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Purpose To compare K-wire and screw fixation of distal phalanx (DP) fractures with respect to union and functional outcome. Methods This retrospective study identified patients with DP fractures from a clinic registry taken from 2007 to 2013. Clinical data collected included patient demographics, range of motion (ROM), removal of implant (ROI), and complications. Radiographic data collected included fracture type, location, configuration, fracture displacement, and radiographic union. Statistical analysis was done using a chi-squared test for categorical variables and paired Student’s t test for continuous variables. Results A total of 172 patients with DP fractures were seen in our clinic between 2007 and 2013. Of these, 141 patients were managed conservatively and 31 patients had surgery for 33 DP fractures, of which 12 had K-wire and 21 had screw fixation. Mean union incidence for screw was 100% compared with 83% for K-wire. Time to union was 2.4 months for screw fixation compared with 4.1 months for K-wire fixation. ROM for screw fixation was significantly better (60°) compared with K-wire fixation (45°). ROM for non-transarticular K-wire (46°) was similar to transarticular K-wire (44°). ROI was performed in 52% of patients with screw fixation. Other than fingertip tenderness, which resolved after ROI, no other complications were noted. Conclusions Our study showed that the union incidence and time to union for screw fixation were comparable to those for K-wire fixation. Screw fixation of DP fractures resulted in greater distal interphalangeal joint motion compared with K-wire fixation but required removal in half of cases. Type of study/level of evidence Therapeutic III. [ABSTRACT FROM AUTHOR]

Purpose To compare the strength of 6-strand Lim-Tsai repair with 4-strand cruciate and Becker repair, which were done using braided polyblend. We hypothesized that the biomechanical strength of 4-strand repair could be as strong as 6-strand repair because of different flexor tendon repair configurations and uneven load bearing. Methods We harvested 60 porcine flexor tendons. A transverse cut at the middle of the tendons was made to perform tendon repair. Six-strand Lim-Tsai repair (consisting of 2 Lim-Tsai locking loops), 4-strand cruciate repair (with 3 cross-stitch loops), and 4-strand Becker repair (with 2 double cross-stitch locking loops) were used for the repairs. The repaired tendons were pulled until failure using a mechanical tester. We recorded ultimate tensile strength, load to 2-mm gap force, stiffness, and mechanism of failure. Results The Becker repairs had significantly greater tensile strength than the cruciate and Lim-Tsai repairs. The load to 2-mm gap force and stiffness were significantly greater for cruciate repairs and Becker repairs than Lim-Tsai repairs. Conclusions The biomechanical strength of 4-strand and Becker repairs could be as strong as 6-strand Lim-Tsai repairs. This study implies that the number of strands crossing the repair site of tendons may not be proportional to the biomechanical strength of flexor tendon repair. Clinical relevance Hand surgeons are urged to be aware of the biomechanic characteristics of different flexor tendon repair techniques used in the clinical setting. [ABSTRACT FROM AUTHOR]

Purpose: The braided polyblend (FiberWire) suture is recognized for its superiority in tensile strength in flexor tendon repair. The purpose of this study was to compare the biomechanical performance of 3 loop-suture materials used in a locking 6-strand flexor tendon repair configuration: braided polyblend (FiberLoop 4-0), cable nylon (Supramid Extra II 4-0), and braided polyester (Tendo-Loop 4-0). We hypothesized that, using this technique, the braided polyblend suture would give superior tensile strength compared with the other 2 suture materials. Methods: We divided 30 fresh porcine flexor tendons transversely and repaired each with 1 of the 3 suture materials using a modified Lim-Tsai 6-strand suture technique. We loaded the repaired tendons to failure using a materials testing machine and collected data on the mechanism of failure, ultimate tensile strength, gap strength, and stiffness. Results: Failure mechanisms for the repaired specimens were as follows: the braided polyblend had 50% suture breakage and 50% suture pullout; the cable nylon had 100% suture breakage; and the braided polyester had 80% suture breakage and 20% suture pullout. Specimens repaired with the braided polyblend suture had the highest mean ultimate tensile strength (97 N; standard deviation, 22) and the highest mean gap force (35 N; standard deviation, 7). Conclusions: This study supports the findings of previous studies showing superior strength of the braided polyblend suture. Clinical relevance: We were able to achieve up to 124 N in ultimate tensile strength and 48 N of gap force with this suture in porcine tendons. This gives greater confidence in starting immediate controlled passive or active rehabilitation after repair of flexor tendon injuries. [ABSTRACT FROM AUTHOR]

Double-plate fixation is a popular treatment method for intercondylar humeral fractures. Ulnar nerve complications are emphasized, but radial nerve complications are rarely mentioned. We present a case of iatrogenic radial nerve palsy following open reduction and double plating of a supracondylar/intercondylar fracture of the humerus. Before surgery, only a sensory deficit in the radial nerve territory was present, but after surgery, there was a complete motor deficit of the wrist and finger extensors. On exploration, a segment of nerve was found crushed within the reduced lateral condyle fracture site, with a screw from the posteroradial plate going through the nerve. Although rare, radial nerve injury can occur with posteriorly displaced supracondylar/intercondylar humerus fractures. When preoperative signs of radial nerve injury are present, we recommend that the radial nerve be identified and protected during double-plate fixation. [Copyright &y& Elsevier]

Currently described sources of bone graft, such as iliac crest and distal radius, for supplemental fixation of scaphoid fractures are suboptimal. In our experience, olecranon bone has the advantage of providing a convenient source of corticocancellous block graft that can be harvested within the same sterile operative field used for fixation of the scaphoid fracture, and it also causes less postoperative pain compared to that obtained from iliac crest. Here, we describe our surgical technique for harvest and use of olecranon bone graft for fixation of scaphoid fractures. [ABSTRACT FROM AUTHOR]

Mycobacterium abscessus hand infections are rare and usually occur in immunocompromised patients or after injection with contaminated injectables. This article describes 2 cases of M abscessus infection of the hand in otherwise healthy fish handlers. Mycobacterium abscessus can cause severe chronic tenosynovitis even in immunocompetent patients and should be suspected alongside the more common M marinum as a cause of nontuberculous mycobacterial hand infections in patients with aquatic and fish exposure. [Copyright &y& Elsevier]

Purpose: Trapeziectomy for the treatment of trapeziometacarpal (TM) osteoarthritis (OA) disrupts the scaphotrapezium-trapezoidal ligament complex and may be associated with carpal collapse in a subset of patients in the form of nondissociative dorsal intercalated segment instability (DISI). The purpose of this study was to examine the clinical and radiographic outcomes of trapeziectomy, documenting the incidence of postoperative carpal collapse, and to determine whether this outcome is correlated with preoperative radiographic findings. Methods: A retrospective chart and radiographic review was performed on 33 wrists having trapeziectomy from January 1999 to January 2006. Three surveys were administered to patients after surgery to assess subjective levels of pain, function, and satisfaction. The Wilcoxon signed-rank test was used to determine significant differences in radiographic angles, and McNemar''s chi-square test was used to determine significant differences in the frequency of a DISI finding. Results: Stage IV disease was present in 58% of wrists; all wrists were followed up at a mean of 10.5 months after surgery. The mean postoperative change in the radiolunate angle was 4.4° of increased dorsal tilt. Radioscaphoid angles changed after surgery by a mean of 6.3° of increased extension. The frequency of DISI as measured by the radiolunate angle increased significantly, from 27% before surgery to 50% after surgery. Scaphotrapezium-trapezoidal arthritis was observed in 58% of wrists; within this subset, DISI was present in 39% before surgery and 62% after surgery. Those patients with a DISI deformity were significantly less satisfied following surgery than those without this finding. Conclusions: Patients having trapeziectomy for treatment of TM OA may be at risk for the development of carpal instability. This instability may manifest through either a DISI posture of the wrist or abnormal extension of the scaphoid in the presence of a normal scapholunate angle. The presence of stage IV TM OA may be correlated with an increased incidence of carpal instability after surgical intervention. These radiographic findings are mirrored by a trend toward increased levels of pain and decreased levels of function and satisfaction in those patients with evidence of DISI. Type of study/level of evidence: Therapeutic IV. [Copyright &y& Elsevier]

Purpose: The in vivo displacement of the distal radioulnar joint (DRUJ) while under resisted pronation or supination has never been previously quantified. Being a joint with 3 dimensions of motion (dorsopalmar translation, changes in ulnar variance, and radioulnar coaptation), our purpose was to determine its 3-dimensional (3D) displacement during resisted rotational torque. Methods: Ten normal subjects (aged 31.8 years ± 7.8; F, 5; M, 5) were recruited. Computed tomography scans of a subjects’ distal forearms were obtained while grasping the handles of a custom apparatus to keep the fist and forearm in neutral rotation. Scanning was performed in 3 conditions: no rotational torque (control), maximum isometric supination, and maximum isometric pronation. The 3D displacement of the DRUJ, using the ulnar fovea as the reference point, during isometric rotational torque was determined using markerless bone registration techniques. Results: The mean 3D displacement of the ulnar fovea during maximum isometric pronation and maximum isometric supination was 3.09 mm ± 0.94 and 2.17 mm ± 1.55, respectively. During maximum isometric pronation, the ulnar fovea displaced a mean of 0.51 mm ± 1.79 dorsally. During maximum isometric supination, the ulnar fovea displaced a mean of 0.13 mm ± 2.07 volarly. In both conditions, ulnar variance increased (0.23 mm ± 2.52 for isometric pronation and 0.44 mm ± 1.57 for isometric supination), and there was increased radioulnar coaptation (0.37 mm ± 0.86 for isometric pronation, 0.039 mm ± 0.66 for isometric supination). Conclusions: Resisted rotational torque can be applied to the DRUJ while in neutral rotation during computed tomography imaging, producing measurable displacements in 3D. This technique of studying the DRUJ has the potential to improve our ability to detect and quantify instabilities of the DRUJ. [Copyright &y& Elsevier]

Purpose: Eliciting tenderness in the region of the ulnar fovea is a possibly useful clinical test for defining the source of ulnar-sided wrist pain. Until now, no reports of the clinical sensitivity and specificity of this test have been available. Based on anecdotal observations, a hypothesis was developed stating that ulnar fovea tenderness (positive “ulnar fovea sign”) is sensitive and specific in detecting two ulnar-sided wrist conditions: foveal disruption of the distal radioulnar ligaments and ulnotriquetral (UT) ligament injuries. Methods: The clinical records of 272 consecutive patients with wrist arthroscopy performed by the senior author from 1998 through to 2005 were reviewed. Relevant clinical and surgical data were abstracted. The ulnar fovea sign test is executed by pressing the examiner’s thumb distally into the interval between the ulnar styloid process and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform. A positive ulnar fovea sign is designated when there is exquisite tenderness that the patient claims replicates their pain, with comparisons made with the contralateral side. Results: There were a total of 90 foveal disruptions and 68 UT ligament injuries diagnosed during wrist arthroscopy. The ulnar fovea sign was positive in 156 patients. The sensitivity of the fovea sign in detecting foveal disruptions and/or UT ligament injuries was 95.2%. Its specificity was 86.5%. Conclusions: The hypothesis stating that the ulnar fovea sign is a useful clinical maneuver to detect foveal disruptions and UT ligament tears is supported. The conditions represent 2 common sources of ulnar-sided wrist pain. The differentiation between the 2 conditions may be made clinically, where UT ligament tears are typically associated with a stable distal radioulnar joint and foveal disruptions are typically associated with an unstable distal radioulnar joint. Type of study/level of evidence: Diagnostic II. [Copyright &y& Elsevier]

Purpose: Common causes of dorsal intercalated segment instability (DISI) include scapholunate dissociations and scaphoid fracture nonunions. Although less common than these, scaphotrapezium-trapezoidal (STT) osteoarthritis (OA) may also be associated with the development of a DISI deformity. The clinical implications of this form of carpal instability in cases of STT arthritis are still unknown. To study the radiographic progression and incidence of this entity, we reviewed our patients and report on 24 wrists with DISI in the presence of STT arthritis. Methods: A retrospective chart and radiographic review was performed on all patients seen between 1994 and 2004, with the diagnosis of STT arthritis to identify a subgroup of patients with DISI deformity on the presenting radiographs. Patients’ clinical and surgical courses were noted. Postoperative radiographic changes were recorded, as were clinical outcomes. Results: Sixteen patients with 24 wrists having STT arthritis and DISI deformity on presenting radiographs were identified. The median STT arthritis grade was 3.0 based on a modified Eaton and Glickel grading system. The median radiolunate angle was −21° of dorsal tilt. All patients had normal scapholunate angles. Abnormal scaphoid extension was seen in 19 of 24 wrists as measured by the radioscaphoid angle. Concomitant carpometacarpal arthritis was seen in 67% (n = 16) of the wrists, and midcarpal arthritis was identified in 50% (n = 8) of patients. Fifteen wrists required surgery for the symptoms and were followed up for a mean of 29 months after surgery. In the surgical group the radiolunate angles increased by mean of 6° after surgery. Four of the 15 wrists required revisional surgery for persistent pain. Conclusions: Patients with STT arthritis may present with carpal instability that is not related to radiographic scapholunate instability. This instability is characterized by a normal scapholunate angle with an extension stance of the scaphoid and lunate. Midcarpal arthritis may be present. Surgical intervention for patients with STT arthritis and DISI deformity may lead to radiographic progression of midcarpal instability. [Copyright &y& Elsevier]

Purpose In this study, we compared the Tang repair technique with the 6-strand modified Lim-Tsai repair technique under cyclic testing conditions. Methods Twenty fresh-frozen porcine flexor tendons were randomized into 2 groups for repair with either the modified Lim-Tsai or the Tang technique using Supramid 4-0 core sutures and Ethilon 6-0 epitendinous running suture. The repaired tendons were subjected to 2 stage cyclic loading. The survival rate and gap formation at the repair site were recorded. Results Tendons repaired by the Tang technique achieved an 80% survival rate. None of the modified Lim-Tsai repairs survived. The mean gap formed at the end of 1000 cycles was 1.09 mm in the Tang repairs compared with 4.15 mm in the modified Lim-Tsai repairs. Conclusions The Tang repair is biomechanically stronger than the modified Lim-Tsai repair under cyclic loading. Clinical relevance The Tang repair technique may exhibit a higher tolerance for active mobilization after surgery with less propensity for gap formation. [ABSTRACT FROM AUTHOR]