Journal of Hand Surgery RSS feed: Articles in Press. The Journal of Hand Surgery publishes original, peer-reviewed articles related to the diagnosis, treatment, and pathophysiology of diseases and conditions of the upper extremity; these include both clinical and basic science studies, along with case reports. Special features include Clinical Perspective and History of Hand Surgery articles, Comprehensive Review manuscripts, and Surgical Technique articles that provide an overview of hand surgery, technical aspects of surgery, and current controversial topics. Beginning in January 2006, the Journal of Hand Surgery will incorporate the Journal of the American Society for Surgery of the Hand . http://www.jhandsurg.org//inpress?rss=yesElsevier Inc.en © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved. Journal of Hand Surgery0363-50232012-02-13 © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.jhandsurg.org/article/PIIS0363502311015796/abstract?rss=yes We present a case of a young woman with Birt-Hogg-Dubé syndrome and multiple neurilemmomas involving different nerves in a single extremity. Birt-Hogg-Dubé is an uncommon but increasingly recognized syndrome. Hand surgeons may wish to consider this disease when faced with a patient with multiple neurilemmomas, especially when associated with renal tumors, spontaneous pneumothoraces, or other benign or malignant neural or non-neural tumors. Multiple Neurilemmomas in Birt-Hogg-Dubé Syndrome: Case Report - Corrected ProofKevin J. Renfree, Kara L. Lawless10.1016/j.jhsa.2011.12.011Journal of Hand Surgery (2012)2012-02-13Journal of Hand Surgery2012-02-13SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311013803/abstract?rss=yes Purpose: To evaluate the clinical outcomes of corrective osteotomy and ligament repair for longstanding radial collateral ligament tears of the proximal interphalangeal (PIP) joint. Methods: We retrospectively evaluated 4 patients with 5 longstanding tears in the radial collateral ligaments of the PIP joints. The average age at the time of surgery was 51 years (range, 40–62 y). The average time from the initial injury to surgery was 31 years (range, 22–40 y). Plain radiographs revealed an ulnar slope at the PIP joint surface with degenerative changes in all fingers. We corrected the slope using a closing wedge osteotomy of the neck of the proximal phalanx secured with a headless screw. We then repaired the radial collateral ligament by overlapping the elongated ligament. Range of motion exercises were started 2 weeks after surgery. To evaluate the results, we compared preoperative and postoperative range of motion, ulnar deviation, instability, pain, and level of satisfaction. Average follow-up was 27 months (range, 18–48 mo). Results: All osteotomies had united at an average of 3 months. We observed no major changes in range of motion, but flexion contracture gradually appeared in 1 high-demand patient. The average preoperative angle of ulnar deviation was 36° and was corrected to a postoperative angle of 2°. The average angle of lateral instability improved after surgery from 22° to 1°. Finger pain disappeared or decreased in 3 low-demand patients but persisted in 1 high-demand patient. Two low-demand patients were very satisfied and 1 low-demand patient was satisfied; however, 1 high-demand patient was dissatisfied with the results of surgery. Conclusions: Corrective osteotomy and ligament repair can result in a straight and stable joint with a good range of motion in low-demand patients. This method could be a treatment option for carefully selected patients. Type of study/level of evidence: Therapeutic IV. Corrective Osteotomy and Ligament Repair for Longstanding Radial Collateral Ligament Tear of the Proximal Interphalangeal Joint: Case Series - Corrected ProofJunichi Miyake, Takashi Masatomi, Tsuyoshi Murase, Koichiro Takahi, Hisao Moritomo, Hideki Yoshikawa10.1016/j.jhsa.2011.10.054Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311014316/abstract?rss=yes Purpose: Although outcomes after flexor tendon repair have reportedly improved with modern treatment, complications are common. The purpose of this study was to determine the incidence of these complications and the potential contributory factors within the published literature. Methods: We performed a systematic review of the available literature to identify publications in which patients with flexor tendon ruptures were surgically treated. We extracted demographics, zone of injury, core suture technique (only modified Kessler or a combination of techniques), use of epitendinous suture, and date of publication (before or after January 1, 2000). We excluded articles if they did not report information on reoperation, rupture, or adhesions. We used unadjusted pooled meta-analysis to report the incidence of complications, and meta-regression to describe the potential contributory factors for each complication while controlling for age, gender, and zone of injury. Results: Unadjusted meta-analysis revealed rates of re-operation of 6%, rupture of 4%, and adhesions of 4%. Meta-regression analysis of 29 studies showed that core suture technique or use of an epitendinous suture does not influence rupture. However, the presence of an epitendinous suture decreases re-operation by 84%. Adhesion development is 57% lower when the modified Kessler technique is used. The incidence of complications did not vary with publication date. Conclusions: The published literature supports use of the modified Kessler repair technique with an epitendinous suture to minimize complications. Although complication rates are low, our data suggest that there has been no definitive improvement in reported complications before and after 2000. Type of study/level of evidence: Therapeutic III. Complications After Flexor Tendon Repair: A Systematic Review and Meta-Analysis - Corrected ProofChristopher J. Dy, Alexia Hernandez-Soria, Yan Ma, Timothy R. Roberts, Aaron Daluiski10.1016/j.jhsa.2011.11.006Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS036350231101433X/abstract?rss=yes Purpose: We tested the hypothesis that there are no differences between apparently isolated fractures of the radial diaphysis and isolated fractures of the radial diaphysis with concomitant dislocation of the distal radioulnar joint (DRUJ) in function, disability, and DRUJ stability more than 13 years after near-anatomic open reduction with plate and screw fixation. Methods: We evaluated 17 adult patients with a diaphyseal fracture of the radius without a fracture of the ulna an average of 19 years after surgery (range, 13–33 y). Of these patients, 7 had concomitant dislocation of the DRUJ (Galeazzi fracture). At the long-term follow-up, we evaluated function with several composite scores, stability of the DRUJ, and arm-specific disability by using the Disabilities of Arm, Shoulder, and Hand questionnaire. Results: The average scores were 96 (range, 85–100) on the Mayo Modified Wrist Score, 95 (range, 80–100) on the Mayo Elbow Performance Index, and 5 (range, 0–33) on the Disabilities of Arm, Shoulder, and Hand questionnaire. There were no significant differences between patients with and without DRUJ dislocation. No patients had greater laxity of the DRUJ than the opposite uninjured side. Conclusions: Near-anatomic open reduction and internal fixation of diaphyseal radius fractures with and without associated DRUJ dislocation have comparable long-term results. Type of study/level of evidence: Therapeutic IV. Long-Term Outcome of Isolated Diaphyseal Radius Fractures With and Without Dislocation of the Distal Radioulnar Joint - Corrected ProofDennis C. van Duijvenbode, Thierry G. Guitton, Ernst L. Raaymakers, Peter Kloen, David Ring10.1016/j.jhsa.2011.11.008Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311014353/abstract?rss=yes Cutaneous mucormycosis, a relatively common infection in immunocompromised patients, remains rare in the immunocompetent patient outside the setting of major trauma. We report a case of an immunocompetent patient who developed left upper extremity Rhizopus infection following arterial puncture. Treatment included surgical debridement, liposomal amphotericin B, and hyperbaric oxygen wound therapy; the patient recovered fully. A review of the literature of cases of upper extremity Mucor infection is included for context. We feel that a high degree of suspicion for Mucor infection is warranted in patients with the described risk factors who do not respond to first-line antibiotics. Cutaneous Mucormycosis of the Upper Extremity in an Immunocompetent Host: Case Report - Corrected ProofKyle D. Lineberry, Adam K. Boettcher, Andrew L. Blount, Scott D. Burgess10.1016/j.jhsa.2011.11.010Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311014365/abstract?rss=yes Purpose: To investigate the incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures and to determine the risk factors for this combination. Methods: We retrospectively analyzed 161 consecutive patients with 170 distal radius fractures who were treated between 2007 and 2011. Posteroanterior, lateral, and oblique radiographs of the wrist were examined, as were computed tomography scans when available. We evaluated the incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures and the patient factors of gender, age, AO/ASIF classification, and energy of the injury. Results: Of the 170 distal radius fractures, 11 (7%) also had 1 or 2 carpal fractures. Of the 15 carpal fractures, 8 were scaphoid, 2 triquetrum, 2 pisiform, 1 capitate, 1 trapezium, and 1 hamate. Eleven of the 15 carpal fractures were diagnosed by computed tomography alone. Male gender, patients of lower mean age, AO/ASIF type B, and high-energy trauma significantly raised the risk of simultaneous fractures of the distal radius and carpals. Conclusions: The incidence of carpal fractures occurring concurrently with distal radius fractures was not negligible, and almost all carpal fractures had no or minimal displacement. Suspicion of carpal fractures occurring concurrently with distal radius fracture should be high, and computed tomography should be considered, in males, young patients, and those with AO/ASIF type B fractures and high energy trauma. Type of study/level of evidence: Diagnostic III. Incidence and Characteristics of Carpal Fractures Occurring Concurrently With Distal Radius Fractures - Corrected ProofShingo Komura, Tatsuo Yokoi, Hidehiko Nonomura, Hiroyuki Tanahashi, Takashi Satake, Norihito Watanabe10.1016/j.jhsa.2011.11.011Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015000/abstract?rss=yesA 46-year-old, right hand–dominant woman presents to the emergency room with pain in the right index finger. It started 3 days prior and has progressively worsened. Examination reveals a tender, swollen, and erythematous eponychium. A purulent collection seems to be present under the nailfold, but not under the nail plate itself, with no active drainage. The erythema does not extend proximal to the distal interphalangeal joint. Radiographs are normal except for some soft tissue swelling dorsally in the region described.Evidence-Based Medicine: Acute Paronychia - Corrected ProofAndrew W. Ritting, Michael P. O'Malley, Craig M. Rodner10.1016/j.jhsa.2011.11.021Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10EVIDENCE-BASED MEDICINEhttp://www.jhandsurg.org/article/PIIS0363502311015012/abstract?rss=yesA 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.Epinephrine and Hand Surgery - Corrected ProofTobias Mann, Warren C. Hammert10.1016/j.jhsa.2011.11.022Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10EVIDENCE-BASED MEDICINEhttp://www.jhandsurg.org/article/PIIS0363502311015024/abstract?rss=yesA 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.Distal Humerus Fractures: Handling of the Ulnar Nerve - Corrected ProofOlukemi Fajolu, Kavita Iyengar, Christopher S. Litts10.1016/j.jhsa.2011.11.023Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10EVIDENCE-BASED MEDICINEhttp://www.jhandsurg.org/article/PIIS0363502311015036/abstract?rss=yesA 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.Recurrent or Persistent Cubital Tunnel Syndrome - Corrected ProofAmirhesam Ehsan, Douglas P. Hanel10.1016/j.jhsa.2011.11.024Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10EVIDENCE-BASED MEDICINEhttp://www.jhandsurg.org/article/PIIS0363502311015711/abstract?rss=yes Giant cell tumors of bone in the hand are rare. We present a case of a recurrent giant cell tumor in the metacarpal 42 years after intralesional excision and autogenous bone grafting. The possibility of recurrent disease should be considered in the evaluation of any patient presenting with new onset of pain at the site of a previously addressed giant cell tumor. Management of these recurrent lesions should include wide excision with digit salvaging procedures or ray amputation owing to the high rates of treatment failures seen with marginal excision. Recurrence of a Giant Cell Tumor of the Hand After 42 Years: Case Report - Corrected ProofKeith Jackson, Charles Key, Michelle Fontaine, Richard Pope10.1016/j.jhsa.2011.12.005Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015723/abstract?rss=yes We present the case of a young patient with a severely comminuted, malunited, intra-articular distal radius fracture and complete disruption of the sigmoid notch. We reconstructed the malunited distal radioulnar joint by osteotomy and repositioning the displaced sigmoid notch fragments through a combined dorsal and volar approach. At the same time, we carried out a radioscapholunate arthrodesis with distal scaphoid excision. We used a free vascularized corticoperiosteal flap from the medial femoral condyle to span the massive bone defect in the radius to obtain union. At the 2.5-year follow-up, the patient had essentially normal function of the distal radioulnar joint (painless, with 85° of active pronation and 75° of supination). He resumed work as a bricklayer without limitations. We conclude that sigmoid notch reconstruction by osteotomy is worthwhile in the setting of malunited distal radius whether or not the radiocarpal joint is reconstructable. Sigmoid Notch Reconstruction and Limited Carpal Arthrodesis for a Severely Comminuted Distal Radius Malunion: Case Report - Corrected ProofFrancisco del Piñal, Alexis Studer, Carlos Thams, Eduardo Moraleda10.1016/j.jhsa.2011.12.006Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015735/abstract?rss=yes Although there is no record of them ever physically meeting, in 1896 the footsteps of Sigmund Freud and William Halsted surely crossed inside the cavernous wards and cacophonous halls of Vienna's primary public hospital, the Allgemeines Krankenhaus. We know them both because of their lasting contributions to their respective fields: Freud as the father of psychoanalysis, “the talking cure,” and Halsted as the innovative architect of the system of progressive surgical education that we term “residency.” In An Anatomy of Addiction, subtitled Sigmund Freud, William Halsted, and the Miracle Drug Cocaine, physician-author Howard Markel explores another intersection in the lives of these two singular individuals: the impact of Freud's and Halsted's addiction to cocaine on their careers and medicine in general. For more than a decade, Freud inhaled it, whereas for half his life, Halsted injected it, both in ever-increasing quantities.Corrected ProofVincent R. Hentz10.1016/j.jhsa.2011.11.026Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10BOOK REVIEWhttp://www.jhandsurg.org/article/PIIS0363502311015747/abstract?rss=yesDay of Issue: April 20, 1991 Size: 30 × 40 mmHands on Stamps: China 1991—Family Planning Policy - Corrected ProofLe Qi10.1016/j.jhsa.2011.12.007Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10A TOUCH OF HUMANITYhttp://www.jhandsurg.org/article/PIIS0363502311015759/abstract?rss=yes Purpose: We studied the utility of magnetic resonance imaging (MRI) studies for workers' compensation patients with hand conditions in which the referring doctor obtained the images. We compared the MRI findings with the eventual clinical findings. We also investigated the approximate cost of these MRI studies. Methods: We retrospectively reviewed the charts of all workers' compensation patients seen in a hand and upper extremity practice over the course of 3 years. We selected patients who had MRI studies of the affected upper extremities before referral to the senior author (G.R.). We reviewed the charts for information regarding demographics, referral diagnoses, MRI diagnoses made by the radiologist, the area of the upper extremity studied, and eventual clinical diagnoses by the senior author. We made a determination as to whether a hand surgeon could have adequately diagnosed and treated the patients' conditions without the imaging studies. We also investigated the cost associated with these MRIs. Results: We included 62 patients with a total of 67 MRI scans in this study. The MRI studies did not contribute to clinically diagnosing the patients' conditions in any of the cases we reviewed. The hand surgeon's clinical diagnosis disagreed with the radiologist's MRI diagnosis in 63% of patients. The MRI was unnecessary to arrive at the clinical diagnosis and did not influence the treatment offered for any of the 62 patients. The total cost for the 67 non-contrast MRI studies was approximately $53,000. Conclusions: Costly imaging studies are frequently done to determine the validity of a patient's reported problems; unfortunately, these tests are frequently unnecessary and waste resources. Magnetic resonance imaging scans may not be the standard for accurate diagnosis and can misdirect care. Type of study/level of evidence: Therapeutic III. Magnetic Resonance Imaging in Evaluating Workers' Compensation Patients - Corrected ProofDaniel Babbel, Ghazi Rayan10.1016/j.jhsa.2011.12.008Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015760/abstract?rss=yes Purpose: To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improve the outcome of trapezial excision for the treatment of basal joint arthritis after a minimum follow-up of 5 years. Methods: We randomized 174 thumbs with trapeziometacarpal osteoarthritis into 3 groups to undergo simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void and retained for 4 weeks, and a thumb spica was used for 6 weeks in all 3 groups. We reviewed 153 thumbs after a minimum of 5 years (median, 6 y; range, 5–18 y) after surgery with subjective and objective assessments of thumb pain, function, and strength. Results: There was no difference in the pain relief achieved in the 3 treatment groups, with good results in 120 (78%) patients. Grip strength and key and tip pinch strengths did not differ among the 3 groups and range of movement of the thumb was similar. Few complications persisted after 5 years, and these were distributed evenly among the 3 groups. Compared with the results at 1 year in the same group of patients, the good pain relief achieved was maintained in the longer term, irrespective of the type of surgery. While improvements in grip strength achieved at 1 year after surgery were preserved, the key and tip pinch strengths deteriorated with time, but the type of surgery did not influence this. Conclusions: The outcomes of these 3 variations of trapeziectomy were similar after a minimum follow-up of 5 years. There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term. Type of study/level of evidence: Therapeutic I. Five- to 18-Year Follow-Up for Treatment of Trapeziometacarpal Osteoarthritis: A Prospective Comparison of Excision, Tendon Interposition, and Ligament Reconstruction and Tendon Interposition - Corrected ProofSoham Gangopadhyay, Helen McKenna, Frank D. Burke, Tim R.C. Davis10.1016/j.jhsa.2011.11.027Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015772/abstract?rss=yes Purpose: Non-anatomic reduction of the sigmoid notch in distal radius fractures may lead to limited motion, instability, or pain with pronation and supination. Standard radiological projections only poorly capture the sigmoid notch contours in the axial plane. The purpose of this study was to find an intraoperatively feasible radiological projection that will facilitate an axial view of the distal radioulnar joint. Methods: We modified a previously described radiographic projection termed the skyline view for evaluating the distal radius axially. We created intra-articular steps at the sigmoid notch in solid foam forearm models to identify the best of 12 projections using an image intensifier. Four observers scored each projection based on the clarity of the sigmoid notch contour and indicated the presence and location of an intra-articular stepoff. Results: The sigmoid notch was best visualized in the modified skyline view with the wrist in extension and 10° to 15° of dorsal forearm angulation relative to the x-ray path. All observers correctly recognized the presence and location of intra-articular steps at the sigmoid notch with this view. The same forearm angulation with the wrist in flexion did not reach equally good visibility of the sigmoid notch. Arm position (wrist flexion, forearm rotation, or forearm angulation) and intra-articular stepoff (none, palmar, or dorsal) were dependent determinates. Elimination of the variable forearm rotation had minimal effect, indicating that forearm rotation is not important for visualization of the sigmoid notch. Conclusions: The modified skyline view for visualization of the distal radioulnar joint in an axial plane allows good visibility of the sigmoid notch and reliable identification of stepoffs. Further cadaver and in vivo studies are required to verify the validity of this method. Type of study/level of evidence: Diagnostic IV. Intraoperative Imaging of the Distal Radioulnar Joint Using a Modified Skyline View - Corrected ProofG. Klammer, M. Dietrich, M. Farshad, L. Iselin, L. Nagy, A. Schweizer10.1016/j.jhsa.2011.12.009Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015784/abstract?rss=yes Purpose: Free nonvascularized toe phalangeal transfer is an established surgical option for the reconstruction of hypoplastic digits. This study assessed long-term morbidity in the feet using this technique. Methods: We reviewed 40 children treated between 1991 and 2007 by free nonvascularized toe phalangeal transfer. The diagnosis was digital hypoplasia resulting from symbrachydactyly in 33 cases, constriction ring syndrome in 3 cases, thumb hypoplasia in 3 cases, and perinatal subclavian venous thrombosis in 1 case. The patients were followed up after surgery for a mean of 10 years (range, 3–19 y). The Oxford Ankle Foot Questionnaire was administered to patients and families to assess patient symptoms and patient and parental satisfaction. We assessed toe length ratio, the presence of visible deformity, and distal hypoplasia of the donor toes clinically and radiographically. Results: Emotional problems related to foot appearance were common. We also found functional problems with footwear in some patients. All patients had floppy unstable toes with visible deformity. Increasing foot deformity was seen with growth, which led to deterioration in foot aesthetics, particularly where multiple donor toes had been harvested. We identified distal and middle phalangeal and metatarsal hypoplasia in the donor toes. Conclusions: Donor site morbidity for free toe phalangeal transfer is greater than previously documented. This should be considered during surgical decision making for reconstruction of hypoplastic digits. Preoperative counseling should include discussion regarding possible consequences of phalangeal harvest on donor toes and options for donor site reconstruction. Long-term follow-up of the donor site is essential to accurately assess results. Type of study/level of evidence: Therapeutic III. Long-Term Donor Site Morbidity After Free Nonvascularized Toe Phalangeal Transfer - Corrected ProofLorenzo Garagnani, Marc Gibson, Paul J. Smith, Gillian D. Smith10.1016/j.jhsa.2011.12.010Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015802/abstract?rss=yesThumb basilar or carpometacarpal arthritis is a common and often debilitating condition seen in more than half of women aged over 71 years. It manifests as pain localized to the base of the thumb, as well as global hand dysfunction including weak grip and pinch, and inability to grasp large objects. Eaton and Glickel described the radiographic severity of basilar joint arthritis, and these stages are often used to dictate treatment. Several interventions have been described, including volar ligament reconstruction, trapeziometacarpal arthrodesis, trapeziectomy alone, trapeziectomy with ligament reconstruction, and arthroplasty. Despite this, comparatively little has been described about how to manage the accompanying hyperextension deformity of the metacarpophalangeal (MCP) joint that often exists. Failure to recognize and treat this deformity may lead to suboptimal results.Metacarpophalangeal Joint Hyperextension and the Treatment of Thumb Basilar Joint Arthritis - Corrected ProofDavid M. Brogan, Sanjeev Kakar10.1016/j.jhsa.2011.12.012Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10IN BRIEFhttp://www.jhandsurg.org/article/PIIS0363502311015814/abstract?rss=yes Purpose: Volar plating for distal radius fractures has caused extensor tendon ruptures resulting from dorsal screw prominence. This study was designed to determine the biomechanical impact of placing unicortical distal locking screws and pegs in an extra-articular fracture model. Methods: We applied volar-locking distal radius plates to 30 osteoporotic distal radius models. We divided radii into 5 groups based on distal locking fixation: bicortical locked screws, 3 lengths of unicortical locked screws (abutting the dorsal cortex [full length], 75% length, and 50% length to dorsal cortex), and unicortical locked pegs. Distal radius osteotomy simulated a dorsally comminuted, extra-articular fracture. We determined each construct's stiffness under physiologic loads (axial compression, dorsal bending, and volar bending) before and after 1,000 cycles of axial conditioning and before axial loading to failure (2 mm of displacement) and subsequent catastrophic failure. Results: Cyclic conditioning did not alter constructs' stiffness. Stiffness to volar bending and dorsal bending forces were similar between groups. Final stiffness (N/mm) under axial load was statistically equivalent for all groups: bicortical screws (230), full-length unicortical screws (227), 75% length unicortical screws (226), 50% length unicortical screws (187), and unicortical pegs (226). Force (N) at 2 mm displacement was significantly less for 50% length unicortical screws (311) compared with bicortical screws (460), full-length unicortical screws (464), 75% length unicortical screws (400), and unicortical pegs (356). Force (N) to catastrophic fracture was statistically equivalent between groups, but mean values for pegs (749) and 50% length unicortical (702) screws were 16% to 21% less than means for bicortical (892), full-length unicortical (860), and 75% length (894) unicortical constructs. Conclusions: Locked unicortical distal screws of at least 75% length produce construct stiffness similar to bicortical fixation. Unicortical distal fixation for extra-articular distal radius fractures should be entertained to avoid extensor tendon injury because this technique does not appear to compromise initial fixation. Clinical relevance: Using unicortical fixation during volar distal radius plating may protect extensor tendons without compromising fixation. The Effects of Screw Length on Stability of Simulated Osteoporotic Distal Radius Fractures Fixed With Volar Locking Plates - Corrected ProofLindley B. Wall, Michael D. Brodt, Matthew J. Silva, Martin I. Boyer, Ryan P. Calfee10.1016/j.jhsa.2011.12.013Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015863/abstract?rss=yes Maintaining ulnohumeral stability can be difficult when either the coronoid is too fragmented for primary repair or operative delay makes repair difficult or impossible. In addition to ligament repair, restoration of radiocapitellar contact using radial head arthroplasty, and hinged external fixation, reconstruction of the coronoid using a fragment of the discarded radial head—a technique describe in this article—can help restore elbow stability and function. Reconstruction of the Coronoid Process Using a Fragment of Discarded Radial Head - Corrected ProofDavid Ring, Daniel Guss, Jesse B. Jupiter10.1016/j.jhsa.2011.12.016Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SURGICAL TECHNIQUEhttp://www.jhandsurg.org/article/PIIS0363502311015887/abstract?rss=yes Dieterich disease is characterized by avascular necrosis of the metacarpal head. The recent literature has described surgical management of this condition relatively soon after its presentation. We present a case treated conservatively with a satisfactory outcome at 28 months. Conservative Management of Dieterich Disease: Case Report - Corrected ProofMalin D. Wijeratna, James A. Hopkinson-Woolley10.1016/j.jhsa.2011.12.018Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015899/abstract?rss=yesThe patient was a 22-year-old Iranian combatant during the Iran–Iraq war (1980–1988). His left upper limb was hit by a 60-mm mortar shell in 1984. He sustained the injury while he was talking on a wireless communication device and holding the hearing piece of the apparatus with his left hand. Fortunately, the mortar shell did not explode, but it pierced and passed through his left forearm and arm. The head of the shell emerged over his posteromedial surface of the left arm. The fin of the shell was lodged on the dorsal surface of his forearm (). Five hours after the injury he arrived at a field hospital. However, when he arrived at the hospital, both his comrades and the medical professionals assigned to his case were reluctant to come close to the man for fear of an impending explosion. An immediate upper limb amputation was considered and discussed with the patient. However, the patient absolutely refused the amputation and insisted that his limb be saved.First Hand: Unexploded Mortar Shell in an Upper Extremity - Corrected ProofAhmadreza Afshar, Shojaedin Sheikholeslamzadeh, Majid Eyvaz Ziaei10.1016/j.jhsa.2011.12.019Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10A TOUCH OF HUMANITYhttp://www.jhandsurg.org/article/PIIS0363502311015905/abstract?rss=yes Bone substitutes are being increasingly used and may avert the need for autogenous bone graft in orthopedic surgery. Thus it is important to note complications that occur with them to better understand the limitations. We report on early mechanical failure of injectable calcium sulfate leading to implant failure in 2 elderly patients who had corrective osteotomies for malunited distal radius fractures. We hypothesize that these occurred because there was inadequate new bone formation to replace the resorbing bone substitute. We advise caution when using bone substitutes in patients with expected delayed fracture healing. Rapid Resorption of Calcium Sulfate and Hardware Failure Following Corrective Radius Osteotomy: 2 Case Reports - Corrected ProofThilak S. Jepegnanam, Herbert P. von Schroeder10.1016/j.jhsa.2011.12.020Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015929/abstract?rss=yes Purpose: To evaluate the functional and radiographic results of a scaphoid excision and four-corner arthrodesis technique using percutaneous headless compression screws. Methods: A cohort of 33 patients, mean age 51 (range, 20–72) years, was treated for scapholunate advanced collapse (19), scaphoid nonunion advanced collapse (12), midcarpal instability (1), and Preiser disease (1). After scaphoid excision and removal of cartilage and subchondral bone in the midcarpal joint through a limited arthrotomy, capitolunate fixation was achieved with a percutaneous, transmetacarpal Acutrak screw (Acumed LLC, Hillsboro, OR), and triquetrohamate fixation was done with a percutaneous screw. Scaphoid was used as a bone graft. The average follow-up time was 8 months (n = 32; range, 6–64 mo). Results: Union occurred in 31 of 33 wrists (94%). One of the 33 patients had total wrist arthrodesis. Average total active flexion-extension arc was 71° after surgery and 83° before surgery. The postoperative carpal height averaged 0.47 compared to preoperative values of 0.45. The percentage of grip strength significantly improved from 41% before surgery to 80% after surgery. Postoperative mean verbal numerical rating scale pain score was less than 1, statistically better than preoperative score of 7. Twenty-five of 33 patients were completely pain free. The average postoperative Mayo wrist score was 74, a significant improvement over the preoperative average of 40. Final Disabilities of the Arm, Shoulder, and Hand scores averaged 13 (n = 32; range, 0–49). Conclusions: These results were comparable to or better than the results of previously published techniques in terms of fusion rates, alleviation of pain, grip strength, range of motion; Mayo wrist score; and Disabilities of the Arm, Shoulder, and Hand questionnaire score. The technique exploits the theoretical advantages of strong compression between carpal bones while avoiding a screw-head sized hole in the lunate articular cartilage and preserving the dorsal capsular ligament attachments to the triquetrum. Type of study/level of evidence: Therapeutic IV. Results of a Method of Four-Corner Arthrodesis Using Headless Compression Screws - Corrected ProofTuna Ozyurekoglu, Tolga Turker10.1016/j.jhsa.2011.12.022Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015930/abstract?rss=yes Purpose: We describe a variant of triangular fibrocartilage complex (TFCC) tears in which the superficial fibers attaching to the ulnar capsule are torn, with preservation of deep fibers inserting on the fovea. We present the clinical and magnetic resonance imaging findings and the results of arthroscopic repair in patients with this injury. Methods: Twenty-nine wrists were treated arthroscopically for peripheral TFCC tears with outside-in suture repair of the TFCC to the ulnar capsule. A retrospective review of all cases was performed to assess the physical examination, magnetic resonance imaging, and intraoperative findings. Patients were evaluated at greater than 1 year with range of motion, grip strength, standard outcome measures, and a survey assessing return to work and sports. Results: Before surgery, all patients had complaints of ulnar-sided wrist pain with a stable distal radioulnar joint on examination. Twenty-six wrists (90%) were available for follow-up at a mean of 31 months. There was one repeat surgery, a re-tear that required revision TFCC repair. The preoperative visual analog scale and Disabilities of the Arm, Shoulder, and Hand scores improved from 5 and 38 to 1 and 9 at final follow-up, respectively. Side-to-side comparisons demonstrated no measurable loss in motion or grip strength. There were no cases of distal radioulnar joint instability at final follow-up. Of 11 high-level athletes in the total cohort, 7 (64%) were able to return to sports including all of those in racquet sports; however, athletes who bore weight through their hands were unable to return to their sporting activity. Conclusions: Tears of the TFCC superficial fibers with the deep fibers intact present with ulnar-sided wrist pain but without distal radioulnar joint instability. The results of outside-in repair of the articular disk back to the ulnar capsule demonstrated improvement in pain and function with no measurable objective losses. Return to sport was variable and appeared worse for those who bear weight through the hands. Type of study/level of evidence: Therapeutic IV. Arthroscopic Treatment of Peripheral Triangular Fibrocartilage Complex Tears With the Deep Fibers Intact - Corrected ProofRobert W. Wysocki, Marc J. Richard, Matthew M. Crowe, Fraser J. Leversedge, David S. Ruch10.1016/j.jhsa.2011.12.023Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015942/abstract?rss=yesIn july 2008, congress passed HR 6331, also known as “Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)” (http://www.govtrack.us/congress/billtext.xpd?bill=h110-6331). Section 132, which introduced incentives for electronic prescribing (e-prescribe or eRx), is now becoming extremely relevant for hand surgeons. Compliance with this new program offered financial incentives from 2009 to 2010, but failure to comply is now costing practitioners future Medicare revenue. All eligible practitioners who failed to dispense 10 e-prescriptions during the first 6 months of 2011 will forfeit 1% of their 2012 Medicare reimbursement, and those who fail to reach 25 e-prescriptions by the end of this year will lose an additional 1.5% in 2013. Proposed benefits of e-prescription include decreasing health care costs and minimizing medication errors. Unfortunately, the challenges to compliance as well as ethical implications for hand surgeons are numerous.e-Prescribe Meaningful Use Requirement - Corrected ProofR. Glenn Gaston, Elliott P. Robinson10.1016/j.jhsa.2011.12.024Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10IN BRIEFhttp://www.jhandsurg.org/article/PIIS0363502311015954/abstract?rss=yes Purpose: To describe and assess a tension band wiring technique for the treatment of Bennett fractures and to compare this technique of open reduction and internal fixation versus closed reduction and percutaneous pinning. Methods: From July 2005 to April 2008, we treated 56 Bennett fractures in 56 patients using tension band wiring. The mean age of the patients was 32 years. There were 37 dominant hands and 19 nondominant hands. The mean time between the injury and operation was 5 days. In this open tension band fixation group, the mean joint surface involvement was 39%, and all injuries were associated with carpometacarpal joint subluxation. At final follow-up, we assessed the thumbs for range of motion and assessed the hands for pinch and grip strength. For comparison, we also included 21 patients who were treated using closed reduction and percutaneous pin fixation from January 2003 to May 2005. Results: We noted no fixation failures in the open reduction internal fixation group. Radiographic fracture healing was achieved in all patients at a mean time of 4 weeks. Patient follow-up averaged 39 months. At final follow-up, the mean extension-flexion arc of the first carpometacarpal joint was 49°. Mean thumb abduction was 82° and mean pinch and grip strength of the injured hands were 7.4 and 43 kg, respectively. There were no significant differences between groups regarding the extension-flexion arc of the first carpometacarpal joint and grip strength. The 2 groups were similar in thumb abduction and pinch strength. Conclusions: Open tension band wiring is a useful and reliable technique and presents another fixation option for the treatment of Bennett fractures. Type of study/level of evidence: Therapeutic II. Treatment of a Bennett Fracture Using Tension Band Wiring - Corrected ProofXu Zhang, Xinzhong Shao, Zhijie Zhang, Sumin Wen, Jianxin Sun, Bin Wang10.1016/j.jhsa.2011.12.025Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311015978/abstract?rss=yesSeveral injectable substances have been studied for the treatment of tendinitis of the hand, wrist, and elbow, including corticosteroids, botulinum toxin, autologous blood, and platelet-rich plasma (PRP). Whereas empiric data suggest a beneficial effect of many treatments for tendinitis, defined roles for these various injections remain unclear. For several years, orthopedic surgeons have used PRP to treat conditions such as tendinitis about the knee, hip, and shoulder; however, data are inconclusive as to its precise mechanism of action as well as whether it demonstrates lasting benefit. We review the composition and preparation of PRP and list several of the available kits for its preparation.Platelet-Rich Plasma - Corrected ProofJames M. Saucedo, Mark A. Yaffe, John C. Berschback, Wellington K. Hsu, David M. Kalainov10.1016/j.jhsa.2011.12.026Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10IN BRIEFhttp://www.jhandsurg.org/article/PIIS0363502311015991/abstract?rss=yes The Andrew J. Weiland Medal is presented each year by the American Society for Surgery of the Hand and the American Foundation for Surgery of the Hand for a body of work related to hand surgery research. This essay, awarded the Weiland Medal in 2011, focuses on the clinical need for flexor tendon reconstruction and on investigations into flexor tendon biology. Reconstruction of the upper extremity is limited by 2 major problems after injury or degeneration of the flexor tendons. First, adhesions formed after flexor tendon repair can cause decreased postoperative range of motion and hand function. Second, tendon losses can result from trauma and degenerative diseases, necessitating additional tendon graft material. Tendon adhesions are even more prevalent after tendon grafting; therefore these 2 problems are interrelated and lead to considerable disability. The total costs in terms of disability and inability to return to work are enormous. In this essay, published work in the past 12 years in our basic science laboratory is summarized and presented with the common theme of using molecular techniques to understand the cellular process of flexor tendon wound healing and to create substances and materials to improve tendon repair and regeneration. These are efforts to address 2 interrelated and clinically relevant problems that all hand surgeons face in their practice. Studies in Flexor Tendon Reconstruction: Biomolecular Modulation of Tendon Repair and Tissue Engineering - Corrected ProofJames Chang10.1016/j.jhsa.2011.12.028Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-102011 WEILAND MEDAL RECIPIENThttp://www.jhandsurg.org/article/PIIS0363502311016005/abstract?rss=yes This report describes 2 patients with apparent ulnar to radial dorsal fracture-dislocation: 1 had a transtriquetrum, translunate fracture dislocation and the other had a reverse stage 2 lesser arc perilunate dislocation with fracture of the ulnar styloid at its base. Ulnar to Radial Dorsal Fracture-Dislocations of the Wrist: A Report of 2 Cases - Corrected ProofDiederik H. van Leeuwen, Geert A. Buijze, David Ring10.1016/j.jhsa.2011.12.029Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311016017/abstract?rss=yes Scleroderma, or systemic sclerosis (SS), is an autoimmune disease leading to ischemic fibrosis and widespread collagen deposition, invariably affecting the hands. Optimized medical management remains the mainstay of therapy for SS. Surgery can be considered in refractory or severely disabling cases. However, microvascular insufficiency and fibrosis can lead to wound complications and, ultimately, amputation. We present the case of a 61-year-old man with a known history of scleroderma who presented with pain, chronic infection, and ulcerations in the left hand. Initially, amputation seemed a reasonable intervention. After medical optimization with tadalafil, his ulcerations persisted. Instead of amputation, we applied a subatmospheric pressure wound therapy device to his hand. In 4 months, his wounds had healed, there was no evidence of infection, and no digits were amputated. Nonoperative Management of Scleroderma of the Hand With Tadalafil and Subatmospheric Pressure Wound Therapy: Case Report - Corrected ProofRonak M. Patel, Daniel J. Nagle10.1016/j.jhsa.2011.12.030Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311016315/abstract?rss=yes Purpose: Major injuries of the hand with skin loss often require early flap cover, which should be versatile, simple in technique, and safe. The reverse posterior interosseus flap satisfies all of these requirements. Over the years, refinements in the technique of harvesting this flap have evolved to prevent venous congestion and flap necrosis. This study presents adaptations to avoid such complications and raise a successful flap. Methods: A total of 21 patients underwent this flap between January 2008 and November 2010 for injuries around the wrist and hand. The average follow-up period was 6 months; 19 were male and 2 were female. The average age was 33 years (range, 9–70 y). In 17 flaps were done for posttraumatic injuries, in 2 after skin defects following tumor resection, and 1 each after defects resulting from release of first web contracture in multiple congenital contractures and burns. Average size of the flap was 51 cm2 (range, 90– 30 cm2). The donor area was covered by a split skin graft. Results: All flaps survived without major complications. Generally the flap matched the surrounding skin except for palmar defects. No patients reported donor skin graft color mismatch. Conclusions: The reverse posterior interosseous flap is a reliable and safe flap for soft tissue cover to the wrist, palm, dorsum of hand, first web space, and metacarpophalangeal joints. Thorough attention to the technical details, including performing a proximo-distal flap dissection with the deep fascia, avoiding dissection of the anastomotic arc between posterior and anterior interosseous artery, creating a broad pedicle with a cutaneous handle, and avoiding its tunneling for inset, will contribute to survival of the flap. The Reverse Posterior Interosseous Artery Flap: Technical Considerations in Raising an Easier and More Reliable Flap - Corrected ProofA.M. Acharya, A.K. Bhat, K. Bhaskaranand10.1016/j.jhsa.2011.12.031Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10SURGICAL TECHNIQUEhttp://www.jhandsurg.org/article/PIIS0363502311016534/abstract?rss=yes Graphs, figures, and tables can save readers time and energy, aid their understanding of an article, and reduce the word count of the main text. However, many graphics submitted to and published in scientific journals fail to meet their potential and include mistakes that jeopardize their clarity. Many formats are available for presenting data, as well as a variety of techniques for enhancing their interpretability. When the appropriate format is used to depict data, it conveys the greatest amount of information in the clearest fashion, complements the text, and deepens readers' understanding. The aims of this article are to draw attention to the necessity of well-constructed graphs, tables, and figures in scientific publications, and to show how to create them. Graphs, Tables, and Figures in Scientific Publications: The Good, the Bad, and How Not to Be the Latter - Corrected ProofLauren E. Franzblau, Kevin C. Chung10.1016/j.jhsa.2011.12.041Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10CURRENT CONCEPTShttp://www.jhandsurg.org/article/PIIS0363502312000020/abstract?rss=yes The number of therapeutic modalities available to the hand surgeon has greatly increased over the past several decades. A field once predicated only on heat, massage, and cold therapy now uses electrical stimulators, ultrasound, biofeedback, iontophoresis, phonophoresis, mirror therapy, lasers, and a number of other modalities. With this expansion in choices, there has been a concurrent effort to better define which modalities are truly effective. In this review, we aim to characterize the commonly used modalities and provide the evidence available that supports their continued use. Therapeutic Modalities—An Updated Review for the Hand Surgeon - Corrected ProofTristan L. Hartzell, Roee Rubinstein, Mojca Herman10.1016/j.jhsa.2011.12.042Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10CURRENT CONCEPTShttp://www.jhandsurg.org/article/PIIS0363502312000627/abstract?rss=yesWe present a case of a 65-year-old, right-handed man with Dupuytren disease in his left long and ring fingers, with metacarpophalangeal and proximal interphalangeal joint contractures to both. He was offered a needle aponeurotomy to his ring finger as a temporizing measure while awaiting surgery because he wished to postpone surgical intervention. The procedure restored full extension of the ring metacarpophalangeal joint and partially corrected the proximal interphalangeal joint contracture. No complications were reported. The patient returned 9 months later. There was disease progression at the proximal interphalangeal joint, and an open palmar fasciectomy was performed.Traversing Neurovascular Bundle at the Level of the Metacarpophalangeal Joint in Palmar Fasciectomy for Dupuytren Disease - Corrected ProofDina Popovic, Bing Siang Gan, Ruby Grewal10.1016/j.jhsa.2011.12.045Journal of Hand Surgery (2012)2012-02-10Journal of Hand Surgery2012-02-10LETTER TO THE EDITORhttp://www.jhandsurg.org/article/PIIS0363502311014262/abstract?rss=yes Purpose: The teardrop angle (TDA) is a newly characterized radiographic parameter that some authors propose as an indicator of articular incongruity of the lunate facet. The purposes of this study were to investigate intra-observer and interobserver reliability of the measurements of the TDA and to determine whether the TDA is a reliable indicator of articular step and gap formation after distal radius fracture. Methods: We studied radiographs of 24 uninjured wrists and 24 wrists with intra-articular distal radius fractures. On standard and 10° tilt views of lateral wrist radiographs, the teardrop represents the volar rim of the lunate facet, and the TDA is defined as the angle between the central axis of the teardrop and the radial shaft. We examined interobserver and intra-observer reliability for 3 observers using the intraclass correlation coefficient (ICC) for measurements of the uninjured and fractured wrists. For subjects with fractures, we determined correlation of the TDA-volar tilt with the articular step and gap measured by computed tomography using simple linear regression. Results: There was almost perfect intra-observer (ICC = 0.95) and interobserver (ICC = 0.93) reliability in the fractured wrists. We observed substantial intra-observer (ICC = 0.64) and fair interobserver (ICC = 0.28) reliability in the uninjured wrists on the standard lateral radiographs. On the 10° tilt views, intra-observer and interobserver reliability in the uninjured wrists increased to substantial levels (ICC = 0.76 and 0.61, respectively). The TDA-volar tilt was significantly associated with articular step and gap on computed tomography. Conclusions: The TDA, measured on the lateral radiograph of the wrist, exhibits higher intra-observer and interobserver reliability in fractured wrists compared with uninjured wrists. On the 10° tilt views, the reliability increased in the uninjured wrists. Measurement of the TDA in plain radiographs may allow direct estimation of articular incongruity as seen on sagittal computed tomography reconstruction images. Type of study/level of evidence: Diagnostic II. Reliability and Clinical Importance of Teardrop Angle Measurement in Intra-articular Distal Radius Fracture - Corrected ProofRyotaro Fujitani, Shohei Omokawa, Akio Iida, Shigeru Santo, Yasuhito Tanaka10.1016/j.jhsa.2011.10.056Journal of Hand Surgery (2012)2012-01-30Journal of Hand Surgery2012-01-30SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311014869/abstract?rss=yes Chondroblastoma of the carpals is rare, can mimic other benign bone tumors, and presents a diagnostic challenge. There have been few cases of benign tumors involving the hamate, with only one reported case of chondroblastoma, which was treated with complete hamate excision. We present a case of chondroblastoma with secondary aneurysmal bone cyst of the hamate treated with curettage, high-speed burring, phenol, and autogenous iliac crest bone grafting. At the time of the most recent radiographic follow-up, there was full graft incorporation, preserved hamate morphology, and no evidence of recurrence. Chondroblastoma With Secondary Aneurysmal Bone Cyst of the Hamate: Case Report - Corrected ProofPeter C. Rhee, Eduardo N. Novais, Thomas C. Shives, Alexander Y. Shin10.1016/j.jhsa.2011.11.014Journal of Hand Surgery (2012)2012-01-30Journal of Hand Surgery2012-01-30SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311014870/abstract?rss=yes Painful clicking of the interphalangeal joint of the thumb caused by a sesamoid bone is rare. We present 3 cases of painful thumb interphalangeal joint clicking with motion, all following hyperextension injuries. No other source of symptoms was determined, and in each instance the sesamoid was removed. All patients were clinically assessed at 2 years after surgery and were noted to have relief of pain and clicking with full recovery of strength and activities. Painful Clicking of the Thumb Interphalangeal Joint Caused by a Sesamoid Bone: A Report of Three Cases - Corrected ProofShannon Jane Edwick, Jay Robert Ebert, Jeff Oscar Ecker10.1016/j.jhsa.2011.11.015Journal of Hand Surgery (2012)2012-01-30Journal of Hand Surgery2012-01-30SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311014997/abstract?rss=yesA 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.Complex Distal Humerus Fractures in Elderly Patients: Open Reduction and Internal Fixation Versus Arthroplasty - Corrected ProofJuan M. Patino10.1016/j.jhsa.2011.11.020Journal of Hand Surgery (2012)2012-01-30Journal of Hand Surgery2012-01-30EVIDENCE-BASED MEDICINEhttp://www.jhandsurg.org/article/PIIS0363502311013724/abstract?rss=yes Hemophilic pseudotumors are rare, particularly when they occur in the distal extremity of an adult patient. We present the case of a 68-year-old man with well-controlled factor VIII deficiency who presented with a lytic lesion of the distal radius that was identified as an intraosseous pseudotumor. Intraosseous Pseudotumor of the Distal Radius in a Patient With Hemophilia: Case Report - Corrected ProofJason S. Pruzansky, Marvin S. Gilbert, Roberto A. Garcia, Richard S. Gilbert10.1016/j.jhsa.2011.10.046Journal of Hand Surgery (2012)2012-01-03Journal of Hand Surgery2012-01-03SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311014328/abstract?rss=yesWound coverage for damaged or incompetent dermis remains a frequent and often challenging problem in hand surgery. Integra (Integra Life Sciences, Plainsboro, NJ) is an acellular bilaminate membrane that has been used to reestablish a neo-dermis in full-thickness wounds. It consists of a porous surface of cross-linked bovine tendon collagen and chondroitin-6-sulfate and has been shown to facilitate migration of fibroblasts, macrophages, lymphocytes, and capillary ingrowth onto the surface and effectively regenerating the dermis. Histologic and clinical examination of skin greater than 2 years after application of Integra has demonstrated excellent patient satisfaction with respect to softness, mobility, and appearance. Histologically, the authors found that, whereas there was an absence of adnexal structures, collagen and elastin fibers were present in all specimens and nerve regeneration in the lower and reticular dermis was present. Integra is easy to use and apply, readily available, and lacks donor site morbidity, and has been extensively used in burn patients where significant wound coverage is routinely necessary.The Use of Integra in Hand and Upper Extremity Surgery - Corrected ProofMarco Rizzo10.1016/j.jhsa.2011.11.007Journal of Hand Surgery (2012)2012-01-03Journal of Hand Surgery2012-01-03IN BRIEFhttp://www.jhandsurg.org/article/PIIS036350231101344X/abstract?rss=yesA 45-year-old woman presented reporting pain at the tip of her right, dominant thumb, which became worse when she held a cold drink or bumped the thumb and has been gradually increasing over the last two years. Physical examination revealed no deformity, normal range of motion, and severe tenderness to palpation at the tip of the thumb. Close inspection shows redness to one side of the lunula. The provisional diagnosis was subungual glomus tumor.Subungual Glomus Tumor - Corrected ProofDavid T. Netscher, Jaime Aburto, Matthew Koepplinger10.1016/j.jhsa.2011.10.026Journal of Hand Surgery (2011)2011-12-23Journal of Hand Surgery2011-12-23EVIDENCE-BASED MEDICINEhttp://www.jhandsurg.org/article/PIIS0363502311013670/abstract?rss=yes Purpose: Intramedullary fixation is one treatment option for distal radius fractures. Our purpose was to compare the outcomes of intramedullary nailing to those of casting for these injuries. Methods: From 2006 to 2009, we reviewed 63 adult patients with isolated distal radius fractures. Thirty-one patients had surgical fixation with an intramedullary device (IMN group) within 4 weeks of the injury, and 32 (CAST group) had casting as definitive treatment of the fracture. Clinical outcomes (grip strength; Disabilities of the Arm, Shoulder, and Hand scores; active wrist range of motion; and complications) and radiographic indices (radial inclination, radial height, ulnar variance, and tilt) of both groups were analyzed for the 1-, 2-, 4-, 6-, and 12-month follow-up periods. Results: The flexion–extension arc was significantly higher in the IMN group than in the CAST group at 2-, 6-, and 12-month follow-up. The IMN group exhibited significantly greater grip strength and lower DASH scores throughout the follow-up period. At final follow-up, all radiographic indices were significantly better in the IMN group than in the CAST group. There was no significant difference between the initial reduction to final position in the IMN group, but the CAST group showed an increase in ulnar variance and a significant change in dorsal–volar tilt. In addition, the CAST group experienced more clinical complications in the delayed period compared to the IMN group. Conclusions: Intramedullary nail fixation, as compared to casting, results in less functional disability, not only in the early postoperative period but also up to a year after treatment. On the basis of our data, intramedullary fixation should be considered for patients with unstable extra-articular or simple intra-articular distal radius fractures. Type of study/level of evidence: Prognostic II. Comparative Analysis of Intramedullary Nail Fixation Versus Casting for Treatment of Distal Radius Fractures - Corrected ProofVirak Tan, Walter Bratchenko, Ali Nourbakhsh, John Capo10.1016/j.jhsa.2011.10.041Journal of Hand Surgery (2011)2011-12-22Journal of Hand Surgery2011-12-22SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311013736/abstract?rss=yes We report a case of a radial head dislocation that was successfully treated 8 years after the initial injury, by open reduction of the radial head and 3-dimensional ulnar osteotomy, using a computer-generated template based on preoperative 3-dimensional computer simulation. Open Reduction and Three-Dimensional Ulnar Osteotomy for Chronic Radial Head Dislocation Using a Computer-Generated Template: Case Report - Corrected ProofJunichi Miyake, Kunihiro Oka, Hisao Moritomo, Kazuomi Sugamoto, Hideki Yoshikawa, Tsuyoshi Murase10.1016/j.jhsa.2011.10.047Journal of Hand Surgery (2011)2011-12-22Journal of Hand Surgery2011-12-22SCIENTIFIC ARTICLEhttp://www.jhandsurg.org/article/PIIS0363502311014341/abstract?rss=yes “A picture paints a thousand words.” We all know that. This picture book, a compendium of hand photographs entitled Manual: the Personalities of Hands could spark a novel. Thankfully, the 800-word review limits that.Corrected ProofAmy L. Ladd, Robert A. Chase Hand Center10.1016/j.jhsa.2011.11.009Journal of Hand Surgery (2011)2011-12-22Journal of Hand Surgery2011-12-22BOOK REVIEWhttp://www.jhandsurg.org/article/PIIS0363502311012937/abstract?rss=yesCigar 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.Hand Made: Bill's Humidor - Corrected ProofJeffrey Alan Greenberg10.1016/j.jhsa.2011.10.015Journal of Hand Surgery (2011)2011-11-28Journal of Hand Surgery2011-11-28A TOUCH OF HUMANITYhttp://www.jhandsurg.org/article/PIIS0363502311013438/abstract?rss=yesA 40-year-old, healthy, active patient comes to the emergency department after a bicycling accident in which he sustained a closed, displaced intra-articular distal humerus fracture (AO/Orthopaedic Trauma Association type C3). After a discussion of the risks and benefits, the patient gives informed consent to proceed with open reduction and internal fixation.Parallel Versus Orthogonal Plating for Distal Humerus Fractures - Corrected ProofMarco Vennettilli, George S. Athwal10.1016/j.jhsa.2011.10.025Journal of Hand Surgery (2011)2011-11-28Journal of Hand Surgery2011-11-28EVIDENCE-BASED MEDICINEhttp://www.jhandsurg.org/article/PIIS0363502311010926/abstract?rss=yesA 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.The Use of Low-Intensity Pulsed Ultrasound Bone Stimulators for Fractures of the Hand and Upper Extremity - Corrected ProofJonathan C. Riboh, Fraser J. Leversedge10.1016/j.jhsa.2011.08.037Journal of Hand Surgery (2011)2011-10-28Journal of Hand Surgery2011-10-28EVIDENCE-BASED MEDICINEhttp://www.jhandsurg.org/article/PIIS0363502311010896/abstract?rss=yesA 40-year-old, right-handed man sustained a laceration over the palmar surface of the middle phalanx of his right middle finger. The wound was sutured in a local emergency room, and he presented 3 months later complaining of an inability to actively flex the distal interphalangeal (DIP) joint of the middle finger. Our examination found that he had full active proximal interphalangeal (PIP) joint flexion and extension but no active DIP joint flexion. Passive motion of the DIP joint was 0° to 45° of flexion. The patient was unhappy with his inability to actively flex the DIP joint of the digit and wanted to discuss options for surgical correction.Management of Late-Presenting Isolated Flexor Digitorum Profundus Injuries - Corrected ProofMichael V. Birman, Robert J. Strauch10.1016/j.jhsa.2011.08.034Journal of Hand Surgery (2011)2011-10-24Journal of Hand Surgery2011-10-24EVIDENCE-BASED MEDICINE