Journal of Hand Surgery

Finding Joy in Your Hand Surgery Practice

Terry R. Light — 2010-01-15

Richard smith and Adrian Flatt were my heroes and friends as I embarked upon my hand surgery career. Early in my practice, each provided encouragement and guidance to me. I am grateful to have the opportunity to recognize both for their kindness and dedication to hand surgery.

Rate of Infection After Carpal Tunnel Release Surgery and Effect of Antibiotic Prophylaxis

Neil G. Harness, Maria C. Inacio, Faith F. Pfeil, Liz W. Paxton — 2010-02-01

Purpose: To determine the rate of postoperative wound infection and the association with prophylactic antibiotic use in uncomplicated carpal tunnel release surgery.Methods: We performed a multicenter, retrospective review of all the carpal tunnel release procedures performed between January 1, 2005, and August 30, 2007. Data reviewed included the use of prophylactic antibiotics, diabetic status, and the occurrence of postoperative wound infection. We determined the overall antibiotic usage rate and analyzed the correlation between antibiotic use and the development of postoperative wound infection.Results: The rate of surgical site infections in the 3003 patients who underwent carpal tunnel release surgery (group A) was 11. Antibiotic usage data were available for 2336 patients (group B). Six patients without prophylactic antibiotics had infection, as did 5 patients with prophylactic antibiotics. This difference was not statistically significant. Of the 11 surgical site infections, 4 were deep (organ/space) and 7 superficial (incisional). The number of patients with diabetes in the overall study population was 546, 3 of whom had infections. This was not statistically different from the nondiabetic population infection rate (8 patients).Conclusions: The overall infection rate after carpal tunnel release surgery is low. In addition, the deep (organ/space) infection rate is much lower than previously reported. Antibiotic use did not decrease the risk of infection in this study population, including patients with diabetes. The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated. Surgeons should carefully consider the risks and benefits of routinely using prophylactic antibiotics in carpal tunnel release surgery.Type of study/level of evidence: Therapeutic III.

Dynamics of Intracarpal Tunnel Pressure in Patients With Carpal Tunnel Syndrome

Ben C. Goss, John M. Agee — 2009-12-21

Purpose: To measure pressure within the carpal tunnel (intracarpal tunnel pressures) in patients with carpal tunnel syndrome and determine the effect of quantified active hand use on both the magnitude and location of peak pressures, before and after division of the transverse carpal ligament.Methods: We measured intracarpal tunnel pressures intraoperatively in 12 patients with carpal tunnel syndrome at 5 standardized locations based on the distance between each patient's proximal pisiform and hook of hamate (HH) before endoscopic division of the ligament, using a semiconductor gauge pressure sensor inserted from proximal to distal into the tunnel under fluoroscopic control. At each location, pressure was recorded with fingers extended, fingers flexed, and 50% maximum grip using a grip dynamometer. Additional hand use activities, including maximum key and pulp pinch using a pinch dynamometer, 25% maximum grip, and maximum grip, were performed by a subset of these patients. After ligament division, we measured pressures during the same hand activities at a single location, HH. We analyzed the effect of hand activity, measurement location, and ligament division using repeated measures analysis of variance.Results: Compared with fingers extended (mean pressure, 56 mm Hg), all pinch and grip activities caused significant increases in pressure at HH, with a mean peak pressure of 1151 mm Hg during maximum grip. After endoscopic release, pressures decreased significantly at HH for all hand activities.Conclusions: In patients with carpal tunnel syndrome, intracarpal tunnel pressures during active hand use are substantially greater than previously reported. Peak pressures occur at the HH, where the tunnel is most constricted and the median nerve is most compressed in carpal tunnel syndrome.Type of study/level of evidence: Therapeutic IV.

Five-Year Follow-Up of Carpal Tunnel Release in Patients Over Age 65

Robert A. Weber, Daniel J. DeSalvo, Malcolm J. Rude — 2010-01-11

Purpose: In 2005, a prospective clinical trial with a 6-month follow-up demonstrated the efficacy of carpal tunnel release in patients 65 years and older and showed that age is not a contraindication to surgery. The purpose of this study was to determine whether there was any further improvement, maintenance of results, or recurrence of carpal tunnel symptoms 5 years after surgery.Methods: We contacted all 66 patients (with a total of 92 hands involved) from the original study to be enrolled for re-evaluation. Of the original cohort, 12 were unavailable because of death or severe neurologic impairment. Of the remaining 54 patients, 19 agreed to participate in this follow-up study of their 29 hands. For the 5-year follow-up, patients underwent a repeat history and physical examination with particular emphasis on the status of their hands over the past 5 years. The Michigan Hand Outcome Questionnaire was again used to determine overall hand function, activities of daily living, work performance, pain, aesthetics, and satisfaction with hand function.Results: The mean age of patients available for 5-year follow-up was 78 ± 3 years. The patients maintained their symptom improvement, demonstrating no significant difference between the 6-month and 5-year follow-up data; their physical findings, except for grip strength, were likewise unchanged. The patients also retained their improved 2-point discrimination. Scar tenderness decreased over the 5 years. The Michigan Hand Outcome Questionnaire confirmed the fact that initial postoperative improvement in all parameters persisted at least 5 years. One patient underwent repeat carpal tunnel release of 1 hand for recurrent symptoms. Overall, 94% of patients were either very or completely satisfied with their results.Conclusions: Patients who were 65 years of age or older at the time of surgery maintained their clinical improvement for at least 5 years after surgery.Type of study/level of evidence: Therapeutic IV.

Intra- and Inter-Examiner Variability in Performing Tinel's Test

Scott D. Lifchez, Kenneth R. Means, Reginald E. Dunn, Eric H. Williams — 2010-02-01

Purpose: The Tinel sign was adopted in the early 1950s to detect sites of nerve compression. There have been few attempts to standardize how one elicits Tinel's sign. The goal of this study was to evaluate intra- and inter-examiner variability in the force generated using different techniques to elicit Tinel's sign.Methods: Nine clinicians, consisting of 3 experienced hand and peripheral nerve surgeons, 3 junior hand and peripheral nerve surgeons, and 3 surgeons in training were included in the study. Three different Tinel-type maneuvers were evaluated: (1) striking the load cell using the dominant middle finger only (“single-finger strike”), (2) using the dominant index and middle finger together (“double-finger strike”), and (3) preloading with the nondominant thumb and then striking the thumb with the dominant middle finger (“preload”). Test subjects were instructed to use their customary range of force during the testing. Each subject performed 3 sets of 5 strikes per technique.Results: There was a significant difference in nearly all subjects between the range of force generated with single- or double-finger techniques and preload technique. There was also a difference in nearly all subjects when comparing the range of forces using the single-and double-finger techniques. In addition, there were large differences in the range of forces produced by the examiners for each technique.Conclusions: There is no standardization for eliciting the Tinel sign. This study demonstrates considerable intra- and inter-examiner differences in the range of forces generated by the different Tinel's techniques that are used in clinical practice. This variability might explain clinical differences between examiners in the ability to obtain a Tinel sign in a patient and might explain the inconsistency of sensitivity and specificity reported for Tinel's sign. Further research on standardization is needed, and future study protocols using Tinel's sign should take these findings into account.

Single-Incision Extensile Volar Approach to the Distal Radius and Concurrent Carpal Tunnel Release: Cadaveric Study

2010-02-01

Purpose: To determine whether a single-incision extensile approach to the distal radius used for open reduction internal fixation and a concomitant radial sided carpal tunnel (CT) release safely and effectively decompresses the carpal tunnel.Methods: Five pairs of cadaveric forearms were mounted to a tabletop with a cable pulley system attached to the long finger. Each paired specimen was randomized to volar plating via either the flexor carpi radialis approach (control group) or the extensile volar exposure (combined flexor carpi radialis and radial-sided carpal tunnel release). Before and after the respective exposure and plating, increased CT pressures were created with 2.27, 4.54, and 6.81 kg of distraction. We used a paired t-test to compare the change in CT pressure at each level of distraction before and after intervention for the 2 groups, with significance set at p ≤ .05. A dissection of each exposure was performed with attention given to the radial aspect of the transverse carpal ligament (TCL) and any possible iatrogenic injuries.Results: Carpal tunnel pressure increased with increasing distraction. We noted a statistically significant reduction in CT pressure after the extensile exposure and plating with 4.54 (p = .023) and 6.81 (p < .001) kg of distraction, respectively. No significant reduction in mean CT pressure for the control group specimens occurred at any level of distraction force. The average length of the radial TCL was 22 mm (range, 18–31 mm); the average distance between the recurrent motor branch and distal TCL was 11 mm (range, 8–15 mm). No iatrogenic tendon or nerve injury occurred with the extensile volar exposure.Conclusions: Carpal tunnel pressure is safely reduced and the distal radius is adequately exposed for fixation with the extensile volar approach.

Clinical Impact of United Versus Nonunited Fractures of the Proximal Half of the Ulnar Styloid Following Volar Plate Fixation of the Distal Radius

Geert A. Buijze, David Ring — 2010-01-15

Purpose: Distal radius fractures are often associated with a fracture of the ulnar styloid at its base. This study tested the null hypothesis that there is no difference in outcome between patients with union and nonunion of a fracture of the proximal half of the ulnar styloid 6 months after volar plate fixation of a fracture of the distal radius.Methods: A total of 36 consecutive patients with fractures of both distal radius and the proximal half of the ulnar styloid enrolled in 1 of 2 clinical trials evaluating volar plate fixation of the distal radius had no treatment of the ulnar styloid fracture. Six months after surgery, wrist function was assessed using the Mayo wrist score and the Gartland and Werley score system, and arm-specific health status was measured using the Disabilities of the Arm, Shoulder, and Hand questionnaire. Pain was assessed on a 10-point ordinal scale. Nonunion of the fracture of the proximal half of the ulnar styloid was defined as no signs of consolidation on 6-month postoperative radiographs. At the 6-month follow-up, patients were assessed for overall wrist function but not specifically for ulnar-sided wrist problems or stability.Results: Sixteen ulnar styloid fractures had united, and 20 had not. There were no differences in demographic and injury characteristics. There were no significant differences in motion; strength; Gartland and Werley scores; Mayo scores; Disabilities of the Arm, Shoulder, and Hand scores; or pain scores 6 months after fracture.Conclusions: Nonunion of a fracture of the proximal half of the ulnar styloid has no effect on wrist function, pain, and upper extremity–specific health status 6 months after volar plate fixation of a fracture of the distal radius.Type of study/level of evidence: Therapeutic III.

Correlation of Malrotation Deformity in Distal Radius Fractures With Radiographic Analysis: Cadaveric Study

Steve K. Lee, Robert Shin, Alissa Zingman, Justin Loona, Martin A. Posner — 2010-01-11

Purpose: The radiographic parameters commonly used for evaluating distal radius fractures are radial length, palmar tilt, radial inclination, and articular congruity. Rotation of the distal fragment is not routinely evaluated after distal radius fractures. The purpose of this study was to define the appearance of distal fragment malrotation on conventional radiographs and to correlate varying degrees of malrotation with the corresponding radiographic findings.Methods: Six distal radiuses from embalmed cadavers were cut and stabilized in 10°, 20°, and 30° of pronated malrotation. Posteroanterior, lateral, and oblique (45° pronated view) radiographs were taken and radiographic measurements were made of radial length, palmar tilt, radial inclination, and rotation.Results: With malrotation, the visible cortical width of the distal fragment mismatched the visible cortical width of the proximal fragment. This was most evident on the oblique view (p < .05) and measured 2.2 mm for 10° of rotation (standard deviation [SD] 0.6), 3.4 mm for 20° of rotation (SD 0.8), and 5.3 mm for 30° of rotation (SD 2.2).Conclusions: The radiographic parameter of rotation should be considered when evaluating distal radius fracture reduction. Malrotation is best seen on a 45° oblique pronated radiographic view as a mismatch of the cortical width of the distal fragment compared with the cortical width of the proximal fragment. In the absence of radial shortening, a 5.3-mm mismatch is associated with 30° of malrotation and is the upper limit of acceptability.

Delayed-Onset Ulnar Neuropathy at the Wrist Associated With Distal Radioulnar Joint Arthritis After Radius Malunion: Report of Two Cases

2010-02-01

Although ulnar neuropathy can occur at the wrist in association with distal radius fractures, few late-onset cases have been reported. The authors describe 2 cases of delayed-onset ulnar neuropathy at the wrist, which developed 12 and 30 years after sustaining a conservatively treated distal radius fracture. During late neurolysis, both patients were found to have a perforation in the volar wrist capsule and synovitis and arthritis in the distal radioulnar joint.

Conformational Changes in the Carpus During Finger Trap Distraction

2010-02-01

Purpose: Wrist distraction is a common treatment maneuver used clinically for the reduction of distal radial fractures and midcarpal dislocations. Wrist distraction is also required during wrist arthroscopy to access the radiocarpal joint and has been used as a test for scapholunate ligament injury. However, the effect of a distraction load on the normal wrist has not been well studied. The purpose of this study was to measure the three-dimensional conformational changes of the carpal bones in the normal wrist as a result of a static distractive load.Methods: Using computed tomography, the dominant wrists of 14 healthy volunteers were scanned at rest and during application of 98 N of distraction. Load was applied using finger traps, and volunteers were encouraged to relax their forearm muscles and to allow distraction of the wrist. The motions of the bones in the wrist were tracked between the unloaded and loaded trial using markerless bone registration. The average displacement vector of each bone relative to the radius was calculated, as were the interbone distances for 20 bone–bone interactions. Joint separation was estimated at the radiocarpal, midcarpal, and carpometacarpal joints in the direction of loading using the radius, lunate, capitate, and third metacarpal.Results: With loading, the distance between the radius and third metacarpal increased an average of 3.3 mm ± 3.1 in the direction of loading. This separation was primarily in the axial direction at the radiocarpal (1.0 mm ± 1.0) and midcarpal (2.0 mm ± 1.7) joints. There were minimal changes in the transverse direction within the distal row, although the proximal row narrowed by 0.98 mm ± 0.7. Distraction between the radius and scaphoid (2.5 mm ± 2.2) was 2.4 times greater than that between the radius and lunate (1.0 mm ± 1.0).Conclusions: Carpal distraction has a significant (p < .01) effect on the conformation of the carpus, especially at the radiocarpal and midcarpal joints. In the normal wrist, external traction causes twice as much distraction at the lunocapitate joint than at the radiolunate joint.

Differential Strain of the Axially Loaded Scapholunate Interosseus Ligament

2010-01-11

Purpose: To directly measure strain changes in the scapholunate ligament via magnetic resonance imaging (MRI) when axially loading the wrist in the neutral and extended positions.Methods: Six asymptomatic male volunteers without known history of previous wrist injury were enrolled in this MRI-based study. Each subject underwent 3 MRI scans in a 3T scanner: in resting neutral position, in neutral with axial load applied, and in extension with axial load applied. Axial load was applied via extension of an elastic band with known force/elongation curve. We analyzed images and converted them to 3-dimensional stereolithographs. Attachment points of the palmar, proximal, and dorsal sections of the scapholunate interosseus ligament (SLIL) were identified. The lengths of the resulting vectors were recorded for each position. Strain, defined as change in length divided by original length, was calculated for the axially loaded neutral and extended wrists. We used the Bonferroni adjusted multiple comparisons from an analysis of variance model, with statistical significance defined as p < .05.Results: Strains were significantly greater in the palmar (p = .02) and proximal (p = .01) subregions of the SLIL in loaded extension versus loaded neutral positions. In contrast, the strain on the dorsal component in extension was not statistically greater than in the neutral position (p = .45). Axial load in neutral resulted in minimal strain of all 3 components of the SLIL complex, and these were not significantly different from each other (p > .99). With extension, the strains of the palmar (p = .03) and proximal (p = .006) regions were statistically greater than that of the dorsal component.Conclusions: In extension, strain is greatest in the palmar and proximal portions of the intact SLIL. Axial load in neutral applies minimal strain to the SLIL complex. Avoiding axial loading in extension and encouraging loading in neutral position may allow for decreased injury and more effective healing of the scapholunate ligament.

Gender Differences in Carpal Height Ratio in a Taiwanese Population

2010-02-01

Purpose: To discover whether there is a significant difference in carpal height ratio (CHR) between men and women aged 20 to 50 years.Methods: We retrospectively reviewed 261 cases of normal plain wrist radiographs and measured the CHR using the Picture Achieving and Communication System. Each case was then stratified by gender and age (20–29, 30–39, and 40–50 y).Results: The mean CHR was 0.52 ± 0.03 for men (range, 0.43–0.59), 0.50 ± 0.03 for women (range, 0.43–0.57), and 0.51 ± 0.03 for the total population (range, 0.43–0.59). The difference in CHR between men and women was statistically significant (p<.01). However, there was no significant difference (p=.13) among age groups in either men or women.Conclusions: We recommend using gender-specific norms (ie, 0.52 ± 0.03 for men and 0.50 ± 0.03 for women, respectively) for CHR. Without gender specification, a subtle abnormality may be overlooked in men, and there may be an overdiagnosis of carpal disorder in women. Further investigations are needed to look into possible racial differences, because our study is based on a homogeneous ethnic Chinese population.

A Radiocarpal Ligament Reconstruction Using Brachioradialis for Secondary Ulnar Translation of the Carpus Following Radiocarpal Dislocation: A Cadaver Study

Steven D. Maschke, Kenneth R. Means, Brent G. Parks, Thomas J. Graham — 2010-01-11

Purpose: Radiocarpal dislocation damages the radiocarpal ligaments, typically eliminating the possibility for repair. The goals of this study were to create a model for ulnar translation of the carpus and design a soft-tissue reconstruction using the brachioradialis (BR) to prevent ulnar translation of the carpus. We primarily sought to recreate the stabilizing effect of the radioscaphocapitate ligament.Methods: Eight cadaveric upper limbs were dissected, leaving only the BR tendon. The wrist was loaded perpendicular to the long axis of the forearm, and load-displacement curves for ulnar translation were generated. The radiocarpal ligaments were sectioned. Substantial ulnar translation was seen only after complete release of the palmar and dorsal radiocarpal ligaments. Reconstruction was performed with the BR tendon, maintaining the insertion on the radial styloid. The proximal tendon stump was brought distally through a drill hole in the center of the capitate, palmar to dorsal, and secured to the dorsal rim of the radius with a suture anchor. The specimens were then retested after this reconstruction. Qualitative evaluation of graphs plotted, mini c-arm fluoroscopy, and visual observation was also performed.Results: Comparison of the intact specimens and the specimens after sectioning of the radiocarpal ligaments revealed a significant difference between mean ulnar translation (11.1 mm vs 18.4 mm; p < 0.05). Comparison of the sectioned specimens before and after BR reconstruction demonstrated a statistically significant difference in mean ulnar translation (18.4 mm vs 10.6 mm; p < 0.05). Comparison of the intact specimens and the specimens after sectioning-reconstruction did not demonstrate a significant difference, indicating that the BR reconstruction re-established the stability seen in the intact specimens with regard to ulnar translation (11.1 mm vs 10.6 mm; p > 0.05).Conclusions: The model consistently produced significant ulnar translation after division of the radiocarpal ligaments. The BR reconstruction was primarily designed to restore the function of the radioscaphocapitate ligament. This biomechanical study demonstrates the ability of this reconstruction to generate a statistically significant restraint to ulnar translation in a cadaver model of radiocarpal dislocation.

Effects of Distal Radius Bone Graft Harvest on the Axial Compressive Strength of the Radius

Landon T. Horne, Peter M. Murray, Subrata Saha, Kathryn Sidhar — 2010-02-01

Purpose: The effect of metaphyseal cancellous bone graft harvest on distal radius compressive strength is unknown. The purpose of this study was to analyze, in a cadaveric model, changes in distal radius axial compressive strength after distal radius metaphyseal cancellous bone graft harvest.Methods: We randomized 15 matched pairs of cadaveric radiuses into 2 groups. In group I, a target harvest of 25% of the total metaphyseal cancellous bone volume was attempted through a standardized oval cortical window. In group II, a target of 50% harvest was attempted. The study specimens and their matched controls from the contralateral side were loaded to failure in axial compression. The amount of bone graft harvested was calculated. The resulting ultimate loads to failure were measured, then expressed as ultimate stress (millipascals – MPa). We analyzed data for the 2 groups and the matched controls using paired Student's t-tests.Results: A smaller amount of bone was harvested than anticipated in both groups. The final average distal radius bone graft harvest for group I was 10%, and for group II, 22.5%. Group I had no statistically significant difference in ultimate stress compared with the contralateral specimens that acted as matched controls (p = .273). Group II had a statistically significant decrease in ultimate stress values compared with matched controls (p = .002). The ultimate stress of group I averaged 92.67% of its matched control, whereas the ultimate stress of group II was 74.8% of its matched control (p = .027).Conclusions: A significant decrease in distal radius ultimate stress occurs when approximately 23% of the metaphyseal cancellous bone is removed through a standardized oval cortical window. When the distal radius is chosen as the bone graft harvest site, we recommend harvest of less than 25% of the total available distal radius metaphyseal cancellous bone to prevent alteration of the load characteristics of the bone.

Role of Low-Affinity Nerve Growth Factor Receptor Inhibitory Antibody in Reducing Pain Behavior and Calcitonin Gene-Related Peptide Expression in a Rat Model of Wrist Joint Inflammatory Pain

2010-01-11

Purpose: Nerve growth factor (NGF), via the high-affinity receptor, tyrosine kinase A, has been widely reported as a mediator of pain caused by inflammation. A clinical trial has suggested that anti-NGF antibody is effective for pain caused by osteoarthritis of the knee. However, adverse events such as headache (8.9%), upper respiratory tract infection (7.3%), and paresthesia (6.8%) were reported. We hypothesized that inhibition of the low-affinity NGF receptor, p75 neurotrophin receptor (p75NTR), is also effective for joint pain and may reduce side effects. This study examined suppression of pain behavior and expression of pain-inducing neuropeptides such as calcitonin gene-related peptide (CGRP) and p75NTR in dorsal root ganglia neurons by a p75NTR inhibitory antibody in a rat model of wrist joint inflammatory pain.Methods: We injected complete Freund's adjuvant (CFA) into the wrist joint of rats and used this as a model of inflammatory pain. We applied 10 μL of saline (CFA + saline group; n = 20) or 1, 10, or 50 μL of a p75NTR inhibitory antibody (CFA + p75NTR inhibitory antibody group; n = 40) directly to the inflamed joint in the rats. Mechanical hyperalgesia was measured for 2 weeks using von Frey filaments. We assessed CGRP and p75NTR expression in C8 dorsal root ganglia immunochemically. Adverse events such as loss of weight and/or appetite, constipation, and infection were examined.Results: p75NTR inhibitory antibody reduced mechanical hyperalgesia caused by CFA (p<.05 vs controls) in the rat model (p<.01 vs saline), without any adverse events. We found that 10 and 50 μL of a p75NTR inhibitory antibody were more effective for pain, without a significant difference between doses. CGRP and p75NTR immunoreactivity was upregulated in the CFA + saline groups compared with a control group (p<.01). However, direct p75NTR inhibitory antibody application decreased CGRP and p75NTR expression after wrist inflammation (p<.01).Conclusions: p75NTR inhibition may be a therapeutic target for inflamed joint pain treatment with reduced adverse events.

Tardy Palsy of Descending Branch of Posterior Interosseous Nerve: Sequela to Plate Osteosynthesis of Forearm Bones

Hitesh Lal, Pankaj Bansal, Rahul Khare, Deepak Mittal — 2010-02-01

We report a case of tardy paralysis of the descending branch of the posterior interosseous nerve as a consequence of plate osteosynthesis for fracture of both bone forearms. The patient had been operated on 23 years earlier and palsy occurred after a gap of 19 years. The most probable antecedent cause of the palsy was the use of a high-profile implant. The patient was treated by removal of the plate and tendon transfer.

Functional Outcomes After Upper Extremity Surgery for Cerebral Palsy: Comparison of High and Low Manual Ability Classification System Levels

2010-02-01

Purpose: The heterogeneity of cerebral palsy makes interpretation and prediction of outcome after upper extremity surgery difficult. We hypothesized that the outcome of upper extremity surgery for cerebral palsy is related to the Manual Ability Classification System (MACS) level.Methods: We reviewed 27 patients with a mean age of 22 years, who underwent upper extremity surgery for spastic cerebral palsy at a mean follow-up of 29 months. Patients were classified into 5 MACS levels using a standardized questionnaire completed by their primary caregivers. Preoperatively and at most recent follow-up visits, patients were assessed using the House scale and patient-reported functional outcomes on a 5-point scale. We compared the outcomes of patients with high (I–II, independence in daily activities) and low (III–V, dependence in daily activities) MACS levels.Results: The overall mean House scale improved from 2.9 to 4.6 postoperatively (p<.001), dressing ability from 3.7 to 4.2 (p=.005), hygiene from 4.2 to 4.9 (p=.005), and appearance from 2.4 to 4.2 (p<.001). A total of 13 patients had a high MACS level (7 had I and 6 had II) and 14 had a low MACS level (8 had III, 6 had IV, and none had V). The high-MACS group had a greater improvement according to the House scale (p=.009) and the low-MACS group had a larger improvement in hygiene status (p=.043). There were no differences in the amount of improvement in dressing ability (p=.169) and appearance (p=.765). Overall satisfaction with surgery was higher for the high-MACS group (p=.038).Conclusions: The high-MACS group had a greater improvement in rating according to the House scale and higher satisfaction than the low-MACS group after upper extremity surgery for cerebral palsy in our small number of patients. This study suggests that the MACS level can be used to predict upper extremity surgery outcomes for cerebral palsy.Type of study/level of evidence: Prognostic II.

Follow-Up Motion Laboratory Analysis for Patients With Spastic Hemiplegia Due to Cerebral Palsy: Analysis of the Flexor Carpi Ulnaris Firing Pattern Before and After Tendon Transfer Surgery

Ann Van Heest, Jean Stout, Roy Wervey, Louis Garcia — 2009-12-21

Purpose: To compare the preoperative and postoperative pattern of firing of the flexor carpi ulnaris (FCU) in a grasp and release functional activity for children treated with an FCU to extensor carpi radialis brevis tendon transfer for wrist flexion deformity associated with spastic hemiplegia from cerebral palsy.Methods: Seven children, evaluated by a preoperative EMG video analysis and treated with an FCU to extensor carpi radialis brevis transfer, had a follow-up postoperative EMG/video motion laboratory analysis at an average follow-up of 3.5 years (range, 1.0–6.8 years). Each preoperative and postoperative EMG/video was reviewed for the task of lifting heavy cans, as described by Jebson et al. The EMG activity of the FCU was described as active or relaxed during grasp and during release.Results: Preoperatively, the most common pattern was to activate the FCU during grasp and to relax the FCU during release (4 patients). Postoperatively, 6 patients activated the FCU during grasp and relaxed the FCU during release; 1 patient activated the FCU during both grasp and release.Conclusions: Of the 7 patients studied, the FCU changed phase from preoperative to postoperative in only 1. This study concludes that most commonly the FCU does not predictably change phase when transferred from a position of wrist flexion to wrist extension.Type of study/level of evidence: Therapeutic IV.

Partial Hand Preservation for Large Soft Tissue Sarcomas of the Hand

Mark E. Puhaindran, Matthew R. Steensma, Edward A. Athanasian — 2010-02-01

Purpose: Hand amputations cause marked functional loss for patients. In patients with large soft tissue sarcomas of the hand, partial hand preservation is extremely challenging for surgeons attempting a complete resection of the tumor with negative resection margins. We conducted this review to examine the oncologic outcome, including local recurrence rate and patient overall survival, and functional outcome after resections for large soft tissue sarcomas with partial hand preservation.Methods: We performed a retrospective review of all patients with soft tissue sarcomas of the hand treated at our institution from 1995 to 2007. We identified 8 patients who had tumors at least 5 cm in maximum dimension and had tumor resection with partial hand preservation. The mean age at the time of surgery was 49 years (range, 10–80 years). Two patients had myxofibrosarcoma, 2 patients had synovial sarcoma, 2 patients had malignant fibrous histiocytoma, 1 patient had a malignant peripheral nerve sheath tumor, and 1 patient had a liposarcoma. Two patients had low-grade tumors, and 6 patients had high-grade tumors. Two patients had American Joint Committee on Cancer stage 1b tumors, and 6 patients had American Joint Committee on Cancer stage 3 tumors. No patients had distant metastases at the time of surgery. Hand function was evaluated using Musculoskeletal Tumor Society criteria.Results: Of the 8 patients, 1 died of distant metastatic disease, 1 developed local tumor recurrence and is alive with locally recurrent disease, and the other 6 patients are completely disease-free. The mean Musculoskeletal Tumor Society score was 26 (range, 19–29), with the 2 patients who had received double-ray amputations having the lower scores (19 and 24).Conclusions: Partial hand preservation is possible in selected patients with large soft tissue sarcomas of the hand, obtaining low local recurrence rates, good overall survival, and good functional outcome. However, all effort should be made to achieve negative resection margins.Type of study/level of evidence: Therapeutic IV.

Subungual Extraskeletal Chondroma With Finger Nail Deformity: Case Report

Takayuki Ishii, Masayoshi Ikeda, Yoshinori Oka — 2010-01-11

We report a subungual extraskeletal chondroma with a convex nail deformity originating from the index finger in a 39-year-old man. The tumor was excised and its histopathology showed obvious nuclear pleomorphism. However, the Ki-67 (MIB-1) labeling index was less than 1%, indicating low proliferative activity; it was classified as an extraskeletal chondroma with atypical features. There was no recurrence over a 3-year postoperative period.

Journal CME Instructions

2010-02-01

Treatment of Distal Diaphyseal Humerus Fractures

Andrew Jawa — 2010-02-01

A 25-year-old, otherwise healthy man presents 1 week after sustaining a closed distal-third, extra-articular humeral shaft fracture while playing basketball. He went to the emergency room where he was placed in a posterior splint and a sling. Radiographs today show a spiral fracture, with 15° of varus and 10° of apex posterior angulation. Distal sensation is normal, and the patient's radial nerve function is intact.

Journal CME Questions

2010-02-01

Magnetic Resonance Imaging for Ulnar Wrist Pain

Kenneth J. Faber, Sorin Iordache, Ruby Grewal — 2010-02-01

A 20-year-old student athlete gradually developed ulnar-sided wrist pain. The pain was not associated with a specific injury and she was otherwise well. There were no mechanical symptoms of catching or clunking. The pain was aggravated by athletic activities and the patient was avoiding competition. On examination, the wrist appeared normal. The range of motion of the wrist was full. Diffuse tenderness was present over the distal radioulnar joint and the head of the ulna. The ulnocarpal stress test, performed by applying an axial load during passive pronation–supination with the wrist in ulnar deviation, did not increase the pain. Application of a shear force between the lunate and triquetrum did not reproduce her pain. Wrist radiographs were normal. A plan including rest, anti-inflammatory medication, and observation was suggested. After reviewing information available on the Internet, the patient was concerned that this approach would delay diagnosis, whereas a magnetic resonance imaging (MRI) scan would direct the treatment and hasten her return to volleyball.

Radial Artery Perforator Flap

Andrew M. Ho, James Chang — 2010-02-01

Soft tissue defects in the hand and wrist can be challenging problems for the hand surgeon. The retrograde radial forearm fasciocutaneous flap has emerged in recent years as the workhorse flap to cover many hand and wrist defects. However, recognition of the intrinsic limitations of this flap has led to the development of other alternative flaps to provide soft tissue coverage for this region. The radial artery perforator flap has many of the benefits of the radial forearm flap but minimizes the disadvantages, such as the need to sacrifice the radial artery, color and bulk mismatch of the flap and recipient tissues, and donor site appearance. In this article, we will review the indications for using the radial artery perforator flap to cover hand and wrist soft tissue defects. We will discuss the surgical anatomy, indications, operating technique, rehabilitation protocol, potential complications, and pearls and pitfalls for use of this flap for upper-extremity defects.

Surgical Technique of Harvesting Vascularized Superficial Radial Nerve Graft

Mohamed Shafi, Yasunori Hattori, Kazuteru Doi — 2010-02-01

We describe our surgical technique for harvesting the free vascularized superficial radial nerve graft based on the radial artery and its venae comitantes. Anatomy and preoperative preparation are also presented, as well as the indications and some contraindications.

Perioperative Steroid Dosing in Patients Receiving Chronic Oral Steroids, Undergoing Outpatient Hand Surgery

Kristen Fleager, Jeffrey Yao — 2009-11-27

Historically, patients who are receiving oral glucocorticoids and undergo surgical procedures were administered supplemental intravenous steroids during the perioperative period. This practice remains controversial, however, for less invasive outpatient procedures such as those performed by hand surgeons on a routine basis. To date, there are no evidence-based treatment guidelines that provide firm recommendations for the administration of perioperative steroids; rather, present management is based on case reports and observational studies. In this article, we discuss the pathophysiology behind acute adrenal insufficiency, the stress response and its suppression, patients who may be at risk, the effect of inhaled and topical steroids, and published data that guide our practice concerning the administration of perioperative corticosteroids to patients undergoing outpatient hand surgery.

Journal CME Questions

2010-02-01

Perioperative Insulin Dosing in Diabetic Patients Undergoing Outpatient Upper Extremity Surgery

Robert H. Ablove — 2010-02-01

Normal glucose metabolism is controlled by the liver, pancreas, and peripheral tissue. The liver extracts glucose from circulation and stores it as glycogen and releases glucose into circulation via glycogenolysis. The pancreas secretes regulatory hormones to modulate serum glucose levels: alpha islet cells release glucagon to raise it and beta islet cells secrete insulin to lower it. Catabolic hormones including epinephrine, growth hormone, and corticosteroids also trigger glucose release. Peripheral tissues extract glucose from serum to fulfill energy needs. Type 1 diabetes mellitus is characterized by lack of insulin production, whereas type 2 is characterized by a combination of insulin resistance and relative insulin insufficiency.

Current Concepts in the Management of Brachial Plexus Birth Palsy

Holly B. Hale, Donald S. Bae, Peter M. Waters — 2010-02-01

Brachial plexus birth palsy, although rare, may result in substantial and chronic impairment. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed to help the child maximize function in the affected upper extremity. Many present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery remain unresolved in infants with brachial plexus birth palsies. Recent literature has enhanced our understanding of the pathoanatomy and natural history of the injury as well as the surgical indications, expected outcomes, and complications; this literature has led to improved care of these patients. Based on the present evidence, recommendations for both microsurgery and shoulder reconstruction with tendon transfer and arthroscopic and open reductions are presented.

Journal CME Questions

2010-02-01

Nerve Transfers: Indications, Techniques, and Outcomes

Thomas H. Tung, Susan E. Mackinnon — 2010-02-01

This article provides an update of the current strategies of motor and sensory nerve transfers for peripheral nerve lesions of the upper extremity. Indications, techniques, and outcomes are summarized for both well-established transfers used in the management of proximal and brachial plexus injuries as well as those more recently developed for more distal and isolated nerve injuries in the forearm and hand.

Kevin C. Chung — 2010-02-01

With so many hand surgery textbooks available in the marketplace, how is this new, one-volume textbook written by Dr. R. Venkataswami, who is one of the most prominent hand surgeons in India, distinguishable from the products presented by many large, international medical publishing houses? This textbook, published by Jaypee Brothers Medical Publishers in New Delhi, employs the strategies of setting a modest price ($65 for Indians and $150 for non-Indians) and having contributions from many senior hand surgeons in India and from around the world. I think the most distinguishing feature of this textbook is its presentation. Dr. Venkatswami notes in the Preface that he is not aiming to cover every aspect of hand surgery in a single textbook, but he strives to ask his contributing authors to provide their own perspectives based on their unique experiences. For example, Chapter 1 relays the history of hand surgery, and who better to talk about hand surgery history than the senior author of the chapter, Harold E. Kleinert? Similarly, the comprehensive chapter “Structural Basis of Functioning of the Hand,” by Dr. H. Srinivasan, carefully and concisely presents the anatomy, biomechanics, and structures of the hand. Dr. Venkataswami writes in Chapter 3 about his experience organizing a hand injury service. As the former Head of the Institute for Research and Rehabilitation of the Hand at Stanley Medical College in Chennai, Dr Venkataswami retraces his journey in building one of the largest hand surgery centers in India from a modest beginning. Granted, in developed countries where hand surgery services are already in place, this chapter may not be relevant in adding insight regarding the formulation of a hand surgery center in countries with abundant resources. However, in many regions of the world, funding is scarce, and the sheer volume of hand surgery pathology strains the capability of a government to adequately supply help to its people. From this vantage point, this chapter is a welcome guide in understanding how to organize a streamlined, highly efficient facility when resources are in short supply. In this chapter, Dr. Venkataswami shares his experiences in South India, from when he founded this center in 1971 with 20 hand surgery beds and performed 5 to 6 hand surgery cases per day, to 1991, when this hospital had 80 hand surgery beds and performed more than 20 to 25 cases per day. More important, this center provides fertile ground for training a cadre of hand surgeons who propagate the teaching of hand surgery throughout the country.

Erratum

2010-02-01

In the article by Stuffmann E and Baratz ME, (“Radial Head Implant Arthroplasty,” Vol. 34A, No. 4, pp. 745–754, 2009), the authors neglected to include a Conflict of Interest disclosure. Mark E. Baratz, MD, receives royalties from Integra Life Sciences, the manufacturer of a radial head implant.

Masthead

2010-02-01

Editorial Board

2010-02-01

Instructions to Authors

2010-02-01

Journal of Hand Surgery

Finding Joy in Your Hand Surgery Practice

Rate of Infection After Carpal Tunnel Release Surgery and Effect of Antibiotic Prophylaxis

Dynamics of Intracarpal Tunnel Pressure in Patients With Carpal Tunnel Syndrome

Five-Year Follow-Up of Carpal Tunnel Release in Patients Over Age 65

Intra- and Inter-Examiner Variability in Performing Tinel's Test

Single-Incision Extensile Volar Approach to the Distal Radius and Concurrent Carpal Tunnel Release: Cadaveric Study

Clinical Impact of United Versus Nonunited Fractures of the Proximal Half of the Ulnar Styloid Following Volar Plate Fixation of the Distal Radius

Correlation of Malrotation Deformity in Distal Radius Fractures With Radiographic Analysis: Cadaveric Study

Delayed-Onset Ulnar Neuropathy at the Wrist Associated With Distal Radioulnar Joint Arthritis After Radius Malunion: Report of Two Cases

Conformational Changes in the Carpus During Finger Trap Distraction

Differential Strain of the Axially Loaded Scapholunate Interosseus Ligament

Gender Differences in Carpal Height Ratio in a Taiwanese Population

A Radiocarpal Ligament Reconstruction Using Brachioradialis for Secondary Ulnar Translation of the Carpus Following Radiocarpal Dislocation: A Cadaver Study

Effects of Distal Radius Bone Graft Harvest on the Axial Compressive Strength of the Radius

Role of Low-Affinity Nerve Growth Factor Receptor Inhibitory Antibody in Reducing Pain Behavior and Calcitonin Gene-Related Peptide Expression in a Rat Model of Wrist Joint Inflammatory Pain

Tardy Palsy of Descending Branch of Posterior Interosseous Nerve: Sequela to Plate Osteosynthesis of Forearm Bones

Functional Outcomes After Upper Extremity Surgery for Cerebral Palsy: Comparison of High and Low Manual Ability Classification System Levels

Follow-Up Motion Laboratory Analysis for Patients With Spastic Hemiplegia Due to Cerebral Palsy: Analysis of the Flexor Carpi Ulnaris Firing Pattern Before and After Tendon Transfer Surgery

Partial Hand Preservation for Large Soft Tissue Sarcomas of the Hand

Subungual Extraskeletal Chondroma With Finger Nail Deformity: Case Report

Journal CME Instructions

Treatment of Distal Diaphyseal Humerus Fractures

Journal CME Questions

Magnetic Resonance Imaging for Ulnar Wrist Pain

Radial Artery Perforator Flap

Surgical Technique of Harvesting Vascularized Superficial Radial Nerve Graft

Perioperative Steroid Dosing in Patients Receiving Chronic Oral Steroids, Undergoing Outpatient Hand Surgery

Journal CME Questions

Perioperative Insulin Dosing in Diabetic Patients Undergoing Outpatient Upper Extremity Surgery

Current Concepts in the Management of Brachial Plexus Birth Palsy

Journal CME Questions

Nerve Transfers: Indications, Techniques, and Outcomes

Erratum

Masthead

Editorial Board

Table of Contents

Instructions to Authors