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 Surgery0363-5023375May 2012 © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.jhandsurg.org/article/PIIS0363502312004297/abstract?rss=yes “What's in a name? That which we call a rose by any other name would smell as sweet.” Possibly so, but Juliet was not an anthropologist. “When I use a word, it means just what I choose it to mean—neither more nor less.” That worked for Humpty Dumpty, but he did not bill Medicare.Orthoses and Sex, Changes to ExpectRoy A. Meals10.1016/j.jhsa.2012.03.025Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Editorial881881http://www.jhandsurg.org/article/PIIS0363502312002237/abstract?rss=yes Purpose: To report the outcome and complications from pyrocarbon proximal interphalangeal (PIP) joint arthroplasty at a minimum of 2 years of follow-up. Methods: A retrospective case review was performed on 72 patients with an average age of 57 years, and a total of 97 pyrocarbon PIP joint arthroplasties. Patient demographics, diagnosis, implant revisions, and other repeat surgeries were recorded. Subjective outcome was evaluated at latest follow-up with the Disabilities of the Arm, Shoulder, and Hand score; Patient Evaluation Measure; and visual analog scores of pain, satisfaction, and appearance. Objective outcomes included PIP joint range of motion, grip strength, and radiographic assessment of alignment and loosening. Results: The principal diagnosis was primary osteoarthritis in 43 patients(60%), posttraumatic arthritis in 14 (19%), rheumatoid arthritis in 9 (13%), and psoriatic arthritis in 6 (8%). The average follow-up was 60 months (range, 24–108 mo). Twenty-two of 97 digits (23%) had repeat surgery without revision, and 13 digits (13%) had revision at an average of 15 months. There were no significant differences in preoperative and postoperative range of motion. The average Disabilities of the Arm, Shoulder, and Hand score was 22, and the average pain score was zero. Implant migration and loosening was observed but was not related to clinical outcome or revision. Conclusions: The survival of pyrocarbon PIP joint arthroplasty was 85% (83 of 97) at 5 years of follow-up, with high patient satisfaction. Patients should be advised that the procedure achieves good relief of pain but does not improve range of motion. Type of study/level of evidence: Therapeutic IV. Pyrocarbon Proximal Interphalangeal Joint Arthroplasty: Minimum Two-Year Follow-UpA.C. Watts, A.J. Hearnden, I.A. Trail, M.J. Hayton, D. Nuttall, J.K. Stanley10.1016/j.jhsa.2012.02.012Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Scientific Articles882888http://www.jhandsurg.org/article/PIIS0363502312002286/abstract?rss=yes Purpose: For nonsurgical treatment of fractures of the proximal phalanges of the triphalangeal fingers, different dynamic casts have been described. The main principle behind these casts is advancement and tightening of the extensor hood, caused by a combination of blocking the metacarpophalangeal joints in flexion and actively flexing the proximal interphalangeal joints. In contrast to established treatment protocols using functional forearm casts, the Lucerne cast allows for free mobilization of the wrist joint. The purpose of the current multicenter study was to compare the results of conservative, functional treatment using 2 different methods, either a forearm cast or a Lucerne cast. Methods: Over a 2-year-period, a prospective, randomized, multicenter study was conducted at 4 hospitals in Switzerland. Clinical and radiological results of 66 consecutive patients having 75 extra-articular fractures of the proximal phalanges were recorded through a minimum follow-up of 3 months. Intra-articular and physeal fractures, pathological fractures, open fractures, concomitant injuries of the tendons or collateral ligaments, and accidents more than 7 days before presentation were excluded from the study. Results: Radiographically, there were no statistically significant differences between the 2 groups in terms of palmar apex angulation and radial or ulnar angulation. There were no differences in total active range of finger motion. Wrist joint motion at the time of cast removal was statistically superior in patients treated with Lucerne cast. However, there were no significant differences in wrist joint motion at 12 weeks of follow-up. Conclusions: The clinical and radiological results achieved with the Lucerne cast are comparable to those of established treatment. Well-reduced, minimally angulated, or nonangulated fractures of the proximal phalanges of the fingers can be effectively treated using functional casts without immobilizing the wrist. Type of study/level of evidence: Therapeutic II. Extra-Articular Fractures of the Proximal Phalanges of the Fingers: A Comparison of 2 Methods of Functional, Conservative TreatmentT. Franz, U. von Wartburg, S. Schibli-Beer, F.J. Jung, A.R. Jandali, M. Calcagni, U. Hug10.1016/j.jhsa.2012.02.017Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles889898http://www.jhandsurg.org/article/PIIS0363502312002274/abstract?rss=yes Purpose: To study the configuration of the proximal interphalangeal joint volar plate (VP) in the crimp grip position (metacarpophalangeal joint at 0° to 45° flexion, proximal interphalangeal joint at 90° to 100° flexion, and distal interphalangeal joint at 0° to 10° hyperextension) using magnetic resonance imaging techniques in healthy volunteers and cadaver fingers and to compare the results with histological sections. Methods: Magnetic resonance imaging was performed on 24 fingers of 8 healthy volunteers and 12 fingers of 4 embalmed cadaver hands in the neutral position and in the crimp grip position. The translation of the VP body relative to the middle phalanx base during finger flexion was measured. In 6 of 12 cadaver specimens, a load of 10 N was applied to the flexor tendons to examine how this would affect the histological VP fiber configuration. Results: When the flexor tendons were under load in the crimp grip position, the volunteers' VP body was translated an average of 3.2 mm, and the cadaver fingers' VP body was translated an average of 3.0 mm, relative to the middle phalanx base in a distal direction. Histological analysis of the crimp grip position revealed reversing fibers in the VP insertion at the base of the middle phalanx when the flexor tendons were under load and the VP body was translated. When no load was applied in the crimp grip position, no translation of the VP body occurred. Conclusions: This article describes a VP translation in a distal direction relative to the middle phalanx base in the crimp grip position when the flexor tendons are under load. Clinical relevance: A more precise knowledge of the histological properties of the proximal interphalangeal joint VP during finger flexion can be expected to provide greater diagnostic capabilities and can lead to a better comprehension of injuries. Proximal Interphalangeal Joint Volar Plate Configuration in the Crimp Grip PositionThomas Bayer, Andreas Schweizer, Magdalena Müller-Gerbl, Georg Bongartz10.1016/j.jhsa.2012.02.016Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles899905http://www.jhandsurg.org/article/PIIS0363502312000603/abstract?rss=yes Purpose: Tendons repaired with varying amounts of tension result in different degrees of shortening of the tendon segment within core sutures, which may affect tensile strengths. We aimed to investigate the effects of tension across the repair site on gap formation forces and ultimate strength. Methods: Fifty-seven porcine flexor tendons were repaired with a 2-strand modified Kessler repair or a 4-strand cross-lock repair. For each type of repair, the tendons were divided into 3 groups: by 0%, 10%, or 20% shortening of tendon segment encompassed within core sutures. The repaired tendons had a single load-to-failure test in a materials testing machine. The forces required for initial and 2-mm gap formation and ultimate failure were recorded and statistically compared for each group. Results: With either 2-strand or 4-strand repair, the tendons in the 10% tendon-segment shortening group withstood significantly higher initial and 2-mm gap formation forces than those in the group with no shortening, with average increases of 5 to 10 N after 10% shortening. Increasing the tendon-segment shortening to 20% produced a slight increase in the initial and 2-mm gap forces compared with those with 10% shortening, which was statistically significant only in the tendons with the 4-strand repair. The ultimate strengths were not significantly different among the tendons with either 2-strand or 4-strand repair of any degrees of shortening. Conclusions: Tensioning the core suture to shorten its encompassed tendon segment by 10% substantially increases resistance to postoperative gapping. Further tensioning to produce 20% shortening of the tendon segment increased the gapping forces by a much smaller amount. This study suggests that a slightly tensioned surgical repair, shortening the encompassed tendon segment by approximately 10%, is appropriate. Clinical relevance: Slightly tensioning core sutures across the tendon repair site, such as adding tension to cause 10% tendon-segment shortening, would greatly increase the gap resistance of the surgical repair. Effects of Tension Across the Tendon Repair Site on Tendon Gap and Ultimate StrengthYa Fang Wu, Jin Bo Tang10.1016/j.jhsa.2012.01.004Journal of Hand Surgery 37, 5 (2012)2012-03-05Journal of Hand Surgery2012-03-05375S0363-5023(11)X0018-7Scientific Articles906912http://www.jhandsurg.org/article/PIIS0363502311016479/abstract?rss=yes Purpose: Palm and finger pulley anatomy has been well described in relation to osseous structures. The goal of this study was to describe skin surface markers that locate the underlying flexor tendon and pulley system. We describe the anatomic detail of these structures and provide a guide for the surgeon for making small incisions. Using this approach, extensile exposure can be avoided, and the integrity of the complex pulley system is maintained. Methods: We dissected 12 palms and 48 fingers in 12 cadaver hands. We marked the palm and finger creases with methylene blue before dissection. We removed palm skin, finger skin, and subcutaneous tissue over the flexor tendon sheath and retained a 2-mm strip of each skin crease in its native position. We divided the palm and palmar surface of the fingers into 4 distinct zones and measured the location of the proximal and distal extent of each pulley and the tendon anatomy relative to the proximal and distal skin crease. Results: We documented the location of the proximal and distal extent of the annular and cruciate pulleys as well as the decussation of the flexor digitorum superficialis (FDS) tendon and Camper chiasm. The results allow us to establish a relationship between the skin creases and underlying anatomy by dividing the palm and finger into 4 zones. In zone A, in the palm, the A2 pulley is located in the distal third and the FDS decussation is at the proximal extent of the A2 pulley. Zone B is in the proximal phalanx and A2 lies in the proximal third of this zone, whereas the Camper chiasm lies in the middle third. Zone C is in the middle phalanx and A4 and the insertion of FDS lie in the middle third of this zone. Zone D lies in the distal phalanx and the flexor digitorum profundus tendon inserts into the middle third of this zone. Conclusions: Skin creases can be used as surface markers to accurately locate the underlying pulley and tendon system and plan for limited incisions. Clinical relevance: These anatomic descriptions can aid surgeons in preoperative planning and may also help minimize the required exposure for flexor tendon repair and other surgery in the fingers and palm. Surface Markers for Locating the Pulleys and Flexor Tendon Anatomy in the Palm and Fingers With Reference to Minimally Invasive IncisionsJoshua A. Gordon, Lindsay Stone, Leonard Gordon10.1016/j.jhsa.2011.12.036Journal of Hand Surgery 37, 5 (2012)2012-02-27Journal of Hand Surgery2012-02-27375S0363-5023(11)X0018-7Scientific Articles913918http://www.jhandsurg.org/article/PIIS0363502312002134/abstract?rss=yes Purpose: To describe the incidence of reoperation and the demographic factors that may be associated with reoperation after flexor tendon repair. Methods: Using a New York statewide hospital administrative database covering an 8-year period, we examined unique patient discharges with an index procedure of flexor tendon repair for reoperation (re-repair or tenolysis). We compared the age, sex, race, and insurance type by reoperation status using standard univariate statistics and multivariate regression analysis. We performed trend analysis using the Cochran-Armitage trend test. Results: From 1998 to 2005, there were 5,229 flexor tendon repairs with a frequency of reoperation of 6%; of these, 91% were in the first year after the primary procedure. Those who underwent reoperation were significantly older than those who did not undergo reoperation. Patients with workers' compensation were 63% more likely to undergo reoperation than those with other forms of insurance. Patients who had concomitant nerve repair during the index procedure were 26% less likely to undergo reoperation. The rate of reoperation did not change during the study period. Conclusions: These results may be useful in shaping research agendas to evaluate sociodemographic factors contributing to reoperations. Type of study/level of evidence: Prognostic II. The Epidemiology of Reoperation After Flexor Tendon RepairChristopher J. Dy, Aaron Daluiski, Huong T. Do, Alexia Hernandez-Soria, Robert Marx, Stephen Lyman10.1016/j.jhsa.2012.02.003Journal of Hand Surgery 37, 5 (2012)2012-03-30Journal of Hand Surgery2012-03-30375S0363-5023(11)X0018-7Scientific Articles919924http://www.jhandsurg.org/article/PIIS0363502312000974/abstract?rss=yes Purpose: Tenosynovial fistulas in the palm are rare. If conservative treatment is unsuccessful, surgical treatment may include excision of the fistula and local flap coverage. In this article, I report 15 patients who were surgically treated for tenosynovial fistulas in the palm. Methods: Between 1996 and 2009, I treated 15 patients for tenosynovial fistulas in the palm. There were 9 women and 6 men, with an average age of 42 years (range, 21–63 y). The index finger was involved in 5 patients, the long finger in 7, and the ring finger in 3. One patient had a fish fin injury, 6 had multiple surgeries for release of stenosing flexor tenosynovitis with intraoperative steroid injections, 1 had a pellet gun injury, and 7 had lacerations in the distal palm. Four patients had had unsuccessful closure of the fistula. All patients presented with a distal palm sinus draining clear frothy fluid. There were no signs of infection. Gram stains and cultures were negative. Smear and culture for Mycobacterium marinum were negative in the patient who had the fish fin injury. I tried conservative treatment in all patients for an average of 7 weeks. All patients were treated with excision of the sinus tract with partial resection of the A1 pulley and soft tissue coverage with a transposition flap. Pathological examination revealed epithelialization with nonspecific chronic inflammation. Results: Postoperative follow-up averaged 59 months (range, 6–148 mo). All fistulas healed. Patients regained full range of motion and normal grip and pinch strength. One patient had transient tenderness of the scar for 3 months. There were no recurrences. Conclusions: Tenosynovial fistulas may develop after an injury to the flexor tendon sheath or following the use of steroids after release of trigger fingers recurring after an initial surgical release. Surgical treatment with excision of the fistula and local flap coverage yields excellent results. Type of study/level of evidence: Therapeutic IV. Flexor Tenosynovial Fistulas in the PalmNash H. Naam10.1016/j.jhsa.2012.01.010Journal of Hand Surgery 37, 5 (2012)2012-03-05Journal of Hand Surgery2012-03-05375S0363-5023(11)X0018-7Scientific Articles925929http://www.jhandsurg.org/article/PIIS0363502312001116/abstract?rss=yes Purpose: To obtain epidemiologic data on the Linburg-Comstock anomaly in Malaysia and to study the effect of the anomaly on key pinch strength. Methods: We examined 292 healthy subjects (162 female and 130 male) bilaterally for the presence of the Linburg-Comstock anomaly. Each subject's key pinch strength was measured bilaterally using a pinch meter. Results: The Linburg-Comstock anomaly was present in 101 of the 292 subjects (35%). Sixty-five subjects (22%) had it unilaterally, and 36 subjects (6%) had it bilaterally. The anomaly was associated with superior key pinch strength. Conclusions: The study provides epidemiologic data of this anomaly in Malaysia and considers its anatomical influence on key pinch strength. Type of study/level of evidence: Prognostic IV. The Linburg-Comstock Anomaly: Incidence in Malaysians and Effect on Pinch StrengthTze Hau Low, Nur Aida Faruk Senan, Tunku Sara Ahmad10.1016/j.jhsa.2012.01.020Journal of Hand Surgery 37, 5 (2012)2012-03-05Journal of Hand Surgery2012-03-05375S0363-5023(11)X0018-7Scientific Articles930932http://www.jhandsurg.org/article/PIIS036350231200130X/abstract?rss=yes Purpose: To investigate the influence of a dynamic splinting protocol on outcomes of extensor tendon repairs. Methods: All patients in a prospectively collected database underwent extensor tendon repair by a single surgeon between 2004 and 2008. The inclusion criterion was simple extensor tendon repairs in zone IV and V in the fingers and zones TI to TIII in the thumb. The tendon repairs used a 4-strand core technique and running epitendinous suture. Within 7 days, each subject began using a dynamic extension splint during the day and a static extension splint at night. The extension splint allowed the patient to passively extend and actively flex the digits. After 3 weeks, the dynamic splint was discontinued and the patients were started on active digital motion. Static night splinting was continued for the next 3 weeks, after which time splinting was discontinued and strengthening was instituted. A total of 17 patients with 19 tendon lacerations met the inclusion criterion. There were 5 patients with lacerations of the thumb extensors and 12 patients with zone IV/V finger extensor tendon lacerations. The average time from injury to surgery was 11 days (range, 2–39 d). The follow-up was 43 to 215 days, with an average of 96 days. Results: A total of 16 patients achieved good or excellent results by 6 weeks according to our grading system. One patient had a fair result. There were no ruptures and no tenolysis surgeries performed. Conclusions: Dynamic splinting resulted in generally good functional outcomes for extensor tendon laceration repairs in zone IV/V and TI to TIII, without complications. Type of study/level of evidence: Therapeutic IV. Dynamic Splinting With Early Motion Following Zone IV/V and TI to TIII Extensor Tendon RepairsValentin Neuhaus, Grace Wong, Katherine E. Russo, Chaitanya S. Mudgal10.1016/j.jhsa.2012.01.039Journal of Hand Surgery 37, 5 (2012)2012-04-01Journal of Hand Surgery2012-04-01375S0363-5023(11)X0018-7Scientific Articles933937http://www.jhandsurg.org/article/PIIS0363502312002250/abstract?rss=yes Purpose: To evaluate the incidence and anatomic insertion sites of extensor medii proprius and extensor indicis medii communis tendons to the long finger in cadaveric dissection and to describe the insertion of the extensor medii proprius. Methods: Thirty randomly selected adult cadavers, 44 upper extremities, were examined for the presence or absence of an anomalous extensor tendon to the long finger. If present, tendon origin and insertion sites were documented, and the width of the tendon was evaluated. Results: The extensor medii proprius was observed in 4 of 44 extremities, an incidence of 9%. The extensor indicis medii communis was observed in 7 of 44 extremities, an incidence of 16%. Tendon widths for both the extensor medii proprius and extensor indicis medii communis specimens ranged from 1.5 to 3.0 mm. Conclusions: The incidence of an anomalous slip of tendon to the long finger might be higher than previously reported, with a combined incidence of 25% in this cadaveric study. This anomalous slip can be a resource for surgical reconstruction. Clinical relevance: The presence of anomalous tendinous slips to the long finger can be easily overlooked. Understanding the anatomical relationships, incidence, and donor tendon availability of these anomalous tendons might aid with surgical planning. Anomalous Extensor Tendons to the Long Finger: A Cadaveric Study of IncidenceJoel C. Klena, John T. Riehl, John D. Beck10.1016/j.jhsa.2012.02.014Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles938941http://www.jhandsurg.org/article/PIIS036350231200216X/abstract?rss=yes Purpose: The incidence of extensor pollicis longus (EPL) tendon rupture in the setting of nondisplaced distal radius fractures is unknown. Extensor pollicis longus rupture is a known complication after distal radius fractures and is believed to occur more frequently after minimally displaced and nondisplaced distal radius fractures. Our study sought to define the incidence of EPL tendon rupture after nondisplaced distal radius fractures presenting to a level 1 trauma center. Methods: Using our billing database, we identified distal radius fractures presenting to our institution between 2006 and 2009. We reviewed injury radiographs to identify fractures in which radiographic measurements were within predefined radiographic norms. Two fellowship-trained orthopedic hand surgeons, 1 fellowship-trained musculoskeletal radiologist, and 1 senior orthopedic surgery resident then reviewed these fractures. Only those fractures thought by all 4 reviewers to be nondisplaced were classified as nondisplaced for the purposes of this study. We then reviewed charts of these nondisplaced fractures to identify patients who subsequently sustained an EPL tendon rupture. Results: We identified 3 EPL ruptures out of 61 nondisplaced fractures (5%). These occurred at an average of 6.6 weeks after distal radius fractures. Conclusions: The incidence of EPL rupture is higher than previously reported in the literature. Type of study/level of evidence: Therapeutic IV. Incidence of Extensor Pollicis Longus Tendon Rupture After Nondisplaced Distal Radius FracturesKevin M. Roth, Philip E. Blazar, Brandon E. Earp, Roger Han, Albert Leung10.1016/j.jhsa.2012.02.006Journal of Hand Surgery 37, 5 (2012)2012-04-01Journal of Hand Surgery2012-04-01375S0363-5023(11)X0018-7Scientific Articles942947http://www.jhandsurg.org/article/PIIS0363502312002808/abstract?rss=yes Purpose: To evaluate internal distraction plating for the management of comminuted, intra-articular distal radius fractures in patients greater than 60 years of age at two level 1 trauma centers. We specifically desired to determine whether patients would have acceptable results from the clinical standpoint of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and the radiographic measurements of ulnar variance, radial inclination, and palmar tilt. Our hypothesis was that distraction plating of comminuted distal radius fractures in the elderly would result in acceptable outcomes regarding range of motion, DASH score, and radiographic parameters and would, thereby, provide the upper extremity surgeon with another option for the treatment of these fractures. Methods: A retrospective review was performed on 33 patients over 60 years of age with comminuted distal radius fractures treated with internal distraction plating at two level 1 trauma centers. Patients were treated with internal distraction plating across the radiocarpal joint. At the time of final follow-up, radiographs were evaluated for ulnar variance, radial inclination, and palmar tilt. Range of motion, complications, and DASH scores were also obtained. Results: We treated 33 patients (mean age, 70 y) with distraction plating for comminuted distal radius fractures. At final follow-up, all fractures had healed, and radiographs demonstrated mean palmar tilt of 5° and mean positive ulnar variance of 0.6 mm. Mean radial inclination was 20°. Mean values for wrist flexion and extension were 46° and 50°, respectively. Mean pronation and supination were 79° and 77°, respectively. At final follow-up, the mean DASH score was 32. Conclusions: In the elderly, distraction plating is an effective method of treatment for comminuted, osteoporotic distal radius fractures. Type of study/level of evidence: Therapeutic IV. Distraction Plating for the Treatment of Highly Comminuted Distal Radius Fractures in Elderly PatientsMarc J. Richard, Leonid I. Katolik, Douglas P. Hanel, Daniel A. Wartinbee, David S. Ruch10.1016/j.jhsa.2012.02.034Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles948956http://www.jhandsurg.org/article/PIIS0363502312001190/abstract?rss=yes Purpose: The correlation between physician-observed parameters and patient-rated disability in distal radius fractures is complex and poorly understood. Anecdotal clinical experience suggests that supination is an important factor in the return of functional status after distal radius fracture. To explore this relationship, we conducted a retrospective multivariate linear regression analysis of an existing patient database to evaluate the hypothesis that range of motion and other objective parameters are important determinants of patient-rated disability. Methods: We analyzed a prospectively gathered registry of patients undergoing operative fixation of distal radius fractures using physical examination parameters measured at each follow-up visit and patient-based outcomes including Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and visual analog scale for pain. We constructed a multivariate linear regression model to evaluate the association of range of motion, grip strength, and visual analog scale score with the DASH score. Results: We analyzed data from 190 patients and 611 total clinic visits. Pain, grip strength, and supination were significantly correlated with DASH scores, controlling for all other factors. These 3 variables were able to predict 56% of the variability of the DASH score. Flexion-extension, radial-ulnar deviation, and pronation had no significant correlation to DASH score. Conclusions: Pain, strength, and supination appear to be important determinants of patient-rated outcomes after distal radius fracture. Pain and strength continuously improve over time up to 2 years after surgery, whereas supination plateaus more quickly, usually within the first 3 to 6 months. Type of study/level of evidence: Diagnostic II. The Effects of Pain, Supination, and Grip Strength on Patient-Rated Disability After Operatively Treated Distal Radius FracturesEric Swart, Kate Nellans, Melvin Rosenwasser10.1016/j.jhsa.2012.01.028Journal of Hand Surgery 37, 5 (2012)2012-03-12Journal of Hand Surgery2012-03-12375S0363-5023(11)X0018-7Scientific Articles957962http://www.jhandsurg.org/article/PIIS0363502312002651/abstract?rss=yes Purpose: To determine whether use of the dorsal tangential view improves the diagnostic accuracy of intraoperative fluoroscopy compared with conventional views in detecting dorsal screw penetrations during volar distal radius plating. Methods: Dorsal cortices of 10 cadaveric distal radii were penetrated in each of the second, third, and fourth dorsal extensor compartments at 0, 1, 2, and 3 mm penetration. We obtained 4 standardized fluoroscopic images of the wrist: lateral, supination, pronation, and dorsal tangential views. Using high-definition digital images, 2 observers blinded to the experimental paradigm determined whether screws were penetrating the dorsal cortex. Results: For screws that penetrated the floor of the second dorsal compartment, the 45° supination view was 92% sensitive for detecting screw penetration of 2 mm, and 98% for 3 mm. For screws that penetrated the third dorsal compartment, the lateral view was 68% and 80% sensitive in detecting screw penetrations of 1 and 2 mm, respectively. However, the dorsal tangential view showed 95% sensitivity for 1 mm and 98% for 2 mm penetrations. On the floor of the fourth dorsal compartment, pronation and dorsal tangential views were both 88% sensitive for 1 mm screw penetration and 90% and 93% for 2 mm, respectively. Conclusions: The standard lateral view of the wrist failed to detect all screw penetrations. The dorsal tangential view increased the accuracy of detecting screw penetrations on the floor of the third dorsal compartment, whereas we needed oblique views to detect screw penetrations on the floors of second and fourth dorsal compartments. Clinical relevance: Routine clinical use of the dorsal tangential view has the potential to increase accuracy in detecting dorsal screw penetration during volar plating of the distal radius. Comparison of 4 Fluoroscopic Views for Dorsal Cortex Screw Penetration After Volar Plating of the Distal RadiusKagan Ozer, Jennifer M. Wolf, Bruce Watkins, David J. Hak10.1016/j.jhsa.2012.02.026Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles963967http://www.jhandsurg.org/article/PIIS0363502312001323/abstract?rss=yes Purpose: To determine the reliability and efficacy of clenched-fist stress radiographs in patients with radioulnar ligament injury. Methods: We examined 30 patients with chronic radioulnar ligament injury. These patients underwent stress radiography, which included clenched-fist posteroanterior (PA) views in forearm pronation and computed tomography in pronation. We measured distal radioulnar joint (DRUJ) gap distance and ulnar variance using clenched-fist PA views. We measured the radioulnar ratio with pronated computed tomography to quantify dorsal translation of the ulnar head. We analyzed these radiographic data and compared them between the injured and contralateral sides. We examined test-retest reliability and interobserver and intraobserver reliability using intraclass correlation coefficients as a measurement of the DRUJ gap distance in clenched-fist PA views. Results: The DRUJ gap distance observed with clenched-fist PA views in injured wrists was significantly greater than in the contralateral side. The DRUJ gap distance observed with stress radiography significantly correlated with the magnitude of the radioulnar ratio in forearm pronation. We found a significant test-retest reliability for measuring DRUJ gap distance using clenched-fist PA views, as well as a significant level of intraobserver and interobserver reliability. Conclusions: The DRUJ gap distance observed with clenched-fist PA radiography in forearm pronation was a reliable parameter and may be useful for evaluating DRUJ instability. Type of study/level of evidence: Diagnostic II. Distal Radioulnar Joint Stress Radiography for Detecting Radioulnar Ligament InjuryAkio Iida, Shohei Omokawa, Manabu Akahane, Kenji Kawamura, Katsutoshi Takayama, Yasuhito Tanaka10.1016/j.jhsa.2012.01.041Journal of Hand Surgery 37, 5 (2012)2012-03-30Journal of Hand Surgery2012-03-30375S0363-5023(11)X0018-7Scientific Articles968974http://www.jhandsurg.org/article/PIIS0363502312002845/abstract?rss=yes Purpose: Radiographic carpal chondromalacia (RCC) was defined as the presence of cortical sclerosis or subchondral changes, such as a lucent defect or cystic changes in a carpal on plain radiographs. The purpose of this study was to investigate the factors associated with the occurrence of RCC in idiopathic ulnar impaction syndrome and to determine the efficacy of ulnar shortening osteotomy on patient outcome and RCC. Methods: Thirty-nine patients (42 wrists) with idiopathic ulnar impaction syndrome were treated with either ulnar shortening osteotomy or arthroscopic wafer resection. Patients were divided into 2 groups according to the presence (RCC group; 17 patients, 19 wrists) or absence (non-RCC group: 22 patients, 23 wrists) of RCC on preoperative radiographs. To determine the factors associated with RCC, a comparative analysis of these 2 groups was performed with respect to sex, age, duration of symptoms, positive ulnar variance, pain scores, and Chun and Palmer grading system. The RCC area was measured on serial radiographs taken during follow-up. Progressive changes of RCC area and clinical outcomes were evaluated. Results: Patients in the RCC group were older, exhibited greater positive ulnar variance, and demonstrated a significantly higher mean pain score before surgery. The RCC was found to reverse over the year following ulnar shortening osteotomy and did not recur up to 2 years after surgery. In 3 wrists, RCC had completely disappeared at the last follow-up. All patients showed improved clinical outcomes. Conclusions: The RCC changes correlated with older age, a positive ulnar variance, and preoperative pain severity. The RCC progressively reversed after ulnar shortening osteotomy, and this reversal of radiographic changes correlated with clinical improvements. Type of study/level of evidence: Therapeutic IV. Radiographic Appearance and Patient Outcome After Ulnar Shortening Osteotomy for Idiopathic Ulnar Impaction SyndromeJung Il Lee, Dong Hun Suh, Joon Sung Byun, Ji Hoon Bae, Jae Young Hong, Jung Ho Park, Jong Woong Park10.1016/j.jhsa.2012.02.038Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Scientific Articles975981http://www.jhandsurg.org/article/PIIS0363502311016467/abstract?rss=yes Purpose: The contralateral unaffected side is often used as a reference in planning a corrective osteotomy of a malunited distal radius. Two-dimensional radiographs have proven unreliable in assessing bilateral symmetry, so we assessed 3-dimensional configurations to assess bilateral symmetry. Methods: We investigated bilateral symmetry using 3-dimensional imaging techniques. A total of 20 healthy volunteers without previous wrist injury underwent a volumetric computed tomography of both forearms. The left radius and ulna were segmented to create virtual 3-dimensional models of these bones. We selected a distal part and a larger proximal part from these bones and matched them with a mirrored computed tomographic image of the contralateral side. This allowed us to calculate the relative displacements (Δx, Δy, Δz) and rotations (Δφx, Δφy, Δφz) for aligning the left bone with the right bone segments. We investigated the relation between longitudinal length differences in radiuses and ulnas. Results: Relative differences of the radiuses were (Δx, Δy, Δz): −0.81 ± 1.22 mm, −0.01 ± 0.64 mm, and 2.63 ± 2.03 mm; and (Δφx, Δφy, Δφz): 0.13° ± 1.00°, −0.60° ± 1.35°, and 0.53° ± 5.00°. The same parameters for the ulna were (Δx, Δy, Δz): −0.22 ± 0.82 mm, 0.52 ± 0.99 mm, 2.08 ± 2.33 mm; and (Δφx, Δφy, Δφz): −0.56° ± 0.96°, −0.71° ± 1.51°, and −2.61° ± 5.58°. There is a strong relation between absolute length differences (Δz) between the radiuses and ulnas of individuals. Conclusions: We observed substantial length and rotational differences around the longitudinal bone axis in healthy individuals. Surgical planning using the unaffected side as a reference may not be as useful as previously assumed. However, including the length difference of the adjacent forearm bones can be useful in improving length correction in computer-assisted planning of radius or ulna osteotomies and in other reconstructive surgery procedures. Clinical relevance: Bilateral symmetry is important in reconstructive surgery procedures where the contralateral unaffected side is often used as a reference for planning and evaluation. Three-Dimensional Assessment of Bilateral Symmetry of the Radius and Ulna for Planning Corrective SurgeriesJ.C. Vroemen, J.G.G. Dobbe, R. Jonges, S.D. Strackee, G.J. Streekstra10.1016/j.jhsa.2011.12.035Journal of Hand Surgery 37, 5 (2012)2012-03-01Journal of Hand Surgery2012-03-01375S0363-5023(11)X0018-7Scientific Articles982988http://www.jhandsurg.org/article/PIIS0363502312002584/abstract?rss=yes Purpose: To define the pronosupination arc for various types of forearm immobilization. We hypothesized that these methods of immobilization offer control of forearm pronosupination proportional to the loss of elbow motion, and that the Muenster cast may offer the most practical method of limiting forearm motion without eliminating elbow motion. Methods: We enrolled 15 subjects in the study. We took measurements using computerized biometrics with the elbow free of immobilization and in a long-arm cast, a Muenster cast, a removable splint set to 90° elbow flexion, and a splint set to allow elbow flexion permissible by the Muenster cast. We recorded measurements for pronation and supination arcs. Results: We obtained average pronosupination arcs for the unrestricted elbow (189°), long arm cast (11°), Muenster cast (35°), removable splint set to 90° (124°), and splint set to the flexion-extension arc of the Muenster cast (139°). We found statistically significant differences for pronation and supination for all comparisons between immobilization methods, with the exception of the splints compared with each other. The least motion was found in the long-arm cast, whereas the Muenster cast offered the only option allowing minimal pronosupination without strict elbow immobilization. Conclusions: The Muenster cast offers reasonable immobilization of the forearm without fully immobilizing the elbow. The long-arm cast option offers significantly more forearm stability at the cost of any elbow motion. The 2 splints tested do not effectively immobilize the forearm compared with the other modalities tested. Clinical relevance: This study provides good biomechanical support for using a Muenster cast when limiting forearm rotation is desirable. Biomechanical Measurements of Forearm Pronosupination With Common Methods of ImmobilizationAron M. Trocchia, John C. Elfar, Warren C. Hammert10.1016/j.jhsa.2012.02.019Journal of Hand Surgery 37, 5 (2012)2012-04-09Journal of Hand Surgery2012-04-09375S0363-5023(11)X0018-7Scientific Articles989994http://www.jhandsurg.org/article/PIIS0363502312001311/abstract?rss=yes Stress fractures in the forearm are rare events. Failure to detect a nondisplaced stress fracture could lead to further injury or fracture displacement. We present a case of a 15-year-old male wrestler without overt risk factors, who presented with a transverse stress fracture in the middle third of the radial diaphysis. The clinician should consider this diagnosis when examining athletes with otherwise unexplained forearm pain. Stress Fracture of the Radius Diaphysis in a Skeletally Immature WrestlerKathleen E. McKeon, Michael T. Talerico, Ryan P. Calfee10.1016/j.jhsa.2012.01.040Journal of Hand Surgery 37, 5 (2012)2012-04-01Journal of Hand Surgery2012-04-01375S0363-5023(11)X0018-7Scientific Articles995998http://www.jhandsurg.org/article/PIIS0363502312002833/abstract?rss=yes Anterior transolecranon fracture dislocation of the elbow is relatively uncommon in children. We reviewed the experience over the past 5 years at our institution in treating this injury to identify pediatric variants and outline a rational treatment strategy. We found 2 pediatric variants to the injury pattern and determined that tension band constructs can successfully be used to treat certain pediatric transolecranon fracture dislocations. The pediatric variants identified in this report are fracture dislocations with associated medial epicondyle fracture and radial neck fracture. We recommend a heightened vigilance in looking for a fracture through the ulna when an anterior dislocation is present, as physeal injuries can be challenging to see on plain radiographs. Pediatric Variants of the Transolecranon Fracture Dislocation: Recognition and Tension Band Fixation: Report of 3 CasesMatthew A. Butler, Jeffrey E. Martus, Jonathan G. Schoenecker10.1016/j.jhsa.2012.02.037Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Scientific Articles9991002http://www.jhandsurg.org/article/PIIS0363502312001177/abstract?rss=yes Purpose: Reconstruction of triceps function in persons with tetraplegia is an established surgical intervention. The purpose of this study was to investigate and evaluate patient perspective of gains in activity and satisfaction after surgical reconstruction of triceps function and subsequent rehabilitation. Methods: We studied the effects of surgery and rehabilitation in 14 persons (19 arms) treated with deltoid-to-triceps transfer. We used Canadian Occupational Performance Measurement standards to capture the performance and satisfaction of patient-identified activity goals. Follow-up was performed at 6 and 12 months postoperatively. To make group analyses, we classified activity goals according to the International Classification of Function, Disability, and Health categories of activities and participation, as well as relative to the position of the arm in space. Results: Patients reported improvement in performance after surgery, and satisfaction was rated even higher. Improvement was seen in all types of activities that patients had prioritized. No single goal was rated lower at 12 months' follow-up than before surgery. The most common activity gains were related to “driving a wheelchair” and the ability to “reach out,” each of which represented 20% of expressed goals. Although “driving a wheelchair” and “moving the body” (transfers) were common goals, the smallest improvements for both performance and satisfaction after 12 months were seen in these areas. We observed the highest performance improvement in the category of “writing” and the ability to “stretch out the arm when lying down.” Conclusions: Improvement in activity continues over the first year after triceps reconstruction. Complex activities continue to improve over a longer period than simpler activities. We saw the highest improvement in activities performed without the aid of gravity and activities highly dependent on coordination. Such actions are difficult to compensate for by technique or skills, and therefore elbow extension is essential for performance. Type of study/level of evidence: Therapeutic IV. Activity Gains After Reconstructions of Elbow Extension in Patients With TetraplegiaJohanna Wangdell, Jan Fridén10.1016/j.jhsa.2012.01.026Journal of Hand Surgery 37, 5 (2012)2012-03-15Journal of Hand Surgery2012-03-15375S0363-5023(11)X0018-7Scientific Articles10031010http://www.jhandsurg.org/article/PIIS036350231200264X/abstract?rss=yes We present the case of a 61-year-old woman with a subacute elbow dislocation, who was referred to our institution 4 weeks after a fall. She was treated with open reduction and temporary bridging internal fixation through a posterior approach with a limited contact dynamic compression plate. After 4 weeks, the hardware was removed. One year postoperatively, the patient had nearly pain-free motion of 20° short of full extension and full flexion. Her radiographs showed residual incongruity and degenerative arthritis of the elbow. Open Reduction and Temporary Internal Fixation of a Subacute Elbow DislocationValentin Neuhaus, Arnold Alqueza, Chaitanya S. Mudgal10.1016/j.jhsa.2012.02.025Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles10111014http://www.jhandsurg.org/article/PIIS0363502312002158/abstract?rss=yes Purpose: In fractures of the radial head and neck requiring open reduction and internal fixation, osteosynthesis may be safely applied in a limited zone. We conducted a morphometric study of the proximal radius at the level of the safe zone to identify different morphologic types of this anatomical region. Methods: We analyzed 44 dried cadaveric radii. We measured the whole length of the radius, the length of the neck and head, and the minimum and maximum diameter of the radial head. The morphologic aspect of the neck–head curvature of the safe zone was evaluated qualitatively and quantitatively. Results: The proximal radius at the level of the safe zone exhibited different radii of bending. In particular, we identified a morphologic type A, which showed a flat profile (25% of cases), morphologic types B and C, which showed a low concave curvature (64%), and a marked concave curvature (11%), respectively, of the safe zone. Conclusions: The profile of the proximal radius in the safe zone shows substantial morphologic variations that should be taken into account when operating on fractures of the proximal radius, to avoid malunions, pain, and stiffness of the elbow joint. A preoperative radiograph of the contralateral uninjured radius may be helpful in selecting the most appropriate internal fixation device to reconstruct the proximal radius after comminuted fractures. Clinical relevance: Knowledge of the proper bending radius of the safe zone allows the surgeon to select the most appropriate plate, and to achieve good fracture reduction and anatomical restoration of the proximal radius. Anatomical Variations of the Proximal Radius and Their Effects on OsteosynthesisGiuseppe Giannicola, Erica Manauzzi, Federico M. Sacchetti, Alessandro Greco, Gianluca Bullitta, Annarita Vestri, Gianluca Cinotti10.1016/j.jhsa.2012.02.005Journal of Hand Surgery 37, 5 (2012)2012-03-30Journal of Hand Surgery2012-03-30375S0363-5023(11)X0018-7Scientific Articles10151023http://www.jhandsurg.org/article/PIIS0363502312002602/abstract?rss=yes Purpose: Radiocapitellar arthroplasty has been proposed as a reconstructive option for combined radial head and capitellar deficiency. The purpose of this study was to assess the impact of radiocapitellar replacement on elbow kinematics. We hypothesized that with the medial collateral ligament (MCL) intact, radiocapitellar arthroplasty would replicate normal kinematics, and that a radiocapitellar arthroplasty would more closely approximate normal kinematics than an elbow with a deficient lateral column or with a deficient MCL. Methods: We tested 7 cadaveric arms in an upper extremity joint simulator. Each arm underwent computed tomographic scanning to aid implant size selection and computer-assisted implant insertion. We obtained kinematic data using an electromagnetic tracking system during elbow flexion. The capitellar and radial head implants were placed through an extended lateral epicondylar osteotomy. We sectioned the anterior bundle of the MCL, leaving the flexor-pronator mass intact. Outcomes of interest were varus-valgus and rotational kinematics of the ulnohumeral joint. Results: The radiocapitellar arthroplasty showed no difference in kinematics compared with the postosteotomy control. The MCL-deficient elbow showed more valgus angulation and more external ulnar rotation than the control or radiocapitellar arthroplasty in the pronated, valgus loaded position. The deficient lateral column demonstrated increased external ulnar rotation kinematics during active elbow flexion. Conclusions: Radiocapitellar arthroplasty can restore normal elbow kinematics with the MCL intact. If the MCL is deficient, radiocapitellar arthroplasty does not restore normal kinematics. Clinical relevance: Radiocapitellar arthroplasty should be considered in cases of lateral column deficiency because it maintains normal elbow kinematics during active motion. Whereas radiocapitellar arthroplasty improves the stability of the MCL-deficient elbow with deficiency of the lateral column, reconstruction of the MCL may further improve normal kinematics. Elbow Kinematics After Radiocapitellar ArthroplastyM.T. Sabo, H. Shannon, S. De Luce, E. Lalone, L.M. Ferreira, J.A. Johnson, G.J.W. King10.1016/j.jhsa.2012.02.021Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles10241032http://www.jhandsurg.org/article/PIIS0363502312002791/abstract?rss=yes Purpose: The medial femoral condyle flap is used for treatment of nonunions with or without intercalary bone loss. Most reported uses have been without a skin segment, but this flap can provide a skin component supplied by the saphenous artery branch (SAB) of the descending genicular artery (DGA) pedicle. Experience with this flap suggests that an additional distinct, reliable, more-distal, DGA-cutaneous branch can be found at condyle level, capable of supporting skin without using the SAB. This cadaver study evaluated SAB and DGA-cutaneous branch angiosome territories. A clinical case series assesses the DGA-cutaneous branch's clinical utility. Methods: The DGA and SAB were isolated in 12 cadaveric legs, divided, and separately cannulated. Red dye and methylene blue were selectively injected into each vessel manually. Skin perfusion was measured and photographed. Results: In all specimens, the DGA was present, originating 14.2 cm proximal to the joint line, and demonstrated a distinct cutaneous branch at condyle level. This vessel provided an average perfusion area of 70 cm2, centered over the medial knee. The SAB was identified in 11 specimens (92%), with an average perfusion area of 361 cm2 along the medial aspect of the distal thigh and proximal leg. The DGA communicating branch was present and used for perfusion of the skin paddle in 17 of 20 cases. The SAB was present in 18 of 20 cases, used with DGA-communicating branch in 4 cases, and the sole source of skin perfusion in 1 case. In 2 remaining cases, neither the SAB nor DGA communicating branch was adequate for perfusion of a skin segment. Conclusions: The medial femoral condyle flap can be harvested with a large skin paddle based on the SAB. A smaller skin segment can be harvested using the more distal DGA-communicating branch at condyle level. Clinical relevance: Improved understanding of the skin island associated with the DGA's saphenous and cutaneous branches can provide a rapid, reliable method of skin-segment harvest. Cutaneous Angiosome Territory of the Medial Femoral Condyle Osteocutaneous FlapMatthew L. Iorio, Derek L. Masden, James P. Higgins10.1016/j.jhsa.2012.02.033Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles10331041http://www.jhandsurg.org/article/PIIS0363502312002201/abstract?rss=yes Purpose: To investigate the results of resurfacing completely degloved digits using a parallelogram free flap from the medial arm in a spiral fashion. Methods: We reviewed the reconstruction of 26 digits in 21 patients with a parallelogram free flap from the medial arm in a spiral fashion following a non-replantable degloving injury. Results: The sizable perforator was observed consistently in the medial arm with 13 of 21 (62%) originating from the superior ulnar collateral artery, 6 of 21 (29%) directly from the brachial artery, and 2 of 21 (9%) from the superficial brachial artery. All the flaps but one, which sustained partial flap loss, survived uneventfully. Total active motion ranged from 93° to 145° and 112° to 154° in the cases with and without metacarpophalangeal joint involvement, respectively. The static 2-point discrimination test varied from 6 to 13 mm. No scar contracture was recorded in these patients. All the patients were satisfied with the overall results. Conclusions: Resurfacing the defect in a spiral fashion is a valuable and reliable technique for the reconstruction of complete finger degloving injuries. The medial arm flap is a good candidate for this procedure, with satisfactory functional recovery and good aesthetic restoration. Type of study/level of evidence: Therapeutic IV. Reconstruction of Totally Degloved Fingers With a Spiraled Parallelogram Medial Arm Free FlapZhenglin Chi, Weiyang Gao, Hede Yan, Zhijie Li, Xinglong Chen, Feng Zhang10.1016/j.jhsa.2012.02.010Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles10421050http://www.jhandsurg.org/article/PIIS0363502312002638/abstract?rss=yes Hydatid cyst caused by Echinococcus granulosus is a parasitic disease that can affect different organs. It is difficult to diagnose and has a tendency to recur. Primary bone involvement occurs in 0.5% to 4.0% of all patients with hydatid cysts. We present a 31-year-old woman with a primary hydatid cyst in the left scaphoid. Despite the availability of advanced imaging and laboratory investigation modalities (such as magnetic resonance imaging and serological studies) to make an adequate differential diagnosis of a cystic lesion in our case, intraoperative clinical suspicion led to the diagnosis. This was followed by a successful outcome without recurrence after 12 months. Primary Hydatid Cyst of the Scaphoid: Case ReportMehmet Bulut, H. Bayram Tosun, Bengu Cobanoglu Simsek, Lokman Karakurt10.1016/j.jhsa.2012.02.024Journal of Hand Surgery 37, 5 (2012)2012-04-06Journal of Hand Surgery2012-04-06375S0363-5023(11)X0018-7Scientific Articles10511053http://www.jhandsurg.org/article/PIIS0363502311016522/abstract?rss=yes Purpose: Self-inflicted wrist or forearm laceration is a specific type of injury presenting to emergency departments. Many investigators have described wrist-cutting from a psychiatric viewpoint. We hypothesized that the character of patients with deep wounds is different from those with superficial wounds. We investigated patients who cut their wrist or forearms as an act of self-mutilation from the viewpoint of wound severity. Methods: We reviewed 31 patients with self-inflected wrist injuries who were treated in our medical center from 2004 through 2009. We divided them into 2 groups: deep (15 patients) and superficial (16 patients). We investigated differences in age and gender, sites of self-cutting, frequency of self-injury attempts, object used for wrist cutting, group psychiatric parameters, required wound treatments, and psychiatric history and follow-up. Results: Younger patients were more likely to have injured themselves severely compared with older patients. Differences in clinical findings between deep and superficial injury groups included the following: (1) all male patients had deep injuries; (2) patients with superficial wounds were more likely to have cut themselves previously; (3) patients in the deep injury group tended to injure themselves at multiple sites; (4) patients in the deep injury group tended to perform self-cutting with any sharp-edged object at hand; (5) 50% of our patients had received no psychiatric care before being seen by us for their injury; and (6) one-third discontinued the psychiatric treatment prematurely. Conclusions: There are differences between patients who perform self-inflicted deep versus superficial wrist cutting. We also found that the ages and psychiatric diagnoses of our patients differed from previous reports. This is likely because the available literature includes only patients who received psychiatric care. We found that 50% of our patients had received no psychiatric care, which highlights the importance of hand surgeons treating these patients to initiate psychiatric consultation. Evaluation of Superficial and Deep Self-Inflicted Wrist and Forearm LacerationsMasaki Fujioka, Chikako Murakami, Kana Masuda, Hanako Doi10.1016/j.jhsa.2011.12.040Journal of Hand Surgery 37, 5 (2012)2012-03-05Journal of Hand Surgery2012-03-05375S0363-5023(11)X0018-7Clinical Perspective10541058http://www.jhandsurg.org/article/PIIS0363502312002213/abstract?rss=yesEarly in my career, i treated an Amish farmer from Lancaster, Pennsylvania, who had amputated 3 digits. After successful digital replantation, the farmer noted that his community did not carry medical insurance and he had limited financial resources. Would I accept handmade quilts as payment? I agreed, and the women of his community held a quilting bee to produce 3 quilts (), one for each digit replanted.Hand Made: Three QuiltsJohn S. Taras10.1016/j.jhsa.2012.02.011Journal of Hand Surgery 37, 5 (2012)2012-04-01Journal of Hand Surgery2012-04-01375S0363-5023(11)X0018-7A Touch of Humanity10591059http://www.jhandsurg.org/article/PIIS0363502312001670/abstract?rss=yesIt has often been stated that physicians generally do not take care of themselves, and when they do fall ill, it is with great reluctance that they seek help. As physicians, we are conditioned to solve problems and pride ourselves in our ability to make instantaneous decisions for our patients on a daily basis. We are also proud of our ability to execute complicated procedures with precision while achieving excellent outcomes. However, even with our expert skills, there are moments when we are presented with scenarios that push us beyond our physical and mental limits. Falling ill and being unable to perform is far removed from a surgeon's characteristic mental state, and when this occurs it can help bring life and the importance of work into perspective.First Hand: Illness Befallen a Hand SurgeonKevin C. Chung10.1016/j.jhsa.2012.02.001Journal of Hand Surgery 37, 5 (2012)2012-03-29Journal of Hand Surgery2012-03-29375S0363-5023(11)X0018-7A Touch of Humanity10601061http://www.jhandsurg.org/article/PIIS0363502312002663/abstract?rss=yesA string figure is a form created by manipulating a loop of string around one's fingers or sometimes between the fingers of multiple people (). The origin of string figures is not known; string figures have been identified in ancient cultures all over the world.Hand Made: String Figures—Strings, Loops, and Knots Beyond the Sterile FieldShafic A. Sraj10.1016/j.jhsa.2012.02.027Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7A Touch of Humanity10621063http://www.jhandsurg.org/article/PIIS036350231200500X/abstract?rss=yesJournal CME Instructions10.1016/S0363-5023(12)00500-XJournal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-710641064http://www.jhandsurg.org/article/PIIS0363502311010896/abstract?rss=yesA 40-year-old, right-handed man sustained a laceration over the palmar surface of the middle phalanx of his right middle finger. The wound was sutured in a local emergency room, and he presented 3 months later complaining of an inability to actively flex the distal interphalangeal (DIP) joint of the middle finger. Our examination found that he had full active proximal interphalangeal (PIP) joint flexion and extension but no active DIP joint flexion. Passive motion of the DIP joint was 0° to 45° of flexion. The patient was unhappy with his inability to actively flex the DIP joint of the digit and wanted to discuss options for surgical correction.Management of Late-Presenting Isolated Flexor Digitorum Profundus InjuriesMichael V. Birman, Robert J. Strauch10.1016/j.jhsa.2011.08.034Journal of Hand Surgery 37, 5 (2012)2011-10-24Journal of Hand Surgery2011-10-24375S0363-5023(11)X0018-7Evidence-Based Medicine10651067http://www.jhandsurg.org/article/PIIS0363502311015000/abstract?rss=yesA 46-year-old, right hand–dominant woman presents to the emergency room with pain in the right index finger. It started 3 days prior and has progressively worsened. Examination reveals a tender, swollen, and erythematous eponychium. A purulent collection seems to be present under the nailfold, but not under the nail plate itself, with no active drainage. The erythema does not extend proximal to the distal interphalangeal joint. Radiographs are normal except for some soft tissue swelling dorsally in the region described.Acute ParonychiaAndrew W. Ritting, Michael P. O'Malley, Craig M. Rodner10.1016/j.jhsa.2011.11.021Journal of Hand Surgery 37, 5 (2012)2012-02-10Journal of Hand Surgery2012-02-10375S0363-5023(11)X0018-7Evidence-Based Medicine10681070http://www.jhandsurg.org/article/PIIS0363502312004431/abstract?rss=yesJournal CME Questions10.1016/j.jhsa.2012.03.033Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Evidence-Based Medicine10701070http://www.jhandsurg.org/article/PIIS0363502312002778/abstract?rss=yes Ulnar impaction is a common condition encountered by hand surgeons. Historically, treatment of this condition has been with wafer resection of the distal ulna, by either open or arthroscopic means, or diaphyseal ulnar shortening osteotomy; however, both of these have the potential for prolonged recovery or a need for additional procedures. Wafer procedures, whether done by open or arthroscopic techniques, can result in hemarthrosis, and diaphyseal osteotomies can require hardware removal. Recently, Slade and Gillon described a technique of ulnar shortening in the osteochondral region of the ulnar head, which offers advantages over previously used techniques. The purpose of this manuscript is to describe this technique, as well as pearls and pitfalls associated with the procedure. To more accurately describe the location of the osteotomy, we have changed the name of the procedure from Dr. Slade's original description to distal metaphyseal ulnar-shortening osteotomy. Distal Metaphyseal Ulnar-Shortening Osteotomy: Surgical TechniqueWarren C. Hammert, Richard B. Williams, Jeffrey A. Greenberg10.1016/j.jhsa.2012.02.031Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Surgical Technique10711077http://www.jhandsurg.org/article/PIIS036350231200278X/abstract?rss=yes Children with arthrogryposis often lack the ability to feed themselves, largely due to limited shoulder external rotation and elbow flexion. Patients who can achieve passive elbow flexion through a surgical release but who cannot externally rotate their shoulders are still unable to reach their mouths with their hands. Combining a posterior elbow capsular release with a simultaneous humeral osteotomy in these patients places the forearm and hand in a much better position for function with minimal additional surgical exposure. Posterior Elbow Release and Humeral Osteotomy for Patients With ArthrogryposisDan A. Zlotolow, Scott H. Kozin10.1016/j.jhsa.2012.02.032Journal of Hand Surgery 37, 5 (2012)2012-04-09Journal of Hand Surgery2012-04-09375S0363-5023(11)X0018-7Surgical Technique10781082http://www.jhandsurg.org/article/PIIS0363502312000615/abstract?rss=yesPyoderma gangrenosum (pg) is a rare, painful, ulcerative lesion that is frequently misdiagnosed by hand surgeons as an infection. It usually occurs on the trunk and lower extremities but occasionally appears on the hand. Misdiagnosis can lead to considerable morbidity—specifically, unnecessary treatments, multiple ineffective surgeries, and possible amputation.Pyoderma GangrenosumLindley B. Wall, Peter J. Stern10.1016/j.jhsa.2011.12.044Journal of Hand Surgery 37, 5 (2012)2012-02-27Journal of Hand Surgery2012-02-27375S0363-5023(11)X0018-7In Brief10831085http://www.jhandsurg.org/article/PIIS0363502312001219/abstract?rss=yesMore than 80,000 nonobstetric surgical procedures requiring anesthesia in pregnant patients occur in the United States every year, but the decision to perform such surgery is fraught with concern about maternal and fetal well-being. Although elective surgery should be delayed until after delivery, pregnancy is not a contraindication to necessary surgery. A large meta-analysis on nonobstetric surgery in pregnancy found that maternal mortality is less than 1 in 10,000, surgery does not increase the risk of major birth defects, and surgery and general anesthesia are not major risk factors for spontaneous abortion.Hand Surgery: Considerations in Pregnant PatientsCasey J. Humbyrd, Dawn M. LaPorte10.1016/j.jhsa.2012.01.030Journal of Hand Surgery 37, 5 (2012)2012-03-12Journal of Hand Surgery2012-03-12375S0363-5023(11)X0018-7In Brief10861089http://www.jhandsurg.org/article/PIIS0363502312004443/abstract?rss=yesJournal CME Questions10.1016/j.jhsa.2012.03.034Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7In Brief10891089http://www.jhandsurg.org/article/PIIS0363502312002894/abstract?rss=yes Scaphoid fractures that fail to unite are at risk of developing avascular necrosis and progressive structural collapse, thereby complicating attempts at revision surgical treatment. Vascularized bone grafts have demonstrated utility in promoting consolidation in the treatment of scaphoid nonunions complicated by avascular necrosis. Numerous pedicled and free vascularized grafts have been described with variable, but generally favorable, outcomes. Understanding the indications for different grafts is critical to the successful application of these techniques and grafts in the treatment of challenging scaphoid nonunions. Vascularized Bone Grafts for Scaphoid NonunionsD.B. Jones, P.C. Rhee, A.Y. Shin10.1016/j.jhsa.2012.03.001Journal of Hand Surgery 37, 5 (2012)2012-04-09Journal of Hand Surgery2012-04-09375S0363-5023(11)X0018-7Current Concepts10901094http://www.jhandsurg.org/article/PIIS0363502312002900/abstract?rss=yes The primary risk factor for nonunion of the scaphoid is displacement/instability, but delayed or missed diagnosis, inadequate treatment, fracture location, and blood supply are also risk factors. Untreated nonunion leads to degenerative wrist arthritis—the so-called scaphoid nonunion advanced collapse wrist. However, the correlation of symptoms and disease is poor; the true “natural history” is debatable because we evaluate only symptomatic patients presenting for treatment. It is not clear that surgery can change the natural history, even if union is attained. The diagnosis of nonunion is made on radiographs, but computed tomography or magnetic resonance imaging scans can be useful to assess deformity and blood supply. Treatment options vary from percutaneous fixation to open reduction and internal fixation with vascularized or nonvascularized bone grafting to salvage procedures involving excision and/or arthrodesis of carpals. Management of Scaphoid NonunionGeert A. Buijze, Lidewij Ochtman, David Ring10.1016/j.jhsa.2012.03.002Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Current Concepts10951100http://www.jhandsurg.org/article/PIIS0363502312004455/abstract?rss=yesJournal CME Questions10.1016/j.jhsa.2012.03.035Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Current Concepts11011101http://www.jhandsurg.org/article/PIIS0363502312002122/abstract?rss=yes Excellence with an Edge is not the usual medical book that you find reviewed in these pages. Rather than dealing with hand surgery itself, it challenges you to think of new ways of conceiving the practice of hand surgery as the business of hand surgery, both from a purely financial viewpoint and from a service to the customer viewpoint.David L. Nelson10.1016/j.jhsa.2012.02.002Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Book Review11021103http://www.jhandsurg.org/article/PIIS0363502312004340/abstract?rss=yesI read with interest the article by Stone et al, entitled “The Effect of Botulinum Neurotoxin-A on Blood Flow in Rats: A Potential Mechanism for Treatment of Raynaud Phenomenon.” The authors introduce the possible mechanism of botulinum toxin-A for treatment of Raynaud phenomenon. They are to be commended for their efforts.Letter Regarding “The Effect of Botulinum Neurotoxin-A on Blood Flow in Rats: A Potential Mechanism for Treatment of Raynaud Phenomenon”Tae Hwan Park10.1016/j.jhsa.2012.03.030Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Letters to the Editor11041105http://www.jhandsurg.org/article/PIIS0363502312004339/abstract?rss=yesWe thank Dr. Park for a careful review of our article and an insightful commentary on the actions of botulinum toxin-A. Dr. Park suggested that botulinum toxin may also have a substantial role in angiogenesis through a Rho-GTPase–mediated pathway. We also found evidence supporting the role of Rho-GTPases in angiogenesis through multiple mechanisms involved in increasing vascular permeability through the formation of new vessels. Although the Clostridium exoenzyme C3 inhibits Rho-GTPase activity through ADP-ribosylation in laboratory studies, we could find no references demonstrating that botulinum toxin-A directly increases angiogenic factors through Rho inhibition. Our report examined the effects of botulinum toxin-A on vasodilation by sympathetic neural inhibition, and not through angiogenesis. Dr. Park's proposed mechanism is intriguing, but it is unlikely to be responsible for the rapid vasodilation observed with botulinum toxin-A; nevertheless, this mechanism may have a role in the longer-term clinical improvement reported with botulinum toxin-A. We hope that Dr. Park will continue to explore the proposed mechanism and look forward reading the findings.In ReplyAustin V. Stone10.1016/j.jhsa.2012.03.029Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Letters to the Editor11051105http://www.jhandsurg.org/article/PIIS0363502312002298/abstract?rss=yesThere has been considerable interest in the treatment of Dupuytren contracture by collagenase Clostridium histolyticum therapy. I am not a hand surgeon, but I thought it would be of interest to report an experience of my 56-year-old niece who has had Dupuytren contracture for several years, mainly affecting the fingers of her left hand. Hard nodules are present over the proximal phalanges of these fingers, and extension of the index, middle, and ring fingers is limited by 20° at the metacarpophalangeal joints and a further 20° at the proximal interphalangeal joints. She had surgical correction to her little finger, which was more severely affected, although with little improvement.Partial Improvement of Dupuytren Contracture Following a Wasp StingDavid K.C. Cooper10.1016/j.jhsa.2012.02.018Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Letters to the Editor11051106http://www.jhandsurg.org/article/PIIS0363502312004352/abstract?rss=yesIn the article by Marzke MW, Tocheri MW, Marzke RF, and Femiani JD that appeared in the January 2012 issue of the Journal (“Three-Dimensional Quantitative Comparative Analysis of Trapezial-Metacarpal Joint Surface Curvatures in Human Populations,” J Hand Surg 2012;37A:72–76), editorial processing erroneously replaced the word sex with gender. The second paragraph of the Materials and Methods section should read, “In contrast to previous studies of TM joint variability in humans, the joint surfaces lack articular cartilage and notable evidence for osteoarthritis. Joint surface eburnation and osteophytes were minimal throughout the sample. When sex was known from cadaver records or other standard osteological criteria, we pooled male and female specimens from the population samples to examine whether sex contributes to significant differences in joint surface curvatures.” The opening 2 sentences in the third paragraph of the Discussion section should read, “The lack of significant sex difference in TM joint curvature in our sample is consistent with findings reported for cartilage-covered metacarpal joint surfaces in 2 previous studies.4,10 However, these studies did find significant sex differences in trapezial surface curvature.” The title of Table 5 should read “Pairwise Comparisons of Normalized Mean Curvatures, by Sex” and columns 1 and 2 of this table should have the headings “Sex A” and “Sex B.” The Journal has taken steps to prevent the repetition of this error.Erratum10.1016/j.jhsa.2012.03.031Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7Erratum11061106http://www.jhandsurg.org/article/PIIS0363502312004546/abstract?rss=yesMasthead10.1016/S0363-5023(12)00454-6Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7FrontmatterA2A2http://www.jhandsurg.org/article/PIIS0363502312004558/abstract?rss=yesEditorial Board10.1016/S0363-5023(12)00455-8Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7FrontmatterA4A4http://www.jhandsurg.org/article/PIIS036350231200456X/abstract?rss=yesTable of Contents10.1016/S0363-5023(12)00456-XJournal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7FrontmatterA7A7http://www.jhandsurg.org/article/PIIS0363502312004571/abstract?rss=yesInstructions to Authors10.1016/S0363-5023(12)00457-1Journal of Hand Surgery 37, 5 (2012)2012-05-01Journal of Hand Surgery2012-05-01375S0363-5023(11)X0018-7FrontmatterA20A24