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Osteonecrosis affecting the carpal bones is rare and is mostly seen in the lunate (Kienböck’s disease). Osteonecrosis of the scaphoid (Preiser disease) is even rarer. There are only four individual case reports published on patients presenting with trapezium necrosis, none with previous history of corticosteroid injection. This case report is the first presentation of isolated trapezial necrosis in the setting of prior corticosteroid injection for thumb basilar arthritis. Level of Evidence: Level V (Therapeutic)

Introduction Die punch (DP) fragments are among the most common fracture fragments to lose reduction after volar locked plating of articular distal radius fractures (DRFs). We aimed to report the number of patients in our institution who had a computed tomography (CT)-confirmed DP fragment and who had open reduction and internal fixation (ORIF) through a dorsal approach; to report the length of the radioulnar portion of the DP fragment relative to the total distal radioulnar joint (DRUJ) length; and to identify if an association exists between this length and the choice for a volar versus a dorsal operative approach to the DP fragment. Materials and Methods We performed measurements on the preoperative CT scans of 94 skeletally mature patients with a DP fragment. We also collected data related to their demographics, injury, and treatment. Of the 94 patients in this study, 84 (89%) had AO type C fractures. Results Thirteen out of 94 patients (14%) who had ORIF of their DRF with a DP fragment had a separate dorsal incision. The mean proportion of the DP fragment length relative to the total DRUJ length was 0.51 ± 0.19. There was no association between the length of the DP fragment and volar versus dorsal approach. Conclusion DP fragment size is not an indicator of the need for or use of a dorsal approach in DRF fixation. Level of Evidence This is a Level IV,—retrospective study.

Background Tendon transfer in the upper extremity represents a powerful tool in the armamentarium of a reconstructive surgeon in the setting of irreparable nerve injury or the anatomic loss of key portions of the muscle-tendon unit. The concept uses the redundancy/expendability of tendons by utilizing a nonessential tendon to restore the function of a lost or nonfunctional muscle-tendon unit of the upper extremity. This article does not aim to perform a comprehensive review of tendon transfers. Instead it is meant to familiarize the reader with salient historical features, common applications in the upper limb, and provide the reader with some technical tips, which may facilitate a successful tendon transfer.Learning Objectives (1) Familiarize the reader with some aspects of tendon transfer history. (2) Identify principles of tendon transfers. (3) Identify important preoperative considerations. (4) Understand the physiology of the muscle-tendon unit and the Blix curve. (5) Identify strategies for setting tension during a tendon transfer and rehabilitation strategies.Design This study was designed to review the relevant current literature and provide an expert opinion.Conclusions Tendon transfers have evolved from polio to tetraplegia to war and represent an extremely powerful technique to correct neurologic and musculotendinous deficits in a variety of patients affected by trauma, peripheral nerve palsies, cerebral palsy, stroke, and inflammatory arthritis. In the contemporary setting, these very same principles have also been very successfully applied to vascularized composite allotransplantation in the upper limb.

A volar approach is commonly used for fixation of distal radius fractures with a volar locking plate. There are certain fracture patterns for which volar locked plating is not suitable. This case based review outlines such case examples.

Objectives Our understanding of distal radius fractures with concomitant scapholunate (SL) diastasis primarily comes from plain radiographs and arthroscopy. The clinical implications of SL diastasis are not clear. The aim of this study is to describe fracture characteristics of distal radius fractures on computed tomography (CT) scans in patients with distal radius fractures and static SL diastasis. Methods We queried our institutional databases to identify patients who were treated for a distal radius fracture, had a CT scan with a wrist-protocol, and static SL diastasis on their CT scan. Our final cohort consisted of 26 patients. We then collected data on their demographics, injury, treatment, evaluated injury patterns, and measured radiographic SL characteristics. Our study cohort consisted of 11 men (42%) and almost half of our cohort (n = 12; 46%) had a high-energy mechanism of injury. The majority of the patients (n = 20; 77%) had operative treatment for their distal radius fracture and two patients (7.7%) had operative treatment of their SL injury. Results The mean SL distance was 3.5 ± 1.1 mm. Twenty patients (77%) had an intra-articular fracture. In these patients, we observed three patterns: (1) scaphoid facet impaction; (2) lunate facet impaction; and (3) no relative impaction. We observed other injury elements including rotation of the radial styloid relative to the lunate facet and partial carpal subluxations. Conclusion Static SL dissociation in the setting of distal radius fractures may be an indication of a complex injury of the distal radius, which may not be directly apparent on plain radiography. If these radiographs do not demonstrate impaction of the lunate or scaphoid facet, a CT scan may be warranted to have a more detailed view of the articular surface. Level of Evidence This is a Level III, diagnostic study.

Background Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial. Objectives To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius. Patients and Methods After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of “proximal pole scaphoid fractures” who underwent surgical fixation by a single surgeon over an 11-year period (2006–2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft. Results The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm3 and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm3. Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8–16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications. Conclusions Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure. Level of Evidence This is a Level IV, case series study.

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.

We conducted a retrospective review of six patients with carpometacarpal (CMC) ⅘ fracture-dislocations managed with ORIF by a single surgeon between October 2006 and August 2017. An open, dorsal approach to the hamate was used with a combination of interfragmentary screw fixation and Kirschner wire reduction in the CMC joints. At a mean of 96 days follow-up (range: 31–265), all patients had recovered wrist motion, excellent grip strength, and complete resolution of pain. There were no complications or reoperations during the postoperative period. Radiographic review showed restoration of anatomy and well-maintained congruity of the CMC joints. Our study has shown favorable outcomes after open reduction and internal fixation of the hamate body fracture with interfragmentary screws, when combined with stabilization of the CMC dislocation with percutaneous Kirschner wires. Fracture morphology does not appear to guide choice for specific hardware (size screw, headed/headless) or use of a washer. This is a level IV, therapeutic study.

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.

Tension band wiring is a simple, inexpensive, and effective technique to treat many upper extremity fractures. When tension forces result in a mechanical failure of bone, tension band wiring provides stability and promotes early mobilization by converting tensile forces across a fracture into compressive forces. The tension band principle has distinct advantages of reducing periosteal stripping, technical ease, and cost effectiveness when compared with other operative strategies. This technique can be implemented in a variety of fractures and avulsions about the upper extremity as well as small bone arthrodeses.

Objective: This study aimed to explore the clinical application of preoperative precise design for 3D printing and thumb reconstruction, which could help manage the patients with thumb defect and achieve better function and appearance. Methods: This was a retrospective study of 20 patients who underwent the surgery of harvesting toe transplant and thumb reconstruction between January 2015 and December 2016. The 3D model of the thumb defect was created and printed. The dimensions of skin and bones from donor site were precisely designed as reference for surgical operation. The surgery was performed according to the model. Results: Perfect repair of defects was achieved with satisfying appearance and function. The reconstructed thumbs all survived (survival rate of 100%). Follow-up was 3-9 months. The maximum dorsiflexion was 8-30° and the maximum flexion was 38-58°. The two-point sensory discrimination was 9-11 mm. In total, 17 patients reposted “Excellent” satisfaction and three “Good”, each for the reconstructed thumb and hand function, respectively. The satisfaction rate was 85%. Conclusion: Preoperative digital design and 3D printing according to the donor and recipient sites allowed a tailored operation. The operation was more precise, the appearance of the reconstructed thumb was good. Level of Evidence II, Retrospective Study. RESUMO Objetivo: Este estudo explorou a aplicação clínica do desenho pré-operatório preciso para impressão 3D e reconstrução do polegar, para ajudar no controle e melhorar função e aparência. Métodos: Estudo retrospectivo de 20 pacientes submetidos à cirurgia de colheita de transplante de dedo do pé e reconstrução do polegar entre janeiro de 2015 e dezembro de 2016. O modelo 3D do defeito do polegar foi confeccionado e impresso. As dimensões da pele e dos ossos da área doadora foram precisamente projetadas como referência para a operação cirúrgica, realizada de acordo com o modelo. Resultados: O reparo perfeito foi alcançado com aparência e função satisfatórias. Todos os polegares reconstruídos sobreviveram (taxa de sobrevivência de 100%). O acompanhamento foi de 3-9 meses. A dorsiflexão máxima foi de 8-30° e a flexão máxima foi de 38-58°. A discriminação sensorial de dois pontos foi de 9-11 mm. No total, 17 pacientes reportaram índice “Excelente” e três índice “Bom” cada para a função reconstruída do polegar e da mão, respectivamente. O índice de satisfação foi de 85%. Conclusão: O design digital pré-operatório e a impressão 3D de acordo com os locais doador e receptor permitiram uma operação customizada. A operação foi mais precisa, com bom aspecto. Nível de Evidência II, Estudo Retrospectivo.

Dupuytren contracture is a progressive disease involving collagen within the palmar fascia. When the contracture progresses to meet specific parameters, intervention is considered and includes collagenase injection, percutaneous or open fasciotomy, or palmar fasciectomy. Complications after treatment include contracture recurrence, digital nerve injury or postoperative neurapraxia, flexor tendon injury/rupture, delayed wound healing or skin necrosis, dysvascular digit/arterial injury, hematoma, and infection. Patients with severe or recurrent Dupuytren contracture are more likely to experience complications. Patient education is paramount; one must consider the patient's goals for treatment, functional requirements, time frame for recovery, and tolerance for complications when deciding about treatment.

Objective Closed reduction and percutaneous pinning (CRPP) is losing popularity as a treatment modality for distal radius fractures. However, in select cases, CRPP may have advantages relative to open reduction and internal reduction. We aimed to retrospectively assess the outcomes after CRPP for the treatment of distal radius fractures. Study Design This is a retrospective cohort study. Methods We used billing records to identify all skeletally mature patients with a distal radius fracture who were treated with CRPP by a single surgeon at a level I trauma center in an urban city in the United States. We assessed the medical charts and recorded demographics, trauma and treatment characteristics, radiographic characteristics, and outcomes. Results All patients had a good or excellent range of motion regarding forearm rotation, and almost 80% had good or excellent range of motion regarding flexion or extension of their wrist. One patient had a concern for pin tract infection, and one had subcutaneous migration of a pin, which were both treated by pin removal. Conclusion CRPP is a good option in patients with few and sizeable fracture fragments in patients with a distal radius fracture, and it should be considered as an effective tool to restore radiographic parameters and functional outcomes.

Introduction The purpose of this study is to examine the clinical results of retrograde intramedullary headless screw (IMHS) fixation for metacarpal fractures. Methods A retrospective review was performed on 16 patients with 18 metacarpal fractures who underwent IMHS fixation at a single institution. The average age was 32 years. The indications for surgery included rotational malalignment (five patients), multiple metacarpal fractures (five patients), angular deformity (four patients), and shortening greater than 5 mm (two patients). The average length of follow-up was 19.4 weeks (median 10.2 weeks). Results Functional outcome was considered excellent in all patients with total active motion in excess of 240 degrees. Active motion was initiated within 1 week of surgery. No secondary surgeries were performed related to a complication of IMHS fixation. Conclusion IMHS fixation of metacarpal fractures is an efficacious treatment modality for patients with comminution, multiple fractures, malrotation, and those who require rapid mobilization. It obviates the need for immobilization or more extensive plate and screw fixation techniques with excellent clinical results.

To tests the hypothesis that classification and characterization of fractures of the radial head is more accurate with 3D than 2D computed tomography images and radiographs, using a prospective study design with intraoperative inspection as the reference standard. Treating surgeons and first assistants completed a questionnaire assigning a fracture type according to the Broberg and Morrey modification of Mason's classification, evaluating selected fracture characteristics, and electing preferred management based upon radiographs and 2D images alone; then adding 3D-CT; then 3D printed physical models; and finally intra-operative visualization. The addition of the 3D CT and physical models improved the sensitivity for fracture line separating the entire head from the neck, comminution of the radial neck, fracture involving the articular surface, articular fracture gap greater than 2 mm, impacted fracture fragments, greater than 3 articular fragments, and articular fragments judged too small to repair. There were no significant differences in diagnostic performance with the addition of 3D models. The addition of 3D CT and models improved the reliability of Broberg and Morrey classification. We conclude that 3DCT and 3D physical modeling provide more accurate fracture classification and characterization of fracture of the radial head with less proposed variability in treatment. We did not demonstrate a clear advantage for modeling over 3DCT reconstructions. Level of Evidence: Diagnostic, Level I

Trapeziometacarpal arthrosis is expected with advancing age and a limited percentage of people seek medical attention for it. We studied patients after their first appointment to address trapeziometacarpal arthrosis with a hand surgeon to determine factors associated with return for a second visit and eventual election of operative treatment. A billing database identified 306 patients in the practice of three hand surgeons with a new diagnosis of TMC arthrosis and no associated diagnoses. Bivariate and multivariable logistic regression analyses sought factors associated with a second visit and operative treatment among demographic and visit related factors. One hundred and forty-three patients (47 %) returned for one or more additional visits and 46 (15 %) eventually elected operative treatment within the study period. Independent predictors of a return visit included injection at first visit, splint at first visit, and doctor's recommendation for a return visit. The predictors of surgery were treating surgeon and prescription of a splint at the first visit, but splint at first visit was only predictive for one of the three surgeons. When patients first learn about their trapeziometacarpal arthrosis, the behavior of the hand surgeon may have a strong influence on return visits and eventual choice of operative treatment.

Background Conventional angiography is an invasive technique. Submillimeter computed tomography angiography (CTA) has been shown to be an effective alternative for peripheral artery branches. This study aimed to assess the use of CTA to guide the choice and design of foot donor area for finger or thumb reconstruction. Methods This was a retrospective study of 79 patients who underwent finger or thumb reconstruction between January, 2011 and March, 2014. All these patients underwent preoperative CTA to determine the exact blood supply at the donor site. Preoperative imaging and intraoperative findings at the donor site were compared. Results Among the 79 patients (158 feet), 474 artery segments (dorsalis pedis artery [DPA], first dorsal metatarsal artery [FDMA], and toe web artery [TWA]) were evaluated using CTA. Image satisfaction rates of the vessels were 100.0 ± 0.0%, 89.2 ± 3.2%, and 60.1 ± 5.0% for DPA, FDMA, and TWA, respectively. Among the 158 feet, 90 were Gilbert type I (57.0%), 52 were Gilbert type II (32.9%), 13 were Gilbert type III (8.2%), and 3 were with poor visibility and could not be classified (1.9%). In all 79 patients, the CTA image of the FDMA was consistent with the intraoperative observations. All reconstructed fingers survived. Follow-up was available for 69 patients. After a 6- to 18-month follow-up, the reconstructed fingers and donor area recovered well, and the reconstructed fingers had strong holding power, without pain. Conclusion CTA can produce three-dimensional images for extremity arteries, allowing the preoperative assessment of blood supply and planning of donor site.

Purpose The degree to which patients' expectations are met during an office visit consistently correlates with patients' satisfaction, whereas the relationship between previsit expectations and satisfaction varies. Objective The aim of this pilot study was to preliminarily assess the relationship of psychosocial factors, pain intensity, and magnitude of disability to previsit expectations, met expectations, and satisfaction with medical care in patients with hand and upper extremity conditions in a surgical outpatient clinic. Methods A cohort of 85 outpatients with upper extremity illnesses indicated their previsit expectations (Patients Intention Questionnaire), degree to which these expectations were met (Expectations Met Questionnaire), level of depressive symptoms (Patient Health Questionnaire-2), confidence about the ability to achieve one's goals in spite of pain (Pain Self-Efficacy Questionnaire), pain intensity (Numerical Rating Scale for pain), disability (Disabilities of the Arm Shoulder and Hand, short version; QuickDASH), and satisfaction with the medical visit (Medical Interview Satisfaction Scale). Results Higher previsit expectations were associated with more depressive symptoms, lower pain self-efficacy, higher pain intensity, and fewer years of education. Patients in the low and moderate met expectations categories had significantly more symptoms of depression, fewer years of education, and more pain compared to those in the high-met expectations category. Fewer years of education and higher pain intensity predicted higher previsit expectations and explained 19% of variance. Conclusion Psychosocial factors affect both previsit expectations and met expectations during an outpatient visit to a hand surgeon. Met expectations, but not previsit expectations, affect satisfaction. Level of Evidence Prognostic, level II.

Computed tomography (CT) is increasingly used not just to diagnose union but also to estimate the percentage of the fracture gap that is bridged by healing bone. This study tested the primary null hypothesis that there is no agreement between observers on the extent of union of a scaphoid waist fracture on CT. CT scans of 13 nondisplaced scaphoid waist fractures treated nonoperatively were rated by 145 observers. CT scans were done 10 to 12 weeks after injury. Observers were asked to “eyeball” measure percentage of union. We found that there was a moderate agreement on the categorical degree of partial union of a scaphoid waist fracture on CT (k = 0.34). Agreement on the location of bony bridging was slight (k = 0.31). We concluded that there is limited reliability of diagnosis of partial union of a scaphoid waist fracture on CT and that this should be taken into account in both patient care and research. This is a Level III, diagnostic study.

Rupture of triceps tendons is uncommon. Bilateral triceps ruptures are even rarer [1, 2]. There are very few case reports in women [3]. The first triceps rupture was reported in 1868 [4]. Although many cases have been reported since then, reports of bilateral ruptures still remain rare [1, 2]. The etiology of triceps tendon rupture is still under debate. Multiple etiologies have been proposed for making the tendon insertion susceptible to weakness and tear. In case of a complete triceps tendon rupture, surgical repair is the preferred treatment [4, 5]. Timely rehabilitation is mandatory to regain the triceps strength and elbow range of motion after surgery [4].

Radial head arthroplasty remains a good treatment option for fractures not amenable to fixation. Several variations exist in technique and implant type. This review discusses the insertion techniques, implant types available, and literature outcomes associated with radial head arthroplasty.

Objectives A lack of conclusive evidence on the treatment of acute median neuropathy (AMN) in patients with distal radius fractures has led to inconsistent surgical guidelines and recommendations regarding AMN in distal radius fractures. There is a wide variation in surgical decision-making. We aimed to evaluate international differences between surgical considerations and practices related to carpal tunnel release (CTR) in the setting of distal radius fractures. Methods We approached surgeons who were a member of the Orthopaedic Trauma Association (United States) or of the Dutch Trauma Society (the Netherlands) and asked them to provide sociodemographic information and information on their surgical practice regarding CTR in the setting of distal radius fractures. After applying our exclusion criteria, our final cohort consisted of 127 respondents. Results Compared with Dutch surgeons, surgeons from the United States are more of the opinion that displaced distal radius fractures are at risk of developing acute carpal tunnel syndrome (ACTS), consider persistent paresthesia in the median nerve distribution after closed reduction to be a surgical emergency less often, and are more likely to perform a CTR if there are signs of ACTS in the setting of a distal radius fracture. Conclusion A lack of conclusive evidence has led to international differences in surgical practice regarding the treatment of ACTS in the setting of distal radius fractures. Future research should guide surgeons in making appropriate evidence-based decisions when performing CTR in the setting of distal radius fractures. Level of Evidence This is a Level V study.

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: Accurate identification of surface anatomy is critical to identify the location of the A1 pulley. The intercrease line (ICL) describes a transverse line between the radial edge of the proximal palmar crease and the ulnar edge of the distal palmar crease. We hypothesize that this easily identifiable surface landmark approximates the location of the A1 pulley. Methods: The ICL was marked on 7 cadaver hands. We marked a point proximal to the proximal digital crease (PDC) equal to the distance between each digit’s proximal interphalangeal crease (PIC) and PDC (the PIC/PDC point). We calculated the distance between PIC/PDC points and proximal edge of the A1 pulleys. Results: The ICL was proximal to A1 in all digits. The PIC/PDC point was distal to A1 in the ring finger, and proximal to A1 in the index, middle, and small fingers. The PIC/PDC point was closer to the A1 pulley than the ICL in the middle and ring fingers. Conclusions: Despite less accuracy than the PIC/PDC point at approximating the location of the A1 pulley, the ICL is reliably proximal to the A1 pulley.

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.

Introduction: Patient interpretation of advice from hand therapists may be related to nonadaptive pain thoughts (automatic, overprotective, unduly pessimistic statements triggered by nociception and exacerbated by psychological distress). Purpose of the study: This study aimed to determine whether there were correlations between participants' hand therapy goals, interpretation of advice from hand therapists, nonadaptive pain thoughts, and upper extremity-specific disability. Methods: One hundred and five participants completed questionnaires assessing nonadaptive pain thoughts, upper extremity-specific disability, lessons from hand therapists, and hand therapy goals. Results: Nonadaptive pain thoughts correlated with disability and were bi-directionally related to participant goals and interpretation of advice from hand therapists. Discussion: Patients' nonadapative pain thoughts and the words/concepts used by hand therapists are both important in recovery from upper extremity illness. Conclusions: Hand therapists should be mindful that nonadaptive pain thoughts are an important determinant of disability and that such thoughts can affect and be affected by their recommendations. Level of evidence: n/a (C) 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved

Background Psychological factors, such as depression, catastrophic thinking, and self-efficacy, account for more of the variation in upper extremity disability than motion and other impairments, but their influence in the setting of hand trauma is less well studied. Objective The aim of this study was to determine which factors account for variation in disability 1 month after fingertip injuries. Methods We enrolled 82 patients with finger injuries distal to the proximal interphalangeal joint, and 70 patients completed the study. Questionnaires and measurements were taken at the initial visit and approximately 1 month later. Patients completed the short version of the Disabilities of the Arm Shoulder and Hand questionnaire, the pain self-efficacy questionnaire, and the Patient Health Questionnaire to assess depressive symptoms. Bivariate and multivariable analyses determined factors associated with QuickDASH scores. Results The mean disabilities of the arm shoulder and hand questionnaire score was 35 at the initial visit (the US norm is 10) and 17 approximately 1 month later. The best model explained 54% of the variation in disabilities of the arm shoulder and hand questionnaire 1 month after injury and included symptoms of depression (Patient Health Questionnaire; partial R 2 0.43) and injury mechanism (saw injury compared with sport injury; partial R 2 0.14). The criterion symptoms of depression was also the factor most strongly associated with both pain intensity and time off work. Conclusions In patients with fingertip injury, symptoms of depression account for most of the variability in hand and arm-specific disability, pain intensity, and days to return to work. Identification and treatment of symptoms of depression might facilitate recovery from fingertip injuries.

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.

Coronal (or frontal plane) fractures of the scaphoid are distinctly uncommon. There are few published reports of coronal fractures of the scaphoid. This fracture is often missed on the initial X-ray films. A high index of suspicion should exist when there is a double contour of the proximal scaphoid pole on the anteroposterior X-ray view. A computed tomography scan is integral in making the diagnosis. Early recognition is key in salvaging the scaphoid fracture and in preventing articular damage. Level of Evidence IV. Retrospective case series.

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.

Treatment failure and complications are encountered in 1% to 25% of all carpal tunnel releases. Besides hematoma, infection, skin necrosis, and intraoperative iatrogenic injuries, persistence and recurrence should be included in this discussion. Persistence is often related to incomplete release. Similar symptoms recurring after a symptom-free interval of 6 months are considered recurrent and may be caused by intraneural or perineural scarring. Adequate diagnosis and treatment of these failures can be challenging. Operative release is the main treatment consisting of complete decompression of the median nerve. In some circumstances, coverage of the median nerve may be necessary.

Purpose This investigation used prospectively recorded intraoperative evaluation as the reference standard for distal humerus fracture type and characteristics, in order to measure the diagnostic performance characteristics of computed tomography (CT) and physical models. In secondary analyses, we assessed the reliability of classification. Methods Thirty-five fractures were evaluated by the treating surgeon and first assistant on radiographs and 2-dimensional CT (2DCT) images first; a second time based on radiographs and 2- and 3-dimensional CT (3DCT) images; a third time based on 2- and 3DCT as well as 3D physical models; and a fourth time based on intraoperative visualization of the fracture characteristics. The intraoperative evaluation of the attending surgeon was used as the reference standard. Results The addition of 3DCT and the 3D models to 2DCT and radiographs led to significant improvements in sensitivity, but not specificity, in the diagnosis and proposed treatment, and improved the interobserver agreement with respect to specific fracture characteristics but not classification. Conclusion Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics.

We present the case of a 61-year-old woman with a subacute elbow dislocation, who was referred to our institution 4 weeks after a fall. She was treated with open reduction and temporary bridging internal fixation through a posterior approach with a limited contact dynamic compression plate. After 4 weeks, the hardware was removed. One year postoperatively, the patient had nearly pain-free motion of 20° short of full extension and full flexion. Her radiographs showed residual incongruity and degenerative arthritis of the elbow.

Purpose To investigate the influence of a dynamic splinting protocol on outcomes of extensor tendon repairs. Methods All patients in a prospectively collected database underwent extensor tendon repair by a single surgeon between 2004 and 2008. The inclusion criterion was simple extensor tendon repairs in zone IV and V in the fingers and zones TI to TIII in the thumb. The tendon repairs used a 4-strand core technique and running epitendinous suture. Within 7 days, each subject began using a dynamic extension splint during the day and a static extension splint at night. The extension splint allowed the patient to passively extend and actively flex the digits. After 3 weeks, the dynamic splint was discontinued and the patients were started on active digital motion. Static night splinting was continued for the next 3 weeks, after which time splinting was discontinued and strengthening was instituted. A total of 17 patients with 19 tendon lacerations met the inclusion criterion. There were 5 patients with lacerations of the thumb extensors and 12 patients with zone IV/V finger extensor tendon lacerations. The average time from injury to surgery was 11 days (range, 2–39 d). The follow-up was 43 to 215 days, with an average of 96 days. Results A total of 16 patients achieved good or excellent results by 6 weeks according to our grading system. One patient had a fair result. There were no ruptures and no tenolysis surgeries performed. Conclusions Dynamic splinting resulted in generally good functional outcomes for extensor tendon laceration repairs in zone IV/V and TI to TIII, without complications. Type of study/level of evidence Therapeutic IV.

Purpose To report on 4 cases of avascular necrosis of the metacarpal head. Methods We retrospectively reviewed 4 patients who received a diagnosis of avascular necrosis of the metacarpal head and were treated from 2000 to 2016. Results All patients were males with involvement of the dominant hand. Three patients had a history of trauma and/or fractures in another finger and one had a history of fracture in the same finger. The diagnosis was confirmed on regular x-rays and magnetic resonance imaging. Nonsurgical management was offered to all patients (rest, placement of an orthosis, and nonsteroidal anti-inflammatory drugs) for 3 to 6 months. Two patients responded well to nonsurgical management and improved in their symptoms. One patient refused surgical intervention and continued to have persistent pain. The other patient was treated with curettage and bone graft and had total resolution of pain symptoms with full active range of motion. Conclusions A high index of suspicion is required to diagnose and treat avascular necrosis of the metacarpal head correctly. Treatment options are numerous and require further studies to investigate their effectiveness in the treatment of this rare disease. Type of study/level of evidence Therapeutic V.

Locked fixed-angle plating in the hand and wrist helps to optimize outcomes following surgical fixation of select acute fractures and complex reconstructions. Select indications include unstable distal ulna head/neck fractures, periarticular metacarpal and phalangeal fractures, comminuted/multifragmentary diaphyseal fractures with bone loss (ie, combined injuries of the hand), osteopenic/pathologic fractures, nonunions and corrective osteotomy fixation, and small joint arthrodesis. Locked plating techniques in the hand should not be seen as a panacea for wrist and digital acute trauma and delayed reconstructions. An understanding of the biomechanics of fixed-angle plating and proper technical application of locking constructs will optimize outcomes and minimize complications. As clinical experience with locking technology in hand trauma broadens, new indications and applications will emerge. Currently, several systems are available. The specific implants share common features in their protocols for insertion, but unique differences in their design (ie, individual locking mechanisms, uniaxial vs polyaxial locking capability, metallurgy, and plate profiles) must be appreciated and considered preoperatively.

This case report describes an alternative technique for the fixation of displaced comminuted subcapital fractures of the metacarpal with limited distal bone stock. Using a cannulated headless screw as an intramedullary device placed through the articular surface, we were able to secure proximal and distal bone purchase without excessive soft tissue stripping or disruption of the fracture hematoma. This technique allows early rehabilitation, and our patient went on to uneventful healing with excellent functional results.

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.