Journal of Hand Surgery RSS feed: Current Issue. The Journal of Hand Surgery publishes original, peer-reviewed articles related to the diagnosis, treatment, and pathophysiology of diseases and conditions of the upper extremity; these include both clinical and basic science studies, along with case reports. Special features include Clinical Perspective and History of Hand Surgery articles, Comprehensive Review manuscripts, and Surgical Technique articles that provide an overview of hand surgery, technical aspects of surgery, and current controversial topics. Beginning in January 2006, the Journal of Hand Surgery will incorporate the Journal of the American Society for Surgery of the Hand . http://www.jhandsurg.org/?rss=yesElsevier Inc.en © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved. Journal of Hand Surgery0363-5023372February 2012 © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.jhandsurg.org/article/PIIS036350231101375X/abstract?rss=yes Purpose: Cellular apoptosis might be an important molecular event in the middle or late healing periods of intrasynovial tendons, but this has not been studied. We aimed to investigate cellular apoptosis and corresponding cellular proliferation in the middle and late healing stages of intrasynovial tendons. Methods: The flexor digitorum profundus tendons of 48 long toes (24 chickens) were completely transected within the sheath region and were repaired surgically. At days 28, 42, 56, and 84 after surgery, tendons were harvested and sectioned. In situ terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay was performed to detect apoptotic cells. The sections were stained immunofluorescently with antibodies to proliferating cell nuclear antigen to assess proliferation and to Bcl-2 (an anti-apoptotic protein). Positively stained tenocytes were counted, and their distributional differences were verified in 3-dimensional images. Results: The repaired intrasynovial tendons exhibited generally greater apoptosis in the surface region than in the core. The differences were more remarkable in the extended region than in the junction region of the cut tendon. At the core of the junction site, apoptosis of tenocytes was pronounced at all time points, but it was less severe at the core of the extended region. The proliferating cell nuclear antigen–positive and Bcl-2–positive tenocytes decreased significantly and continually at days 28, 42, and 56, respectively; these tenocytes were at a minimum at days 56 and 84. Conclusions: Apoptotic changes of tenocytes are most marked in the surface region and in the junction region of the healing tendon in the middle and late healing stages. Apoptosis in the core is less dramatic compared to that in the surface in the extended tendon regions. Cellular proliferation declines drastically and is minimal at days 56 and 84. Clinical relevance: Tenocyte apoptosis in the middle and late stages might be an important event contributing to intrasynovial tendon remodeling, which affects the healing strength and formation of adhesions. Cellular Apoptosis and Proliferation in the Middle and Late Intrasynovial Tendon Healing PeriodsYa Fang Wu, You Lang Zhou, Wei Feng Mao, Bella Avanessian, Paul Y. Liu, Jin Bo Tang10.1016/j.jhsa.2011.10.049Journal of Hand Surgery 37, 2 (2012)2012-01-03Journal of Hand Surgery2012-01-03372S0363-5023(11)X0015-1Scientific Articles209216http://www.jhandsurg.org/article/PIIS0363502311013657/abstract?rss=yes Purpose: New, stronger suture materials have been introduced for flexor tendon surgery. The advantage of these materials can be lost if the suture loop pulls out from the tendon. The aim of this study was to compare the ability of various locking loops to grip the tendon. Methods: We inserted 4 different standard and 2 experimental locking loops with 200-μm nitinol wire into human cadaveric flexor digitorum profundus tendons. The standard loops were: group 1, cruciate; group 2, Pennington modified Kessler; group 3, cross-stitch; and group 4, Lim-Tsai. The experimental loops were: group 5, a composition of Pennington modified Kessler with a cross-stitch loop; and group 6, a locking Kessler type of loop with a superficial transverse component. We loaded the loops until failure. We recorded the pull-out strength and stiffness and documented failure mechanisms during the pull-out test. Results: The cruciate loop had the weakest holding capacity, 20 N, which was significantly less than in groups 2 to 6. The cross-stitch loop, Lim-Tsai loop, and modified Kessler loop performed similarly (36 N, 37 N, and 39 N, respectively). The experimental loops had the highest pull-out strength (group 5, 59 N; and group 6, 60 N, both significantly greater than groups 1 to 4). The mode of failure was pull-out for all of the standard loops and 7 of the experimental loops. Of 20 experimental loops, 13 failed by suture rupture. Conclusions: The 2 experimental loop configurations demonstrated higher pull-out strength and may have advantages when used with newer and stronger suture materials. The number of the locking components in the loops and the way the tension is transmitted to the tendon fibrils explain the results. Clinical relevance: The loops presented in this study and that grip the tendon better may be useful with new materials that have high tensile strength. An Analysis of the Pull-Out Strength of 6 Suture Loop Configurations in Flexor TendonsT. Karjalainen, M. He, A.K.S. Chong, A.Y.T. Lim, J. Ryhanen10.1016/j.jhsa.2011.10.039Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Scientific Articles217223http://www.jhandsurg.org/article/PIIS036350231101286X/abstract?rss=yes Purpose: We report on a combined repair of multiple annular pulley tears using 1 continuous palmaris longus tendon graft to restore strength and function. Methods: We treated 6 rock climbers with grade 4 pulley injuries (multiple pulley injuries) using the combined repair technique and re-evaluated them after a mean of 28 months. Results: All patients had excellent Buck-Gramcko scores; the functional outcome was good in 4, satisfactory in 1, and fair in 1. The sport-specific outcome was excellent in 5 and satisfactory in 1. Proximal interphalangeal joint flexion deficit slightly increased in 1 patient and remained the same in the other 5. Climbing level after the injury was the same as before in 4 and decreased slightly in 2 climbers. Conclusions: The technique is effective with good results and has since become our standard treatment. Nevertheless, it is limited in patients with flexion contracture of the proximal interphalangeal joint. Type of study/level of evidence: Therapeutic III. Surgical Repair of Multiple Pulley Injuries—Evaluation of a New Combined Pulley RepairV. Schöffl, T. Küpper, J. Hartmann, I. Schöffl10.1016/j.jhsa.2011.10.008Journal of Hand Surgery 37, 2 (2012)2012-01-03Journal of Hand Surgery2012-01-03372S0363-5023(11)X0015-1Scientific Articles224230http://www.jhandsurg.org/article/PIIS0363502311012822/abstract?rss=yes Purpose: The optimum number of cross-stitches in modified Becker repair for extensor tendon injury is not known. The purpose of this study was to compare the biomechanical characteristics of 1, 2, and 3 cross-stitches in modified Becker extensor repairs. Methods: We used 8 fresh-frozen cadaveric hands (24 fingers). We exposed extensor tendons of the index, middle, and ring fingers over the proximal phalanx, cut them transversely at the mid-portion of zone IV (proximal phalanx), and repaired them in situ with a modified Becker technique with 1, 2, or 3 cross-stitches using 4-0 braided suture. We randomized the tendons within each hand for the number of cross-stitches. Stiffness, yield load, ultimate load, energy absorbed, and gap formation were measured. After a 5 N preload, each repair was cyclically loaded from 5 to 25 N for 30 cycles and from 5 to 35 N for 30 cycles at a rate of 20 mm/min to simulate loads during postoperative rehabilitation. After cyclic loading, the specimens were loaded to failure. Results: The repair with 1 cross-stitch showed superior gap resistance and stiffness during cyclic loading compared with 2 and 3 cross-stitches. One cross-stitch also resulted in higher stiffness and yield strength in load to failure testing. However, 3 cross-stitch configurations displayed higher ultimate strength. All repairs failed by knot slippage. Conclusions: A modified Becker extensor tendon repair with 1 cross-stitch provides superior mechanical properties for loads seen with postoperative rehabilitation compared with 2 and 3 cross-stitches for similar loads. Clinical relevance: These findings may lead to reduced operative time and decreased tendon damage with superior results. The Effect of the Number of Cross-Stitches on the Biomechanical Properties of the Modified Becker Extensor Tendon RepairKyung-Chil Chung, Bong Jae Jun, Michelle H. McGarry, Thay Q. Lee10.1016/j.jhsa.2011.10.004Journal of Hand Surgery 37, 2 (2012)2011-11-28Journal of Hand Surgery2011-11-28372S0363-5023(11)X0015-1Scientific Articles231236http://www.jhandsurg.org/article/PIIS0363502311013815/abstract?rss=yes Purpose: Some patients report a transient increase in pain the day after a corticosteroid injection. We investigated factors associated with greater pain during and the day after a corticosteroid injection for idiopathic trigger finger. Methods: A total of 100 patients with trigger finger completed questionnaires measuring heightened illness concern, catastrophic thinking, depression, perceived health, expected pain, pain with injection, and pain the day after injection. We performed bivariate analysis to determine variables associated with pain with injection, next-day pain, and next-day pain greater than 4 points on an 11-point ordinal scale. We entered variables with a significant correlation into multivariable linear regression models. Results: The average pain with injection and the day after injection were 4.3 (SD 2.8) and 1.8 (SD 2.0), respectively. Expected pain, heightened illness concern, catastrophic thinking, depression, physician, and gender correlated with pain with injection. A multivariable regression model conducted in backward stepwise fashion demonstrated that physician, depression, expected pain, and female gender explained 28% of the variance in pain with injection. Pain with injection was the only significant predictor of next-day pain and pain greater than 4 points the day after injection. Conclusions: Our data suggest that psychosocial factors are the strongest correlates of pain with corticosteroid injection, but a large portion of the variability remains unexplained. Future research will investigate cognitive/behavioral methods for decreasing pain with injection. Type of study/level of evidence: Prognostic I. Predictors of Pain During and the Day After Corticosteroid Injection for Idiopathic Trigger FingerAbhishek Julka, Ana-Maria Vranceanu, Apurva S. Shah, Frank Peters, David Ring10.1016/j.jhsa.2011.10.055Journal of Hand Surgery 37, 2 (2012)2011-12-23Journal of Hand Surgery2011-12-23372S0363-5023(11)X0015-1Scientific Articles237242http://www.jhandsurg.org/article/PIIS0363502311013645/abstract?rss=yes Purpose: To compare the effectiveness of 2 splint designs in treating trigger finger. Methods: This prospective, randomized study of 30 subjects evaluated splinting efficacy for trigger finger, comparing 2 splint designs: a custom metacarpophalangeal (MCP) joint blocking splint and a distal interphalangeal (DIP) joint blocking splint. We evaluated range of motion, grip strength, severity and frequency of triggering, functional impact, and performance measure scores. Subjects recorded frequency of splint use, splint comfort, and functional impact of the splint. We undertook statistical analysis of splint effectiveness before and after treatment and of differences between the 2 splint groups. We evaluated qualitative data to identify trends in subjective preference toward splint design. Results: Both groups showed quick and significant improvement of triggering; however, the MCP joint blocking splint was successful in providing at least partial relief of triggering and pain in 10 of 13 trigger finger subjects, whereas the DIP joint blocking splint provided at least partial relief of triggering and pain in 7 of 15 subjects after 6 weeks of treatment. Data showed statistically significant improvement in both groups at 6 weeks, which was maintained in a minority of the cohort for 1 year. There was little difference between the 2 splint groups for impact on function. Subjects who wore the MCP joint blocking splint reported higher rates of comfort compared with those who wore the DIP joint blocking splint. Conclusions: Subject comfort with the MCP joint blocking splint allowed for longer periods of usage. Selection of a splint design depends on clinical presentation, vocation, and leisure activities. Initiating conservative treatment with the MCP joint blocking splint has value for patients with trigger finger and positive outcomes in 77% of subjects, whereas use of the DIP joint splint was effective in about half of subjects. Type of study/level of evidence: Therapeutic I. Trigger Finger Treatment: A Comparison of 2 Splint DesignsKauser Tarbhai, Susan Hannah, Herbert P. von Schroeder10.1016/j.jhsa.2011.10.038Journal of Hand Surgery 37, 2 (2012)2011-12-22Journal of Hand Surgery2011-12-22372S0363-5023(11)X0015-1Scientific Articles243249.e1http://www.jhandsurg.org/article/PIIS0363502311013773/abstract?rss=yes Purpose: To determine the interobserver agreement and diagnostic performance characteristics of computed tomography (CT) for determining union of scaphoid waist fractures. Methods: A total of 59 orthopedic and trauma surgeons rated for union a set of 30 sagittal CT scans of 30 scaphoid waist fractures. Of these fractures, 20 were treated nonoperatively, were imaged between 6 and 10 weeks after injury, and were known to have eventually achieved union. Ten were operatively confirmed to be ununited. We rated each scan as united or ununited using a Web-based rating application. We assessed interobserver reliability using Siegel's multirater Kappa. We calculated diagnostic performance characteristics using Bayesian formulas. Results: The interobserver agreement among 59 raters was substantial. The average sensitivity, specificity, and accuracy of diagnosing union of scaphoid waist fractures on sagittal CT scans were 78%, 96%, and 84%, respectively. Assuming a 90% prevalence of fracture union of the scaphoid, the positive predictive value of a diagnosis of union on sagittal CT scan was 0.99 and the negative predictive value was 0.41. Conclusions: Our results suggest that CT scans are accurate and reliable for diagnosis of union but inadequate for ruling out nonunion of scaphoid waist fractures between 6 and 10 weeks after injury. Type of study/level of evidence: Diagnostic III. Interobserver Reliability of Computed Tomography to Diagnose Scaphoid Waist Fracture UnionGeert A. Buijze, Mathieu M.E. Wijffels, Thierry G. Guitton, Ruby Grewal, C. Niek van Dijk, David Ring, The Science of Variation Group10.1016/j.jhsa.2011.10.051Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Scientific Articles250254http://www.jhandsurg.org/article/PIIS0363502311012998/abstract?rss=yes Purpose: To compare the compression strength and pull-apart resistance of 5 single-piece scaphoid bone compression screws (Acutrak, Asnis, Herbert, Herbert-Whipple, and Little Grafter), with those of 2 dual-component screws (Kompressor and TwinFix). Methods: Two blocks of polyurethane foam were compressed with a screw while held in a tension test machine, with the force measured at full insertion of the screw. The 2 blocks were then pulled apart, and the maximum resistive force was measured. Results: The dual-component screws (Kompressor and TwinFix) gave greater compression force than the single-component screws, with the Kompressor screw giving statistically significantly greater compression than the TwinFix. The pull-apart resistance forces did not show such clear differences. Conclusions: The Kompressor screw achieves the greatest compressive forces and has one of the highest pull-apart forces. Clinical relevance: When compression and pull-apart resistance are considered, the Kompressor screw has advantages over other methods of scaphoid fixation. The Fixation Strength of Scaphoid Bone Screws: An In Vitro Investigation Using Polyurethane FoamLouise A. Crawford, Eric S. Powell, Ian A. Trail10.1016/j.jhsa.2011.10.021Journal of Hand Surgery 37, 2 (2012)2011-12-12Journal of Hand Surgery2011-12-12372S0363-5023(11)X0015-1Scientific Articles255260http://www.jhandsurg.org/article/PIIS0363502311012962/abstract?rss=yes Purpose: Although the end-to-side nerve repair technique has been used clinically, it has not yet produced consistent motor and sensory recovery in patients. The aim of this study was to investigate whether end-to-side double nerve grafts display more axonal regeneration compared with a single nerve graft in a rat lower limb preparation. Methods: The lower limbs of 96 Wister rats were used in experiments comparing single and double end-to-side nerve grafts. Left peroneal nerves were harvested and grafted between the right peroneal and tibial nerves. A single graft was attached end-to-side to the peroneal and tibial nerves through an epineural window (single graft group, n = 24). Two grafts were performed in the same manner in the double graft group (n = 24). The peroneal nerve was exposed in positive controls (n = 24) and no graft was performed in negative controls (n = 24). We recorded action potentials and moist weights of the left tibialis anterior muscle at each time point. Fluoro-Gold-labeled (Fluorochrome, Denver, CO) dorsal root ganglion neurons from L1 to L6 were counted using fluorescence microscopy and compared among the 4 groups. Results: In both single and double groups, the amplitude and the tibialis anterior muscle weight increased significantly compared with negative controls but remained lower than those measured in positive controls. There was no significant difference between single and double groups. In Fluoro-Gold-labeled neurons, there was also no significant difference between single and double groups. Conclusions: The study showed that regeneration of motor and sensory nerve fibers was possible using 2 end-to-side nerve grafts. However, there was no significant difference between single and double grafts. This might suggest a therapeutic limitation of nerve transplants using 2 end-to-side nerve grafts. Clinical relevance: Double end-to-side repair attracts both motor and sensory axons, and this results in a medium degree of recovery of function; however, double end-to-side nerve grafting does not appear to offer any advantage over a single end-to-side graft. Single Versus Double End-to-Side Nerve Grafts in RatsNahoko Iwakura, Seiji Ohtori, Tomonori Kenmoku, Takane Suzuki, Kazuhisa Takahashi, Kazuki Kuniyoshi10.1016/j.jhsa.2011.10.018Journal of Hand Surgery 37, 2 (2012)2011-12-12Journal of Hand Surgery2011-12-12372S0363-5023(11)X0015-1Scientific Articles261269http://www.jhandsurg.org/article/PIIS0363502311012925/abstract?rss=yes Purpose: Contralateral C7 (CC7) transfer for brachial plexus injuries (BPI) can benefit finger sensation but remains controversial regarding restoration of motor function. We report our 20-year experience using CC7 transfer for BPI, all of which had at least 4 years of follow-up. Methods: A total of 137 adult BPI patients underwent CC7 transfer from 1989 to 2006. Of these patients, 101 fulfilled the inclusion criteria for this study. A single surgeon performed all surgeries. A vascularized ulnar nerve graft, either pedicled or free, was used for CC7 elongation. The vascularized ulnar nerve graft was transferred to the median nerve (group 1, 1 target) in 55 patients, and to the median and musculocutaneous nerves (group 2, 2 targets) in 23 patients. In another 23 patients (group 3, 2 targets, 2 stages), the CC7 was transferred to the median nerve (17 patients) or to the median and musculocutaneous nerve (6 patients) during the first stage, followed by functioning free muscle transplantation for finger flexion. Results: We considered finger flexion strength greater or equal to M3 to be a successful functional result. Success rates of CC7 transfer were 55%, 39%, and 74% for groups 1, 2, and 3, respectively. In addition, the success rate for recovery of elbow flexion (strength M3 or better) in group 2 was 83%. Conclusions: In reconstruction of total brachial plexus root avulsion, the best option may be to adopt the technique of using CC7 transfer to the musculocutaneous and median nerve, followed by FFMT in the early stage (18 mo or less) for finger flexion. Such a technique can potentially improve motor recovery of elbow and finger flexion in a shorter rehabilitation period (3 to 4 y) and, more importantly, provide finger sensation to the completely paralytic limb. Type of study/level of evidence: Therapeutic II. Minimum 4-Year Follow-Up on Contralateral C7 Nerve Transfers for Brachial Plexus InjuriesDavid Chwei-Chin Chuang, Catherine Hernon10.1016/j.jhsa.2011.10.014Journal of Hand Surgery 37, 2 (2012)2011-12-15Journal of Hand Surgery2011-12-15372S0363-5023(11)X0015-1Scientific Articles270276http://www.jhandsurg.org/article/PIIS0363502311012810/abstract?rss=yes Purpose: We reviewed 18 patients who had received double free muscle transfers and wrist arthrodesis to determine the effect of the stiff wrist on digital motion and function. Methods: The patients were 15 men and 3 women with a mean age of 24 years. We determined the total active motion of the metacarpophalangeal and interphalangeal joints just before performing the arthrodesis and at final follow-up. We recorded the Disabilities of the Arm, Shoulder, and Hand functional score at the same times. Results: All of our patients showed evidence of fusion at a mean of 12 ± 2 weeks (range, 10–15 wk). The digital mean total active motion was 39° ± 21° before arthrodesis and 49° ± 25° after arthrodesis. Preoperative Disabilities of the Arm, Shoulder, and Hand scores significantly decreased after fusion. Three cases were complicated postoperatively by wound hematoma. Five patients required wrist arthrodesis hardware removal because of skin irritation. Conclusions: Wrist fusion in patients receiving double free muscle transfers resulted in improved finger range of motion and overall hand function. Type of study/level of evidence: Therapeutic IV. Role of Wrist Arthrodesis in Patients Receiving Double Free Muscle Transfers for Reconstruction Following Complete Brachial Plexus ParalysisAhmad Addosooki, Kazuteru Doi, Yasunori Hattori, Abhijeet Wahegaonkar10.1016/j.jhsa.2011.10.003Journal of Hand Surgery 37, 2 (2012)2011-12-01Journal of Hand Surgery2011-12-01372S0363-5023(11)X0015-1Scientific Articles277281http://www.jhandsurg.org/article/PIIS0363502311013669/abstract?rss=yes Purpose: To test the hypothesis that the result of steroid injection in the carpal tunnel in a patient with recurrent carpal tunnel symptoms would serve as a good predictor of the outcome of later carpal tunnel release (CTR). Methods: We conducted a retrospective review of all patients who underwent revision CTR for recurrent or persistent carpal tunnel syndrome over a 2-year period at our institution. A total of 28 wrists in 23 patients met inclusion criteria. We evaluated patients to determine whether preoperative factors or the result of injection predicted the outcome of revision CTR. We used a multivariate logistic regression analysis to predict surgical success when multiple preoperative findings were considered. Results: Of the 23 wrists that had relief from injection, 20 had symptom improvement with surgery. Although they did not reach statistical significance, the sensitivity and positive predictive value for injection alone predicted outcome of revision CTR in 87%. No patient characteristic or physical examination finding predicted successful revision CTR. Multivariate logistic regression analysis combining preoperative injection results with physical examination findings (numbness and/or motor weakness in median nerve distribution, positive Durkin test, and positive Phalen test) provided a sensitivity of 100% and a specificity of 80%. Conclusions: In a small group of patients with recurrent carpal tunnel syndrome, cortisone injection into the carpal tunnel was not, by itself, a statistically significant predictor of successful revision surgery. However, relief from injection as a diagnostic test for predicting successful revision CTR was found to have both a high sensitivity and a positive predictive value. Coupled with the components of the physical examination, injection provides a good screening test to establish surgical success with revision CTR. Type of study/level of evidence: Therapeutic III. Predicting the Outcome of Revision Carpal Tunnel ReleaseJohn D. Beck, Justin G. Brothers, Patrick J. Maloney, John H. Deegan, Xiaoqin Tang, Joel C. Klena10.1016/j.jhsa.2011.10.040Journal of Hand Surgery 37, 2 (2012)2011-12-22Journal of Hand Surgery2011-12-22372S0363-5023(11)X0015-1Scientific Articles282287http://www.jhandsurg.org/article/PIIS0363502311013530/abstract?rss=yes Purpose: To compare the effectiveness of imaging techniques in aiding and confirming the diagnosis of complex regional pain syndrome (CRPS) type I. Methods: We conducted a meta-analysis of randomized controlled studies that evaluated the effectiveness of 3 different imaging techniques in aiding the diagnosis of CRPS type I. A systematic search in bibliographical databases resulted in 24 studies with 1,916 participants. Results: To determine the effectiveness of each imaging technique, we determined the average specificity, sensitivity, negative predictive value, and positive predictive value and then statistically compared them using the analysis of variance statistical test, which indicated that compared with magnetic resonance imaging and plain film radiography, triple-phase bone scan had a significantly better sensitivity and negative predictive values. However, there appeared to be no statistical significance between imaging techniques when we evaluated specificity and positive predictive value using the analysis of variance test. Conclusions: The findings of this meta-analysis support the use of triple-phase bone scan in ruling out CRPS type I, owing to its greater sensitivity and higher negative predictive value than both magnetic resonance imaging and plain film radiography. Type of study/level of evidence: Diagnostic I. Meta-analysis of Imaging Techniques for the Diagnosis of Complex Regional Pain Syndrome Type IZachary J. Cappello, Morton L. Kasdan, Dean S. Louis10.1016/j.jhsa.2011.10.035Journal of Hand Surgery 37, 2 (2012)2011-12-16Journal of Hand Surgery2011-12-16372S0363-5023(11)X0015-1Scientific Articles288296http://www.jhandsurg.org/article/PIIS0363502311013633/abstract?rss=yes Purpose: Near infrared spectroscopy (NIRS), a noninvasive means for monitoring muscle oxygenation, may be useful in the diagnosis of acute compartment syndrome, a condition characterized by poor tissue perfusion. This study used the decrease in muscle oxygenation caused by exercise to investigate the ability of anatomic placement of NIRS sensor pads over compartments of the forearm to isolate perfusion values of a specific compartment. Methods: We recruited 63 uninjured volunteers from a private clinic-based setting and placed NIRS sensor pads over the dorsal, volar, and mobile wad compartments of 1 forearm. A total of 49 participants also had the contralateral forearm monitored, which served as an internal control. Participants performed a series of 3 exercises designed to sequentially activate the muscles of each compartment. A washout period separated each exercise to allow perfusion to return to baseline. We compared NIRS values of each compartment recorded during muscle contraction with baseline values. Results: Mean NIRS values decreased significantly from baseline during muscle contraction for all compartments, whereas mean NIRS values of muscle compartments that remained at rest showed little or no change. We observed no changes in NIRS values of the contralateral arm, which remained at rest during the entire data collection period. Conclusions: Although lack of an existing method for quantifying muscle perfusion precludes validation of this technique against a reference standard, this study suggests that NIRS can provide oxygenation values that are both sensitive and specific to muscle compartments of the forearm. Future studies should investigate NIRS among patients with upper extremity injuries. Type of study/level of evidence: Diagnostic III. Ability of Near Infrared Spectroscopy to Measure Oxygenation in Isolated Upper Extremity Muscle CompartmentsAshley L. Cole, Richard A. Herman, Jonathan B. Heimlich, Sahir Ahsan, Brett A. Freedman, Michael S. Shuler10.1016/j.jhsa.2011.10.037Journal of Hand Surgery 37, 2 (2012)2011-12-22Journal of Hand Surgery2011-12-22372S0363-5023(11)X0015-1Scientific Articles297302http://www.jhandsurg.org/article/PIIS0363502311012871/abstract?rss=yes Purpose: In this article, we report the reconstruction of degloved fingers using a combination of a cross-finger flap and a composite-free flap from the dorsal aspect of the second toe. Methods: From May 2006 until April 2009, we treated 18 degloved fingers in 18 patients (13 male and 5 female patients; mean age, 22 y) using the technique. There were 11 index and 7 ring fingers. The mean volar and dorsal defects were 2.5 × 1.9 cm and 2.7 × 2 cm, respectively. The cross-finger flaps ranged in size from 2.3 × 1.6 cm to 3.5 × 2.6 cm, with a mean of 2.8 × 2.3 cm. The flaps from the dorsal second toe ranged in size from 2.4 × 2.1 cm to 4.5 × 2.3 cm, with a mean of 3.0 × 2.2 cm. At follow-up, we assessed motion and sensation. Results: All cross-finger and free flaps survived. At final follow-up (mean, 17 mo; range, 14–25 mo), motion in the injured fingers averaged 102° and 28° at the proximal and distal interphalangeal joints, respectively. The mean static 2-point discrimination of the reconstructed finger pulps was 5 mm (range, 4–7 mm). Conclusions: The combination of a cross-finger flap and a composite-free flap from the dorsum of the second toe is a useful and reliable technique for reconstruction of a degloved finger. Type of study/level of evidence: Therapeutic IV. Reconstruction of Distally Degloved Fingers With a Cross-Finger Flap and a Composite-Free Flap From the Dorsum of the Second ToeBin Wang, Xu Zhang, Wenping Jiang, Tiepeng Ma, Hao Li, Hui Wang10.1016/j.jhsa.2011.10.009Journal of Hand Surgery 37, 2 (2012)2011-11-28Journal of Hand Surgery2011-11-28372S0363-5023(11)X0015-1Scientific Articles303309.e4http://www.jhandsurg.org/article/PIIS0363502311013499/abstract?rss=yes Radical resection of the entire ring finger metacarpal for a giant cell tumor resulted in a bony defect extending from the distal surface of the hamate to the proximal surface of the proximal phalanx. We reconstructed the metacarpal with a custom-contoured free fibular osteocutaneous flap and maintained motion at the new fibulophalangeal joint using a silicone arthroplasty. At 4.5 years postoperatively, the patient has shown no signs of recurrence of the giant cell tumor. The silicone arthroplasty has maintained 15° to 85° of motion at the new joint. Because of its similar shape to a metacarpal and because it allows faster bony healing compared with a nonvascularized fibular bone graft, a free vascularized fibular bone graft is an ideal candidate for reconstruction of extensive defects of the metacarpals, and placement of a silicone spacer in its distal medullary cavity can preserve motion at the new metacarpophalangeal joint. Reconstruction of an Entire Metacarpal and Metacarpophalangeal Joint Using a Fibular Osteocutaneous Free Flap and Silicone ArthroplastyNeil F. Jones, Brian P. Dickinson, Scott L. Hansen10.1016/j.jhsa.2011.10.031Journal of Hand Surgery 37, 2 (2012)2011-12-12Journal of Hand Surgery2011-12-12372S0363-5023(11)X0015-1Scientific Articles310315http://www.jhandsurg.org/article/PIIS0363502311012858/abstract?rss=yes The Food and Drug Administration (FDA) indicates that bone morphogenetic protein (BMP) products are contraindicated in pediatric patients. However, it acknowledges the off-label use of BMP in difficult cases. Although the relative safety of BMP in children has been reported for lower extremity and spine procedures, little information exists for the safety of BMP used in the pediatric upper extremity. We present a case of a massive inflammatory reaction after use of recombinant human BMP-2 for repair of a symptomatic ulnar nonunion in a child. The case illustrates the potential difficulties of using the dose-dependent properties of BMP in the treatment of pediatric upper extremity nonunions when the dose calculations of BMP for children have not yet been defined. Exaggerated Inflammatory Response and Bony Resorption From BMP-2 Use in a Pediatric Forearm NonunionAndrew W. Ritting, Elizabeth W. Weber, Mark C. Lee10.1016/j.jhsa.2011.10.007Journal of Hand Surgery 37, 2 (2012)2011-11-28Journal of Hand Surgery2011-11-28372S0363-5023(11)X0015-1Scientific Articles316321http://www.jhandsurg.org/article/PIIS0363502311012913/abstract?rss=yes Purpose: To perform a long-term review of results of forearm shortening osteotomies, tenotomy, and volar wrist capsulotomy for treatment of typical wrist flexion deformities in children with the amyoplasia form of arthrogryposis, a procedure originally reported and described as “most rewarding” by Lexington Shriners Hospital for Children in 1965. Methods: A retrospective review of operating room and clinic records was done. An attempt to contact all patients produced 1 current follow-up. Results: Nine extremities in 6 patients had undergone the procedure. Of the 9 extremities, 3 subsequently underwent salvage procedures, 2 had salvage procedures recommended, and 1 had a distal forearm fracture angular malunion that compensated for the wrist flexion contracture. The charts for the patients with the 3 remaining extremities showed that at 3-year follow-up, the wrist flexion contractures had recurred. Conclusions: Long-term follow-up of the procedure shows that the initial improvement in wrist position is not maintained. This procedure is not recommended for correction of the wrist deformity in amyoplasia. Type of study/level of evidence: Therapeutic IV. Long-Term Results of Forearm Shortening and Volar Radiocarpal Capsulotomy for Wrist Flexion Deformity in Children With AmyoplasiaRonald C. Burgess, Rudy Robbe10.1016/j.jhsa.2011.10.013Journal of Hand Surgery 37, 2 (2012)2011-12-05Journal of Hand Surgery2011-12-05372S0363-5023(11)X0015-1Scientific Articles322325http://www.jhandsurg.org/article/PIIS0363502311013748/abstract?rss=yes Purpose: Recent studies have reported rates of methicillin-resistant Staphylococcus aureus (MRSA) hand infections in patients without risk factors ranging from 26% to 73%. The purpose of our study was to review a large series of pediatric hand infections to determine the rate of MRSA and identify potential risk factors. Methods: A retrospective review was performed on patients younger than 15 who were seen for hand infections (2001–2010). Patients were categorized according to medical problems, need for operation, abscess location, and mechanism of injury. Potential MRSA risk factors were assessed using a multivariate-regression model. Results: During the 10-year period, 415 patients were seen for hand infections. A total of 146 patients met the inclusion criteria: patients younger than 15 years of age who presented to the plastic surgery service requiring consultation for hand infections. The overall prevalence of MRSA-positive cultures was found to be 30%. The prevalence of MRSA was 29% in healthy patients and 0% in immunocompromised patients. The prevalence of MRSA increased in a linear fashion from patients without documentation of incision and drainage procedures to patients adequately treated with bedside incision and drainage to patients who required surgical drainage. There was a trend toward a higher prevalence of MRSA in deep space abscesses compared to other abscesses. Patients with a history of trauma and previous MRSA infections had a higher rate of MRSA than other patients. Conclusions: Traditionally, MRSA has been associated with hospitalization, intravenous drug use, recent antibiotic use, and compromised immunity. In our study, more severe, deep-space abscesses requiring surgical drainage and patients with a history of previous MRSA infections were found to have a higher prevalence of MRSA. The immunocompromised patients had no cases of MRSA and had higher incidences of less virulent bacterial infections. This suggests that acquisition of community-acquired MRSA skin and soft tissue infections in children and adolescents might not be associated with the traditional risk factors. Type of study/level of evidence: Prognostic IV. Community-Acquired Methicillin-Resistant Staphylococcus aureus Hand Infections in the Pediatric PopulationMichael Thomas Chung, Patrick Wilson, Brian Rinker10.1016/j.jhsa.2011.10.048Journal of Hand Surgery 37, 2 (2012)2011-12-23Journal of Hand Surgery2011-12-23372S0363-5023(11)X0015-1Scientific Articles326331http://www.jhandsurg.org/article/PIIS0363502311013761/abstract?rss=yes Purpose: Objective assessment of technical skills in hand surgery has been lacking. This article reports on an Objective Structured Assessment of Technical Skills format of a multiple bench-station evaluation of orthopedic surgery residents' technical skills for 3 common upper extremity surgeries. Methods: Twenty-seven residents (6 postgraduate year [PGY] 2, 8 PGY 3, 8 PGY 4, and 5 PGY 5) participated in the examination. Each resident performed surgery on a cadaveric specimen at 3 stations, trigger finger release (TFR), open carpal tunnel release, and distal radius fracture fixation. A board-certified hand surgeon evaluated trainee performance at each station, using a procedure-specific detailed checklist, a validated global rating scale, and pass/fail assessment. A resident post-testing evaluation was collected. Results: Construct validity with correlation between year in training and detailed checklist scores was demonstrated for TFR and carpal tunnel release; between year in training and global rating scores for TFR and distal radius fracture fixation; and between year in training and pass/fail assessment for TFR. Criterion validity was demonstrated by the correlation between global rating scale scores, detailed checklist scores, and pass/fail assessment for TFR, carpal tunnel release, and distal radius fracture fixation. Time to complete the surgery was not correlated with surgical performance. Residents rated the multiple-station Objective Structured Assessment of Technical Skills format as highly educational. Conclusions: This study reports that a surgeon's ability to release a trigger finger does not correlate specifically to his or her ability to perform a carpal tunnel release or to perform plate fixation of a radius fracture. The results of this study would indicate that, for 3 different surgical simulations representing procedures of varying complexity, assessments by a single assessment tool is not adequate. To completely understand a resident's abilities, assessment by checklist (understanding the steps of the surgery), global rating scales (assessment of basic surgical skills in light of lesser or greater complexity surgeries), and pass/fail assessment (examination of adverse events) are all necessary components. Type of study/level of evidence: Therapeutic II. Objective Structured Assessment of Technical Skill in Upper Extremity SurgeryAnn VanHeest, Bradley Kuzel, Julie Agel, Matthew Putnam, Loree Kalliainen, James Fletcher10.1016/j.jhsa.2011.10.050Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Scientific Articles332337.e4http://www.jhandsurg.org/article/PIIS0363502311004692/abstract?rss=yesOur home in Los Angeles was built in 1932 by a Connecticut native. He told us that because of the Depression he had only enough money to give this entirely traditional house “good bones” and that he would ornament it later. Susan and I have owned the home for nearly 30 years, and we have enjoyed fulfilling the first owner's dream. While Susan has focused on interior embellishments, I have designed and built various exterior features.Hand Made: Doors and GatesRoy A. Meals10.1016/j.jhsa.2011.03.046Journal of Hand Surgery 37, 2 (2012)2011-05-27Journal of Hand Surgery2011-05-27372S0363-5023(11)X0015-1A Touch of Humanity338338http://www.jhandsurg.org/article/PIIS0363502311012986/abstract?rss=yes presents an oil painting of one of my favorite spots on the Wörthersee, Carinthia, Austria. This is where I spend much of my free time in the summer, relax from work, or follow my passions: painting and swimming. The painting was made with oil colors on canvas and took me about 2 hours.Hand Made: My Favorite SpotLukas A. Holzer10.1016/j.jhsa.2011.10.020Journal of Hand Surgery 37, 2 (2012)2011-11-28Journal of Hand Surgery2011-11-28372S0363-5023(11)X0015-1A Touch of Humanity339339http://www.jhandsurg.org/article/PIIS0363502312000214/abstract?rss=yesJournal CME Instructions10.1016/S0363-5023(12)00021-4Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1340340http://www.jhandsurg.org/article/PIIS0363502311007520/abstract?rss=yesA 74-year-old, right-handed woman presents with a painful left elbow following a fall from standing height. She has coronary artery disease, hypertension, and hypothyroidism, but she is independent and mobilizes without aids. On examination in the emergency room, there is diffuse elbow tenderness, swelling, and ecchymosis with a reduced range of motion. It is a closed injury, and there is no neurovascular deficit. Radiographs of the elbow () show a displaced fracture of the olecranon with minimal comminution, no other associated fractures around the elbow, and no evidence of subluxation or dislocation.Isolated Displaced Olecranon FractureAndrew D. Duckworth, Charles M. Court-Brown, Margaret M. McQueen10.1016/j.jhsa.2011.06.005Journal of Hand Surgery 37, 2 (2012)2011-07-11Journal of Hand Surgery2011-07-11372S0363-5023(11)X0015-1Evidence-Based Medicine341345http://www.jhandsurg.org/article/PIIS0363502311007519/abstract?rss=yesA 35-year-old, right-handed man complains of pain and instability of the right thumb after falling off his bicycle 1 year ago. He has not sought previous medical attention. Clinical examination reveals metacarpophalangeal joint laxity (greater than 15° of laxity compared to the contralateral thumb) at full extension and 30° of flexion. He has no signs of generalized ligament laxity. Radiographs reveal no evidence of previous proximal phalanx base fracture or arthrosis.Chronic Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament InsufficiencyPeter C. Rhee, Sanjeev Kakar10.1016/j.jhsa.2011.06.004Journal of Hand Surgery 37, 2 (2012)2011-07-11Journal of Hand Surgery2011-07-11372S0363-5023(11)X0015-1Evidence-Based Medicine346348http://www.jhandsurg.org/article/PIIS036350231101570X/abstract?rss=yesJournal CME Questions10.1016/j.jhsa.2011.12.004Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Evidence-Based Medicine349349http://www.jhandsurg.org/article/PIIS0363502311014614/abstract?rss=yes Peripheral tears to the articular disk of the triangular fibrocartilage complex are fairly common. Patients complain of ulnar-sided wrist pain with ulnar deviation and forearmrotation along the prestyloid recess. The peripheral tears of the articular disk are amenable to arthroscopic repair due to its blood supply. All-arthroscopic knotless repair of peripheral ulnar-sided tears of the articular disk has several advantages. This technique allows for repair of the superficial and deep layers of the articular disk directly down to bone. In addition, by being knotless, it avoids irritation to the surrounding soft tissues by suture knots. This article describes arthroscopic repair of peripheral ulnar-sided tears of the articular disk down to bone with a knotless technique. Arthroscopic Knotless Peripheral Triangular Fibrocartilage RepairWilliam B. Geissler10.1016/j.jhsa.2011.11.012Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Surgical Technique350355http://www.jhandsurg.org/article/PIIS0363502311014626/abstract?rss=yes Subcapital ulnar fractures in association with distal radius fractures in elderly patients increase instability and pose a treatment challenge. Fixation of the ulnar fracture with traditional implants is difficult due to the subcutaneous location, comminution, and osteoporosis. We describe an intrafocal pin plate that provides fixation by a locking plate on the distal ulna and intramedullary fixation within the shaft. The low profile and percutaneous technique make this device a useful alternative for treatment of subcapital ulna fractures in the elderly. Intrafocal Pin Plate Fixation of Distal Ulna Fractures Associated With Distal Radius FracturesBrian J. Foster, Randy R. Bindra10.1016/j.jhsa.2011.11.013Journal of Hand Surgery 37, 2 (2012)2011-12-22Journal of Hand Surgery2011-12-22372S0363-5023(11)X0015-1Surgical Technique356359http://www.jhandsurg.org/article/PIIS0363502311013463/abstract?rss=yesInjury from extravasation of intravenous chemotherapeutic drugs can lead to severe disability and morbidity. Although the annual incidence of extravasation injury is only 0.1% to 0.7%, it is 4.7% in the chemotherapy patient population and ranges from 11% to 58% in children. These high-risk populations—neutropenic cancer patients and neonates in the intensive care unit—cannot physiologically afford such an injury. Peripheral intravenous devices placed in the upper extremity and used for chemotherapy put the dorsum of the hand and the antecubital fossa at substantial risk for injury. Although intravenous extravasation prevention is paramount, swift treatment in the event of an accident is critical in avoiding morbidity. Appropriate treatment requires knowledge of the nature of the toxic agent extravasated as well as an understanding of the medical and surgical treatment options available.Chemotherapy Extravasation InjuriesJesse C. Hahn, Adam B. Shafritz10.1016/j.jhsa.2011.10.028Journal of Hand Surgery 37, 2 (2012)2011-12-12Journal of Hand Surgery2011-12-12372S0363-5023(11)X0015-1In Brief360362http://www.jhandsurg.org/article/PIIS0363502311013505/abstract?rss=yesFractures of the forearm are among the most common fractures in children, with the vast majority of these injuries requiring no more than immobilization with or without closed reduction. Children with open physes are capable of remodeling mild to moderate posttraumatic deformities, but the remodeling potential depends on the amount of remaining growth at the nearest physis, the proximity of the injury to the physis, and the plane of motion of the nearest joint. Rotational deformities and joint dislocations, however, will not remodel. For forearm fractures that compromise joint congruity or limit forearm rotation, as can occur with both Monteggia- and Galeazzi-type injuries, an anatomic or nearly anatomic reduction should be sought. Treatment decisions are based on the individual circumstances of the patient by weighing the risks of closed, percutaneous, or open management with the likelihood of long-term disability from a nonanatomic reduction.Pediatric Forearm Fractures: Spotting and Managing the Bad ActorsDan A. Zlotolow10.1016/j.jhsa.2011.10.032Journal of Hand Surgery 37, 2 (2012)2011-12-12Journal of Hand Surgery2011-12-12372S0363-5023(11)X0015-1In Brief363366http://www.jhandsurg.org/article/PIIS0363502311015693/abstract?rss=yesJournal CME Questions10.1016/j.jhsa.2011.12.003Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1In Brief366366http://www.jhandsurg.org/article/PIIS0363502311014912/abstract?rss=yes Cutaneous malignancies are the most common primary malignancies of the hand. The hand surgeon may be the first physician to see these patients or may have the patients referred to them because of expertise in this anatomical region. This article reviews diagnosis and treatment, including margin of resection and need for sentinel lymph node biopsy, for the 3 most common cutaneous malignancies: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. Cutaneous Malignancies of the Upper ExtremityChristopher English, Warren C. Hammert10.1016/j.jhsa.2011.11.019Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Current Concepts367377http://www.jhandsurg.org/article/PIIS0363502311015048/abstract?rss=yes Numerous dermatologic conditions may be visualized by the hand surgeon during office hours, including when examining patients for an alternative chief problem. Although the primary focus of the visit may be unrelated to a skin lesion, it is important for the hand surgeon to be familiar with these lesions to address patient inquiries and determine which lesions may require some form of treatment. This article reviews some of the most common benign acquired superficial skin lesions of the hand. Particular attention will be paid to epidermal lesions, pigmented lesions, vascular lesions, dermal fibrous/fibrohistiocytic lesions, and infections that can be confused with skin neoplasms or tumor-like conditions. Diagnostic clues, including photographs, will be provided for each lesion described, as well as the recommended treatment. Benign Acquired Superficial Skin Lesions of the HandJoshua M. Abzug, Mark A. Cappel10.1016/j.jhsa.2011.11.025Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Current Concepts378393http://www.jhandsurg.org/article/PIIS0363502311015681/abstract?rss=yesJournal CME Questions10.1016/j.jhsa.2011.12.002Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Current Concepts393393http://www.jhandsurg.org/article/PIIS0363502311015826/abstract?rss=yesTrigger fingers are a common hand condition caused by the inability of the flexor tendon to glide within the sheath owing to a size mismatch of the tendon and its sheath. The condition can present as pain in the region of the metacarpal head, as a digit that locks occasionally, or as a digit locked in flexion. Because other conditions can cause similar pain, it is essential to witness the triggering in the clinic to determine the proper treatment for the patient. Often the patient's history is that of triggering but at the time of examination the finger does not trigger. The senior author has observed that many suspected trigger digits can be provoked into triggering with a unique diagnostic maneuver in clinic.An Observation on Trigger FingersBlaine T. Bafus, Avrum I. Froimson10.1016/j.jhsa.2011.12.014Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Letters to the Editor394394http://www.jhandsurg.org/article/PIIS036350231101584X/abstract?rss=yesThe recent publication “Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for dupuytren contracture” is interesting. Chen et al concluded that “open partial fasciectomy is not cost-effective.” Indeed, this work should ideally include a cost-utility study that deals directly with the estimated quality of life adjustment. The medical cost is only 1 important concern included in the cost analysis. Indeed, there are other aspects to be considered, such as indirect cost resulting from loss of work and complications as well as the cost of time required by the practitioner to provide care. To complete the analysis, all costs, both direct and indirect aspects, should be included and analyzed.Cost of Open Partial Fasciectomy, Needle Aponeurotomy, and Collagenase Injection for Dupuytren ContractureViroj Wiwanitkit10.1016/j.jhsa.2011.11.028Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Letters to the Editor394394http://www.jhandsurg.org/article/PIIS0363502311015838/abstract?rss=yesThe question raised by Professor Wiwanitkit is a common one and worthwhile clarifying when discussing cost-effectiveness analyses. It is agreed that there are indirect costs when a patient undergoes surgery, including lost time from work and lost productivity; however, it is important to understand that when a decision analysis is performed, by necessity, the framework is predefined. All decision analyses have a context of original assumptions and inherent limitations that are critically taken into account when evaluating the conclusions.In ReplyNeal C. Chen, Kevin C. Chung10.1016/j.jhsa.2011.12.015Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Letters to the Editor394395http://www.jhandsurg.org/article/PIIS0363502311015966/abstract?rss=yesWe read with interest Vitale and colleagues' article describing a novel approach to treating dorsal fracture–dislocations of the proximal interphalangeal (PIP) joint. Their results are promising for these challenging injuries. However, we are intrigued by aspects of the surgical technique described and the postoperative regimen of rehabilitation.RE: A Percutaneous Technique to Treat Unstable Dorsal Fracture–Dislocations of the Proximal Interphalangeal JointD.B. Saleh, S. Southern10.1016/j.jhsa.2011.10.057Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Letters to the Editor395396http://www.jhandsurg.org/article/PIIS036350231101598X/abstract?rss=yesWe appreciate the opportunity to respond to the points raised by Mr. Saleh and Mr. Southern in their Letter to the Editor. The first point raised in the letter concerns dorsal versus volar K-wire insertion across the fracture. We would be interested to know whether the “bone holding clamp” described in the letter is passed through the flexor tendons, as is done in our technique. If so, this may somewhat offset the potential benefit of placing the K-wires from a dorsal approach in an effort to avoid the flexor tendons. We have no experience with dorsal K-wire insertion across the fracture, although it is certainly possible that such a technique would prove equally successful.In ReplyRobert J. Strauch, Mark A. Vitale, Neil J. White10.1016/j.jhsa.2011.12.027Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Letters to the Editor396396http://www.jhandsurg.org/article/PIIS036350231101567X/abstract?rss=yesIn the article by Lindenhovius A, Karanicolas PJ, Bhandari M, van Dijk N, Ring D, and the Collaboration for Outcome Assessment in Surgical Trials (“Interobserver Reliability of Coronoid Fracture Classification: Two-Dimensional Versus Three-Dimensional Computed Tomography,” J Hand Surg 2009;34A:1640–1646), J.C. Goslings of the Collaboration for Outcome Assessment in Surgical Trials was incorrectly listed as Carel Goslings.Erratum10.1016/j.jhsa.2011.12.001Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1Erratum396396http://www.jhandsurg.org/article/PIIS0363502311016364/abstract?rss=yesMasthead10.1016/S0363-5023(11)01636-4Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1FrontmatterA2A2http://www.jhandsurg.org/article/PIIS0363502311016376/abstract?rss=yesEditorial Board10.1016/S0363-5023(11)01637-6Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1FrontmatterA4A4http://www.jhandsurg.org/article/PIIS0363502311016388/abstract?rss=yesTable of Contents10.1016/S0363-5023(11)01638-8Journal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1FrontmatterA7A7http://www.jhandsurg.org/article/PIIS036350231101639X/abstract?rss=yesInstructions to Authors10.1016/S0363-5023(11)01639-XJournal of Hand Surgery 37, 2 (2012)2012-02-01Journal of Hand Surgery2012-02-01372S0363-5023(11)X0015-1FrontmatterA18A22