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

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

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

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

Background Patient expressions reflect disability and psychological factors. The aim of this study was to list common phrases and feelings in hand surgery practice and to prospectively study the correlation of these phrases and to correlate them with possible associated feelings and disability. Methods Eighty-three patients completed the short version of the disabilities of arm, shoulder and hand (QuickDASH) questionnaire to measure disability, the pain self-efficacy questionnaire (PSEQ) to study coping, and a pain scale. The patients also completed the phrases and feelings questionnaire, which list verbal expressions patients often use. Pearson's correlation was used to test the correlation of continuous variables, and independent t test and one-way ANOVA were used for categorical variables. All variables with p Results There was a large correlation between the individual phrases and feelings questions with PSEQ and QuickDASH. The best model for the combined phrases questionnaire included pain, PSEQ, smoking, and other pain conditions. The best model for the combination of all the feelings questions included PSEQ, pain, and marital status. The best model for QuickDASH included phrases, PSEQ, prior treatment, and working status, with phrases being the strongest factor. Conclusions Patients use specific phrases that indicate the magnitude of their disability and the effectiveness of their coping strategies. Providers should respond to these phrases by empathetically acknowledging these aspects of the human illness experience.

This prospective study measured and compared the diagnostic performance characteristics of various clinical signs and physical examination manoeuvres for carpal tunnel syndrome (CTS), including the scratch collapse test. Eighty-eight adult patients that were prescribed electrophysiological testing to diagnose CTS were enrolled in the study. Attending surgeons documented symptoms and results of standard clinical manoeuvres. The scratch collapse test had a sensitivity of 31%, which was significantly lower than the sensitivity of Phalen’s test (67%), Durkan’s test (77%), Tinel’s test (43%), CTS-6 lax (88%), and CTS-6 stringent (54%). The scratch test had a specificity of 61%, which was significantly lower than the specificity of thenar atrophy (96%) and significantly higher than the specificity of Durkan’s test (18%) and CTS-6 lax (13%). The sensitivity of the scratch collapse test was not superior to other clinical signs and physical examination manoeuvers for CTS, and the specificity of the scratch collapse test was superior to that of Durkan’s test and CTS-6 lax. Further studies should seek to limit the influence of a patient’s clinical presentation on scratch test performance and assess the scratch test’s inter-rater reliability.

Background Questionnaires are often used to quantify the subjective aspects of illness such as disability, coping strategies, or symptoms of depression. Most questionnaires were validated in a paper-based format, but direct entry into a computer is becoming commonplace. The aim of this study was to assess differences in outcome of questionnaires pertinent to hand and upper extremity illness when they were administered in a computer or paper format. Method Ninety-nine patients completed both paper and web versions of the short forms of the Disabilities of Arm, Shoulder, and Hand; the Pain Catastrophizing Scale; the Short Health Anxiety Index (SHAI-6); the Patient Health Questionnaire Depression Scale; and a pain scale and the Pain Self-Efficacy Questionnaire sequentially during a single visit. We alternated starting with the paper or the web version after every five patients. Results The cohort consisted of 46 females and 53 males with a mean age of 49 years. There were significant differences in SHAI-6 and the pain scale, but not in the other measures. The intraclass correlation was high. Conclusions The use of these questionnaires in electronic format is valid provided that the small differences we observed are not important to the primary study question. In our opinion, for most studies, the advantages of using an electronic format outweigh the small additional variation that might be introduced in the measures in an electronic format.

Background This study addresses factors associated with apparent resolution and recurrence of triggering using data from providers with various treatment strategies. Method A retrospective review identified 878 adult patients with 1,210 Quinnell grade 2 or 3 trigger fingers that had one or more corticosteroid injections by one of three surgeons between 2001 and 2011. Two surgeons injected dexamethasone, but one had patients return 1 month after injection and was quick to recommend surgery (strategy A) and the other had patients return 2 months after injection, offered another injection or surgery, and followed the patient's preference. One surgeon used triamcinolone, had patients return only if the injection did not work, and waited at least 3 months to offer surgery. Factors associated with apparent resolution and recurrence of triggering were sought in bivariable and multivariable statistical analysis. Results Triamcinolone injection was associated with more frequent apparent resolution (83 %), than dexamethasone injection (30 %). Apparent resolution of triggering was also associated with a delayed surgery treatment strategy (B and C) and the affected finger (long and ring fingers were less likely to resolve). Return with triggering after documented or presumed resolution occurred in 188 fingers (33 %) and was associated with triamcinolone injection, index, long and ring finger, and orally treated non-insulin-dependent diabetes mellitus. Strategy A had the lowest initial apparent resolution rate, the highest proportion of patients having surgery, and the lowest final triggering rate of 10 %. Conclusion Both treatment strategy and type of corticosteroid determine apparent resolution and recurrence rates.

The diagnosis of carpal tunnel syndrome (CTS) is often applied in the absence of objectively verifiable pathophysiology (i.e. electrophysiologically normal carpal tunnel syndrome). The primary purpose of this study was to determine whether depressive symptoms, heightened illness concern, and pain catastrophizing are associated with an absence of electrophysiological abnormalities. The secondary purpose was to examine the correspondence between the Levine scale, the CTS-6, and electrophysiological abnormalities. Ninety-eight participants completed validated questionnaires assessing psychosocial factors at the initial visit, and surgeons recorded clinical data and their confidence that the diagnosis was carpal tunnel syndrome. Symptoms and signs that are characteristic of carpal tunnel syndrome (e.g. the CTS-6 and Levine scale) significantly, but incompletely coincided with electrophysiological testing. Psychological factors did not help distinguish patients with normal and abnormal objective testing and it remains unclear if symptoms that do not coincide with abnormal tests represent very mild, immeasurable median nerve dysfunction or a different illness altogether. Future studies should address whether outcomes are superior and resource utilization is optimized when surgery is offered based on symptoms and signs (e.g. the CTS-6) or when surgery is offered on the basis of measurable pathophysiology.

Closed multiple metacarpal fractures are uncommon. They are usually associated with significant soft tissue swelling. Early stable fixation and functional rehabilitation optimises outcome. We present a review of 19 patients with 43 metacarpal fractures treated by early open reduction and internal fixation with 2 mm plates. Eighteen patients recovered a full range of motion, while one patient was lost to follow-up. Implant removal on account of extensor irritation was required in only two metacarpals in two patients. Plating of multiple closed metacarpal fractures is a safe, reliable and consistently reproducible treatment method.

Combined fractures of the distal radius and scaphoid are uncommon, are usually the result of a high-energy trauma and there is no consensus regarding their optimal management. We present a retrospective study of ten patients, out of whom nine underwent internal fixation of their fractures. Open reduction and internal fixation were performed in six of the eight intraarticular fractures of the distal radius. After a mean follow-up of 40 months, eight patients reported no pain and the mean range of wrist motion was 55° flexion and 71° extension. Our current management protocol is outlined. Emphasis on treatment of this combined fracture should be placed on the management of the distal radius fracture. Internal fixation of both fractures, followed by early rehabilitation, optimises outcomes. Cast treatment is indicated only in patients with completely undisplaced fractures of both the radius and the scaphoid.

This study aims to present the functional outcome in patients who sustained paint-gun injuries to the hand with latex paint and review the current trends, recommendations, and pitfalls of surgical treatment in contemporary literature. Five male patients with an average age of 35 years were treated between 2000 and 2003 after sustaining a paint-gun injury with latex paint. All wounds were located volarly on the digits of the nondominant hand. Preoperative radiographs were obtained in every patient. All patients underwent debridement of the affected digit. Despite delayed presentation, more than 24 h post injury, our patients recovered substantial function at an average follow-up of 12 months. Every patient returned to his previous occupation and there were no amputations. Paint-gun injuries with latex paint appear to be associated with an outcome that is superior to the poor outcome traditionally associated with oil-based paints.

Radiocarpal fracture-dislocation is an uncommon but complex injury that is often the result of high energy trauma. The combination of ligamentous and osseous injuries demands meticulous attention to restoration of anatomy, especially of the radial styloid. Open reduction and internal fixation is often necessary to restore the relationship of the end of the radius to the carpus and distal ulna. We present a retrospective review of 12 patients treated over a 10-year period and review the literature.

Isolated primary bony lesions of the digits are infrequent. A phalangeal lesion in the hand is most likely to be benign. Rarely, however, primary benign tumour-like conditions affecting the handmay radiologically mimic an osteochondroma and histologically mimic a malignancy. We describe a case of bizarre parosteal osteochondromatous proliferation (Nora’s lesion, BPOP), which may do both and mislead the unsuspecting surgeon. The aim of this paper is to present our experience with this case, review existing literature and promote awareness among hand surgeons of a condition that can often be misdiagnosed.

Ten cases of fractures of the distal radius associated with scapho-lunate diastasis are reported. The mechanism of injury has been described and an attempt made to analyse the implications in treating such an injury.

This report describes a closed rupture of the entire extensor digitorum communis and extensor indicis proprius.