Journal of Hand Surgery - Articles in Press

Painful Nodules and Cords in Dupuytren Disease - Corrected Proof

A. von Campe, K. Mende, H. Omaren, C. Meuli-Simmen — 2012-05-07

Purpose: The etiology of Dupuytren disease is unclear. Pain is seldom described in literature. Patients are more often disturbed by impaired extension of the fingers. We recently treated a series of patients who had had painful nodules for more than 1 year and, therefore, decided to investigate them for a possible anatomical correlate. Methods: Biopsies were taken during surgery from patients with Dupuytren disease and stained to enable detection of neuronal tissue. Results: We treated 17 fingers in 10 patients. Intraoperatively, 10 showed tiny nerve branches passing into or crossing the fibrous bands or nodules. Of 13 biopsies, 6 showed nerve fibers embedded in fibrous tissue, 3 showed perineural or intraneural fibrosis or both, and 3 showed true neuromas. Enlarged Pacinian corpuscles were isolated from 1 sample. All patients were pain free after surgery. Conclusions: Although Dupuytren disease is generally considered painless, we treated a series of early stage patients with painful disease. Intraoperative inspection and histological examination of tissue samples showed that nerve tissue was involved in all cases. The pain might have been due to local nerve compression by the fibromatosis or the Dupuytren disease itself. We, therefore, suggest that the indication for surgery in Dupuytren disease be extended to painful nodules for more than 1 year, even in the early stages of the disease in the absence of functional deficits, with assessment of tissue samples for histological changes in nerves. Type of study/level of evidence: Therapeutic II.

Corrected Proof

Timothy R. Judkins, Douglas T. Hutchinson — 2012-05-07

This “master skills publication” does the title justice. It takes an impressive group of experts from all of North America and covers (with the notable exception of the shoulder) arthritis problems and surgical solutions for the entire upper extremity. This was a serious undertaking, and they did an excellent job in covering this expansive topic. Although the writers did not individually list industry relationships, it seemed as though they were cognizant of potential conflicts of interest, and the influence of industries seemed minimal overall.

Benign Subungual Tumors - Corrected Proof

Katherine J. Willard, Mark A. Cappel, Scott H. Kozin, Joshua M. Abzug — 2012-05-07

A variety of benign and malignant processes may affect the subungual region; however, most are relatively rare lesions. We present a review of the current literature regarding benign tumors affecting the subungual region.

Hand Education for Emergency Medicine Residents: Results of a Pilot Program - Corrected Proof

Scott D. Lifchez — 2012-05-04

Purpose: Multiple studies have demonstrated the lack of knowledge of hand anatomy and pathology among those who first see patients with hand disorders. The goal of this study was to determine whether a hand surgery rotation for emergency medicine residents would improve this group's knowledge of the hand and its disorders as assessed at the end of their residency training. Methods: Seven postgraduate year (PGY) 2 emergency medicine residents completed a 4-week hand surgery rotation. Hand knowledge was assessed at the start, at the end, and 1 year after this rotation (end of PGY 3). Knowledge of a control group of 7 PGY 3 emergency medicine residents who did not have this rotation was also assessed. Results: Hand knowledge in the residents who completed the rotation was significantly improved. This was true for overall test performance (88% vs 70% correct responses), as well as for each of the anatomy and function (89% vs 57%), diagnosis (96% vs 86%), and treatment (79% vs 51%) categories. Overall test performance (78% vs 66%) and anatomy and function category performance (75% vs 43%) were significantly better at the end of PGY 3 for the residents who completed the rotation as compared to the control residents. Conclusions: A hand surgery rotation during an emergency medicine residency program improved the knowledge of hand anatomy and disorders. This knowledge was retained 1 year later and was greater than the knowledge of matched emergency medicine residents who did not have this rotation. Better knowledge of hand anatomy and disorders among emergency physicians might improve their ability to initially evaluate and treat patients with these conditions. Such knowledge might allow emergency department physicians to play a more important role in the management of hand emergencies. A hand surgery rotation has been incorporated into the PGY 2 curriculum for all emergency medicine residents at my institution.

Laxity of the Ulnar Nerve During Elbow Flexion and Extension - Corrected Proof

Christine B. Novak, Hossein Mehdian, Herbert P. von Schroeder — 2012-05-03

Purpose: To evaluate the dynamic anatomy of the ulnar nerve at the elbow. Methods: We studied 11 fresh cadavers. We placed metal clips on the ulnar nerve at three locations: at the medial epicondyle (point A), 3 cm proximal to the epicondyle (point B), and 14 cm proximal to the epicondyle (point C). The distances from the medial epicondyle to points A, B, and C on the ulnar nerve and between each pair of points were measured in full elbow extension and flexion. Results: With full elbow flexion, there was no movement of the ulnar nerve at point A (adjacent to the medial epicondyle). Point A and the adjacent distal ulnar nerve moved as a unit with the forearm around the medial epicondyle. Proximal to the cubital tunnel, there was significant ulnar nerve excursion (P < .01) at points B (0.7 ± 0.3 cm) and C (0.2 ± 0.2 cm). There was differential excursion of the ulnar nerve at points B and C relative to the medial epicondyle. The distances between the markers revealed that the nerve did not stretch to account for the discrepant distances of the 3 points, but a slack region of the nerve proximal to the medial epicondyle was taken up with flexion. Release of the intermuscular septum and the canal of Struthers did not influence movement of the nerve. Conclusions: With elbow flexion, the ulnar nerve did not move appreciably in the distal–proximal direction directly at the cubital tunnel, but maximal excursion was in the fatty region proximal to the elbow. This slack region of the nerve was taken up during flexion, whereas only 2 mm of motion occurred through the canal of Struthers. The slack region might predispose to subluxation of the nerve. Conversely, decreased laxity might result in increased traction of the nerve contributing to cubital tunnel syndrome. Type of study/level of evidence: Therapeutic II.

Neurothekeoma of the Median Nerve: Case Report - Corrected Proof

Salvatore A. Fanto, Emilio Fanto — 2012-05-02

We report the case of a large intraneural neurothekeoma of the median nerve at the wrist. Neurothekeomas are rare; they are small, superficial, and typically asymptomatic benign tumors of undetermined cellular origin. Complete excision is usually curative. This case is interesting owing to the tumor's large size and location within the median nerve, which made it highly symptomatic, mimicking carpal tunnel syndrome.

Risk Factors for Posttraumatic Heterotopic Ossification of the Elbow: Case-Control Study - Corrected Proof

Andrea S. Bauer, Bryan K. Lawson, Robin L. Bliss, George S.M. Dyer — 2012-05-02

Purpose: Heterotopic ossification (HO) is well-known after surgical repair of elbow fractures, but little is known about risk factors for its development in these patients. The purpose of this study was to define factors associated with development of HO. Methods: We used a prospective fracture registry collected in 2 Level I trauma centers and medical chart review to examine all elbow fractures treated surgically between 2002 and 2009. We determined which of these patients developed HO with an impact on range of motion (Hastings class II and III). We conducted a matched case-control study to examine factors associated with risk of HO. We used conditional logistic regression to compare occurrences of risk factors between cases and controls, matched by fracture type, age, and sex. Results: Our database contained 786 elbow fractures treated surgically. Of these, 55 developed clinically relevant HO. The risk of HO varied among types of elbow fractures, with combined olecranon and radial head fractures having no HO and floating elbows (fractures on both sides of the elbow joint) having the highest incidence of HO at 36%. In multiple conditional logistic regression, risk factors for the development of HO were days to surgery, with subjects waiting 8 or more days having 12 times the odds of HO than subjects having surgery within a day of injury, and time to postoperative mobilization, with subjects with at least 15 days to mobilization having greater odds of HO than those with less than 7 days to mobilization. Conclusions: Heterotopic ossification of the elbow occurs frequently after surgical repair of elbow fractures, with an incidence of 7% in this registry. In the case-control sample, conditions associated with development of HO included longer time to surgery and longer time to mobilization after surgery. Type of study/level of evidence: Prognostic III.

Incidence of Bilateral Scapholunate Dissociation in Symptomatic and Asymptomatic Wrists - Corrected Proof

Brad M. Picha, Emmanuel K. Konstantakos, Douglas A. Gordon — 2012-05-02

Purpose: Scapholunate dissociation (SLD) is thought to be a common cause of both acute and chronic wrist pain. Classically, this condition is attributed to a traumatic event and is thought to inevitably lead to the development of degenerative arthritis. Bilateral findings should thus be infrequent. The purpose of the present study was to determine the incidence of bilateral radiographic SLD and associated arthritic changes. Methods: Demographic, radiographic, and clinical data were obtained from 124 patients with abnormal x-ray findings in at least 1 wrist. Radiographs reviewed included posteroanterior, lateral, and Moneim views of both symptomatic and asymptomatic wrists. Pathology was defined as a scapholunate gap ≥ 5 mm and/or a scapholunate angle ≥ 60°. Arthritic changes were assessed. Results: A majority of the 124 patients (51%) were unable to recall any specific injury to their wrist. On the symptomatic side, 101 (81%) patients had a pathologic measurement for their scapholunate gap, and 109 (88%) had an abnormal angle measurement. On the asymptomatic side, 64 (52%) of the gap measurements and 87 (70%) of the angle measurements were pathologic. Ninety-nine patients (80%) had abnormal radiographic findings bilaterally for at least 1 variable on each side. Only 13 patients (11%) had a clinical instability pattern typical of SLD. Half the patients had radiographic degenerative changes at presentation. Conclusions: Bilateral radiographic SLD is much more common than previously assumed, is often asymptomatic, and does not inevitably lead to degenerative arthritis. These findings should call into question the assumption of a uniquely traumatic etiology. Further, most patients presented with pathologies unrelated to the scapholunate articulation. Surgical intervention chosen on the basis of radiologic findings, in the absence of clinical instability, might not be the best course of action, unless criteria are established to determine which patients eventually develop arthritic changes or become symptomatic. Type of study/level of evidence: Therapeutic III.

Overview of Injectable Corticosteroids - Corrected Proof

Jason Dahl, Warren C. Hammert — 2012-04-30

Injectable corticosteroids remain an important intervention in the management of multiple hand and upper extremity conditions. Common uses include intra-articular applications, with the goal of symptomatic relief in osteoarthritis, rheumatoid arthritis, and crystal deposition diseases, as well as extra-articular injections for tendinopathies and nerve compression syndromes. There is little high-quality evidence to guide which steroid to use in a given clinical situation; however, an understanding of the mechanisms of action, pharmacologic profiles, and associated complications of different steroid preparations can help guide the clinician in appropriate corticosteroid selection.

Hands on Stamps: China 1991—Disaster Relief - Corrected Proof

Zhiwu Ren, Xin Wang, Bing Wang — 2012-04-30

Achinese postage stamp () issued in 1991 shows images of 2 grasped hands in the shape of a heart to appeal for disaster relief donations after heavy rainstorms caused a disastrous flood in the Changjiang River, Huaihe River, and Taihu Lake basins. It is the first stamp issued by China for an extraordinarily serious natural calamity. The motto states, “When disasters struck, help came from all sides.” A total sales revenue of 32 million yuan was donated entirely to the disaster area.

Spontaneous Rupture of the Extensor Carpi Radialis Brevis in a 51-Year-Old Man: Case Report - Corrected Proof

Stephen J. Huffaker, Dimitrios C. Christoforou, Jesse B. Jupiter — 2012-04-30

Dorsal hand osteophytes are common findings in the general population, frequently presenting with dorsal pain and treated with surgical excision. We report the spontaneous rupture of the extensor carpi radialis brevis in association with a previously asymptomatic dorsal scaphoid spur. Following conservative management, surgical excision of dorsal hand osteophytes should be considered for both resolution of pain and prevention of attritional tendon rupture.

Enchondromas of the Hand: Factors Affecting Recurrence, Healing, Motion, and Malignant Transformation - Corrected Proof

Adam A. Sassoon, Patrick D. Fitz-Gibbon, William S. Harmsen, Steven L. Moran — 2012-04-30

Purpose: Enchondromas represent the most common primary bone tumor in the hand. Despite their frequency, a standardized treatment protocol is lacking. This study examines the outcome of surgically treated enchondromas of the hand with regard to tumor location, graft choice, and presence or absence of fracture. Methods: We retrospectively reviewed 102 enchondromas in 80 patients, identified between 1991 and 2008, with a mean clinical follow-up of 38 months. We assessed the effects of age, tumor location, and graft choice on outcomes for all lesions. Patients presenting with Ollier disease, Maffucci syndrome, pathologic fractures, or recurrent disease were separated for additional analysis. Results: Of the 102 lesions, 62 (61%) achieved complete radiographic healing in a median time of 6 months. Full range of motion was achieved following treatment of 68 lesions (67%) in a median time of 3 months. A total of 95 lesions (93%) remained recurrence free following surgery. One case of malignant transformation occurred in a patient with Maffucci syndrome. Tumor location and graft choice did not affect healing grade, time to healing, range of motion, or recurrence rate. Age at presentation older than 30 was associated with more rapid healing. Monocentric, nonexpanding lesions were associated with improved postoperative range of motion. Patients with a diagnosis of multiple enchondromas had a higher rate of recurrence following surgery, and patients presenting with a recurrent lesion had a higher rate of complications. Following pathologic fracture, no differences in outcomes were observed when enchondromas were treated primarily or following fracture healing. Conclusions: Following surgical treatment of enchondromas in the hand, the majority of patients achieve complete bony healing and full range of motion, regardless of the graft material used. Malignant transformation is rare, and aggressive follow-up measures should be reserved for patients with a diagnosis of multiple enchondromas. Type of study/level of evidence: Therapeutic IV.

Biomechanical Properties of Fixed-Angle Volar Distal Radius Plates Under Dynamic Loading - Corrected Proof

2012-04-30

Purpose: To evaluate and compare the biomechanical properties of 8 different locked fixed-angle volar distal radius plates under conditions designed to reflect forces seen in early fracture healing and postoperative rehabilitation. Methods: We evaluated the Acumed Acu-Loc (Acumed, Hillsboro, OR), Hand Innovations DVR (Hand Innovations, Miami, FL), SBi SCS volar distal radial plate (Small Bone Innovations, Morrisville, PA), Synthes volar distal radius plate and EA extra-articular volar distal radius plate (Synthes, Paoli, PA), Stryker Matrix-SmartLock (Stryker Leibinger, Kalamazoo, MI), Wright Medical Technology Locon VLS (Wright Medical Technology, Arlington, TN), and Zimmer periarticular distal radius locking plate (Zimmer, Warsaw, IN). After affixing each plate to a synthetic corticocancellous radius, we created a standardized dorsal wedge osteotomy. Each construct had cyclic loading of 100 N, 200 N, and 300 N for a total of 6000 cycles. Outcomes, including load deformation curves, displacement, and ultimate yield strengths, were collected for each construct. Results: The Wright plate was significantly stiffer at the 100 N load than the Zimmer plate and was stiffer at the 300 N load than 4 other plates. The Zimmer and Hand Innovations plates had the highest yield strengths and significantly higher yield strengths than the Wright, SBi, Stryker, and Synthes EA plates. Conclusions: Given the biomechanical properties of the plates tested, in light of the loads transmitted across the native wrist, all plate constructs met the anticipated demands. It seems clear that fracture configuration, screw placement, cost, and surgeon familiarity with instrumentation should take priority in selecting a plating system for distal radius fracture treatment. Clinical relevance: This study provides further information to surgeon regarding the relative strengths of different plate options for the treatment of distal radius fractures.

Domestic Bird Bites - Corrected Proof

Carissa L. Meyer, Joshua M. Abzug — 2012-04-27

Companion animal bite wounds pose a notable health care concern, with an incidence of 2 million cases per year, and they account for approximately 300,000 emergency department visits annually. Most of these wounds are due to cat and dog bites, making up approximately 95% of all animal bite wounds, with considerable literature available regarding management of these wounds. Little literature exists, however, regarding the treatment of domestic avian wounds.

Distal Sensory Nerve Transfers in Lower-Type Injuries of the Brachial Plexus - Corrected Proof

Jayme A. Bertelli — 2012-04-26

Purpose: To report the results of sensory nerve transfers to reconstruct sensation on the ulnar side of the hand in lower-type palsies of the brachial plexus. Methods: From 2007 to 2009, we operated on 6 men and 2 women with a lower-type injury of the brachial plexus and observed them for a minimum of 24 months. The mean interval between the injury and surgery was 8 months (SD ± 8.6 mo). Before surgery, we documented anesthesia on the ulnar side of the hand in all patients. Donor nerves included cutaneous branches of the median nerve to the palm (n = 5) or the palmar cutaneous branch of the median nerve (n = 3). The ulnar proper digital nerve of the little finger was the recipient nerve. We evaluated sensory recovery by assessing static 2-point discrimination and sensation to Semmes-Weinstein monofilaments. Results: According to the British Medical Council system of evaluation, 5 patients scored S3 and 3 scored S3+. Conclusions: In lower-type injuries of the brachial plexus, transfer of median nerve branches that innervate the palm of the hand to the ulnar proper digital nerve of the little finger predictably restored protective sensation on the ulnar side of the hand. Type of study/level of evidence: Therapeutic IV.

Biomechanical Differences of the Proximal Interphalangeal Joint Volar Plate During Active and Passive Motion: A Dynamic Ultrasonographic Study - Corrected Proof

Susumu Saito, Shigehiko Suzuki, Yoshihisa Suzuki — 2012-04-26

Purpose: To define the biomechanical differences of the volar plate (VP) of the proximal interphalangeal joint during active and passive motion, which may provide clues to understanding the functional importance of the volar elevation of the VP. Methods: We imaged the volar aspect of the proximal interphalangeal joint in 10 healthy middle fingers using ultrasonography. Cine videos recorded the movements of the VP during joint motion from full extension to more than 60° of flexion both actively and passively. We plotted 5 points on the volar surface of the VP and traced them for motion analysis. We statistically analyzed the volar distances and volar angulation of the VP in full extension, 30°, 45°, and 60° of flexion to determine the differences between active and passive flexion. Results: In active flexion, the VP showed significantly higher volar distances in 45° and 60° and changed its configuration from the original flattened figure to an inverted U shape, with a significant higher angulation at 45° compared with passive flexion. Conversely, in passive flexion, we did not observe the volar elevation of the VP and the flattened configuration was maintained throughout the motion arc. Conclusions: From an anatomical viewpoint, volar elevation of the VP seen in active flexion could provide dynamic stresses on the adjacent ligaments and contribute to the stability and smooth gliding of the joint.

Trapezial Metastasis as the First Indication of Primary Non–Small Cell Carcinoma of the Lung - Corrected Proof

Yohan Song, Jeffrey Yao — 2012-04-26

Metastasis to the bones of the hand and wrist is not common, and its discovery may reveal an advanced primary tumor located centrally. Clinically, hand metastasis is hard to differentiate from other more common hand pathologies. Its rarity, coupled with a lack of unique clinical manifestations, makes hand and wrist metastasis difficult to diagnose. However, its diagnosis is critical to initiate an appropriate course of treatment. We present a patient in whom lung carcinoma metastasis to the trapezium was definitively diagnosed upon surgical management of symptoms that were consistent with thumb carpometacarpal arthritis.

Distal Interphalangeal Joint Arthrodesis for Degenerative Osteoarthritis With Compression Screw: Results in 102 Digits - Corrected Proof

Federico Villani, Bastian Uribe-Echevarria, Luca Vaienti — 2012-04-26

Purpose: To assess objective and subjective outcomes of distal interphalangeal joint arthrodesis with a headless compression screw for degenerative osteoarthritis. Methods: We retrospectively analyzed 102 cases of distal interphalangeal joint arthrodesis performed with headless compression screws on 59 patients. We included only primary cases of degenerative osteoarthritis with a minimum follow-up of 7 months. We identified appropriate bone coaptation and hardware positioning on postoperative radiographs in all digits. The mean follow-up period was 26 months (range, 7–67 mo). Results: In 89 of 102 cases, patients were fully satisfied; in 9 cases, they were satisfied. Four complications occurred: 2 cases of prominent hardware, 1 complex regional pain syndrome type 1, and 1 symptomatic bony callus on the fused joint. Secondary surgery was required in each of these 4 cases. No nonunion, malunion, nail dystrophy, pseudarthrosis, or infection occurred. All arthrodeses healed. Conclusions: Distal interphalangeal joint arthrodesis with headless compression screws was shown to be safe and effective in cases of degenerative osteoarthritis, with a low complication rate. Type of study/level of evidence: Therapeutic IV.

Applicability of Large Databases in Outcomes Research - Corrected Proof

Sunitha Malay, Melissa J. Shauver, Kevin C. Chung — 2012-04-23

Outcomes research serves as a mechanism to assess the quality of care, cost effectiveness of treatment, and other aspects of health care. The use of administrative databases in outcomes research is increasing in all medical specialties, including hand surgery. However, the real value of databases can be maximized with a thorough understanding of their contents, advantages, and limitations. We performed a literature review pertaining to databases in medical, surgical, and epidemiologic research, with special emphasis on orthopedic and hand surgery. This article provides an overview of the available database resources for outcomes research, their potential value to hand surgeons, and suggestions to improve their effective use.

Predictors of Diagnosis of Ulnar Neuropathy After Surgically Treated Distal Humerus Fractures - Corrected Proof

Jimme K. Wiggers, Kim M. Brouwer, Gijs T.T. Helmerhorst, David Ring — 2012-04-23

Purpose: Ulnar nerve dysfunction is a common sequela of surgical treatment of distal humerus fractures. This study addresses the null hypothesis that different types of distal humerus injuries have comparable rates of diagnosis of ulnar neuropathy. Methods: We assessed diagnosis of ulnar neuropathy in 107 consecutive adults who had a surgically treated fracture of the distal humerus followed at least 6 months after injury. Diagnosis of ulnar neuropathy was defined as documentation of sensory and motor dysfunction of the ulnar nerve in the medical record. Fractures were categorized as either columnar fractures or fractures of the capitellum and trochlea. The explanatory (independent) variables included age, sex, fracture type, AO type, associated wound, associated elbow dislocation, mechanism of trauma, ipsilateral skeletal injury, olecranon osteotomy, implant over or below the medial epicondyle, infection, time from injury to surgery, the number of surgeries within 4 weeks and 6 months of injury, the total number of surgeries, and whether the nerve was transposed. Results: Postoperative ulnar neuropathy was diagnosed in 17 of 107 patients (16%), including 16 of 59 columnar fractures (21%). The only risk factor for ulnar neuropathy was columnar fracture. Conclusions: Patients with columnar fractures might be at higher risk for the development of postoperative ulnar neuropathy than patients with capitellum and trochlea fractures, regardless of whether the ulnar nerve was transposed. Type of study/level of evidence: Prognostic IV.

Trapezoid Fractures: Report of 11 Cases - Corrected Proof

Nakul Kain, Carlos Heras-Palou — 2012-04-23

Purpose: Trapezoid fractures are rare. Mostly single cases reports appear in the literature. The purpose of this study was to review 11 patients treated for trapezoid fractures at our center. Methods: We reviewed all trapezoid fractures that presented over the past 10 years at our institution. We reviewed case notes regarding mechanism of injury, fracture pattern, mode of diagnosis, and time to diagnosis and treatment. Results: We treated 11 patients for trapezoid fractures over the 10-year period. A correct diagnosis was made in 5 cases on initial evaluation. Most trapezoid fractures were diagnosed on computed tomographic scan. The fracture plane was predominantly sagittal. Coronal fractures could not be diagnosed on plain radiographs. Conclusions: Fractures of the trapezoid should be suspected from the mechanism of injury, in particular, axial force, and from local tenderness. These fractures may be underdiagnosed. We recommend computed tomography rather than plain radiography alone in case of clinical suspicion. Type of study/level of evidence: Diagnostic IV.

Glomus Tumor of Digital Nerve: Case Report - Corrected Proof

2012-04-16

Glomus tumors consist of modified perivascular, smooth muscle involved in thermoregulatory activity of digital blood flow. Digits, especially in the subungual region, are often affected. These tumors only rarely arise in peripheral nerves; digital nerve involvement is exceptional. We describe a glomus tumor occurring in the digital nerve at the level of the distal phalanx.

Hepatitis C and the Hand Surgeon: What You Should Know - Corrected Proof

Nick Pappas, Donald H. Lee — 2012-04-16

Chronic hepatitis C has recently become the number one cause of liver-related mortality in the United States. A blood-borne infection, it is most commonly spread by intravenous drug use. However, health care workers such as hand surgeons can be exposed through “sharp” injuries (eg, accidental needle sticks) both in clinic and in the operating room. If one acquires hepatitis C, there is approximately an 80% chance that it will develop into a chronic infection. Hepatitis C infection is deemed chronic if detectable hepatitis C virus (HCV) ribonucleic acid (RNA) is present for at least 6 months. After hepatitis C has developed into a chronic infection, there is roughly a 30% chance that cirrhosis of the liver will manifest within the next 20 years. Cirrhosis develops because the HCV targets hepatocytes, causing damage to them through a mechanism which is not completely understood. There is no vaccine for the prevention of hepatitis C infection. In this article, we review the transmission, diagnosis, treatment, and prevention of hepatitis C as it pertains to practicing hand surgeons.

Hand Made: Recreating an Ancient Chinese Instrument, the Guqin - Corrected Proof

Montri Daniel Wongworawat — 2012-04-16

Having some music background, I was inspired to create the most ancient of Asian instruments—the guqin—because it heralds from the dawn of Chinese civilization. After finding a construction manual published in 1855, I translated the text into mathematical plots, which allowed me to recreate the basic design. Tradition calls for paulownia and catalpa lumber, but I used more readily accessible materials—spruce for the soundboard and maple for the back. Pearl inlay mark the natural harmonic nodes ().

Hand Made: An Anatomical Study of the Human Spirit - Corrected Proof

Kristy L. Hamilton — 2012-04-16

The act of dissecting a real, organic person is both an absolute privilege and a very strange thing indeed. I approached my first foray into the human form with butterflies in my stomach. The humanistic side of my mind needed to come to terms with these procedures even while the analytical side reveled in the knowledge and wonder found beneath the skin. There is something so profoundly real, human, and raw about a person's hand. Hands make one's way through life; they are our interface with so much of the world. I chose to celebrate them by placing an outstretched hand in a vibrant, vivid, and living setting with the very butterfly I felt in my stomach, softly alighting on its fingertips (). Through this drawing, I hope that the life represented by the body can come to light. This colored-pencil drawing on paper took 40 hours to create.

Mobile Software Applications for Hand Surgeons - Corrected Proof

Orrin I. Franko — 2012-04-16

As smartphones and tablet computers gain increasing popularity among physicians and trainees, recent articles have focused on mobile applications (apps) for particular specialties. Most recently, authors Barr and Yao discussed the uses, capabilities, and regulations of smartphones as they apply to hand surgeons. In their article, the authors elucidated many of the useful features of smartphones, including the utility of apps, software developed specifically for mobile devices. They noted that no study had specifically examined apps designed for the hand surgeon. This article describes many of the currently available apps that would be most useful to practicing hand surgeons. Many of the presented apps are available for both iPhone and Android devices, although most are available exclusively for the iPhone and iPad. Many are free, others require purchase, and all are available through the iTunes App Store or Android Market (). I encourage readers who are interested in these apps or others to seek additional reviews from app review websites such as www.TopOrthoApps.com, which reviews only orthopedic apps.

Electrothermal Collagen Shrinkage - Corrected Proof

Pedro K. Beredjiklian, Michael Rivlin — 2012-04-16

The application of heat for coagulation and ablation of human tissues has traditionally posed an appealing method of treating a variety of pathologic conditions. In ophthalmology, the alteration of corneal curvature by means of thermal energy to correct various disorders affecting vision dates back to the 1960s. In cardiac surgery, electrochemical ablators have been used to disrupt abnormal conductive properties of cardiac tissues in patients with electrophysiological conductive alterations. After their introduction in cardiac surgery, electrothermal probes gained preference as a means to deliver heat to tissues due to lower operating costs, safer use, ease of maneuverability, and accuracy.

Major Upper-Limb Amputations for Malignant Tumors - Corrected Proof

Mark E. Puhaindran, Joanne Chou, Jonathan A. Forsberg, Edward A. Athanasian — 2012-04-06

Purpose: With the continued advancement of limb salvage surgery, major upper-limb amputations are being performed less frequently and are generally reserved for patients with large, multifocal, or recurrent tumors for whom limb salvage is no longer an option. We conducted a retrospective review of the current indications and patient outcomes after major upper-limb amputations for malignant tumors. Methods: Using the institution surgical database, we identified 43 patients who underwent major upper-limb amputation for primary and metastatic malignant tumors from 1996 to 2008. Results: Of these 43 patients, 25 had soft tissue sarcoma, 7 had bone sarcoma, and 11 had carcinoma. Two patients had stage I, 3 had stage II, 21 had stage III, and 17 had stage IV disease. We performed 45 amputations: 5 below the elbow, 14 above the elbow, and 26 at the forequarter. Among the 45 amputations, 2 patients underwent a second more proximal amputation for local tumor recurrence. Of the 17 patients with stage IV disease, 10 underwent palliative amputation for symptom control. A total of 28 patients (65%) died. Median survival after amputation was 13 months (95% confidence interval, 8–19 mo). The 6-month cumulative incidence of local recurrence was 22%. Overall survival after forequarter amputations was 42% at 1 year. Conclusions: Survival after major upper-limb amputation is poor, especially because amputations are reserved for patients with advanced tumors. However, amputation remains an option for local tumor control and can palliate symptoms in selected patients. Improvement of survival requires more effective systemic treatment strategies. Type of study/level of evidence: Therapeutic IV.

Repair of Distal Biceps Ruptures - Corrected Proof

Mark Baratz, Graham J.W. King, Scott Steinmann — 2012-04-06

A 47-year-old, self-employed contractor lifts a large board and feels a “pop” on the anterior aspect of his elbow. He continues to work but experiences anterior elbow pain and realizes he is weak when he tries to tighten a screw with a screwdriver. The next morning the arm is swollen and ecchymotic. He cannot fully extend the elbow and has pain trying to turn the palm up. He is evaluated 8 days later and has regained full elbow motion. The biceps tendon cannot be palpated in the antecubital fossa with the elbow flexed and the forearm supinated. He has no noticeable difference in elbow flexion strength but has reduced supination strength. Radiographs and a magnetic resonance imaging scan were obtained before presentation. The radiographs are normal. The magnetic resonance imaging scan shows a complete rupture of the distal biceps. The patient's contracting business is the sole support for his family. He wants to know what will happen if he “leaves this alone,” and “If I get it fixed, will I be as good as new?”

Nonoperative Treatment of Digital Ischemia in Systemic Sclerosis - Corrected Proof

Lindley B. Wall, Peter J. Stern — 2012-04-06

A 46-year-old, right hand–dominant woman presents with a 3-month history of painful ulcerations on the tips of the dominant ring and small fingers. There is no history of diabetes, coagulopathy, or atherosclerosis. She has a history of dysphagia and Raynaud phenomenon (RP) for the past 18 months. She has a 30–pack-year smoking history. Plain radiographs of the hand are normal.

Corrected Proof

Vincent R. Hentz — 2012-04-06

As a hand surgeon, I was taught that one of the first questions I should ask my patients is, “Are you left-handed or right-handed?” Thus, this book's title caught my eye, and, having read it, I recommend it. Before we begin, however, answer the following questions either true or false: (answers later).

Synovial Fistula as a Complication of Recurrent Dorsal Wrist Ganglion Excision: Case Report - Corrected Proof

Nash H. Naam — 2012-04-06

A wrist synovial fistula is rare. The author reports a patient who developed a synovial fistula following excision of a recurrent dorsal wrist ganglion.

Three-Dimensional Computed Tomographic Analysis of 11 Scaphoid Waist Nonunions - Corrected Proof

Andreas Schweizer, Philipp Fürnstahl, Ladislav Nagy — 2012-04-06

Purpose: To virtually assess nonunions of the scaphoid waist using 3-dimensional computed tomogram (CT) reconstruction for the amount of displacement of the distal fragment and the postfracture reduction position using the intact opposite scaphoid for reference. Methods: We generated 3-dimensional reconstructions for 11 nonunions of the scaphoid waist and the contralateral intact scaphoids based on CT. The mean age of the patients was 25 years and the time from injury to the CT scan was 2.4 years. We used the mirrored 3-dimensional model of the healthy scaphoid to guide virtual reduction of the nonunion, and calculated the amount of displacement of the distal pole fragment from prereduction to postreduction. We compared the results with the intrascaphoid angles calculated using single CT slices. Results: The scaphoid nonunions showed a mean flexion deformity of 23°, an ulnar deviation of 5°, and a pronation deformity of 10°. Mean translation was 0.9 mm volarward, 0.2 mm radialward, and 3.3 mm distalward. After reduction, all scaphoids showed a bony overlap on the dorsoradial side; the mean volume of this region was 3% of total bone volume. There was no correlation between the degree of displacement and the intrascaphoid angle measurements. Conclusions: Preoperative planning for scaphoid reconstruction is usually performed using conventional radiographs and single CT slices. However, by synthesizing the information from the CT into a 3-dimensional reconstruction, an exact analysis is possible. This method also allows quantification of prosupination displacement. The postreduction area of dorsal bone overlap may be due to appositional callus formation. Clinical relevance: Simple volar opening of the scaphoid allows correction of angulation deformities but the scaphoid will be lengthened. Correct reduction of the scaphoid fragments is often only possible if the dorsal appositional callus is resected.

Partial Extensor Carpi Radialis Longus Turn-Over Tendon Transfer for Reconstruction of the Extensor Pollicis Longus Tendon in the Rheumatoid Hand: Case Report - Corrected Proof

Matthew D. Chetta, Shimpei Ono, Kevin C. Chung — 2012-04-06

Reconstruction of a distally ruptured extensor pollicis longus tendon in the rheumatoid patient generally involves a tendon transfer or intercalary graft. We present an alternative technique using the radial half of the extensor carpi radialis longus as a turn-over graft. Using the turn-over technique with a half-slip of the extensor carpi radialis longus avoids the traditional limitations of the extensor carpi radialis longus tendon in distal extensor pollicis longus tendon repairs and precludes the need for a free tendon graft.

The Radiologic Relationship of the Shoulder Girdle to the Thorax as an Aid in Diagnosing Neurogenic Thoracic Outlet Syndrome - Corrected Proof

2012-04-05

Purpose: Neurogenic thoracic outlet syndrome (NTOS) is produced by compression of the brachial plexus in the thoracic outlet. The lower position of the shoulder girdle relative to the upper thorax may be related to NTOS. We investigated this hypothesis using plain cervical radiographs. Methods: We conducted this case-control study using plain cervical anteroposterior and lateral radiographs in 63 NTOS patients and 126 carpal tunnel syndrome patients who were matched for age and sex. To estimate the position of the shoulder girdle relative to the upper thorax, we analyzed the level of the clavicle using 2 parameters: the number of vertebrae visible in a lateral radiograph and the number of vertebrae above the line connecting both sternal ends of the clavicles in an anteroposterior radiograph. The number of vertebrae visible in a lateral radiograph was the parameter for the level of the lateral part of the clavicle relative to the upper thorax, whereas we used the number of vertebrae above the line connecting both sternal ends of the clavicles in an anteroposterior radiograph to determine the level of the medial part of the clavicle. Results: Both parameters were greater in the NTOS group than in the control group, which suggests that the level of the shoulder girdle was lower in the NTOS group than in the control group. In addition, the risk of NTOS was increased in patients with lower shoulder girdle position. Conclusions: The lower placement of the shoulder girdle relative to the upper thorax was related to NTOS. Physicians may be able to estimate the position of the shoulder girdle using plain cervical radiographs when NTOS is clinically suspected. Type of study/level of evidence: Diagnostic IV.

Endoscopic-Assisted Decompression for Pronator Syndrome - Corrected Proof

2012-04-02

Purpose: Traditional surgical management for pronator syndrome results in a relatively long and possibly disfiguring scar across the antecubital fossa. The purposes of this study were to present an endoscopic technique that facilitates the decompression of the proximal median nerve without extensile incisions, and to evaluate whether this minimally invasive procedure could adequately and safely treat the condition to improve outcome scores. Methods: We treated 13 patients (14 cases) with isolated pronator syndrome with endoscopic-assisted decompression and retrospectively reviewed them. We excluded patients with concomitant carpal tunnel syndrome or other compression neuropathies. The average age of the patient at presentation was 41 years. Final follow-up averaged 22 months. We asked all patients to rate their preoperative and postoperative condition and functional capabilities using the validated Disabilities of the Shoulder, Arm, and Hand (DASH) scoring protocol. Results: All 13 patients improved symptomatically as reflected in the DASH score assessment. The preoperative scores averaged 56 and the postoperative scores were significantly reduced and averaged 6. There were 3 minor complications, which resolved spontaneously. Conclusions: The endoscopic-assisted, minimally invasive approach to treat pronator syndrome adequately and safely decompressed all anatomical points of compression and improved DASH scores. This may reduce morbidity and facilitate a quicker recovery compared with the traditional open incision techniques. Type of study/level of evidence: Therapeutic IV.

The Scaphotrapezial Joint After Partial Trapeziectomy for Trapeziometacarpal Joint Arthritis: Long-term Follow-up - Corrected Proof

Shelley S. Noland, Sepideh Saber, Ryan Endress, Vincent R. Hentz — 2012-04-01

Purpose: Partial trapeziectomy addresses trapeziometacarpal (TM) joint arthritis without the risk of destabilizing the scaphotrapezial (ST) joint. However, partial trapeziectomy has been criticized because of concern that ST joint arthritis will develop, requiring additional surgery. We hypothesized that partial trapeziectomy is a durable treatment for TM joint arthritis, even in patients with radiographically abnormal but asymptomatic ST joints. Methods: We evaluated 13 patients (16 thumbs) who underwent a partial trapeziectomy between 1995 and 2005. Assessment included grip strength, pinch strength, ST joint direct palpation, and ST joint stress testing. We classified standardized radiographs of the ST joint using a simple scoring system. Subjective data included the Disabilities of the Arm, Shoulder, and Hand questionnaire, a pain scale, and a satisfaction survey. Results: The length of follow-up averaged 9 years (range, 5–13 y). No patient had pain at the ST joint with direct palpation or stress testing. Radiographs demonstrated a mean ST joint arthritis score of 1, indicating mild arthritic changes. Mean grip strength was 28 kg on the operated hand and 28 kg on the nonoperated hand. Mean pinch strength was 5 kg on the operated hand and 5 kg on the nonoperated hand. Scores on the pain scale averaged 6 (range, 0–100; 100 = worst). Average Disabilities of the Arm, Shoulder, and Hand score was 11 (range, 0–100; 100 = worst). Of 13 patients, 12 were very satisfied or extremely satisfied, and 1 was not satisfied. Conclusions: Partial trapeziectomy for TM joint arthritis provides long-lasting relief of symptoms in patients with radiographically abnormal but clinically insignificant ST joint degeneration. Satisfaction is equivalent to other published series. The radiographic appearance of the ST joint did not correlate with symptoms at this joint. Unless the patient has symptomatic ST joint arthritis, the ST joint may be retained. Type of study/level of evidence: Therapeutic IV.

Nerve Injuries Resulting From Arthroscopic Treatment of Lateral Epicondylitis: Report of 2 Cases - Corrected Proof

Bradley C. Carofino, Allen T. Bishop, Robert J. Spinner, Alexander Y. Shin — 2012-03-30

Arthroscopic management of lateral epicondylitis is a commonly performed procedure that has a good track record of efficacy and safety based on the current literature. Here, we report 2 cases of nerve injuries resulting from this operation: 1 posterior interosseous nerve transection and 1 partial median nerve laceration.

Hands on Stamps: China 2005—World Earth Day - Corrected Proof

Le Qi — 2012-03-12

Date of issue: April 22, 2005 Size: 36 × 36 mm Value: 80 Fen (cents) China issued this stamp () on April 22, 2005, to celebrate the 36th World Earth Day. As 1 of 4 basic policies of the People's Republic of China, environmental protection policy plays a substantial role in keeping the environmental development sustainable. It was the first time that China issued a World Earth Day themed stamp. The stamp depicts two colorful hands holding up our very own planet, Mother Earth. It symbolizes the beautiful sunshine, signifying that the Earth belongs to all the people with different colors of skin. The concept conveyed to the world through this stamp is government's determination to protect the environment positively as well as the attitude to the whole world.

Injuries Complicating Musical Practice and Performance: The Hand Surgeon's Approach to the Musician-Patient - Corrected Proof

Andrew J. Rosenbaum, Jacqueline Vanderzanden, Andrew S. Morse, Richard L. Uhl — 2012-03-05

High-performance musculoskeletal injuries in the instrumental musician stem from repetitive motions, awkward postures, and long practice hours. Although their precise prevalence in this population is unclear, many have attempted to quantify this number and delineate the specific problems.

Epinephrine and Hand Surgery - Corrected Proof

Tobias Mann, Warren C. Hammert — 2012-02-10

A 45-year-old man injured his dominant hand at work, with zone II flexor tendon injuries to the index and middle fingers. He states he has severe nausea after general anesthesia and would prefer local anesthesia for repair of the injuries.

Distal Humerus Fractures: Handling of the Ulnar Nerve - Corrected Proof

Olukemi Fajolu, Kavita Iyengar, Christopher S. Litts — 2012-02-10

A 70-year-old woman with a 20-year history of diabetes mellitus undergoes open reduction and plate and screw fixation (medial and posterolateral plates) of a bicolumnar fracture of the distal humerus, using an olecranon osteotomy for exposure. The ulnar nerve is protected by mobilizing it completely from at least 10 cm proximal through the flexor pronator aponeurosis, and then is left transposed anteriorly in the subcutaneous tissues at the end of the surgery. Approximately 2 months after surgery, the patient notices numbness in the small and ring fingers. Electrodiagnostic testing demonstrates nonrecordable latencies in the left ulnar nerve, suggestive of a severe, active left ulnar neuropathy at or distal to the elbow. The patient incidentally also has bilateral moderately severe median neuropathies.

Recurrent or Persistent Cubital Tunnel Syndrome - Corrected Proof

Amirhesam Ehsan, Douglas P. Hanel — 2012-02-10

A 38-year-old, right hand–dominant woman presents 1 year after subcutaneous ulnar nerve transposition with constant numbness of the right ring and small fingers and decreased dexterity for the past 6 months. Notes from her surgeon indicate that before surgery she had numbness to the right ring and small fingers and weakness of the first dorsal interosseous muscle. Electrodiagnostic testing before surgery demonstrated delayed conduction velocity of the ulnar nerve across the elbow. She reports complete relief of symptoms after surgery, but now she cannot sleep well and cannot work as a nursing assistant.

Complex Distal Humerus Fractures in Elderly Patients: Open Reduction and Internal Fixation Versus Arthroplasty - Corrected Proof

Juan M. Patino — 2012-01-30

A 66-year-old man injured his elbow in a fall on stairs. He had normal neurovascular function, no wound, and no other injuries. Anteroposterior and lateral radiographs showed a bicolumnar articular (AO type C3) fracture of the distal humerus.

Hand Made: Bill's Humidor - Corrected Proof

Jeffrey Alan Greenberg — 2011-11-28

Cigar aficionados need a place to store their treasured smokes. My senior partner and good friend Bill Kleinman is one of those folks. For years, he has been asking me to build him a humidor, and I have been putting it off. I knew that his 65th birthday was this year, and I felt that it was an appropriate occasion to present him with this handmade gift (. The humidor is made of cherry and mahogany, with a veneered lacewood top and ebony accents. The inlay is handmade of stacked ebony, birch, and mahogany veneers, and it is lined with Spanish cedar. This project took about 20 hours to complete, working for about 3 months on nights and weekends.

The Use of Low-Intensity Pulsed Ultrasound Bone Stimulators for Fractures of the Hand and Upper Extremity - Corrected Proof

Jonathan C. Riboh, Fraser J. Leversedge — 2011-10-28

A 28 year-old, right-handed man, a construction worker, presents to the hand clinic for evaluation and treatment of a right, non-displaced scaphoid waist fracture, confirmed by computed tomography. He reports no medical comorbidities and stopped smoking 1 year previously at the heeding of his wife. He is anxious to return to work, but he is unable to perform his duties until he has been released to unrestricted duty. He is ineligible for workers' compensation because the injury occurred during participation in his club soccer match. He does not wish to pursue surgical repair, but he asks about the benefits of a bone-growth stimulator and queries why his medical insurance company would not pay the costs of such a device for acute fracture management but would authorize its use if a diagnosis of nonunion was determined.

Septic Olecranon Bursitis - Corrected Proof

Joshua M. Abzug, Neal C. Chen, Sidney M. Jacoby — 2011-10-21

A 40-year-old man, a carpenter, presents to the emergency room with a 2-day history of increasing pain, swelling, and erythema of his posterior elbow. The patient reports bumping his elbow on a piece of wood while hammering 3 days ago. Our examination noted no open wounds. A fever of 101°F is recorded, but his vital signs are otherwise normal. Elbow motion is nearly full and painful with elbow flexion beyond 70°. The emergency room physician requests a consultation for presumed septic olecranon bursitis.

Hands on Stamps: Iran 1966—National Census - Corrected Proof

Ahmadreza Afshar — 2011-05-09

The stamp depicts counting hands and random numbers. The subject is a national census. The 10-year national census in Iran began in 1956, and this stamp commemorates the second national census in 1966. The hands represent the direct count of subjects around the country, which was accomplished house by house.

Hands on Stamps: Iran—Helping Hands - Corrected Proof

Ahmadreza Afshar — 2011-05-09

To help means to assist somebody, to be useful to somebody, and to make it easier for somebody to do something. These meanings are demonstrated by hands on some Iranian stamps ().

Hands on Stamps: Iran—Agricultural Training and Extension - Corrected Proof

Ahmadreza Afshar — 2011-05-09

Iran issued 2 stamps in 1985 () and 1991 () to increase public awareness about agricultural training and extension. The aims of agricultural training and extension are to produce more food. The hand represents the human willpower that actively supports the programs; therefore, hands are the most prominent element in the theme of the stamps.