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Background and Aim: The vascular anatomy of the hand has already been widely described macroscopically. However, there are very few papers that study the pattern of normality of in vivo vascularisation that describe and analyse the main arteries of the hand. The aim of this paper was to carry out a study to serve as a reference for the normal values of size and flow of the radial and ulnar artery at the level of the wrist, and the digital radial and ulnar arteries at the level of the fingers., Material and Method: A descriptive observational cross-sectional study on 200 hands in 100 healthy volunteers aged between 20-30years. Doppler-colour ultrasound was performed on the ulnar and radial arteries in the wrist, as well as on the radial and ulnar digital arteries in each finger. Once the measurements had been taken, a general comparative analysis was performed also taking laterality, dominance and gender into account., Results: It was observed that the radial artery is larger in size than the ulnar at wrist level, however, it was the ulnar artery that showed flow dominance at this level. At finger level, the arteries are greater in size and flow in the areas of the fingers more protected from injury (digital ulnar artery in the first three and radial artery in the fourth and fifth digits)., (Copyright © 2020 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Numerous publications have studied the regional anatomy of the carpal tunnel to define a "safe zone" to reduce the risk of perioperative neurovascular complications. This zone, located between the ulnar neurovascular bundle and the median nerve, is considered to be safe mainly because of the absence of vascular structures. This study aims to assess the presence of arterioles within this area using superb microvascular imaging (SMI)., Materials and Methods: The images from patients who underwent a bilateral routine wrist ultrasound with SMI, between January 28 and February 28, 2019, were retrospectively reviewed by two radiologists to evaluate the presence and location of arterioles in the safe zone. In addition, cadaveric wrists injected with intra-arterial red latex underwent dissection of the carpal tunnel., Results: The images from 27 patients (54 wrists) were reviewed. In the safe zone, arterioles were seen superficial to the retinaculum in 36 wrists (36/54; 66.7%) and deep to the retinaculum in 21 wrists (21/54; 38.9%). The arterioles located deep to the retinaculum were more frequently found close to the median nerve (21/54; 38.9%) than to the ulnar artery (9/54; 16.7%). In five cadaveric wrists, arterioles were detected superficial to the retinaculum in 3 wrists (3/5; 60%) and deep to the retinaculum in 2 wrists (2/5; 40%)., Conclusion: Arterioles can be seen in the safe zone both superficial and deep to the flexor retinaculum. Deep to the retinaculum, they are mainly observed in the proximal aspect of the carpal tunnel and more frequently close to the median nerve., Key Points: • Superb microvascular imaging (SMI) enables the visualization of arterioles within the "safe zone" of the carpal tunnel (visible both superficial and deep to the flexor retinaculum). • Arterioles were more frequently observed in the proximal aspect of the carpal tunnel. • Deep to the retinaculum, arterioles were more frequently seen in proximity to the median nerve.

The purpose of this cadaveric study is to determine safe zones utilizing volar portals for wrist arthroscopy, by quantitatively describing the neurovascular relationships of a volar radial and a volar ulnar wrist arthroscopy portals in comparison with those of a newly described volar central portal (7) , considering the advantages in visualization of volar portals for wrist arthroscopy over the standard dorsal (19) . The neurovascular structures and the tendons of nine frozen human cadaveric upper limbs were exposed, while the aforementioned volar portal sites were pointed out with pins. The horizontal distance between the portals and the closest neurovascular branch or tendon was measured with a digital caliper, followed by statistical analysis of the data. The median interquartile range distances from portals to structures at risk were measured and safe zones around each portal were established. This study provides a safe approach to the volar radial and ulnar aspects of the radiocarpal and midcarpal joints, while volar radial and ulnar portals should be considered for inclusion in the arthroscopic examination of any patient with radial and ulnar sided wrist pain respectively (17,18) . Regarding the volar central portal, it is reproducible, safe and both the above joints can be inspected through one single incision (7) .

It is not known whether there are any consistent non-serological differences between seropositive and seronegative rheumatoid arthritis, and if any, whether they depend upon rheumatoid factor (RF), anti-citrullinated peptide antibodies (ACPA), or both. In a pilot study, we showed that the two forms could be differentiated using power-Doppler sonography (PDS), and that the difference is ACPA dependent. This extended study explored whether the previous findings could be confirmed. 103 patients 51 ACPA positive (ACPA +), 52 ACPA negative (ACPA -) with active wrist arthritis were examined using PDS. By means of a temporal image series, pulsatility was evaluated over a 3-5-s period, maximum and minimum perfusion signal were determined using a computer program counting the number of coloured pixels for each frame. Maxima (P max ) and minima (P min ) were determined, and the standardized peak-to-peak amplitude sA was calculated (sA = (P max  - P min )/P max ). This parameter was then compared for ACPA + and ACPA- patients. In addition, a multivariate regression was performed, to determine which factors influence sA. sA differed significantly between ACPA + and ACPA- patients [20% (13-26) vs. 41% (32-57), p < 0. 0001]. In the multivariate analysis, age (t = 2.5, p = 0.02) and ACPA status (t = - 4.8, p < 0.0001) were independent predictors of sA. PDS perfusion patterns are different in seropositive and seronegative RA. The difference appears to be ACPA, not RF dependent. This suggests that the underlying pathophysiological process is different in ACPA-positive and ACPA-negative RA.

The absence of an adequate recipient vessel for free flap pedicle anastomosis near local defect sites discourages surgeons from performing free flap transfers over the scalp because of the challenging neck dissection and the thrombogenic potential of vein grafts for pedicle elongation. We present a case in which a large scalp defect was successfully reconstructed using the wrist as a "free flap carrier," which is an alternative method. A 78-year-old patient with a totally occluded common carotid artery presented to our clinic with a large scalp defect. Reconstruction of the scalp defect was performed in a 2-stage procedure. In the first stage, a free latissimus dorsi (LD) muscle flap was transferred to the defect site, and the pedicle anastomosis was held at the ipsilateral wrist to provide inflow and outflow of blood through the radial artery and vena comitante and cephalic vein that were anastomosed to the flap pedicle. After subsequent split-thickness skin graft, the elevated position of the arm was achieved using a splint and sutures for 3 weeks. In the second stage, the flap was divided, and an additional skin graft over the flap division site and radial artery repair with vein graft was performed. Successful coverage of the scalp defect was confirmed on postoperative day 14 of the second procedure with no complications.

Background: Microvascular problems like increased intraosseous pressure or venous congestion may influence the development of Kienböck's disease. We examined if wrist position modifies the blood flow in the nutrient vessels., Methods: Retrospective analysis of 17 patients with Kienböck's disease who had a superselective microangiography of the radial, ulnar and interosseous artery in different wrist positions under general anaesthesia. We analysed the data with Fisher's exact and Wilcoxon-test., Results: We found vessels that entered the bone, that ended at the bone edge, and that supplied a vascular plexus. The origins were the anterior interosseous artery in 10 of 17 cases, the radial artery in seven cases, and the ulnar artery in five cases. Movement of the wrist could reduce or stop the blood flow. Type of lunate configuration showed no significant influence on the blood supply in neutral position., Conclusion: The radial, ulnar, and anterior interosseous artery contribute to the vascular supply of the lunate bone in different combinations. Wrist movement can reduce blood flow to the lunate bone.

Purpose: We retrospectively reviewed the results of 89 patients with proximal pole scaphoid nonunion, 58 with avascular necrosis, treated with a capsular-based vascularized distal radius graft., Methods: Seventy-one male and eighteen female patients with symptomatic nonunion at the proximal pole of the scaphoid were included in this study. No patient had a humpback deformity. In all patients, the vascularized bone graft was harvested from the dorsum of the distal radius and was attached to a capsular flap of the dorsal wrist capsule. After fixation of the scaphoid with a small cannulated screw, the graft was inserted press-fit into the scaphoid trough in the nonunion site. Supplementary fixation of the graft with a microsuture anchor into the scaphoid was used in 66 patients., Results: At a mean time of 12.3 weeks (range 6-24) after surgery, solid union was achieved in 76 of 89 patients (49 of 58 with avascular necrosis). Eleven patients had persistent nonunion and two fibrous union as determined by CT scan. Sixty-six of the patients with solid bone union were completely pain free, and ten complained of slight pain with strenuous activities. No donor site morbidity was observed., Conclusions: The capsular-based vascularized bone graft from the distal radius is a reliable alternative technique for scaphoid nonunions. It is a simple and expedient harvesting technique without the need for a microsurgical anastomoses. The supplemental fixation with a microsuture anchor eliminates the risk of graft displacement.

The utility of superb microvascular imaging (SMI) for evaluating hand joint lesions in patients with rheumatoid arthritis (RA) in clinical remission is unreported. This study aimed to compare SMI and power Doppler imaging (PDI) for the evaluation of hand joint lesions in these patients. Twenty-six patients with RA in clinical remission were enrolled. A total of 572 joints (52 wrist, 260 proximal interphalangeal, and 260 metacarpophalangeal joints) were detected by SMI and PDI. A semi-quantitative scale of 0-3 was used to compare the detection of synovial blood flow signal by SMI and PDI. Inter-observer agreement for the assessment of SMI and PDI scores was measured with kappa values. In the ten healthy volunteers, SMI and PDI signals were both scored 0. In the 26 RA patients, the remission rate via PDI was 65.4% but was only 42.3% via SMI. SMI also detected microvessel flow signal in seven patients diagnosed with clinical remission via PDI. Moreover, a total of 106 blood flow signals (18.5%) were detected by SMI, while 50 blood flow signals (8.7%) were detected by PDI. Compared with PDI, SMI increased 18.0% of power flow signals from Grade 0-1 and increased 13.7% of power flow signals from Grade 1-2. One joint classified as Grade 1 by PDI was classified as Grade 0 by SMI. Inter-observer agreement for PDI and SMI semi-quantitative scoring was moderate (kappa = 0.463). SMI seems more sensitive than PDI for detecting hand joint lesions in RA in clinical remission PDI, and could aid the achievement of true remission in RA patients.

Purpose: To examine the effects of neuromuscular electrical stimulation (NMES) and blood flow restricted (BFR) exercise on wrist extensors cross-sectional area (CSA), torque and hand functions compared NMES only in individuals with incomplete tetraplegia. The acute effect of an acute bout of NMES with BFR on flow mediated dilation (FMD) was compared with BFR only., Method: Nine men completed 6 weeks twice weekly of bilateral NMES training of the wrist extensor muscles. The right forearm received NMES + BFR (30 % above the resting systolic blood pressure), while the left forearm received NMES only. The CSA of the extensor carpi radialis longus (ECRL) and extensor digitorum communis (EDC) muscles was measured on ultrasound images. Torque was measured isometrically and hand function with grasp and release test. Another eight men with SCI received NMES+BFR to the right forearm, while the left forearm received BFR only. Immediately, the FMD of the brachial artery was measured., Result: Following training, the ECRL CSA was 17 % greater in the NMES+BFR forearm (mean difference = 0.6 cm(2), p = 0.003) compared with the NMES only. The NMES+BFR had a 15 % increase in ECRL CSA (mean increase = 0.58 cm(2), p = 0.048). FMD increased (p = 0.05) in the exercise arm (12 ± 3 %) compared with the control arm (6.5 ± 6 %)., Conclusion: NMES training with BFR is a strategy that can increase skeletal muscle size. NMES with and without BFR can improve wrist strength and hand function. The acute effects of NMES+BFR may suggest that an increase in FMD may partially contribute to skeletal muscle hypertrophy.

The cardiovascular responses to passive limb movement (PLM) at the knee are well established, however, responses to PLM at other joints involving smaller muscle volume are unknown. To compare the cardiovascular responses to passive movement at other joints, 10 participants underwent a PLM protocol in which the wrist, elbow, ankle, and knee joints were passively extended and flexed at 1 Hz for 1 min. Heart rate (HR), mean arterial blood pressure (MAP), and arterial blood flow to that limb segment (BF) were measured and vascular conductance (VC) was calculated for a 30-sec baseline period and for 3-sec intervals throughout PLM protocols. PLM of the knee and elbow resulted in significant increases in BF and VC from baseline values with peak values 180% (P < 0.001) greater than baseline. PLM of the elbow resulted in significant increases in BF and VC from baseline values with peak values 109% and 115% (P < 0.001) greater than baseline, respectively. No changes in BF and VC were observed in the ankle and wrist. Furthermore, the greater increase in blood flow per limb segment volume in the thigh and upper arm (62.8 ± 36.5 and 55.5 ± 30.3 mL min(-1) L(-1), respectively) compared to the forearm and lower leg (23.6 ± 16.7 and 19.1 ± 10.3 mL min(-1) L(-1), respectively) indicates the limb volume is not solely responsible for the differences in the hyperemic responses. These data indicate that the use of PLM to assess vascular function or as a rehabilitation modality to maintain vascular health may be most appropriate for the muscles that span the elbow and knee., (Published 2016. This article is a U.S. Government work and is in the public domain in the USA. Physiological Reports published by Wiley Periodicals, Inc. on behalf of the American Physiological Society and The Physiological Society.)

Context: Successful arterial cannulation requires wide and patent arterial lumen. A recent study has shown that success rate of radial arterial cannulation at first attempt is more at 45° angle of wrist extension in both young and elderly patients. No study has reasoned whether these high success rates at 45° is because of less compression of the radial artery at this particular angle of wrist extension. Hence, we attempted to study whether the radial artery dimensions changes with increasing angles of wrist extension in young, healthy female volunteers using ultrasound examination., Aim: To investigate the effect of increasing angle of wrist extension of 0, 15, 30, 45, 60, and 75° on radial artery dimensions at the level of the wrist joint using ultrasound examination., Settings and Design: A prospective single blinded study in volunteers., Subjects and Methods: Sonographic measurements of radial artery dimension at the wrist level were performed in 48 young, healthy female subjects. Height (anteroposterior in mm), width (mediolateral in mm) and depth (skin to artery) were measured at wrist extension of 0, 15, 30, 45, 60, and 75°. The dimensions at each angle are compared with 0° as the control and statistical analysis done., Statistical Analysis: One-way analysis of variance test., Results: No statistically significant change in dimension of the radial artery is observed with increasing angle of wrist extension., Conclusion: Ultrasound evaluation showed that increasing angle of wrist extension does not significantly change the dimensions of radial artery at the wrist joint level in young healthy female volunteers.

Background: Sonographic assessment, measuring grey scale (GS) and power Doppler (PD) signals, is a sensitive tool for the evaluation of inflammatory joint activity in patients with rheumatoid arthritis (RA). We evaluated the persistence of PD and GS signals in previously clinically active RA joints that have reached a state of continuous clinical inactivity., Methods: We performed sonographic imaging of 22 joints of the hands of patients with RA, selected all joints without clinical activity but showing ongoing sonographic signs of inflammation, and evaluated the time from last clinical joint activity., Results: A total of 90 patients with RA with 1980 assessed joints were included in this study. When comparing the mean time from clinical swelling, we found a significantly longer period of clinical inactivity in joints showing low sonographic activity (mean±SD time from swelling of 4.1±3.2 vs 3.1±2.9 years for PD1 vs PD≥2, p=0.031 and 4.5±3.4 vs 3.3±3.2 years for GS1 vs GS≥2, p≤0.0001)., Conclusions: We conclude that subclinical joint activity is long-lasting in RA joints in clinical remission, but attenuates over time. The latter conclusion is based on the observed shorter time duration from last clinical activity for strong compared with weaker sonographic signals., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

In 90% of patients with rheumatoid arthritis (RA), the joints of the hand are affected. Studies of grip strength training have not indicated a negative effect on disease activity after training. Introduction of ultrasound Doppler (USD) to measure increased blood flow induced by inflammation has made it possible to investigate the direct effect on blood supply in the synovium after training. In this case-control study, 24 patients with RA with USD activity in the wrist joint participated. The USD activity was measured by the color fraction (CF) (CF = colored pixels/total number of pixels in ROI). Twenty-four patients were assigned to an 8-week grip strength training program. At baseline and after 8 weeks of training, an USD examination of the wrist joint was performed. In the training group, we measured grip strength and pain in the wrist joint. Six patients withdrew from the training because of pain or change in medication. Eighteen patients served as control group. There was a modest, not significant, decrease in the CF in response to training (1.86%; P = 0.08). Grip strength increased 8.8% after training (P = 0.055). Pain in motion deceased after training (P = 0.04). No difference in the CF was seen between the training and control groups, neither at baseline nor at follow-up (P = 0.82 and P = 0.48). Patients withdrawing from training had a significantly higher CF than the other patients (P > 0.001). The results in this study might indicate that the flow in the synovium assessed by USD is not affected by grip strength training.

Kienböck disease is an isolated disorder of the carpal lunate associated with characteristic, and often progressive, clinical and radiographic changes. Appropriate intervention at specific disease stages represents the best opportunity to achieve good outcomes. As understanding of the disease improves, new therapeutic and diagnostic innovations have surfaced that further augment existing treatment options. Biologic, not just traumatic, processes may explain the onset and progression through the disease continuum. In addition to observing the obvious osseous changes, there has been renewed interest in understanding the vascular and cartilaginous manifestations of the disorder. Recognition of these factors can permit focused areas of intervention, including gene and cell-based therapies in the earliest stages. New diagnostic techniques are also being investigated. Advanced imaging modalities can facilitate the earlier recognition of Kienböck disease and enhance the assessment of lunate vascularity. Moreover, diagnostic arthroscopy permits us to directly visualize and characterize affected structures, including cartilage. Finally, there has been much recent interest in the natural history of Kienböck disease. Infantile, juvenile, and geriatric forms have been described. It has been suggested that the disease pathway in these individuals may differ from the typical adult patient population. Integrating these contemporary findings with the classic information on Kienbock disease can permit a more sophisticated approach to stage-specific treatment. This article reexamines the current classification systems to account for these emerging concepts.

The purpose of this study was to assess vascularity of the lunate by number of foramina and radiography of vessels of the wrist. The genesis of lunatomalacia requires some vascular risk and mechanical predisposition. The findings were correlated with the cause of Kienböck's disease. The vascular foramina were more than two in 91.33% of the lunate. The lunate had consistent dorsal and palmar branches from radial artery. The additional branches from anterior interosseous artery in 72.22% and a branch of palmar inter carpal arch in 69.44% cases contributed in arterial anastomosis on palmar aspect of lunate. The dorsal blood supply was found by anterior interosseous artery in 85.71% of specimens and dorsal branch from dorsal intercarpal arch in 50% of specimens. The blood supply of lunate comes along with various ligaments which may be disrupted due to trauma or strain leading to avascular necrosis. The present observations are suggestive of rich blood supply of lunate in comparison of other investigations. Therefore Kienböck's disease is less common in northern India.

Diphosphonate bone scintigraphy is used since the 1970s for studying bone pathology; it is increasingly common because of increased physical activity of the population. The disphosphonate uptake in bone requires the preservation of bone vascularity and reflects osteoblastic activity; it allows studying the viability of bone. Using data from the literature and our experience, we tried to take stock of its main uses in routine emphasizing the study of vascular and describe its use in fractures of the scaphoid and in the study of vascularised bone transfers. If the value of scintigraphy is well known, the use made by means of pinhole collimator and the market entry of new and more sensitive detectors with better resolution could allow the side of the imaging anatomy of improving the study of the vascularisation of small bone transfers which are increasingly used, particularly at wrist and hand., (Copyright © 2010. Published by Elsevier SAS.)

The design and the realization of vascularized osseous grafts at the hand and the wrist require a precise knowledge of the general and regional anatomy. This article gives first a progress report on current knowledge about the general organization of arterial and venous vascularization, of the long bones (number and localization of the nutrient foramina, communication between the epiphyseo-metaphyseal and diaphyseal networks) and of the short bones, in the adult and the child, before the closing of the growth plate. The general organization of arterial vascularization of the hand and the wrist is pointed out, with the current nomenclature and the contribution of the recent publications, in particular in these, which relate to the distal extremity of the radius. The vascularization of each bone (radius and ulna, carpal bones, metacarpals and phalanges) is then described; making way, the anatomical bases of each vascularized bone graft, which can be harvested there, are described. The last technical projections are included, in particular the realization of the reverse flow vascularized bone grafts harvested from the metacarpals. This article still gives a progress report on the osseous vascularization of the short bones, in particular of those which are exposed the most to the osteonecrosis (scaphoid, lunatum). It has the ambition to light the reader and to prepare him (her) with the reading of the following chapters., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

The viability of the bone is compromised in two main situations at the wrist: Kienböck's disease and scaphoid nonunion with avascular necrosis. Plain radiography and CT allow an accurate anatomical approach of morphological changes associated with avascular necrosis of the lunate and the scaphoid fracture with complications. CT is readily available to detect nondisplaced fractures. However, early forms of necrosis can be misdiagnosed and evaluation of bone vitality is impossible. MRI is the best imaging modality to detect avascular necrosis and the intravenous injection of gadolinium improves the specificity of diagnosis of necrosis. The lack of enhancement of the proximal fragment of the scaphoid leads the surgeon to use a vascular graft in the treatment of nonunion. The technique has its limitations. The bone necrosis is histologically complex and contrast enhancement does not mean necessarily viability. However, MRI is still the most powerful imaging modality in the assessment of the bone marrow., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

We present a 52-year-old male patient suffering from Marfan syndrome who developed an aneurysm of the distal radial artery. The histology showed the typical marfanoid structure of a thrombosed aneurysm. As far as we know, this is the first description of a hand aneurysm in a patient with Marfan syndrome., (© Georg Thieme Verlag KG Stuttgart · New York.)

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand., (Copyright © 2010. Published by Elsevier Inc.)

A giant cell tumour of the distal radius or of the carpal bones, verified by incisional biopsies, should be approached as a low-grade malignancy. Lesions that arise in the bones of the hand or the wrist have a greater propensity to metastasise, and have a higher risk of local recurrence. In this case report we describe a 54-year-old women with a giant cell tumour of the distal radius (Campanacci grade III lesion), having a follow-up of five years without signs of local recurrence or metastatic disease. The general principles of and options for surgical treatment are discussed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The hands and wrists are very important for performing the activities of daily life independently. The spaghetti wrist may involve major nerves and arteries, as well as the wrist and finger flexors. The purpose of this study was to evaluate the rehabilitation results of postoperative early mobilization in patients with repaired flexor tendons of the wrist., Methods: Thirty-three patients with repaired flexor tendon injuries were included. Patients were divided into two groups due to ethylogy. Group 1 included 23 patients who incurred tendon injuries during fights with their family members or friends or due to broken glass after fighting. Two patients had cut their hands with a razor. The other patient had cut his hands during discussion. The Group 2 included 10 patients. The injuries in this group were due to work and home accidents., Results: The functional result was excellent in 46% of fingers, good in 22%, fair in 17%, and poor in 15% in the Group 1 patients. The results were excellent in 55% of fingers, good in 17%, fair in 18%, and poor in 10% in the Group 2 patients., Conclusion: Early primary repair and effective rehabilitation are of great importance during the postoperative period for successful results in the treatment of extensive volar wrist lacerations.

Introduction: We sought to assess vascularity in wrist tenosynovitis by using power Doppler ultrasound (PDUS) and to compare detection of intra- and peritendinous vascularity with that of contrast-enhanced grey-scale ultrasound (CEUS)., Methods: Twenty-six tendons of 24 patients (nine men, 15 women; mean age ± SD, 54.4 ± 11.8 years) with a clinical diagnosis of tenosynovitis were examined with B-mode ultrasonography, PDUS, and CEUS by using a second-generation contrast agent, SonoVue (Bracco Diagnostics, Milan, Italy) and a low-mechanical-index ultrasound technique. Thickness of synovitis, extent of vascularized pannus, intensity of peritendinous vascularisation, and detection of intratendinous vessels was incorporated in a 3-score grading system (grade 0 to 2). Interobserver variability was calculated., Results: With CEUS, a significantly greater extent of vascularity could be detected than by using PDUS (P < 0.001). In terms of peri- and intratendinous vessels, CEUS was significantly more sensitive in the detection of vascularization compared with PDUS (P < 0.001). No significant correlation between synovial thickening and extent of vascularity could be found (P = 0.089 to 0.097). Interobserver reliability was calculated to be excellent when evaluating the grading score (κ = 0.811 to 1.00)., Conclusions: CEUS is a promising tool to detect tendon vascularity with higher sensitivity than PDUS by improved detection of intra- and peritendinous vascularity.

Objective: The aim of this study was to test the feasibility of arterial spin labeling (ASL) perfusion imaging of synovitis in inflammatory joint diseases on a clinical 3.0 T whole-body scanner., Materials and Methods: Fifteen patients (geometric mean 47 years, range 8-69 years) with different types of inflammatory arthritis of the finger or wrist joints participated in the study. In addition to conventional spin-echo and dynamic contrast-enhanced FLASH3D sequences, a novel spin-labeling technique (FAIR-TrueFISP) for quantitative assessment of tissue perfusion was applied. Perfusion maps were calculated pixel-wise by means of the extended Bloch equations., Results: Perfusion maps showed good image quality with clear visualization of hyperaemia in synovitis. The computed perfusion maps corresponded best to subtraction images of the dynamic series from 30 to 60 s after contrast-medium injection. The quantitative perfusion values of synovitis showed a good correlation with the disease activity. Perfusion values for inflamed synovium in phase of high activity were up to 230 ml/100 g tissue/min., Conclusion: The proposed modality allows for the assessment of disease activity in arthritis without the application of contrast-medium offering a new tool for therapy monitoring. As the technique provides quantitative information on hyperaemia, it potentially offers new insights in the pathophysiology of arthritic diseases.

The aetiology of the carpal tunnel syndrome is unknown in most cases. Among our patients we found four with acute thrombosis occurring in a persistent median artery which led to acute carpal tunnel symptoms. The purpose of this study was to compare our cases with those from the literature and to show possible causes for the thrombosis. In conclusion, thrombosis of a persistent median artery as a cause of acute carpal tunnel syndrome is certainly very rare. Sudden onset of pain, local tenderness at the palm and decreased sensation in the median nerve distribution may provide clues for the diagnosis. Prior to surgery ultrasound can be performed to confirm the diagnosis.

The objective of the study is to examine the relationship between synovial blood flow signals and vascular endothelial growth factor (VEGF) involved in angiogenesis by Doppler ultrasound. Twenty-one patients meeting the diagnostic criteria of the American College of Rheumatology (ACR) were enrolled in this study. Doppler ultrasound signals of blood flow in the wrist synovial membrane were measured and classified into three grades: grade 1 = no flow; grade 2 = mild flow; grade 3 = intense flow. A significant correlation was observed between blood flow signals in the wrist synovial membrane and serum VEGF levels (r = 0.5681, P = 0.0072). These results suggest that the measurement of Doppler ultrasound signals of blood flow in the wrist synovial membrane is useful in the evaluation of angiogenesis.

We report our experience of the use of callus distraction with a monolateral fixator for the treatment of acquired radial club-hand deformity after osteomyelitis. Between 1994 and 2004, 13 patients with a mean age of eight years (4 to 15) were treated by callus distraction with a monolateral fixator after a preliminary period of at least four weeks in a corrective short-arm cast. All patients achieved bony union and were satisfied with the functional and cosmetic outcome. There were no major complications, but three patients required cancellous bone grafting at the docking site for delayed union. Local treatment and oral antibiotics were required for pin-site infection in six patients. There were no deep infection or recurrence of osteomyelitis.

Ulnar lengthening is an accepted modality of treatment to achieve joint levelling in Kienbock's disease. The conventional method of ulnar lengthening with a plate and bone graft is fraught with complications including graft site morbidity, non-union, hardware removal and difficulty in the achievement of a proper length. We used a Umex distractor to achieve distraction osteogenesis in a group of 12 patients and assessed them over an average follow-up period of 29.5 months. We had one excellent, ten good and one fair result. We conclude that distraction osteogenesis addresses all the complications of coventional lengthening in addition to providing an increase in the local blood supply, which might be beneficial in a disease that is primarily an avascular necrosis. This procedure addresses both the biomechanical and the biological aspects of this disease.

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

Objective: To compare three-dimensional (3D) power Doppler ultrasonography (PDUS) with contrast enhanced magnetic resonance imaging (MRI) in their capability to visualize synovial vascularity in inflamed wrists of patients with rheumatoid arthritis (RA)., Methods: Nine patients with RA showing clinically active arthritis of the wrist as determined by tenderness and swelling were examined by contrast enhanced MRI and 3D PDUS. Vascularity close to and inside the joint capsule was visualized by conventional power Doppler mode. In a region with high Doppler signal intensity (=region of interest/ROI) a 3D blood vessel tree was obtained by a free-hand sweep. 3D images were evaluated with regard to the number of blood vessels in the intra- and peri-articular region. MRI examinations were performed using a 1.5 T Scanner. In MRI, time resolved coronal contrast enhanced T1-weighted sequences with fat suppression were acquired during an 8 min period to assess tissue enhancement. Relative enhancement was calculated and compared to 3D PDUS findings., Results: A 3D vascular tree consisting of peri- and intra-articular blood vessels could be demonstrated in the same anatomical ROI in which an increased gadolinium enhancement was measured by MRI in all examined RA patients. The number of penetrating vessels into the joint capsule, the number of intra-articular vessels and a semiquantitative estimation of the strength of blood flow were used to generate a 3D score for the intensity of synovial vascularity., Conclusion: When compared with clinical symptoms and the gold standard dynamic MRI, 3D PDUS is a reliable imaging technique for assessing synovial vascularity in inflamed wrists of RA patients.

Purpose: To examine synovial vascularity and flow patterns in hand and wrist joints--metacarpophalangeal (MCP) joints and ulnar stiloid (USTL) regions--of patients with rheumatoid arthritis (RA) using power Doppler sonography (PDUS) and spectral Doppler analysis and to assess the accuracy of PDUS in detecting overall disease activity in RA patients., Methods: Two hundred forty MCP joints and 48 USTL regions in 24 RA patients were examined. Patients were categorized into 2 groups--active and inactive--according to the American College of Rheumatology remission criteria. Resistance indexes (RIs) were measured., Results: Flow signals were detected in 50 MCP joints (in 13 patients) and 24 USTL regions (in 16 patients) and spectral analysis was performed in 46 MCP joints (12 patients) and 23 USTL regions (16 patients). The sensitivity and specificity of PDUS in detecting disease activity in RA were 92% and 40%, respectively. There was a negative correlation between flow signal number and RI, with higher scores of flow signals corresponding to lower RIs., Conclusion: PDUS appears to be a reliable method for assessing inflammatory activity in rheumatoid synovium., (Copyright 2006 Wiley Periodicals, Inc.)

Anomalies of the ramification of arteries in the upper extremity are an important consideration due to the large number of invasive procedures, both diagnostic and therapeutic, performed particularly in the cubital region of the upper limb. It is important for health professionals to be aware of arterial variation to prevent complications during diagnostic and therapeutic procedures. Here, we describe a rare unilateral anomaly of the brachial artery which courses subcutaneously through the right arm to the cubital region in a 75 year-old female patient.

Objective: To evaluate angiogenesis as an essential component of pannus formation and cartilage destruction in rheumatoid arthritis (RA) using power Doppler ultrasonography (PDUS) and serum vascular endothelial growth factor (VEGF) measurement., Methods: Twenty-one RA patients with a painful and swollen wrist and 12 healthy controls were examined with ultrasound. By means of standard scans, vascularity near and inside the joint capsule was visualized with PDUS. Two trained investigators performed sonography. Representative video clips were stored and read by two independent investigators, under blinded conditions, with regard to the microvascular Doppler flow being either inside or outside the joint capsule and with respect to a qualitative estimate of the intensity of blood flow, according to a grading from 1 to 3. Serum levels of VEGF were measured with a standard quantitative sandwich ELISA., Results: The power Doppler mode identified increased synovial microvascular blood flow inside the joint capsule in 17 of 21 RA patients (81%) vs one of the healthy controls. We found large variation in serum VEGF levels in RA patients and in healthy controls. The degree of synovial vascularity determined by PDUS showed no correlation with the immediate serum VEGF level in the same patient., Conclusion: The high correlation between intra-articular microvascular power Doppler flow and clinical synovitis in RA patients (P<0.0001) indicates that PDUS may be helpful in studying the role of synovial blood vessels in rheumatoid inflammation.

Objective: To define joint alterations in the wrists of patients with systemic lupus erythematosus (SLE) by ultrasonography (US)., Methods: Fifty-two wrists of 26 SLE patients and 30 wrists of 15 healthy controls were evaluated using US by two different experienced operators, blinded to the clinical data. A 14 MHz linear probe was used. Power Doppler (PD) was applied to evaluate the presence of synovial neoangiogenesis as a parameter of active local synovitis. The findings were correlated to the clinical evaluation, serological systemic disease activity parameters (ESR, C3 levels) and the SLE-disease activity score (SLEDAI). Statistical analysis was performed by the EPISTAT program., Results: Signs of synovitis were found in 22 wrists (42.3%). Synovial proliferation was present in 10 joints (19.2%), PD positivity in 5 (9.6%) and joint effusion in 13 (25%). Erosions were present in both wrists (3.8%) of one patient. Signs of tenosynovitis of one or more tendons were shown in 23 cases (44.2%). Ganglia were found in 2 joints (3.8%). Changes of the median nerve, joint dislocations, tendons' ruptures, cysts and nodules were never detected. In 14 wrists (26.9%) no alterations were found. There was no correlation between sonographic findings and clinical, laboratory and indexes signs of disease activity. In the control group the only alteration found was tenosynovitis in 1 joint (p < 0.0001)., Conclusion: US proved to be an useful technique to detect wrist joint alterations in SLE. These findings may help the physician to modulate treatment strategies and to perform a low cost monitoring of joint disease activity.

This article outlines the vascular anatomy of the carpus, describing the extraosseous and intraosseus vascular systems and emphasizing the carpal bones at risk for osteonecrosis. Separate discussions of etiology, diagnosis, and treatment of osteonecrosis of the commonly involved carpal bones are included.

More and more vascularised bone transfer (VBT) sites, free or pedicled, in the wrist and hand have been described since the 1980s. In the distal forearm, two main VBT: the fibula and the iliac crest, are used for large bone loss (> 6 cm) or for radio-carpal reconstruction. We report our experience of radio-carpal reconstruction using the distal-radio-ulnar joint transfer. At the carpal level, VBT are essentially used for "difficult" scaphoid pseudarthrosis: osteonecrosis, sclerotic bone or failures of conventional grafts and for lunate necrosis. Two pedicled VBT are frequently used for the scaphoid, a graft harvested from the antero-medial part of the distal radius (Kuhlmann) or a graft harvested from the postero-lateral part of the distal radius (Zaidemberg). For the trapezo-metacarpal joint, two new articular pedicle transfers can be used in some cases of trapezo-metacarpal arthritis. At the hand level, VBT are used for distal bone loss, "en bout de chaîne". Bone vascularisation is indispensable to preserve sub-chondral bone and avoid articular destruction. In children VBT are necessary to preserve the growth cartilage.

A bone defect of 14 cm resulted after wrist implant removal because of loosening in a 46-year-old patient. Performing wrist arthrodesis the defect was reconstructed by a vascularized fibular transfer. Solid bone fusion was complete in six weeks. Free function of the digits was seen because of length reconstruction.

Overuse syndromes in the wrist or hand can occur from repetitive use of the wrist and hand or from recurrent direct trauma to the hand area. Tendinitis syndromes due to overstretching or shear stress are seen commonly on both the extensor and flexor sides of the wrist. Overuse syndromes also can take the form of neurovascular syndromes, resulting in compression syndromes of the median, ulnar, and superficial branch of the radial nerve in the wrist area and trauma to the ulnar and digital vessels supplying the hand. Treatment in most cases involves rest with splinting, icing, and NSAIDs in acute cases, although surgical decompression is indicated in chronic or recurrent cases.

Previous studies have shown that magnetic resonance imaging is more sensitive in assessing soft tissue and bone involvement in inflammatory arthritis than conventional radiography. Therefore the main objects of this study were to evaluate the frequency of hand involvement in psoriatic patients free from arthritic symptoms, and to compare the results with those of a healthy control population (age- and sex-matched). Twenty-five patients suffering from active nummular and/or plaque psoriasis with no arthritic signs or symptoms were studied together with 12 healthy control subjects. The articular structures of both hands in all patients were screened using both traditional radiological techniques and magnetic resonance imaging. Specifically, we examined: soft tissue swelling, periarticular effusion, joint effusion-synovial pannus, tendon sheath effusion, bone erosion, luxation, sub-luxation, bone cysts and subchondral signal intensity abnormalities. Sixty-eight percent of our psoriatic patients were found to be positive with at least one arthritic sign using magnetic resonance imaging, while with the standard X-ray procedure, only 32% of the same group of patients were found to be positive. Specifically, abnormal signal intensity in the subchondral focal areas were seen in 9 patients using the magnetic resonance imaging technique, while in the control group, no significant abnormalities were detected. A high percentage of psoriatic patients without apparent arthritic signs and symptoms were shown to have hand articular involvement, in particular in the distension of the capsular and periarticular oedema when examined with magnetic resonance imaging. In our experience, the use of magnetic resonance imaging allows a clear and adequate evaluation of the cartilage, bone and soft tissue material, and is diagnostically superior to X-ray in demonstrating clinically silent and radiologically invisible articular lesions. Moreover, the subchondral changes detected by magnetic resonance imaging were unexpected findings which could imply an ischaemic origin.

A retrospective review of 60 patients with "spaghetti wrist" lacerations operated on by the authors between July of 1988 and June of 1996 was completed. Spaghetti wrist injuries were defined as those occurring between the distal wrist crease and the flexor musculotendinous junctions involving at least three completely transected structures, including at least one nerve and often a vessel. A total of 41 men and 19 women, average age of 29.0 years (range, 5 to 54 years), sustained spaghetti wrist injuries. The most frequent mechanisms of injury were accidental glass lacerations (61.0 percent), knife wounds (23.7 percent), and suicide attempts (8.5 percent). An average of 7.8 structures were injured including 5.8 tendons, 1.2 nerves, and 0.73 arteries. The most frequently injured structures were flexor carpi ulnaris (66.7 percent), median nerve (60.0 percent), flexor digitorum superficialis 2-5 (59.2 percent), ulnar nerve (58.3 percent), and ulnar artery (56.7 percent). A predilection for injury to the ulnar structures was observed. The flexor carpi ulnaris was more commonly injured than the more superficial central and radial palmaris longus (48.3 percent) and flexor carpi radialis (45.0 percent). The most common pattern of injury involved the ulnar nerve and artery and flexor carpi ulnaris, or so-called ulnar triad (41.7 percent). Combined median nerve, flexor carpi radialis, and palmaris longus lacerations occurred in 26.7 percent. Simultaneous lacerations of both median and ulnar nerves occurred in 23.3 percent. No distinct pattern of injury was noted in patients with simultaneous injury to both nerves. Simultaneous lacerations of both ulnar and radial arteries occurred in 6.7 percent; neither artery was injured in 33.3 percent. In the subset of 19 patients available for follow-up examination, range of motion was excellent in 12 patients and good in 7 patients. In 12 patients with sufficient follow-up, intrinsic muscle recovery was good in 7 patients and fair to poor in 5 patients. Sensory return was disappointing: seven patients recovered only protective sensation and five patients demonstrated return of two-point discrimination that ranged from 7 to 12 mm in three patients and from 2 to 6 mm in two patients.

Background: The ulnar artery has been used as a coronary bypass graft in 8 patients when it was deemed unsafe to harvest the radial artery after evaluation of the arterial circulation in the forearm and hand., Methods: The ulnar artery was removed from the lower three quarters of the forearm, along with its satellite veins. Dissection was commenced distally near the wrist and extended proximally to where the ulnar artery passed between the two heads of origin of the flexor digitorum superficialis. The artery was divided distally above the wrist joint and proximally at a point immediately below the origin of the common interosseus artery., Results: Ten ulnar arteries were removed for use as coronary artery bypass grafts; two were rejected, one because of severe calcification and the other because of atherosclerotic occlusion. The remaining eight ulnar arteries were grafted successfully to coronary arteries other than the left anterior descending. No early hand or cardiac complications were observed., Conclusions: The ulnar artery is an alternative coronary artery bypass graft that may be used when the radial artery is dominant and cannot be removed without risk. The ulnar artery is in close proximity to the ulnar nerve and harvesting has the potential to injure the nerve. Therefore, until the use of the ulnar artery has been more fully evaluated it should be used only when other options have been exhausted.

Twenty-three preserved cadaver upper limbs were dissected to show the level of the nerve supply to flexor carpi radialis and the extent of exposure of a new approach to the flexor surface of the distal radius. We describe a new approach to the flexor surface of the distal radius in which both the radial artery and the median nerve are protected by muscles or tendons.

The detailed anatomy of the tendon apparatus, the blood supply of the superficial (FDS) and profundus (FDP) flexor muscles and the blood supply of the common synovial sheath in the carpal tunnel were studied on 200 hundred upper extremities from fresh human cadavers. The injection of coloured latex or the aqueous solution of India ink and gelatin revealed a complex arterial network. Dissection of the carpal tunnel revealed the existence of different sources of the blood supply of the tendons of the flexor muscles and carpal sheath. The different sources and zones of vascularization are described. This study concerns the synovial and tendinous apparatus of the flexor muscles as well as their blood supply in the carpal tunnel. These data may be of interest hand surgeons.

In cases of advanced osteoarthritis of the wrist, in which the radiocarpal and midcarpal joint spaces have been destroyed, the authors propose island transfer of the distal radioulnar joint. They studied the blood supply of the distal radioulnar joint from the interosseous arteries on 40 fresh cadaver upper limbs. The anatomical study showed that the dorsal epiphyseal periosteal network was supplied by the lower perforator of the anterior interosseus artery in every case and by the posterior interosseous artery in 38 out of 40 cases. The distal radioulnar joint can be harvested "en bloc" and rotated 90 degrees so that the joint space can be placed in radio-carpal position while preserving its blood supply on the anterior interosseous pedicle. The authors describe their operating technique and present their first clinical case. This new operation represents a non prosthetic alternative to arthrodesis.

We reviewed 49 cases of flexor to extensor tendon transfer following injury to the radial nerve (22) or brachial plexus (27). Post-operative follow-up average 5.6 years (0.5-12.5). Function was improved in 84% (41) of patients. 16% (8) reported no improvement; of these, four (50%) had associated vascular injuries. In those with improvement, impaired coordination and dexterity were reported by 79% (15 of 19) of the plexus injuries and in 64% (14 of 22) of the radial nerve palsies. Premature fatigue was noted by 89% (17 of 19) of plexus injuries and in 82% (18 of 22) of radial nerve palsies. The power of wrist extension averaged 22% of the contralateral side (8% to 80%), power of digital extension was 31% (5% to 130%), and power grip was reduced to 40% (5% to 86%).

Wrist arthroscopy has become an accepted diagnostic technique, and it is starting to be a useful therapeutic tool. Extensor tendons, the radial artery, and dorsal sensory nerve branches are at risk of injury during this procedure; however, understanding periportal anatomy should make wrist arthroscopy safer. Wrist arthroscopic portals were established in 19 fresh cadaver wrists, after which the limbs were dissected and periportal anatomy was described and quantified. The 1-2, 6R, and 6U portals were the most perilous, while the midcarpal, 3-4, 4-5, and distal radioulnar joint portals were relatively safe. Even "safe" portals had occasional adjacent sensory nerve branches and tendons. A safe technique of establishing wrist arthroscopy portals is emphasized.

Wrist arthroscopy is now an accepted technique in the evaluation of radiocarpal intra-articular pathology. An understanding of the surface anatomic landmarks and articular anatomy is required to safely and effectively perform the technique. Multiple portals are used to arthroscopically view the radiocarpal joint and provide access for irrigation and surgical instruments.

The diagnosis and treatment of those injuries most commonly seen in conjunction with distal radius fractures are reviewed in this article. Concomitant tendon, arterial, and nerve injuries often are associated with a high-energy mechanism of trauma. These injuries may complicate an already difficult fracture care plan, especially if the diagnosis of these injuries is delayed. Late tendon rupture and intercarpal injuries are discussed also.