Journal of Hand Surgery

JHS Guidelines on Systematic Review and Meta-analysis Submissions

Kevin C. Chung — 2012-06-01

There is a growing interest in applying systematic review and meta-analysis methodology to synthesize the enormous amount of data currently available in the medical literature. Approximately 600,000 new articles are indexed in MEDLINE each year, and the exponential increase in medical knowledge makes it difficult for physicians to keep up with the latest trends and advances in research. In particular, individual studies often add more confusion to a topic of interest by reporting conflicting results. Narrative reviews arose years ago to combat this problem and help physicians stay current with the newest findings in the literature. In recent years, however, the narrative review has come under heavy criticism, partly stemming from the fact that this form of review is subject to a substantial amount of bias. In a study on the validity of the narrative review, Mulrow found that 49 of 50 articles that were reviewed did not specify data collection methods or failed to explain the study design, whereas only 3 articles performed a quantitative assessment of the data. As a result, the systematic review and meta-analysis were developed to provide an objective and standardized assessment of randomized controlled trials (RCTs) that would limit the bias inherent in the traditional narrative review. In fact, it is now generally accepted that systematic reviews and meta-analyses of RCTs, if performed correctly, offer the highest level of evidence. Despite the allure of being able to pool data to arrive at a summary conclusion, systematic reviews or meta-analyses can lead to erroneous conclusions if rigorous methodology criteria are not followed. This editorial outlines how the Journal of Hand Surgery will evaluate systematic review or meta-analysis submissions to ensure that the authors have conducted an acceptable level of quality check of their article submissions.

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

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.

Incidence of Bilateral Scapholunate Dissociation in Symptomatic and Asymptomatic Wrists

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.

Lunatocapitate and Triquetrohamate Arthrodeses for Degenerative Arthritis of the Wrist

Mark L. Wang, John M. Bednar — 2012-06-01

Purpose: Proximal row carpectomy and 4-corner arthrodesis are 2 well-established motion-preserving treatment strategies for scapholunate advanced collapse. In this study, we present an arthrodesis technique involving the capitolunate and triquetrohamate joints as another potential treatment option. Methods: From 2000 to 2009, 27 consecutive patients with degenerative scapholunate advanced collapse and scaphoid nonunion advanced collapse were evaluated prospectively and treated with scaphoid excision and intercarpal arthrodesis between the capitate and lunate and between the hamate and triquetrum. This cohort consisted of 18 men and 9 women, involving dominant-sided surgery in 20 of 27 patients. Two patients were active smokers, and 3 cases were work related. Average age at time of surgery was 55 ± 3 years, and average follow-up was 51 ± 7 months. Preoperative and postoperative range of motion, grip strength, and radiographic evidence of osseous union were documented. Standardized Patient-Rated Wrist Evaluation scores for both pain and function were collected. Results: Wrist extension and flexion were decreased after surgery by 17% and 25% respectively, yielding a 21% decrease in mean flexion–extension arc. There was no significant difference with regard to postoperative radial and ulnar deviation or mean coronal plane arc compared to preoperative values. Compared to the contralateral side, preoperative and postoperative grip strength were 53% and 70%, respectively. The average operative-sided grip strength increased by 27%. The mean Patient-Rated Wrist Evaluation pain score was 11 ± 3 (of 50). The mean Patient-Rated Wrist Evaluation functional score was 17 ± 5 (of 100). Complications included 1 nonunion (yielding a 96% fusion rate), 1 median neuropathy (which resolved), and 2 superficial wound infections (treated successfully with oral antibiotics). Conclusions: Arthrodesis of the capitolunate and triquetrohamate joints offers a motion-preserving strategy with a high union rate and good clinical function and pain outcomes for the treatment for scapholunate advanced collapse and scaphoid nonunion advanced collapse. Type of study/level of evidence: Therapeutic IV.

The Durability of the Intrascaphoid Compression of Headless Compression Screws: In Vitro Study

D.S. Gruszka, K.J. Burkhart, T.E. Nowak, T. Achenbach, P.M. Rommens, L.P. Müller — 2012-06-01

Purpose: To test a new generation of compression screws: the Acumed Acutrak 2 Mini (AA; Acumed, Hillsboro, OR), the Stryker TwinFix (ST; Stryker, Kalamazoo, MI), and the Synthes 3.0 headless compression screw (SH; Synthes, Solothurn, Switzerland). Methods: We used 40 fresh-frozen human scaphoids for this study. Bone density was measured. A K-wire was inserted centrally. A perpendicular osteotomy was created in the middle third (Herbert B2 fracture). A custom-made load sensor was placed between the bone fragments. All screws were implanted according to the manufacturers' instructions. The Synthes 2.0 cortical screw (SC), implanted as a lag screw, was used as a reference. The compression force during each experiment was digitally monitored for 12 hours while the data were acquired. The data were analyzed using analysis of variance with the Bonferroni correction. Results: Immediately after screw insertion, ST reached 226 N, followed by AA with 191 N, SH with 137 N, and SC with 72 N. After 12 hours, ST displayed the highest residual compression force, 141 N, followed by AA with 121 N, SH with 78 N, and SC with 32 N. The differences were significant for ST and AA compared to SC. The loss of compression force over 12 hours was 39% for ST, 42% for AA, 49% for SH, and 55% for SC. Conclusions: The new generation of headless compression screws, especially ST and AA, provided significantly higher compression forces after 12 hours, as well as the least loss of compression force over time, in comparison to a classic cortical lag screw. Clinical relevance: A new generation of headless compression screws, by producing higher compression forces, increase stability at the fracture site and might thereby promote bone healing.

Three-Dimensional Computed Tomographic Analysis of 11 Scaphoid Waist Nonunions

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

Purpose: To virtually assess nonunions of the scaphoid waist using 3-dimensional computed tomography (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 results in lengthening of the scaphoid. Correct reduction of the scaphoid fragments is often only possible if the dorsal appositional callus is resected.

Trapezoid Fractures: Report of 11 Cases

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.

Laxity of the Ulnar Nerve During Elbow Flexion and Extension

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.

Predictors of Diagnosis of Ulnar Neuropathy After Surgically Treated Distal Humerus Fractures

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 up 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.

Endoscopically Assisted Decompression for Pronator Syndrome

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 endoscopically 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 endoscopically 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.

Glomus Tumor of Digital Nerve: Case Report

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.

Neurothekeoma of the Median Nerve: Case Report

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.

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

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.

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

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.

The Vascularization of the Median Nerve in the Distal Forearm and Its Potential Clinical Importance

T. Giesen, R.D. Acland, S. Thirkannad, D. Elliot — 2012-06-01

Purpose: The aims of this anatomical study were to identify any extrinsic blood supply to the median nerve in the distal forearm and to measure the tension required to approximate the severed nerve after and before dissecting it while maintaining its extrinsic blood supply. Methods: We injected the arterial system of 15 lightly embalmed forearms with red latex to define the vascular anatomy of the median nerve in the distal forearm. We measured the gap resulting from spontaneous retraction of the cut ends of the divided median nerve and the average tension needed to reapproximate the ends before and after resection of the attachments to the nerve on its superficial, deep, and ulnar aspects. Results: A constant branch to the median nerve arises from the radial artery approximately 5 cm proximal to the radial styloid process. The mean gap between the severed nerve ends was 1.2 cm (range, 0.9–1.7 cm). The mean tension required to coapt the nerve ends was 231 g force (range, 200–280 g), reducing to 89 g force (range, 60–110 g) when only its radial attachments, including this vessel, were preserved. Conclusions: This cadaveric study suggests that it may be possible to advance the median nerve at the wrist while retaining the vascular connection and blood supply from the radial artery, and so maintain the vascularity of the nerve at the common site of nerve repair in the distal forearm. Clinical relevance: This cadaveric study identifies constant arterial feeding branches from the radial artery to the median nerve in the distal forearm, and is a preliminary investigation into the possibility of advancing the median nerve for repair in the distal forearm while maintaining the continuity of this branch.

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

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.

Comparison of Splinting Versus Nonsplinting in the Treatment of Pediatric Trigger Finger

2012-06-01

Purpose: Because pediatric trigger finger is much less common than pediatric trigger thumb, there is no consensus on the efficacy of splinting, owing to both the rarity of the condition and a lack of natural history and comparative therapeutic data. We performed the present retrospective study on 47 fingers to compare pediatric trigger finger treatment by splinting and nonsplinting. Methods: We included 24 children with a total of 47 trigger fingers. Affected fingers included 4 index, 28 middle, 11 ring, and 4 little fingers. Patient age at initial examination ranged from 1 month to 9 years (mean, 2 y). We observed 24 fingers treated with a static splint and 23 fingers treated without it. The time from initial examination to follow-up ranged from 2 to 18 years. Results: In the splinting group, 16 fingers (67%) resolved, 4 fingers (17%) improved, and 4 fingers (17%) remained unchanged. Seven fingers (29%) ultimately required surgery. In the nonsplinting group, 7 fingers (30%) resolved spontaneously, 1 (4%) improved, and 15 (65%) remained unchanged. Fifteen fingers (65%) later underwent surgical release. The rate of resolution in the splinting group was significantly higher than that in the nonsplinting group. The proportion of fingers needing surgical treatment in the splinting group was significantly lower than that in the nonsplinting group. Conclusions: For treatment of pediatric trigger finger, it is advisable to fit a static splint at the first visit. Type of study/level of evidence: Therapeutic IV.

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

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.

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

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.

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

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.

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

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 greater 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.

Major Upper-Limb Amputations for Malignant Tumors

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.

Trapezial Metastasis as the First Indication of Primary Non–small Cell Carcinoma of the Lung

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.

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

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.

Hand Made: Recreating an Ancient Chinese Instrument, the Guqin

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 harks back to 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 marks the natural harmonic nodes ().

Hands on Stamps: China 2005—World Earth Day

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.

Journal CME Instructions

2012-06-01

Septic Olecranon Bursitis

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

A 40-year-old man who works as 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 the patient's 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.

Epinephrine and Hand Surgery

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.

Journal CME Questions

2012-06-01

The Anterolateral Corner of the Radial Metaphysis as a Source of Bone Graft for the Treatment of Scaphoid Nonunion

Luis Aguilella, Marc Garcia-Elias — 2012-06-01

As a source of corticocancellous grafts for treating scaphoid nonunions, the anterolateral corner of the distal radial metaphysis has several advantages over other alternatives: it provides good-quality corticocancellous bone, it allows one to harvest the graft and treat the scaphoid through the same incision, it does not require general anesthesia, and it has less morbidity than occurs when obtaining the graft from the iliac crest.

Another Light in the Dark: Review of a New Method for the Arthroscopic Repair of Triangular Fibrocartilage Complex

Chris Y.K. Tang, B. Fung, Chan Rebecca, C.P. Lung — 2012-06-01

The triangular fibrocartilage complex (TFCC) is an anatomically and biomechanically important structure. Repair of radial-sided TFCC tear has previously been challenging. We designed a new method of radial-sided TFCC tear repair and found that it was also applicable for ulnar-sided TFCC tear repair. From October 2006 to December 2010, 10 patients underwent this operation and were reviewed: 9 men and 1 woman, with a mean age of 33.9 years. Average postoperative follow-up was 8 months. We graded results according to the Mayo modified wrist score. We rated 2 of the 10 patients (20%) as “excellent,” 3 (30%) as “good,” and 5 (50%) as “fair.” The 5 patients who were rated as “fair” returned to regular jobs or had restricted employment. Based on this small sample, we recommend that this technique be considered an alternative method for TFCC repair.

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

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.

Journal CME Questions

2012-06-01

Mobile Software Applications for Hand Surgeons

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.

Benign Subungual Tumors

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.

Journal CME Questions

2012-06-01

Lessons for Adult Fingertip Regeneration: Glimpses From Basic Research

Amit Roshan, Ian Grant — 2012-06-01

Understanding the mechanisms involved in limb and finger regeneration holds promise for improving current treatment therapies. Recent animal studies have improved our understanding of the limb regeneration process markedly. Improved sophistication in experimentation has allowed results that partly reveal the cells of origin in fingertip regeneration in mouse models, which implicates a tissue-resident progenitor cell population. The impressive regeneration of amputated salamander limbs has been shown to work through an evolutionarily divergent mechanism and may not be open to direct translational approaches in mammals. In addition, researchers are beginning to understand the complexity of the interrelated mechanisms of axis determinants in chick embryo limb development. In this article, we review lessons to be learned from these divergent experiments, to understand fingertip regeneration in humans.

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).

Paul R. Manske 2011 Award for Best Upper Extremity Congenital Research Manuscript

Charles A. Goldfarb, Ann Van Heest, Michelle A. James, H. Relton McCarroll — 2012-06-01

Paul Manske made numerous contributions to our understanding of congenital anomalies over the last 30 years. They included manuscripts establishing more effective classifications (radial deficiency, ulnar deficiency, central deficiency, hypoplastic thumb) and surgical techniques (for hypoplastic thumb and radial deficiency, among others). These contributions have improved our understanding and our ability to care for children with congenital anomalies of the upper extremity.

Masthead

2012-06-01

Editorial Board

2012-06-01

Instructions to Authors

2012-06-01

Journal of Hand Surgery

JHS Guidelines on Systematic Review and Meta-analysis Submissions

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

Incidence of Bilateral Scapholunate Dissociation in Symptomatic and Asymptomatic Wrists

Lunatocapitate and Triquetrohamate Arthrodeses for Degenerative Arthritis of the Wrist

The Durability of the Intrascaphoid Compression of Headless Compression Screws: In Vitro Study

Three-Dimensional Computed Tomographic Analysis of 11 Scaphoid Waist Nonunions

Trapezoid Fractures: Report of 11 Cases

Laxity of the Ulnar Nerve During Elbow Flexion and Extension

Predictors of Diagnosis of Ulnar Neuropathy After Surgically Treated Distal Humerus Fractures

Endoscopically Assisted Decompression for Pronator Syndrome

Glomus Tumor of Digital Nerve: Case Report

Neurothekeoma of the Median Nerve: Case Report

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

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

The Vascularization of the Median Nerve in the Distal Forearm and Its Potential Clinical Importance

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

Comparison of Splinting Versus Nonsplinting in the Treatment of Pediatric Trigger Finger

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

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

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

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

Major Upper-Limb Amputations for Malignant Tumors

Trapezial Metastasis as the First Indication of Primary Non–small Cell Carcinoma of the Lung

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

Hand Made: Recreating an Ancient Chinese Instrument, the Guqin

Hands on Stamps: China 2005—World Earth Day

Journal CME Instructions

Septic Olecranon Bursitis

Epinephrine and Hand Surgery

Journal CME Questions

The Anterolateral Corner of the Radial Metaphysis as a Source of Bone Graft for the Treatment of Scaphoid Nonunion

Another Light in the Dark: Review of a New Method for the Arthroscopic Repair of Triangular Fibrocartilage Complex

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

Journal CME Questions

Mobile Software Applications for Hand Surgeons

Benign Subungual Tumors

Journal CME Questions

Lessons for Adult Fingertip Regeneration: Glimpses From Basic Research

Paul R. Manske 2011 Award for Best Upper Extremity Congenital Research Manuscript

Masthead

Editorial Board

Table of Contents

Instructions to Authors