Journal of Hand Surgery

It's in Your Hands

Paul R. Manske — 2010-07-01

It's in your hands—the future of hand surgery, that is. This editorial is directed primarily to those 140 or so hand surgery fellows who are completing their specialty training this month at various North American hand centers, as well as those surgeons who are completing similar preceptorships or periods of study at academic institutions throughout the world.

Desensitizing the Posterior Interosseous Nerve Alters Wrist Proprioceptive Reflexes

Elisabet Hagert, Jonas K.E. Persson — 2010-07-01

Purpose: The presence of wrist proprioceptive reflexes after stimulation of the dorsal scapholunate interosseous ligament has previously been described. Because this ligament is primarily innervated by the posterior interosseous nerve (PIN) we hypothesized altered ligamento-muscular reflex patterns following desensitization of the PIN.Methods: Eight volunteers (3 women, 5 men; mean age, 26 y; range 21–28 y) participated in the study. In the first study on wrist proprioceptive reflexes (study 1), the scapholunate interosseous ligament was stimulated through a fine-wire electrode with 4 1-ms bipolar pulses at 200 Hz, 30 times consecutively, while EMG activity was recorded from the extensor carpi radialis brevis, extensor carpi ulnaris, flexor carpi radialis, and flexor carpi ulnaris, with the wrist in extension, flexion, radial deviation, and ulnar deviation. After completion of study 1, the PIN was anesthetized in the radial aspect of the fourth extensor compartment using 2-mL lidocaine (10 mg/mL) infiltration anesthesia. Ten minutes after desensitization, the experiment was repeated as in study 1. The average EMG results from the 30 consecutive stimulations were rectified and analyzed using Student's t-test. Statistically significant changes in EMG amplitude were plotted along time lines so that the results of study 1 and 2 could be compared.Results: Dramatic alterations in reflex patterns were observed in wrist flexion, radial deviation, and ulnar deviation following desensitization of the PIN, with an average of 72% reduction in excitatory reactions. In ulnar deviation, the inhibitory reactions of the extensor carpi ulnaris were entirely eliminated. In wrist extension, no differences in the reflex patterns were observed.Conclusions: Wrist proprioception through the scapholunate ligament in flexion, radial deviation, and ulnar deviation depends on an intact PIN function. The unchanged reflex patterns in wrist extension suggest an alternate proprioceptive pathway for this position. Routine excision of the PIN during wrist surgical procedures should be avoided, as it alters the proprioceptive function of the wrist.Type of study/level of evidence: Therapeutic IV.

Commentary: Desensitizing the Posterior Interosseous Nerve Alters Wrist Proprioceptive Reflexes: It Is OK to Lose Your Nerve

A. Lee Dellon — 2010-07-01

There are 2 major issues related to the article by Hagert and Persson and its 2 companion articles. Neither concern relates to the research efforts of the authors, who have proven that, in the absence of sensory function of the terminal branch of the posterior interosseous nerve (PIN), motor reflexes related to wrist position are altered. My primary concern is that hand surgeons, hand therapists, and pain management doctors will hesitate to recommend removal of a source of pain if it originates in a peripheral nerve that innervates part of a joint. In their abstract, Hagert and Persson raise concerns about losing wrist joint proprioception if the PIN is resected. In my experience, this loss of proprioception does not occur. My secondary concern is the authors' choice of words, which, Hagert admits, is “somewhat confusing,” leading her to define her terms. Terminology reflects our understanding of normal and pathophysiologic processes and guides our treatment. Substituting desensitization for anesthetic block and sensorimotor for neuromuscular confuses clinical thinking.

Nerve-Sparing Dorsal and Volar Approaches to the Radiocarpal Joint

Elisabet Hagert, Àngel Ferreres, Marc Garcia-Elias — 2010-06-14

Surgical approaches to the wrist joint have traditionally been focused on providing wide exposure to allow adequate access to the carpus. In light of recent investigations on the innervation and proprioception of the wrist joint, one should also take into consideration not to denervate the wrist capsule and ligaments. In this manuscript, we propose 2 surgical approaches to the dorsal and volar radiocarpal joint, intended to minimize damage to the innervation of the capsule while providing ample access to the wrist.

Scapholunate Dissociation With Radiolunate Arthritis Without Radioscaphoid Arthritis

Lewis B. Lane, Robert J. Daher, Andrew J. Leo — 2010-07-01

Purpose: Watson and Ballet introduced the concept of a direct association between scapholunate (SL) dissociation and radioscaphoid (RS) arthritis with preservation of the radiolunate (RL) articulation in 1984. This principle has served as the anatomic, biomechanical, and pathophysiological basis for reconstructive surgery in the carpus. Recently, we have noted cases of concurrent SL dissociation and RL arthritis without RS arthritis, which is contrary to the accepted concept of wrist arthritis due to SL advanced collapse. The purpose of this study was to determine whether Watson and Ballet's thesis that SL dissociation results in RS joint degeneration with sparing of the RL joint can be confirmed, or whether another joint degeneration pattern can be associated with SL dissociation.Methods: The 3 authors independently reviewed 897 radiographs of the wrist in 691 male patients (206 bilateral and 485 unilateral) with diagnosis codes of wrist osteoarthritis (715.13), wrist instability (718.83), and wrist sprain (842.00). Posterior-anterior, oblique, and lateral views were available for all wrists. Elements assessed were RS joint, RL joint, SL joint, midcarpal joint, ulnar variance, ulnolunate joint, SL angle, and lunocapitate angle.Results: There were 146 wrists with radiographic SL dissociation. Nine wrists in 6 patients had radiographic SL dissociation and RL arthritis but no RS arthritis. An additional 6 wrists in 6 patients had radiographic RL arthritis but no SL dissociation or RS arthritis; however, 5 of these did have an SL angle of 60° or greater.Conclusions: Our results show that RL arthritis can occur in association with SL dissociation, and that the generally held view that the RL articulation is spared in SL advance collapse is not universally true. Consequently, it is our recommendation that both the RL and RS joints should be carefully evaluated for degenerative changes when planning treatment for patients with SL dissociation, because it should not be assumed that the RL joint has been spared.

Volar Plate Osteosynthesis of Distal Radius Fractures With Concurrent Prophylactic Carpal Tunnel Release Using a Hybrid Flexor Carpi Radialis Approach

F. Winston Gwathmey, Lance M. Brunton, Raymond A. Pensy, A. Bobby Chhabra — 2010-07-01

Purpose: To evaluate the safety and efficacy of a hybrid flexor carpi radialis (FCR) approach for volar plate osteosynthesis of displaced distal radius fractures with concurrent prophylactic carpal tunnel release (CTR) in patients without preoperative signs or symptoms of acute carpal tunnel syndrome secondary to the fracture.Methods: A total of 68 displaced distal radius fractures in 65 eligible adult patients (35 men, 30 women; mean age, 48.6 ± 15.4 y) who had volar plate osteosynthesis and concomitant prophylactic CTR through a hybrid FCR approach by a single surgeon were included in this study. A systematic chart review and subsequent telephone questionnaire were performed to identify any postoperative median nerve dysfunction, recurrent motor or palmar cutaneous branch injury, tendon injury, or other complications directly related to the approach.Results: Reported symptoms consistent with late median nerve dysfunction were identified in 2 cases; however, no patients in this series required additional surgery for early or late median neuropathy. Furthermore, no cases of median nerve sensory or motor branch injury or tendon injury were identified. No other unforeseen complications specifically related to the approach were observed.Conclusions: Volar plate osteosynthesis of distal radius fractures with a concurrent prophylactic CTR can be safely performed through the described hybrid FCR approach in patients without signs or symptoms of acute CTS. Routine release of the transverse carpal ligament with the hybrid FCR approach at the time of fracture fixation might reduce the incidence of postoperative median nerve dysfunction.Type of study/level of evidence: Therapeutic IV.

Volar Radioscapholunate Arthrodesis for Malunited Distal Radius Fracture With Unsalvageable Wrist Articular Degeneration: Case Report

Evan Argintar, Scott Edwards — 2010-07-01

Fractures of the distal radius occur commonly, and volar plating has emerged as a current, successful, and popular treatment for this injury. When this technology fails, salvage procedures must be selected that aim to maximize wrist motion and minimize pain. We present a case of volar radioscapholunate wrist arthrodesis in the setting of unfeasible intraoperative volar osteotomy to treat a malunited distal radius fracture.

Trans-Scaphoid Transcapitate Transhamate Fracture of the Wrist: Case Report

2010-07-01

We describe a new pattern of upper limb injury: a combination of fractures of both radius and ulna, with a rare type of trans-scaphoid transcapitate transhamate greater arc injury of the wrist and fractures of metacarpals, managed successfully.

Carpal and Forearm Kinematics During a Simulated Hammering Task

2010-07-01

Purpose: Hammering is a functional task in which the wrist generally follows a path of motion from a position of combined radial deviation and extension to combined ulnar deviation and flexion, colloquially referred to as a dart thrower's motion. The purpose of this study was to measure wrist and forearm motion and scaphoid and lunate kinematics during a simulated hammering task. We hypothesized that the wrist follows an oblique path from radial extension to ulnar flexion and that there would be minimal radiocarpal motion during the hammering task.Methods: Thirteen healthy volunteers consented to have their wrist and distal forearm imaged with computed tomography at 5 positions while performing a simulated hammering task. The kinematics of the carpus and distal radioulnar joint were calculated using established markerless bone registration methods. The path of wrist motion was described relative to the sagittal plane. Forearm rotation and radioscaphoid and radiolunate motion were computed as a function of wrist position.Results: All volunteers performed the simulated hammering task using a path of wrist motion from radial extension to ulnar flexion that was oriented an average of 41° ± 3° from the sagittal plane. These paths did not pass through the anatomic neutral wrist position; rather, they passed through a neutral hammering position, which was offset by 36° ± 8° in extension. Rotations of the scaphoid and lunate were not minimal but averaged 40% and 41%, respectively, of total wrist motion. The range of forearm pronation-supination during the task averaged 12° ± 8°.Conclusions: The simulated hammering task was performed using a wrist motion that followed a coupled path of motion, from extension and radial deviation to flexion and ulnar deviation. Scaphoid and lunate rotations were greatly reduced, but not minimized, compared with rotations during pure wrist flexion/extension. This is likely because an extended wrist position was maintained throughout the entire task studied.

Oblique Pedicled Paraumbilical Perforator–Based Flap for Reconstruction of Complex Proximal and Mid-Forearm Defects: A Report of Two Cases

Kristina D. O'Shaughnessy, Vinay Rawlani, John B. Hijjawi, Gregory A. Dumanian — 2010-06-14

Reconstruction of complex proximal and mid-forearm wounds can be challenging. Free tissue transfer might not be feasible in certain patients or at institutions lacking microsurgical expertise and equipment. Traditional pedicled flaps are either insufficient in length to reach more proximal forearm defects or are used sparingly due to donor site complications and extremity stiffness. We present a novel technique to reconstruct forearm defects using the oblique pedicled paraumbilical perforator (PUP) based flap. This flap is simple to harvest, has low donor site morbidity, and allows elbow and shoulder range of motion during the interval between flap transfer and pedicle division.

Surgical Treatment of Partial Distal Biceps Tendon Ruptures

M. Shane Frazier, Matthew J. Boardman, Maureen Westland, Joseph E. Imbriglia — 2010-07-01

Purpose: To demonstrate that surgical repair of partial distal biceps tendon ruptures allows return of supination and flexion strength nearly equal to the contralateral side without compromising range of motion.Methods: We performed a retrospective study of 17 patients with unilateral partial biceps tendon ruptures who underwent surgical repair between 2003 and 2009, and who returned for further evaluation and strength testing. The follow-up examination included questionnaires, x-rays, strength testing, and range of motion with comparison to the opposite side. We used the Baltimore Therapeutic Equipment work simulator to objectively test isometric and dynamic elbow flexion and forearm supination strength of both extremities.Results: A total of 17 patients returned for additional testing, 14 of whom had failed nonsurgical treatment. One patient had asymptomatic heterotopic ossification. Two patients reported mild lateral antebrachial cutaneous nerve dysesthesias. There was one partial re-rupture 4 years after the original surgery. The second repair consisted of suture anchor fixation; 15 months after re-repair, the patient remains asymptomatic. Average postoperative Disabilities of the Arm, Shoulder, and Hand score was 9 (range, 0–33). One patient had limited pronation (50° degrees). The average isometric and dynamic elbow flexion was 3% and 11% stronger, respectively, compared with the opposite side. Average isometric supination was 6% and average dynamic supination was 10% weaker.Conclusions: After surgical treatment of partial distal biceps tendon tears, most patients achieved good return of strength with full motion. Surgical treatment of partial distal biceps tendon tears is a viable option after failed nonsurgical treatment.Type of study/level of evidence: Therapeutic IV.

Resection of Heterotopic Ossification of the Elbow: A Comparison of Ankylosis and Partial Restriction

2010-06-14

Purpose: This study tests the hypothesis that the results of release of elbow stiffness related to heterotopic ossification (HO) are comparable whether there is partial or complete restriction (ankylosis) of flexion and extension.Methods: Eighteen patients who had surgical release of complete bony ankylosis between the humerus and ulna were retrospectively compared to 27 matched patients who had surgical release of partial restriction of elbow flexion and extension related to HO. Patients were evaluated a minimum of 10 months after surgery, using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Broberg and Morrey rating system.Results: An average of 22 months after surgery (range, 10 to 62 mo), the arc of flexion and extension averaged 95° in the ankylosis cohort and 93° in the partial HO cohort. Forearm rotation averaged 131° versus 134°; the mean Disabilities of the Arm, Shoulder, and Hand score was 28 versus 30 points; and the mean Broberg and Morrey score was 81 versus 84 points, respectively.Conclusions: After controlling for other factors, patients with elbow stiffness related to HO can recover comparable motion after surgical release at short-term follow-up whether they have complete ankylosis or only partial restriction of motion.Type of study/level of evidence: Therapeutic III.

Articular Surface Area of the Coronoid Process and Radial Head in Elbow Extension: Surface Ratio in Cadavers and a Computed Tomography Study In Vivo

2010-07-01

Purpose: To quantify the articular surface area ratio of the radial head to the coronoid process to gain a better understanding of the stress distribution across these articulations and possibly to explain the patterns of osteoarthritis that are commonly seen in the elbow.Methods: Thirty cadaveric elbows were harvested and dissected to allow measurement of the radial head and coronoid process articular surfaces. The articular surface areas were measured using the Image J program (National Institutes of Health, Chicago, IL). Twelve men were recruited for this study, and all received a computed tomography (CT) scan of the elbow. A 3-dimensional image of the proximal radioulnar articular surface was created using volume rendering. All specimens were measured 3 times by 2 observers.Results: In the cadaveric measurements, the mean area of the radial head articular fossa was 247.3 ± 52.6 mm2 (mean ± SD). The mean area of the medial facet of the coronoid process was 232.29 ± 36.5 mm2, and the mean area of the lateral facet was 141.9 ± 33.3 mm2. The articular surface area ratio of radial head to coronoid process was 1:1.5. In the CT measurement, the mean area of the radial head articular fossa was 258.9 ± 26.3 mm2. The mean area of the coronoid process articular surface was 376.9 ± 37.0 mm2. The articular surface area ratio of radial head to coronoid process was 1:1.46.Conclusions: The ratio of articular surface area of radial head to coronoid process is 1:1.51 in cadavers and 1:1.46 using a CT in vivo, which is the reverse of the reported force transmission ratio across the elbow joint.

Elbow Instability Associated With Bicolumnar Fracture of the Distal Humerus: Report of Three Cases

Huangling T. Lu, Thierry G. Guitton, John T. Capo, David Ring — 2010-07-01

Ulnohumeral subluxation or dislocation is rare after open reduction and internal fixation of a bicolumnar fracture of the distal humerus. We report 3 patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle contributed to postoperative instability after open reduction and internal fixation of a fracture of the distal humerus. This may be due to either unrecognized ligament injury or iatrogenic injury during surgical dissection.

Osseocutaneous Integration of an Intraosseous Transcutaneous Amputation Prosthesis Implant Used for Reconstruction of a Transhumeral Amputee: Case Report

Norbert V. Kang, Catherine Pendegrass, Linda Marks, Gordon Blunn — 2010-06-14

Exoprosthetic replacement with an artificial limb is the main option for reconstruction after traumatic amputation of an upper limb. Direct skeletal attachment using an osseointegrated implant improves the ease of fixation of the exoprosthesis to the amputation stump. We now report the use of an intraosseous transcutaneous amputation prosthesis that is designed to achieve osseocutaneous integration. Osseocutaneous integration differs from osseointegration because the aim is to create a stable interface among the implant, the bone, and the soft tissues. This reduces the risk of soft tissue infection and troublesome discharge, which are problems encountered with current osseointegrated implants that focus largely on the bone–implant interface. We describe our experience with an intraosseous transcutaneous amputation prosthesis in a case of transhumeral amputation with 2 years of follow-up.

Stratification of the Risk Factors of Community-Acquired Methicillin-Resistant Staphylococcus Aureus Hand Infection

Ali Nourbakhsh, Sotirios Papafragkou, Lisa L. Dever, John Capo, Virak Tan — 2010-06-18

Purpose: Several recent studies showed an increase in methicillin-resistant Staphylococcus aureus (MRSA) hand infections. The purpose of this study was to determine the prevalence of community-acquired MRSA hand infections in an urban setting and to determine independent risk factors for such infections.Methods: A retrospective chart review of patients with hand infections was performed from 2002 to 2009. Those with community-acquired hand infections who had surgical irrigation and debridement and intraoperative culture were entered into the study. Patient demographics—including age and gender; mechanism of injury; infection risk factors (diabetes, chronic hepatitis, intravenous intravenousdrug use, and immune-compromised conditions); place of residence/housing status; history of hospitalization, prior antibiotics use and surgery; and culture results, erythrocyte sedimentation rate, C-reactive protein, and white blood cell count—were extracted from the medical records. Regression analyses were performed to identify significant risk factors for MRSA infection.Results: A total of 102 patients met our inclusion criteria. The MRSA organism was identified in 32 patients. In the analysis of all the potential risk factors, only intravenous drug use showed significant correlation with MRSA infection.Conclusions: In our patients, only intravenous drug use correlated with community-acquired MRSA hand infections. Patient education about intravenous drug use and empiric treatment with MRSA-appropriate antibiotics for intravenous drug users presenting with hand infections are recommended.Type of study/level of evidence: Prognostic IV.

Mycobacterium abscessus Hand Infections in Immunocompetent Fish Handlers: Case Report

Gavin C.W. Kang, Aaron W.T. Gan, Andrew Yam, Agnes B.H. Tan, Shian Chao Tay — 2010-07-01

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.

Evaluation of Function and Appearance of Adults With Untreated Triphalangeal Thumbs

J. Michiel Zuidam, Marjolein de Kraker, Ruud W. Selles, Steven E.R. Hovius — 2010-06-21

Purpose: Triphalangeal thumb is a congenital malformation characterized by an additional phalanx of the thumb. Although surgical treatment of this condition is common practice, in the past this was not generally advised. Therefore, a population with an untreated triphalangeal thumb is still present. The purpose of this study is to compare function and appearance of adults with an untreated triphalangeal thumb to a normal population.Methods: Twelve adults with 23 hands with an untreated triphalangeal thumb, unilateral or bilateral, were examined using objective measurements (thumb movement, joint instability, pain, and strength) and subjective measurements (visual analog scale; Disabilities of the Arm, Shoulder, and Hand questionnaire; and Short Form 36 health survey).Results: Objective measurements showed no limitations in range of motion or in grip and pinch strength. No joint instability was found in the interphalangeal joints. Five thumbs had instability in the metacarpophalangeal joint. Strength of the thumb in anteposition was diminished to 64% compared to a normal population. Opposition was diminished to 62%, and metacarpophalangeal joint flexion strength was diminished to 61%. The patients scored lower compared to a normal population for the domain of social functioning in the Medical Outcome Study 36-item short form health survey; the Disabilities of the Arm, Shoulder, and Hand questionnaire showed no differences. Visual analog scale scores for appearance of the thumb were scored low (2.2 of 10) by the adults, in contrast to visual analog scale scores for function (7.7).Conclusions: The examined group of adults with an untreated triphalangeal thumb had adequate thumb movement. Thumb strength was diminished for all specific thumb functions (anteposition, opposition, and thumb flexion), as low as 55%, compared to normal controls. Self-rated scores indicate that patients perceived their functionality as good. The appearance, however, was rated much lower, implying a dislike of the thumb by the patients. This indicates that the main impact of an untreated triphalangeal thumb in daily functioning might not be the diminished function but rather the dissimilar appearance.Type of study/level of evidence: Therapeutic IV.

Effects of Synovial Interposition on Healing in a Canine Tendon Explant Culture Model

Jun Ikeda, Chunfeng Zhao, Steven L. Moran, Kai-Nan An, Peter C. Amadio — 2010-06-14

Purpose: To investigate whether synovium interposition between repaired tendon ends can integrate into the tendon repair and improve tendon healing strength in a canine tendon explant culture model.Methods: We used 80 flexor digitorum profundus tendons from 10 mixed-breed dogs for this study. The flexor digitorum profundus tendons were assigned to 2 groups: repaired tendons with synovium implanted between the cut tendon ends and repaired tendons without any implantation between the tendon ends. The repaired tendons were cultured for either 2 or 4 weeks and then assessed mechanically for rupture strength and histology.Results: The strength of the repaired tendons with the synovium interposition was significantly higher (p < .001) than the repaired tendons without interposition at both 2 and 4 weeks. The strength of the repaired tendons at 4 weeks was significantly higher than that at 2 weeks in both groups.Conclusions: Interpositional synovial grafts have the potential to accelerate tendon healing when they are implanted at the repair site. The exact mechanism of this effect remains to be elucidated.

Nickel-Titanium Wire in Circumferential Suture of a Flexor Tendon Repair: A Comparison to Polypropylene

T. Karjalainen, M. He, A.K.S. Chong, A.Y.T. Lim, J. Ryhanen — 2010-07-01

Purpose: Nickel-titanium (NiTi) has been proposed as an alternative material for flexor tendon core suture. To our knowledge, its suitability as a circumferential suture of flexor tendon repair has not been investigated before. The purpose of this ex vivo study was to investigate the biomechanical properties of NiTi circumferential repairs and to compare them with commonly used polypropylene.Methods: Forty porcine flexor tendons were cut and repaired by simple running or interlocking mattress technique using 100 μm NiTi wire or 6-0 polypropylene.Results: The NiTi circumferential repairs showed superior stiffness, gap resistance, and load to failure when compared to polypropylene repairs with both techniques.Conclusions: Nickel-titanium wire seems to be a potential material for circumferential repair of flexor tendons.

The Effects of Core Suture Purchase on the Biomechanical Characteristics of a Multistrand Locking Flexor Tendon Repair: A Cadaveric Study

2010-06-14

Purpose: To determine the effects of suture purchase on work of flexion (WOF), 2-mm gap force, and load to failure on the combination cross-locked cruciate–interlocking horizontal mattress (CLC-IHM) flexor tendon repair in zone II.Methods: A total of 33 fresh-frozen cadaveric fingers were mounted in a custom jig, and the flexor digitorum profundus of each finger was fixed to the mobile arm of a tensile strength machine. Initial measurements of WOF were obtained. Each tendon was repaired with the CLC core suture, randomly assigned to placement of 3, 5, 7 or 10 mm from the cut edge of the tendon, and completed with the IHM circumferential suture. After the repair was completed, measurements of WOF were repeated. Each finger was cycled 1000 times. After each 250 cycles, gapping was recorded, and WOF was measured again. Change in WOF (WOF after repair − WOF of intact tendon) was calculated. Tendons were then dissected from the fingers and linearly tested for 2-mm gap force and ultimate load to failure.Results: The group repaired at 10 mm had the lowest percent increase in WOF (5.2%), the highest 2-mm gap force (89.8 N), and the highest ultimate load to failure (111.5 N). The group repaired at 3 mm had the highest percent increase in WOF (22.1%), the lowest 2-mm gap force (54.6 N), and the lowest ultimate load to failure (84.6 N).Conclusions: A 10-mm suture purchase is the recommended distance for optimal performance for the CLC-IHM combination repair method. This method with a 10-mm suture purchase has a low increase in WOF, high strength, and high resistance to gapping, and it should be strong enough to tolerate early motion.

Genome-Wide High-Resolution Screening in Dupuytren's Disease Reveals Common Regions of DNA Copy Number Alterations

2010-06-21

Purpose: Dupuytren's disease (DD) is a familial disorder with a high genetic susceptibility in white people; however, its etiopathogenesis remains unknown. Previous comparative genomic hybridization studies using lower-resolution, 44-k oligonucleotide-based arrays revealed no copy number variation (CNV) changes in DD. In this study, we used a higher-resolution genome-wide screening (next-generation microarrays) comprising 963,331 human sequences (3 kb spacing between probes) for whole genome DNA variation analysis. The objective was to detect cryptic chromosomal imbalances in DD.Methods: Agilent SurePrint G3 microarrays, one million format (Agilent Technologies, Santa Clara, CA), were used to detect CNV regions (CNVRs) in DNA extracted from nodules of 4 white men with DD (age, 69 ± 4 y). Reference samples were from the DNA of 10 men who served as control patients. Copy number variations that were common to greater than 3 assessed DD individuals (p < .05) were selected as candidate loci for DD etiology. In addition, quantitative polymerase chain reactions (qPCR) assays were designed for selected CNVRs on DNA from 13 DD patients and 11 control patients. Independent t-tests and Fisher's exact tests were carried out for statistical analysis.Results: Three novel CNVs previously unreported in the phenotypically normal population were detected in 3 DD cases, located at 10q22, 16p12.1, and 17p12. Nine polymorphic CNVRs potentially associated with DD were determined using our strategic selection criteria, locating to chromosomes 1q31, 6p21, 7p14, 8p11, 12p13, 14q11, 17q21 and 20p13. More than 3 of the DD cases tested had a CNVR located to a small region on 6p21 and 4 CNVRs within 6p21–22 of the human leukocyte antigen (HLA) genes.Conclusions: Three novel copy number alterations were observed in 3 unrelated patients with sporadic (no known family history) DD. Nine polymorphic CNVRs were found to be common among the DD cases. These variants might contain genes involved in DD formation, indicating that important gene networks expressed within the palmar fascia might contribute to genetic susceptibility of DD.

Nodular Fasciitis of the Finger and Hand: Case Report

2010-07-01

Nodular fasciitis rarely arises in the hand. We describe 4 cases that were histologically diagnosed as nodular fasciitis on biopsy specimens arising in the hands. The masses of 2 patients were excised due to rapid growth. Both of these patients had no recurrence. The other 2 patients were followed without surgical excision, and the masses partially regressed without functional impairment.

Journal CME Instructions

2010-07-01

Osteochondritis Dissecans of the Elbow

Neal C. Chen — 2010-06-14

A 14-year-old boy, a baseball pitcher, presents with a history of elbow pain. Physical examination demonstrates lateral elbow tenderness around the radiocapitellar joint and a flexion contracture of 20°. He has rested for 6 months and done exercises with physical therapy supervision but has not had improvement of his symptoms. Radiographs and magnetic resonance imaging demonstrate a focal osteochondral defect (OCD) with a displaced fragment. The osteochondral defect is surrounded by a healthy rim of cartilage. At the time of surgery, the loose fragment is small, has no bony attachment, and cannot be repaired.

Proximal Interphalangeal Joint Prosthetic Arthroplasty

Thomas M. Sweets, Peter J. Stern — 2010-07-01

A 63-year-old woman presents with a 4-year history of pain, swelling, and progressive limitation in range of motion of the proximal interphalangeal (PIP) joints of the index, middle, and ring fingers in her dominant hand. She reports increasing difficulty turning keys and door knobs and holding a frying pan. She has used heat application, acupuncture, and nonsteroidal anti-inflammatory medications, with limited relief, and she has received intra-articular corticosteroid injections from her rheumatologist. She requests information regarding surgical treatment options. On examination, we find that she has prominent Bouchard's nodes and fusiform swelling of the PIP joints of the affected fingers. There is pain with flexion, and she cannot touch her palm. The affected fingers also lack 20° of extension. Grip and pinch strength are reduced compared to her contralateral hand. Radiographs confirm osteoarthritis of the index, long, and ring finger PIP joints ().

Journal CME Questions

2010-07-01

Extensor Tendon Centralization at the Metacarpophalangeal Joint: Surgical Technique

Lana Kang, Michelle G. Carlson — 2010-07-01

Injury to the extensor hood at the level of the dorsal metacarpophalangeal joint with instability and subluxation of the extensor tendon might require surgical treatment after failing conservative methods. Surgical techniques for chronic injuries have used local tissue or nearby tendon slips as grafts for tendon realignment, with or without soft tissue release and imbrication. Here we present a technique that creates a bone tunnel for a graft that is sutured upon itself and effectively creates a new pulley.

Description and Outcomes of a New Technique for Thumb Basal Joint Arthroplasty

Douglas M. Sammer, Peter C. Amadio — 2010-07-01

Purpose: Many surgeries have been described for thumb basal joint arthroplasty, but none is clearly superior to the others. The purposes of this study were to describe a simple technique for trapeziectomy and ligament reconstruction, and to determine its objective and subjective outcomes.Methods: The surgical technique involves trapeziectomy, interposition of tissue, and abductor pollicis longus ligament reconstruction around the extensor carpi radialis longus tendon through a single incision. A retrospective chart review was performed on 48 patients who had undergone this surgery over an 11-year period by a single surgeon.Results: At a minimum of 8 months' follow-up, grip had improved from 71% of contralateral strength to 93% of contralateral strength (p = .02), an increase of 32%. Appositional pinch had improved from 66% of contralateral strength to 98% of contralateral strength (p = .03), an increase of 49%. Radial abduction did not change to a statistically significant degree. Trapezial space ratio measured 0.44 preoperatively and 0.31 postoperatively (p < .01), a decrease of 30%. Of 42 patients, 27 had little or no pain and an additional 11 had improved pain postoperatively. Of 41 patients, 26 were very or extremely satisfied and 13 were satisfied with the outcome of the surgery.Conclusions: The described technique for trapeziectomy and ligament reconstruction is easy to perform, has a number of potential advantages over other arthroplasty techniques, and has similar short-term outcomes compared with ligament reconstruction and tendon interposition.

Aromatase Inhibitors and Their Side Effects: What Hand Surgeons Should Know

Bryan J. Loeffler, R. Glenn Gaston — 2010-02-25

Aromatase inhibitors are gradually replacing tamoxifen as the gold standard in the adjuvant treatment of hormone-receptor–positive breast cancer in postmenopausal women. Inhibiting the aromatase enzyme prevents androgen conversion to estrogen, which lowers estrogen-modulated stimulation of estrogen-responsive breast cancers.

Journal CME Questions

2010-07-01

Sentinel Lymph Node Biopsy for Tumors of the Hand and Wrist

Daniel W. Suver, Jeffrey B. Friedrich — 2010-02-22

Since its introduction and widespread adoption in the 1990s, sentinel lymph node biopsy has become the standard method of sampling regional lymph node basins in early-stage cutaneous melanoma. Although it can be used for a variety of hand and wrist tumors, its predominant use in this area is for melanoma, given the rarity of other applicable tumor types.

Shoulder Tendon Transfer Options for Adult Patients With Brachial Plexus Injury

Bassem Elhassan, Alan Bishop, Alexander Shin, Robert Spinner — 2010-07-01

Enhancement of upper-extremity function, specifically shoulder function, after brachial plexus injury requires a good understanding of nerve repair and transfer, with their expected outcome, as well as shoulder anatomy and biomechanics enabling the treating surgeon to use available functioning muscles around the shoulder for transfer, to improve shoulder function. Surgical treatment should address painful shoulder subluxation in addition to improvement of function. The literature focuses on improving shoulder abduction, but improving shoulder external rotation should take priority because this function, even if isolated, will allow patients to position their hand in front of their body. With a functional elbow and hand, patients will be able to do most activities of daily living. The lower trapezius has been shown to be a good transfer to restore external rotation of the shoulder. Other parts of the trapezius, levator scapulae, rhomboids, and, when available, the latissimus dorsi, pectoralis major, teres major, biceps, triceps, and serratus anterior muscles can all be used to replace the rotator cuff and deltoid muscle function. To optimize the results, a close working relationship is required between surgeons reconstructing brachial plexus injury and shoulder specialists.

Traumatic Elbow Instability

Mohamed H. Ebrahimzadeh, Husain Amadzadeh-Chabock, David Ring — 2010-07-01

Trauma can render the elbow unstable via a combination of bone and ligament injuries. Some of these injuries feature subluxation rather than dislocation of the elbow. Effective treatment centers on restoring enough of the bony and ligamentous structures to keep the elbow in joint so that recovery can proceed as for a simple elbow dislocation. Recognition of distinct patterns of injury can help determine the structures injured and the best methods for repairing them.

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2010-07-01

Erratum

2010-07-01

In the article by Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin AY, which appeared in the April 2010 issue of the Journal (“Current Concepts of the Treatment of Adult Brachial Plexus Injuries,” Vol. 35A, No. 4, pp. 678–688), Dr. Kakar's name was misspelled. The correct spelling of his name is Sanjeev Kakar.

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2010-07-01

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2010-07-01

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2010-07-01

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Shoulder Tendon Transfer Options for Adult Patients With Brachial Plexus Injury

Traumatic Elbow Instability

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