation and healing stimulation. [Copyright &y& Elsevier]

Skelite, a silicon-stabilized tricalcium phosphate-based bone substitute, is a synthetic alternative to the autogenous bone graft. We present a foreign body inflammatory reaction resulting in extensive osteolysis that occurred after use of Skelite as a void filler in the surgical reconstruction of a distal radius fracture. [Copyright &y& Elsevier]

This study evaluated the effect of forearm or hand warming versus bare hand conditions to improve cold-induced symptoms and skin temperatures in hand trauma patients. Adults with symptoms of cold intolerance at least 3 months following hand trauma and age-/sex-matched controls were included. Testing sessions (bare hand, hand warming, forearm warming) were completed in a climate laboratory with continuous temperature monitoring. Outcomes included physical findings (skin temperature) and self-report symptoms (thermal comfort, pain). Eighteen participants (9 hand trauma patients, 9 control subjects) underwent testing. More severe cold intolerance was associated with higher Disabilities of the Arm, Shoulder, and Hand scores. With bare hands, skin temperatures changed significantly from baseline to cold exposure and to rewarming. Hand trauma patients had the lowest skin temperatures with cold exposure in the injured digits (14.3°C ± 3.5°C) compared with the contralateral uninjured (16.9°C ± 4.1°C) digits. Compared with bare hands, wearing gloves significantly increased the minimum temperature during cold exposure and the maximum temperature after rewarming. Patients reported higher pain with cold exposure. All participants reported significantly more comfort with less coldness with forearm and hand warming. There was cold response variability in hand trauma patients and control subjects. Hand trauma patients had greater changes in skin temperature during cold exposure that improved with glove warming. Continuous temperature monitoring identified subtle physiological changes associated with cold-induced pain and with warming interventions. Therapeutic III. [ABSTRACT FROM AUTHOR]

Purpose: To compare the effectiveness of 2 splint designs in treating trigger finger. Methods: This prospective, randomized study of 30 subjects evaluated splinting efficacy for trigger finger, comparing 2 splint designs: a custom metacarpophalangeal (MCP) joint blocking splint and a distal interphalangeal (DIP) joint blocking splint. We evaluated range of motion, grip strength, severity and frequency of triggering, functional impact, and performance measure scores. Subjects recorded frequency of splint use, splint comfort, and functional impact of the splint. We undertook statistical analysis of splint effectiveness before and after treatment and of differences between the 2 splint groups. We evaluated qualitative data to identify trends in subjective preference toward splint design. Results: Both groups showed quick and significant improvement of triggering; however, the MCP joint blocking splint was successful in providing at least partial relief of triggering and pain in 10 of 13 trigger finger subjects, whereas the DIP joint blocking splint provided at least partial relief of triggering and pain in 7 of 15 subjects after 6 weeks of treatment. Data showed statistically significant improvement in both groups at 6 weeks, which was maintained in a minority of the cohort for 1 year. There was little difference between the 2 splint groups for impact on function. Subjects who wore the MCP joint blocking splint reported higher rates of comfort compared with those who wore the DIP joint blocking splint. Conclusions: Subject comfort with the MCP joint blocking splint allowed for longer periods of usage. Selection of a splint design depends on clinical presentation, vocation, and leisure activities. Initiating conservative treatment with the MCP joint blocking splint has value for patients with trigger finger and positive outcomes in 77% of subjects, whereas use of the DIP joint splint was effective in about half of subjects. Type of study/level of evidence: Therapeutic I. [ABSTRACT FROM AUTHOR]