Journal of Hand Surgery-American Volume最新文献

Purpose: The radial head and neck feature a unique anatomical structure, whereby the application of a plate in certain areas can lead to impingement, subsequently restricting the forearm rotation. Various techniques have been suggested to identify the appropriate region for plate fixation. We propose an alternative method to locate a safe zone for plate placement and conduct a comparative analysis with previously established methods.

Methods: The study included 30 embalmed cadavers. All specimens demonstrated a full passive range of forearm rotation. A plate was positioned on the most anterior aspect of the radial head/neck with the forearm in full pronation (anteroposterior position) and on the most posterior aspect with the forearm in full supination (P-S position). We assessed the range of motion to identify proximal radioulnar joint impingement and compared the plate's positioning to the safe zone described by Caputo and Smith.

Results: All specimens maintained a full passive range of motion following plate fixation in all positions. The plate placement fell within the boundaries of Caputo's radial styloid direction and Smith's Lister's tubercle direction. The average plating zone measured 94°.

Conclusions: Positioning the plate at the most anterior aspect during forearm pronation or at the most posterior aspect during forearm supination may serve as an alternative method for identifying a safe fixation zone that avoids proximal radioulnar joint impingement. Using this technique, all specimens demonstrated a full passive range of motion after plate placement, and the plates were positioned within the standard safe zone of the proximal radius.

Fractures of the thumb encompass a diverse spectrum of injury patterns, each requiring nuanced consideration of various treatment strategies. Associated conditions include injuries to the ulnar collateral ligament and radial collateral ligament of the metacarpophalangeal joint, which can significantly impact thumb stability and function. Although extra-articular fractures of the thumb metacarpal and phalanges are more tolerant of residual deformity due to compensatory movement of the carpometacarpal joint, intra-articular fractures, including Bennett and Rolando fractures, often benefit from surgical intervention to restore articular congruity. This review provides an updated analysis of the treatment and fixation options for thumb fractures and associated ligamentous injuries.

Purpose: The management of chronic tendinous mallet finger resulting from extensor tendon insertion rupture presents a considerable challenge. To our knowledge, this study describes a clinical technique using a brachioradialis tendon-bone graft to reconstruct the extensor apparatus.

Methods: Ten patients who remained unable to actively extend the distal interphalangeal joint despite nonsurgical treatment were included; of these, two demonstrated secondary swan-neck deformities. All patients demonstrated satisfactory passive range of motion in flexion and extension at the distal interphalangeal joint. Preoperative x-ray revealed no fractures involving the base of the distal phalanx. All surgeries took place between 3 months and 14 years after the initial injury. During the procedure, we inserted the graft's bone block into a prepared bone groove at the base of the distal phalanx and sutured the harvested brachioradialis tendon to the ruptured stump of the extensor tendon. This technique transforms the healing process at the extensor tendon insertion from tendon-bone healing to bone-bone healing.

Results: The follow-up period ranged from 3 to 5 years. We assessed postoperative finger function using the Crawford criteria, rating four cases as excellent and six as good. We evaluated overall patient satisfaction using a Likert scale, with scores of 5 in 2 cases, 4 in 6 cases, and 3 in 2 cases. The mean active range of motion was 82°, ranging from 75° to 90°. Only one patient experienced a complication, a slight dorsal protuberance at the distal phalanx.

Conclusions: This technique is viable for reconstructing chronic tendinous mallet finger caused by extensor tendon insertion rupture.

Type of study/level of evidence: Therapeutic IV.

Ring avulsion injuries, though rare, represent a uniquely devastating subset of hand trauma, with circumferential damage to skin, tendon, bone, and neurovascular structures. Historically, these injuries were almost universally treated with amputation; however, advances in microsurgical repair have transformed management and opened the possibility of finger salvage. We review the epidemiology, classification systems, treatment options, and biomechanical studies that have prompted innovations in ring manufacturing. Over time, classification systems have shifted treatment emphasis from survival to functional prognosis. Contemporary microsurgical practice supports revascularization and replantation for injuries distal to the flexor digitorum superficialis insertion, with survival rates approaching 80% to 85%. Proximal injuries, however, continue to carry a poor functional prognosis, making amputation the preferred option in most cases. As wearable technology drives renewed interest in ring design, future innovations should incorporate failure mechanisms that prevent tissue injury without sacrificing aesthetics. Ultimately, optimal management of ring avulsion injuries requires excellent microsurgical technique, appropriate functional expectations, an understanding of patient preferences, and incorporation of preventive measures.

Purpose: This study aims to determine the impact of injury mechanism energy level on clinical outcomes following Galeazzi fracture.

Methods: A retrospective review was performed on 116 skeletally mature patients treated operatively for Galeazzi fractures between January 2000 and October 2023. Patients were categorized by mechanism of injury into high-energy (HE, n = 92) and low-energy (LE, n = 24) groups. Demographics, fracture characteristics, fixation details, and postoperative outcomes, including wrist and elbow range of motion, complications, radiographic healing time, and reoperations, were collected and compared between groups using standard parametric and nonparametric tests with significance set at P < .05. Normality was assessed using the Shapiro-Wilk test, and Fisher exact test was used for categorical variables with low expected counts.

Results: No differences were observed in body mass index or injury characteristics between groups. The HE group was younger and included a higher proportion of men. Wrist motion was more limited in the HE group across dorsiflexion, palmar flexion, pronation, and supination, and time to radiographic healing was longer compared with the LE group. Elbow motion and rates of nonunion, fracture-related infection, contracture, readmission, and distal radioulnar joint symptoms were similar between groups.

Conclusions: HE Galeazzi fractures were associated with poorer wrist range of motion and toward delayed radiographic healing compared with LE injuries. Recognition of this association underscores the prognostic value of injury mechanism and may inform surgical planning, rehabilitation expectations, and patient counseling.

Type of study/level of evidence: Prognostic III.

Purpose: Clinical management for brachial plexus birth injuries (BPBI) is often focused on childhood, leaving a gap in understanding of how this condition impacts individuals into young adulthood. Recent studies suggest that pain persists beyond pediatric care, although the long-term trajectory of pain and function remains poorly understood. This study compares pain interference in young adults with BPBI to matched controls. Secondary objectives were to compare pain intensity between groups, examine the relationship between upper limb function and pain, and identify common areas of pain using self-reported body maps.

Methods: A cross-sectional study was performed comparing 26 young adults with BPBI and 26 healthy controls, matched by age and sex. Participants completed the Brief Pain Inventory and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire online. Mann-Whitney U tests, Spearman correlations, and Fisher's exact tests were used to analyze group differences and associations.

Results: Compared with controls, BPBI participants (n = 21, 81%) reported pain beyond everyday types of pain and had significantly higher pain interference and upper limb activity limitation (P < .001). Pain interference was strongly positively correlated with activity limitation. Prevalence of ipsilateral truncal and upper-extremity pain was significantly higher than in the same regions on the unaffected side (P ≤ .004). However, the unaffected posterior neck, shoulder joint, upper and lower back, hand, and wrist demonstrated elevated reports of pain.

Conclusions: Young adults with BPBI experience widespread pain that interferes with daily life, which is greater than previously recognized. Pain screening, including potential overuse of the unaffected side, are recommended.

Type of study/level of evidence: Cross-sectional study with cases and controls; Level IV.

Purpose: To develop a classification system for extra-articular distal radius fractures (DRFs) integrating radiographic parameters of instability, ulnar fractures, distal radioulnar (DRU) joint disruption, and carpal involvement and to evaluate its reliability.

Methods: A multicenter study across three university-affiliated orthopedic centers identified 1,239 extra-articular DRFs from 3,784 radiographs. Radiographic features were categorized into four domains: (1) DRF instability (radial inclination <15°, radial height loss ≥5 mm, dorsal angulation >15° in dorsally displaced fractures or volar tilt >15° in volarly displaced fractures, or metaphyseal comminution); (2) distal ulnar fractures (simple vs comminuted); (3) DRU joint disruption (bony vs soft tissue); and (4) carpal involvement. A hierarchical classification system with four types and eight subtypes was developed: Type I (isolated DRFs: IA stable, IB unstable), type II (ulnar fracture: IIA simple, IIB comminuted), type III (DRU joint disruption: IIIA bony, IIIB soft tissue), and type IV (carpal involvement: IVA isolated, IVB with DRU joint disruption). Reliability was assessed using a stratified random sample of 80 cases (10 per subtype) independently reviewed by six trained observers (two per center). Reliability was determined using Cohen's kappa with 95% confidence intervals.

Results: Reliability testing of the classification system across centers demonstrated mean k values ranging from 0.81 to 0.88 for Type I (IA and IB), Type IIA (simple ulnar), and Type IIIA (bony DRU joint) subtypes and mean k values ranging from 0.75 to 0.79 for Types IIB (comminuted ulnar), IIIB (soft tissue DRU joint), IVA (carpal only), and IVB (carpal + DRU joint).

Conclusions: This classification system provides reliable and reproducible classification of extra-articular DRFs with meaningful inter- and intraobserver reliability across all fracture types.

Clinical relevance: This proposed classification may improve comparability across studies and assist in clinical management and evidence synthesis for extra-articular DRFs.

Purpose: To assess scapholunate bridge augmentation with all-suture, knotless anchors in cadaveric wrists through evaluation of radiographic parameters, by comparing the bridged wrist to the wrist with an intact scapholunate interosseous ligament (SLIL) and sectioned SLIL.

Methods: Nine cadaveric specimens were tested in 6 positions: wrist flexion, extension, ulnar deviation (UD), radial deviation (RD), clenched fist, and neutral. Radiographic parameters including scapholunate interval (SLI), scapholunate angle (SLA), and dorsal scaphoid translation (DST) were measured for each position. The SLIL was then sectioned, and parameters were measured in all 6 positions. The SLIL was repaired using one knotless anchor in the scaphoid and one in the lunate, with the repair suture from each anchor shuttled into the opposing anchor and tensioned to bridge the interval. Parameters were again measured in the 6 positions. Scapholunate interval was evaluated using repeated measures analysis of variance at α = 0.05; descriptive statistics were performed for SLA and DST.

Results: Scapholunate interval was different between testing states in flexion (P < .001), UD (P < .001), RD (P = .01), clenched fist (P < .001), and neutral (P = .02). Post hoc testing revealed SLI was wider in the sectioned state than the intact state and bridged states in flexion, UD, and clenched fist. Scapholunate interval in these 3 states was similar between intact and bridged states. In neutral, SLI was narrower in the bridged state compared with intact and sectioned states. In RD, SLI was narrower in the bridged state compared with the sectioned state. Abnormal SLA (>60°) was only seen in flexion, across all 3 states. Mean DST increased after sectioning, then decreased after bridging, in extension, UD, RD, clenched fist, and neutral, although statistical conclusions cannot be drawn.

Conclusions: Scapholunate bridge augmentation restored radiographic parameters of carpal alignment.

Clinical relevance: With further cadaveric testing followed by clinical study, this technique may prove to be a useful treatment for SLIL injury.

Lymphedema may be primary (because of congenital lymphatic abnormalities) or secondary (commonly caused by cancer treatments). It progresses from pitting edema to fibrotic, nonpitting swelling. Diagnosis involves limb measurements and imaging like lymphoscintigraphy, indocyanine green lymphography, and magnetic resonance imaging lymphangiography. Treatment begins with complete decongestive therapy, and unresponsive cases may undergo microsurgical procedures such as lymphaticovenous shunts or vascularized lymph node transfer. Historically clinicians advised against procedures like needle sticks or tourniquet use in lymphedema-affected limbs. However, recent evidence disproves these concerns. Surveys show hand surgeons are more open to operating on lymphedema patients than other specialists. Several small studies report no considerable worsening of lymphedema after surgery, although transient flare-ups and minor infections have been noted. No studies confirmed deep infections, and most erythema-related cases resolved with oral antibiotics. Patients with prior breast cancer surgery, especially those who underwent axillary lymph node dissection, were previously thought to be at high risk. However, multiple studies show that hand surgery does not increase the risk of developing lymphedema in this group. Tourniquet use and avoiding routine prophylactic antibiotics are generally considered safe. Hand surgery appears safe for patients with or at risk of lymphedema; however, caution is warranted given the lack of consensus guidelines and recommendations. There is a lack of standardized guidelines, and surgeon practices vary widely. Further interdisciplinary research is needed to establish clear protocols and ensure optimal outcomes for these vulnerable patients.

Purpose: Although carpal tunnel release (CTR) is the most common upper-extremity orthopedic procedure in the United States, revision surgery can be indicated when symptoms of carpal tunnel syndrome persist, recur, or worsen after primary surgery. Understanding the revision surgery profile after CTR is important for preoperative counseling and treatment decision-making, yet published rates of revision surgery vary widely. In our study, we aimed to establish the rate of revision CTR and describe temporal patterns of revisions after primary surgery for patients with long-term follow-up at our institution.

Methods: We performed a retrospective chart review of 1,328 primary CTR procedures performed from July 2008-June 2013 with a minimum follow-up period of 10 years at our center and at least one documented encounter within our integrated health network within the last 3 years (2021-present). Of the 1,328 cases originally reviewed, 783 (59%) met our inclusion criteria. We conducted bivariate analyses to assess for risk factors associated with revision CTR.

Results: Of the 783 patients included in our study, 20 (2.6%) underwent revision CTR at a median of 5.2 years (interquartile range [IQR], 0.48-8.2 years) after primary surgery. Of the revision CTRs, 80% were performed for recurrent symptoms and 20% for persistent symptoms. Median follow-up after primary surgery with the surgeon was 3.6 years (IQR, 0.4-9.6 years) and median follow-up within the integrated health system was 12.8 years (IQR, 11.9-14.4 years). The rate of revision surgery for recurrent carpal tunnel syndrome remained constant and linear throughout the follow-up period, whereas for persistent carpal tunnel syndrome, all revisions were performed within 2 years of the primary surgery.

Conclusions: The rate of revision CTR with long-term follow-up is low. Our finding expands upon the existing literature to further characterize the revision surgery rate of this common hand procedure, helping to inform preoperative counseling.

Type of study / level of significance: Prognostic IV.