Journal of Hand Surgery

Publication Bias in Kienböck's Disease: Systematic Review

Lee Squitieri, Elizabeth Petruska, Kevin C. Chung — 2010-03-01

Purpose: Kienböck's disease is considered rare and currently affects fewer than 200,000 people in the United States. Given the inherent challenges associated with researching rare diseases, the intense effort in hand surgery to treat this uncommon disorder may be influenced by publication bias in which positive outcomes are preferentially published. The specific aim of this project was to conduct a systematic review of the literature with the hypothesis that publication bias is present for the treatment of Kienböck's disease.Methods: We conducted a systematic review of all available abstracts associated with published manuscripts (English and non-English) and abstracts accepted to the 1992 to 2004 American Society for Surgery of the Hand (ASSH) annual meetings. Data collection included various study characteristics, direction of outcome (positive, neutral/negative), complication rates, mean follow-up time, time to publication, and length of patient enrollment.Results: Our study included 175 (124 English, 51 non-English) published manuscripts and 14 abstracts from the 1992 to 2004 annual ASSH meetings. Abstracts from published manuscripts were associated with a 53% positive outcome rate, which is lower than the 74% positive outcome rate found among other surgically treated disorders. Over the past 40 years, studies have become more positive (36% to 68%, p=.007) and are more likely to incorporate statistical analysis testing (0% to 55%, p .999).Conclusions: The acceptance rate for negative outcomes studies regarding Kienböck's disease is higher than for other surgical disorders. This may indicate a relative decrease in positive outcome bias among published Kienböck's disease studies compared with other surgical disorders. However, the increasing positive outcome rate for published Kienböck's disease studies over time may suggest a trend of increasing publication bias among journals toward Kienböck's disease studies.

The Incidence of Intrinsic and Extrinsic Ligament Injuries in Scaphoid Waist Fractures

2010-03-01

Purpose: To determine the incidence of associated intrinsic and extrinsic ligament injuries in patients with a nondisplaced or displaced scaphoid waist fracture.Methods: During a 3-year period, a study of all scaphoid fractures was performed at our institution. Diagnosis was confirmed by plain radiographs, computed tomography, and magnetic resonance imaging. A 3-part anatomic classification was used to categorize the scaphoid fractures. The study population comprised 40 patients with 41 scaphoid waist fractures who had wrist arthroscopy for treatment and evaluation of the scaphoid fracture and associated carpal injuries.Results: We observed fresh intrinsic ligament injuries in 34 of 41 wrists. In 29 cases, the scapholunate ligament was injured, with complete rupture occurring in 10 wrists. The lunotriquetral ligament was injured in 8 wrists, and the triangular fibrocartilage complex was injured in 11 wrists. Statistically, the number of intrinsic ligament injuries did not differ between nondisplaced and displaced scaphoid fractures (p> .30).Conclusions: In this study of acute scaphoid waist fractures, the overall incidence of associated ligament injuries was surprisingly high, at 34 of 41 wrists. Complete scapholunate ligament rupture was found in 10 of 41 wrists. This incidence is higher than previously reported and emphasizes the need for careful assessment of the intrinsic and extrinsic ligaments, particularly the scapholunate ligament, before deciding on treatment.

Surgical Treatment of Pediatric Posttraumatic Palmar Midcarpal Instability: Case Report

Kent H. Chou, Franklin H. Chou, Robert J. Goitz — 2010-01-11

We treated a 6-year-old child able to extend her wrist only to within 30° of the neutral position secondary to posttraumatic palmar midcarpal instability with palmar and dorsal capsulodesis and pinning. More than 8 years after surgery, she has no complaints referable to her wrist and has 30° of active wrist extension. Although unpredictable in adults, soft-tissue reconstruction is a treatment option in the pediatric patient with posttraumatic palmar midcarpal instability.

A Cost-Utility Analysis of Nonsurgical Management, Total Wrist Arthroplasty, and Total Wrist Arthrodesis in Rheumatoid Arthritis

Christi M. Cavaliere, Kevin C. Chung — 2010-03-01

Purpose: Management of end-stage rheumatoid wrist disease remains controversial. Total wrist arthrodesis provides reliable pain relief and stability and is the most commonly applied management strategy. Total wrist arthroplasty is a motion-preserving alternative that is gaining popularity. The purpose of this study was to perform a cost-utility analysis comparing nonsurgical management, total wrist arthroplasty, and total wrist arthrodesis for the rheumatoid wrist.Methods: A time trade-off utility survey was developed to investigate patient and physician preferences for the potential outcomes of total wrist arthroplasty and total wrist arthrodesis. The study sample consisted of rheumatoid patients (N = 49) recruited as part of an ongoing prospective study and a national random sample of hand surgeons and rheumatologists (N = 109). A decision tree was created using utility values derived from the survey, and the expected quality-adjusted life-years (QALYs) for each procedure were determined. Using the societal perspective, costs were based on the Medicare fee schedules for the Current Procedural Terminology codes associated with total wrist arthroplasty and total wrist arthrodesis and their potential complications. Costs per QALY were calculated and compared.Results: Patients and physicians both showed a preference for surgical management over nonsurgical management. Application of cost data indicated that the incremental cost per additional QALY gained for total wrist arthroplasty over nonsurgical management was $2,281 and the incremental cost per QALY gained with total wrist arthroplasty over total wrist arthrodesis was $2,328, which is substantially less than the national standard of $50,000/QALY deemed acceptable for adoption.Conclusions: In the absence of rigorous outcome data, cost-utility analysis is a useful tool to guide treatment decisions. Total wrist arthroplasty and total wrist arthrodesis are both extremely cost-effective procedures. This study incorporated patient and physician utilities to demonstrate that total wrist arthroplasty has only a small incremental cost over the traditional total wrist arthrodesis procedure. Based on this economic model, total wrist arthroplasty may be worthy of further consideration, and cost should not be considered prohibitive.Type of study/level of evidence: Decision Analysis II.

Arthroscopically Guided Osteotomy for Management of Intra-Articular Distal Radius Malunions

2010-02-12

Purpose: A malunion with a step-off of 1 mm or more after an intra-articular distal radius fracture may cause pain and arthritic changes at midterm follow-up. We present our technique for treating intra-articular distal radius malunions by carrying out an osteotomy from inside the joint outward under arthroscopic guidance using the dry arthroscopy technique, with emphasis on the clinical and radiologic outcomes.Methods: We performed surgery on 11 patients for intra-articular malunion of the distal radius 1 to 5 months after the injury. Preoperative step-offs ranged from 2 to 5 mm (average, 2.5 mm) on plain radiographs. Original fracture patterns involved 1 radial styloid fracture, 1 radiocarpal fracture–dislocation, and 9 comminuted intra-articular fractures. In 5 cases an anterior-ulnar or radial styloid fragment was repositioned. In the rest, more than 1 fragment (up to 3) was osteotomized. In 1 patient the articular osteotomy was combined with an ulnar shortening osteotomy.Results: Follow-up ranged from 12 to 48 months. Step-offs were reduced in most cases to 0 mm; however, localized gaps (<2 mm) and cartilage defects were commonly seen intraoperatively because the fragments did not accurately fit. According to the Gartland and Werley score, there were 4 excellent and 7 good results (mean score of 2.8). The Modified Green and O'Brien system achieved a mean score of 83, with 3 excellent, 5 good, and 3 fair results. One patient showed radiolunate narrowing on follow-up radiographs.Conclusions: Arthroscopically assisted osteotomy permits direct visualization of the osteotomy site with good midterm clinical and radiologic outcomes. The technique can be used in irregularly defined fragments.Type of study/level of evidence: Therapeutic IV

Comparison of Functional Outcome After Volar Plate Fixation With 2.4-mm Titanium Versus 3.5-mm Stainless-Steel Plate for Extra-Articular Fracture of Distal Radius

2010-02-08

Purpose: Open reduction and locked volar plate and screw fixation is a popular treatment method for extra-articular distal radius fractures with dorsal metaphyseal comminution. In this study, we compared the use of a titanium 2.4-mm precontoured plate with that of a stainless-steel oblique 3.5-mm T-shaped plate to test the null hypothesis that there would be no difference in wrist function or upper extremity–specific health status in the internal fixation of AO-type A3.2 distal radius fractures.Methods: We retrospectively analyzed 24 patients treated with a 2.4-mm titanium plate and 38 patients treated with a 3.5-mm stainless-steel plate for an extra-articular and dorsally angulated distal radius fracture, from data gathered in a prospective cohort study of plate and screw fixation of distal radius fractures. The 2 cohorts were analyzed for differences in motion, grip strength, pain, Gartland and Werley score, Disabilities of the Arm, Shoulder, and Hand score, and Short Form-36 score at 6, 12, and 24 months of follow-up. Group differences and their change over time were determined using regression analysis and the likelihood ratio test.Results: There were no significant differences in wrist function and arm-specific health status between patients treated with a 2.4-mm plate and those treated with a 3.5-mm plate at 6, 12, or 24 months of follow-up. However, we observed a trend toward greater wrist flexion at 1 year (66° vs 55°; p=.07) and greater flexion–extension arc (137° vs 123°; p=.08) and pronation–supination arc (172° vs 160°; p=.07) at 24 months after surgery in patients treated with a 2.4-mm plate.Conclusions: Patients with a dorsally angulated extra-articular distal radius facture can expect similar results when treated with either a precontoured 2.4-mm titanium plate or a 3.5-mm stainless-steel T-shaped plate.Type of study/level of evidence: Therapeutic III.

Congenital Pseudarthrosis of the Radius Treated With Gradual Distraction and Free Vascularized Fibular Graft: Case Report

2010-02-05

Only 18 cases of congenital radial pseudarthrosis have been reported in the English literature; of these, 4 have been treated with free vascularized fibular graft. We present a case of a 9-year-old female patient with neurofibromatosis type 1 who underwent gradual distraction through the pseudarthrosis site and subsequent vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius and concomitant longitudinal and angular deformity of the wrist joint. At the last follow-up, 10 years postoperatively, the patient has maintained bony union, with full wrist flexion–extension and forearm pronation–supination.

Trans-Web Approach for Fixation of Avulsion Fractures of the Proximal Phalangeal Base: Report of Two Cases

2010-01-11

Although displaced fractures of the lateral aspect of the base of the proximal phalanx can be treated surgically, previously described approaches to the fracture are not necessarily easily performed. We describe a trans-web approach to the metacarpophalangeal joint and report 2 clinical cases. This technique allows the fracture fragments to be reduced and fixed with minimal risk of damage to the adjacent structures.

Acellular Dermal Regeneration Template for Soft Tissue Reconstruction of the Digits

John S. Taras, Anthony Sapienza, Josh B. Roach, John P. Taras — 2010-02-08

Purpose: Trauma to the digits often leaves soft tissue defects with exposed bone, joint, and/or tendon that require soft tissue replacement. The objective of this study was to evaluate the effectiveness of acellular dermal regeneration template combined with full-thickness skin grafting for soft tissue reconstruction in digital injuries with soft tissue defects.Methods: Acellular dermal regeneration template was used to reconstruct digital injuries with exposed bone, joint, tendon, and/or hardware not amenable to treatment with healing by secondary intention, rotation flaps, or primary skin grafts. Acellular dermal regeneration template was applied to 21 digits in 17 patients. Nineteen digits had exposed bone, 8 digits had exposed tendon, 6 digits had exposed joints, and 2 digits had exposed hardware. The acellular dermal regeneration template was sutured over the soft tissue defect. Over 3 weeks, a neodermis formed. The superficial silicone layer of the acellular dermal regeneration template was removed, and the digits received full-thickness epidermal autografting with cotton bolster.Results: The duration of postoperative follow-up extended to a minimum of 12 months. For the injury sites where acellular dermal regeneration template was applied, the total area of application ranged from 1 cm2 to 24 cm2, with the largest individual site measuring 12 cm2. Twenty of 21 digits demonstrated 100% incorporation of the acellular dermal regeneration template skin substitute. One digit that had sustained multilevel trauma developed necrosis requiring revision amputation. Full-thickness epidermal autografting was performed an average of 24 days after acellular dermal regeneration template skin substitute application and demonstrated a 100% take in 16 of 20 digits and partial graft loss of 15% to 25% in 4 of 20 digits that did not require further treatment.Conclusions: Acellular dermal regeneration template combined with secondary full-thickness skin grafting is an effective method of skin reconstruction in complex digital injuries with soft tissue defects involving exposed bone, tendon, and joint. The neodermis increases tissue bulk and facilitates epidermal autografting with digital injuries that otherwise would require flap coverage or skeletal shortening of the digit.Type of study/level of evidence: Therapeutic IV.

Irreducible Dislocation of the Thumb Interphalangeal Joint With Digital Nerve Interposition: Case Report

Samir R. Shah, Randy Bindra, Justin W. Griffin — 2010-02-01

Irreducible open dislocation of the thumb interphalangeal joint is a rare injury with several factors responsible for blocking reduction. We describe a case of a 32-year-old man who, on surgical exploration, was found to have an irreducible thumb dislocation due to flexor pollicis longus tendon, ruptured volar plate, and the digital nerve interposed in the interphalangeal joint.

Rotation in the Interphalangeal Thumb Joint In Vivo

Barbara Jemec, Liaquat Suleman Verjee, Abhilash Jain, Fiona Sandford — 2010-03-01

Purpose: To investigate rotation at the thumb interphalangeal (IP) joint in vivo to optimize the position of fusion of this joint.Methods: Standardized photographs were taken of 176 thumbs end-on (88 asymptomatic volunteers) placed on a custom-made splint with the IP joint at 40°. Three blinded investigators measured rotation at the IP joint from these photographs as the angle between a line aligning the eponychial folds and a line aligning the proximal phalanx condyles. Gender, age, hand dominance, and type of occupation of the asymptomatic vounteers were recorded.Results: The variable pronation at the IP joint of the thumb (range, 0° to 12°) was significantly greater on the left than right (p=.001), although the actual difference was only 1°. In subjects who performed fine dexterous work, thumb IP joint pronation was significantly less than in subjects who performed administrative or manual work (p=.009), but we found no statistical difference between manual and administrative groups. There was no correlation between thumb IP joint rotation and hand dominance (p=.2), age (p=.4) or gender (p=.5).Conclusions: There is functional pronation at the IP joint of the thumb. We propose that this should be taken into account when performing arthrodesis on the joint or designing a joint replacement. The degree of rotation may be associated with occupation.

Responsiveness of the Michigan Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder, and Hand Questionnaire in Patients With Hand Injury

2010-02-08

Purpose: To compare responsiveness of the Michigan Hand Outcomes Questionnaire (MHQ) with that of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire in patients with hand injuries. We postulated that the MHQ may be more sensitive to functional changes in the hands, whereas the DASH questionnaire would have a closer association with days of disability.Methods: Patients with hand injuries were consecutively recruited from 2 community hospitals. Each patient was asked to complete out the MHQ, the DASH questionnaire, the satisfaction with their health-related quality of life (Sat-HRQOL) measure, and Chinese Health Questionnaire (CHQ), which is a measure of psychological stressors. Disability days were defined as the duration of restricted activities of daily living during the previous 4 weeks. Patients repeated the same questionnaires between 2 and 9 months after enrollment (average: 4 mo).Results: A total of 105 patients with hand injuries were recruited, and 50 of the 105 patients returned for the second evaluation. There were no statistical differences between responders and nonresponders for age, gender, disability days, the MHQ, the DASH questionnaire, the CHQ, or the Sat-HRQOL. Responsiveness was evaluated by effect sizes and standardized response means: Those for the MHQ were 0.84 and 1.05, and those for the DASH were 0.67 and 0.86, respectively. A mixed model analysis for repeated measurements of the 50 participants showed a significant influence of psychological factors (CHQ) for both the Sat-HRQOL and disability days. After adjustment for the effects of age, gender, and the CHQ, there was an increment of one Sat-HRQOL unit for an MHQ score increment of 3.2, whereas the score decrement for the DASH questionnaire was 3.3 units.Conclusions: The MHQ might be slightly more sensitive to functional changes, but the DASH questionnaire seemed more correlated with disability days. Psychological factors are the strongest determinants of the HRQOL and disability.

Percutaneous Carpal Tunnel Release Compared With Mini-Open Release Using Ultrasonographic Guidance for Both Techniques

Ken-ichi Nakamichi, Shintaro Tachibana, Seizo Yamamoto, Masayoshi Ida — 2010-03-01

Purpose: To compare the outcomes of percutaneous carpal tunnel release (PCTR) and mini-open carpal tunnel release (mini-OCTR) using ultrasonographic guidance for both techniques.Methods: We included 74 hands of 65 women with idiopathic carpal tunnel syndrome (age, 52–71 y; mean, 58 y). Thirty-five hands of 29 women had the PCTR (release with a device consisting of an angled blade, guide, and holder, along a line midway between the median nerve and ulnar artery (safe line) under ultrasonography (incision, 4 mm), and 39 hands of 36 women had the mini-OCTR (release along the safe line, distally under direct vision (incision, 1–1.5 cm) and proximally under ultrasonography, using a device consisting of a basket punch and outer tube.Results: Assessments at 3, 6, 13, 26, 52, and 104 weeks showed no significant differences in neurologic recovery between the groups (p > .05). The PCTR group had significantly less pain, greater grip and key-pinch strengths, and better satisfaction scores at 3 and 6 weeks (p < .05), and less scar sensitivity at 3, 6, and 13 weeks (p < .05). There were no complications.Conclusions: The PCTR provides the same neurologic recovery as does the mini-OCTR. The former leads to less postoperative morbidity and earlier functional return and achievement of satisfaction.Type of study/level of evidence: Therapeutic III.

Intrinsic Hand Muscle Reinnervation by Median-Ulnar End-to-Side Bridge Nerve Graft: Case Report

M. Magdi Sherif, Adel H. Amr — 2010-01-11

Recovery of either the motor or sensory functions has not been consistently achieved in upper extremity end-to-side neurorrhaphy; this technique was only indicated when more conventional nerve repair was not possible. In most studies, the whole median or ulnar nerve was used for end-to-side neurotization. In this report, we present 4 cases of high-median or ulnar nerve laceration in which a nerve graft was placed end-to-side between the median and ulnar motor fascicles close to the wrist. At 4 months after surgery, 3 of 4 patients began to recover active movement of the affected small muscles of the hand. EMG and nerve conduction studies confirmed that nerve conduction was through the nerve grafts.

Recurrence of Giant Cell Tumors in the Hand: A Prospective Study

Jeffrey Williams, Arielle Hodari, Peter Janevski, Aamir Siddiqui — 2010-03-01

Purpose: Giant cell tumors of the hand remain a treatment dilemma: treatment requires a balance between extensive dissections for excision versus risk of recurrence. There is no consensus regarding how best to manage this balance. The purpose of this study was to identify the recurrence rate of giant cell tumors of the hand, as well as the correlation with the specific tissue type involved.Methods: Two hundred thirteen cases of giant cell tumor of the hand were recorded in a prospectively designed, anatomically based registry that identified tumor location and surgical planes entered and tissues excised during the procedure. Mean follow-up was 51 months. Demographic and follow-up data were also tracked. The primary outcome tracked was tumor recurrence. Statistical analysis was conducted using chi-square analysis and the Fisher exact test to determine which perioperative and intraoperative factors were associated with tumor recurrence.Results: There were 27 recurrences among our cases. Tumors involving the extensor tendon, flexor tendon, or joint capsule had the strongest correlation with recurrence: 12, 8, and 12 cases, respectively. Conversely, there was only one recurrence among the patients who did not have any involvement of either the flexor or extensor tendons or joint capsules. There was no association for involvement of skin, neurovascular bundle, tendon sheath, or bone at the initial excision. No identifiable preoperative or postoperative factors were linked to recurrence.Conclusions: Our study shows that direct involvement of the extensor tendons, flexor tendons, or joint capsule puts patients in a high-risk category with respect to recurrence. Based on these findings, efforts regarding close monitoring and the role of adjuvant therapy should be directed at the high-risk population. This information may be helpful for hand surgeons developing evidence-based treatment algorithms for giant cell tumor in the hand.Type of study/level of evidence: Prognostic III.

Quantitative Measurements of the Volume and Surface Area of the Radial Head

Thierry G. Guitton, Huub J. van der Werf, David Ring — 2010-02-04

Purpose: We investigated the hypothesis that a quantitative 3-dimensional computed tomography (Q3DCT) modeling technique based on anatomical and demographic data that can measure size, shape, and proximal articular surface area can be used to develop formulas that could predict the volume and proximal surface area of the intact radial head in patients with fractures of the radial head.Methods: We used a consecutive series of 50 computed tomography scans with a slice thickness of 1.25 mm or less obtained in patients with fracture of the distal humerus, but no injury to the radial head, to create 3-dimensional models. The volume and proximal articular surface area of the radial head were measured, and predictive formulas based on anatomical measurements and gender were calculated using multiple linear regression.Results: There were significant correlations between total radial head volume and proximal radial head articular surface area for height, weight, radial head diameter, radial neck diameter, coronoid diameter, and gender. Multiple linear regression modeling resulted in formulas that could account for 89% of the variation in radial head volume and 75% of the variation in proximal articular surface area.Conclusions: The volume and proximal articular surface area of the radial head can be estimated based on anatomical measurements and gender. This may lead to better estimates of lost fragments when it is not possible to directly model the fractured radial head and computed tomography scan of the opposite limb is not available.

Nonsurgically Treated Terrible Triad Injuries of the Elbow: Report of Four Cases

Thierry G. Guitton, David Ring — 2010-03-01

This case series describes 4 patients with terrible triad injury of the elbow (dislocation with fractures of the radial head and coronoid) who were treated nonsurgically. Following nonsurgical treatment in this select group of patients, the elbow was well aligned, and the patients regained good elbow function. Three of these 4 patients had good results. One patient had surgery for residual stiffness, ulnar neuropathy, and a radial head deformity. We conclude that, in selected terrible triad cases, when the elbow is well aligned and the radial head and coronoid fractures are relatively small and minimally displaced after closed reduction and there is no mechanical block to motion, patients might regain good elbow function without surgery.

Journal CME Instructions

2010-03-01

Low-Level Laser Treatment

Joshua G. Bales, Roy A. Meals — 2010-03-01

A 55-year-old, right-handed man presents with numbness and pain in his right thumb, index, and long fingers that wakes him from sleep. Electrodiagnostic studies are consistent with carpal tunnel syndrome (CTS) with a motor latency greater than 7 ms. He received transient relief from a steroid injection. The wrist brace that prevented night symptoms for years is no longer helpful. The patient prefers to avoid surgery and requests low-level laser therapy (LLLT), which he read about on the Internet.

Journal CME Questions

2010-03-01

More Experiments

David Ring — 2010-03-01

Just over 18 months into the new format for the Journal of Hand Surgery, I'm reflecting on the Evidence-Based Medicine (EBM) section. I've had great authors and enthusiastic feedback and would encourage hand surgeons to email me with ideas for a review in this format.

Reconstruction of the Hypoplastic Thumb

Terry R. Light, John L. Gaffey — 2010-02-08

Thumb hypoplasia is characterized by diminished thumb size, metacarpal adduction, metacarpophalangeal joint instability, thenar muscle hypoplasia or aplasia, extrinsic tendon dysplasia, and in the most severe cases, carpometacarpal joint instability or thumb aplasia. Severe thumb hypoplasia and aplasia are best treated by thumb ablation and pollicization of the index finger. Less severe thumb hypoplasia can be reconstructed by a combination of soft tissue release, first web space local flap coverage, metacarpophalangeal joint collateral ligament and capsule reconstruction, extrinsic tendon tenolysis, and muscle or tendon transfers.

Correction of the Typical Cleft Hand

Joseph Upton, Amir H. Taghinia — 2010-02-08

The correction of type II and III typical cleft hands can be complicated because each hand can contain a variation of congenital problems including syndactyly, camptodactyly, thumb hypoplasia, deficiency of the first web space, abnormal phalanges, maligned joints, and abnormal intrinsic muscles and extrinsic tendons. The most difficult problem is the index ray, which lies in a “no man's land” between the central cleft and the mobile thumb. Presented in this paper is a technique for correction and transposition of the index ray through a simple incision, which separates the glabrous from the dorsal skin surfaces. Skeletal alignment must be precise. Preservation of the adductor pollicis muscle, if present, is crucial to a functional pinch. Long-term problems such as persistent radial deviation of the index finger and unyielding flexion contractures can be avoided.

Chemistry and Mechanics of Commonly Used Sutures and Needles

Daniel E. Firestone, Anthony J. Lauder — 2010-03-01

Suture choice seems anecdotal. As hand surgeons, we have been taught the principles of suture and needle selection; however, if asked to cite evidence for our preferred choice, most of us would be hard-pressed. The following brief review is a summary of the characteristics of commonly used suture and needle types, in an attempt to better understand why we follow the hidden curriculum of our mentors.

Journal CME Questions

2010-03-01

Electrocautery Use in Hand Surgery: History, Physics, and Appropriate Usage

Christopher Cox, Jeffrey Yao — 2009-11-27

Electrocautery provides a convenient method of obtaining hemostasis that is indispensable to the practicing hand surgeon. Whereas virtually all surgeons appreciate its utility, few are aware of its history and relevant physics that underlie its appropriate usage.

Treatment of Acute Peripheral Nerve Injuries: Current Concepts

Jonathan Isaacs — 2010-02-08

Although clinical outcomes of peripheral nerve injuries are often suboptimal, an adherence to well-established basic principles of evaluation and repair can optimize results of even the most complex injuries. Proper assessment of injury patterns both preoperatively and intraoperatively can guide treatment, and multiple repair techniques including strategies for overcoming both small and large gaps offer different advantages and disadvantages. New technologies and ideas address some unsolved problems, but more experience and research is necessary to elucidate fully their roles in the treatment algorithm.

Journal CME Questions

2010-03-01

Neuromas of the Hand and Upper Extremity

Jonathan Watson, Mark Gonzalez, Alex Romero, James Kerns — 2010-03-01

The painful neuroma is an often debilitating sequela of nerve injury about the hand. The exact pathophysiology of this condition is poorly understood. After sharp trauma to a peripheral nerve, as nerve ends try to connect with their end organs and “find” the distal nerve stump, fascicular escape and scarring can lead to the development of a painful neuroma. Painful neuromas can even be associated with blunt trauma or retraction of a nerve when the nerve is not actually divided. Green's definition of a neuroma is “the inevitable, unavoidable, and biologic response of the proximal stump after it has been divided in situations where regenerating axons are impeded from re-entering the distal stump.”1 A number of unknown factors make certain patients more susceptible to neuroma formation. In addition, certain nerves such as the superficial radial nerve are more prone to the development of a painful neuroma. Treatment of neuromas of the hand is important because they can be quite debilitating and painful, often preventing patients from continuing with their normal daily activities. There are a number of approaches to the painful neuroma, and the treatment plan must be tailored to the individual patient.

Computer-Assisted Navigation of Volar Percutaneous Scaphoid Placement

Musa Citak, Karsten Knobloch — 2010-03-01

We read with great interest the recent experimental work regarding the computer-assisted navigation of volar percutaneous scaphoid screw placement. We would appreciate the opportunity to comment on some issues raised by the authors. The authors explain that 10 cadaver wrists were randomized to either computer-assisted volar percutaneous scaphoid screw placement or traditional volar percutaneous screw placement. In fact, it is of importance what type of cadaver wrist was used. Studies have highlighted that fresh-frozen specimens should be rewarmed for at least 48 hours before use. During measurement, the temperature must be stable and controlled. Cadaver wrists that are not fully rewarmed do not necessarily move as much as fully rewarmed cadaver wrists are expected to move. A comment by the authors would be greatly appreciated in this regard.

In Reply

Eric Walsh, Joseph J. Crisco, Scott W. Wolfe — 2010-03-01

We address the 3 issues presented by Dr. Citak and Dr. Knobloch as follows: Temperature of cadaver specimens

Small Finger Metacarpal Neck Fractures

Jeffrey E. Budoff — 2010-03-01

I read with interest the article by Beredjiklian. After reviewing extensive clinical data that indicated little or no problem with residual deformity, Dr. Beredjiklian favored surgical treatment for a fracture with 40° of angulation and no rotational malalignment, according to a rationale based on 2 cadaveric studies. I was puzzled that, after noting that cadaveric biomechanical studies often do not translate to the clinical setting, he remained concerned about this degree of angulation.

In Reply

Pedro K. Beredjiklian — 2010-03-01

I thank Dr. Budoff for his letter and for his interest in this article. Dr. Budoff's concern seems to be that my recommendation for surgical treatment in this particular case was not appropriate because my opinion relied on cadaveric studies and is contrary to his experience. I strongly disagree.

Two-Dimensional Versus Three-Dimensional Computed Tomography

Viroj Wiwanitkit — 2010-03-01

I read the recent publication by Lindenhovius et al with a great interest. The authors concluded that “Three-dimensional computed tomography [CT] reconstructions improve interobserver agreement with respect to fracture classification compared with 2-dimensional CT.” Indeed, there are some previous reports comparing 2-dimensional and 3-dimensional CT. Doornberg et al found similar results in the scenario of distal humeral fracture. However, there are some concerns. First, it is still a question as to whether the sequence of testing, “first with radiographs and 2-dimensional CT and then with radiographs and 3-dimensional CT,” influences the perception of the observer. The order might reflect the experience of the observer and therefore affect the results. Second, the usefulness of using 3-dimensional CT relative to the additional cost for this investigation is a topic that needs to be discussed.

In Reply

Anneluuk Lindenhovius, David Ring — 2010-03-01

Thank you for the opportunity to clarify these important points, and we apologize that our coverage of these issues was unclear in the article. As stated, we randomized the order of presentation of 3-dimensional or 2-dimensional CT scans; thus, approximately half of the observers had a 1st round with 2-dimensional images, and the other half a 1st round with 3-dimensional images. As noted in the Discussion, the addition of a 3-dimensional reconstruction resulted in an increase of approximately 20% in costs. A true accounting for costs would need to account for the fact that proper initial treatment may decrease the overall medical costs. It is worth noting that 3-dimensional images are simple to make with the appropriate software, and some surgeons have learned to do this on their own.

Masthead

2010-03-01

Editorial Board

2010-03-01

Instructions to Authors

2010-03-01

Journal of Hand Surgery

Publication Bias in Kienböck's Disease: Systematic Review

The Incidence of Intrinsic and Extrinsic Ligament Injuries in Scaphoid Waist Fractures

Surgical Treatment of Pediatric Posttraumatic Palmar Midcarpal Instability: Case Report

A Cost-Utility Analysis of Nonsurgical Management, Total Wrist Arthroplasty, and Total Wrist Arthrodesis in Rheumatoid Arthritis

Arthroscopically Guided Osteotomy for Management of Intra-Articular Distal Radius Malunions

Comparison of Functional Outcome After Volar Plate Fixation With 2.4-mm Titanium Versus 3.5-mm Stainless-Steel Plate for Extra-Articular Fracture of Distal Radius

Congenital Pseudarthrosis of the Radius Treated With Gradual Distraction and Free Vascularized Fibular Graft: Case Report

Trans-Web Approach for Fixation of Avulsion Fractures of the Proximal Phalangeal Base: Report of Two Cases

Acellular Dermal Regeneration Template for Soft Tissue Reconstruction of the Digits

Irreducible Dislocation of the Thumb Interphalangeal Joint With Digital Nerve Interposition: Case Report

Rotation in the Interphalangeal Thumb Joint In Vivo

Responsiveness of the Michigan Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder, and Hand Questionnaire in Patients With Hand Injury

Percutaneous Carpal Tunnel Release Compared With Mini-Open Release Using Ultrasonographic Guidance for Both Techniques

Intrinsic Hand Muscle Reinnervation by Median-Ulnar End-to-Side Bridge Nerve Graft: Case Report

Recurrence of Giant Cell Tumors in the Hand: A Prospective Study

Quantitative Measurements of the Volume and Surface Area of the Radial Head

Nonsurgically Treated Terrible Triad Injuries of the Elbow: Report of Four Cases

Journal CME Instructions

Low-Level Laser Treatment

Journal CME Questions

More Experiments

Reconstruction of the Hypoplastic Thumb

Correction of the Typical Cleft Hand

Chemistry and Mechanics of Commonly Used Sutures and Needles

Journal CME Questions

Electrocautery Use in Hand Surgery: History, Physics, and Appropriate Usage

Treatment of Acute Peripheral Nerve Injuries: Current Concepts

Journal CME Questions

Neuromas of the Hand and Upper Extremity

Computer-Assisted Navigation of Volar Percutaneous Scaphoid Placement

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Small Finger Metacarpal Neck Fractures

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Two-Dimensional Versus Three-Dimensional Computed Tomography

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