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The effects of short-term dependency and immobility on skin temperature were assessed in two experiments. In the first study, ten volunteers hung their left arm dependent and motionless while using their right hand for light office work. After 30 minutes, the dependent left hands were cooler (mean=0.9 degrees C: 95% CI=0.7-1.1) than the active right hands and exhibited a deeper colour with significantly increased green intensity (P=0.03) as assessed on digital images. In the second study, seven volunteers submerged both their hands in water at 15 degrees C for 15 minutes. The left arm was then left dependent and motionless while the right hand was placed on the table and its fingers were flexed and extended every 10 seconds. The left hands remained cooler than the right and were a median of 3.6 (range 2.9-4.5) degrees C cooler after 60 minutes. These studies demonstrate that skin temperature and colour differences between the hands, which are sometimes used to support the diagnosis of CRPS-1, can be produced and maintained by short-term immobility and dependency of the hand.

The radiographic density of the proximal fragments of 16 scaphoid fractures was assessed on scaphoid series radiographs taken at 6 to 12 weeks. In addition, dual energy X-ray absorptiometry measurements of bone mineral density in the distal radius and proximal and distal fracture fragments were performed at 1 to 2 weeks and 6 to 12 weeks. Median reductions of 9% and 10% were observed in bone mineral density in the proximal fracture fragment and the distal radius respectively, but these did not correlate with the radiographic density of the proximal fragment. A greater median reduction in bone mineral density (27%) was observed in the distal fracture fragment and more bone loss occurred at this site when there was an apparent increase in the radiographic density of the proximal fragment (median fall of 0.23 g/cm2 versus 0.14 g/cm2). Thus, apparent increased radiographic density of the proximal fragment may be due to increased bone loss from the distal fragment.

Sixty-six patients with acute scaphoid fractures were treated non-operatively in a below elbow plaster for 8 to 12 weeks and underwent CT scans along the longitudinal axis of the scaphoid at 12 to 18 weeks. These scans showed that 14 fractures had not united and that 30 had united throughout the whole cross-section of the scaphoid. The other 22 had partially united with bridging trabeculae in some areas of the cross-section. These 22 partial unions were graded as 0% to 24% union (0 cases), 25% to 49% union (5 cases), 50% to 74% union (7 cases), and 75% to 99% union (10 cases). The 12 patients who had less than 75% fracture union were followed-up further and nine underwent another CT scan at 23 to 40 weeks after the initial injury. These showed union across the whole of the cross-section of the fracture in seven cases and 75% to 99% union in the other two cases, who had full and painless wrist function. We conclude that partial union of the scaphoid is a common occurrence but, in most cases, it progresses to full union without the need for prolonged plaster immobilization.

This study compares the mechanical properties of locking Kessler and four-strand flexor tendon repairs and examines for difficulties related to technical ability. Two trainee surgeons each carried out 10 locking Kessler and 10 four-strand single-cross flexor tendon repairs on an in vitro porcine model. Outcome measures included gap formation and ultimate forces, operative time and repair bulk. Ultimate force was 81% greater for the four-strand repair compared to the Kessler (52 N, SD 5, versus 29 N, SD 6). Operating times were similar between the two techniques (Kessler 10.0 minutes, four strand 10.1 minutes). Rupture force and operating times improved slightly during the study for the Kessler repairs, but in the four strand repairs results remained stable throughout the study. We conclude that the single-cross four-strand repair tolerates superior loads yet is no more technically demanding than the modified Kessler, and can be reliably performed without additional operating time.

Nineteen patients with a dorsal fracture-dislocation of the proximal interphalangeal joint of a finger were treated with either closed reduction and transarticular Kirschner wire fixation (eight cases) or open reduction and internal fixation, using either one or two lag screws (six cases) or a cerclage wire (five cases). At a mean follow-up of 7 (range 6-9) years, most patients reported satisfactory finger function, even though some of the injuries healed with proximal interphalangeal joint incongruency (seven cases) or subluxation (four cases). Those treated by open reduction complained of more "loss of feeling" in the affected finger and those specifically treated by cerclage wire fixation reported more cold intolerance and had a significantly larger fixed flexion deformity (median, 30 degrees : range 18-38 degrees ) and a smaller arc of motion (median, 48 degrees : range 45-60 degrees ) at the proximal interphalangeal joint, despite having the best radiological outcomes. Closed reduction and transarticular Kirschner wire fixation produced satisfactory results, with none of the eight patients experiencing significant persistent symptoms despite a reduced arc of proximal interphalangeal joint flexion (median=75 degrees ; range 60-108 degrees ). The results of this relatively simple treatment appear at least as satisfactory as those obtained by the two techniques of open reduction and internal fixation, both of which were technically demanding.

This prospective study investigated whether dual energy X-ray absorptiometry (DXA) could detect acute scaphoid fractures. We blindly compared 10 normal and 10 fractured scaphoid images produced with a new technique of DXA scan analysis. This measured and plotted the density of the scaphoid throughout its length, producing a linear graph of the scaphoids' density instead of a single area (g/cm2) measurement of bone density. These new plots only detected six of the 10 fractures and suggested that four of the normal controls were fractured. Thus, this technique of DXA scan analysis is neither sensitive nor specific for the detection of acute scaphoid fractures.

To assure readers that study results are scientifically valid, the methods of a clinical trial should be described adequately. Since randomization, blinding, and intention-to-treat-analysis are major bias-reducing techniques, these aspects should be reported most accurately. The Consolidated standards of reporting trials (CONSORT) are recommendations to improve the reporting of trials. CONSORT requires that trial authors describe basic methodological aspects that readers need to appraise the strengths of reported clinical trials. This article presents the CONSORT recommendations and explains some of their main aspects. From now on, the Journal of Hand Surgery will use CONSORT to assist authors of randomized controlled trials in improving the description of their studies. We believe that this decision increases the scientific validity of study reports and helps readers when critically appraising articles.

This study investigated whether the outcome of bone graft and internal fixation surgery for nonunion of scaphoid fractures could be predicted by gadolinium-enhanced MR assessments of proximal fragment vascularity. Sixteen established scaphoid fracture nonunions underwent gadolinium-enhanced MR scanning before surgical treatment with bone grafting and internal fixation. No relationship was found between MR enhancement and the outcome of surgery. Union was achieved in eight of the 12 nonunions with more than 50% enhancement, and three of the four with less than 50% enhancement, of the proximal pole. Furthermore, union was achieved in both of the nonunions which had less than 25% enhancement of the proximal pole. We conclude that enhanced MR assessments of the vascularity of the proximal fragment of a scaphoid fracture nonunion do not accurately predict the outcome of reconstructive surgery.

The aim of this prospective study was to assess whether the fibrous thickening of the carpal tunnel tenosynovium is influenced by working practices. We did this by investigating 50 men (58 hands) with idiopathic carpal tunnel syndrome, who were undergoing carpal tunnel decompression. Occupational history, including vibration tool exposure, and presence of callosities and/or ingrained dirt on hands was recorded at the time of surgery. The flexor tenosynovium was biopsied, and assessed histologically by an observer blinded to occupational history. Occupational group, age, weight and smoking showed no significant association with fibrous tenosynovial thickening. There was also no significant association between fibrous tenosynovial thickening and the presence of hand callosities/in-grained dirt or regular use of vibration tools. Thus no association was found between heavy occupational hand usage and the development of fibrous tenosynovial thickening around tendons within the carpal tunnel.

This prospective study describes the use of a short hand cast, which leaves the finger metacarpophalangeal and wrist joint free, for angularly displaced little finger metacarpal shaft fractures which require reduction. Twenty-seven patients with a mean age of 25 (range, 16-39) years with little finger or combined ring and little finger displaced metacarpal shaft fractures were prospectively recruited. All were treated by closed fracture reduction and immobilization in the cast. Patients were followed up at 1 week, 4 weeks, and between 6 and 12 months. At each of these follow-up visits posteroanterior and lateral radiographs of the metacarpals were performed to assess angulation of the fracture. The mean initial angulation of the 17 little finger metacarpal fractures with complete follow up was 40 degrees (range, 20-60 degrees ). Their mean final angulation at 6 to 12 months was 8 degrees. The fracture reduction was lost in three patients in whom the final angular deformities were 15 degrees (one patient) and 20 degrees (two patients). Journal of Hand Surgery (British and European volume, 2004)

Patients with an isolated spiral or long oblique fracture of the proximal phalanx were randomized into two groups. One was treated by closed reduction and Kirschner wire fixation and the second treated by open reduction and lag screw fixation. An independent observer assessed function, pain, movement, grip strength and intrinsic muscle function. X-rays were assessed for malunion. Thirty-two patients were entered the study and 15 in the Kirschner wire and 13 in the lag screw group were reviewed at a mean follow-up of 40 months. There was no significant difference in the functional recovery rates or in the pain scores for the two groups. X-rays showed similar rates of malunion and there were no statistically significant differences in range of movement or grip strength.

Pedicled vascularized bone grafts (Zaidemberg's technique) were used to treat 22 established scaphoid fracture nonunions, 16 of which were found to have avascular proximal poles at surgery. After a follow-up of 1-3 years, only six (27%) of the 22 fracture nonunions had united. Only two of the 16 nonunions with avascular proximal poles united, compared with four of the six nonunions with vascular proximal poles. We conclude that this technique of pedicled vascularized bone grafting may not improve the union rate for scaphoid fracture nonunions with avascular proximal pole fragments.

Ten patients who had sustained 11 unstable dorsal fracture-dislocations of finger proximal interphalangeal joints were reviewed at a mean follow-up of 16 years. All had been treated acutely by closed reduction and transarticular Kirschner wire fixation of the proximal interphalangeal joint, without any attempt at reduction of the fracture of the base of the middle phalanx, which probably involved 30-60% of the articular surface. Seven of the ten patients complained of no finger pain or stiffness, and none complained of severe pain. There was a mean fixed flexion deformity of 8 degrees at the proximal interphalangeal joint, which had a mean arc of movement of 85 degrees. Although subchondral sclerosis and mild joint space narrowing were observed in some instances, there were no severe degenerative changes. These results confirm that this technique is a reliable treatment method for these injuries, and produces satisfactory long-term results., (Copyright 2001 The British Society for Surgery of the Hand.)

The outcome of 169 fractures of the distal radius in adults under the age of 50 were assessed at least 18 months after injury (mean follow-up, 4.9 years) using a validated, patient-based outcome questionnaire. The questionnaire responses demonstrated that neither the Frykman nor the Mayo classifications of distal radial fractures predicted outcome. Fracture union with more than 10 degrees of dorsal tilt was associated with increased difficulty with everyday activities and work, while union with a step in the radiocarpal articular surface was associated with loss of wrist mobility and difficulty with fine dextrous tasks. No measure of either intra- or extra-articular malunion influenced the severity or frequency of persistent wrist pain., (Copyright 2000 The British Society for Surgery of the Hand.)

This study investigates the concerns of 50 patients with ganglia and their reasons for primary care consultation and referral to a hand unit. Although a minority of patients sought advice and treatment because of pain, more (38%) were concerned about the cosmetic appearance and a significant number (28%) were concerned that their ganglion was a malignant growth. The general practitioners referred 70% of patients to the hand clinic for "excision of the ganglion" and 30% for further "advice and treatment". However, 74% of patients were satisfied with aspiration of the ganglion and general advice., (Copyright 2000 The British Society for Surgery of the Hand.)

This study assessed the use of rapid, repeated measurement of grip strength to detect feigned hand weakness. Normal participants, performing with maximum effort or feigning hand weakness, and patients recovering from carpal tunnel surgery were asked to grip a Jamar dynamometer alternately with each hand on ten occasions. The results showed that grip strength fatigued by an average of 23% during the test in the normal participants, 18% in participants faking weakness, and increased by 2% in the carpal tunnel decompression patients. An increase in grip strength after the first effort was found in 39% of normal participants, 52% of participants faking hand weakness and in 69% of the carpal tunnel decompression patients. These results suggest that rapid, repeated measurement of grip strength is not a reliable discriminator of true and faked hand weakness.

We investigated whether the radiological features of the fractured scaphoid could be reproducibly measured and used to predict the likelihood of union with conservative plaster cast immobilization. We found that the inter- and intra-observer reproducibility of the Compson, Herbert and Russe classification systems were only fair and that none predicted fracture union. Assessments of fracture level, comminution and displacement showed moderate inter- and intra-observer reproducibility but did not predict the likelihood of fracture union. We conclude that the radiological features of acute scaphoid fractures cannot be used to predict the likelihood of fracture union.

This study assessed the sensitivity and specificity of the five-position grip strength test (5PGST) for detecting feigned hand weakness in healthy volunteers. The 5PGST reliably detected feigned hand weakness in only 15% of cases. Thirty-three per cent of volunteers demonstrated an entirely normal pattern of grip strength when feigning weakness.

We prospectively randomized 100 patients following carpal tunnel decompression who were having a 2-week postoperative assessment and removal of stitches to either their local general practitioner (GP) or the hospital outpatient department. All patients were seen at hospital 6 weeks postoperatively for a final assessment. The waiting time for assessment and suture removal was shorter at the GP surgery than in the outpatient department (mean 13 min and 28 min respectively) but significantly more patients were diagnosed as having wound infections (14% and 0% respectively); most were given antibiotics, perhaps unnecessarily.

This randomized prospective study assessed whether multiple puncture of the ganglion wall improves the results of simple ganglion aspiration. We found that 32% of ganglia resolved after aspiration alone in comparison with 22% after aspiration and multiple puncture. This difference was not significant. However, only 18% of patients requested formal surgical excision, suggesting that aspiration allays fears of malignancy and allows the patient to accept a minor cosmetic embarrassment.

Twenty-two displaced metacarpal shaft fractures in 19 patients were stabilized with multiple intramedullary K-wires. These were inserted percutaneously through a small window in the base of the metacarpal and were buried in the bone. No external splintage was routinely used postoperatively and all patients were encouraged to mobilize their fingers immediately: formal physiotherapy was not usually required. All the fractures that we were able to follow-up united, but the K-wires bent at the fracture site in two instances, producing 20 degrees angular deformities. The buried K-wires had to be removed in one instance as a result of protrusion into the carpometacarpal joint.

We investigated the occupation histories of 178 patients with idiopathic trigger finger. When compared with the 1991 Census data, the distribution of their occupations was not significantly different from the local general population. It is concluded that the vast majority of trigger fingers develop for reasons other than occupation.

This randomized prospective study compared the results of trapeziectomy alone, or combined with tendon interposition or ligament reconstruction in 76 women with basal thumb osteoarthritis. At 3 month and 1 year follow-up the results of the three procedures were indistinguishable in terms of pain relief, hand function and thumb strength. In the short term at least, tendon interposition and ligament reconstruction do not improve the results of trapeziectomy.

Wrist ganglia were randomly allocated for conservative treatment by either aspiration or aspiration and injection of steroid. Both treatment methods had 33% success rates. Almost all ganglia which recurred after one aspiration did not resolve with further aspirations. After aspiration and explanation of the benign nature of ganglia, only a quarter of patients requested surgical treatment.

We report the results of five interposition palmar plate (Tupper) arthroplasties for post-traumatic or post-infection osteoarthritis of metacarpophalangeal joints. All were pain free at a median follow-up of 4 years. The mean arc of joint flexion was 55 degrees and finger to thumb tip pinch was 60% of normal. All patients had reduced grip strength, but were satisfied with the procedure.

In a prospective study we investigated 12 clinical features for scaphoid fractures in 52 patients: 23 in whom a fracture of the scaphoid was diagnosed radiologically and 29 patients in whom a fracture was clinically suspected but could not be confirmed by radiography or scintigraphy. The signs were tested within a few days of injury and again 2 weeks later. None was reliable in diagnosing a scaphoid fracture.

In a prospective study we performed bone scans on 84 patients who had sustained a wrist injury and in whom a scaphoid fracture was clinically suspected but could not be confirmed on the original set of five routine "scaphoid view" radiographs. In 40 patients the bone scan was normal and in 25 there was increased uptake in areas other than the scaphoid. In 19 there was localized increased uptake in the scaphoid bone. In seven of these a scaphoid fracture was subsequently demonstrated on repeat radiographs (five cases) or a CT scan (two cases). In the remaining 12 no fracture could be demonstrated.

The prevalence of basal thumb osteoarthritis was assessed in 143 post-menopausal women. The radiological prevalences of isolated carpometacarpal and scapho-trapezial osteoarthritis were 25% and 2% respectively. The prevalence of combined carpometacarpal and scapho-trapezial osteoarthritis was 8%. 28% of women with isolated carpometacarpal osteoarthritis and 55% with combined carpometacarpal and scapho-trapezial osteoarthritis complained of basal thumb pain.

The quality of the treatment of finger fractures by Accident and Emergency Department staff has been prospectively assessed during a six-month period. 678 finger fractures were seen in the A. & E. Department. The primary treatment of 624 of these was performed by the A. & E. staff, but in 169 of these (27%), the treatment was inappropriate. Most management errors were elementary; they included failure to prescribe antibiotics for compound fractures, failure to reduce displaced fractures accurately and unsatisfactory splintage. It is recommended that all finger fractures should be assessed and treated by surgeons with training in the management of hand injuries.